الفهرس 
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Abstract
Introduction
Substance use disorder is one of the most complicated problems that face not only medical professionals but the whole community. Problems of substance abuse produce dramatic costs for all societies in the term of low productivity, medical complications, family and social troubles as well as crimes.
There are numerous mentions in the literature to a protracted- abstinence (PA) syndrome enduring beyond the acute withdrawal phase following acute abstinence from opioids. It is proposed that the treatment of the PA might offer new paths in relapse prevention.
Surprisingly, there seem to be few studies in which PA symptoms are studied in former heroin users. Such studies would help to assess whether drug-free former heroin users spend some time in greater discomfort than, for instance, former heroin users maintained on methadone even after acute withdrawal symptoms have resolved. This would be important to know in order to inform treatment decisions and to help prepare patients for the first weeks or months of abstinence.
PA was formerly described as a lack of psychologic comfort during the initial period (first several months) of abstinence from heroin. Currently, affective, cognitive, and behavioral components are identified in PA.(1) The affective element includes depressed mood, anxiety, irritability, inner tension, nervousness, feelings of discomfort without any cause, a feeling that life is dull and empty, lack of interest, heroin craving, and sleep disturbances. (21, 22) The cognitive element of PA includes thoughts, fantasies, memories, and dreams about the drug and drug paraphernalia linked to past heroin use. The behavioral element of PA usually presents with different activities aimed to acquire heroin. During an inpatient treatment period, the behavioral component can also present through patients
exchanges involving discussions of previous experiences of heroin use.
The successful treatment of PA is an important approach to relapse prevention. Various therapies involving antidepressants for stabilization of abstinence in recovering opiate addicts were described in literature within the last several years.(26,27) However, despite some initial results, the clinical outcomes of these treatments still required more rigorous therapeutic strategies.
Aim of the work
Study goals:
1. To determine prevalence and presentation pattern of protracted symptoms of withdrawal in opiate users.
2. To determine if there are any polysomnographic changes characteristic of recovering opiate users.
3. To determine if there is a correlation between presences of any protracted symptoms of withdrawal and the 6-month relapse rates in recovering opiate users.
Patients & Methods
Participants will be patients diagnosed with Substance Use Disorder according to DSM 5 criteria. They will be referred from the inpatients clinic of Maamoora Mental Health Hospital. Informed consent will be obtained from all patients. The study will be conducted on 90 subjects divided into 2 groups: group I will include 60 cases and group II will include 30 controls. Both groups will be selected according to inclusion and exclusion criteria.
Inclusion criteria:
1. Age 18-60 years.
2. Both genders.
3. Opiate Use Disorder according to DSM 5 criteria.
4. Negative urine drug screen tests (patients in early full remission).
Exclusion criteria:
1. Patients who suffer general medical conditions that are relieved by using opiates.
2. Dual diagnosis
3. Inability to provide informed consent.
Results
As regard demographics there was no difference found between study sample and control group as regard age and type of discharge. A difference was found in type of opiate agonist used between opiate only users and poly substance users. The former group were found more likely to take heroin as an opiate agonist (100%) whereas group A used heroin less frequently (70%)
Analysis of data comparing ASI scores between the two test groups found a significant difference in the subdomains of medical status, drug status, legal status, social status, and total score. all scores were higher in polysubstance users except drug status which was the only sub score higher in opiate only users.
Analyzing PSG data found that total sleep time, sleep efficiency and NREM stages 1 and 2 were significantly reduced in sample group compared to controls. NREM stage 3 was found to be increased significantly in study sample. It is to be noticed that 100% of sample whether poly or single use reached stage 4. REM percentage was found to be significantly reduced in sample with further significant reduction in poly substance users over opiate only users.
As regard HDRS Results show a higher score In group A Initially that rapidly dissipates after 3 months of follow-up. group B shows high OCDUS scores over the entire period of follow-up while somatization scale is mostly significantly increased in group B as well.
Comparing relapse rates between groups A and B reveal that during the first 3 months of follow-up there was a significant difference in relapse rates (10 relapses in group B versus 3 relapses in group A) this difference however caught up later as group A patients continued to relapse while group B relapse rates remained the same.
Correlating Relapse rates with ASI scores revealed that no sub- domain score In ASI could predict relapse in any of the sample patients whether polysubstance use or single use. Also,
Total ASI score was found to be insignificant between the relapse group and the non-relapse groups
There was a significant difference In HDRS Score between the relapse and non-relapse groups Suggesting that HDRS can predict relapse In opiate users. A significant difference was also found between the relapse and relapse groups as regard OCDUS scores which also indicates that OCUDS may predict relapse. SSS-8 however did not score a difference between the 2 groups.
Correlating PSG data with relapse rates it was found that increase in stage one and reduction in stage 2 NREM sleep were predictive of relapse among opiate patients in both groups. Other measures in PSG were not as successful in predicting relapse.