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Review
Heroin Addict Relat Clin Probl 2012; 14(4): 81-94
81
Corresponding Author: Silvia Bacciardi, School of Psychiatry, Santa Chiara University Hospital, Department of Neurosciences,
University of Pisa, Via Roma 67, 56100-PISA, Italy, EU
E-mail: s.baciard@gmail.com
Aggressive behaviour and heroin addiction
Silvia Bacciardi 1, Angelo Giovanni Icro Maremmani 1,2, Luca Rovai 1, Fabio Rugani 1,
Francesco Lamanna 4, Liliana Dell’Osso 1, Matteo Pacini 3 and Icro Maremmani 1,2,3
1. Vincent P. Dole Dual Diagnosis Unit, Department of Neurosciences, Santa Chiara University Hospital, University of Pisa, Italy,
EU
2. Association for the Application of Neuroscientic Knowledge to Social Aims (AU-CNS), Pietrasanta, Lucca, Italy, EU
3. G. De Lisio Institute of Behavioural Sciences Pisa, Italy, EU
4. SerT (Drug Addiction Unit), Pisa, Italy, EU
Summary
In this review we discuss the correlations between aggressiveness, dened according to a behaviourist model, and heroin
dependence according to DSM-IV-R criteria. Criminality appears to be only an indirect, partial index of aggressive be-
haviour in heroin addicts. The aggressive behaviour of heroin addicts is probably different from that of other kinds of
mentally ill patients, non-opiate substance abusers and the general population, and seems to be specically related to
the degree of chronic intoxication. Gender differences, aggressive habits before heroin use, and modulation during in-
toxication and/or withdrawal states have been documented. The association between cerebral opioidergic abnormalities
and psychiatric disorders characterized by affective instability,feelingsof angerand hostility, perception abnormalities
andsexual dysfunction, could explain highly aggressive behaviours of heroin addicts which are not directly related to drug
supply. Knowledge about the anti-aggressive property of non-opioid drugs is limited. On the other hand, opioid agonists
are promising agents for the treatment of aggressive behaviours in non-addicted patients, too.
Key Words: Aggressive behaviour; heroin dependence; agonist opioid treatment.
1. Background
In this review we deal with the correlation be-
tween aggressive behaviour and heroin dependence,
according to the behaviourist model of aggressive-
ness and the DSM-IV diagnosis of heroin dependence
[1, 8, 11, 39].
The term “aggression” can be used to describe
either active, creative adaptation to the environment
or negative, destructive behaviour. According to the
‘behaviourist model’, aggressiveness is not a consti-
tutional trait, but an acquired one. According to the
‘Yale school’ denition, aggression is always sec-
ondary to frustration [39]. However, the “frustration-
aggression theory” postulates that frustration is just
one of the many factors that can stimulate aggression,
another factor being instigation. Many types of ac-
quired latent aggression can be manifested too, of-
ten in response to appropriate stimuli, not necessarily
eliciting frustration [11]: aggression could be evoked,
beyond its original meaning, by specic stimuli, but
only in people who have learned aggressive behav-
iours [8]. According to Buss we should distinguish
between aggression and feelings of anger or hostile
attitudes. He denes aggression as the production of
a noxious stimulus in an interpersonal context, di-
rected from one person against another, whether it
is physical or verbal, direct or indirect. On the other
hand, anger is dened as an emotional reaction, and
hostility as a negative attitude towards a person, not
necessarily preliminary to aggression and not always
required to underlie aggression. Each of these aspects
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Heroin Addiction and Related Clinical Problems 14 (4): 81-94
can be displayed either separately or together with
the others, independently or in a sequence leading
from feelings to action. Aggression is more likely to
be unleashed as a way of reaching goals, rather than
of taking pleasure in victimizing someone [23-25].
Impulsivity and aggressiveness (a tendency towards
aggression) are not the same, either. According to the
“behaviourist theory”, an impulse is triggered by an
environmental or inner stimulus; it stems from an al-
teration to homeostatic balance, and action is the di-
rect consequence of that. Aggressiveness is a planned,
premeditated act, whereas impulsive ‘acting-outs’
are unplanned, overwhelming and inadequate out-
bursts of rage and anger, which do not help anyone to
reach any actual goal. Impulse control disorders were
rst described in 1838 by Esquirol, who suggested
the denition “monomanies instinctives” to describe
states of behavioural excitement characterized by
recurrent, irresistible urges of a single kind, leading
someone to approach the environment or other people
in an appetitive or destructive way, going beyond his/
her intention or attempt to control themselves.
Buss and Durke described seven different types
of hostile-aggressive behaviours, which are some-
times expressed in people who have no psychiatric
history: assault; indirect hostility; irritability; nega-
tivism; resentment; suspicion; verbal hostility. “As-
sault” is the tendency to carry out actions that aim
to harm and injure people without that occurring in
an impulsive way. “Indirect hostility” is aggression
perpetrated without any physical contact, for exam-
ple by denigrating someone in an unpleasant way or
slamming doors; “irritability” is characterized by a
low threshold for verbal quarrelling and arguing, with
a subjective urge to prevail or ght back as a means
of achieving one’s goals. “Negativism” consists in a
strong and persistent opposition in an interactive rela-
tionship, with the refusal to perform any task, ranging
from simple movements to verbal answers and emo-
tional rejection; “resentment” corresponds to feelings
of envy or retaliation that derive from underlying dis-
satisfaction arising from one’s personal condition,
which is often blamed on others; “suspicion” is the
belief that one is victimized, disliked or even hated by
others; “verbal hostility” is the tendency to explicitly
disapprove of the actions of others and the tendency
to cause controversy, or an inability to avoid it, by
overreacting verbally. Lastly, to determine the level
of aggression inhibition, there are 7 different grades,
from assault down to guilt. People who feel guilty are
frequently characterized by a strong ethical or moral
rigidity, or a prick of conscience, and they are often
worried about their deeds or even thoughts [26].
2. Heroin Addiction and Criminality
Criminality appears to be an indirect, partial cor-
relate of aggressiveness displayed by heroin addicts,
since the intersection between the two merely reects
acts of violent assaultive behaviour. In fact, offences
perpetrated by heroin addicts can be divided into 3
major categories: crimes against 1) property, 2) peo-
ple (assaultive violence) and 3) oneself (suicidality).
Although drug users have always been regarded
as a single violent social group [103, 135] and their
involvement in crime is commonly reported [3, 7, 65,
103]; their commitment to the criminal world is often
related to the fact that heroin is expensive and illegal
[65, 103]. In any case, many of the crimes committed
by heroin addicts do not consist merely in drug selling
or trafcking, but also involve other elds of crimi-
nal behaviour such as violent assaults; in particular,
heroin addiction seems to be closely connected with
offences against property [101] of which shoplifting,
burglary and robbery, are the most common [10, 78,
87, 123]. In a longitudinal perspective (addiction his-
tory), the predominant type of illegal activity varies
according to the recurrence of drug-related crime.
At the same time, the incidence of violent crime
and acts of hooliganism invariably decreases, while
the number of people who have committed property
crimes shows only a slightly falling trend [80].
Compared with the general population, offend-
ers report higher rates of drug use, and drug users are
more frequently found to be offenders. One study
reported that 79% of heroin-dependent individuals
had been arrested and 60% had been convicted for
a criminal offence [81]. Criminal trends assessed by
drug of abuse for 2010 conrmed the transition from
a downward to an upward trend, starting in 2009, for
heroin-related offences; before that, the EU average
for such offences had fallen by 39% during the 2003-
2008 period. The number of heroin-related offences
increased in 16 reporting countries, while a fall was
reported in Bulgaria, Germany, Italy and Austria over
the same period [43]. A few studies have aimed to
investigate the relationship between crime and heroin
abuse/dependence [101].
Among heroin addicts entering methadone treat-
ment, a majority (55%) had been criminally active in
the month before the interview [117], and over 90%
had been convicted at least once of property or drug
offences [65].
Homicide perpetrated by heroin addicts is rare,
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S. Bacciardi et al.: Aggressive behaviour and heroin addiction
but lifetime opioid use by serial murderers was re-
lated to a preference for female victims, with a disor-
ganized pattern of behaviour [105]. Heroin addiction
was also signicantly associated with non-homicidal,
but severe, intimate partner violence [41].
3. Heroin Addiction and Suicidality
A positive history of attempted or accomplished
suicide is common in heroin-dependent people [89].
Studies have reported a 7-fold relative risk of sui-
cide among heroin addicts with respect to the gen-
eral population [68, 107, 112] and a 14-fold risk rate
with respect to age-matched peers [20]. Between 10%
and 35% of deaths in heroin-dependent individuals
are due to suicide, with about 40% of heroin abusers
reporting at least one attempt to commit suicide [20].
Independent variables associated with suicidal idea-
tion in this population are receiving welfare benets,
a bipolar spectrum disorder, unemployment, early
onset of addiction, living alone, as well as experi-
encing social life and leisure time impairment [94].
Also, the number of overdoses can increase the risk of
suicide attempts [17]. Attempters were younger and
more likely to be female; they more often reported
childhood trauma, a family history of suicidal be-
haviour, a history of aggressive behaviour, treatment
with antidepressant medications, alcohol and cocaine
addiction [118]. Another study identies a personal
history of suicide attempts and the early onset of her-
oin addiction, but without any gender difference, as
correlates of suicidal risk in heroin addicts [138]. As
far as the relationship between suicide and the psy-
chopathology of heroin addicts is concerned, mood
disorders, in particular, depression, prove to be major
correlates of suicide. Approximately 90% of heroin
addicts who attempt suicide have a history of depres-
sive disorder with a higher prevalence of atypical de-
pression. In bipolar I patients without mixed states
there is a higher risk of substance abuse, but a lower
risk of suicide; on the other hand, the risk of suicide
is high in patients who display depressive symptoms
and go through mixed states [89].
4. Heroin addicts’ aggressive behaviour
4.1. Aggressive behaviour and psychiatric illness
Correlations between psychiatric illnesses and
aggressive behaviour have been well summarized in
many manuals of psychiatry [50]. It should be noted
that those with depressive or anxiety symptoms, and
those with traits of sensitivity and shyness traits tend
to be less aggressive. Borderline personality disorder
(BDP) and antisocial personality disorder (APD) fea-
ture impulsive violence and feelings of rage as a main
psychopathological component. Patients with BPD
are unstable and impulsive, have precarious social
relationships, family conicts that can result in out-
bursts of rage, peak anxiety, negativism, suspicious-
ness, destructive reactions and suicidal acts. These
subjects are likely to beat people, engage in ghts,
offend people, and break objects. Antisocial patients
too show impaired impulse control: they are extreme-
ly irritable, will often produce gratuitous aggressive
behaviours towards animals and people; they may
steal or destroy things, and often run away from their
homes. In mood disorders, the presence of aggres-
siveness takes different forms during the depressive
and the maniac phase: in depressed patients hostil-
ity is expressed as irritability, impatience, non-coop-
eration with others, criticism and blame directed at
oneself or others, with reference to past, present and
future events. These features can culminate in self-
directed aggressive behaviours such as suicide. In
the maniac phase, on the basis of unstable mood and
psychomotor excitement, physical offence can easily
take place. In catatonic schizophrenia, psychomotor
arrest alternates with extreme violence and restless-
ness. In some cases, auditory hallucinations may in-
duce patients to take violent actions. Violence is un-
likely in pure anxiety disorders, where emotion often
springs from self-frustration towards one’s own dis-
order, and is usually expressed by verbal rage rather
than assaults.
There is general agreement on the higher risk
of violence among people with severe mental illness
(SMI) that is worsened by concomitant substance
abuse, medication non-compliance, or lack of insight
[133, 134]. Nevertheless, a recent report claimed that
SMI alone was not statistically related to future vio-
lence behaviours [42, 139]. More precisely, the in-
cidence of violence was only higher for people with
SMI who had co-occurring substance abuse and/
or dependence [9, 42, 130]. As regards the relation-
ship between specic diagnoses and violence in the
absence of concomitant substance use, the strongest
association was that found with the bipolar disorder,
followed by schizophrenia and major depression.
Since the rates of violence seem to show no correla-
tion with the severity of bipolar disease or with the
various episodes of disease, the association between
bipolar disorder and violent crime (including suicide)
was largely mediated by substance abuse comorbidity
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Heroin Addiction and Related Clinical Problems 14 (4): 81-94
[48]. However, if we consider the association between
SMI and concurrent substance abuse, schizophrenia
showed the greatest risk of violence. Substance abus-
ers were associated with increased odds of current
and future violent behaviours in the schizophrenia
spectrum disorder [18, 34, 46, 137].
Moreover, the trait impulsivity of bipolar sub-
jects appears to show a positive correlation with sub-
stance abuse. Likewise, the episodic impulsivity of
bipolar subjects increases during periods of symptom
remission only for those with a history of substance
abuse. This enhanced disposition to impulsivity even
in the absence of full-blown mania, may be the reason
for the increased risk of suicide and aggressive behav-
iours in bipolar substance abusers [132].
4.2. Aggressive behaviour of non-opiate substance
abusers
Substance use elicits aggressiveness and im-
pulsivity, especially in those who have a biologically
violent” disposition [70]. Certain individuals only be-
come hyperactive, violent and dangerous under the
inuence of psychoactive substances, whether rec-
reational (alcohol and drugs) or therapeutic (antide-
pressants), a phenomenon that has been described and
classied as Bipolar Disorder type III [5]: that condi-
tion looms as an atypical variant of bipolar disorder,
rather than an expected reaction to psychoactive sub-
stances [105]. In drug addiction, the risk of violence
also depends on the type of substance that is being
abused; for example, heroin abusers are hardly ever
violent under the inuence of narcotics, but they can
be aggressive during withdrawal, while those who use
stimulants are likely to be violent under the effects
of those drugs, even in cases of episodic exposure.
Actually, violent crime is less frequent in heroin-de-
pendent people than in alcohol an/or stimulant abus-
ers [20, 41, 101].
People who consume alcohol often turn violent
during intoxication, but alcohol withdrawal can also
feature restlessness, agitation and irritability, espe-
cially as a result of hallucinations [40]. Alcohol con-
sumption is associated with various types of violence,
including but not limited to sexual aggression, family
and marital violence, child abuse and suicide. Reports
suggest a close link between acute alcohol intoxica-
tion and aggressive behaviour, whereby larger quanti-
ties of alcohol are associated with more severe ag-
gressiveness [64, 111].
As regards benzodiazepines, the intake of high
doses in non-tolerant individuals can lead to violent
outbursts, or escalations of anger, while chronic in-
toxication may cause an increase in hostile and ag-
gressive tendencies [50].
Data gathered in psychiatric hospitals have
proved that cannabis-positive acute bipolar psycho-
ses display a characteristically violent clinical pattern
[90]. Recent data showed that this trend also applies
to ecstasy users undergoing acute psychotic episodes
[119].
In comparing the rate of violent offences among
heroin users and methamphetamine abusers, no dif-
ferences emerged for life-time violence, whereas
subjects on methamphetamine were signicantly
more likely to have committed violence in the past
12 months, so prompting the conclusion that regular
methamphetamine use appears to be associated with
an increased frequency of violent offences, probably
with an earlier onset of violent behaviour within the
history of substance use [37].
4.3. Are heroin addicts more violent than the
general population?
To our knowledge, few studies have focused on
comparisons between the aggressiveness of heroin
addicts and that displayed by the general population.
Gerra and co-workers demonstrated that the enhance-
ment of aggressive response in heroin-dependent pa-
tients on agonist treatment when faced by a laborato-
ry task (Point Subtraction Aggression Paradigm) was
higher than in the control group, independently of ag-
onist treatment [59]. Also, heroin addicts who had un-
dergone long-term opioid tapering regimens showed
a higher degree of outwardly directed aggressiveness
than healthy subjects [57]. Moreover, as long as we
consider suicide to be a form of aggressive behaviour,
heroin users are 14 times more likely than the general
population to commit suicide, and the prevalence of
attempted suicide too is far higher than it is among
community samples [36].
4.3.1. Gender differences
Male and female opioid-dependent patients dif-
fer in their antisocial attitudes and criminal history.
In particular, females were signicantly more hos-
tile than males [109]. A positive criminal record was
much less likely among females than among males,
and the recurrence of criminal acts was higher for
males. Also, the pattern of criminality was different:
in women, the onset of criminal behaviour occurred at
a higher age, and their commitment was to drug deal-
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S. Bacciardi et al.: Aggressive behaviour and heroin addiction
4.5. Aggressive behaviour during intoxication
and/or withdrawal states
The simplest way to explain the co-presence of
heroin addiction and violent behaviour is that chronic
heroin intoxication can enhance aggressive behav-
iour. The evidence of a causal relationship between
narcotic drug use and crime is derived from longitudi-
nal studies in which the frequency and seriousness of
crimes committed during periods of active addiction
far exceed what is reported during non symptomatic
periods [7, 78, 103, 127]. It was ascertained that, as
addiction history evolves, the intensity of illegal ac-
tivities does increase, but only slightly. On the other
hand, the proportion of addicts involved in any crimi-
nal activity rises signicantly through time, starting
from as early as the rst two years of addiction. Af-
ter that the rate of increase declines noticeably [80].
The association between drug use and impulsivity,
out of intoxication, is well documented [55]. More
precisely, stimulants can induce an elevation of ag-
gressiveness during intoxication [70], and levels of
aggressiveness fall as an acute effect of opiate admin-
istration [60], while enduring exposure to the same
narcotics can lead to a lowered threshold for aggres-
siveness [84]. A four-year trial of methadone treat-
ment (at a narcotic blocking dosage) in 750 criminal
addicts showed that a majority of patients stopped
heroin use completely after starting methadone treat-
ment, with high rates of social productivity as dened
by stable employment and responsible behaviour, and
with no evidence of on-going illicit drug use or fur-
ther criminal convictions, which indicated that crimi-
nal and disruptive behaviours dwindle concomitantly
with the extinction of drug related urges [38]. Opiate
withdrawal is often associated with crime (64.4%),
intoxication by alcohol (13.68%) or other psycho-
active substances (4.27%); three-quarters of all prop-
erty crimes (76.19%) and over a third of all personal
crimes (35.48%) were committed by patients show-
ing signs of opiate withdrawal [80].
5. Neurobiological correlates of aggressive
behaviour in heroin addicts
The hypothesis of an association between cer-
ebral opioidergic abnormalities and psychiatric disor-
ders characterized by affective instability,feelingsof
angerand hostility, sensory abnormalities andsexual
dysfunction, could explain some of the behaviours of
heroin addicts, especially in connection with women
[105]. There has been widespread agreement on the
ing rather than the violent crime frequently recorded
for men [27, 98]. Nevertheless, women reported in-
volvement in illegal activity more often during the
year prior to treatment entry [144] and the incidence
of incarceration had risen faster than that of men, by
an average rate of 4.6% a year, from 1995 to 2005
[69]. Gender differences in hostile attitude seem to
inuence treatment dropout, as women, who have
greater levels of hostility at baseline, are more likely
to drop out. On the other hand, men’s endurance in
treatment did not vary according to their level of hos-
tility [109].
4.4. Aggressive attitude before heroin use
Common people are afraid of drug addicts, be-
cause of their violent and antisocial behaviour and
their generally aggressive attitude, whether primary,
or else induced by drug intoxication or withdrawal
[76]. Aggressiveness and violence in heroin addicts
before the onset of heroin use, is a poorly investigated
issue; but at least one study identied marked premor-
bid traits of irritability [52]. Few studies shed light
on the possible mechanism by which subjects choose
between drugs and become attached to specic ones.
On one hypothesis, drugs are not chosen randomly;
on the other, the choice is the result of an interaction
between psychopharmacological action and the dom-
inant painful feelings, which were buffered as a result
of drug self-administration. In line with this interpre-
tation, addicts-to-be are likely to different substances
for self-medication on the basis of their personality
aws [77]. As a result, narcotic addicts may prefer
opiates because of their positive effects in suppress-
ing rage and aggressiveness. Hence, heroin addiction
appears to result from the self-medication dynamics
by which the substance helps to manage pre-existing
aggressive distress. [4]. There is some evidence that
the aggressiveness and violence of heroin addicts are
frequently associated with the presence of an antiso-
cial personality [33, 35, 51]. Antisocial traits seem to
be more important than drug effects in determining
outward aggressiveness among heroin addicts [57].
An association has been documented between pre-
morbid personality terms and the clinical features of
heroin addiction, and the severity of the withdrawal
syndrome [2]. In the light of this evidence, it may be
the case that individuals who become opiate users are
more likely to show aggressiveness not because of the
drug itself, but because of a pre-existing premorbid
aggressive disposition, leading them to form ties se-
lectively with narcotics [70].
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Heroin Addiction and Related Clinical Problems 14 (4): 81-94
patients with severe mental illness showed a better
long-term outcome than treatment-resistant patients
without psychiatric comorbidity [93]. In order to bet-
ter understand the dynamics of violence among her-
oin addicts, we have looked into the correlation with
drug abuse history variables: those for whom crime
preceded heroin use (primary criminals) were young-
er and more likely to be male than those for whom
heroin use preceded crime (secondary criminals). Pri-
mary criminals were also more likely to have com-
mitted violent crime and to qualify for a diagnosis of
antisocial personality disorder (ASPD). The criminal
behaviour of the secondary antisocials, especially fe-
males, may be brought on by heroin addiction rather
than being an expression of the underlying antisocial
personality [75]. A large body of literature on the ef-
fects of opiates on aggressive behaviour in animals
suggests that morphine and other opiates temporarily
reduce aggressive behaviour [67], although this effect
is subject to tolerance [116]. Conversely, controlled
studies in humans have demonstrated heightened ag-
gressive behaviour by carrying out laboratory meas-
urements of aggressive behaviour after the adminis-
tration either of codeine [128] or morphine [12].
From a neuropsychological point of view, heroin
use has implies short- and long-term consequences.
In particular, impulse control dysfunction and nega-
tive affective states have been reported [82, 131]. The
continuous intake of this substance increases levels
of impulsivity that return to baseline (pre-heroin) lev-
els throughout abstinence: in heroin-dependent sub-
jects, impulsivity therefore becomes more intense as
a result of chronic heroin exposure, rather than being
a vulnerability trait [120]. Aggressiveness and self-
injurious behaviour usually run parallel, as both are
supported by impulsiveness, and usually mirror the
severity of opiate intoxication [94]. The most com-
mon form of impulsiveness in addicts is connected
with their extreme proneness to react to drug-related
stimuli [19, 142, 143, 145], but a more general reduc-
tion of inhibitory control over impulsiveness can be
observed in behavioural patterns not directly linked
with drug use. The performance of habitual smokers,
alcoholics, cocaine users and opiate addicts in carry-
ing out behavioural tasks designed to measure impul-
siveness, such as the Iowa Gambling Task Stroop test,
indicates a general increase in the level of impulsive-
ness [49, 83, 110, 115]. The altered response to these
tests may also depend on an underlying, previously
active mental disorder or condition [30, 79, 100, 102,
136]. Data consistent with the direct pro-impulsive
action of drugs have been reported for nicotine, al-
existence of a direct relationship between heroin use
and crime, but no consensus as to its nature. It seems
not to be a straightforward or direct cause-effect re-
lationship, as other factors (such as psychiatric co-
morbidity, age and ethnicity) show their inuence
on criminal activity [101]. Most probably, the need
for opiates does not simply lead to crime: rather, opi-
ate use and certain types of criminal activity tend
to inuence each other via an aggressive link [66].
Back in the eighties, authors explained the increase
in crime rates among narcotic addicts on the basis
of pre-addictive characteristics, especially criminal
habits and drug use prior to narcotic addiction. Early
family inuences such as parental crime, the use of
drugs and alcohol by other family members, and a
lack of religious upbringing also appear to play an
important role [124]. It is true that illegal activities
could be detected as result of chronic intoxication at-
tributable to drug abuse; it is the mental attitudes that
had already been developing in the premorbid period
that contribute most to an understanding of individual
behaviours and the nature of addicts’ illegal activi-
ties [38, 80]. Antisocial personality disorder (ASPD)
is a commonly diagnosed, serious health mental dis-
order in substance users, with approximately 16-27%
meeting DSM-IV for ASPD [6]. Psychopathological
symptoms such as impulsive-aggressive behaviour,
irresponsibility, egocentricity, lack of conscience, and
social maladjustment are diagnostic features of ASPD
[99]. Antisocial personality traits, in addition to a
nding of lifetime antisocial behaviour, do increase
the risk both of violent and non-violent offences [16].
A study on aggressive responses in abstinent heroin
addicts showed no correlation between the degree of
exposure to heroin (substance abuse history duration)
and levels of aggressiveness, but heroin-dependent
patients seemed to have higher outwardly directed
aggressiveness than healthy subjects, possibly as a
result of monoamine hyper-reactivity after long-term
opiate discontinuation. Authors have concluded that
aggressiveness seems to be related more to premorbid
personalities than to addiction itself [58]. High lev-
els of aggressiveness have also been found in heroin-
dependent patients treated with methadone, suggest-
ing that the level of aggressiveness demonstrated by
methadone patients seemed to be related to personal-
ity factors rather than pharmacological ones [56, 70].
On the other hand, heroin-dependent patients with
severe psychopathological features need a higher
dosage of methadone to become stabilized. Contra-
ry to expectations, when behavioural stabilization is
pursued with no dose threshold, treatment-resistant
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S. Bacciardi et al.: Aggressive behaviour and heroin addiction
inhibitors (SSRI) are believed to have a potential role
in the treatment of aggressive behaviours [14].
Two studies evaluated the role of anti-aggres-
sive drugs as adjunctive agents in the treatment of
heroin addicts on methadone maintenance therapy,
indicating that the antipsychotic olanzapine [54] and
the SSRI sertraline [72], respectively, could be help-
ful in reducing aggressive and hostile behaviours.
6.2. Agonist opioid treatment of aggressive
behaviour
The body of data available on the impact of dif-
ferent treatments for aggressive phenomena related
to heroin addiction is far from being exhaustive. De-
spite this, some of the data acquired so far allow us to
comment on the role of the pharmacological proles
of methadone, buprenorphine and naltrexone within
maintenance treatment regimens.
There is general agreement that effective treat-
ment reduces violence and rates of incarceration
among opiate addicts [28, 61], and patients who stop
using heroin regularly after treatment are also likely
to stop offending, or to reduce their levels of offend-
ing behaviour [59, 62, 63, 67, 71, 125]. Adopting a
prospective view, those who were enrolled in metha-
done treatment at the 4- or 10-month follow-up as-
sessment had fewer arrests at their 12- and 24-month
post-baseline follow-ups [122].
Aggressiveness seems to inuence methadone
stabilization dosage, which is higher for addicts with
high-aggression baseline scores [96, 109].
Therapeutic effects on mental disorders can be
expected from buprenorphine, in line with its dis-
tinctive receptorial prole. Buprenorphine combines
μ-agonism, which is closely linked to its anticraving
properties and is shared with methadone, with a k-
antagonist activity [104]. This particular combination
makes it easier to assess the psychotropic effects of
k-antagonism, since retention rates are higher than
those made possible by pure antagonists, such as nal-
trexone, which are poorly tolerated by heroin addicts,
in general, and mentally ill ones, in particular [91,
92]. The buprenorphine-naltrexone combination (ver-
sus naltrexone only) produced a higher retention rate,
with a better psychopathological adjustment (dys-
phoria, depression, irritability, depression, anxiety,
asthenia, nausea, sickness or stomach ache) than the
same patients had experienced before dropping out of
previous naltrexone maintenance [53].
The highest retention rates and long-term results
in buprenorphine treatment are obtained at dosages
cohol, heroin and cocaine [15, 108, 113, 114, 140].
Subjects with impulsive personality structures and
earlier involvement in drug use are those who seem
to develop the most severe withdrawal syndromes,
suggesting that opiate balance and control over ag-
gressiveness share some brain areas. Before the onset
of addiction, impulsive subjects display proneness to
aggressive behaviour, together with a disposition to-
wards risk taking, drug use included. In the context of
drug use, these subjects experience a quicker transi-
tion to regular drug use and tolerance. Once addiction
has developed, the two kinds of functional damage
run in parallel, and mirror the severity of addiction it-
self, together with the disruptive behaviour associated
with drug seeking. It therefore appears awkward to
disentangle earlier mental conditions from those that
follow the onset of addiction, since they have com-
mon neurobiological roots, and inuence each other
through a reverberating brain pathway [95].
6. Pharmacological treatment of aggressive
behaviour and violence
6.1. Non-opioid medications
Several drugs are currently employed in the
treatment of aggressive behaviours, but at the mo-
ment the US Food and Drug Administration has not
approved any specic drug for aggressiveness [32,
86]. In recent years, antiepileptic drugs have become
increasingly popular for the management of aggres-
sive behaviour, and strong evidence exists for most of
them, such as phenytoin, carbamazepine, lamotrigine,
valproate/divalproex sodium, topiramate [129]. The
role of antipsychotics is well established, both for
typical and atypical drugs, and they are recommended
in cases of acute aggressive behaviour [22, 121, 141],
while clozapine should be considered when aggres-
sive behaviour persists or recurs despite treatment
[21, 29]. Benzodiazepines have a role in controlling
acute agitation, but their long-term use for persistent
aggressive behaviour is not recommended [141]. Be-
ta-blockers have been reported as useful in the man-
agement of aggressive behaviour in elderly demented
patients [126] and they are also effective in treating
impulsive aggression in patients with other kinds of
brain damage [74]. Aggressive behaviour is associ-
ated with reduced central serotoninergic functioning
in some areas, so there seems to be an inverse rela-
tionship between platelet 5-HTT and aggressive be-
haviour [31]; in addition, selective serotonin reuptake
- 88 -
Heroin Addiction and Related Clinical Problems 14 (4): 81-94
suicidality and violent behaviour than with naltrexone
treatment, during both the early and the later phases of
treatment [89, 97]; highly aggressive patients at treat-
ment entrance are likely to drop out during long-term
naltrexone maintenance, like those with mood disor-
ders or psychotic disorders [92]. Despite the reborn
interest in sustained-release naltrexone for the treat-
ment of narcotic addiction, the available data indicate
that, with this type of naltrexone, retention rates and
outreach are the poorest among potentially effective
treatments: in particular, aggressive addicts are one of
those categories which achieve the worst results when
they enter naltrexone maintenance. The employment
of naltrexone in rapid detoxication regimens, or as a
trail to detoxication as a means to prevent short-term
relapse into use, although somewhat popular, cannot
be discussed here, as that topic pertains to the issue of
addiction treatment.
No data are available on the specic effects
of slow-release morphine on the aggressiveness of
treated subjects [73], whereas some data indicate the
advantages of methadone maintenance over heroin
maintenance, in terms of a reduction in levels of new-
ly recorded crimes [85].
7. Points of interest and future research
outlines
According to the behaviourist model, most be-
haviours originate in learning processes. In this way,
aggressiveness could be explained in terms of a learn-
ing reaction to frustrating and aversive experiences,
which can later be evoked more and more readily.
The ‘addiction world’ could represent an environ-
mental substrate on which abusers learn aggressive
dynamics, and at the same time a context in which
the practice of aggression may turn out to be useful or
necessary in maintaining support for the habit. Heroin
addicts seem to be best characterized by a non-im-
pulsive aggressive attitude, underlying a habitual an-
tisocial behaviour, rather than an impulsive, explosive
aggressiveness that is matched with affective insta-
bility and disinhibition, but not necessarily linked to
habitual antisocial behaviour.
The crimes perpetrated by heroin addicts ap-
pear to have the aim of supplying oneself with the
substance, whereas the effects of heroin intrinsically
tend to favour control over aggressiveness. Rising ag-
gressiveness as the course of heroin addiction goes
forward may stem from a progressive imbalance of
the opioid function, due to high tolerance levels. Al-
cohol and psychostimulants, on the other hand, ap-
that provide a combination of k-antagonism with pre-
plateau levels of μ-mediated stimulation [104]. Other
studies have stressed that buprenorphine seems to be
more effective in opioid-dependent patients affected
by depression, probably due to the action of kappa
opioid-receptor antagonists in counteracting dyspho-
ria, negativism and anxiety [54]. As previously men-
tioned, in reviewing the SCL-90 ve factor solution,
buprenorphine seemed to produce better results than
methadone in patients with prominently violent-sui-
cidal behaviours [88].
The idea that the impact of opioid agonist treat-
ment is inuenced by the psychopathological prole
of heroin addicts has been rarely investigated: we have
tried to assess the differential impact of opioid ago-
nist treatment (methadone and buprenorphine) on the
psychopathological dimensions found by a factorial
analysis of the SCL-90 as administered to a sample of
1,055 patients under agonist treatment. Patients were
sub-grouped into ve categories according to which
of the ve following dominant factors were shown:
(1) depressive symptomatology with prominent feel-
ings of worthlessness-being trapped or caught, (2)
somatization symptoms, (3) interpersonal sensitivity
and psychotic symptoms, (4) panic symptomatology,
and (5) violence and self-injurious behaviour. The
groups did not differ on the basis of sex or duration
of dependence. The fth factor group (violence-sui-
cide) features impulsive acting-outs and self-directed
aggressiveness. These patients may cry out loud or
throw objects with the aim of smashing them into
pieces, or suffer from outbursts of rage. They often
argue and feel the urge to push, hurt or beat up others.
At the same time, they also report suicidal thoughts,
or longings for death, are upset, excited or restless,
and nd it hard to stay seated or lie down, even for
a while. Younger patients with heroin addiction were
more strongly represented in the dominant violence-
suicide group [95].
No statistically signicant differences were ob-
served for subjects belonging to the ‘worthlessness-
being trapped’, ‘somatization’ and ‘panic-anxiety’
dominant groups by type of agonist treatment (i.e.
whether they were taking buprenorphine or metha-
done). Methadone treatment was correlated with be-
longing to the ‘sensitivity-psychoticism’ dominant
group, whereas buprenorphine was associated with
belonging to the ‘violence-suicide’ dominant symp-
tomatology [88]. On the whole, no difference in as-
sault emerged between treatment groups, either in the
early or the maintenance stage of treatment. However,
any agonist treatment was related to lower levels of
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pear to raise rates of aggressiveness, so leading to the
perpetration of violent crimes such as homicide and
physical assault, with a weaker link with the need to
support regular use.
According to Khantzian’s self-medication hy-
pothesis, narcotic addicts prefer opiates because of
their powerful buffering action on the disorganizing
and threatening affects of pre-existent rage and ag-
gressive behaviours. In the light of our review, how-
ever, that hypothesis has received hardly any support
from statistical analyses. Most aggressive behaviours
appear in non-compensated heroin addicts, so that it
could be counter-hypothesized that it is substance-
related damage that causes an increase in levels of ag-
gression, whereas the brain substrate corresponds to
premorbid personality traits. Consequently, we could
consider the standard aggressiveness displayed by
heroin addicts as a symptom of heroin addiction itself,
worsening as the loss of opioid balance increases, and
becoming exacerbated by repeated learning cycles of
violent behaviour that aim to ensure self-supplying
of the substance. If that is so, not only do treatments
provide aggression control along with their action on
core addictive symptoms, but it also follows that ag-
gressiveness itself may be seen as a useful parameter
for monitoring the effectiveness of addiction treat-
ment, together with urinalyses and improvements in
social functioning.
Lastly, given the effectiveness of opioids as
anti-aggressive drugs in heroin addicts and the in-
volvement of the opioid system in modulating ag-
gressiveness, we may also regard them as candidates
for future use in violent non-addicted psychiatric pa-
tients, at least for slow-acting opiates involving no
addiction risk, such as oral methadone, slow release
morphine and sublingual buprenorphine. In addition,
the possible antidepressant [13, 45, 47], mood-stabi-
lizing [44, 106] anti-psychotic [84] effects of opioids
could support their employment as a core psychotrop-
ic treatment in a wide range of psychiatric disorders.
Buprenorphine may be the optimal drug for this new
form of use, because of its kinetics and potency. Un-
like methadone, buprenorphine has a longer half-life,
it is safer for the induction of non-tolerant subjects,
and its abuse liability is limited to injective misuse by
heroin addicts.
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Role of the funding source
This review was supported by internal funds.
Contributors
All authors contributed equally to this review, had
full access to the collected literature, critically reviewed the
manuscript and had full editorial control, and nal respon-
sibility for the decision to submit the paper for publication.
Conict of interest
All authors declared no conict of interest in writing
this review
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Received July 4, 2012 - Accepted October 22, 2012
