Addressing Co-Occurring Disorders in an Opioid Treatment Program

Transcription

1 Addressing Co-Occurring Disorders in an Opioid Treatment Program Joan M. Striebel, MD Medical Director, Addiction Consultation and Treatment Palo Alto VA Medical Center

2 We have an ambitious goal! With a focus on opioid treatment program (OTP) patients, we ll review the role of medications in substance use disorders (SUDs) as well as in some psychiatric disorders that often co-occur with SUDs

3 How we ll proceed Using a vignette to set the stage, I ll discuss: - Distinguishing between substance-induced disorders and primary psychiatric illnesses - Medications used in drug/alcohol detoxification - Medications used for treatment of SUDs and of comorbid psychiatric illnesses

4 38 yo man, stable on MMT for 6 mos, tells his counselor, I m depressed, I can t stop drinking, and I just want it to be over. He describes being severely depressed and anxious as an adolescent. Started using alcohol in his late teens to cope. Then added opioids. He was drinking daily by his 20s. Longest time abstinent has been 2 years while incarcerated for assault. After a suicide attempt, he was treated for depression in prison and did well on nortriptyline. No psychiatric care on release. He s been drinking 2 pints/day. Breathalyzer result is 0.09.

5 Suicide Opioid Users 14x more likely to die by suicide than non-heroin-users 40% have history of attempted suicide Alcohol Up to 15% of alcoholics commit suicide 25% of suicides involve alcohol Intoxicated patients are more, not less, dangerous than other psychiatric patients Mood Disorders 40-75% of suicides have mood disorder Darke and Ross 2001 Kaplan and Saddock 10 th Ed. 2007

6 Assessing and Managing Suicide Risk SAMHSA s SAFE-T Pocket Card

7 5 Step Suicide Evaluation and Triage

8 Alcohol Withdrawal

9 Medications to Treat Alcohol Withdrawal Benzodiazepines are cornerstone of treatment Act on same receptor as alcohol (GABA receptor) All benzos work, choice depends on patient Dosing Symptom-triggered vs fixed Outpatient example: Chlordiazepoxide 50 mg every 6 hours x 4 doses THEN 25 mg every 6 hours x 8 doses Leo Sternbach Synthesized 1 st benzodiazepine (chlordiazepoxide/librium) in 1957

10 Medications for Alcohol Use Disorder FDA Approved Disulfram (Antabuse) Acamprosate (Campral) Naltrexone (Revia, Vivitrol) Non-FDA Approved (off-label) Topiramate (Topamax) Gabapentin

11 Disulfiram Erik Jacobsen and Jens Hald discovered the disulfiram-ethanol reaction Alcohol-sensitizing agent Interferes with metabolism of alcohol Disulfiram-Ethanol Reaction Flushing, increased heart rate, nausea/vomiting, dizziness Monitoring Check liver function prior to and monthly for 1 st three mos Baseline EKG OTP is ideal place to dispense, observed dosing

12 Naltrexone Blocks mu-opioid receptor Cannot be used if patient is taking opioids Decreases reinforcing effects of alcohol Preparations Pill (ReVia) 50mg a day Long-acting injection (Vivitrol) 380 mg IM, q 4 wk Safety Check liver function prior to, at 1,3, 6 mos and yearly Wallet card

13 Acamprosate Amino acid derivative Interacts w/ glutamate neurotransmitter system Reduces symptoms of postacute withdrawal Insomnia, anxiety, restlessness Two 333 mg capsules three times daily Mild/transient side effects GI (diarrhea, bloating) and Derm (itching) Processed by kidneys No known studies of acamprosate in patients w/ alcohol and opioid dependence

14 Non-FDA Approved Medications for Gabapentin Alcohol Use Disorder Anticonvulsant that modulates GABA (neurotransmitter) Diminishes relapse-related symptoms: craving, insomnia, and dysphoria Few side effects Topiramate Anticonvulsant that modulates GABA neurotransmission Decreases reinforcing effects of alcohol Problematic side effects: numbness/tingling, loss of appetite, problems concentrating

15 Returning to the Vignette Mental Health Setting Depression Bipolar Disorder Borderline PD Medical illness 20-50% have co-occurring SUD Substance Abuse Setting Depression 2/2 alcohol Alcohol withdrawal Other substance withdrawal 50-70% have some type of mental disorder In any behavioral health setting, the presence of co-occurring disorders should be the expectation not the exception. (SAMHSA s TIP 42)

16 Scenarios and Evaluation Strategies New patient with both SUD and mood symptoms Known SUD and new mood symptoms Known mood disorder and new SUD Self report measures and time line follow back Collateral information Urine drug tests Clinical or criminal justice records

17 Opioids, Mood, and OTPs Opioids used to treat depression until 1950s Bidirectional effect Entry into treatment/otp associated w/ decrease in depressive symptoms Kreek hypothesized that methadone normalized chronically dysregulated neuroendocrine system Buprenorphine as kappa antagonist reduces dysphoria 10 20% of opiate addicts remain depressed after initiation of MMT Nunes Biol Psychiatry Kreek and Hartman 1982 Kosten et al J Subst Abuse Treat

18 Medications: Provider Resource

19 Medications for Depression SSRI SNRI bupropion (NDRI) mirtazapine TCA T3 lamotrigine Atypical Antipsychotic Illustrations from Stahl s Essential Psychopharmacology 4 th Ed. 2013

20 Antidepressants Side Effects and Adverse Reactions SSRIs and SNRIs Early side effects (transient) GI and Neuro On-going side effects Sexual, weight changes TCAs Dry mouth, constipation, sedation Dizziness, hypotension Sexual dysfunction Rare Needs Immediate Attention! Suicidal ideation in young adults Induction of mania/hypomania Seizures Others Mirtazapine wt gain, sedation Bupropion anxiety, insomnia

21 Drug Interactions: Methadone and Antidepressants Mechanism of interaction is drug effect on liver enzyme that metabolizes methadone Speed up enzyme = decreased plasma methadone Stop enzyme = increased plasma methadone Fluvoxamine Stops enzyme, plasma methadone Opiate withdrawal associated w/ dc of medication

22 Treating Depression in OTP Patients 2-4 Week Drug Free Interval If possible, severe symptoms require more rapid management Complete Full Therapeutic Trial Adequate doses, adequate time period (to 12 weeks) 1-2 weeks before any effect (sleep, anx, improve 1 st ) 4-8 weeks before full effect Conduct Systematic Medication Trials Sequential monotherapy vs augmentation Treatment of Depression Allows Better Recovery!

23 Summary Opioids, alcohol, mood disorders are significant risk factors for suicide Hospitalize intoxicated patients with SI Benzodiazepines are 1 st line for alcohol withdrawal Disulfiram is best option to treat AUD in OTP Depression often resolves on OTP entry If depression remains: SSRIs are 1 st line in terms of safety TCAs are 1 st line in terms of efficacy

24 Questions?

25 55 yo woman returns to OTP fixated on remote experience of maintenance man who entered her apartment when she was not there. She s disheveled, smells of nicotine, is wide-eyed w/ intense stare, flushed, fidgeting, and spontaneous speech is profuse. TP is loose, disorganized and TC w/ persecutory delusions, paranoia. She admits to smoking meth but says that she hasn t done any in several days. Urine toxicology is positive for opiates. She requests to restart methadone and a refill of Thorazine to help her sleep.

26 Thoughts Mental Health Setting Primary psychosis Mood disorder w/ psychosis PTSD Micropsychosis in Borderline PD Medical illness 20-50% have co-occurring SUD Substance Abuse Setting Psychosis 2/2 stimulants Psychosis 2/2 designer drugs Spice, bath salts, etc Alcohol withdrawal Opiate withdrawal 50-70% have some type of mental disorder In any behavioral health setting, the presence of co-occurring disorders should be the expectation not the exception. (SAMHSA s TIP 42)

27 Disorders w/ Psychosis as Defining Feature Paul Eugen Bleuler Introduced the term Schizophrenia Schizophrenia Delusional Disorder Brief Psychotic Disorder Substance-induced Psychosis Onset during intoxication Onset during withdrawal Psychotic disorder due to a general medical condition

28 Substances Causing Psychotic Symptoms During Intoxication Old drugs of abuse New drugs of abuse Synthetic cathinones Synthetic cannabinoids Others During Withdrawal Alcohol Sedatives Opioids Multiple classes of medications

29 Alcohol and Psychosis Alcoholic Hallucinosis Predominantly auditory hallucinations in alert, oriented person Can look very similar to schizophrenia Usually of brief duration (<6 mos) Alcohol Withdrawal Delirium Visual hallucinations in very ill patient Medical emergency!

30 Cannabis and Psychosis Moderate Intoxication Euphoria Altered thought process, altered perceptions Suspiciousness, paranoia Chronic High Dose Cannabis Depersonalization, derealization Paranoia, hallucinations Typically acute and of short duration

31 Stimulants and Psychosis Cocaine Transient paranoia in chronic intoxication Sensitization Paranoid delusions, hallucinations Amphetamine Three stages Curiosity, repetitive behaviors Paranoia Persec delusions, IOR, hallucinations, fear, agitation >50% long-term stimulant users report psychosis Stimulant psychosis may closely resemble acute schizophrenia.

32 Differentiating Substance-Induced from Primary Psychotic Disorders Shaner et al

33 Antipsychotics: Typical vs Atypical Haloperidol, Fluphenazine Perphenazine Chlorpromazine Clozapine, Olanzapine Risperidone, Quetiapine Aripiprazole, Lurasidone

34 Antipsychotics: Side Effects EPS Sedation Wt Gain Glucose Ach Effects Orthostatic Hypotension

35 Depot Antipsychotics Monthly Haloperidol decanoate Paliperidone palmitate Olanzapine pamoate Aripiprazole monohydrate Every 2 weeks Fluphenazine decanoate Risperidone microspheres Long acting injectables might reduce both intentional and unintentional medication nonadherence

36 Schizophrenia, Methadone, and Antipsychotics Case reports that both methadone and buprenorphine have antipsychotic action Interfere with action of dopamine No good studies re superiority of agent in OTP patients with schizophrenia Strain and Stitzer 2006

37 Medications Targeting Stimulant Use Disorders No FDA approved medications Multiple medication trials, few showing any significant benefit Exceptions: Methamphetamine: Mirtazapine 30 mg daily reduced Meth + urines in MSM Cocaine: Possibly N-acetylcysteine, modafinil Colfax et al

38 Upcoming Treatment Approaches: Vaccines

39 PTSD and SUD Interrelated Clinical Syndromes SUD Intrusions Cravings Hyperarousal Withdrawal Loss of goal-directed behaviors Drug-seeking behavior Psychosocial consequences PTSD Intrusions Re-experiencing Nightmares Hyperarousal Irritability, insomnia Loss of goal-directed behaviors Avoidance, Isolation Psychosocial consequences Slide content courtesy John Straznickas, MD.

40 PTSD Among Inner City MMT Patients Women Lifetime prevalence: 20% (community sample: 10.4%) Most common stressor: rape Men Lifetime prevalence: 11% (community sample: 5%) Most common stressor: seeing someone hurt/killed Slide content courtesy Joan Zweben, PhD Kessler et al. 1995; Villagomez et al 1995

41 Simple vs Complex PTSD C-PTSD Psychological injury due to prolonged exposure to social +/- interpersonal trauma from which victim cannot escape Six symptom clusters Simple PTSD (DSM-5) Stressor Intrusion symptoms Negative alterations in cognition or mood Alterations in arousal and reactivity Duration, functional impairment, exclusion criteria Herman 1992

42 Medications to treat PTSD SSRIs sertraline, paroxetine (FDA approved) May be more helpful in civilian populations Prazosin for nightmares Others Trazodone for sleep Augmentation w/ atypical antipsychotics Multimodal approach is best team-based care, therapy (exposure based therapy, cognitive processing, or integrated CBT) and medication.

43 PTSD Complicates Treatment Complex, crisis-prone condition Expect more crisis management, more relapses, etc Don t blame the patient or yourself for poor outcomes Difficulty in establishing therapeutic alliance Expect an erratic and labile alliance Alliance building first, abstinence second My medication vs your medication PTSD symptoms get worse in early treatment Treatment requires a supportive team Slide content courtesy John Straznickas, MD

44 Smoking Status According to Psychiatric Diagnosis Current Smoker, % No Mental Illness Major Depression Alcohol Abuse or Dependence PTSD Drug Abuse or Dependence Bipolar Disorder Psychosis Lasser et al JAMA. Data from 1989 US National Health Interview Survey

45 Cigarette Smoking and Methadone Smoking is highly prevalent in OTPs (85-98%) Methadone increases smoking rates in dosedependent manner Buprenorphine also increases rate of smoking Mechanism complex Methadone attenuates nicotine withdrawal Nicotine increases positive effect of methadone Elkader et al J Clinical Psychpharm

46 Medications for Tobacco Use Disorder Nicotine Replacement Short-acting: gum, lozenge, nasal inhaler, nasal spray Long-acting: patch Bupropion SR (Zyban) Acts on pleasure and reward pathways Can lessen weight gain if used for one year Varenicline (Chantix) Nicotine receptor partial agonist Effective in those w/ severe mental illness w/o worsening symptoms Hays et al Ann Intern Med. Williams et al J Clin Psychiatry

47 Varenicline Mechanism: Nicotine Receptor Partial Agonist Nicotine ON! Full agonist at nicotine receptor Varenicline Partial On Partial agonist at nicotine receptor

48 Smoking Cessation Meds: Effectiveness Nicotine Replacement Approx 17% on solo and 31% on combo are smoke free at 6 mos Bupropion (Wellbutrin/Zyban) Approx 19% are smoke free at 6 mos Varenicline (Chantix) Approx 27% are smoke free at 6 mos Combining Medications and Behavioral Interventions Doubles Quit Rate Cahill et al JAMA

49 Medications for Smoking Cessation: Combination Therapy is the Rule Combining Long-Acting and Short-Acting Drugs LONG ACTING Pick 1 or 2 from here: Nicotine patch Bupropion SR Varenicline SHORT ACTING Pick 1 or 2 from here: Nicotine gum Nicotine Inhaler Nicotine lozenge Nicotine nasal spray The ASAM Principles of Addiction Medicine 5 th Ed

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51 Summary Substance-induced psychosis can look very similar to schizophrenia Diagnosis remains uncertain in many cases PTSD is common in the OTP population Integrated treatment, alliance is key The interaction between methadone and nicotine is complex Medication strategies w/ limited success in OTP patients

52 Questions?

53 Finis! For questions and/or more information, please contact me: