Mental Health Consequences of Prescription Drug Addictions Opioids, Hypnotics and Benzodiazepines Learning Objectives 1. To review epidemiological data on prescription drug use disorders Ayal Schaffer, MD, FRCPC Head, Mood & Anxiety Disorders Program, Deputy Psychiatrist-in-Chief, Sunnybrook Health Sciences Centre Associate Professor, Department of Psychiatry, University of Toronto ayal.schaffer@sunnybrook.ca 2. To discuss clinical examples of the presentation and impact of prescription drug use disorders 3. To examine treatment approaches for these complex patients Group Question #1: What is the most common source of nonmedical use or abuse of prescription opioids? A. One doctor B. More than one doctor C. Free from a friend / relative D. Bought / taken from friend / relative E. Drug dealer Group Question #2: Sedative / hypnotics are present at lethal levels in what % of people who die by suicide via self-poisoning? A. <10% B. 10-20% C. 20-30% D. 30-40% E. >40% 1
Group Question #3: Patients with depression and a drug use disorder (but no alcohol use disorder) are. The State of US Health 1990-2010: Years Lost to Disability (Gains and Losses) A. Less likely to respond to antidepressants B. More likely to respond to antidepressants C. Equally as likely to respond to antidepressants D. Not to be prescribed antidepressants until they stop the substance From: The State of US Health, 1990-2010: Burden of Diseases, Injuries, and Risk Factors JAMA. Aug 14, 2013;310(6):591-608 Non-Medical Prescription Opioid Use and Prescription Opioid Use Disorder Co-occurrence of Major Depression and Substance Use Disorders N = 2876 outpatients with depression 4.9% Current SUD symptoms, 29% 5.5% 18.9% Alcohol use disorder Drug use disorder Alcohol and drug use disorder No SUD symptoms, 71% Tetrault JM, Butner JL. Yale J Biol Med 2015 Sep 3;88(3):227-33. ecollection 2015 Davis et al. Drug Alcohol Depend 2010; 107: 161-70. 2
Opioids and Sedatives / Hypnotics Are the 1 st and 2 nd Most Common Substances Taken in Suicides by Overdose Case Vignette #1: The Hidden Issue Illegal Drug Other Antidperessant Mood Stabilizer Figure 2. Counts of Substances Causing Death in Overdose Suicide in Toronto from 1998-2007 Other 48 y.ofemale, married, two school age children, works in an executive position 12 month course of worsening symptoms, isolation, sick leaves, and rapid declines in mood and functioning SSRI/SNRI Alcohol Antipsychotic Tricyclic Antidepressant Over the Counter Sedative Hypnotic Opioid 0 5 10 15 20 25 30 35 % of Cases Where a Substance Caused Death Sinyor, Howlett, Cheung, Schaffer. Can J Psychiatry 2012;57(3):184-191 Recurrent depression, usually responds to antidepressants Husband discovers 18- month history of opioid abuse Marital separation, acute crisis, overdose, hospitalization Case Vignette #2: The Incidental Finding Case Vignette #3: The Self-Medication Rationale 41 y.ofemale, married, referred by obstetrician for anxiety following loss of pregnancy Screening for substance use reveals 10-year hxof intermittent prescription opioid abuse being given for MSK pain caused by MVA 56 y.ofemale, divorced, teacher Intermittent use of zopiclonein the morning when I just can t face the day Works in the health care field No clear relationship with anxiety. Longstanding history of bipolar disorder with partial insight Longstanding insomnia, with sleep disruption as a trigger for mood instability Don t tell my doctor Sorry, I lost my prescription can I get another one, I need my sleep! 3
Implications of Prescription Drug Abuse Aberrant Drug-Taking Behaviors in Patients Receiving Opioids for Pain Careful screening, detection, treatment, and management of prescription drug abuse is essential Clearly Problematic Selling Forging prescriptions Stealing drugs from others Using by nonprescribed route (e.g., injecting or crushing and snorting) Doctor shopping Repeated losing, running out early Multiple dosage increases Possibly Problematic Hoarding Specific type of drug requested Single loss, running out early Single dosage increase McIntyre et al. Ann Clin Psychiatry 2012;24:69-81. Brady et al. Am J Psychiatry 2015 Sep 4 epub Signs Indicating a Primary Mood or Anxiety Disorder is Present Typical mood or anxiety symptoms predate substance use Persistent symptoms despite abstinence from substances Full mood disorder criteria met Strong family or personal history of mood disorder Substances used in a limited quantity or duration E.g. symptom intensity out of keeping with amounts Type of substance used does not match symptoms E.g., mania with benzodiazepine abuse History of good response to mood-related treatments or substance use treatment failures Antidepressant Efficacy In MDD Patients With or Without Concurrent Substance Use Disorder Similar efficacy in MDD patients ±alcohol ordrug SUD but significantly lower remission and longer time to remission if MDD + alcohol + drug SUD present CDF 1.00 0.75 0.50 0.25 0.00 Both Alcohol and Drug Drug Only Alcohol Only No SUD 0 2 4 6 9 12 14 Weeks on Citalopram Treatment Brady & Malcolm. Textbook of Substance Abuse Treatment, 3rd Ed (2004). CDF: Cumulative distribution function (the cumulative proportions of each group that failed to remit/respond by various time points was plotted using Kaplan Meier curves, and log rank tests were used to compare the cumulative proportions of the two groups). MDD: major depressive disorder; SUD: substance use disorder. Davis et al. Drug Alcohol Depend 2010; 107: 161-70. 4
General Approach To Treatment of Comorbid Substance Use Disorders and Mental Illness Integrated approach that simultaneously addresses the mood disorder, SUD, and other life areas Multimodal components: Pharmacologic Mood-related treatments Withdrawal and relapse management Non-pharmacological Contingency management Family involvement Regular monitoring of symptoms and substance use Social Housing, employment Development of a recovery network (e.g., Alcoholics Anonymous) Working with Stages of Change Pre-contemplation or contemplation Preparation or action Maintenance, relapse, recycling Are you ready to change your substance use at this time? Restate your concern Encourage consideration State continued willingness to help Motivational interview or brief intervention Goal setting, active treatment Relapse prevention Help set a goal Develop a plan Provide education Beaulieu et al. Ann Clin Psychiatry 2012;24:38-55 Skinner et al. Concurrent Substance Use and Mental Health Disorders: An Information Guide. www.camh.net NIAAA. Helping Patients Who Drink Too Much, 2005 Miller WR, Rollnick S. Motivational Interviewing, 2nd ed, 2002 Brief Intervention: FRAMES Feedback:convey concern & connect current health status to substance F use behaviour Responsibility: open acknowledgment that you can t make them change, R that only they can effect change A Advice: to reduce or abstain from use M E Menu of options: provide a variety of reasonable options to choose from* Empathy: non-confrontational, attempt to see the situation from the patient s perspective while still maintaining objectivity S Self-efficacy: encouraging belief they can change *E.g., limiting amounts, pacing / spacing use, not using to cope, limiting use to social situations, keeping track, trial of abstinence or treatment. Moyer et al. Addiction2002; 97: 279-92. Moyer et al. Alcohol Res Health 2004; 28: 44-50. Group Question #1: What is the most common source of nonmedical use or abuse of prescription opioids? A. One doctor B. More than one doctor C. Free from a friend / relative D. Bought / taken from friend / relative E. Drug dealer 5
Group Question #2: Sedative / hypnotics are present at lethal levels in what % of people who die by suicide via self-poisoning? A. <10% B. 10-20% C. 20-30% D. 30-40% E. >40% Group Question #3: Patients with depression and a drug use disorder (but no alcohol use disorder) are. A. Less likely to respond to antidepressants B. More likely to respond to antidepressants C. Equally as likely to respond to antidepressants D. Not to be prescribed antidepressants until they stop the substance Learning Objectives 1. To review epidemiological data on prescription drug use disorders 2. To discuss clinical examples of the presentation and impact of prescription drug use disorders 3. To examine treatment approaches for these complex patients 6