Learning Objectives Mental Health Consequences of Prescription Drug - - PDF document

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Learning Objectives Mental Health Consequences of Prescription Drug Addictions Opioids, Hypnotics and Benzodiazepines 1. To review epidemiological data on prescription drug use disorders Ayal Schaffer, MD, FRCPC 2. To discuss clinical

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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

Mental Health Consequences of Prescription Drug Addictions – Opioids, Hypnotics and Benzodiazepines

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

Group Question #1: What is the most common source of non- medical 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%

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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

The State of US Health 1990-2010: Years Lost to Disability (Gains and Losses)

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

Tetrault JM, Butner JL. Yale J Biol Med 2015 Sep 3;88(3):227-33. eCollection 2015

Co-occurrence of Major Depression and Substance Use Disorders

Current SUD symptoms, 29% No SUD symptoms, 71% N = 2876 outpatients with depression 18.9% 5.5% 4.9%

Alcohol use disorder Drug use disorder Alcohol and drug use disorder Davis et al. Drug Alcohol Depend 2010; 107: 161-70.

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5 10 15 20 25 30 35 Opioid Sedative Hypnotic Over the Counter Tricyclic Antidepressant Antipsychotic Alcohol SSRI/SNRI Other Mood Stabilizer Other Antidperessant Illegal Drug % of Cases Where a Substance Caused Death

Figure 2. Counts of Substances Causing Death in Overdose Suicide in Toronto from 1998-2007

Sinyor, Howlett, Cheung, Schaffer. Can J Psychiatry 2012;57(3):184-191

Opioids and Sedatives / Hypnotics Are the 1st and 2nd Most Common Substances Taken in Suicides by Overdose

Case Vignette #1: The Hidden Issue

48 y.o female, 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 Husband discovers 18- month history of opioid abuse Recurrent depression, usually responds to antidepressants Marital separation, acute crisis, overdose, hospitalization

Case Vignette #2: The Incidental Finding

41 y.o female, married, referred by obstetrician for anxiety following loss of pregnancy Screening for substance use reveals 10-year hx of intermittent prescription

pioid abuse being given for

MSK pain caused by MVA No clear relationship with anxiety. Works in the health care field “Don’t tell my doctor”

Case Vignette #3: The Self-Medication Rationale

56 y.o female, divorced, teacher Intermittent use of zopiclone in the morning “when I just can’t face the day” Longstanding insomnia, with sleep disruption as a trigger for mood instability Longstanding history of bipolar disorder with partial insight “Sorry, I lost my prescription – can I get another one, I need my sleep!”

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Implications of Prescription Drug Abuse

Careful screening, detection, treatment, and management of prescription drug abuse is essential

McIntyre et al. Ann Clin Psychiatry 2012;24:69-81.

Aberrant Drug-Taking Behaviors in Patients Receiving Opioids for Pain

Clearly Problematic Possibly Problematic Selling Hoarding Forging prescriptions Specific type of drug requested Stealing drugs from others Using by nonprescribed route (e.g., injecting or crushing and snorting) Doctor shopping Repeated losing, running out early Single loss, running out early Multiple dosage increases Single dosage increase

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

Brady & Malcolm. Textbook of Substance Abuse Treatment, 3rd Ed (2004).

Antidepressant Efficacy In MDD Patients With or Without Concurrent Substance Use Disorder

Weeks on Citalopram Treatment

Both Alcohol and Drug Drug Only No SUD Alcohol Only

CDF 2 4 6 9 12 14 0.00 0.25 0.50 0.75 1.00

Similar efficacy in MDD patients ± alcohol or drug SUD but significantly lower remission and longer time to remission if MDD + alcohol + drug SUD present

Davis et al. Drug Alcohol Depend 2010; 107: 161-70. 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.

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General Approach To Treatment

f 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)

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

Working with Stages of Change

Restate your concern
Encourage consideration
State continued willingness to help
Help set a goal
Develop a plan
Provide education

Are you ready to change your substance use at this time?

NIAAA. Helping Patients Who Drink Too Much, 2005

Miller WR, Rollnick S. Motivational Interviewing, 2nd ed, 2002

Pre-contemplation or contemplation Motivational interview or brief intervention Preparation or action Goal setting, active treatment Maintenance, relapse, recycling Relapse prevention

Brief Intervention: FRAMES

F

Feedback: convey concern & connect current health status to substance use behaviour

R

Responsibility: open acknowledgment that you can’t make them change, that only they can effect change

A

Advice: to reduce or abstain from use

M Menu of options: provide a variety of reasonable options to choose

from*

E

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

Moyer et al. Addiction 2002; 97: 279-92. Moyer et al. Alcohol Res Health 2004; 28: 44-50.

*E.g., limiting amounts, pacing / spacing use, not using to cope, limiting use to social situations, keeping track, trial of abstinence or treatment.