Learning Objectives Mental Health Consequences of Prescription Drug - PDF document

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 examples of the presentation and Head, Mood & Anxiety Disorders Program, impact of prescription drug use disorders Deputy Psychiatrist-in-Chief, Sunnybrook Health Sciences Centre Associate Professor, 3. To examine treatment approaches for these complex Department of Psychiatry, University of Toronto ayal.schaffer@sunnybrook.ca patients Group Question #2: Group Question #1: Sedative / hypnotics are present at lethal levels in What is the most common source of non- what % of people who die by suicide via medical use or abuse of prescription opioids? self-poisoning? A. One doctor A. <10% B. More than one doctor B. 10-20% C. Free from a friend / relative C. 20-30% D. Bought / taken from friend / relative D. 30-40% E. Drug dealer E. >40% 1

The State of US Health 1990-2010: Group Question #3: Years Lost to Disability (Gains and Losses) 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 From: The State of US Health, 1990-2010: Burden of Diseases, Injuries, and Risk Factors JAMA. Aug 14, 2013;310(6):591-608 Co-occurrence of Major Depression and Non-Medical Prescription Opioid Use and Prescription Opioid Use Disorder Substance Use Disorders N = 2876 outpatients with depression 4.9% 5.5% 18.9% Current SUD symptoms, 29% Alcohol use disorder Drug use disorder Alcohol and drug use disorder No SUD symptoms, 71% Davis et al. Drug Alcohol Depend 2010; 107: 161-70. Tetrault JM, Butner JL. Yale J Biol Med 2015 Sep 3;88(3):227-33. eCollection 2015 2

Opioids and Sedatives / Hypnotics Are the 1 st and 2 nd Most Case Vignette #1: The Hidden Issue Common Substances Taken in Suicides by Overdose Figure 2. Counts of Substances Causing Death in Overdose Suicide in 12 month course of Toronto from 1998-2007 worsening symptoms, Illegal Drug 48 y.o female, married, two isolation, sick leaves, and Other Antidperessant school age children, works rapid declines in mood in an executive position Mood Stabilizer and functioning Other SSRI/SNRI Husband discovers 18- Alcohol month history of opioid Antipsychotic abuse Tricyclic Antidepressant Recurrent depression, usually responds to antidepressants Over the Counter Sedative Hypnotic Marital separation, acute Opioid crisis, overdose, 0 5 10 15 20 25 30 35 hospitalization % of Cases Where a Substance Caused Death Sinyor, Howlett, Cheung, Schaffer. Can J Psychiatry 2012;57(3):184-191 Case Vignette #2: The Incidental Finding Case Vignette #3: The Self-Medication Rationale Screening for substance use Intermittent use of reveals 10-year hx of 41 y.o female, married, zopiclone in the morning intermittent prescription 56 y.o female, divorced, referred by obstetrician for “when I just can’t face the opioid abuse being given for anxiety following loss of teacher day” MSK pain caused by MVA pregnancy Longstanding insomnia, No clear relationship with with sleep disruption as a anxiety. trigger for mood Longstanding history of bipolar Works in the health care field instability disorder with partial insight “Sorry, I lost my prescription “Don’t tell my doctor” – can I get another one, I need my sleep!” 3

Aberrant Drug-Taking Behaviors in Patients Implications of Prescription Drug Abuse Receiving Opioids for Pain Careful screening, detection, treatment, and Clearly Problematic Possibly Problematic management of prescription drug abuse is essential 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 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 Antidepressant Efficacy In MDD Patients With or Disorder is Present Without Concurrent Substance Use Disorder • Typical mood or anxiety symptoms predate substance use Similar efficacy in MDD patients ± alcohol or drug SUD but significantly lower remission and longer time to remission if MDD + alcohol + drug SUD present • Persistent symptoms despite abstinence from substances Both Alcohol and Drug 1.00 • Full mood disorder criteria met Drug Only Alcohol Only 0.75 No SUD • Strong family or personal history of mood disorder CDF 0.50 Substances used in a limited quantity or duration • – E.g. symptom intensity out of keeping with amounts 0.25 • Type of substance used does not match symptoms 0.00 – E.g., mania with benzodiazepine abuse 0 2 4 6 9 12 14 • History of good response to mood-related treatments or substance Weeks on Citalopram Treatment use treatment failures 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 Brady & Malcolm. Textbook of Substance Abuse Treatment, 3rd Ed (2004). cumulative proportions of the two groups). Davis et al. Drug Alcohol Depend 2010; 107: 161-70. MDD: major depressive disorder; SUD: substance use disorder. 4

General Approach To Treatment Working with Stages of Change of Comorbid Substance Use Disorders and Mental Illness • Integrated approach that simultaneously addresses the mood Pre-contemplation or contemplation Motivational interview or brief disorder, SUD, and other life areas intervention Preparation or action Goal setting, active treatment Multimodal components: Maintenance, relapse, recycling Relapse prevention – Pharmacologic • Mood-related treatments • Withdrawal and relapse management Are you ready to change your substance use at this time? – Non-pharmacological • Contingency management • Family involvement • Regular monitoring of symptoms and substance use – Social Restate your concern Help set a goal • • • Housing, employment • Encourage consideration • Develop a plan • Development of a recovery network (e.g., Alcoholics Anonymous) • State continued willingness to help • Provide education NIAAA. Helping Patients Who Drink Too Much , 2005 Beaulieu et al. Ann Clin Psychiatry 2012;24:38-55 Miller WR, Rollnick S. Motivational Interviewing , 2nd ed, 2002 Skinner et al. Concurrent Substance Use and Mental Health Disorders: An Information Guide. www.camh.net Group Question #1: Brief Intervention: FRAMES What is the most common source of non- medical use or abuse of prescription opioids? Feedback: convey concern & connect current health status to substance F use behaviour A. One doctor Responsibility: open acknowledgment that you can’t make them change, R that only they can effect change B. More than one doctor A Advice: to reduce or abstain from use M Menu of options : provide a variety of reasonable options to choose from* C. Free from a friend / relative Empathy: non-confrontational, attempt to see the situation from the E patient’s perspective while still maintaining objectivity D. Bought / taken from friend / relative S Self-efficacy: encouraging belief they can change E. Drug dealer *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. Addiction 2002; 97: 279-92. Moyer et al. Alcohol Res Health 2004; 28: 44-50. 5

Group Question #2: Group Question #3: Sedative / hypnotics are present at lethal levels in Patients with depression and a drug use disorder what % of people who die by suicide via (but no alcohol use disorder) are…. self-poisoning? A. <10% A. Less likely to respond to antidepressants B. 10-20% B. More likely to respond to antidepressants C. 20-30% C. Equally as likely to respond to antidepressants D. 30-40% D. Not to be prescribed antidepressants until they stop the substance E. >40% 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