psych meds for harm reduction providers barry zevin md tom waddell health center san francisco...
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Psych Meds for Harm Reduction Providers
Barry Zevin MD
Tom Waddell Health Center
San Francisco Department of Public Health Homeless Programs
Board Certified Internal Medicine
Board Certified Addiction Medicine
Disclosures And Disclaimer
• Barry Zevin accepts no payments, samples, or gifts from any pharmaceutical companies
• The opinions expressed here are those of the presenter
• All information regarding medications expressed here should be checked out!
Medications for Mental Health Disorders
• Basic Pharmacology Concepts• Medications for Depression• Medications for Anxiety• Medications for Psychosis• Medications for Bipolar Disorders• Medications for ADHD• Medications for Sleep• Questions / Discussion• Medications for Addiction Disorders
– Come back for presentation tomorrow at 11am Salon D
Basic Pharmacology• Medications receive FDA approval for specific
indications but are also very commonly used for other indications (off label)
• Any substance can have adverse effects if used in the wrong way at the wrong time– Even water can kill you– Any drug can cause an allergy and if severe it
(and closely related drugs) should not be used– Many drugs can have idiosyncratic (unpredictable)
liver, kidney, or other toxicity
• Some side effects are relatively mild but so common that they are important
• Some side effects are rare but so severe that they are important
Basic Pharmacology
• What is a “psych med”?
• Why do or don’t medical providers prescribe psych meds?
• Why do or don’t people take psych meds?
• Harm reduction vs. harm production– Are psych meds part of harm reduction?– Can psych meds produce harm?
Basic Pharmacology
• Reducing Risk for Prescribed Drugs– Rationale for Using the Medication– Informed Consent
• True informed consent not the fake kind
– Follow Up• Is it working? Could it be working better? Make
changes when needed
Basic Pharmacology
• What I’m not going to talk about
Basic Pharmacology• In general medication should be started at the
lowest possible dose and gradually increased to the lowest effective dose– In some urgent situations higher doses must be
used right away– Many adverse effects are dose dependent– Some medications require monitoring of blood
levels for effective levels and to prevent toxic levels
• In general, when stopping a medication, slowly decreasing the dose decreases the risk of discontinuation symptoms– In some cases of adverse reactions medications
must be stopped immediately
Basic Pharmacology
• Medications can interact with each other, some foods, or street drugs in ways which change how they act, how long or short they act, how toxic they are, and how high a dose is needed
• Medications can act synergistically in causing adverse effects including risk of overdose
Medications for Depression• SSRI• Other Meds• TCAs• Atypical anti-psychotics
Antidepressants (and other meds) and suicide– Overall medications appear to reduce suicide
attempts and completed suicides– Studies of antidepressants in children and
adolescents show risk of increased suicide esp. when 1st starting medications
• This may also be true in adults
Medications for Depression
• SSRIs – Fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil),
citalopram (Celexa), escitalopram (Lexapro), etc.
• Tricyclic Anti-Depressant– Amitryptaline (Elavil), Nortryptaline (Pamelor), Desipramine
(Norpramin), Doxepin (Sinequan), etc
• Other anti-depressants – MAO Inhibitor
• Phenalzine (Nardil), tranylcypromine (Parnate), etc.– SNRI
• Vanlafaxine (Effexor), duloxetine (Cymbalta), desvenlafaxine (Pristiq)– Bupropion (Wellbutrin)– Mirtazapine (Remeron)– Trazadone
• Placebo
SSRIs
Main Intended Effects• Anti-depressant• Anti-anxiety• Anti-OCD
Other Intended Effects• Sleep• Activation / energy
SSRIsCommon Side Effects
• Sexual side effects– Orgasm delay or
anorgasmia– Low libido, ED
• Stomach discomfort, jitteriness in 1st 1-2 wks
• Mild sedation• Insomnia• Uncomfortable effects
when abruptly stopped– Esp. paroxetine (Paxil)
• Emotional Blunting
Rare but Severe Side Effects
• Serotonin syndrome– At very high doses or
when used in combination with other meds effecting serotonin system
• MDMA, (PMA), amphetamines, fentanyl, tramadol, cocaine, LSD
TCAs
Main Intended Effects• Anti-depressant
Other Intended Effects• Sleep• Pain relief• Anti-itching
– Doxepin
• Anti-anxiety
TCAs
Common Side Effects• Anti-cholinergic
– Dry mouth, sedation, urinary retention,
• Sedation
Rare but Severe Side Effects
• Acute anti-cholinergic syndrome (delirium)– High dose or
combination of anti-cholinergics (promethazine, datura, brugmansia,)
• Heart rhythm effects including death
• Death in overdose
Other anti-depressants
Main Intended Effects• Anti-depressant• Anti-anxiety
– Not bupropion (Wellbutrin)
• Fight neuropathic pain-SNRIs
Other Intended Effects• Sleep• Weight gain
– mirtazapine (Remeron)
Other anti-depressants
Common Side Effects• Sedation• Weight gain
– Mirtazapine (Remeron), etc.
• Over-activation– Bupropion (Wellbutrin),
etc.
Rare But Severe Side Effects
• Priapism - erection that won’t go away– Trazadone
• Seizures– Bupropion (Wellbutrin)
• Potentially fatal interactions with food and other medications– MAO Inhibitors
Placebo
• Main Intended Effects– Anti-depressant– Anti-anxiety– ???
• Other Intended Effects– Eliminate “side
effects”
Placebo (Nocebo)
• Common Side Effects– Expected adverse
effects are more likely to occur
– Often interfere with effective treatment
• Rare But Severe Side Effects– ???
Medications for Anxiety
• SSRIs (and other anti-depressants)
• Benzodiazepines– Diazapam (Valium), lorazapam (Ativan),
alprazolam (Xanax), clonazapam (Klonapin)
• Other – Buspirone (Buspar)– Atypical anti-psychotics, anti-psychotics (major tranquilizers)
Benzodiazepines
Main Intended Effects• Anti-anxiety• Anti-panic attack• Sleep
Other Intended Effects• Decrease “agitation”
in any condition• Treat alcohol
withdrawal• Treat intoxication
due to stimulants• Amnesia
Benzodiazepines
Common Side Effects• Sedation• Interferes with
memory and learning
• Unpleasant withdrawal when stopped abruptly
Rare but Severe Side Effects
• Addiction especially in people with other addictive disorders
• Fatal overdose when mixed with alcohol or other sedatives or opioids
• Severe withdrawal including seizures and delirium
• Falls and fractures esp. in elderly
Medications for Psychosis
• Atypical anti-psychotic– Olanzapine (Zyprexa), quetiapine (Seroquel),
risperidone (Risperdal), aripiprazole (Abilify), ziprasadone (Geodon), paliperidone (Invega), clozapine (Clozaril)
– Injectable long lasting atypical- risperdal consta, Invega Sustenna
• Older anti-psychotic– Chlorpromazine (Thorazine), haloperidol (Haldol),
thioridazine (Melloril), etc.
Atypical antipsychotic
Main Intended Effects• Anti-psychotic• Anti-mania• Mood stabilizer
Other Intended Effects• Anti-depressant• Decrease agitation
due to any cause• Anti-anxiety• Sleep• Practically anything
anybody can think of
Atypical anti-psychotics
Common Side Effects• Weight gain• Diabetes• Abnormal lipids
(cholesterol, LDL, etc)• Sedation• Sexual side effects• Movement disorders
– Akithisia, tremor, dystonic reactions, repetitive movements
– Less common than older antispychotics
Rare but Severe Side Effects
• Prolong QT interval causing fatal heart arrythmia
– Esp when combined with other medications that prolong QT interval (e.g. methadone)
• Depersonalization / feeling like a zombie
• Tardive dyskinesia• Neuroleptic malignant
syndrome• Excess prolactin production• Increased risk of stroke and
death in elderly
Older anti-psychotics
Main Intended Effects• Anti-psychotic• Anti-mania
Other Intended Effects• Decrease any kind
of agitation
Older anti-psychotics
Common Side Effects• Movement disorders
– EPS, TD, Akithesia
• Sexual side effects• Sedation• Weight gain
Rare but Severe Side Effects
• Neuroleptic malignant syndrome
• Irreversible TD
Medications for Bipolar Disorders
• Lithium
• Anti-epileptic drugs– Lamotragine (Lamictal), divalproex
(Depakote), topiramate (Topamax), carbamazepine (Tegretol), oxcarbazapine (Trileptal)
• Atypical anti-psychotics
Lithium
Main Intended Effects• Anti-manic• Mood stabilizer
Other Intended Effects• Anti-depressant
Lithium
Common Side Effects• Tremor• Diarrhea, nausea• Weight gain• Inability to concentrate
urine– Increased urination– Increased need to drink
water– Easy tendency to
dehydration
• Thyroid dysfunction– hypothyroidism
Rare but Severe Side Effects
• Toxic levels can be fatal– Can occur quickly in
overdose or if at normal dose patient becomes dehydrated
• Kidney failure
Anti-epileptic drugs
Main Intended Effects• Mood stabilizer• (prevent seizures)
Other Intended Effects• Decrease impulsivity
and aggressiveness• Adjunct to pain control• Decrease craving and
relapse in alcoholism – topiramate (topamax)
• Prevent migraine– Divalproex
(Depakote),topiramate (topamax)
• Many other possible effects being studied
Anti-epileptic drugs
Common Side Effects• Cognitive slowing / brain
fog– Esp topirimate (Topamax)
• GI effects– Abdominal pain, nausea
and vomiting
• Sedation• Weight gain• Weight loss
– topiramate (Topamax)
• dizziness
Rare but Severe Side Effects
• Severe skin rash– Esp. lamotrigine
(Lamictal)
• Blood and liver problems– Esp. carbamazepine
(Tegretol)
• Confusion, Ataxia, Delirium– Esp. at high doses or
overdose
Medications for ADHD
• Psychostimulants– Methylphenidate (Ritalin, Focalin, etc),
mixed amphetamine salts (Adderall, Adderall XR), others
• Others– Atomoxetine (Strattera)
Medications for ADHD
Main Intended Effects• Improve
concentration and focus
• Decrease hyperactivity
Other Intended Effects• Anti-depressant• Decrease substance
abuse
Medications for ADHD
Common Side Effects• Tremor• Poor sleep• Feeling of being
slowed down
Rare but Severe Side Effects
• Psychosis / mania• Addiction potential
esp. in those with underlying addiction problems
Medications for Sleep• Benzodiazepines
– Temazapam (Restoril), Flurazapam (Dalmane)
• Benzadiazepine - like– Zolpidem (Ambien), zaleplon (Sonata),
eszopiclone (Lunesta)
• Anti-Histamines– Diphenhydramine (Benedryl), hydroxyzine (Atarax)
• Melatonin receptor agonist– Melatonin, ramelteon (Rozerem)
• Antidepressants– Trazadone, amitryptaline (Elavil)
• Atypical antipsychotics
Medications for Sleep
Main Intended Effects• Faster onset of
sleep• Maintain sleep• Normalize sleep
architecture– Claimed for
trazadone, ramelteon (Rozerem)
Other Intended Effects• Anti-anxiety• Decrease allergic
symptoms
Medications for Sleep
Common Side Effects• Sedation / hangover
effect• Anticholinergic effects
with antihistamines• Memory effects and
amnesia• Tolerance• Confusion, falls,
delirium in elderly / chronically ill
Rare but Severe Side Effects
• Potentiation of other sedatives with overdose
• Potential for addiction– Esp. benzodiazepines in
patients with underlying addiction disorders
– Potential trigger for relapse in patients with alcoholism in recovery
Thank you to my colleagues at Tom Waddell Health Center
and Harm Reduction Therapy Center
and especially to my patients who I learn from every day