Who Am I? Why ME? Nothing to Disclose 1/23/2017

Transcription

1 Dr. Lydia Anne M Bartholow, DNP, PMHNP, CARN-AP XANAX IS THE ONLY THING THAT WORKS AND OTHER TALES OF WOE: TREATING ANXIETY AND DEPRESSION IN THE CONTEXT OF SUBSTANCE USE DISORDERS Who Am I? Why ME? Associate Medical Director Of Substance Use Disorders at Central City Concern Practicing in Primary Care Setting for the last 5 years Lived Experience of SUDS, Long Term Recovery Nothing to Disclose 1

2 Ice Breaker: Why do you hate working with People with SUDS? (Laney Video Video here) Agenda I. Case Study II. The Necessity of Trauma Informed Care III. The Elephant in the Room: Benzos IV. Treatment: a. Trauma b. Depression c. Anxiety I. Case Study: Meet Laney, again History of IPV History of IVDU Stably housed No emergent medical concerns Multiple complaints, including depressed mood and anxiety Never had trauma treatment previously Biggest strength: her dog, Chloe 2

3 II. The necessity of Trauma Informed Care Trauma-informed care is an organizational structure and treatment framework that involves understanding, recognizing and responding to the effects of all types of trauma Tenets of Trauma Informed Care Universal precautions TIC asks that we not re-traumatize patients TIC asks that we change systems, including systems of communication, in order to provide best care Also prioritizes provider well being This is not trauma treatment (Trauma informed vs trauma specific) Tenets, continued The co-morbidity of early-life trauma and later SUDs is astounding We inform systems by understanding the epidemiology and neurobiology of trauma 3

4 ACES STUDY 4

5 Brief Overview of the Neurobiology of Trauma 5

6 Initial signs and symptoms of the stress response: (aka fight, flight or freeze or HPA axis) Blurred vision Muscle tension nausea Increased heart rate Sweaty palms Increased blood pressure shaky Inability to focus/ think straight Thoughts of impending doom Stressor or Threat: (cop in rearview mirror) Amygdala attaches fear to stimuli Stressor or Threat: (cop in rearview mirror) Amygdala Hypothalamus 6

7 Stressor or Threat: (cop in rearview mirror) Amygdala Hypothalamus Direct stimulation of fight or flight neurons Adrenal Glands Stressor or Threat: (cop in rearview mirror) Amygdala Hypothalamus Direct stimulation of fight or flight neurons adrenaline/catec holamines Adrenal Glands cortisol Adrenal Glands cortisol adrenaline/catec holamines -- pupil dilation -- sweat -- muscle contractility -- increased HR -- increased BP -- blow flow away from stomach -- blow flow away from brain -- blood flow to vital organs -- increased blood sugar -- immune system suppression/dysregulation -- water retention -- hyperglycemia -- muscle breakdown -- fat redistribution -- increased gastric juices -- removal of calcium from bones -- decreased serotonin 7

8 Affects of long term cortisol -- immune system suppression/dysregulation = -- water retention = -- hyperglycemia = -- fat redistribution = -- removal of calcium from bones = -- decreased serotonin (for some people) = Stressor or Threat: (cop in rearview mirror) Hippocampus negative feedback adrenaline/catec holamines Adrenal Glands cortisol Hippocampus The Hippocampus is responsible for: 1. Fear and anxiety regulation 2. Anger regulation 3. Allowing your prefrontal cortex to override old brain 4. Sleep regulation 5. Experience of pain 6. Organizing memories 8

9 III. Elephant in the room: benzos No. Just no. No evidence for use beyond 2-4 wks (Mehdi, 2012) Increase Cognitive Impairment (Tennebaum, 2012 and a ton of others) Increased risk for Alzeimers (Gage, et al., 2014 and a ton of others) Increase in long term Anxiety and Depression (Michelini, 1996 and tons of others) Prolonged PTSD symptoms & Poorer trauma therapy outcomes (Guina et all, 2015) 9

10 How to say No: Truly understand their anxiety. Sit with it. Focus the conversation on safety (not clinic policy) Not working? Bring it back to Safety. Still not working? There is nothing you can do or say that will make me write a benzodiazapine script for you. Your safety and wellness is my priority. How else would you like to spend the visit today? Anderson, 2016 A plug for co-prescribed Naloxone If not Benzos, then what? Let s go back to Laney for a second 2 benzos!!! How do you conceptualize getting her off? And onto what? 10

11 Benzo Detox If possible, go slower than you think you need to. Think months to years Convert the benzos to Valium (Ashton, 2002) Utilize gabapentin liberally (and phenobarbital sparingly) Reductionist Benzo Alternatives Clonidine Propranolol Gabapentin 11

12 III. Treatment: PTSD and other trauma sequelae Therapy EMDR Seeking Safety (Van Derkolk, 2014 & Najavits, 2015) Prazosin Not just for nightmares anymore (also treats hypervigilance) 1 tab po QHS x 3 nights. 2 tabs po qhs the following 3 nots. 3 tabs po QHS thereafter. Stop if any dizzyness (Raskind, 2015) III.I Case Study Laney joins us once again. Where do you begin with her trauma treatment? Who do you want to refer her to and why? What is your role in her trauma treatment? 12

13 III. Treatment: Anxiety Disorders Rule out Bipolar DO. MDQ anyone? Rule out PTSD. SSRIs Start LOW, go extra slow, aim high. Think: Zoloft Clonidine vs Propranolol Gabapentin Seroquel XR Refer to talk therapy (e.g. CBT) III. Treatment: Major Depression Rule out Bipolar DO. MDQ anyone? Rule out PTSD. Refer to talk therapy SSRIs Start low, aim for symptom relief Track efficacy with PHQ9 My favorite: Lexapro Great efficacy Minimal side effects If SSRIs Only work a little, or not at all. Augmentation strategies: Buproprion For the slowed, amotivated person Use with caution in the anxious person Mirtazapine For the anxious insomniac Everyone will gain weight! Lithium Yup. Lithium. Often get response from low dose Targets suicidal thoughts specifically Promotes long term brain health (Wade, 2005) 13

14 IV. Asking for help Whats protocol for when to ask for help? What s the system? Useful pieces of information for consult: Previous med trials PHQ9 scores MDQ Trauma HX References Anderson, B How to Have difficult conversations. Lecture. Portland, OR. Gage, S.B.G., Moride, Y. Ducruet, T., Kurth, T., Verdoux, H., Tournier, M. Pariente, A., and Begaud, B. (2014). Benzodiazapine use and risk of Alzheimer s disease: a case control study. British Journal of Medicine, 349, Guina, J., Rossetter, S., DeRhodes, B.J., Nahhas, R., and Welton, R.S. (2015). Benzodiazapines for PTSD: A Systematic Review and Meta-Analysis. Journal of Psychiatric Practice, 21, 4, Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V.,... & Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study. American journal of preventive medicine, 14(4), Mehdi, Tauseef (2012). Benzodiazapines Revisited. British Journal of Medical Practitioners, 5, 1, 1-8. Michelini, S., Cassano, G.B., Frare, F., and Perugi. G. (1996). Long-term use of benzodiazapines: tolerance, dependence and clinical problems in anxiety and mood disorders. Pharmacopsychiatry, 29, 4, References, cont. Najavits, L. M., Lande, R. G., Gragnani, C., Isenstein, D., & Schmitz, M. (2016). Seeking Safety Pilot Outcome Study at Walter Reed National Military Medical Center. Military medicine, 181(8), Raskind, M. A. (2015). Prazosin for the treatment of PTSD. Current Treatment Options in Psychiatry, 2(2), Rush, A. J., Fava, M., Wisniewski, S. R., Lavori, P. W., Trivedi, M. H., Sackeim, H. A.,... & Kupfer, D. J. (2004). Sequenced treatment alternatives to relieve depression (STAR* D): rationale and design. Controlled clinical trials, 25(1), Tannenbaum, C., Paquette, A., Hilmer, S., Holroyd-Leduc, and Carnahan, R. (2012). A systematic review of amnestic and non-amnestic mild cognitive impairment induced by anticholinergic, antihistamine, GABAergic and opioid drugs. Drugs and Aging, 29, 8, Tien, A.Y., and Anthony, J.C. (1990). Epidemiological analysis of alcohol and drug use as risk factors for psychotic experiences. The Journal of Nervous and Mental Disorders, 178, 8, Van Der Kolk, B. (2014) The Body Keeps the Score: brain, mind and body in the healing of trauma. New York. Viking. Wada, A., Yokoo, H., Yanagita, T., & Kobayashi, H. (2005). Lithium: potential therapeutics against acute brain injuries and chronic neurodegenerative diseases. Journal of pharmacological sciences, 99(4),