Treating Anxiety in the Substance Use Disordered Patient

Transcription

1 Treating Anxiety in the Substance Use Disordered Patient August 26, 2015 Stephen A. Wyatt, D.O. Med. Dir., Addiction Medicine Carolina HealthCare System Charlotte, NC 1

2 No Financial Disclosures

3 Target Audience The overarching goal of PCSS-O is to offer evidence-based trainings on the safe and effective prescribing of opioid medications in the treatment of pain and/or opioid addiction. Our focus is to reach providers and/or providers-in-training from diverse healthcare professions including physicians, nurses, dentists, physician assistants, pharmacists, and program administrators. 3

4 Educational Objectives At the conclusion of this activity participants should be able to: have an understanding of the difficulties in diagnosis and treatment of anxiety in the substance use disordered population. have a working understanding of other medications that can assist in treating anxiety in this population. consider various psychotherapeutic interventions to reduce anxiety with or without concurrent medication. understand ways to approach this often anxiety producing subject in order better engage the patient in considering discontinuing their use of benzodiazepines. 4

5 Assessment of Anxiety General Medical Considerations Thyroid disease Vestibular disorders Cardiac disease Respiratory disease Cancer Mitral valve prolapse Irritable bowel syndrome Allergic conditions Migraine Chronic pain 5

6 Anxiety Disorders panic disorder, post-traumatic stress disorder (PTSD), social phobia (or social anxiety disorder), specific phobias, generalized anxiety disorder (GAD), obsessive-compulsive disorder (OCD) 6

7 Co-Morbidity with Anxiety Psychiatric symptoms need to be considered, however an evaluation for substance-induced disorders is important A different clinical course may be expected if psychiatric symptoms are substance induced. 85% or more of substance-induced symptoms improve rapidly with abstinence Schuckit MA. Addiction, 2006, 101: Generalized Anxiety Disorder with a concurrent SUD is associated with high overall vulnerability for additional psychopathology, e.g. externalization, higher disability and continued higher use of alcohol and drugs to relieve anxiety symptoms. Alegria AA, et.al., J Clin Psychiatry, (9),

8 Anxiety Disorders in the Substance Use Disorder Patient genetic predisposition to anxiety disorders as a precursor to an SUD. higher incidence of adverse childhood events. social problems secondary to high risk behavior and deviance. neurobiology of the adaptation to alcohol and other drugs resulting in anxiety seen in both intoxication and withdrawal. 8

9 Management Acute Anxiety Anxiety can be adequately treated either Medication or Psychotherapy There is ample evidence the combination is most effective. Hyman SE, Scientific American Medicine Abstinence of Alcohol and other Drugs 9

10 Benzodiazepines The most widely used tranquilizer in America is more addictive than Valium and is often less effective than nondrug treatments for anxiety Consumer Reports, January 1993 XANAX 10

11 Treatment of Anxiety in the Vulnerable Population Intentional abusers of benzodiazepines usually have other substance abuse problems. Benzodiazepines are usually a secondary drug of abuse-used augment the high received from another drug to offset the adverse effects of other drugs. Specific drug use patterns To ease the "crash" from cocaine 29%-33% of alcohol abusers take BZs Up to 80% of opiate abusers have taken BZs O Brien C, J Clin Psychiatry 2005;66 (suppl 2) Benzodiazepine Dependence, Toxicity, and Abuse: Task force report, APA,

12 Treatment Admissions Number of benzodiazepine and opiate combination admissions: 2000 to 2010 Increased from 5,032 to 33, percent of benzodiazepine and opiate combination admissions reported daily use of any substance compared with 34.6 percent of other admissions SAMHSA Treatment Episode Data Set (TEDS), 2000 to

13 Medication Management of Anxiety Non-benzodiazepine pharmaco-management is preferable in treating co-occurring depression in substance use disordered patients. Hazards of BDZ use potential dependence with prolonged use, potential for withdrawal syndromes rebound effects on abrupt discontinuation Disclaimer: Benzodiazepines may be useful adjunctively with other psychotropic medications to treat patients with very distressing or impairing symptoms. The benefit of more rapid response to benzodiazepines balanced against troublesome side effects (e.g., sedation, cognition) and physiological dependence. 13

14 Pharmacologic Management Acute Anxiety/PTSD Cochrane meta-analysis 2006, 35 short-term randomized controlled trials 17 of the trials, symptom severity was significantly reduced in the medication groups relative to placebo. Evidence of efficacy for the SSRIs, across all symptom clusters and for co-occurring depression. 14 Stein DJ, Cochrane Database Syst Rev 2006

15 Pharmacotherapies PTSD SSRIs Paroxitine Positive study Marshall et. al Sertraline Positive study Stein et.al

16 Pharmacotherapies PTSD SSRIs Negative Trials Combat Veterans Sertraline vs. placebo combat veterans with PTSD 12 weeks of flexibly dosed sertraline (mean dosage = 156 mg/day) (n169) PTSD symptom reduction not significant both groups, combat-related PTSD associated with poorer out- come compared with non-combat-related PTSD. Friedman MJ,J Clin Psychiatry 2007; 68: Similar results in an Isreali combat veteran trial, 2002 Zohar,J, J Clin Psychopharmacol

17 Pharmacotherapies PTSD SSRIs Positive Trials Combat Veterans Bosnian veterans Fluoxitine vs placebo 24 wk trial (n144) Improvement in acute, depression, prevention Martenyi F, Eur Neuro- psychopharmacol 2006 These veterans were younger and had been in combat more recently than previous trials SSRI remain first line medication in the treatment of PTSD Koen N; Dialogues in Clinical Neuroscience

18 Pharmacotherapies PTSD Venlafaxine XR Improvement over placebo PTSD symptoms of avoidance/numbing and reexperiencing, not hyperarousal. Davidson J, Arch Gen Psychia- try 2006; Venlafaxine vs Sertraline vs Placebo Venlafaxine statistically better than both Davidson J, J Clin Psychopharmacol 2006 Bupropion XL vs placebo no differences in PTSD Becker ME, J Clin Psychopharmacol

19 Pharmacotherapies PTSD Trazodone (5-HT 2 antagonist and SSRI) Antidepressant, sleep and antianxiety Decrease benzodiazepine use Frecska E, Neuropsychopharmacologia Hungarica Alpha adrenergic antagonists prazocin (3-15mg) used in treatment as usual including other medications. primary outcome sleep/nightmares significant o improve total sleep time and REM also showed improvement in PTSD duplicate studies consistent Raskind MA, Am J Psychiatry 2003; Raskind MA, Biol Psychiatry 2007; Taylor FB, Biol Psychiatry

20 Pharmacotherapies GAD SSRI in treatment of Generalized Anxiety Disorder (GAD) evidence-based guidelines recommend initial treatment with either SSRI or SNRI Some selectivity in efficacy and the tolerability of treatment GAD with SSRIs or SNRIs should usually be continued for 6 12 months Comparative studies show superiority to placebo but not to one antidepressant over another. Baldwin DS, Current Topics in Behavioral Neurosciences Nefazodone vs placebo GAD significant improvement Davis LL, J Clin Psychopharmacol 2004 Mirtazapine vs placebo GAD significant improvement Davidson JR, Biol Psychiatry

21 Pharmacotherapies GAD Buspirone reducing serotonin (5-HT) release as a partial agonist at 5-HT1A receptors and as a presynaptic full agonist comparable but slightly weaker efficacy than benzodiazepines and a slower onset known to relieve the cognitive aspects of GAD questionable long-term efficacy Bupropion XL positive trial in comparison study with escitalopram Alexander Bystritsky, et.al.psychopharmacol Bull. 2008;41(1):

22 Pharmacotherapies GAD Tricyclic Antidepressants Kahn RJ, J Affect Disord 1987 Imipramine comparable to SSRIs Hoffman EJ. Mount Sinai J Med 2008 Doxepin comparable anxiolytic to diazepam Greater side effects d'elia G, Acta Psychiatr Scand Suppl Comparison Imipramine with Mirtazipine Similar response in anxiety and sleep some greater prolonged effect of imipramine on anxiety mirtazipine greater improvement in depression Moleman, P, Pharmcopsychiatry,

23 Pharmacotherapies Anxiety Clonidine (alpha 2 agonist) Superior to placebo in GAD and Panic D/O Hoehn-Saric R, Arch Gen Psychiatry Reduces symptoms of anxiety Giannini, AJ. Drugs of Abuse 1997 Hyperarousal in PTSD van der Kolk, BA. Journal of Affective Disorders 1987 Abuse potential Dennson SJ, Psychiatr Q May be helpful in induction of sleep without effecting REM latency Beta blockers early after trauma Ineffective longterm Pitman RK, Biol. Psychiatry,

24 Pharmacotherapies Anxiety Atypical antipsychotics Risperidone vs placebo (n20 women) significant in reduction of hyperarousal, intrusive Padala PR, Int Clin Psychopharmacol 2006; Reich DB, J Clin Psychiatry 2004 Reproduced showing equivocal results. some evidence risperidone and olanzepine may augment sertraline Hamner MB, Int Clin Psychopharmacol 2003 Stein MB, Am J Psychiatry

25 Pharmacotherapies Anxiety Symptoms Anticonvulsants Topiramate non significant except for re-experiencing symptoms. Tucker P, J Clin Psychiatry 2007 Divalproate no improvement Davis LL, J Clin Psychopharmacol

26 Pharmacotherapies Anxiety Symptoms Gabapentin GABA agonist Less effect than SSRIs in placebo trials good side effect profile Pande AC, J Clin Psychpharmacology, 1999 Pregabolin Evidence of augmentation of SSRI, SNRI and combination Vitali M, J Clinical Psychopharm, 2013 Tiagabine (selective GABA reuptake inhibitor (SGRI).) some efficacy in panic disorder mostly non significant but some mild early improvement that was sustained Connor KM, Psychopharmacology (Berl)

27 Psychotherapeutic Management CBT Cognition Psycho-education Behavior breathing relaxation training 27

28 Psychotherapeutic Management Psychoeducational normalization of the response not life threatening somatic response to stress the fight or flight response importance of identifying the stressor and cognitively determining the level of safety 28

29 An approach to talking to patients about anxiety Avoid the word anxiety. Instead talk about the stress response (SR). Describe what is meant by the SR. Describe the importance of the SR. Describe how their SR might be used in a positive way, normalizing the response

30 Psychotherapeutic Management Breathing recognition of exhalation as a relaxation state understanding the importance of avoiding hyperventilation review the physiology of breathing o drive to breathe is associated with levels of CO 2 chest pressure on blowing off CO 2 o excess levels of O 2 have detrimental effects electrolyte imbalance vasoconstriction numbness of highly vascularized areas. localized cramping fainting 30

31 An approach to talking to patients about panic Talk to them about the importance of not panicking! Cognitive restructuring Talk them through the physiology hyperventilation or their experience. SOB Numbness and tingling of mouth and fingers Upset stomach Chest heaviness Visual abnormalities Fainting 31 31

32 Psychotherapeutic Management Relaxation through breathing progressive relaxation exercises meditation visualization 32

33 Psychotherapeutic Management Exposure Therapy It is well established that exposure-based behavior therapies are effective treatments for anxiety. Torres AR, et al.. Psychiatr Serv. 2007;58: Foa EB, et al. J Consult Clin Psychol. 2005;73: Develop an exposure hierarchy Subjective Units of Discomfort Gradual systematic exposure Elimination of safety behaviors Cognitive restructuring 33

34 Psychotherapeutic Management Exposure Therapy Re-exposure imagining in vivo directed therapeutic written verbal taped narrative 34

35 Psychotherapeutic Management Brief exposure therapy single episode exposure-based behavioral therapy intensity of stimuli adjusted to patient s comfort 35

36 Psychotherapeutic Management Eye Movement Desensitization and Reprocessing (EMDR) with or without CBT typically this is done following a prolonged period of CBT so the patient has some skill in self relaxation. evidence of improvement of PTSD, depression, dissociative symptoms. 36

37 Promote Healthy Behaviors Promote healthy behaviors exercise; sleep hygiene; decreased use of caffeine, tobacco, alcohol, and other potentially deleterious substances. 37

38 Summary Make an appropriate diagnosis Reduce towards discontinuation all alcohol and illicit drug use. Consider medication management along with psychotherapy and encouragement of a healthy lifestyle. 38

39 PCSS-O Colleague Support Program PCSS-O Colleague Support Program is designed to offer general information to health professionals seeking guidance in their clinical practice in prescribing opioid medications. PCSS-O Mentors comprise a national network of trained providers with expertise in addiction medicine/psychiatry and pain management. Our mentoring approach allows every mentor/mentee relationship to be unique and catered to the specific needs of both parties. The mentoring program is available at no cost to providers. For more information on requesting or becoming a mentor visit: Listserv: A resource that provides an Expert of the Month who will answer questions about educational content that has been presented through PCSS-O project. To join pcss-o@aaap.org. 39

40 PCSS-O is a collaborative effort led by American Academy of Addiction Psychiatry (AAAP) in partnership with: Addiction Technology Transfer Center (ATTC), American Academy of Neurology (AAN), American Academy of Pain Medicine (AAPM), American Academy of Pediatrics (AAP), American College of Physicians (ACP), American Dental Association (ADA), American Medical Association (AMA), American Osteopathic Academy of Addiction Medicine (AOAAM), American Psychiatric Association (APA), American Society for Pain Management Nursing (ASPMN), International Nurses Society on Addictions (IntNSA), and Southeast Consortium for Substance Abuse Training (SECSAT). For more information visit: For questions pcss-o@aaap.org Funding for this initiative was made possible (in part) by Providers Clinical Support System for Opioid Therapies (grant no. 1H79TI025595) from SAMHSA. The views expressed in written conference materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department 40 of Health and Human Services; nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.