Treatment of Addictive Disorders Alcohol and Opiates October 22, 2017

Transcription

1 Treatment of Addictive Disorders Alcohol and Opiates October 22, 2017 John A. Renner, Jr., MD Consultant, Department of Psychiatry Massachusetts General Hospital Professor of Psychiatry Boston University School of Medicine

2 Disclosures I have the following relevant financial relationship with a commercial interest to disclose: Johnson & Johnson: stockholder General Electric: stockholder

3 Agenda Alcohol Use Disorder Drinking Trends SBIRT & Screening for Alcohol Related Problems DSM-5 Alcohol Biomarkers Alcohol Withdrawal Medications Anticraving Medications Opiate Use Disorder Changes in Abuse Patterns Treating Opioid Overdose Opioid Withdrawal Protocols Opioid Agonist Therapy Opioid Antagonist Therapy Appendix Managing Dual Diagnosis Patients

4 Alcohol Use; Monitoring The Future,

5 Alcohol Use Disorders Epidemiology: Alcohol use accounts for 1 in 10 deaths in US adults age 20 to 64, approximately 88,000 deaths per year Drinkers lives are shortened by about 30 years Drinking costs US $224 billion a year due to lost productivity, including reduced wages and health care costs CDC

6 SBIRT & SCREENING FOR PROBLEM DRINKING Screening, Brief Intervention, Referral to Treatment (SBIRT): Single Alcohol Screening Question (SASQ) How many times in the past year have you had 5 or more drinks in one day? (4 drinks for women) Any positive response within the past year warrants assessment for problem drinking. Review drinking during the last 28 days. Review DSM-5 criteria. (Canagasby & Vinson, Alcohol Alcohol, May-June 2005) A large British study has questioned the effectiveness of screening and brief interventions in primary care settings E Kaner, et al. BMJ 2013;346:e8501

7 RECOMMENDATIONS FOR SCREENING The SBIRT approach is effective for individuals with heavy/at risk drinking There is little evidence of efficacy for individuals with an alcohol use disorder or a drug use disorder More intensive counseling or interventions are required for individuals with more serious problems None the less all patients should be screened to identify risky or problem drinking R.Saitz JAMA 2014;312(5):

8 DSM-5 CHANGES CRITERIA FOR SUBSTANCE USE DISORDERS 1. USE IN LARGER AMOUNTS / LONGER PERIODS THAN INTENDED 2. UNSUCCESSFUL EFFORTS TO CUT DOWN 3. EXCESSIVE TIME SPENT TAKING DRUG 4. FAILURE TO FULFILL MAJOR OBLIGATIONS 5. CONTINUED USE DESPITE KNOWLEDGE OF PROBLEMS 6. IMPORTANT ACTIVITIES GIVEN UP 7. RECURRENT USE IN PHYSICALLY HAZARDOUS SITUATIONS 8. CONTINUED USE DESPITE SOCIAL OR INTERPERSONAL PROBLEMS 9. TOLERANCE 10. WITHDRAWAL 11. CRAVING SEVERITY: 0 TO 1 CRITERIA: NO DIAGNOSIS 2 TO 3 CRITERIA: MILD 4 TO 5 CRITERIA: MODERATE 6 OR MORE CRITERIA: SEVERE

9 ALCOHOL BIOMAKERS INDIRECT TESTS all measure long-term drinking only 1. Carbohydrate-Deficient Transferrin (CDT): most sensitive indicator of relapse (serum) > 20 units/l in men > 26 units/l in women 2. GGT: > 65 units/l in men > 50 units/l in women 3. MCV> 95 microns/cubic ml. in males > 100 microns/cubic ml. in females 4. LFT s: AST, ALT, & Alk. Phos. 5. CAMP in WBC are 3 x normal

10 ALCOHOL BIOMARKERS DIRECT TESTS can detect recent relapse / drinking 1. Blood Alcohol Concentration (BAC) 2. Ethyl Glucuronide (EtG) is present for 5 days in urine, very sensitive and may have a high incidence of false positives. Use can be problematic in monitoring situations. 3. Phosphatidyl Ethanol (Peth): 2 drinks/day for 2 weeks (in RBCs) will track moderate drinking; is positive for 2-4 weeks

11 ALCOHOL SUBTYPES NESARC study, adapted from Moss H, Drug Alc Depend, 2007 YOUNG ADULTS 32% LATE ONSET 38% EARLY ONSET 30% EPISODIC HEAVY BINGE DRINKING MODERATE DRINKING SEVERE CHRONIC DRINKING LITTLE PSYCHO-PATHOLOGY MINIMAL PSYCHO-PATHOLOGY SEVERE PSYCHO-PATHOLOGY MINIMAL GENETIC RISK MODERATE GENETIC RISK SEVERE GENETIC RISK

12 NEUROBIOLOGY OF ALCOHOL: CHRONIC ALCOHOL USE UP-REGULATION OF NMDA RECEPTORS: EXCITATORY NEUROTRANSMISSION, PRIMARY CAUSE OF WITHDRAWAL SYMTPOMS DOWN-REGULATION OF INHIBITORY GABA RECEPTORS DOWN-REGULATION OF EXCITATORY DOPAMINE D-2 RECEPTORS INCREASED NOREPINEPHRINE ACTIVITY

13 NEUROBIOLOGY OF ALCOHOL EFFECTS OF ALCOHOL WITHDRAWAL: CNS HYPERACTIVITY- NO OPPOSITION TO ALCOHOL INDUCED EXCITATORY STATE (NMDA HYPERACTIVITY) RELEASE OF CRF PREDICTORS OF RELAPSE: DELAYED RECOVERY OF D-2 RECEPTOR SENSITIVITY AFTER DETOX ELEVATED ACTIVITY IN THE VENTROMEDIAL PREFRONTAL CORTEX (vmpfc) R. Sinha, JAMA Psychiatry 2013

14 MEDICATIONS FOR ALCOHOL WITHDRAWAL Benzodiazepines remain the standard of care Anticonvulsants (carbamazine & valproic acid) are effective but have significant side effects (Myrick, 2003) Gabapentin may offer an alternative option for ambulatory withdrawal treatment: 400 mg TID for 8-10 days Effective control of withdrawal As compared to lorazepam, less craving, anxiety & sedation Reduced probability of relapse in postwithdrawal week (Myrick, Alcohol Clin Exp Res, : ) Can present abuse problems in some patients

15 RELAPSE PREVENTION PHARMACOTHERAPY ANTICRAVING MEDICATIONS AS THE NEW STANDARD OF CARE Consider, immediately post-detoxification for ALL alcoholics Efficacy requires counseling and/or frequent physician monitoring; med compliance is critical for success

16 ADDICTION PHARMACOTHERAPY: MEDICATIONS IN THE LONG-TERM MANAGEMENT OF ALCOHOLISM DISULFIRAM * NALTREXONE (PO* & IM* formulations) ACAMPROSATE * TOPIRAMATE ONDANSETRON SSRIs CLOZAPINE QUETIAPINE * FDA APPROVED

17 NALTREXONE (ReVia) Opioid antagonist / oral formulation Modulates the mesolimbic dopamine system in the VTA & projections to the nucleus accumbens Reduces alcohol craving and euphoric effects of alcohol Dose: 50 to 100 MG QDaily with meals Side effects GI: abdominal pain, decreased appetite, nausea Sedation: daytime sleepiness, fatigue, insomnia, headache Works best with compliant patients(zweben, 2008); requires counseling (CBT) or frequent MD monitoring visits (Project Combine, 2006) Efficacy questioned in women (O Malley, 2007)

18 Naltrexone Outcome associated with variants of opioid receptor gene OPRM 1 Asp 40 Allel Asn 40 Allel NALTREXONE 87% GOOD OUTCOME 55% GOOD OUTCOME PLACEBO 49% GOOD OUTCOME 54% GOOD OUTCOME Project Combine; Anton R. Arch Gen Psychiatry In meta-analysis of 6 studies, patients carrying the G allele of A118G polymorphism of OPRM1 had lower relapse rates, but no difference in abstinence rates (Chamorro et al, 2012)

19 ER-NALTREXONE (Vivitrol) Long-acting injectible formulation: 80 mg IM q 28 days Screen LFTs More stable plasma concentrations compared to the oral formulation Side effects: NAUSEA & HEADACHE; more sedation than with the oral formulation Injection site reactions possible Best results in patients sober 1 week prior to starting the medication Efficacy shown in more severe alcoholics Reduction in heavy-drinking days (48.9% vs 30.9% on placebo) Pettinati HM, Alcohol Clin Exp Res, May 2011

20 RECOMMENDATIONS FOR USE OF NALTREXONE Screening tests for hepatic function Begin 50 mg ORAL Naltrexone after 4-5 days sobriety (post detox) If no response after 2 weeks, go to 100 mg If no response or minimal responses, add Gabapentin 12OO mg/day Anton R. Am J Psychiatry, July 2011 If no response, switch to ER-Naltrexone Pettinati HM. Alcohol Clin Exp Res, May 2011 If no response consider Acamprosate or Disulfiram

21 DISULFIRAM (Antabuse) DOSE: 500 mg po qd x 10 days; then 250 mg po qd SIDE EFFECTS: drowsiness, headache, metallic taste, decreased libido/potency SUPPORTIVE COUNSELING NECESSARY SUPERVISED DOSING recommended Follow serial LIVER FUNCTION TESTS Monitor for ALCOHOL-INDUCED HEPATITIS Rx for Antabuse reaction: BENADRYL 50 mg IM or IV Jergensen CH, Alcohol Clin Exp Res, Oct 2011

22 ACAMPROSATE (Campral) Glutamate antagonist Alters GABA & NMDA systems Restores balance between inhibitory & excitatory neurotransmission Attenuates acute & prolonged withdrawal Reduces rewarding effects of alcohol No tolerance, withdrawal or sedation Minimal side effects (mild diarrhea) Excreted through the kidneys No drug-drug interactions Dose: 666 mg PO TID

23 ACAMPROSATE (Campral) COCHRANE REVIEW, Rosner S, RCT s with 6915 subjects Reduced risk of relapse to 86% of the risk in the placebo group Increased by 3 the number of abstinent days per month NNTB = 9 Authors anticipate better results in fully compliant patients Post-treatment benefit (10 RCT s) effect sustained 3 to 12 mos. after end of treatment ACA vs. NTX (6 trials; inconclusive data) ACA plus NTX results promising but inconclusive 41% higher dropout rate than ACA alone

24 PROJECT COMBINE 1383 patients randomized to varying combinations of oral Naltrexone, Acamprosate, combined behavioral intervention (CBI) and medical management (MM) ALL groups improved Naltrexone + MM had the best outcome Adding CBI did not improve results Adding Acamprosate did not improve results One-year outcome: no significant differences among the groups JAMA. 2006;295:

25 TOPIRAMATE (Topamax) Facilitates GABA Inhibits Glutamate Reduced drinking and craving: DBPC trial (Johnson. Lancet. 2003) 150 subjects Dose: 25 mg PO QD, then increase dose up to 100 mg TID over an 8 week period Side effects: fatigue & cognitive dulling Replicated in 371 subjects DBPC randomized trial (Johnson. JAMA. 2007) Changed to pregnancy CATEGORY D in 2011

26 ONDANSETRON (Zofran) Anti-nausea drug approved 1991 Selective 5-HT 3 blocker Reduced drinking in EARLY-ONSET Alcoholism (Type B) Dose: 4 microgm/kg po bid equivalent dose not currently marketed DBPC 11-week trial; 321 patients Johnson BA. JAMA. Aug 23, 2000 Less expensive generic version available since 2008 Higher efficacy in individuals with the LL GENOTYPE of the 5-HTT gene Johnson BA. AM J PSYCHIATRY, Jan 2011

27 SSRIs May Reduce Drinking in Some Alcohol Subtypes CITALOPRAM: Reduced drinking in nondepressed male alcoholics; no efficacy in non-depressed female alcoholics (Naranjo, 2000) SERTRALINE: Reduced drinking in Late Onset men; no efficacy, or made drinking worse in Late Onset women or Early Onset men or women (Pettinati, 2004)

28 QUETIAPINE (Seroquel) Atypicals target both DA & 5-HT Systems Reduced substance use on clozapine 12-week DBPC trial in 61 subjects 11 of 61 achieved total abstinence: 9 were on quetiapine 2 were on placebo TYPE B/Early Onset marked quetiapine benefit TYPE A/Late Onset no difference from placebo Kampman & Pettinati. J Clin Psychopharmacology A large meta-analysis of 13 DB studies of antipsychotics failed to demonstrate efficacy for relapse prevention. Subjects were not categorized by subtypes. T. Kishi, J Clin Psych 2013

29 ALCOHOLISM PHARMACOTHERAPY SUGGESTIONS ALCOHOLISM SUBTYPE Binge Drinking Young Adults Early Onset; Severe Psychiatric Co-morbidity Late Onset; Moderate Late Onset; Severe Psychiatric Co-morbidity Elderly Onset INTERVENTION Education Motivational Enhancement Therapy Naltrexone - oral Ondansetron Topiramate; Atypical Antipsychotics? Naltrexone ER formulation Topiramate SSRIs in males Naltrexone ER formulation Topiramate Naltrexone ER formulation

30 Marijuana as a Medication for Alcoholism? Among other purported benefits of marijuana, it has been recommended as a substitute for alcohol in some alcohol-dependence individuals A review of the literature concluded that there is no clear pattern of outcomes related to marijuana substitution. Any clinical recommendations were thought to be premature. Subbaraman MS, Alcohol Alcohol 2014, 49(3): People using both marijuana and alcohol reported increased alcohol consumption and greater prescription drug misuse (Osilla et al, 2014)

31 Treatment Costs Alcohol Dependent Patients

32 Patient Management Techniques SOBRIETY is the primary goal Supportive care - BUILD DEFENSES MEDICATIONS for relapse; monitor compliance Treat co-morbid psychiatric disorders Learn to work with A.A. CBT & relapse prevention counseling Anticipate lapses & relapses Active therapeutic stance For persistent insomnia: TRAZODONE Avoid prescription tranquilizers

33 Substances for Which Most Recent Treatment Was Received in the Past Year among Persons Aged 12 or Older:

34 Heroin Use; Monitoring The Future,

35 Narcotics use other than heroin, Monitoring the Future

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37 National Survey of Drug Use and Health 2014, SAMHSA

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39 CDC 3/18/17

40 National Survey of Drug Use and Health 2014, SAMHSA

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46 The Treatment of Opioid Overdose Signs: Coma, pinpoint pupils, depressed pulse and respirations, hypothermia Treatment Naloxone (Narcan) 0.4 mg (1ml) iv, q.4 min., prn If no response, treat for sedative/hypnotic OD Monitor methadone overdose patients for hrs. Single naloxone dose lasts 1-4 hours Fentanyl may require multiple doses of naloxone to reverse Major public health initiative with Naloxone Rescue formulations; new standard of care

47 Heroin-related Deaths, San Francisco: begins, 2003 Introduction of intranasal naloxone *Data compiled from San Francisco Medical Examiner s Reports, **no data available for FY

48 Neurobiology of Opioid Withdrawal Hyperactivity of nor-adrenergic neurons in the locus coeruleus causes: Increased BP, HR, respirations Increased sweating, diarrhea Clonidine & opiates reverse these effects Increased GABA effects; reduced dopamine in the nucleus accumbens cause: Dysphoria, depression, craving Only opiates (methadone & buprenorphine) reverse these effects

49 Withdrawal Treatment - Methadone Initiate treatment only after documenting withdrawal Do not exceed initial dose of 20 mg methadone (10 mg in younger addicts) May repeat dose in 2 hrs., if withdrawal increases Inpatients rarely require over 40 mg / 24 hours Titrate dose to avoid intoxication or withdrawal Detox taper: cut by 10 mg / day down to 20 mg then cut by 5 mg / day down to zero Adding Very Low Dose Naltrexone (0.125 or mg q daily) may improve outcome and ease transition to postdetox care (Mannelli, Am J Addict 2009)

50 Inpatient Buprenorphine Withdrawal Rx Document withdrawal before giving 1 ST dose DAY 1: BUP/NALOXONE 4/1 mg SL, may redose in 2 to 4 hrs, up to 8/2 mg SL DAY 2: 8/2 to 12/3 mg SL DAY 3: 6/1.5 mg SL, final dose; may also taper 2-3 days 7 day protocol may be more effective Addicts prefer buprenorphine over methadone or clonidine Umbricht, 2003

51 Withdrawal Rx - Outcome Data Percent patients drug-free at 13 weeks, MEDICATION BUPRENORPHINE / NALOXONE INPATIENT DETOXIFICATION 77 % 29 % CLONIDINE 22 % 5 % OUTPATIENT DETOXIFICATION W. Ling, 2005

52 Opioid Agonist Therapy BUPRENORPHINE: High affinity partial MU-opioid agonist / ceiling effect for respiratory depression Low overdose risk Kappa receptor antagonist Sublingual buprenorphine/naloxone tablet New film strip formulation in 2010 Generic sublingual formulations 2013 Extended release subdermal rods 2016 Over 400,000 patients currently in active treatment Prescribing requires training & CSAT / DEA WAIVER waiver limit can be increased from 30 to 100 to 275

53 Opioid Agonist Therapy BUPRENORPHINE: DSM-5 criteria for addiction (Opioid Use Disorder Moderate) Can treat patients age 16 and older Rapid stabilization in 1-2 days Maintenance range: mg Long half-life: 24 to 72 hr dosing No evidence of hepatoxicity (Bogneschutz, 2010) Best option for younger, motivated patients with shorter addiction histories and less sociopathy Not recommended in severe chronic pain syndromes

54 Opioid Agonist Therapy BUPRENORPHINE OUTPATIENT INDUCTION RECOMMENDATIONS: Abstinence prior to first BUP/NX dose: 16 hrs for short-acting opioids (heroin) 24 hrs for sustained-release opioid medications 36 hrs for methadone (30mg x 2 weeks; 15mg x 1 day; no methadone x 1 day; then induce on BUP/NX) COWS score 8-10 before 1 st dose (2 or 4 mg) Rapid escalation to 16mg, if needed, by end of day 1 Gunderson EW, et al. Am J Addiction Sept, 2011

55 The Role of Counseling Standard recommendations since 1965 have stressed the importance of ancillary counseling for success in opioid agonist therapy Benefits are well documented by research Ball & Ross, 1991; McLellan,1993 Four recent buprenorphine trials suggest that brief, frequent physician medication monitoring visits are equal to, if not more effective than more intensive drug counseling Fiellin, 2006; Weiss, 2011

56 BUPRENORPHINE IN PREGNANCY The MOTHER Study: 175 pregnant opioid dependent women 8 international sites DB, double-dummy, flexible-dosing, randomized, controlled trial (methadone PO vs. buprenorphine SQ) Both drugs safe and effective Retention: 72% methadone vs. 67% buprenorphine* * Most BUP dropouts in first few days, or with first dose Comparison of 131 neonates (BUP vs. Methadone) Morphine dose required for NAS: 1.1 vs mg morphine Duration NAS: 4.1 vs. 9.9 days Duration hospital stay: 10.0 vs days Jones HE, et al. N Eng J Med, Dec 2010

57 Neonatal Abstinence Syndrome Jones et al, N Engl J Med,

58 Buprenorphine Recommendations for minimizing diversion & abuse: Use BUP/NX for all patients except pregnant women Whenever possible keep dose to 16/4 mgs or below After initial stabilization, wait at least 5-7 days to assess benefit of any dose increase Over 16/4 mg, emphasize psychosocial techniques to manage ongoing craving or use Weekly physician visits until stable Regular urine toxicology screens Regular check of state Prescription Drug Monitoring Program Call-backs for pill counts and tox screens, as needed Dose reductions to 8/2 mg for long-term patients Encourage AA / NA

59 Opiate Agonist Therapy Pain Management Opioid agonist maintained patients do experience pain and will have high tolerance to opioids Manage with non-opioids meds if possible For Methadone patients a full opioid agonist can be added as needed, or dispense methadone in divided doses For Buprenorphine patients add supplemental BUP dose or dispense in divided doses or add full agonists to daily buprenorphine dose switch to methadone or morphine For patients with chronic pain and addiction Buprenorphine/Naloxone in divided doses may be ideal for long term management

60 COMPARING METHADONE & BUPRENORPHINE / NX BUP/NX METHADONE Setting Office-based Clinic-based Diagnosis DSM-5 1 year proven history Age > 16 > 18 Target dose 12 to 16 mg 80 to 120 mg Safety (risk of OD) Ceiling effect No ceiling effect Cardiac risks None Over 100 mg, QTc risk Pregnancy Safe; less NAS Safe Efficacy Comparable in multiple studies Pain treatment Off-label FDA approved Diversion risk Higher Low from clinics

61 NEW PHARMACOTHERAPIES Lofexidine for opioid withdrawal treatment comparable to clonidine but fewer side effects and better efficacy. Has not yet been approved by FDA Probuphine - extended release subdermal buprenorphine implant rods. (R. Rosenthal, W. Ling, et al. Addiction 8/2013) FDA approved Patients must be stabilized 1 st on BUP/NX SL, 8mg/2mg or a lower dose Patients may require supplemental SL BUP/NX Improved medication compliance Option for stable long term patients; not appropriate for patients new to treatment or unstable patients Monthly injectable buprenorphine / NDA submitted

62 Opioid Antagonist Therapy ER-NALTREXONE (Vivitrol) Long-acting injectable formulation 380 mg IM every 28 days FDA approved for opioid use disorder in 2010 Questions: 24 week placebo controlled trial in Russia 250 patients in randomized control design FDA approval prior to publication Krupitsky E, Lancet, April, 2011 Many positive clinical reports, but no well designed studies comparing ER-NX to Methadone or to BUP/NX. NIDA trial of BUP/NX vs ER-NX is in final stages.

63 Opioid Antagonist Therapy ER-NALTREXONE (Vivitrol) Clinical Concerns Identification of appropriate patients Difficulty initiating treatment risk of precipitated opioid withdrawal; patients must be opioid free for 3 days from shortacting opiates; 7 days from long-acting opioids Risk for accidental overdoses and death: Opioid use at end of 1 month dosing interval Opioid use after missing monthly injection Attempts to overcome opioid blockade Contraindicated in acute hepatitis / liver failure Lack of long-term studies Managing need for acute analgesia has not been a problem; Naltrexone blockade can be over-ridden in inpatient settings

64 Treatment Costs Opiate Dependent Patients

65 Cost Containment Issues State efforts to limit funding for treatment of opioid use disorder Illinois has limited BUP/NX Medicare coverage to 1 year Ohio and other states have proposed dose limit of 16/4 mg BUP/NX Pending budget tsunami for new Hep C drugs: sofosbuvir (Solvaldi) from Gilead Sciences $1000 per pill or $84,000 to $100,000 for 12 week course of treatment ($ 2.27 Billion sales 1 st quarter 2014) 90% efficacy 3 million US infected; 50% in public sector (Veterans Administration, Medicare, prison population) primarily IV drug users States fear out of control costs Buprenorphine plus counseling reduced total health care costs compared to untreated individuals (Lynch FL, Addiction Science & Clinical Practice 2014, 9:16)

66 Questions?

67 Alcoholism: Rank of Co-morbid Conditions 1. Abuse of a second substance 2. Antisocial personality disorder 3. Phobias (& other anxiety disorders) 4. Major depressive disorder: 13% of women alcoholics 3% of male alcoholics 5. Dysthymic disorder NOTE: Co-Morbidity is the norm for most alcoholics seen in any clinical setting

68 Depression in Alcoholics 20% of SUD patients have a co-occurring mood or anxiety disorder (NESARC, 2004) Prolonged dysphoria & depression - rule out substance-induced depression For alcoholics with an independent major depressive disorder or dysthymic disorder. Review of randomized, DBPC trials, 1980 to 2009: Efficacy shown for tricyclics and nefazodone SSRI s data currently inadequate Iovieno N, et al. J Clin Psychiatry, August 2011

69 Failure to Respond to Antidepressant Meds Medication NON-COMPLIANCE Check for RELAPSE: CDT GGT Check plasma levels of TCAs Consider enforced therapy Consider adding NALTREXONE or ACAMPROSATE

70 Bipolar Disorder and Co-Occurring Alcoholism Drinking typically follows onset of mania Patients rarely relapse when depressed or euthymic Alcoholism often remits after moods are stabilized Medication SUGGESTIONS (no adequate DBPC trials): BIPOLAR I LITHIUM BIPOLAR II VALPROIC ACID ATYPICAL ANTISPYCHOTICS

71 Anxiety Disorders in Alcoholics DIAGNOSIS: Wait 4 to 6 weeks for withdrawal symptoms to clear Positive family history +/- Symptoms antedate alcohol use TREATMENT RECOMMENDATIONS: Generalized anxiety dis.: BUSPIRONE Panic disorder: ANTIDEPRESSANTS BEHAVIORAL THERAPY Agoraphobia: ANTIDEPRESSANTS BEHAVIORAL THERAPY Social phobia: PROPRANOLOL or CLONIDINE

72 Treating ADHD in at Risk Patients 20% to 25% incidence of ADHD with any psychoactive substance use disorder TREATMENT PROTOCOL Adults with SUD & co-occurring ADHD: CBT X 2 weeks without medication Then start meds if symptoms persist medication choices ranked by risk potential Atomoxetine (Stratera) has no abuse potential Bupropion Desipramine Extended Release Stimulants: Methylphenidate ER generic (Concerta) or Adderal XR (amphetamine/dextroamphetamine mixed salts) T. Wilens, 2012

73 Anxiety Disorders in Addicts The Role of Benzodiazepines: Comprehensive literature review Efficacy demonstrated for: GAD, panic disorder and agoraphobia Probable efficacy for: Social phobia, alcohol induced anxiety disorders Little evidence of added risk for medication abuse or increased relapse Posternak & Mueller. Am J Addict. 2001;10:48-68.

74 Naloxone Rescue Formulations