Psychotropic Medication Management on Center

1. Psychotropic Medication Management on Center David P. Kraft, MD, MPH Region I Mental Health Consultant National Health and Wellness Conference Orlando, Florida June 7, 2005

2. Psychotropic Medication Management on Center • How can we help students on psychotropic medications while in Job Corps and when preparing to leave Job Corps?

3. A. Principles of Psychiatric Medications • Medications are a TOOL to help students control feelings, thoughts and behavior • Medications are best when COMBINED with counseling and behavioral techniques

4. A. Principles of Psychiatric Medications (continued) • Medications take AT LEAST 2 WEEKS to begin to work (except side-effects, which can begin immediately, then usually subside after 5 days) • Medications need to be taken at least ONCE A DAY • Medications take BETWEEN 1 and 2 WEEKS to stop working, in most cases

5. A. Principles of Psychiatric Medications (continued) • Major CHANGES in medication should be AVOIDED during Job Corps stay (minimize lost training time) • Newer medications have FEWER SIDE-EFFECTS • Newer medications are usually MORE EXPENSIVE

6. B. Common Problems Helped with Psychiatric Medications • DEPRESSION, especially if chronic, not situational • ANXIETY states, including panic, phobic, obsessive-compulsive disorders, and general stress not responsive to counseling or behavior techniques

7. B. Common Problems Helped with Psychiatric Medications(continued) • IMPULSIVE tendencies, especially if explosive and can injure student or others • FLASHBACKS from earlier traumatic events, especially if disrupting sleep or concentration • LEARNING DIFFICULTIES, especially if ADHD is involved

8. C. Less Common Problems Helped with Medications • PARANOID PSYCHOSIS, may be stabilized on antipsychotic medications and supportive therapy • OTHER PSYCHOTIC DISORDER, such as Schizophrenia, Schizoaffective Disorder, where antipsychotic medication can help student overcome some of abnormal features of these disorders

9. C. Less Common Problems Helped with Medications (continued) • BIPOLAR DISORDER, usually stabilized on mood stabilizer and/or atypical antipsychotic agents • ADJUSTMENT DISORDERS, if last more than a few weeks, may be helped short-term

10. D. Obtaining Psychotropic Medications for Students • Student brings medications from home, and gets from doctor at home • Student’s health insurance pays for medications while in Job Corps • Student enrolled in Medicaid at center

11. D. Obtaining Psychotropic Medications for Students (continued) • Job Corps Center provides medications through local pharmacy or government supply house (JC Information Notice 02-18) • Center physician/psychiatrist applies for patient assist program of specific drug company for each medication

12. E. Helping Students Comply with Taking Medications • Supply each student a list of medications, when taken, and instructions (if any) • Ask wellness staff to tailor times of taking medications to minimize interference with learning schedule • Teach students ways to remember to take chronic medications (e.g., dispenser, daily reminder, convenient times)

13. E. Helping Students Comply with Taking Medications (continued) • Help students take medications on own (e.g. over weekends or 2-3 days supply at a time, if safe for them to have medications at dorm) • For addictive and abusable substances (sedatives, hypnotics, stimulants), provide no more than a one day supply at a time, to minimize risk of other students getting into medications

14. E. Helping Students Comply with Taking Medications (continued) • Train residential staff in safe use of medications, in order to help students comply with medication regimens • Provide training to education and vocation staff, as well as support personnel, concerning the basic principles of using psychotropic medications safely and effectively

15. F. Preparing Students for Life Beyond Job Corps • Update lists of medications, doses, side-effects, and reason for use • Help students practice asking their doctors and nurses questions about the medications, and options for care • Teach students how to keep track of compliance and recognize changes in their symptoms

16. F. Preparing Students for Life Beyond Job Corps (continued) • Help student develop plans to transfer care and obtain services upon leaving Job Corps, if possible, schedule appointments with doctors, therapists, etc. before leaving • Give student written summary of current health and wellness concerns, treatments, present needs, future goals and plans

17. G. Common Medications Used • DEPRESSION • Selective Serotonin Reuptake Inhibitors (SSRIs) • citalopram (Celexa) • escitalopram (Lexapro) • fluoxetine (Prozac) • paroxetine (Paxil) • Atypical Antidepressants • buproprion (Wellbutrin SR) • venlafaxine (Effexor XR) • duloxetine (Cymbalta) • Tricyclic Antidepressants (TCAs) • desipramine (Norpramin) • nortriptyline (Pamelor) • amitriptyline (Elavil)

18. G. Common Medications Used (continued) • ANXIETY • Selective Serotonin Reuptake Inhibitors (SSRIs) • citalopram (Celexa) • escitalopram (Lexapro) • fluoxetine (Prozac) • fluvoxamine (Luvox) • paroxetine (Paxil) • Atypical Antidepressants • venlafaxine (Effexor XR) • duloxetine (Cymbalta)

19. G. Common Medications Used (continued) • ANXIETY (continued) • Tricyclic Antidepressants (TCAs--older drugs) • desipramine (Norpramin) • nortriptyline (Pamelor) • amitriptyline (Elavil) • Benzodiazepines (minor tranquilizers)--[ADDICTIVE, not use with substance abusers] • clonazepam (Klonopin) • lorazepam (Ativan) • diazepam (Valium) • alprazolam (Xanax)

20. G. Common Medications Used (continued) • Bipolar Disorders (manic depression) • Mood Stabilizers • lithium carbonate (Eskalith) • divalproate (Depakote) • carbamazepine (Tegretol) • oxcarbazepine (Trileptal) • Atypical Antipsychotic Agents • olanzapine (Zyprexa) • risperidone (Risperdal) • ziprasidone (Geodon) • aripiprazole (Abilify) • quetiapine (Seroquel) • Typical Antipsychotic Agents • haloperidol (Haldol)

21. G. Common Medications Used (continued) • Bipolar Depression (Bipolar Type II-usually treated with mood stabilizer and antidepressant) • Mood Stabilizers • lamotrigine (Lamictal) • lithium carbonate (Eskalith) • divalproate (Depakote) • carbamazepine (Tegretol) • Atypical Antipsychotic Agents • olanzapine (Zyprexa) • risperidone (Risperdal) • aripiprazole (Abilify) • ziprasidone (Geodon)

22. G. Common Medications Used (continued) • Psychotic Disorder (including Schizophrenia, Schizoaffective Disorder, and Paranoid Psychosis) • Atypical Antipsychotic Agents • olanzapine (Zyprexa) • risperidone (Risperdal) • ziprasidone (Geodon) • quetiapine (Seroquel) • aripiprazole (Abilify) • clozapine (Clozaril) • Typical Antipsychotic Agents • haloperidol (Haldol), perphenazine (Trilafon), thioridazine (Mellaril)

23. G. Common Medications Used (continued) • Impulsive Disorders (treated according to underlying disorder, if any) • SSRI and Atypical Antidepressants • citalopram, escitalopram, fluoxetine, paroxetine, sertraline, venlafaxine, duloxetine • Mood Stabilizers • lithium carbonate, divalproate, carbamazepine • Atypical and Typical Antipsychotic Agents • risperidone, olanzapine, quetiapine • haloperidol , thioridazine (Mellaril) • Adrenergic Agents (higher doses may help) • propranolol (Inderal LA, Inderal)

24. G. Common Medications Used (continued) • ADHD • Selected Antidepressants (SSRIs, Atypicals, TCAs) • buproprion (Wellbutrin SR) • venlafaxine (Effexor XR) • fluoxetine (Prozac), citalopram (Celexa) • desipramine (Norpramin) • SNRI (Selective Norepinephrine Reuptake Inhibitor)--[NEW] • atomoxetine (Strattera) • Psychostimulants (easily ABUSED by other students, paradoxical calming effect on ADHD student) • amphetamine salts (Adderall) • dextroamphetamine (Dexedrine) • methylphenidate (Ritalin, Metadate, Concerta) • pemoline (Cylert)

25. G. Common Medications Used (continued) • Alcohol & Drug Abuse • Alcohol Abuse Prevention • disulfiram (Antabuse) • naltrexone (Revia) • acamprosate (Campral) • Opiates & Other Drugs • naltrexone (Revia) • buprenorphine (Buprenex) • levomethadyl (ORLAAM) • methadone (Dolophine)

26. Summary • Encourage students to take medications as prescribed, or consult with wellness center staff if problems • Support overall goal of student responsibility for behavior, whether or not taking medication

27. Summary (continued) • Discourage students from only using medications “when I remember”--to do any good, most need to be taken at least once a day • If asked about whether a student should take his/her medication, share your observations of how the medicine may be helping

28. Summary (continued) • Look for ways to make medication compliance easier for students • Help wellness center staff with ideas about helping students plan for their future

29. References • Mosby’s Drug Consult 2005, Mosby, Inc., St. Louis, MO, 2005. • Physicians’ Desk Reference 2005, Edition 58, Medical Economics Co., Inc., Montvale, NJ, 2005. • Psychotropic Drugs Fast Facts, by Maxmen JS, Ward NG, WW Norton & Co., New York, 2002. • Job Corps TAG H: Mental Health Disabilities, Section 5, September 2003.

30. Appendix: Newest Medications • Antidepressant/Antianxiety Agents (older = fluoxetine, sertraline, paroxetine, fluvoxamine, buproprion) • escitalopram (Lexapro), 10-30 mg daily • citalopram (Celexa), 20-80 mg daily • venlafaxine (Effexor XR), 37.5-300 mg daily • duloxetine (Cymbalta), 40-120 mg daily

31. Latest Medications (continued) • Mood Stabilizing Agents (usual = lithium, valproate, carbamazepine) • lamotrigine (Lamictal), 100-500 mg daily (bipolar depression) • oxcarbazepine (Trileptal), 600-2400 mg daily (no blood levels needed) • topiramate (Topamax), 50-400 mg daily (weight loss side-effect, often second agent)

32. Latest Medications (continued) • Antipsychotic Agents (usual = risperidone, olanzapine, quetiapine, clozapine) • ziprasidone (Geodon), 80-200 mg daily (with food, weight loss side-effect) • aripiprazole (Abilify), 10-30 mg daily (weight neutral) • risperidone long-acting injection (Risperdal Consta), 25-75 mg every 2 weeks (microspheres in diluent, 3 week lag-time to work)

33. Latest Medications (continued) • Antianxiety and Sedative Agents (usual = lorazepam, clonazepam, zolpidem, buspirone) • alprazolam extended-release (Xanax XR), 1-10 mg daily (11 hour half-life, panic disorder indication) • zaleplon (Sonata), 5-20 mg bedtime (short duration, 1 hour half-life) • eszopiclone (Lunesta), 1-3 mg bedtime (short duration, 6 hour half-life)

34. Latest Medications (continued) • ADHD Medications (usual = methylphenidate, dextroamphetamine, desipramine) • amphetamine mixed salts extended-release (Adderall XR), 5-30 mg once daily (half-life 10-13 hours, abuse can cause psychosis) • methylphenidate extended-release (Ritalin LA), 10-80 mg once daily (half-life 3-4 hours, more reliable than SR form)

35. Latest Medications (continued) • ADHD Medications (continued) • atomoxetine (Strattera), 40-100 mg daily (selective norepinephrine reuptake inhibitor, similar action of older TCAs, fewer side-effects) • modafinil (Provigil), 100-600 mg daily (for narcolepsy, does NOT seem helpful for ADHD in first open label studies)

36. Latest Medications (continued) • Substance Abuse [usual = disulfiram, naltrexone, methadone] • buprenorphine (Subutex), 12-16 mg sublingual daily, for induction; buprenorpine, naloxone (Suboxone), 12/3-16/4 mg sublingual daily, for opioid dependence • acamprosate (Campral), 666-1998mg daily, half-life 20-33 hours, for alcohol dependence