Psych Meds for Harm Reduction Providers

1. 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 Barry_Zevin@sfdph.org

2. 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!

3. 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

4. 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

5. 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?

6. 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

7. Basic Pharmacology • What I’m not going to talk about

8. 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

9. 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

10. 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

11. 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

12. SSRIs Main Intended Effects • Anti-depressant • Anti-anxiety • Anti-OCD Other Intended Effects • Sleep • Activation / energy

13. SSRIs Common 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

14. TCAs Main Intended Effects • Anti-depressant Other Intended Effects • Sleep • Pain relief • Anti-itching • Doxepin • Anti-anxiety

15. TCAs 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 Common Side Effects • Anti-cholinergic • Dry mouth, sedation, urinary retention, • Sedation

16. 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)

17. 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

18. Placebo • Main Intended Effects • Anti-depressant • Anti-anxiety • ??? • Other Intended Effects • Eliminate “side effects”

19. Placebo (Nocebo) • Common Side Effects • Expected adverse effects are more likely to occur • Often interfere with effective treatment • Rare But Severe Side Effects • ???

20. 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)

21. 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

22. Benzodiazepines 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 Common Side Effects • Sedation • Interferes with memory and learning • Unpleasant withdrawal when stopped abruptly

23. 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.

24. 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

25. Atypical anti-psychotics 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 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

26. Older anti-psychotics Main Intended Effects • Anti-psychotic • Anti-mania Other Intended Effects • Decrease any kind of agitation

27. 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

28. Medications for Bipolar Disorders • Lithium • Anti-epileptic drugs • Lamotragine (Lamictal), divalproex (Depakote), topiramate (Topamax), carbamazepine (Tegretol), oxcarbazapine (Trileptal) • Atypical anti-psychotics

29. Lithium Main Intended Effects • Anti-manic • Mood stabilizer Other Intended Effects • Anti-depressant

30. 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

31. 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

32. 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

33. Medications for ADHD • Psychostimulants • Methylphenidate (Ritalin, Focalin, etc), mixed amphetamine salts (Adderall, Adderall XR), others • Others • Atomoxetine (Strattera)

34. Medications for ADHD Main Intended Effects • Improve concentration and focus • Decrease hyperactivity Other Intended Effects • Anti-depressant • Decrease substance abuse

35. 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

36. 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

37. 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

38. 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

39. 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