Psych Meds for Harm Reduction Providers

Barry Zevin MDTom Waddell Health Center

San Francisco Department of Public Health Homeless Programs

Board Certified Internal MedicineBoard Certified Addiction Medicine

Barry_Zevin@sfdph.org

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!

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

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

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?

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

Basic Pharmacology• What I’m not going

to talk about

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

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

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

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

SSRIs

Main Intended Effects• Anti-depressant• Anti-anxiety• Anti-OCD

Other Intended Effects• Sleep• Activation / energy

SSRIsCommon 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

TCAs

Main Intended Effects• Anti-depressant

Other Intended Effects• Sleep• Pain relief• Anti-itching

– Doxepin• Anti-anxiety

TCAs

Common Side Effects• Anti-cholinergic

– Dry mouth, sedation, urinary retention,

• Sedation

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

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)

Other anti-depressantsCommon 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

Placebo

• Main Intended Effects– Anti-depressant– Anti-anxiety– ???

• Other Intended Effects– Eliminate “side

effects”

Placebo (Nocebo)

• Common Side Effects– Expected adverse

effects are more likely to occur

– Often interfere with effective treatment

• Rare But Severe Side Effects– ???

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)

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

Benzodiazepines

Common Side Effects• Sedation• Interferes with

memory and learning

• Unpleasant withdrawal when stopped abruptly

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

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.

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

Atypical anti-psychotics

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

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

Older anti-psychotics

Main Intended Effects• Anti-psychotic• Anti-mania

Other Intended Effects• Decrease any kind

of agitation

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

Medications for Bipolar Disorders

• Lithium• Anti-epileptic drugs

– Lamotragine (Lamictal), divalproex (Depakote), topiramate (Topamax), carbamazepine (Tegretol), oxcarbazapine (Trileptal)

• Atypical anti-psychotics

Lithium

Main Intended Effects• Anti-manic• Mood stabilizer

Other Intended Effects• Anti-depressant

LithiumCommon 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

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

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

Medications for ADHD

• Psychostimulants– Methylphenidate (Ritalin, Focalin, etc),

mixed amphetamine salts (Adderall, Adderall XR), others

• Others– Atomoxetine (Strattera)

Medications for ADHD

Main Intended Effects• Improve

concentration and focus

• Decrease hyperactivity

Other Intended Effects• Anti-depressant• Decrease substance

abuse

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

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

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

Medications for SleepCommon 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

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