Treatment of Anxiety in the Methadone Maintained...
Transcript of Treatment of Anxiety in the Methadone Maintained...
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Treatment of Anxiety in the Methadone Maintained Patient
Abigail Kay M.D., M.A.Medical Director
Narcotic Addiction Rehabilitation ProgramDepartment of Psychiatry and Human Behavior
Thomas Jefferson University
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OutlineI Introductory comments
II Benzodiazepine issues
III Key points prior to initiating treatment for anxiety
IV Pharmacological treatment of anxiety
V Non-Pharmacologic treatment of anxiety
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I Introductory Comments
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“Lessened Anxiety Hour 5-6”
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Thought Process• Me: I liked the 800mg of Ibuprofen b/c it treated the pain
• My Patient: I prefer [opiate] because then I don’t care about the pain
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Trauma History
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II Benzodiazepines issues
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Note
• This talk will not cover how to medically taper a patient off of benzodiazepines
• Patients with substance use disorders (SUD) are at high risk for misusing/abusing medications with addictive potential and therefore these medications should be avoided whenever possible
• Benzodiazepines have the potential to be addictive, especially in patients with other addiction disorders
• It can be lethal to mix methadone and benzodiazepines
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Benzodiazepines in Tx of Anxiety
• Generally safe for patients WITHOUT SUD– Often prescribed by primary care doctor or psychiatrist
because they work quickly
• Standard of care to avoid in the patient with SUD – Because of the high risk of addiction
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Benzodiazepines• Lifetime benzodiazepine use reported to be 66% – 100% in MMT
population
• Current use 51% - 70%*
• Estimated abuse/dependence 18% - 50%*
*in tx agonist/partial agonist therapy or not in tx
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III Key points prior to initiating treatment
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“Your therapy will be a combination of drugs and clowns”
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Prior to treatment
• Strong doctor-patient relationship• Make sure your treatment goal = patient’s treatment goal
– Eg pt wants to numb their feelings• Treat co-morbid medical or psychiatric disorders• Promote healthy behaviors
– Sleep hygiene– Decreased caffeine– Decreased (no) EtOH – can cause rebound anxiety
• Educate Patient on what to expect– understanding of rebound vs. return of original anxiety– Time frame for medication to work
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Medication Issues• Patient’s with panic disorder sensitive to side effects medications
– Discuss with patient expected side effects• Start low – go slow
– Allow Patient to stay at lower dose until they feel comfortable increasing it
• Make sure patient isn’t under dosed – Common reason for treatment failure
• Make sure they have anxiety disorder and not substance induced anxiety disorder– Eg cocaine induced panic attacks/depression
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III Pharmacological treatment of anxiety -FDA approved-Off label-PRNs
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Top 3 Medications for Anxiety disorders
• SSRI
• SSRI
• SSRI
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Medications for Anxiety Disorder• SSRI’s
– Not all are FDA approved for treatment of anxiety d/o’s, but in practice all are generally effective
– Choose based on patient • See next slide
– Not 100% effective• SNRI’s
– Venlafaxine• TCA’s
– Safety issues– Increased side effect profileGabbard’s Treatment of Psychiatric Disorders, 4th ed, Chap. 29 Panic Disorder
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Choosing a Medication• Has patient found one helpful in the past?
– The patient who has tried them all
• Has a family member found one helpful in the past?
• Has a friend found one helpful in the past?
• Is there a second reason they would want to take it?– May help increase compliance
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Meds Without Supportive Data• Mirtazapine
– Individual pt’s may appreciate sedating effect• Trazadone
– Risk of priapism in men– Individual pt’s may appreciate sedating effects
• Buproprion– No effect on anxiety– Stimulant effect may worsen symptoms
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Problem: These medications take weeks to work
What do you and the patient do in the mean time?
• PRN medications
• Use non-pharmacologic options– Next section
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Antiepileptics as PRN medications*exciting new option*• Gabapentin
– One study showed no difference from placebo for panic d/o– BUT subanalysis showed for moderate to severely ill patients that
there was a significant improvement– More research needed
• Valproate– Small non-RCT showed improvement for social anxiety disorder
(SAD)
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Antiepileptics – con’t
• Pregabalin
– Multiple DBPC randomized studies have shown there is a decrease in anxiety in patients with generalized anxiety d/o
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PRN Medications• Hydroxyzine aka Vistaril aka Atarax
– Large dosing range options– Instructions to patient
• Buspirone– Generally not useful for pt’s with h/o benzo use
• Atypical Antipsychotics– Risks: TD, NMS, metabolic syndrome, DM
• Avoid first line– Some now have street value
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IV Non-Pharmacologic treatment of anxiety
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Next slide is an example of the wrong way to treat anxiety
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“I medicate first and ask questions later”
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CBT• Effective for GAD and panic d/o
• Effective 1-1 or in group setting
• One study (Clark et al, 1999) showed 5 session CBT + self study was essentially as good as 12 session (for panic d/o)– 71-79% panic free at 12mn f/u
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Generalized Anxiety Disorder• Psychodynamic psychotherapy• CBT• Relaxation techniques – must practice
– Progressive muscle relaxation– Biofeedback– Relaxing imagery– Meditation– Breathing techniques
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Conclusion• Anxiety disorders are very
common in the methadone maintained patient population
• In general there isn’t one “whole pie” we can give our patients but we can help them get a whole pie made up with several different treatment pieces
• We must have belief in our patients until they are able to have it for themselves
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References• J of Clin Pharm, vol 20(4) 8/2000, pg. 467-471 Placebo Controlled Study of Gabapentin
Treatment of Panic Disorder• J of Clin Pharm, vol 27(3) 6/2007, pg. 263-272 The Role of Anticonvulsant Drugs in
Anxiety Disorder, a Critical Review of the Evidence• J Addict Med, vol5(4) 12/2011, pg. 233-247 Understanding and Treating Comorbid
Anxiety Disorders in Substance Users. Review and Future Directions• J Addict Med, vol5(4) 12/2011, pg. 248-253 Treatment of Comorbid Substance Use and
Anxiety Disorders: A Case Study• Gabbard's Treatments of Psychiatric Disorders, 4th Edition• American J on Addictions, 19:59-72, 2009 Benzodiazepines, Methadone and
Buprenorphine: Interactions and Clinical Managment