A strong association exists between epilepsy and psychiatric comorbidities, especially depression, anxiety, attention deficit disorders, and psychosis. The impact of psychotropic medications in lowering seizure threshold both directly and indirectly, hypersensitivity reactions to antiepileptic and other psychotropic medications, and how antiepileptic drugs affect psychiatric disorders are explored through three patient cases. Ultimately, in selecting an appropriate psychotropic medication for an individual with epilepsy and psychiatric comorbidities, it is important to consider the clinical and quality-of-life impacts that a particular medication will have on that individual.Abstract
The use of antipsychotic medications has now expanded to multiple mental health conditions beyond schizophrenia. This has increased the overall population exposure to these medications, which have been associated with both metabolic changes and adverse cardiovascular effects. QTc prolongation, torsades de pointes, sudden cardiac death, myocarditis, and cardiomyopathy are all very real concerns that clinicians face on a regular basis. One must take these risks into consideration when selecting antipsychotic therapy and also when determining whether therapeutic changes and adjustments are necessary. This review examines a number of cardiac-associated concerns, the role that antipsychotics may play in contributing to these adverse events, and suggested management interventions.Abstract
The management of bipolar disorder during reproductive years is a challenge to both patient and clinician. The rapidly changing landscape of medical literature, newly available medications, and implementation of the Pregnancy and Lactation Labeling Final Rule by the Food and Drug Administration can be dizzying. This article serves as a brief, practical guide on the use of medications for the treatment of bipolar disorder before, during, and immediately after pregnancy. Special focus is devoted to the risk-benefit analysis of using potentially teratogenic medications during pregnancy. Availability and appropriateness of various contraceptive methods and folic acid supplementation in combination with mood stabilizers is also addressed. Every clinician managing bipolar disorder in adult women should be knowledgeable of family planning resources and what to do in the setting of unintended pregnancy.Abstract
Persistent psychotic symptoms will develop in up to 60% of patients with Parkinson disease (PD). The initial approach to the management of PD psychosis (PDP) begins with addressing concurrent systemic conditions associated with psychotic behavior, such as delirium, medical conditions (eg, infections), psychiatric disorders (eg, major depression with psychotic symptoms, mania, schizophrenia), and substance misuse or withdrawal. A review of current medications is recommended, and medications that may trigger psychotic symptoms should be eliminated. If possible, antiparkinson medications should be reduced to the minimum therapeutic dose or discontinued in a sequential manner. Generally, dose reduction or discontinuation of anticholinergics is attempted first, followed by that of monoamine oxidase B inhibitors, amantadine, dopamine agonists, catechol-O-methyltransferase inhibitors, and lastly carbidopa/levodopa. The aim of antiparkinson medication dose reduction is to achieve a balance between improving drug-related psychotic symptoms and not significantly worsening the motor symptoms of PD. If additional measures are needed for chronic PDP treatment, the use of second-generation antipsychotics, such as clozapine, pimavanserin, or quetiapine, must be considered. The first-generation antipsychotics (eg, fluphenazine, haloperidol) are not recommended. In the patient with comorbid dementia, the addition of a cholinesterase inhibitor might also be beneficial for PDP. The choice of agent is based on patient-specific parameters, potential benefit, and side effects.Abstract
This retrospective cohort study evaluated effects of buprenorphine/naloxone dose and concomitant use of selected sedating medications on treatment outcomes in patients with opioid use disorder. Patients enrolled in the buprenorphine/naloxone clinic at the study institution from 2009 until April 2013 were included. There were no exclusion criteria. Part 1 assessed treatment failure within 6 months and time to treatment failure with buprenorphine doses >8 mg and ≤8 mg. Part 2 assessed for treatment failure within 6 months and time to treatment failure with use of selected sedating medications. Sedating medications were cyproheptadine, hydroxyzine, quetiapine, and trazodone. Treatment failure was defined as documentation of illicit opioid use per patient report, urine drug screen showing opioid use, or patient lost to follow-up. There were 132 patients included in this study, but 163 separate encounters due to multiple enrollments. Treatment failure was experienced within 6 months 51 times a patient was prescribed ≤8 mg (66.2%) and 26 times a patient was prescribed >8 mg (33.8%) (P = .0005). Average time to treatment failure was 5.1 months with ≤8 mg and 8.4 months with >8 mg. The 48% of patients who received sedating medications did not demonstrate any significant differences in treatment response at 6 months (P = .2746) or time to treatment failure (P = .2209). Doses of buprenorphine/naloxone >8 mg demonstrated better treatment response and prolonged time to treatment failure. Concomitant sedating medications did not have a statistically significant effect on treatment response or time to treatment failure.Abstract
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Opioid-related overdoses have risen despite extensive media coverage and apparent awareness of this public health crisis. Emergency department visits related to opioid use nearly tripled from 2004 to 2011. Patients with mental illness are more likely to be prescribed opioids and have higher rates of overdose. This retrospective chart review sought to determine if opioid represcribing occurred after patients were treated for a nonfatal opioid overdose (NFO) at a Veterans Affairs hospital. Patients who experienced an NFO between 2009 and 2013 were included and charts reviewed until January 1, 2016. Review of the electronic medical record (EMR) was performed to determine if and when opioids were again prescribed after NFO. Fifty-six veterans met the inclusion criteria. A new opioid prescription was issued to 82% of patients within 3 months following the index NFO date. The average daily morphine equivalent dose prescribed before (122 mg) and after (120 mg) NFO did not differ. A subsequent opioid overdose event occurred in 25% of patients, and there was 1 fatal event. Only 1 patient had medication overdose on the problem list of their EMR. Despite experiencing NFO, veterans continued to be prescribed opioids without significant changes in the drug or dose; some experienced repeated overdose events, possibly due to poor communication and documentation of NFO. Pharmacists can play a key role in clinical interventions and education of patients and prescribers.Abstract
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The Chillicothe Veterans Affairs Medical Center serves veterans from southern Ohio, Kentucky, and West Virginia, where the rates of non-medical opioid use are some of the highest in the nation. Prior to this project, there was not a standardized practice for the treatment of veterans undergoing opioid withdrawal at the facility. In May 2015, a symptom-triggered protocol was initiated to improve the quality of care and decrease the length of detoxification for veterans treated at the Chillicothe Veterans Affairs Medical Center. This paper reflects a 2-phase project that took place from August 2014 through June 2016. Phase 1 focused on the development of a symptom-triggered opioid withdrawal protocol using the Clinical Opiate Withdrawal Scale for assessment and buprenorphine/naloxone or clonidine for treatment. Phase 2 was a retrospective cohort analysis comparing outcomes between group 1, before protocol initiation; group 2, after protocol initiation with clonidine; and group 3, after protocol initiation with buprenorphine/naloxone. The primary outcome assessed was length of detoxification (in days). Secondary outcomes included length of hospitalization (in days) for the index admission, outpatient substance abuse treatment program participation rates, and opioid sobriety rates at 3 months after detoxification. A statistically significant reduction in the duration of detoxification days was detected after protocol initiation in veterans who received buprenorphine/naloxone or clonidine in accordance with the protocol. This retrospective quality analysis supports the use of a symptom-triggered opioid withdrawal protocol using the Clinical Opiate Withdrawal Scale for assessment and clonidine or buprenorphine/naloxone for detoxification treatment.Abstract
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Opioid overdose–related morbidity and mortality remain one of the most pressing public health crises. Overdose education and naloxone distribution have emerged as an effective initiative for mitigating overdose deaths. This case highlights areas of patient education essential to optimizing treatment outcome when using a naloxone reversal kit. The patient is a 46-year-old white male with a past medical history significant for opioid use disorder, alcohol use disorder, stimulant use disorder, sedative-hypnotic use disorder, and posttraumatic stress disorder. The patient received an intranasal naloxone kit during residential substance abuse treatment. Five months later, the patient requested a new kit and was asked about the disposition of his previous kit. The patient recounted how he was telephoned to pick up an unconscious friend (and fellow veteran) from a nonresidential location. Upon arrival, the patient recognized opioid products near his friend and took steps to reverse the suspected opioid overdose with his 2 mg/2 mL naloxone intranasal kit. The reversal was successful, but many critical rescue response steps were omitted. This case report may guide future changes to educating patients on appropriate responses to opioid overdoses with naloxone. A PubMed search located one other case report of successful naloxone reversal of opioid overdose in the veteran population, which involved fentanyl sold as heroin. In our case report, a veteran successfully used his naloxone kit to reverse a suspected opioid overdose in another veteran, but he incompletely provided the rescue response. This experience may influence content changes for future overdose education and naloxone distribution training.Abstract