Heidi Anne Duerr, MPH

“Our task in the next 20 minutes is to go through a whirlwind tour of the treatments for opioid use disorder [OUD],” Edward V. Nunes, MD, told attendees of the 

 “And the idea I want to sell is that psychiatry should really lead the way on this. This is a national priority and crisis, and psychiatry has a lot to offer in terms of treatment… we have the expertise.”

Medication is the cornerstone of treatment for OUDs, and psychiatrists are the experts in this area, explained Nunes, who is professor of psychiatry at Columbia University Irving Medical Center, research psychiatrist at New York State Psychiatric Institute, and principal investigator of the Greater New York Node of the National Institute on Drug Abuse (NIDA) Clinical Trials Network. Unfortunately, most people with OUDs are not receiving effective medication treatment. This may be why there is a high mortality rate (1% annually), due largely to overdose and suicide. There are currently 3 main options available: methadone, buprenorphine, and extended release injection naltrexone, Nunes noted.

Methadone is an oral full opioid agonist with slow absorption and a slow elimination (ie, long half-life).When titrated to an effective dose range of at least 80 mg/day, it induces tolerance in the brain’s opioid system, which results in a tolerance blockade for illicit opioid. “So when a patient gets up on a dose of methadone, you know that dose has gotten high enough for this patient when they say, ‘I took some heroin and nothing happened. I was wasting my money, so I stopped using it.’,” Nunes shared.

Importantly, methadone is effective, not just in efficacy but also with retention, Nunes said. In clinical trials lasting more than 6 months, 70% of patients were retained. Of those, he noted 50% were found to be in sustained abstinence. “Most importantly, because of inducing tolerance, it protects against overdose and death,” Nunes added.

There are limitations to this strategy, Nunes told attendees, with accessibility and acceptability being important issues. Methadone is only available in special licensed clinics, and at least half of US communities do not have a methadone clinic within a reasonable distance, he reported. Also, daily attendance is required for the first 3 to 6 months. Direct observation is necessary because if you raise a dose too quickly, it can result in an overdose, he said. There is also the potential for diversion.

Nunes noted methadone clinics run a little differently outside of the United States. “Other countries, including Canada, have more flexible models such as primary care and pharmacy based methadone,” he explained. “So, hopefully in the future the United States will begin working with some of these models to make it widely available. In the meantime, if you have a methadone clinic in your community, by all means, think about referring for methadone maintenance.”

Buprenorphine maintenance is a second option for addressing OUDs. Buprenorphine is a high affinity mu partial agonist and kappa antagonist with less opioid-like effects and thus less adverse effects, Nunes told attendees. It sticks really tightly to the receptor, he explained, so it is long-acting and it is safer, with less risk of respiratory depression. Perhaps more importantly, it is much more convenient than methadone, as it can be prescribed by any physician who gets an X-waiver from SAMHSA. A previously required course is no longer needed for physicians, he said, but it is still required for nurse practitioners and physician assistants to prescribe. Buprenorphine is available in a sublingual dose as tablets or films, with dose ranging from 8 to 32 mg/day. An extended release injection is also available, he said, with dose at 300 mg or 100 mg which has a 28 day duration.

Like methadone, there are some limitations to this treatment, Nunes noted. Retention is less favorable with buprenorphine, with rates close to 40% to 50% over 6 months. Ironically, he said because there is less tolerance and less withdrawal, it is easier for patients to walk away from treatment, so clinicians have to work harder to motivate patients to stay with the program. Similarly, patients need to abstain from opioids long enough to manifest withdrawal symptoms before initiating treatment. At that time, he explained a test dose is used. There are microdosing strategies available if you want to start sooner, Nunes noted.

Overall, both methadone and buprenorphine are effective strategies, Nunes said. “There's going to be some ongoing drug use, and that's grist for the mill. But these medicines are very powerful at reducing and often eliminating the opioid use,” he told attendees. Younger age and severity of OUD are associated with worse adherence and therefore worse outcomes, he added. “Staying on methadone or buprenorphine is what predicts long term abstinence severity.”

Naltrexone, another high affinity opioid receptor antagonist, binds to the opioid receptors very tightly, and actually blocks the effects of other opioids, Nunes explained. Further good news is limited adverse effects; he reported that patients generally feel well on naltrexone. However, patients must be fully detoxified before initiating treatment, he said, which present a real barrier, especially for more severe patients. This results in the need to hospitalize patients, which is a limitation. Another option, Nunes explained, was to induce with ascending doses of naltrexone and clonidine and other nonopioid medications that attenuate withdrawal. Once initiation is successful, natrexone’s efficacy is comparable with buprenorphine. Nunes noted naltrexone should be accompanied by strong motivational counseling.

“Pay close attention to overdose risk when choosing naltrexone,” Nunes cautioned attendees,“especially if the patient has a particularly high risk of overdose, or a history of overdoses. When you take up high doses of opioids, I would be inclined to go with methadone.”

Nunes reminded attendees to consider psychosocial treatment and counselling. Not only is psychosocial treatment a requirement for methadone, but it also provides what may be much-needed structure. Inpatient and residential treatment may be especially helpful because it removes the patient from toxic environments as well as access to drugs. Plus, it also provides an opportunity to initiate the aforementioned medications.

Ultimately, Nunes told attendees treating OUDs is not unlike leveraging other psychopharmacological treatments. He reminded clinicians to keep it simple and remember the 3 As:

This article originally appeared on Psychiatric Times.

Articles

Opioid use disorder—how can we battle the epidemic of overdoses?

Examining OUD Treatment Strategies

Although psychotherapy is first-line treatment for posttraumatic stress disorder (PTSD), there are a few psychopharmacological options that may be useful, Mark B. Hamner, MD, told attendees at the 

Antidepressants are currently considered the mainstay medication for PTSD, Hamner said, and sertraline and paroxetine are the 2 selective serotonin reuptake inhibitors approved by the FDA for this indication. Hamner is professor of psychiatry and behavioral sciences at the Medical University of South Carolina as well as the director of psychopharmacology research and medical director of the PTSD Clinical Team in the Department of Veterans Affairs Medical Center in Charleston.

Venlafaxine, a serotonin and noradrenaline reuptake inhibitor, has also shown efficacy in clinical trials, he reported. Specifically, in a 6-month placebo-controlled randomized trial (RCT) (N=329), venlafaxine (mean dose = 221.5 mg/day) has been shown to be helpful in reducing re-experiencing and avoidance/numbing; however, it did not seem to address hyperarousal. He also discussed a 12-week RCT of venlafaxine, placebo

 In addition to improvement as measured by Clinician-Administered PTSD Scale (CAPS), investigators found remission in 30.2% of patients on venlafaxine versus 24.3% on sertraline and 19.6% on placebo.

Hamner said other classes of the medications have been discussed for addressing PTSD. Although benzodiazepines have been considered, he noted they are not indicated per current treatment guidelines. Mixed data is the name of the game for other classes, according to Hamner. For antipsychotics, for instance, one VA cooperative study of risperidone was negative, while another RCT of quetiapine was positive, he said.

 A current study of hypnotics is in progress, he added.

Antiadrenergic agents have also seen mixed data. The α1-adrenoreceptor antagonist prazosin has also been of interest, Hamner reported, with some efficacy in alleviating nightmares associated with PTSD in military veterans. However, Hamner also reported results of a large RCT VA cooperative study (N=304, 13 sties) in which participants were randomly assigned to receive prazosin or placebo for 26 weeks.

 Investigators failed to find a significant differences between the prazosin group and the placebo group in the mean change from baseline in the CAPS item B2 score, in the mean change in Pittsburgh Sleep Quality Index (PSQI) score, or in the Clinical Global Impression of Change (CGIC) score, he said.

“More studies are needed of medications alone or in combination,” Hamner concluded. He further reminded attendees, “Psychotherapy is an essential, first line treatment for PTSD; evidence-based psychotherapies that are trauma-focused have larger treatment effect sizes than antidepressant medications.”

1. Davidson J, Baldwin D, Stein DJ, et al. Treatment of posttraumatic stress disorder with venlafaxine extended release: a 6-month randomized controlled trial. 

2. Davidson J, Rothbaum BO, Tucker P, Asnis G, Benattia I, Musgnung JJ. Venlafaxine extended release in posttraumatic stress disorder: a sertraline- and placebo-controlled study [published correction appears in J Clin Psychopharmacol. 2006 Oct;26(5):473. Dosage error in article text]. 

3. VA/DoD Clinical Practice Guidelines: Management of Posttraumatic Stress Disorder and Acute Stress Reaction 2017. Accessed August 18, 2022. 

https://www.healthquality.va.gov/guidelines/MH/ptsd/

4. Raskind MA, Peskind ER, Chow B, et al. Trial of Prazosin for Post-Traumatic Stress Disorder in Military Veterans. 

Despite mixed data, there are some psychopharmacological options for treating PTSD.

Available Psychopharmacology for PTSD

“The opioid epidemic has raged on despite the development of evidence-based treatment for opioid use disorders,” explained Kimberly Hu, MD, at the 

2022 American Psychiatric Association Annual Meeting

. “About 70% of the nearly 71,000 drug overdose deaths in 8 states involved opioids. That's a huge, staggering number.”

Recognizing the role that insufficient access to medications plays in this epidemic, Hu and colleagues at the 

Ohio State University Wexner Medical Center

, designed and implemented an opioid use disorder (OUD) curriculum for third-year medical students. The students (n=405) were provided with in-person or virtual buprenorphine waiver training and in-person clinical experiences between January 2019 and April 2021. Pre- and post-intervention tests,along with self-reported clinical management surveys,assessedthe students’ability to screen patients with OUD and manage acute and chronic pain. Paired sample t-tests were estimated to assess improvement in knowledge and approach to clinical management principles.

Hu, a resident at the Ohio State University Wexner Medical Center, and colleagues found a statistically significant increase in both their knowledge as seen in the pre- and post-test scores as well as their self-reported understanding of management principles. A follow-up study at the end of the year also provided positive feedback. Hu reported: “83% [of the participants] said that they felt they knew how to manage acute pain, about 62% felt that they knew how to manage chronic pain, and about 77% said that they knew how to screen the patient for opioid use disorder.” This is important no matter which specialty the students pursue, as these students will be able to “link patients with resources early and make sure that there aren’t patients slipping through the cracks,” Hu explained.

She noted that educating third-year medical students gives them—and their future patients—an advantage. “They're a little over halfway through medical school, and then they'll go into residency in a number of different specialties. So giving them this knowledge early helps them to incorporate [the information and skills] as they continue their training.”

Hu noted that the educational program is ongoing and supported by the 

Substance Abuse and Mental Health Services Administration

. Her study co-authors included Julie Niedermier, MD; Amanda Start, PhD;Casia Horseman, MD; and Julie Teater, MD.

“If we can educate the next generation physicians and increase access to care, this is one way we can combat the opioid crisis,” Hu concluded.

New research presented at the 2022 American Psychiatric Association Annual Meeting evaluated program to help address the opioid epidemic.

Program Offers New Way to Fight Against Opioid Use Disorders

Steven Pliszka, MD, chair of The American Professional Society of ADHD (attention-deficit/hyperactivity disorder) and Related Disorders (APSARD) annual program committee, joined Jeffrey Newcorn, MD, APSARD president, in welcoming attendees to their virtual 2022 Annual Meeting, noting the conference was putting attendees “on the ground floor of exciting developments in the field.” Pliszka said the conference would highlight issues in genetics, neuroimaging, psychological variables, and environmental variables. “I think we’re moving to really integrating all these different aspects so we can think much more broadly about where ADHD fits into psychopathology in general,” he added. “And it will get us thinking more about new ways to intervene and to treat people.”

The 4-day meeting was held January 13 to 16, 2022. In-depth coverage can be found online at 

www.psychiatrictimes.com/conferences/apsard

As separate groups, college students with ADHD and college students who identify as a sexuality and gender minority (SGM) have increased risk for functional impairments, psychiatric comorbidities, and risky behaviors.

 According to Destiny Orantes, PhD, from Syracuse University, and colleagues, previous research had not considered if these outcomes are further increased in SGM students who have ADHD. Orantes shared findings from their recent research in a poster presentation.

The study assessed functional impairments, psychiatric comorbidities, and engagement in risky behaviors in 4 groups: (1) SGM students with ADHD, (2) SGM students without ADHD, (3) non-SGM students with ADHD, and (4) non-SGM students without ADHD. Data from the American College Health Association-National College Health Assessment 2019-2021 III were used. The researchers also sought to examine the prevalence of ADHD in SGM college students.

They found ADHD prevalence increased in SGM populations: 15% compared with 8% in non-SGM individuals. Additionally, SGM students with ADHD reported the highest levels of functional impairments, substance use, and psychiatric comorbidities.

The research results suggest, Orantes said, that future studies should consider the underlying reasons for SGM students having high rates of ADHD, and how best to reduce these negative outcomes. Specifically, treatment plans should take into account the separate difficulties students face from their ADHD diagnosis and their SGM identities, as well as how best to target the risky behaviors and comorbidities.

1. Auerbach RP, Mortier P, Bruffaerts R, et al; WHO WMH-ICS Collaborators. 

Mental disorder comorbidity and suicidal thoughts and behaviors in the World Health Organization World Mental Health Surveys International College Student initiative.

“The [APSARD] task force was launched in relation to the amazing societal changes that are happening...in association with the awareness that equity means creating fair, equitable opportunities for all of us,” Martin Katzman, MD, FRCP(C), APSARD Health Equity Task Force chair, told attendees. “We’re hoping to build connections within the APSARD community, to enhance diversity of the organization, and to reach out across boundaries as well as to partner within all of our communities to raise awareness and to increase opportunities for treatment for populations that may not get the same access to treatment.”

Amy Glasofer, DPN, RN, nurse scientist with Virtua, shared an analysis of 41 studies relating to ADHD, race, ethnicity, and disparity; Catherine Dingley, PhD, RN, FNP, FAAN, associate professor in the Nursing Department of the University of Las Vegas, Nevada, also worked on the project.

They found 66.7% of studies noted Black children were significantly less likely than white children to be diagnosed with ADHD, and 65% of Black children with ADHD were significantly less likely than white children to receive medication. In addition, compared to white children, she noted Black children were more likely to discontinue medication and more likely to experience gaps in treatment; less likely to receive an α2 agonist alone; and more likely to receive significantly lower doses of stimulant. The findings suggest that, although diagnostic disparities have been reduced over time, treatment disparities still exist for minority children with ADHD.

1. Katzman M, Higgins N, Glasofer A, et al. Introducing the APSARD Health Equity Task Force. Presented at 2022 APSARD Conference. January 14, 2022.

“ADHD in preschool children is a valid and reliable condition,” reported Ann Childress, MD, president of the Center for Psychiatry and Behavioral Medicine, Inc, in Las Vegas, Nevada.

According to the 2014 National Survey of Diagnosis and Treatment of ADHD and Tourette’s, 30% of children diagnosed with ADHD receive their diagnosis before age 6; 16% receive the diagnosis at 4 years or younger.

 Impairment can be great for these patients, Childress said. For example, an epidemiological review of preschoolers diagnosed with ADHD found more than 40% had been suspended from school or daycare and about 16% had been expelled.

 In comparison, less than 1% of young children without ADHD were suspended.

The actions of young children with ADHD pose safety risks to themselves due the higher levels of hyperactive impulsivity, she said. “These are kids who are running out in traffic. They’re jumping off of things and breaking bones. They’re doing things that are dangerous, and they really need treatment for their safety,” she explained.

Childress reviewed efficacy and safety data for a number of common medications, noting some small behavior improvements as a result of the study medications. However, medications were associated with adverse events, including insomnia, gastrointestinal issues, irritability, sedation, and repetitive behaviors and thoughts. She also noted not all of these medications have been approved for the youngest patients.

Fortunately, there is good evidence for the efficacy of nonpharmacological interventions for preschoolers with ADHD, Childress reported. The New Forest Therapy, Helping the Noncompliant Child, and the Incredible Years series were among the programs she noted that have demonstrated efficacy. Furthermore, she spoke highly of parent training models that foster the implementation of positive reinforcement to promote positive behaviors; ignoring low-level provocative behaviors; and responding in a clear, consistent, and safe manner to unacceptable behaviors.

“You have to carefully consider both developmental aspects and comorbidity when you’re establishing a diagnosis, and the medication efficacy and tolerability profile may not look as good in the little guys as it does in older children,” she concluded.

1. Visser SN, Zablotsky B, Holbrook JR, et al. 

Diagnostic experiences of children with attention-deficit/hyperactivity disorder.

The epidemiology and diagnostic issues in preschool attention-deficit/hyperactivity disorder: a review.

Catch up on all the latest in ADHD from the virtual APSARD 2022 Annual Meeting. 