Welcome, everyone. You are going to join us for our updated version of the module on Managing Common Psychiatric Conditions in Primary Care. I don't have any disclosures for this presentation. Our audience today are health care professionals who wish to use evidence-based practices for the prevention and treatment of opiate use disorder problems, particularly the use of medications and the general prevention and treatment of substance use disorders. Our educational objectives are the following. We want to identify the most common psychiatric disorders seen in individuals with substance use disorders, discuss the impact of co-occurring psychiatric conditions on the course of substance use disorders, describe procedures for screening individuals with substance use disorders for common psychiatric disorders, and finally explain the management of substance use disorders and co-occurring psychiatric disorders in the primary care setting. We'll begin with a case presentation, then we're going to cover some epidemiology. We'll talk a while about suicide, talk about diagnosing and identifying substance-induced versus independent psychiatric disorders, how we screen patients for common psychiatric disorders, and then we'll briefly go through the management of depression, anxiety-related disorders, bipolar disorder, ADHD, and insomnia. And finally, we'll end up with some general recommendations on patient care management. Let's begin with our case. Anna is a 25-year-old Army veteran who overdosed on heroin. She returned from Afghanistan 20 months ago. Her boyfriend brought her to the emergency room after she overdosed on heroin. She was breathing but unconscious. I'd like you to think about how you would manage her before you have any other questions. We'll come back to this case as we go through the presentation. Anna was successfully revived after multiple doses of intranasal naloxone. History revealed opiate treatment for combat injuries. She is now sniffing heroin on a daily basis. Her boyfriend thinks she may have gotten some heroin laced with fentanyl. My questions are how likely is this a suicide attempt and what diagnosis should be considered and what's your initial treatment plan? Let's begin with some general consideration of the epidemiology of alcohol and drug use disorders and co-occurring psychiatric problems. We begin with the most critical issue, and that is suicide. Completed suicides are higher among patients with substance use disorders. For people with heavy alcohol use, it's more than 10 times what you would see in the normal population. If the individual actually has an alcohol use disorder, it's more than 10 times the general population. And if they have an opioid use disorder, the suicide risk rate increases to 14 times that seen in the general population. About 65% of the almost 190,000 calls to poison control centers for any prescription opioid misuse documented as suicide intent. So it's very common. 75% of prescription opioid deaths were suicide. 85% of prescription opioid deaths in individuals over 60 were suicides. And 93,000 overdose deaths in 2020 were reported. That number has now gone to over 100,000 for the current year. So what are our treatment issues with Anna? First of all, we want to begin with a suicide assessment. We want to consider her motivation for treatment. We would like to know her prior substance use history, her medical history, and in particular, her psychiatric history. Does she have any ongoing pain requirements? Will that affect her treatment? Is she suffering from a depression? Now the most common co-occurring psychiatric disorders in substance use disorder patients begin with alcohol use disorder or another drug disorder. Nicotine use disorder in this population is very common. Bipolar I disorder is very frequent. Mood disorders are frequent. We see panic disorder with agoraphobia. And lastly, we may see antisocial personality disorder. These are the most common conditions that you will encounter. This information comes from the NESARC study. And here we're looking at the odds ratio for alcohol use disorder patients to have other psychiatric disorders. So these are all individuals with alcohol use disorder. The odds ratio in the latest 12-month period for these individuals is very high. Most common is drug dependence with an odds ratio of order of 15. We also see nicotine dependence. Mood disorder is more than twice what you would see in the normal population. Bipolar I disorder almost three times. Anxiety disorder 1.9. Panic disorder and panic with and without agoraphobia are really quite common. Generalized anxiety disorder or 2.1. Antisocial personality disorder is 2.9. If we now look at the slide for individuals who have drug use disorders and ask the question, what other psychiatric disorders will we see in that population? First of all, alcohol use disorder is very common. Alcohol dependence is as high as 9.7 odds ratio. Nicotine dependence, very common. Mood disorder, 3.5. Bipolar disorder, 5.1. Any anxiety disorder, 2.7. Panic with agoraphobia, 5.8. Generalized anxiety disorder, 4.5. And antisocial personality disorder, 6.4. All in all, there are a very large number of co-occurring psychiatric disorders in the group of patients with a drug use disorder. So what is the lifetime prevalence of these problems in individuals with bipolar I disorder? Any alcohol use disorder is 58%. Any drug use disorder is 37.5%. And nicotine use disorder is 44.4%. And it's interesting that there's no difference noted between men and women in these percentages. What about post-traumatic stress disorder 34% of PTSD occurs with patients with substance use disorders. 5 to 12 times more PTSD occurs in women who misuse drugs. Suicide attempts occur in 20% of patients with PTSD and the risk doubles if PTSD is combined with the substance use disorder. Among U.S. Iraq veterans, 50% binge the use of alcohol and tobacco. We need to begin our assessment with the critical question of whether this was a suicide or homicide attempt. We want to screen the patient for suicidality. We want to look for current suicidal ideation and a specific plan. We want to check for past history, previous suicide attempts or plans. We want to check their access for weapons or other means of committing suicide. I recommend using the Columbia Suicide Screening Rating Scale and I'll go to that in just a second. We also want to screen for homicidality. Is there an identified victim and a specific plan or intent? Does the individual have a history of violence? Do they have access to weapons or other means of inflicting harm? We want to obtain immediate assistance if the answer to any of these questions are positive. It's important when you're assessing patients to come across positive responses for suicidality and homicidality that you do not leave the patients alone and that they are kept with other treating staff until it is clear that they are in a safe environment. Now go to the Columbia Suicide Severity Screening Scale. This is a simple, easy test to use. If you get a yes to the first two answers, have you ever wished you were dead or wished you would go to sleep and not wake up or have you had any thoughts about killing yourself? If someone answers yes to those first two questions, then they should be referred for mental health care. If they answer yes to the next three to four questions, they are at very high and immediate risk. If they're thinking about things and how they do it, if they have a plan, if they intend to act on the plan, if they ever started to work out the details of how they're going to commit suicide, if they've ever done anything or started to do anything or prepared to do anything to end their life. In all of these situations, this should be considered a need for immediate help and the patient should be referred to an emergency room or to immediate attention from skilled mental health professionals. So what are the principles of assessment? How do we care for individuals who are intoxicated? We want to begin with screening for suicidality and homicidality. We want to inquire about the interest in inpatient medication withdrawal treatment. Are they on a drug or alcohol that needs immediate withdrawal treatment? You have to review their vital signs and attend to any other acute medical needs and hospitalize if necessary. We do not recommend a probing psychiatric evaluation of any intoxicated patient, even if only mildly intoxicated. It can be risky to explore some of these issues in individuals who are disinhibited. You should reschedule a more in-depth evaluation as soon as the patient is sober. You want to explain to the patient that sobriety is important to complete a successful psychiatric assessment. We now come to the question of how do we understand any psychiatric symptoms that are present. Is this a set of symptoms induced by their substance use or are these independent psychiatric disorders that simply are occurring in an individual who also uses substances or has substance use disorders? We want to screen for common psychiatric disorders and during the talk we'll get to the management of some of the disorders that are most frequent. So how do we establish the diagnosis of an independent psychiatric disorder? First of all, do not attempt to confirm the psychiatric diagnosis while the patient is intoxicated or within two to three weeks of substance use or withdrawal. The patient must be sober during the evaluation. You should verify their drug-free state with laboratory tests and only assess when their psychiatric status is sober. You want to obtain a careful longitudinal history tracking both substance use and psychiatric systems. Track parallel symptom courses. Assess to distinguish independent disease from substance-induced disorder. Confirm their history with relatives. Relatives may have a perspective on the patient's symptoms that the patient does not see. You want to also review the family history for psychiatric disorders. Most of the conditions that we are concerned about are those of a family member or their family suffering from this condition. So how do we clarify the diagnosis? How do we identify substance-induced psychiatric disorders? According to DSM-5, these occur within 30 days of intoxication or withdrawal or occur only when the patient is using the substance. The symptoms are associated with the substance. That is, the substance is known to cause these complaints. These are psychotic disorders, mood disorders, anxiety disorders, or personality disorders. So there's a wide range of symptomatology that can be induced by drugs. Let's go back to Anna. Her initial diagnosis is an opioid use disorder. We also see that she has a post-traumatic stress disorder. Our question here, is this an independent disorder or was this induced by her substance use? Is this combat-related? Is this a reaction to a single episode? Or is she experiencing complex PTSD that is related to multiple traumas or perhaps early childhood traumas? And finally, she is diagnosed with a major depressive disorder. And here again, we want to understand, is this an independent disorder or is this a reaction to a single episode? We need to reassess her more carefully after she has achieved sobriety. So what about substance-induced psychiatric disorders? Substance intoxication and withdrawal can mimic almost any psychiatric disorder. Stimulants, cannabinoids, and leucogens can mimic mania and schizophrenia. Alcohol, opioids, sedative-hypnotic withdrawal We try to clarify the diagnosis. If we are dealing with an independent psychiatric disorder, we would expect a history that may antedate their drug use. We notice that the symptoms don't diminish post-withdrawal. However, we must note that in situations where a psychosis has been precipitated by methamphetamine abuse, the psychosis may be quite withdrawn and may not diminish very probably after they stop using. Symptoms continue during extended periods of sobriety. If it's an independent psychiatric disorder, we would expect that the patient has been sober for over one month yet is still experiencing symptoms. And finally, it would be much more likely to see there is a family history of a similar psychiatric disorder. All of these symptoms suggest that this disorder is independent, that it has been in the patient perhaps even before they started using substances, and that it was not caused by the substance. Going back to Anna, a follow-up interview reveals that she has no suicidal ideation. She's sad. She's had increased social isolation for the last three months. She finds that she does not want to leave her apartment unless she takes extra opioids She has insomnia. She has frequent nightmares. She's jumpy. She panics in reaction to loud noises. Is there a particular diagnosis that that is suggestive of? Now let's talk about more details about screening for common psychiatric disorders. What are things that you can do within your primary care practice The first two slides I'm going to show here are simple screening devices, in this case depressive disorders and the second slide by anxiety disorders. These can be a single sheet that you can give the patient. They can fill it out in the waiting room. It's scored very easily, and it permits you to both identify the disorder and also track changes in this disorder These depressive symptoms are very common among substance users. The PHQ-9 is a free, widely used screening test and the patient can complete it. Scores under 10 do not have a major predictive value, but scores over 10 should be referred for more detailed screening to establish a diagnosis. And this is a GAD-7, the screening for anxiety disorders. Again, simple screen, widely used. Any score that's greater than 10 suggests a moderate to severe anxiety disorder. But screening a positive on this screener does not make a diagnosis. The patient still need to be evaluated against the diagnostic criteria for any specific anxiety disorder diagnosis. What about panic disorder? Panic disorders are intense surges of fear or discomfort. They peak very rapidly. They come on quite quickly. They may dissipate within 15 or 20 minutes. They often have more than four panic symptoms. There may be fear, dizziness, trouble breathing, sweating, pounding heart, trembling. A whole variety of symptoms can be present. A number of drugs can cause a panic attack, stimulants particularly, but alcohol and opiate withdrawal can also cause panic attacks. And you may eventually develop a panic disorder, particularly if there's been chronic use of these substances. You also may want to screen for obsessive compulsive disorders. Obsessions are persistent thoughts, images, or urges. Compulsions are repetitive behaviors such as hand washing or mental acts or rituals. For DSM-5 OCD diagnosis, the symptoms must be either impairing or distressing, and they must consume greater than an hour a day of the patient's time. So what are the clinical implications of a co-occurring disorder? Substance-induced psychiatric disorders, these symptoms typically clear with sobriety. They've been caused by the drug use, and in most cases, once the individual stops active drug use, the symptoms will clear. In some situation, post-acute psychotic symptoms may persist, particularly with chronic methamphetamine use. But in general, additional psychiatric treatment is not usually required. The primary treatment can be on the substance use disorder, and once the patient achieves sobriety, you would expect that the psychiatric symptoms would clear. On the other hand, if the patient has an independent psychiatric disorder, they're going to require specific treatment. If this condition has preexisted, their substance use occurs even when they have periods of sobriety, then they need to have treatment. The treatment should be integrated with their substance use treatment, not sequential. So you need to find a program that has the capability of managing both their substance use disorder and their psychiatric disorder. Both the substance use disorder and the symptoms of the co-occurring disorder are going to be more severe. The fact that they occur together really intensifies both sets of symptoms. They lead to higher levels of disability, and treatment can be more complicated than managing either set of symptoms alone. We're now going to focus on specific psychiatric disorders and talk about ways that they can be managed in the primary care setting. We'll begin with anxiety disorders, including PTSD, then talk about depression, bipolar disorder, ADHD, and insomnia. A few general principles before we start. This has to do with your attitudes and your approach to treatment irregardless of the condition. First of all, you need to evaluate the patient when they're not intoxicated. You need to integrate their psychiatric treatment with their substance abuse treatment. Sobriety is the first priority. What that means is that if they are not able to achieve stable sobriety, it's very unlikely that you will effectively manage their psychiatric condition. So I think your first priority is to make sure that you maintain sobriety, and then I think you will see a more positive response to the psychiatric treatment. Medication treatment for opioid use disorder, alcohol use disorder, and tobacco use disorder can be used in most patients experiencing these problems. However, when you approach the patient, I would try to begin with psychotherapy interventions first as long as there is evidence-based treatment available. I would add to that psychopharmacology if they did not respond effectively to psychotherapy. So first try to apply psychotherapy, see if that will be effective. If not, you want to add the psychopharmacology. You want to begin with non-scheduled medications. Avoid using any psychiatric medications that are scheduled. You want to also engage the patient in community support groups such as AA, NA, or SMART Recovery. But it's important that you understand the specific group that the patient attends, and you need to find community support groups that are comfortable with medication. You will find that there are some groups that say it's fine if the patient is taking medication as prescribed. There are other groups that may communicate a message that the patient is not really in recovery unless they stop all their medications, and this, of course, will cause problems with effective treatment for psychiatric conditions. So what's our initial stabilization? First of all, we may need to apply medication withdrawal treatment, particularly with alcohol use disorder or a benzodiazepine use disorder. For opioid use disorder, initial stabilization usually will involve treatment with methadone or buprenorphine. If you're going to start extended release naltrexone, medication withdrawal treatment is often required first because they may need to go through seven days drug-free before you can begin naltrexone. And recognize that no other treatment may be possible for these patients until their alcohol opiate use is stabilized. Going back to our case of Anna, after initial stabilization on buprenorphine naloxone, her depressive symptoms begin to clear. This suggests that her depression was substance-induced and was not a separate psychiatric condition. Her clinician decides to focus her treatment on her opioid use disorder, but also clearly recognizes her combat-related PTSD is a serious problem and needs to be treated. Anna agrees to participate in an intensive outpatient dual diagnosis program for women veterans. I think this is a particularly good referral because it provides both the specific treatment for PTSD and substance use, but also puts her in a group setting where she will have support from her peers. So how do we begin with managing post-traumatic stress disorder? I would first try psychotherapy. Once the patient is stable, I would consider this as the first option, and particularly if they have less severe depression or anxiety complaints. I would begin with either prolonged exposure therapy, cognitive processing therapy, or CBT that is trauma-focused. If the patient does not respond to the psychotherapy interventions, then I would consider addings, pharmacology. Sertraline, paroxetine, fluoxetine, and venlafaxine are all proven effective in this population. Well, let's talk about some of this in more detail. What is the role of cognitive behavior therapy? CBT is well-established as an effective evidence-based therapy for substance use disorders, depression, anxiety, PTSD, and chronic pain. So it has a wide variety of applications and may be useful for many co-occurring conditions together. CBT typically involves skill acquisition. Patients are taught relaxation therapy. They may be taught cognitive restructuring. They are taught to be more effective communicators, and they may be taught various tools for stress management. This is followed by skill consolidation and rehearsal. The expectation is the patient will become comfortable and able to use the skills they have learned almost automatically, and successfully. You want to give them training to generalize their new skills. You want to help maintain these behavioral changes, and you want to particularly teach them strategies that will help them avoid relapses to alcohol or other substance use. In managing co-occurring PTSD, if you're going to use medications, I would recommend the following, which have all got good evidence bases. First of all, SSRIs or Ventilifaxon Extended Release have been demonstrated to be effective. There are a number of specialized therapies that are useful. Exposure therapy is a type of CBT. It teaches the patient to gradually focus on any traumatic memories or feelings and situations. And they may be asked to explore in great detail what the details and the history are of these events. Cognitive processing therapy is a type of exposure therapy, but specifically involves written reconstructions of the traumatic event. The patient is asked to write their story, and they may be asked to write it in great detail over an extended period of time. Cognitive behavioral therapy was developed by Lisa Najovitz and can be useful for patients with combined PTSD and substance use disorders. And finally, eye movement desensitization and reprocessing. This is a specialized form of psychotherapy. I would suggest the Shapiro reference, but we will not talk about it in more detail here. What about medications for nightmares? Interestingly enough, the drug Prazosin has been discovered to be quite effective for PTSD-related nightmares. The patient may need to be titrated to an adequate dose, but you'll find that in many cases this will resolve the problem with their nightmares. I would clearly avoid the use of benzodiazepines or marijuana. Patients often ask for these drugs or will use them on their own. And there's no evidence at this point that these drugs are effective for PTSD treatment. I'm going to talk now about managing co-occurring psychiatric disorders, specifically pharmacotherapy. Pharmacotherapy may be the initial option for most patients. Generally, medication should not be started until the patient is sober. Treatment can be started earlier in patients with more severe symptoms. People with psychosis or severe depressions, you may not be able to wait for their sobriety to be total or be stable before you want to start treating the depression. Standard pharmacotherapy for psychiatric disorders will work in most patients. Most treatment options will work. We're not limited to a smaller number of specific medications. However, we need to avoid medications that have abuse liability, and that includes most scheduled medications. We have to have particular caution when prescribing benzodiazepines and gabapentin. If you've begun with pharmacotherapy with patients, if the pharmacotherapy alone has not been adequate to control their symptoms, you want to add medications, but be careful about adding benzodiazepines or gabapentin. So, focusing on this in more detail, you want to begin with non-scheduled medications. The SSRIs are a good choice for treating both depression and anxiety. You need to make sure the patient is receiving an adequate dose and they should be getting it for six to eight weeks. If there's no response to SSRIs, I would consider SNRIs or dual action agents. CBT will improve the response of these medications. Benzodiazepines have no role as the primary treatment for depression, anxiety, or PTSD in patients with a substance use disorder. You should never begin with benzodiazepines for treatment. However, they can be used with caution in some anxiety disorders if the patient has not responded to CBT and other standard antidepressant medications, and if they have no individual history of the misuse of benzodiazepines. As long as you are careful about prescribing the medications and monitoring the patient clearly, I think you can use it with caution. Now, what about depressive disorders? First of all, you want to confirm the diagnosis. Wait two to three weeks for withdrawal symptoms to clear. Frequently, you will obtain a positive Hamlin history for a similar depressive disorder. You will get a history that symptoms often antedated the drug or alcohol use. You want to monitor these patients carefully for suicidal ideation, changes in mood, appetite, or sleep patterns that occur during treatment. You want to consider pharmacotherapy if the patient refuses or has not responded to psychotherapy alone. So again, if possible, begin with psychotherapy, then add the pharmacotherapy, and monitor the patient's progress. You're going to find that most standard pharmacotherapies for depression are effective in patients with substance use disorders. The majority of well-done clinical trials have been with SSRIs in individuals with alcohol use disorders. There is not a robust research database for the treatment of co-occurring disorders in other groups of patients beyond those with alcohol use disorder. There are relatively few trials on people with opioid use and stimulant use disorder. There are very few trials with other classes of antidepressants. Most trials show improvement in the depression, but the results on the substance use disorder symptoms are mixed, and I'll come back to this in a second. So you can often expect that you will see an improvement in the depression, but it may not have any direct effect on their substance use. But in general, you can expect that SSRIs are considered the first-line medications for these dual-diagnosis patients. Now I've listed here a total of eight trials that have been published. These are all double-blind studies by respected researchers. As you can see from the second column here, there's a list of different medications that were used in the trials. The third column shows how the depression symptoms responded in the trial. The fourth column shows how their drinking symptoms responded in the trial. You can see here that in six out of the eight trials, the depressive symptoms improved as compared to placebo. On the other hand, in the drinking column, you find that only three out of the eight trials showed an improvement in the drinking. And in the other trials, the placebo and medication had similar effects. So we did not see a robust response for treatment effect in this set of trials analyzed by Helen Patinati. I have presented some common antidepressant medications here just so that you can see some of the characteristics of these drugs. They are all effective for treating depression. None of the drugs listed here are particularly effective for managing sleep disorders. Few of them work for generalized anxiety disorder, but not all of them. However, you will see that sexual dysfunction is very common except in patients treated with bupropion and weight gain is very problematic except in patients treated by bupropion. This gives you a general idea of some of the side effects of these medications. This is another trial that was done by Helen Patinati. This was a very interesting trial where she combined the use of SSRIs and naltrexone in treating alcohol use disorder. This was a double-blind placebo-controlled trial of 170 depressed patients who all had alcohol use disorder. She used sertraline up to 200 milligrams a day and combined it with naltrexone up to 100 milligrams a day. All of the patients received psychotherapy, that is CBT. The patients that received the combination of both drugs achieved more abstinence and had a lower likelihood of being depressed compared to those who received placebo or either drug alone. This showed a benefit of the combined medication of naltrexone and an SSRI, but Dr. Patinati felt when this was published that the data was rather intriguing, but that it needed to be repeated in more trials. We'll now spend a few moments talking about treating co-occurring anxiety disorders. The first thing you need to do is wait often four to six weeks for withdrawal symptoms to clear or for the patient to stabilize on medications before you approach the treatment of the anxiety disorder. You're going to see a positive family history with people with co-occurring independent anxiety disorders, and you should expect to see that these anxiety disorders may have started before they began their alcohol or drug use. In these patients, I would always begin with behavioral therapies. I would try them for several weeks, usually focusing on CBT. If I saw no response after three weeks, then I would consider adding pharmacotherapy. So what are the evidence-based pharmacotherapies for co-occurring anxiety disorders and substance use? A systematic review of randomized controlled trials, including a Cochrane database, reported on data from trials demonstrating more than 50% reduction in anxiety scores in generalized anxiety disorder. Drugs that showed the most promise were fluoxetine and sertraline. There was a sub-analysis for medication for generalized anxiety disorders specifically used in the United Kingdom, and their preference and success was shown to duloxetine, escitalopram, and pregabalin. But again, this is the extent of the literature base, which is really not terribly robust in most of these situations. If we're looking at evidence-based treatment for co-occurring anxiety and substance use disorders, we know that there is little research on the topic. There was a comprehensive review of studies published by McHugh in 2015, showed that CBT is generally effective, but may be hard to find, and there may not be enough people trained to provide CBT for substance use disorders. Medication treatment had some benefits on anxiety, but the medication did not appear to have any significant benefit on the substance use disorder. Buspirone reduced anxiety and drinking in one trial, but there were not clear results in two other trials. However, it was noted that medication misuse was not seen with benzodiazepines. Naltrexone plus exposure therapy had better outcomes for PTSD, and in all trials, integrated treatments for substance use disorder and exposure therapy for anxiety had the best outcomes. Now, if we try to summarize some of this data, these are the most common medication recommendations and therapy interventions for these patients. For generalized anxiety disorder, it's SSRIs, duloxetine, or buspirone. For panic disorder, any of the antidepressant medications and behavioral therapy. For agoraphobia, again antidepressant medications and behavioral therapy. For social phobia, propranolol or clonidine. For OCD, SSRIs. And benzodiazepines are only recommended if the patient has failed to respond to medications with less abuse liability. Again, to review some of the comments and the research about the use of benzodiazepines, a meta-analysis revealed no advantage for antidepressants over benzodiazepines in the range of treating anxiety disorders. So in sort of unselected patients, that is individuals with not co-occurring disorders, benzodiazepines and benzodiazepines did about the same. If we have a comprehensive literature review demonstrating the efficacy of benzodiazepines for panic disorder, generalized anxiety disorder, agoraphobia, probable efficacy for social phobias and alcohol-induced anxiety disorders, there was little evidence in these studies that adding a benzodiazepines caused misuse or increased the relapse. So despite the anxiety about providing benzodiazepines for this patient, the literature does not support the level of anxiety that's present. That being said, it's well known that there is a subsection of these patients who have a primary benzodiazepine abuse disorder, and these individuals obviously should not be treated with benzodiazepines. You want to avoid the use whenever you see a primary sedative hypnotic use disorder. And deaths have also been reported in the combination of buprenorphine and benzodiazepines. So caution should be used when prescribing these medications to individuals who take buprenorphine or methanone or abuse opioids. We haven't mentioned bipolar disorder. There's some interesting patterns that have been observed in the relationship to bipolar disorder and substance use disorder, particularly alcohol use disorder, which is the thing that has been studied the most carefully. Drinking typically follows the onset of mania. You see mixed or dysphoric mania. You see rapid cycling. You see a greater incidence of severity and suicidality. But patients rarely relapse when they're depressed or euthymic. So the problem in terms of their substance use with alcohol mainly occurs during periods of mania. There is a suboptimal response to lithium, and patients often show a relapse in their substance use, or they may stabilize fairly quickly once their mood has become stabilized. If we're looking at other studies in pharmacotherapy, there are two randomized double-blind placebo-controlled trials, one in alcohol patients by Saloom and one in cocaine-dependent patients by Brady. There are six open-label, non-randomized trials that use a variety of different medications, and these were treating patients with alcohol, cocaine, opiate use problems, a wide variety in terms of the number of patients in the study, no consistency in the study, and the database is really not rich enough to provide any clear guidance on what to expect with most of these medications. There's one interesting trial by Saloom that showed double-blind placebo-controlled use in 59 patients who had bipolar disorder and co-occurring alcohol use disorder. Patients were given valproate plus treatment as usual versus placebo and treatment as usual. Treatment as usual in this study was lithium plus psychosocial treatment. So what we see here is people who got lithium psychosocial treatment and then a placebo added compared to a group of patients who got lithium psychosocial treatment and valproate. The results showed that the individuals who received valproate had a better outcome. They had less heavy drinking days. They had fewer any drinking days, and both groups showed fewer mood swings. So the response to the psychiatric disorder itself was similar in both groups, but responses to the alcohol use disorder was better in the group who received valproate. We'll now talk about treating ADHD in substance use disorder patients. This is a very common syndrome. As high as 35% to 45% of individuals with opioid use disorder also have histories of attention deficit disorder. Dr. Willis has recommended that treatment begin with two weeks of cognitive behavior therapy without any medication. If the symptoms begin to improve during that period, then you can just continue with the cognitive behavior therapy. If the symptoms don't improve during the first two weeks without medication, then you can consider adding the following medications. Atomoxetine, which has no abuse potential, would be the first drug to consider. Also consider bupropion or consider methylphenidate extended release or amphetamine-dextroamphetamine mixed salts. So this is the order of medications that I would recommend using as you approach patients with ADHD and substance use disorders. Now insomnia is a very common problem in all of these patients. Substance use tends to alter the cycles between non-REM and REM sleep. Insomnia may be prolonged during periods of sobriety, so patients may go many, many months sober but unable to sleep well. And these patients appear to have a higher risk for relapse if they are unable to get adequate sleep. Standard medications for insomnia have a high risk for relapse and misuse and may cause physiologic dependence. So what medications can we consider using in this population? The medications listed here have no misuse potential. Antidepressants such as trazodone or mirtazapine, melatonin agonists, sedating anticonvulsants such as gabapentin or tepiramate, and parazepam for the nightmares of PTSD. So these are all relatively safe medications that would be appropriate to use in patients with a substance use disorder history. I would caution you, however, that there are few individuals who misuse gabapentin. And if you notice that in your patient population, then I think you would have to avoid that drug with any patient with that propensity. And finally, I want to end up with some general treatment recommendations and summarize the discussion. First of all, evaluate the patient when they are substance-free. Do not attempt a thorough evaluation when they are still intoxicated or actively using substances. You want to make sure that the psychiatric treatment is integrated with their substance use disorder treatment, that it's all provided in the same site, ideally by the same set of treaters or at least by clinicians who are in frequent communication with each other. So you want to integrate the two aspects of their care. Sobriety is your first priority. And that is required because if the patient does not achieve sobriety, it's very unlikely that you will be effective in treating their psychiatric condition. So you can't forget a focus on sobriety if you attempt to achieve success in managing psychiatric conditions. Medications are very effective for alcohol use disorder and opiate use disorder where there is an approved database and evidence for success. Propharmacology should be used whenever indicated. You want to avoid scheduled medications if possible and only focus on medications where there is no possibility or at least less incidence of misuse. Psychotherapy interventions are applicable in most of these cases and are often very helpful. And you want to try to include self-help mutual support groups, but you want to be careful to find mutual support groups that support the use of pharmacotherapy treatment and not groups that will discourage the patient from complying with treatment. You also want to make sure that you check the state PDNP with any of the patients to know if they're getting medication beyond your treatment site. You want to use, in most cases, standard pharmacotherapy medications for psychiatric disorders. Choose drugs with no abuse liability. You want to provide adequate doses for adequate periods of time, but you don't have to go beyond the usual repertoire of psychiatric medications. You want to be cautious with any scheduled medication use. You want to begin very low doses with scheduled medications, go slowly, use non-refillable prescriptions, monitor the patient carefully, get frequent urines and frequent patient visits, and make sure that the patient does not develop a problem with the scheduled medication. This summarizes again the most common drugs in these conditions. In depression, SSRIs, venlafax, and duloxetine bupropion. For generalized anxiety disorder, SSRIs, duloxetine, buspirone, escitalopram. Panic disorder, SSRIs, social anxiety, paroxetine, PTSD, SSRIs, venlafax, and parazepine. And bipolar disorder, valproate. These are the drugs that have the strongest sets of research base, but I would just add the caution that we need more medication in all of these patients, and the research base is not deep in many of these situations. I've included two pages of references here that will give you more details on these various studies, and I also would mention information here about the PCSS mentor program, which is available at no charge to help you manage these patients, and that we are prepared to help you with education and patient management, and there's no cost for the mentoring services. And finally, the PCSS program is a shared activity of many medical specialty societies, and we wish to thank them very much for their support, and thank you for attending.

management

psychiatric conditions

primary care

substance use disorders

integration

sobriety

co-occurring conditions

treatment options