Friday, April 24, 2015

Experts Consider Best Options for Treatment, Prevention of Opioid Abuse


Opioid addiction experts from across the country were on Capitol Hill yesterday to provide expert testimony on the growing opioid epidemic in the United States and common misperceptions about factors driving this trend.

“Let me state clearly so as to leave no room for doubt,” said Rep. Tim Murphy (R-Pa., left), the chair of the U.S. House Energy and Commerce Subcommittee on Oversight and Investigations. “Our current strategies are failing, and I am not going to stop until we start moving in the direction of success defined not just as getting individuals off of street drugs and onto a government-approved opioid, but getting them to the point of drug-free living.”

The hearing included perspectives from leading experts in opioid addiction, who discussed the best options for treatment and prevention, including medication-assisted treatment and prescription drug–monitoring programs.

“I fully recognize the importance of medication-assisted treatment as a transition from street drugs and to prevent overdose from heroin,” Murphy remarked, “but relying on this as the one and only solution shouldn’t be the strategy.”

“Unlike many other disorders with high mortality rates, opioid use disorder is treatable, and a joint effort of health professionals, community advocates, and policymakers is urgently needed to reverse this tragic trend,” testified Adam Bisaga, M.D., a professor of psychiatry at Columbia University School of Medicine.

The scientific evidence base for medication-assisted treatment as part of an overall strategy to fight opioid addiction was highlighted by several members of the expert witness panel. "Opioid-addicted people need access to a broad range of treatments for opioid addiction,” said Laurence Westreich, M.D., president of the American Academy of Addiction Psychiatry. "This must include access to medication-assisted therapy and treatment for co-occurring psychiatric disorders.”

“We don’t have just an opioid misuse epidemic or an opioid overdose epidemic, we also have an opioid overprescribing epidemic,” explained Anna Lembke, M.D., an assistant professor of psychiatry and behavioral sciences at Stanford University Medical Center. “Contrary to what is commonly believed, doctors who treat addiction are not the source of the problem. The methadone that accounts for 40 percent of deaths by a single-drug opioid pain reliever is almost entirely in the form of pills prescribed for the treatment of pain, rather than coming from methadone maintenance clinics that treat individuals who are heroin dependent. Thus, it’s very important that we not only scrutinize physicians who prescribe opiates for the treatment of addiction, but also for those physicians who treat other common chronic illnesses such as pain.”

After the testimonies, Murphy told Psychiatric News that the hearing was an eye opener. “A lot of Americans who need treatment for opioid addiction are not getting the needed treatment. We need more providers to treat addiction and more regulation of the prescription practices that involve opiates," he said. "The subcommittee is definitely going to take the recommendations that were made today into consideration in hopes of bringing about change.”

To watch a recording of the hearing, click here. To read about more treatments for opioid addiction, see Psychiatric News articles "Psychiatrists Describe Trends in Medications to Treat Addiction" and "SAMHSA Releases Guidance for Initiating Medication Treatment for Opioid Overdose."



(Image: Vabren Watts/Psychiatric News)



Thursday, April 23, 2015

Scientists Identify Molecular Marker of Major Depression


Increased amounts of mitochondrial DNA (mtDNA) may serve as a molecular marker of major depression, according to a study published today in Current Biology.

Researchers at the University of Oxford obtained genome sequences from 5,864 women with recurrent major depression and 5,783 women without a history of major depression who were participants in the China, Oxford, and VCU Experimental Research on Genetic Epidemiology (CONVERGE) Project. The researchers also interviewed the study participants to assess lifetime adversities, including a history of childhood sexual abuse and other stressful life events.

Sequencing of the amount of mtDNA and mean telomere length—two components of the genome suspected to be associated with adverse life experiences—revealed a significant association between major depression and the amount of mtDNA. While additional analysis found that mtDNA amount and telomere length were associated with adverse life events, conditional regression analyses showed that the molecular changes were contingent on the presence of major depression.

“We could find no evidence that stressful life events act via changes in mtDNA or telomere length to increase the risk of major depression,” the study authors noted. Nonetheless, “these findings identify increased amounts of mtDNA as a molecular marker of major depression and have important implications for understanding how stress causes the disease,” the authors concluded.

"We have only a snapshot of the relationship between the molecular markers and depression," Jonathan Flint, a professor of molecular psychiatry at the University of Oxford and senior author on the paper, stated in a press release. "We want to know how they change over time—before, during, and after a depressive illness. That information will tell us much about their clinical utility."

To read more on biomarkers for depression, see the Psychiatric News article “Scientists Closer to Finding Tests for DepressionBiomarkers.”

(The Biochemist Artist/Shutterstock)

Wednesday, April 22, 2015

SAMHSA, NIAAA Develop New Guidance on Pharmacotherapy for Alcohol Use Disorders


In recognition of April as Alcohol Awareness Month, the Substance Abuse and Mental Health Services Administration (SAMHSA) and National Institute on Alcohol Abuse and Alcoholism (NIAAA) have released a new guidance on the use of medications to assist in the treatment of alcohol disorders.

Despite the high prevalence of alcohol use problems in the United States and the growing recognition that these problems are a legitimate medical condition, only a fraction of people participating in counseling or a specialized treatment program receive medication to supplement their therapy.

This new guide, developed by a panel of experts in alcohol research, clinical care, medical education, and public policy, was designed for use by primary care and specialty providers, though patients and their families may find it informative as well.

The SAMHSA/NIAAA guide provides detailed information on the four medications approved by the Food and Drug Administration to treat alcohol use disorder, prevent relapse, or both: disulfiram, oral naltrexone, extended-release injectable naltrexone, and acamprosate. It includes recommendations on screening and assessing patients for potential medication use, selecting the appropriate medication based on needs and circumstances, developing a treatment plan, and monitoring patient progress.

To learn more about the topics--including medication therapy--that NIAAA will be discussing at the APA's 2015 annual meeting next month, see the Psychiatric News article “NIAAA Track Focuses on Pharmacotherapy, Alcohol Disorder Guidelines.”

Also, check out The American Psychiatric Publishing Textbook of Substance Abuse Treatment, Fifth Edition from American Psychiatric Publishing. The editors of the book are Marc Galanter, M.D., Herbert D. Kleber, M.D., and Kathleen T. Brady, M.D., Ph.D.

Tuesday, April 21, 2015

Study Finds Stimulants, CBT Combination Effective for Treating Patients With ADHD, Cocaine Use Disorder


Extended-release mixed amphetamine salts in robust doses along with cognitive behavioral therapy appears to be effective for treatment of co-occurring attention-deficit/hyperactivity disorder (ADHD) and cocaine use disorder (CUD), improving ADHD symptoms and reducing cocaine use, according to a report published online April 18 in JAMA Psychiatry.

Frances Levin, M.D., of the New York State Psychiatric Institute and colleagues randomized 126 patients meeting DSM-IV-TR criteria for ADHD and CUD to receive 60 mg of extended-release mixed amphetamine salts (n=40), 80 mg of the same (n=43), or placebo (n=43) daily for 13 weeks. All participants received cognitive-behavioral therapy (CBT)/relapse prevention treatment weekly from experienced M.A.- or Ph.D.-level therapists.

The main outcome for ADHD was the percentage of participants achieving at least a 30 percent reduction in ADHD symptom severity, measured by the Adult ADHD Investigator Symptom Rating Scale; for cocaine use, the main outcome was cocaine-negative weeks (by self-report of no cocaine use and weekly benzoylecgonine urine screens) and the percentage of participants achieving abstinence for the last three weeks.

More patients achieved at least a 30 percent reduction in ADHD symptom severity in the medication groups (60 mg: 30 of 40 participants; and 80 mg: 25 of 43 participants) compared with placebo (17 of 43 participants). Rates of continuous abstinence in the last three weeks were greater for the medication groups than the placebo group: 30.2 percent for the 80 mg group and 17.5 percent for the 60 mg group vs 7.0 percent for the placebo group.

“Often, stimulants are withheld from individuals with co-occurring substance use disorders because of concern of diversion and clinical worsening,” Levin and colleagues state. “Instead, this study found the opposite—patients benefited from treatment. Thus, under closely monitored conditions, pharmacotherapy should be promoted, not barred. These data emphasize the importance of screening adults with CUD for ADHD. Future research might test long-acting stimulant formulations for other substance-abusing adult populations with ADHD, such as those with alcohol or cannabis use disorders.”

For related information on the consequences of ADHD in childhood, see the Psychiatric News article, “ADHD Outcome Data in Adults Show Value of Early Treatment.”

Monday, April 20, 2015

Boston Strong as Marathon Goes On; MH Help Still Available


Runners took off this morning in the Boston Marathon, two years after the bombing that claimed three lives and left 257 injured. A jury on April 8 convicted Dzhokhar Tsarnaev on 30 counts related to the crime.

The Boston-area health care system responded well to the immediate disaster thanks to extensive prior training, said Frederick Stoddard, M.D. (left), a psychiatrist at the Massachusetts General Hospital. However, some of those wounded in 2013 or members of their families continue to face the physical and psychological consequences of the bombing. 

Since then, many have turned for help to the Massachusetts Resiliency Center, created by the state’s Office of Victim Assistance.

“We’re helping normal people dealing with abnormal circumstances that disrupt daily functioning,” the center’s executive director, Kermit Crawford, Ph.D., told Psychiatric News. He is an associate professor of psychiatry at Boston University Medical Campus. “We are a hub for services, not just providing them ourselves but coordinating with other agencies.”

The center addresses not only behavioral health issues but also matters relating to employment, compensation, medical services, brain injury, hearing loss, caregiver and peer support, and legal services—all of which can affect victims or their survivors. During the recent trial, the center placed clinicians and patient navigators in the court building for survivors or family members who chose to attend. Such options for care may be needed for some time.

“As a psychiatrist, I understand that reactions to trauma may not occur right away but often come out months or years later,” said Brent Forester, M.D., a geriatric psychiatrist at McLean Hospital who completed the 2013 marathon. “It’s important to get that message out.”

For more in Psychiatric News about the response to the Boston Marathon bombing, see “Boston Continues to Heal as Trial Wraps Up for Accused Marathon Bomber” and “Psychiatrists Act Quickly After Bombings In Boston.”

The book Disaster Psychiatry: Readiness, Evaluation, and Treatment is available from American Psychiatric Publishing at http://www.appi.org/SearchCenter/Pages/SearchDetail.aspx?ItemId=7217.

--aml  (Image: Courtesy Frederick Stoddard)

Friday, April 17, 2015

Brexpiprazole Found Safe, Effective for Patients With Schizophrenia, AJP Reports


New findings from a phase 3 clinical trial, published today in AJP in Advance, suggest that a recently developed antipsychotic may prove to be one of the next treatments for schizophrenia.

Researchers from the Department of Psychiatry at Hofstra North Shore-LIJ School of Medicine conducted a randomized, double-blind, placebo-controlled study with 636 patients with schizophrenia to investigate the efficacy, safety, and tolerability of brexpiprazole—a  serotonin-dopamine activity modulator that acts as a partial agonist at serotonin 5-HT1A receptors and dopamine D2 receptors, while antagonizing serotonin 5-HT2A receptors and noradrenaline alpha receptors. 

The results showed that after six weeks of treatment, patients taking 2 mg and 4 mg of brexpiprazole had, respectively, Positive and Negative Syndrome Scale scores approximately 9 and 8 points lower than that of the placebo group. Weight gain from baseline was found to be moderate among the active groups, with the 2 mg cohort gaining an average of 1.45 kg and the 4 mg cohort gaining 1.28 kg. The most common treatment-emergent adverse event reported for brexpiprazole was akathisia, at a rate of 4.4 percent in the 2 mg cohort and 7.2 percent in the 4 mg cohort. No clinically or statistically significant changes were observed from baseline in lipid and glucose levels and extrapyramidal symptom ratings.

“Schizophrenia is a complicated disease, and while advances have been made, patients often still lack an effective treatment path,” the study’s lead author, Christoph Correll, M.D., a professor of psychiatry at Hofstra, told Psychiatric News. “It is important for clinicians and patients to have a range of treatment options to manage symptoms effectively and safely ... as response to therapy can vary greatly from individual to individual and from one medication to the next.” Correll informed Psychiatric News that the Food and Drug Administration will make its final decision about the approval of brexpiprazole for the treatment of schizophrenia as well as major depressive disorder in July.

The research was funded by Otsuka Pharmaceuticals, the manufacturer of brexpiprazole.

To read about the pipeline for psychotropic medications, see the Psychiatric News article “Candidates, Innovation Missing From Psychotropic Drug Pipeline.”

(Image: Vashchig/shutterstock.com)

Thursday, April 16, 2015

Comorbid Depression, Type 2 Diabetes Associated With Increased Risk of Dementia, Study Finds


Researchers have known for some time that a diagnosis of depression or type 2 diabetes mellitus (DM) may increase a patient's risk for dementia later in life. Now, a study published online in JAMA Psychiatry on April 15 finds people diagnosed with both are at an even higher risk for dementia.

Dimitry Davydow, M.D., M.P.H., an associate professor of psychiatry and behavioral sciences at the University of Washington School of Medicine, and colleagues analyzed data on more than 2.4 million Danish citizens, 50 years or older, who were free of dementia from January 1, 2007, through December 31, 2013, to estimate the risk of all-cause dementia associated with DM, depression, or both. Within this population, 477,133 (19.4 percent) had been diagnosed with depression, 223,174 (9.1 percent) with DM, and 95,691 (3.9 percent) with both.

The researchers found that over the course of the study, 59,663 participants (2.4 percent) developed dementia, and of these, 6,466 (10.8 percent) had DM, 15,729 (26.4 percent) had depression, and 4,022 (6.7 percent) had both. Compared with people without depression or DM, the authors reported that DM alone was associated a 20 percent greater risk of dementia, depression alone was associated with an 83 percent greater risk, and comorbid depression and DM were associated with a 117 percent greater risk, after adjusting for such factors as age, sex, and marital status. For those under 65 years with depression and DM, the risk for dementia appeared to be even greater.

"Given that depression in patients with DM is associated with poor self-care, nonadherence to treatment regimens, and adverse psychobiological changes, this younger group with comorbid depression and DM may be vulnerable to developing dementia later in life," the authors wrote. "From a public health perspective, developing screening and interventions to improve the quality of treatment of depression and DM in this subgroup of patients could be important in reducing the risk for dementia.”

For more on the association between diabetes and mental disorders, see the Psychiatric News article “Link Seen Between Mental Disorders, Diabetes in New Study.”

(bikeriderlondon/Shutterstock)

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