1. Psych Meds for Harm Reduction Providers Barry Zevin MD Tom Waddell Health Center San Francisco Department of Public Health Homeless Programs Board Certified Internal Medicine Board Certified Addiction Medicine Barry_Zevin@sfdph.org

2. Disclosures And Disclaimer Barry Zevin accepts no payments, samples, or gifts from any pharmaceutical companies The opinions expressed here are those of the presenter All information regarding medications expressed here should be checked out!

3. Medications for Mental Health Disorders Basic Pharmacology Concepts Medications for Depression Medications for Anxiety Medications for Psychosis Medications for Bipolar Disorders Medications for ADHD Medications for Sleep Questions / Discussion Medications for Addiction Disorders –Come back for presentation tomorrow at 11am Salon D

4. Basic Pharmacology Medications receive FDA approval for specific indications but are also very commonly used for other indications (off label) Any substance can have adverse effects if used in the wrong way at the wrong time –Even water can kill you –Any drug can cause an allergy and if severe it (and closely related drugs) should not be used –Many drugs can have idiosyncratic (unpredictable) liver, kidney, or other toxicity Some side effects are relatively mild but so common that they are important Some side effects are rare but so severe that they are important

5. Basic Pharmacology What is a “psych med”? Why do or don’t medical providers prescribe psych meds? Why do or don’t people take psych meds? Harm reduction vs. harm production –Are psych meds part of harm reduction? –Can psych meds produce harm?

6. Basic Pharmacology Reducing Risk for Prescribed Drugs –Rationale for Using the Medication –Informed Consent True informed consent not the fake kind –Follow Up Is it working? Could it be working better? Make changes when needed

7. Basic Pharmacology What I’m not going to talk about

8. Basic Pharmacology In general medication should be started at the lowest possible dose and gradually increased to the lowest effective dose –In some urgent situations higher doses must be used right away –Many adverse effects are dose dependent –Some medications require monitoring of blood levels for effective levels and to prevent toxic levels In general, when stopping a medication, slowly decreasing the dose decreases the risk of discontinuation symptoms –In some cases of adverse reactions medications must be stopped immediately

9. Basic Pharmacology Medications can interact with each other, some foods, or street drugs in ways which change how they act, how long or short they act, how toxic they are, and how high a dose is needed Medications can act synergistically in causing adverse effects including risk of overdose

10. Medications for Depression SSRI Other Meds TCAs Atypical anti-psychotics Antidepressants (and other meds) and suicide –Overall medications appear to reduce suicide attempts and completed suicides –Studies of antidepressants in children and adolescents show risk of increased suicide esp. when 1st starting medications This may also be true in adults

11. Medications for Depression SSRIs –Fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), citalopram (Celexa), escitalopram (Lexapro), etc. Tricyclic Anti-Depressant – Amitryptaline (Elavil), Nortryptaline (Pamelor), Desipramine (Norpramin), Doxepin (Sinequan), etc Other anti-depressants –MAO Inhibitor Phenalzine (Nardil), tranylcypromine (Parnate), etc. –SNRI Vanlafaxine (Effexor), duloxetine (Cymbalta), desvenlafaxine (Pristiq) –Bupropion (Wellbutrin) –Mirtazapine (Remeron) –Trazadone Placebo

12. SSRIs Main Intended Effects Anti-depressant Anti-anxiety Anti-OCD Other Intended Effects Sleep Activation / energy

13. SSRIs Common Side Effects Sexual side effects –Orgasm delay or anorgasmia –Low libido, ED Stomach discomfort, jitteriness in 1st 1-2 wks Mild sedation Insomnia Uncomfortable effects when abruptly stopped –Esp. paroxetine (Paxil) Emotional Blunting Rare but Severe Side Effects Serotonin syndrome –At very high doses or when used in combination with other meds effecting serotonin system MDMA, (PMA), amphetamines, fentanyl, tramadol, cocaine, LSD

14. TCAs Main Intended Effects Anti-depressant Other Intended Effects Sleep Pain relief Anti-itching –Doxepin Anti-anxiety

15. TCAs Common Side Effects Anti-cholinergic –Dry mouth, sedation, urinary retention, Sedation Rare but Severe Side Effects Acute anti- cholinergic syndrome (delirium) –High dose or combination of anti-cholinergics (promethazine, datura, brugmansia,) Heart rhythm effects including death Death in overdose

16. Other anti-depressants Main Intended Effects Anti-depressant Anti-anxiety –Not bupropion (Wellbutrin) Fight neuropathic pain-SNRIs Other Intended Effects Sleep Weight gain –mirtazapine (Remeron)

17. Other anti-depressants Common Side Effects Sedation Weight gain –Mirtazapine (Remeron), etc. Over-activation –Bupropion (Wellbutrin), etc. Rare But Severe Side Effects Priapism - erection that won’t go away –Trazadone Seizures –Bupropion (Wellbutrin) Potentially fatal interactions with food and other medications –MAO Inhibitors

18. Placebo Main Intended Effects –Anti-depressant –Anti-anxiety –??? Other Intended Effects –Eliminate “side effects”

19. Placebo (Nocebo) Common Side Effects –Expected adverse effects are more likely to occur –Often interfere with effective treatment Rare But Severe Side Effects –???

20. Medications for Anxiety SSRIs (and other anti-depressants) Benzodiazepines –Diazapam (Valium), lorazapam (Ativan), alprazolam (Xanax), clonazapam (Klonapin) Other –Buspirone (Buspar) –Atypical anti-psychotics, anti-psychotics (major tranquilizers)

21. Benzodiazepines Main Intended Effects Anti-anxiety Anti-panic attack Sleep Other Intended Effects Decrease “agitation” in any condition Treat alcohol withdrawal Treat intoxication due to stimulants Amnesia

22. Benzodiazepines Common Side Effects Sedation Interferes with memory and learning Unpleasant withdrawal when stopped abruptly Rare but Severe Side Effects Addiction especially in people with other addictive disorders Fatal overdose when mixed with alcohol or other sedatives or opioids Severe withdrawal including seizures and delirium Falls and fractures esp. in elderly

23. Medications for Psychosis Atypical anti-psychotic –Olanzapine (Zyprexa), quetiapine (Seroquel), risperidone (Risperdal), aripiprazole (Abilify), ziprasadone (Geodon), paliperidone (Invega), clozapine (Clozaril) –Injectable long lasting atypical- risperdal consta, Invega Sustenna Older anti-psychotic –Chlorpromazine (Thorazine), haloperidol (Haldol), thioridazine (Melloril), etc.

24. Atypical antipsychotic Main Intended Effects Anti-psychotic Anti-mania Mood stabilizer Other Intended Effects Anti-depressant Decrease agitation due to any cause Anti-anxiety Sleep Practically anything anybody can think of

25. Atypical anti-psychotics Common Side Effects Weight gain Diabetes Abnormal lipids (cholesterol, LDL, etc) Sedation Sexual side effects Movement disorders –Akithisia, tremor, dystonic reactions, repetitive movements –Less common than older antispychotics Rare but Severe Side Effects Prolong QT interval causing fatal heart arrythmia –Esp when combined with other medications that prolong QT interval (e.g. methadone) Depersonalization / feeling like a zombie Tardive dyskinesia Neuroleptic malignant syndrome Excess prolactin production Increased risk of stroke and death in elderly

26. Older anti-psychotics Main Intended Effects Anti-psychotic Anti-mania Other Intended Effects Decrease any kind of agitation

27. Older anti-psychotics Common Side Effects Movement disorders –EPS, TD, Akithesia Sexual side effects Sedation Weight gain Rare but Severe Side Effects Neuroleptic malignant syndrome Irreversible TD

28. Medications for Bipolar Disorders Lithium Anti-epileptic drugs –Lamotragine (Lamictal), divalproex (Depakote), topiramate (Topamax), carbamazepine (Tegretol), oxcarbazapine (Trileptal) Atypical anti-psychotics

29. Lithium Main Intended Effects Anti-manic Mood stabilizer Other Intended Effects Anti-depressant

30. Lithium Common Side Effects Tremor Diarrhea, nausea Weight gain Inability to concentrate urine –Increased urination –Increased need to drink water –Easy tendency to dehydration Thyroid dysfunction –hypothyroidism Rare but Severe Side Effects Toxic levels can be fatal –Can occur quickly in overdose or if at normal dose patient becomes dehydrated Kidney failure

31. Anti-epileptic drugs Main Intended Effects Mood stabilizer (prevent seizures) Other Intended Effects Decrease impulsivity and aggressiveness Adjunct to pain control Decrease craving and relapse in alcoholism –topiramate (topamax) Prevent migraine –Divalproex (Depakote),topiramate (topamax) Many other possible effects being studied

32. Anti-epileptic drugs Common Side Effects Cognitive slowing / brain fog –Esp topirimate (Topamax) GI effects –Abdominal pain, nausea and vomiting Sedation Weight gain Weight loss –topiramate (Topamax) dizziness Rare but Severe Side Effects Severe skin rash –Esp. lamotrigine (Lamictal) Blood and liver problems –Esp. carbamazepine (Tegretol) Confusion, Ataxia, Delirium –Esp. at high doses or overdose

33. Medications for ADHD Psychostimulants –Methylphenidate (Ritalin, Focalin, etc), mixed amphetamine salts (Adderall, Adderall XR), others Others –Atomoxetine (Strattera)

34. Medications for ADHD Main Intended Effects Improve concentration and focus Decrease hyperactivity Other Intended Effects Anti-depressant Decrease substance abuse

35. Medications for ADHD Common Side Effects Tremor Poor sleep Feeling of being slowed down Rare but Severe Side Effects Psychosis / mania Addiction potential esp. in those with underlying addiction problems

36. Medications for Sleep Benzodiazepines –Temazapam (Restoril), Flurazapam (Dalmane) Benzadiazepine - like –Zolpidem (Ambien), zaleplon (Sonata), eszopiclone (Lunesta) Anti-Histamines –Diphenhydramine (Benedryl), hydroxyzine (Atarax) Melatonin receptor agonist –Melatonin, ramelteon (Rozerem) Antidepressants –Trazadone, amitryptaline (Elavil) Atypical antipsychotics

37. Medications for Sleep Main Intended Effects Faster onset of sleep Maintain sleep Normalize sleep architecture –Claimed for trazadone, ramelteon (Rozerem) Other Intended Effects Anti-anxiety Decrease allergic symptoms

38. Medications for Sleep Common Side Effects Sedation / hangover effect Anticholinergic effects with antihistamines Memory effects and amnesia Tolerance Confusion, falls, delirium in elderly / chronically ill Rare but Severe Side Effects Potentiation of other sedatives with overdose Potential for addiction –Esp. benzodiazepines in patients with underlying addiction disorders –Potential trigger for relapse in patients with alcoholism in recovery

39. Thank you to my colleagues at Tom Waddell Health Center and Harm Reduction Therapy Center and especially to my patients who I learn from every day