Critique of Different Approaches to Treat Addiction
Psychotropics in problem areas
1. Choosing PsychotropicChoosing Psychotropic
in Patientsin Patients
with Medical Problemswith Medical Problems
A. Albehairy , M.DA. Albehairy , M.D
Psychiatry Consultant, MOHPPsychiatry Consultant, MOHP
2. Medical Problem ConditionsMedical Problem Conditions
( one or more):( one or more):
Breast feeding.Breast feeding.
Pregnancy.Pregnancy.
Old age.Old age.
CardiovascularCardiovascular
diseases.diseases.
Chest problem.Chest problem.
Renal impairment.Renal impairment.
Liver impairment.Liver impairment.
Diabetes.Diabetes.
Epilepsy .Epilepsy .
In surgery.In surgery.
Glaucoma .Glaucoma .
3. General Principles , in approachingGeneral Principles , in approaching
the problemsthe problems
- Breast-feedingBreast-feeding: no risk free, drug level in milk 1% of: no risk free, drug level in milk 1% of
maternal plasma. Drug accumulates in milk bec. Ofmaternal plasma. Drug accumulates in milk bec. Of
acidity and lipid and protein binding .drugs should beacidity and lipid and protein binding .drugs should be
avoided if premature or has renal.liver.cardiac,oravoided if premature or has renal.liver.cardiac,or
neurological problem.neurological problem.
Avoid sedating,long half-lives. Once daily dose before theAvoid sedating,long half-lives. Once daily dose before the
infant longest sleep,dnt switch drug (preg- lactat),avoidinfant longest sleep,dnt switch drug (preg- lactat),avoid
polypharmacy.polypharmacy.
4. General Principles , in approachingGeneral Principles , in approaching
the problems (cntthe problems (cnt(.(.
PregnancyPregnancy :FDA, 5 categories, to indicate drug:FDA, 5 categories, to indicate drug
teratogencity. Each drug has to be sought.teratogencity. Each drug has to be sought.
Teratogenecity in the 1Teratogenecity in the 1stst
trimester, growth retardationtrimester, growth retardation
and neurological damage in 2and neurological damage in 2ndnd
&3&3rdrd
trimester.trimester.
Drug withdrawal.Drug withdrawal.
Diabetus vulnerability, macrosomia.Diabetus vulnerability, macrosomia.
Hyperyensive mother .Hyperyensive mother .
Psycho education for care in planned and non plannedPsycho education for care in planned and non planned
conception.conception.
Lowest viable dose.Lowest viable dose.
Adjusting dose.Adjusting dose.
5. General Principles , in approachingGeneral Principles , in approaching
the problems (cntthe problems (cnt(.(.
11stst
2 wks –stop medications, nutritional supplement folic2 wks –stop medications, nutritional supplement folic
acid, reduce dose if after 60 days,dnt stop lithiumacid, reduce dose if after 60 days,dnt stop lithium
abruptly,care in stop anticonvulsants.abruptly,care in stop anticonvulsants.
TCA & Discontinuation,/ myclonus ttt byTCA & Discontinuation,/ myclonus ttt by
phenobarbitol.phenobarbitol.
If depakin unavoidable , low , divided doses and folicIf depakin unavoidable , low , divided doses and folic
acid 5mg .acid 5mg .
Most serious, bzd,lithium, phenytoin,topraimate, andMost serious, bzd,lithium, phenytoin,topraimate, and
vigabatrin and valproate.vigabatrin and valproate.
6. General Principles , in approachingGeneral Principles , in approaching
the problems (cntthe problems (cnt(.(.
Old age :Old age : age related increases SE, sedation,age related increases SE, sedation,
orthostatic hypotension, reduced metabolism oforthostatic hypotension, reduced metabolism of
liver.liver.
Inc. fat in body--- inc half life of the drugs used.Inc. fat in body--- inc half life of the drugs used.
Other system affected.Other system affected.
Low and slowLow and slow
Poor compliancePoor compliance
7. General Principles , in approachingGeneral Principles , in approaching
the problems (cntthe problems (cnt(.(.
CardiovascularCardiovascular ::
Polypharmacy avoided, with drug likely to affectPolypharmacy avoided, with drug likely to affect
pulse or electrolyte balance, QTprolongation.pulse or electrolyte balance, QTprolongation.
Low and slowLow and slow
Angina,avoidAngina,avoid drugs of othostatic hypotension,drugs of othostatic hypotension,
tachycardia.tachycardia.
ArrhythmiaArrhythmia:TCA, phenothiazines and:TCA, phenothiazines and
butyrophenones and pimozide arebutyrophenones and pimozide are harmfulharmful..
Sulpride, olanzapine ofSulpride, olanzapine of low risklow risk..
8. General Principles , in approachingGeneral Principles , in approaching
the problems (cntthe problems (cnt(.(.
CHFCHF: avoid B blocker, drugs causing orthostatic: avoid B blocker, drugs causing orthostatic
hypotension(phenothiazines, clozapine , risperidone and TCA).hypotension(phenothiazines, clozapine , risperidone and TCA).
MIMI: SSRI, TRAZODONE , mianserin,safer: SSRI, TRAZODONE , mianserin,safer
Butryphenone safer than pimozide, phenothizines.Butryphenone safer than pimozide, phenothizines.
Lithium & diuretic may be serious.Lithium & diuretic may be serious.
HypertensionHypertension, avoid MAOI, venlafaxine of high dose,, avoid MAOI, venlafaxine of high dose,
clozapineclozapine
QTC prolongationQTC prolongation 450ms,care of electrolyte, and drug450ms,care of electrolyte, and drug
combination , antipsychotics, TCA, flouroquinolone abio,combination , antipsychotics, TCA, flouroquinolone abio,
antimalarila, antihistamine.antimalarila, antihistamine.
9. General Principles , in approachingGeneral Principles , in approaching
the problems (cntthe problems (cnt(.(.
Chronic lung dis.
- Depression 18.8% in COPD, & up to 62% in severe COPD.
- Panic disorder among COPD,8-34%.
- Buspirone and SSRI are preferred anxiolytic more than
BZD.
- TCA, is good for COPD, esp for somatic sx. without heart
effect,
- ECT, only in severe depression with COPD , BUT take
care of prolonged seizure in thyophylline use.
- In asthma , Avoid non specific b blocker , bupropion ,
relaxation therapy and CBT are promising in depression
and anxiety sx.
10. General Principles , in approaching theGeneral Principles , in approaching the
problems (cnt).problems (cnt).
Liver and renal impairmentLiver and renal impairment
Grade of renalGrade of renal impairment,impairment,
Mild 150-300 S.cre.micromole/LMild 150-300 S.cre.micromole/L
Moderate 300-700Moderate 300-700
Severe > 700Severe > 700
Low and slowLow and slow
SE, of anticholinergic, urinary retentionSE, of anticholinergic, urinary retention
Accumulation of drugAccumulation of drug
11. General Principles , in approachingGeneral Principles , in approaching
the problems (cntthe problems (cnt(.(.
In surgery:In surgery:
DecisionDecision to continue or not the drug during surgery andto continue or not the drug during surgery and
perioperative period.perioperative period.
Discussing the anesthetistDiscussing the anesthetist
Enflurane---seizure in TCAEnflurane---seizure in TCA
Pethidine ---fatal excitatory reaction with SSRI (serotenorgicPethidine ---fatal excitatory reaction with SSRI (serotenorgic
syndrome or respiratory depression ) and MAOI --- switch tosyndrome or respiratory depression ) and MAOI --- switch to
moclobamide 2wks before operation.moclobamide 2wks before operation.
operation stress:Elyctrolyteoperation stress:Elyctrolyte distubance and cortisol anddistubance and cortisol and
catecholamine changes.catecholamine changes.
Gastric stasis.Gastric stasis.
Abrupt cessation of nicotine in some pt.Abrupt cessation of nicotine in some pt.
12. General Principles , in approachingGeneral Principles , in approaching
the problems (cntthe problems (cnt(.(.
In surgeryIn surgery::
- AnticonvulsantAnticonvulsant CNS depressant activity may reduceCNS depressant activity may reduce
anaesthetic requirements.anaesthetic requirements.
- SSRISSRI, may induce seizure,, may induce seizure, VenlafaxineVenlafaxine may provokemay provoke
opioid rigidity, increase bleeding time. ( avoid anyopioid rigidity, increase bleeding time. ( avoid any
serotenorgic agent).serotenorgic agent).
- TCA:TCA: seizure, seroenorgic s, hypotension, it needs o beseizure, seroenorgic s, hypotension, it needs o be
stopped several days before surgery.stopped several days before surgery.
- Antipsychotics,hypotension,arrythmia,hypothermia,Antipsychotics,hypotension,arrythmia,hypothermia,
clozapine may delay recovery .clozapine may delay recovery .
13. General Principles , in approachingGeneral Principles , in approaching
the problems (cntthe problems (cnt(.(.
in surgeryin surgery
BZDBZD, sedation and withdrawel, sedation and withdrawel
LithiumLithium : electrolyte imbalance may ppt, toxicity,: electrolyte imbalance may ppt, toxicity,
avoid dehydration/arrythmia develop.avoid dehydration/arrythmia develop.
OpiateOpiate, methadone, naloxone may induce, methadone, naloxone may induce
withdrawel– avoid bupernorphinwithdrawel– avoid bupernorphin
NaltrexoneNaltrexone
14.
15. Low Risk PsychotropicsLow Risk Psychotropics
Br.feedingBr.feeding,sulpride, moclobamide, TCA,,sulpride, moclobamide, TCA,
tryptophan,BZD,chloral,temazepam,carbamezaptryptophan,BZD,chloral,temazepam,carbamezap
ine,valproate.ine,valproate.
Pregnancy : moderate riskPregnancy : moderate risk. All antipsychotic. All antipsychotic
except zotepine high. All antidepressant exceptexcept zotepine high. All antidepressant except
reboxetin high, safer carbamezapine and ox,, andreboxetin high, safer carbamezapine and ox,, and
lamotriginelamotrigine