Psychopharmacology Flashcards
Drug Metabolism
The process of breaking down drugs into metabolites for excretion from the body; usually happens in the liver.
Synapse
The space between neurons in the brain.
Neurotransmitters
Chemical that moves from one neuron to the next.
ex) serotonin, dopamine, noreprinephine
Scheduling of Controlled Substances
Schedule I - no current legal medical use; high potential for physical and/or psychological dependence; high risk for misuse
ex) heroin, marijuana, bath salts
Schedule II - restricted use; high potential for physical/psychological dependence and misuse.
ex) fentanyl, morphine, methadone
Schedule III - accepted legal medical use; low/moderate physical dependence, moderate/high psychological dependence;
moderate risk for misuse.
Schedule IV - accepted legal medical use; low potential for dependence; low risk for misuse
ex) benzos
Schedule V - accepted legal medical use; limited potential for dependence; low risk for misuse
Schedule VI - legend drugs; any drug that is not considered to be a controlled substance
Classification of Common Drugs
1) Opioids
ex) morphine, fentanyl, heroin
2) Stimulants
ex) amphetamine, cocaine, bath salts
3) Hallucinogens
ex) PCP, LSD, ketamine
4) Inhalants
5) Cannabinoids
Opioid Withdrawal Symptoms
- agitation, muscle aches, anxiety, runny nose, sweating, yawning, diarrhea, nausea/vomiting, dilated pupils, rapid heartbeat, elevated blood pressure
- sometimes described at the worse flu people have ever had
- treated in medical aspect. ex) sometimes given meds for diarrhea, etc.
Cocaine Withdrawal Symptoms
- anxiety, increased appetite, agitation, chills, problems concentrating, depression, insomnia, lethargy, mood swings, restlessness
- cocaine withdrawal can cause profound depression that can last for months; cocaine withdrawal is sometimes treated with antidepressants.
Marijuana Withdrawal Symptoms
decreased appetite, mood changes, irritability, insomnia, headaches, sweating, chills, upset stomach
Alcohol Withdrawal Symptoms
- anxiety, insomnia, tremors, nausea/vomiting, headache, confusion, delirium tremens (DTs)/seizures (life -threatening)
- each time you have DTs, you are more at risk for having DTs every single time.
- drinking a pint of alcohol for 14 days puts you at serious risk of going through withdrawal
Benzo Withdrawal Symptoms
anxiety, insomnia, seizures (life-threatening)
4 Types of Antidepressants
1) Selective Serotonin Reuptake Inhibitors (SSRIs)
- most common
2) Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)
3) Novel Antidepressants
- do not impact serotonin
4) Tricyclic Antidepressants
- Very sedating; not used often
- All equally effective for pain.
Examples of Selective Serotonin Reuptake Inhibitors (SSRIs)
Fluoxetine (Prozac) Citalopram (Celexa) Escitalopram (Lexapro) Paroxetine (Paxil) Sertraline (Zoloft) Fluvoxamine (Luvox)
Examples of Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)
Duloxetine (Cymbalta) --also used for pain Venlafaxine (Effexor) Desvenlafaxine (Pristiq) Levomilnacipran (Fetzima) Milnacipran (Savella)
Examples of Novel Antidepressants
Bupropion (Wellbutrin) Mirtazapine (Remeron) Trazodone (Desyrel) - sedative; helps with sleep Vilazodone (Viibryd) Vortioxetine (Trintellix)
Examples of Tricyclic Antidepressants
Amitriptyline (Evavil) Nortriptyline (Pamelor) Imipramine (Tofranil) Desipramine (Norpramin) Doxepin (Adapin, Sinequan)
What to know about antidepressants:
- take several weeks of routine dosing to work appropriately
- “boxed” warning for clients under 24 years old
- should not be abruptly discontinued
- side effects can keep people from staying adherent - depends on drug, but can have sexual dysfunction (those who take SSRIs), weight gain/loss, insomnia, bleeding risk, seizures (bupropion)
Antidepressant Withdrawal Syndrome
Occurs with every antidepressant - looks like recurrence of depression, but happens within hours to days after discontinued use. May be irritable, agitated, anxious, and have difficulty sleeping.
- Does not happen with Prozac, but does with every other drug.
Anti-Anxiety Medications
- used to treat: anxiety disorder
panic disorder
social anxiety disorder
OCD
PTSD
- SSRIs/SNRIs - antidepressants are first choice medications for anxiety disorders
- Non-drug treatment is needed along with medication (ex. therapy)
- Busprione (Buspar) - medication that is only really useful to treat generalized anxiety - often takes several weeks to work - has a max dosage.
OCD and PTSD
- Commonly, meds do not fully treat symptoms.
- Psychotherapy and CBT is used with meds
- Nightmares from PTSD may be treated with Prazosin, some atypical antipsychotics, and Topiramate
- Some atypical antipsychotics may be used as adjunctive therapy in OCD
Benzodiazepines
- the most effective!
- very effective for short-term treatment and as-needed for anxiety/panic disorders
- use is limited because of their abuse potential
- withdrawal effects after long-term (weeks) use can be severe and life-threatening
- can take several weeks/months to appropriately discontinue use
- used in hospital setting for alcohol withdrawal and are very effective in decreasing symptoms and DTs
- Not for PTSD!!!!
What to know about antipsychotics:
- for symptom management only!
- used to treat psychotic disorders (schizophrenia), as mood stabilizers in bipolar disorder, and as adjuncts to antidepressants for major depression, and agitation
- for schizophrenia: can only treat positive symptoms
- hallucinations, delusions, disorganized thinking and behavior
- NOT effective for negative of “cognitive” symptoms of schizophrenia
- social isolation, lack of motivation, apathy, inattention
- Abrupt discontinuation may cause withdrawal and relapse
- all antipsychotics have different receptor pharmacology and ARE NOT INTERCHANGEABLE!
- If dx with schizophrenia, you do not have to be prescribed an antipsychotic
- Some meds are extremely expensive
Two Types of Antipsychotics
1) Conventional/Typical Antipsychotics (older ones)
2) Atypical Antipsychotics (newer ones)
Examples of Conventional/Typical Antipsychotics (older)
Chlorpromazine (Thorazine) - max dose is 600 mg/day
- 1st choice
Haloperidol (Haldol)
Perphenazine (Trilafon)
Thiothixene (Navane)
Fluphenazine (Prolixin)
Loxapine (Loxitane)
Thioridazine (Mellaril)
Trifluoperazine (Stelazine)
- Older antipsychotics are more likely to cause extrapyramidal (movement) side effects and can make negative symptoms of amotivation and apathy worse;
- Equally effective for positive symptoms as the newer antipsychotics
- All are generic, so less expensive!
Examples of Atypical Antipsychotics (newer)
Aripiprazole (Abilify)
Brexpiprazole (Rexulti)
Clozapine (Clozaril)
- most effective but causes weight gain and a lot of other side effects. Requires a lot of monitoring!
Lurasidone (Latuda)
Paliperidone (Invega)
Risperidone (Risperdal)
Asenapine (Saphris)
Cariprazine (Vraylar)
Iloperidone (Fanapt)
Olanzapine (Zyprexa)
Quetiapine (Seroquel)
Ziprasidone (Geodon)
- less likely to cause movement side effects, except Risperdal and Invega, but more likely to cause significant weight gain, diabetes, hypertension, elevated cholesterol (metabolic syndrome)
- do not worsen negative symptoms
- these are preferred for initial treatment
Long-Acting Injectable Antipsychotics
Abilify Maintena (aripiprazole) - requires 2 week oral overlap, very expensive
Aristada - depending on dose, eveery 4, 6, or 8 weeks; intramuscularly; requires 3 weeks of oral overlap
Invega Sustenna - every 4 weeks; no overlap required; more side effects
Invega Trinza - every 12 weeks; can be initiated after 4 stable doses of Invega Sustenna
Risperdal Consta - every 2 weeks; 3-4 weeks oral overlap; has to be refrigerated
Perseris (risperidone) - newest injectable; every 4 weeks in abdomen; no overlap required
Antipsychotic Withdrawal Syndromes
- Abrupt withdrawal of antipsychotic treatment can lead to symptoms including irritability and agitation.
- Rebound psychosis or psychotic relapse can occur within days to weeks of discontinued use.
- Cross-titration of antipsychotics over week when switching drug therapy can minimize these effects.
Antipsychotic Movement Side Effects
- Looks like Parkinson’s disease
- Called extrapyramidal side effects
- May be acute dystonic reactions (ex. contractions of muscle groups in eye, neck, back) Benadryl can help with this. Painful.
- Tremors and stiffness are common, especially in higher doses of some antipsychotics
- Tardive Dyskinesia - cause by long-term and high-dose use, may be irreversible but can diminish over time
Antipsychotic Key Points
Monotherapy is first choice! Using more than one increases type of severity of side effects.
Less is more! - to avoid long-term side effects
Dosing based on individual patient
May take up to 2 weeks to see initial effects on symptoms; if no effect in two weeks, change med!
Some newer injectables are very expensive - $1500-$2000/month
Mood Stabilizers
- Commonly used to treat bipolar disorder
- Lithium and Divalproex Sodium (Depakote) are first choice for bipolar I disorder (mania)
- Lithium or Lamotrigine used to treat bipolar II disorder (hypomania/depression)
- antidepressants can also be used to treat bipolar disorder ; antidepressants can cause a “manic switch” that triggers a hypomanic or manic episode
- Mood stabilizers are foundational treatment - patients must be on a mood stabilizer before an antidepressant or other med is used to treat bipolar
Meds: Lithium (primary)
Lamotrigine (Lamictal) - also used for seizure disorders
Depakote - also used for seizure disorders
Topiramate (Topamax) - also used for seizure disorders
Trileptal - also used for seizure disorders
Carbamazpine (Tegretol, Equetro) - also used for seizure disorders
Schizoaffective Disorder
- Diagnosed when a patient has significant, primary, consistent mood symptoms, but also experiences a period of psychosis without primary mood symptoms.
- Mood stabilizers can be used to treat
- Patients may be taking a mood stabilizer and an antipsychotic for this disorder
- Atypical antipsychotics are considered to be mood stabilizers, can be used for mood or psychosis
Lithium
Significant side effects: hypothyroidism, tremor, sedation, weight gain, acne, renal failure
Baseline and routine monitoring of serum lithium concentration and renal function/sodium concentration are needed!!!!!
Fluid and sodium intake should be consistent to maintain consistent lithium concentration!!
Can be toxic/fatal if overdose
Divalproex Sodium (Depakote)
1st -line alternative to lithium
Side effects: weight gain, sedation, hair loss, elevated serum ammonia, pancreatitis, decreased platelets, polycystic ovarian syndrome, hepatotoxicity
Take at bedtime for sleep - sedative
Baseline and routine monitoring - serum concentration, liver function tests, complete blood count with platelets
Do not use if pregnant
Serum ammonia - if patient exhibits acute mental status changes, may be due to elevated ammonia - will reverse if Depakote is held, may be rechallenged
Lamotrigine
Useful only for depressive mood pole of bipolar - does not treat mania
Usually well-tolerated, rash may be side effect
Very slow titration due to risk of developing Stevens-Johnson syndrome, which is a life-threatening rash that moves quickly into systemic involvement - the skin looks like a severe burn and skin grafts have been required
Treating Insomnia
- Meds are not first-line recommended treatment; sleep hygiene is first-line! Meds not suggested until apnea is diagnosed and treated
- Insomnia can occur for primary and secondary reasons: obstructive sleep apnea (breathing stops because of problem in airway), restless leg syndrome, shift-work sleep disorder
- Person may wake up not feeling rested and be tired all day
- CPAP machine plus weight loss are often necessary
- Sleep medications may lead patient to not wake up to the hypoxia experienced when they stop breathing during the night and they may not wake up
Sleep Medications
Temazepam (Restoril)* - a benzo Zaleplon (Sonata)* Doxepin Tasimelteon (Hetlioz) Hydroxyzine (Pamelor) Zolpidem (Ambien)* Eszopiclone (Lunesta)* Ramelteon (Rozerem) Trazodone (Desyrel) Suvorexant (Belsomra)*
- = controlled substance
Benzos used for anxiety, as well as Depakote, can also help with sleep
Stimulant Medications
Used to treat ADHD - increase focus and concentration
ADHD from childhood can continue into adulthood
Adult ADHD that is not treated can cause difficulties in everyday life related to lack of attention, getting easily bored, and not being able to complete tasks.
Meds: Methylphenidate (Ritalin, Metadate, Concerta, Daytrana) - 1st LINE!!!!
- Daytrana is a patch; applied in morning; lasts 9 hours; takes 2 hours to work; must respond to oral tablets
before trying the patch
Dexmethylphenidate (Focalin)
Dextroamphetamine (Dexedrine, Dextrostat)
Vyvanse - considered to be “abuse deterrant”
Mixed ampetamine salts (Adderall)
Atomoxetine (Strattera) - NOT 1st LINE; takes 2-4 weeks to work; warning for suicidal thinking
Medication-Assisted Treatment -Nicotine
- Nicotine-replacement therapy (patches, gum, lozenges)
- Chantix
- Wellbutrin
Treatment is for as long as patient needs it in order to stop using - relapse is less likely if there is NOT a time limit
Varenicline is a nicotine receptor partial agonist that helps with cravings
Medication-Assisted Treatment (MAT) - Alcohol
Meds: Disulfiram (Antabuse), Acamprosate (Campral), Naltrexone (Revia, Vivitrol)
- Disulfiram (Antabuse) - known as aversive treatment; blocks enzyme that breaks down alcohol so person will get very sick if drinks and this can be life-threatening; takes 14 days of discontinuance for a person to be able to metabolize alcohol
- Acamprosate (Campral) - oral med that works in brain to reduce cravings for alcohol; doesn’t harm patient if alcohol is consumed; not every effective versus naltrexone; take 3x/day; warning for suicidal thinking; don’t use if history of depression
- Naltrexone - drug of choice to treat alcohol dependence; opioid receptor antagonist and stops pleasurable/euphoric effects of alcohol, interacts with neurotransmitters related to pleasure response; oral and injection; must prove tolerability to oral before can use injection; must monitor liver function; decreases binge drinking days and drinks per binge episode; VERY EFFECTIVE
MAT - Opioids
- Total abstinence is goal but not possible for everyone
- Methadone - extremely effective; daily, observed dose; considered to be replacement/maintenance therapy; goal is to administer dose that stops craving but not provide euphoric effect; ECG must be monitored as well as eval of drug interactions for each patient; 2 years tx minimum recommended
- Treatment very individualized, but also includes psychotherapy, group therapy, and drug screening - Buphrenorphine - office based tx; given with naloxone orally to reduce abuse potential; too high a dose can cause opioid withdrawal; will not give any effect or high; street use if often because purchaser is trying to avoid withdrawal, not for a high; must be prescribed by a DATA 2000 waivered prescriber
- implant - outpatient surgical procedure; replaced every 6 months; not used often
- injection (sublocade) - every 4 weeks into abdomen; not for new patients - Naltrexone (Vivitrol) - abstinence drug; oral and injection; blocks effects of opioids; must not take opioid for ANY reason, must tell doc if they are on this; not for everyone, can increase risk of death due to unintended overdose if relapses; used after the other medications.
- Naloxone (Narcan) - immediate release opioid antagonist; works quickly and lasts up to 20 mins
Prescription Drug Misuse - Other than Opioids
- Gabapentin - added to prescription drug monitoring program; misused sometimes for effects of opioids
- Clonidine - can be used to opioid withdrawal symptoms to decrease blood pressure and anxiety; sometimes misused to get effects of opioids
- Quetiapine (Seroquel) - sedating atypical antipsychotic; similar to benzos; misuse to come down from stimulants; sometimes is crushed to snort and inject for abuse
Dual Diagnosis Treatment - MH and SUD
50-60% of patients in treatment have both a mental health and substance use disorder
Both disorders need to be treated at the same time!
Eval for SUD should also include eval for MH and medical eval
Shared Decision Making/Patient Autonomy
Inform of treatment options; seek preferences and integrate those preferences into care; PATIENT-CENTERED CARE
People will only do what they want to do, so decisions are more successful if person is involved in making those decisions
Healthcare providers have to accept that sometimes patient don’t do what we would like them to do
