anxiety & other mood disorders

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DEPRESSION/ANXIETY & OTHER MOOD DISORDERS

Depression/Anxiety & Other Mood Disorders Michelle Weckmann MD MS FAAHPM University of Iowa Hospitals & Clinics Iowa City, IA [email protected]

Disclosure • No financial disclosures • I will be discussing off label use of various medication – Anti-depressants – Stimulants – Anti-psychotics

Session Objectives • Review diagnosis, treatment and impact of anxiety & depression. • Discuss substance abuse. • Review other psychiatric illness including PTSD and personality disorders. =additional information-slide won’t be discussed

DEPRESSION/ANXIETY & OTHER MOOD DISORDERS

Mrs. A • 63 with severe COPD, oxygen dependent, short of breath with activity, uses a scooter when she is out of the house. • She has been losing weight. • She worries about “every little thing” and starts to panic when she can’t catch her breath. • She tells you that she is afraid that she will “suffocate”.

Anxiety Prevalence • Anxiety symptoms are 10X more common than a DSM 5 anxiety disorder • Most common DSM 5 anxiety disorders at EOL – Generalized Anxiety Disorder (GAD) – Anxiety secondary to a medical condition Miovic M, Block S. Psychiatric disorders in advanced cancer. Cancer. 2007 Oct 15;110(8):1665-76

Anxiety Symptoms • •

Common and distressing (25-70%) Somatic symptoms are common – – – – – – –

• •

Tension or restlessness Jitteriness or autonomic hyperactivity Hypervigilance Insomnia Distractibility Worry, apprehension, rumination Shortness of breath

Need to evaluate carefully for medical causes such as pain and dyspnea, environmental factors Often looks like GAD and can include panic attacks

DEPRESSION/ANXIETY & OTHER MOOD DISORDERS

Potential Sources of Anxiety Symptoms • • • • • • • • •

Actual underlying anxiety disorder Fear of death and the dying process Spiritual or existential concerns Chronic coping or personality style Medication side effects (akathisia from anti-emetics) Undertreated symptoms (pain, dyspnea, sepsis) Withdrawal states (sedatives, opioids) Delirium Anticipatory response to repeated aversive treatment (chemo)

Mrs. A • 63 with severe COPD, oxygen dependent, short of breath with activity, uses a scooter when she is out of the house. • She has been losing weight. • She worries about “every little thing” and starts to panic when she can’t catch her breath. • She tells you that she is afraid that she will “suffocate”.

ARS Question 1 How would you treat Mrs. A’s anxiety? 1. Tell her to stop drinking coffee and smoking cigarettes 2. Stop her steroids 3. Change her Allegra-D to Allegra 4. Stop her levothyroxine

DEPRESSION/ANXIETY & OTHER MOOD DISORDERS

Anxiety • Withdrawal from sedatives can trigger • Medication that can cause anxiety – Caffeine – Steroids – Nicotine – Antidepressants, antipsychotics, stimulants – Phenylephrine (Sudafed) – Synthroid over replacement

Anxiety Screening Tools • Clinical Exam very effective – Do you feel nervous or jittery? – Have you felt fearful, distressed, or tense? Of anything in particular? – Do you avoid certain activities or people because of fear? – Are you afraid to close your eyes at night because of fear that you will die in your sleep?

• Hospital Anxiety and Depression Screen (HADS) • Patient Health Questionnaire (PHQ-9)

Non-pharmacological Strategies to Decrease Anxiety • Explore fears/concerns in non-judgmental fashion – Listen, acknowledge, normalize, remain available

• Reassurance not usually effective – Can make highly anxious pts more anxious

• Supportive-expressive therapy – Aims to reduce symptoms and maintain coping not cure

DEPRESSION/ANXIETY & OTHER MOOD DISORDERS

Non-pharmacological Strategies to Decrease Anxiety • Music Therapy • Relaxation/ Guided Imagery/ Hypnosis • Mindfulness Based Stress Reduction (MBSR) • Psychotherapy – Cognitive behavioral therapy – Interpersonal therapy (IPT) grief work

Pharmacological Anxiety Treatment Benzodiazepines: drugs of choice at EOL (in order of preference) – – – –

Ativan (lorazepam) 0.5-2 mg q4-6hrs prn Xanax (alprazolam) 0.25-0.5 mg q4-6hrs prn Clonazepam (klonopin) for long-acting coverage Can cause sedation, confusion, tolerance, abuse, disinhibition, gait instability, falls

Trazodone – Sedating but can be given in low doses during the day (12.5-50 mg q4hrs prn) – Black box warning - suicidality

Buspirone (BuSpar) – Should be scheduled, takes 4-6 weeks to see an effect (5-15 mg BID-TID)

Pharmacological Anxiety Treatment Consider antipsychotics – More sedating • Chlorpromazine (Thorazine) 12.5-50 mg q4hrs prn • Olanzapine (Zyprexa) 2.5-5 mg q 4hrs prn • Quetiapine (Seroquel) 12.5-50 mg q4hrs prn

– Less sedating • Haloperidol (Haldol) 0.5-2 mg q4hrs prn • Risperidone (Risperdal) 0.25-1 mg q4hrs prn

Anti-histamines can be beneficial – Hydroxyzine 25-50mg q6hrs prn (may also potentiate effects of morphine)

DEPRESSION/ANXIETY & OTHER MOOD DISORDERS

Pharmacological Anxiety Treatment Antidepressants if life expectancy >8 weeks – SSRI’s • Sertraline (Zoloft) 25-200 mg qd • Citalopram (Celexa) 10-40 mg qd • Escitalopram (Lexapro) 5-20mg qd

– Mirtazapine (Remeron) 7.5-30mg qhs • May help with sleep and appetite

– Antidepressants to avoid • Paroxetine (Paxil): anti-cholinergic • Venlafaxine (Effexor): withdrawal • Bupropion (Wellbutrin): lowers seizure threshold

– Start low and go slow to avoid increasing anxiety

Mrs. A • Music therapy – Guided meditation and breathing exercises

• Pet therapy • Regular sessions with chaplain • Medication: – Sertraline 25mg QHS – Lorazepam 0.25mg prn panic attacks

“If I was dying I would be depressed too” • Sadness is common but not pervasive sadness and despair • Depression is not a normative response to a terminal diagnosis • Grief over losses – social, functional, personal perception, future goals – is near universal and should not be confused with depression

DEPRESSION/ANXIETY & OTHER MOOD DISORDERS

Mr. G • Active 82 y/o, just moved into a “senior-living” condo with his wife • Hypertension, diet controlled DM • Metastatic prostate CA • Going out less, making statements that life is not “worth it” • Some weight loss • Tired and sleeping more • Wife says he is more forgetful

Depression • Depression and medical conditions are closely linked. • Depression worsens illness and illness worsens depression. • Can be hard to separate from severe illness. • Need to focus on neurovegetative symptoms – Dysphoria – Anhedonia – Feeling worthless, hopeless, helpless, guilt, despair

Impact of Depression • • • • • • • • •

Reduces ability to find meaning and purpose Impairs quality of life Shortens survival in some illnesses Worsens physical symptoms such as pain Interferes with relationships Causes anguish to family and friends Interferes with treatment adherence Risk factor for suicide and requests to hasten death Bereavement outcomes worse in family members of depressed patients. Widera, E, Block, S. Am Fam Physician. 2012;86(3):259-264

DEPRESSION/ANXIETY & OTHER MOOD DISORDERS

Major Depression Criteria At least 5 symptoms daily for 2 weeks 1. 2. 3. 4. 5. 6. 7. 8. 9.

*Depressed mood most of the day, nearly every day *Markedly diminished interest or pleasure Unintentional (significant) change in weight Insomnia or hypersomnia Psychomotor agitation or retardation Fatigue or loss of energy *Feelings of worthlessness or excessive or inappropriate guilt Diminished ability to think or concentrate, or indecisiveness *Recurrent thoughts of death or suicide

*=more useful for diagnosis in HPM population

Additional Criteria for MDD • Symptoms cause clinically significant distress or psychosocial impairment. • Symptoms are not the direct result of a substance or general medical condition. • Bereavement does not exclude the diagnosis of a major depressive episode.

Signs of Major Depression •

•

May be hard to determine in advanced disease – the somatic symptoms of fatigue, decreased appetite, decreased libido, sleep disturbances may all be related to the underlying disease Need to focus on neurovegetative symptoms – Dysphoria – sad, flat affect, distraught – Anhedonia – lack of anything pleasurable – Feelings of worthlessness, hopelessness, helplessness, guilt, and despair

•

Have a high index of suspicion if: – Pain not responding as expected – Requests to end life early

DEPRESSION/ANXIETY & OTHER MOOD DISORDERS

Screening Tools for Depression • 2 questions (97% sensitive, 67% specific) – “During the past month, have you been bothered by feeling down, depressed or hopeless?” – “During the past month, have you been bothered by little interest or pleasure in doing things?” – At EOL Sensitivity of 55%, specificity of 75%

• Hospital Anxiety and Depression Scale • Patient Health Questionnaire (PHQ) • Geriatric Depression Screen

ARS Question 2 Mr. G now has pulmonary mets and has enrolled in hospice. He is experiencing distressing shortness of breath. He tells the hospice staff that he has been thinking about committing suicide. Which of the following is the most appropriate initial response? A. B. C. D.

Administer IV ketamine for depression. Admit to a locked psychiatric ward. Improve symptom control. Inquire about suicidal ideation and plans.

Suicide • • • •

Women attempt 2x as much, men are 4x more likely to succeed Always assess in patients with depressive symptoms Talking about it decreases risk (does not increase risk) Red flags: – – – –

• •

Socially isolated Has concrete plan History of serious attempt Knows someone who committed suicide

Complete a risk assessment (intent, plan, means) If risk high – DON’T leave patient alone, immediately consult a psychiatrist – may need in-patient care or involvement of authorities

DEPRESSION/ANXIETY & OTHER MOOD DISORDERS

Treatment of Depression • Aggressively treat other physical symptoms • Consider psychotherapy (CBT) – 2018 meta-analysis shows efficacy

• Encourage exercise/movement • Antidepressants (SSRIs) for a life expectancy over two months • Psychostimulants

Psychosocial Interventions •

•

•

Supportive psychotherapy – Supports adaptive coping mechanisms and minimizes maladaptive – Uses active listening and supportive verbal interventions, rare interpretations Structured Cognitive Therapies – Focus on cognitive distortions – Correction of maladaptive thoughts and provides new coping skills Existential psychotherapy (dignity therapy) – Explore meaning, purpose and value of life

Antidepressants for Depression • 2011 meta-analysis of antidepressants in: – cancer, renal failure, COPD, CHF, Parkinson’s disease, multiple sclerosis, and HIV/AIDS.

• Anti-depressants superior to placebo • NNT decreased by time – 9 at 4-5 weeks decreased to 5 at 9-18 weeks

• Trend towards TCAs having greater efficacy earlier on Palliative Medicine, 2011. 25(1) 36–51

DEPRESSION/ANXIETY & OTHER MOOD DISORDERS

Antidepressants for Depression • SSRIs (sertraline, fluoxetine, citalopram) – Good for co-morbid anxiety and irritability – Nausea, diarrhea, and sexual side-effects – Potential for QTc prolongation (citalopram dose >40mg)

• SNRI (venlafaxine, duloxetine) – Can be effective if there is co-morbid pain or hot flashes – Can increase blood pressure (venlafaxine) – Withdrawal syndrome common

Antidepressants for Depression • TCA’s (amitriptyline, nortriptyline, doxepin) – Can assist with appetite, pruritus, neuropathic pain and sleep – Inexpensive – Anticholinergic (constipation, dry mouth, orthostatic hypotension, urinary retention) – Generally contraindicated in cardiac disease or liver failure – Avoid if high-risk for overdose

• Other – Mirtazepine (Remeron) can increase appetite and improve sleep, increases warfarin levels. Low doses work for sedation. – Buproprion (Wellbutrin) can reduce fatigue but also lowers the seizure threshold

Antidepressants and Tamoxifen • 20-30% of women on tamoxifen also use antidepressants • Some antidepressants (fluoxetine, paroxetine, bupropion) inhibit CYP2D6 and decrease tamoxifen’s conversion to its active form (endoxifen) • Venlafaxine is the safest choice with tamoxifen – Sertraline and citalopram are other options

• Largely theoretical – studies don’t show a robust decrease in mortality if taking a CYP2D6 inhibitor and tamoxifen

BMJ 2016; 354 doi: https://doi.org/10.1136/bmj.i5309

DEPRESSION/ANXIETY & OTHER MOOD DISORDERS

Antidepressants for Depression • Dose like you would for an elderly patient – Start low and go slow – Aggressive dosing can cause/worsen anxiety

• Choose agent taking advantage of side effects • NNT is 9 at 4-5 weeks and 5 at 9-18 weeks – NNT for flu vaccine is 12

Additional Treatments for Depression • Stimulants – – – –

methylphenidate 5 mg Qam, Qnoon Double if no effect in 2 days Stop if no improvement in a week Can go to 60 mg/d

• Antipsychotics – Low dose atypicals most common

• Ketamine – Experimental only, not standard of care

Benefits of Psychostimulants • Response often seen within 2 days – 73% response in cancer pts (non-controlled) – Discontinuation from side effects <10%

• Augment opioid analgesia • Diminish opioid sedation • May increase appetite • Can be used in conjunction with SSRIs

DEPRESSION/ANXIETY & OTHER MOOD DISORDERS

Methylphenidate Review • •

1950-2008 (includes case studies, focus on elderly with medical illness) Mechanism of action: – Blocks dopamine reuptake (striatum) – Blocks norepi and serotonin receptors (weak)

• •

“mixed results” overall beneficial with mood and fatigue, +/- apathy, cognition, motivation, may help with “hard to wean” vent patients Side effects uncommon: agitation/restless, tachycardia, confusion, insomnia – Resolve with dose decrease or discontinuation

•

Monitoring: consider EKG with cardiac history, check warfarin levels, use caution with TCAs

Ketamine • N-methy-d-aspartate (NMDA) receptor antagonist • Response rate 14-85% • Single infusion can have an impact for 1-2 weeks – repeat infusions may not be effective

• May decrease suicidal ideation • May accelerate tumor growth • One study in hospice (n=14) – Oral dose (0.5mg/kg) daily for 4 weeks – About half (n=8) had an improvement

ARS Question 3 Stem Mr. G is seen in clinic acutely because of new onset agitation and diarrhea for 2 days. His mood has been stable with sertraline and sleep is good with trazodone. His fentanyl patch was increased 3 days ago due to increased pain. Upon examination, Mr. G is agitated and disoriented, with occasional twitching and myoclonus.

DEPRESSION/ANXIETY & OTHER MOOD DISORDERS

ARS Question 3 Options Given Mr. G’s clinical presentation, what is most likely? A. B. C. D.

Serotonin syndrome NMS Anticholinergic toxicity Meningitis

Serotonergic Medications Class

Medication

Analgesics

Codeine, fentanyl, meperidine, tramadol, cyclobenzaprine

Antibiotics

Linezolid

Antidepressants

SSRIs, SNRIs, TCAs, MAOIs, bupropion, trazodone

Dopamine Agents

Amantadine, bromocriptine, levodopa

Triptans

Sumatriptan

Anti-nausea Agents

Metoclopramide, ondansetron, droperidol

Herbals/supplements

St. John’s wort, panax ginseng, tryptophan, 5HTP

Drugs of Abuse

Cocaine, amphetamines, ecstasy, LSD

Misc

Buspirone, dextromethorphan, lithium

Serotonin Syndrome Triad • Mental status changes – anxiety, agitated delirium, restlessness, disorientation

• Autonomic hyperactivity – diaphoresis, tachycardia, hyperthermia, hypertension, vomiting, diarrhea

• Neuromuscular abnormalities – tremor, muscle rigidity, myoclonus, hyperreflexia

DEPRESSION/ANXIETY & OTHER MOOD DISORDERS

Hunter Toxicity Criteria for Dx • 84% sensitive and 97% specific • Patient must have taken a serotonergic agent and meet ONE of the following conditions: – – – – –

Spontaneous clonus Inducible clonus PLUS agitation or diaphoresis Ocular clonus PLUS agitation or diaphoresis Tremor PLUS hyperreflexia Hypertonia PLUS temperature above 38ºC PLUS ocular clonus or inducible clonus

Serotonin Syndrome vs NMS Serotonin Syndrome

NMS

Develops over 24 hrs

Develops slowly (day to weeks)

Neuromuscular hyperactivity (tremor, hyperreflexia, myoclonus)

Neuromuscular slowing (rigidity, bradyreflexia)

Resolves < 24hrs

Resolves in ave 9 days

Common findings to both: Hyperthermia, altered mental status, muscle rigidity, leukocytosis, elevated creatine phosphokinase, elevated hepatic transaminases, and metabolic acidosis

Treatment of Serotonin Syndrome • Review goals of care • Discontinue serotonergic agents • Supportive care, including benzodiazepines for agitation and autonomic hyperactivity • Severe case: administer serotonin antagonist (cyproheptadine)

DEPRESSION/ANXIETY & OTHER MOOD DISORDERS

Depression Pearls • Depression is not a normal part of the dying process • Have a high index of suspicion – Consider routine screening

• Treatment is effective • Consider a psychostimulant trial early

Serious and Persistent Mental Illness • 6% of adult population • Decreased access and assistance from medical system • Double risk of dying from natural causes at any age compared with general population • Co-morbid substance abuse and psychosocial issues are common

Serious and Persistent Mental Illness • Very little published • Patients with SPMI are able to engage in ACP conversations • Know your state’s rules regarding guardianship and their ability to make EOL decisions • Involve the mental health team – Management decisions may need to be based on compassion and maintaining a relationship and not “best medical practice”

DEPRESSION/ANXIETY & OTHER MOOD DISORDERS

ARS Question 4 Stem A 57-year-old Vietnam war veteran with metastatic lung cancer enrolled in hospice. His pain is well controlled on sustained-release morphine sulfate 45 mg every 8 hours, but he is very anxious. On further gentle questioning, the patient reveals that he was in combat and saw one of his colleagues being killed brutally during the war. He admits to having frequent nightmares and often waking up in the night thinking that he is “back in Nam in the line of fire.” He also reports that he is afraid of falling asleep because he knows that he is going to have these nightmares, which are “so real and vivid, like it is all happening all over again.” His family reports that he seems to be incapable of relaxing and is constantly on guard and vigilant.

ARS Question 4 Options Which of the following medications will help alleviate his condition? A. Risperidone B. Zolpidem C. Immediate release morphine D. Sertraline

PTSD • 7.8% in adult population • Often has co-morbid chronic pain • Symptoms can flare at EOL • Anxiety and mistrust can impede care • SSRI or SNRI for overall symptoms • Prazosin or topiramate for nightmares

DEPRESSION/ANXIETY & OTHER MOOD DISORDERS

Schizophrenia • 1.1% of adult population – 2.2 million in US

• Often have a muted pain response • Increased delusional behaviors may be a sign of increased distress • Smoking (common) leads to a decrease in drug levels of many psychotropic medications

Bipolar Disorder • 2.6% of adult population – 5.7 million in US

• As many as 1 in 5 complete suicide • Co-morbid substance abuse is common • Steroids and poor sleep can precipitate a mania – Use medications as needed to maintain good sleep architecture

Personality Disorders • Cluster A (odd or excentric-”weird”) – Paranoid, schizoid, schizotypal

• Cluster B (dramatic, emotional or erratic-”wild”) – Narcissistic, histrionic, borderline, antisocial

• Cluster C (anxious or fearful- “worried”) – Avoidant, dependent, obsessive-compulsive

DEPRESSION/ANXIETY & OTHER MOOD DISORDERS

Personality Disorders A

B

C

Paranoid personality disorder: characterized by a pattern of irrational suspicion and mistrust of others, interpreting motivations as malevolent. Schizoid personality disorder: lack of interest and detachment from social relationships, apathy, and restricted emotional expression. Schizotypal personality disorder: pattern of extreme discomfort interacting socially, and distorted cognitions and perceptions. Antisocial personality disorder: pervasive pattern of disregard for and violation of the rights of others, lack of empathy, bloated self-image, manipulative and impulsive behavior. Borderline personality disorder: pervasive pattern of abrupt mood swings, instability in relationships, self-image, identity, behavior and affect, often leading to self-harm and impulsivity. Histrionic personality disorder: pervasive pattern of attention-seeking behavior and excessive emotions. Narcissistic personality disorder: pervasive pattern of grandiosity, need for admiration, and a perceived or real lack of empathy. Avoidant personality disorder: pervasive feelings of social inhibition and inadequacy, extreme sensitivity to negative evaluation. Dependent personality disorder: pervasive psychological need to be cared for by other people. Obsessive-compulsive personality disorder: characterized by rigid conformity to rules, perfectionism, and control to the point of satisfaction and exclusion of leisurely activities and friendships

Personality Disorders-DSM 5 An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture. This pattern is manifested in two (or more) of the following areas: • Cognition (i.e., ways of perceiving and interpreting self, other people, and events). • Affectivity (i.e., the range, intensity, lability, and appropriateness of emotional response). • Interpersonal functioning. • Impulse control. • The enduring pattern is inflexible and pervasive across a broad range of personal and social situations. • The enduring pattern leads to clinically significant distress or impairment in social, occupational, or other important areas of functioning. • The pattern is stable and of long duration, and its onset can be traced back at least to adolescence or early adulthood. • The enduring pattern is not better explained as a manifestation or consequence of another mental disorder. • The enduring pattern is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition (e.g., head trauma).

Personality disorder in HPM • Estimated prevalence of 10% • We all regress during times of stress • Borderline, Narcissistic, Obsessive-Compulsive – More likely to request PAD – Can be challenging to manage

DEPRESSION/ANXIETY & OTHER MOOD DISORDERS

ARS Question 5 What is most helpful when working with a patient with Borderline PD? A. Setting consistent clear limits with concrete consequences B. Respond quickly to all patient requests C. Increase the medication whenever the patient has a complaint D. Change care providers frequently so that no-one gets burned out

Borderline PD • Common struggles – – – –

Abandonment Splitting Black/white thinking Impulsivity, mood lability, anger

• Useful responses – – – –

Reassure of non-abandonment (consistent staff) Calm response to emotion (don’t debate/argue) Be caution of being idealized Increase their sense of control (consistency, positive reinforcement)

Substance Abuse in Palliative Medicine

DEPRESSION/ANXIETY & OTHER MOOD DISORDERS

Case 1: • 56 y/o heroin addict with metastatic lung cancer • Presented disheveled, malodorous, in severe pain (from brachial plexopathy) with daughter who was exhausted and frustrated • Admitted and treated with IV fentanyl and gabapentin • Comfortable within 12 hrs, eating and bathing, interacting pleasantly with daughter • Conversion to fentanyl patch and discharged with plan for radiation

Case 1: • 4 days later presented to ER disheveled in terrible pain • Had missed radiation appointment • Daughter frustrated • PE reveals five 3-day-old fentanyl patches – Wanted to see if he could “catch a buzz” by escalating dose

Reasons Given to Not Treat Addiction in EOL Patients • Why bother patient is going to die anyway? • A little alcohol (pot etc) never hurt anyone • Alcohol (the substance) is one of the few sources of pleasure left for the patient

DEPRESSION/ANXIETY & OTHER MOOD DISORDERS

Untreated Substance Use Disorders: •

Complicate diagnosis and treatment of psychological (depression) and physical (pain) symptoms

•

Impairs compliance with treatment plan

•

Can impair a stressed social network

•

Often weakens trust in medical relationships

•

Encourages “chemical coping” strategies (esp. during times of stress/decision making)

Reason to Address Addiction: • Substance abuse causes stress and suffering (not pleasure) • Preservation/restoration of damaged social supports • Restore self-dignity and respect • Allow completion of end-of-life work • Improve patient and family quality of life

Frequency • 21.6 million with substance abuse/dependence in 2013 – 14.7 million alcohol only – 4.3 million illicit drugs only – 2.6 million both

• 7.1 million with illicit drug use disorder (2014) − Of that about 50% marijuana dependence

DEPRESSION/ANXIETY & OTHER MOOD DISORDERS

Myths • Opioids always cause euphoria – False (only in abuse)

• Opioid therapy always has a high rate of addiction – False

• Agonist-antagonist drugs are safer in terms of addiction liability – False (based on fact that addicts more likely to prefer pure mu agonists)

• Short-acting oral opioids more likely to cause addiction – False (these perceptions are derived from observations of a healthy addict population)

Substance Abuse in Patients Without a Previous History is Rare • 11,882 inpt received opioids 4 developed addiction – Boston Collaborative Drug Study

• 10,000 burn pts (nationwide) receiving opioids – No cases of addiction

• 2,369 patients admitted for headache treatment – Opioid abuse in 3 www.nci.nih.gov/cancertopics

Definition of Substance Abuse • Increasing degrees of craving, compulsive use, loss of control, and continued use despite harm • Tolerance ≠ addiction • Physical dependence ≠ addiction • Psychological dependence = addiction

DEPRESSION/ANXIETY & OTHER MOOD DISORDERS

Signs Concerning for Addiction • Loss of control of drug use – No partially filled bottle, won’t bring in bottles

• Adverse life consequences • Drug taking reliability – Frequent use extra doses, doesn’t take meds as prescribed

• Abuse of other drugs (past or present) • Contact with drug culture • Cooperation with treatment plan – Follow-up with referrals, use of non-drug treatments

ARS Question 6 Stem 17 y/o male with acute leukemia who is hospitalized with pneumonia and chest wall pain. Started with 5mg IV morphine Q4hrs prn. After a few days, he began requesting medication prior to scheduled dosing, requesting specific opioids, and engaging in pain behaviors (e.g., moaning, crying, grimacing, and complaining about various aches and pains) when staff was present but not when he was alone. The nurses are concerned about addiction.

ARS Question 6 Options What should you do? A. Start a scheduled benzodiazepine to “calm and quiet” the patient B. Get a chemical dependency consult C. Start a PCA with a 1mg/hr basal rate D. Increase the morphine to 5mg Q2 hrs PRN

DEPRESSION/ANXIETY & OTHER MOOD DISORDERS

Pseudoaddiction • Term first used 1989 • Iatrogenic syndrome • 3 phases – Stimulus: at pain onset, the patient receives inadequate analgesia and requests more medication, frequently requesting specific drugs by name – Escalation: the patient realizes that to receive additional medication, he has to convince a health care provider of the legitimacy of the pain – Crisis: culminating when unrelieved pain continues, the patient engages in increasingly bizarre drug-seeking behaviors, leading to “a crisis of mistrust” with anger and isolation by the patient and frustration and avoidance by the health care team Weissman DE, Haddox JD: Opioid Pseudoaddiction-an iatrogenic syndrome. Pain 36 (3): 363-6, 1989.

Pseudoaddiction •

Diagnostic features: – Behaviors that cause you to think of addiction – Behaviors by patient to demonstrate he is in pain (ie. moaning) – Clock-watching or early requests for meds – Pain complaints “excessive” – Inadequately prescribed or titrated opioids • Inadequate potency • Excessive dosing interval – Improves with adequate analgesia and trust (patient trusts the caregiver believes the pain is real)

Case 2 • 61 y/o married male with metastatic adenocarcinoma, 60 pack-year history of smoking, still smoking • Wife is primary caregiver, increasing distressed by decline and alcohol use • For 3 yrs prior pt drank 4-5 quarts of whiskey a week • Brief trial outpt treatment not effective • 15 day hospitalization for pleural effusion and thoracotomy – Surgeon used ativan taper and told pt not to drink – Pt returned to drinking after discharge 2-3 quarts whiskey a week

DEPRESSION/ANXIETY & OTHER MOOD DISORDERS

Case 2: •

•

•

•

At palliative care referral pt expressed some motivation to stop drinking but replied it was the only way he could sleep − Was also having increasing pain and had been given some vicodin with partial relief − Wife very concerned with pt using “strong medicine” with alcohol Team offered education on alcohol dependence, cancer symptoms, and appropriate pharmacological interventions focused on symptoms − Started on lorazepam taper under wife’s control − Trazodone for sleep − Stronger opioids started for pain − Informed entire team of decision such as oncology nurse planning chemo, so that everyone was involved in assessment and symptom management Frank discussion of fears of pt and wife − Clarified use of alcohol from medical need for pain control − Acknowledged negative consequences of alcohol use − Decision made not to stop smoking in short term Was able to maintain sobriety for a few months with good symptom control

Clinical Management • • •

Take a thorough Substance Abuse history Evaluate and treat comorbid psychiatric disorders Set realistic goals for therapy − Encourage participation in recovery − Remember this is a disease with frequent relapse − Consider written opioid contract • Treat pain aggressively − Remember tolerance (studies show previous drug users need higher doses of opioids for pain control) − Prevent or minimize withdrawal symptoms • Use non-opioids and non-pharmacologic methods

Clinical Management • •

Remember pseudoaddiction esp in patients without a substance abuse history Monitor closely − Recognize specific drug abuse behaviors − Consider urine drug screening

•

Involve a multidisciplinary team

•

Recognize addiction is an illness-be compassionate

− Helps deal with medical, psychosocial and administrative problems

DEPRESSION/ANXIETY & OTHER MOOD DISORDERS

References 1. J Palliat Med. 2010 Jul;13(7):903-8 Oral ketamine for the rapid treatment of depression and anxiety in patients receiving hospice care. Irwin SA, Iglewicz A. 2. Palliat Med. 2011 Jan;25(1):36-51. Epub 2010 Oct 8 Antidepressants for the treatment of depression in palliative care: systematic review and meta-analysis. Rayner L, Price A, Evans A, Valsraj K, Hotopf M, Higginson IJ. 3. Cancer. 2007 Oct 15;110(8):1665-76. Psychiatric disorders in advanced cancer. Miovic M, Block S.

References (Continued) 4. J Pain Symptom Manage. 2012 Jan;43(1):68-77 Effects of methylphenidate on fatigue and depression: a randomized, doubleblind, placebo-controlled trial. Kerr CW, Drake J, Milch RA, Brazeau DA, Skretny JA, Brazeau GA, Donnelly JP. 5. Am J Geriatr Pharmacother. 2009 Feb;7(1):34-59 Methylphenidate for the treatment of depressive symptoms, including fatigue and apathy, in medically ill older adults and terminally ill adults. Hardy SE.

References (Continued) 6.

Ann Intern Med. 2000 Feb 1;132(3):209-18 Assessing and managing depression in the terminally ill patient. ACP-ASIM End-of-Life Care Consensus Panel. American College of Physicians American Society of Internal Medicine. Block SD.

7.

Curr Opin Support Palliat Care. 2007 Apr;1(1):50-6. Anxiety and its management in advanced cancer. Roth AJ, Massie MJ.

DEPRESSION/ANXIETY & OTHER MOOD DISORDERS

ZDoggMD • https://www.youtube.com/watch?v=ay5_H gZLDoE&list=PLqBLoScSYEGdUQXeQv mPR_FoghKOsVH-Q&index=25

Questions? Please fill out a card for a response during the question and answer session at the end of the day.

Further Questions after the course? [email protected]