Chantix FDA Warning

The Food and Drug Administration has recommended a safety labeling change for varenicline( Chantix) which is manufactured by Pfizer and is used as an aid to nicotine cessation. This seems to me to be a good idea as it has been known to have psychiatric side effects in some people.

My experience with Chantix has been mixed. It clearly is effective and has worked for a number of my patients who were motivated to quit smoking. But I had a few experiences that have taught me a few lessons and made me more cautious about prescribing this medication. One case is that of Mrs.G, a 45 year old woman who was at Cottonwood for treatment of alcoholism. She had a history of depression and was on antidepressant medication although she was not depressed at the time of admission. She was doing quite well in treatment and understanding the link between tobacco use and alcoholism decided to quit smoking while she was here. She had tried quitting before with the help of the nicotine patch but was unsuccessful so I prescribed Chantix. About one week later she went into a profound depression which was worse than she had ever had before. There had been no apparent psychological trigger so we discontinued the Chantix and about 5-6 days later the depression had resolved completely. Fortunately she was able to quit smoking, used the nicotine patch again and was successful this time.

Not that long afterwards I had a similar experience with Mr. S., a 38 year old man who was at Cottonwood for treatment of polysucbstance dependence. He had a concurrent anxiety disorder which we treated along with his substance abuse problem. He did not want to attempt to quit smoking here but was doing well at the time of discharge so he decided it might be a good time to quit. I prescribed Chantix for him at the time of his going home and did warn him about the possibility of return of anxiety or depressive symptoms while taking Chantix. He called me in a frantic state about 10 days later saying he had a severe exacerbation of his anxiety disorder. I recommended he stop taking the Chantix and several days later his anxiety resolved. Interestingly enough to me he had not recalled our previous conversation about Chantix side effects. This taught me two lessons, first to not prescribe any new medication as the patient is leaving, and secondly a reminder that many patients have too much to remember and may not remember verbal instructions.

It has been known since February of 2008 that some people on Chantix develop behavior changes, depression, or suicidal thoughts. The manufacturer Pfizer did not attempt to hide this data but immediately made changes in the product labeling to include these side effects. What is new in the FDA recommendation is that Chantix carry a "black box " warning in the prescribing instructions. The black box warning means that this information is highlighted in bold letters in a black box which is the first thing a prescriber will see when looking up the medication.

Does this mean Chantix should not be used? This information about Chantix needs to be taken to account in the context that tobacco related illnesses are by far the greatest cause of death in the United States. The people that I see at Cottonwood though may represent a high risk group for psychiatric side effects so will continue to use Chantix only when other smoking cessation efforts fail.

Thought for the day

I will say it once more. All medical treatments carry some risk as well as their benefits.

Suicide Alcohol Abuse Link

A recent report in the Center for Disease Control and Prevention's (CDC's) Morbidity and Mortality Weekly Report (MMWR) confirmed what many of us in the substance abuse field have long seen, the connection and link between suicide and alcohol abuse. Here at Cottonwood we see many patients who have made suicide attempts, sometimes multiple attempts, in states of intoxication but who never struggle with suicidality when sober. The report does not touch on non successful suicide attempters but indicates that 24% of those who die from suicide showed evidence of alcohol intoxication.

It is not surprising to me that the CDC was able to clearly establish a link. The rates are lower than I expected , though they were higher than the CDC researchers expected. One important finding was that alcohol involvement was a factor across all populations and age groups. It highlights the need for all suicide prevention programs and all mental health centers to address substance abuse problems as a major part of treatment. Unfortunately this is not usually done to to funding issues and historical precedent. I am very happy that I work at a facility that takes both mental health problems and substance abuse problems as truly co occurring.

Thought for the day

We cannot address mental health problems without addressing the substance abuse problems that are highly prevalent and co occurring.

Michael Jackson Opioids Addiction

Like most people I was sad to hear of Michael Jackson's untimely death. I really did not care much for his music and didn't listen to it but he did have remarkable talent and charisma.

What is especially saddening to me is to learn that he was addicted to opioids. As I have discussed before in this blog oral opioids (pain pills) are the biggest drugs of abuse now with the exception of alcohol and tobacco and are increasingly being used now even by young adolescents. I haven't heard anything about the toxicology reports on Michael Jackson but I will not be surprised if it is determined that opioids were somehow implicated in his death.

Whether or not opioids were a cause or factor it is also sad to me that he didn't receive treatment. Either he stayed in denial or was enabled by those around him to continue his addiction. It does show again that addictions know no bounds and transcend all socioenomic demographics.

Thought for the day,

May God bless all those family members whose lives have been torn apart by addictions.

Serotonin Transporter Gene Depression

The Daily Musings of an Addiction Psychiatrist is back after a short hiatus. For some reason I have not been sleeping well so instead of getting up early which I enjoy and writing I have been dragging myself to work at the last possible minute. Maybe it is a guilty conscience as they say but I don't feel anxiuous at night - just awake.

A recent study has once again caused dissapointment in those of us who are continuing to hope that we will learn more about the genetic links that predispose us to depression. It had recently been thought that mutations in the gene coding for the serotonin transporter protein might be one of those factors. This seemed to make sense as we have known that the neurotrasmitter serotonin is associated with depression and that many of our antidepressant medications have an effect on serotonin. A large scale study though has shown that this gene is not a factor. Instead what is more associated with depression are the number of stressful life events.

This once again show that enviromental factors strongly influence the occurence of depression but leaves us wondering what the genetic differences are that would make one person respond to life stressful events with depression and another doesn't. What are the genetic differences that either protect us from or make us more vulnerable to depreesion? We still don't know.

Thought for the day

"In all things give thanks".

St. Paul

Attention Deficit Hyperactivity Disorder Update

I recently completed a series on Attention Deficit Hyperactivity Disorder (ADHD) where I mentioned the possibility of increased risk of sudden cardiac death in those children taking Ritalin or other stimulant medication. This was based on anecdotal reports. A study just published in the American Journal of Psychiatry demonstrates fairly conclusively that there is some small risk. This has been difficult to study as sudden death in children is a very rare event. Because of this and the methodological limitations of the study the FDA has urged caution in interpreting the results.

The FDA released a statement that says "Given the limitation of this study's methodology, the FDA is unable to conclude that these data affect the overall risk and benefit profile of stimulant medication used to treat ADHD in children. FDA believes that this study should not serve as a basis for parents to stop a child's stimulant medication".

It does serve as a reminder though that all medical treatments carry some risk. It also confirms my idea that the American Heart Association is correct by recommending routine electrocardiogram screening in addition to taking a careful history prior to stating someone on stimulant medication for ADHD. The American Academy of Pediatrics has disagreed with this recommendation but perhaps may change their viewpoint in light of this study.

Thought for the day

All medical treatments carry some risk.

Health Care Reform, American Medical Association, Public Health Insurance Option

I read an article in the New York Times the other day that indicated the American Medical Association submitted comments to Congress in opposition to a public run insurance option for those who are non disabled and under 65 years of age. The public run insurance option is being strongly pushed by the Obama administration. I have previously discussed this option in my series on health care reform. This plan is essentially Medicare for everyone. While clearly needing reform, the public health insurance option has the potential of completely destroying the health care system we have now including the many parts of the system that do work. For this reason it is opposed by the American Medical Association which comments to the Senate Finance Committee.

Why is a public health insurance option a bad idea? It sounds at first look like a pretty good idea. After all, Medicare seems to work fairly well. The problem is though that Medicare works only because 70 % of patient care is provided under private insurance programs. Medicare payments are not enough to keep hospitals in business nor some medical practices, particularly psychiatric practices. While the Obama administration says it wants a publicly funded plan to keep private insurers fair and honest there are many other ways of doing this. Issues of preexisting conditions and excessive rates do need to be dealt with. A publicly funded plan will do more than keep private insurers honest and fair though. It will drive them out of business.

Another problem with this plan is the question of where the public funding will come from. Medicare is facing a financial crisis. To open up a similar plan to all Americans would come at an exorbitant cost, transferring many of the health care costs from private insurers to taxpayers. In regard to health care reform ideas the American Medical Association is right in my opinion to oppose any plan that includes an expansion of a public health insurance option.

Thought for the day

"All good gifts come from above"

St. James

Attention Deficit Hyperactivity Disorder part 7

This is a last in a series on Attention Deficit Hyperactivity Disorder (ADHD). I would like to talk a bit on psychosocial treatments which are very effective when combined with medication use. The focus is on various aspects of behavior modification which includes behavioral treatment, parent education and training, school interventions, and home interventions. Various other "talk therapies" have been tried but behavioral modification is the only treatment that has shown effectiveness with this disorder.

What is behavioral modification? It is a treatment where parents, teachers, and children learn specific techniques and skills which are used consistently in daily interactions. Behavioral modification focuses on identifying things that set off troublesome behavior, the behaviors themselves, and the consequences of the behavior such as how parents and teachers act in response to the behavior. The idea is to teach everyone skills in how to react differently and make the child's environment and experiences better when the good behavior that is desired is engaged in by the child. The only problem I have seen with behavioral interventions is that some people make them too complex. They must be simple and easy to implement and easily sustained over long periods of time. Many of them seem to be common sense approaches but parents and teachers must be encouraged to use the interventions as many of the behaviors with ADHD are very trying and tend to bring about negative reactions from parents and teachers.

Some behavioral interventions include ignoring mild inappropriate behaviors (choose your battles) use many more praises than negative comments, use clear short and specific instructions, reprimands should be brief, clear, neutral in tone, and as immediate as possible, placing the student's desk near the teacher, computer assisted instruction, simple behavior charts with points or tokens that can later be exchanged for rewards and many others. Again a lot of common sense approaches. I think one of the most difficult things is keeping reprimands brief and neutral in tone. We tend to speak angrily and give too many long explanations for why we are criticizing the behavior.

For more information on ADHD and behavioral strategies you can go to http://www.help4adhd.org/.

Thought for the day

Everyone deserves respect.