American Academy Addiction Psychiatry 2009 part 2

I want to continue to update you on some of the studies recently presented at the annual meeting of Addiction Psychiatry held earlier this month. As I said before I did not attend the conference. I received my information from medical sites on the web. There was an interesting presentation The study was conducted by a professor of psychiatry at the University of Colorado School of medicine funded by National Institute on Drug Abuse and involved Concerta ( a slow release version of methylphenidate) which is used to treat attention deficit hyperactivity disorder.

The findings from 303 adolescents ranged in age from 13-18 from 11 community based treatment programs who had both ADHD and substance abuse showed that Concerta after a 16 weeks was no more effective in the treatment group than the placebo group. The drugs that were used were marijuana (91%) alcohol (56%) hallucinogens (12%) cocaine 10%) and smaller numbers for opioid and amphetamine abuse. One confounding factor which needs to be investigated further is that both the treatment and placebo groups received cognitive behavioral therapy. Both groups showed improvement but there is always improvement in placebo groups so we don't know whether the cognitive behavioral therapy had any effect or not. The study was not designed to address that question. But it is clear that Concerta is generally of no value in treating adolescents with ADHD who are abusing alcohol and drugs. It will be interesting to see if similar studies will show the same lack of effectiveness. I don't think any of the pharmaceutical companies will funding or helping fund such research.


Thought for the day


If you are abusing alcohol and drugs you might as well quit taking your medication as it won't work unless you quit.

American Academy Addiction Psychiatry 2009

For the next several days I will be presenting some highlights from the 2009 annual meeting of the American Academy of Addiction Psychiatry recently held in Los Angeles December 3-6. I did not attend the meeting. I don't usually attend this meeting as it is always in December and I am already taking some time off for the holidays. I also don't like going out of town in December. I did attend the meeting several years ago when it was held in Phoenix, Arizona and it was interesting and worthwhile.

A study conducted at the University of California is interesting as it looked at a group of methamphetamine addicts that were "pure". That is they had no other substance abuse except for nicotine and had no co-occurring psychiatric disorder. This is not a patient population we normally see in the "real world" but it did give a chance to look at the effects of methamphetamine itself uncomplicated by other factors.

They recruited 56 volunteers who stayed at an inpatient clinical research center for 5 weeks. Generally at time of admission they had high levels depressive, mood, and psychotic symptoms which resolved in 2-3 days. The withdrawal was mild, consisting of red and itchy eyes, poor memory, lack of energy, lack of motivation and irritability and lasted from 2-6 days. The most important finding though was that at the end of 5 weeks 30% of the patients had drug cravings as intense as they were when they came in to treatment. This magnitude of continued intense cravings has not been found for other drugs except for possibly nicotine. It is also probable that in the average methamphetamine dependent population in which there are high levels of co-occurring psychiatric problems and other substance abuse problems this percentage of continued intense cravings may be more than 30%.

At the moment there are no medications available to treat methamphetamine cravings. Cognitive behavioral therapy has been shown to have some efficacy in other studies but it is not always easy to obtain and the results take time. We don't know how long the cravings persist after 5 weeks but it does remind us that methamphetamine addicts in particular need very close follow-up after inpatient treatment, active psychotherapy, and strong early participation in Narcotics Anonymous or other support groups.

Thought for the day

Methamphetamine use is increasing.

Breast Cancer Screening USPSTF

As many of you know the United States Preventive Services Task Force (USPSTF) recently came out with new recommendations for mammogram screening for breast cancer that included the recommendation that women 40-49 not be screened routinely despite approximately 35,000 breast cancers are detected in this age group each year and that each year there are over 4,000 deaths in women in their 40's. USPSTF is not a government agency but it is funded by the federal government so although the recommendations are not official US policy they are pretty close to being so in actual practice. The American Cancer Society has been very active in refuting this recommendation.

I indicated before that I thought this recommendation was entirely based upon desire for cost control with the sense that women in their 40's could go ahead and die with breast cancer as the number of cases detected by mammograms each year was not enough to justify routine screening according to USPSTF. We were assured that this was not primarily a cost saving recommendation but already USPSTF recommendations are being used to deny screening to poor women. Most states have been providing free mammogram and Pap smear screenings for the uninsured poor. But already less than a month after the USPSTF recommendations the state of New York has changed it's policy. Women less than 50 are no longer eligible for free screening unless they have a "serious" family cancer history. We will have to see how soon other states follow New York's lead.

Thought for the day

"Let justice roll down like waters and righteousness like an ever flowing stream".

OTC Drug Abuse Dextromethorphan

It is nice to be writing again. I have been on a very pleasant at home vacation but am now back at work. It is good to get back in the swing of things including this blog.


I have discussed several times the problem of the increasing abuse of prescription pain pills (the opioids) among adolescents and the potential dangers of that abuse but I would like to talk about another aspect of teen drug use and that is misuse of over the counter medications, in particular dextromethorphan, The federal Substance Abuse and Mental Health Services Administration (SAMHSA) has indicated that there are currently approximately 3 million teens who are abusing dextromethorphan which is found in cough medicines. There has been a 7 fold increase since 1999. It is likely that the use is increasing because like the pain pills they are easily accessible and perceived as harmless by many young people.

Dextromethorphan( DXM) is found primarily in OTC cough syrups and the pill form Coricidin. It's chemical structure is very close to that of codeine, an opioid with abuse potential. The first use of a similar medication came out in 1958 as Remilor which was subsequently removed from the market due to extensive misuse. The most popular form used by teens today is Coricidin which are little red tablets each containing 30 mg of dextromethorphan. Because of their appearance they are known a skittles or red hots by many teens. Cough syrup was previously the main formulation use and still is but a whole bottle must be taken to get the euphoric effect so the tablets are easier.

Use of high amounts of DXM has a simlar effect to the use of ketamine and PCP, both of which are referred to as dissociative drugs. DXM provides euphoria, a sense of unreality, and a stimulant effect. It does not show up on urine drug screens. Referred to as "robo tripping'"it is seen as a "safe" drug but results in 6,000 emergency department visits per year. It is often mixed with alcohol which intensifies it's effects and can lead to respiratory depression and even death. If used by a person taking antidepressants it can cause the serotonin syndrome, a triad of mental changes, autonomic nervous system abnormalities and muscle twitching and tremor. The serotonin syndrome is seen as a medical emergency and can be life threatening. DXM is often found in preparations that contain antihistamines such as chlorpheneramine which can cause seizures in high doses or acetaminophen which can cause liver toxicity.

I believe that the best way to combat the increasing use of DXM is education both for physicians, teens, and the general public. We need to be aware that it is important to ask about this specific drug use in the same way that we do with alcohol and marijuana.

Thought for the day

There is no such thing as a "safe drug".

Dementia Worldwide Disability

The Center for Public Mental Health in London reported recently on a research study looking at various diseases which are contributors to chronic disability in the elderly. The research was sponsored in part by the World Health Organization and the study looked at more than 15,000 people in China, India, Dominican Republic, Venezuela, Mexico, and Peru. It had previously been thought that blindness, deafness, and heart disease were the major contributors to disability but this study found that dementia is "overwhelmingly and consistently the largest contributor to disability". Stroke and arthritis were the next other high ranking contributors.

The disability was determined using the 12 item World Health Organization disability assessment schedule. I have not seen that so am not really sure what that entails. Dementia, depression, hypertension, and chronic obstructive pulmonary disease were measured by clinical assessment but other diseases were determined by self report which the investigators acknowledge is a limitation of their study. The findings do remind us though of a significant impending problem as the incidence of dementia in the United States alone is estimated to triple by mid century.

I hope that we will have found ways by then to prevent dementia as enormous financial resources are required to care for individuals with dementia that as of now is not reversible.

Thought for the day

Show kindness to all as everyone you meet is fighting a battle of some kind.