Expert offers strategies for detecting, managing sedative hypnotic, stimulant use disorders

NEW YORK — According to John J. Mariani, MD, associate professor of clinical psychiatry and director of Substance Treatment and Research Service at Columbia University, it is a core clinical skill for psychiatrists to detect when the controlled substances they prescribe are being misused. In a session here, Mariani detailed clinical strategies to minimize the potential for misuse, as well as how to detect and manage sedative hypnotic and stimulant use disorders.

“Why talk about sedative hypnotics and stimulants together, since pharmacologically they have opposite mechanisms of action? These are the controlled substances that psychiatrists are commonly prescribing, and there are difficulties — controlled substances have an inherent risk of misuse and addiction,” he said during his presentation.

Benzodiazepines are among the most frequently used psychopharmaceuticals worldwide, with more than 20 agents currently approved for use across the globe, according to Mariani. Similarly, stimulant prescribing has increased in the U.S. over the past 10 to 20 years, due in part to an increase in awareness and diagnosis of ADHD in both children and adults, the primary indication.

“Both drug categories contain agents that are effective treatments for the disorders they’re prescribed for, but they both have liability for misuse,” he said.

Mariani outlined three important pathological patterns of controlled substance use: nonmedical use, that is not using the drug as it was specifically prescribed; misuse, which he defined as use not consistent with medical purposes or advice; and substance use disorder, or a maladaptive pattern of substance use that causes some level of distress.

“These terms are important to think about because when we talk about this we tend to conflate all problems with using these drugs into one category,” he said.

Prescribing medications with misuse potential

Data from 2016 on misuse of psychotherapeutics showed 3.3 million people were past-month-users of prescription painkillers, 2 million were past-month tranquilizer users and 500,000 were past-month sedative users. Mariani described it as a public health problem, “This is happening in a large number of people, and ultimately the supply of these medications is coming from prescriptions from doctors,” he said. The most common age group for misuse was 18 to 25 years.

The first step in prescribing medications with misuse potential is to recognize their misuse potential, he said. “Nonprescribed use, misuse, diversion [and] addiction are inherent risks for prescribing controlled substances — you can take measures to reduce the risk of these problems, but these problems will occur.”

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Assessing risk must be done at the individual patient level, which Mariani suggested attendees do regularly and in a nonthreatening and nonjudgmental way, while also adhering to regulatory responsibilities when prescribing.

“Addiction psychiatrists are used to people coming in and reporting all types of relatively dangerous and deviant behaviors with injecting medications and stealing things, but when someone does something you don’t think is appropriate with something you prescribed, you tend to take it personally,” he said. “When prescribing and there starts to be problems, it’s very easy to lose track of how we’re responding to [the situation] because it seems like it involves us.”

Identifying those at risk

Mariani suggested a multimodal approach, gathering information from as many sources as possible, to identify patients at risk for substance use disorders. While some patients may make their risk apparent by specifically asking for the medication, it may be more difficult to detect in others. He listed the following red flags:

intoxication or withdrawal, either observed or via reports from others;

insisting on fast-acting preparations;

repeated lost prescriptions;

discordant pill count;

excessive preoccupation with securing medication supply; and

multiple prescribers.

When assessing patients at risk, consider whether they have an active substance use disorder, or a history of substance use disorders; look at medication supply; assess reports from family members; utilize state databases; identify patterns of prescription refills; and examine urine toxicology, he said.

To manage those at-risk, he suggested the following:

stratify risk;

closely monitor medication;

treat current substance use disorders; and

use overall clinical stability and optimal functioning as treatment goals.

In closing, Mariani addressed the question of whether patients with a history of misuse can be prescribed a different medication in the same drug class. The answer: “often not.” However, he did offer two options: Find a medication with similar pharmacology but lower potential for misuse, eg gabapentin or pregabalin for benzodiazepines, or modafinil or armodafinil for amphetamines; or choose a medication in the same pharmacologic class with different formulation in the same class, eg clonazepam for alprazolam, or methylphenidate patch or lysdexamfetamine for amphetamines.

“There is a lot of opportunity for psychoeducation in trying to help patients understand how the drugs are affecting them,” he said. – by Stacey L. Adams

Reference:

Mariani JJ. Choosing the right treatment for substance use disorders. Presented at: American Psychiatric Association Annual Meeting; May 5-9, 20178; New York.

Disclosures: Mariani reports no relevant financial disclosures.