Experts weigh in: An introduction. Thomas R. Kosten, MD, Chair of our Special Report on SUDS, provides highlights on new findings and introduces topics that will be of interest to practicing psychiatrists, including important drug indications, life-threatening complications, pharmacotherapy for adolescent ADHD, self-medicating, cannabis use, benzodiazepines in patients with addiction problems, and other issues. See: SUDs: Cautions, Considerations, and Treatment Strategies
It’s complicated. In this clinical review, Christopher Hammond, MD, PhD, and Pravesh Sharma, MD describe the challenges of treating adolescent abuse disorders, which often relies on nonpharmacological interventions. With a clinically focused introduction to treatment principles for adolescent substance abuse disorders, the authors review evidence-based approaches. Practicing psychiatrists will learn about important drug indications but should not avoid the FDA-approved medications for SUD—whether naltrexone for alcohol or buprenorphine for opiates. The life-threatening complications of SUD such as overdoses can be prevented in adolescents who are well-treated pharmacologically. See: Treatment Strategies for Substance Use Disorders in Adolescents
Alcohol and sleep, or lack thereof. Dual diagnosis is a term commonly employed in substance abuse treatment. What is less recognizable is the concept of disturbed sleep as a co-occurring disorder in need of management. The complexities are vast and clinicians remain appropriately circumspect about prescribing medications with potential abuse liability. Sleep disturbance may often be perceived by clinicians and patients alike as a natural consequence of substance withdrawal that should remit in time. Kristen Schmidt, MD, and Bhanu Kolla, MD, remind us that overall, this problem is very relevant for clinicians and may be so problematic for patients with alcohol use disorder that it leads them to relapse. Finally, sleep disruptions often persist long after alcohol withdrawal. See: Understanding and Addressing Sleep Disruptions in Alcohol Use Disorders
CBT-I in alcohol recovery. Whether sleep disturbance is a residue of substance use or substance use is a consequence of historically complicated sleep patterns is up for debate. What has been shown, however, is that a failure to treat the comorbid sleep disorder may predict relapse. Nonpharmacological interventions such as cognitive behavioral therapy for insomnia (CBT-I) have been effective at minimizing sleep disturbance in recovery populations and may have positive effects on relapse. CBT-I consists of behavioral and cognitive strategies aimed at improving sleep quality and daytime functioning. For a mobile-friendly view of the table, click here.
Treatment or addiction risk? In patients with a substance use disorder, knowing what and when to treat is an important skill. George Dawson, MD informs readers on important considerations and provides clinicians with clear guidelines about 2 key issues: (1) Which patients should be given long-term benzodiazepines? and (2) What doses are appropriate for patients with affective and anxiety disorders, particularly those with comorbid SUD? Illicit uses of benzodiazepines include combinations with alcohol to get high or after alcohol to reduce withdrawal, with opiates to augment euphoria, and after stimulants to reduce withdrawal. Good clinical care requires knowing which of the anxiety disorders—PTSD, generalized anxiety, panic, somatization, or OCD—poses the greatest risk for lack of efficacy and concomitant abuse of benzodiazepines. See: Benzodiazepines and Their Role in Substance Use Disorders
6 tips for benzodiazepine prescribing. Guidelines on benzodiazepine use have evolved over the years. As psychiatrists know, they are no longer regarded as first-line treatment. The evolution of thought on the addictive potential of benzodiazepines ranges from low abuse potential to observations that benzodiazepines are frequently used in combination with drugs of abuse and are commonly seen in polydrug overdose scenarios. For a mobile-friendly view of the table, click here.
Cannabis: just the facts. It is vital that psychiatrists are able to identify and characterize cannabis use disorders; provide education; and offer effective, evidence-based treatments. Christina Brezing, MD, and Frances Levin, MD provide a brief overview of each of these topics, all of which are becoming increasingly relevant as cannabis is legalized in many parts of the US. In addition, they remind us that synthetic cannabinoids are typically and inaccurately viewed by adolescents as equivalent to cannabis and its perceived medical safety. Thus, clinicians need to consider not only the parent drug, but also its more dangerous and deceptive synthetic cousins. See: Treatment for Cannabis Use Disorders: A Case Report
A complex issue. Because comorbid substance abuse is the rule rather than the exception in individuals with ADHD, accurate diagnosis, prognosis, and management of ADHD is challenging even for the most skilled practitioners. Providing pharmacotherapy for adolescent ADHD offers different challenges. Also, stimulants may be problematic, particularly when a patient describes “self-medication” as the reason for his or her illicit stimulant abuse. Chardeé Galan, MS, and Kathryn Humphreys, PhD offer useful advice on making an accurate diagnosis of ADHD in patients with SUD and on treatment options. See: ADHD and Substance Use: Current Evidence and Treatment Considerations
Booming business. Clinicians need to know both sides of the ongoing debate contained in this article by Smita Das, MD, PhD, MPH, and Judith Prochaska, PhD, MPH. E-cigarettes have been endorsed by Great Britain’s health authorities for harm reduction, while the FDA is developing ways to regulate their use for safety concerns. The authors summarize data on e-cigarettes, provide recommendations and resources to learn more, and emphasize the evidence for treating tobacco (traditional cigarettes) addiction in people with mental illness. They provide a thoughtful and balanced discussion of this rapidly proliferating device. See: E-Cigarettes, Vaping, and Other Electronic Nicotine Products: Harm Reduction Pathways or New Avenues for Addiction?