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 socioeconomic 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.

Narcissists & Their Relationships by Rokelle Lerner

In 1958, Bill Wilson in the newsletter The Grapevine said, "the first job in recovery is sobriety, the second is emotional recovery." We all know that sobriety is quite different than recovery. Recovery means finding a way of living that works; physically, emotionally and spiritually. Sadly, many can get sober, but are still left with behaviors that don't disappear with treatment or sobriety. In fact, sometimes the qualities of entitlement and contempt are worse after treatment than before. It's for this reason I wrote a book on narcissism and how it relates to addiction recovery.

We are all aware of the term "King Baby." Although the image conjured up by this phrase is someone who's arrogant, snobbish, demanding, and aloof, the truth is that these are the very men who feel painfully inferior inside. In fact, the more a person displays this "kingly" behavior, the more second-rate he feels. These addicts/alcoholics are hiding tremendous shame with their pride. Feelings of entitlement, grandiosity, and contempt are a part of the disease of addiction. For someone living with a narcissistic addict or alcoholic, the devastation caused by addiction coupled with narcissistic traits feels insurmountable.

An addict has difficulty coping with the normal frustrations of life. The "king," however, because of his feeling of omnipotence and impatience, is constantly creating unnecessary roadblocks by storming ahead despite the cost. The narcissistic alcoholic shouldn't have to be bothered with recovery and may see the fellowship as trivial and boring; that is, unless he's in charge. He has little staying power for sobriety and expects quick results. Since recovery is one day at a time, and the surrender to the notion of powerlessness is tantamount to recovery, the prognosis is questionable, but not hopeless. There's always the chance that he'll pick up a sponsor who has some good recovery from addiction as well as entitlement.

Bob Brissette in his lecture at Hazelden in 1971 gave the following description of "king baby."
"Like babies, alcoholics assume that the world is our little private oyster. We tyrannize our homes, our wives, and our children: we demand meals to be served before there has been an opportunity to prepare them. Then we throw tantrums if everything isn't done thoroughly. We demand that food be of our choice, not the family's choice. We demand that our TV program be tuned in, not the family's program. And we deserve this, we tell ourselves--didn't we work hard all day down at the office? What if we did have five coffee breaks, a three-martini lunch that lasted 'til 2:45, and a couple of long, warm counseling sessions with that pretty girl employee who told us how kind and understanding we were. He's adept at twisting knives, cutting people up and humiliating them and making them frightened and insecure about their jobs. And he does this because it makes him feel better; it makes him feel more powerful."

I would be remiss if I didn't point out that the king baby has a female counterpart called the "Queen." Although we rarely speak about this female counterpart, some women possess these characteristics in spades. We all know those females that sweep into the room a half-hour late and demand that everyone must drop what they're doing and notice her. Her great need is to be the constant center of attention wherever she is. Frequently she speaks and laughs in a loud voice and assumes that what she has to say is absolutely fascinating--but it isn't. If the queen feels like granting you a sexual favor, you are expected to be grateful to her to your death for having had the privilege of romancing her. She demands absolute respect from her family and children. She whines and whimpers when all of her demands are not met promptly. (And whining, by the way, is anger coming through a tiny opening.) She feels entitled to proper gratitude for your having the privilege of serving her.

The queen is in deadly competition with her daughters. When they get to be teenagers and mom is starting to sag a little, an ugly, hateful battle develops between the queen and her children. Like the king, she sees other people as things, not as human beings or equals. To her, people are objects to be terrorized, bullied, and manipulated into loving, serving, and being loyal to her.

If you're reading this and diagnosing yourself or your loved ones as narcissists, please stop! Everyone is a bit narcissistic and only a caring, empathic therapist can make this diagnosis. Also, we need to have compassion for those that have this disorder. For the most part, narcissism is developed from an upbringing of trauma and neglect. However, since entitlement is such a part of the disease of addiction, emotional recovery means that we must do a fearless inventory on how our behavior affects others. Only then do our relationships begin to thrive.

Rokelle Lerner is one of the most sought after speakers and trainers on relationships, women's issues and addicted family systems. She has inspired audiences throughout the world with her ability to address difficulties with insight, humor, and astounding clarity.

She has received numerous awards for her work with children and families including Esquire Magazine's "Top 100 Women in the U.S. Who Are Changing the Nation." Rokelle has been an advisor and consultant with foreign governments, US agencies, corporations, schools and hundreds of individuals on relationships, boundary issues and addiction. She is also co-founder and consultant to Children Are People, Inc., a program used in thousands of schools throughout the country. Rokelle has appeared as a guest consultant on numerous television shows such as Oprah, Good Morning America, CBS Morning News and 20/20. Her articles and interviews have been featured in the Washington Post, New York Times, Newsweek, Time, People Magazine and Parents Magazine.

Rokelle has published the best selling books, Living in the Comfort Zone: The Gift of Boundaries in Relationships, Affirmations for Adult Children of Alcoholics and Affirmations for the Inner Child. Her latest book is The Object of My Affection is in My Reflection: Narcissists and Their Relationships. Ms. Lerner also facilitates the InnerPath Retreats for Cottonwood de Tucson in Arizona.

Attention Deficit Disorder part 6

This is the second to the last in a series on Attention Deficit Hyperactivity Disorder (ADHD). Today I would like to talk about the unique medication atomoxatine or Strattera. Next we will review some behavioral and psychosocial treatments.

Strattera is the only non stimulant medication that is FDA approved for the treatment of ADHD. It is a selective norepinephrine reuptake inhibitor that works by making available more of the neurotransmitter norepinephrine which is responsible for alertness and attention focusing. It is very similar to some antidepressant medications and unlike stimulants has no abuse potential. This makes it an ideal medication to use in those patients who have substance abuse problems as well as ADHD.

Unlike the stimulants Strattera does not carry a "black box warning" about abuse potential. Instead, like antidepressants it carries a black box warning of increased risk of suicidal ideation in children or adolescents which is the same for all
antidepressants. The black box indicates though that no suicides have been reported and recommends close monitoring. Like all medication it carries some risks and I will discuss these below.

Like the stimulants two of the major risks are cardiovascular and psychiatric. Strattera does increase the blood pressure to a small degree and should be used with caution in those who have hypertension, cerebral vascular disease or underlying cardiac disease. There have been reports of sudden death in those taking Strattera who have underlying cardiac disease and like the stimulants I strongly recommend a baseline electrocardiogram as well as a careful medical history. Unlike the stimulants it has no net effect on growth taken long term. The psychiatric risks of Strattera are the same as for the stimulants and include emergence of new manic or psychotic symptoms as well as increase in aggression or hostility. So the main difference between Strattera and the stimulants is the lack of abuse potential.

After reading of the possible risks of both the stimulants and Strattera you may be wondering why anyone would even take these medications? There are three factors to take into consideration. The first is that these risks are relatively small. The second is to realize that all medications of any type carry some possible serious risks. The third is that ADHD is very often severely disabling and affects psychological development, school and occupational functioning, and impairs interpersonal relationships to a great extent. I am bringing the problems with these medications to attention to emphasize that the use of ADHD medications should not be taken lightly, involve a thorough assessment and require close monitoring which is not the normal standard practice among many pediatricians, primary care physicians,and psychiatrists at this time. This leads to charges of overuse and inappropriate use which threaten the availability of these medications for those who very much need them.

Again I welcome any comments or questions.

Thought for the day

The same as yesterday. All medical treatments involve possible risks as well as benefits.

Attention Deficit Hyperactivity Disorder part 5

Yesterday I discussed the medications that are used to treat Attention Deficit Hyperactivity Disorder (ADHD). Today I want to talk a bit about the potential side effects and risks of the medications. I will take the stimulants first as the possible problems are basically the same for all of them and secondly to review Strattera.

Adderall and the other stimulants all carry a "black box warning". This refers to the FDA instruction to manufacturers requiring them to outline a particular drug risk, put in in a box with the warning highlighted as the first piece of prescribing information that any clinician will review. The stimulants all carry the warning of the possibility of misuse and drug dependence as well as the risk for serious cardiovascular complications if misused. Although it appears that almost any medication can occasionally cause almost any side effects the main risks are the cardiovascular events, psychiatric events, drug dependency, and growth retardation.

Stimulants can increase the heart rate, blood pressure, put more demands upon the heart, and in people with underlying structural cardiac defects or other serious heart problems there have been reports of sudden death. For this reason the American Heart Association has recommended that all patients being placed on stimulants be prescreened with a baseline electrocardiogram or EKG. Because this raises the cost of providing treatment this stance is somewhat controversial as the history, family history, and physical exam are likely to pick up any heart problems.The American Psychiatric Association and the American Academy of Child and Adolescent Psychiatry have not yet adopted this position but it is one that I very much agree with and I will not start a patient on stimulant medication without having a baseline EKG.

The second group of potential complications are psychiatric problems. Although these medications are used to treat a psychiatric disorder they can occasionally cause exacerbation of symptoms of patients with an underlying psychotic disorder, induce mania in patients with bipolar disorder, cause treatment emergent new onset of manic or psychotic symptoms, and aggressive behavior or hostility.

Careful followup studies have shown that persistent use of the medications seven days per week can result in growth suppression between the ages 5 to 10 or 13 of an average of 2 centimeters of height and 2.7 kilograms of weight with no growth rebound after cessation of the medication. Two centimeters average in itself is not a huge issue but this average means that some children have significantly more growth retardation therefore growth rates need to be monitored.

The issue of drug dependency is a difficult one. Most patients on stimulants for ADHD do not develop a drug dependency, need for higher and higher doses of the medication or misuse the medication but the possibility exists. The complicated thing however is that substance abuse is a risk of untreated AHHD so many with this disorder have co occurring substance abuse problems. In many cases the problems can be avoided by treating ADHD with Strattera instead of stimulants but what about the many patients who do benefit from or cannot tolerate Strattera? The decision of whether or not to use stimulants in patients with any kind of substance abuse disorder needs to be individualized but I will not use these medications in anyone with a history of stimulant, cocaine, or methamphetamine abuse. For others risk can be decreased by using one of the stimulant formulations that are slow release and compounded in a way unlikely to give the high that people are seeking. These are methylphenidate in the form of Concerta and amphetamine in the form of Vyvanse but both are expensive medications with no generic substitutions available.

I will talk about the problems of Strattera tomorrow. I welcome any questions or comments.

Thought for the day

All medical treatments involve both potential benefits as well as risks.

Attention Deficit Hyperactivity Disorder part 4

I want to talk a little bit about medication treatment for Attention Deficit Hyperactivity Disorder (ADHD). First of all, medications are effective at improving not only symptoms of the disorder but also can increase the level of functioning and complications of the associated features such as poor academic performance, decreased self esteem and demoralization, anger outbursts and mood problems as well as decreasing the likelihood of development of Oppositional Defiant Disorder and Conduct Disorder. Secondly as I mentioned before the psychosocial and behavioral interventions for this disorder are generally not very effective in the absence of medication treatment. Thirdly, any medication is not without it's hazards and difficulty and the medications used to treat ADHD are no different.

A number of medications have been tried and used for ADHD including antidepressants, anti hypertensives, and stimulants but there are two groups of medications that have current FDA approval for the treatment of this disorder. The first are the stimulants. These are amphetamines or amphetamine like drugs. Some commonly known ones are methlyphenidate (Ritalin), and the amphetamines Adderall and Dexedrine. Methlyphenidate now comes in various extended release forms for ease of use which include Concerta, Focalin, and the transdermal patch Daytrana. In addition to the amphetamines Dexedrine and Adderall there is a relatively new medication, Vyvanse, which when first metabolized becomes dextroamphetamine. All of these medications work by increasing the availability of the neurotransmitter dopamine. The second type of medication FDA approved for the treatment of ADHD has only one drug, atomoxatine (Strattera) which works by increasing the availability of the neurotransmitter norepinephrine. Both dopamine and norepinephrine are neurotransmitters that are necessary for many brain functions and include the functioning of the prefrontal cortex which is responsible for planning and foresight, monitoring and error correction, delayed gratification, impulse inhibition ,decision making, abstract thinking, attention shifting, information manipulation and social functioning all of which are impaired in ADHD.

Like all medications the use of the stimulants and atomoxatine carry some risks as well as benefits and these must be carefully weighed in each individual situation. I will outline some of these tomorrow.

Thought for the day

" Sometimes and ending can be the beginning of something wonderful".

Winnie Haller