Transcript Opioid Dependence During Pregnancy

Bipolar Disorder and
Alcohol Use Disorders
Marcy Verduin, M.D.
University of Central Florida
© AMSP 2010
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Challenging to Treat

Lack of treatment research

Dx challenge = symptom overlap

Rx challenges = toxicity & nonadherence

Integrated Rx difficult to find
© AMSP 2010
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This Lecture Reviews

Definitions

Prevalence, course, & causes

Treatment
© AMSP 2010
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Bipolar Disorder

1+ manic episode:
 1+ week euphoric or irritable mood
 3+ (or 4+ if irritable):

 self-esteem

 need for sleep



Distractibility

 goal-directed activity

 pleasurable activities
 talkativeness
Racing thoughts
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Depressive Episodes

Major depression = 5 lasting 2+ weeks:

Depressed mood

Sleep  or 

Interest 



Concentration 

Appetite  or 

Psychomotor  or 

Suicidal thoughts/attempt
Guilt  or worth 
Energy 
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Abuse & Dependence

Abuse 1+ of:


Obligations
Hazardous use

Legal

Interpersonal
problems

Dependence 3+ of:

Tolerance

Withdrawal

 Amounts or more time

Desire or unable cut down

 time get, use, or recover

 non-drug activities

Physical/psychological
problems
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Symptom Overlap

Alc → symptoms of BP

BP → symptoms of AUD

Use timing of sx’s to clarify
 Mania
before AUD
BP dx
 Mania
during sobriety
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Time Line Approach
Mania
18 20 23
Grad
HS
AUD
28
32
Married
Son
born
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This Lecture Reviews

Definitions ✓

Prevalence, course, & causes

Treatment
© AMSP 2010
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Prevalence
BP + AUD
Abuse
15%
No
AUD
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Dep
30%
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Prevalence of BP + AUDs

Alc Dep 6 x  mania
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BP 6 x  AUDs

BP = #1 Ψ disorder assoc with AUDs
© AMSP 2010
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AUDs Impact BP Symptoms
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3 x  onset < 20
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4 x  comorbid dx
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2-3 x  sx of:
 Impulsivity
 Violence
 Suicide
attempt
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AUDs Impact Recovery

 risk Ψ hospitalization (45% vs 15%)

~4 x faster relapse to mania

Slower mood episode recovery by ~2 wks
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Order of Onset Matters


Alc 1st:
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Older BP onset by ~10 years

Longer time in mood recovery
BP 1st:

 time in mood episodes

Longer time with AUD sx
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AUD Impact Adherence
70%
40%
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Shared Genetic Risk Factors
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~2 x  SUDs if relatives with BP or MDD
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Common chromosomal regions:
 Chr

9  BP risk
effect in AUD families
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Dysfunctional NTs
Dopamine (DA)
Reward
Pathway
Mania
Norepinephrine (NE)
Withdrawal
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Depression
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How Risk Factors → BP + AUD
No Alc
No BP
BP risk
Alc
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BP
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How Risk Factors → BP + AUD

BP → mania → all acts done to excess
 Excess

→  drink
drink → AUD
 Mania
resolves, but AUD remains
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Self-Medication

Theory:

 Alc to  BP sx
 But
prior MDD →  AUD
 Alc
→  dep sx
 Alc
→  mania
© AMSP 2010
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This Lecture Reviews

Definitions ✓

Prevalence, course, & causes ✓

Treatment
© AMSP 2010
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What We Know

BP + AUD excluded from studies

Joint BP + AUD difficult to study

Joint dx often mixed episodes

Are dangers to use antidepressants
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Recall Clinical Vignette
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42 yo man
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History of BP and Alc Dep
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Residential rehab
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30 days sober

Not taking meds

Mania + depression
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Initial Assessment
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Medical & Ψ issues, rx plan
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Most immediate need – rx withdrawal

Consider Ψ emergencies
 Suicide
 Violence
 Psychosis
 Self-neglect
© AMSP 2010
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Rx Setting
Suicide/
violence
Severe
mood sx
Severe
w/d
Compliant
Psychosis
Mild/mod
mood sx
Hospital
Selfneglect
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Social
support
Outpatient
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Alc Detox

Standard rx = bz
 Lorazepam

(Ativan): 2-4mg qid day 1
Taper over ~ 5 days
© AMSP 2010
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Also for Detox

+/- Anticonvulsants

side-effects & cost
 Valproate
(Depakote):
20mg/kg/day ( bid) day 1

Taper over ~ 5 days
© AMSP 2010
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Rx Mood Sx in BP

Mood stabilizer +/- adjunctive meds
 Lithium
 Anticonvulsants
 Antipsychotics
(e.g., valproate)
(e.g., olanzapine)
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Lithium (Lithobid)

Dose 600-1200mg/day ( bid)

Rx & prevent mania

Blood levels: 0.6-1.2 mEq/L

Side effects (SE):  thirst/urination,
tremor, nausea, birth defects
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Anticonvulsants

Often used + Li

Interactions with alc = dangerous

Most common:
 Valproate
(Depakote)
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Valproate

Usual dose = 1000-1500mg/day ( bid)

Mixed mania & rapid cycling

Blood levels: 50-100 μg/mL

SE: GI upset, tremor,  weight, birth
defects
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Atypical Antipsychotics

Often temporary for acute mania
 Olanzapine

(Zyprexa): 10-20mg/day
Many SE:  weight, sedation, dry mouth,
 glucose,  lipids
© AMSP 2010
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Rx in BP + AUD
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VPA > Li for mood stabilization

Mixed mania & rapid cycling
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Adherence

Beware:  risk lethal OD with alc

Avoid antidepressants

Choose mood stabilizer effective in w/d
© AMSP 2010
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AUD Medications

Disulfiram (Antabuse)

Naltrexone (Revia)

Acamprosate (Campral)
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Disulfiram (Antabuse)

Sensitizing agent to alc

Few controlled trials in AUD

Too dangerous in BP?

Many SE: depression, psychosis

Usual dose 250mg/day
© AMSP 2010
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Naltrexone (Revia)

 rewarding effects of alc
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No data in BP

Blocks opioid receptor →  DA
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2 formulations:

Oral – usual dose 50-100mg/day

Depot (Vivitrol) – 380mg IM/month
© AMSP 2010
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Acamprosate (Campral)

Improves abstinence

No data in BP

Stabilizes glutamate in protracted w/d

Usual dose ~2g/day
© AMSP 2010
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Psychotherapy

Cognitive-Behavioral Therapy (CBT)

Individual & group

Effective for both BP and AUD

For BP:  adherence, monitor relapse,
 communication

For AUD: behavior change, prevent
relapse, self-help groups
© AMSP 2010
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Clinical Vignette - Outcome

Valproate:  mood sx,  liver enzymes

Lithium:  mania, no effect depression

Depression →  craving

Antidepressant + naltrexone → stable

CBT + Alc Anon
© AMSP 2010
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Summary of BP + AUD Rx

Initial assessment: safety, dx

Determine rx setting

Stabilize mood

Add meds for AUD

Psychotherapy
© AMSP 2010
40
This Lecture Reviews

Definitions ✓

Prevalence, course, & causes ✓

Treatment ✓
© AMSP 2010
41