Pharmacology

Clinical Update

PrEP: Introduction to the Basics

Topics: Addiction | Addiction Treatment | HIV | Medical Comorbidities | Medication | Pharmacology | Prevention | Substance Use | Substance use disorders

Great strides have been made in HIV treatment and prevention during the last 2 decades, resulting in falling numbers of new HIV infections during that time span. But since 2013, the rate of new infections has mostly plateaued at just under 40,000 new infections per year (www.hiv.gov). Those at highest risk of infection remain men who have sex with men,

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Expert Q&A

Perioperative Management of Patients on Buprenorphine Maintenance

Topics: Addiction | Addiction Treatment | Buprenorphine | Medical Comorbidities | Medication | Opioid epidemic | Opioid Use Disorder | Opioids | Pain | Pharmacology | Suboxone | Substance Use | Substance use disorders

CATR: Can you tell us about your background? Dr. Acampora: I used to work as a cardiac anesthesiologist. Later, my interest turned to addiction medicine, and I trained in psychiatry and addiction psychiatry. I currently work in a pain clinic where I helped develop a strategy for managing buprenorphine in the perioperative period. CATR: Where does th

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Research Update

Varenicline and Bupropion: Soaring Again With EAGLES?

Topics: Addiction | Addiction Treatment | Bupropion | Chantix | Co-occurring disorders | Dual diagnosis | FDA Warnings | Medication | Pharmacology | Research | Research Update | Side Effects | Smoking Cessation | Smoking Cessation Agents | Substance Use | Substance use disorders | Suicidality | Suicide | Tobacco | Varenicline | Wellbutrin

Review of: Anthenelli RM et al, Lancet 2016;387(10037):2507–2520 Varenicline (Chantix) and bupropion (Zyban and others) are effective treatments for tobacco use disorder, but their use (and sales) took a big hit in 2009 when the FDA slapped both with black box warnings linking them to psychiatric complications, including suicidal ideation. Although

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Research Update

The COMBINE Study: A Core Paper in the Treatment of AUD

Topics: Acamprosate | Addiction | Addiction Treatment | Alcohol | Alcohol Use | Alcohol use disorder | Alcoholism | Medication | Naltrexone | Pharmacology | Psychotherapy | Research | Research Update | Substance Use | Substance use disorders | Therapy during medication appointment | Therapy with Med Management

Review of: Anton RF et al, JAMA 2006;295(17):2003–2017 Conducted from 2001 to 2004 and published in 2006, the COMBINE study was the largest pharmacotherapy study that assessed the treatment of alcohol use disorder (AUD). Although there were significant data on the use of naltrexone and acamprosate (both had been FDA approved), widespread use had no

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Clinical Update

“What About the Implant, Doc?” Appraising Various Formulations of Buprenorphine

Topics: Buprenorphine | extended-release | Medication | Medication adherence | Opioid epidemic | Opioid Use Disorder | Pharmacology | safety | Side Effects

With other epidemics in the world dominating our attention, let’s not forget the epidemic of opioid-related deaths. Unlike the current viral epidemic, the opioid epidemic is eminently treatable. The figure on page 3 shows the reduction in heroin overdoses in Baltimore, MD, as increasing numbers of patients received opioid agonist treatment (Schwartz R

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Clinical Update

Updated Guidelines for Treating Opioid Use Disorder

Topics: Addiction Treatment | Buprenorphine | Medication | Methadone | Opioid epidemic | Opioid Use Disorder | Pain | Pharmacology

Before the COVID-19 pandemic, America was in the grip of an opioid crisis. Now, the medical community is sounding alarms that shelter-in-place orders may have triggered drug and alcohol relapses (Silva MJ et al, Am J Manag Care 2020;26(7):1–3). The American Medical Association has noted that at least 30 states have reported increases in opioid-related

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Research Update

A Possible Option in Opioid-Related Harm Reduction

Topics: Harm reduction | Heroin | Opioid epidemic | Opioid Use Disorder | Pharmacology

REVIEW OF: Oviedo-Joekes E et al, JAMA Psychiatry 2016;73(5):447–455 We have effective FDA-approved medications for opioid use disorder (OUD): buprenorphine, methadone, and injectable naltrexone. Yet some patients with severe OUD decline these options. Many other countries offer a more controversial treatment—medically supervised IV administratio

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Research Update

Efficacy and Acceptability of Varenicline for Alcohol Use Disorder

Topics: Alcohol | Alcohol use disorder | Pharmacology | Tobacco use disorder | Varenicline

REVIEW OF: Oon-Arom A et al, Drug Alcohol Depend 2019;205:1–9 Varenicline, a partial agonist of one of the nicotinic receptors, is approved for the treatment of tobacco use disorder and has also been found to decrease alcohol use in some individuals who smoke. Naltrexone, acamprosate, and disulfiram are FDA approved and effective for alcohol use di

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Clinical Update

The “Z-Drugs”: Safety Issues and Misuse Potential

Topics: Anxiety | Clinical practice | Deprescribing | Free Articles | Pharmacology | polypharmacy | prescribing patterns | Risk Management | Sleep | Sleep Disorders

Originally marketed as safer alternatives to benzodiazepines, the Z-drugs—eszopiclone (Lunesta), zaleplon (Sonata), and zolpidem (Ambien)—were considered devoid of misuse potential. But recent data and FDA warnings suggest we’ve been hitting the snooze on them for too long. Here, we review their risks and discuss safe prescribing. Medical risks

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Clinical Update

Muscle Relaxants: Sedatives Often Under the Radar

Topics: Clinical practice | Deprescribing | Opioids | Pain | Pharmacology | polypharmacy | prescribing patterns | Risk Management

Muscle relaxants are a diverse group of medications with varying mechanisms of action (see Commonly Prescribed Muscle Relaxants table below). They are indicated for short-term treatment (2–3 weeks) of acute, painful muscle spasms, as well as some chronic neurologic conditions associated with spasticity. However, many patients with chronic pain are on

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Research Update

Amphetamines and Topiramate for Cocaine Use Disorder

Topics: Cocaine | Pharmacology | Research | Research Update

Review of: Levin FR et al, Drug Alcohol Depend 2020;206:107700 In 2017, an estimated 2.2 million Americans used cocaine, with about 966,000 of them meeting criteria for cocaine use disorder (CUD) (SAMHSA, 2018). Unfortunately, there are still no FDA-approved treatments for CUD. Amphetamines increase synaptic dopamine transmission and may therefore re

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Research Update

Does Baclofen Titrated to High Doses Reduce Alcohol Use?

Topics: Alcohol | Alcohol Use | Alcohol use disorder | Pharmacology | Research | Research Update

Review of: Rigal L et al, Addiction 2019 Dec 13 [Epub ahead of print] Baclofen is a muscle relaxant and anti-spasmodic that has been used off-label for treating alcohol use disorder for many years. The research base is mixed, with studies showing inconsistent efficacy and tolerability at different doses. In this latest randomized, placebo-controlled

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Research Update

Gabapentin for Alcohol Use Disorder, Redux

Topics: Alcohol | Alcohol Use | Alcohol use disorder | gabapentin | Pharmacology | Research | Research Update

Review of: Anton RF et al, JAMA Intern Med 2020;180(5):1–9 Gabapentin has had mixed results in the treatment of alcohol use disorder (AUD), but it is clearly effective in the treatment of alcohol withdrawal syndrome (AWS). In this study, researchers tested whether gabapentin might be effective specifically in treating adults with AUD who also had a

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News of Note

New Generic Versions of Naloxone

Topics: Addiction | Addiction Treatment | Clinical practice | Medication | Naloxone | News of Note | Opioid epidemic | Opioid Use Disorder | Opioids | Overdose | Pharmacology

Naloxone, a rescue medication effective for reversing opioid overdoses, will soon be available in two generic forms for layperson use. Naloxone nasal spray is the generic version of branded Narcan Nasal, which currently sells for $150 for two doses. The generic version will be much cheaper. Naloxone auto-injector is the generic version of Evzio au

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Research Update

Gabapentin Enacarbil XR Efficacy Less Than Expected for AUD

Topics: Addiction | Addiction Treatment | Alcohol | Alcohol use disorder | Alcoholism | Clinical practice | extended-release | Medication | Novel Medications | Pharmacology | Psychopharmacology | Research Update

Review of: Falk DE et al, Alcohol Clin Exp Res 2019;43(1):158–169 Gabapentin enacarbil extended-release (GE-XR) (Horizant) is an extended-release version of gabapentin. GE-XR is a prodrug, meaning that once ingested it is metabolized into gabapentin. It is currently approved for treatment of postherpetic neuralgia and restless legs syndrome. It di

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Research Update

Can Buprenorphine Improve PTSD Symptoms?

Topics: Addiction | Addiction Treatment | Antidepressants | Buprenorphine | Co-occurring disorders | Comorbidity | Dual diagnosis | Medication | Opioid Use Disorder | Pharmacology | PTSD | Research Update | SSRIs

Review of: Lake EP et al, Am J Addict 2019;28(2):86–91 For many years, the mainstay of treatment for PTSD has been the SSRI class of medications, but many of our patients still suffer crippling symptoms despite optimal antidepressant medication dosing. PTSD is often accompanied by opioid misuse, sometimes in an effort to self-treat the hyperarousal

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Expert Q&A

Assessing and Treating Traumatic Brain Injury

Topics: Bipolar Disorder | Bipolar II | Coronavirus | COVID19 | Lithium | Mania | Mood Stabilizers | Pharmacology | Pharmacology Tips | Psychopharmacology | Psychopharmacology Tips

TCPR: Lithium has been called the gold-standard treatment in bipolar disorder. Why is it not used more often?Dr. Rybakowski: That is a paradox. On the one hand, lithium is accepted as a first-line treatment for bipolar disorder, but it is also greatly underutilized. And I think there are two main reasons. One is aggressive promotion of branded mood stab

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Research Update

Two Augmentation Strategies Compared in Bipolar I

Topics: Bipolar Disorder | Lithium | Mania | Mood Stabilizers | Oxcarbazepine | Pharmacology | Psychopharmacology | Research | Research Update

Review of: Missio G et al, Trials 2019;20(1):608 STUDY TYPE: Randomized, open-label controlled trial It’s rare to see full recovery in bipolar I disorder with a single medicine, so we often depend on some combination of mood stabilizers and/or antipsychotics. Even then, weight gain and metabolic problems are deal-breakers. Some experts favor the c

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Clinical Update

Oxcarbazepine: Close, but no Cigar

Topics: Bipolar Disorder | Carbamazepine | Free Articles | Mania | Mood Stabilizers | Oxcarbazepine | Pharmacology | Psychopharm Myths | Psychopharmacology

You are selecting a mood stabilizer for a 29-year-old woman with mania. If it works, she’ll need to take it long term, but with adherence rates hovering around 50% in this illness, that’s not a likely prospect. The FDA-approved options are not very high on tolerability, but what about oxcarbazepine? Oxcarbazepine (Trileptal) is often used in bipo

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News of Note

Lumateperone and lemborexant

Topics: Antipsychotics | Belsomra | Caplyta | Dayvigo | Hypnotics | Lemborexant | Lumateperone | News of Note | Orexin | Pharmacology | Psychopharmacology | Suvorexant

Two new psychiatric medications were approved in the final days of 2019. One is the first of its kind, an antipsychotic with minimal dopaminergic blockade: lumateperone (Caplyta). The other is lemborexant (Dayvigo), a variation on the hypnotic suvorexant (Belsomra). Lumateperone (Caplyta)Though classified as an atypical antipsychotic, lumateperone is u

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