Category: Addiction Medicine

Crush Long Hours: The Ultimate Hack for Demanding Jobs!

It seems like ADHD medication is following me this week—or maybe it’s the law of attraction at work as I keep coming across articles aligned with the key points I’ve been reflecting on recently.

A recent Wall Street Journal article highlights the growing use of prescription stimulants like Adderall and Vyvanse among young investment bankers, helping them manage the grueling demands of 90-hour workweeks. While the prevalence of substances to enhance performance isn’t new (cocaine was once the drug of choice), it’s become much easier to obtain legal alternatives. A quick five-minute online questionnaire can now yield a prescription, no shady drug dealers required.

The article centers on a young professional who, despite his own skepticism about having ADHD, found the medication transformative for surviving the intense pace of his job. Predictably, dependency followed.

This isn’t an isolated issue, nor is it exclusive to investment banking. We’ve seen a marked increase in adult ADHD diagnoses, likely tied to the expansion of telehealth and more relaxed prescribing practices.

While the article rightly calls for reevaluating workplace expectations and support systems, let’s be honest—this phenomenon isn’t going anywhere soon. The stakes are too high: major profits for companies and career-defining opportunities for individuals.

We need to acknowledge this for what it really is: the use of performance-enhancing drugs (PEDs) to gain an edge in professional life. In many ways, it’s no different from using steroids in sports. Maybe the real question isn’t how to stop it, but whether we should allow informed adults to use PEDs under careful medical supervision.

I’ll let you all weigh in on that one.

Cheers,
Dr. G

LInk: https://www.wsj.com/finance/banking/young-banker-finance-adhd-medication-adderall-d578a16f

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Buprenorphine vs. Methadone: The Battle for Opioid Use Disorder Treatment Supremacy

A recent study in JAMA compared the effectiveness of buprenorphine/naloxone versus methadone for opioid use disorder (OUD), focusing on treatment retention and mortality outcomes. The findings highlight important differences in these two mainstay treatments:

  1. Treatment Retention: Methadone demonstrated significantly higher retention rates compared to buprenorphine/naloxone. Retention is a critical metric, as staying in treatment reduces the risk of relapse and overdose. In flexible-dose studies, buprenorphine/naloxone patients were 37–40% more likely to discontinue treatment than methadone recipients. This aligns with its pharmacological profile, as methadone provides more consistent suppression of withdrawal symptoms.
  2. Mortality Rates: There were no significant differences in mortality risks between the two treatments, indicating both are comparably safe when provided in a supervised setting.
  3. Dosing Implications: Higher doses of buprenorphine (≥16 mg/day) were associated with better retention and reduced emergency care visits, suggesting dose adequacy is vital in achieving optimal outcomes. However, underdosing or rigid dosing protocols may limit buprenorphine’s effectiveness in real-world settings.
  4. Practical Considerations: Methadone requires daily visits to specialized clinics, which can be a barrier to care for some patients. In contrast, buprenorphine/naloxone can often be prescribed in primary care settings, improving accessibility.

The choice between methadone and buprenorphine/naloxone should be individualized, considering patient preferences, clinical circumstances, and potential barriers to adherence. These findings underscore the need for flexible treatment options tailored to the patient population.

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Buprenorphine and Psychosis: Unraveling the Risks of Abrupt Discontinuation

This post is inspired by a real case from my practice involving a patient with no significant past psychiatric history but a strong history of substance use, including opioids and cocaine. The patient had been on buprenorphine maintenance therapy for several decades, providing stability in their recovery. However, following an abrupt discontinuation of buprenorphine, the patient developed acute psychotic symptoms. This case highlights an uncommon but important phenomenon clinicians should be aware of when managing buprenorphine discontinuation, especially in individuals with a history of substance use.

Emerging evidence suggests that abrupt discontinuation of buprenorphine may induce psychosis in some individuals, though this appears to be a relatively uncommon occurrence.

Documented Cases

  • New-onset psychotic symptoms have been reported after sudden cessation of buprenorphine in patients with no prior psychosis.
  • Common symptoms include auditory hallucinations, paranoid ideation, and delusions of reference.
  • Psychotic symptoms typically emerge within days to weeks after discontinuation.

Potential Mechanisms

  1. Loss of buprenorphine’s antipsychotic effects through kappa-opioid receptor antagonism.
  2. Interaction between neurobiological vulnerabilities and the stress of withdrawal.
  3. Possible unmasking of latent psychotic disorders.

Risk Factors

  • History of substance use.
  • Early adverse life events.
  • Underlying psychiatric conditions (e.g., bipolar disorder).

Outcomes and Management

  • Symptoms may resolve in weeks to months, though some cases persist longer.
  • Reintroduction of buprenorphine has led to symptom remission in some cases, suggesting a causal relationship.
  • Gradual tapering of buprenorphine might mitigate this risk, though more research is needed.

Clinical Implications

Clinicians should remain vigilant when discontinuing buprenorphine, especially in individuals with risk factors for psychosis. A gradual tapering strategy is recommended to reduce potential risks, though further studies are necessary to guide best practices.

Understanding this phenomenon highlights the importance of individualized care when managing buprenorphine discontinuation in vulnerable populations.

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Abrupt Discontinuation of Buprenorphine and Risk of Psychosis: Clinical Considerations

This post is inspired by a real case from my practice involving a patient with no significant past psychiatric history but a strong history of substance use, including opioids and cocaine. The patient had been on buprenorphine maintenance therapy for several decades, providing stability in their recovery. However, following an abrupt discontinuation of buprenorphine, the patient developed acute psychotic symptoms. This case highlights an uncommon but important phenomenon clinicians should be aware of when managing buprenorphine discontinuation, especially in individuals with a history of substance use.

Emerging evidence suggests that abrupt discontinuation of buprenorphine may induce psychosis in some individuals, though this appears to be a relatively uncommon occurrence. Here are the key findings:

Documented Cases

  • New-onset psychotic symptoms have been reported after sudden cessation of buprenorphine in patients with no prior psychosis.
  • Common symptoms include auditory hallucinations, paranoid ideation, and delusions of reference.
  • Psychotic symptoms typically emerge within days to weeks after discontinuation.

Potential Mechanisms

  1. Loss of buprenorphine’s antipsychotic effects through kappa-opioid receptor antagonism.
  2. Interaction between neurobiological vulnerabilities and the stress of withdrawal.
  3. Possible unmasking of latent psychotic disorders.

Risk Factors

  • History of substance use.
  • Early adverse life events.
  • Underlying psychiatric conditions (e.g., bipolar disorder).

Outcomes and Management

  • Symptoms may resolve in weeks to months, though some cases persist longer.
  • Reintroduction of buprenorphine has led to symptom remission in some cases, suggesting a causal relationship.
  • Gradual tapering of buprenorphine might mitigate this risk, though more research is needed.

Clinical Implications

Clinicians should remain vigilant when discontinuing buprenorphine, especially in individuals with risk factors for psychosis. A gradual tapering strategy is recommended to reduce potential risks, though further studies are necessary to guide best practices.

Understanding this phenomenon highlights the importance of individualized care when managing buprenorphine discontinuation in vulnerable populations.

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Beyond Blood Sugar: GLP-1 Agonists Show Promise in Cutting Alcohol Cravings

Recent research in JAMA and JCI Insight on repurposing GLP-1 receptor agonists, particularly semaglutide and liraglutide, for Alcohol Use Disorder (AUD) shows promise.

  1. Mechanism of Action: Semaglutide and liraglutide, commonly used to manage diabetes and obesity, activate the GLP-1 receptor, which plays a role in satiety and reward pathways. This activation has shown to suppress the rewarding effects of alcohol, aligning with existing data on the overlap between mechanisms regulating food intake and addictive behaviors.
  2. Preclinical Findings: In rodent models, semaglutide reduced alcohol intake in a dose-dependent manner, with promising results across both binge drinking and alcohol-dependent models. Compared to other GLP-1 agonists, semaglutide’s potent binding and prolonged action make it a strong candidate for further study.
  3. Clinical Potential: The findings provide a foundation for testing semaglutide in clinical trials for people with AUD, where it could potentially serve as an alternative to traditional treatments by targeting alcohol cravings and reducing consumption patterns in those with AUD.

The promising preclinical data suggests that further investigation could potentially lead to semaglutide as a viable treatment for AUD, adding to the treatment options for substance use disorders that overlap with metabolic disorders. This research is ongoing, and clinical trials may help solidify its role in AUD treatment in the future.

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Clearing the Smoke: What We Know About Cannabis for Mental Health Treatment

Research into the therapeutic potential of cannabis for mental health disorders has grown in recent years, with mixed findings from randomized controlled trials (RCTs).

Anxiety Disorders

  • CBD (Cannabidiol) has shown promise in reducing anxiety symptoms in RCTs, particularly for social anxiety disorder (SAD). For instance, a small RCT found that a single dose of 300 mg of CBD reduced anxiety levels in participants undergoing a simulated public speaking test.
  • Some RCTs suggest that CBD may be anxiolytic without causing impairment or euphoria, making it preferable for anxiety compared to THC-dominant cannabis products, which may exacerbate anxiety in some users.

Post-Traumatic Stress Disorder (PTSD)

  • RCTs exploring THC and CBD combinations in PTSD have had mixed outcomes. Some studies indicate that THC may reduce nightmares and improve sleep in PTSD patients, though these findings are generally based on small sample sizes and short-term trials.
  • A recent RCT with a synthetic cannabinoid (nabilone) reported some symptom improvement in PTSD-related insomnia and nightmares. However, larger trials with longer follow-ups are necessary to clarify the efficacy and safety for PTSD.

Depression

  • Few RCTs show consistent evidence supporting cannabis (CBD or THC) as an effective treatment for major depressive disorder. Some trials indicate that CBD may have antidepressant-like effects, possibly due to serotonin receptor activity, but more robust and long-term studies are needed.
  • Concerns persist over THC’s potential to exacerbate depressive symptoms, particularly with regular or heavy use.

Schizophrenia and Psychotic Disorders

  • THC-dominant products have been associated with increased risk of psychosis and exacerbation of symptoms in people predisposed to psychotic disorders. This has led to caution against THC use in people with schizophrenia.
  • CBD has shown promise as an adjunctive treatment in some RCTs, with findings suggesting that it may have antipsychotic effects without the psychoactive effects of THC. For example, an RCT found that CBD reduced psychotic symptoms and improved cognitive function when added to standard antipsychotic treatment, though the effects were modest.

Bipolar Disorder

  • Evidence from RCTs on the use of cannabis in bipolar disorder is sparse and generally negative. Some trials indicate that THC may worsen manic and depressive symptoms in bipolar patients, and there is little to no support for cannabis as a treatment for bipolar depression.

Sleep Disorders

  • Some RCTs have evaluated cannabinoids for sleep disturbances, with CBD showing potential for improving sleep quality. However, THC may reduce REM sleep, which could impact sleep architecture negatively over time.
  • For PTSD-related insomnia, cannabinoids like nabilone have shown some benefit, but the effects on sleep in general populations remain uncertain.

Limitations

  • Sample Sizes and Duration: Many RCTs are small and short-term, limiting the generalizability and understanding of long-term effects.
  • Dosing and Formulations: Variability in cannabinoid content (THC vs. CBD), formulations (edibles, oils, vapes), and dosages across studies makes comparison challenging.
  • Side Effects: Both CBD and THC can have side effects, though THC’s psychoactive properties can lead to cognitive impairment, addiction potential, and negative impact on mood in some patients.

While CBD shows some promise in anxiety, PTSD, and psychotic disorders, RCT evidence for other mental health conditions remains inconclusive or even negative, especially with THC. Further large-scale, long-term RCTs are needed to establish the efficacy and safety profile of cannabis-based treatments in mental health.

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Raising the Bar: Should Buprenorphine Doses Be Higher to Combat Opioid Use Disorder?

The study “Association of Daily Doses of Buprenorphine With Urgent Health Care Utilization” explored how different buprenorphine doses affect emergency department (ED) and inpatient service use among individuals with opioid use disorder (OUD).

  1. Higher Doses Associated with Fewer Acute Care Visits: Patients receiving higher doses of buprenorphine (above 16 mg/day) had a longer time to ED or inpatient visits compared to those on lower doses (8-16 mg/day). Those on doses over 24 mg saw a significant reduction in the need for urgent care, particularly related to behavioral health crises.
  2. Implications for Fentanyl Users: The findings are particularly relevant for those using synthetic opioids like fentanyl, which often require higher doses of buprenorphine to manage withdrawal symptoms effectively. These higher doses may reduce acute care needs and improve overall treatment outcomes.
  3. Policy Considerations: The study highlights potential barriers, such as restrictive state laws or insurance limitations, that may prevent patients from accessing higher buprenorphine doses, which could limit effective treatment.

These results suggest that modifying buprenorphine dosing guidelines could be beneficial, especially as the opioid crisis evolves with the prevalence of fentanyl​

Link to article: https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2824049

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Liam Payne and Pink Cocaine: What You Need to Know About the Party Drug

Pink cocaine, also known as tucibi or 2C-B, is a synthetic hallucinogen from the phenethylamine family, first synthesized in the 1970s. Despite the “cocaine” in its street name, it is chemically unrelated to cocaine. It usually comes in powder form but can also be found in tablets. It’s popular in party scenes for its euphoric and stimulant effects, which are often compared to a combination of MDMA and LSD.

Key Points for Addiction Psychiatrists:

  1. Effects:
    • Euphoria, enhanced sensory perception, hallucinations.
    • At higher doses, it can cause anxiety, paranoia, and dissociation.
    • Effects can last from 4-8 hours depending on the dose and mode of administration (oral, nasal).
  2. Health Risks:
    • Cardiovascular issues, including hypertension and tachycardia.
    • Risk of psychosis and mood disorders, especially with repeated use.
    • Hyperthermia and dehydration, especially in party environments.
    • Possible neurotoxic effects, though research is limited.
  3. Addiction and Dependence:
    • While physical dependence is not common, psychological dependence can develop due to its euphoric effects.
    • Patients may use it in cycles with other substances (e.g., MDMA, alcohol), leading to polysubstance abuse.
  4. Withdrawal:
    • No specific withdrawal syndrome has been documented, but patients may experience depression, anxiety, and cravings after discontinuation.
    • Management may require addressing underlying mental health issues or substance use patterns.
  5. Treatment:
    • Cognitive-behavioral therapy (CBT) or motivational interviewing may help address compulsive use.
    • Monitor for concurrent use of other drugs, especially stimulants or hallucinogens, as polysubstance abuse is common.
    • Referral to harm-reduction programs may be beneficial for patients unwilling to quit completely.
  6. Legal Status:
    • It is illegal in most countries, classified as a Schedule I drug in the U.S. However, enforcement is inconsistent, and it continues to be accessible in underground markets.

For addiction psychiatrists, it’s crucial to recognize tucibi use, especially in patients with party-drug histories. Understanding the psychological effects and potential for dependence will aid in developing a comprehensive treatment plan. Monitoring for concurrent substance use and educating patients on the risks is key.

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Contingency Management: The Overlooked Game-Changer for Methamphetamine Use Disorder

I frequently encounter patients with methamphetamine use disorder, and I don’t know about you, but finding effective interventions in the inpatient psychiatric setting can be a real challenge. Unlike opioid or alcohol use disorders, where we have biological interventions like buprenorphine or naltrexone, methamphetamine use disorder lacks such clear pharmacological treatments. Because of this, many rehab facilities are reluctant to admit patients whose primary issue is methamphetamine use.

In my practice, I often turn to combinations like bupropion and naltrexone since they’re among the few studied pharmacological options for methamphetamine use disorder. However, based on my experience, the results are modest at best—but I suppose it’s better than nothing.

That said, there’s a much simpler, evidence-based option that doesn’t even require inpatient treatment, and it’s been around since the 1980s: Contingency Management. The concept is straightforward: reward patients with small incentives—like gift cards worth $30 or less—for each negative drug screen they produce. As patients continue to test negative, the rewards increase. This approach has been shown to double the chances of success in stopping methamphetamine use.

Of course, there are potential issues, such as concerns about fraud or patients providing fake samples. But let’s be real—how much are we already spending on treating methamphetamine users without seeing much improvement? Probably a lot more. With contingency management, we’re not just spending money—we’re actually seeing patients get better.

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Recent Data Shows Marijuana Use Surpasses Alcohol in the U.S.

For the first time in U.S. history, recent data shows that marijuana use has overtaken alcohol consumption. According to surveys and studies, more Americans now regularly consume cannabis than alcohol, marking a significant cultural and behavioral shift. This trend is driven by several factors:

  • Legalization: Recreational marijuana is now legal in 23 states and Washington, D.C., making it more accessible to adults across the country.
  • Changing Social Attitudes: Perceptions about marijuana have shifted, with more people viewing it as a safer, less harmful alternative to alcohol.
  • Health and Wellness Trends: Some individuals are opting for cannabis to manage stress, anxiety, and pain without the perceived risks of alcohol, such as liver damage and hangovers.

As a frontline healthcare worker, I can say with certainty that chronic, high-potency marijuana use can have serious implications for both physical and mental health. While some claim potential benefits, we currently lack comprehensive data on its medical efficacy, and more importantly, we do not yet fully understand the long-term consequences of regular, heavy consumption. As marijuana use increases, it’s critical to approach it with caution and prioritize further research into its effects on overall health.

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