Resiliency Psychiatry

Restless Legs after Opioid Use

stefuclamed@gmail.com (Stefani LaFrenierre) — Tue, 17 May 2022 17:23:04 GMT

How can you relieve Restless Leg Syndrome after Opioid detox?

Restless Leg Syndrome (RLS) is a distressing symptom clinicians sometimes see in people coming off of opioids in early detox, with symptoms lasting up to several weeks. This phenomenon is poorly studied, but there are case reports demonstrating that up to 13% of people detoxifying from opioids report symptoms of RLS with co-occurring mental health symptoms including restlessness, insomnia, agitation, anxiety, and depression from the RLS. For some people, this condition can be so distressing and uncomfortable that it can trigger opioid relapse, depression, anxiety, even thoughts of self-harm.

Restless Leg Syndrome-What is it?

RLS is a condition where the person feels an uncontrollable urge to move their legs, usually at night when lying in bed. Movement can often relieve the symptoms but exacerbate insomnia. Some people also experience periodic limb movement of sleep, a condition of leg twitches and kicks during sleep which can cause frequent awakenings at night and disturb sleeping partners. It presents in both legs, and occasionally can effect both arms in severe cases. Over time chronic sleep disturbance from RLS can lead to severe mental and physical health changes.

People often describe the sensation as:

crawling
creeping
pulling
throbbing
aching
itching
electric

Why does RLS occur when Opioid Use stops?

Opioids modulate the dopamine system via their receptors and change the brain's sensitivity to dopamine. This is part of the pathway that creates a euphoria effect when using opioids. Stopping opioids can disturb the dopamine system by leading to a sudden decrease in dopamine, which can lead to a transient dopamine dysfunctional state and trigger RLS symptoms.

What are some treatment options?

Treatment guidelines for RLS after Opioid Use are sparse, although several clinical studies are in process. Primary treatment involves medication recommendations used in non-Opioid induced RLS, with some additional recommendations below from my own clinical experience treating RLS.

Symptoms can be minimized or avoided if a patient meets criteria for buprenorphine/naloxone (Suboxone) use for OUD detoxification and medication assisted treatment for Opioid Use Disorder. See my previous Blog Post for more information about Suboxone MAT and how it can help prevent overdose and relapse.

Non-Opioid Options for RLS:

Dopamine agonists: pramipexole and ropinirole
Anticonvulsants: carbamazepine, gabapentin, pregabilin-->both gabapentin and pregablin have potential for dependency and abuse so utilize caution if using these in early recovery
Anti-hypertensives: clonidine, Lucemyra
Dopamine agonist: cabergoline, levodopa/carbidopa
Iron replacement when serum ferritin is low
OTC remedies: magnesium malate (Mag Calm) , pyridoxine (vitamin B6), tonic water with quinine (avoid in patients with cardiac history), Hyland's Restful Legs tablets

References

Young-Min Park, MD, PhD, Department of Psychiatry, Ilsan Paik Hospital, Inje University College of Medicine, 170 Juhwa-ro, Ilsanseo-gu, Goyang 10380, Korea., Opioid Withdrawal and Restless Legs Syndrome. Chronobiology in Medicine. Published online: December 15, 2020. DOI: https://doi.org/10.33069/cim.2020.0026

Walters AS. Opioids and restless legs syndrome. Lancet Neurol. 2013 Dec;12(12):1128-9. doi: 10.1016/S1474-4422(13)70248-5. Epub 2013 Oct 18. PMID: 24140443.

Mackie SE, Winkelman JW. Therapeutic Utility of Opioids for Restless Legs Syndrome. Drugs. 2017 Aug;77(12):1337-1344. doi: 10.1007/s40265-017-0773-6. PMID: 28616844.

Mackie SE, McHugh RK, McDermott K, Griffin ML, Winkelman JW, Weiss RD. Prevalence of restless legs syndrome during detoxification from alcohol and opioids. J Subst Abuse Treat. 2017;73:35-39. doi:10.1016/j.jsat.2016.10.001

Kratom-What is it ?

stefuclamed@gmail.com (Stefani LaFrenierre) — Fri, 06 May 2022 04:37:09 GMT

A Review of Kratom and Recommendations for Detox

What is Kratom?

Kratom is a tropical tree (Mitragyna speciosa) native to Southeast Asia with leaves that contain compounds that can have psychotropic effects.

Kratom is not currently an illegal substance and has been easy to order on the internet. It is sometimes sold as a green powder in packets labeled "not for human consumption." It is also sometimes sold as an extract or gum.

How is it Used?

Many people try Kratom to manage symptoms of chronic pain, depression, anxiety, or for the same effects provided with opiate and/or stimulants.

Route: pill, capsule, or extract, chew kratom leaves or brew as a tea, leaves can be smoked or eaten

1 ounce = 28 grams

Why do people use Kratom?

It causes effects similar to both opioids and stimulants.

Mitragynine and 7-α-hydroxymitragynine are the active compounds that interact with mu-opioid receptors in the brain, producing sedation, pleasure, and decreased pain—>the same receptors targeted during heroin, oxycodone, and other pain pill use.

Mitragynine--also interacts with other receptor systems in the brain to produce stimulant effects with dopamine and serotonin surges, and users report increased energy, sociability, and alertness instead of sedation.

Withdrawals

Onset: 12-24 hours after last use

Symptoms are similar to withdrawal from Opiates AND Stimulants :
Runny nose
Muscle aches
Joint or bone pain
Jerky movements of arms and legs
Hostility
Aggression
Mood swings
Hallucinations
Delusions
Confusion
Seizures-rare

Duration: peaks within 2-3 days and can last 3-10 days

Cravings: may not ease for months

Risk for dependence and potential withdrawal tends to increase at higher doses — usually 5 grams or more taken more than 3 times per day

What are the options to Detox from Kratom?

Detox protocols largely depend on the estimated amount being used prior to seeking help to detox

COWS protocol to monitor severity of withdrawals is helpful, as symptoms closely mimic withdrawal symptoms seen in opiate use disorder.

If LESS THAN 20gm of Kratom per day, then detox with an opioid partial agonist can be helpful
Start with Suboxone 4/1 mg-8/2 mg buprenorphine-naloxone per day
Detox with Suboxone over 3-7 days
Medications like Lucemyra (lofexidine ) can be used if the individual is opposed to Suboxone, as well as alternative comfort medications commonly used in OUD withdrawals (clonidine, gabapentin, trazodone, quetiapine, to name a few)

If MORE THAN 40 gm of Kratom per day, then higher doses of an opioid partial agonist can be helpful
Start with Suboxone 12/3 mg-16/4 mg (buprenorphine-naloxone) per day
Detox with Suboxone over 7 days
Lucemyra unlikely to be helpful for severe withdrawals at this level of use
Comfort medications can be helpful in combination with an opioid partial agonist.

Cravings: maintenance with an opioid partial agonist (i.e. Suboxone) may be needed in high frequency users due to prolonged cravings that can last months and risk of relapse.

Other Considerations : some people experience severe psychiatric symptoms, including depression, apathy, anhedonia (loss of pleasure in all things), loss of libido (sex drive), and even psychotic symptoms. For these patients a psychiatric consult would be recommended to determine if psychotropic medications might be helpful to manage mental health symptoms.

References

https://www.drugabuse.gov/publications/drugfacts/kratom

https://www.health.harvard.edu/blog/kratom-fear-worthy-foliage-or-beneficial-botanical-2019080717466

The Case For Maternity Leave

stefuclamed@gmail.com (Stefani LaFrenierre) — Tue, 26 Apr 2022 16:58:57 GMT

If you or someone you know is postpartum and struggling, please visit my website to book a consultation to learn more about how Dr. LaFrenierre can help with postpartum adjustment and maternal infant bonding.

Methamphetamine Treatment Options

stefuclamed@gmail.com (Stefani LaFrenierre) — Sat, 26 Mar 2022 03:12:18 GMT

What is Methamphetamine and How Can Addiction be Treated?

Methamphetamine is powerful central nervous system stimulant that produces a surge in dopamine and serotonin with first use. Use is on the rise across all populations, with abuse of both "legal" and "illegal" stimulants increasing. "Legal" stimulants are prescribed medications often used in the treatment of ADHD (think Adderall, Ritalin, etc). "Illegal" stimulants are manufactured and distributed out of clandestine labs.

Overdose deaths due to stimulant use is also on the rise. A recent study by NIH’s National Institute on Drug Abuse (NIDA) examined data from almost 200,000 people nationwide, aged 18-64, who participated in the 2015-2019 National Surveys on Drug Use and Health (NSDUH). Researchers found that overdose deaths from stimulants other than cocaine almost tripled from 2015 to 2019. The number of people using methamphetamine and cocaine together increased by 60%. Frequent methamphetamine use, defined as using for at least 100 days in the past year, increased by 66%. These results point to a growing trend in risky use patterns.

What Makes Meth So Addictive?

Stimulants boost the normal brain levels of the neurotransmitter dopamine, which produces feelings of pleasure and increases energy. People also experience euphoria, appetite suppression, and decreased need for sleep, which makes this drug very appealing for many seeking these effects. Methamphetamine specifically causes an excessive spike in dopamine, with as much as 10x the amount of dopamine released when using meth compared to other stimulants such as nicotine and cocaine. This excessive spike in dopamine is neurotoxic, which contributes to the destruction of the brain over time with repeated use. This toxic damage can lead to serious and even permanent mental health and neurologic impairments.

Mental Illness and Meth Abuse

Approximately 2/3 of methamphetamine users experience psychotic symptoms, including paranoia, visual and auditory hallucinations, mood disturbances, delusions (often tactile, the sensation of insects creeping on the skin), homicidal thoughts, suicidal thoughts, and out of control rages. The longer one uses, the higher the risk of developing serious mental health symptoms. Various studies have examined the risk of psychotic symptoms becoming permanent, and estimates range that approximately 10-20% of all users can have permanent psychotic symptoms even years after quitting methamphetamine.

What are Treatment Options?

Sobriety from Methamphetamine use disorder is best addressed from a multi-specialty collaborative approach involving both therapy and, if indicated, medications. Specialized therapy from a professionally trained substance use therapist can be especially valuable.

A thorough assessment by a psychiatrist can be helpful for those experiencing mental health symptoms. An experienced psychiatrist can recommend medications that can help with symptoms of depression, insomnia, and psychosis, and order laboratory tests to monitor baseline physical health.

For Methamphetamine cravings, there are currently no FDA-approved treatment options. However, a recent evidence-based medication approach with the monthly injection naltrexone (Vivitrol) 380mg dose combined with Buproprion (Wellbutrin) 450mg dose resulted in reduction of methamphetamine cravings and abstinence from methamphetamine in 13.6% of moderate to severe users vs. only 2.5% of those on placebo treatment. Although this number does not seem high, this small but meaningful finding opens a door for those seeking medication options to help with this devastating addiction.

References:

Methamphetamine Use, Methamphetamine Use Disorder, and Associated Overdose Deaths Among US Adults. Han B, Compton WM, Jones CM, Einstein EB, Volkow ND. JAMA Psychiatry. 2021 Sep 22. doi: 10.1001/jamapsychiatry.2021.2588. Online ahead of print. PMID: 34550301.

Bupropion and Naltrexone in Methamphetamine Use Disorder

Trivedi MH, Walker R, Ling W, et al. The New England Journal of Medicine. 2021 Jan 14. doi: https://www.nejm.org/doi/full/10.1056/NEJMoa2020214

Suboxone Maintenance Can Help Prevent Relapse and Death

stefuclamed@gmail.com (Stefani LaFrenierre) — Fri, 25 Feb 2022 00:00:14 GMT

Exploring the benefits of Suboxone MAT for high risk users

Per the CDC, over 70% of overdose deaths in 2019 were related to opiates. One of the main interventions in treating opiate dependency is using a long-acting, partial opiate agonist called buprenorphine. Buprenorphine is long-acting opiate that has been shown to significantly reduce the number of opiate-related deaths due to relapse. The evidence is robust: abstinence-based approaches for opiate dependency result in relapse within weeks for more than 90% of opiate dependent patients . Patients who continue to take Suboxone in early recovery do far better overall, die by overdose less frequently, and are more successful getting back to functioning in their day to day life (presuming they are motivated to stop using other kinds of opiates).

There is (unfortunately) no significant evidence that abstinence based approaches are superior to MAT treatments.

Nalrexone/Vivitrol is also a good option for patients who are motivated to take the medication. This medication acts as a complete opiate receptor blocker. However, many of these patients will ultimately relapse. The outcomes with opiate replacement therapies (ie Suboxone) are generally more sustainable. A recent article in the Journal of Addiction Medicine found a 2.4x increase in overdose with use of Naltrexone versus Buprenorphine.

Facts about Suboxone:

Suboxone/buprenorphine is a medication used to help people quit or reduce their use of heroin or other opioids (pain relievers like morphine).

It comes as a dissolvable film strip (or sometimes a pill). The medication contains buprenorphine (an opioid medication) and naloxone (Narcan). If you take it under the tongue, the buprenorphine works in your body but the naloxone is not absorbed (not active). But if you crush it up and inject it or snort it, the naloxone is active and will make you withdraw if you have other opioids in your body (such as heroin or pain pills).

This helps to make sure people only take it under the tongue and not inject the medicine.

What is maintenance treatment with Suboxone?

Suboxone acts as a “chemical shield” – Suboxone acts at the same place in the brain as heroin/pain pills, while you are taking Suboxone it prevents you from getting high from other opioids.

It is taken daily to help modulate opiate receptor activity in the brain to reduce cravings.

Who needs treatment with Suboxone/buprenorphine?

Suboxone/buprenorphine is a medicine that helps to treat addiction to heroin, pain pills, and other types of opioids. It does not treat other kinds of addictions, such as alcohol, methamphetamine, marijuana, etc.

Medication treatment is very effective in keeping patients off heroin or pain pills. It treats withdrawal, cravings and decreases the risk of overdose.

Are there risks or side effects from taking Suboxone/buprenorphine?

Suboxone/buprenorphine is very safe with a low risk of overdose. But, when mixed with benzodiazepines (Zanax, Ativan, Valium, lorazepam, clonazepam) in large doses, or with large amounts of alcohol, there is a risk of overdose (a chance of stopping breathing and dying)

Just like taking pain pills or heroin regularly, your body becomes used to (physically dependent) on the Suboxone/buprenorphine so if you stop it suddenly, you will withdraw (“kick”). If you want to stop taking it every day, talk with your doctor first and it can be slowly stopped

Side effects are rare, but they can include constipation, headache, trouble sleeping, ankle swelling, trouble urinating; and rarely, liver irritation.

Pregnant women should not take Suboxone/buprenorphine. Instead, they should use methadone or a different form of buprenorphine called Subutex.

Small children and babies should never take Suboxone/buprenorphine, since it can cause them to stop breathing and die. It is very important to keep all Suboxone/buprenorphine away from babies and small children, and call 911 if they accidentally taste or swallow some.

When people take Suboxone/buprenorphine every day, aren’t they just substituting one addiction for another one?

When people are addicted to a drug, they crave it, want larger and larger quantities, can’t stop, and often do risky things in order to get it. They also feel high when they take it. None of these is true with Suboxone/buprenorphine. Suboxone/Buprenorphine does not make you addicted.

Many patients say that Suboxone/buprenorphine makes them feel “normal” rather than “high”.

We also cap the daily dose to 16mg to provide maximal benefits with minimal risk.

How can a person get Suboxone/buprenorphine treatment?

Suboxone/buprenorphine can only be prescribed by a doctor with a special license. Working with our psychiatrist at Resiliency Psychiatry and Addiction Treatment, we can initiate treatment with close monitoring monthly.

Without insurance, it costs around $500 per month.

How long can a person stay on Suboxone/buprenorphine?

There is no limit to how long someone can take Suboxone/buprenorphine, but the initial recommendation is at least 6 months.