Addiction Treatment Blog

Barbiturates

Concerns about the over-prescription of benzodiazepines in recent years have led some prescribers to look at alternative hypnotic agents – either older compounds such as members of the barbiturate or chloral families, antidepressants, or neuroleptics with a sedative profile. There are a number of problems with such prescriptions as will become clear.

Chloral Compounds

Chloral compounds (see the table below) were first produced in 1869. Their sedative effects were quickly recognised, leading to their use as hypnotics among other things. A number of factors militated against their widespread use. One was the difficulty in making them in other than foul tasting liquid formats. The subsequent discovery of the barbiturates, just before the First World War, largely put paid to them. Before that, however, many patients admitted to mental hospitals were treated with chloral draughts and would appear to have done well. Read more…

As with almost any other pills, antidepressants has their own side effects.

For the first 2 weeks of taking an antidepressant, there may be little other than side effects. Generally, these will be mild. In some cases, however, they may be irritating or even intolerable. The first point to be made is that an antidepressant should only cause tolerable side effects. If treatment makes someone clearly worse, it should be stopped until advice has been sought and until that advice addresses the problem in hand.

Where side effects are more tolerable, there can be a great problem in distinguishing the effects of treatment from some of the symptoms of the illness. Both drugs and illness may cause a dry mouth, headache, indigestion, increased anxiety, sleeplessness or sedation for example.

There is a further unusual aspect to antidepressant side effects. When individuals are depressed, they are often much less sensitive to the effects of anything. They can’t smell, taste or hear as acutely before, for example. It is also common to find that sleeping pills don’t help the insomnia that goes with depression – even three to four times the recommended dose may not bring about sleep. After recovery, some people may be knocked by a low dose of the same sleeping pill that appeared inactive several weeks previously.

However, while some people are less sensitive to side effects when they are depressed, others seem more sensitive. It is very difficult, therefore, to predict the side effects that an antidepressant will have.

The side effects listed are typical. Some occur in everyone to some extent, depending on the particular compound, but they are usually mild and wear off after a few days. Even if they are severe, it should be noted that these side effects are reversible and will halt almost immediately on stopping the drugs.

As with the neuroleptics, there are two sorts of side effects to note. There are those which may feel like a worsening of the illness, like feeling more nervous, feeling strange or unreal, or even hearing voices. These latter side effects are the ones that need careful judgement. Read more…

There are seven major physical treatments for depression at present.

• Tricyclic Antidepressants (Table 1). These have until recently been by far the most widely used.
• The Monoamine Oxidase Inhibitors (MAOIs) (Table 2).
• Reversible Inhibitors of Monoamine Oxidase (RIMAs) (Table 3).
• 5-HT Reuptake Inhibitors (Table 4).
• Other Antidepressants (Table 5).
• Treatments for Bipolar Disorders or Prophylaxis of Recurrent Disorders (Table 6).
• Others (Table 7)

In the last category, a number of other treatments are marketed for or used for depression and they often work, but whether they are antidepressants in the same sense as electroconvulsive therapy (ECT), imipramine or phenelzine is a matter of dispute. The 5-HT-1a agonist, buspirone, has in addition been marketed as an antidepressant, and a further compound from this group, flesinoxan, looks as though it may also emerge as an antidepressant.

Finally, there is also ECT, the mechanism of action of which, and its use clinically will not be discussed at any length in this article. Its role when antidepressants fail to work and in cases of mania will be considered at a later stage. Read more…

Coping with stress can be hard at times.

The term ‘affective disorder‘ is sometimes taken to encompass both the mood and anxiety disorders. In this blog, it will be restricted to the former. Two disorders will be considered, depression and mania. Depression will be covered first followed by a consideration of mania and then the question of prophylaxis of recurrent episodes of a bipolar disorder, be they depressive or manic.

It is perhaps more difficult to specify exactly what antidepressants do than it is for any other drug that acts on the brain. In the following articles, I will employ an ulcer model of depression in an attempt to clarify the issues. This model, however, simplifies both ulcers and depression and this should be borne in mind. In clear cut cases of depression, an ulcer model performs passably. But in less clear-cut cases, the difficulty in pinpointing what it is that antidepressants do re-emerges.

Another way to consider the issues is by considering what the terms ‘mood’ and ‘emotion’ mean. These are notoriously difficult to define, but one way the problem has been approached is to define them in relation to each other – to compare, for instance, the relation of mood to emotions with the relation between climate and weather, or the relation between the pedal and the keys of the piano. Read more…

The medicine increases the disease.

Virgil (70-19BC), ‘The Aeneid’.

Prescription Drugs

This chapter highlights the important areas of abuse of prescription drugs. Opioids, cocaine, dexamphetamine, anabolic steroids and many of their derivatives are prescription medicines in the UK but these have been the subject of earlier chapters. Similarly, some ‘smart drugs‘ and certain preparations used in association with anabolic steroids are also prescription drugs and are discussed elsewhere in the blog.

Anaesthetics

Many gaseous anaesthetics have been subject to abuse but in practice these all have a low abuse potential because although they may produce pleasurable effects they are not easily available and are inconvenient to use, even for healthcare professionals with access to them. The exception is ketamine abuse which is well-described problem at street level.

Nitrous oxide

Nitrous oxide gas is not a prescription medicine in the UK but is included in this chapter for ease of reference. It is used therapeutically to induce anaesthesia and also as an analgesic. In this setting it is usually mixed with oxygen and is available commercially as Entonox in characteristic blue and white cylinders. Abuse is most likely to involve healthcare personnel who use nitrous oxide in the workplace, e.g. dentists, anaesthetists and theatre staff. However, the gas is also the propellant used in many canisters of pressurised whipped cream. The experienced abuser is able to release the gas into containers, allowing subsequent gas inhalation with minimum cream contamination. Inhalation is usually via a plastic bag, balloon or similar device. Healthcare staff may, of course, use anaesthetic administration equipment. In 1979, a US survey of 524 medical and dental students showed that 16 per cent of those questioned had abused nitrous oxide on at least one occasion. Read more…

There are many antidepressant pills on the market, of which none of them should be used without consulting your GP.

Three main types of drugs are used in manic depression: drugs to stabilize the mood; drugs to calm and lower mood in hypomania and mania; and drugs to improve and raise the mood in depression. The number of drugs available for treating manic depression increases year on year, either as new drugs are specifically developed to treat mental illnesses, or as a result of discovering mood-altering properties of existing drugs. A number of anti-epilepsy drugs have proved particularly useful in manic depression.

There are three main types of drugs used in treating manic depressive disorder, as well as other, less common ones:

• Mood stabilizing drugs
• Mood lowering, anti-psychotic drugs
• Anti-depressants
• Sleeping tablets

1. Mood stabilizing drugs

Three mood stabilizing drugs are prescribed for the majority of people with manic depression. These are lithium, valproate or depakote and carbamazepine.

These drugs are well established in treatment, relatively safe and almost certainly do not hold and unpleasant surprises for the future. Other newer drugs are constantly under development and review and can be used if a person has frequent further episodes whilst on standard treatment or the standard treatment is causing too many side effects.

Valproate, like carbamazepine is used to treat epilepsy. However, it is also a mood stabilizer as well as having anti-manic properties. As with lithium, it is not yet clear how valproate works. It can be effective when lithium has not been, either instead of, or in combination with, lithium. Side effects include weight gain and tremor.

Carbamazepine has mood-stabilizing properties and can be used together with or instead of lithium and valproate. Side effects include dizziness, intestinal upset and drowsiness, though it does have fewer side effects than most of the other drugs prescribed for manic depression. However, one rare side effect is severe skin reaction and loss of white blood cells known as Stevens Johnson syndrome.

Newer mood stabilizing drugs include lamotrigine and gabapentine. Lamotrigine and gabapentine were, like carbamazepine and valproate, originally prescribed for epilepsy and were found, like carbamazepine and valproate, to additionally reduce mood swings in patients with both epilepsy and manic depression. Read more…