Simultaneous Cocaine, Alcohol Use Linked to Suicide Risk

Photo By Psychonaught - Own work, Public Domain, https://commons.wikimedia.org/w/index.php?curid=9818612

Newswise, April 14, 2016--In a general sense, medical studies support the popular intuition -- a staple of movies and literature -- that suicidal behavior and substance misuse are linked. But the relationship between the two is not so simple.

A new study of hundreds of suicidal emergency department (ED) patients from around the U.S. found that the significance of the link varied with age, gender and race. Across the board, however, the use of cocaine and alcohol together was a red flag.

"One unexpected finding was that, when examined independently, alcohol use had no significant association and cocaine use had a borderline significant association," wrote authors of the study in the journal Crisis.

"However, reporting both alcohol misuse and cocaine use was significantly associated with a future suicide attempt."

Led by Sarah Arias, assistant professor (research) of psychiatry and human behavior in the Alpert Medical School of Brown University, the team examined 874 men and women who presented at one of eight emergency departments around the country between 2010 and 2012.

The patients were participants in the Emergency Department Safety Assessment and Follow-up Evaluation study, led by the University of Massachusetts Medical School. Individuals included in the analysis received standard care and either reported a recent suicide attempt or were actively engaged in suicidal thoughts at the time of the initial ED visit.

In another arm of the study, not included in this analysis, patients received an experimental intervention. Researchers gathered demographic and substance use information from the participants and then followed them for a full year afterward.

The key outcome in Arias' new study was whether people attempted suicide in the year following the ED visit. Of the 874 people, 195 people did at least once.

What Arias, who is also a research psychologist at Butler Hospital, and her colleagues found was that although people in the study reported misusing many different substances, including marijuana, prescription painkillers, tranquilizers and stimulants, only cocaine and alcohol appeared to have a significant association with suicide risk.

Of the entire study population, 298 misused alcohol, 72 were using cocaine and 41 were using both. Specifically, of those using both, the chance of attempting suicide again was 2.4 times greater than among people in the study who were not.

They also found that substance misuse was less likely an indicator of suicide risk among whites and women. Older people, meanwhile, were more likely to have an association between substance misuse and suicide.

Women are not less likely to be suicidal, the researchers note. In fact, they were more likely than men to have reported prior attempts. But the data showed that substance abuse was less likely to be involved among women.

"These disparate findings emphasize the complex interaction of sex, substance use, and suicide attempts," Arias and her co-authors wrote. "They also suggest women may be differentially at risk depending on whether they report substance use or past suicide attempts."

The study does not say anything about whether substance abuse causes suicidal behavior because it only reports observations of associations.

But Arias said she hopes the data will advance the understanding of how misuse of particular substances, among particular patients, may affect their risk of suicide.

"It's not a clear-cut, straightforward association," Arias said. "Even though substance use is often touted as a very strong predictor of suicidal intentions and behaviors, when we look at individual substances we're seeing that there's not that consistency in the future association with behavior."

Figuring out the specific cases where substance misuse is predictive could help save lives.

"We're on our way to trying to identify factors that can be used to better assess and identify people who are at risk for suicide, and ultimately I think this is a step in the right direction to get a better picture," she said.

"Patients who have potentially comorbid alcohol and cocaine use may be at a higher risk. Findings like these can be useful for informing suicide risk assessment."

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In addition to Arias, the study's other authors are Orianne Dumas, Ashley Sullivan, Edwin Boudreaux, Ivan Miller and Carlos Camargo Jr. The research was funded by the National Institute of Mental Health (grant: U01MH088278).

Parkinson’s Disease Medications Increase Risk of Compulsive Gambling, Shopping and Binge Eating in Some Patients

Newswise, April 7, 2016 – Drugs commonly prescribed to treat Parkinson’s disease have been linked to impulse control disorders such as pathological gambling, compulsive buying, hypersexuality and binge eating in some patients, according to a review article by neurologists at Loyola Medicine and Loyola University Chicago Stritch School of Medicine.

These disorders can have disastrous personal, professional and financial consequences if not recognized or treated, according to the article in the journal Expert Review of Neurotherapeutics. Authors of the paper include José Biller, MD, and first author Adolfo Ramirez-Zamora, MD, who completed a residency in neurology at Loyola.

The paper details the latest findings for treating impulse control disorders (ICDs) in Parkinson’s disease patients, including adjusting medications, deep brain stimulation and a counseling technique called cognitive behavioral therapy.

One large, previous national study found that approximately 14 percent of Parkinson’s disease patients experience at least one ICD. The disorders are more common in men.

Men are more likely to display hypersexuality and pathological gambling, while women are more likely to exhibit compulsive eating and buying. Potentially catastrophic consequences include financial ruin, divorce and loss of employment.

Patients often lack insight and underestimate the presence and severity of ICDs and related conditions, the authors write. ICDs are probably more prevalent in Parkinson’s disease patients than previously reported.

The primary risk factor for ICDs is the use of a class of Parkinson’s disease medications called dopamine agonists, which help control tremors and other Parkinson’s symptoms.

These drugs include pramipexole (Mirapex®) and ropinirole (Requip®). Other risk factors include younger age, smoking, alcohol abuse and personality traits such as impulsivity, obsessive-compulsive disorder, depression and anxiety.

Management of ICDs is particularly difficult and no treatment guidelines for ICDs in Parkinson’s patients are available. Treatment should be individualized, and careful selection of specific interventions is critical. Treatments that have been considered include switching, reducing or discontinuing Parkinson’s medications.

But this can be challenging. Patients often are reluctant to change medications because they do not want their tremors to get worse. Patients also can experience withdrawal symptoms when taken off dopamine agonists, including anxiety, panic attacks, depression, irritability and fatigue.

The authors discuss alternative treatment strategies for Parkinson’s disease and medications that may help control ICDs, such as antidepressants, atypical antipsychotics and antiepileptic drugs.

Other potential nondrug treatments include cognitive behavioral therapy and a “brain pacemaker” called deep brain stimulation. The authors provide a much-needed, practical and detailed review of the factors important making management decisions

Families also play a critical role. Spouses and other family members should be warned that Parkinson’s medications can cause ICDs. Families should report to the patient’s physician any “unexplained absences, changes in routine behaviors, irritability, hiding evidence of the impulse control disorders and monetary consequences,” the authors write. Helpful non-pharmacological approaches include limiting access to bank accounts, credit cards and the internet.

Dr. Biller is chair of the department of neurology of Loyola University Chicago Stritch School of Medicine. Dr Ramirez-Zamora, a former resident in Loyola’s department of neurology, is now at Albany Medical College and serves as the Phyllis E. Duke Endowed Chair in Movement Disorders. Other co-authors are Lucy Gee of Albany Medical College and James Boyd, MD, of the University of Vermont College of Medicine.

Their article is titled, “Treatment of impulse control disorders in Parkinson’s disease: Practical considerations and future directions.”

In-Car Breathalyzers for DUI Offenders Curb Drunk-Driving Deaths by 15 Percent

So-Called “Ignition Interlocks” Save Lives with Similar Success as Airbag Laws, Penn Study Says

Newswise, March 18, 2016 —  State laws that require drivers who’ve been convicted of drunk driving to pass a breathalyzer-type test before starting their cars saved an estimated 915 lives between 2007 and 2013, according to a study published in the American Journal of Public Health by researchers at the Perelman School of Medicine at the University of Pennsylvania.

The findings represent a 15 percent reduction in drunk driving-related deaths compared to states without legislation requiring DUI offenders to use “mandatory ignition interlock.”

The research, led by Elinore J. Kaufman, MD, a student in Penn’s Health Policy master’s degree program and a resident at New York-Presbyterian Weill Cornell Medical College, used National Highway Traffic Safety Administration data to compare alcohol-related crash deaths in the 18 states that required ignition interlocks for all those convicted of DUI as of 2013 with the number of alcohol-related crash deaths in states without mandatory interlocks.

States with mandatory interlock laws saw a 0.8 decrease in deaths for every 100,000 people each year – which is comparable to lives shown to have been saved from mandatory airbag laws and the 21-year minimum legal drinking age combined (0.9 and 0.2 lives saved per 100,000 people, respectively).

Car crashes involving alcohol make up 30 percent of vehicular fatalities, resulting in 11,000 deaths each year. The National Highway Traffic and Safety Administration estimates that for each of the million drunk driving convictions each year, there are 88 previous instances of drunk driving.

“These laws are proven feasible and effective, and they are low hanging fruit for the remaining half of states, including Pennsylvania, that don’t have this protection in place yet,” Kaufman said.

Following increasing support for interlock laws in other states, Pennsylvania’s House of Representative’s Transportation Committee is considering legislation – SB 290 – that would require first-time DUI offenders with a blood-alcohol content of .10 or higher to install these devices.

“Our findings show that by preventing intoxicated drivers from starting their vehicles, these ignition interlock laws can directly prevent drunk driving and save lives,” Kaufman said. “We are encouraged by growing public and governmental support for expansion of interlock programs and innovative ways to use this technology to prevent more lives lost resulting from drunk driving.”

Previous research on mandatory interlock laws focused on recidivism rates, but the new Penn study serves as the first national analysis of the impact of a universal interlock requirement on alcohol-involved crash deaths.

“Although crashes and crash fatalities decline, we’re not seeing a significant reduction in those involving alcohol,” said the study’s senior author, Douglas J. Wiebe, PhD, an associate professor of epidemiology in the department of Biostatistics and Epidemiology and a senior scholar in the Center for Clinical Epidemiology and Biostatistics.

“We’re encouraged by the increasing number of states enacting mandatory interlock laws since 2013 and hope these findings advance public health conversations aimed at saving more lives.”

The researchers note that the variation in state ignition interlock laws and enforcement of those laws further illustrates the importance of taking a comprehensive approach to ensuring driving safety.

While mandatory minimum drinking age and interlock laws have shown progress in curbing drunk-driving incidence, the authors call for further steps, including new strategies to encourage alternative forms of transportation and changing “alcohol culture” and social behaviors to reduce binge drinking.

The Medical Minute: The Path From Prescription Pain Killers to Addiction

Newswise, March 9, 2016 — Abuse of prescription pain killers has become an epidemic in the United States, according to the Centers for Disease Control and Prevention (CDC). Even more concerning is that those going through withdrawal may turn to heroin as an inexpensive, easy-to-access substitute.

 

Dr. Vitaly Gordin, division chief of chronic pain management in the Department of Anesthesiology at Penn State Hershey Medical Center said it’s because heroin is an opiate analgesic, just like drugs such as oxycodone and tramadol, which are frequently prescribed for pain control.

The problem is not with patients who use the medicines to relieve short-term acute pain, like the kind after surgery. 

“The vast majority of them will very easily get off these medications as their condition improves and pain is decreasing,” he said.

Nor does it lie with those who have chronic conditions that require them to be on high doses of narcotic painkillers for long periods of time: “There are a lot of very legitimate patients who are receiving these medicines in a chronic setting who are not abusing them.”

The challenge comes when someone is taken off the medication after using a high dose for a length of time.

“Because of this declared epidemic, many primary care physicians, specialists and surgeons are taking these patients off the narcotics,” Gordin said. “But if they don’t have an exit strategy and get referred for alternate treatment, addictions counseling or rehabilitation, they can become desperate as they go through withdrawal.”

Without a renewing prescription for narcotics, the patients may turn to heroin.

Unlike with prescription painkillers, which are regulated by the Food and Drug Administration, it’s hard to verify exactly what is in the heroin you buy from a dealer.

“Several years ago there was a string of deaths of addicts who bought heroin laced with a potent painkiller called fentanyl,” Gordin said. “Because it’s all an underground, illegal business, you don’t know exactly what you’re getting.”

Many of the 20,000 deaths that occur each year from abuse of prescription pain killers happen when the narcotics are combined with another substance such as benzodiazepine or alcohol, which creates a dangerous – if not deadly – mix.

Gordin said patients with a history of drug abuse, untreated psychiatric conditions or pre-adolescent abuse of any kind are much more likely to develop addictions.

“In my 17 years working here, I have never seen as many inpatients on heroin as I have in the past six to 12 months,” he said. “Those who have abused heroin are getting into car accidents or involved in violent crimes because of being on the drug or trying to obtain it. I think it’s directly related.”

Gordin also said it is important that society begin to de-stigmatize addiction as a character flaw. “We need to understand it is a disease with psycho-social components and we need to have resources available to both prescribing physicians and patients who need drug rehabilitation.”

The Medical Minute is a weekly health news feature produced by Penn State Milton S. Hershey Medical Center. Articles feature the expertise of Penn State Hershey faculty physicians and staff, and are designed to offer timely, relevant health information of interest to a broad audience.

Overdose Deaths from Common Sedatives Have Surged, New Study Finds

 Newswise, February 21, 2016--Headlines about America’s worsening drug epidemic have focused on deaths from opioids—heroin and prescription painkillers such as OxyContin.

But overdose deaths have also soared among the millions of Americans using benzodiazepine drugs, a class of sedatives that includes Xanax, Valium, and Klonopin, according to a study led by researchers at Albert Einstein College of Medicine, Montefiore Health System and the Perelman School of Medicine at University of Pennsylvania. Their findings appear online today in the American Journal of Public Health.

“We found that the death rate from overdoses involving benzodiazepines, also known as ‘benzos,’ has increased more than four-fold since 1996—a public health problem that has gone under the radar,” said lead author Marcus Bachhuber, M.D., MS., assistant professor of medicine at Einstein and attending physician, internal medicine at Montefiore. 

“Overdoses from benzodiazepines have increased at a much faster rate than prescriptions for the drugs, indicating that people have been taking them in a riskier way over time.”

An estimated 1 in 20 U.S. adults fills a benzodiazepine prescription during the course of a year. The drugs are prescribed for conditions including anxiety, mood disorders and insomnia.

In 2013, benzodiazepine overdoses accounted for 31 percent of the nearly 23,000 deaths from prescription drug overdoses in the U.S. But little was known about the national trends in benzodiazepine prescribing or in fatalities from the drugs. To find out, the researchers examined data for the years 1996-2013 from two sources:

•The Medical Expenditure Panel Survey. This federally sponsored survey includes a nationally representative sample of families and individuals who provide information about healthcare purchases including prescription drugs.

•Multiple-cause-of-death data from the Centers for Disease Control and Prevention. The researchers extracted reports from physicians, medical examiners or coroners on all overdose deaths involving a benzodiazepine, including deaths also involving other medications, alcohol or illicit drugs.

Their analysis revealed that the number of adults purchasing a benzodiazepine prescription increased by 67 percent over the 18-year period, from 8.1 million prescriptions in 1996 to 13.5 million in 2013.

 For those obtaining benzodiazepine prescriptions, the average quantity filled during the year more than doubled between 1996 and 2013. Most crucially, the overdose death rate over the 18-year period increased from 0.58 deaths per 100,000 adults in 1996 to 3.14 deaths per 100,000 adults in 2013, a more than four-fold increase.

Overall, the rate of overdose deaths from benzodiazepines has leveled off since 2010. But for a few groups—adults aged 65 and over and for blacks and Hispanics—the rate of overdose deaths after 2010 continued to rise.

“The greater quantity of benzodiazepines prescribed to patients—more than doubling over the time period—suggests a higher daily dose or more days of treatment, either of which could increase the risk of fatal overdose,” said senior author Joanna Starrels, M.D., M.S., associate professor of medicine at Einstein and attending physician, internal medicine at Montefiore.

Dr. Starrels also offered two other possible reasons for the spike in benzodiazepine deaths. “People at high risk for fatal overdose may be obtaining diverted benzodiazepines [i.e., not from medical providers], and we know that combining benzodiazepines with alcohol or drugs—including opioid painkillers—can lead to fatal overdoses,” she said.

She noted that opioid prescribing has increased rapidly during most of the period covered in her study and that opioids are involved in 75 percent of overdose deaths involving benzodiazepines.

“An obvious way to improve benzodiazepine safety would be for people to reduce their use of these medicines,” said study co-author Chinazo Cunningham, M.D., M.S., professor of medicine and of family and social medicine at Einstein and associate chief of the division of general internal medicine at Einstein and Montefiore.

“But we should also be emphasizing the danger of fatal overdose from taking benzodiazepines concurrently with opioid painkillers or with alcohol.”

“This epidemic is almost entirely preventable, as the most common reason to use benzodiazepines is anxiety—which can be treated effectively and much more safely with talk therapy,” said Sean Hennessy, Pharm.D., Ph.D., professor of epidemiology at Penn’s Perelman School of Medicine and co-author of the study.

“Given the high prevalence of anxiety symptoms, we need a more constructive approach to the problem than popping pills.”

The study is titled “Increasing benzodiazepine prescription and overdose mortality in the United States, 1996-2013.” The research was supported by the National Institutes of Health (NIH K24DA036955, R25DA023021 and K23DA027719). The authors report no conflicts of interest.

Marijuana Use Now Could Pose Verbal Memory Risk Later

Newswise, February 10, 2016 — Marijuana is the most frequently used illicit drug in the United States, according to a recent survey from the National Survey on Drug Use and Health, and new data suggest that marijuana use now could pose a serious cognitive function risk later in life.

Stefan Kertesz, M.D., an associate professor with the University of Alabama at Birmingham School of Medicine, is part of a recently published nationwide study reporting potential long-term consequences with implications for public health.

Impaired cognitive functioning is an acute effect of marijuana use, and there is increasing evidence that such effects may persist later in life after marijuana use has ceased. Heavy, long-term use of marijuana has been associated with cognitive impairment, particularly in learning and remembering new information.

Kertesz and other researchers found past exposure to marijuana use to be significantly associated with worse verbal memory in middle age.

Their paper used data from the Coronary Artery Risk Development in Young Adults (CARDIA) study which started in 1985, where more than 5,000 healthy adults were regularly asked about marijuana use. 

In contrast to studies that focus on people known to have an addiction, this study focused on community-based adults, where casual use tends to be more common than addiction.

In the final year of the study, CARDIA participants underwent simple cognitive tests, including a word memory test. Individuals were presented with 15 words and then asked to try to remember them. After 25 minutes, they were later asked to recall the words. 

The tests showed that there was a significant decline in verbal memory among persons whose cumulative marijuana use exceeded the equivalent of one joint a day for five years.

“For every five years of marijuana exposure, one out of two participants would remember one word less,” Kertesz said.

Kertesz also said that it is important to realize that marijuana is more potent today than it was in the 1980s, raising the possibility that users of today’s marijuana may face cognitive consequences of greater magnitude than those reported.

“It’s crucial to recognize that young brains are truly different and not fully developed until age 22 and are at more risk from marijuana,” he said. 

“Parents and teachers need to be vigilant that this poses a larger risk to adolescents.”

Data from 2012 indicates that, among students in the 12th grade (ages 17-18 years), 37 percent had used marijuana within the last year, 23 percent within the last 30 days and 6.5 percent daily.

Alcohol Withdrawal Adds Challenges to Caring for Critically Ill Patients

Article in Critical Care Nurse provides guidance on identifying, managing and assessing critically ill patients experiencing alcohol withdrawal

Newswise, February 1, 2016 — Alcohol withdrawal adds challenges to caring for critically ill patients, and nurses must be diligent at each stage of care to minimize complications, according to an article in the February issue of Critical Care Nurse (CCN).

The article, “Alcohol Withdrawal Syndrome in Critically Ill Patients: Identification, Assessment, and Management,” provides much-needed guidance to critical care nurses and other clinicians whose patients may have alcohol use disorder (AUD), including abuse and dependency conditions of varying severity.

Lead author Lynsey Sutton, RN, MNclin, is associate charge nurse manager of a level 3 intensive care unit, Capital and Coast District Health Board, Wellington Regional Hospital, Wellington, New Zealand. She is a guest teaching assistant in the postgraduate nursing program at Victoria University of Wellington, Wellington, New Zealand.

“The abrupt cessation of alcohol places patients with an AUD at risk for additional complications, and nurses are perfectly placed at the bedside to obtain histories of alcohol consumption from patients or the patients’ families. This may help identify those at risk for withdrawal early,” she said.

For the study, the researchers reviewed more than 100 articles related to alcohol use and critically ill patients that had been published in peer-reviewed journals.

Their work can help frontline nurses who are caring for critically ill patients at risk for alcohol withdrawal syndrome (AWS).

Managing alcohol withdrawal effectively begins with the identification of patients with an AUD as indicated by the patients’ medical histories. 

Unfortunately, a patient’s history of alcohol consumption is often poorly obtained, not detailed enough or not obtained at all.

The researchers recommend that a validated tool be developed to enable nurses to obtain a more comprehensive history of alcohol use, including past withdrawal or detoxification episodes.

If patients at risk are identified at the time of admission, nurses will be better able to detect signs and symptoms of alcohol withdrawal and initiate treatment early. This practice might halt the progression from mild to severe withdrawal and prevent delirium tremens.

The researchers also suggest development of a laboratory test or biomarker to highlight chronic alcohol use, especially when an alcohol history is unobtainable. Current blood tests focus on recent alcohol consumption, which may not help identify those at risk for withdrawal.

“The clinical manifestations of critical illness and alcohol withdrawal are often similar, and a worsening clinical condition in a patient with AWS should not always be assumed to be withdrawal related,” Sutton said.

The article also discusses various therapies, tools and assessment scales nurses can use to evaluate and monitor response to treatment.

The researchers call for further studies related to nearly every aspect of alcohol withdrawal in critically ill patients to help validate tools and develop evidence-based practice guidelines.

As the American Association of Critical-Care Nurses’ bimonthly clinical practice journal for high acuity, progressive and critical care nurses, CCN is a trusted source for information related to the bedside care of critically and acutely ill patients.

Access the article abstract and full-text PDF by visiting the CCN website at http://ccn.aacnjournals.org/.

About Critical Care Nurse: Critical Care Nurse (CCN), a bimonthly clinical practice journal published by the American Association of Critical-Care Nurses, provides current, relevant and useful information about the bedside care of critically and acutely ill patients. The journal also offers columns on traditional and emerging issues across the spectrum of critical care, keeping critical care nurses informed on topics that affect their practice in high acuity, progressive and critical care settings. CCN enjoys a circulation of more than 106,000 and can be accessed at http://ccn.aacnjournals.org/.

About the American Association of Critical-Care Nurses: Founded in 1969 and based in Aliso Viejo, California, the American Association of Critical-Care Nurses (AACN) is the largest specialty nursing organization in the world. AACN represents the interests of more than 500,000 acute and critical care nurses and includes more than 225 chapters worldwide. The organization’s vision is to create a healthcare system driven by the needs of patients and their families in which acute and critical care nurses make their optimal contribution. www.aacn.org; www.facebook.com/aacnface; www.twitter.com/aacnme