# Presentation: 167386

## Psychotropic Medication Management on Center

- David P. Kraft, MD, MPH
- Region I Mental Health Consultant
- National Health and Wellness Conference
- Orlando, Florida
- June 7, 2005

## Psychotropic Medication Management on Center

- How can we help students on psychotropic medications while in Job Corps and when preparing to leave Job Corps?

## A.  Principles of Psychiatric Medications

- Medications are a TOOL to help students control feelings, thoughts and behavior
- Medications are best when COMBINED with counseling and behavioral techniques

## A. Principles of Psychiatric Medications (continued)

- Medications take AT LEAST 2 WEEKS to begin to work (except side-effects, which can begin immediately, then usually subside after 5 days)
- Medications need to be taken at least ONCE A DAY
- Medications take BETWEEN 1 and 2 WEEKS to stop working, in most cases

## A. Principles of Psychiatric Medications (continued)

- Major CHANGES in medication should be AVOIDED during Job Corps stay (minimize lost training time)
- Newer medications have FEWER SIDE-EFFECTS
- Newer medications are usually MORE EXPENSIVE

## B. Common Problems Helped with Psychiatric Medications

- DEPRESSION, especially if chronic, not situational
- ANXIETY states, including panic, phobic, obsessive-compulsive disorders, and general stress not responsive to counseling or behavior techniques

## B. Common Problems Helped with Psychiatric Medications (continued)

- IMPULSIVE tendencies, especially if explosive and can injure student or others
- FLASHBACKS from earlier traumatic events, especially if disrupting sleep or concentration
- LEARNING DIFFICULTIES, especially if ADHD is involved

## C. Less Common Problems Helped with Medications

- PARANOID PSYCHOSIS, may be stabilized on antipsychotic medications and supportive therapy
- OTHER PSYCHOTIC DISORDER, such as Schizophrenia, Schizoaffective Disorder, where antipsychotic medication can help student overcome some of abnormal features of these disorders

## C. Less Common Problems Helped with Medications (continued)

- BIPOLAR DISORDER, usually stabilized on mood stabilizer and/or atypical antipsychotic agents
- ADJUSTMENT DISORDERS, if last more than a few weeks, may be helped short-term

## D. Obtaining Psychotropic Medications for Students

- Student brings medications from home, and gets from doctor at home
- Student’s health insurance pays for medications while in Job Corps
- Student enrolled in Medicaid at center

## D. Obtaining Psychotropic Medications for Students (continued)

- Job Corps Center provides medications through local pharmacy or government supply house (JC Information Notice 02-18)
- Center physician/psychiatrist applies for patient assist program of specific drug company for each medication

## E. Helping Students Comply with Taking Medications

- Supply each student a list of medications, when taken, and instructions (if any)
- Ask wellness staff to tailor times of taking medications to minimize interference with learning schedule
- Teach students ways to remember to take chronic medications (e.g., dispenser, daily reminder, convenient times)

## E. Helping Students Comply with Taking Medications (continued)

- Help students take medications on own (e.g. over weekends or 2-3 days supply at a time, if safe for them to have medications at dorm)
- For addictive and abusable substances (sedatives, hypnotics, stimulants), provide no more than a one day supply at a time, to minimize risk of other students getting into medications

## E. Helping Students Comply with Taking Medications (continued)

- Train residential staff in safe use of medications, in order to help students comply with medication regimens
- Provide training to education and vocation staff, as well as support personnel, concerning the basic principles of using psychotropic medications safely and effectively

## F. Preparing Students for Life Beyond Job Corps

- Update lists of medications, doses, side-effects, and reason for use
- Help students practice asking their doctors and nurses questions about the medications, and options for care
- Teach students how to keep track of  compliance and recognize changes in their symptoms

## F. Preparing Students for Life Beyond Job Corps (continued)

- Help student develop plans to transfer care and obtain services upon leaving Job Corps, if possible, schedule appointments with doctors, therapists, etc. before leaving
- Give student written summary of current health and wellness concerns, treatments, present needs, future goals and plans

## G. Common Medications Used

- DEPRESSION
- Selective Serotonin Reuptake Inhibitors (SSRIs)
- citalopram (Celexa)
- escitalopram (Lexapro)
- fluoxetine (Prozac)
- paroxetine (Paxil)
- Atypical Antidepressants
- buproprion (Wellbutrin SR)
- venlafaxine (Effexor XR)
- duloxetine (Cymbalta)
- Tricyclic Antidepressants (TCAs)
- desipramine (Norpramin)
- nortriptyline (Pamelor)
- amitriptyline (Elavil)

## G. Common Medications Used (continued)

- ANXIETY
- Selective Serotonin Reuptake Inhibitors (SSRIs)
- citalopram (Celexa)
- escitalopram (Lexapro)
- fluoxetine (Prozac)
- fluvoxamine (Luvox)
- paroxetine (Paxil)
- Atypical Antidepressants
- venlafaxine (Effexor XR)
- duloxetine (Cymbalta)

## G. Common Medications Used (continued)

- ANXIETY (continued)
- Tricyclic Antidepressants (TCAs--older drugs)
- desipramine (Norpramin)
- nortriptyline (Pamelor)
- amitriptyline (Elavil)
- Benzodiazepines (minor tranquilizers)--[ADDICTIVE, not use with substance abusers]
- clonazepam (Klonopin)
- lorazepam (Ativan)
- diazepam (Valium)
- alprazolam (Xanax)

## G. Common Medications Used (continued)

- Bipolar Disorders (manic depression)
- Mood Stabilizers
- lithium carbonate (Eskalith)
- divalproate (Depakote)
- carbamazepine (Tegretol)
- oxcarbazepine (Trileptal)
- Atypical Antipsychotic Agents
- olanzapine (Zyprexa)
- risperidone (Risperdal)
- ziprasidone (Geodon)
- aripiprazole (Abilify)
- quetiapine (Seroquel)
- Typical Antipsychotic Agents
- haloperidol (Haldol)

## G. Common Medications Used (continued)

- Bipolar Depression (Bipolar Type II-usually treated with mood stabilizer and antidepressant)
- Mood Stabilizers
- lamotrigine (Lamictal)
- lithium carbonate (Eskalith)
- divalproate (Depakote)
- carbamazepine (Tegretol)
- Atypical Antipsychotic Agents
- olanzapine (Zyprexa)
- risperidone (Risperdal)
- aripiprazole (Abilify)
- ziprasidone (Geodon)

## G. Common Medications Used (continued)

- Psychotic Disorder (including Schizophrenia, Schizoaffective Disorder, and Paranoid Psychosis)
- Atypical Antipsychotic Agents
- olanzapine (Zyprexa)
- risperidone (Risperdal)
- ziprasidone (Geodon)
- quetiapine (Seroquel)
- aripiprazole (Abilify)
- clozapine (Clozaril)
- Typical Antipsychotic Agents
- haloperidol (Haldol), perphenazine (Trilafon), thioridazine (Mellaril)

## G. Common Medications Used (continued)

- Impulsive Disorders (treated according to underlying disorder, if any)
- SSRI and Atypical Antidepressants
- citalopram, escitalopram, fluoxetine, paroxetine, sertraline, venlafaxine, duloxetine
- Mood Stabilizers
- lithium carbonate, divalproate, carbamazepine
- Atypical and Typical Antipsychotic Agents
- risperidone, olanzapine, quetiapine
- haloperidol , thioridazine (Mellaril)
- Adrenergic Agents  (higher doses may help)
- propranolol (Inderal LA, Inderal)

## G. Common Medications Used (continued)

- ADHD
- Selected Antidepressants (SSRIs, Atypicals, TCAs)
- buproprion (Wellbutrin SR)
- venlafaxine (Effexor XR)
- fluoxetine (Prozac), citalopram (Celexa)
- desipramine (Norpramin)
- SNRI (Selective Norepinephrine Reuptake Inhibitor)--[NEW]
- atomoxetine (Strattera)
- Psychostimulants (easily ABUSED by other students, paradoxical calming effect on ADHD student)
- amphetamine salts (Adderall)
- dextroamphetamine (Dexedrine)
- methylphenidate (Ritalin, Metadate, Concerta)
- pemoline (Cylert)

## G. Common Medications Used (continued)

- Alcohol & Drug Abuse
- Alcohol Abuse Prevention
- disulfiram (Antabuse)
- naltrexone (Revia)
- acamprosate (Campral)
- Opiates & Other Drugs
- naltrexone (Revia)
- buprenorphine (Buprenex)
- levomethadyl (ORLAAM)
- methadone (Dolophine)

## Summary

- Encourage students to take medications as prescribed, or consult with wellness center staff if problems
- Support overall goal of student responsibility for behavior, whether or not taking medication

## Summary (continued)

- Discourage students from only using medications “when I remember”--to do any good, most need to be taken at least once a day
- If asked about whether a student should take his/her medication, share your observations of how the medicine may be helping

## Summary (continued)

- Look for ways to make medication compliance easier for students
- Help wellness center staff with ideas about helping students plan for their future

## References

- Mosby’s Drug Consult 2005, Mosby, Inc., St. Louis, MO, 2005.
- Physicians’ Desk Reference 2005, Edition 58, Medical Economics Co., Inc., Montvale, NJ, 2005.
- Psychotropic Drugs Fast Facts, by Maxmen JS, Ward NG, WW Norton & Co., New York, 2002.
- Job Corps TAG H: Mental Health Disabilities, Section 5, September 2003.

## Appendix:  Newest Medications

- Antidepressant/Antianxiety Agents (older = fluoxetine, sertraline, paroxetine, fluvoxamine, buproprion)
- escitalopram (Lexapro), 10-30 mg daily
- citalopram (Celexa), 20-80 mg daily
- venlafaxine (Effexor XR), 37.5-300 mg daily
- duloxetine (Cymbalta), 40-120 mg daily

## Latest Medications (continued)

- Mood Stabilizing Agents (usual = lithium, valproate, carbamazepine)
- lamotrigine (Lamictal), 100-500 mg daily (bipolar depression)
- oxcarbazepine (Trileptal), 600-2400 mg daily (no blood levels needed)
- topiramate (Topamax), 50-400 mg daily (weight loss side-effect, often second agent)

## Latest Medications (continued)

- Antipsychotic Agents (usual = risperidone, olanzapine, quetiapine, clozapine)
- ziprasidone (Geodon), 80-200 mg daily (with food, weight loss side-effect)
- aripiprazole (Abilify), 10-30 mg daily (weight neutral)
- risperidone long-acting injection (Risperdal Consta), 25-75 mg every 2 weeks (microspheres in diluent, 3 week lag-time to work)

## Latest Medications (continued)

- Antianxiety and Sedative Agents (usual = lorazepam, clonazepam, zolpidem, buspirone)
- alprazolam extended-release (Xanax XR), 1-10 mg daily (11 hour half-life, panic disorder indication)
- zaleplon (Sonata), 5-20 mg bedtime (short duration, 1 hour half-life)
- eszopiclone (Lunesta), 1-3 mg bedtime (short duration, 6 hour half-life)

## Latest Medications (continued)

- ADHD Medications (usual = methylphenidate, dextroamphetamine, desipramine)
- amphetamine mixed salts extended-release (Adderall XR), 5-30 mg once daily (half-life 10-13 hours, abuse can cause psychosis)
- methylphenidate extended-release (Ritalin LA), 10-80 mg once daily (half-life 3-4 hours, more reliable than SR form)

## Latest Medications (continued)

- ADHD Medications (continued)
- atomoxetine (Strattera), 40-100 mg daily (selective norepinephrine reuptake inhibitor, similar action of older TCAs, fewer side-effects)
- modafinil (Provigil), 100-600 mg daily (for narcolepsy, does NOT seem helpful for ADHD in first open label studies)

## Latest Medications (continued)

- Substance Abuse [usual = disulfiram, naltrexone, methadone]
- buprenorphine (Subutex), 12-16 mg sublingual daily, for induction; buprenorpine, naloxone (Suboxone), 12/3-16/4 mg sublingual daily, for opioid dependence
-  acamprosate (Campral), 666-1998mg daily, half-life 20-33 hours, for alcohol dependence