Psychotropic medications and substances of abuse interactions in youth

Bad trip due to anticholinergic effect of cannabis

Cannabis in its various forms has been known since time immemorial, the use of which has been rising steadily in India. 'Bad trips' have been documented after cannabis use, manifestations ranging from vague anxiety and fear to profoundly disturbing states of terror and psychosis. Cannabis is known to affect various neurotransmitters, but 'bad trip' due to its anticholinergic effect has never been described in literature to the best of author's knowledge. Hereby, the author describes a case of a young adult male experiencing profound anticholinergic effects after being exposed for the first time in his life to bhang, a local oral preparation of cannabis.

Combination pharmacotherapy for psychiatric disorders in children and adolescents: prevalence, efficacy, risks and research needs

Polypharmacy, defined as the concomitant use of two or more psychotropic drugs, has become increasingly common in the paediatric and adolescent population over the past two decades. Combining psychotropic drugs leads to possible increases in benefits, but also in risks, particularly given the potential for psychotropic drug interactions. Despite the increasing use of concomitant therapy in children and adolescents, there is very little evidence from controlled clinical trials to provide guidance for prescribers. Even while acknowledging the small evidence base, clinical practice guidelines from eminent medical organizations are either relatively silent on or tend to support the use of concomitant treatments more enthusiastically than the evidence would warrant, so that practice and guidance are running ahead of the science. Our narrative review shows that the published evidence for efficacy and safety of concomitant psychotropic drugs in children and adolescents is scanty. A comprehensive search located 37 studies published over the last decade, of which 18 were randomized controlled trials (RCTs). These focused mainly on stimulants, central sympatholytics (such as clonidine), antipsychotics and 'mood stabilizers'. While several small, often methodologically weak, RCTs demonstrated statistically significant advantages for dual pharmacotherapy over monotherapy, only adding central sympatholytics to stimulants for treating attention-deficit hyperactivity disorder (ADHD) symptoms was supported by substantial studies with an effect size large enough to suggest clinical importance. Non-randomized studies tended to have results that supported concomitant treatment, but all have design-related problems that decrease the reliability of the results. Two studies that specifically examined tolerability of combination pharmacotherapy compared with monotherapy showed significant increases in adverse effects, both subjective and objective, and other studies confirmed a statistically significant increase in adverse effects, including sedation and self-harm. Given the extent of combination therapy occurring, particularly in conditions such as ADHD, and the ambiguous evidence for benefit with clear evidence of harm, we propose that further research should be carried out as a matter of urgency. Until such a time, the attitude to combination pharmacotherapy should be conservative, and combining psychotropic medications should be considered as an 'n of 1' trial to be closely monitored.

Pharmacokinetics and pharmacodynamics of 3,4-methylenedioxymethamphetamine (MDMA): interindividual differences due to polymorphisms and drug-drug interactions

Clinical outcome following 3,4-methylenedioxymethamphetamine (MDMA) intake ranges from mild entactogenic effects to a life-threatening intoxication. Despite ongoing research, the clinically most relevant mechanisms causing acute MDMA-induced adverse effects remain largely unclear. This complicates the triage and treatment of MDMA users needing medical care. The user's genetic profile and interactions resulting from polydrug use are key factors that modulate the individual response to MDMA and influence MDMA pharmacokinetics and dynamics, and thus clinical outcome. Polymorphisms in CYP2D6, resulting in poor metabolism status, as well as co-exposure of MDMA with specific substances (e.g. selective serotonin reuptake inhibitors (SSRIs)) can increase MDMA plasma levels, but can also decrease the formation of toxic metabolites and subsequent cellular damage. While pre-exposure to e.g. SSRIs can increase MDMA plasma levels, clinical effects (e.g. blood pressure, heart rate, body temperature) can be reduced, possibly due to a pharmacodynamic interaction at the serotonin reuptake transporter (SERT). Pretreatment with inhibitors of the dopamine or norepinephrine reuptake transporter (DAT or NET), 5-HT(2A) or α-β adrenergic receptor antagonists or antipsychotics prior to MDMA exposure can also decrease one or more MDMA-induced physiological and/or subjective effects. Carvedilol, ketanserin and haloperidol can reduce multiple MDMA-induced clinical and neurotoxic effects. Thus besides supportive care, i.e. sedation using benzodiazepines, intravenous hydration, aggressive cooling and correction of electrolytes, it is worthwhile to investigate the usefulness of carvedilol, ketanserin and haloperidol in the treatment of MDMA-intoxicated patients.

Pharmacotherapy for adolescent alcohol use disorder

Alcohol use disorder (AUD) occurs in few young adolescents, but is as common as in adults by the late teens. To address problems with the current American Psychiatric Association DSM-IV criteria, the anticipated DSM-V will eliminate the distinction between substance abuse and dependence in favour of a single category. For adolescents, pharmacotherapy for AUD may target alcohol withdrawal symptoms, alcohol consumption reinforcement properties, craving or co-morbid mental disorders. While uncommon among adolescents, severe alcohol withdrawal may require the closely monitored application of benzodiazepines. Disulfiram alters alcohol metabolism and has been shown to increase abstinence in adolescents with AUD, but sufficient motivation to maintain abstinence is needed for this approach to be appropriate. Medications to reduce alcohol craving, including naltrexone and acamprosate, may also assist some adolescents in maintaining abstinence. Adolescents with AUD typically also have co-morbid mental disorders and problems with other substances. Co-morbid mental disorders, such as major depressive disorder and attention-deficit hyperactivity disorder, may be addressed by pharmacotherapy. The potential for interactions between prescribed medications and alcohol or illicit substances necessitates patient education and monitoring. While there is a paucity of empirical information on the applicability of these pharmacotherapy approaches in adolescents, cautious application of these medications in selected cases in the context of systematic psychosocial interventions is warranted to promote abstinence and address associated problems.

Problematic use of energy drinks by adolescents

Energy drinks (EDs) are caffeine-based beverages that commonly contain large doses of sugar, carbohydrates, and a variety of legal stimulants and supplements, such as guarana, taurine, ginseng, and vitamin B complex. These drinks are marketed for young people as natural alternatives that increase fun and improve physical and cognitive performance such as concentration, attention, and alertness. There are commonly held false perceptions that the consumption of EDs can reverse alcohol-related impairment, including motor coordination and visual reaction time, which are crucial for driving safety. This article reviews the literature on EDs and examines problematic use and potential negative consequences in young people. Special emphasis is devoted to safety concerns following combination of EDs with alcohol, which gives the user a false sense of control.

Pharmacotherapies for adolescent substance use disorders

There is a paucity of research on pharmacotherapies in adolescents with substance use disorders. This paucity is partly because of the fact that most people with substance dependence do not get diagnosed until early adulthood, that is, after 18 years of age. This article reviews pharmacotherapies used for aversion, substitution, anti-craving, and detoxification of alcohol, nicotine, cocaine, and opioids dependence. Adult research is referenced when applicable and generalized to adolescents with caution. Continued evaluation and development of pharmacotherapy for youth in controlled studies are needed to examine medication effectiveness, safety, potential for abuse, compliance, and potential interactions with other medications or substances of abuse.