Combination of Olanzapine With Opioid-Agonists in the Treatment of Heroin-Addicted Patients Affected by Comorbid Schizophrenia Spectrum Disorders

IUPHAR review - Data-driven computational drug repurposing approaches for opioid use disorder

Opioid Use Disorder (OUD) is a chronic and relapsing condition characterized by the misuse of opioid drugs, causing significant morbidity and mortality in the United States. Existing medications for OUD are limited, and there is an immediate need to discover treatments with enhanced safety and efficacy. Drug repurposing aims to find new indications for existing medications, offering a time-saving and cost-efficient alternative strategy to traditional drug discovery. Computational approaches have been developed to further facilitate the drug repurposing process. In this paper, we reviewed state-of-the-art data-driven computational drug repurposing approaches for OUD and discussed their advantages and potential challenges. We also highlighted promising repurposed candidate drugs for OUD that were identified by computational drug repurposing techniques and reviewed studies supporting their potential mechanisms of action in treating OUD.

Atypical antipsychotic drugs in dual disorders: current evidence and clinical guidelines

BACKGROUND

Concurrent disorder or dual diagnosis refers to a combination of substance use disorders and mental disorders that occur in the same patient simultaneously. These conditions pose significant clinical and healthcare impacts and are often underdiagnosed, undertreated, and complex to manage.

OBJECTIVE

We assessed the quality of current pharmacological recommendations for the management of dual diagnosis, particularly by evaluating the use of second-generation antipsychotics (SGA).

METHOD

A literature search was performed using the PubMed and Scopus databases for publications up to September 21, 2021, without any time restrictions. The following search strings were used: (aripiprazole OR brexpiprazole OR cariprazine OR paliperidone OR risperidone OR quetiapine OR clozapine OR olanzapine) AND (psychosis OR schizophrenia OR schizoaffective) AND ("substance use disorder" OR cocaine OR alcohol OR cannabis OR heroin OR "double diagnosis" OR "dual diagnosis")) NOT (animal OR rat OR mouse) NOT (review or meta-analysis).

RESULTS

The search produced a final set of 41 articles. Most patients were males and were affected by schizophrenia, with cannabis the most abused substance, followed by alcohol. Aripiprazole was the most used drug, either orally or by long-acting formulations, followed by risperidone with oral and long-acting formulations, clozapine, olanzapine, and quetiapine.

CONCLUSION

The findings highlight the use of SGA for the treatment of psychotic symptoms in comorbidity with substance use. Future studies on people with dual diagnosis and focused on long-term evaluations are warranted and need to investigate the efficacy of newly introduced molecules, such as partial D2 agonists and long-acting injectable antipsychotics.

The Benefits of Olanzapine in Palliating Symptoms

OPINION STATEMENT

Olanzapine has become a major drug in the management of chemotherapy-induced nausea and vomiting as a prophylactic agent. In addition, a recent randomized trial has demonstrated its benefits in treating nausea and vomiting associated with advanced cancer. The added benefit to olanzapine is that it also stimulates appetite. As a result, since it treats multiple symptoms associated with advanced cancer, it is likely to become the antiemetic of choice in palliative care at least in the USA. The added benefit of treating insomnia and the avoidance of benzodiazepines should place olanzapine in at the top of the list of drugs to use for patients who do complain of insomnia. There is no good evidence that it potentiates the respiratory depression of opioids unlike benzodiazepines. The evidence is weak that olanzapine in as an adjuvant analgesic. Hopefully, future trials will explore this in greater depth. The benefits of adding olanzapine to potent opioids are that it may reduce craving, drug cues, and opioid misuse. Other symptoms like anxiety and depression may be addressed by the addition of olanzapine to standard antidepressants.

Opioid use and schizophrenia

PURPOSE OF REVIEW

To summarize the current literature regarding comorbid schizophrenia and opioid use disorder (OUD).

RECENT FINDINGS

Epidemiological evidence is unclear on whether patients with schizophrenia have a higher rate of OUD. Patients with OUD have been shown to have a higher risk of developing schizophrenia. However, it is clear that patients with both schizophrenia and OUD are less likely to receive standard of care including medication-assisted treatment (MAT) for opiate use disorder and have worse outcomes compared with patients with schizophrenia who do not abuse opioids. OUD significantly increases the risk of converting patients from prodromal schizophrenia states to schizophrenia or schizoaffective disorder. Shared pathophysiology involving the kappa opioid receptor may help explain the relationships between schizophrenia and OUD. Second-generation antipsychotics, long-acting injectables, and MAT for OUD should be utilized in a dual-diagnosis and treatment approach for patients with schizophrenia and OUD.

SUMMARY

Exploration into the relationship between schizophrenia and opiate abuse is still in its infancy and requires a significant amount of future attention to clarify the epidemiology of this comorbidity, neurobiological relationship, shared genetic underpinnings, and possible treatments for both the psychotic symptoms and substance abuse.

Comorbid opioid use is undertreated among forensic patients with schizophrenia

BACKGROUND

Substance use disorders are associated with poorer clinical outcomes in patients with schizophrenia. There is no specific treatment for amphetamine or cannabis use disorder, but methadone and buprenorphine are used as replacement therapy in the treatment of opioid dependence. Our aim was to study whether patients with schizophrenia have received opioid replacement therapy for their opioid use disorder.

METHODS

The study sample consisted of 148 individuals diagnosed with schizophrenia who were in involuntary psychiatric treatment as forensic patients in Finland in 2012. The proportion of the study sample with comorbid opioid use disorder having received opioid replacement therapy prior to their forensic psychiatric treatment was compared to the available information of opioid dependent patients in general. The data were collected from forensic examination statements, patient files and other medical registers retrospectively.

RESULTS

Of the study sample, 15.6% (23/148) had a history of opioid use disorder, of whom 8.7% (2/23) had received opioid replacement treatment (95% confidence interval (Cl): 1.1-28.0), even though opioid use disorder had been diagnosed in the treatment system. According the available information the corresponding proportion among patients with opioid use disorder and using substance use disorder services was 30.4% (565/1860, 95% Cl: 28.3-32.5). The fraction of patients receiving opioid replacement therapy was significantly lower among patients with schizophrenia (p = 0.022).

CONCLUSIONS

Opioid replacement therapy was seldom used among schizophrenia patients who were later ordered to involuntary forensic psychiatric treatment. More attention should be paid to the possible use of opioids when planning treatment for patients with schizophrenia.

TRIAL REGISTRATION

Our study is not a randomized controlled trial (but a register-based study); thus the trial registration is not applicable.

Demographic and clinical factors predicting retention in methadone maintenance: results from an Irish cohort

BACKGROUND

Retention in Methadone Maintenance Treatment (MMT) is superior to that of other therapies for opioid addiction, but with international retention rates around 50 % after 1 year of treatment, there remains a need for improved retention rates.

AIMS

This study aimed to explore the demographic and clinical factors predicting retention in MMT.

METHODS

Face-to-face surveys with MMT patients in a Dublin methadone clinic were conducted. Retention was assessed by the presence and duration of breaks in treatment at any stage.

RESULTS

189 patients participated in the study. 46 % (n = 87) reported having at least one break in treatment, and the median duration of a break was 3 months. Age, current methadone dose and prescription of antipsychotic medication were significant predictors of retention. Patients who were older, single, living in their own home, on a higher dose of methadone, or taking antipsychotic medications had fewer breaks in treatment. Males tended to have significantly longer breaks. Patients reported that the main reasons for breaks were relapse into drug use (21.8 %, n = 19), incarceration (11.4 %, n = 10), weary of MMT (13.7 %, n = 12) or problems at the clinic (10.3 %, n = 9). Factors enabling regular attendance included wanting to get or stay clean (37.5 %, n = 51), avoidance of withdrawal symptoms (16.1 %, n = 22), methadone dependence (13.9 %, n = 19) and services provided (10.2 %, n = 14).

CONCLUSION

Patients who were older, single, living in their own home, on a higher dose of methadone, or taking antipsychotic medications had fewer breaks in treatment.

New developments in the management of opioid dependence: focus on sublingual buprenorphine-naloxone

Opioid maintenance therapy is a well-established first-line treatment approach in opioid dependence. Buprenorphine, a partial opioid agonist, has been found by numerous studies to be an effective and safe medication in the treatment of opioid dependence. At present, buprenorphine is available as a monodrug or in a fixed 4:1 ratio combination with naloxone. A diminished risk of diversion and abuse for the buprenorphine-naloxone combination is likely but not firmly established. Conventional formulations are given sublingually to avoid the hepatic first-pass effect. A novel film tablet is available only in the US and Australia. Other novel, sustained-release formulations (implant, depot) are currently being developed and tested. Recent studies, including a Cochrane meta-analysis, suggest that the retention with buprenorphine is lower than for methadone, but that buprenorphine may be associated with less drug use. Higher doses of buprenorphine are associated with better retention rates. Buprenorphine has a ceiling effect at the opioid receptor with regard to respiratory depression, and may cause fewer fatal intoxications than methadone. Possible antidepressant effects of buprenorphine and its use in comorbid psychiatric patients has not been studied in much detail. Clinical implications are discussed.

A comprehensive approach to addiction medicine as an appropriate response to the HIV epidemic among drug users

The services for drug-dependence treatment and care, particularly in low-income countries, should not be fragmented and uncoordinated. A basic package of interventions should be provided in the same place and managed by the same team, with a one-stop shop approach. The services for substance use disorders should be appealing, accessible, voluntary-based, and science-based. They should also, like efforts to fight other diseases, be included in the community and the public health systems; that is, those who are affected by drug use and those who serve them should not face discrimination. The first-line assistance and the second-line essential elements of the comprehensive package will be described. The work of the United Nations Office on Drugs and Crime (UNODC) and World Health Organization (WHO) to promote science-based and voluntary-based ethical treatment in Asia will be illustrated.

Effectiveness of short-term olanzapine in patients with bipolar I disorder, with or without comorbidity with substance use disorder

OBJECTIVES

Prognosis of comorbid bipolar disorder (BD) and drug abuse is poor. We assessed the efficacy of olanzapine in manic or mixed BD patients, with (SUD) or without (N-SUD) comorbidity with substance use disorder (SUD) and its effect on drug abuse, days of abuse, and craving.

METHODS

Eighty patients with BD-I (40 SUD) were hospitalized for a manic or mixed episode and received add-on olanzapine. Assessments were conducted at admission, discharge, and 4 and 8 weeks after discharge. Primary outcome was the proportion of responders and remitters in each group. We used a logistic regression model to adjust for possible confounders. We assessed craving and drug-abuse days with a visual analog scale and the Timeline Follow-Back.

RESULTS

SUD and N-SUD were similar on response and remission, adjusted for sex, age, years ill, age at first episode, first episode depressive, number of hospitalizations, and duration of hospitalization (odds ratio, 1.09; 95% confidence interval, 1.02-2.29). Mood rating scores dropped significantly from baseline to end point in both groups. Timeline follow-back decreased in SUD from 22.5 to 7.3 at 8 weeks postdischarge, whereas craving dropped from 8.3 to 5.1 (P < 0.03).

CONCLUSIONS

The effectiveness of short-term olanzapine in BD-I mania or mixed mania did not differ according to SUD comorbidity. Treatment was followed by less substance use/abuse and craving in comorbid bipolar-SUD patients.

Antipsychotic treatment of adolescent dual diagnosis patients

BACKGROUND

A diagnosis of schizophrenia requires development of a pharmacotherapy regimen that balances many factors in the therapeutic decision-making process. Patient age and the presence or absence of comorbid chemical dependency represent two factors. Comorbid chemical dependency can have a profound impact on the successful treatment of schizophrenia, making patients with dual diagnoses of schizophrenia and chemical dependence a uniquely challenging population. There is little information regarding treatment of schizophrenia and chemical dependence in the pediatric population. Existing data from pediatric and adult populations may facilitate a well-guided and knowledgeable approach to treating pediatric dual diagnosis patients.

METHODS

A review of the literature for medication trials evaluating antipsychotic medication used to treat schizophrenia in childhood and adolescence as well as antipsychotic use in the treatment of the dual diagnoses of schizophrenia and chemical dependence was done. Databases for Ovid MEDLINE, PubMed, and PsycInfo were searched using the terms "addiction," "adolescence," "childhood," "dual diagnosis," "schizophrenia," and "substance abuse." Results were limited to English-language articles.

RESULTS

Seven articles were identified related to psychotic disorders and substance abuse in pediatric populations. Psychosis measurement instruments included the Brief Psychiatric Rating Scale, Positive and Negative Syndrome Scale, and Clinical Global Impression. Mean improvements were insignificant in most cases. Medication trials included clozapine, olanzapine, risperidone, and molindone. Trial safety concerns included metabolic effects, increased prolactin levels, and akathisia. One study with random assignment to olanzapine was discontinued early because of substantial weight gain without evidence of superior efficacy. Clozapine treatment was associated with more adverse drug events.

CONCLUSION

There is a great need for more research and use of available data to develop safe and effective treatment guidelines for childhood and adolescent dual diagnosis patients. When appropriate decisions are made regarding treatment of patients with comorbid schizophrenia and chemical dependence, both conditions may benefit with increased remission.

BAP updated guidelines: evidence-based guidelines for the pharmacological management of substance abuse, harmful use, addiction and comorbidity: recommendations from BAP

The British Association for Psychopharmacology guidelines for the treatment of substance abuse, harmful use, addiction and comorbidity with psychiatric disorders primarily focus on their pharmacological management. They are based explicitly on the available evidence and presented as recommendations to aid clinical decision making for practitioners alongside a detailed review of the evidence. A consensus meeting, involving experts in the treatment of these disorders, reviewed key areas and considered the strength of the evidence and clinical implications. The guidelines were drawn up after feedback from participants. The guidelines primarily cover the pharmacological management of withdrawal, short- and long-term substitution, maintenance of abstinence and prevention of complications, where appropriate, for substance abuse or harmful use or addiction as well management in pregnancy, comorbidity with psychiatric disorders and in younger and older people.

Psychiatric co-morbidity and substance use disorders: treatment in parallel systems or in one integrated system?

Psychiatric co-morbidity among substance users refers to the simultaneous presence of at least another psychiatric disorder in a person diagnosed with a substance use disorder. Co-morbid patients represent a substantial number of people in treatment and present greater disorder severity from both the clinical and social perspectives than those people diagnosed with only one type of disorder. We present an overview of the current state of the art concerning the choice of site of treatment, the kind of intervention, the length of such treatment, and future goals, aiming to establish a more effective intervention, and finally so as to further improve clinical outcomes.

Predictors of continuation with olanzapine during the 1-year naturalistic treatment of patients with schizophrenia in Japan

PURPOSE

Treatment continuation is considered an important measure of antipsychotic effectiveness in schizophrenia, reflecting the medication's efficacy, safety, and tolerability from both patients' and clinicians' perspectives. This study identified characteristics of patients with schizophrenia who continue olanzapine therapy for a 1-year period in Japan.

METHODS

In a large (N = 1850), prospective, observational study, Japanese patients with schizophrenia who initiated treatment with olanzapine were followed for 1 year. Baseline characteristics were compared using t-tests and chi-square tests. Stepwise logistic regression was used to identify independent baseline predictors of treatment continuation.

RESULTS

Most patients (68.2%) continued with olanzapine therapy for the full 1-year study period, with an average duration of 265.5 ± 119.4 days. At baseline, patients who continued were significantly more likely to be male, older, and inpatients; have longer illness duration, higher negative and cognitive symptoms, better health-related quality of life, and prior anticholinergic use. Continuers were significantly less likely to engage in social activities, live independently, work for pay, or have prior antidepressant use. Continuers showed significantly greater early (3-month) improvement in global symptom severity. Logistic regression found that continuation was significantly predicted by longer illness duration, lower positive symptoms, higher negative symptoms, and better health-related quality of life.

CONCLUSIONS

In this large naturalistic study in Japan, most patients with schizophrenia stayed on olanzapine therapy for the full 1-year study period. Treatment completion with olanzapine was independently predicted by longer illness duration, lower positive symptoms, higher negative symptoms, and better health-related quality of life.

Antipsychotic agents for the treatment of substance use disorders in patients with and without comorbid psychosis

Substance dependence has serious negative consequences upon society such as increased health care costs, loss of productivity, and rising crime rates. Although there is some preliminary evidence that atypical antipsychotic agents may be effective in treating substance dependence, results have been mixed, with some studies demonstrating positive and others negative or no effect. The present study was aimed at determining whether this disparity originates from that reviewers separately discussed trials in patients with (DD) and without (SD) comorbid psychosis. Using electronic databases, we screened the relevant literature, leaving only studies that used a randomized, double-blind, placebo-controlled or case-control design that had a duration of 4 weeks or longer. A total of 43 studies were identified; of these, 23 fell into the category of DD and 20 into the category of SD. Studies in the DD category suggest that atypical antipsychotic agents, especially clozapine, may decrease substance use in individuals with alcohol and drug (mostly cannabis) use disorders. Studies in the SD category suggest that atypical antipsychotic agents may be beneficial for the treatment of alcohol dependence, at least in some subpopulations of alcoholics. They also suggest that these agents are not effective at treating stimulant dependence and may aggravate the condition in some cases.

Pharmacotherapy of schizophrenia with comorbid substance use disorder--reviewing the evidence and clinical recommendations

Substance use disorder is the most common psychiatric comorbidity in schizophrenic patients, with prevalence rates of up to 65%. Recommendations for antipsychotic pharmacotherapy in schizophrenia are based on studies that excluded patients with this dual diagnosis. In the present comprehensive systematic review, the pharmacological studies performed in this subgroup of patients are summarised and discussed from the standpoint of evidence-based medicine. Unfortunately, randomized controlled studies, providing a high evidence level, in patients with this dual diagnosis are rare. Data, mainly based on open studies or case series, suggest superior efficacy for second generation antipsychotic agents (SGAs) (aripiprazole, clozapine, olanzapine, quetiapine, risperidone) with regard to improvement of distinct psychopathological symptoms, reduced craving and greater reduction of substance use compared with orally administered conventional antipsychotics (FGAs). Tricyclic antidepressants given adjunctive to antipsychotic maintenance therapy showed efficacy in reducing substance use and craving. The administration of anti-craving agents (naltrexone) led to a decrease of drug intake. Unfortunately, there is no clinical experience with acamprosate in schizophrenic patients with comorbid alcoholism. In conclusion, there are more theoretically based arguments for the preferential use of SGAs in schizophrenic patients with comorbid substance use disorder while the empirical evidence is weak. The early initiation of treatment with antidepressants, depending on the patient's psychopathology, as well as add-on medication with anti-craving agents should be considered.