Full Transcript Case Introduction and Referral 0:10 a 61-year-old woman who was chronic pain 0:10 a 61-year-old woman who was chronic pain psychiatry clinic 0:13 psychiatry clinic 0:13 psychiatry clinic in which individuals with chronic pain 0:15 in which individuals with chronic pain 0:15 in which individuals with chronic pain but also mental health concerns be 0:18 but also mental health concerns be 0:18 but also mental health concerns be evaluated for both coing or coexisting 0:22 evaluated for both coing or coexisting 0:22 evaluated for both coing or coexisting problems is actually referred by her 0:24 problems is actually referred by her 0:24 problems is actually referred by her primary care physician 0:27 primary care physician 0:27 primary care physician and the reason or the chief complaint 0:29 and the reason or the chief complaint 0:29 and the reason or the chief complaint Complaint was for psychosis 0:32 Complaint was for psychosis 0:32 Complaint was for psychosis other words hearing voices.
New-Onset Psychosis and Withdrawal History 0:38 Patient came with a past medical history 0:38 Patient came with a past medical history of endometriosis, 0:40 of endometriosis, 0:40 of endometriosis, mild degenerative joint disease, chronic 0:43 mild degenerative joint disease, chronic 0:43 mild degenerative joint disease, chronic pain syndrome in so many words. Uh that 0:46 pain syndrome in so many words. Uh that 0:46 pain syndrome in so many words. Uh that included dismenorhea or irregular 0:49 included dismenorhea or irregular 0:49 included dismenorhea or irregular menstrual cycles, migraines, sciatic 0:52 menstrual cycles, migraines, sciatic 0:52 menstrual cycles, migraines, sciatic pain that's nerve pain traveling down 0:54 pain that's nerve pain traveling down 0:54 pain that's nerve pain traveling down the leg and muscularkeeletal pain. 0:57 the leg and muscularkeeletal pain. 0:58 the leg and muscularkeeletal pain. At this point, immediately might 1:00 At this point, immediately might 1:00 At this point, immediately might generate some questions. Good point to 1:02 generate some questions. Good point to 1:02 generate some questions. Good point to reflect what could be occurring right 1:05 reflect what could be occurring right 1:05 reflect what could be occurring right away based on the past medical history, 1:07 away based on the past medical history, 1:08 away based on the past medical history, age, and other features that were 1:09 age, and other features that were 1:10 age, and other features that were already shared. 1:11 already shared. 1:11 already shared. It asks the question or begs the 1:13 It asks the question or begs the 1:13 It asks the question or begs the question, what else do you want to know? 1:15 question, what else do you want to know? 1:15 question, what else do you want to know? What else do you want to do in terms of 1:18 What else do you want to do in terms of 1:18 What else do you want to do in terms of evaluations, tests, exams, 1:21 evaluations, tests, exams, 1:21 evaluations, tests, exams, laboratory analysis, etc. 1:24 laboratory analysis, etc. 1:24 laboratory analysis, etc. And where is your mind going when it 1:26 And where is your mind going when it 1:26 And where is your mind going when it comes to considering what could be 1:28 comes to considering what could be 1:28 comes to considering what could be causing this presentation, this set of 1:31 causing this presentation, this set of 1:31 causing this presentation, this set of symptoms, so-called differential 1:34 symptoms, so-called differential 1:34 symptoms, so-called differential diagnosis, as well as what are the 1:36 diagnosis, as well as what are the 1:36 diagnosis, as well as what are the therapeutics, treatments that you might 1:38 therapeutics, treatments that you might 1:38 therapeutics, treatments that you might be considering. 1:40 be considering. 1:40 be considering. But we'll advance the story to see what 1:42 But we'll advance the story to see what 1:42 But we'll advance the story to see what else unfolds. 1:44 else unfolds. 1:44 else unfolds. Turns out from the history of present 1:46 Turns out from the history of present 1:46 Turns out from the history of present illness or HPI that for about four 1:50 illness or HPI that for about four 1:50 illness or HPI that for about four months, the patient has had a new onset 1:51 months, the patient has had a new onset 1:51 months, the patient has had a new onset psychosis. So this is not something that 1:54 psychosis. So this is not something that 1:54 psychosis. So this is not something that has been going on most of her life in 1:56 has been going on most of her life in 1:56 has been going on most of her life in the context of recurrent opioid 1:58 the context of recurrent opioid 1:58 the context of recurrent opioid withdrawal meaning she's going through 2:01 withdrawal meaning she's going through 2:01 withdrawal meaning she's going through the after effects of stopping her opioid 2:04 the after effects of stopping her opioid 2:04 the after effects of stopping her opioid complicated by intermittent delirium.
Hallucinations, Delusions, and Distress 2:06 complicated by intermittent delirium. 2:06 complicated by intermittent delirium. Delirium is confusion or medical 2:08 Delirium is confusion or medical 2:08 Delirium is confusion or medical confusion. So you have a lot to unpack 2:11 confusion. So you have a lot to unpack 2:11 confusion. So you have a lot to unpack there. You have a new 2:14 there. You have a new 2:14 there. You have a new or brand new set of symptoms in the 2:17 or brand new set of symptoms in the 2:17 or brand new set of symptoms in the context of some med changes important 2:19 context of some med changes important 2:19 context of some med changes important ones. and and so you have a few hints 2:22 ones. and and so you have a few hints 2:22 ones. and and so you have a few hints there as to what could be going on. 2:25 there as to what could be going on. 2:25 there as to what could be going on. Turns out that uh you know psychosis is 2:29 Turns out that uh you know psychosis is 2:29 Turns out that uh you know psychosis is not typically something that presents at 2:31 not typically something that presents at 2:31 not typically something that presents at that age for the first time. Usually 2:34 that age for the first time. Usually 2:34 that age for the first time. Usually presents in younger age. Psychosis as in 2:37 presents in younger age. Psychosis as in 2:37 presents in younger age. Psychosis as in schizophrenia or schizopeeffective 2:39 schizophrenia or schizopeeffective 2:39 schizophrenia or schizopeeffective disorder or delusional disorders. Those 2:41 disorder or delusional disorders. Those 2:41 disorder or delusional disorders. Those typically affect individuals starting in 2:43 typically affect individuals starting in 2:43 typically affect individuals starting in the ages of late teens or 20s. Turns out 2:47 the ages of late teens or 20s. Turns out 2:47 the ages of late teens or 20s. Turns out that the patient was running out of her 2:49 that the patient was running out of her 2:49 that the patient was running out of her opioid early for about four months. So, 2:52 opioid early for about four months. So, 2:52 opioid early for about four months. So, she was running out of the medication 2:55 she was running out of the medication 2:55 she was running out of the medication and was treating her withdrawal from 2:57 and was treating her withdrawal from 2:58 and was treating her withdrawal from running out with over-the-counter 2:59 running out with over-the-counter 2:59 running out with over-the-counter benadryil. And this was contributing to 3:02 benadryil. And this was contributing to 3:02 benadryil. And this was contributing to confusion and psychosis. We know that 3:04 confusion and psychosis. We know that 3:04 confusion and psychosis. We know that benadryil or dyenhydramine, which is an 3:08 benadryil or dyenhydramine, which is an 3:08 benadryil or dyenhydramine, which is an antihistamine, can cause confusion, 3:11 antihistamine, can cause confusion, 3:11 antihistamine, can cause confusion, particularly when you're a bit older. So 3:13 particularly when you're a bit older. So 3:13 particularly when you're a bit older. So that plus running out of her opioid was 3:15 that plus running out of her opioid was 3:16 that plus running out of her opioid was contributing to this confusion and 3:18 contributing to this confusion and 3:18 contributing to this confusion and so-called psychosis. 3:21 so-called psychosis. 3:21 so-called psychosis. She was never combative or agitated 3:23 She was never combative or agitated 3:23 She was never combative or agitated throughout this. Never had safety 3:25 throughout this. Never had safety 3:25 throughout this. Never had safety concerns like suicidal ideation or 3:27 concerns like suicidal ideation or 3:27 concerns like suicidal ideation or homicidal ideiation thankfully. 3:31 homicidal ideiation thankfully. 3:31 homicidal ideiation thankfully. However, there were other psychiatric 3:32 However, there were other psychiatric 3:32 However, there were other psychiatric symptoms of note. So this psychosis 3:36 symptoms of note. So this psychosis 3:36 symptoms of note. So this psychosis was characterized as having uh three 3:39 was characterized as having uh three 3:39 was characterized as having uh three parts. Visual hallucinations, delusions 3:42 parts. Visual hallucinations, delusions 3:42 parts. Visual hallucinations, delusions and auditory hallucinations. The visual 3:44 and auditory hallucinations. The visual 3:44 and auditory hallucinations. The visual hallucinations for example included 3:46 hallucinations for example included 3:46 hallucinations for example included abnormal experiences of street lights. 3:50 abnormal experiences of street lights. 3:50 abnormal experiences of street lights. These would resolve rapidly within days. 3:53 These would resolve rapidly within days. 3:53 These would resolve rapidly within days. And so this this was the least 3:54 And so this this was the least 3:54 And so this this was the least distressing or problematic of the 3:56 distressing or problematic of the 3:56 distressing or problematic of the symptoms. She did have delusions or 3:58 symptoms. She did have delusions or 3:58 symptoms. She did have delusions or fixed false beliefs about her neighbors 4:02 fixed false beliefs about her neighbors 4:02 fixed false beliefs about her neighbors conspiring against her. bugging her 4:04 conspiring against her. bugging her 4:04 conspiring against her. bugging her place and broadcasting thoughts to her. 4:06 place and broadcasting thoughts to her. 4:06 place and broadcasting thoughts to her. In other words, some paranoia. This did 4:09 In other words, some paranoia. This did 4:09 In other words, some paranoia. This did not resolve immediately and actually 4:11 not resolve immediately and actually 4:11 not resolve immediately and actually required some treatment. This persisted 4:14 required some treatment. This persisted 4:14 required some treatment. This persisted despite the visual hallucinations going 4:16 despite the visual hallucinations going 4:16 despite the visual hallucinations going away quickly. Auditory hallucinations 4:19 away quickly. Auditory hallucinations 4:19 away quickly. Auditory hallucinations were characterized as negative 4:22 were characterized as negative 4:22 were characterized as negative commentary or chatter from male and 4:24 commentary or chatter from male and 4:24 commentary or chatter from male and female voices. Maybe the neighbors, but 4:28 female voices. Maybe the neighbors, but 4:28 female voices. Maybe the neighbors, but also some strangers. And there were some 4:31 also some strangers. And there were some 4:31 also some strangers. And there were some condemnatory religious themes meaning 4:33 condemnatory religious themes meaning 4:33 condemnatory religious themes meaning some u very harsh critical themes and 4:38 some u very harsh critical themes and 4:38 some u very harsh critical themes and and religious sort of guilt themes. This 4:42 and religious sort of guilt themes. This 4:42 and religious sort of guilt themes. This also did not resolve immediately and 4:43 also did not resolve immediately and 4:43 also did not resolve immediately and required treatment. You had some 4:45 required treatment. You had some 4:45 required treatment. You had some lingering effects 4:47 lingering effects 4:47 lingering effects despite uh some of these symptoms 4:51 despite uh some of these symptoms 4:51 despite uh some of these symptoms disappearing. All of these were each of 4:53 disappearing. All of these were each of 4:53 disappearing. All of these were each of these were characterized as egoistonic. 4:55 these were characterized as egoistonic. 4:55 these were characterized as egoistonic. That's fancy speak and psychiatry for 4:58 That's fancy speak and psychiatry for 4:58 That's fancy speak and psychiatry for symptoms that are really distressing and 5:00 symptoms that are really distressing and 5:00 symptoms that are really distressing and bothersome. There are individuals who 5:02 bothersome. There are individuals who 5:02 bothersome. There are individuals who have hallucinations and delusions and 5:05 have hallucinations and delusions and 5:05 have hallucinations and delusions and that are not bothered by these or that 5:07 that are not bothered by these or that 5:07 that are not bothered by these or that do see them as consistent with reality. 5:10 do see them as consistent with reality. 5:10 do see them as consistent with reality. She understood that this was not her 5:13 She understood that this was not her 5:13 She understood that this was not her reality, her usual state of mind, and 5:15 reality, her usual state of mind, and 5:15 reality, her usual state of mind, and that something was wrong. She found it 5:17 that something was wrong. She found it 5:18 that something was wrong. She found it extremely distressing and uncomfortable 5:19 extremely distressing and uncomfortable 5:19 extremely distressing and uncomfortable and wanted it treated. 5:22 and wanted it treated. 5:22 and wanted it treated. So, with all the information that's been
Initial Workup and Medication Changes 5:24 So, with all the information that's been 5:24 So, with all the information that's been shared, this is another good stopping 5:26 shared, this is another good stopping 5:26 shared, this is another good stopping point to reflect. What else do you want 5:28 point to reflect. What else do you want 5:28 point to reflect. What else do you want to know at this point? What other 5:30 to know at this point? What other 5:30 to know at this point? What other information might be useful to 5:32 information might be useful to 5:32 information might be useful to disentangle what's been going on? What 5:35 disentangle what's been going on? What 5:35 disentangle what's been going on? What else do you want to do in terms of 5:37 else do you want to do in terms of 5:37 else do you want to do in terms of tests, analyses, interviews, physical 5:39 tests, analyses, interviews, physical 5:39 tests, analyses, interviews, physical exams, and again, where is your mind 5:42 exams, and again, where is your mind 5:42 exams, and again, where is your mind taking you in terms of your differential 5:44 taking you in terms of your differential 5:44 taking you in terms of your differential diagnosis, your treatment 5:45 diagnosis, your treatment 5:45 diagnosis, your treatment considerations, and such. 5:48 considerations, and such. 5:48 considerations, and such. I'll advance further. The primary care 5:50 I'll advance further. The primary care 5:50 I'll advance further. The primary care physician actually ordered a number of 5:52 physician actually ordered a number of 5:52 physician actually ordered a number of labs when she started to present with 5:54 labs when she started to present with 5:54 labs when she started to present with these symptoms. And the workup included 5:57 these symptoms. And the workup included 5:57 these symptoms. And the workup included labs like complete blood cell count, 6:00 labs like complete blood cell count, 6:00 labs like complete blood cell count, complete metabolic panel, thyroid 6:02 complete metabolic panel, thyroid 6:02 complete metabolic panel, thyroid stimulating hormone, vitamin levels like 6:05 stimulating hormone, vitamin levels like 6:05 stimulating hormone, vitamin levels like B12 and folic acid or folate and a CAT 6:08 B12 and folic acid or folate and a CAT 6:08 B12 and folic acid or folate and a CAT scan of the head. All of these were 6:10 scan of the head. All of these were 6:10 scan of the head. All of these were found to be within normal limits. So 6:12 found to be within normal limits. So 6:12 found to be within normal limits. So negative, they were normal. There were 6:15 negative, they were normal. There were 6:15 negative, they were normal. There were also no significant physical exam 6:17 also no significant physical exam 6:17 also no significant physical exam findings. She had no constitutional 6:19 findings. She had no constitutional 6:19 findings. She had no constitutional symptoms that she reported meaning like 6:21 symptoms that she reported meaning like 6:21 symptoms that she reported meaning like malaise fatigue. She had no weight loss. 6:25 malaise fatigue. She had no weight loss. 6:25 malaise fatigue. She had no weight loss. So that was a negative exam as well. 6:28 So that was a negative exam as well. 6:28 So that was a negative exam as well. Terms of treatment for about 2 months 6:31 Terms of treatment for about 2 months 6:31 Terms of treatment for about 2 months the primary care doctor actually resumed 6:35 the primary care doctor actually resumed 6:35 the primary care doctor actually resumed Percoet which is an oxycodin acophen 6:39 Percoet which is an oxycodin acophen 6:39 Percoet which is an oxycodin acophen opioid to prevent withdrawal. Tried to 6:42 opioid to prevent withdrawal. Tried to 6:42 opioid to prevent withdrawal. Tried to resume opioids to offset that. also 6:46 resume opioids to offset that. also 6:46 resume opioids to offset that. also started a medication known as cerakolar 6:48 started a medication known as cerakolar 6:48 started a medication known as cerakolar quitipene 25 milligrams at bedtime and 6:51 quitipene 25 milligrams at bedtime and 6:51 quitipene 25 milligrams at bedtime and increased it to 50 milligrams. This is 6:53 increased it to 50 milligrams. This is 6:53 increased it to 50 milligrams. This is an antiscychotic actually that can be 6:56 an antiscychotic actually that can be 6:56 an antiscychotic actually that can be helpful in states of confusion or in 6:58 helpful in states of confusion or in 6:58 helpful in states of confusion or in psychosis. 6:59 psychosis. 7:00 psychosis. Additionally started some zoloft or 7:01 Additionally started some zoloft or 7:02 Additionally started some zoloft or certain ssrrii or conventional 7:05 certain ssrrii or conventional 7:05 certain ssrrii or conventional anti-depressant 50 milligrams daily and 7:09 anti-depressant 50 milligrams daily and 7:09 anti-depressant 50 milligrams daily and increased that to 75 milligs. These were 7:11 increased that to 75 milligs. These were 7:11 increased that to 75 milligs. These were the efforts by the primary care 7:13 the efforts by the primary care 7:13 the efforts by the primary care physician to offset some of the symptoms 7:16 physician to offset some of the symptoms 7:16 physician to offset some of the symptoms that he was observing in his patient. 7:19 that he was observing in his patient. 7:19 that he was observing in his patient. The effects included that the delusions 7:21 The effects included that the delusions 7:22 The effects included that the delusions or the paranoia improved but had 7:25 or the paranoia improved but had 7:25 or the paranoia improved but had persistent auditory hallucinations 7:27 persistent auditory hallucinations 7:27 persistent auditory hallucinations alongside the concern for over this 7:31 alongside the concern for over this 7:31 alongside the concern for over this chronic opioid use. This all led to the 7:33 chronic opioid use. This all led to the 7:33 chronic opioid use. This all led to the referral to the chronic pain site
Psychiatric Exam and Symptom Summary 7:35 referral to the chronic pain site 7:35 referral to the chronic pain site clinic. So instead of referring to just 7:37 clinic. So instead of referring to just 7:37 clinic. So instead of referring to just conventional psychiatry 7:39 conventional psychiatry 7:40 conventional psychiatry or conventional pain management felt 7:42 or conventional pain management felt 7:42 or conventional pain management felt that it was valuable to refer to a 7:45 that it was valuable to refer to a 7:45 that it was valuable to refer to a clinic that can handle both issues given 7:47 clinic that can handle both issues given 7:47 clinic that can handle both issues given that there were chronic opioids in the 7:50 that there were chronic opioids in the 7:50 that there were chronic opioids in the mix as well as now psychiatric symptoms. 7:55 mix as well as now psychiatric symptoms. 7:55 mix as well as now psychiatric symptoms. on exam by myself and psychiatry team 7:59 on exam by myself and psychiatry team 7:59 on exam by myself and psychiatry team found that the patient was u in terms of 8:03 found that the patient was u in terms of 8:03 found that the patient was u in terms of appearance in uh no apparent distress so 8:07 appearance in uh no apparent distress so 8:07 appearance in uh no apparent distress so was not overwhelmed or distressed was 8:09 was not overwhelmed or distressed was 8:09 was not overwhelmed or distressed was age appearing matched her age well 8:11 age appearing matched her age well 8:11 age appearing matched her age well nourished well-groomed so she was taking 8:13 nourished well-groomed so she was taking 8:13 nourished well-groomed so she was taking care of herself eating well her behavior 8:15 care of herself eating well her behavior 8:15 care of herself eating well her behavior was pleasant she was cooperative she was 8:17 was pleasant she was cooperative she was 8:17 was pleasant she was cooperative she was a bit fidgety 8:19 a bit fidgety 8:19 a bit fidgety and her mood was described by her as 8:21 and her mood was described by her as 8:21 and her mood was described by her as depressed her affect meaning how she 8:24 depressed her affect meaning how she 8:24 depressed her affect meaning how she looked physically in her face was full 8:27 looked physically in her face was full 8:27 looked physically in her face was full range, meaning that she was 8:29 range, meaning that she was 8:29 range, meaning that she was appropriately changing how um her face 8:34 appropriately changing how um her face 8:34 appropriately changing how um her face would match her mood depending on what 8:36 would match her mood depending on what 8:36 would match her mood depending on what she was talking about. In this case, it 8:38 she was talking about. In this case, it 8:38 she was talking about. In this case, it was inongruent. It did not match what 8:40 was inongruent. It did not match what 8:40 was inongruent. It did not match what she was stating as this persistent 8:42 she was stating as this persistent 8:42 she was stating as this persistent sadness or depression. She would smile 8:44 sadness or depression. She would smile 8:44 sadness or depression. She would smile at times and that didn't make entire 8:47 at times and that didn't make entire 8:47 at times and that didn't make entire sense, if you will. Her eye contact was 8:49 sense, if you will. Her eye contact was 8:49 sense, if you will. Her eye contact was within normal limits. Her speech was of 8:51 within normal limits. Her speech was of 8:52 within normal limits. Her speech was of normal rate and rhythm. Her thoughts 8:54 normal rate and rhythm. Her thoughts 8:54 normal rate and rhythm. Her thoughts were linear, meaning that they were 8:56 were linear, meaning that they were 8:56 were linear, meaning that they were normal, goal oriented, and organized. 8:59 normal, goal oriented, and organized. 8:59 normal, goal oriented, and organized. Her thought content lacked any suicidal 9:02 Her thought content lacked any suicidal 9:02 Her thought content lacked any suicidal ideiation, homicidal ideiation. It also 9:05 ideiation, homicidal ideiation. It also 9:05 ideiation, homicidal ideiation. It also lacked illusions and paranoia. So 9:07 lacked illusions and paranoia. So 9:07 lacked illusions and paranoia. So thankfully, that had gotten better. Her 9:09 thankfully, that had gotten better. Her 9:09 thankfully, that had gotten better. Her perception, meaning how she perceives 9:11 perception, meaning how she perceives 9:11 perception, meaning how she perceives the world, did include those auditory 9:13 the world, did include those auditory 9:13 the world, did include those auditory hallucinations I mentioned. In terms of 9:15 hallucinations I mentioned. In terms of 9:15 hallucinations I mentioned. In terms of her sensorium or how aware or alert she 9:19 her sensorium or how aware or alert she 9:19 her sensorium or how aware or alert she is, she was awake and alert as well as 9:23 is, she was awake and alert as well as 9:23 is, she was awake and alert as well as oriented times four meaning oriented to 9:26 oriented times four meaning oriented to 9:26 oriented times four meaning oriented to self, oriented to place, to time and to 9:28 self, oriented to place, to time and to 9:28 self, oriented to place, to time and to context. So she was quite intact in this 9:30 context. So she was quite intact in this 9:30 context. So she was quite intact in this sense. Her insight and judgment were 9:32 sense. Her insight and judgment were 9:32 sense. Her insight and judgment were also very good. Insight is a measure of 9:36 also very good. Insight is a measure of 9:36 also very good. Insight is a measure of how aware you are of what's going on 9:38 how aware you are of what's going on 9:38 how aware you are of what's going on with you and judgment is also what kind 9:41 with you and judgment is also what kind 9:41 with you and judgment is also what kind of behavioral choices you might be 9:42 of behavioral choices you might be 9:42 of behavioral choices you might be employing. they were both good and her 9:45 employing. they were both good and her 9:45 employing. they were both good and her motor exam meaning how her body was sort 9:48 motor exam meaning how her body was sort 9:48 motor exam meaning how her body was sort of moving um lacked any major findings. 9:52 of moving um lacked any major findings. 9:52 of moving um lacked any major findings. It was within normal limits. 9:55 It was within normal limits. 9:55 It was within normal limits. So to summarize the presenting symptoms, 9:58 So to summarize the presenting symptoms, 9:58 So to summarize the presenting symptoms, she had the auditory hallucinations, 9:59 she had the auditory hallucinations, 9:59 she had the auditory hallucinations, depressed mood, insomnia both at the 10:02 depressed mood, insomnia both at the 10:02 depressed mood, insomnia both at the beginning and during the night. So 10:04 beginning and during the night. So 10:04 beginning and during the night. So that's onset and maintenance insomnia 10:06 that's onset and maintenance insomnia 10:06 that's onset and maintenance insomnia respectively. She felt fatigued but had 10:09 respectively. She felt fatigued but had 10:09 respectively. She felt fatigued but had reduced appetite, was also socially 10:12 reduced appetite, was also socially 10:12 reduced appetite, was also socially withdrawing and also had some amount of 10:15 withdrawing and also had some amount of 10:15 withdrawing and also had some amount of guilt secondary to smoking um smoking 10:18 guilt secondary to smoking um smoking 10:18 guilt secondary to smoking um smoking cigarettes. She had some difficulty with 10:20 cigarettes. She had some difficulty with 10:20 cigarettes. She had some difficulty with concentration and focus as well as 10:22 concentration and focus as well as 10:22 concentration and focus as well as anxiety over her auditory 10:24 anxiety over her auditory 10:24 anxiety over her auditory hallucinations. They were egoistonic 10:26 hallucinations. They were egoistonic 10:26 hallucinations. They were egoistonic again and distressing. 10:29 again and distressing. 10:29 again and distressing. I've shared a lot of information thus 10:31 I've shared a lot of information thus 10:31 I've shared a lot of information thus far. This is another good stopping point 10:33 far. This is another good stopping point 10:33 far. This is another good stopping point to reflect.
Chronic Pain, Opioids, and Psychiatric Background 10:35 to reflect. 10:35 to reflect. One might ask as a clinician, what else 10:38 One might ask as a clinician, what else 10:38 One might ask as a clinician, what else do you want to know at this point? What 10:40 do you want to know at this point? What 10:40 do you want to know at this point? What else do you want to elucidate? What else 10:42 else do you want to elucidate? What else 10:42 else do you want to elucidate? What else do you want to do in terms of again 10:45 do you want to do in terms of again 10:45 do you want to do in terms of again tests, analyses, interview questions, 10:48 tests, analyses, interview questions, 10:48 tests, analyses, interview questions, treatments, and where is your mind going 10:50 treatments, and where is your mind going 10:50 treatments, and where is your mind going in terms of what's causing all of this? 10:52 in terms of what's causing all of this? 10:52 in terms of what's causing all of this? It's important to stop, reflect, stop, 10:55 It's important to stop, reflect, stop, 10:55 It's important to stop, reflect, stop, reflect, stop, reflect repeatedly so 10:57 reflect, stop, reflect repeatedly so 10:57 reflect, stop, reflect repeatedly so that we can really promote the best 11:00 that we can really promote the best 11:00 that we can really promote the best individualized care for the patient in 11:03 individualized care for the patient in 11:03 individualized care for the patient in front of us. To advance the case a 11:06 front of us. To advance the case a 11:06 front of us. To advance the case a little bit more, 11:08 little bit more, 11:08 little bit more, we learned that she had a chronic pain 11:09 we learned that she had a chronic pain 11:10 we learned that she had a chronic pain as well as psychiatric history. In terms 11:11 as well as psychiatric history. In terms 11:11 as well as psychiatric history. In terms of chronic pain, her history included 11:13 of chronic pain, her history included 11:13 of chronic pain, her history included endometriosis, mild degenerative joint 11:15 endometriosis, mild degenerative joint 11:16 endometriosis, mild degenerative joint disease, chronic pain syndrome. I 11:17 disease, chronic pain syndrome. I 11:17 disease, chronic pain syndrome. I mentioned these earlier. 11:19 mentioned these earlier. 11:19 mentioned these earlier. She had chronic opioid history that 11:21 She had chronic opioid history that 11:21 She had chronic opioid history that actually amounted to 50 years. It's a 11:24 actually amounted to 50 years. It's a 11:24 actually amounted to 50 years. It's a very long time, five decades. Started at 11:27 very long time, five decades. Started at 11:27 very long time, five decades. Started at age 12, so she was quite young for 11:29 age 12, so she was quite young for 11:29 age 12, so she was quite young for dismenoria. So abnormal menstrual cycles 11:34 dismenoria. So abnormal menstrual cycles 11:34 dismenoria. So abnormal menstrual cycles um at the time of puberty. This is a 11:36 um at the time of puberty. This is a 11:36 um at the time of puberty. This is a very unusual trajectory, very young age. 11:40 very unusual trajectory, very young age. 11:40 very unusual trajectory, very young age. Um and yet she was placed on opioids 11:42 Um and yet she was placed on opioids 11:42 Um and yet she was placed on opioids then and never quite discontinued off of 11:45 then and never quite discontinued off of 11:45 then and never quite discontinued off of them. Her most recent dose from a 11:48 them. Her most recent dose from a 11:48 them. Her most recent dose from a primary care physician included percoet 11:50 primary care physician included percoet 11:50 primary care physician included percoet again oxycodone/ 11:53 again oxycodone/ 11:53 again oxycodone/ acceto medicine 5 to 10 milligrams every 11:57 acceto medicine 5 to 10 milligrams every 11:57 acceto medicine 5 to 10 milligrams every 4 to 6 hours as needed for any 11:59 4 to 6 hours as needed for any 11:59 4 to 6 hours as needed for any muscoskeleletal pain that she 12:00 muscoskeleletal pain that she 12:00 muscoskeleletal pain that she experienced. And remember she was on 12:02 experienced. And remember she was on 12:02 experienced. And remember she was on that but she was running out early for 12:05 that but she was running out early for 12:05 that but she was running out early for about 4 months. So she may have 12:07 about 4 months. So she may have 12:07 about 4 months. So she may have developed some kind of dependence and 12:10 developed some kind of dependence and 12:10 developed some kind of dependence and needed more of that of that agent. Also 12:13 needed more of that of that agent. Also 12:13 needed more of that of that agent. Also she was taking gabapentin 900 milligrams 12:15 she was taking gabapentin 900 milligrams 12:15 she was taking gabapentin 900 milligrams three times a day. That is an 12:17 three times a day. That is an 12:17 three times a day. That is an anti-epileptic that is used for 12:18 anti-epileptic that is used for 12:18 anti-epileptic that is used for neuropathic pain. And rarely she would 12:22 neuropathic pain. And rarely she would 12:22 neuropathic pain. And rarely she would get some um articular injections meaning 12:24 get some um articular injections meaning 12:24 get some um articular injections meaning injections in the joints for her pain. 12:29 injections in the joints for her pain. 12:29 injections in the joints for her pain. In terms of past psychiatric history, 12:31 In terms of past psychiatric history, 12:31 In terms of past psychiatric history, she really had none none formally at 12:33 she really had none none formally at 12:33 she really had none none formally at least. She had no medication trials with 12:36 least. She had no medication trials with 12:36 least. She had no medication trials with anti-depressants and other meds. Uh she 12:38 anti-depressants and other meds. Uh she 12:38 anti-depressants and other meds. Uh she had no inpatient or outpatient 12:40 had no inpatient or outpatient 12:40 had no inpatient or outpatient psychiatric care and no suicide 12:41 psychiatric care and no suicide 12:41 psychiatric care and no suicide attempts. Her 12:44 attempts. Her 12:44 attempts. Her family psychiatric history did include a 12:46 family psychiatric history did include a 12:46 family psychiatric history did include a history of a mother who had alcohol use 12:49 history of a mother who had alcohol use 12:49 history of a mother who had alcohol use disorder, ETOH use disorder. 12:55 Patient herself had a substance use 12:55 Patient herself had a substance use history of remote alcohol use disorder 12:58 history of remote alcohol use disorder 12:58 history of remote alcohol use disorder that had been full and sustained 13:00 that had been full and sustained 13:00 that had been full and sustained remission. So at some point she also 13:02 remission. So at some point she also 13:02 remission. So at some point she also struggled with controlling her alcohol 13:04 struggled with controlling her alcohol 13:04 struggled with controlling her alcohol intake. She also as mentioned earlier 13:07 intake. She also as mentioned earlier 13:07 intake. She also as mentioned earlier smoked regularly. She smoked about a 13:09 smoked regularly. She smoked about a 13:09 smoked regularly. She smoked about a pack a day for those same 50 years. 13:15 She did share that she had a trauma 13:16 She did share that she had a trauma history. She had childhood physical as 13:19 history. She had childhood physical as 13:19 history. She had childhood physical as well as emotional abuse. Physical trauma 13:22 well as emotional abuse. Physical trauma 13:22 well as emotional abuse. Physical trauma did not result in any major injuries. 13:25 did not result in any major injuries. 13:25 did not result in any major injuries. She just described her parents as quite 13:27 She just described her parents as quite 13:27 She just described her parents as quite strict. She also had some emotional 13:29 strict. She also had some emotional 13:29 strict. She also had some emotional abuse in terms of that um strict 13:33 abuse in terms of that um strict 13:33 abuse in terms of that um strict parenting but denied having to relive or 13:36 parenting but denied having to relive or 13:36 parenting but denied having to relive or reexperience the symptoms and no 13:39 reexperience the symptoms and no 13:39 reexperience the symptoms and no hypervigilance that she was aware of. So 13:42 hypervigilance that she was aware of. So 13:42 hypervigilance that she was aware of. So in other words, she was not revisiting 13:44 in other words, she was not revisiting 13:44 in other words, she was not revisiting those moments in traumatic reminders 13:47 those moments in traumatic reminders 13:47 those moments in traumatic reminders like flashbacks or nightmares. nor was 13:50 like flashbacks or nightmares. nor was 13:50 like flashbacks or nightmares. nor was she on to her knowledge on pins and 13:53 she on to her knowledge on pins and 13:53 she on to her knowledge on pins and needles um scared of of anything that
Treatment Plan and Medication Titration 13:56 needles um scared of of anything that 13:56 needles um scared of of anything that resembled her earlier trauma. 13:59 resembled her earlier trauma. 13:59 resembled her earlier trauma. Terms of her social history and 14:00 Terms of her social history and 14:00 Terms of her social history and developmental history, she completed 14:02 developmental history, she completed 14:02 developmental history, she completed high school and had numerous clerical 14:05 high school and had numerous clerical 14:05 high school and had numerous clerical jobs for decades, then went on 14:07 jobs for decades, then went on 14:07 jobs for decades, then went on disability for chronic pain at some 14:09 disability for chronic pain at some 14:09 disability for chronic pain at some point. She was married um and did 14:12 point. She was married um and did 14:12 point. She was married um and did describe her partner to be somewhat 14:14 describe her partner to be somewhat 14:14 describe her partner to be somewhat doing meaning someone who would sort of 14:17 doing meaning someone who would sort of 14:17 doing meaning someone who would sort of take care of everything for her. um 14:19 take care of everything for her. um 14:19 take care of everything for her. um arguably even enabling um but no 14:22 arguably even enabling um but no 14:22 arguably even enabling um but no children and they were financially 14:24 children and they were financially 14:24 children and they were financially stable. So they had no major stressors 14:26 stable. So they had no major stressors 14:26 stable. So they had no major stressors when it came to money or the law or 14:28 when it came to money or the law or 14:28 when it came to money or the law or anything of the sort. 14:30 anything of the sort. 14:30 anything of the sort. So at this point once again encouraging 14:33 So at this point once again encouraging 14:33 So at this point once again encouraging reflection and integration of all the 14:35 reflection and integration of all the 14:35 reflection and integration of all the information you might ask what else do 14:37 information you might ask what else do 14:37 information you might ask what else do you want to know? What else do you want 14:40 you want to know? What else do you want 14:40 you want to know? What else do you want to do in terms of interview test, 14:42 to do in terms of interview test, 14:42 to do in terms of interview test, physical exam analyses and where is your 14:45 physical exam analyses and where is your 14:45 physical exam analyses and where is your mind as a clinician going in thinking 14:47 mind as a clinician going in thinking 14:47 mind as a clinician going in thinking about the differential diagnosis or 14:50 about the differential diagnosis or 14:50 about the differential diagnosis or possible treatment directions? 14:54 possible treatment directions? 14:54 possible treatment directions? I'll share that uh in terms of 14:57 I'll share that uh in terms of 14:57 I'll share that uh in terms of psychopharmarmacologic treatment or 14:59 psychopharmarmacologic treatment or 14:59 psychopharmarmacologic treatment or medication treatment. We basically made 15:02 medication treatment. We basically made 15:02 medication treatment. We basically made the decision when we met her integrating 15:04 the decision when we met her integrating 15:04 the decision when we met her integrating all of this that we might want to rotate 15:07 all of this that we might want to rotate 15:07 all of this that we might want to rotate her her antiscychotic medication. She 15:09 her her antiscychotic medication. She 15:09 her her antiscychotic medication. She was having persistent psychotic 15:10 was having persistent psychotic 15:10 was having persistent psychotic symptoms. She was not delirious. She was 15:12 symptoms. She was not delirious. She was 15:12 symptoms. She was not delirious. She was not encphilopathic or confused. Um this 15:16 not encphilopathic or confused. Um this 15:16 not encphilopathic or confused. Um this no longer looked like it was just due to 15:19 no longer looked like it was just due to 15:19 no longer looked like it was just due to withdrawal and benadryil. This was a 15:22 withdrawal and benadryil. This was a 15:22 withdrawal and benadryil. This was a lasting symptom that was not better 15:25 lasting symptom that was not better 15:25 lasting symptom that was not better explained by her benadryil use since she 15:26 explained by her benadryil use since she 15:26 explained by her benadryil use since she had curbed that. So we decided to switch 15:31 had curbed that. So we decided to switch 15:31 had curbed that. So we decided to switch over from quitipene or cerakquil over to 15:34 over from quitipene or cerakquil over to 15:34 over from quitipene or cerakquil over to zyprea also known as alanzipene and 15:36 zyprea also known as alanzipene and 15:36 zyprea also known as alanzipene and started 2 and a half milligrams at night 15:40 started 2 and a half milligrams at night 15:40 started 2 and a half milligrams at night uh excuse me twice a day and 15 15:42 uh excuse me twice a day and 15 15:42 uh excuse me twice a day and 15 milligrams at night. Now this was 15:43 milligrams at night. Now this was 15:43 milligrams at night. Now this was gradually um increased um over time and 15:47 gradually um increased um over time and 15:48 gradually um increased um over time and this was titrated or increased every 2 15:50 this was titrated or increased every 2 15:50 this was titrated or increased every 2 to four weeks for up to 27.5 milligrams 15:53 to four weeks for up to 27.5 milligrams 15:53 to four weeks for up to 27.5 milligrams total. And this finally did have a 15:56 total. And this finally did have a 15:56 total. And this finally did have a significant reduction in her anxiety and 15:58 significant reduction in her anxiety and 15:58 significant reduction in her anxiety and auditory hallucinations. 16:00 auditory hallucinations. 16:00 auditory hallucinations. The the rationale for choosing this 16:02 The the rationale for choosing this 16:02 The the rationale for choosing this medication was based on a study that I 16:04 medication was based on a study that I 16:04 medication was based on a study that I had performed a systematic review that 16:06 had performed a systematic review that 16:06 had performed a systematic review that is shown in the box below where we had 16:09 is shown in the box below where we had 16:09 is shown in the box below where we had reviewed the role of atypical 16:10 reviewed the role of atypical 16:10 reviewed the role of atypical anticycchotics in chronic pain. In other 16:13 anticycchotics in chronic pain. In other 16:13 anticycchotics in chronic pain. In other words, second generation anticycchotics. 16:15 words, second generation anticycchotics. 16:15 words, second generation anticycchotics. Now there is no uh suggestion here that 16:18 Now there is no uh suggestion here that 16:18 Now there is no uh suggestion here that these anticycotics are meant to treat 16:20 these anticycotics are meant to treat 16:20 these anticycotics are meant to treat pain but we wanted to choose the one 16:23 pain but we wanted to choose the one 16:23 pain but we wanted to choose the one that did have some possible role in 16:25 that did have some possible role in 16:25 that did have some possible role in muscularkeeletal pain, migraines, 16:27 muscularkeeletal pain, migraines, 16:27 muscularkeeletal pain, migraines, fibromyalgia. 16:29 fibromyalgia. 16:29 fibromyalgia. And for those who are interested in this 16:32 And for those who are interested in this 16:32 And for those who are interested in this in this topic, they can you know visit 16:35 in this topic, they can you know visit 16:35 in this topic, they can you know visit the systematic review and the and the 16:37 the systematic review and the and the 16:37 the systematic review and the and the article that that dives into greater 16:39 article that that dives into greater 16:39 article that that dives into greater detail. 16:40 detail. 16:40 detail. We also felt that it was important to 16:42 We also felt that it was important to 16:42 We also felt that it was important to continue to increase the certuline or 16:45 continue to increase the certuline or 16:45 continue to increase the certuline or zoloft which was an SSRI and a 16:47 zoloft which was an SSRI and a 16:47 zoloft which was an SSRI and a depressant. It is indicated for both 16:49 depressant. It is indicated for both 16:49 depressant. It is indicated for both treatment of depression but also 16:50 treatment of depression but also 16:50 treatment of depression but also anxiety. And so we increased that to 100 16:53 anxiety. And so we increased that to 100 16:53 anxiety. And so we increased that to 100 milligrams. We introduced a different 16:56 milligrams. We introduced a different 16:56 milligrams. We introduced a different agent known as or hydroxazine which is a 16:59 agent known as or hydroxazine which is a 16:59 agent known as or hydroxazine which is a cousin of benadryil. It is also an 17:02 cousin of benadryil. It is also an 17:02 cousin of benadryil. It is also an antihistamine 17:04 antihistamine 17:04 antihistamine in order to help with anxiety. 17:07 in order to help with anxiety. 17:07 in order to help with anxiety. And so she was instructed to use 25 17:09 And so she was instructed to use 25 17:09 And so she was instructed to use 25 milligrams three times a day or TID as 17:12 milligrams three times a day or TID as 17:12 milligrams three times a day or TID as needed and to avoid benadryil. This is a 17:15 needed and to avoid benadryil. This is a 17:15 needed and to avoid benadryil. This is a less deliric or confuse confusionprone 17:19 less deliric or confuse confusionprone 17:19 less deliric or confuse confusionprone medication than benadryil. 17:27 We also went ahead and looked at how to 17:27 We also went ahead and looked at how to manage the opioid in the midst of all of 17:29 manage the opioid in the midst of all of 17:29 manage the opioid in the midst of all of this. Remember this is somebody who was 17:30 this. Remember this is somebody who was 17:30 this. Remember this is somebody who was for five decades on chronic opioids and 17:34 for five decades on chronic opioids and 17:34 for five decades on chronic opioids and as a result of of that uh was was 17:37 as a result of of that uh was was 17:37 as a result of of that uh was was starting to rely on it more frequently 17:40 starting to rely on it more frequently 17:40 starting to rely on it more frequently was not doing well with it and uh needed 17:43 was not doing well with it and uh needed 17:43 was not doing well with it and uh needed to um you know was running out early and 17:46 to um you know was running out early and 17:46 to um you know was running out early and and going into withdrawal. So we decided 17:49 and going into withdrawal. So we decided 17:49 and going into withdrawal. So we decided actually to to change the short acting 17:51 actually to to change the short acting 17:51 actually to to change the short acting opioid to a long acting opioid. The 17:53 opioid to a long acting opioid. The 17:53 opioid to a long acting opioid. The short acting opioid was percoet every 17:55 short acting opioid was percoet every 17:56 short acting opioid was percoet every six hours. We changed it to caden or mor 17:58 six hours. We changed it to caden or mor 17:58 six hours. We changed it to caden or mor mor morphine extended release 30 18:00 mor morphine extended release 30 18:00 mor morphine extended release 30 milligrams daily. So, it's roughly uh 18:03 milligrams daily. So, it's roughly uh 18:03 milligrams daily. So, it's roughly uh you know a morphine equivalent to where 18:06 you know a morphine equivalent to where 18:06 you know a morphine equivalent to where we reduced it to about 30, but that's a 18:09 we reduced it to about 30, but that's a 18:09 we reduced it to about 30, but that's a 24-hour 18:10 24-hour 18:10 24-hour uh extended release version of morphine. 18:13 uh extended release version of morphine. 18:13 uh extended release version of morphine. And this led to a wean over time, a 18:16 And this led to a wean over time, a 18:16 And this led to a wean over time, a reduction, a detox if you will, over 18:18 reduction, a detox if you will, over 18:18 reduction, a detox if you will, over time where we had Kadine 30 milligrams 18:21 time where we had Kadine 30 milligrams 18:21 time where we had Kadine 30 milligrams per day for one week, then down to 20 18:23 per day for one week, then down to 20 18:23 per day for one week, then down to 20 millig per day for 3 weeks, then 10 18:26 millig per day for 3 weeks, then 10 18:26 millig per day for 3 weeks, then 10 millig per day for another 3 weeks, and 18:29 millig per day for another 3 weeks, and 18:29 millig per day for another 3 weeks, and then finally stopped. And of course we 18:31 then finally stopped. And of course we 18:31 then finally stopped. And of course we followed her closely during this process 18:33 followed her closely during this process 18:33 followed her closely during this process so that we can assist with any uh
Outcome, Publication, and Clinical Lessons 18:36 so that we can assist with any uh 18:36 so that we can assist with any uh symptoms, discomfort, etc. That's an 18:39 symptoms, discomfort, etc. That's an 18:39 symptoms, discomfort, etc. That's an image of what um the Cadian paperwork 18:42 image of what um the Cadian paperwork 18:42 image of what um the Cadian paperwork looks like. 18:45 looks like. 18:45 looks like. We also introduced a couple of other 18:46 We also introduced a couple of other 18:46 We also introduced a couple of other agents to help with pain and with mood. 18:51 agents to help with pain and with mood. 18:51 agents to help with pain and with mood. Symbalta or deluxitine which is an SNRI 18:54 Symbalta or deluxitine which is an SNRI 18:54 Symbalta or deluxitine which is an SNRI and has some impact in muscoskeleletal 18:56 and has some impact in muscoskeleletal 18:56 and has some impact in muscoskeleletal pain and neuropathy was introduced and 18:58 pain and neuropathy was introduced and 18:58 pain and neuropathy was introduced and it was increased to 60 milligrams a day 19:00 it was increased to 60 milligrams a day 19:00 it was increased to 60 milligrams a day and dicophenic an anti-inflammatory was 19:03 and dicophenic an anti-inflammatory was 19:03 and dicophenic an anti-inflammatory was introduced as well to assist with her 19:06 introduced as well to assist with her 19:06 introduced as well to assist with her arthritis and her muscularkeeletal pain. 19:11 arthritis and her muscularkeeletal pain. 19:11 arthritis and her muscularkeeletal pain. She was also 19:13 She was also 19:13 She was also uh sent to physical therapy within our 19:16 uh sent to physical therapy within our 19:16 uh sent to physical therapy within our our division within our department and 19:19 our division within our department and 19:19 our division within our department and did physical therapy one to two times a 19:22 did physical therapy one to two times a 19:22 did physical therapy one to two times a week for about 12 weeks to help 19:26 week for about 12 weeks to help 19:26 week for about 12 weeks to help complement what we were doing with 19:27 complement what we were doing with 19:27 complement what we were doing with pharmarmacology. 19:29 pharmarmacology. 19:29 pharmarmacology. In addition to that sort of as a perfect 19:33 In addition to that sort of as a perfect 19:33 In addition to that sort of as a perfect you know biocschosocial 19:35 you know biocschosocial 19:35 you know biocschosocial model of care we included cognitive 19:38 model of care we included cognitive 19:38 model of care we included cognitive behavioral therapy or CBT and with 19:41 behavioral therapy or CBT and with 19:41 behavioral therapy or CBT and with cognitive be behavioral therapy. We were 19:43 cognitive be behavioral therapy. We were 19:43 cognitive be behavioral therapy. We were trying to invite her to reflect more on 19:46 trying to invite her to reflect more on 19:46 trying to invite her to reflect more on some of the stressors that came about 19:49 some of the stressors that came about 19:49 some of the stressors that came about with her chronic pain and also um social 19:53 with her chronic pain and also um social 19:53 with her chronic pain and also um social stressors that she carried about from 19:55 stressors that she carried about from 19:55 stressors that she carried about from her trauma. The focus was self-critical 19:57 her trauma. The focus was self-critical 19:58 her trauma. The focus was self-critical cognitive distortions that we started to 19:59 cognitive distortions that we started to 19:59 cognitive distortions that we started to identify early on. meaning that she had 20:03 identify early on. meaning that she had 20:03 identify early on. meaning that she had the propensity to have certain thoughts 20:05 the propensity to have certain thoughts 20:05 the propensity to have certain thoughts that were very negative about herself 20:07 that were very negative about herself 20:07 that were very negative about herself and we thought that they were not very 20:09 and we thought that they were not very 20:09 and we thought that they were not very productive that they were distortions 20:11 productive that they were distortions 20:11 productive that they were distortions and they weren't helping really with 20:13 and they weren't helping really with 20:13 and they weren't helping really with everything that she was experiencing. 20:15 everything that she was experiencing. 20:15 everything that she was experiencing. She tended to have rejection 20:17 She tended to have rejection 20:17 She tended to have rejection sensitivities meaning that she was prone 20:20 sensitivities meaning that she was prone 20:20 sensitivities meaning that she was prone to being very injured by others not 20:22 to being very injured by others not 20:22 to being very injured by others not accepting her. She had a lack of 20:24 accepting her. She had a lack of 20:24 accepting her. She had a lack of assertiveness about her. Uh she would 20:27 assertiveness about her. Uh she would 20:27 assertiveness about her. Uh she would not assert her needs. She had body image 20:30 not assert her needs. She had body image 20:30 not assert her needs. She had body image issues as well and possibly uh some 20:34 issues as well and possibly uh some 20:34 issues as well and possibly uh some alexathyia. It was very difficult for 20:36 alexathyia. It was very difficult for 20:36 alexathyia. It was very difficult for her to name her emotions. Alexia is 20:39 her to name her emotions. Alexia is 20:39 her to name her emotions. Alexia is Greek for lack for lack of words for 20:42 Greek for lack for lack of words for 20:42 Greek for lack for lack of words for mood. And so sometimes she just couldn't 20:44 mood. And so sometimes she just couldn't 20:44 mood. And so sometimes she just couldn't access her feelings and describe them in 20:47 access her feelings and describe them in 20:47 access her feelings and describe them in appropriate ways. And CBT was meant to 20:50 appropriate ways. And CBT was meant to 20:50 appropriate ways. And CBT was meant to assist her with this. This was done on a 20:52 assist her with this. This was done on a 20:52 assist her with this. This was done on a weekly basis. We also included nicotine 20:56 weekly basis. We also included nicotine 20:56 weekly basis. We also included nicotine replacement therapy. So that's where um 20:59 replacement therapy. So that's where um 20:59 replacement therapy. So that's where um she was able to reduce her nicotine down 21:02 she was able to reduce her nicotine down 21:02 she was able to reduce her nicotine down from 15 cigarettes per day down to five 21:04 from 15 cigarettes per day down to five 21:04 from 15 cigarettes per day down to five cigarettes per day with the use of um 21:07 cigarettes per day with the use of um 21:07 cigarettes per day with the use of um nicoderm patches and and other coping 21:11 nicoderm patches and and other coping 21:11 nicoderm patches and and other coping strategies. 21:13 strategies. 21:13 strategies. And while you know the CBT and the 21:17 And while you know the CBT and the 21:17 And while you know the CBT and the nicotine replacement therapy was started 21:18 nicotine replacement therapy was started 21:18 nicotine replacement therapy was started while on zipa 27.5 milligrams which is a 21:21 while on zipa 27.5 milligrams which is a 21:21 while on zipa 27.5 milligrams which is a very high amount. We are aware of of how 21:24 very high amount. We are aware of of how 21:24 very high amount. We are aware of of how that can come with various side effects 21:27 that can come with various side effects 21:27 that can come with various side effects and and metabolic burdens. Um she did 21:30 and and metabolic burdens. Um she did 21:30 and and metabolic burdens. Um she did have actually some weight gain which 21:32 have actually some weight gain which 21:32 have actually some weight gain which wasn't all bad. She came in actually 21:33 wasn't all bad. She came in actually 21:33 wasn't all bad. She came in actually rather thin and underweight and um she 21:37 rather thin and underweight and um she 21:37 rather thin and underweight and um she did have some CBT anxiety reduction. So 21:40 did have some CBT anxiety reduction. So 21:40 did have some CBT anxiety reduction. So we were able to reduce her zip prea or 21:43 we were able to reduce her zip prea or 21:43 we were able to reduce her zip prea or lanzipene from 27.5 all the way to 5 mg 21:46 lanzipene from 27.5 all the way to 5 mg 21:46 lanzipene from 27.5 all the way to 5 mg but her auditory hallucinations returned 21:49 but her auditory hallucinations returned 21:49 but her auditory hallucinations returned and we found the sweet spot finally at 21:51 and we found the sweet spot finally at 21:51 and we found the sweet spot finally at 7.5 milligrams a day. So we were able to 21:54 7.5 milligrams a day. So we were able to 21:54 7.5 milligrams a day. So we were able to stabilize things. If you think about 21:56 stabilize things. If you think about 21:56 stabilize things. If you think about that dose, alanzipene 7.5 milligrams a 21:59 that dose, alanzipene 7.5 milligrams a 21:59 that dose, alanzipene 7.5 milligrams a day, that really isn't a typical dose 22:01 day, that really isn't a typical dose 22:01 day, that really isn't a typical dose for conventional or typical psychiatric 22:05 for conventional or typical psychiatric 22:05 for conventional or typical psychiatric uh disorders with psychosis like 22:08 uh disorders with psychosis like 22:08 uh disorders with psychosis like schizophrenia or schizophffective 22:09 schizophrenia or schizophffective 22:09 schizophrenia or schizophffective disorder. So this was an unusual case in 22:12 disorder. So this was an unusual case in 22:12 disorder. So this was an unusual case in which 7.5 milligrams with some other 22:14 which 7.5 milligrams with some other 22:14 which 7.5 milligrams with some other strategies of course took care of of the 22:17 strategies of course took care of of the 22:17 strategies of course took care of of the psychosis but um it's probably because 22:20 psychosis but um it's probably because 22:20 psychosis but um it's probably because this we were dealing with a primary 22:23 this we were dealing with a primary 22:23 this we were dealing with a primary schizophrenia. 22:25 schizophrenia. 22:25 schizophrenia. So what was the outcome? At 12 months, 22:27 So what was the outcome? At 12 months, 22:27 So what was the outcome? At 12 months, the patient was euthyic, meaning that 22:28 the patient was euthyic, meaning that 22:28 the patient was euthyic, meaning that she had good normal mood without 22:31 she had good normal mood without 22:31 she had good normal mood without psychosis, 22:33 psychosis, 22:33 psychosis, was socially active and doing well. Her 22:36 was socially active and doing well. Her 22:36 was socially active and doing well. Her pain was well controlled with no 22:37 pain was well controlled with no 22:37 pain was well controlled with no resumption of opioids and she had no 22:39 resumption of opioids and she had no 22:40 resumption of opioids and she had no cravings for them. So this was arguably 22:42 cravings for them. So this was arguably 22:42 cravings for them. So this was arguably a win and we were very pleased and so 22:45 a win and we were very pleased and so 22:45 a win and we were very pleased and so was she with the outcome of this. 22:48 was she with the outcome of this. 22:48 was she with the outcome of this. We actually published this case, we as 22:51 We actually published this case, we as 22:51 We actually published this case, we as in myself and and a colleague um in the 22:54 in myself and and a colleague um in the 22:54 in myself and and a colleague um in the journal of psychiatric practice titled 22:57 journal of psychiatric practice titled 22:57 journal of psychiatric practice titled case report denovo and persistent 22:59 case report denovo and persistent 22:59 case report denovo and persistent psychosis after withdrawal from chronic 23:00 psychosis after withdrawal from chronic 23:00 psychosis after withdrawal from chronic opioid therapy. So it's a very unusual 23:03 opioid therapy. So it's a very unusual 23:03 opioid therapy. So it's a very unusual case. If somebody wants to read it in 23:05 case. If somebody wants to read it in 23:05 case. If somebody wants to read it in greater detail, they can of course read 23:07 greater detail, they can of course read 23:07 greater detail, they can of course read the article. Uh but it was uh a very 23:11 the article. Uh but it was uh a very 23:11 the article. Uh but it was uh a very important case to prevent to to present 23:13 important case to prevent to to present 23:13 important case to prevent to to present excuse me to the literature because 23:15 excuse me to the literature because 23:15 excuse me to the literature because number one it talked it was an unusual 23:18 number one it talked it was an unusual 23:18 number one it talked it was an unusual case of somebody on opioids from a very 23:20 case of somebody on opioids from a very 23:20 case of somebody on opioids from a very early age. It was also an unusual case 23:22 early age. It was also an unusual case 23:22 early age. It was also an unusual case of a mixed picture of delirium and 23:24 of a mixed picture of delirium and 23:24 of a mixed picture of delirium and psychosis in the context of stopping 23:26 psychosis in the context of stopping 23:26 psychosis in the context of stopping those opioids. Additionally, it was very 23:29 those opioids. Additionally, it was very 23:29 those opioids. Additionally, it was very interesting um case that sort of 23:33 interesting um case that sort of 23:33 interesting um case that sort of illustrated how biocschosocial care can 23:36 illustrated how biocschosocial care can 23:36 illustrated how biocschosocial care can be conducted with a mix of medication 23:39 be conducted with a mix of medication 23:39 be conducted with a mix of medication adjustments, opioid we psychotherapy, 23:42 adjustments, opioid we psychotherapy, 23:42 adjustments, opioid we psychotherapy, physical therapy, and substance use care 23:44 physical therapy, and substance use care 23:44 physical therapy, and substance use care in terms of nicotine replacement 23:46 in terms of nicotine replacement 23:46 in terms of nicotine replacement therapy. All of these things working in 23:48 therapy. All of these things working in 23:48 therapy. All of these things working in concert to help an individual with a 23:51 concert to help an individual with a 23:51 concert to help an individual with a complex presentation. 23:53 complex presentation. 23:53 complex presentation. This is the timeline of the case that I 23:56 This is the timeline of the case that I 23:56 This is the timeline of the case that I just presented. How it all sort of 23:58 just presented. How it all sort of 23:58 just presented. How it all sort of occurred. You see at the beginning 50 24:00 occurred. You see at the beginning 50 24:00 occurred. You see at the beginning 50 years of chronic opioids, a 4month 24:04 years of chronic opioids, a 4month 24:04 years of chronic opioids, a 4month period of overuse/withdrawal 24:06 period of overuse/withdrawal 24:06 period of overuse/withdrawal cycle mixed with not just opioids and 24:09 cycle mixed with not just opioids and 24:10 cycle mixed with not just opioids and withdrawal but also dyenhydramine or 24:12 withdrawal but also dyenhydramine or 24:12 withdrawal but also dyenhydramine or benadryil uh over the counter which was 24:15 benadryil uh over the counter which was 24:15 benadryil uh over the counter which was causing delirum and confusion. You had 24:17 causing delirum and confusion. You had 24:17 causing delirum and confusion. You had the psychosis onset. You had delusions. 24:21 the psychosis onset. You had delusions. 24:21 the psychosis onset. You had delusions. this bar here that lasted up until a 24:24 this bar here that lasted up until a 24:24 this bar here that lasted up until a certain point and visual hallucinations 24:25 certain point and visual hallucinations 24:26 certain point and visual hallucinations which were very transient but the 24:27 which were very transient but the 24:27 which were very transient but the auditory hallucinations were the longest 24:29 auditory hallucinations were the longest 24:29 auditory hallucinations were the longest of the psychotic symptoms that resumed 24:32 of the psychotic symptoms that resumed 24:32 of the psychotic symptoms that resumed or or that persisted excuse me. Here you 24:34 or or that persisted excuse me. Here you 24:34 or or that persisted excuse me. Here you have opioid resumption and 24:35 have opioid resumption and 24:35 have opioid resumption and psychopharmacologic titration that we 24:37 psychopharmacologic titration that we 24:37 psychopharmacologic titration that we just reviewed. We weaned off of the 24:40 just reviewed. We weaned off of the 24:40 just reviewed. We weaned off of the opioid over time took about two months 24:43 opioid over time took about two months 24:43 opioid over time took about two months and then we downtitrated or reduced 24:47 and then we downtitrated or reduced 24:47 and then we downtitrated or reduced alanzipene. So initially we really 24:49 alanzipene. So initially we really 24:49 alanzipene. So initially we really relied heavily on alanzipene but then we 24:52 relied heavily on alanzipene but then we 24:52 relied heavily on alanzipene but then we decreased it and then achieved 24:54 decreased it and then achieved 24:54 decreased it and then achieved maintenance cycle 24:56 maintenance cycle 24:56 maintenance cycle um in terms of the final regimen and 24:59 um in terms of the final regimen and 24:59 um in terms of the final regimen and again her symptoms disappeared 25:01 again her symptoms disappeared 25:01 again her symptoms disappeared eventually. So it took a while and the 25:04 eventually. So it took a while and the 25:04 eventually. So it took a while and the other thing that's important from this 25:06 other thing that's important from this 25:06 other thing that's important from this image to to take home is that something 25:08 image to to take home is that something 25:08 image to to take home is that something that has been going on for 50 years or 25:10 that has been going on for 50 years or 25:10 that has been going on for 50 years or or or longer is clearly not going to 25:13 or or longer is clearly not going to 25:13 or or longer is clearly not going to take a week or two to address. um 25:17 take a week or two to address. um 25:17 take a week or two to address. um something that has been uh treated with 25:21 something that has been uh treated with 25:21 something that has been uh treated with you know highdosese opioids for a long 25:24 you know highdosese opioids for a long 25:24 you know highdosese opioids for a long time and then altered is not going to be 25:27 time and then altered is not going to be 25:27 time and then altered is not going to be fixed rather you know simplistically 25:30 fixed rather you know simplistically 25:30 fixed rather you know simplistically with one or two interventions. It's 25:33 with one or two interventions. It's 25:33 with one or two interventions. It's going to take time. It's going to take 25:35 going to take time. It's going to take 25:35 going to take time. It's going to take individualized care. It's going to take 25:37 individualized care. It's going to take 25:37 individualized care. It's going to take biocschosocial interventions. So it's a 25:40 biocschosocial interventions. So it's a 25:40 biocschosocial interventions. So it's a good image to remind us that there are 25:42 good image to remind us that there are 25:42 good image to remind us that there are no no shortcuts in this kind of care. 25:49 Just as a reminder of the various things 25:50 Just as a reminder of the various things that could have been at play in this 25:51 that could have been at play in this 25:51 that could have been at play in this case in terms of the differential 25:53 case in terms of the differential 25:53 case in terms of the differential diagnoses, the different uh conditions 25:56 diagnoses, the different uh conditions 25:56 diagnoses, the different uh conditions to consider included a primary psychotic 25:58 to consider included a primary psychotic 25:58 to consider included a primary psychotic process underneath these chronic 26:00 process underneath these chronic 26:00 process underneath these chronic opioids. What if for instance she had 26:03 opioids. What if for instance she had 26:03 opioids. What if for instance she had all along a chronic primary 26:06 all along a chronic primary 26:06 all along a chronic primary schizophrenia, delusional disorder, 26:08 schizophrenia, delusional disorder, 26:08 schizophrenia, delusional disorder, something of that sort, but it was 26:10 something of that sort, but it was 26:10 something of that sort, but it was masked or indirectly even treated by the 26:13 masked or indirectly even treated by the 26:13 masked or indirectly even treated by the opioids. If you think of opioids as uh 26:17 opioids. If you think of opioids as uh 26:17 opioids. If you think of opioids as uh CNS or central nervous system 26:19 CNS or central nervous system 26:19 CNS or central nervous system suppressants, they can reduce anxiety. 26:22 suppressants, they can reduce anxiety. 26:22 suppressants, they can reduce anxiety. They can sometimes blunt some of those 26:26 They can sometimes blunt some of those 26:26 They can sometimes blunt some of those effects that are coming from the brain. 26:28 effects that are coming from the brain. 26:28 effects that are coming from the brain. So, who knows? She could have already 26:30 So, who knows? She could have already 26:30 So, who knows? She could have already had a chronic psychiatric disorder that 26:33 had a chronic psychiatric disorder that 26:33 had a chronic psychiatric disorder that was just masked, if you will, or covered 26:35 was just masked, if you will, or covered 26:35 was just masked, if you will, or covered up by the opioid. Um, maybe she had 26:38 up by the opioid. Um, maybe she had 26:38 up by the opioid. Um, maybe she had obsessivempulsive disorder or OCD with 26:41 obsessivempulsive disorder or OCD with 26:41 obsessivempulsive disorder or OCD with some egoistonic or unpleasant features. 26:45 some egoistonic or unpleasant features. 26:45 some egoistonic or unpleasant features. Maybe this could have been complex 26:46 Maybe this could have been complex 26:46 Maybe this could have been complex post-traumatic stress disorder with 26:49 post-traumatic stress disorder with 26:50 post-traumatic stress disorder with personality disorder and so-called 26:51 personality disorder and so-called 26:51 personality disorder and so-called microcsychosis. These are these are 26:53 microcsychosis. These are these are 26:53 microcsychosis. These are these are jargon terms from psychiatry where 26:55 jargon terms from psychiatry where 26:56 jargon terms from psychiatry where somebody with complex trauma might have 26:59 somebody with complex trauma might have 26:59 somebody with complex trauma might have changes in their identity, personality 27:01 changes in their identity, personality 27:01 changes in their identity, personality and then as a result of that also be 27:03 and then as a result of that also be 27:03 and then as a result of that also be prone especially under stress to 27:05 prone especially under stress to 27:05 prone especially under stress to experience brief psychotic breaks from 27:08 experience brief psychotic breaks from 27:08 experience brief psychotic breaks from reality such as delusions, paranoia etc. 27:12 reality such as delusions, paranoia etc. 27:12 reality such as delusions, paranoia etc. Maybe she had major depressive disorder 27:14 Maybe she had major depressive disorder 27:14 Maybe she had major depressive disorder or depression with psychotic features. 27:17 or depression with psychotic features. 27:17 or depression with psychotic features. There are variants of major depressive 27:19 There are variants of major depressive 27:19 There are variants of major depressive disorder that include psychotic 27:21 disorder that include psychotic 27:21 disorder that include psychotic features. 27:23 features. 27:23 features. It could have been an atypical delirium. 27:27 It could have been an atypical delirium. 27:27 It could have been an atypical delirium. So an atypical delirium would would be 27:30 So an atypical delirium would would be 27:30 So an atypical delirium would would be again a medical confusion or 27:31 again a medical confusion or 27:31 again a medical confusion or encphylopathy secondary to medication 27:34 encphylopathy secondary to medication 27:34 encphylopathy secondary to medication effects, other medical matters. And of 27:37 effects, other medical matters. And of 27:37 effects, other medical matters. And of course there could have been other 27:38 course there could have been other 27:38 course there could have been other considerations here. Um but it is a rich 27:41 considerations here. Um but it is a rich 27:41 considerations here. Um but it is a rich case that illustrates that we must be 27:43 case that illustrates that we must be 27:43 case that illustrates that we must be thinking about all of these 27:44 thinking about all of these 27:44 thinking about all of these possibilities and holding them 27:45 possibilities and holding them 27:45 possibilities and holding them simultaneously in our heads as 27:48 simultaneously in our heads as 27:48 simultaneously in our heads as clinicians. 27:50 clinicians. 27:50 clinicians. terms of literature on this topic, 27:52 terms of literature on this topic, 27:52 terms of literature on this topic, there's actually very little out there. 27:54 there's actually very little out there. 27:54 there's actually very little out there. There's very few or sparse examples of 27:57 There's very few or sparse examples of 27:57 There's very few or sparse examples of opioid withdrawal, quote unquote 27:59 opioid withdrawal, quote unquote 27:59 opioid withdrawal, quote unquote psychosis. In fact, what is described 28:02 psychosis. In fact, what is described 28:02 psychosis. In fact, what is described more often is a delirium, if you will, 28:05 more often is a delirium, if you will, 28:05 more often is a delirium, if you will, or encphylopathy. Um, where somebody 28:07 or encphylopathy. Um, where somebody 28:07 or encphylopathy. Um, where somebody might have very transient, temporary, 28:10 might have very transient, temporary, 28:10 might have very transient, temporary, uh, reversible psychotic symptoms. Um, 28:13 uh, reversible psychotic symptoms. Um, 28:13 uh, reversible psychotic symptoms. Um, and it's really confounded or or or 28:17 and it's really confounded or or or 28:17 and it's really confounded or or or complicated by the possibility that this 28:19 complicated by the possibility that this 28:19 complicated by the possibility that this is actually more so confusion, temporary 28:21 is actually more so confusion, temporary 28:22 is actually more so confusion, temporary brain disruption from medication 28:23 brain disruption from medication 28:24 brain disruption from medication changes, not exactly the same as 28:26 changes, not exactly the same as 28:26 changes, not exactly the same as psychosis. Our case really stood out 28:28 psychosis. Our case really stood out 28:28 psychosis. Our case really stood out because after controlling for attention 28:33 because after controlling for attention 28:33 because after controlling for attention and orientation, we did feel strongly 28:35 and orientation, we did feel strongly 28:36 and orientation, we did feel strongly that this was no longer a delirium and 28:37 that this was no longer a delirium and 28:37 that this was no longer a delirium and the person had for weeks, if not months, 28:41 the person had for weeks, if not months, 28:41 the person had for weeks, if not months, persistent psychotic symptoms. So this 28:44 persistent psychotic symptoms. So this 28:44 persistent psychotic symptoms. So this did stand out from what most of the 28:46 did stand out from what most of the 28:46 did stand out from what most of the literature talks about when it comes to 28:47 literature talks about when it comes to 28:47 literature talks about when it comes to opioid withdrawal. And again, these are 28:49 opioid withdrawal. And again, these are 28:49 opioid withdrawal. And again, these are very rare reports. 28:52 very rare reports. 28:52 very rare reports. This raises the question as to what was 28:54 This raises the question as to what was 28:54 This raises the question as to what was going on here. What could be the 28:57 going on here. What could be the 28:57 going on here. What could be the mechanism of action of this? How does 28:59 mechanism of action of this? How does 28:59 mechanism of action of this? How does this occur? One theory is that again 29:03 this occur? One theory is that again 29:03 this occur? One theory is that again maybe opioids as central nervous system 29:06 maybe opioids as central nervous system 29:06 maybe opioids as central nervous system suppressants meaning things that calm 29:07 suppressants meaning things that calm 29:08 suppressants meaning things that calm the central nervous system or blunt it 29:10 the central nervous system or blunt it 29:10 the central nervous system or blunt it basically simply reduce distress, 29:13 basically simply reduce distress, 29:13 basically simply reduce distress, anxiety and even psychosis. In other 29:15 anxiety and even psychosis. In other 29:15 anxiety and even psychosis. In other words, uh if you have strong opioids on 29:18 words, uh if you have strong opioids on 29:18 words, uh if you have strong opioids on board, maybe you're just sort of 29:20 board, maybe you're just sort of 29:20 board, maybe you're just sort of blunting again the brain so that one 29:23 blunting again the brain so that one 29:23 blunting again the brain so that one doesn't feel anxiety, distress, 29:24 doesn't feel anxiety, distress, 29:24 doesn't feel anxiety, distress, psychosis. I do see this clinically 29:27 psychosis. I do see this clinically 29:27 psychosis. I do see this clinically regularly where individuals uh tend to 29:30 regularly where individuals uh tend to 29:30 regularly where individuals uh tend to to feel like their psychiatric symptoms 29:32 to feel like their psychiatric symptoms 29:32 to feel like their psychiatric symptoms do improve as a result of opioids. Now 29:35 do improve as a result of opioids. Now 29:35 do improve as a result of opioids. Now of course there are other side effects 29:37 of course there are other side effects 29:37 of course there are other side effects and other problems with that. So it's 29:39 and other problems with that. So it's 29:39 and other problems with that. So it's not meant to suggest that we should be 29:40 not meant to suggest that we should be 29:40 not meant to suggest that we should be giving opioids for those conditions but 29:43 giving opioids for those conditions but 29:43 giving opioids for those conditions but I have seen that before. Another theory 29:45 I have seen that before. Another theory 29:45 I have seen that before. Another theory is that maybe the kappa opioid receptor 29:49 is that maybe the kappa opioid receptor 29:49 is that maybe the kappa opioid receptor is being involved or implicated. So the 29:51 is being involved or implicated. So the 29:51 is being involved or implicated. So the kappa opioid receptor is one that is is 29:54 kappa opioid receptor is one that is is 29:54 kappa opioid receptor is one that is is is 29:55 is 29:56 is rarely uh you know discussed in 29:58 rarely uh you know discussed in 29:58 rarely uh you know discussed in medicine. So when we think of opioids 30:00 medicine. So when we think of opioids 30:00 medicine. So when we think of opioids and where they work in the brain, they 30:02 and where they work in the brain, they 30:02 and where they work in the brain, they work on mu receptors. Um these receptors 30:05 work on mu receptors. Um these receptors 30:05 work on mu receptors. Um these receptors are all named after Greek letters. And 30:07 are all named after Greek letters. And 30:07 are all named after Greek letters. And so the mu receptor is really usually the 30:10 so the mu receptor is really usually the 30:10 so the mu receptor is really usually the one that that gets the most attention 30:12 one that that gets the most attention 30:12 one that that gets the most attention because that's where opioids work and 30:14 because that's where opioids work and 30:14 because that's where opioids work and activate and and they touch up on that 30:17 activate and and they touch up on that 30:17 activate and and they touch up on that little mu receptor and that causes 30:19 little mu receptor and that causes 30:19 little mu receptor and that causes analesia. In other words, reduction of 30:21 analesia. In other words, reduction of 30:21 analesia. In other words, reduction of pain. But opioids actually affect many 30:24 pain. But opioids actually affect many 30:24 pain. But opioids actually affect many different receptors as most of our meds 30:26 different receptors as most of our meds 30:26 different receptors as most of our meds do. And kappa receptors are a different 30:30 do. And kappa receptors are a different 30:30 do. And kappa receptors are a different uh opioid receptor that are important to 30:32 uh opioid receptor that are important to 30:32 uh opioid receptor that are important to consider. When you u involve the kappa 30:36 consider. When you u involve the kappa 30:36 consider. When you u involve the kappa receptor, it can be what's called 30:38 receptor, it can be what's called 30:38 receptor, it can be what's called psychotimedic. That's a long word for 30:40 psychotimedic. That's a long word for 30:40 psychotimedic. That's a long word for saying it can induce psychosis. It can 30:42 saying it can induce psychosis. It can 30:42 saying it can induce psychosis. It can induce psychotic symptoms. Uh which is 30:45 induce psychotic symptoms. Uh which is 30:45 induce psychotic symptoms. Uh which is very interesting. And so the chronic use 30:47 very interesting. And so the chronic use 30:47 very interesting. And so the chronic use of K receptor agonist meaning meds or 30:51 of K receptor agonist meaning meds or 30:51 of K receptor agonist meaning meds or opioids that activate the K receptor can 30:55 opioids that activate the K receptor can 30:55 opioids that activate the K receptor can lead to dopamine receptor up regulation 30:58 lead to dopamine receptor up regulation 30:58 lead to dopamine receptor up regulation in the misolyic and negro pathways. 31:00 in the misolyic and negro pathways. 31:00 in the misolyic and negro pathways. That's a long way of saying that if we 31:03 That's a long way of saying that if we 31:03 That's a long way of saying that if we use opioids for a very long time and 31:04 use opioids for a very long time and 31:04 use opioids for a very long time and they activate the kappa receptor, you 31:08 they activate the kappa receptor, you 31:08 they activate the kappa receptor, you can get more dopamine in the brain 31:11 can get more dopamine in the brain 31:11 can get more dopamine in the brain pathways that can themselves contribute 31:13 pathways that can themselves contribute 31:13 pathways that can themselves contribute to psychosis. And so this is one 31:17 to psychosis. And so this is one 31:17 to psychosis. And so this is one possible pathway or one mechanism that 31:19 possible pathway or one mechanism that 31:20 possible pathway or one mechanism that could be involved. 31:21 could be involved. 31:21 could be involved. The table that I'm showing here actually 31:24 The table that I'm showing here actually 31:24 The table that I'm showing here actually shows um how through through certain you 31:28 shows um how through through certain you 31:28 shows um how through through certain you know experiments we've shown that kappa 31:31 know experiments we've shown that kappa 31:31 know experiments we've shown that kappa opioid receptor agonism meaning again 31:34 opioid receptor agonism meaning again 31:34 opioid receptor agonism meaning again activation of the kappa opioid receptor 31:37 activation of the kappa opioid receptor 31:37 activation of the kappa opioid receptor can be blocked with opioid antagonist. 31:41 can be blocked with opioid antagonist. 31:41 can be blocked with opioid antagonist. So in other words, we can prevent 31:44 So in other words, we can prevent 31:44 So in other words, we can prevent psychotic effects if we block that 31:47 psychotic effects if we block that 31:47 psychotic effects if we block that receptor. And and like that we learn 31:50 receptor. And and like that we learn 31:50 receptor. And and like that we learn that these receptors, these kappa opioid 31:53 that these receptors, these kappa opioid 31:53 that these receptors, these kappa opioid receptors really are involved in um in 31:57 receptors really are involved in um in 31:57 receptors really are involved in um in in kappa induced psychotic effects. And 32:01 in kappa induced psychotic effects. And 32:01 in kappa induced psychotic effects. And nlloxxone, which you hear a lot about, 32:03 nlloxxone, which you hear a lot about, 32:03 nlloxxone, which you hear a lot about, and now trexone as well are um blockers 32:07 and now trexone as well are um blockers 32:07 and now trexone as well are um blockers of these of these receptors. and um they 32:10 of these of these receptors. and um they 32:10 of these of these receptors. and um they can prevent these kappa opioid receptor 32:13 can prevent these kappa opioid receptor 32:13 can prevent these kappa opioid receptor agonists from causing psychosis. 32:20 This image is also from the article that 32:20 This image is also from the article that we published on this case that I just 32:22 we published on this case that I just 32:22 we published on this case that I just presented and it's basically 32:25 presented and it's basically 32:25 presented and it's basically taking a stab at what the mechanism is 32:27 taking a stab at what the mechanism is 32:27 taking a stab at what the mechanism is here. This is by no means um you know uh 32:31 here. This is by no means um you know uh 32:31 here. This is by no means um you know uh etched in sand. Uh this is or etched in 32:35 etched in sand. Uh this is or etched in 32:35 etched in sand. Uh this is or etched in stone, excuse me. This is basically a a 32:37 stone, excuse me. This is basically a a 32:38 stone, excuse me. This is basically a a a potential mechanism as to why this 32:41 a potential mechanism as to why this 32:41 a potential mechanism as to why this specific individual might have had uh 32:45 specific individual might have had uh 32:45 specific individual might have had uh you know psychotic effects or psychotic 32:47 you know psychotic effects or psychotic 32:47 you know psychotic effects or psychotic symptoms way after uh many years of 32:50 symptoms way after uh many years of 32:50 symptoms way after uh many years of taking chronic opioids. So obviously um 32:53 taking chronic opioids. So obviously um 32:53 taking chronic opioids. So obviously um there's the long-term opioid use in the 32:55 there's the long-term opioid use in the 32:55 there's the long-term opioid use in the middle here, but remember long-term 32:57 middle here, but remember long-term 32:57 middle here, but remember long-term opioid use mixed with certain risk 33:00 opioid use mixed with certain risk 33:00 opioid use mixed with certain risk factors is really what's most important. 33:02 factors is really what's most important. 33:02 factors is really what's most important. So somebody might have had psychiatric 33:04 So somebody might have had psychiatric 33:04 So somebody might have had psychiatric or psychosocial risk factors or genetic 33:07 or psychosocial risk factors or genetic 33:07 or psychosocial risk factors or genetic loading or diiathesis. Diiathesis is a 33:10 loading or diiathesis. Diiathesis is a 33:10 loading or diiathesis. Diiathesis is a fancy word for risk. And so somebody 33:13 fancy word for risk. And so somebody 33:13 fancy word for risk. And so somebody might have been loaded with certain risk 33:14 might have been loaded with certain risk 33:14 might have been loaded with certain risk factors. Remember her her history 33:16 factors. Remember her her history 33:16 factors. Remember her her history included trauma and included genetic 33:19 included trauma and included genetic 33:19 included trauma and included genetic history of maternal alcohol use 33:22 history of maternal alcohol use 33:22 history of maternal alcohol use disorder. So, there may have been 33:24 disorder. So, there may have been 33:24 disorder. So, there may have been something already there that then with 33:27 something already there that then with 33:27 something already there that then with the mix of long-term opioid use might 33:29 the mix of long-term opioid use might 33:29 the mix of long-term opioid use might have led to psychotic disorder via these 33:32 have led to psychotic disorder via these 33:32 have led to psychotic disorder via these smaller arrows. Um, so you can see um 33:35 smaller arrows. Um, so you can see um 33:35 smaller arrows. Um, so you can see um each one has smaller um header numbers. 33:39 each one has smaller um header numbers. 33:39 each one has smaller um header numbers. These are all references in our article 33:41 These are all references in our article 33:41 These are all references in our article that that are meant to um offer support 33:44 that that are meant to um offer support 33:44 that that are meant to um offer support for these theories. But one we talked 33:47 for these theories. But one we talked 33:47 for these theories. But one we talked about was chronic cappa opioid receptor 33:49 about was chronic cappa opioid receptor 33:49 about was chronic cappa opioid receptor activation. I just referred to that in 33:51 activation. I just referred to that in 33:51 activation. I just referred to that in the previous slide. This can lead to 33:53 the previous slide. This can lead to 33:53 the previous slide. This can lead to misolyic or midbrain to limbic uh area 33:58 misolyic or midbrain to limbic uh area 33:58 misolyic or midbrain to limbic uh area dopamine release. DA being dopamine. Um 34:01 dopamine release. DA being dopamine. Um 34:01 dopamine release. DA being dopamine. Um you can also have some other changes 34:04 you can also have some other changes 34:04 you can also have some other changes over time in terms of neuron maturation. 34:08 over time in terms of neuron maturation. 34:08 over time in terms of neuron maturation. Oligodendrites are a type of neuron in 34:10 Oligodendrites are a type of neuron in 34:10 Oligodendrites are a type of neuron in our brain. Um as well as abnormal 34:14 our brain. Um as well as abnormal 34:14 our brain. Um as well as abnormal mileelination and and pruning. So these 34:16 mileelination and and pruning. So these 34:16 mileelination and and pruning. So these are these are complex processes that are 34:19 are these are complex processes that are 34:19 are these are complex processes that are part of neurode development. how our 34:21 part of neurode development. how our 34:22 part of neurode development. how our brains develop. And during adolescence, 34:25 brains develop. And during adolescence, 34:25 brains develop. And during adolescence, particularly when somebody so young as 34:26 particularly when somebody so young as 34:26 particularly when somebody so young as her, age 12, was exposed to highdosese 34:29 her, age 12, was exposed to highdosese 34:29 her, age 12, was exposed to highdosese opioids, you might presume that that had 34:32 opioids, you might presume that that had 34:32 opioids, you might presume that that had an impact actually on on brain pathways 34:35 an impact actually on on brain pathways 34:35 an impact actually on on brain pathways to the point of maybe impacting her risk 34:37 to the point of maybe impacting her risk 34:37 to the point of maybe impacting her risk for psychotic disorder. Now, all of 34:39 for psychotic disorder. Now, all of 34:39 for psychotic disorder. Now, all of these things in concert, of course, and 34:41 these things in concert, of course, and 34:41 these things in concert, of course, and maybe even other factors contributed to 34:44 maybe even other factors contributed to 34:44 maybe even other factors contributed to this picture. 34:46 this picture. 34:46 this picture. [Music]
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