Short-acting  generally refers not only to how long a drug carries the desired effect, but the speed of the onset of the drug, and how fast it drops off toward the end of the dose.  Quick onset and fast dropoff are major determinants for abuse.  Short-acting opiods (SAO’s) are not necessarily quick-onset medications.  Most oral SAO tablets are slow to take effect.  A short duration of action then leads to frequent administration and overuse may occur.  However, it has not been proven conclusively that SAO’s lead to less or more abuse, or are “more dangerous” than long-acting opioids (LAO’s).  Although certain drugs are more “abusable” it is the person rather than the drug who governs abuse.

Several previous studies have evaluated daily opiods for severe chronic daily headache.  While success rates have been relatively low, these are patients who have failed the usual ministrations, with few options available.  The advantages of long-acting opioids include:

1. Avoidance of the “end of the dose” phenomenon, with mini-withdrawls throughout the day.

2. Consistent dosing one or two times daily, decreasing the obsession with the next dose.

3. Maintenance of stable blood levels.

4. Avoidance of acetaminophen, aspirin, or NSAIDS that are included in many short-acting preparations.

5. A diminished risk of significant abuse.

6. Better compliance, with less psychological dependency on the drug.

Disadvantages of the long-acting opiods include:

1.stigma

2. fatigue and constipation

3.difficulty in obtaining scripts, with no refills available

4. need for frequent office visits and monitoring

5. risk of abuse

6. interactions with other sedating drugs or alcohol

7. risk of overdose

Most of the opioid abuse is secondary to immediate-acting opioids, or the longer ones that are easily convertible to short-acting ones (ex: Oxycodone CR).  Younger people, particularly adolescents, are the most frequent abusers.

Since their introduction in 1982, the LAO’s have not been shown to be widely abused.  A balanced approach to prescribing opioids is the best method in order to prevent over or underprescribing opioids.  In various studies, the effects of opioids on quality of life are inconsistent.  Generally, at least half of the patients prescribed opioids abandon them due to side effects or lack of efficacy.

Most herbal and vitamin supplements have not held up to scrutiny in controlled trials; some have turned out to be harmful.  Even multivitamins are questionable; a large study released in 2009 showed no improvement in cancer or heart disease rates among women who took multivitamins.  Another study linked multivitamins to an increase in cancer.  Don’t believe the advertising claims-multivitamins and many other supplements are not necessary for good health.

It can be confusing to know which supplements are helpful, but the following have held up to scrutiny and are recommended: Vitamin D: 2,000 I.U. daily (avoid generics) and Omega-3’s (see below).

Vitamin D is known to be important for our skin and bones, and it may help fight hypertension and autoimmune diseases.  Recently, adequate levels of Vitamin D have been linked to lowered rates of cancer, especially colorectal cancer.  People who live in cold climates are often low in Vitamin D, as they are not in the sun enough.  Most need to take a Vitamin D supplement.  The latest studies suggest that adults need at least 2,000 International Units a day.  Avoid the generic Vitamin D; use a name brand.  The Nature’s Finest brand at Walgreen’s is 2,000 I.U. in a small gelcap, easy to take.  If you take calcium with added D, you probably still need to take an extra D supplement.  Do not take more than 4,000 units of vitamin D without consulting your physician.

Omega-3’s (Fatty Acids).  Many studies have shown the benefits of Omega-3’s for the heart, for moods, and possibly for headaches.  Eating fish twice a week is a good goal, particularly fatty fish such as tuna, salmon, trout and mackerel.  Fish oil capsules are also beneficial.  Read the ingredients on the bottle and choose the brand with the most EPA and DHA.  One or two capsules a day is recommended.  Flaxseed capsules are also helpful.  Other sources of Omega-3’s in the diet are tofu, soybeans, walnuts, and canola oil.

Calcium is necessary for the heart, muscles, and nerves to function and for blood to clot.  Low intake of calcium leads to the development of osteoporosis and is associated with high rates of bone fractures.  Absorption of calcium decreases as we age.  After 45, most people, particularly post-menopausal women, should take calcium supplements.  Eating too much salt and protein, especially animal protein, increases calcium loss.

Calcium is found in milk, yogurt, cheese, broccoli, tofu, beans, sardines, calcium-enriched fruit juices, fortified cereals, and other foods.  Our systems cannot absorb more than 500mg of calcium at a time.  Calcium in the form of calcium citrate, such as in citrocal, is more easily absorbed than calcium carbonate.  Citrocal Caplets plus D are a good form of calcium (315 mg) and vitamin D (200 IU).  The usual dose is one or two tablets, twice a day; consult your physician.  To learn more about calcium, visit www.health.nih.gov . 

Aspirin.  If you are at risk for heart disease, your doctor may recommend a daily dose of aspirin.  Its properties may help prevent heart attacks and strokes, and even headaches and certain cancers.  The usual dose is one aspirin (325mg)a day.  Generic aspirin are fine.  Taking a baby aspirin (81mg) or 1/2 tablet of regular aspirin (162mg) may be sufficient; the dose varies by person.  Aspirin can cause stomach ulcers; if it hurts your stomach or causes heartburn, stop taking it and consult your doctor.

Coenzyme Q10 (CoQ10) is a crucial compound, important for your heart, muscles and nerves.  It is naturally produced by your body.  However, the statins (cholesterol-lowering drugs like Simvastatin, Lipitor, Pravochol, Vytorin and crestor) deplete the body’s CoQ10.  Sutdies have indicated a possible benefit from CoQ10 for migraine and the heart.  I suggest taking 200 mg per day of CoQ10 if you take one of the statin drugs.  It has not yet been proven that this helps the muscles, but CoQ10 is generally safe and may prevent headaches.

1. Petadolex: Commonly used in Europe, this herb has been successful in several well-designed blinded studies.  The usual dose is two per day.  Earlier concerns about carcinogenisis with this family of herbs have decreased with Petadolex.  It is prudent to stop it every three months or so.  Available at 1-888-301-1084.  Petdolex is a very effective preventive.  Patients occasionally experience GI upset or a bad taste.  Usually well tolerated.

2. Magnesium Oxide: It has been shown that magnesium levels are low in the brain of migraine patients.  400 or 500 mg per day is used as a preventive; mild GI side effects may limit use.  250 mg tablets are found in most pharmacies.  Only mildly effective.

3. Feverfew: Feverfew has been demonstrated to be mildly effective in some patients for prevention of migraine headache.  Feverfew can cause a mild increased tendency toward bleeding, and should be discontinued two weeks prior to surgery.  Feverfew should not be used during pregnancy and patients are occasionally allergic to it.  The problem with many herbal supplements is quality control, and certain farms consistently have better quality than others.  The parthenolide content (the active ingredient) varies widely from farm to farm.  The usual dose is two capsules each morning.  Eclectic Institute (a blue and white bottle, widely available in health food stores and Whole Foods) freeze dries their herbs, and the product is highly consistent and reliable.

4. Long Chain Fatty Acids (Omega-3 fatty acids): These may play a role in headache prevention, as well as (possibly) useful for anxiety, HTN, arthritis, high lipids, depression and heart disease.  We usually recommend fish oil or Flaxseed oil, 1000 mg., two or four per day (in studies on depression, eight per day have been utilized).  Fish oil capsules may be more effective than Flaxseed oil.  Oily, fatty fishes 9Salmon, Tuna) contain more than other fishes.  Look for the brands with the highest amounts (EPA/DHA) listed on the back.

5. Coenzyme Q-10: COQ-10 is relatively safe, and has started to be investigated as a headache preventive.  Doses for headache are not known.  COQ-10 may have some positive effects on the heart as well.  We usually recommend 150 to 300 mg daily.

GAD may cycle in people’s lives, and certainly is worse with stress.  There is almost always a family history of anxiety, and anxiety usually starts in childhood.  Other anxiety disorders that may occur in childhood or adolescence include: obsessive-compulsive disorder, separation anxiety, and panic disorder.

As with depression, there are a number of differences in the brain, and nervous system, in people with anxiety.  There are changes in certain neurochemicals or transmitters, and genetics has a major role to play.  It is as much a physical disorder as asthma, headaches, or diabetes.

Certainly stressful events may trigger anxiety, but most people with GAD have an inherited physical and chemical difference in their brain.

Anxiety is eminently treatable with exercise, yoga, psychotherapy, biofeedback, and medication.  The medications primarily involve use of the antidepressants and/or the “pure” antianxiety medicines, in particular the benzodiazepines.  Examples of antidepressants include the SSRI’s such as Prozac, Zoloft, etc., and the benzodiazepines include Xanax, Ativan, etc.  While it is inconvenient, and somewhat expensive, to go to a psychotherapist on an ongoing basis,  is very helpful in the long run.

Rules for Better Sleep:

1. Sleep as much as needed to feel refreshed and healthy during the following day, but not more.  Curtailing the time in bed seems to slidify sleep; excessively long times in bed seem related to fragmented and shallow sleep.

2.Set the alarm and get up at the same time every morning, regardless of how much you slept during the night.  A regular awakening time strengthens circadian cycling and, finally, leads to regular times of sleep onset.

3. A steady daily amount of exercise probably deepns sleep.  Yoga, deep breathing/relaxtion excercises may help.

4.Hunger may disturb sleep; a light snack may help sleep.  Caffeine in the evening disturbs sleep, even in those who feel it does not.

5. Alcohol helps tense people fall asleep more easily, but the ensuing sleep is then fragmented.  The chronic use of tobacco disturbs sleep.

6. Use the bed only for sleeping; do not read, watch television or eat in bed.  If unable to sleep, get up and move to another room until you are really sleepy, then return to bed.  The goal is to associate bed with falling asleep quickly.

7. Occasional loud noises disturb sleep even in people whoa re not awakened by noises and cannot remember them in the morning.  Sound attenuated bedrooms may help those who must sleep close to noise.  White noise sound machines or ear plugs help to blunt outside noise.

8. An occasional sleeping pill may be of some benefit, but their chronic use is ineffective in most insomniacs.

9. People who feel angry and frustrated because they cannot sleep should not try harder and harder to fall asleep, but should turn on the light and do something different.

10. Keep the lights in the bedroom down low, even prior to sleeping, because bright lights will awaken your brain.  If a night light is needed, keep it in the bathroom.

The symptoms in depression vary widely.  There is usually a depressed mood, with feelings of helplessness, sadness, and hopelessness.  Decreased motivation and loss of interest in the usual pleasurable activities often occurs.  There may be sleep disturbances, either sleeping too much, not enough, difficulties falling asleep, or easy awakening during sleep.  Concentration problems are seen, with a difficult time making decisions, often along with agitation, irritability, fatigue, and feelings of worthlessness.  There may be no interest in sex, and weight can be increased or decreased due to appetite changes.  A serious side effect of depression is suicidal thoughts, or actually committing suicide.

Some people have a “major depression”, where they ahve at least 2 weeks of serious depression, while others have ongoing mild or moderate chronic depression.  Depression may be worse in certain seasons, such as Seasonal Affective Disorder-depression in winter primarily related to a lack of sunlight.  Stressful life events may trigger depression or it may cycle in and out of people’s lives regardless of stress.  Chronic medical illnesses, sickness in one’s family, financial difficulties, and hormonal changes (particularly with postpartum depression) all may trigger depression.

The two primary treatments are medication and psychotherapy.  Exercise may help.  The combination of meds plus therapy is ideal.

Personality disorders have a wide range of severity, from mild to very severe.  They often flip between victim, rescuer, and persecutor.  Personality disorder patients often create chaos and drama and comorbid substance abuse is common.

In general, therapy only helps people with personality disorders over long periods of time (5-7 years).  The concept of “plasticity” of the brain is very important, as some people can improve naturally over time.  However, our goals and expectations are limited.  The following is a description of some of the more severe personality disorder types.  Many people do not fit neatly into any of these categories, but have features of two or three personality disorder types.

Paranoid Personality Disorder: They tend to be non-trusting, suspicious, very secretive, and see the world as dangerous and themselves as constantly being mistreated.  They doubt the loyalty of anybody around them, are reluctant to confide in others, and believe they are being exploited or harmed.  They become angry very easily and can become violent and dangerous, as most spree killers are examples of paranoid personality disorder.

Antisocial Personality Disorder: These people generally have no regard for the rights of others; they are exploitative, they see themselves as superior, and are very opportunistic.  They are deceitful, steal from people around them, and often have trouble with the law.  They frequently engage in fraudulent activities, make very good ’scam artists’, and generally have no remorse.

Bordlerline Personality Disorder: They have instability of mood, poor self image, and pervasive abandonment fears.  There is an identity disturbance and major boundary issues.  Borderlines usually demonstrate suicidal behavior, very quick shifts from depression to anxiety to irritability, and paranoia under stress.  They tend to split, which is, they see people as wonderful or as terrible, with nothing in between.  suicide becomes more likely as patients get into their high 20’s and 30’s.

Narcissistic Personality Disorder: This is less common, and the people see themselves as being above others, they are grandiose, have a lack of empathy, and have a true sense of entitlement.  They may be very vain and require constant attention.

Many patients do not have all of the characterisitics of one particular personality disorder, but it is a spectrum with several characteristics of a number of personality disorders.  Treatment consists of maintaining limits and boundaries on the person, encouraging long-term weekly therapy, and medications (mood stabilizers/antidepressants) to reduce the anxiety and depression aspects of personality disorder.

To have ADD as an adult, you must have had the condition as a child or adolescent.  If you did not,the attention problem as an adult is not ADD, but is a combination of stress, insomnia, medication, or other factors.  Adults with true ADD remember that they had difficulty handing in homework, troubles with boring projects or reading assignments, poor attention span, and working twice as much to achieve half the amount.  The features of ADD include: trouble starting and finishing projects (especially more boring assignments), careless mistakes, irritability, impulsivity, easily distracted, tendency to misplace things, poor attention span, and difficulty remembering appointments.

The cost of untreated ADD is enormous, with a major increase in substance abuse, auto accidents, jail time, and broken or unfulfilled lives.  While many people do learn to compensate for their attentional problem and achieve much in their lives, ADD still takes a great toll on the quality of life, and patients usually do better when treated.

ADD often has other comorbid psychological conditions such as anxiety and depression.  The attention problem interferes with life’s functioning, and leads to more anxiety, stress, and depression in people’s lives. 

The ASRS, Adult Self Report Scale, is commonly used as a screening test for ADD in adults.  The primary and most successful mode of treatment for ADD has been medication.  The “first-line” medications are the amphetamines (Adderall, Adderall XR, Vyvanse) and methyphenidates (Ritalin, Ritalin LA, Focalin, Focalin XR, Concerta).  Side effects of these meds include, among others, anxiety, faster heart rate, and insomnia.  However, these medications do, at times, help headaches and fatigue.

If Adderall or Ritalin-type medications are ineffective, or can’t be used, the second-line drugs include Strattera, bupropion (Wellbutrin), nortriptyline, despiramine or other antidepressants.  As usual, the idea with medication treatment is to find an effective dose, but try and minimize medication.

Several studies have shown that incidences of bipolar I and bipolar II were found to be increased in migraineurs.  Recent studies have confirmed that at least 7% of headache patients fit into the bipolar spectrum and 40 to 50% of bipolar patients have migraines.

The clinical spectrum of bipolar disorders is an evolving concept.  It is the milder end of the bipolar spectrum that tends to be missed; look for those with persistently agitated, angry personalities, with frequent depressions and/or “too much energy”, with a strong bipolar or depressive family history.  They may not have a clear hypomanic or manic episode.  Soft bipolar signs include: early (teens) depression, severe depression, quick onset depression, “bipolar” reaction to certain meds (up all night, mind racing, etc.), agitated angry depression, very high anxiety and mood swings, poor response to medication, and moody personality.  Sleep disorders are commonly seen.  Cyclical depression “for no reason”, with high anxiety, is common for bipolar depression.

Recognizing bipolarity and establishing the bipolar diagnosis is essential for a client’s therapeutic implications.  Undiagnosed bipolar patients often are given a number of antidepressants, with predictable hypomanic (poor) results.  Mood stabilizers often are very helpful for the moods and headaches.  Divalproex sodium (Depakote) is effective for mania, hypomania, depression associated with bipolar disorder, and for headache prevention.  Divalproex sodium has become one of the primary migraine and chronic daily headache preventives.  Lamictal is also becoming one of the most commonly used mood stabilizers and is one of the only effective medications for bipolar depression.  Additionally, the new antiepiletics may prove to be helpful for bipolar disorders and/or migraine. 

The recognition of increased comorbidity between migraine and bipolar illness has important clinical implications.  By broadening our concept of the bipolar realm, we can improve outcome in these patients.  Recognition of the milder end of the bipolar spectrum is crucial, as the clinical stakes for missing bipolar ilness are enormous. 

Unfortunately, medications used for bipolar patients are often more effective for the manic/hypomanic symptoms, leaving the depression frequently untreated.  Bipolar patients spend the majority of their time in depression, and we need better medications.  Many patients need two to four meds (such as Lamictal, Lithium, and an antidepressant).

Chronic daily headache poses a significant problem, with 3 to 4% of the population suffering from this condition.  There are a variety of preventative medications available, including (but not limited to): sodium valproate, antidepressants, beta blockers, muscle relaxants, NSAIDS, gabapentin and topiramate.  Many patients cannot tolerate these medications, or efficacy is lacking.  Among those who do benefit, over time the side effects (such as weight gain or fatigue) may cause discontinuation of the medication.  Alternatively, the patient may experience declining efficacy.  Most of the new breakthrough medications have been in the abortive category (particularly the triptans).  There has been a lack of new, novel headache preventatives.

Overuse of analgesics, on a chronic basis, may cause or exacerbate daily headaches.  For these patients, withdrawal of the analgesics often will lead to an improvement in the headache.  The usual preventative medications may be ineffective for those who are overusing analgesics.

There is no doubt that chronic daily headache sufferers are difficult to successfully treat, and medication overuse is a major factor.  Initially, studies indicate a widely varying success rate for the treatment of chronic daily headache, between 47 and 97%.  However, after four years, many of the patients who were able to discontinue their analgesics relapsed into medication abuse (44% in one study, 60% in another study).  Even after one year, 30 to 35% of patients relapsed into overuse of the analgesics.  These patients usually have a poor quality of life.  One major contributing factor to the medication overuse is the failure of the preventattive medications to adequately decrease the chronic daily headache.

There is a disconnect between the results of company-sponsored short-term studies and what we observe, albeit anecdotally, regarding long-term success of dailly preventatives.  We need long-term studies, at least six to nine months, in order to adeequately evaluate daily preventatives.  In addition, we need novel, more effective daily preventatives for chronic daily headache.