APA Annual Meeting Highlights, Broad Spectrum Micronutrient Treatments, and Best Practices for Benzodiazepine Use

In this newsletter, we share some tips we bring home from the APA Annual Meeting, which focused on the theme of confronting addiction.

We also share key points from an interview on considerations for using broad-spectrum micronutrients in clinical practice, a presentation on key aspects of benzodiazepine prescribing, and practical research summaries on adult psychiatry.

APA’s Annual Meeting: Tips We Learned

The 2024 Annual Meeting of the American Psychiatric Association (APA) was held in New York from May 4th to 8th.

The main theme was “Confronting Addiction from Prevention to Recovery.” Our editorial team was fully immersed in multiple sessions and managed to distill the most essential points for your clinical practice.

Part of the Psychopharmacology Institute’s editorial team. From left to right, Lorena Rodriguez, M.D.; Flavio Guzman, M.D.; and Paz Badia, M.D.

Buprenorphine Treatment Still Relevant in the Age of Fentanyl

Standard buprenorphine treatment remains viable in the age of fentanyl.
People who use fentanyl may need closer monitoring and follow-up early in treatment vs those using natural opioids.
You may need to adapt buprenorphine initiation strategies to people who use fentanyl.
Consider starting with:
- Higher doses (e.g., 20 mg daily)
  - This maximizes buprenorphine potency and blocks lingering fentanyl.
- Lower doses (2 mg or less) over several days.
  - This allows fentanyl to clear naturally and minimizes the risk of precipitated withdrawal.
The risk of buprenorphine-precipitated withdrawal among people who use fentanyl is still debated.

Tips extracted from “Practice-Based Guidelines: Buprenorphine Treatment in the Age of Fentanyl”, presented by Jeffrey DeVido, M.D.

Addiction Psychopharmacology Tips

Benzodiazepine use disorder
- A tapering method using a long-acting agent is advisable.
- Carbamazepine, valproate, gabapentin, and oxcarbazepine may be used as supplementary options.
Cannabis use disorder
- Currently, there are no FDA-approved medications.
Alcohol use disorder
- For alcohol dependency, detoxification can be achieved using benzodiazepines tapering or phenobarbital.
- Disulfiram, naltrexone, acamprosate, topiramate, and gabapentin have been proven effective in preventing relapses.

Tips extracted from “How to Incorporate Addiction Psychopharmacology into Psychiatric Practice: A Case-Based”, presented by Jeffrey DeVido, M.D.

Prescribing in Pregnancy: What Every Psychiatrist Should Know

Almost all psychiatric medications can be continued during pregnancy.
Few demonstrate clear evidence of increased risk of congenital malformations:
- Valproate shows a high risk, whereas lithium and methylphenidate present a lower risk.
For most psychiatric medication, infant serum levels are <10% of maternal levels and considered safe during breastfeeding.
Tips for prescribing in pregnancy:
- Trust your clinical judgment: What would you do if the patient was not pregnant?
- Be aware that pregnancy impacts the absorption, distribution, metabolism, and elimination of many medications, including SSRIs, lamotrigine, and lithium.
- Monitor for changes in symptoms, and consider dose adjustments, especially in later pregnancy.
- Aim to use the fewest medications at the lowest doses necessary to achieve maternal euthymia.
- For more detailed information on specific drugs or situations, consider using online resources, such as LactMed, ReproTox, and MotherToBaby.

Tips extracted from “Prescribing in Pregnancy: What Every Psychiatrist Should Know”, presented by Amanda Koire, M.D., and Reid Mergler, M.D.

Clozapine Revisited: Recent Advances and Clinical Updates

A delay in initiating clozapine treatment is associated with poorer outcomes.
Clozapine should be initiated after 2 failed trials of standard antipsychotics.
Some European groups recommend initiating clozapine after just 1 failed trial to improve patient outcomes.
Monitoring ANC:
- Some hospitals now offer point-of-care or finger stick blood tests to monitor ANC.
- These tests ease the monitoring burden and streamline clozapine management.
Myocarditis poses a higher risk than agranulocytosis.
- The highest risk is during the first 4 weeks.
- There is no agreed-upon monitoring scheme, but weekly troponin testing for 6–8 weeks can aid in detection and efficient management.

Tips extracted from “Clozapine Revisited: Recent Advances and Clinical Updates”, presented by Oliver Freudenreich, M.D.

Every Reason to Continue Lithium!

Discontinuing lithium is a last resort, given its important benefits for mood disorders.
Kidney problems and tips from nephrologists:
- Refer patients to nephrology if eGFR is <60 mL/min.
- Consider stopping lithium if eGFR is <45 mL/min, especially with comorbidities.
- Manage polyuria with amiloride or thiazide diuretics.
- Protein in urine predicts faster progression of chronic kidney disease.
Lithium-related hypothyroidism:
- Treat overt hypothyroidism (high TSH, low free T4) with levothyroxine.
- If the TPO antibody is positive or symptomatic, consider treating subclinical hypothyroidism (TSH 5-10).
Hypercalcemia and hyperparathyroidism:
- Check calcium and PTH before starting lithium and every 3–6 months.
- If persistently elevated, consider reducing lithium dose, cinacalcet, or surgery.
- Continue to monitor even after parathyroidectomy.

Tips extracted from “Every Reason to Continue Lithium!”, presented by Balwinder Singh, M.D.; Michael Gitlin, M.D.; Vishnu Sundaresh, M.D.; and Maria Lourdes Gonzalez Suarez, M.D.

Exploring the Clinical Implications of Broad-Spectrum Micronutrient Treatment

In this interview, we explore the clinical implications of treating psychiatric disorders such as ADHD with broad-spectrum micronutrients (BSMs).

Interview highlights include:

Ideal candidates for BSMs include those with emotional dysregulation, a history of inadequate response to psychotropic medication, younger patients, and individuals motivated to adhere to the supplementation regimen.
The patient’s dietary habits, lifestyle, and gastrointestinal (GI) health should also be considered.
Side effects of BSMs include transient headaches, insomnia, GI side effects, and worsening of a pre-existing GI dysfunction.

Learn more and earn 0.75 CME credits here .

Understanding Benzodiazepine Prescribing: A Clinician’s Guide

Dr. Ritvo discusses the appropriate use of benzodiazepines, their potential risks, and specific contraindications, underscoring the significant dangers linked to misuse and addiction. She also focuses on benzodiazepine use disorder and examines the drug’s effects in high-risk groups, particularly during pregnancy, breastfeeding, and adolescence.

Consequences of Benzodiazepine Use in Pregnancy, Breastfeeding, and Adolescence

When possible, avoid benzodiazepine use in pregnancy.
- Encourage pregnant patients to taper off by the third trimester.
If benzodiazepines are necessary during pregnancy:
- Opt for those with shorter half-lives.
- Be aware that benzodiazepines pass into the breast milk and pose a risk to the infant.
Benzodiazepine use should be avoided and, if necessary, used in a limited fashion in adolescents.

Learn more and earn 1 CME credit here.

Quick Takes: Research, Digested

Famotidine for COVID-19 Brain Fog: A Promising Treatment Option

Brain fog is a common and distressing symptom after COVID-19 infection, affecting up to one-third of patients.
Famotidine may improve cognitive function in patients with COVID-19 brain fog.
- Famotidine is safe and well-tolerated, making it a reasonable option.
- Learn more.

Listen to or read the full volume and earn 0.5 CME credits here.

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Lorena Rodríguez, M.D.