Designer products, a term referring to analogs of known chemical compounds with no established medical use, represent an easily accessible alternative to prescription-only products. During the past decade, designer benzodiazepines have become widely available on the online forums. Although these agents offer individuals an inexpensive and accessible alternative to prescription-only products, they are not without risk. Because of the lack of federally enforced quality standards, these designer products come with an intrinsic risk of unpredictable and potentially toxic adverse effects. This article presents a 36-year-old male with prolonged bradycardia resulting from the use of flubromazolam, a designer benzodiazepine purchased from the Internet. A PubMed search was conducted for flubromazolam, designer benzodiazepine, and flumazenil. This article will summarize the available literature regarding flubromazolam and the role of flumazenil in managing these overdoses.

Stimulant use disorder (SUD) is a public health problem in the United States that is associated with increased morbidity and mortality. Psychosocial interventions, such as cognitive behavioral therapy and contingency management, are the main treatment modality for SUDs and no pharmacotherapy is currently FDA approved for this indication. Although some medications show promising data for the treatment of SUD, the evidence remains inconsistent, and the clinical application is limited due to the heterogenicity of the population and the lack of studies in patients with various comorbidities. Selection of pharmacotherapy treatment for methamphetamine intoxication, persistent methamphetamine-associated psychosis with methamphetamine use disorder, and cocaine use disorder in patients with co-occurring OUD are discussed in 3 patient cases.

Introduction:Many psychotropic medications carry a risk of prolonging the QT interval and increasing the risk of developing Torsade de pointes (TdP). The goal of this study was to evaluate whether patients taking psychotropic agents with a known risk of TdP are being monitored at a community hospital through the use of electrocardiograms (EKGs).Methods:This was a retrospective chart review of 100 adult patients—50 from general medicine floors and 50 from psychiatric units—who were taking at least one psychotropic agent with a known risk of TdP during hospitalization.Results:The mean number of medications with QT-prolongation risk administered to the psychiatric and general medicine patients was 4.2 ± 1.7 and 3.9 ± 2.0, respectively (P = .7484). Thirty-two of the psychiatric patients (64%) and 48 of the general medicine patients (96%) received EKGs during their hospitalization (P < 0.0001). Of those newly starting the target medications, 58% (18 of 31) of the psychiatric patients and 71% (5 of 7) of the general medicine patients received a baseline EKG. The difference was not statistically significant (P = .6807). Overall, 8 patients (8%) had corrected QT (QTc) intervals >500 ms. Four had repeat EKGs performed, and none had medication changes made to decrease TdP risk.Discussion:Many inpatients on psychiatric medications received multiple medications with a risk of TdP, but not all received monitoring through baseline or repeat EKGs when warranted. Patients with QTc intervals >500 ms were not appropriately managed to lower their risk of TdP. Pharmacists thus can help improve the monitoring and management of QT prolongation.

Anxiety disorders comprise the most common group of mental disorders to affect the general population in the United States. These disorders are heterogeneous in nature, highly comorbid with one another, and pose a degree of difficulty regarding diagnosis and management. The exact etiology and pathophysiology of anxiety remains to be elucidated; however, it is likely that it is multifactorial, and all potential causes of anxiety must be investigated, including substance-induced anxiety. Among substances that may induce anxiety are dietary supplements. As utilization of these products appears to be high in the US population, it is important to identify which of available supplements may cause anxiety. Objective: To review the scientific literature to identify dietary supplements associated with induction of anxiety and related symptoms. Methods: A search of Natural Medicines Comprehensive Database, MedlinePlus Herbs and Supplements, and Natural Standard was performed to identify dietary supplements with anxiogenic properties. Dietary supplements were included based on product availability, utilization trends, and if there was sufficient evidence that the substance could elicit anxiety via direct pharmacologic effects. Agents were excluded from the review if anxiety was solely due to withdrawal from the substance or only occurred in the setting of intoxication. A search of MEDLINE and PUBMED was performed to identify relevant peer reviewed publications concerning induction of anxiety and/or its associated symptoms by those dietary supplements chosen for review. Conclusions: Dietary supplements can contribute to and cause anxiety and its related symptoms via overstimulation of the Central Nervous System. Healthcare professionals should screen all patients presenting with symptoms consistent with anxiety for recent or current use of all products capable of inducing anxiety, including dietary supplements.

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