Attention-deficit hyperactivity disorder (ADHD) is a chronic neurodevelopmental disorder characterized by persistent symptoms of inattention, hyperactivity and/or impulsivity. The proportion of patients diagnosed with ADHD receiving pharmacological treatments has increased enormously in recent years. Despite the well established efficacy and the good safety and tolerability profile, there is concern about the potential for rare but serious cardiovascular adverse events, as well as sudden cardiac death, with pharmacotherapies used for treating ADHD in children, adolescents and adults. The present paper aims to comprehensively and critically review the published evidence on the controversial association between medications approved for treating patients with ADHD and the risk of serious cardiovascular problems, specifically the risk of corrected QT interval (QTc) prolongation, and the risk of sudden cardiac death. A comprehensive search of relevant databases (PubMed, EMBASE and PsychINFO) was conducted to identify studies published in peer-reviewed journals until 21 July 2012. Clinical reports, as well as retrospective or prospective population-based studies with children, adolescents or adults as participants, of pharmacotherapies for ADHD reporting cardiovascular adverse events were included. Stimulant medications for ADHD, including methylphenidate and amphetamine derivatives, are generally safe and well tolerated. Small but statistically significant increases in blood pressure (BP) and heart rate (HR) are among the adverse events of stimulant treatment in all age groups. Similarly, the non-stimulant medication atomoxetine has also been associated with increased HR and BP, although as is the case with stimulants, these are generally minor, time limited and of minor clinical significance in children, adolescents or adults. Growing evidence suggests that these medications do not cause sudden and unexpected cardiac death or serious cardiovascular problems including statistically or clinically significant increases in QTc, at therapeutic doses in ADHD patients across the lifespan. Small decreases in mean systolic BP, diastolic BP and HR have been observed in studies with guanfacine-extended release (-XR) or clonidine-XR, two α(2)-adrenergic receptor agonists, administered alone or in combination with psychostimulants to children and adolescents with ADHD. There are also no statistically or clinically significant increases in QTc associated with clonidine or guanfacine. There are no reports of torsades de pointes clearly and directly related to medications used for treating ADHD in patients of all age groups. The risk for serious cardiovascular adverse events, including statistically or clinically significant increases in QTc, and sudden cardiac death associated with stimulants, atomoxetine or α(2)-adrenergic agonists prescribed for ADHD is extremely low and the benefits of treating individual patients with ADHD, after an adequate assessment, outweigh the risks. However, great caution is advised when considering stim...

Management of patients with opioid use disorder (OUD) commonly includes opioid agonist therapy (OAT) as a part of an integrated treatment plan. These interventions are associated with proven benefits to the individual and society. Areas covered: The use of methadone and buprenorphine within an integrated treatment plan in the management of patients with OUD: this work provides consensus recommendation on pharmacotherapy in OUD to assist clinicians with practical decision making in this field. Expert opinion: Pharmacotherapy is recommended as part of an integrated OUD treatment approach with psychosocial interventions, with the goal of reducing risks of illicit opioid use, overdose mortality, infection with HIV or HCV, improving health, psychological and social outcomes. Access to OAT should be prioritised in the treatment of OUD. Treatment choices in OUD pharmacotherapy should be based on the needs of the individual and characteristics of medications. Recommendations for choices of OAT are based on clinical efficacy, safety, patient preference, side effects, pharmacological interactions, quality of life, dose titration potential and outcomes (control craving, ongoing opioids consumption or other drugs, and potentially psychiatric comorbidities). Special groups, pregnant women, prisoners, patients with mental health problems have specific needs which must be addressed with expert input.

Resumen AbstractThe objective was to quantify the prevalence of dual diagnosis and to evaluate the characteristics of these patients from community mental health and substance misuse services in Madrid. The sample consisted of 837 outpatients from Madrid, 208 from mental health services and 629 from substance misuse services. We used the Mini International Neuropsychiatric Interview (MINI) and Personality Disorder Questionnaire (PDQ4+) to evaluate disorders from axis I and II. It was considered that 517 (61.8%) patients had dual pathology (current diagnoses of axis I or II disorders and an addictive disorder): 36,1% in mental health services and 70,3% in substance misuse services. There were fewer males amongst the dual patients and it was also found that they had a worse employment situation, along with higher figures of alcohol and cannabis dependence than addicts without dual diagnoses (n=194). When comparing them with patients with mental disorder diagnoses only, excluding substance use disorder (n=126), there were differences in all socio-demographic characteristics analyzed, and dual patients were associated with diagnoses of bipolar disorder, agoraphobia, generalized anxiety disorder, post-traumatic stress disorder, and had more suicide risk and different personality disorders. Thus, dual pathology is higher in patients who are in treatment and have differential characteristics (higher suicide risk, worse employment situation) that suggest greater severity that could be of help in the planning of care resource policies for these patients.Key Words: Drug dependence, dual diagnosis, personality disorders, bipolar disorder, anxiety disorders.Se valora la prevalencia y características de los pacientes de patología dual (diagnóstico actual de un trastorno mental y de un trastorno por uso de sustancias (TUS)): en las redes asistenciales de Salud Mental y Drogodependencias de la Comunidad de Madrid. Se consigue una muestra de 837 sujetos (208 de la red de Salud Mental y 629 de la red de Drogodependencias). Se usó la entrevista MINI (Mini International Neuropsychiatric Interview) y el cuestionario PDQ4+ (Personality Disorder Questionnaire) para la valoración de los trastornos del eje I y II. Se hallaron 517 (61,8%) pacientes con patología dual (un 36,1% en la red de salud mental y un 70,3% en la red de drogas). Al compararlos con el grupo de sujetos con TUS sin patología dual (n=194), había entre los duales menos varones y peor situación laboral, siendo las drogas más consumidas el alcohol y cannabis. Al compararlos con el grupo de trastornos mentales sin uso de sustancias (n=126), encontramos diferencias en todas las características sociodemográficas analizadas y los casos de patología dual son diagnosticados más frecuentemente como trastorno bipolar, agorafobia, trastorno por ansiedad generalizada, trastorno por estrés postraumático, mayor riesgo de suicidio y distintos trastornos de personalidad. Por lo tanto, la presencia de patología dual es elevada en sujetos en tratamiento y presentan unas características ...

No abstract