William V. Bobo

The management of post traumatic stress disorder (PTSD) in the primary care setting

Recent geopolitical events, including the terrorist attacks on the United States on September 11, 2001, and ongoing military operations in Iraq, have raised awareness of the often severe psychological after-effects of these and other types of traumatic events. Post traumatic stress disorder (PTSD) represents the most severe of these sequelae. PTSD is an under-recognized and under-treated chronic anxiety disorder associated with significant psychosocial morbidity, substance abuse, and a number of other negative health outcomes. Fortunately, the biologic underpinnings of this complex disorder and new advances in treatment are being realized. Early detection by primary care providers and rapid initiation of treatment are the keys to successful management of the disorder.

Ketamine as a preferred substance of abuse.

etamine is a cyclohexane anesthetic agent legally manufactured in the United States. It is pharmacologically similar to the illicit substance phencyclidine, though with a much lower potency. 1 As such, ketamine carries with it a significant abuse potential; however, it is rarely identified as a patient’s substance of choice. We present such a case below, with a discussion concerning potential contributory factors that may have led to his preference for ketamine. CC is a 20-year-old male who selfreferred to an intensive addiction rehabilitation facility after an accidental lorazepam and ketamine overdose. The patient had an extensive substance use history, including abuse of cannabis, LSD, PCP, barbiturates, cocaine, opioids, and MDMA, and dependence upon alcohol and benzodiazepines; however,CCdefinedhissubstanceofchoice as ketamine. Ketamine was mostly used alone in its injectable form in order to achieve the desired effect of rapid onset dissociation. Even though agents such as cocaine, other stimulants, and benzodiazepines were sometimes used in order to augment this dissociative effect, CC insisted that his preference for ketamine was based largely upon his belief that it ``was not a bad drug’’ because of its FDA approval as being ``safe to use on humans.’’ He rationalized thatbecause ketaminecould be obtained in a sterile and unadulterated form, it was both ``clean and safe.’’ He was also aware that ketamine carried a lower potential for cardio-respiratory sequelae than PCP, another dissociative agent. The frequency of ketamine injections increased as greater amounts of the substance became required in order to achieve the target dissociative effect. While heat first exercised at leastsomemeasureofcautionin monitoring hisuseof thesubstance,CCdescribeda progressively intense yearning for the dissociative effects of ketamine as a means to ``escape’’ from a myriad of interpersonal problems, giving way to the misuse of the substance in greater amounts than at first intended during individual injections and repetition of this increasingly compulsive pattern of use over a longer period of time

The Abuse Liability of Dextromethorphan Among Adolescents: A Review

ABSTRACT Dextromethorphan (DM) is a popular over-the-counter antitussive medication. Although adverse effects from appropriate use are rare, a specific toxidrome with significant psychomimetic effects occurs with ingestions in excess of those recommended. Both DM and its active metabolite, dextrorphan (DOR), share pharmacologic and neurobehavioral properties similar to opiates and phencyclidine (PCP). As such, cases of recreational DM abuse and, rarely, dependence, have been reported, and some data suggest that such abuse is on the rise. DM may be considered by substance abusers, especially adolescents, to be a dissociative agent devoid of financial concerns, legal limitations, negative stigma, problems with access or adverse health consequences. However, DMs popularity among adolescent substance abusers is generally not matched by adequate health care provider awareness, pharmacological understanding or epidemiological characterization. In this review, we summarize the current understanding of DMs addiction medicine-based neuropharmacology and epidemiology, describe social characteristics more unique to DM as an agent of abuse, review treatment and prevention issues, and identify areas in need of further research.

Not a usual suspect; rabeprazole therapy presenting as a severe neuropsychiatric illness: Case report

We report the case of a patient who, as a result of exposure to the proton pump inhibitor rabeprazole, developed a severe and disabling admixture of neuropsychiatric symptoms. Because of its widely appreciated placebo-like side effect profile, rabeprazole was never suspected as being the cause of his symptoms. Instead, a somatoform spectrum disorder was assigned based on the patients atypical symptom presentation, progressive course, subjective psychological distress, intemperate consumption of healthcare resources over a relatively brief period of time and lack of any medical explanation for his symptoms at that time, despite exhaustive laboratory and radiologic work-ups. This case report reinforces the notion that even a medication such as rabeprazole, with an established safety and tolerability profile, may be associated with side effects severe enough to mimic disabling neuropsychiatric illness.