TCA question

[nancysinatra]

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Does anyone know why it is that TCAs are included on some urine tox screens? Can they be abused? If not, why would they be on the screen? There are tons of drugs you can get a level for (from lithium to vancomycin), but not all are on the tox screen.

 

[splik]

well technically anything psychoactive can be a drug of abuse. my understanding however is that TCAs are still part of the drug screen because of their high toxicity in overdose, and a UDS is a quick screen for potential TCA OD in the overdose patient.

This is a good paper on urine drug screening in general.

 

[Scorcher31]

Although there are reports of them rarely being abused, there are many regularly prescribed pscyh meds that are easier to abuse that we don't check in a UDS. My understanding is similar to Spilks. TCAs used to be widely used, and were easy to detect in the urine and toxic in a OD. It's more an artificat of the times than anything else. Some meds don't have significant concentrations in urine so it makes since why they wouldn't be checked. Why TCAs instead of lithium? I have no clue.

 

[nancysinatra]

Although there are reports of them rarely being abused, there are many regularly prescribed pscyh meds that are easier to abuse that we don't check in a UDS. My understanding is similar to Spilks. TCAs used to be widely used, and were easy to detect in the urine and toxic in a OD. It's more an artificat of the times than anything else. Some meds don't have significant concentrations in urine so it makes since why they wouldn't be checked. Why TCAs instead of lithium? I have no clue.

That's a good point about some drugs not being detectable in the urine.

I guess I just wondered how useful a urine test would be to an ER or ICU doc in terms of deciding whether to treat for a TCA o/d or not. Isn't the treatment supportive and non-specific anyway? Maybe it helps psychiatrists who are consulted to r/o SA by OD.

How long have UDS existed? In the days of regular TCA use for depression, were they even available? They did not exist for cocaine in the 1980s. I would think the heyday for TCA OD's would have ended when SSRIs came on the market. Yeah they're still out there but not as much.

Thanks for the link, Splik!

 

[OldPsychDoc]

That's a good point about some drugs not being detectable in the urine.

I guess I just wondered how useful a urine test would be to an ER or ICU doc in terms of deciding whether to treat for a TCA o/d or not. Isn't the treatment supportive and non-specific anyway? Maybe it helps psychiatrists who are consulted to r/o SA by OD.

How long have UDS existed? In the days of regular TCA use for depression, were they even available? They did not exist for cocaine in the 1980s. I would think the heyday for TCA OD's would have ended when SSRIs came on the market. Yeah they're still out there but not as much.

Thanks for the link, Splik!

Oh they're still out there--and prescribed for pain, sleep, and migraines by PCPs who think they're doing pts a favor by not warning them that their meds can kill them. Most of the TCA ODs we see are "accidental". But it makes sense that getting a quick screen from urine might be helpful, especially since the TCA blood levels are sendouts most places, and we don't get results until after the patient's discharged.

 

[vistaril]

Oh they're still out there--and prescribed for pain, sleep, and migraines by PCPs who think they're doing pts a favor by not warning them that their meds can kill them.

A lot of tricyclics are prescribed by neurology, neurology subspecialists, and fellowship trained pain medicine physicians....it's certainly not my place to tell these people how to treat their patients for things that know much more about than us.

 

[OldPsychDoc]

A lot of tricyclics are prescribed by neurology, neurology subspecialists, and fellowship trained pain medicine physicians....it's certainly not my place to tell these people how to treat their patients for things that know much more about than us.

Not buying it, Vist. If we prescribed say, Depakote, for one of our conditions and didn't do a decent job of educating patients about risks and benefits, because maybe we think we know more about bipolar disorder than an epileptologist, and the patient has an adverse outcome--how does our "superior knowledge" excuse us? Yes, the neurologist may know more about chronic pain or migraine--but if the patient thinks these meds are safe because the "neurologist knows their stuff", and they start double, triple dosing themselves "because it's for pain and I still hurt", and get themselves delirious or toxic or dead...

I think it IS our place to remind other doctors that TCAs are an accidental overdose risk. When I was doing outpatient, I'd get about one patient a week that was referred from a primary care MD for "needs antidepressant"--and they'd already be on amitriptylline "for sleep" and duloxtine "for pain" and topiramate "for migraines"... Yeah it IS my place to educate these colleagues. 😡

 

[digitlnoize]

I think it's because the UDS screens are typically TOX screens and TCAs are pretty toxic in overdose.

 

[nancysinatra]

Not buying it, Vist. If we prescribed say, Depakote, for one of our conditions and didn't do a decent job of educating patients about risks and benefits, because maybe we think we know more about bipolar disorder than an epileptologist, and the patient has an adverse outcome--how does our "superior knowledge" excuse us? Yes, the neurologist may know more about chronic pain or migraine--but if the patient thinks these meds are safe because the "neurologist knows their stuff", and they start double, triple dosing themselves "because it's for pain and I still hurt", and get themselves delirious or toxic or dead...

I think it IS our place to remind other doctors that TCAs are an accidental overdose risk. When I was doing outpatient, I'd get about one patient a week that was referred from a primary care MD for "needs antidepressant"--and they'd already be on amitriptylline "for sleep" and duloxtine "for pain" and topiramate "for migraines"... Yeah it IS my place to educate these colleagues. 😡

I think you both have good points. I have seen some psych attendings who refuse, refuse, refuse to ever use TCAs. If the neurologist has the pt on a low dose of amitriptylene, this attending will d/c it because he is "not comfortable" with anyone anywhere being on any tricyclic for any reason. Without citing any evidence this attending will give anecdotal accounts of why TCAs are just so horrible and zoloft or cymbalta are so much better. This attending has a few preferred drugs, and to be honest, they're all newer, "safer," highly advertised ones.

To me that's not good medicine because you need to look at situations case by case and incorporate some science into the decision.

Now on the other hand we do see people whose PCPs have them on some meds that might be risky from a psych perspective, where the benefit or rationale is not entirely clear. But give the PCPs a break because they are doing a lot all at once.

Very often I think the problem is that in big health care systems with multiple hospitals and record systems, we do not know the other doctors and we never talk to them.

 

[vistaril]

Not buying it, Vist. If we prescribed say, Depakote, for one of our conditions and didn't do a decent job of educating patients about risks and benefits, because maybe we think we know more about bipolar disorder than an epileptologist, and the patient has an adverse outcome--how does our "superior knowledge" excuse us? Yes, the neurologist may know more about chronic pain or migraine--but if the patient thinks these meds are safe because the "neurologist knows their stuff", and they start double, triple dosing themselves "because it's for pain and I still hurt", and get themselves delirious or toxic or dead...

I think it IS our place to remind other doctors that TCAs are an accidental overdose risk. When I was doing outpatient, I'd get about one patient a week that was referred from a primary care MD for "needs antidepressant"--and they'd already be on amitriptylline "for sleep" and duloxtine "for pain" and topiramate "for migraines"... Yeah it IS my place to educate these colleagues. 😡

I think there are two different issues at work here. One is that I agree of course that any prescriber in any field(whether it's a physician, optometrist, NP, whatever) should always educate pts on the drugs they prescribe. That's just common sense standard of care. Psychiatrists certainly aren't immune to those criticisms, just as other physicians aren't. The pain medicine and neurology people out there I know are very familar with side effects of tricylclics, in many cases as much or more as psych.

The second issue is that it is very difficult to coordinate care in such situations where a pt has multiple comorbities(seizure d/os, chronic pain, and mood/anxiety d/os).....that's just the reality of the situation. It doesn't neccessarily mean that those people 'need educating'....it's likely that they know very well what they are doing. If it puts us in a bind to some degree with our pharm options, it is always possible to get in touch with them and try to coordinate care for the patient in an attempt to optimize both all problems(sleep, pain, mood).....

 

[vistaril]

I think you both have good points. I have seen some psych attendings who refuse, refuse, refuse to ever use TCAs. If the neurologist has the pt on a low dose of amitriptylene, this attending will d/c it because he is "not comfortable" with anyone anywhere being on any tricyclic for any reason. Without citing any evidence this attending will give anecdotal accounts of why TCAs are just so horrible and zoloft or cymbalta are so much better. This attending has a few preferred drugs, and to be honest, they're all newer, "safer," highly advertised ones.
QUOTE]

I love tricyclics, and use them frequently. Often in combination with other drugs. Honestly, I think a lot of psychiatrists just use the same combination of drugs for their patients again and again because they know that they aren't familar with the most common drug interactions when using drugs outside their comfort zone, so they figure if they just play it safe with the drugs that they are comfortable they can't get into trouble with things will be ok. I guess, in a way, that strategy is better than not knowing what you don't know.