Thinking Holistically – attempting to change the Status Quo

In our experience, using anger or name-calling isn’t usually very effective when trying to fight the “establishment” or status quo. Something we teach all of our patients in our program is that you can’t change anyone else; the only person you can change is yourself. And once you change yourself, others tend to change as well. We have been slowly trying to change the established way of treating people with co-occurring disorders, at least in this state—by changing the way we treat them.

One example of this is our request that patients be off of all addictive medications for 30 days prior to admission. In fact, we won’t give someone a bed date until we have confirmation of this. This includes benzodiazepines for anxiety and sleep, stimulants for ADHD and narcotics for chronic pain. Since we are mandated to treat the people who have failed everything else, we see patients who have been in numerous previous treatment programs. When we get an application for someone with alcohol dependence who keeps drinking in spite of treatment and consequences and is on prescription benzodiazepines, our message to the referring agency/individual is perhaps this medication is one of the reasons this person has not been able to remain sober.

There is a great deal of literature that indicates that the use of addictive medications can trigger people to relapse to their substance of choice. Because of cross-tolerance and the fact that all the addicting drugs/medications basically work in the same area of the brain, these medications can potentially trigger a relapse. We have frequently seen people relapse to alcohol after receiving narcotics for pain. This usually isn’t when they receive appropriate doses in a controlled setting to manage acute pain but when they get a prescription for a large amount with numerous refills. Most people I know with addiction issues, when being honest and self-aware, can tell the minute their use of narcotic medications goes from “I need it” to “I want it”. We do a great deal of education with our patients about pain management so that they can educate their physicians. We tell them it is important to tell their physician about their addiction problems and have them write letters that they can give to all their physicians asking that they treat them appropriately and not set them up for relapse. We let them know that at some point in their lives they may need narcotics for acute pain management and that initially they may need more than the average, non-addicted person, primarily because they have increased their tolerance (activated their liver metabolism) by their drug/alcohol abuse. However, this does not mean they need it longer than anyone else and they have to be honest with themselves about when it is no longer about physical pain but more about emotional pain and stop taking it.

We educate patients that narcotics are not the treatment of choice for chronic pain. We want the patients off these medications for 30 days prior to admission so that we don’t have to deal with the problems with withdrawal that make it difficult for patients to be involved in treatment. The majority of these patients are amazed to find that their pain is actually less by the time they get to us and they are able to see they were in a vicious cycle of withdrawal causing pain and making their initial pain worse. They usually then come in on other non-addictive medications to help with pain such as anticonvulsants and/or SSRI medications that have been substituted for their narcotic medications. We initially allow them to stay on these medications but introduce them to a myriad of other ways to manage pain and at times, can get them off of their medications. We involve these patients in physical therapy, pool therapy, Tai Chi, yoga, 5-point NADA ear acudetox, thought field therapy, biofeedback based on heart rate variability and a form of EMDR therapy to help them resolve issues from the past, all of which can help with pain management. (I hope to talk about these individually in more depth in future blogs.) Most patients with chronic pain issues find that holding on to emotional pain from past trauma comes out in the form of physical pain. When they work through this and are able to let it go, the physical pain greatly diminishes.

While there may be a place for the short-term use of benzodiazepines such as when someone is in the hospital and can’t sleep because of fear of being in a new environment or what they are there for, I do not believe the long term use of benzodiazepines—greater than one month—is good for anyone. The only time when I think benzodiazepines should be considered as the first line medication is when treating alcohol withdrawal. However, they are prescribed extensively, especially by psychiatrists, mainly because they are effective immediately in relieving anxiety and initiating sleep.  The problem is however, when used for anxiety and sleep the pill becomes the coping mechanism and people don’t bother to learn any other coping mechanisms—“why go to the trouble when these work so well?” Then, after months and years of taking them the person cannot stop them abruptly for fear of having a seizure and possibly dying.  If the person misses a dose, withdrawal causes more anxiety and sleep architecture is disturbed with diminished restorative sleep. The latter is the most problematic for the people we see and withdrawal symptoms can last for months to years. With any patients who have been on benzodiazepines for extended periods of time we have to use other medications initially to help them sleep. But we have found that if patients use the 5-point NADA ear acudetox protocol on a regular basis they are much more likely to be able to sleep. Also if they are willing to learn and use the biofeedback technique we teach them, they can use this to relax enough to sleep. The patients who are willing to put the effort into learning this coping mechanism often don’t require medication to sleep and can get off these medications.

We have medical students, physician assistant students, nurse practitioner students and family medicine residents rotating through the program all the time as part of their training. If given the opportunity for only one lecture—I make sure it is about benzodiazepines and narcotics and how to use these appropriately and how to say no to patients who are seeking these. In December 2011 two other psychiatrists and I were able to present a workshop on the problems with benzodiazepines at the American Academy of Addiction Psychiatry annual meeting. I was gratified to see that there were many there who felt the same way about benzodiazepines as we do.

Finally, I realize that many psychiatrists are of the belief that prescribing stimulants to treat ADHD symptoms will prevent substance abuse problems. Interestingly enough, we have the exact opposite experience. We have had a significant number of patients who were prescribed stimulants as children for many years and now have significant addiction issues. This is most common in the patients we treat for methamphetamine dependence but this occurs with other substances as well. In fact, we have admitted patients who continued to get a prescription for stimulant medication from their treating physician even though this doctor knew they had a problem with chemical dependence, most likely contributing to them continuing to relapse and need this program. Most of these patients learn alternative coping mechanisms for their symptoms in our program and then decide they don’t really need medication for them. I have tried to reconcile our experience with that in the literature and I think one of the confounding variables is the fact that most of our patients have experienced a great deal of abuse and trauma growing up. I wonder if since stress has been shown to cause long term potentiation (LTP) in the learning and memory part of the brain – does the abuse/trauma  perhaps cause these individuals to be more sensitive to the dopamine activation of the stimulant and thus more likely to develop addiction?