Thinking Holistically – attempting to change the Status Quo

Elizabeth Stuyt, M.D.

March 3, 2012

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?

Elizabeth Stuyt, M.D.

Thinking Holistically: A psychiatrist and medical director of an innovative, 90-day inpatient treatment program in Colorado for people with chemical dependence and mental illness writes on the components that empower people to recover in mind, body and spirit.

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7 thoughts on “Thinking Holistically – attempting to change the Status Quo

  1. Thank you for recognizing the problems with benzo withdrawal. Yes, benzo and antidepressant withdrawal syndrome can last months or years.

    Speaking of which, I find it interesting that antidepressants are not included on your list of “addictive medications” to be discontinued before treatment begins.

    While antidepressants are not technically addictive, they certainly can cause a whopping physical dependency. They also generate side effects, such as emotional anesthesia, and drug-drug interactions that may interfere with treatment for addiction.

    They, and the psychiatric labels they bring with them, also foster a sense of dependency on the all-knowing doctor and perpetual patienthood that may work against achieving real emotional resilience.

    It’s merely medical politics that has antidepressants on the “good drugs” side vs those “bad drugs” that fit the definition of addictive.

    Of course, discontinuing antidepressants may be easier said than done. For some people, it can take years to get off them with tolerable withdrawal symptoms.

    I’ve always found it curious that addiction medicine addresses sinful drugs and pays no attention whatsoever to — even endorses — psychiatric drugs of dubious virtue that promote physical dependency, emotional dependency on a medical authority figure, and a belief that oneself is crippled by psychiatric disorder.

  2. Will you be writing about medication assisted therapy? Suboxone was widely promoted here in Vermont (and still is). At the same time, we seem to be having a big problem with diversion and abuse of this drug.

    Also, some of my colleagues are diagnosing ADHD for the first time in adults. This often happens in the context of someone who is in treatment for substance abuse. I worry about introducing yet another addictive substance and it seems to me that it is impossible to make some clear distinction between this entity labeled as ADHD vs. the effects of long term exposure to drugs vs. the impact of other life trauma. They tell me that stimulants are only effective in the first group and I find it hard to believe that their effects are that specific.

    Thank you for your highly informative posts.

    Sandy Steingard

    • Hi Sandy,
      Thanks for your comments. I do plan to address these types of things more but briefly, I do like Suboxone to help people detox from opiates (heroin, prescription opiates and methadone). It makes the very painful and anxiety ridden process of opiate withdrawal much more tolerable and it is much easier to get someone off of this than methadone in my experience. I do have a problem with agonist therapy as maintenance, at least in the population I work with. I have heard from others that there are people who function quite well on stable doses of Suboxone for long periods of time but this isn’t true for the people I work with – they are referred to us because this hasn’t worked. We usually taper them off of this.

      As to the use of stimulants in people for ADHD – I strongly recommend against it and don’t prescribe stimulants at all. The reality is they help everyone focus better or concentrate better – this is why many college kids “borrow” their friend’s medications for studying or taking tests. And you can’t use the effect of the drug to diagnosis “ADHD/ADD”. However, the drug doesn’t help in the long run. I used to be in a position where I was sent medical students who were failing, to evaluated why and what could be done to help them. I saw a common theme. The student would tell me that they had no idea why they were not doing well – they stayed up all night studying for the test but then couldn’t remember the material. I asked how they were staying up all night and they were invariably smoking cigarettes, drinking coffee, taking NoDose and Ritalin or Adderall. I asked if they were taking all these things into the test with them and they thought I was absurd but I explain the concept of “state induced learning” and how if you learn under the influence of something you may have to be under the influence of it to retain it. Then I explained that no one would want a doctor who could only remember what they learned if they were under the influence of a drug.
      I especially have real concerns about giving some one with drug or alcohol problems a stimulant. I have seen this become a relapse factor on numerous occasions. A common theme I have seen is someone with methamphetamine or cocaine problems stating that they use those because they help them calm down and focus and this invariably gets them a diagnosis of ADHD and a prescription for a stimulant. I have yet to see anyone I work with stay sober because they were given the drug. They end up with us. We teach them ways to manage their problems with focus and concentration. If they insist that they have to have a medication I have used buproprion or amoxetine but really try to get them to practice what we teach so they don’t have to use medications. I recall one person, a methamphetamine addict prescribed Ritalin who did really well in our program on buproprion and then stayed sober for an entire year. The person began to have problems with anxiety (common side effect of buproprion). The treating psychiatrist asked what the buproprion was for and then prescribed Adderall. Within 2 weeks the person relapsed – first to marijuana and alcohol and then to methamphetamine. The person got new legal charges and was referred back to the program. The second time the person was willing to forgo medications and did very well.

    • Scott,
      SSRI medications are not truly “addictive”. They do not result in an increase in dopamine in the reward pathway and they do not result in long term potentiation or an increase in glutamate receptor ratios which happens with drugs that are considered addictive. So people generally do not continue to take higher and higher doses to get the same effect.
      That being said, I agree with you that, especially some of the SSRIs have a very miserable discontinuation or withdrawal syndrome. I have lots of experience with that in the attempts to get people off of these. I have found that switching patients to fluoxetine for a period of time is helpful due to its much longer half-life which is essentially three days. Most people in my experience can then stop the fluoxetine without significant problems.

  3. Perhaps I’m missing your treatment goal or outcome measures. You are targeting a treatment-resistant patient population but require that they have been off of ‘addictive’ substances for 30 days prior to entry into your program. Your use of the term ‘addictive’ is misleading, at best. Benzodiazepines, while producing DEPENDENCE are not ‘addictive’ as tolerance is not developed necessitating higher dosage for the same therapeutic effect. The same can be said for ADHD medications which do not produce tolerance.
    ‘Narcotic’ not a medically useful term, is quite confusing is this context.
    Most notably, as others have stated, your perception of SS/NRIs as safe alternatives in treating pain is ludicrous. As is well pub-
    icized, the trials for these drugs for depression are fraudulent. There is little to no benefit in mild to moderate depression and only a slight benefit in severe depression. Perhaps you can enlighten this audience as to the validity of trials in chronic pain. How are functional outcomes measured and, most importantly, what is your protocol for tapering and discontinuing? The withdrawal of SS/NRIs is very similar to that of benzodiazepines and takes several months to years in many cases. There have been no studies done to establish guidelines for the safe discontinuation. SS/NRIs produce rapid changes to the neuroendocrine system, effecting virtually every system in the body. I know people who have had significant distress after a few months and, in a few isolated cases, after a few doses. There are many reports of Cymbalta, in particular, causing neuropathic-type pain in people. A condition that it supposedly treats.
    I agree that SS/NRIs are not technically ‘addictive’ although the withdrawal symptoms can be so severe in some people that they are desperate for a missed dose.
    I was on opiates for chronic pain for 8 years under the supervision of an interventional pain specialist. I discontinued in less than a month with little distress. I tapered off of an SNRI over 10 months and am experiencing protracted withdrawal syndrome at 10 months after my last dose. Addiction medicine will catagorize that in whatever way is politically correct. I call it hell. Getting off of opiates was a nonevent in contrast to the SNRI. My experience is not unusual.
    SS/NRIs do not effect the reward circuitry causing cravings and addiction. However, there is a substantial body of evidence that serotonergics cause an apathy or amotivational syndrome possibly through disruption of dopamine-mediated reward system. Lastly, benzos are commonly used to treat the side effects of SS/NRIs of akathisia, movement disorders, anxiety.

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