Psych meds in early sobriety

[BobA]

The earlier thread about T-shirts got me thinking about my experience as a summer scholar at the Betty Ford Center. They were on the extreme end of not prescribing psych meds in early sobriety, and I was wondering what other people thought of this.

On the one hand, the DSM usually just says that a mood state can't be due to the influence of a substance in order to be diagnosable (and presumably treatable) with psych meds. On the other hand, in my limited experience from my prior career as a counselor, people in early sobriety seem to go through a type of adjustment reaction that lasts for several months even after the substance is gone.

These are just my own observations, based on a very limited sample size. But a adjustment reaction would make sense given the loss, and change the person is going through, let alone dealing with life without their substance of choice.

Is this "newly sober" adjustment reaction a known thing, or have I made something up from a limited sample size? Should psych meds be avoided in the newly sober?

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[whopper]

I was having similar thoughts myself on this matter.

E.g. there are guidelines saying to not treat someone with substance abuse for months to clearly delineate if the psychiatric symptoms were from substance abuse, or a pure mood or anxiety disorder.

However, if someone were having panic disorder for real, and became alcohol dependent as a result of self medication--wouldn't that be absolute hell to make someone go through that?

Wouldn't a more humane approach be to put them on an SSRI, especially ince the person would most definitely deal with acute stressors while making the adjustment to going sober?

And take into considering that pretty much all the substances of abuse if taken to the level of causing dependence can cause long term effects to the biochemstry of the CNS. E.g. opioid dependence causes desensitization of the pain receptors. Alcohol & benzo dependence is known to increase gluatamate & decrease GABA etc.

I've noticed several patients coming off of opioids go through bouts of anxiety, usually because they used the opioid as their coping mechanism, while also having to deal with higher sensitivity to pain. Several of them became dependent as a result of over prescription of opioids. If the person didn't have a true anxiety or pain disorder (in the DSM sense), would Duloxetine help? What do the studies say, and if there are none--why not? Maybe one of us should do one.

 

[OldPsychDoc]

The earlier thread about T-shirts got me thinking about my experience as a summer scholar at the Betty Ford Center. They were on the extreme end of not prescribing psych meds in early sobriety, and I was wondering what other people thought of this.

On the one hand, the DSM usually just says that a mood state can't be due to the influence of a substance in order to be diagnosable (and presumably treatable) with psych meds. On the other hand, in my limited experience from my prior career as a counselor, people in early sobriety seem to go through a type of adjustment reaction that lasts for several months even after the substance is gone.

These are just my own observations, based on a very limited sample size. But a adjustment reaction would make sense given the loss, and change the person is going through, let alone dealing with life without their substance of choice.

Is this "newly sober" adjustment reaction a known thing, or have I made something up from a limited sample size? Should psych meds be avoided in the newly sober?

I'm a strong proponent of APPROPRIATELY applying psychotropics in this period. There is good evidence (just presented at the ASAM meeting last month) that the HPA axis remains hyperactive for several months post-intoxication, so modulating this with an SSRI or anticonvulsant makes sense and is compassionate. In addition we know that plenty of the patients we treat for addiction have legitimate co-occuring Axis I comorbidity that needs to be treated if sobreity is to be established and maintained.

The "purists" at places like Betty Ford I think are reacting against the bad old days when valium was handed out as an "antidepressant"...

There is growing evidence for the utility of buproprion in stimulant dependence, topiramate for alcohol dependence, etc. To say nothing of the approved buprenorphine for opiates, and naltrexone and acamprosate for alcohol...

 

[MoodDoc]

I treat a lot of dual diagnosis patients and am currently doing a funded study looking at bipolar disorder co-morbid with substance abuse. There is a huge overlap between psychiatrically ill patients and substance abusers. Lifetime risk of substance abuse in bipolar patients is 61% and for major depression about 25%. Depending on what camp you approach the patient from--the substance abuse community or psychiatric, you will see very different styles.
It often helps to get a baseline to see if there was a mood disorder that preceeded substance abuse. Often mood disorders appear after substance abuse has started.
I do not feel the goal is to expose as few folks as possible to psychiatric drugs. The goal is to help folks as much as possible. If there is any evidence of depression, I have a low threshold to prescribe something and will re-evaluate after six months. Brains take a long time to dry out. You can still see EEG changes (particularly alpha-delta rhythms in sleep) up to six months into sobriety.

 

[Faebinder]

I'm a huge fan of SSRIs and Naltrexone for post alcohol period. Unfortunately, primary care doesn't follow with these recommendations (not to mention many psychiatrists).

I would love to see Topomax more in action as well... but you get the evil look from attendings occasionally.

 

[whopper]

The use of anticonvulsants has some data behind it. There was a good double blinded placebo study in the Green Journal using Gabapentin, patients on it if I remember correctly slept better, and were more likely to abstain for longer periods of time.

Topamax too has some promising data.

 

[kugel]

The goal is to help folks as much as possible.

If we all start there, we'll rarely go wrong.

I, too, have a pretty low threshold for antidepressants and mood stabilizers. However, out here there's now a large contingent abusing bupropion and quetiapine, so you have to be careful. Of course, I'm loathe to Rx or even refill BZD's (unless we're tapering) in this pop'n even when "it's the only thing that's ever helped me and it was prescribed by a doctor. If you won't prescribe my Xanax, you're forcing me to start using again."

In a few cases where I believe the patient is using the meds or the dx to excuse other behavior (incl drugs/alcohol), I'll tell the pt that I won't Rx until there's some sobriety, but that's pretty rare.

 

[BobA]

I'm a strong proponent of APPROPRIATELY applying psychotropics in this period. There is good evidence (just presented at the ASAM meeting last month) that the HPA axis remains hyperactive for several months post-intoxication, so modulating this with an SSRI or anticonvulsant makes sense and is compassionate. In addition we know that plenty of the patients we treat for addiction have legitimate co-occuring Axis I comorbidity that needs to be treated if sobreity is to be established and maintained.

The "purists" at places like Betty Ford I think are reacting against the bad old days when valium was handed out as an "antidepressant"...

There is growing evidence for the utility of buproprion in stimulant dependence, topiramate for alcohol dependence, etc. To say nothing of the approved buprenorphine for opiates, and naltrexone and acamprosate for alcohol...

Thanks for the really informative post!

Like all good answers, it raises more questions. When you prescribe an SSRI for the HPA hypersensitivity, do you tell the patient that you are treating "depression" or do you tell them that you're just trying to help them through a rough patch and will revisit the meds once they've got some sobriety?

 

[OldPsychDoc]

If we all start there, we'll rarely go wrong.

I, too, have a pretty low threshold for antidepressants and mood stabilizers. However, out here there's now a large contingent abusing bupropion and quetiapine, so you have to be careful. Of course, I'm loathe to Rx or even refill BZD's (unless we're tapering) in this pop'n even when "it's the only thing that's ever helped me and it was prescribed by a doctor. If you won't prescribe my Xanax, you're forcing me to start using again."

In a few cases where I believe the patient is using the meds or the dx to excuse other behavior (incl drugs/alcohol), I'll tell the pt that I won't Rx until there's some sobriety, but that's pretty rare.

Yep--Adderall and Xanax. The Only Meds That Ever Worked.

 

[OldPsychDoc]

Thanks for the really informative post!

Like all good answers, it raises more questions. When you prescribe an SSRI for the HPA hypersensitivity, do you tell the patient that you are treating "depression" or do you tell them that you're just trying to help them through a rough patch and will revisit the meds once they've got some sobriety?

Both--most of them are already telling me they're depressed, anxious, not sleeping, etc. I try to do good education about what the meds will/won't do. E.g.--it's not going to help them find a job in spite of their felony record, it's not going to get them housing, or bring their girlfriend back, or get their kids out of foster care...it will "turn down the volume" on some of the intensity of the emotion, help them deal with chronic stress better, etc...

 

[PsyDGrrrl]

Yep--Adderall and Xanax. The Only Meds That Ever Worked.

Valium and Norco too, according to one of my patients. The only thing that helped his "bipolar," "anxiety," "voices" or whatever symptom he was maligering that week.