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When Dual Diagnosis Patients Request Addictive Medications: What to Do?
Charles Atkins, MD
Chief medical officer, Community Mental Health Affiliates, CT
Dr. Atkins has disclosed that he has no relevant financial or other interests in any commercial companies pertaining to this educational activity.
CATR: A common dual diagnosis scenario is that we are treating a patient for depression or anxiety, the patient is on an SSRI and a benzodiazepine, and then suddenly we find out the patient is also on methadone maintenance or has been using medical marijuana regularly. Then we have to decide what to do. For example, should we continue to prescribe the benzo?
Dr. Atkins: The first thing is to make sure that you do have access to this information. It’s better to learn it ahead of time, rather than the patient springing it on you. The best way to do this is to follow your state’s prescription monitoring program (Editor’s note: See CATR, Nov/Dec 2016 on PDMPs). In most cases, the database will include stimulants, opiates, benzodiazepines, and in some cases medical marijuana. Prior to the intake, pull up the database. But regardless of how you find out—whether from the patient or the prescription monitoring program—the first thing to do is educate the patient about the risk. The fact is, the majority of lethal overdoses involve a combination of opioids with benzodiazepines, and patients are putting themselves at risk with the combination. Some will have an “aha” moment and say, “I didn’t realize that!” and will want to stop it, but others will be too attached to their Klonopin, Xanax, or Ativan.
CATR: The latter has been more my experience!
Dr. Atkins: Assuming that they are not moved by the overdose risks, there’s another piece of education that applies to a surprisingly large proportion of such patients. If they have sleep issues—and this may be why they want to take benzos—you can tell them that they may well have sleep apnea from the combination of opioids and benzos. I was a busy buprenorphine prescriber for many years, and I was surprised at how many of my young, non-obese, otherwise healthy patients had moderate sleep apnea—I would guess about a third of those I referred for sleep studies had it. This makes sense because both of these drugs are central respiratory depressants. So I recommend referring these patients for sleep studies; if they have apnea, we’ll know what they need to do to treat it, and if they don’t have apnea, we may feel more comfortable prescribing a sleep aid.
CATR: And if you are going to taper an opioid-using patient off benzos, how would you go about it?
Dr. Atkins: You’re going to go slowly, especially if you are treating an anxiety disorder. Decreasing by 10% per week works. Just be aware that we’re sometimes fooling ourselves if we think patients are taking meds as prescribed, so even if you write out a lovely tapering strategy, many of them will run out early. So tell them that if they are shaky or tremulous, they need to go to an ER.
CATR: Do you have a policy of never prescribing benzos to opioid users?
Dr. Atkins: No, I don’t advocate a flat no-benzo rule because some patients will not accept that and will drop out of treatment, which is not helpful. It’s important to adopt a harm-reduction approach and realize that people will engage in risky behavior. If someone refuses to stop benzos, you can try to diminish the risk, document your discussions, keep the dose as low as possible, limit the size of prescriptions, and require regular urine tox screens. I may refer patients to an intensive outpatient program, where staff might be able to convince them to do a medically supervised outpatient taper. And some patients will require inpatient treatment to safely taper off the benzodiazepine.
CATR: What about patients who inform you they have been using cannabis for some time? Is there a danger associated with combining cannabis with opioids?
Dr. Atkins: We don’t have a lot of information on marijuana and opioids. However, unlike benzos, cannabis is not a respiratory depressant, and there are some patients who will say, “If you stop my Klonopin, can you let me smoke marijuana?” And indeed, given the choice, I would rather they smoke pot than incur the risk of respiratory depression with benzos. It’s not something I would have said five years ago, but in the face of the current fatal overdose epidemic, it seems the lesser of two evils.
CATR: Putting aside the issue of combining marijuana with opioids, there are patients who are being treated with antidepressants and anti-anxiety drugs, and who are smoking marijuana every day. They may tell us using marijuana works for them, but we have no way of knowing if that’s true, or if they are just using it recreationally. This is especially problematic with patients on disability who are not working, for whom we feel we shouldn’t be condoning marijuana use.
Dr. Atkins: Right, so you have patients who are sitting at home smoking marijuana and watching junk TV, and you don’t feel that much is being accomplished. At this point, talk to the patients about what they are really working on in treatment—are they moving in the direction of a goal, are they stagnating, or are they moving away from the goal? For disabled patients smoking pot, ask them, “Is this the life that you want?” You might find that they do have goals, like wanting to reunify with their children, doing more fishing, or getting involved in their church or other volunteerism. (See the accompanying article by Dr. Minkoff, which advises using the stages of change model to help patients get on a clear path for reaching their goals.)
CATR: Shifting gears a bit, let’s talk about alcoholism. What are your thoughts about treating patients with alcohol use disorder and mood disorders?
Dr. Atkins: Bipolar disorder and alcohol abuse are so commonly paired, I think of them like peanut butter and jelly. My colleague Karen Kangas, EdD, a leader in the advocacy community, says that when you are talking to someone with bipolar disorder, it’s not a question of whether the patient does drugs; rather, it’s which drugs the patient does. The percentage of patients with bipolar and co-occurring substance use is 60%–90%, depending on the population studied (American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders, 5th ed. American Psychiatric Press: Washington, DC). Alcohol can put the brakes on when a patient feels manic and agitated, and it makes the patient feel better, at least temporarily, when depressed. I do believe that among substance users, there are more patients with bipolar than many of us realize. I’ve certainly had the experience of treating a patient for “depression” for years and then having the patient come into the office one day and talk about not sleeping for three days and being overly energetic—at which point I realize the patient is bipolar. I would steer your readers to the Mood Disorder Questionnaire, which is freely available and is a very good screen for bipolar disorder. Other symptom screens I use frequently are the PHQ-9 for depression and the PCL-5 (PTSD Checklist for DSM-5) available from the Veteran’s Administration’s National Center for PTSD (https://www.ptsd.va.gov).
CATR: One of the treatment issues we see with alcohol users is trying to come up with a non-addictive treatment for anxiety/insomnia.
Dr. Atkins: Yes, and there are some off-label medications that can be helpful, such as gabapentin, antihistamines, and others. I find the most value in non-medication strategies, such as mindfulness meditation and CBT for insomnia. I point out to patients that while medications are helpful, they are essentially rented solutions—in contrast, therapy is something you own forever and always. These therapeutic treatments may not be widely available or affordable for patients, but there are free apps that can be helpful. One is CBT-I Coach, which was developed by the federal government and Stanford. While its emphasis is on improving sleep, it also includes many tools that are great for anxiety, including audio for doing progressive relaxation, guided imagery, and meditative breathing. I also recommend the book The Miracle of Mindfulness to teach people about the basics of medication—it is available for free as a PDF (https://tinyurl.com/yd7hytn5).
CATR: How do patients respond to suggestions to try non-medication strategies?
Dr. Atkins: It runs the gamut, from enthusiastic to “I don’t have time for that.” You really want to match the person to something palatable. Keep in mind that while there is an incredible amount of marketing from drug companies to advocate pharmacologic solutions, no one’s putting the same effort into “selling” exercise and meditation. That sometimes leaves not just patients but also psychiatrists unfamiliar with non-medication strategies. Some doctors are getting on board these days, but it can be hard when you’re trying to manage patients every 15–20 minutes and feel you don’t have time to explore these options with them. What I would recommend, if you yourself are not going to become familiar, is to find some competent cognitive behavioral therapists, or dialectical behavior therapists, to whom you can refer patients for these kinds of help. It’s a way of increasing your armamentarium.
CATR: Is there any way to put a face on today’s patient with co-occurring disorders? Has it morphed from when the condition was first coined?
Dr. Atkins: Co-occurring disorders were first conceptualized when the big state hospitals were closing back in the 1980s. People with serious schizophrenia, mood disorders, and other severe types of mental health problems that caused psychosis were suddenly being released from 24/7 residential settings and almost immediately getting into trouble with alcohol and street drugs. That’s when we began to have these very high rates of homelessness and alcoholism in that population. Flash forward to the last decade and what has been happening with the opioid epidemic—a whole new population of people with co-occurring disorders has emerged.
CATR: Can you elaborate?
Dr. Atkins: Today, it’s not so much about people who are on society’s margins. People have their anxiety disorder, their depression, their PTSD, and they’re silently miserable—they take care of it at home as best they can. But then they get hurt during football practice or hurt their back and get put on Oxycontin, and they find that not only is the knee or back injury feeling better, but also suddenly the anxiety is gone. When they finally decide to come see you, it’s not for the mental health issue; it’s because they’ve gotten into trouble with opiates and need to do something about it. That’s what gets them into treatment—that they’re doing something illegal or morally reprehensible to support their addiction. These days, it’s more the mental health end that’s hidden rather than the substance abuse issue.
CATR: What can we do to determine whether there’s something going on beside the addiction problem?
Dr. Atkins: Anxiety disorders, PTSD, depression—these are high-volume mental health disorders. So when someone comes in with a drug problem, even someone who came out from behind the picket fence and otherwise seems to have an orderly life, use it as an opportunity to screen for these problems. Even if someone’s not talking about depression or anxiety, you want to look for it. Remember, people who don’t become addicted to opioids are the ones who tend not to have mental health disorders. The people who are much more likely to become dependent—the ones who end up in your office—do have mental health problems. If you screen for the high-ticket items like the anxiety disorders, the mood disorders, the PTSD—there’s a lot of that one—you’ll probably catch the majority of stuff.
CATR: That’s really useful. Anything else?
Dr. Atkins: Yes. Anyone interested in prescribing buprenorphine can get free, online 8-hour training from the Provider Clinical Support System. It’s available at https://pcss-o.org.
CATR: Thank you for your time, Dr. Atkins.
Addiction TreatmentDr. Atkins: The first thing is to make sure that you do have access to this information. It’s better to learn it ahead of time, rather than the patient springing it on you. The best way to do this is to follow your state’s prescription monitoring program (Editor’s note: See CATR, Nov/Dec 2016 on PDMPs). In most cases, the database will include stimulants, opiates, benzodiazepines, and in some cases medical marijuana. Prior to the intake, pull up the database. But regardless of how you find out—whether from the patient or the prescription monitoring program—the first thing to do is educate the patient about the risk. The fact is, the majority of lethal overdoses involve a combination of opioids with benzodiazepines, and patients are putting themselves at risk with the combination. Some will have an “aha” moment and say, “I didn’t realize that!” and will want to stop it, but others will be too attached to their Klonopin, Xanax, or Ativan.
CATR: The latter has been more my experience!
Dr. Atkins: Assuming that they are not moved by the overdose risks, there’s another piece of education that applies to a surprisingly large proportion of such patients. If they have sleep issues—and this may be why they want to take benzos—you can tell them that they may well have sleep apnea from the combination of opioids and benzos. I was a busy buprenorphine prescriber for many years, and I was surprised at how many of my young, non-obese, otherwise healthy patients had moderate sleep apnea—I would guess about a third of those I referred for sleep studies had it. This makes sense because both of these drugs are central respiratory depressants. So I recommend referring these patients for sleep studies; if they have apnea, we’ll know what they need to do to treat it, and if they don’t have apnea, we may feel more comfortable prescribing a sleep aid.
CATR: And if you are going to taper an opioid-using patient off benzos, how would you go about it?
Dr. Atkins: You’re going to go slowly, especially if you are treating an anxiety disorder. Decreasing by 10% per week works. Just be aware that we’re sometimes fooling ourselves if we think patients are taking meds as prescribed, so even if you write out a lovely tapering strategy, many of them will run out early. So tell them that if they are shaky or tremulous, they need to go to an ER.
CATR: Do you have a policy of never prescribing benzos to opioid users?
Dr. Atkins: No, I don’t advocate a flat no-benzo rule because some patients will not accept that and will drop out of treatment, which is not helpful. It’s important to adopt a harm-reduction approach and realize that people will engage in risky behavior. If someone refuses to stop benzos, you can try to diminish the risk, document your discussions, keep the dose as low as possible, limit the size of prescriptions, and require regular urine tox screens. I may refer patients to an intensive outpatient program, where staff might be able to convince them to do a medically supervised outpatient taper. And some patients will require inpatient treatment to safely taper off the benzodiazepine.
CATR: What about patients who inform you they have been using cannabis for some time? Is there a danger associated with combining cannabis with opioids?
Dr. Atkins: We don’t have a lot of information on marijuana and opioids. However, unlike benzos, cannabis is not a respiratory depressant, and there are some patients who will say, “If you stop my Klonopin, can you let me smoke marijuana?” And indeed, given the choice, I would rather they smoke pot than incur the risk of respiratory depression with benzos. It’s not something I would have said five years ago, but in the face of the current fatal overdose epidemic, it seems the lesser of two evils.
CATR: Putting aside the issue of combining marijuana with opioids, there are patients who are being treated with antidepressants and anti-anxiety drugs, and who are smoking marijuana every day. They may tell us using marijuana works for them, but we have no way of knowing if that’s true, or if they are just using it recreationally. This is especially problematic with patients on disability who are not working, for whom we feel we shouldn’t be condoning marijuana use.
Dr. Atkins: Right, so you have patients who are sitting at home smoking marijuana and watching junk TV, and you don’t feel that much is being accomplished. At this point, talk to the patients about what they are really working on in treatment—are they moving in the direction of a goal, are they stagnating, or are they moving away from the goal? For disabled patients smoking pot, ask them, “Is this the life that you want?” You might find that they do have goals, like wanting to reunify with their children, doing more fishing, or getting involved in their church or other volunteerism. (See the accompanying article by Dr. Minkoff, which advises using the stages of change model to help patients get on a clear path for reaching their goals.)
CATR: Shifting gears a bit, let’s talk about alcoholism. What are your thoughts about treating patients with alcohol use disorder and mood disorders?
Dr. Atkins: Bipolar disorder and alcohol abuse are so commonly paired, I think of them like peanut butter and jelly. My colleague Karen Kangas, EdD, a leader in the advocacy community, says that when you are talking to someone with bipolar disorder, it’s not a question of whether the patient does drugs; rather, it’s which drugs the patient does. The percentage of patients with bipolar and co-occurring substance use is 60%–90%, depending on the population studied (American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders, 5th ed. American Psychiatric Press: Washington, DC). Alcohol can put the brakes on when a patient feels manic and agitated, and it makes the patient feel better, at least temporarily, when depressed. I do believe that among substance users, there are more patients with bipolar than many of us realize. I’ve certainly had the experience of treating a patient for “depression” for years and then having the patient come into the office one day and talk about not sleeping for three days and being overly energetic—at which point I realize the patient is bipolar. I would steer your readers to the Mood Disorder Questionnaire, which is freely available and is a very good screen for bipolar disorder. Other symptom screens I use frequently are the PHQ-9 for depression and the PCL-5 (PTSD Checklist for DSM-5) available from the Veteran’s Administration’s National Center for PTSD (https://www.ptsd.va.gov).
CATR: One of the treatment issues we see with alcohol users is trying to come up with a non-addictive treatment for anxiety/insomnia.
Dr. Atkins: Yes, and there are some off-label medications that can be helpful, such as gabapentin, antihistamines, and others. I find the most value in non-medication strategies, such as mindfulness meditation and CBT for insomnia. I point out to patients that while medications are helpful, they are essentially rented solutions—in contrast, therapy is something you own forever and always. These therapeutic treatments may not be widely available or affordable for patients, but there are free apps that can be helpful. One is CBT-I Coach, which was developed by the federal government and Stanford. While its emphasis is on improving sleep, it also includes many tools that are great for anxiety, including audio for doing progressive relaxation, guided imagery, and meditative breathing. I also recommend the book The Miracle of Mindfulness to teach people about the basics of medication—it is available for free as a PDF (https://tinyurl.com/yd7hytn5).
CATR: How do patients respond to suggestions to try non-medication strategies?
Dr. Atkins: It runs the gamut, from enthusiastic to “I don’t have time for that.” You really want to match the person to something palatable. Keep in mind that while there is an incredible amount of marketing from drug companies to advocate pharmacologic solutions, no one’s putting the same effort into “selling” exercise and meditation. That sometimes leaves not just patients but also psychiatrists unfamiliar with non-medication strategies. Some doctors are getting on board these days, but it can be hard when you’re trying to manage patients every 15–20 minutes and feel you don’t have time to explore these options with them. What I would recommend, if you yourself are not going to become familiar, is to find some competent cognitive behavioral therapists, or dialectical behavior therapists, to whom you can refer patients for these kinds of help. It’s a way of increasing your armamentarium.
CATR: Is there any way to put a face on today’s patient with co-occurring disorders? Has it morphed from when the condition was first coined?
Dr. Atkins: Co-occurring disorders were first conceptualized when the big state hospitals were closing back in the 1980s. People with serious schizophrenia, mood disorders, and other severe types of mental health problems that caused psychosis were suddenly being released from 24/7 residential settings and almost immediately getting into trouble with alcohol and street drugs. That’s when we began to have these very high rates of homelessness and alcoholism in that population. Flash forward to the last decade and what has been happening with the opioid epidemic—a whole new population of people with co-occurring disorders has emerged.
CATR: Can you elaborate?
Dr. Atkins: Today, it’s not so much about people who are on society’s margins. People have their anxiety disorder, their depression, their PTSD, and they’re silently miserable—they take care of it at home as best they can. But then they get hurt during football practice or hurt their back and get put on Oxycontin, and they find that not only is the knee or back injury feeling better, but also suddenly the anxiety is gone. When they finally decide to come see you, it’s not for the mental health issue; it’s because they’ve gotten into trouble with opiates and need to do something about it. That’s what gets them into treatment—that they’re doing something illegal or morally reprehensible to support their addiction. These days, it’s more the mental health end that’s hidden rather than the substance abuse issue.
CATR: What can we do to determine whether there’s something going on beside the addiction problem?
Dr. Atkins: Anxiety disorders, PTSD, depression—these are high-volume mental health disorders. So when someone comes in with a drug problem, even someone who came out from behind the picket fence and otherwise seems to have an orderly life, use it as an opportunity to screen for these problems. Even if someone’s not talking about depression or anxiety, you want to look for it. Remember, people who don’t become addicted to opioids are the ones who tend not to have mental health disorders. The people who are much more likely to become dependent—the ones who end up in your office—do have mental health problems. If you screen for the high-ticket items like the anxiety disorders, the mood disorders, the PTSD—there’s a lot of that one—you’ll probably catch the majority of stuff.
CATR: That’s really useful. Anything else?
Dr. Atkins: Yes. Anyone interested in prescribing buprenorphine can get free, online 8-hour training from the Provider Clinical Support System. It’s available at https://pcss-o.org.
CATR: Thank you for your time, Dr. Atkins.
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