Addiction Medicine Made Easy | Fighting back against addiction

Dual Diagnosis: Why Treating One Without the Other Never Works

• Casey Grover, MD, FACEP, FASAM

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Mental health conditions and addiction are deeply intertwined, creating complex treatment challenges that require addressing both simultaneously. Dr. Mark Hrymoc, an addiction psychiatrist, shares insights on effectively treating dual diagnosis patients through parallel treatment plans that address both substance use and underlying mental health conditions.

• Dual diagnosis (co-occurring disorders) describes patients with both mental health conditions and substance use disorders
• Many patients use substances to self-medicate underlying mental health conditions rather than for euphoria
• 50-80% of patients with addiction also have PTSD or significant trauma histories
• SSRIs like Zoloft and Lexapro are first-line treatments for anxiety disorders including PTSD
• Prazosin is effective for PTSD-related nightmares
• Propranolol, clonidine, and gabapentin offer non-addictive options for anxiety management
• ADHD is a major risk factor for developing substance use disorders
• Non-stimulant options like Strattera, Qelbree, and Wellbutrin should be tried first for ADHD with comorbid addiction
• Insomnia treatment options include trazodone, mirtazapine, quetiapine, and newer DORA medications
• Ketamine therapy shows promise for treatment-resistant depression and suicidality

Remember, treating addiction saves lives.

To contact Dr. Grover: ammadeeasy@fastmail.com

SPEAKER_01:

Welcome to the Addiction Medicine Made Easy Podcast. Hey there, I'm Dr. Casey Grover, an addiction medicine doctor based on California's Central Coast. For 14 years, I worked in the emergency department seeing countless patients struggling with addiction. Now I'm on the other side of the fight helping people rebuild their lives when drugs and alcohol take control. Thanks for tuning in. Let's get started. Today's episode is on the intersection between mental health and addiction. This is an interview with Dr. Mark Reimach, who is an addiction psychiatrist, and we discuss how mental health conditions affect patients with addiction and what medications can be used to treat those mental health conditions in patients with addiction. You might have heard the term dual diagnosis or co-occurring disorders. These are the terms used by medical providers when describing a patient who has both a mental health condition and a substance use disorder. When I first started as an addiction medicine doctor, I focused on using medications to reduce the desire for drugs and alcohol. For example, I prescribed a lot of naltterexone to patients with alcohol use disorder. And I would wonder why for some patients it didn't really work. And then I asked them why they drank, and they would tell me that they had horrible insomnia and anxiety. Oops. They weren't drinking for the euphoria. They were drinking because their brain wanted the downer effect from the alcohol to deal with anxiety and insomnia. So then I started to learn that I had to identify comorbid mental health conditions in my patients with addiction and treat those too. Dr. Reimach and I had a fantastic conversation, and I hope you find it helpful. One quick point before we start. I usually try to use the generic names of medications on my podcast, but often the brand names are easier to say and are more well known. We ended up using mostly brand names for medications during this discussion. Here we go. All right. Good morning. Happy Friday. Why don't we start by telling us who you are and what you do?

SPEAKER_00:

Sure. I'm Mark Reimach. I'm a psychiatrist. I specialize in addiction. I also started a group psychiatric practice, and we have a number of psychiatrists with various specialties that treat people with medications therapy. And we also have a ketamine therapy program within our office as well.

SPEAKER_01:

Very nice. So I'm board certified in addiction medicine, and you do addiction psychiatry. What's the difference?

SPEAKER_00:

The addiction psychiatry is considered a sub-specialty of psychiatry. So I did a four-year psychiatric residency and then a one-year addiction psychiatry fellowship after that. So that's a training program where basically we approach addiction treatment from a psychiatric angle, which includes a lot of common ground with the way addiction medicine approaches it. So we do detoxes, I do detox on an outpatient basis, commonly work with anti-craving medications, but we also do therapy or work with therapists who are doing therapy in parallel to medication management that we might be doing with a certain patient.

SPEAKER_01:

So I'm going to pick on mental health providers. Oftentimes I refer my patients for mental health services, whether it be a psychologist, an LMFT, or a psychiatrist, and they tell me I can't treat this person because they have active addiction. Right. And the way I look at it as an addiction doctor is I don't have that luxury. Their depression and their alcohol are so intertwined, it's hard to know which is which and which came first, but I need them to stop drinking. Can you talk to me about how you, as an addiction psychiatrist, approach things like substance-induced mood disorders, whereas your colleagues might say, get sober and then I'll see you?

SPEAKER_00:

Yeah, that's a pet peeve of mine, also. The concept being like cherry picking your patients. I actually don't think that's ethically correct. It is reflective of a more conservative attitude and probably a stigmatizing attitude about addiction as a disorder, also. You know, I think thankfully, with each decade, we're making more and more progress, even within the healthcare field, on how we regard addiction and how we treat patients with addiction issues. One of the premises of addiction psychiatry is we treat the person where they are. And so if they have addiction issues, we come up with a treatment plan for that. If they have comorbid mental health issues, which is actually much more the rule than the exception, then we also address those. Personally, I also believe that every person at least deserves an evaluation. I might not be able to continue treating you if your disorder, whether it's addiction or mental health, is so severe that it might require, let's say, residential treatment or even hospitalization for detox or some other psychiatric stabilization. But once you are stable and appropriate to participate in outpatient treatment, which is a setting that I work in, then you know I'm I'm happy to treat you. So I also have a belief that any everyone at least deserves an evaluation to know like where they are and what the next step should be, which might not be staying with me, at least not for the next few months anyway.

SPEAKER_01:

You and I think exactly the same way on that. I think my number one prescribed medications are probably clonidine, properanolol, and SSRIs or SNRIs. Again, those are selective serotonin reptake inhibitors and serotonin norepinephrine reptake inhibitors. I came into addiction medicine thinking that everybody needed naltrectone. And I clearly was missing the mental health component as I started. And from my personal lived experience, I got diagnosed with post-traumatic stress disorder last year as a part of my work in the emergency department. And living with a post-traumatic stress disorder has changed my perspective entirely on how I treat my patients with addiction. And PTSD and addiction seems to be one of my niches now, given my lived experience. The famous addiction doctor, Dr. Gabor Mate, says that all people with addiction have been traumatized. What percentage of your patients with addiction would you estimate have comorbid PTSD?

SPEAKER_00:

I mean, honestly, I'd say all people have been traumatized in some way. You know, there's a spectrum of trauma. We've all had tough experiences. Part of the human condition is negative experiences, things that teach us to avoid certain people, places, things, let's say. But some of us also have had experiences that lead to like even a formal diagnosis of post-traumatic stress. So as you're asking me that question, but yeah, I'd say 50 to 80% is definitely high. And then that's one diagnosis, but trauma can also lead to depression, it can lead to other anxiety disorders or insomnia. So all of these are possible and they all often present together.

SPEAKER_01:

Yeah. So we obviously do not live in an ideal world, given that health insurance dictates a lot of what we can do. But if you were practicing medicine in an ideal world, how would you approach the patient with comorbid PTSD and addiction? Let's say it's alcohol addiction.

SPEAKER_00:

Parallel treatment and parallel treatment plans for the substance issue, so alcohol and then the mental health issue. So from the alcohol perspective, we establish if someone has a physiologic dependence on alcohol, if you know we encourage them to stop drinking and they actually do cold turkey stop, does that cause any risk of seizure or any other problematic withdrawal symptoms? And then also other aspects of alcohol treatment can be some type of psychosocial treatment, so AA or therapy, individually, you know, what have you, but just so someone can work on things from a psychological perspective. And then, yeah, the PTSD part of things, very often an SSRI is helpful. PTSD ultimately is a type of anxiety disorder, and SSRIs are considered a first-line treatment for anxiety. And then therapy helps there too. So ideally, they have a therapist that can both treat trauma and the mental health part of things as well as the addiction part of things.

SPEAKER_01:

Do you use much of propranololol or clonidine for triggering in your PTSD patients?

SPEAKER_00:

I actually use a lot more prososin at bedtime for nightmares associated with PTSD. I might go to clonidine as a second choice if prosocin does not seem to be strong enough. Clonidine I use much more often as a treatment for opioid withdrawal because it is pretty potent. It can drop blood pressure and cause dizziness, lightheadedness at times. But yes, I also prescribe a good amount of propranolol, also gabapentin and hydroxazine. To me, those are the three main non-benzodiazepine, so non-habit forming, but still fast-acting medications for anxiety.

SPEAKER_01:

Do you have a particular preference among the SSRIs as which ones you use most often?

SPEAKER_00:

I tend to start with either Zoloft or Lexapro, primarily because those have been shown to have a lower side effect profile, but not by much. I mean, honestly, the SSRIs are much more similar to each other than different. And if someone has a strong belief that Prozac is going to help them because two of their siblings are on Prozac and they're doing great, you know, we actually do try to take advantage of the placebo effect in psychiatry. You know, a person's expectation about how well a medicine is going to work can actually be responsible for a third of people benefiting, is what the research shows. So I'll happily prescribe any SSRI that a person really believes in because they're all much more similar to each other than different. Usually after a person has failed two different SSRIs, or if they have a comorbid pain disorder, SNRIs are good for that. Or if they have a depression associated with fatigue, SNRIs can be more activating. So those might be reasons that an SNRI might be higher on my list. The only downside of SNRIs is that they are notoriously difficult to come off of. And not very difficult. I successfully take people off of SNRIs all the time, but you do need a specific plan. You can't just take a person off over the course of one week, especially if they've been on a high dose SNRI for years. It might need to be tapered over the course of a few months.

SPEAKER_01:

One thing you didn't mention on your list of meds around anxiety that are non-addictive is busporone. Any reason why that medication didn't come up on your list?

SPEAKER_00:

Well, the list I gave you was the fast-acting PRN meds, whereas Busperone is one that I use as the daily preventative type of treatment. So yeah, in treating anxiety with medications, there's two main arms of treatment. One is like the fast acting as needed approach, and the other is like the daily foundational. You know, it takes a while to build up, but then it actually helps prevent the formation of anxiety or just globally reduce anxiety in your emotional climate. So I actually do prescribe a good amount of Busperone. Uh it's got a bad reputation for not being effective, but I honestly find that people just don't dose it aggressively enough. 10 milligrams three times a day, like the standard starting dose, doesn't often help people. I always go up to 23 times a day, which is actually the FDA-approved max on Busparone, and we do get benefit there. And then if there is benefit with no side effects, which is often the case with that dose of buspar, then I'll even go up to 90 milligrams a day on that.

SPEAKER_01:

I did not know that.

SPEAKER_00:

Yeah.

SPEAKER_01:

Some of my colleagues in Australia have been in correspondence with me about the combination of naltrexone and baclefin for alcohol addiction, particularly when there's comorbid anxiety. Any experience with bacclefin when you have comorbid anxiety and let's say alcohol addiction, but really in general?

SPEAKER_00:

Baclefin in my mind belongs to a class of medications that have some anecdotal evidence, some case reports, but not a whole bunch of great research supporting its use. So, yeah, baclefin is there, topiramate is there, zofran, I think also has some evidence for alcoholism. I don't use a lot of baclefin. I've used it a handful of times. I've not seen it all that helpful. I interview patients all the time. I've never heard it as being pivotal in a person's recovery, not the way that naltrexone has or even an abuse has. So I tend not to prescribe a lot of baclefin. And recently I actually had a patient that seemed to have a baclefin abuse issue where she was already above the FDA approved max and then taking more and only escalating doses. So I have a recent, even stronger aversion to baclefin, personally. That's just my my experience.

SPEAKER_01:

Yeah, I did a podcast episode on it maybe 18 months ago, two years ago, and the data's really conflicting. There are some positive studies and then there are some neutral studies. Yeah. So we've been hinting a lot at anxiety. So we've covered PTSD with comorbid substance use disorder. Talk to me about how you approach the patient with comorbid anxiety and addiction.

SPEAKER_00:

Similar to what I was saying, yeah, with the two arms of treatment, the alcohol treatment plan and the anxiety one. Anxiety, especially like generalized anxiety, is much more of what I'll see comorbid with alcoholism than even PTSD. But the strategies are similar. PTSD is an anxiety disorder. So again, the daily preventative med, which could be an SSRI or BUSPAR or Remron mertazepine is nice if they aren't sleeping, aren't eating, and anxious because Remron can actually help all three. And then the fast acting as needed option of either Galbapatin, hydroxizine, papranolol tends to be what I do from the medication perspective.

SPEAKER_01:

Is there anything else unique to generalized anxiety disorder with comorbid substance use outside of PTSD? Anything different?

SPEAKER_00:

I mean, honestly, not really. Anxiety disorders in general, I think of as on a spectrum, going from generalized, which means low grade, or significant anxiety a lot of the day or most of the day. So just speaks to its presentation throughout the day, versus like acute and episodic, with panic attacks being the example of that end of the spectrum. So sometimes we just need to pay more attention to preventing that ongoing daily, day-long type of anxiety versus something that maybe putting more emphasis if someone has panic disorder on putting down anxiety, the panic when it starts, or even noting when it's building up to arrest that self-building cycle that panic often presents with. So that might be where the strategy differs. But yeah, I'd say that's still the general spectrum.

SPEAKER_01:

I'm going to ask this question fully knowing it's a loaded question, and I'm curious as to how you respond. What are your thoughts on benzodiazepines in patients with anxiety disorders with comorbid addiction?

SPEAKER_00:

It's a good question. And there are analogous questions with controlled substances being used to treat ADHD or insomnia.

SPEAKER_01:

We're going to get there.

SPEAKER_00:

Yeah, that's great. So yeah, look, the clean textbook answer is always avoid benzos. You know, there's no risk of any benzo problems if you don't prescribe a benzo, right? So the only way to really reduce risk to zero is to just avoid it completely. I am a psychiatrist, I treat addiction, I see a lot of tough cases. And I also see people that have tried the gabapatin visceral proprianol route, and it's helped maybe half of their anxiety, but there's still a good amount left. And maybe they've already had a history of being treated with a benzodiazepine and just never developed a problem with them in general, in looking at the risk potential of various benzodiazepines. The longer acting something is, the less addictive it is. So the longest acting benzos are clonopin, valium. So those are the ones I would lean towards with Xanax being notorious for having the highest abuse issues, and therefore I don't really prescribe Xanax in addiction patients. I do think that's basically like asking for trouble. Honestly, a lot of times if they haven't had alcohol as a problem, benzos are more likely even to be okay because benzos work on the GABA receptor, alcohol works on the GABA receptor. But I also have a good amount of patients who've had issues with alcohol, and and maybe even they've had issues with Xanax in the past, but yet they can handle like a prescription of clonopin 0.5 milligrams twice a week. The intermittent use is always favorable to the chronic daily use, too. So again, it's just layers of risk. And the goal in general in addiction treatment, in a lot of ways, is harm reduction. And so we do a risk assessment and the physician oath of do no harm. So we try to do no harm. We monitor for potential harm if we are considering a certain path. And we gauge the patient too. How much do they understand the harm? Do they have a healthy respect or a healthy fear of this medication? I mean, honestly, I see a lot of people in recovery, especially like solid multi-year recovery, that they themselves are anxious about taking a benzo. And they may not even like it when I bring it up for the first time. You know, and honestly, I love that dynamic, that presentation, because it means they already have this protective factor built within them where if they're anxious about getting hooked on a benzo. I can't remember the last time I saw a person actually develop an issue with the benzo if they come in to the treatment with that mindset about benzos.

SPEAKER_01:

So I didn't know about bind until maybe three or four months ago when one of my patients was looking on Reddit as to why he felt so weird after he was taking a friend's Xanax. And I actually don't know if he had BIND just because he'd only been on it for like a month or so. But BIND being benzodazipine-induced neurological dysfunction. What are you seeing in your practice around this?

SPEAKER_00:

Yeah, actually, I had not heard that acronym BIND, if it might refer to like people developing issues with being on it for years and then paresthesias and things like that.

SPEAKER_01:

I came to it on my own. You're obviously familiar with the term opiate-induced hyperalgesia. Yeah. Right. And the way I was seeing it is I was seeing all of these patients that had been on benzos some longer than I'd been alive. And they just had incredible anxiety, minimal emotional resilience, horrible insomnia. And I was going to coin the term benzodazipine-induced emotional fragility. I'll see these folks on four milligrams of clonazepam a day, and they're like, Doc, I'm so anxious. And I'm just thinking, what am I missing? And so there's been some recent naming of this phenomenon of some of the chronic changes around emotional resilience after being on benzodazines for many years, and this particular term has come up. I looked on open evidence. I don't know if you use open evidence, but I love it, right? The way I discovered to my patients is you combine the power of AI with the National Library of Medicine, and I can get an evidence-based answer in 30 seconds. So I searched on open evidence, and yes, there's some signal there around bind. I'm assuming you've seen this phenomenon, maybe just not heard that name.

SPEAKER_00:

Yeah. First of all, if a person is on a benzodiazepine for long-term use, it actually means that they have had a severe anxiety disorder such that physicians in the past have justified prescribing benzos in an ongoing way. So I do think they represent the most severe subset of anxiety patients. And so I definitely see people with bad anxiety disorders that then want to come off of benzos and then have difficulty doing that. Yeah, there could be a question as to how much is just their underlying anxiety coming back up as the benzos are reduced versus any actual worsening because of the long-term benzodiazepine prescription. And as I look at the symptoms of bind, I've not seen like the weakness in coordination, difficulty walking. So, like any of the motor symptoms for people being on benzos. Emotional sleep, I mean, to me, I just interpret those as anxiety, and I would treat them in the same way with non-benzodiazepine medications while implementing a slow taper. Psychiatrists very much are used to treating symptoms regardless of what the label we put on it is. So that would be my general approach in general in trying to taper a benzodiazepine off of someone that has been on it for years and years. It's just slow and steady and give supplemental medications to help treat any symptoms that might arise as we go down on the dose.

SPEAKER_01:

One of my patients described it to me this way He has a history of multiple addictions, cannabis, opioids, benzodiazepines, alcohol. He's been through a lot, has a lot of insight. He has bipolar disorder and has a pretty, pretty good insight into his diagnosis. And he came to me and he said, Alcohol's put me in the hospital four times in the last year with pancreatitis. I need to with alcohol, but my anxiety is debilitating. Could you please give me four doses of larze pam a week? Because I want to work on my anxiety. And if I have a little bit of anxiety, I'm gonna work on a therapist, I'm gonna develop some coping skills, and if my anxiety gets worse, I'm gonna try a non-addictive anxiety med. But when my anxiety is just nuclear and I'm gonna go buy a bottle of Jack Daniels, I need that Loraze Pam as just a, okay, I can take a breath. And and I thought there was some wisdom there that he's telling me by only having a few doses a week, he actually has to confront and work on his anxiety. And I like that idea because I think part of where this mind phenomenon comes from is benzos are very effective at treating anxiety, but the brain doesn't learn any other coping skills for anything besides benzodazipines. And that's kind of how I think about it. I'm curious how that resonates with you.

SPEAKER_00:

The general premise I'll use in describing the frequency of using a benzo for treating anxiety is if you use it less days of the week or more than half the days of the week, right? And so the more your body is used to the chronic presence of a benzodiazepine in the bloodstream, the more it actually then becomes physiologically dependent on it, and the more likely you are to run into issues with withdrawal. So physiologic dependence alone is noteworthy, but it's not the same as addiction. So physiologic dependence can occur as a side effect to many medications, including steroid medications, beta blockers, things, anything that causes rebound phenomena upon withdrawal of the medications. Whereas addiction is a behavioral disorder, people changing their behavior and people having problems functioning in their life as the result of a use of a substance, which may or may not include an element of physiologic dependence. The four doses premise there, it's right on the line of physiologic dependence. Lurazepam is a mid-duration benzo lasting four to six hours. So, you know, body does clear it pretty quickly. It's it's probably okay. And if the patient is reliable, trustworthy, that sounds like an okay treatment plan. In general, I'm also a person that I always have flags that go up whenever I hear any absolutes, you know, always-never sort of statements. And so, like if a benzo is in the system, then the person can't learn coping skills. To me, there is an absolute statement in there, which is probably not true. I mean, to me, the goal of a benzo or any fast-acting medicine for anxiety is to take the edge off the anxiety, to reduce it from being something that actually impairs your functioning, because that is the goal of any psychiatric treatment, is to improve functioning and to remove any barriers to good functioning day to day. And instead to have just enough to be able to function, but they'll still feel some anxiety, but instead of being the 10 out of 10, it's three out of 10. And they can at least work on that three out of 10. And then if they're good on working on the three out of 10 anxiety, then they may also find their in general, their worst anxiety is no longer 10 out of 10. Maybe that drops to be more like 7 out of 10, you know, and so the scale recalibrates, and maybe as their psychological skills improve and their ability to manage their anxiety using psychological skills and techniques gets better, they may find that they need the benzo less and less, and maybe then they can taper off the benzo, right? Yeah, there's this premise about there's psychiatric medicines in general, but benzos are probably one of the best examples of this of like being a crutch. But sometimes you need crutches, especially in that acute time that a person might be first presenting for treatment. They've reached some crisis point in their lives that's driving them to treatment. Maybe they've never had any kind of mental health treatment before. We do want to cover them with support, which can include a benzo, very much like a broken bone, we cover with a cast and it helps stabilize a person's bone while it does the healing and growth from within. So, likewise, psychologically, medications can be seen as like a stabilizing force that allows them to work on things from within, and then they may be able to remove them completely. Or if someone has a genetic predisposition, a long family history, I mean, they just have anxiety the way that some people have high blood pressure or asthma or any other medical condition, they may need, they may function best on medications, quote, indefinitely, and they might then be best off just taking it regularly and thinking of it as a vitamin that they take every day for optimal functioning. You know, with the goal being with this medicine, you don't have barriers to functioning optimally. There's nothing holding you back. You can be all that you can be occupationally, socially, and everything else, all the other realms of a person's life.

SPEAKER_01:

Makes good sense. So let's pivot a little bit and move on to ADHD. This is something that I probably had the least experience with from the emergency department. My first career was emergency medicine, and then I uh did addiction medicine because we really don't see a ton of ADHD presentations coming into the emergency department. It's usually just I'm out of Adderall, can I have a refill, which always feels great as an ER doc. So talk to me about the intersection between ADHD and addiction.

SPEAKER_00:

Uh ADHD is a huge risk factor for addiction issues. ADHD is a crippling disorder for people, especially who have severe manifestations. It is considered a childhood onset disorder that can derail a person's functioning and even development, if we're thinking of childhood onset, socially, academically, a lot of different important ways. And so it is important to identify and treat ADHD when you see it, and it often does present in childhood. If people have milder cases, it may not be really picked up until later in adulthood. Very often, once they get to college or graduate school or need to work in any setting that requires ongoing concentration and organization, or even just adulting nowadays, there's so much with forms and bills and all this other things that uh we all have to deal with in modern Western society. So ADHD is a huge risk factor for addiction, should be treated. If someone develops an addiction issue before we identify an ADHD issue, then once we do start treating the ADHD, we'll always go with non-stimulant medications. So Stratera, also known as adamoxetine, Kelbury is a newer sort of cousin of Stratera, and occasionally well-butrined buproprion can also be used to treat ADHD. So if a person has a history of addiction, then we always go with the non stimulants first. If a person does not have a history of addiction, stimulants are considered the first line treatment. They do have one of the highest effect sizes of any medication in psychiatry. They are highly successful and well tolerated for people that don't have histories of addiction.

SPEAKER_01:

So we got lots to unpack here because I have a number of patients that tell me I use methamphetamine because it calms me down. And if they had told me that five years ago, I would have told them they were liars because I didn't realize that when we give hyperactive people amphetamines, it helps them focus. I have one patient, I just saw her this week, and she had significant educational issues and she had to have an individualized learning plan going back to middle school, wasn't able to finish high school because of severe learning issues. And I asked her what methamphetamine did for her, and she goes, Oh, it was my thinking cap. I could get more done, I could pair my kids. And I was like, Oh, how's your ADHD? And she had never been diagnosed with it, unfortunately. So I use five non-addictive ADHD meds in my practice, and I think it's probably the same for everybody, right? So it'd be proprienor well-butrined, adamoxetine or Stratera, Viloxazine or Calbury, Guanthazine, I think the brand name is Intunive, and then Clonidine or CAVE. I know how I've used them, but I've worked a lot of this out on my own. Can you give me a sense of what's the right patient to choose for each one of those five?

SPEAKER_00:

The last two, Intunive and CapVey, actually have the best data supporting their use in kids and adolescents. So not quite as much adults. It doesn't mean it can't help adults, but it just hasn't really been shown to be as effective in adult patients. They are better at treating hyperactivity, which is more a hallmark of ADHD in kids and adolescents as opposed to adults. Adults tend to have more of the inattention symptoms. But to treat ADHD, if they have comorbid depression or cigarette smoking or nicotine use that they want to address, then yeah, well butrin is a great choice. I mean, in general, well butrin is one of my favorite antidepressants to prescribe because it helps with energy and motivation and doesn't have a lot of the side effects that SSRIs can have. If a person has just pure ADHD, I'll go to Stratera first. That one is generic, so insurance always approves it. Calbury, I would go to as a second choice just because most insurance companies would require evidence of the failure on Stratera to justify paying for it.

SPEAKER_01:

In our practice, we have five addiction docs. We're very proud of our little community-based clinic with five addiction medicine docs. We just put together a protocol for the management of ADHD with comorbid stimulant addiction. We do have an approach that we're taking around starting stimulants for people who have ADHD and are in recovery from stimulant addiction. And our go-to is usually Vivans, just because it is a pro-drug and therefore has a lower risk of misuse. But talk to me about how you, as an addiction psychiatrist, approach using stimulants for people with ADHD and stimulant addiction who have failed the non-stimulant meds.

SPEAKER_00:

Sure. So yeah, and also as you were telling the story about your patient with uh methamphetamine being a thinking cap. Fun fact, many people don't know, including physicians, that methamphetamine actually is an FDA-approved medication. It's given orally as a pill, so it does behave much differently using that route than the way that people might abuse methamphetamine.

SPEAKER_01:

One funny point on that. On a night shift once, when I was a little baby new attending, someone came in and they said, I need to refill in my psych meds. I need desoxin. Right. And I got desoxin and dissiparamine mixed up. And so I wrote a refill and the pharmacy called, Why are you writing for methamphetamine? And I looked it up and I was just so yes, I'm aware that we can prescribe methamphetamine. Please go ahead.

SPEAKER_00:

So I don't prescribe that ever, by the way. That makes two of us. And I think pharmacies don't like stalking it either. So but people with stimulant addiction, again, Stratera Calbury first. And then I'll often go to provigil, modafinel, or new vigil, which you know it's a histamine agonist, right? So if you think of antihistamines like Benadryl being sedating, this is a histamine stimulating medication, which is activating. So it is considered wakefulness promoting agent. The official FDA indications are narcolepsy, shift work sleep disorder, and fatigue associated with sleep apnea. It's sometimes covered as an antidepressant augmentation as well, even though that's not an official FDA-approved indication. Insurance doesn't love paying for it, so that's just the one drawback. But honestly, I have never seen a pro-vigilal, new vigil, modafinyl, or armodapinyl abuse issue. And there are actually some studies showing that it can actually help with stimulant dependence as well, in being a lower potency stimulating medication that can maybe take away craving for stimulants too. So that is one type of medication that I'll often go to before getting into the quote real stimulants. Vivance is a good one. It's long-acting. It is an amphetamine, though. So I tend to prescribe methylphenidate products first. And the standard algorithms for treating ADHD actually encourage the use of methylphenidate first because it is better tolerated, it's gentler, it's less likely to trigger anxiety, especially if people have had issues with anxiety first. So I tend to go with the methylphenidate. To me, the analogously safe version of methylphenidate is concerta, which is an extended release coated pill that actually needs to be swallowed for the medication to come out. It can't really be crushed and snorted in the way that immediate release methylfenidate or Ritalin can be. If not, though concerta that doesn't work, let's say not strong enough, then yeah, I'll definitely go to Vivance, which is a great medication. Not without risk. I have seen people with Vivance issues where the problem tends to be they take more than prescribed. And I've even seen people that take two or three hundred milligrams of Vivance daily. So it's not common, but it's also not risk-free.

SPEAKER_01:

Yeah, my friends at the Addiction Medicine Journal Club podcast just covered a study on that. I don't know if you found their podcast. Two addiction docs in Pennsylvania have a great evidence-based podcast. Where was it? Here we go. May 26th, episode 60 of the Addiction Medicine Journal Club LizDexamphetamine. That's the generic name of Vivands for methamphetamine use disorder. And there was a study looking at fairly high doses of Liz dexamphetamine to try to reduce the use of stimulants. And it was interesting. It really wasn't that effective, but people really liked being on the high dose of vivans. In other words, it was a patient pleaser. There was high satisfaction with the treatment protocol, but it didn't actually treat methamphetamine use disorder that well.

SPEAKER_00:

Right, right.

SPEAKER_01:

I found that study very interesting.

SPEAKER_00:

Yeah. Yeah. There's not great evidence. There's equivocal evidence on the role of stimulants to actually treat stimulant dependence.

SPEAKER_01:

My understanding is it's because the amount of stimulant people can get buying methamphetamine from the illicit market is just so much higher than we can prescribe. And my understanding is if somebody uses methamphetamine and then we try to put them on, say Adderall, it's like less than a tenth of the dose they're getting from the illicit market.

SPEAKER_00:

Yeah, I could well be, sure.

SPEAKER_01:

Yeah. Okay. Is there any other condition that you think would be useful to call out in terms of a comorbid mental health condition along with addiction?

SPEAKER_00:

Insomnia is a big one. So yeah, similar strategies I'll employ, trazidone being the first choice of a medication that has no habit forming potential, very safe, well tolerated, often effective for treating insomnia. If we even think about reasons people might use certain substances, especially alcohol, like a lot of it is to treat their own insomnia. So yeah, whenever I see like a self-medication tendency in a person, then I'll try to talk to them about how their attempt, while well-intentioned, is actually not the best choice. And maybe now they've developed an alcohol problem and instead try this medication that's not habit-forming and can help with insomnia. Yeah, Remron is another one that has more antidepressant activity. It does stimulate appetite, so they either have to want some weight gain or have it not bother them if they do gain some weight. And Cerequel often is the third one. If those two don't work, then Cerequel usually does, but it can be very weight-gaining for folks too. There is a new class of medicines for insomnia, the DORAS, the dual orexin receptor antagonists, which include Belsamra, Day Vigo, QV, and those while technically a schedule five substance, so the DEA does regard it as having abuse potential. The reason that it's Schedule 5 is more so like drug likability, like that's one of the aspects that they'll use to consider if a medicine should be scheduled. So people like taking it. I can also tell you, I've never seen a person develop an addiction issue to any of the Dora medications. So I'll go to that class if the standard sort of trazenone seroquil don't work for a person. And they very often do work. You they usually have to be dosed at the max doses. So like balsamara is 20 milligrams. That's often what I'll prescribe. That actually does help in a way, and it's well tolerated. And it often doesn't lead to sedation the next day. People often ask, is this gonna make me groggy the next day? I always tell them that's a dose-related response with the right choice of medicine. It'll work to help you fall asleep, stay asleep. But ideally, your body is broken most of it down in the morning so you could wake up feeling refreshed and start your day. So yeah, that tends to be the type of medicine that I'll prescribe, sort of a second choice. You use much Remelteon? I do. It's not quite sedating. It's I I think it is analogous to melatonin. It is a melatonin stimulating medication. So it is milder. It does help some people. It's just it's not gonna put them down in a way that like trazodon seroquel or even any of the DORAs will, and that's often what people are seeking and and also the need for treatment of insomnia.

SPEAKER_01:

With somebody who has bipolar disorder, do you worry about trazodone or remron causing mania? They are technically antidepressants.

SPEAKER_00:

Yeah, technically they are. I've never actually seen a case of either one causing mania. If someone has a history of bipolar disorder, I'll often then just go to CerroQL first or a senopene sapphorous is actually another sedating second generation atypical medication like Cerquel that does not have weight gain associated with it. So that is actually a really good choice for people with bipolar two and bipolar also, whether it's type one or type two. And it really does help a lot of people with mood stability too, in a way that CeroQL doesn't, because Ceracol actually needs to be dosed at 400 milligrams or more to have anti-manning properties.

SPEAKER_01:

That was a good catch. It's bipolar, also, not bipolar too. Well played. Well, I was gonna say this has been a fascinating conversation. Anything we missed?

SPEAKER_00:

In general, I certainly encourage people to get assessed for anything that resembles a mental health issue. There is a lot of stigma, as we discussed, with mental health treatment. And it does not need to be mental health issues or as much medical issues as physical issues like high blood pressure or asthma. And if the concept of taking medicines is averse to you, then you don't even have to commit to that too. It all starts with one visit and assessment where you speak with a psychiatrist that actually treats issues that you might have, and you can at least know what your options are. In psychiatry, most of the issues can also be treated with therapy, too. So even just getting an assessment with a referral to therapy is often the best place to start, and then medications can always be reassessed later on.

SPEAKER_01:

Well said. Anything you've got in the near future that you're working on? Projects, new protocols, new treatment pathways?

SPEAKER_00:

A lot of my project in our office is working on the ketamine therapy work. Even though we started that program six years ago, there's just uh constant protocols that still need to be created. We are creating a lot of good things. In our office, we do incorporate psychotherapy with ketamine treatment, but also offer just the standard evidence-based IV, no therapy type of treatment, too. So I definitely see a new chapter in psychiatry opening up where a number of psychedelics are actually being studied and will be coming soon to psychiatry in the next few years. And our work with ketamine, in my mind, is representative of the type of work that we'll be doing with other analogous medications in the future.

SPEAKER_01:

Just one point on that, and please correct me if I misunderstand this. My understanding of the use of ketamine to treat a mental health condition is it rapidly improves things like mood and suicidality to allow other things like antidepressants and therapy to work. Because my patients come in, particularly the ones that use multiple substances, and I get something to the effect of, hey, doc, I want to do a bunch of K and I'll get sober. And that just seems to not quite be how it's meant to be done. I'm just curious as to your thoughts.

SPEAKER_00:

Yeah. So doing K is in the column of drug use. Right. And there is the big difference between drug use and medication treatment. The contexts are different. And an exactly analogous conversation could be had with the use of ketamine and people who may have had issues with addiction too. Ketamine can be used to get people out of the most severe holes in depression. It does work for suicidal thinking and behaviors. Sprovato, which is the only actually FDA-approved form of ketamine, does have an official FDA indication for treating suicidality even outside of depression. But sprovato actually also recently picked up an FDA indication as a maintenance treatment for depression, too. So ketamine is an antidepressant, happens to be one that also works quickly and has a strong anti-suicide benefit, which is something that many of the traditional oral antidepressants don't have. And so I see roles for ketamine in all of the above, and also augmenting psychotherapy. People, when they receive ketamine, do go to a different place. They have a different perspective on things, their lives, and even traumas. And so there's a potential role and a lot of research interest in psychedelic assisted psychotherapy as well. And ketamine is definitely a part of that.

SPEAKER_01:

Well said. Well, I have to say, Mark, I feel a lot better. A lot of the things that I thought I was doing on my own, you've reaffirmed that a lot of the stuff I've been doing is is actually okay. And I appreciate your expertise and wisdom on going through the therapeutic medications we have for mental health as it relates to treating addiction.

SPEAKER_00:

Yeah, thank you very much. It's been great talking to you, and thanks for having me on your show.

SPEAKER_01:

Before we wrap up, a huge thank you to the Montage Health Foundation for backing my mission to create fun, engaging education on addiction. And a shout out to the nonprofit Central Coast Overdose Prevention for teaming up with me on this podcast. Our partnership helps me get the word out about how to treat addiction and prevent overdoses. To those healthcare providers out there treating patients with addiction, you're doing life-saving work, and thank you for what you do. For everyone else tuning in, thank you for taking the time to learn about addiction. It's a fight we cannot win without awareness and action. There's still so much we can do to improve how addiction is treated. Together, we can make it happen. Thanks for listening. And remember, treating addiction saves lives.