May 26, 2025 • 33 mins
Dr. Casey Grover breaks down psychiatric medications and their role in addiction treatment, explaining how different medications work, when they're most appropriate, and which ones to avoid. He provides a practical overview based on his extensive experience treating patients with substance use disorders.
• Psychiatric medications get developed through research on brain receptors and undergo rigorous testing before FDA approval
• Medications often have "off-label" uses that weren't originally intended but provide benefits in certain situations
• Antidepressants like SSRIs and SNRIs serve as the foundation for treating depression in people with addiction
• Using non-addictive options like hydroxyzine, clonidine, and buspirone is crucial when treating anxiety in recovery
• Trazodone and mirtazapine are preferred for sleep issues over benzodiazepines and "Z-drugs" that can create dependence
• ADHD treatment requires careful consideration when patients have stimulant use disorder histories
• Benzodiazepines should be avoided when possible as they paradoxically worsen anxiety over time
• Medication selection should consider urgency of conditions, past medication responses, and potential side effects
• Some psychiatric conditions may improve with therapy allowing medication reduction, while others require long-term treatment
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. Remember, treating addiction saves lives.
To contact Dr. Grover: ammadeeasy@fastmail.com
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:00):
Welcome to the Addiction Medicine Made Easy
Podcast.
Hey there, I'm Dr Casey Grover,an addiction medicine doctor
based on California's CentralCoast.
(00:22):
For 14 years I worked in theemergency department seeing
countless patients strugglingwith addiction.
Now I'm on the other side ofthe fight, helping people
rebuild their lives when drugsand alcohol take control.
Thanks for tuning in.
Let's get started.
This episode is on psychiatricmedication.
(00:43):
As you've heard me say, I am amedical director for one of the
drug and alcohol treatmentprograms near me and I give
educational lectures oncemonthly to the staff on various
topics in addiction medicine,and last month they asked me to
give an overview of psychiatricmedications.
It was a really big topic, butI did my best to give a
high-level overview of thedifferent psychiatric
(01:04):
medications.
It was a really big topic, butI did my best to give a
high-level overview of thedifferent psychiatric
medications, including whatclass they are in, when they are
used, how they can be used totreat patients with addiction
and which meds are my go-to forwhen I am treating my own
patients.
It's obviously not acomprehensive review of the
topic, but it gives a niceoverview and with that here we
(01:26):
go.
Okay, so we're going to gothrough an overview of the
different classes of psychiatricmedications and I hope it'll be
helpful to understand why somemeds get used and how we can
integrate psychiatricmedications into treating
addiction.
So I think to really understandwhy there are so many
(01:50):
medications, we have tounderstand how medications get
developed, so it's a fairly longprocess.
So scientists are always lookingto make new discoveries,
understand more about theconditions that we have, and as
an example, we'll say that aresearcher is trying to
(02:11):
understand bipolar disorder andthey find a new receptor in the
brain that controls emotion inbipolar disorder.
And it's a eureka moment.
And now drug companies canstart to target molecules that
mimic this new receptor thataffects bipolar disorder.
And so now that we've got thisnew chemical target, this new
(02:34):
receptor with bipolar disorder,companies are synthesizing
different molecules and seeinghow they interact with the
receptor.
And we'll say, a pharmaceuticalcompany has a breakthrough
moment and they find a drug thatthey think interacts with this
hypothetical new bipolardisorder receptor and that it's
going to be great to managingmood and emotions in bipolar
(02:54):
disorder.
And again, none of this is real, it's just hypothetical, just
understand the process.
And so this company then wouldapply for an investigational new
drug application with the Foodand Drug Administration and
every country does it a littlebit differently, but in America
it's the Food and DrugAdministration.
And then that company takesthat new potential medicine and
(03:15):
runs it through a series oftrials, each getting bigger as
it proves safety and efficacy.
So the first trial is phase one, usually very small, maybe
trying to find the right dose,understanding safety.
Then they move on to phase twoand phase three and then, if it
turns out it's safe andeffective, then the medication
gets approved for use.
(03:36):
And then for me as a doctor, Iget notified that a new
medication has been approved andI can start prescribing it.
Now I will not make a politicalstatement on this, but our
medical system in this countryis profit-based, meaning if you
make a new drug you make lots ofmoney.
(03:58):
So essentially what happens isonce a new target is found and a
new drug is made, that drug ison patent and so that company is
going to make a lot of moneywith their new medicine.
And other companies will try tomake a similar medicine to
target the same molecule,because they want to make their
own medicine and maybe it'sbetter and maybe they can make
(04:19):
more.
And my med school professorcalled these me too drugs, and
the one people might remember isthat the first really new
antidepressant was fluoxetine,also known as prozac, and all
these other drug companies madelots of other similar
antidepressants, and so now wehave sertraline, which is zoloft
, and acetalopram, which islexapro.
(04:40):
Again, it's all about makingnew medicines to compete with
the breakthrough medicine.
Now, as a doctor, I want toexplain to you how we actually
prescribe medications.
Now, every medication inAmerica is approved by the FDA
for a specific indication Againwe'll say bipolar disorder and
(05:01):
it might work for otherindications and those are called
off-label.
Like the bipolar disordermedicine might turn out to also
suppress migraines.
So I prescribe it as indicatedby the FDA for bipolar, but my
patient who has migraines mightget it because it suppresses her
migraines.
And essentially what we find is, as we get more experience with
(05:24):
the medicine, we learn that itdoes other things or that
sometimes side effects areuseful.
Like this new bipolar disordermedication might be really
sedating and it turns out itworks well for sleep too.
So let's actually take a lookat some real-life examples, and
again I was coming up with ahypothetical example.
I would love a new medicine forbipolar disorder, but I'm not
(05:46):
aware of said hypotheticalbreakthrough drug existing in
real life.
So let's look at Topiramate,also known as Topamax, and then
just a level set.
I know we all know this, but,just to be sure, medications
have a generic name and thenthey may have one or more brand
names.
So the generic name isTopiramate, the brand name is
Topamax.
(06:07):
Now this medication is FDAapproved for seizures and
migraine prevention and we canuse it off-label for binge
eating, weight loss, alcohol usedisorder and stimulant use
disorder.
Now, one of the major sideeffects of tapiramate is that it
causes taste changes.
So we're actually using a sideeffect for good in that when you
(06:31):
eat, when you take tapiramate,the food tastes different, which
is one of the reasons it may beassociated with weight loss.
Now how did people find out thattapiramate was helpful for
alcohol use disorder andstimulant use disorder?
Well, we treated people withseizures and migraines and
they'd make a comment like hey,doc, does this medicine make you
(06:52):
not want to drink alcohol?
I have no desire to drink.
In fact, one of my staff in myoffice is on tapiramate for
migraine prevention and sheactually asked me that exact
question hey, does tapirabatemake you not want to drink
alcohol, and so we learn thatthese medications do other
things.
Let's look at a second example.
Let's look at trazodone.
So trazodone is a genericantidepressant and, believe it
(07:17):
or not, there is only one FDAapproved indication, and that's
depression, which is amazing,because no one uses it for
depression.
It is too sedating, so weactually only use it for sleep.
We almost only use it off-labelbecause it has a beneficial
side effect of making peoplesleepy, so we now use it as a
(07:39):
sleeping med.
So that's hopefully a goodsense of why we have so many
medications to understand thedrug development process and
then the so-called copycat drugs, and then to understand what
drugs are indicated for and thenhow we can prescribe them.
Now I'm a pretty simple guy.
I like to keep things simple inmy brain and we all know lots
(08:03):
about cars.
Cars are everywhere in ourlives, and so usually, when I
make analogies to patients aboutmedications, I make analogies
to cars, and what I mean by thatis you can think of drug
classes like different types ofcars.
So trucks, there's tons of them.
There's little, tiny Fords upto big Fords.
(08:25):
There's the Toyota Tacoma,there's the Toyota Tundra, but
they're all trucks, but they dodifferent things.
And then you have SUVs.
They're different.
They're different than trucks,but similar.
And then you have sports carsand sedans.
And that's one of the ways thatI help patients understand the
similarities and differencesbetween medications.
So let me give you someexamples.
(08:48):
So on the screen here you cansee a GMC Sierra and a Chevy
Silverado.
Now I don't know about you, butI don't actually know why GM
makes Chevy and GMC, because itseems like the same cars.
The differences are very minute.
So let's say, a patient isbeing switched from medication A
to medication B and they'revery similar.
And the patient will ask me,doc, what's the difference?
(09:10):
And I usually say, meh, gmcChevrolet.
And they're like oh, okay, Iget that, the medications are
very similar.
There are some subtledifferences, but not so big.
Now, let's say, the medicationdifference is slightly bigger.
On the screen you can see a FordF-150 and a GMC Sierra and I'll
explain to the patient likewell, they're both trucks, but
(09:33):
they're different.
It's like a Ford F-150 and aGMC Sierra.
And the patient's like okay, Iget it, they're both big trucks,
but there's some nuance.
Maybe one has a differentappearance, maybe one has more
torque.
They're similar, but I dounderstand that there's
differences.
And then here on the screen youcan see a Chevy Silverado and a
Chevy Corvette, minus the factthat these two cars are both
(09:56):
made by Chevrolet.
They are completely different.
You have a truck which is fortowing and hauling and maybe
going off-road, and then youhave a sports car.
Right, you would not take theCorvette to a dump to pick up
junk, just as much as youwouldn't race the Silverado on
the racetrack.
And that's an example of I'lltell the patient yeah, this is
(10:17):
like a truck and a sports car.
They're very different.
So that's an analogy that I usewhen I'm trying to explain the
differences between differentmedications.
Okay, now, I love this graphic.
It's obviously a hamster tryingto swallow a whole carrot and
not able to do so because it'stoo big.
And the reason I say this isthis is an enormous topic.
(10:39):
There's no way I can actuallygive you all of the medications
in detail.
So we're really going to lookat just some drug classes and
then we're actually also goingto look at the medications that
I use most and talk about why.
Okay, so our first big drugclass are the antidepressants,
and, as an example, you canthink of these as trucks.
(11:01):
Right, they make a small FordMaverick, they make a giant GMC
Sierra Super Duty.
They're both trucks.
You can use them to haul andpull stuff.
But there's differences.
All of these medications can beused for depression and we've
actually found over the yearsthat they also have other
(11:22):
benefits.
They help with binge eatingdisorder and anxiety and they
help with OCD.
There's a lot of benefits.
So let's go through the classes.
So you have your SSRIs, orselective serotonin reuptake
inhibitors, and if you switchbetween medicines in that class
that's where I tell people GMCand Chevrolet You're switching
(11:44):
within the same class ofantidepressants.
Minute differences, not majordifferences.
Now the next class are theserotonin and norepinephrine
reuptake inhibitors, and thatwould be like going from a
Toyota Tundra to a Ford F-150.
Big truck to big truck from adifferent manufacturer.
They do different things from adifferent manufacturer.
(12:07):
They do different things.
Now.
Ssris some examples would beSertraline or Zoloft, fluoxetine
or Prozac, acetalopram orLexapro and the SNRIs, the
serotonin and norepinephrinereuptake inhibitors.
Some examples would beVenlafaxine, also known as
Effexor, or Duloxetine, alsoknown as Cymbalta.
Next we have the two olderclasses of antidepressants the
tricyclic antidepressants.
(12:27):
That's named for the shape ofthe molecule.
There's a triple cyclicstructure within the molecule.
And then there are themonoamine oxidase inhibitors.
We really don't use the MAOIs,the monoamine oxidase inhibitors
, very much anymore because ofsome bad side effects.
And we occasionally use thetricyclics much anymore because
of some bad side effects and weoccasionally use the tricyclics,
but we largely use the SSRIsand SNRIs and then other
(12:49):
antidepressants mirtazapine isalso known as remeron, and
bupropion also known as wellbuterin or zyban.
I'm going to talk about thoseindividually a little bit later.
Now this is a screenshot from acompany that I have zero
financial ties to, calledGeneSight, and what they do is
what's called pharmacogenomictesting.
(13:09):
So this is a test I do in theoffice I swab your cheek and we
collect cheek cells and then Isend it off to the company and
then they extract the DNA fromthe cheek cells and then they
actually look to see, based onyour genetics, how you
metabolize different meds and wecan actually choose which meds
you are likely to have the mostpredictable response to.
(13:31):
And the reason I use theirscreenshots is it lists all of
the dozens and dozens of namesof antidepressants and it puts
them very nicely in a graphic.
So thank you, genesight, fordoing this.
But you can see there's tons ofdifferent antidepressants.
A lot of these I have to lookup on my own, but again, high
level.
You can think of these astrucks.
(13:51):
They all kind of do a similarthing.
Okay, let's move on to the nextclass of psychiatric medications
, which are anxiolytics andhypnotics.
So these are medications thatare basically just general
sedatives and we can say these,for example, are sedans.
They're dissimilar from trucks,they're both cars, they both
have uses, but we use them fordifferent things than we do a
(14:14):
truck right.
So these are medications thatare generally used for anxiety
and sleep.
The ones people know the mostare the benzodiazepines diazepam
or valium, alprazolam or Xanax,clonazepam or Klonopin.
We have the Z drugs.
The one people know the most isZolpidem, which is Ambien, and
(14:36):
I apologize, I don't rememberthe generic names off the top of
my head, but the other two Zdrugs that are in America their
brand names are, I think,lunesta and Sonata.
Buspirone is a little bitdifferent, it's in this class
but it acts differently.
And then we also have theantihypertensives, which I'll
talk about.
So, again, these are allmedications that we use to
(14:58):
suppress anxiety and promotesleep.
The benzos and the Z drugs actin a particular way to make the
brain's natural downer chemicalswork more.
They function, quite frankly,almost exactly the same as
alcohol.
So I often tell people, whenthey say Xanax is so helpful, I
say, well, it's not greatbecause it's basically alcohol
and a pill.
Boosperone's a little bitdifferent.
(15:20):
We haven't fully figured outwhy it works for anxiety, but
it's something that when it'staken over time it has a little
bit of an antidepressant-likeeffect in helping anxiety, but
it also can provide relief inthe moment when someone just
needs to calm down and need alittle bit of a downer effect.
And then the last two,propranolol and clonidine, are
actually used to control bloodpressure, and the way they do
(15:42):
that is by reducing the amountof stress hormones that the
brain releases.
So clonidine we use for opioidwithdrawal, we use for PTSD
triggering, and the reason we dois because it actually takes
the amount of adrenaline, thestress hormone, coming out of
the brain and it reduces it.
So therefore it doesn't bringthe blood pressure up as much
(16:03):
but it also blunts the stressresponse of withdrawal and then
the PTSD stress response.
Here again are some names on thescreen from the gene site
report and you can see againthere's lots of these.
I usually have to to look themup.
Okay, the next class ofmedications we'll call these
COOPS.
These are antipsychotics.
(16:23):
There's three basic generations.
For thousands of years,schizophrenia was not something
that we could treat Basicallypeople would hear voices and be
disorganized and paranoid, andthere was nothing we can do
about it.
And then we synthesized thefirst antipsychotics decades ago
, and it was an incrediblebreakthrough.
The first generation aremedications that are much older.
(16:46):
You might know Haldol orhaloperidol.
That's one of thefirst-generation antipsychotics
and it helps treat schizophreniaand other conditions of
psychosis.
Now the older meds had a lot ofside effects, and so the drug
companies went back andinnovated and changed the
molecules around and theycreated the second-generation
(17:06):
antipsychotics, which werebetter.
They had fewer side effects.
In some cases they were moreeffective, and examples of these
would be olanzapine, also knownas Zyprexa, and Seroquel, also
known as Cotopine.
There are obviously others.
And then we've now eveninnovated to a third generation
which is even better in terms ofits side effect profile than
either the first or secondgeneration, and the one that
(17:29):
people most know of in thisclass or this generation is
aripiprazole, also known asAbilify.
And again, these are medicineswe use for significant mental
health conditions.
We can use them sometimes forbipolar disorder, particularly
the second and third generation,but usually it's for
schizophrenia.
They tend to be very sedating.
Here's a list of all of them.
(17:49):
And because they're sedating,sometimes we can use them for
sleep.
Seroquel or cataepine, inparticular, is very commonly
used for sleep.
Again, that's using a positiveside effect of sleepiness as a
benefit.
Okay, the next drug class moodstabilizers.
(18:10):
We'll say these are SUVs Again,a totally new class here.
These are really used forbipolar disorder and just a
level set.
Bipolar disorder is a conditionwhere the mood is unstable.
So the mood goes down andthere's depression and then the
mood comes up and that's mania.
And mania is really reallydestructive to someone's life.
(18:33):
If you've never seen it, peopleare just their mood is so far
up, they are completely out ofreality.
They are spending thousands ofdollars, they are buying
multiple cars at the same time,they are staying up all night.
They're on Tinder getting asmany sexual partners as possible
.
Staying up all night, they're,you know, on Tinder getting as
(18:54):
many sexual partners as possible.
It is really destructive tosomeone's life.
So a lot of these moodstabilizers are really meant to
keep people out of mania, butthey can also help to level up
the mood and blunt some of thedepression.
It's kind of a mixed group.
A lot of these are actuallyanti-seizure medications that
were found to be helpful overthe years when we treated people
with seizures and we saw it hadeffect on bipolar disorder.
(19:15):
I don't use a ton of these inmy practice.
If someone has significantbipolar disorder, I usually
refer them to psychiatry because, again, an unmanaged manic
state is just really destructive.
Okay, I think this is the lastclass.
Okay, so this is our last class.
We'll just say arbitrarily,these are race cars.
Again, we're just trying tohighlight that these are all
(19:37):
different classes of drugs, likedifferent classes of cars, to
remind us that they're different.
So, adhd medications we have twomain classes.
We have the stimulants andnon-stimulants.
And if you've ever wondered whytaking hyperactive, fidgety,
distractible people and givingthem stimulants makes them focus
(19:58):
, if you've ever wondered whythat is, it's a really
interesting phenomenon.
So if you've ever had a patienttell you that meth calms them
down, I used to hear that and Iwould look at, look at people
and be like, no, you must belying.
That doesn't calm anybody down.
That's an upper, and it turnsout that a lot of people who
gravitate towards stimulantsActually have untreated adhd and
(20:22):
they use the stimulant toactually self-regulate.
If you didn't know, the genericname for the adhd medication,
adderall, is amphetamine.
We are literally giving uppersto people with adhd and it works
.
I'm not 100 sure that we knowwhy.
Maybe it, maybe someone does, II personally don't.
But but yes, the other class ofmedications would be
(20:45):
non-stimulants and these workthrough a different mechanism.
Here are some examples thestimulant medications.
There's really three of themMethylphenidate, amphetamines
and lisdexamphetamine.
And then the non-stimulantsadamoxetine, guanfacine,
vilocizine and clonidine.
You can see all the brand nameson the screen.
(21:07):
For me, really, if somebody hasa history of stimulant
addiction, I really do not godown the stimulant route.
For this.
I focus on the non-stimulantsbecause it can be really
triggering for them to have astimulant in their system.
I used to not think that ADHDwas that big of a deal, but if
you can imagine you're trying todo therapy or focus in a
(21:28):
12-step meeting and you'reconstantly distractible and you
can't focus, it's really hard todo the recovery work.
So I try to be reallyaggressive in treating ADHD in
people with addiction becausethe recovery work is much easier
for them.
So I'll talk about which are mygo-to meds in just a sec.
Okay, so that's again theoverview.
(21:48):
We have our antidepressants,our antialytics and hypnotics,
we have our mood stabilizers, wehave our antipsychotics and
then we have our ADHDmedications.
So depression, as we all know,is a major issue in recovery.
My first-line medications areusually the selective serotonin
reuptake inhibitors Sertralineor Zoloft, acetalopram or
(22:11):
Lexapro, fluoxetine or Prozac.
That's usually what I go to.
If I've tried a couple of medsor the patient's tried a couple
of meds in that class, then I'llusually go to the SNRIs.
That's again the serotoninnorepinephrine reuptake
inhibitors.
Usually what I go to there isvenlafaxine or Effexor or a
medicine called desvenlaf.
(22:33):
Mirtazapine, also known asRamiron, is very sedating.
We'll come back to that in asec.
We tend to use it for sleep.
And then Welbutrin or Bupropion.
I tend to use this when aperson has a history of
stimulant use disorder, adhd orsmoking.
So Welbutrin is very activating, it tends to help people feel
mentally really up and awake andso it works for people who use
(22:57):
stimulants to get going.
It also can work for ADHD.
So again, it might help someonewho uses stimulants because of
ADHD.
And then it's also approved forsmoking cessation and the brand
name for that in America iscalled Zyban.
So these are the meds I go to mygo-to medications for anxiety.
I'm going to start in themiddle section here.
(23:20):
The antidepressants actuallywork very well for anxiety and
the way to think of it is, let'ssay, somebody feels overwhelmed
really easily.
The antidepressant basicallytakes that threshold to be
overwhelmed and brings it up.
It's almost like it builds in alittle bit of emotional
resilience.
In other words, it takes moreto trigger their anxiety.
(23:41):
The other meds just tend to bemildly sedating.
Hydroxazine I'm sure you've allgiven to clients too many times
to count.
It's an antihistamine like forallergies, and it tends to have
a mild sedative effect.
It doesn't cause addiction.
It doesn't have a withdrawalsyndrome.
It's a very effectivemedication.
So that's one I use prettyfrequently.
(24:04):
For people with a lot of PTSD Itend to use medicines that make
triggering less, like clonidineor propranolol.
Those are the ones that reducethe stress hormones in the brain
.
Buspirone works great for somepeople, not as much for others.
Definitely worth trying forsomeone in anxiety.
And then gabapentin.
And the best way to manageanxiety is to give people an
(24:25):
antidepressant, because itstarts to work over time and
gives them some daily relieffrom the anxiety, and then also
to give them something as needed, like a clonidine or a
hydroxyzine or a gabapentin thatthey can take when they're
feeling overwhelmed.
My go-to medications for sleep,the two antidepressants that I
(24:46):
use the most, are trazodone andmirtazapine.
Again, mirtazapine is alsoknown as Remeron.
They are basically justantidepressants that are very
sedating and they tend to bevery effective.
They may also help mood alittle bit.
Hydroxazine is an antihistaminethat can be a little bit
(25:06):
sedating we often give a biggerdose at bedtime and that can
help with sleep.
And then we haven't talkedabout this one yet, but
romeltion is a non-scheduled,non-addictive sleep medication
that works by modulating themelatonin system, and melatonin
is one of the hormones thathelps us regulate our sleep-wake
cycle.
So these are the ones I go tofor sleep.
(25:28):
Now, what classes of meds do Iavoid?
Benzos, benzos, oh, benzos,benzos, benzos, benzos are
really really hard.
So benzodiazepines areextremely effective for anxiety
and insomnia, but they work in away that actually paradoxically
(25:50):
lead to anxiety over time, andhere's the way I think about
this.
So we are wired as human beingsfor threat.
So we've been living forthousands and thousands of years
in small villages as huntersand gatherers.
Okay, the modern world has onlybeen about maybe 200 years.
(26:12):
Our brains still see the worldas though we are living in small
, primitive villages.
And when we were living insmall, primitive villages we
were potentially going to bevictims of attack from a
neighboring tribe or a wildanimal, and so we, like a
squirrel who knows he could beeaten, we are constantly
scanning the world around us forthreat.
(26:33):
The benzodiazepines are soeffective at suppressing that
threat response by changing howthe brain works In other words,
it increases the natural downerchemicals in the brain that
basically the threat response issuppressed and the brain
doesn't like it.
The brain doesn't want to havethe threat and scanning for
(26:56):
threat response suppressed tothat level.
So the brain actually dials upthe anxiety.
The brain dials up the fight orflight response because it's
worried that if it's too sedatedit won't be able to actually
respond in the case of a truethreat.
The other anxiety medicationsthat I went over don't affect
(27:17):
the brain in the same way, andwe see this with alcohol.
Right, you get people who drinkalcohol because of anxiety and
their anxiety just gets worseover time and they have to drink
more and drink more and theyjust cannot control their
anxiety.
And benzos are very similar.
So what we see is, over time,people come up with no other
coping skill besides their benzoand their brain's anxiety.
Over time, people come up withno other coping skill besides
(27:38):
their benzo and their brain'sanxiety over time gets worse,
which is one of the reasons whygetting off benzos is so painful
, because there was such anemergence of the anxiety and
insomnia they were originallyprescribed for.
Now, the Z drugs I try to avoidas well.
Again, these are thebenzodiazepines similar sleeping
medications like Zolpidem orAmbienz, the one everyone thinks
(28:01):
of these medications.
If you don't sleep on them, itcan do some really weird things.
People can hallucinate.
There's been cases of peoplebuying cars in a trance-like
state while they're under theinfluence of these medications.
People sometimes have beenreported to gamble online while
they're under the influence ofthese medications.
People sometimes have beenreported to gamble online while
they're under the effect ofthese medications.
I really try to avoid themunless absolutely nothing else
(28:23):
works, and then it's really onlyfor a short period of time.
I really try to avoid the Zdrugs as well.
Now, how do we, as doctors,decide which medication of all
the ones we just went over.
Which one do we choose?
Well, the first thing is whatconditions do they have?
Do we have the right diagnosis?
Do we understand what mentalhealth conditions have
(28:45):
contributed to their addiction?
And then, with that, which ofthe conditions is most urgent to
treat?
So let's say somebody has knowPTSD and ADHD and alcohol use
disorder.
We might say, okay, well,there's a lot of PTSD and that
triggering is what's making theperson drink.
Let's really focus on the PTSDfirst, kind of reduce their
(29:08):
alcohol consumption, and thenwe'll come back to the ADHD.
So I really try to prioritizeand with some of these, these
patients who have a lot ofdifferent conditions, we might
be talking about getting tohaving them on six to seven
medications.
Starting them all at once isgoing to be overwhelming, so we
might just start one or two at atime.
And then one of the most usefulquestions I can ask is what meds
(29:30):
have you been on before?
Were they helpful or were theynot?
I love it when somebody comesin and they say, dr Grover, oh
my gosh, hydroxyzine was sohelpful.
Can you restart it?
Yes, that's so easy.
Or, gosh, dr Grover, I tookhydroxyzine and it was not
helpful at all.
We got to try somethingdifferent.
Great, no-transcript.
(30:01):
Okay.
So we've started the patient ona medication.
Let's say I'm seeing them attheir two-week follow-up visit.
So the first thing we have toreally ask is is this medication
giving them really bad sideeffects?
Do we need to take them off ofhydroxyzine because they're
sleeping through their recoverymeetings?
We start by really assessingare the side effects manageable
(30:26):
or intolerable or non-existent?
And if the side effects areintolerable, we're going to have
to discontinue that med and trysomething else.
Now let's say the patient saysthe medication's helping Great.
If they feel like they've had areally good response to it,
then we might leave the dosethere.
But if they say it's helping alittle, then we're probably
going to bring the dose up.
And if they say it's nothelping at all, we'll probably
(30:49):
try to bring the dose up.
And then, if it's not helpingat all, even with an increased
dose, we'll probably leave thatclass of medications behind.
And then let's say somebody'sdoing really well with their
PTSD on their clonidine andthey've stopped drinking.
Now is the time to say can weadd in another medication to
treat your ADHD?
Now, some of these medicationsare very much long-term.
(31:14):
Schizophrenia is a chronicmental illness.
There is no cure.
We can just manage it with themedications that we have.
However, other conditions doget better with time.
Post-traumatic stress disordermight need a lot of medication
initially, but with traumatherapy and building a strong
support network a person mightbe able to come off some of
(31:36):
their medications as they'velearned to emotionally
self-regulate.
And this is where therapy andcounseling and support meetings
can be so helpful.
And then the other thing is inthe world of addiction we have
long-acting injectablemedications, and these are
medications that are given oncea month because the patient
(31:57):
can't remember to take them.
So, for schizophrenia, ifsomebody forgets to take their
medicine or has paranoiddelusions about their medicine
and stops taking it, they willget a lot worse and they will
decompensate.
So long-acting injectablemedications can be given once a
month to ensure compliance, andthat's very common with
schizophrenia.
Just as a reminder, the ones weuse in addiction medicine
(32:20):
Vivitrol is long-actinginjectable naltrexone for
alcohol use disorder or opiateuse disorder.
And then there's long-actinginjectable buprenorphine for
opioid use disorder and that'seither Brixati or Sublicate.
Okay, I think I'm going to stopthere, because that was a ton
of information and I want to geta sense of where we need to
(32:44):
pause and clarify, but I'mhopeful that that was a good
overview of the various classesof psychiatric medication.
Before we wrap up, a huge thankyou to the Montage Health
Foundation for backing mymission to create fun, engaging
education on addiction, and ashout out to the nonprofit
(33:04):
Central Coast OverdosePrevention for teaming up with
me on this podcast.
Our partnership helps me getthe word out about how to treat
addiction and prevent overdosesTo those healthcare providers
out there treating patients withaddiction.
You're doing life-saving workand thank you for what you do
For everyone else tuning in.
Thank you for taking the timeto learn about addiction.
(33:26):
It's a fight we cannot winwithout awareness and action.
There's still so much we can doto improve how addiction is
treated.
Together we can make it happen.
Thanks for listening andremember treating addiction
(33:54):
saves lives.
Welcome to the Addiction Medicine Made Easy
Podcast.
Hey there, I'm Dr Casey Grover,an addiction medicine doctor
based on California's CentralCoast.
(00:22):
For 14 years I worked in theemergency department seeing
countless patients strugglingwith addiction.
Now I'm on the other side ofthe fight, helping people
rebuild their lives when drugsand alcohol take control.
Thanks for tuning in.
Let's get started.
This episode is on psychiatricmedication.
(00:43):
As you've heard me say, I am amedical director for one of the
drug and alcohol treatmentprograms near me and I give
educational lectures oncemonthly to the staff on various
topics in addiction medicine,and last month they asked me to
give an overview of psychiatricmedications.
It was a really big topic, butI did my best to give a
high-level overview of thedifferent psychiatric
(01:04):
medications.
It was a really big topic, butI did my best to give a
high-level overview of thedifferent psychiatric
medications, including whatclass they are in, when they are
used, how they can be used totreat patients with addiction
and which meds are my go-to forwhen I am treating my own
patients.
It's obviously not acomprehensive review of the
topic, but it gives a niceoverview and with that here we
(01:26):
go.
Okay, so we're going to gothrough an overview of the
different classes of psychiatricmedications and I hope it'll be
helpful to understand why somemeds get used and how we can
integrate psychiatricmedications into treating
addiction.
So I think to really understandwhy there are so many
(01:50):
medications, we have tounderstand how medications get
developed, so it's a fairly longprocess.
So scientists are always lookingto make new discoveries,
understand more about theconditions that we have, and as
an example, we'll say that aresearcher is trying to
(02:11):
understand bipolar disorder andthey find a new receptor in the
brain that controls emotion inbipolar disorder.
And it's a eureka moment.
And now drug companies canstart to target molecules that
mimic this new receptor thataffects bipolar disorder.
And so now that we've got thisnew chemical target, this new
(02:34):
receptor with bipolar disorder,companies are synthesizing
different molecules and seeinghow they interact with the
receptor.
And we'll say, a pharmaceuticalcompany has a breakthrough
moment and they find a drug thatthey think interacts with this
hypothetical new bipolardisorder receptor and that it's
going to be great to managingmood and emotions in bipolar
(02:54):
disorder.
And again, none of this is real, it's just hypothetical, just
understand the process.
And so this company then wouldapply for an investigational new
drug application with the Foodand Drug Administration and
every country does it a littlebit differently, but in America
it's the Food and DrugAdministration.
And then that company takesthat new potential medicine and
(03:15):
runs it through a series oftrials, each getting bigger as
it proves safety and efficacy.
So the first trial is phase one, usually very small, maybe
trying to find the right dose,understanding safety.
Then they move on to phase twoand phase three and then, if it
turns out it's safe andeffective, then the medication
gets approved for use.
(03:36):
And then for me as a doctor, Iget notified that a new
medication has been approved andI can start prescribing it.
Now I will not make a politicalstatement on this, but our
medical system in this countryis profit-based, meaning if you
make a new drug you make lots ofmoney.
(03:58):
So essentially what happens isonce a new target is found and a
new drug is made, that drug ison patent and so that company is
going to make a lot of moneywith their new medicine.
And other companies will try tomake a similar medicine to
target the same molecule,because they want to make their
own medicine and maybe it'sbetter and maybe they can make
(04:19):
more.
And my med school professorcalled these me too drugs, and
the one people might remember isthat the first really new
antidepressant was fluoxetine,also known as prozac, and all
these other drug companies madelots of other similar
antidepressants, and so now wehave sertraline, which is zoloft
, and acetalopram, which islexapro.
(04:40):
Again, it's all about makingnew medicines to compete with
the breakthrough medicine.
Now, as a doctor, I want toexplain to you how we actually
prescribe medications.
Now, every medication inAmerica is approved by the FDA
for a specific indication Againwe'll say bipolar disorder and
(05:01):
it might work for otherindications and those are called
off-label.
Like the bipolar disordermedicine might turn out to also
suppress migraines.
So I prescribe it as indicatedby the FDA for bipolar, but my
patient who has migraines mightget it because it suppresses her
migraines.
And essentially what we find is, as we get more experience with
(05:24):
the medicine, we learn that itdoes other things or that
sometimes side effects areuseful.
Like this new bipolar disordermedication might be really
sedating and it turns out itworks well for sleep too.
So let's actually take a lookat some real-life examples, and
again I was coming up with ahypothetical example.
I would love a new medicine forbipolar disorder, but I'm not
(05:46):
aware of said hypotheticalbreakthrough drug existing in
real life.
So let's look at Topiramate,also known as Topamax, and then
just a level set.
I know we all know this, but,just to be sure, medications
have a generic name and thenthey may have one or more brand
names.
So the generic name isTopiramate, the brand name is
Topamax.
(06:07):
Now this medication is FDAapproved for seizures and
migraine prevention and we canuse it off-label for binge
eating, weight loss, alcohol usedisorder and stimulant use
disorder.
Now, one of the major sideeffects of tapiramate is that it
causes taste changes.
So we're actually using a sideeffect for good in that when you
(06:31):
eat, when you take tapiramate,the food tastes different, which
is one of the reasons it may beassociated with weight loss.
Now how did people find out thattapiramate was helpful for
alcohol use disorder andstimulant use disorder?
Well, we treated people withseizures and migraines and
they'd make a comment like hey,doc, does this medicine make you
(06:52):
not want to drink alcohol?
I have no desire to drink.
In fact, one of my staff in myoffice is on tapiramate for
migraine prevention and sheactually asked me that exact
question hey, does tapirabatemake you not want to drink
alcohol, and so we learn thatthese medications do other
things.
Let's look at a second example.
Let's look at trazodone.
So trazodone is a genericantidepressant and, believe it
(07:17):
or not, there is only one FDAapproved indication, and that's
depression, which is amazing,because no one uses it for
depression.
It is too sedating, so weactually only use it for sleep.
We almost only use it off-labelbecause it has a beneficial
side effect of making peoplesleepy, so we now use it as a
(07:39):
sleeping med.
So that's hopefully a goodsense of why we have so many
medications to understand thedrug development process and
then the so-called copycat drugs, and then to understand what
drugs are indicated for and thenhow we can prescribe them.
Now I'm a pretty simple guy.
I like to keep things simple inmy brain and we all know lots
(08:03):
about cars.
Cars are everywhere in ourlives, and so usually, when I
make analogies to patients aboutmedications, I make analogies
to cars, and what I mean by thatis you can think of drug
classes like different types ofcars.
So trucks, there's tons of them.
There's little, tiny Fords upto big Fords.
(08:25):
There's the Toyota Tacoma,there's the Toyota Tundra, but
they're all trucks, but they dodifferent things.
And then you have SUVs.
They're different.
They're different than trucks,but similar.
And then you have sports carsand sedans.
And that's one of the ways thatI help patients understand the
similarities and differencesbetween medications.
So let me give you someexamples.
(08:48):
So on the screen here you cansee a GMC Sierra and a Chevy
Silverado.
Now I don't know about you, butI don't actually know why GM
makes Chevy and GMC, because itseems like the same cars.
The differences are very minute.
So let's say, a patient isbeing switched from medication A
to medication B and they'revery similar.
And the patient will ask me,doc, what's the difference?
(09:10):
And I usually say, meh, gmcChevrolet.
And they're like oh, okay, Iget that, the medications are
very similar.
There are some subtledifferences, but not so big.
Now, let's say, the medicationdifference is slightly bigger.
On the screen you can see a FordF-150 and a GMC Sierra and I'll
explain to the patient likewell, they're both trucks, but
(09:33):
they're different.
It's like a Ford F-150 and aGMC Sierra.
And the patient's like okay, Iget it, they're both big trucks,
but there's some nuance.
Maybe one has a differentappearance, maybe one has more
torque.
They're similar, but I dounderstand that there's
differences.
And then here on the screen youcan see a Chevy Silverado and a
Chevy Corvette, minus the factthat these two cars are both
(09:56):
made by Chevrolet.
They are completely different.
You have a truck which is fortowing and hauling and maybe
going off-road, and then youhave a sports car.
Right, you would not take theCorvette to a dump to pick up
junk, just as much as youwouldn't race the Silverado on
the racetrack.
And that's an example of I'lltell the patient yeah, this is
(10:17):
like a truck and a sports car.
They're very different.
So that's an analogy that I usewhen I'm trying to explain the
differences between differentmedications.
Okay, now, I love this graphic.
It's obviously a hamster tryingto swallow a whole carrot and
not able to do so because it'stoo big.
And the reason I say this isthis is an enormous topic.
(10:39):
There's no way I can actuallygive you all of the medications
in detail.
So we're really going to lookat just some drug classes and
then we're actually also goingto look at the medications that
I use most and talk about why.
Okay, so our first big drugclass are the antidepressants,
and, as an example, you canthink of these as trucks.
(11:01):
Right, they make a small FordMaverick, they make a giant GMC
Sierra Super Duty.
They're both trucks.
You can use them to haul andpull stuff.
But there's differences.
All of these medications can beused for depression and we've
actually found over the yearsthat they also have other
(11:22):
benefits.
They help with binge eatingdisorder and anxiety and they
help with OCD.
There's a lot of benefits.
So let's go through the classes.
So you have your SSRIs, orselective serotonin reuptake
inhibitors, and if you switchbetween medicines in that class
that's where I tell people GMCand Chevrolet You're switching
(11:44):
within the same class ofantidepressants.
Minute differences, not majordifferences.
Now the next class are theserotonin and norepinephrine
reuptake inhibitors, and thatwould be like going from a
Toyota Tundra to a Ford F-150.
Big truck to big truck from adifferent manufacturer.
They do different things from adifferent manufacturer.
(12:07):
They do different things.
Now.
Ssris some examples would beSertraline or Zoloft, fluoxetine
or Prozac, acetalopram orLexapro and the SNRIs, the
serotonin and norepinephrinereuptake inhibitors.
Some examples would beVenlafaxine, also known as
Effexor, or Duloxetine, alsoknown as Cymbalta.
Next we have the two olderclasses of antidepressants the
tricyclic antidepressants.
(12:27):
That's named for the shape ofthe molecule.
There's a triple cyclicstructure within the molecule.
And then there are themonoamine oxidase inhibitors.
We really don't use the MAOIs,the monoamine oxidase inhibitors
, very much anymore because ofsome bad side effects.
And we occasionally use thetricyclics much anymore because
of some bad side effects and weoccasionally use the tricyclics,
but we largely use the SSRIsand SNRIs and then other
(12:49):
antidepressants mirtazapine isalso known as remeron, and
bupropion also known as wellbuterin or zyban.
I'm going to talk about thoseindividually a little bit later.
Now this is a screenshot from acompany that I have zero
financial ties to, calledGeneSight, and what they do is
what's called pharmacogenomictesting.
(13:09):
So this is a test I do in theoffice I swab your cheek and we
collect cheek cells and then Isend it off to the company and
then they extract the DNA fromthe cheek cells and then they
actually look to see, based onyour genetics, how you
metabolize different meds and wecan actually choose which meds
you are likely to have the mostpredictable response to.
(13:31):
And the reason I use theirscreenshots is it lists all of
the dozens and dozens of namesof antidepressants and it puts
them very nicely in a graphic.
So thank you, genesight, fordoing this.
But you can see there's tons ofdifferent antidepressants.
A lot of these I have to lookup on my own, but again, high
level.
You can think of these astrucks.
(13:51):
They all kind of do a similarthing.
Okay, let's move on to the nextclass of psychiatric medications
, which are anxiolytics andhypnotics.
So these are medications thatare basically just general
sedatives and we can say these,for example, are sedans.
They're dissimilar from trucks,they're both cars, they both
have uses, but we use them fordifferent things than we do a
(14:14):
truck right.
So these are medications thatare generally used for anxiety
and sleep.
The ones people know the mostare the benzodiazepines diazepam
or valium, alprazolam or Xanax,clonazepam or Klonopin.
We have the Z drugs.
The one people know the most isZolpidem, which is Ambien, and
(14:36):
I apologize, I don't rememberthe generic names off the top of
my head, but the other two Zdrugs that are in America their
brand names are, I think,lunesta and Sonata.
Buspirone is a little bitdifferent, it's in this class
but it acts differently.
And then we also have theantihypertensives, which I'll
talk about.
So, again, these are allmedications that we use to
(14:58):
suppress anxiety and promotesleep.
The benzos and the Z drugs actin a particular way to make the
brain's natural downer chemicalswork more.
They function, quite frankly,almost exactly the same as
alcohol.
So I often tell people, whenthey say Xanax is so helpful, I
say, well, it's not greatbecause it's basically alcohol
and a pill.
Boosperone's a little bitdifferent.
(15:20):
We haven't fully figured outwhy it works for anxiety, but
it's something that when it'staken over time it has a little
bit of an antidepressant-likeeffect in helping anxiety, but
it also can provide relief inthe moment when someone just
needs to calm down and need alittle bit of a downer effect.
And then the last two,propranolol and clonidine, are
actually used to control bloodpressure, and the way they do
(15:42):
that is by reducing the amountof stress hormones that the
brain releases.
So clonidine we use for opioidwithdrawal, we use for PTSD
triggering, and the reason we dois because it actually takes
the amount of adrenaline, thestress hormone, coming out of
the brain and it reduces it.
So therefore it doesn't bringthe blood pressure up as much
(16:03):
but it also blunts the stressresponse of withdrawal and then
the PTSD stress response.
Here again are some names on thescreen from the gene site
report and you can see againthere's lots of these.
I usually have to to look themup.
Okay, the next class ofmedications we'll call these
COOPS.
These are antipsychotics.
(16:23):
There's three basic generations.
For thousands of years,schizophrenia was not something
that we could treat Basicallypeople would hear voices and be
disorganized and paranoid, andthere was nothing we can do
about it.
And then we synthesized thefirst antipsychotics decades ago
, and it was an incrediblebreakthrough.
The first generation aremedications that are much older.
(16:46):
You might know Haldol orhaloperidol.
That's one of thefirst-generation antipsychotics
and it helps treat schizophreniaand other conditions of
psychosis.
Now the older meds had a lot ofside effects, and so the drug
companies went back andinnovated and changed the
molecules around and theycreated the second-generation
(17:06):
antipsychotics, which werebetter.
They had fewer side effects.
In some cases they were moreeffective, and examples of these
would be olanzapine, also knownas Zyprexa, and Seroquel, also
known as Cotopine.
There are obviously others.
And then we've now eveninnovated to a third generation
which is even better in terms ofits side effect profile than
either the first or secondgeneration, and the one that
(17:29):
people most know of in thisclass or this generation is
aripiprazole, also known asAbilify.
And again, these are medicineswe use for significant mental
health conditions.
We can use them sometimes forbipolar disorder, particularly
the second and third generation,but usually it's for
schizophrenia.
They tend to be very sedating.
Here's a list of all of them.
(17:49):
And because they're sedating,sometimes we can use them for
sleep.
Seroquel or cataepine, inparticular, is very commonly
used for sleep.
Again, that's using a positiveside effect of sleepiness as a
benefit.
Okay, the next drug class moodstabilizers.
(18:10):
We'll say these are SUVs Again,a totally new class here.
These are really used forbipolar disorder and just a
level set.
Bipolar disorder is a conditionwhere the mood is unstable.
So the mood goes down andthere's depression and then the
mood comes up and that's mania.
And mania is really reallydestructive to someone's life.
(18:33):
If you've never seen it, peopleare just their mood is so far
up, they are completely out ofreality.
They are spending thousands ofdollars, they are buying
multiple cars at the same time,they are staying up all night.
They're on Tinder getting asmany sexual partners as possible
.
Staying up all night, they're,you know, on Tinder getting as
(18:54):
many sexual partners as possible.
It is really destructive tosomeone's life.
So a lot of these moodstabilizers are really meant to
keep people out of mania, butthey can also help to level up
the mood and blunt some of thedepression.
It's kind of a mixed group.
A lot of these are actuallyanti-seizure medications that
were found to be helpful overthe years when we treated people
with seizures and we saw it hadeffect on bipolar disorder.
(19:15):
I don't use a ton of these inmy practice.
If someone has significantbipolar disorder, I usually
refer them to psychiatry because, again, an unmanaged manic
state is just really destructive.
Okay, I think this is the lastclass.
Okay, so this is our last class.
We'll just say arbitrarily,these are race cars.
Again, we're just trying tohighlight that these are all
(19:37):
different classes of drugs, likedifferent classes of cars, to
remind us that they're different.
So, adhd medications we have twomain classes.
We have the stimulants andnon-stimulants.
And if you've ever wondered whytaking hyperactive, fidgety,
distractible people and givingthem stimulants makes them focus
(19:58):
, if you've ever wondered whythat is, it's a really
interesting phenomenon.
So if you've ever had a patienttell you that meth calms them
down, I used to hear that and Iwould look at, look at people
and be like, no, you must belying.
That doesn't calm anybody down.
That's an upper, and it turnsout that a lot of people who
gravitate towards stimulantsActually have untreated adhd and
(20:22):
they use the stimulant toactually self-regulate.
If you didn't know, the genericname for the adhd medication,
adderall, is amphetamine.
We are literally giving uppersto people with adhd and it works
.
I'm not 100 sure that we knowwhy.
Maybe it, maybe someone does, II personally don't.
But but yes, the other class ofmedications would be
(20:45):
non-stimulants and these workthrough a different mechanism.
Here are some examples thestimulant medications.
There's really three of themMethylphenidate, amphetamines
and lisdexamphetamine.
And then the non-stimulantsadamoxetine, guanfacine,
vilocizine and clonidine.
You can see all the brand nameson the screen.
(21:07):
For me, really, if somebody hasa history of stimulant
addiction, I really do not godown the stimulant route.
For this.
I focus on the non-stimulantsbecause it can be really
triggering for them to have astimulant in their system.
I used to not think that ADHDwas that big of a deal, but if
you can imagine you're trying todo therapy or focus in a
(21:28):
12-step meeting and you'reconstantly distractible and you
can't focus, it's really hard todo the recovery work.
So I try to be reallyaggressive in treating ADHD in
people with addiction becausethe recovery work is much easier
for them.
So I'll talk about which are mygo-to meds in just a sec.
Okay, so that's again theoverview.
(21:48):
We have our antidepressants,our antialytics and hypnotics,
we have our mood stabilizers, wehave our antipsychotics and
then we have our ADHDmedications.
So depression, as we all know,is a major issue in recovery.
My first-line medications areusually the selective serotonin
reuptake inhibitors Sertralineor Zoloft, acetalopram or
(22:11):
Lexapro, fluoxetine or Prozac.
That's usually what I go to.
If I've tried a couple of medsor the patient's tried a couple
of meds in that class, then I'llusually go to the SNRIs.
That's again the serotoninnorepinephrine reuptake
inhibitors.
Usually what I go to there isvenlafaxine or Effexor or a
medicine called desvenlaf.
(22:33):
Mirtazapine, also known asRamiron, is very sedating.
We'll come back to that in asec.
We tend to use it for sleep.
And then Welbutrin or Bupropion.
I tend to use this when aperson has a history of
stimulant use disorder, adhd orsmoking.
So Welbutrin is very activating, it tends to help people feel
mentally really up and awake andso it works for people who use
(22:57):
stimulants to get going.
It also can work for ADHD.
So again, it might help someonewho uses stimulants because of
ADHD.
And then it's also approved forsmoking cessation and the brand
name for that in America iscalled Zyban.
So these are the meds I go to mygo-to medications for anxiety.
I'm going to start in themiddle section here.
(23:20):
The antidepressants actuallywork very well for anxiety and
the way to think of it is, let'ssay, somebody feels overwhelmed
really easily.
The antidepressant basicallytakes that threshold to be
overwhelmed and brings it up.
It's almost like it builds in alittle bit of emotional
resilience.
In other words, it takes moreto trigger their anxiety.
(23:41):
The other meds just tend to bemildly sedating.
Hydroxazine I'm sure you've allgiven to clients too many times
to count.
It's an antihistamine like forallergies, and it tends to have
a mild sedative effect.
It doesn't cause addiction.
It doesn't have a withdrawalsyndrome.
It's a very effectivemedication.
So that's one I use prettyfrequently.
(24:04):
For people with a lot of PTSD Itend to use medicines that make
triggering less, like clonidineor propranolol.
Those are the ones that reducethe stress hormones in the brain
.
Buspirone works great for somepeople, not as much for others.
Definitely worth trying forsomeone in anxiety.
And then gabapentin.
And the best way to manageanxiety is to give people an
(24:25):
antidepressant, because itstarts to work over time and
gives them some daily relieffrom the anxiety, and then also
to give them something as needed, like a clonidine or a
hydroxyzine or a gabapentin thatthey can take when they're
feeling overwhelmed.
My go-to medications for sleep,the two antidepressants that I
(24:46):
use the most, are trazodone andmirtazapine.
Again, mirtazapine is alsoknown as Remeron.
They are basically justantidepressants that are very
sedating and they tend to bevery effective.
They may also help mood alittle bit.
Hydroxazine is an antihistaminethat can be a little bit
(25:06):
sedating we often give a biggerdose at bedtime and that can
help with sleep.
And then we haven't talkedabout this one yet, but
romeltion is a non-scheduled,non-addictive sleep medication
that works by modulating themelatonin system, and melatonin
is one of the hormones thathelps us regulate our sleep-wake
cycle.
So these are the ones I go tofor sleep.
(25:28):
Now, what classes of meds do Iavoid?
Benzos, benzos, oh, benzos,benzos, benzos, benzos are
really really hard.
So benzodiazepines areextremely effective for anxiety
and insomnia, but they work in away that actually paradoxically
(25:50):
lead to anxiety over time, andhere's the way I think about
this.
So we are wired as human beingsfor threat.
So we've been living forthousands and thousands of years
in small villages as huntersand gatherers.
Okay, the modern world has onlybeen about maybe 200 years.
(26:12):
Our brains still see the worldas though we are living in small
, primitive villages.
And when we were living insmall, primitive villages we
were potentially going to bevictims of attack from a
neighboring tribe or a wildanimal, and so we, like a
squirrel who knows he could beeaten, we are constantly
scanning the world around us forthreat.
(26:33):
The benzodiazepines are soeffective at suppressing that
threat response by changing howthe brain works In other words,
it increases the natural downerchemicals in the brain that
basically the threat response issuppressed and the brain
doesn't like it.
The brain doesn't want to havethe threat and scanning for
(26:56):
threat response suppressed tothat level.
So the brain actually dials upthe anxiety.
The brain dials up the fight orflight response because it's
worried that if it's too sedatedit won't be able to actually
respond in the case of a truethreat.
The other anxiety medicationsthat I went over don't affect
(27:17):
the brain in the same way, andwe see this with alcohol.
Right, you get people who drinkalcohol because of anxiety and
their anxiety just gets worseover time and they have to drink
more and drink more and theyjust cannot control their
anxiety.
And benzos are very similar.
So what we see is, over time,people come up with no other
coping skill besides their benzoand their brain's anxiety.
Over time, people come up withno other coping skill besides
(27:38):
their benzo and their brain'sanxiety over time gets worse,
which is one of the reasons whygetting off benzos is so painful
, because there was such anemergence of the anxiety and
insomnia they were originallyprescribed for.
Now, the Z drugs I try to avoidas well.
Again, these are thebenzodiazepines similar sleeping
medications like Zolpidem orAmbienz, the one everyone thinks
(28:01):
of these medications.
If you don't sleep on them, itcan do some really weird things.
People can hallucinate.
There's been cases of peoplebuying cars in a trance-like
state while they're under theinfluence of these medications.
People sometimes have beenreported to gamble online while
they're under the influence ofthese medications.
People sometimes have beenreported to gamble online while
they're under the effect ofthese medications.
I really try to avoid themunless absolutely nothing else
(28:23):
works, and then it's really onlyfor a short period of time.
I really try to avoid the Zdrugs as well.
Now, how do we, as doctors,decide which medication of all
the ones we just went over.
Which one do we choose?
Well, the first thing is whatconditions do they have?
Do we have the right diagnosis?
Do we understand what mentalhealth conditions have
(28:45):
contributed to their addiction?
And then, with that, which ofthe conditions is most urgent to
treat?
So let's say somebody has knowPTSD and ADHD and alcohol use
disorder.
We might say, okay, well,there's a lot of PTSD and that
triggering is what's making theperson drink.
Let's really focus on the PTSDfirst, kind of reduce their
(29:08):
alcohol consumption, and thenwe'll come back to the ADHD.
So I really try to prioritizeand with some of these, these
patients who have a lot ofdifferent conditions, we might
be talking about getting tohaving them on six to seven
medications.
Starting them all at once isgoing to be overwhelming, so we
might just start one or two at atime.
And then one of the most usefulquestions I can ask is what meds
(29:30):
have you been on before?
Were they helpful or were theynot?
I love it when somebody comesin and they say, dr Grover, oh
my gosh, hydroxyzine was sohelpful.
Can you restart it?
Yes, that's so easy.
Or, gosh, dr Grover, I tookhydroxyzine and it was not
helpful at all.
We got to try somethingdifferent.
Great, no-transcript.
(30:01):
Okay.
So we've started the patient ona medication.
Let's say I'm seeing them attheir two-week follow-up visit.
So the first thing we have toreally ask is is this medication
giving them really bad sideeffects?
Do we need to take them off ofhydroxyzine because they're
sleeping through their recoverymeetings?
We start by really assessingare the side effects manageable
(30:26):
or intolerable or non-existent?
And if the side effects areintolerable, we're going to have
to discontinue that med and trysomething else.
Now let's say the patient saysthe medication's helping Great.
If they feel like they've had areally good response to it,
then we might leave the dosethere.
But if they say it's helping alittle, then we're probably
going to bring the dose up.
And if they say it's nothelping at all, we'll probably
(30:49):
try to bring the dose up.
And then, if it's not helpingat all, even with an increased
dose, we'll probably leave thatclass of medications behind.
And then let's say somebody'sdoing really well with their
PTSD on their clonidine andthey've stopped drinking.
Now is the time to say can weadd in another medication to
treat your ADHD?
Now, some of these medicationsare very much long-term.
(31:14):
Schizophrenia is a chronicmental illness.
There is no cure.
We can just manage it with themedications that we have.
However, other conditions doget better with time.
Post-traumatic stress disordermight need a lot of medication
initially, but with traumatherapy and building a strong
support network a person mightbe able to come off some of
(31:36):
their medications as they'velearned to emotionally
self-regulate.
And this is where therapy andcounseling and support meetings
can be so helpful.
And then the other thing is inthe world of addiction we have
long-acting injectablemedications, and these are
medications that are given oncea month because the patient
(31:57):
can't remember to take them.
So, for schizophrenia, ifsomebody forgets to take their
medicine or has paranoiddelusions about their medicine
and stops taking it, they willget a lot worse and they will
decompensate.
So long-acting injectablemedications can be given once a
month to ensure compliance, andthat's very common with
schizophrenia.
Just as a reminder, the ones weuse in addiction medicine
(32:20):
Vivitrol is long-actinginjectable naltrexone for
alcohol use disorder or opiateuse disorder.
And then there's long-actinginjectable buprenorphine for
opioid use disorder and that'seither Brixati or Sublicate.
Okay, I think I'm going to stopthere, because that was a ton
of information and I want to geta sense of where we need to
(32:44):
pause and clarify, but I'mhopeful that that was a good
overview of the various classesof psychiatric medication.
Before we wrap up, a huge thankyou to the Montage Health
Foundation for backing mymission to create fun, engaging
education on addiction, and ashout out to the nonprofit
(33:04):
Central Coast OverdosePrevention for teaming up with
me on this podcast.
Our partnership helps me getthe word out about how to treat
addiction and prevent overdosesTo those healthcare providers
out there treating patients withaddiction.
You're doing life-saving workand thank you for what you do
For everyone else tuning in.
Thank you for taking the timeto learn about addiction.
(33:26):
It's a fight we cannot winwithout awareness and action.
There's still so much we can doto improve how addiction is
treated.
Together we can make it happen.
Thanks for listening andremember treating addiction
(33:54):
saves lives.
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