October 13, 2025 • 47 mins
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
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
SPEAKER_01 (00:00):
Welcome to the Addiction Medicine Made Easy
Podcast.
Hey there, I'm Dr.
Casey Grover, an addictionmedicine doctor based on
(00:20):
California's Central Coast.
For 14 years, I worked in theemergency department seeing
countless patients strugglingwith addiction.
Now I'm on the other side of thefight helping people rebuild
their lives when drugs andalcohol take control.
Thanks for tuning in.
Let's get started.
Today's episode is on theintersection between mental
(00:43):
health and addiction.
This is an interview with Dr.
Mark Reimach, who is anaddiction psychiatrist, and we
discuss how mental healthconditions affect patients with
addiction and what medicationscan be used to treat those
mental health conditions inpatients with addiction.
You might have heard the termdual diagnosis or co-occurring
(01:05):
disorders.
These are the terms used bymedical providers when
describing a patient who hasboth a mental health condition
and a substance use disorder.
When I first started as anaddiction medicine doctor, I
focused on using medications toreduce the desire for drugs and
alcohol.
For example, I prescribed a lotof naltterexone to patients with
(01:26):
alcohol use disorder.
And I would wonder why for somepatients it didn't really work.
And then I asked them why theydrank, and they would tell me
that they had horrible insomniaand anxiety.
Oops.
They weren't drinking for theeuphoria.
They were drinking because theirbrain wanted the downer effect
from the alcohol to deal withanxiety and insomnia.
(01:47):
So then I started to learn thatI had to identify comorbid
mental health conditions in mypatients with addiction and
treat those too.
Dr.
Reimach and I had a fantasticconversation, and I hope you
find it helpful.
One quick point before we start.
I usually try to use the genericnames of medications on my
podcast, but often the brandnames are easier to say and are
(02:09):
more well known.
We ended up using mostly brandnames for medications during
this discussion.
Here we go.
All right.
Good morning.
Happy Friday.
Why don't we start by telling uswho you are and what you do?
SPEAKER_00 (02:24):
Sure.
I'm Mark Reimach.
I'm a psychiatrist.
I specialize in addiction.
I also started a grouppsychiatric practice, and we
have a number of psychiatristswith various specialties that
treat people with medicationstherapy.
And we also have a ketaminetherapy program within our
(02:44):
office as well.
SPEAKER_01 (02:46):
Very nice.
So I'm board certified inaddiction medicine, and you do
addiction psychiatry.
What's the difference?
SPEAKER_00 (02:54):
The addiction psychiatry is considered a
sub-specialty of psychiatry.
So I did a four-year psychiatricresidency and then a one-year
addiction psychiatry fellowshipafter that.
So that's a training programwhere basically we approach
addiction treatment from apsychiatric angle, which
includes a lot of common groundwith the way addiction medicine
(03:16):
approaches it.
So we do detoxes, I do detox onan outpatient basis, commonly
work with anti-cravingmedications, but we also do
therapy or work with therapistswho are doing therapy in
parallel to medicationmanagement that we might be
doing with a certain patient.
SPEAKER_01 (03:34):
So I'm going to pick on mental health providers.
Oftentimes I refer my patientsfor mental health services,
whether it be a psychologist, anLMFT, or a psychiatrist, and
they tell me I can't treat thisperson because they have active
addiction.
Right.
And the way I look at it as anaddiction doctor is I don't have
that luxury.
Their depression and theiralcohol are so intertwined, it's
(03:56):
hard to know which is which andwhich came first, but I need
them to stop drinking.
Can you talk to me about howyou, as an addiction
psychiatrist, approach thingslike substance-induced mood
disorders, whereas yourcolleagues might say, get sober
and then I'll see you?
SPEAKER_00 (04:11):
Yeah, that's a pet peeve of mine, also.
The concept being like cherrypicking your patients.
I actually don't think that'sethically correct.
It is reflective of a moreconservative attitude and
probably a stigmatizing attitudeabout addiction as a disorder,
(04:32):
also.
You know, I think thankfully,with each decade, we're making
more and more progress, evenwithin the healthcare field, on
how we regard addiction and howwe treat patients with addiction
issues.
One of the premises of addictionpsychiatry is we treat the
person where they are.
And so if they have addictionissues, we come up with a
(04:53):
treatment plan for that.
If they have comorbid mentalhealth issues, which is actually
much more the rule than theexception, then we also address
those.
Personally, I also believe thatevery person at least deserves
an evaluation.
I might not be able to continuetreating you if your disorder,
whether it's addiction or mentalhealth, is so severe that it
(05:13):
might require, let's say,residential treatment or even
hospitalization for detox orsome other psychiatric
stabilization.
But once you are stable andappropriate to participate in
outpatient treatment, which is asetting that I work in, then you
know I'm I'm happy to treat you.
So I also have a belief that anyeveryone at least deserves an
evaluation to know like wherethey are and what the next step
(05:36):
should be, which might not bestaying with me, at least not
for the next few months anyway.
SPEAKER_01 (05:41):
You and I think exactly the same way on that.
I think my number one prescribedmedications are probably
clonidine, properanolol, andSSRIs or SNRIs.
Again, those are selectiveserotonin reptake inhibitors and
serotonin norepinephrine reptakeinhibitors.
I came into addiction medicinethinking that everybody needed
naltrectone.
And I clearly was missing themental health component as I
(06:04):
started.
And from my personal livedexperience, I got diagnosed with
post-traumatic stress disorderlast year as a part of my work
in the emergency department.
And living with a post-traumaticstress disorder has changed my
perspective entirely on how Itreat my patients with
addiction.
And PTSD and addiction seems tobe one of my niches now, given
(06:24):
my lived experience.
The famous addiction doctor, Dr.
Gabor Mate, says that all peoplewith addiction have been
traumatized.
What percentage of your patientswith addiction would you
estimate have comorbid PTSD?
SPEAKER_00 (06:36):
I mean, honestly, I'd say all people have been
traumatized in some way.
You know, there's a spectrum oftrauma.
We've all had tough experiences.
Part of the human condition isnegative experiences, things
that teach us to avoid certainpeople, places, things, let's
say.
But some of us also have hadexperiences that lead to like
(06:58):
even a formal diagnosis ofpost-traumatic stress.
So as you're asking me thatquestion, 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 otheranxiety disorders or insomnia.
So all of these are possible andthey all often present together.
SPEAKER_01 (07:21):
Yeah.
So we obviously do not live inan ideal world, given that
health insurance dictates a lotof what we can do.
But if you were practicingmedicine in an ideal world, how
would you approach the patientwith comorbid PTSD and
addiction?
Let's say it's alcoholaddiction.
SPEAKER_00 (07:35):
Parallel treatment and parallel treatment plans for
the substance issue, so alcoholand then the mental health
issue.
So from the alcohol perspective,we establish if someone has a
physiologic dependence onalcohol, if you know we
encourage them to stop drinkingand they actually do cold turkey
stop, does that cause any riskof seizure or any other
(07:57):
problematic withdrawal symptoms?
And then also other aspects ofalcohol treatment can be some
type of psychosocial treatment,so AA or therapy, individually,
you know, what have you, butjust so someone can work on
things from a psychologicalperspective.
And then, yeah, the PTSD part ofthings, very often an SSRI is
(08:20):
helpful.
PTSD ultimately is a type ofanxiety disorder, and SSRIs are
considered a first-linetreatment for anxiety.
And then therapy helps theretoo.
So ideally, they have atherapist that can both treat
trauma and the mental healthpart of things as well as the
addiction part of things.
SPEAKER_01 (08:40):
Do you use much of propranololol or clonidine for
triggering in your PTSDpatients?
SPEAKER_00 (08:46):
I actually use a lot more prososin at bedtime for
nightmares associated with PTSD.
I might go to clonidine as asecond choice if prosocin does
not seem to be strong enough.
Clonidine I use much more oftenas a treatment for opioid
withdrawal because it is prettypotent.
It can drop blood pressure andcause dizziness, lightheadedness
(09:11):
at times.
But yes, I also prescribe a goodamount of propranolol, also
gabapentin and hydroxazine.
To me, those are the three mainnon-benzodiazepine, so non-habit
forming, but still fast-actingmedications for anxiety.
SPEAKER_01 (09:28):
Do you have a particular preference among the
SSRIs as which ones you use mostoften?
SPEAKER_00 (09:33):
I tend to start with either Zoloft or Lexapro,
primarily because those havebeen shown to have a lower side
effect profile, but not by much.
I mean, honestly, the SSRIs aremuch more similar to each other
than different.
And if someone has a strongbelief that Prozac is going to
help them because two of theirsiblings are on Prozac and
(09:54):
they're doing great, you know,we actually do try to take
advantage of the placebo effectin psychiatry.
You know, a person's expectationabout how well a medicine is
going to work can actually beresponsible for a third of
people benefiting, is what theresearch shows.
So I'll happily prescribe anySSRI that a person really
believes in because they're allmuch more similar to each other
(10:16):
than different.
Usually after a person hasfailed two different SSRIs, or
if they have a comorbid paindisorder, SNRIs are good for
that.
Or if they have a depressionassociated with fatigue, SNRIs
(10:36):
can be more activating.
So those might be reasons thatan SNRI might be higher on my
list.
The only downside of SNRIs isthat they are notoriously
difficult to come off of.
And not very difficult.
I successfully take people offof SNRIs all the time, but you
(10:56):
do need a specific plan.
You can't just take a person offover the course of one week,
especially if they've been on ahigh dose SNRI for years.
It might need to be tapered overthe course of a few months.
SPEAKER_01 (11:07):
One thing you didn't mention on your list of meds
around anxiety that arenon-addictive is busporone.
Any reason why that medicationdidn't come up on your list?
SPEAKER_00 (11:15):
Well, the list I gave you was the fast-acting PRN
meds, whereas Busperone is onethat I use as the daily
preventative type of treatment.
So yeah, in treating anxietywith medications, there's two
main arms of treatment.
One is like the fast acting asneeded approach, and the other
is like the daily foundational.
(11:36):
You know, it takes a while tobuild up, but then it actually
helps prevent the formation ofanxiety or just globally reduce
anxiety in your emotionalclimate.
So I actually do prescribe agood amount of Busperone.
Uh it's got a bad reputation fornot being effective, but I
honestly find that people justdon't dose it aggressively
(11:57):
enough.
10 milligrams three times a day,like the standard starting dose,
doesn't often help people.
I always go up to 23 times aday, which is actually the
FDA-approved max on Busparone,and we do get benefit there.
And then if there is benefitwith no side effects, which is
often the case with that dose ofbuspar, then I'll even go up to
(12:18):
90 milligrams a day on that.
SPEAKER_01 (12:19):
I did not know that.
SPEAKER_00 (12:21):
Yeah.
SPEAKER_01 (12:21):
Some of my colleagues in Australia have
been in correspondence with meabout the combination of
naltrexone and baclefin foralcohol addiction, particularly
when there's comorbid anxiety.
Any experience with bacclefinwhen you have comorbid anxiety
and let's say alcohol addiction,but really in general?
SPEAKER_00 (12:39):
Baclefin in my mind belongs to a class of
medications that have someanecdotal evidence, some case
reports, but not a whole bunchof great research supporting its
use.
So, yeah, baclefin is there,topiramate is there, zofran, I
think also has some evidence foralcoholism.
(13:00):
I don't use a lot of baclefin.
I've used it a handful of times.
I've not seen it all thathelpful.
I interview patients all thetime.
I've never heard it as beingpivotal in a person's recovery,
not the way that naltrexone hasor even an abuse has.
So I tend not to prescribe a lotof baclefin.
(13:22):
And recently I actually had apatient that seemed to have a
baclefin abuse issue where shewas already above the FDA
approved max and then takingmore and only escalating doses.
So I have a recent, evenstronger aversion to baclefin,
personally.
That's just my my experience.
SPEAKER_01 (13:41):
Yeah, I did a podcast episode on it maybe 18
months ago, two years ago, andthe data's really conflicting.
There are some positive studiesand then there are some neutral
studies.
Yeah.
So we've been hinting a lot atanxiety.
So we've covered PTSD withcomorbid substance use disorder.
Talk to me about how youapproach the patient with
comorbid anxiety and addiction.
SPEAKER_00 (14:01):
Similar to what I was saying, yeah, with the two
arms of treatment, the alcoholtreatment plan and the anxiety
one.
Anxiety, especially likegeneralized anxiety, is much
more of what I'll see comorbidwith alcoholism than even PTSD.
But the strategies are similar.
(14:22):
PTSD is an anxiety disorder.
So again, the daily preventativemed, which could be an SSRI or
BUSPAR or Remron mertazepine isnice if they aren't sleeping,
aren't eating, and anxiousbecause Remron can actually help
all three.
And then the fast acting asneeded option of either
(14:45):
Galbapatin, hydroxizine,papranolol tends to be what I do
from the medication perspective.
SPEAKER_01 (14:51):
Is there anything else unique to generalized
anxiety disorder with comorbidsubstance use outside of PTSD?
Anything different?
SPEAKER_00 (14:59):
I mean, honestly, not really.
Anxiety disorders in general, Ithink of as on a spectrum, going
from generalized, which meanslow grade, or significant
anxiety a lot of the day or mostof the day.
So just speaks to itspresentation throughout the day,
versus like acute and episodic,with panic attacks being the
(15:20):
example of that end of thespectrum.
So sometimes we just need to paymore attention to preventing
that ongoing daily, day-longtype of anxiety versus something
that maybe putting more emphasisif someone has panic disorder on
putting down anxiety, the panicwhen it starts, or even noting
when it's building up to arrestthat self-building cycle that
(15:44):
panic often presents with.
So that might be where thestrategy differs.
But yeah, I'd say that's stillthe general spectrum.
SPEAKER_01 (15:52):
I'm going to ask this question fully knowing it's
a loaded question, and I'mcurious as to how you respond.
What are your thoughts onbenzodiazepines in patients with
anxiety disorders with comorbidaddiction?
SPEAKER_00 (16:02):
It's a good question.
And there are analogousquestions with controlled
substances being used to treatADHD or insomnia.
SPEAKER_01 (16:12):
We're going to get there.
SPEAKER_00 (16:13):
Yeah, that's great.
So yeah, look, the cleantextbook answer is always avoid
benzos.
You know, there's no risk of anybenzo problems if you don't
prescribe a benzo, right?
So the only way to really reducerisk to zero is to just avoid it
completely.
I am a psychiatrist, I treataddiction, I see a lot of tough
(16:38):
cases.
And I also see people that havetried the gabapatin visceral
proprianol route, and it'shelped maybe half of their
anxiety, but there's still agood amount left.
And maybe they've already had ahistory of being treated with a
benzodiazepine and just neverdeveloped a problem with them in
(17:03):
general, in looking at the riskpotential of various
benzodiazepines.
The longer acting something is,the less addictive it is.
So the longest acting benzos areclonopin, valium.
So those are the ones I wouldlean towards with Xanax being
notorious for having the highestabuse issues, and therefore I
(17:26):
don't really prescribe Xanax inaddiction patients.
I do think that's basically likeasking for trouble.
Honestly, a lot of times if theyhaven't had alcohol as a
problem, benzos are more likelyeven to be okay because benzos
work on the GABA receptor,alcohol works on the GABA
receptor.
But I also have a good amount ofpatients who've had issues with
(17:48):
alcohol, and and maybe eventhey've had issues with Xanax in
the past, but yet they canhandle like a prescription of
clonopin 0.5 milligrams twice aweek.
The intermittent use is alwaysfavorable to the chronic daily
use, too.
So again, it's just layers ofrisk.
And the goal in general inaddiction treatment, in a lot of
(18:11):
ways, is harm reduction.
And so we do a risk assessmentand the physician oath of do no
harm.
So we try to do no harm.
We monitor for potential harm ifwe are considering a certain
path.
And we gauge the patient too.
How much do they understand theharm?
Do they have a healthy respector a healthy fear of this
medication?
I mean, honestly, I see a lot ofpeople in recovery, especially
(18:35):
like solid multi-year recovery,that they themselves are anxious
about taking a benzo.
And they may not even like itwhen I bring it up for the first
time.
You know, and honestly, I lovethat dynamic, that presentation,
because it means they alreadyhave this protective factor
built within them where ifthey're anxious about getting
(18:59):
hooked on a benzo.
I can't remember the last time Isaw a person actually develop an
issue with the benzo if theycome in to the treatment with
that mindset about benzos.
SPEAKER_01 (19:09):
So I didn't know about bind until maybe three or
four months ago when one of mypatients was looking on Reddit
as to why he felt so weird afterhe was taking a friend's Xanax.
And I actually don't know if hehad BIND just because he'd only
been on it for like a month orso.
But BIND beingbenzodazipine-induced
neurological dysfunction.
(19:29):
What are you seeing in yourpractice around this?
SPEAKER_00 (19:32):
Yeah, actually, I had not heard that acronym BIND,
if it might refer to like peopledeveloping issues with being on
it for years and thenparesthesias and things like
that.
SPEAKER_01 (19:42):
I came to it on my own.
You're obviously familiar withthe term opiate-induced
hyperalgesia.
Yeah.
Right.
And the way I was seeing it is Iwas seeing all of these patients
that had been on benzos somelonger than I'd been alive.
And they just had incredibleanxiety, minimal emotional
resilience, horrible insomnia.
(20:02):
And I was going to coin the termbenzodazipine-induced emotional
fragility.
I'll see these folks on fourmilligrams of clonazepam a day,
and they're like, Doc, I'm soanxious.
And I'm just thinking, what am Imissing?
And so there's been some recentnaming of this phenomenon of
some of the chronic changesaround emotional resilience
after being on benzodazines formany years, and this particular
(20:25):
term has come up.
I looked on open evidence.
I don't know if you use openevidence, but I love it, right?
The way I discovered to mypatients is you combine the
power of AI with the NationalLibrary of Medicine, and I can
get an evidence-based answer in30 seconds.
So I searched on open evidence,and yes, there's some signal
there around bind.
I'm assuming you've seen thisphenomenon, maybe just not heard
that name.
SPEAKER_00 (20:44):
Yeah.
First of all, if a person is ona benzodiazepine for long-term
use, it actually means that theyhave had a severe anxiety
disorder such that physicians inthe past have justified
prescribing benzos in an ongoingway.
So I do think they represent themost severe subset of anxiety
(21:07):
patients.
And so I definitely see peoplewith bad anxiety disorders that
then want to come off of benzosand then have difficulty doing
that.
Yeah, there could be a questionas to how much is just their
underlying anxiety coming backup as the benzos are reduced
versus any actual worseningbecause of the long-term
(21:30):
benzodiazepine prescription.
And as I look at the symptoms ofbind, I've not seen like the
weakness in coordination,difficulty walking.
So, like any of the motorsymptoms for people being on
benzos.
Emotional sleep, I mean, to me,I just interpret those as
anxiety, and I would treat themin the same way with
(21:51):
non-benzodiazepine medicationswhile implementing a slow taper.
Psychiatrists very much are usedto treating symptoms regardless
of what the label we put on itis.
So that would be my generalapproach in general in trying to
taper a benzodiazepine off ofsomeone that has been on it for
(22:11):
years and years.
It's just slow and steady andgive supplemental medications to
help treat any symptoms thatmight arise as we go down on the
dose.
SPEAKER_01 (22:19):
One of my patients described it to me this way He
has a history of multipleaddictions, cannabis, opioids,
benzodiazepines, alcohol.
He's been through a lot, has alot of insight.
He has bipolar disorder and hasa 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 withpancreatitis.
(22:41):
I need to with alcohol, but myanxiety is debilitating.
Could you please give me fourdoses of larze pam a week?
Because I want to work on myanxiety.
And if I have a little bit ofanxiety, I'm gonna work on a
therapist, I'm gonna developsome coping skills, and if my
anxiety gets worse, I'm gonnatry a non-addictive anxiety med.
(23:03):
But when my anxiety is justnuclear and I'm gonna go buy a
bottle of Jack Daniels, I needthat Loraze Pam as just a, okay,
I can take a breath.
And and I thought there was somewisdom there that he's telling
me by only having a few doses aweek, he actually has to
confront and work on hisanxiety.
And I like that idea because Ithink part of where this mind
phenomenon comes from is benzosare very effective at treating
(23:27):
anxiety, but the brain doesn'tlearn any other coping skills
for anything besidesbenzodazipines.
And that's kind of how I thinkabout it.
I'm curious how that resonateswith you.
SPEAKER_00 (23:36):
The general premise I'll use in describing the
frequency of using a benzo fortreating anxiety is if you use
it less days of the week or morethan half the days of the week,
right?
And so the more your body isused to the chronic presence of
a benzodiazepine in thebloodstream, the more it
(23:58):
actually then becomesphysiologically dependent on it,
and the more likely you are torun into issues with withdrawal.
So physiologic dependence aloneis noteworthy, but it's not the
same as addiction.
So physiologic dependence canoccur as a side effect to many
medications, including steroidmedications, beta blockers,
(24:22):
things, anything that causesrebound phenomena upon
withdrawal of the medications.
Whereas addiction is abehavioral disorder, people
changing their behavior andpeople having problems
functioning in their life as theresult of a use of a substance,
which may or may not include anelement of physiologic
dependence.
The four doses premise there,it's right on the line of
(24:44):
physiologic dependence.
Lurazepam is a mid-durationbenzo lasting four to six hours.
So, you know, body does clear itpretty 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 personthat I always have flags that go
(25:05):
up whenever I hear anyabsolutes, you know,
always-never sort of statements.
And so, like if a benzo is inthe system, then the person
can't learn coping skills.
To me, there is an absolutestatement in there, which is
probably not true.
I mean, to me, the goal of abenzo or any fast-acting
medicine for anxiety is to takethe edge off the anxiety, to
(25:25):
reduce it from being somethingthat actually impairs your
functioning, because that is thegoal of any psychiatric
treatment, is to improvefunctioning and to remove any
barriers to good functioning dayto day.
And instead to have just enoughto be able to function, but
they'll still feel some anxiety,but instead of being the 10 out
(25:48):
of 10, it's three out of 10.
And they can at least work onthat three out of 10.
And then if they're good onworking on the three out of 10
anxiety, then they may also findtheir in general, their worst
anxiety is no longer 10 out of10.
Maybe that drops to be more like7 out of 10, you know, and so
the scale recalibrates, andmaybe as their psychological
skills improve and their abilityto manage their anxiety using
(26:11):
psychological skills andtechniques gets better, they may
find that they need the benzoless and less, and maybe then
they can taper off the benzo,right?
Yeah, there's this premise aboutthere's psychiatric medicines in
general, but benzos are probablyone of the best examples of this
of like being a crutch.
But sometimes you need crutches,especially in that acute time
(26:32):
that a person might be firstpresenting for treatment.
They've reached some crisispoint in their lives that's
driving them to treatment.
Maybe they've never had any kindof mental health treatment
before.
We do want to cover them withsupport, which can include a
benzo, very much like a brokenbone, we cover with a cast and
it helps stabilize a person'sbone while it does the healing
(26:53):
and growth from within.
So, likewise, psychologically,medications can be seen as like
a stabilizing force that allowsthem to work on things from
within, and then they may beable to remove them completely.
Or if someone has a geneticpredisposition, a long family
history, I mean, they just haveanxiety the way that some people
(27:14):
have high blood pressure orasthma or any other medical
condition, they may need, theymay function best on
medications, quote,indefinitely, and they might
then be best off just taking itregularly and thinking of it as
a vitamin that they take everyday for optimal functioning.
You know, with the goal beingwith this medicine, you don't
(27:37):
have barriers to functioningoptimally.
There's nothing holding youback.
You can be all that you can beoccupationally, socially, and
everything else, all the otherrealms of a person's life.
SPEAKER_01 (27:48):
Makes good sense.
So let's pivot a little bit andmove on to ADHD.
This is something that Iprobably had the least
experience with from theemergency department.
My first career was emergencymedicine, and then I uh did
addiction medicine because wereally don't see a ton of ADHD
presentations coming into theemergency department.
It's usually just I'm out ofAdderall, can I have a refill,
(28:09):
which always feels great as anER doc.
So talk to me about theintersection between ADHD and
addiction.
SPEAKER_00 (28:16):
Uh ADHD is a huge risk factor for addiction
issues.
ADHD is a crippling disorder forpeople, especially who have
severe manifestations.
It is considered a childhoodonset disorder that can derail a
person's functioning and evendevelopment, if we're thinking
(28:38):
of childhood onset, socially,academically, a lot of different
important ways.
And so it is important toidentify and treat ADHD when you
see it, and it often doespresent in childhood.
If people have milder cases, itmay not be really picked up
(28:58):
until later in adulthood.
Very often, once they get tocollege or graduate school or
need to work in any setting thatrequires ongoing concentration
and organization, or even justadulting nowadays, there's so
much with forms and bills andall this other things that uh we
all have to deal with in modernWestern society.
(29:20):
So ADHD is a huge risk factorfor addiction, should be
treated.
If someone develops an addictionissue before we identify an ADHD
issue, then once we do starttreating the ADHD, we'll always
go with non-stimulantmedications.
So Stratera, also known asadamoxetine, Kelbury is a newer
(29:45):
sort of cousin of Stratera, andoccasionally well-butrined
buproprion can also be used totreat ADHD.
So if a person has a history ofaddiction, then we always go
with the non stimulants first.
If a person does not have ahistory of addiction, stimulants
are considered the first linetreatment.
(30:05):
They do have one of the highesteffect sizes of any medication
in psychiatry.
They are highly successful andwell tolerated for people that
don't have histories ofaddiction.
SPEAKER_01 (30:17):
So we got lots to unpack here because I have a
number of patients that tell meI use methamphetamine because it
calms me down.
And if they had told me thatfive years ago, I would have
told them they were liarsbecause I didn't realize that
when we give hyperactive peopleamphetamines, it helps them
focus.
I have one patient, I just sawher this week, and she had
(30:38):
significant educational issuesand she had to have an
individualized learning plangoing back to middle school,
wasn't able to finish highschool because of severe
learning issues.
And I asked her whatmethamphetamine did for her, and
she goes, Oh, it was my thinkingcap.
I could get more done, I couldpair my kids.
And I was like, Oh, how's yourADHD?
And she had never been diagnosedwith it, unfortunately.
So I use five non-addictive ADHDmeds in my practice, and I think
(31:00):
it's probably the same foreverybody, right?
So it'd be proprienorwell-butrined, adamoxetine or
Stratera, Viloxazine or Calbury,Guanthazine, I think the brand
name is Intunive, and thenClonidine or CAVE.
I know how I've used them, butI've worked a lot of this out on
my own.
Can you give me a sense ofwhat's the right patient to
choose for each one of thosefive?
SPEAKER_00 (31:21):
The last two, Intunive and CapVey, actually
have the best data supportingtheir use in kids and
adolescents.
So not quite as much adults.
It doesn't mean it can't helpadults, but it just hasn't
really been shown to be aseffective in adult patients.
They are better at treatinghyperactivity, which is more a
(31:42):
hallmark of ADHD in kids andadolescents as opposed to
adults.
Adults tend to have more of theinattention symptoms.
But to treat ADHD, if they havecomorbid depression or cigarette
smoking or nicotine use thatthey want to address, then yeah,
well butrin is a great choice.
(32:02):
I mean, in general, well butrinis one of my favorite
antidepressants to prescribebecause it helps with energy and
motivation and doesn't have alot 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, soinsurance always approves it.
(32:23):
Calbury, I would go to as asecond choice just because most
insurance companies wouldrequire evidence of the failure
on Stratera to justify payingfor it.
SPEAKER_01 (32:33):
In our practice, we have five addiction docs.
We're very proud of our littlecommunity-based clinic with five
addiction medicine docs.
We just put together a protocolfor the management of ADHD with
comorbid stimulant addiction.
We do have an approach thatwe're taking around starting
stimulants for people who haveADHD and are in recovery from
stimulant addiction.
(32:53):
And our go-to is usually Vivans,just because it is a pro-drug
and therefore has a lower riskof misuse.
But talk to me about how you, asan addiction psychiatrist,
approach using stimulants forpeople with ADHD and stimulant
addiction who have failed thenon-stimulant meds.
SPEAKER_00 (33:10):
Sure.
So yeah, and also as you weretelling the story about your
patient with uh methamphetaminebeing a thinking cap.
Fun fact, many people don'tknow, including physicians, that
methamphetamine actually is anFDA-approved medication.
It's given orally as a pill, soit does behave much differently
using that route than the waythat people might abuse
(33:32):
methamphetamine.
SPEAKER_01 (33:34):
One funny point on that.
On a night shift once, when Iwas a little baby new attending,
someone came in and they said, Ineed to refill in my psych meds.
I need desoxin.
Right.
And I got desoxin anddissiparamine mixed up.
And so I wrote a refill and thepharmacy called, Why are you
writing for methamphetamine?
And I looked it up and I wasjust so yes, I'm aware that we
can prescribe methamphetamine.
(33:55):
Please go ahead.
SPEAKER_00 (33:55):
So I don't prescribe that ever, by the way.
That makes two of us.
And I think pharmacies don'tlike stalking it either.
So but people with stimulantaddiction, again, Stratera
Calbury first.
And then I'll often go toprovigil, modafinel, or new
vigil, which you know it's ahistamine agonist, right?
(34:17):
So if you think ofantihistamines like Benadryl
being sedating, this is ahistamine stimulating
medication, which is activating.
So it is considered wakefulnesspromoting agent.
The official FDA indications arenarcolepsy, shift work sleep
disorder, and fatigue associatedwith sleep apnea.
It's sometimes covered as anantidepressant augmentation as
(34:40):
well, even though that's not anofficial FDA-approved
indication.
Insurance doesn't love payingfor it, so that's just the one
drawback.
But honestly, I have never seena pro-vigilal, new vigil,
modafinyl, or armodapinyl abuseissue.
And there are actually somestudies showing that it can
actually help with stimulantdependence as well, in being a
(35:04):
lower potency stimulatingmedication that can maybe take
away craving for stimulants too.
So that is one type ofmedication that I'll often go to
before getting into the quotereal stimulants.
Vivance is a good one.
It's long-acting.
It is an amphetamine, though.
So I tend to prescribemethylphenidate products first.
(35:29):
And the standard algorithms fortreating ADHD actually encourage
the use of methylphenidate firstbecause it is better tolerated,
it's gentler, it's less likelyto trigger anxiety, especially
if people have had issues withanxiety first.
So I tend to go with themethylphenidate.
To me, the analogously safeversion of methylphenidate is
(35:49):
concerta, which is an extendedrelease coated pill that
actually needs to be swallowedfor the medication to come out.
It can't really be crushed andsnorted in the way that
immediate release methylfenidateor Ritalin can be.
If not, though concerta thatdoesn't work, let's say not
strong enough, then yeah, I'lldefinitely go to Vivance, which
(36:13):
is a great medication.
Not without risk.
I have seen people with Vivanceissues where the problem tends
to be they take more thanprescribed.
And I've even seen people thattake two or three hundred
milligrams of Vivance daily.
So it's not common, but it'salso not risk-free.
SPEAKER_01 (36:31):
Yeah, my friends at the Addiction Medicine Journal
Club podcast just covered astudy on that.
I don't know if you found theirpodcast.
Two addiction docs inPennsylvania have a great
evidence-based podcast.
Where was it?
Here we go.
May 26th, episode 60 of theAddiction Medicine Journal Club
LizDexamphetamine.
That's the generic name ofVivands for methamphetamine use
(36:52):
disorder.
And there was a study looking atfairly high doses of Liz
dexamphetamine to try to reducethe 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 patientpleaser.
There was high satisfaction withthe treatment protocol, but it
didn't actually treatmethamphetamine use disorder
that well.
SPEAKER_00 (37:11):
Right, right.
SPEAKER_01 (37:12):
I found that study very interesting.
SPEAKER_00 (37:14):
Yeah.
Yeah.
There's not great evidence.
There's equivocal evidence onthe role of stimulants to
actually treat stimulantdependence.
SPEAKER_01 (37:23):
My understanding is it's because the amount of
stimulant people can get buyingmethamphetamine from the illicit
market is just so much higherthan we can prescribe.
And my understanding is ifsomebody uses methamphetamine
and then we try to put them on,say Adderall, it's like less
than a tenth of the dose they'regetting from the illicit market.
SPEAKER_00 (37:41):
Yeah, I could well be, sure.
SPEAKER_01 (37:43):
Yeah.
Okay.
Is there any other conditionthat you think would be useful
to call out in terms of acomorbid mental health condition
along with addiction?
SPEAKER_00 (37:51):
Insomnia is a big one.
So yeah, similar strategies I'llemploy, trazidone being the
first choice of a medicationthat has no habit forming
potential, very safe, welltolerated, often effective for
treating insomnia.
If we even think about reasonspeople might use certain
(38:13):
substances, especially alcohol,like a lot of it is to treat
their own insomnia.
So yeah, whenever I see like aself-medication tendency in a
person, then I'll try to talk tothem about how their attempt,
while well-intentioned, isactually not the best choice.
And maybe now they've developedan alcohol problem and instead
(38:33):
try this medication that's nothabit-forming and can help with
insomnia.
Yeah, Remron is another one thathas more antidepressant
activity.
It does stimulate appetite, sothey either have to want some
weight gain or have it notbother them if they do gain some
weight.
And Cerequel often is the thirdone.
If those two don't work, thenCerequel usually does, but it
(38:58):
can be very weight-gaining forfolks too.
There is a new class ofmedicines for insomnia, the
DORAS, the dual orexin receptorantagonists, which include
Belsamra, Day Vigo, QV, andthose while technically a
schedule five substance, so theDEA does regard it as having
(39:21):
abuse potential.
The reason that it's Schedule 5is more so like drug likability,
like that's one of the aspectsthat they'll use to consider if
a medicine should be scheduled.
So people like taking it.
I can also tell you, I've neverseen a person develop an
addiction issue to any of theDora medications.
(39:42):
So I'll go to that class if thestandard sort of trazenone
seroquil don't work for aperson.
And they very often do work.
You they usually have to bedosed at the max doses.
So like balsamara is 20milligrams.
That's often what I'llprescribe.
That actually does help in away, and it's well tolerated.
And it often doesn't lead tosedation the next day.
(40:06):
People often ask, is this gonnamake me groggy the next day?
I always tell them that's adose-related response with the
right choice of medicine.
It'll work to help you fallasleep, stay asleep.
But ideally, your body is brokenmost of it down in the morning
so you could wake up feelingrefreshed and start your day.
So yeah, that tends to be thetype of medicine that I'll
(40:26):
prescribe, sort of a secondchoice.
You use much Remelteon?
I do.
It's not quite sedating.
It's I I think it is analogousto melatonin.
It is a melatonin stimulatingmedication.
So it is milder.
It does help some people.
It's just it's not gonna putthem down in a way that like
trazodon seroquel or even any ofthe DORAs will, and that's often
(40:50):
what people are seeking and andalso the need for treatment of
insomnia.
SPEAKER_01 (40:56):
With somebody who has bipolar disorder, do you
worry about trazodone or remroncausing mania?
They are technicallyantidepressants.
SPEAKER_00 (41:05):
Yeah, technically they are.
I've never actually seen a caseof either one causing mania.
If someone has a history ofbipolar disorder, I'll often
then just go to CerroQL first ora senopene sapphorous is
actually another sedating secondgeneration atypical medication
(41:26):
like Cerquel that does not haveweight gain associated with it.
So that is actually a reallygood choice for people with
bipolar two and bipolar also,whether it's type one or type
two.
And it really does help a lot ofpeople with mood stability too,
in a way that CeroQL doesn't,because Ceracol actually needs
to be dosed at 400 milligrams ormore to have anti-manning
(41:48):
properties.
SPEAKER_01 (41:48):
That was a good catch.
It's bipolar, also, not bipolartoo.
Well played.
Well, I was gonna say this hasbeen a fascinating conversation.
Anything we missed?
SPEAKER_00 (41:57):
In general, I certainly encourage people to
get assessed for anything thatresembles a mental health issue.
There is a lot of stigma, as wediscussed, with mental health
treatment.
And it does not need to bemental health issues or as much
medical issues as physicalissues like high blood pressure
(42:18):
or asthma.
And if the concept of takingmedicines is averse to you, then
you don't even have to commit tothat too.
It all starts with one visit andassessment where you speak with
a psychiatrist that actuallytreats issues that you might
have, and you can at least knowwhat your options are.
In psychiatry, most of theissues can also be treated with
(42:39):
therapy, too.
So even just getting anassessment with a referral to
therapy is often the best placeto start, and then medications
can always be reassessed lateron.
SPEAKER_01 (42:49):
Well said.
Anything you've got in the nearfuture that you're working on?
Projects, new protocols, newtreatment pathways?
SPEAKER_00 (42:56):
A lot of my project in our office is working on the
ketamine therapy work.
Even though we started thatprogram six years ago, there's
just uh constant protocols thatstill need to be created.
We are creating a lot of goodthings.
In our office, we do incorporatepsychotherapy with ketamine
treatment, but also offer justthe standard evidence-based IV,
(43:19):
no therapy type of treatment,too.
So I definitely see a newchapter in psychiatry opening up
where a number of psychedelicsare actually being studied and
will be coming soon topsychiatry in the next few
years.
And our work with ketamine, inmy mind, is representative of
the type of work that we'll bedoing with other analogous
(43:41):
medications in the future.
SPEAKER_01 (43:43):
Just one point on that, and please correct me if I
misunderstand this.
My understanding of the use ofketamine to treat a mental
health condition is it rapidlyimproves things like mood and
suicidality to allow otherthings like antidepressants and
therapy to work.
Because my patients come in,particularly the ones that use
(44:04):
multiple substances, and I getsomething to the effect of, hey,
doc, I want to do a bunch of Kand I'll get sober.
And that just seems to not quitebe how it's meant to be done.
I'm just curious as to yourthoughts.
SPEAKER_00 (44:15):
Yeah.
So doing K is in the column ofdrug use.
Right.
And there is the big differencebetween drug use and medication
treatment.
The contexts are different.
And an exactly analogousconversation could be had with
the use of ketamine and peoplewho may have had issues with
addiction too.
Ketamine can be used to getpeople out of the most severe
(44:37):
holes in depression.
It does work for suicidalthinking and behaviors.
Sprovato, which is the onlyactually FDA-approved form of
ketamine, does have an officialFDA indication for treating
suicidality even outside ofdepression.
But sprovato actually alsorecently picked up an FDA
indication as a maintenancetreatment for depression, too.
(44:59):
So ketamine is anantidepressant, happens to be
one that also works quickly andhas a strong anti-suicide
benefit, which is something thatmany of the traditional oral
antidepressants don't have.
And so I see roles for ketaminein all of the above, and also
(45:19):
augmenting psychotherapy.
People, when they receiveketamine, do go to a different
place.
They have a differentperspective on things, their
lives, and even traumas.
And so there's a potential roleand a lot of research interest
in psychedelic assistedpsychotherapy as well.
And ketamine is definitely apart of that.
SPEAKER_01 (45:40):
Well said.
Well, I have to say, Mark, Ifeel a lot better.
A lot of the things that Ithought I was doing on my own,
you've reaffirmed that a lot ofthe stuff I've been doing is is
actually okay.
And I appreciate your expertiseand wisdom on going through the
therapeutic medications we havefor mental health as it relates
to treating addiction.
SPEAKER_00 (45:58):
Yeah, thank you very much.
It's been great talking to you,and thanks for having me on your
show.
SPEAKER_01 (46:04):
Before we wrap up, a huge thank you to the Montage
Health Foundation for backing mymission to create fun, engaging
education on addiction.
And a shout out to the nonprofitCentral Coast Overdose
Prevention for teaming up withme on this podcast.
Our partnership helps me get theword out about how to treat
addiction and prevent overdoses.
(46:26):
To those healthcare providersout there treating patients with
addiction, you're doinglife-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 winwithout awareness and action.
There's still so much we can doto improve how addiction is
treated.
Together, we can make it happen.
(46:47):
Thanks for listening.
And remember, treating addictionsaves lives.
Welcome to the Addiction Medicine Made Easy
Podcast.
Hey there, I'm Dr.
Casey Grover, an addictionmedicine doctor based on
(00:20):
California's Central Coast.
For 14 years, I worked in theemergency department seeing
countless patients strugglingwith addiction.
Now I'm on the other side of thefight helping people rebuild
their lives when drugs andalcohol take control.
Thanks for tuning in.
Let's get started.
Today's episode is on theintersection between mental
(00:43):
health and addiction.
This is an interview with Dr.
Mark Reimach, who is anaddiction psychiatrist, and we
discuss how mental healthconditions affect patients with
addiction and what medicationscan be used to treat those
mental health conditions inpatients with addiction.
You might have heard the termdual diagnosis or co-occurring
(01:05):
disorders.
These are the terms used bymedical providers when
describing a patient who hasboth a mental health condition
and a substance use disorder.
When I first started as anaddiction medicine doctor, I
focused on using medications toreduce the desire for drugs and
alcohol.
For example, I prescribed a lotof naltterexone to patients with
(01:26):
alcohol use disorder.
And I would wonder why for somepatients it didn't really work.
And then I asked them why theydrank, and they would tell me
that they had horrible insomniaand anxiety.
Oops.
They weren't drinking for theeuphoria.
They were drinking because theirbrain wanted the downer effect
from the alcohol to deal withanxiety and insomnia.
(01:47):
So then I started to learn thatI had to identify comorbid
mental health conditions in mypatients with addiction and
treat those too.
Dr.
Reimach and I had a fantasticconversation, and I hope you
find it helpful.
One quick point before we start.
I usually try to use the genericnames of medications on my
podcast, but often the brandnames are easier to say and are
(02:09):
more well known.
We ended up using mostly brandnames for medications during
this discussion.
Here we go.
All right.
Good morning.
Happy Friday.
Why don't we start by telling uswho you are and what you do?
SPEAKER_00 (02:24):
Sure.
I'm Mark Reimach.
I'm a psychiatrist.
I specialize in addiction.
I also started a grouppsychiatric practice, and we
have a number of psychiatristswith various specialties that
treat people with medicationstherapy.
And we also have a ketaminetherapy program within our
(02:44):
office as well.
SPEAKER_01 (02:46):
Very nice.
So I'm board certified inaddiction medicine, and you do
addiction psychiatry.
What's the difference?
SPEAKER_00 (02:54):
The addiction psychiatry is considered a
sub-specialty of psychiatry.
So I did a four-year psychiatricresidency and then a one-year
addiction psychiatry fellowshipafter that.
So that's a training programwhere basically we approach
addiction treatment from apsychiatric angle, which
includes a lot of common groundwith the way addiction medicine
(03:16):
approaches it.
So we do detoxes, I do detox onan outpatient basis, commonly
work with anti-cravingmedications, but we also do
therapy or work with therapistswho are doing therapy in
parallel to medicationmanagement that we might be
doing with a certain patient.
SPEAKER_01 (03:34):
So I'm going to pick on mental health providers.
Oftentimes I refer my patientsfor mental health services,
whether it be a psychologist, anLMFT, or a psychiatrist, and
they tell me I can't treat thisperson because they have active
addiction.
Right.
And the way I look at it as anaddiction doctor is I don't have
that luxury.
Their depression and theiralcohol are so intertwined, it's
(03:56):
hard to know which is which andwhich came first, but I need
them to stop drinking.
Can you talk to me about howyou, as an addiction
psychiatrist, approach thingslike substance-induced mood
disorders, whereas yourcolleagues might say, get sober
and then I'll see you?
SPEAKER_00 (04:11):
Yeah, that's a pet peeve of mine, also.
The concept being like cherrypicking your patients.
I actually don't think that'sethically correct.
It is reflective of a moreconservative attitude and
probably a stigmatizing attitudeabout addiction as a disorder,
(04:32):
also.
You know, I think thankfully,with each decade, we're making
more and more progress, evenwithin the healthcare field, on
how we regard addiction and howwe treat patients with addiction
issues.
One of the premises of addictionpsychiatry is we treat the
person where they are.
And so if they have addictionissues, we come up with a
(04:53):
treatment plan for that.
If they have comorbid mentalhealth issues, which is actually
much more the rule than theexception, then we also address
those.
Personally, I also believe thatevery person at least deserves
an evaluation.
I might not be able to continuetreating you if your disorder,
whether it's addiction or mentalhealth, is so severe that it
(05:13):
might require, let's say,residential treatment or even
hospitalization for detox orsome other psychiatric
stabilization.
But once you are stable andappropriate to participate in
outpatient treatment, which is asetting that I work in, then you
know I'm I'm happy to treat you.
So I also have a belief that anyeveryone at least deserves an
evaluation to know like wherethey are and what the next step
(05:36):
should be, which might not bestaying with me, at least not
for the next few months anyway.
SPEAKER_01 (05:41):
You and I think exactly the same way on that.
I think my number one prescribedmedications are probably
clonidine, properanolol, andSSRIs or SNRIs.
Again, those are selectiveserotonin reptake inhibitors and
serotonin norepinephrine reptakeinhibitors.
I came into addiction medicinethinking that everybody needed
naltrectone.
And I clearly was missing themental health component as I
(06:04):
started.
And from my personal livedexperience, I got diagnosed with
post-traumatic stress disorderlast year as a part of my work
in the emergency department.
And living with a post-traumaticstress disorder has changed my
perspective entirely on how Itreat my patients with
addiction.
And PTSD and addiction seems tobe one of my niches now, given
(06:24):
my lived experience.
The famous addiction doctor, Dr.
Gabor Mate, says that all peoplewith addiction have been
traumatized.
What percentage of your patientswith addiction would you
estimate have comorbid PTSD?
SPEAKER_00 (06:36):
I mean, honestly, I'd say all people have been
traumatized in some way.
You know, there's a spectrum oftrauma.
We've all had tough experiences.
Part of the human condition isnegative experiences, things
that teach us to avoid certainpeople, places, things, let's
say.
But some of us also have hadexperiences that lead to like
(06:58):
even a formal diagnosis ofpost-traumatic stress.
So as you're asking me thatquestion, 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 otheranxiety disorders or insomnia.
So all of these are possible andthey all often present together.
SPEAKER_01 (07:21):
Yeah.
So we obviously do not live inan ideal world, given that
health insurance dictates a lotof what we can do.
But if you were practicingmedicine in an ideal world, how
would you approach the patientwith comorbid PTSD and
addiction?
Let's say it's alcoholaddiction.
SPEAKER_00 (07:35):
Parallel treatment and parallel treatment plans for
the substance issue, so alcoholand then the mental health
issue.
So from the alcohol perspective,we establish if someone has a
physiologic dependence onalcohol, if you know we
encourage them to stop drinkingand they actually do cold turkey
stop, does that cause any riskof seizure or any other
(07:57):
problematic withdrawal symptoms?
And then also other aspects ofalcohol treatment can be some
type of psychosocial treatment,so AA or therapy, individually,
you know, what have you, butjust so someone can work on
things from a psychologicalperspective.
And then, yeah, the PTSD part ofthings, very often an SSRI is
(08:20):
helpful.
PTSD ultimately is a type ofanxiety disorder, and SSRIs are
considered a first-linetreatment for anxiety.
And then therapy helps theretoo.
So ideally, they have atherapist that can both treat
trauma and the mental healthpart of things as well as the
addiction part of things.
SPEAKER_01 (08:40):
Do you use much of propranololol or clonidine for
triggering in your PTSDpatients?
SPEAKER_00 (08:46):
I actually use a lot more prososin at bedtime for
nightmares associated with PTSD.
I might go to clonidine as asecond choice if prosocin does
not seem to be strong enough.
Clonidine I use much more oftenas a treatment for opioid
withdrawal because it is prettypotent.
It can drop blood pressure andcause dizziness, lightheadedness
(09:11):
at times.
But yes, I also prescribe a goodamount of propranolol, also
gabapentin and hydroxazine.
To me, those are the three mainnon-benzodiazepine, so non-habit
forming, but still fast-actingmedications for anxiety.
SPEAKER_01 (09:28):
Do you have a particular preference among the
SSRIs as which ones you use mostoften?
SPEAKER_00 (09:33):
I tend to start with either Zoloft or Lexapro,
primarily because those havebeen shown to have a lower side
effect profile, but not by much.
I mean, honestly, the SSRIs aremuch more similar to each other
than different.
And if someone has a strongbelief that Prozac is going to
help them because two of theirsiblings are on Prozac and
(09:54):
they're doing great, you know,we actually do try to take
advantage of the placebo effectin psychiatry.
You know, a person's expectationabout how well a medicine is
going to work can actually beresponsible for a third of
people benefiting, is what theresearch shows.
So I'll happily prescribe anySSRI that a person really
believes in because they're allmuch more similar to each other
(10:16):
than different.
Usually after a person hasfailed two different SSRIs, or
if they have a comorbid paindisorder, SNRIs are good for
that.
Or if they have a depressionassociated with fatigue, SNRIs
(10:36):
can be more activating.
So those might be reasons thatan SNRI might be higher on my
list.
The only downside of SNRIs isthat they are notoriously
difficult to come off of.
And not very difficult.
I successfully take people offof SNRIs all the time, but you
(10:56):
do need a specific plan.
You can't just take a person offover the course of one week,
especially if they've been on ahigh dose SNRI for years.
It might need to be tapered overthe course of a few months.
SPEAKER_01 (11:07):
One thing you didn't mention on your list of meds
around anxiety that arenon-addictive is busporone.
Any reason why that medicationdidn't come up on your list?
SPEAKER_00 (11:15):
Well, the list I gave you was the fast-acting PRN
meds, whereas Busperone is onethat I use as the daily
preventative type of treatment.
So yeah, in treating anxietywith medications, there's two
main arms of treatment.
One is like the fast acting asneeded approach, and the other
is like the daily foundational.
(11:36):
You know, it takes a while tobuild up, but then it actually
helps prevent the formation ofanxiety or just globally reduce
anxiety in your emotionalclimate.
So I actually do prescribe agood amount of Busperone.
Uh it's got a bad reputation fornot being effective, but I
honestly find that people justdon't dose it aggressively
(11:57):
enough.
10 milligrams three times a day,like the standard starting dose,
doesn't often help people.
I always go up to 23 times aday, which is actually the
FDA-approved max on Busparone,and we do get benefit there.
And then if there is benefitwith no side effects, which is
often the case with that dose ofbuspar, then I'll even go up to
(12:18):
90 milligrams a day on that.
SPEAKER_01 (12:19):
I did not know that.
SPEAKER_00 (12:21):
Yeah.
SPEAKER_01 (12:21):
Some of my colleagues in Australia have
been in correspondence with meabout the combination of
naltrexone and baclefin foralcohol addiction, particularly
when there's comorbid anxiety.
Any experience with bacclefinwhen you have comorbid anxiety
and let's say alcohol addiction,but really in general?
SPEAKER_00 (12:39):
Baclefin in my mind belongs to a class of
medications that have someanecdotal evidence, some case
reports, but not a whole bunchof great research supporting its
use.
So, yeah, baclefin is there,topiramate is there, zofran, I
think also has some evidence foralcoholism.
(13:00):
I don't use a lot of baclefin.
I've used it a handful of times.
I've not seen it all thathelpful.
I interview patients all thetime.
I've never heard it as beingpivotal in a person's recovery,
not the way that naltrexone hasor even an abuse has.
So I tend not to prescribe a lotof baclefin.
(13:22):
And recently I actually had apatient that seemed to have a
baclefin abuse issue where shewas already above the FDA
approved max and then takingmore and only escalating doses.
So I have a recent, evenstronger aversion to baclefin,
personally.
That's just my my experience.
SPEAKER_01 (13:41):
Yeah, I did a podcast episode on it maybe 18
months ago, two years ago, andthe data's really conflicting.
There are some positive studiesand then there are some neutral
studies.
Yeah.
So we've been hinting a lot atanxiety.
So we've covered PTSD withcomorbid substance use disorder.
Talk to me about how youapproach the patient with
comorbid anxiety and addiction.
SPEAKER_00 (14:01):
Similar to what I was saying, yeah, with the two
arms of treatment, the alcoholtreatment plan and the anxiety
one.
Anxiety, especially likegeneralized anxiety, is much
more of what I'll see comorbidwith alcoholism than even PTSD.
But the strategies are similar.
(14:22):
PTSD is an anxiety disorder.
So again, the daily preventativemed, which could be an SSRI or
BUSPAR or Remron mertazepine isnice if they aren't sleeping,
aren't eating, and anxiousbecause Remron can actually help
all three.
And then the fast acting asneeded option of either
(14:45):
Galbapatin, hydroxizine,papranolol tends to be what I do
from the medication perspective.
SPEAKER_01 (14:51):
Is there anything else unique to generalized
anxiety disorder with comorbidsubstance use outside of PTSD?
Anything different?
SPEAKER_00 (14:59):
I mean, honestly, not really.
Anxiety disorders in general, Ithink of as on a spectrum, going
from generalized, which meanslow grade, or significant
anxiety a lot of the day or mostof the day.
So just speaks to itspresentation throughout the day,
versus like acute and episodic,with panic attacks being the
(15:20):
example of that end of thespectrum.
So sometimes we just need to paymore attention to preventing
that ongoing daily, day-longtype of anxiety versus something
that maybe putting more emphasisif someone has panic disorder on
putting down anxiety, the panicwhen it starts, or even noting
when it's building up to arrestthat self-building cycle that
(15:44):
panic often presents with.
So that might be where thestrategy differs.
But yeah, I'd say that's stillthe general spectrum.
SPEAKER_01 (15:52):
I'm going to ask this question fully knowing it's
a loaded question, and I'mcurious as to how you respond.
What are your thoughts onbenzodiazepines in patients with
anxiety disorders with comorbidaddiction?
SPEAKER_00 (16:02):
It's a good question.
And there are analogousquestions with controlled
substances being used to treatADHD or insomnia.
SPEAKER_01 (16:12):
We're going to get there.
SPEAKER_00 (16:13):
Yeah, that's great.
So yeah, look, the cleantextbook answer is always avoid
benzos.
You know, there's no risk of anybenzo problems if you don't
prescribe a benzo, right?
So the only way to really reducerisk to zero is to just avoid it
completely.
I am a psychiatrist, I treataddiction, I see a lot of tough
(16:38):
cases.
And I also see people that havetried the gabapatin visceral
proprianol route, and it'shelped maybe half of their
anxiety, but there's still agood amount left.
And maybe they've already had ahistory of being treated with a
benzodiazepine and just neverdeveloped a problem with them in
(17:03):
general, in looking at the riskpotential of various
benzodiazepines.
The longer acting something is,the less addictive it is.
So the longest acting benzos areclonopin, valium.
So those are the ones I wouldlean towards with Xanax being
notorious for having the highestabuse issues, and therefore I
(17:26):
don't really prescribe Xanax inaddiction patients.
I do think that's basically likeasking for trouble.
Honestly, a lot of times if theyhaven't had alcohol as a
problem, benzos are more likelyeven to be okay because benzos
work on the GABA receptor,alcohol works on the GABA
receptor.
But I also have a good amount ofpatients who've had issues with
(17:48):
alcohol, and and maybe eventhey've had issues with Xanax in
the past, but yet they canhandle like a prescription of
clonopin 0.5 milligrams twice aweek.
The intermittent use is alwaysfavorable to the chronic daily
use, too.
So again, it's just layers ofrisk.
And the goal in general inaddiction treatment, in a lot of
(18:11):
ways, is harm reduction.
And so we do a risk assessmentand the physician oath of do no
harm.
So we try to do no harm.
We monitor for potential harm ifwe are considering a certain
path.
And we gauge the patient too.
How much do they understand theharm?
Do they have a healthy respector a healthy fear of this
medication?
I mean, honestly, I see a lot ofpeople in recovery, especially
(18:35):
like solid multi-year recovery,that they themselves are anxious
about taking a benzo.
And they may not even like itwhen I bring it up for the first
time.
You know, and honestly, I lovethat dynamic, that presentation,
because it means they alreadyhave this protective factor
built within them where ifthey're anxious about getting
(18:59):
hooked on a benzo.
I can't remember the last time Isaw a person actually develop an
issue with the benzo if theycome in to the treatment with
that mindset about benzos.
SPEAKER_01 (19:09):
So I didn't know about bind until maybe three or
four months ago when one of mypatients was looking on Reddit
as to why he felt so weird afterhe was taking a friend's Xanax.
And I actually don't know if hehad BIND just because he'd only
been on it for like a month orso.
But BIND beingbenzodazipine-induced
neurological dysfunction.
(19:29):
What are you seeing in yourpractice around this?
SPEAKER_00 (19:32):
Yeah, actually, I had not heard that acronym BIND,
if it might refer to like peopledeveloping issues with being on
it for years and thenparesthesias and things like
that.
SPEAKER_01 (19:42):
I came to it on my own.
You're obviously familiar withthe term opiate-induced
hyperalgesia.
Yeah.
Right.
And the way I was seeing it is Iwas seeing all of these patients
that had been on benzos somelonger than I'd been alive.
And they just had incredibleanxiety, minimal emotional
resilience, horrible insomnia.
(20:02):
And I was going to coin the termbenzodazipine-induced emotional
fragility.
I'll see these folks on fourmilligrams of clonazepam a day,
and they're like, Doc, I'm soanxious.
And I'm just thinking, what am Imissing?
And so there's been some recentnaming of this phenomenon of
some of the chronic changesaround emotional resilience
after being on benzodazines formany years, and this particular
(20:25):
term has come up.
I looked on open evidence.
I don't know if you use openevidence, but I love it, right?
The way I discovered to mypatients is you combine the
power of AI with the NationalLibrary of Medicine, and I can
get an evidence-based answer in30 seconds.
So I searched on open evidence,and yes, there's some signal
there around bind.
I'm assuming you've seen thisphenomenon, maybe just not heard
that name.
SPEAKER_00 (20:44):
Yeah.
First of all, if a person is ona benzodiazepine for long-term
use, it actually means that theyhave had a severe anxiety
disorder such that physicians inthe past have justified
prescribing benzos in an ongoingway.
So I do think they represent themost severe subset of anxiety
(21:07):
patients.
And so I definitely see peoplewith bad anxiety disorders that
then want to come off of benzosand then have difficulty doing
that.
Yeah, there could be a questionas to how much is just their
underlying anxiety coming backup as the benzos are reduced
versus any actual worseningbecause of the long-term
(21:30):
benzodiazepine prescription.
And as I look at the symptoms ofbind, I've not seen like the
weakness in coordination,difficulty walking.
So, like any of the motorsymptoms for people being on
benzos.
Emotional sleep, I mean, to me,I just interpret those as
anxiety, and I would treat themin the same way with
(21:51):
non-benzodiazepine medicationswhile implementing a slow taper.
Psychiatrists very much are usedto treating symptoms regardless
of what the label we put on itis.
So that would be my generalapproach in general in trying to
taper a benzodiazepine off ofsomeone that has been on it for
(22:11):
years and years.
It's just slow and steady andgive supplemental medications to
help treat any symptoms thatmight arise as we go down on the
dose.
SPEAKER_01 (22:19):
One of my patients described it to me this way He
has a history of multipleaddictions, cannabis, opioids,
benzodiazepines, alcohol.
He's been through a lot, has alot of insight.
He has bipolar disorder and hasa 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 withpancreatitis.
(22:41):
I need to with alcohol, but myanxiety is debilitating.
Could you please give me fourdoses of larze pam a week?
Because I want to work on myanxiety.
And if I have a little bit ofanxiety, I'm gonna work on a
therapist, I'm gonna developsome coping skills, and if my
anxiety gets worse, I'm gonnatry a non-addictive anxiety med.
(23:03):
But when my anxiety is justnuclear and I'm gonna go buy a
bottle of Jack Daniels, I needthat Loraze Pam as just a, okay,
I can take a breath.
And and I thought there was somewisdom there that he's telling
me by only having a few doses aweek, he actually has to
confront and work on hisanxiety.
And I like that idea because Ithink part of where this mind
phenomenon comes from is benzosare very effective at treating
(23:27):
anxiety, but the brain doesn'tlearn any other coping skills
for anything besidesbenzodazipines.
And that's kind of how I thinkabout it.
I'm curious how that resonateswith you.
SPEAKER_00 (23:36):
The general premise I'll use in describing the
frequency of using a benzo fortreating anxiety is if you use
it less days of the week or morethan half the days of the week,
right?
And so the more your body isused to the chronic presence of
a benzodiazepine in thebloodstream, the more it
(23:58):
actually then becomesphysiologically dependent on it,
and the more likely you are torun into issues with withdrawal.
So physiologic dependence aloneis noteworthy, but it's not the
same as addiction.
So physiologic dependence canoccur as a side effect to many
medications, including steroidmedications, beta blockers,
(24:22):
things, anything that causesrebound phenomena upon
withdrawal of the medications.
Whereas addiction is abehavioral disorder, people
changing their behavior andpeople having problems
functioning in their life as theresult of a use of a substance,
which may or may not include anelement of physiologic
dependence.
The four doses premise there,it's right on the line of
(24:44):
physiologic dependence.
Lurazepam is a mid-durationbenzo lasting four to six hours.
So, you know, body does clear itpretty 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 personthat I always have flags that go
(25:05):
up whenever I hear anyabsolutes, you know,
always-never sort of statements.
And so, like if a benzo is inthe system, then the person
can't learn coping skills.
To me, there is an absolutestatement in there, which is
probably not true.
I mean, to me, the goal of abenzo or any fast-acting
medicine for anxiety is to takethe edge off the anxiety, to
(25:25):
reduce it from being somethingthat actually impairs your
functioning, because that is thegoal of any psychiatric
treatment, is to improvefunctioning and to remove any
barriers to good functioning dayto day.
And instead to have just enoughto be able to function, but
they'll still feel some anxiety,but instead of being the 10 out
(25:48):
of 10, it's three out of 10.
And they can at least work onthat three out of 10.
And then if they're good onworking on the three out of 10
anxiety, then they may also findtheir in general, their worst
anxiety is no longer 10 out of10.
Maybe that drops to be more like7 out of 10, you know, and so
the scale recalibrates, andmaybe as their psychological
skills improve and their abilityto manage their anxiety using
(26:11):
psychological skills andtechniques gets better, they may
find that they need the benzoless and less, and maybe then
they can taper off the benzo,right?
Yeah, there's this premise aboutthere's psychiatric medicines in
general, but benzos are probablyone of the best examples of this
of like being a crutch.
But sometimes you need crutches,especially in that acute time
(26:32):
that a person might be firstpresenting for treatment.
They've reached some crisispoint in their lives that's
driving them to treatment.
Maybe they've never had any kindof mental health treatment
before.
We do want to cover them withsupport, which can include a
benzo, very much like a brokenbone, we cover with a cast and
it helps stabilize a person'sbone while it does the healing
(26:53):
and growth from within.
So, likewise, psychologically,medications can be seen as like
a stabilizing force that allowsthem to work on things from
within, and then they may beable to remove them completely.
Or if someone has a geneticpredisposition, a long family
history, I mean, they just haveanxiety the way that some people
(27:14):
have high blood pressure orasthma or any other medical
condition, they may need, theymay function best on
medications, quote,indefinitely, and they might
then be best off just taking itregularly and thinking of it as
a vitamin that they take everyday for optimal functioning.
You know, with the goal beingwith this medicine, you don't
(27:37):
have barriers to functioningoptimally.
There's nothing holding youback.
You can be all that you can beoccupationally, socially, and
everything else, all the otherrealms of a person's life.
SPEAKER_01 (27:48):
Makes good sense.
So let's pivot a little bit andmove on to ADHD.
This is something that Iprobably had the least
experience with from theemergency department.
My first career was emergencymedicine, and then I uh did
addiction medicine because wereally don't see a ton of ADHD
presentations coming into theemergency department.
It's usually just I'm out ofAdderall, can I have a refill,
(28:09):
which always feels great as anER doc.
So talk to me about theintersection between ADHD and
addiction.
SPEAKER_00 (28:16):
Uh ADHD is a huge risk factor for addiction
issues.
ADHD is a crippling disorder forpeople, especially who have
severe manifestations.
It is considered a childhoodonset disorder that can derail a
person's functioning and evendevelopment, if we're thinking
(28:38):
of childhood onset, socially,academically, a lot of different
important ways.
And so it is important toidentify and treat ADHD when you
see it, and it often doespresent in childhood.
If people have milder cases, itmay not be really picked up
(28:58):
until later in adulthood.
Very often, once they get tocollege or graduate school or
need to work in any setting thatrequires ongoing concentration
and organization, or even justadulting nowadays, there's so
much with forms and bills andall this other things that uh we
all have to deal with in modernWestern society.
(29:20):
So ADHD is a huge risk factorfor addiction, should be
treated.
If someone develops an addictionissue before we identify an ADHD
issue, then once we do starttreating the ADHD, we'll always
go with non-stimulantmedications.
So Stratera, also known asadamoxetine, Kelbury is a newer
(29:45):
sort of cousin of Stratera, andoccasionally well-butrined
buproprion can also be used totreat ADHD.
So if a person has a history ofaddiction, then we always go
with the non stimulants first.
If a person does not have ahistory of addiction, stimulants
are considered the first linetreatment.
(30:05):
They do have one of the highesteffect sizes of any medication
in psychiatry.
They are highly successful andwell tolerated for people that
don't have histories ofaddiction.
SPEAKER_01 (30:17):
So we got lots to unpack here because I have a
number of patients that tell meI use methamphetamine because it
calms me down.
And if they had told me thatfive years ago, I would have
told them they were liarsbecause I didn't realize that
when we give hyperactive peopleamphetamines, it helps them
focus.
I have one patient, I just sawher this week, and she had
(30:38):
significant educational issuesand she had to have an
individualized learning plangoing back to middle school,
wasn't able to finish highschool because of severe
learning issues.
And I asked her whatmethamphetamine did for her, and
she goes, Oh, it was my thinkingcap.
I could get more done, I couldpair my kids.
And I was like, Oh, how's yourADHD?
And she had never been diagnosedwith it, unfortunately.
So I use five non-addictive ADHDmeds in my practice, and I think
(31:00):
it's probably the same foreverybody, right?
So it'd be proprienorwell-butrined, adamoxetine or
Stratera, Viloxazine or Calbury,Guanthazine, I think the brand
name is Intunive, and thenClonidine or CAVE.
I know how I've used them, butI've worked a lot of this out on
my own.
Can you give me a sense ofwhat's the right patient to
choose for each one of thosefive?
SPEAKER_00 (31:21):
The last two, Intunive and CapVey, actually
have the best data supportingtheir use in kids and
adolescents.
So not quite as much adults.
It doesn't mean it can't helpadults, but it just hasn't
really been shown to be aseffective in adult patients.
They are better at treatinghyperactivity, which is more a
(31:42):
hallmark of ADHD in kids andadolescents as opposed to
adults.
Adults tend to have more of theinattention symptoms.
But to treat ADHD, if they havecomorbid depression or cigarette
smoking or nicotine use thatthey want to address, then yeah,
well butrin is a great choice.
(32:02):
I mean, in general, well butrinis one of my favorite
antidepressants to prescribebecause it helps with energy and
motivation and doesn't have alot 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, soinsurance always approves it.
(32:23):
Calbury, I would go to as asecond choice just because most
insurance companies wouldrequire evidence of the failure
on Stratera to justify payingfor it.
SPEAKER_01 (32:33):
In our practice, we have five addiction docs.
We're very proud of our littlecommunity-based clinic with five
addiction medicine docs.
We just put together a protocolfor the management of ADHD with
comorbid stimulant addiction.
We do have an approach thatwe're taking around starting
stimulants for people who haveADHD and are in recovery from
stimulant addiction.
(32:53):
And our go-to is usually Vivans,just because it is a pro-drug
and therefore has a lower riskof misuse.
But talk to me about how you, asan addiction psychiatrist,
approach using stimulants forpeople with ADHD and stimulant
addiction who have failed thenon-stimulant meds.
SPEAKER_00 (33:10):
Sure.
So yeah, and also as you weretelling the story about your
patient with uh methamphetaminebeing a thinking cap.
Fun fact, many people don'tknow, including physicians, that
methamphetamine actually is anFDA-approved medication.
It's given orally as a pill, soit does behave much differently
using that route than the waythat people might abuse
(33:32):
methamphetamine.
SPEAKER_01 (33:34):
One funny point on that.
On a night shift once, when Iwas a little baby new attending,
someone came in and they said, Ineed to refill in my psych meds.
I need desoxin.
Right.
And I got desoxin anddissiparamine mixed up.
And so I wrote a refill and thepharmacy called, Why are you
writing for methamphetamine?
And I looked it up and I wasjust so yes, I'm aware that we
can prescribe methamphetamine.
(33:55):
Please go ahead.
SPEAKER_00 (33:55):
So I don't prescribe that ever, by the way.
That makes two of us.
And I think pharmacies don'tlike stalking it either.
So but people with stimulantaddiction, again, Stratera
Calbury first.
And then I'll often go toprovigil, modafinel, or new
vigil, which you know it's ahistamine agonist, right?
(34:17):
So if you think ofantihistamines like Benadryl
being sedating, this is ahistamine stimulating
medication, which is activating.
So it is considered wakefulnesspromoting agent.
The official FDA indications arenarcolepsy, shift work sleep
disorder, and fatigue associatedwith sleep apnea.
It's sometimes covered as anantidepressant augmentation as
(34:40):
well, even though that's not anofficial FDA-approved
indication.
Insurance doesn't love payingfor it, so that's just the one
drawback.
But honestly, I have never seena pro-vigilal, new vigil,
modafinyl, or armodapinyl abuseissue.
And there are actually somestudies showing that it can
actually help with stimulantdependence as well, in being a
(35:04):
lower potency stimulatingmedication that can maybe take
away craving for stimulants too.
So that is one type ofmedication that I'll often go to
before getting into the quotereal stimulants.
Vivance is a good one.
It's long-acting.
It is an amphetamine, though.
So I tend to prescribemethylphenidate products first.
(35:29):
And the standard algorithms fortreating ADHD actually encourage
the use of methylphenidate firstbecause it is better tolerated,
it's gentler, it's less likelyto trigger anxiety, especially
if people have had issues withanxiety first.
So I tend to go with themethylphenidate.
To me, the analogously safeversion of methylphenidate is
(35:49):
concerta, which is an extendedrelease coated pill that
actually needs to be swallowedfor the medication to come out.
It can't really be crushed andsnorted in the way that
immediate release methylfenidateor Ritalin can be.
If not, though concerta thatdoesn't work, let's say not
strong enough, then yeah, I'lldefinitely go to Vivance, which
(36:13):
is a great medication.
Not without risk.
I have seen people with Vivanceissues where the problem tends
to be they take more thanprescribed.
And I've even seen people thattake two or three hundred
milligrams of Vivance daily.
So it's not common, but it'salso not risk-free.
SPEAKER_01 (36:31):
Yeah, my friends at the Addiction Medicine Journal
Club podcast just covered astudy on that.
I don't know if you found theirpodcast.
Two addiction docs inPennsylvania have a great
evidence-based podcast.
Where was it?
Here we go.
May 26th, episode 60 of theAddiction Medicine Journal Club
LizDexamphetamine.
That's the generic name ofVivands for methamphetamine use
(36:52):
disorder.
And there was a study looking atfairly high doses of Liz
dexamphetamine to try to reducethe 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 patientpleaser.
There was high satisfaction withthe treatment protocol, but it
didn't actually treatmethamphetamine use disorder
that well.
SPEAKER_00 (37:11):
Right, right.
SPEAKER_01 (37:12):
I found that study very interesting.
SPEAKER_00 (37:14):
Yeah.
Yeah.
There's not great evidence.
There's equivocal evidence onthe role of stimulants to
actually treat stimulantdependence.
SPEAKER_01 (37:23):
My understanding is it's because the amount of
stimulant people can get buyingmethamphetamine from the illicit
market is just so much higherthan we can prescribe.
And my understanding is ifsomebody uses methamphetamine
and then we try to put them on,say Adderall, it's like less
than a tenth of the dose they'regetting from the illicit market.
SPEAKER_00 (37:41):
Yeah, I could well be, sure.
SPEAKER_01 (37:43):
Yeah.
Okay.
Is there any other conditionthat you think would be useful
to call out in terms of acomorbid mental health condition
along with addiction?
SPEAKER_00 (37:51):
Insomnia is a big one.
So yeah, similar strategies I'llemploy, trazidone being the
first choice of a medicationthat has no habit forming
potential, very safe, welltolerated, often effective for
treating insomnia.
If we even think about reasonspeople might use certain
(38:13):
substances, especially alcohol,like a lot of it is to treat
their own insomnia.
So yeah, whenever I see like aself-medication tendency in a
person, then I'll try to talk tothem about how their attempt,
while well-intentioned, isactually not the best choice.
And maybe now they've developedan alcohol problem and instead
(38:33):
try this medication that's nothabit-forming and can help with
insomnia.
Yeah, Remron is another one thathas more antidepressant
activity.
It does stimulate appetite, sothey either have to want some
weight gain or have it notbother them if they do gain some
weight.
And Cerequel often is the thirdone.
If those two don't work, thenCerequel usually does, but it
(38:58):
can be very weight-gaining forfolks too.
There is a new class ofmedicines for insomnia, the
DORAS, the dual orexin receptorantagonists, which include
Belsamra, Day Vigo, QV, andthose while technically a
schedule five substance, so theDEA does regard it as having
(39:21):
abuse potential.
The reason that it's Schedule 5is more so like drug likability,
like that's one of the aspectsthat they'll use to consider if
a medicine should be scheduled.
So people like taking it.
I can also tell you, I've neverseen a person develop an
addiction issue to any of theDora medications.
(39:42):
So I'll go to that class if thestandard sort of trazenone
seroquil don't work for aperson.
And they very often do work.
You they usually have to bedosed at the max doses.
So like balsamara is 20milligrams.
That's often what I'llprescribe.
That actually does help in away, and it's well tolerated.
And it often doesn't lead tosedation the next day.
(40:06):
People often ask, is this gonnamake me groggy the next day?
I always tell them that's adose-related response with the
right choice of medicine.
It'll work to help you fallasleep, stay asleep.
But ideally, your body is brokenmost of it down in the morning
so you could wake up feelingrefreshed and start your day.
So yeah, that tends to be thetype of medicine that I'll
(40:26):
prescribe, sort of a secondchoice.
You use much Remelteon?
I do.
It's not quite sedating.
It's I I think it is analogousto melatonin.
It is a melatonin stimulatingmedication.
So it is milder.
It does help some people.
It's just it's not gonna putthem down in a way that like
trazodon seroquel or even any ofthe DORAs will, and that's often
(40:50):
what people are seeking and andalso the need for treatment of
insomnia.
SPEAKER_01 (40:56):
With somebody who has bipolar disorder, do you
worry about trazodone or remroncausing mania?
They are technicallyantidepressants.
SPEAKER_00 (41:05):
Yeah, technically they are.
I've never actually seen a caseof either one causing mania.
If someone has a history ofbipolar disorder, I'll often
then just go to CerroQL first ora senopene sapphorous is
actually another sedating secondgeneration atypical medication
(41:26):
like Cerquel that does not haveweight gain associated with it.
So that is actually a reallygood choice for people with
bipolar two and bipolar also,whether it's type one or type
two.
And it really does help a lot ofpeople with mood stability too,
in a way that CeroQL doesn't,because Ceracol actually needs
to be dosed at 400 milligrams ormore to have anti-manning
(41:48):
properties.
SPEAKER_01 (41:48):
That was a good catch.
It's bipolar, also, not bipolartoo.
Well played.
Well, I was gonna say this hasbeen a fascinating conversation.
Anything we missed?
SPEAKER_00 (41:57):
In general, I certainly encourage people to
get assessed for anything thatresembles a mental health issue.
There is a lot of stigma, as wediscussed, with mental health
treatment.
And it does not need to bemental health issues or as much
medical issues as physicalissues like high blood pressure
(42:18):
or asthma.
And if the concept of takingmedicines is averse to you, then
you don't even have to commit tothat too.
It all starts with one visit andassessment where you speak with
a psychiatrist that actuallytreats issues that you might
have, and you can at least knowwhat your options are.
In psychiatry, most of theissues can also be treated with
(42:39):
therapy, too.
So even just getting anassessment with a referral to
therapy is often the best placeto start, and then medications
can always be reassessed lateron.
SPEAKER_01 (42:49):
Well said.
Anything you've got in the nearfuture that you're working on?
Projects, new protocols, newtreatment pathways?
SPEAKER_00 (42:56):
A lot of my project in our office is working on the
ketamine therapy work.
Even though we started thatprogram six years ago, there's
just uh constant protocols thatstill need to be created.
We are creating a lot of goodthings.
In our office, we do incorporatepsychotherapy with ketamine
treatment, but also offer justthe standard evidence-based IV,
(43:19):
no therapy type of treatment,too.
So I definitely see a newchapter in psychiatry opening up
where a number of psychedelicsare actually being studied and
will be coming soon topsychiatry in the next few
years.
And our work with ketamine, inmy mind, is representative of
the type of work that we'll bedoing with other analogous
(43:41):
medications in the future.
SPEAKER_01 (43:43):
Just one point on that, and please correct me if I
misunderstand this.
My understanding of the use ofketamine to treat a mental
health condition is it rapidlyimproves things like mood and
suicidality to allow otherthings like antidepressants and
therapy to work.
Because my patients come in,particularly the ones that use
(44:04):
multiple substances, and I getsomething to the effect of, hey,
doc, I want to do a bunch of Kand I'll get sober.
And that just seems to not quitebe how it's meant to be done.
I'm just curious as to yourthoughts.
SPEAKER_00 (44:15):
Yeah.
So doing K is in the column ofdrug use.
Right.
And there is the big differencebetween drug use and medication
treatment.
The contexts are different.
And an exactly analogousconversation could be had with
the use of ketamine and peoplewho may have had issues with
addiction too.
Ketamine can be used to getpeople out of the most severe
(44:37):
holes in depression.
It does work for suicidalthinking and behaviors.
Sprovato, which is the onlyactually FDA-approved form of
ketamine, does have an officialFDA indication for treating
suicidality even outside ofdepression.
But sprovato actually alsorecently picked up an FDA
indication as a maintenancetreatment for depression, too.
(44:59):
So ketamine is anantidepressant, happens to be
one that also works quickly andhas a strong anti-suicide
benefit, which is something thatmany of the traditional oral
antidepressants don't have.
And so I see roles for ketaminein all of the above, and also
(45:19):
augmenting psychotherapy.
People, when they receiveketamine, do go to a different
place.
They have a differentperspective on things, their
lives, and even traumas.
And so there's a potential roleand a lot of research interest
in psychedelic assistedpsychotherapy as well.
And ketamine is definitely apart of that.
SPEAKER_01 (45:40):
Well said.
Well, I have to say, Mark, Ifeel a lot better.
A lot of the things that Ithought I was doing on my own,
you've reaffirmed that a lot ofthe stuff I've been doing is is
actually okay.
And I appreciate your expertiseand wisdom on going through the
therapeutic medications we havefor mental health as it relates
to treating addiction.
SPEAKER_00 (45:58):
Yeah, thank you very much.
It's been great talking to you,and thanks for having me on your
show.
SPEAKER_01 (46:04):
Before we wrap up, a huge thank you to the Montage
Health Foundation for backing mymission to create fun, engaging
education on addiction.
And a shout out to the nonprofitCentral Coast Overdose
Prevention for teaming up withme on this podcast.
Our partnership helps me get theword out about how to treat
addiction and prevent overdoses.
(46:26):
To those healthcare providersout there treating patients with
addiction, you're doinglife-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 winwithout awareness and action.
There's still so much we can doto improve how addiction is
treated.
Together, we can make it happen.
(46:47):
Thanks for listening.
And remember, treating addictionsaves lives.
Popular Podcasts
Stuff You Should Know
If you've ever wanted to know about champagne, satanism, the Stonewall Uprising, chaos theory, LSD, El Nino, true crime and Rosa Parks, then look no further. Josh and Chuck have you covered.
Dateline NBC
Current and classic episodes, featuring compelling true-crime mysteries, powerful documentaries and in-depth investigations. Follow now to get the latest episodes of Dateline NBC completely free, or subscribe to Dateline Premium for ad-free listening and exclusive bonus content: DatelinePremium.com
The Burden
The Burden is a documentary series that takes listeners into the hidden places where justice is done (and undone). It dives deep into the lives of heroes and villains. And it focuses a spotlight on those who triumph even when the odds are against them. Season 5 - The Burden: Death & Deceit in Alliance On April Fools Day 1999, 26-year-old Yvonne Layne was found murdered in her Alliance, Ohio home. David Thorne, her ex-boyfriend and father of one of her children, was instantly a suspect. Another young man admitted to the murder, and David breathed a sigh of relief, until the confessed murderer fingered David; “He paid me to do it.” David was sentenced to life without parole. Two decades later, Pulitzer winner and podcast host, Maggie Freleng (Bone Valley Season 3: Graves County, Wrongful Conviction, Suave) launched a “live” investigation into David's conviction alongside Jason Baldwin (himself wrongfully convicted as a member of the West Memphis Three). Maggie had come to believe that the entire investigation of David was botched by the tiny local police department, or worse, covered up the real killer. Was Maggie correct? Was David’s claim of innocence credible? In Death and Deceit in Alliance, Maggie recounts the case that launched her career, and ultimately, “broke” her.” The results will shock the listener and reduce Maggie to tears and self-doubt. This is not your typical wrongful conviction story. In fact, it turns the genre on its head. It asks the question: What if our champions are foolish? Season 4 - The Burden: Get the Money and Run “Trying to murder my father, this was the thing that put me on the path.” That’s Joe Loya and that path was bank robbery. Bank, bank, bank, bank, bank. In season 4 of The Burden: Get the Money and Run, we hear from Joe who was once the most prolific bank robber in Southern California, and beyond. He used disguises, body doubles, proxies. He leaped over counters, grabbed the money and ran. Even as the FBI was closing in. It was a showdown between a daring bank robber, and a patient FBI agent. Joe was no ordinary bank robber. He was bright, articulate, charismatic, and driven by a dark rage that he summoned up at will. In seven episodes, Joe tells all: the what, the how… and the why. Including why he tried to murder his father. Season 3 - The Burden: Avenger Miriam Lewin is one of Argentina’s leading journalists today. At 19 years old, she was kidnapped off the streets of Buenos Aires for her political activism and thrown into a concentration camp. Thousands of her fellow inmates were executed, tossed alive from a cargo plane into the ocean. Miriam, along with a handful of others, will survive the camp. Then as a journalist, she will wage a decades long campaign to bring her tormentors to justice. Avenger is about one woman’s triumphant battle against unbelievable odds to survive torture, claim justice for the crimes done against her and others like her, and change the future of her country. Season 2 - The Burden: Empire on Blood Empire on Blood is set in the Bronx, NY, in the early 90s, when two young drug dealers ruled an intersection known as “The Corner on Blood.” The boss, Calvin Buari, lived large. He and a protege swore they would build an empire on blood. Then the relationship frayed and the protege accused Calvin of a double homicide which he claimed he didn’t do. But did he? Award-winning journalist Steve Fishman spent seven years to answer that question. This is the story of one man’s last chance to overturn his life sentence. He may prevail, but someone’s gotta pay. The Burden: Empire on Blood is the director’s cut of the true crime classic which reached #1 on the charts when it was first released half a dozen years ago. Season 1 - The Burden In the 1990s, Detective Louis N. Scarcella was legendary. In a city overrun by violent crime, he cracked the toughest cases and put away the worst criminals. “The Hulk” was his nickname. Then the story changed. Scarcella ran into a group of convicted murderers who all say they are innocent. They turned themselves into jailhouse-lawyers and in prison founded a lway firm. When they realized Scarcella helped put many of them away, they set their sights on taking him down. And with the help of a NY Times reporter they have a chance. For years, Scarcella insisted he did nothing wrong. But that’s all he’d say. Until we tracked Scarcella to a sauna in a Russian bathhouse, where he started to talk..and talk and talk. “The guilty have gone free,” he whispered. And then agreed to take us into the belly of the beast. Welcome to The Burden.