After substance withdrawal, underlying psychiatric symptoms emerge

Patients with social anxiety disorder might self-medicate with alcohol or drugs, especially benzodiazepines (Box). Residential treatment presents an excellent environment for desensitization to fears of public speaking; early recognition is key. Apprehension about group therapy, present­ing a substance abuse history, or speaking at a 12-step meeting can lead to premature or “against medical advice” discharge.

Panic disorder commonly is comorbid with substance abuse. Many patients will arrive at treatment with a prescription for benzodiaz­epines. Because the risk of cross-addiction is high among recovering addicts, benzodiaze­pines should be avoided. Treating underlying anxiety is crucial for fostering sobriety. Generalized anxiety disorder is common among patients with an addiction, and can lead to relapse if not addressed. Use of non-addictive medications and cognitive therapy is useful in addressing this condition.

A quandary might arise in states where medical marijuana is legal, because Cannabis can be prescribed for anxiety disorders and posttraumatic stress disorder (PTSD). Promoting abstinence from all substances can present a challenge in patients with anxi­ety disorders who live in these states.

Medications for anxiety and panic dis­order include gabapentin, buspirone, hydroxyzine, beta blockers, and atypical antipsychotics (Table 2). Only buspirone and hydroxyzine are FDA-approved for anxiety; buspirone monotherapy generally is ineffec­tive for panic disorder.

Explaining to patients how anxiety arises, such as how classical conditioning leads to specific phobias, can be therapeu­tic. Describing Klein’s false suffocation alarm theory of panic attacks can illustrate the importance of practicing slow, deep breathing to prevent hyperventilation.⁷ Also, relabeling a panic attack with self-talk state­ments such as “I know what this is. It’s just a panic attack” can be helpful. Smartphone apps are available to help patients cope with anxiety and acute panic.⁸

Mood disorders
Many patients with bipolar disorder expe­rience substance abuse at some point; esti­mates are that up to 57% of patients have a comorbid addiction.^6,9 Persons with a mood disorder are at high risk of substance abuse because of genetic factors; patients also might self-medicate their mood symptoms.

After alcohol or drugs are withdrawn, mood disorders can emerge or resurge. Often, patients enter treatment taking antidepressants and mood stabilizers and usually haven’t been truthful with their treatment provider about their substance abuse. Care must be taken to ascertain whether mood symptoms are secondary to substance abuse. Asking “What’s the longest period of abstinence you’ve had in 2 years and how did you feel emotionally?” often will help you identify a secondary mood disorder. For example, a response of “6 months and I felt really depressed the entire time” would indicate a primary depressive disorder.

Because CNS depressants, such as alco­hol and benzodiazepines, can exacerbate a mood disorder, consider continuing or resuming a mood stabilizer or antidepres­sant during substance abuse treatment. When meeting a new patient, perform an independent evaluation, because substance use can mimic bipolar and depressive dis­orders. Careful assessment of suicidal ide­ation is necessary for all patients.

Sleep disorders
Insomnia—as a primary or secondary disorder—is common among patients with a substance use disorder. Insomnia always needs to be addressed. Not sleeping well interferes with cognition and energy and makes depression and bipolar disorder worse. Some experts recommend “waiting out” the insomnia, hoping that sobriety will resolve it—but it might not.

Initial insomnia can be treated with mela­tonin, 3 to 6 mg at bedtime or earlier in the evening.^10-12 Melatonin acts by regulating circadian rhythms, but can cause increased dreaming and nightmares; therefore, it should be avoided in patients who struggle with nightmares. Trazodone, 50 to 150 mg at bedtime, is an inexpensive sleep aid for initial insomnia and doesn’t cause weight gain, which many drugs with antihistaminic properties can. Prazosin, 1 to 2 mg initially, for nightmares in PTSD is effective.¹³

Antipsychotics might be necessary if nothing else works; quetiapine is effective for sleep and the ER form is FDA-approved as an add-on agent in major depression. Low-dose doxepin (≤10 mg) is effective for middle insomnia.¹⁴ At these low dosages, troublesome side effects of tricyclic antide­pressants can be avoided.

As many as 40% of adults with ADHD have a delayed sleep-phase disorder. Ask your patient if she is a “night owl,” how chronic the condition is, and when her best sleep occurs.15-17 Morning light and evening melatonin can help, but often are insufficient. Many patients present with undiagnosed or untreated sleep apnea, which can cause excessive daytime sleepiness. Referral to a sleep center is prudent; use of the Epworth Sleepiness Scale is a quick way to assess excessive daytime sleepiness.¹⁸

ADHD
ADHD commonly is comorbid with a sub­stance use disorder. Patients might pres­ent with an earlier diagnosis, including treatment. Several drugs of abuse can alle­viate ADHD symptoms, including amphet­amines, opioids, cocaine, and Cannabis; self-medicating is common. Because opi­oids increase dopamine release, a report of improved work and school performance while taking opioids early in addiction can be a clue to an ADHD diagnosis.

Explaining ADHD as a syndrome of “interest-based attention” helps. If a resi­dential treatment program uses reading and writing assignments, a patient with ADHD might struggle and will need extra help and time and a quiet place to do assignments.^19,20 A non-addictive medication, such as ato­moxetine, can help, but has an antidepres­sant-like delay of 3 to 5 weeks until onset of symptom relief. Using a long-acting stimu­lant can be effective and quick, with an effect size 3 to 4 times higher than atomoxetine; such agents should be avoided in patients who abuse amphetamines.