After substance withdrawal, underlying psychiatric symptoms emerge
Prompt identification and treatment can ease suffering
Studies show that treating ADHD, even with stimulants, neither helps nor hurts outcomes in substance use. Lisdexamfetamine is difficult to abuse and is an inactive prodrug (a bond of lysine and dextroamphetamine) that requires enzymatic cleavage and activation by red blood cells; these characteristics creates a long-acting medication that has a lower abuse liability than other drugs for ADHD. However, abuse can occur and the drug must be used cautiously. Earley’s medication guide referenced below recommends that lisdexamfetamine and other stimulants should be avoided if possible in patients in recovery. However, it adds that specialists in treating ADHD in substance-abusing patients should weigh the potential benefits of stimulant use against the risk of relapse.17 Many patients enter treatment with a diagnosis of bipolar disorder that might, in fact, be comorbid with ADHD.
Chronic pain
Many substance abuse patients began taking opioids for acute, then chronic, pain before their use escalated to addiction. These are challenging patients; often, they are referred for treatment without true addiction.
Keep in mind that dependence is not addiction. Pseudo-addiction is a condition in which pain is undertreated and the patient takes more medication to obtain relief, calls for early refills, and displays drug-seeking behavior but is not using drugs to achieve euphoria. A thorough history and physical and referrals to specialists such as orthopedic surgeons and pain specialists are necessary. Explaining opioid-induced hyperalgesia is important to help the patient understand that (1) pain can be made worse by increasing the dosage of an opioid because of supersensitivity and (2) many patients who are weaned off these drugs will experience a decrease or complete relief of pain.21
Gabapentin, duloxetine, or amitriptyline can be beneficial for chronic pain, as well as mindfulness techniques, physical therapy, and complementary and alternative medicine. Pregabalin can produce euphoria and often should be avoided.
A medication guide for recovery
Paul Earley, MD, former medical director at Talbott Recovery in Atlanta, Georgia, publishes an online guide that classifies medications into categories:
• A: safe
• B: use only under the supervision of an addiction medicine specialist or doctor
• C: completely avoid if the patient is in recovery.17
The Talbott guide lists all stimulants in category C, (except for atomoxetine, which is category A). Hydroxyzine is listed under category B. Many programs for impaired professionals and state medical boards use the Guide, and will question the prescribing of any medication from categories B and C.17
Related Resources
• Spiegel DR, Kumari N, Petri JD. Safer use of benzodiazepines for alcohol detoxification. Current Psychiatry. 2012;11(10):10-15.
• Kelly TM, Daley DC, Douaihy AB. Treatment of substance abusing patients with comorbid psychiatric disorders. Addict Behav. 2012;37(1):11-24.
Drug Brand Names
Amitriptyline • Elavil Hydrocodone • Vicodin
Atenolol • Tenormin Hydroxyzine • Vistaril, Atarax
Atomoxetine • Strattera Lisdexamfetamine • Vyvanse
Buprenorphine/ naloxone • Suboxone Metoprolol • Lopressor, Toprol
Buspirone • BuSpar Paroxetine • Paxil
Carbidopa-levodopa • Sinemet Pramipexole • Mirapex
Clonazepam • Klonopin Prazosin • Minipress
Diazepam • Valium Pregabalin • Lyrica
Doxepin • Silenor, Adapin, Sinequan Propranolol • Inderal
Duloxetine • Cymbalta Quetiapine • Seroquel
Escitalopram • Lexapro Ropinirole • Requip
Gabapentin • Neurontin, Horizant Sertraline • Zoloft
Trazodone • Desyrel
Disclosure
The author reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.
