Considerations in Assessing Co-Occurring Disorders Part 1

As mentioned in previous narratives regarding Co-Occurring Disorders, the term itself simply means the coexistence of multiple disorders existing simultaneously, but it is mostly used when there are psychiatric diagnoses in combination with substance use disorders, or even more than one type of each. When treating clients that have concurrent disorders especially in more acute settings or later in the progression of their mental health issues it is not necessary to delineate a primary disorder as over time the Axis One Psychiatric Disorder(s) and substance use disorders may predominate equally, although in different patterns of exacerbation and without considering this a clinician could miss this connection.

I have often seen patients in offices with over ten psychiatric diagnoses, many of which no longer apply as there are others that “trump” or supersede the former. It is important to remember these implications.  The clients I have worked with most over the years have had substance issues, often accompanied by medical issues that have arisen from substance use plus psychiatric diagnoses that encompass anxiety, depression, often bipolar disorder, schizoaffective disorder, and sometimes personality issues, as well as some form of eating disorder. It is also important to remember that clients in treatment may appear to be psychotic, bipolar, or something else when they are really in impaired (even delirious) states or in withdrawal… It is in periods of high intensity of both dual disorders that diagnoses of /both would be more difficult to make with absolute accuracy. I encourage providers and patients to remember that MAT medications such as buprenorphine are truly lifesaving, and they should be considered as equal if not more important than other medications that people take such hypertension or diabetes medications. If a medication was efficacious at first at a lower dose such as naltrexone 50 mg then became less effective with no contraindication’s you would raise it just as you would any other medication.  Perhaps some physicians are just not as familiar with prescribing MAT medications. Education about these medications including understanding the psychopharmacological mechanisms is helpful.   Above all, use motivational communication and maintain a considerate bedside manner.   Setting boundaries as a provider and saying “NO” empathetically is also an important skill.

When clients are outpatient and more of a baseline of treatment, it is almost predictable that stopping medication puts them at a higher risk of relapse regarding SUDS (i.e. substance use disorders).  This also includes the potential resurgence of any eating disorders if present that clients may use as maladaptive “coping mechanisms “for stress, and anxiety” and repressed anger.  Conversely, when clients are in psychotherapy, taking medications that they feel are effective and not” triggering “ to them   (e.g. like insufflation of Adderall when they just over dosed on crystal meth), they may have extended periods of remission especially if they feel “connected” to a social network.

For many clients, physically addictive substances, namely those that have tolerance potential and therefore can cause withdrawal may benefit from medications that can keep them out of this withdrawal and reduce the risk of fatal overdoses.  These medications, referred to as MAT (medication-Assisted Treatment) not only help clients manage cravings to use substances and ward off withdrawal symptoms, as well as protect from overdose due to their “ceiling effect” in that they will not continue to slow respiration (as well as other opiate effects) like a full Mu agonist would as the dose is raised in linear fashion… Also, due to these benefits the clients on it may be able to focus more completely on addressing their other comorbid issues in the other Axis one disorders as well as other medical diagnoses and work their recovery program. Some of the newer opiate analogues such as fentanyl which is lipophilic and requires attention to the /induction techniques loading and FLAKKA which has caused necrosis in areas it is used have increased the challenge.  Again, this is another BLOG subject. It is very important to keep up with the newest illicit substances that are on the street because they are becoming more and more deadly.

Alcohol also has some approved and off label MAT medication treatments. It is also important to consider MAT treatment after a detox period, especially when substances such as alcohol or benzodiazepine (or multiple street drugs are involved). This is because the risk of relapses is very high, and relapses can mean an overdose. And overdoses can be due to poly medications/substances that occur due to additional alcohol plus even cold medication or benzodiazepines or tricyclics or opiates, or other combinations.  It is also to combine buprenorphine with other medications such as benzodiazepines, stimulants, etc. This is why prescribing these things together is very risky.    It is important to know that after using benzodiazepines for example for many years a slow taper is preferred if possible. However, there are times that in conjunction with alcohol patients require complete detoxification and clinicians and clients should recognize that post-acute withdrawal symptoms will likely be present for quite some time and will require medication to “take up the slack” In other words taking alcohol and hypnotics/sedatives for some time, then being detoxed will leave almost anyone feeling anxiety and with disrupted sleep for some time. Without attention to these symptoms the risk of relapse would be higher. Often clients want to know if they have now “developed “anxiety or if they had it before since they don’t remember it being this “bad” … That brings me to some other questions about co-occurring disorders such as: which came first? How do you determine baseline diagnoses? What triggers what? How do you treat them.  Lately clients have been particularly vexed about having ADHD in their history and either ending up abusing the stimulant they were on or ending up on methamphetamine.  Then after going to treatment or not going to treatment at all they feel the need to be put on a stimulant for treatment “right away”. This will be in a future blog as it will require some information from literature articles and some time to go over.  Another topic of concern for many clients is clients that have been on benzodiazepines for severe anxiety or “sleep” for many years, usually begun by a well-meaning physician that just was titrated upwards and now is at a level that many newer providers will not prescribe.  The client is not at fault and the client clearly cannot just abruptly stop this medicine.  These sorts of situations will require advanced professional help and psychoeducation as well as the understanding that there is no “quick treatment”.    Psychotherapy plays a critical role in the treatment of co-occurring disorders. Cognitive-behavioral therapy (CBT), dialectical behavior therapy (DBT), and other therapeutic approaches can help clients understand the underlying causes of their disorders and develop coping strategies.

Additionally, social support systems, including family, friends, and support groups (such as 12 step or other forms of recovery groups) provide a network of encouragement and accountability. These elements are essential for maintaining long-term recovery and preventing relapses.  What started in childhood perhaps was anxiety spectrum then due to genetic loading or other vulnerabilities proceeded to either ETOH, benzos, or both or something else. If this was not treated early, for example with primary or even secondary intervention will have to be sorted out later.   And the person who is introduced to maladaptive coping strategies, may progress in tandem course as Co-Occurring Disorders and due to the reward centers in the brain which become “hijacked” and the receptors which become changed over time…then the two disorders become distinct. This means that even treating the anxiety “fully” the benzo or alcohol disorder will still exist. This would lead the addiction psychiatrist to target the receptor that anxiety and the substance have in common so that anxiety could be treated and craving for the substance could be dialed down via the receptor…such an example may be gabapentin if it fit all of the other criteria. This is very important for providers to understand because ALL disorders need to be treated even if the client that is being treated reassures the provider that they are in fact “fine” because this would be a lack of the client’s insight s most likely because at moment they may feel “fine” …but they still need to avoid relapse. It is important to look at the “complete” picture of the client’s journey:  the losses to the substance over time, financially, relationships, social delays in growth, times in treatment, incarcerations, etc. when considering MAT.  It is not just the clients view of the “current situation, cravings” viz at this moment in time…Just as in treating blood pressure and even diabetes, often patients do not “feel” as if they need “treatment” in the earlier stages and that’s why so many “diseases” are “silent” killers.     However, the great thing is that both or all co-occurring disorders can stay in remission! So, it would be like having high blood pressure then doing some behavioral changes that can make you healthier and your blood pressure goes down.  However, you would still likely be at risk for high blood pressure if you stopped doing the healthy things like diet, exercise, stress reduction… So, in effect it’s not gone forever… it depends on what you do!

Continued in “Considerations in Assessing Co-Occurring Disorders Part 2”