Monday, March 2, 2009

Pharmaceutical Therapy Post Addiction

Pharmaceutical Therapy Post Addiction

Just because you once were a toxic wasteland doesn't mean you won't ever again need a pharmaceutical agent. If your alcoholism caused you pancreatitis and you need surgery it's only smart to accept it, plus anesthesia, plus opiates post surgery. That doesn't mean you can pack a pistol to put up the nurses nose demanding more 'till it feels good' and still claim to be in recovery. The key to proper pharmaceutical prescribing is that you let a competent professional, not yourself, do the prescribing and follow their directions. A competent professional is not a drug addicted physician who offers you a shot of whiskey from the lower drawer mid morning. Ideally, the person prescribing is a bit more competent.

Drugs which you can't use are those which are commonly known as "illicit", that is, any thing that there's a law against possessing. Further, if a pharmaceutical agent 'sells' on the street, then it's likely that it's a drug of abuse and should be avoided. Hence the so called "downers", such as the benzodiazepine class of drugs, barbituates and the "upper's", such as the dexedrines and the ritalins.

Claiming to have a diagnosis, doesn't necessarily mean that you should have the drug that goes with that diagnosis. For instance a rabid coke addict humping your leg may claim his doctor said he had ADD (attention deficit disorder) but that doesn't mean more amphetamines are going to make him mellow. Many an acid head insisted they were too 'mellow' for this world and had to 'trip' out to get real. Sometimes a walk -in clinic doctor will say whatever you want to hear just to get you out of their office, especially if you smell or alternatively are seductive and faster if you are both.

Hazelton's research suggests that those who avoid using any pharmaceutical outside of the first week or two of detox when benzos and barbituates,antipsychotics, and anti seizure drugs are normal tend to do better at staying clean and sober for a year. This suggests that you try non pharmaceutical means for addressing negative emotions in the first year of recovery if at all possible. Addicts and alcoholics are routinely called "bipolar' because they are emotionally unstable in the first year or even two of recovery, often called the long hang over. It's typified by irritability, emotional lability, anger episodes, feeling good without cause, feeling sorrow without immediate reason and the general adolescent range of emotional experience. That's not to say everyone has to feel this much, some do 'unthaw' more slowly and not all do it in spurts and starts.

That said, if you are weeping uncontrollably, going to 12 step meetings, exercising, praying, meditating, volunteering at the local community centre, and still feeling suicidal and sitting for long periods of time in the garage in the car with the motor running, you probably do need medication. If you are beating up your loved ones and getting arrested for kicking policeman maybe you too would benefit from seeing a psychiatrist. If you can't sleep for weeks at a time and are down everyone elses throat you too might need medication. Of course if you have heart disease, diabetes, a thyroid condition or any other purely medical condition you'd be unwise to have stopped your medications when you decided to clean up that marijunia and red wine habit.

Antidepressants are the most common medication prescribed in the first year or two of recovery. Mirtazepine has the advantage of being an anti anxiety and sleep inducing antidepresant that causes the least sexual side effects. It tends to improve the appetite which for some is also beneficial. In contrast buproprion is an energizing antidepressant that improves concentration, has been marketted as zyban to reduce smoking, and has the fewest sexual side effects. If you don't want to have to think about sex so much in the first year of recovery, paroxetine is the best antidepressant with a major antianxiety component. The SSRI's such as prozac, celexa and cipralex are themselves very good indeed especially if there are any other complicating medical factors. Because addicts and alcoholics have usually altered their brain chemistry the rule of thumb is to start slow and increase slow without expecting the medication to make you feel like you did when you were 'high'.

It's also not that useful to discuss what you remember you were like before you went on your binge and orgy of self abuse. Your memory is usually impaired and tells you what you want to hear and further your exciting chemistry experiments have thoroughly altered your previous neurochemistry conditons.

Antipsychotic medications or atypicals are commonly used for anxiety. These are used at high dosage in schizophrenia whereas for alcoholics and addicts in recovery they tend to be beneficial in the lowest dosage. The most favoured is quitiapine (seroquel) usually used 25 to 100 mg for anxiety or sleep. It has the least tendency to cause extra pyrimidal side effects therefore there's little fear that your eyes will roll back in your head and stay there till you stop the medication. Also rispiridone .5 mg to 2 mg range per day is commonly used. Olanzepine can also be used but has a greater likelihood of causing metabolic syndrome with weight gain and risk of diabetes. Ziprasidone (Zeldox) is the newest in this class and a real breakthrough medication.

Mood stabilizers are medications which are used in high dosage for seizures but were found in lower dosage to have benefit with migraines, sleep disorders, mood instability or pain disorders. Gabapentin is commonly used in the 100 to 1200 mg range safely. Topiramate has the advantage for some of causing weight loss as well and is commonly used in the 50 to 150 mg range. Valproic Acid has been used but has been associated with spontaneous death from liver collapse, most commonly causes elevated liver enzymes and generally speaking there are better and safer alternatives for those in recovery, especially alcoholics. Carbamezapine is an old stand by which had the benefit of being the drug of choice for the anger associated with temporal lobe epilepsy so is commonly used for those with anger problems, again starting with the lowest dosage.

It is important to note that most 'side effect' profiles especially those appearing on the internet are from 'medical disclaimer' sources and often for very high dosage in very sick people often having taken them for many years. . Dr. Anderson out of San Diego did the key research on what the actual drug side effects are when they're really being used by real doctors for real patients. It's a wholly different story than the one put out by the pharmaceutic industry either to avoid law suit or to get FDA approval. In any case no one is generally enlisting former alcoholics and addicts for brain chemistry research or new general pharmaceutical trials. The data on what works comes mostly empirically from practitioners in the field.

Trazadone is an antidepressant medication that is commonly used as sleep medication sometimes along with gabapentin. Most of the other sleep medications are potentially drugs of abuse. It is common to have sleep disturbances in the first year of recovery and it is one of the joys of recovery that the sleep eventually returns to normal by the second year. Sleep loss for one night at a time isn't a terrible hardship as any on call doctor can testify to but night after night of sleeplessness requires journalling and possible referral to a sleep lab rather than more and more medication.

All these medications can be used individually or in combination if the prescribing physician has experience with multiple prescribing or a nifty little palm pilot device that helps him review the side effects of overlapping medications. The rule should always be 'low and slow' which is the exact opposite of the gut feeling most addicts have about medication usage, ie 'lots and fast".

Recovery is not an overnight process. The brain of an addict or alcoholic is a changed brain. The restoration to some sort of normal takes at least 2 years if not more. The risk of use is increased with mood altering drugs because they can incite a craving or can give one false confidence which distracts one from the normal nonpharmacological approaches to recovery. Medication is an adjunct to the process of restoration of physical health, relationships and community.
That said, it's a good idea to tell your doctor you're in recovery and what you used to use. This is really important if you're going for surgery because commonly addicts and alcoholics in recovery need more rather than less pain killer. It's the exception to the general rule. It may be a really good idea therefore to tell the anesthetist you used to be a cocaine addict or drank excessively rather than waking up in the middle of a heart operation and causing unnecessary fuss about the man with the mask and bloody knife cutting into you.

1 comment:

Bobbi said...

Hi Doc,
Love this info. Interesting reading.
Enjoying your blog, Thanx.
Cheers, Bobbi