What to do about addiction clients with prescribed, potentially addictive medications; Pickleball anyone?
In SAVVY and STUMP THE SHRINK, I respond to a question on what to do about psychiatric prescriptions for benzodiazepines and amphetamines in addiction treatment.
In SKILLS, assessment needs a skilled clinician who is savvy about addiction and mental illness who can evaluate specific diagnostic and treatment questions.
In SOUL, I was introduced to Pickleball and now exercise could actually be fun for me.
savvy and stump the shrink
It is common for addiction treatment programs and Drug Courts to have policies that ban benzodiazepine and stimulant psychotropic medication, even with a legal prescription. A similar dilemma arises when a client says they have a “marijuana card” for chronic pain or anxiety or trauma and should be able to continue marijuana while in addiction treatment.
Whether you work in an addiction program or Drug Court, here are some
tips on how to handle such clinical and policy dilemmas. A Drug Court Coordinator’s question prompted this month’s edition.
TIP 1
Just because a participant has been given a psychiatric diagnosis and a prescription, doesn’t verify the person has that mental disorder and needs that medication
Here is the Coordinator’s question:
Hi Dr. Mee-Lee,
We are struggling here at our Drug Court with participants coming in with medical prescriptions for benzodiazepines and amphetamines, based on mental health diagnoses. Our policy clearly states that these are not allowed, even with a legal prescription. However, our public defender (and mental health clinician) are railing against the policy, saying it is unfair, etc., and that we should change the policy.
I would be interested in your thoughts.
Drug Court Coordinator
Washington State
My response as regards TIP 1:
I don’t think you just trust every provider who can give a diagnosis and a prescription to a person; and then assume that the person does indeed have that mental disorder and needs that medication.
- Such a provider might be a primary care physician or psychiatrist or any physician or prescriber who may not have both addiction and mental health expertise.
- The psychiatric diagnosis and prescription may have been decided after a 15 minute evaluation that did not cover an in-depth substance use history, or the possibility of a substance-induced psychiatric condition.
- Even if the original prescriber does have addiction and mental health expertise, it may be that the diagnosis and prescription were given a while ago before there is now new information. For example, a participant may not have disclosed that they were actively using substances when given the psychiatric diagnosis and prescription. Or the signs and symptoms have changed from before. This is new information that should prompt a new addiction psychiatry or mental health evaluation.
- This doesn’t mean you should just stop the medication or ban it without further evaluation. It means that the next step is to initiate a prompt re-evaluation of a psychiatric diagnosis and medication that could affect addiction recovery.
TIP 2
If a competent psychiatric and addiction evaluation has been completed; and treatment history verifies that the potentially addictive psychotropic medication is needed, then the client should be allowed to continue the medication
My response continues as regards TIP 2:
I understand the dilemma. Policies that do not allow for potentially addictive medications seem to make sense from a sole addiction treatment perspective. However many participants are not ‘sole addiction-only’ people.
- Many people have co-occurring addiction and mental illness. So strict policies on benzodiazepines and amphetamines don’t take into account that participants are often more complex than only having addiction.
- If a person does indeed have co-occurring addiction and mental illness, not allowing them to have their psychotropic medication creates an unstable mental disorder, but then also can destabilize their co-occurring addiction illness as well.
- Having said that, remember that just because a person has been given a mental disorder diagnosis and a prescription doesn’t mean the person actually has that co-occurring disorder and needs the benzodiazepines or amphetamine medication.
- Verify with the prescribing physician or nurse practitioner that they were aware that their patient also has a substance use disorder; that they are sure the psychiatric diagnosis is not a substance-induced disorder; that other non-addictive medications and treatments have not worked; and that such medication is necessary for mental health and addiction stability.
skills
Policies that ban potentially addictive psychotropic medication from addiction treatment can be counterproductive and inhibit recovery from addiction and mental illness. It takes some important co-occurring disorders skills and competencies to resolve the dilemma about who should continue their psychotropic medication and who should not.
TIP 1
Arrange for careful assessment by a psychiatrist or mental health clinician who is also savvy about addiction.
When an addiction participant has a psychiatric diagnosis and prescription, part of a comprehensive addiction and co-occurring disorders assessment in any new treatment episode requires:
- A review and revisiting of the mental health history, signs and symptoms, and evaluation of the prescriber’s expertise in co-occurring disorder addiction and mental illness.
- This is not just a trust issue about the prescriber. It is a review to ensure that the diagnosis is still valid and that the medication is the only safe way to treat both the mental disorder and the addiction illness.
- Because addiction can mimic mental disorders, it is reasonable to re-check the mental disorder diagnosis and treatment. Often clients are actively using substances at the same time that they are being diagnosed as having a mental disorder.
- A review of the mental health treatment: Were all other non-addictive medications and treatment methods tried for a co-occurring Anxiety Disorder or Attention-Deficit/Hyperactivity Disorder (ADHD)? Did the treatment progress clearly indicate that the benzodiazepines or amphetamines were the only medications to keep the mental disorder stable? Was the participant using other substances at the time the psychiatric diagnosis was given? Or was the client substance free for a significant period of weeks and months?
- If it is clear that medication was essential to keeping the mental illness stable, then the participant should not be discriminated against and their treatment compromised by a strict policy banning such psychotropic medications.
It is often hard to get a good evaluation of whether the participant does indeed have co-occurring disorders and needs the benzodiazepines or amphetamines. But working to fill that gap and find clinicians with such expertise in co-occurring disorders is urgently needed, rather than defaulting to a strict ban on medications; or a lax policy of letting anybody take anything so long as they produce a prescription.
TIP 2
Consider some Assessment Issues for Co-Occurring Disorders.
In the SAVVY section of the May 2010 edition of
Tips and
Topics, I outlined some assessment issues for co-occurring disorders.
You can review those there.
soul
I know exercise is good for my physical and mental health. My routine when I am home is to walk/jog/listen to podcasts for 3 miles. Despite my intellectual commitment to exercise, doing it is still in the realm of “eat your vegetables” for me. Eating vegetables would be fine if I was a passionate, vegan zealot.
However this weekend, change maybe around the corner. This weekend, I was introduced to Pickleball.
“
Pickleball is a paddle sport (similar to a racquet sport) that combines elements of badminton, tennis, and table tennis.Two or four players use solid paddles made of wood or composite materials to hit a perforated polymer ball, similar to a Wiffle Ball, over a net….. Pickleball was invented in the mid 1960s as a children’s backyard game.”
What “change maybe around the corner” means is that I think I have found an almost perfect way to have fun while getting my exercise. Pickleball combines my history of being a reasonably good ping pong player with my history of a wannabe good tennis player. “Almost perfect”because:
After 10 games this past weekend, I adapted quickly. I have the muscle soreness to know I got great exercise, and best of all, I had fun serving and volleying as if I was already a pro.
“As if” means that with more consistent practice and games, I could be good at Pickleball. “Pro” means proficient. But who knows, maybe I could start a second career as a Pickleball Professional.
Getting a little ahead of myself. I first better buy a Pickleball paddle and ball.
How fun was your exercise today……..you did exercise didn’t you?