Wednesday, December 13, 2006

To rsp1981 and the List:

Dual-Dx is not intended as a forum for giving or dispensing advice or referrals. However, real-world situations can provide much fruitful material for discussion and deliberation. I think addressing your concerns here may have great merit.

You describe a heart-wrenching situation. I am so sorry for you. Your worries about your son dying may be realistic; addiction is a highly lethal disease, and is even more so when other psychiatric conditions are in the picture. My perspective is informed by personal experience with recovery, and tempered by being a primary care physician and having family members who have struggled with addiction. I have a number of suggestions for you:

1. Education. Inform yourself, and your son. "Recovery Options" is the best book out there, by Volpicelli and Szalavitz. It describes all the treatment alternatives for addiction that have evidence of efficacy, describes how strong that evidence is, and discusses the dual diagnosis complications of addiction.

I really do like the AA Big Book, "Alcoholics Anonymous." If you have any preconceptions about what this book is like, they're probably completely wrong. It's packed with interesting and informative anecdotes and is not at all preachy, dogmatic, ideological, or prescriptive. It's been popular for a very long time for very good reasons. The 12 steps are just one page of hundreds; they've been dreadfully over-emphasized.

2. Dual-diagnosis and professional help. Integrated treatment of addiction and psychiatric disorders is ideal, but commonly unavailable. Separately (but simultaneously) addressing addiction and other psychiatric disorders is not ideal, but can be completely satisfactory in effect.

In terms of professional help, I'd suggest using exactly two professionals. A prescribing psychiatrist who is comfortable with the medications mentioned here -- you may already be using one. Also, one non-MD drug-and-alcohol professional who is familiar with dual diagnosis issues. I might suggest trying one who is in private practice. This professional could be a psychologist, social worker, or licensed drug/alcohol counselor. Professional designation isn't important; respect, compassion, empathy, knowledge, and experience are important. Avoid any who are rigid about pursuing any particular course, such as insisting on 12-Step participation, or avoiding such participation. The psychiatrist might be able to recommend the non-MD professional. Alternatively, the addiction professional might be able to recommend a psychiatrist.

It's possible that having all the family go together to a family therapist might be helpful, so possibly a third professional might be in order. Couples therapy has been shown to be very effective for addicted individuals who are married or coupled. But for a son living with parents, family therapy would be the equivalent. The professionals who do this work are marriage/family therapists, and a smart one is worth his/her weight in gold.

3. Pharmacologic resources for addiction and psychiatric problems. Benzodiazepines (alprazolam, lorazepam) are fairly problematic -- only in small part by their being potentially addictive. These "benzos" can cause or worsen depression if taken in significant doses over significant lengths of time. If dosing is stable, they may help anxiety significantly -- but when trying to taper down or stop, cravings for alcohol may become irresistable.

As long as your son is on benzos, many addiction recovery resources will be unavailable to him. Transitioning him off of these meds may be very, very difficult. An anticonvulsant (e.g., Tegretol) might be used during the benzo taper to ease many of the withdrawal symptoms.

Antitdepressants are generally a much better treatment for anxiety, especially for those also suffering from addiction. Any of them can help anxiety, though Wellbutrin may have the poorest characteristics here. On the other hand, if your son's addiction to methamphetamine is significant, Wellbutrin may have some particular benefit here. Hard to say.

Perhaps the best antidepressant for anxiety, in general, is Effexor. But Effexor can cause a lot of trouble with nausea during the first weeks. Something like Zoloft or Lexapro may be a very helpful antidepressant alternative to either Wellbutrin or Effexor.

If an antidepressant isn't as effective for his anxiety, there are many, many adjunctive approaches available, both pharmacologic and non-pharmacologic. I can expand on this if desired.

If your son has significant alcohol cravings, either Naltrexone or Acamprosate may be very helpful medications. They are extremely safe, and quite effective. Whoever is currently prescribing his psychiatric medications should be competent to prescribe these as well.

Resist calls by "addiction specialists" to avoid medications. Avoiding addictive subtances, however, is quite reasonable. There are occasionally good reasons to use an addictive medication for someone in recovery from an addiction, but those circumstances are not common.

4. Home and residence. Your son may need another 28-day inpatient rehab stay somewhere to get sober and stabilized. The transition off benzos could happen during this stay, if the program has a good prescribing psychiatrist on staff. If, however, he can get a month's sobriety without such a stay, by all means, save your money.

Living with one's parents is not at all ideal for those needing to pursue recovery. Living with people who understand addiction and can supervise the addict's recovery is extremely helpful. Immediate family members typically cannot fill the contrasting roles of supervisor of recovery and loving parent. Many families therefore turn to long-term residential treatment. This can work well, but it's expensive. Also, my own experience with the lower-level staff in such places is that they too often treat clients in a demeaning, disrespectful manner. Occasionally, the top-level supervisory staff is no better. Still, being humiliated over a period of months is better than being dead.

An excellent alternative to either living with family or residential treatment is an Oxford House. See A directory of houses around the world is there. Basic ground rules for a typical house would include regular 12-step meeting attendance, no usage of addictive medications (even prescribed), abstinent for at least 30 days prior to entry, payment of rent on time every week (or month), and reliable perfomance of basic house chores. Employment is typically expected, but some flexibility here is the norm. A recent study in the American Journal of Public Health (October 2006) reported results from Oxford House placement to be as good as any formal treatment program.

Therefore, upon discharge from the 28-day program (or self-directed period of abstinence), I'd suggest he go directly to an Oxford House or other residential placement. Even 24 hours at home or in any other setting that he has associated with using could result in immediate relapse. Therefore, you might find a local Oxford house and try to "buy" him a bed there prior to his entry into the 28-day rehab, if he goes that route.

I view the effectiveness of these placements as deriving primarily from the individual being immersed in a social environment in which sobriety is expected, valued, modeled, and demanded. I view 12-step participation as being effective via this process, primarily. The advantages of Oxford house living is that there is no ideology, and the "meetings" are simply living with others in recovery -- every day, without having to make any particular effort to attend.

5. Nutrition. Particularly with alcoholism, malnutrition is common but often overlooked. On the other hand, scams and nutritional "cures" are endlessly hyped. Great skepticism is warranted. I'd suggest a multivitamin with minerals, and encouraging fruits, vegetables, whole grains, and adequate protein. There are anecdotal reports of great benefit from fish oils (omega-3 fatty acids) in addiction. There are many impressive, unequivocal studies that show benefit from fish oils in a variety of psychiatric disorders. A dose somewhere around 3 grams daily may be reasonable.

6. Motivation. His active involvement in choosing a path to recovery will enhance his motivation. Don't try to force one particular approach on him.

7. Other. There are many, many other approaches which some find helpful in pursuing recovery. Regular vigorous exercise is helpful to many. Music is helpful for others. Simple supportive social networks of any (sober) sort may help. Deep immersion in some other interest or pursuit can take one's attention and time away from addictive use. Seeking to be a helpful volunteer or service worker can be useful. Idle and unstructured time is one of the greatest enemies of recovery.

One last-ditch option would be "abandoning" him into the local homeless shelter system or Salvation Army program. This is high-risk for a dual-diagnosis individual, but might well be better than the status quo, if nothing else is working. These facilities have lots of experience with addicted individuals, and more experience than they realize in dealing with dual-diagnosis issues. It's possible that a particular facility might entail some risk of violence; the local police might be able to lend some perspective. Assuming no major risk of this, the worst risks would be sleep deprivation, an unbalanced diet, and/or meddling in his medications. Any of these are also better than demise.

I'm certain I'm overlooking other good resources, options, approaches, and strategies. By all means, continue soliciting suggestions and recommendations. Unfortunately, bad treatment, bad advice, and bad professionals are all too common in this field. Be skeptical, and demand evidence to back up opinions that don't make sense to you.

Best wishes,

Steve Coulter, MD
SteveMDFP -at- gmail -dot- com

On 11/16/06, rsp** < rsp**> wrote:

Is there anyone who can advise a parent of a 23 year old son (diagnosed complex anxiety disorder, depression, substance abuse, alcohol, meth, other) who is also on various prescriptions (alprazolam, lorazepam, gabitril) of where to turn to who can help with what we now believe is COD. He is in our home dying a slow death and appears to have no control over any aspect of these conditions. I can find no one in the Kansas City metrpolitan area that undestands or recognizes COD and we're willing to take him anywhere so we don't lose him. He has been through all customary treatment and counseling, hospitalizations, therapy, Valley Hope twice - for over 10 years to no avail. Incredibly bright - cannot hold a job - has been to three colleges only to fall back.

It seems that we can only find doctors or clinicans that understand and treat individual issues but don't know how to diagnose and treat what we now believe is COD.

We feel helpless - our choices now appear limited.


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