It is Jason’s third and most violent suicide attempt. Lacey’s oldest daughter comes home to find her dad sitting in his chair slumped over, both wrists slit. She calls the police, and an officer notifies Lacey that they are taking her husband to a nearby psychiatric ward for three days of involuntary observation. Here, Jason is diagnosed with post-traumatic stress disorder (PTSD). He is given a prescription for the antidepressant sertraline and referrals to counseling.
Jason has become obsessed with dying, convinced his days are numbered. Now fifty years old, he is the age at which his father passed. Lacey wonders whether Jason’s suicide attempts are a self-fulfilling prophecy. Jason’s father, a physically and emotionally abusive alcoholic, haunts his memories. Jason has talked about his traumatic childhood with Lacey, who has on more than one occasion comforted him during a nightmare or flashback. But he is not diagnosed with PTSD until well into his opioid addiction.
From the psych ward, Jason is taken directly to a residential treatment facility for men, his second time in residential rehab. This time, he is forced to stay for forty-five days. The center has a special treatment track for trauma and PTSD. It is a hard-core traditional program with no medications allowed: Jason is required to go cold turkey, even during withdrawal. For this, he will later blame and never forgive Lacey, who does not lift a finger to get him out, despite his ongoing laments. Consumed with anger for having to go through yet another dramatic episode, Lacey is unable to drum up any compassion. She does not visit Jason on the psych ward or at the center. It feels good to let go a little. She feels justified, a small sense of pleasure from finally having a smidgen of control.
Jason comes home from his treatment stint acting a little more like his old self and with some useful behavioral skills. He is vigilant about noting his thoughts about pain and using. “It’s just a thought,” he reminds himself. He never attends follow-up counseling sessions. Lacey is grateful for his sobriety but leery. She is waiting for the other shoe to drop.
Within a couple of months, after a blowup with Lacey, Jason threatens to leave. Lacey, fed up, tells him to go ahead. To blow off steam and to try and unravel her confused and tangled up thoughts, she heads out the door for a long walk. When she returns about two hours later, she finds Jason passed out on the floor, barely breathing. She calls 911 and rushes to the kitchen cupboard, where she keeps the Narcan. Paramedics arrive, give him oxygen, and transport him to the hospital. When Jason recovers, he voluntarily goes back to rehab. This time he does not go through detox but is started on Suboxone for his opioid use disorder (OUD) and hydroxyzine for anxiety. No one ever talks to him about methadone.
After twenty-eight days, Jason comes home and takes Suboxone for a week or so. Lacey hates that he is taking pills, although she says nothing. It is still something he puts in his mouth, and she is weary of watching him eat pills. He makes no effort to attend the recommended Narcotics Anonymous meetings and does not show up at counseling appointments. His mood has not improved. If anything, he is more obsessed with getting painkillers.
Medication for OUD can be lifesaving, yet it’s not a silver bullet. People with this disorder come from all walks of life and present with assorted complications that challenge even the most skilled practitioners. By the time those with addiction enter treatment, many are sitting atop a sinkhole of problems: hepatitis and other medical issues, social and vocational problems, and housing and financial concerns, as well as psychiatric symptoms. For the best chance at recovery, people with addiction need to address all these issues or they become reasons to use again. For most patients, taking away the drug is not enough. Recovery is not just abstinence but wellness and quality of life and being free from as many problems as possible. True recovery is building strength.
For professionals, policy makers, and family members alike who are not well versed in treatment issues, this chapter serves as a condensed look at some of the more challenging considerations of treating addiction, including working with teenagers, pregnant women, inmates, chronic pain patients, and people with co-occurring mental health issues. Recognizing some of the complications may help you to know when a person would benefit from seeing a mental health or other professional for screening and higher levels of care, as well as what that care might look like. These challenges are not only difficult for the practitioner—they are without a doubt painful for the individual with OUD and are leading causes of relapse.
Mental Illness and Drug Use: The Chicken or the Egg?
It is safe to say that no one comes to treatment because life is great. By the time I see patients, their drugs have stopped working for them, and they’ve lost jobs and homes, damaged important relationships, and likely acquired medical problems because of their use. Most are also depressed, anxious, or suffering from some other mental health issue. What brings people to treatment is usually the psychological suffering.
How and when they became this way is at first a mystery: depression, anxiety, psychosis, personality problems, and other mental health issues can be the result or the cause of drug use. Nearly half of all people diagnosed with a substance use disorder also have a co-occurring disorder—a mental health issue to accompany addiction—at some point over their life span. The stigma of addiction pales in comparison to that surrounding mental illness. Combine the two—addiction and mental illness—and it adds up to what some in the field call “double trouble.” Having both disorders makes everything twice as difficult. These individuals need twice as much treatment and may find it more difficult to respond to treatment and maintain abstinence. Finding and accessing care, a support group, and employment may be harder for them. And caring for someone with co-occurring disorders can be overwhelming, for family members and even health-care providers.
Understanding how addiction and psychiatric symptoms are related is a first step to more effectively helping such individuals. Someone may have a psychiatric disorder and over time develop a substance use disorder, or they may use substances first and over time develop mental health problems. They can find themselves in any of the following scenarios:
Self-medicating with opioids or other drugs to mask uncomfortable and sometimes undiagnosed mental health symptoms is common. Opioids are such a psychologically powerful medicine that they relieve all sorts of symptoms. They can thwart depression, anxiety, and psychosis all at once. Heroin works amazingly well for quieting the symptoms of PTSD, including distressing flashbacks. In addition, having a psychiatric disorder often increases the risk that a person will try substances. Jason, for instance, wasn’t diagnosed with PTSD until well into his fifties. His first use of opioids at an early age likely had an immediate effect on his PTSD symptoms, which started in childhood. Impulsivity also comes into play. Disorders that make a person more impulsive, such as bipolar disorder or attention-deficit/hyperactivity disorder (ADHD), encourage people to seek out intense experiences, including drug use. Those who use opioids impulsively or to self-medicate and have a genetic vulnerability toward addiction may eventually develop OUD secondary to their psychiatric disorder.
Using drugs to self-medicate unwanted emotions can work temporarily, but eventually it can do the opposite and intensify symptoms of depression or anxiety. For example, someone who starts drinking might at first feel as if alcohol makes living with depression tolerable. As drinking becomes more frequent and heavier, it no longer lifts the depression, which then becomes more pervasive and severe. When this happens, the person who drinks is trapped in cycles of heavier episodes of drinking and deeper, unremitting depression. Opioids can have the same result.
Drugs can also create new moods in a person: A happy-go-lucky individual who starts drinking to excess may develop a newfound melancholy. Like alcohol, opioids are depressants—they slow down the central nervous system, which can, in people vulnerable to depression, create heavy feelings of sadness. Likewise, intoxication with opioids can produce a mellow, worry-free state. Opioid withdrawal produces its own brand of psychiatric syndrome—people who may have felt good on their drug of choice can become agitated and extremely anxious and restless without it, as if they are having an acute anxiety attack.
To add yet another layer of complexity, drug use can also precipitate a mental illness by triggering the expression of certain genes that had until then lain dormant. The classic example is cannabis and schizophrenia. Over and over again, studies have shown that people vulnerable to the mental disorder can trigger it by smoking pot, especially if they start at an early age and smoke large doses of high-potency cannabis. Regardless of the scenario, drug users find themselves in a catch-22: The more they use drugs, the more powerful their depression, anxiety, or other disorder grows, and the more drugs they need to feel better.
Often, people with OUD don’t know themselves which came first, the mental health issue or the drug use. They usually can’t explain it. It’s confusing to them, and they don’t understand what’s happening to them. It’s a chicken-or-egg question. Part of my job is to determine which problem—the mood disorder or the OUD—is driving the other. The answer is important to health-care professionals because it affects how we treat our patients. Whichever course we take, we want to treat both, using all the tools we have: medications, psychotherapy, and, in some cases, an inpatient stay to observe the person drug-free, treat any withdrawal and acute psychiatric symptoms, and then start planning long-term treatment.
What happens when we take away the drugs:
a timeline approach
During an evaluation, a first step to solving the puzzle is to ask the patient questions and create a timeline for each problem. When did you start using substances? Was there a time when you stopped using? When did you start feeling depressed? When did you start to have difficulty sleeping? Were you hyperactive as a child? Did you have trouble going to camp or speaking in front of the class? Did these feelings get worse? When did they get better? Then, we look at how the timelines overlap.
If symptoms disappeared when the patient was abstinent for a prolonged length of time, because of pregnancy or jail time, for instance, there’s a good chance that the substance use caused the mental health disorder. Half of the time, this is the case. People who use drugs develop psychiatric symptoms. A person who binges on cocaine and doesn’t sleep for two days might develop psychosis and paranoia, then, after twenty-four hours in the emergency room and a good night’s rest, wake up completely lucid. It is clear that the symptoms are a direct effect of the stimulant: Take the cocaine out of the equation for a few weeks and the psychiatric symptoms go away. In the case of opioids, some people will develop feelings of sadness, stop enjoying social events, and lose their appetite and interest in sex. Heroin may make it better for short periods of time, but the depression becomes more severe, hopelessness sets in, and suicide becomes a consideration. Once these individuals are abstinent, however, mood dramatically brightens and sleep, appetite, energy, and sex drive improve in a matter of one to two weeks. Such people do not need treatment for depression—once heroin or illicit painkillers are out of the picture, just monitoring mood may be sufficient. In these cases, treatment of addiction may be easier, as there is only one disorder to deal with, and the prognosis is better.
If the symptoms of depression persist during the first two to four weeks of abstinence, we need to dig a little deeper. We need to assume that depression might have been there before addiction developed, and that it needs to be treated. Treating drug addiction while ignoring a mood disorder or other mental health issue is usually futile, as more often than not it leads to relapse. Delaying treatment of a psychiatric disorder because of the notion that most psychiatric problems were substance induced, a dominant belief among psychiatrists in the past, leads to poor outcomes and unnecessary suffering.
Co-occurring disorders: all ready for treatment but no place to go
In the not-too-distant past, addicted individuals who suffered from an untreated mental health issue were denied addiction treatment. The thinking was that they must first be treated for the mental illness before they could focus on the work of recovery. Success rates for treating people with co-occurring disorders were abominable, and the addiction treatment field saw no other solution. Likewise, mental health professionals declared the opposite: Drugs are usually the cause of mental health issues, so abstinence will unveil any real issues, if they do indeed exist. No psychiatrist wanted to treat patients for an illness they didn’t have. Nor did anyone want to give medication to individuals actively using, for fear of what might happen if the drugs interacted in the wrong way. Like fans of two opposing teams, both camps shouted their beliefs from the stands, across a field of potential patients. People with addiction who showed any sign of a co-occurring disorder were left on the sidelines, suffering inadequate treatment.
The problem did not go unrecognized. In the 1980s, the concept of treating co-occurring disorders began to garner a following. Experts tried several approaches. For example, they treated the more “severe” disorder first, or the one that was first diagnosed (the primary disorder). They tried addressing psychiatric problems first, and addiction problems first. Then came the idea of using two different treatment teams to treat both problems at the same time, in parallel, a method known as split treatment.
The most accepted practice now is for one treatment team to recognize and treat both disorders, preferably at the same time. Yet patients run into the same problems that they do with evidence-based treatment for OUD alone: (1) Addiction treatment facilities equipped to treat co-occurring disorders are few and far between. (2) Most traditional programs do not have psychiatrists on staff. (3) Some have consultants visit for one or two hours a week but lack a team of psychologists, therapists, and psychiatrists on board to fully address psychiatric problems. And (4), these settings tend to gloss over patients’ symptoms or refer difficult patients elsewhere. It is not that providers argue with the treatment model—it’s again a matter of staffing and funding, as well as finding psychiatrists with expertise treating patients with addictions, who are in short supply. As with evidence-based treatments for OUD, patients and family members who are dealing with co-occurring disorders have to know what they are looking for and seek it out.
Treating co-occurring disorders
The new model is integrated treatment: We address the mental health issue at the same time that we treat the addiction. Both are chronic conditions with the possibility of remission and relapse, so that treating one and ignoring the other is a great disservice to the patient. The two disorders are by now tightly woven together. Separating them is arduous. If you only treat the addiction, the patient remains depressed and starts thinking of using to feel better; if you only treat the depression, the patient starts feeling good and decides it can’t hurt to use again.
As soon as we know that a patient’s psychiatric symptoms are mostly independent of substance use, or existed before the substance use disorder developed, we can address the issue without delay. Treatment comes in the form of behavioral and medical interventions, which might include medications and focused individual and group therapies. The “knowing,” however, can take time, at least a few weeks of observation during ongoing abstinence. By then, patients stabilizing on naltrexone, buprenorphine, or methadone have gone through acute and most of the protracted withdrawal. What appeared to be a psychiatric symptom may have disappeared by then. It is common for depressed mood, chronic fatigue, anxiety, and suicidal ideation to be replaced with abundant energy, optimism, and a newly found interest in hobbies. For instance, someone who had periods of extreme irritability, euphoric moods, and even psychotic states and was diagnosed with bipolar disorder may become levelheaded, with stable, normal mood. But that isn’t the end of treatment: Should the symptoms of a disorder persist, or get worse despite abstinence from drugs, we are wise to treat it aggressively. Wait too long and the person will relapse. Any untreated psychiatric disorder makes recovery that much harder.
In an ideal world, we would wait through one or two months of abstinence before calling a psychiatric disorder preexisting. But addiction and mental illness is not an ideal world. Prescribed medications might take one or two weeks to kick in. So, even though we are observing, evaluating, and assessing the patient, we face a four- to six-week impasse when psychiatric treatment is at a standstill and the patient is at an ever-increasing risk of relapsing. Close monitoring and intensive therapeutic support are essential during this time.
Patients are tempted to lend more importance to one disorder than the other, but I agree with the approach that gives each equal weight and treats such people as having one disorder—“opioid use and depressive disorder,” for instance—rather than a primary versus a secondary disorder. This is helpful for the patients as well, who see that the disorders are heavily intertwined and that staying away from problematic drugs helps recovery from the psychiatric disorder and that taking psychiatric medications helps recovery from the addiction. Both disorders can produce irrational thinking and a failure to consider consequences, or impair the ability to care for oneself, which can lead to errors in judgment.
The behavioral therapies we use address both (or multiple) disorders in one fell swoop: cognitive behavioral therapy and relapse prevention strategies, for instance, work through ambivalence about medication treatment and focus on activities and skills that help patients navigate toward recovery from both disorders, regardless of which disorder patients consider to be “primary.” Patients also learn much-needed coping skills for high-risk situations, such as what to do when attending a wedding where drugs and using buddies are present, as well as for self-monitoring of cravings and defeatist thought patterns characteristic of a depressive disorder. People in recovery can easily talk themselves into using again without ever saying a word out loud. Therapy helps those in recovery to reroute a negative train of thought to something more useful to protect themselves against relapse. We show them how to modify their lifestyles so that self-care and relationships get more of their attention: Even simple acts, such as making haircut and doctor appointments, and of course being more present with loved ones, can help them stay on track. When the right hand knows what the left hand is doing, treatment success rates for both disorders are quite good.
The approach is straightforward and works when followed. Dr. Roger Weiss, a Harvard addiction psychiatrist, coined a phrase that I really like. He talks about a “central recovery rule,” which can be discussed with a therapist at every opportunity and used by the person in recovery as a kind of mantra, repeated in particular when they struggle: “Don’t drink, don’t use drugs, and take your medications as prescribed no matter what.”
Pregnancy and Opioids
There is a myth that women who have misused drugs cannot by definition be good mothers. But this is far from the truth. I’ve seen many women become abstinent when they find out they are pregnant, start taking care of themselves, and transfer this care to their newborn. They are devoted moms and willing to take professional advice to improve their parenting. For many women, pregnancy is a reason to get off opioids, and the thought of not being able to care for their child fills them with an intense desire to seek help. Yet this is a difficult step to take. Aware of being judged, addicted pregnant women absorb the shame and stigma—both of which are major deterrents to getting good treatment and seeking help. Yet with support, encouragement, and reassurance, along with good medical care, the mother-to-be can have a comfortable, healthy pregnancy, deliver a healthy baby, and be a wonderful new mom.
Take her to see a doctor
Testing of pregnant women for alcohol or drug use is not universal. I recommend that all pregnant women be screened for substances, with the caveat that doctors remain friendly, supportive, and nonjudgmental regardless of the outcome. A big problem is that women who are using substances may fear the legal consequences and choose to neglect pregnancy and newborn care rather than submit to a drug test. In some states, doctors may be mandated to report mothers with substance use problems to child services agencies, while other states offer specialized treatment programs for pregnant women. Pregnant women struggling with addiction should seek legal or trusted professional advice about the state laws with regard to substance use and pregnancy to make an informed choice about treatment for substance use disorder. But identifying and treating a substance use disorder as early as possible is in everyone’s best interests.
Like all pregnant women, those with OUD need good obstetric care, preferably from a doctor who has experience with high-risk pregnancies or at least is friendly toward women who use substances. Ideally, the woman would visit the doctor as soon as possible, tell the obstetrician of her addiction, and get regular checkups so the pregnancy is monitored. The sooner she starts to see a doctor, the better.
Seek treatment for OUD
For the best outcome, pregnant women with OUD need to stop using their drug of choice. The risk of overdose is too great. If the mother-to-be takes too much of an opioid, she might pass out, her breathing may slow down or stop, and she could die or have a miscarriage or a stillbirth. Pregnant women who abuse opioids are also in a very unstable physical state, with periods of opioid intoxication and withdrawal. Heroin and painkillers cross the placenta and get to the fetus. This is not a good environment for fetal development and growth and may lead to premature and complicated labor, which can sicken the newborn.
Untreated addiction in pregnant women has also been linked to high-risk behaviors such as prostitution and crime, which can create a cascade of problems: sexually transmitted infections, violence, legal troubles, and incarceration. A mother-to-be needs proper treatment and support, as early in the pregnancy as possible. Loving family members and friends can help to keep trouble at arm’s length by encouraging her to seek help for her addiction and get good medical care.
Medication-assisted treatment is recommended
Some women who become pregnant while using opioids want to stop using opioids on their own, in secrecy, but this is very risky. Studies have shown that 8 out of 10 pregnant women return to drug use within a month after detoxing on their own and are at greater risk of overdose. In addition, going through opioid withdrawal with no medical support, she and the fetus will experience complete withdrawal, which can result in significant risks to the pregnancy and the fetus.
Offering medication-assisted treatment during pregnancy is the recommended best practice for the care of pregnant women with OUD. Most doctors treat OUD in pregnant women with either methadone or buprenorphine. These medications stop withdrawal, reduce cravings, and prevent further use of illicit opioids. Under medical supervision, methadone or buprenorphine can reduce the risk of complications in pregnancy and labor. These medications are generally safe for the developing fetus and give the mother-to-be a chance to focus on prenatal care and her addiction treatment and recovery goals. As of yet, naltrexone is not recommended for use in pregnancy, mostly because there is very little experience with it.
However, initial experience with naltrexone implants in Australia supports its safety and effectiveness for pregnancy and the newborn.
Treatment of pregnant women with OUD involves taking medications in prescribed doses during pregnancy and after the baby is born. The counseling component helps women avoid and cope with situations that might lead to relapse and supports them through supports them through the process of tackling their addiction. Treatment with methadone is available only in specialized OTP clinics. Buprenorphine may be available from an OTP or a primary care physician or obstetrician who received special training to prescribe buprenorphine.
Methadone used to be the gold standard for treating pregnant women, but this is slowly changing as we gain research and clinical experience with buprenorphine. If a woman wishes to be treated with buprenorphine, providers should offer it over methadone. The preferred formulation of buprenorphine for use in pregnancy is a buprenorphine-only tablet. If, however, she became pregnant while being treated for OUD with methadone, she should be encouraged to remain on methadone. Some pregnant women may need to increase their dose of medicine, or to take it twice per day as they grow in the third trimester, to account for the presence of the growing fetus. They can go back to the lower dose after delivery.
Methadone and buprenorphine cross the placenta and make it to the fetus. Both of these medications carry some risks to the fetus, including a smaller birth weight, though most children eventually catch up in growth and develop normally. These risks are much milder as compared to risks from the use of heroin or other opioids, which also cross over to the fetus.
Decisions about the best course of addiction treatment are best made by each mother-to-be, with the help of doctors and providers who specialize in treating pregnant women. A thorough discussion of the risks and benefits of all treatment decisions should take place, and the doctor should evaluate which treatment setting and medication guarantee the best outcome. Facilities that specialize in treating pregnant women and their families can be found by calling your state’s substance abuse services agency. Encourage the mother-to-be to begin treatment for OUD and support her during treatment, through labor, and afterward.
When MAT Is Not an Option
Preparing for delivery
Delivery for pregnant women with OUD is usually no different than any other delivery, but it does require some additional preparation. First and foremost, it is not an option for the woman to hide the fact that she is taking OUD medication therapy. Many women need a pain management plan for childbirth. The usual doses of methadone or buprenorphine will not treat her pain adequately. The mother-to-be should discuss pain control options with her physician during her prenatal care. She must also let the doctors at the hospital know that she is taking methadone or buprenorphine, so they give her medication that will be helpful and not cause problems. Ideally, the doctor and hospital would have experience working with such women during labor and delivery. At a minimum, they need to be accepting and nonjudgmental. That a patient chooses to be in treatment and is taking responsibility for the well-being of her baby and herself deserves support from the medical community.
The mother-to-be also needs to select a doctor for the baby (a pediatrician or family physician) and meet before delivery to talk about the care of her baby. It is important that this doctor is aware that the mother has been taking methadone or buprenorphine during the pregnancy, and that the baby may need additional monitoring or treatment after delivery. A pediatrician will check the baby after birth and decide whether any medications are needed to help the baby during withdrawal. The baby may need to stay in the hospital for a few days or weeks while taking the medication, until they’re completely well. Friends and family members can play a large role in encouraging the mother to have these discussions with her doctors as far in advance as possible.
Women are often afraid their babies will be taken away
Many babies and mothers get tested for alcohol and other drugs at delivery. A positive drug test, even if it’s the result of prescribed medications, may mean that social workers or a child protection agency will want to talk with the mother and her family. A child services worker may come to the mother’s home to see how safe the environment is for her baby, so it is important to prepare for that. In most cases, child protective services wants to keep the family together, and this is especially true if the new mother is actively involved in treatment. Staying on the medication improves chances that she will be able to care for the baby. Be aware of your state’s laws and practices regarding drug tests and newborns, and ensure that the mother-to-be is aware of the possible visits from child protective services. The thought of having a child taken away is frightening, to say the least. Reassuring the recovering mom and encouraging her to continue treatment and her new, healthy lifestyle has a calming effect.
The newborn’s health
Babies born to women who are addicted to heroin or prescription opioids have been exposed to a similar amount of opioids as the mother. When the baby is born, the supply of opioids is suddenly “cut off,” and the baby can have temporary withdrawal or abstinence symptoms called neonatal abstinence syndrome (NAS). Because both methadone and buprenorphine are also opioids, NAS can also occur in babies whose mothers are on methadone or buprenorphine. It does not mean that the baby is born addicted to opioids; it only means that the baby will be born with some physical distress due to exposure to the medications, which can be medically managed. NAS is a treatable condition with a full recovery in all newborns as long as the newborn has no other medical problems.
Every baby shows withdrawal differently. Some will have mild symptoms and others will not show any signs. Symptoms usually occur on the second or third day after birth and can include shaking and tremors, poor feeding or sucking, incessant crying, fever, vomiting, and sleep problems. Doctors may administer medications to ease these symptoms and may keep the baby in the hospital for a few extra days. Some babies may have discomfort related to withdrawal in the very short term, but in the long term, babies with NAS grow as they would normally. NAS causes no known lasting physical or intellectual problems in the baby. What happens to babies after birth has a much larger impact on their development. Being raised by a mother who is well and in recovery from opioid addiction is a big plus.
NAS can be diminished by “rooming in,” or being near the mother, breastfeeding, swaddling, and skin-to-skin contact, such as holding baby bare chest to bare chest. Breastfeeding is often encouraged for women who are taking methadone or buprenorphine. Only minuscule amounts of medication get into the breast milk, and this has been shown to help lessen the symptoms of NAS. However, breastfeeding is not safe for women with HIV who are taking certain medicines or who have relapsed and are actively using drugs.
The weeks and months after delivery
Medication and therapy should continue after delivery: The mom needs tender loving care and support. Ensuring she has help in learning how to be a mom and has someone available to take care of any other children for periods of time goes a long way. The weeks and months after a baby is born can be a stressful time for women in general, and even more so for those in recovery. The new mother should be sure to continue substance use disorder treatment, including staying on medication and attending parenting support programs and counseling or relapse prevention programs. This is not a time to stop medications or therapy. The longer people remain on the medication, the better the chance that they will avoid relapse. The dose of the medication may need to be adjusted after the delivery.
The weight of the world
The stigma around addiction and pregnant women is compounded: There is stigma with addiction. There is stigma with addiction in women. And there is even more stigma with addiction in pregnant woman. If she has a mental health issue as well, she is carrying not only a child but the weight of the world on her shoulders. Pregnant women with OUD need support and meaningful advice, not judgment. Helping her find a suitable obstetrician is a great start. From there, she will need ongoing reassurance and support from friends and family, who could offer to go with her to prenatal appointments and encourage her to eat nutritious foods and practice relaxation and stress-relieving techniques. Family members should be open to participating in family therapy, if available.
Adolescents, Teenagers, and Young Adults
Most teenagers will at least experiment with alcohol and other drugs at some point. In some respects, it is a rite of passage, a common denominator of all generations. Curiosity, peer pressure, anxiety, or rebelliousness likely play a role in the decision as well. Many will decide that drugs are not for them and simply return to the activities of their youth, unfazed by what their partying peers think of them. Others will dabble for a bit, drink too much beer on occasion, smoke cannabis once in a while, but not take any of it too seriously. Still others will go full throttle and make drug use the center of their teenage existence, yet easily and gladly walk away from the world of drugs as if it never really mattered within the space of ten years. A small fraction of the tens of thousands of adolescents out there experimenting with drugs, however, will start showing signs of addiction before age twenty. The problem is identifying which teens are likely to do so.
We do not have a blood test to identify high-risk adolescents. We have to rely on the traditional tool of a clinical interview. Children who grow up exposed to neglect or abuse, and those with a family history of addiction or psychiatric disorders, are at higher risk for developing substance use disorders. Adolescents with a history of psychological problems or psychiatric disorders as a child, especially if those remain undiagnosed and untreated, will also be at high risk of developing addiction. Growing up in neighborhoods where violence and drugs are often present, with peers who use drugs, and with limited opportunities for non-drug-related social or recreational activities can contribute to the genetic risks and result in addiction in a teenager.
Nothing is simple or straightforward about diagnosing a teenager with substance use disorder. Distinguishing between the follies of youth and a substance use disorder is not clear-cut, especially because many adolescents will neither see nor accept that they have lost the ability to control their substance use. They will not ask for help until it is very late. Others around them need to be the ones to identify it as a problem: parents, teachers, pediatricians, and friends. Routine medical and psychological visits provide opportunity for asking adolescents about substance use. If physicians seem genuinely interested and inquire in an accepting and nonjudgmental manner, teenagers are generally open and talk about their experiences with substances, more so if they can be assured of confidentiality and no immediate negative consequences.
Identifying an adolescent with problematic drug use early on can minimize the toxic effects of substances on the vulnerable and developing brain. Intervening early on can be much more effective in reversing pathological brain changes and preventing further physical and psychological harm that comes with the lifestyle of a regular drug user. Disrupting further exposure to substances is a priority at this stage.
Treating teens
Identifying adolescents who have developed drug use disorder is difficult at best, but treating them is a bit of a mystery. Adolescents may not see the value of treatment and may not have not developed their language and thinking fully enough to express themselves, be introspective, and engage in psychological treatment. They therefore may require different treatment techniques than those developed for adults.
Treatment should target the whole person, not just the problematic drug use, which for adolescents covers a wide swath of developmental skills. As young people, they are already tasked with a monumental job: learning how to navigate the world of people, emotions, social pressures, difficult decisions, and conflict. They don’t have everything figured out, and substance use can cloud this process even more. When adolescents take drugs, they are at the same time feeling grown-up and actually stalling their development: Using drugs hinders the learning of some developmental skills; the drug eases social anxiety or masks hurtful feelings, negating the need for introspection and more mature responses.
Identifying and addressing risk factors and external circumstances that may contribute to teens’ ongoing drug use is essential to successful treatment. Helping adolescents develop and improve personal and social skills improves treatment outcomes. Educating them about what is required for a healthy sex life, minimizing intimate violence, and preventing sexually transmitted diseases are also important factors of treatment. Because adolescents’ lives involve school, hobbies, sports, and peer groups, treatment should support a drug-free life in all of those arenas. Encouraging family members to support the treatment plan and educate and guide their loved one through difficult times goes a long way toward keeping young people who use opioids sober.
Treatment for teens often involves a residential stay as the first step. They spend a month or more in an addiction rehabilitation facility where they have a chance to be drug-free and recover physically. A team of providers is usually on board to evaluate and begin treating co-occurring psychiatric disorders, such as depression or anxiety. Young people in treatment learn about the effects of drugs on the body and mind, how to recognize triggers for relapse, and how to avoid them by using newly learned skills. They can also learn and practice new personal and social skills. Most programs will also introduce teens to the Twelve Step approach to recovery and set a plan at discharge to use their new skills to help them stay sober once they get home.
Still, as yet there is no surefire technique. At fifteen or sixteen, teenagers are told they cannot use drugs, not even legal drugs, ever, for the rest of their lives. Ambivalence is high posttreatment, and such concepts don’t always take hold. Youths are hard to treat. We don’t fully understand how to treat them—should treatment be short-term, lifelong, or somewhere in between? In truth, we need more research.
OUD medication and teenagers
The use of medication to treat teenagers with OUD remains controversial. Long-term studies of teens treated with medications are nonexistent, and it is difficult to reconcile the idea that a young person may need lifelong treatment with medication. Traditional treatment involved methadone maintenance. Very few methadone programs treated sixteen- and seventeen-year-olds. Most programs required, and still require, patients to be a minimum of eighteen years old. Buprenorphine is FDA approved for patients aged sixteen and over and is an option for a large number of adolescents with OUD. However, even fewer teens are offered treatment with medications than adults.
Similar to adults, the longer that adolescent patients are maintained on buprenorphine, the better the outcome. The evidence is limited but suggests that most patients should be encouraged to remain on buprenorphine in the long term, especially if they are doing well. Some providers prefer that adolescents’ treatment with buprenorphine be time limited to one to two years of sobriety, even though no data suggest that this is a good strategy.
The major challenge is to get teens to keep taking their medication. Adolescents are less likely to comply over the long term than adults. The additional challenge is that they may not be responsible enough to hold their supply of buprenorphine. The controlled substance can be diverted, misused, or simply lost, like a set of car keys. We need innovative strategies to help teens adhere to their medications, perhaps strategies that harness the power of social media and gamification.
One of the best strategies is to involve parents in treatment. Parents can securely store the medication and allot their child only a daily dose. Even better, parents can directly supervise each time the medication is taken. It is best to do it first thing in the morning, when the teen may still be in bed. When just waking up, or before they get busy, adolescents are more likely to put the tablet or the film in their mouth. After a few minutes of sitting at the bedside, a parent is reassured that the medication has been absorbed and this day their child will be protected against relapse and overdose. This ritual has to be repeated day after day, but most parents, who understand its importance, are happy to do it. Teens grow to like it as well, especially if it becomes part of a warm, daily greeting that puts a positive spin on the day ahead. The mother of one of my patients lies down with her daughter after giving her the medication. The two are reassured and connected through the gesture. It is as much for the mom as it is for the child. The alternative to a daily supervised dose of buprenorphine may be a long-acting buprenorphine injection.
Naltrexone, by tablet or injection, is not approved for use in children younger than eighteen because we know little about its safety and effectiveness in this population. The few centers that do offer XR-naltrexone to young adults experience mostly positive results. Long-acting naltrexone is a particular favorite of parents as a treatment option for their children. Parents like the assurance that the injection offers—it beats praying every time your children leave the house that they don’t score opioids somewhere and die of an overdose. With XR-naltrexone, parents can watch their children take the monthly dose and know that, if they do use, the drug effects will be blocked. They will not get high. They will not overdose. And they will not die. It is not the easy way out. It is the sane, logical way. Naltrexone may soon be available as an implant lasting several months and offering greater reassurance.
Most adolescents (like many adults) do not like the idea of taking medication indefinitely. They tend to like the idea of using buprenorphine in the long term even less than naltrexone, because they will still be on opioids. We are not sure how long patients need to stay on naltrexone, but we do know that it may need to be longer than one or two years. In practice, it is difficult to keep teens on the injection for more than eighteen to twenty-four months. They grow weary of taking the medication, even if they are doing well. But during this period of time in the life of an adolescent, when brain and psychological development is at a pinnacle, OUD medication is invaluable. It allows for normal psychological development to continue, whereas heroin and other drugs interfere with development. Little in life matters when you are in the grip of addiction. At this point, we do not know whether chronic exposure to medication, be it an agonist or antagonist, alters neurological pathways or the normal development of higher cortical functions. As always, taking medication has to be weighed against the risk of relapse and death.
Prevention: A vaccine for addiction?
The other quandary is how to keep all adolescents, whether they’re just out to have fun or needing a fix, safe from deadly overdoses. We know that the opioids available today are insanely potent. If drugs are seen as a rite of passage, and the drugs available today are deadly, an entire generation is being not only duped but possibly fatally betrayed by their own culture. Adolescents are not always mature enough to understand the potential consequences of taking drugs. Most young people, for instance, do not overdose intentionally. Rarely is overdose connected to suicide in youths. It’s almost always an accident—a bad combination of opioids, sedatives, and alcohol, or unwittingly taking street drugs fortified with fentanyl or some other unexpected substance. They’re just kids—many of them with loving and beaming personalities—who make a poor choice in the wrong place at the wrong time.
All providers should alert parents who know or suspect that their child is taking opioids to seek training on overdose recognition and prevention. These parents should keep one or more doses of naloxone on hand. It is very unsettling to have to be prepared for a child’s overdose, but the idea of being helpless in this situation is even more horrifying. Grassroots organizations, run by parents whose kids have died of opioid overdoses, offer free trainings on how to deliver naloxone to an overdose victim. Countless times, because families are able to act in time, overdoses are prevented.
Traditional, evidence-based methods of prevention that are proving successful, especially those targeted at high-risk youths, include programs that bolster psychological development and teach basic living skills that went unlearned during years of heavy using. However, untargeted prevention, such as public service announcements and police officers visiting schools, is not demonstrably effective.
I once again advocate for the health-care system to get more involved. During annual exams, when pediatricians make a point to discuss sexual health, they could just as easily broach the subject of drug use and even take a confidential urine toxicology test. If necessary, they could conduct a brief intervention. If framed as a way to address overall health, not as a punitive measure, these conversations could greatly increase awareness. Being watched, or monitored, in this way sends the message to youth that adults care what happens to them and that they are accountable for their health.
Criminal Justice System
Every year, about one third of illicit opioid users find themselves behind cell doors, locked up in a correctional facility for one crime or another. About one quarter of all inmates have OUD. Most often, their offense is nonviolent and secondary to having an addiction, such as drug possession or sale, or petty theft. Most of them would not be committing crimes were it not for their addiction. Having such a large number of individuals with OUD in a controlled environment is a great opportunity to offer treatment, which not only benefits the health of an inmate but decreases the spread of infectious diseases, addresses risk factors for reoffending, and greatly benefits public health and security. Yet a great majority of incarcerated individuals with OUD are left untreated. Within three months of release, three quarters of them will relapse to heroin use, even after being referred to treatment in the community. Many will continue their criminal activities. Tragically, many others will overdose when they relapse and never have an opportunity to benefit from treatment.
Upon entry, most new inmates with OUD must go through a forced detoxification. Only a handful of jails and prisons offer medication to ease withdrawal symptoms. Detoxification followed by abstinence is the intended outcome for most prisoners, at least while within prison walls, in most facilities. When a prison offers a drug treatment program, it is usually abstinence based. Rarely is a program based on the medical model. Some US prisons offer methadone. In facilities that offer methadone maintenance, about half restrict the treatment to pregnant women and inmates with chronic pain; even when an inmate comes in on methadone, they may not have the option to continue with it. This practice is very different from that of most other developed countries, where methadone or buprenorphine treatment is widely available in prisons. Even countries that only recently introduced methadone, such as Iran, are now offering it in prisons because the benefits are hard to argue with.
This is yet another situation where a poor understanding of OUD has grave consequences. OUD is a chronic disorder that is unlikely to be “cured” by forced abstinence during incarceration, and psychosocial treatments are rarely sufficient. If left untreated, drug cravings and use will recur, usually as soon as the person becomes exposed to drug triggers and gains access to drugs. Forced abstinence is not treatment. Relapse should be expected on discharge, and referral to an outpatient program, even if that program offers medications, is not enough.
Treatment in prison should be the same as the treatment offered to the general population, similar to treatment offered for other medical conditions. Treatment with medication should be the mainstay. Individuals stabilized on medication are more likely to have fewer psychological symptoms and take advantage of psychosocial interventions and all the other rehabilitative programs offered in prison. Additional psychosocial programs and self-help groups may also be offered. On discharge, individuals stabilized on medication are not only less likely to immediately relapse and overdose, they are also more likely to continue with treatment in the community, adhering to the medication, and attending programs and self-help groups.
If we offer treatment with medication to all inmates with OUD, they are much less likely to be reincarcerated. Medication, backed by some newly learned living skills and behavioral therapies, gives them at least a fighting chance when confronted with difficult circumstances upon reentry, including being surrounded by drug use, rejection from family and employers, and feelings of hopelessness. Offering medication in prison but especially before release, along with some degree of aftercare, not only saves but improves lives and reinforces the separation between addiction and the criminal justice system.
Why referral to treatment after prison is not enough
Treatment with medications is well proven to improve health and reduce recidivism, but many newly released inmates are reluctant to take the medications. Some fear they will become addicted to methadone or buprenorphine, which might reflect attitudes expressed toward medications by treatment providers in prison. Ex-inmates also fear that if reincarcerated, they will have to go through yet another traumatic opioid withdrawal from buprenorphine or methadone. In such cases, treatment with naltrexone may be a preferred option. Individuals who were recently involved in the criminal justice system and were treated with XR-naltrexone are much more likely to remain abstinent and engaged in treatment than those referred to a traditional treatment program. The traditional belief that abstinence is the only real recovery also prevails. Using medication feels like a step backward, especially for those who stay years in prison drug-free. However, its benefits are hard to argue with.
Furthermore, when former prisoners are interested in starting treatment with medication, they may have difficulty finding services, have to wait too long to get medication, or may not have the resources needed to cover the cost of treatment. If free treatment services were available for this population on release, many would avoid reincarceration, which is much more costly.
Chronic Pain and OUD
We know that chronic pain and chronic opioid use are not synonymous, but a percentage of people who are prescribed opioids for chronic pain have OUD, and most of them are undiagnosed and untreated. In these individuals, OUD developed directly as a result of treatment with opioid painkillers. We cannot eliminate painkillers. We cannot deny relief to patients in palliative care or hospice, for instance, where risk of addiction is not an issue and treatment focuses on maximizing pain relief. Nor can we ignore the 11 percent of Americans who suffer from chronic pain. We cannot stop prescribing painkillers for recovery after surgery or a serious acute injury condition. Nor can we turn a blind eye to the fact that a simple prescription can in a few months’ time lead to heroin and fentanyl use and eventually destroy an entire family. How do we address pain and prevent addiction at the same time?
In 2016, twenty years after the opioid prescription frenzy began, the Centers for Disease Control and Prevention (CDC) came out with guidelines for prescribing opioids to patients with chronic pain that highlight addiction as a major consideration. Compared to earlier guidelines, the CDC recommends lower dosages, refers to all patients (except those in palliative care and hospice) as being at “high risk” for OUD, and offers more specific recommendations for how to know when the risks outweigh the benefits. It was a long-awaited step in the right direction.
Treating chronic pain is complex. It is true that if the doctor can identify the cause, the patient has severe chronic pain that is responding to opioids, and there’s an 80 percent chance that the patient will not acquire an addiction, then taking opioids might seem like a good gamble.
This gamble comes with a litany of assumptions, namely that doctors will be able to detect when someone starts becoming addicted and will do something to stop it.
When it comes to the chronic pain conundrum, two very major considerations are almost always overlooked: First, the body naturally develops a tolerance to opioids. Sooner or later, the painkillers will stop working. Nonaddicted pain patients may not crave more opioids, but will experience pain that can now only be relieved with more opioids. Second, painkillers, in time, will not only stop working but also cause increased pain in some patients. In these cases, opioids have sensitized the body, and patients experience more severe pain. These patients find relief only when taken off painkillers.
A range of nonopioid medications and behavioral strategies are available that could be helpful for some people. And, in the midst of our public health emergency, the call to develop nonaddictive painkillers more potent than Tylenol is loud and clear. But in the end, we have to set the expectation that some people will have to live with some pain. The assumption that everyone should have 100 percent of their pain taken away is unrealistic—and quite recent. Up until the 1980s, most Americans outside of a hospital setting took aspirin or Tylenol for pain relief. Eliminating 100 percent of pain in all patients will likely not be possible, as it is not possible to cure many illnesses that cause pain. Making 100 percent pain relief a priority carries too big a risk for the population at large, especially if we think that opioids are the solution. Opioid painkillers are powerful and potentially dangerous medicines, hence they are not available over the counter.
These reasons alone are enough to advocate for pulling back on prescribing opioids to patients who don’t show any real evidence of pain relief and turning instead to less potent but safer pain relievers and nonmedication methods, such as massage, yoga, acupuncture, and meditation. Beyond that, medical professionals should follow the selective prescribing practices outlined in the 2016 CDC guidelines, which advocate for only prescribing very low doses for short periods of time. If the medication doesn’t relieve pain, doctors should not prescribe more but find something else that does help. How to enforce this approach is another story, but accepting that we have to do something to stop unnecessary initiations to opioids is important if we are at all serious about curtailing the opioid epidemic’s accelerating growth.
Another issue is that when doctors stop prescribing opioids, the 20 percent of patients who are dependent will eventually turn to street drugs. This is a clear and unintended consequence, yet we know that, without intervention, it will happen sooner or later for all but a few. Once those patients have been exposed to opioids long enough to become physically dependent, efforts must focus on harm reduction and treatment. Our best hope is preventing exposure to new initiates by trying other, more holistic methods of pain relief first or dispensing more innocent drugs, such as aspirin or ibuprofen, for pain whenever possible.
Treating OUD patients who have chronic pain
Half of all patients being treated for OUD experience pain, and those in recovery from OUD may at some point experience acute or chronic pain worthy of a shot of morphine. If treating chronic pain in otherwise healthy people is complex, it is an even thornier problem for doctors facing patients who are being treated for opioid addiction while complaining of pain. Doctors and patients find themselves in a difficult situation. The stigma of both conditions leads some providers to question the legitimacy of complaints of pain or even reject them outright. In acute situations, providers may not offer treatment that would be offered to patients without addiction. Patients, likewise are reluctant to volunteer information about their OUD because they fear prejudice and mistreatment.
Patients treated with methadone or buprenorphine who experience pain should be offered additional, and highly supervised, pain treatment. Prescribers should work in concert with the patient’s addiction provider. Not addressing pain puts patients in stress and at risk of relapse. Even though methadone and buprenorphine are pain relievers, the doses and dosing frequency used for addiction are not sufficient to provide pain relief. First, the patient is usually tolerant to the maintenance doses. The body adapts and the pain threshold goes up. Patients maintained on methadone and buprenorphine feel pain the same as do other people who are not treated with these medications. Second, these medications produce pain relief for only a few hours after the dose, as opposed to the antiwithdrawal effect, which lasts all day.
In patients maintained on methadone who require treatment for acute pain, the maintenance dose should be continued and additional pain medications offered, but higher and more frequent doses may be needed. In the case of chronic pain, a higher dose of methadone may be necessary, preferably given two or three times per day, if possible.
Less is known about treatment of pain in patients treated with buprenorphine. But as with methadone, the maintenance dose of buprenorphine is continued and additional pain medicine is added. Alternatively, the buprenorphine dose can be increased, with a dose given every four to six hours. And in yet another scenario, buprenorphine can be stopped, and traditional opioid painkillers used as long as the pain is severe. In this case, once the patient no longer needs treatment for pain, the buprenorphine is reintroduced.
It is important that patients discuss the fact they are being treated with OUD medications before scheduled surgery, so that the best approach can be planned. In general, stopping medications days before a planned surgery is ill-advised. The patient may become destabilized and have unnecessary anxiety and even cravings, putting them at risk of relapse. Stopping buprenorphine or methadone one day before a scheduled surgery is usually sufficient. Some addiction experts even suggest that the daily dose of buprenorphine should not be stopped, as additional pain can be managed using more potent opioids that are available in the hospital setting.
Pain management in patients treated with naltrexone is more complex. Naltrexone is a very effective blocker of opioids, and standard doses will not get onto receptors and will have no effect on pain. The blockade from naltrexone tablets lasts for two to three days after the last dose and five to six weeks after the last naltrexone injection. However, this blockade can be overcome using very high doses of potent opioids. Doses ten to twenty times higher than the standard dose may be needed to “overcome” the blockade.
Patients treated with naltrexone are wise to wear a medical bracelet or carry a naltrexone card in their wallet. In case of an emergency, such as a car accident, an anesthesiologist can administer high enough doses of opioids to provide needed pain relief, but it needs to be done under careful observation to monitor breathing. Patients can also be anesthetized without using opioids.
For acute pain that does not require surgery, patients who are blocked with naltrexone can be treated with nonopioid medications, such as anti-inflammatory agents, muscle relaxants, anticonvulsants, or others. Nonmedication strategies can also be used, such as local nerve blockers and anesthetic injections under the skin. If surgery is required but can be postponed, it is best to schedule it for after the effect of naltrexone is expected to wear off. Even though many patients and providers are worried about the problem with pain management in patients on naltrexone, in practice, problems related to pain are very rare.