Addiction Treatment Forum

Addiction Treatment Forum reports on substance use news of interest to opioid treatment programs and patients in medication-assisted treatment.

A.T.F. Volume VIII #4 Fall 1999

by

 

  • Patient’s Perspective – MMT Patients Battle Prejudice
  • Clinical Concepts – Addiction Treatment in the Age of HIV/AIDS
  • From the Editor
  • Events to Note
  • Where to Get Info
  • Readers Survey – Why Measure Methadone SMLs?
  • Brainstorm: Exploring the Bosy, Mind & Soul of Addiction Part 2

 

Patient’s Perspectives – MMT Patients Battle Prejudice

Uphill Struggle
Many have asserted that being a methadone maintenance treatment (MMT) patient means fighting an uphill battle against stigmatization and prejudice. To objectively assess these challenges, Nancy F. Neman, MA, CPC – Tucson Clinical Director at New Hope Behavioral Health Center (NHBHC) – surveyed multiple dimensions of patients’ lives: employment, interactions with medical professionals, family/personal relationships, finances, social life, and self-perception.
NHBHC is an Arizona narcotic treatment program serving 300 patients from two facilities in Tucson and one in Mesa. Program Administrator D. Rick Campbell supported Neman’s research, which gathered voluntary responses to an extensive, anonymous questionnaire from 87 patients.
Employment Discrimination
Significantly, over 66% of respondents reported denial of employment or loss of existing employment due to methadone-positive urine screenings. A high number reported that, even with letters from the MMT clinic explaining the effects of methadone, employers either regarded methadone as a “street drug” or equated it with active drug addiction and were unwilling to employ the patient.
Many employers simply said they would not allow a “drug addict” in the workplace. After reading an informational handout for NHBHC patients regarding the Americans With Disabilities Act, most patients reported that they were unaware that such discrimination in an employment setting is highly illegal.
“Since Arizona is a ‘right to work’ state, and employers do not legally need a specific reason to decline hiring or to fire an employee, the patients incorrectly assumed that the discrimination against them was legitimate,” Neman observes.
Prejudice by Professionals
About half of respondents reported that they had informed their physicians of their MMT status, although very few had told their dentists. Surprisingly, 96% of those patients reported a physician’s refusal to treat them and physician denial of adequate pain medications (even in cases of major surgeries) upon learning that the patients were MMT program participants.
Neman notes that five NHBHC patients with hepatitis C died after being denied liver transplants. Family members reported that those patients were turned down for transplants due to their prior histories of drug abuse, despite situations in which patients were no longer on methadone or any other drugs and had financial support for the procedures.
Sacrificing Social Contacts
Two-thirds of respondents reported that they felt that their social lives were hindered due to the rules and regulations of MMT programs, such as federal and state laws concerning the frequency and number of take-home bottles allowed. An equal number of respondents reported that many times, rather than going through the necessary clinic requests for extra take-home bottles or courtesy dosing at out-of-town clinics, they chose to miss a social event altogether.
“A high number of respondents reported that they made up false excuses to explain why they were unable to attend family or social gatherings,” Neman remarks, “rather than reveal that they were on methadone and had to make special arrangements with their clinics.”
Although most respondents reported that they had told at least one family member of their MMT status, about 2/3 reported that they had not told their non-drug-using friends about their program participation. Neman says, “many respondents reported that this was due to previous bad experiences.”
Shameful Self-Perceptions
One question asked if the respondents sometimes felt ashamed that they were on methadone. Half of the respondents marked “yes.”
Neman questions, “Did the shame originate before coming into the MMT program, or have experiences with discrimination and prejudice while in the program caused such feelings?” She believes the answer involves a bit of both.
“Research shows a high correlation between shame and addiction,” Neman remarks. “Based on other answers in the survey, the experiences encountered while in MMT programs in all areas of a patient’s life surely must contribute to those feelings of shame.”
“Ironically, we as methadone providers expect MMT program participants to willingly tolerate conditions that we might not tolerate ourselves,” she continues. “MMT programs need to remain cognizant that state and federal rules and regulations, along with individual clinic policies, have the potential not only to contribute to patients’ feelings of shame, but to actually induce them.”
Education Key to Winning
Neman concludes that this study appears to indicate that being a methadone patient is something to overcome; whereas the original intent of MMT programs was to be helpful, affording patients opportunities to stabilize their lives, secure employment, and break out of the cycle of addiction. “Ironically,” she says, “our study suggests that it is an uphill battle to get a job, to tell others that one is in recovery, to attend family and social gatherings, to travel and take vacations, and most importantly, to regain the self-esteem that was battered and defeated by addiction.”
She believes that education of both professionals and the general public is a crucial first step towards rectifying the discrimination resulting from a general lack of knowledge about methadone. As a direct result of this study, New Hope Behavioral Health Center established a free methadone-education program.
NHBHC staff go to both private and public agencies and organizations to provide in-service training sessions about methadone. New Hope also sponsors a series of “Drug Screening and Education” days for the general public. These generated widespread support from various organizations and were expanded to include anxiety/depression screening.
For additional information, Neman may be contacted at: 1-800-596-3329 or 520/742-2970, or via e-mail at NancyFN@aol.com.

 

Clinical Concepts – Addiction Treatment in the Age of HIV/AIDS

Prevalent Problem
The link between drug abuse/ dependency and HIV/AIDS continues to be of great concern. More than ever, workers in the addiction treatment field need to be prepared to address issues surrounding this widespread disease, especially among injection drug users (IDUs).
The proportion of new cases attributed to IDUs increased from 23% in 1988 to 26% in 1995.[1] In 1998, it was reported that injection drug abuse directly accounted for approximately one third of individuals with AIDS.[2]
The AIDS epidemic began around 1979, although data were unreliable until 1987 when there were 13,329 deaths attributed to the disease. The trend escalated until 1995 as mortality peaked at 41,699 deaths and then dramatically trended downward. In 1997, for the first time since 1990, AIDS fell out of the top 10 causes of death in the United States.[3]
Worldwide during 1999, 129 countries and territories reported injection drug abuse, with 108 countries reporting HIV/AIDS outbreaks in those drug-using populations.[4] It is currently estimated that 50%[4] to 75%[5] of the 40,000 to 70,000 new HIV infections each year in the U.S. are among IDUs, their sexual partners, and their offspring.
Gay men still account for the largest group of HIV/AIDS patients, although they represent less than half of all new cases. The fastest-growing subset of patients is heterosexuals, increasing from 5% of new HIV cases in 1988 to 11% in 1995.
There also are increasing HIV infection rates among non-IDU recreational drug users. Presumably these infections spread via sexual contacts motivated by the disinhibiting effects of drugs, such as cocaine, alcohol, amphetamines, and nitrate inhalants.[1]
Standards of Care
The American Society of Addiction Medicine (ASAM) recommends that, with today’s effective treatments, there are many reasons to test early for HIV and such testing should not be withheld from any at-risk patients without good reason.[5] Although HIV is a retrovirus directly leading to AIDS, some patients testing positive for the virus progress to AIDS quickly while others can remain quite healthy for 10 or more years.
Current HIV care includes regularly measuring the viral load (plasma HIV RNA) and the CD4 white blood cell count. The half-life of the human immunodeficiency virus is roughly 6 hours, and such rapid HIV replication has led to the emergence of drug-resistant strains. To prevent this, replication must be suppressed, as demonstrated by low viral loads, which also correlates with reduced morbidity and prolonged survival.[5]
Ever since the FDA approved the first drug to combat HIV in 1987 – AZT (zidovudine) – new antiretroviral drug development has accelerated.[3] As of August 1999, there were 15 drugs marketed and used for treating HIV infection, with several others nearing FDA approval.[6]
Pharmacologic care to control HIV usually comprises three or more antiretroviral drugs, including a potent HIV protease inhibitor.[5] Protease inhibitors, first approved in 1995, are typically taken with reverse transcriptase inhibitors in a “triple-drug cocktail treatment” also called HAART (highly active antiretroviral therapy).[3]
Such therapy was credited with helping to attain a 47% decrease in AIDS-related mortality in 1997. However, HAART treatment is not an AIDS cure. Although HIV may become undetectable in the blood following such treatment, the virus may still be present, hiding in lymph nodes, the brain, testes, and the retina. The viral load can rapidly rebound to high levels if all or part of the polydrug therapy is discontinued.[3]
Addiction Treatment Challenges
Addiction treatment programs must be prepared to deal with the special needs of HIV/AIDS patients. Among other concerns, these persons have issues to deal with during treatment that might best be classified under “grief work.”[5] They must cope with remorse over the potentially imminent loss of health, career, social and family life.
Feelings of stigma and shame may vary depending on the patient’s prior risk behaviors, such as, homosexuality, prostitution, or injection drug use. Constant fears of progression to disability and death further complicate the therapeutic milieu.
Greater HIV seroprevalence is reported among dual-diagnosis (psychiatric illness and chemical dependency) populations, approaching 23%.[5] Whether psychopathology is caused by or merely exacerbated by drug use and HIV disease is an open question. It is likely that the frequent co-occurrence of substance abuse and psychopathology may increase a person’s risk for acquiring HIV; however, there is little research evidence to elucidate the extent or nature of that risk.[2]
Aside from any prior or current psychopathology the patient may have, HIV infection itself increases susceptibility to disorders of mood (depression, anxiety), thought disorders (psychosis, delusional states), dementia, and delirium.[5] The potentially multiple causation of these affective states can make diagnosis and addiction treatment more challenging.
For example, encephalopathy or psychiatric illness in a substance abuser with HIV is complicated by possibilities of intoxication or withdrawal, and/or by the long-term physiologic effects of the abused substance.[2] Confronted with multiple contiguous diagnoses, problems need to be organized into here-and-now treatment plans. Assigning all symptoms to the addiction diagnosis, when at least some may be due to HIV infection or medication interactions, could be misleading.
Treatment of persons with triple diagnoses (HIV disease, substance abuse, psychiatric disorder) may be complicated by ongoing substance abuse, higher levels of distress, and poor adherence to medical treatment regimens leading to greater HIV-related morbidity and mortality.[2] Addiction treatment staff should be alert to possible needs for outside consultation in dealing with complex problems.
The Perils of Polypharmacy
With today’s multidrug antiretroviral regimens, the potentials for complex and unpredictable drug interactions are significantly increased. More than half of all metabolized drugs [7,8] and nearly 50% of currently approved antiretroviral agents are substrates for (i.e., metabolized by) the cytochrome P450 family of liver enzymes, mainly the CYP3A4 isoform.[9] However, multiple liver enzymes can be involved in a given drug’s biotransformation.[8]
When co-administered drugs are metabolized in the liver through some of the same chemical pathways (i.e., they are substrates of the same enzymes), they can competitively interact with each other, thereby affecting their rates of metabolism.[8] Patients can risk either medication overdoses or acute and dangerous drug withdrawals.
Some interactions may be dangerous. For example, there has been a case of death reported when the protease inhibitor ritonavir was combined with the recreational drug Ecstasy (MDMA). Ritonavir allegedly may also interact with heroin, producing an opiate rush into the brain causing overdose.[10]
HIV patients may be prescribed complicated regimens of antiretroviral agents and multiple prophylactic drugs to fend off a variety of opportunistic infections. A critical role for all clinic staff is in facilitating patient compliance with sometimes difficult medication regimens.
Many of the antiretroviral drugs tend to have complex metabolisms and, in combination with other medications, may affect each other’s drug levels and potencies.[6,9] ASAM recommends, “Determination of drug protocols and dosages are best handled by an experienced infectious disease or HIV specialist in consultation with the addictionist.”[5]
ASAM further cautions, “Several psychotropic medications [used in addiction treatment] have the potential for drug interactions with antiretroviral agents. Individual decisions need to be made regarding the use of anxiolytics, sleep medications, pain medications, and stimulants, balancing therapeutic benefit against risk to recovery and sobriety as well as adverse interactions with HIV medications.”[5] Drug interactions resulting in adverse reactions can pose frustrating challenges for both patients and addiction treatment staff.
Conclusion
Although research continues to discover new drugs for treating HIV, including the possibility of protective vaccines, the ideal treatment remains elusive. What’s needed are drugs that are potent, inexpensive, nontoxic even after prolonged periods, active against currently resistant viral strains, and easy to administer.[3]
Many questions surrounding current HIV/AIDS treatments remain, such as: the optimal time to initiate therapy, how best to assure drug regimen compliance, and extending the length of patient survival. There are also concerns about treatment costs and who should pay.[1]
According to the CDC, the lifetime medical treatment for a person with HIV costs $154,402.[11] Annual costs of individual antiretroviral drugs range from $2,100 to $8,000 or more.[1] The combined annual costs for the newer polydrug cocktails that have proven so effective are the most expensive and to this must be added costs of medicines to prevent or treat opportunistic infections.
HIV infection rates appear to be increasing at a slower pace than in the past; however, the disease is still particularly problematic among men who have sex with men and injecting drug abusers. It is also growing rapidly among minorities, women, and heterosexuals, especially those using recreational drugs.[1]
Interactions between antiretroviral agents, psychotropic drugs, and medicines for preventing/treating opportunistic infections may complicate the management of HIV disease in addiction treatment programs. Clinic staff at every level must learn about the potential challenges and solutions for meeting the needs of this special population of patients.
1. Haverkos HW. HIV/AIDS, tuberculosis, and other infectious diseases. In: Graham AW, Schultz TK, eds. Principles of Addiction Medicine. 2nd ed. Chevy Chase, MD: American Society of Addiction Medicine, Inc; 1998:825-832.
2. Ferrando SJ. Substance use disorders and HIV illness. The AIDS Reader. 1997;7(2):57-64.
3. Henkel J. Attacking AIDS with a ‘cocktail’ therapy. FDA Consumer; 1999.
4. Cire B. Global network will promote information exchange on HIV prevention in drug-using populations. NIDA Notes. 1999;13(5):12-13.
5. Pohl M (chair). Guidelines for HIV infection and AIDS in addiction treatment. American Society of Addiction Medicine; 1998.
6. Schütz, Malte. Quick reference guide to anti retrovirals. August 1, 1999. Available at: http://hiv.medscape.com/ updates/quickguide. Accessed August 5, 1999.
7. Flexner C, Piscitelli S. The clinical management of HIV/AIDS: drug-drug interactions. HIV Clinical Management. New York, NY: Medscape, Inc; 1999. Available at: www.medscape.com/Medscape/HIV/ClinicalMgmt/CM.drug/public/toc- CM.drug.html. Accessed June 30, 1999.
8. Hardman JG, Limbird LE (eds-in-chief). Goodman & Gilman’s The Pharmacological Basis of Therapeutic [book on CD-ROM]. 9th ed. New York: McGraw-Hill; 1996.
9. Flexner C. Drug interactions [annual update]. Medscape HIV/AIDS. 1999;5(suppl).
10. Garrett L. A dangerous mix revealed: HIV therapy, drugs a danger. Newsday (New York). February 4, 1999.
11. Engelbrecht PJ. More highlights from the 12th World AIDS Conference in Geneva. Outlines (Chicago). 1998 (July 15):7.

From the Editor

Much More Than Methadone

Expanding Horizons
You may have noticed over the past few issues of Addiction Treatment Forum that we’ve broadened our editorial horizons to include outlooks on addiction treatment beyond methadone and methadone maintenance treatment (MMT). During the past year we’ve had feature articles on naltrexone in treating alcoholism, the coming hepatitis C epidemic, social and economic values of addiction treatment, and the start of our “Brainstorms” series exploring all aspects of addiction.
If you’ve been following the “News Updates” posted monthly at our Web site ­ www.atforum.com ­ or receive Forum Fax, you know that we’ve long had a tradition of covering diverse topics of interest to all addiction treatment professionals. Recent news briefs included: opiate addiction and HCV/HBV status; a Darwinian view of addiction, alcohol and stress; SNRIs ­ a new class of antidepressants; the effects of cocaine on health, NIDA’s new network to test drug abuse treatments; and many other topics of general importance.
While we have not overlooked coverage of methadone-related topics, this current issue of AT Forum continues our expanded vision with an article discussing the special needs of patients with HIV/AIDS and an examination of the intriguing, yet controversial, self-medication hypothesis of addiction. As usual, the “Events to Note” and “Where to Get Info” columns feature information that is relevant for everyone in the treatment field.
Tell Your Friends
We will continue offering a broad menu of significant topics in the monthly Web News Updates and via Forum Fax. More than that, future print editions of AT Forum will extend our coverage of modalities concerned with alcoholism and other substance abuse/ dependency treatment, in addition to MMT, plus concepts of addiction in general, including reports of the latest research.
Invite all your associates and friends in the addiction treatment field, including those who have interests aside from methadone, to become regular AT Forum readers. A subscription to the print edition is free, merely by requesting it on the feedback card in this issue or by writing/faxing a request to the address/phone number at the bottom of this column. And, of course, our Web site is always accessible to anyone, anywhere, anytime.
Reader Survey ­ Patients Battling Prejudice?
As a follow-up to our article in this issue regarding the challenges faced by patients in MMT, we want to expand that survey to include patients in all types of addiction treatment programs. Please respond confidentially to the following:
1. Do patients face job discrimination due to their participation in addiction treatment?
Often;
Occasionally;
Rarely;
Never
2. Do you believe health care professionals are prejudiced against chemically dependent persons in treatment?
Often;
Occasionally;
Rarely;
Never
3. Do patients avoid family or social gatherings due to their being in treatment?
Often;
Occasionally;
Rarely;
Never
4. Do you believe the general public understands what addiction and addiction treatment are all about?
Yes;
Somewhat;
No;
Uncertain
5. Are you responding as:
A patient, or
A staff member. Type of treatment program? _____________
There are several ways for you to reply: A. Provide your answers on the postage-free feedback card in this issue; B. Write or fax us [see info below]; or C. Visit our Web site to respond online. As always, your written comments will also help us discuss the results in our next issue.
Stewart B. Leavitt, PhD, Editor
stew202@aol.com
Addiction Treatment Forum
1750 East Golf Rd., Suite 320
Schaumburg, IL 60173
FAX: 847-413-0526
Internet: http://www.atforum.com

Events to Note

For additional postings & information, see: www.atforum.com

January 2000
Preventing Heroin Overdose: Pragmatic Approaches
January 13-14, 2000; Seattle, WA
Sponsor: Alcohol & Drug Abuse Institute, Univ. of Washington
Contact: Nancy Sutherland; 206-543-0937; adailib@u.washington.edu
http://depts.washington.edu.adai/conf/heroin.htm
Partnerships for Health in the New Millennium
January 24-28, 2000
Omni-Shoreham; Washington, DC
Sponsor: US Dept. HHS, Office of Disease Prevention & Health Promotion
Contact: Alyson Chmielewski: 301-468-1273; achmielewski@health.org
www.health.gov/partnerships
February 2000
4th International Conference: Drug Use, Harm & Addiction
February 3-5, 2000; Porto, Portugal
Contact: Luis Patrici
l.patricio@erit.org
www.erit.org/conferenc.htm
13th Annual Conference on Addictions (FSAM + ASAM)
February 4 – 6, 2000
Sheraton Safari Hotel, Orlando, Florida
Contact FSAM Office: 850-484-3560; fsam.asam@usa.net
April 2000
AMTA – Conference 2000
April 9-12, 2000; San Francisco, CA
Contact: 609-423-7222 ext 350; meetings@tmg.smarthub.com
 
ASAM’s Pain in Addiction: Common Threads
April 12, 2000; Chicago, IL
Contact: 301-656-3920; email@asam.org
www.asam.org
ASAM’s 31st Annual Medical-Scientific Conference
April 13-16, 2000; Chicago, IL
Contact: 301-656-3920; email@asam.org
www.asam.org

[To post your event announcement in A.T. Forum and/or our Web site, fax the information to: 847/413-0526 or submit it via e-mail from http://www.atforum.com]

Where to Get Info

Mastering Grantsmanship

Discovering funding opportunities and developing grant proposals can be difficult. Now, a new Web-based grant-writing tutorial is available to help drug abuse researchers and programs locate and apply for federal funding, specifically grants from the National Institutes of Health and other government agencies.

Developed by Danya International, a Maryland-based health and human services consulting firm, the guide provides comprehensive information about formulating a research question, determining what kind of grant is most appropriate, working with a proposal team, writing different types of grants, understanding what happens after submission of the grant, and avoiding fatal flaws and common pitfalls of grant-writers.

The tutorial can be accessed via Danya’s Web site at: www.drugnet.net (click the “on-line training” section) or directly at: http://dar.aspensys.com/ tutorial/index.htm. For information about a hardcopy version in manual format, call: 301/565-2142.

 

Alcohol, Drugs & People with Disabilities

Under the Americans with Disabilities Act of 1990, persons with disabilities are promised equal access to all community facilities, including treatment for substance abuse. Yet, although people with physical and cognitive disabilities are more likely to have substance use disorders, they are less likely to get effective treatment than those without such coexisting disabilities.

“Substance Use Disorder Treatment for People with Physical and Cognitive Disabilities” is a new guide from CSAT, #29 in a series of Treatment Improvement Protocols (TIPs), to help professionals and others in addressing substance abuse treatment issues for those who cannot acclimate to treatment as usual due to physical, sensory, or cognitive disabilities.

The manual provides simple, straightforward guidelines for overcoming barriers and providing effective treatment for this population. It stresses that coexisting disabilities of some type may affect up to 40% of all patients served by substance abuse treatment programs.

TIPs are available on the CSAT Web page at www.samhsa.gov or by calling the National Clearing House for Alcohol and Drug Information, 1-800-729-6686.

Readers Survey – Why Measure Methadone SMLs?

As a follow-up to our story, “Why Measure Methadone Blood Levels” in the last edition of AT Forum (Summer 1999), readers were asked if and why their MMT programs use serum methadone level (SML) tests as a clinical tool.

Our article noted that, since there can be much variation in how patients respond to methadone, SML testing can sometimes be useful when the clinical picture does not agree with the expected response to a given dose of methadone. The test indicates how much of the medication (in terms of nanograms per milliliter or ng/mL) is circulating in the patient’s system.

There were 161 survey responses, either via mail or at our Web site. Nearly half (46%) of the survey respondents indicated that their clinics never or only rarely use such tests. Roughly a third of the responses indicated “occasionally,” and 20% said SMLs are used “often.”

The survey also questioned, when SMLs tests are done, how are the results used? Here are responses to the four feedback choices listed:

  • Guide routine methadone dose adjustments ­ 32%
  • Overcome patient resistance to dose change ­ 9%
  • Analyze dosing problems ­ 47%
  • Other ­ 12%

It was interesting to observe that nearly a third of the time SMLs are used for routine dose adjustments. This was unexpected because dose adjustments are usually guided by clinical signs and symptoms, with blood testing reserved for challenging cases, as 47% of those responding indicated.

 

Who Pays? How Much?

One survey question asked, “Who pays for the test?” Responses were evenly divided among patient, clinic, and insurance. It was unclear if or how clinic costs were ultimately passed on to the patient or to an insurance company.

We also asked how much the SML test costs. The average paid was $48. But there was quite a broad range ­ $5 to $86 ­ and there were three responses well over $100 per test. Since these three seemed inordinately expensive, and the readers might not have understood the question, they were excluded from the average.

 

No “Gold Standard”

A number of readers indicated more specific details of their objectives in using SMLs:

  • To meet state regulations for methadone take-home doses over 100 mg/day.
  • When “high” doses of methadone seem ineffective.
  • Help evaluate possible interactions with other medications, prescribed or illicit.
  • At patient request, to justify dose increase or split dosing.
  • Help assess why the patient experiences withdrawal symptoms.
  • Only done for dose increases beyond 100 mg/day.
  • Check to see if patient is rapidly metabolizing methadone.
  • Split dosing and stabilizing at lowest acceptable dose.

As these readers seem to appreciate, there is no “gold standard” for a methadone dose that is best for all patients. SMLs may help confirm what is happening to methadone in the patient’s body and can be an educational aid for encouraging a fearful patient to accept a more adequate methadone dose, or for assuring a wary relative, reluctant insurance company, or circumspect regulatory agency that a dose increase is needed.

 

Optimizing Dose

Past research has noted a correlation between “poor performance” in MMT programs and lower SMLs, and that there are many patients who have subtherapeutic SMLs despite what are considered “high” daily methadone doses. Some have proposed that the best indicators of inadequate versus adequate dose are withdrawal signs/symptoms, drug craving, and continuing opioid abuse. Therapeutic methadone level monitoring can be useful, but as one reader wrote, “SML testing is not the end all and be all of determining optimal dose.”

On this same subject, there will be an upcoming article in the Mount Sinai Medical Journal by Stewart B. Leavitt, PhD (AT Forum editor); Marc Shinderman, MD; Sarz Maxwell, MD; Chin B. Eap, PhD; and Philip Paris, MD titled, “When ‘Enough’ is Not Enough: New Perspectives on Optimal Methadone Maintenance Dose.”

Brainstorm: Self-Medication Pathways of Addiction – Part 2

We drank for joy and became miserable;
We drank for exhilaration and became depressed;
We drank for friendship and became enemies;
We drank to diminish our problems and saw them multiply.
– excerpt from “Positively Negative,” anonymous
One of the most intuitively appealing theories underlying substance abuse and addiction is the “Self-medication Hypothesis.” Proposed over a decade ago by Khantzian, this concept suggests that preferred drugs of abuse are not chosen randomly or purely circumstantially. Rather, “Individuals discover that the specific actions or effects of each class of drugs relieve or change a range of painful affect states.”[1]
In clinical practice, patients frequently implicate self-medication as a motive for addictive behaviors and this may be a fruitful area of discussion in treatment.[2] A self-medication perspective also may help in developing psychosocial and/or pharmacological treatment plans better tailored to individual patient needs.
Reaching for Normal
Khantzian noted that there is an interaction between the psychopharmacologic action of an individual’s drug of “choice” or “commitment” and the dominant tormenting feelings with which the person is struggling.[3] For example, a heroin addict may prefer the muting action of heroin on disturbing affects of rage or aggression. Whereas cocaine may appeal to another person’s need for relieving stress associated with depression.
Dubey has asserted that drug addicts are not so much after a “high” as just trying to reach ground level – to feel “normal.”[4] Or, some might say, to be “comfortable” in their lives.
Khantzian stresses that the self-medication hypothesis is not intended to substitute for other theories explaining the etiology of substance-related disorders: e.g., neurochemical, sociocultural, or biogenetic. Rather, it can complement other perspectives.[3]
Controlling Emotions
According to Khantzian, persons with substance use disorders suffer intensely with their emotions; either feeling too much, or feeling little or not at all. They may experiment with various classes of drugs to discover those that are most compelling because the substances help ameliorate, relieve, or change those tormenting and extreme emotional states.[3]
Addictions seem to take on lives of their own and persons who abuse drugs – suffering as they do the agonies of withdrawal, unwanted side effects, risks of overdose, personal deterioration and shame, etc. – are willing to accept such distress in exchange for whatever momentary relief they experience with their drug of choice. Khantzian believes patients “actively and often knowingly perpetuate their suffering when they continue to use drugs or when they relapse after periods of abstinence.”[3]
He proposes that, rather than attempting to relieve suffering, people often abuse substances to control their feelings, especially when those affects are confusing or beyond their control. The motive here shifts from relief of suffering to controlling it, even if the results are repeatedly distressing.[3]
Effects & Affects
Various drugs offer selective psychological effects that patients seemingly choose with almost a physician’s attention to medicating specific troublesome affective symptoms. These have been variously described in the literature, as summarized in Table 1.
The table shows that each substance class produces certain psychological effects used to self-medicate disturbing symptoms. There is some crossover in the effects and symptoms that each substance self-medicates. As one example, both opioids and marijuana may have calming effects that help in dealing with symptoms of anger.
The symptoms self-medicated might also be characterized as being generally “negative” or “positive.” Positive symptoms reflect an excess of functioning beyond what might be considered normal, such as rage or aggression. Negative symptoms refer to characteristics reflecting a lessening of normal functioning, such as inattention and disaffection.[3,5]
As Table 1 indicates, opioids and marijuana would mostly modify positive symptoms. Alcohol and stimulants would be used most often to self-medicate negative symptoms.
Paradoxical Effects
There are certain paradoxes to consider. Among them, the calming effect of the stimulant cocaine in self-medicating hypomania or hyperactivity does not fit the typical profile of stimulants used for overcoming negative symptoms of lessened functionality.
Furthermore, there is often a boomerang effect whereby abused substances cause an exaggeration of those very emotions the person seeks to medicate. For example, as stated in the beginning of this article, the person may drink alcohol to overcome sadness and end up depressed. Indeed, Valliant has noted that despite its alleged desired effects, alcohol is a poor choice because it can interfere with sleep, make depression worse, and do little to improve anxiety.[6]
Also, as Khantzian suggests, excessive effects of any particular drug may lead to polydrug addiction. For example, the tranquilizing effects of opioids may be used as an antidote to the more typical stimulating effects of cocaine.[3]
Causes & Consequences
Concerns have been expressed that the self-medication concept “ensnares the clinician and the patient in a potentially unhealthy justification of addiction.”[7] Khantzian concedes that early in treatment the patient may use self-medication reasoning to deny, explain, or rationalize addiction. However, as abstinence and trust are established, a better understanding of why a particular drug is so compelling can be uncovered, helping to counter patients’ prior rationalizations for drug use.[3]
Some authorities also question whether substance abuse/dependence is a cause or consequence of psychiatric disorders. Dual diagnosis is common in this population: roughly three-quarters of men and two-thirds of women with a diagnosis of substance dependency also have another psychiatric diagnosis.[8]
Yet, Khantzian argues that, “it is not so much a psychiatric condition that one self-medicates, but a wide range of subjective symptoms and states of distress that may or may not be associated with a psychiatric disorder.”[3] When distressing symptoms do not meet threshold criteria for psychiatric illness, they may still engender considerable psychological pain and subjective suffering motivating substance abuse.
“[S]ubjective states of distress (not necessarily psychiatric disorders) are the important operatives that govern self-medication,” Khantzian writes.[3] Many individuals find various drugs to be very useful tools in treating their psychological pain, possibly because they are more sensitive to the pain in the first place. “[T]he centrality of human suffering, in both its intense and subtle varieties, [is] a powerful governing influence in the pursuit of, reliance on, and relapse to one’s drug of choice.”
Perspectives on Psychiatric Disorders
Several psychiatric disorders have been discussed in the literature from self-medication perspectives:
Depression – Drug dependency and depression may be associated with alterations in many of the same neurotransmitter systems, particularly those in limbic-related brain structures. It remains unclear whether drug abuse leads to abnormalities mediating depression, or the two disorders are independent expressions of the same preexisting neurobiological abnormalities. However, self-medication may play an important role in either drug-induced or non-drug-induced depression.[9]
Research by Weiss and colleagues found that most hospitalized drug abusers took drugs in response to depressive symptoms and experienced mood elevation regardless of the chosen substances.[10] Many people gravitate to cocaine because it energizes and at least temporarily boosts self-esteem to overcome depression.[11] One author observed, “Cocaine is a formidable mood elevator and acts immediately, as opposed to the two to four weeks of most antidepressants.”[12]
Schizophrenia – Khantzian asserts that the heavy reliance on drugs and alcohol in patients with schizophrenia reflects their discoveries that those substances offer temporary relief from distress and suffering associated with negative affect symptoms.[3]
More than 40% of schizophrenic patients may abuse cocaine. There is some evidence that acute pharmacological actions of cocaine on endogenous reward centers generate euphoria, mainly through stimulation of central dopamine pathways. Psychostimulants and atypical neuroleptics have been proposed as decreasing negative symptoms of schizophrenia and resulting in decreased cocaine use among patients who are self-medicating.[5]
PTSD (posttraumatic stress disorder) – There is a high risk of substance dependency as patients with PTSD find that psychotropic drugs provide powerful short-term antidotes to the positive symptoms (e.g., rage, panic, anxiety) or negative symptoms (eg, anergia, anhedonia, affective flattening) prevailing at any time.[3]
Khantzian observed that drug preference is influenced by whatever distressing emotional symptoms predominate for the individual patient. For example, opioids help calm rage, moderate doses of alcohol reverse psychic numbing or feelings of estrangement, high doses of alcohol dampen emotional flooding, and cocaine is used to offset anhedonia or deactivation.[3]
ADHD (attention deficit hyperactivity disorder) – has been frequently reported among substance abusers, especially cocaine users, who may be self-medicating. For example, cocaine, as a CNS stimulant with properties similar to Ritalin®, may be used by adults with ADHD to alleviate impulsive/hyperactive states.[13,14] Such adult patients are often misdiagnosed as having manic-depressive disorder.[13]
 
Restructuring Defenses
The self-medication model of addiction remains conceptual, awaiting a more significant body of supportive empirical research, and there are some who have questioned its validity for incorporation into treatment practice. Vaillant stresses, “To understand the natural history of addiction, we must track more than drug use.”[6] Khantzian seems to agree by noting, “Longitudinal studies which detail family interaction patterns, tolerance/expression of emotions, and behavioral adjustment seem promising [for testing the hypothesis].”[3]
Still, Khantzian maintains that appreciating the subjective symptoms of distress that substance abusers self-medicate can help guide clinicians and counselors in matching patients to appropriate psychosocial and psychopharmacological treatments.[3] However, clinicians must overcome all-or-none thinking about medications, such as never using benzodiazepines with recovering alcoholics, or prohibiting the use of psychoactive substances for treating psychoactive-substance abusers. For example, stimulants may be helpful in persons with ADHD abusing cocaine.
In the final analysis, as Khantizian suggests, human suffering and behavioral difficulties are important governing influences in people’s lives, making their use of, dependence on, and relapse to addictive substances compelling.[3] At the very least, those persons require a restructuring of personal defense systems to cope with psychological pain and anguish that are natural parts of everyday life.
1. Khantzian EJ. The self-medication hypothesis of addictive disorders: focus on heroin and cocaine dependence. Am J Psychiatry. 1985;142(11):1259-64.
2. Gastfriend DR, Lillar P. Anxiety disorders. In: Graham AW, Schultz TK, eds. Principles of Addiction Medicine. 2nd ed. Chevy Chase, MD: American Society of Addiction Medicine, Inc; 1998:993-1006.
3. Khantzian EJ. The self-medication hypothesis of substance use disorders: a reconsideration and recent applications. Harvard Rev Psychiatry. 1997;4:231-244.
4. Dubey J. Drugs on our minds: perspectives on ‘modifiers of affect.’ Psychiatry Times. July 1997:52-54.
5. Copersino ML, Serper MR. Comorbidity of schizophrenia and cocaine abuse: phenomenology and treatment. Medscape Mental Health. 1998;3(2).
6. Vaillant GE. Natural history of addiction and pathways to recovery. In: Graham AW, Schultz TK, eds. Principles of Addiction Medicine. 2nd ed. Chevy Chase, MD: American Society of Addiction Medicine, Inc; 1998:295-308.
7. Clinical pearls: co-morbidity, according to Robert L. DuPont, MD. The Facts About Tobacco, Alcohol and Other Drugs [from University of Florida]. Winter 1996. Available at: http://pfprevention.com/uffacts/pearlw96.html. Accessed May 28, 1999.
8. Kandel DB. Epidemiological trends and implications for understanding the nature of addiction. In: O’Brien CP, Jaffe JH, eds. Addictive States. New York, NY: Raven Press, Ltd; 1992:23-40.
9. Markou A, Kosten TR, Koob GF. Neurobiological similarities in depression and drug dependence: a self-medication hypothesis. Neuropsychopharmacology. 1998;18(3):135-174.
10. Weiss RD, Griffin ML, Mirin SM. Drug abuse as self- medication for depression: an empirical study. Am J Drug Alcohol Abuse. 1992;18(2):121-129.
11. Davis L. Why do people take drugs? In Health. November/December 1990:52.
12. Shenk JW. America’s altered states: when does legal relief of pain become illegal pursuit of pleasure? Harpers Magazine. May 1999.
13. Plume D. The self-medication hypothesis: ADHD and chronic cocaine abuse. Schaffer Library of Drug Policy, 1995. Available at: www.druglibrary.org/schaffer/cocaine/ addhyp.htm. Accessed May 28, 1999.
14. Levin FR, Donovan SJ. Attention-deficit/hyperactivity disorder, intermittent explosive disorder, and eating disorders. In: Graham AW, Schultz TK, eds. Principles of AddictionMedicine. 2nd ed. Chevy Chase, MD: American Society of Addiction Medicine, Inc; 1998:1029-1046.