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Medications and the Management of CODs

Dr. Mary Brunette answers questions from participants in her Webinar on medication management and the Hazelden Co-occurring Disorders Program.

Q: How long should a person be clean and sober before being evaluated for a mental health disorder?

A. A person does not need to be clean and sober to be evaluated for mental health disorders. Since substance abuse and mental health disorders co-occur, they can be present at the same time. In order to ascertain whether a person's psychiatric symptoms are substance-induced, however, the clinician should create a longitudinal time line that documents the person's substance use and the symptoms of the psychiatric disorder over his or her lifetime. The method for constructing such a time line is detailed in the Medication Management manual in the Hazelden Co-occurring Disorders Program.

Q: When a patient is on methadone, is it OK for this client to use drugs for a mental health disorder, although heroin or methadone may cause depression?

A: Yes. Methadone will not interfere with psychotropic medications that treat mental health disorders such as schizophrenia, bipolar disorder, and major depression.

Q: Is there any information about which antidepressants are safest for persons abusing various drugs? Safest for alcohol dependents? Safest for opioid dependents? etc.

A: Serotonin-reuptake inhibitors (SSRI) are generally pretty safe, both when used with substances of abuse and even in cases of overdosing on SSRIs, which are not uncommon in this population. Some drugs of abuse slow the rate at which the liver metabolizes some medications or compete with their being metabolized, resulting in a somewhat higher level of these medications in the blood. But a slightly increased SSRI level should not be problematic.

Q: Are you aware of any medications that have shown promise in helping to stabilize patients with borderline personality disorder, in order to increase the efficacy of non-medicinal treatment?

A: There is not a large amount of research-based evidence on this topic. Antipsychotics, mood stabilizers, antidepressants and anti-anxiety medications have all been tried with varying levels of success.

Q: I work in a psychiatric hospital on a co-occurring unit. I often get patients on opioids for "pain." What are your thoughts on pain medication for those with co-occurring disorders?

A: Use of opiates for treating people who have addictions is a complex issue. Treatment providers should make sure the medical problem is carefully evaluated and clearly defined and that opiates are indicated. Treatment providers need to carefully monitor the administration of opiates to avoid their being misused or abused. They should also make maximum use of non-opiate pain treatments.

Q: How much is a vitamin deficiency connected to symptoms of mental health and chemical addiction? A client is on methadone and is diagnosed with ADHD along with depression. The client suffers from a vitamin deficiency, especially Vitamin D.

A: Only very severe vitamin deficiencies can induce mental health symptoms, and this is extremely rare in this day and age. It is important, however, to monitor the level of the B vitamins in people with severe alcohol dependence. Providing a multivitamin is a good idea for most clients.

Q: What is the relationship between medication and counseling in treating clients with co-occurring disorders?

A: Both are important. Counseling to teach the skills needed to maintain sobriety and manage a mental health disorder is helpful for most people with co-occurring disorders. However, for people with moderate to severe mental health disorders, medications can be very important and should be offered to treat the mental health disorder. Clients may need to use these medications over the long term. For people with mild to moderate disorders, counseling alone is often sufficient.

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Mary F. Brunette, M.D., is an associate professor of Psychiatry at Dartmouth Medical School. She has been working in the field of treatment for patients with co-occurring disorders for fifteen years. She conducts research on services and medications for people with co-occurring substance use and serious mental illness. She is a clinician who provides treatment to patients with co-occurring disorders.

Dr. Brunette also is medical director of the Bureau of Behavioral Health in the New Hampshire Department of Health and Human Services. She has published more than fifty articles and book chapters, many related to medication treatment for people with co-occurring disorders. She speaks nationally on this topic.

Focus on Integrated Treatment:
This webinar provides an overview of FIT and explains its role in providing the tools and training needed to become certified to treat clients with co-occurring disorders.
Vital information
about medications

The Hazelden Co-occurring Disorders Program helps treatment programs implement effective, integrated services for people with non-severe mental health disorders that co-occur with substance use disorders.

One component, Medication Management, contains vital, current information about
Medication Managementthe complex issues of medication management, including medication compliance and other psychological concerns of the patient.

Read more about the Hazelden Co-occurring Disorders Program

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