More In This Series
Nidal Moukaddam, MD, PhD
Hai Le, MD; Sawsan Khan, MD
Tales From the Clinic: The Art of Psychiatry - Episode 2
A patient presents with multiple substance use disorders super-imposed on mood and anxiety disorders. Where does a clinician even begin?
TALES FROM THE CLINIC
In this installment of Tales From the Clinic: The Art of Psychiatry, we cover an intriguing case of dual substance use super-imposed on mood, anxiety, and trauma clinical picture. A significant challenge for this group of patients is the need for patient, methodical, consistent care to unravel the complex multifaceted triggers and perpetuating factors for continued maladaptive behaviors. The case description spans years of treatment and, while the details may seem sensational, they reflect the reality of what the addiction treatment clinic team encounters. In addition, there is much difficulty in hearing and processing patient accounts of trauma, which could lead to physician burnout.
“Ms Martin” is a 45-year-old female with bipolar disorder, generalized anxiety disorder, and suspected borderline personality disorder. She was transferred to the substance use disorders clinic by another psychiatrist after a diagnosis of opioid use disorder was obvious. At the time of her transfer, she was involved in prostitution to finance her roughly 25 tablets of acetaminophen and hydrocodone daily. Her opioid use disorder history had a protracted course, with her first exposure to prescription opioids at the age of 16 following a significant injury requiring surgical intervention. Her longest lifetime period of sobriety was 2 years.
Nidal Moukaddam, MD, PhD
Hai Le, MD; Sawsan Khan, MD
Her immediate environment was not conducive to recovery, as she lived in a trailer with a male roommate who had mutual acquaintances that provided pain pills. In addition, Ms Martin engaged in sexual activity with the roommate in exchange for opioids. As time progressed, the relationship became physically abusive; she left after her roommate tried to hit her with a vacuum cleaner when she “didn’t do a good job cleaning the trailer.” At the time, she had been in treatment for 1 year, was started in medication-assisted therapy (MAT), and had been prescribed buprenorphine. She moved into an apartment with her mother, which greatly reduced access to opioids. She responded very well to MAT, with an absence of significant relapses as evidenced by the drug screenings during her monthly visits.
Three years into treatment, Ms Martin met a new boyfriend. Her urine drug screen (UDS) resulted positive for amphetamine. He provided her with substances that boosted her energy and aided in weight loss. She was not fully aware of what she was taking, but she thought it might have been amphetamine since it came in a “large jar with many capsules.” Testing verified the presence of methamphetamine.
These results were shared with Ms Martin, to her genuine surprise, and she expressed earnest motivation to stop methamphetamine use. Unfortunately, over the next year, she eventually met criteria for stimulant (methamphetamine) use disorder. This paralleled toxic developments in her relationship. She described a continued strong sexual attachment to her partner, and she remained intimate with him despite knowledge that he was simultaneously sexually active with her mother. She later bashfully admitted engaging in group intercourse with her partner and mother. During intercourse she described her partner’s derogatory and sadistic tendencies, which she felt she “deserved.”
Eventually, she developed disgust toward him. This resulted in an internal conflict because while she described feeling revolted by him, she simultaneously experienced severe loneliness and feelings of abandonment when he did not give her attention. This fueled further methamphetamine use as she wanted to be “skinny and pretty.”
The ongoing sexual relationship between her partner and mother resulted in significant tension within the apartment they all shared. On multiple occasions, Ms Martin described anxiety that her partner and mother were colluding against her. Methamphetamine use may have intensified these feelings. Although at times she expressed a desire to leave, she felt she had nowhere to go. Her partner contributed to paying bills, which further complicated her situation.
For the next year, Ms Martin continued to express significant ambivalence about her relationship. She recognized how the situation placed a strain on her relationship with her mother, yet she simultaneously feared the rejection, abandonment, and loneliness that would result from a breakup. She described symptoms of anxiety and sadness when away from her partner, and he was using methamphetamine pills as a tool to control her. She compared her “love-hate” relationship with her significant other with that of her relationship with the methamphetamine pills.
In addition to work in building Ms Martin’s feelings of self-worth and autonomy, a motivational interviewing style was utilized to help her resolve some of her ambivalence toward the relationship. Although she voiced much more change talk to end the relationship, compared to sustain talk, she had difficulty committing to ending the relationship.
Due to the alarming rate of opioid overdoses secondary to fentanyl, clinicians and those struggling with substance use are becoming aware that the product purchased is not always as marketed. Anecdotal reports of increasing concomitant opioid and amphetamine use abound, but the condition is not well understood, nor systematically studied. In the case of this patient, confirmatory test showed methamphetamine, whereas she believed she was getting amphetamine or methylphenidate; she may have inadvertently gained access to a supply of methamphetamine.
Currently, there are no US Food and Drug Administration-approved treatments for methamphetamine use disorder. Some studies suggest the use of bupropion, naltrexone, and mirtazapine may have some limited efficacy in specific populations.1-3 In addition to treating Ms Martin’s SUD, the team addressed co-occurring mood and anxiety symptoms (she had witnessed her brother injured in a car accident). Her initial regimen included duloxetine and aripiprazole for depression, anxiety, and mood stabilization. Bupropion was not tried due to her concern of its risk of exacerbating her anxiety, and she declined mirtazapine due to its risk of weight gain because she already struggled with her body image. After Ms Martin expressed concerns that aripiprazole may be contributing to her weight gain, she was switched to cariprazine with the perceived potential benefit of weight-neutrality, since a desire for weight loss was a contributing factor to continued methamphetamine use. Another potential benefit of cariprazine includes preliminary interest in the D3 receptor affecting addictive behaviors.
Methylphenidate and lisdexamfetamine were other pharmacological therapies considered for treatment, given that Ms Martin has shown good response to replacement therapy such as buprenorphine. However, agonist substitution, while an excellent harm reduction approach, still faces stigma and resistance in clinical practice, especially for stimulant use.
Higher Levels of Care
According to the Centers for Disease Control, 40.4% of adults using methamphetamine within the last year also misused prescription opioids, and 16.9% used heroin between 2015 and 2018. In the United States there has been an increase in overdose deaths and hospital admissions involving methamphetamine use.4 After limited availability of ephedrine and pseudoephedrine due to regulations, synthesis returned partially back to using phenyl-2-propanone (P2P).5 Due to increased purity and potency, there is concern that the P2P formulation may be contributing to addiction.6 This is something to keep in mind when treating a patient diagnosed with both opioid and stimulant use disorders. Unfortunately, there is no guideline as to whether MAT should be discontinued if a co-occurring substance use is still ongoing.
Ms Martin maintained abstinence from opioids while on MAT, but continued to use methamphetamine pills. The treatment team wondered if she was truly benefiting from the current level of care, and considered tapering off buprenorphine and referring her to a residential treatment program or a methadone clinic. However, Ms Martin did not have the financial resources for the latter and, in regards to the former, expressed anxiety and fear about being separated from her dog as well as the feeling of “being locked up.” Thus, her treatment team sought to maximize psychosocial support and psychotherapy interventions, but she had stopped going to group therapy and declined virtual therapy sessions.
With continued work, despite ongoing significant trauma, interpersonal conflict, financial instability, and continued methamphetamine use, Ms Martin increased engagement in treatment and is adherent with all medication management visits. The treatment team ultimately decided not to taper off the buprenorphine, given her gradual progress toward treatment goals was a product of a harm-reduction approach. She could have benefited from inpatient rehabilitation. However, reluctance to go into rehabilitation is common in patients with SUD. Additionally, most states do not allow involuntary inpatient SUD treatment as they do for involuntary psychiatric care, so patients have to suffer legal repercussion to be forced to attend court-ordered rehabilitation. Finally, many residential treatment programs may not be able to accommodate patients on MAT, as some are not yet comfortable with a harm-reduction approach or medical model of addictions treatment.
This case highlights several clinical and psychotherapeutic challenges that may arise in the treatment of substance use disorders. First, it is important to look for the presence of significant trauma in a patient with several barriers to care preventing access to psychotherapy, as there is a known link between a history of trauma and the development of substance use disorders.7 In this case, Ms Martin was a victim of physical, emotional, and sexual abuse. Unfortunately, there are limited standardized or manualized approaches to addressing trauma in patients with substance use disorders. When trauma informed therapy is available, access is often limited.
Similarly, another significant factor contributing to Ms Martin’s ambivalence about leaving the relationship was the codependency that existed with her partner.
Medication management visits typical to community psychiatry practice are likely not of sufficient length to address complex issues involving psychopharmacology and psychotherapy. Although the COVID-19 pandemic has accelerated the development of telepsychiatry, many patients do not have the technological means to make these visits and may not have private and safe living spaces where they can share sensitive information.
Additionally, drug use is perpetuated by perceived benefits, and cessation of use does not happen unless the patient appreciates the negative impact of substance use on their lives. When Ms Martin finally understood she was taking methamphetamine, it created an opportunity to see its use as a problem instead of an agent for cognitive enhancement/weight loss.
Methamphetamine is commonly used to improve sexual function. In fact, the literature has described methamphetamine as increasing sexual desire, pleasure, reducing the refractory period between intercourse, exacerbating impulsiveness, and impacting behavioral inhibition.6,8 In this case, it would be worth further exploring that idea, as the patient’s partner was supplying methamphetamine and requesting particular sexual demands.
A major challenge in the field continues to be the lack of available effective pharmacologic treatments for stimulant use disorders. Contingency management in combination with community reinforcement is a proven effective behavioral treatment for stimulant use disorders, as confirmed by multiple meta-analyses.9 However, there are considerable barriers to implementing contingency management at this time, including public stigma and limited Medicaid support.10
Lastly, in the context of treatment, it is often easy to feel patients are to blame for maladaptive, promiscuous, or risky behaviors. Countertransference feelings or bias may hinder patients getting expanded treatment options, especially if they display anger and hostility upon exploration of sensitive topics in session.
However, despite significant barriers to care, the presence of trauma, and ongoing struggles with stimulant use, patients demonstrate resilience and often continue to express desire for full recovery. Cognitive-behavioral therapy, relapse prevention, mindfulness, and psychodynamic therapies are all useful in treatment, but the level of complexity of patients with SUD often means a prolonged course of treatment with multiple modalities needed.
Dr Sanchez is a PGY-4 general psychiatry resident in the Menninger Department of Psychiatry & Behavioral Sciences at Baylor College of Medicine. He plans to pursue a fellowship in Addiction Psychiatry after graduation. Dr Li is an associate professor and addiction-boarded faculty at Harris Health System in the Menninger Department of Psychiatry and Behavioral Sciences at Baylor College of Medicine. Dr Moukaddam is associate professor, Menninger Department of Psychiatry & Behavioral Sciences, Baylor College of Medicine, and Ben Taub Adult Outpatient Services director, medical director, Stabilization, Treatment & Rehabilitation (STAR) Program for Psychosis. She also serves on Psychiatric TimesTM Advisory Board.
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