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Specific Addiction Pharmacotherapies for Co-Occurring Disorders (final in a brand-new, three-part series on treating co-occurring disorders)

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May 6, 2013 by Dr. Bob Weathers

Dykeman (2012) provides helpful case examples of applying pharmacotherapeutic interventions to clients with co-occurring disorders.  One example involves an adult male client who presented with both nicotine dependence and a diagnosis of major depression (p. 221).  As it turns out, his cigarette smoking had increased markedly simultaneously to his depressive symptoms (anhedonia, weight loss, insomnia, and “down” mood) also getting worse.

In light of the fact that the client was both depressed and addicted to nicotine, this case represented a happy convergence insofar as the recommended pharmacotherapy for the former dovetailed perfectly with that for the latter.  In this case, Wellbutrin was prescribed to address both sets of symptoms.  At a six-week follow-up to medical treatment, the client evidenced marked remission of depressive symptoms and significant reduction in his craving for nicotine.

Dykeman provides a second case example addressing pharmacotherapy for a client presenting with co-occurring disorders.  In this case, the adult male client presented with diagnoses of both generalized anxiety disorder and alcohol dependence (p. 223).  Ironically, things got more complicated quickly.

His physician prescribed an SSRI to address the anxiety diagnosis; and a benzodiazepine to ease withdrawal from his alcohol addiction.  Unfortunately, the client refused to take the prescribed SSRI.  Instead he got addicted (without being under the physician’s supervision) to the benzodiazepine.  (Once the benzodiazepine course was completed, the client found alternate ways, through friends, to obtain ever larger and larger doses of the medication.)

At last his addiction, now to the benzodiazepine, came to the physician’s attention; which led to a third diagnosis: Sedative, Hypnotic, or Anxiolytic Dependence.  This latter addiction needed to be addressed in two ways.  Part of the client’s vulnerability, first to alcohol, second to benzodiazepine, was owing to his anxiety.  The treating physician therefore mandated cognitive-behavioral treatment to work on the anxiety symptoms psychologically.  Having agreed to that treatment, the client was then monitored through a 3-month, graduated withdrawal (following the Ashton Manual) from the benzodiazepine.

The good news is that the client complied with both treatments, effectively getting completely off the benzodiazepine.  He also evidenced, at the end of therapy, a significant reduction in anxiety-based symptoms.

One brief note in closing: there has recently been research establishing that pharmacotherapy may also be instrumental in addressing behavioral addictions (e.g., sex, gambling, shopping), as well as drug and alcohol addictions.  One example of such research looked at recent findings suggesting that lithium has proven effective in treating bipolar disorder and also the pathological gambling that may be seen to co-morbidly accompany such bipolar diagnoses.  Further, ongoing research is exploring effective medical treatments (e.g., anti-convulsant medications) for eating disorders.  Dykeman summarizes helpfully: “There is evidence that the same neurotransmitter deregulations involved in the etiology of chemical addictions are involved within the etiology of behavioral addictions” (p. 231).  This line of clinical research certainly seems promising!

Reference

Dykeman, C.  (2012).  Addiction pharmacotherapy.  In Capuzzi, D., & Stauffer, M. (Eds.), Foundations of addictions counseling (2nd ed., pp. 211-239).  Upper Saddle River, NJ: Pearson.

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