Comorbidity and a Sad Update



In 2011, I posted the following blog entry, and described an example of a patient from my office-based practice to illustrate:

Addicted patients are twice as likely as non-addicted patients to have mental illnesses such as mood disorders, anxiety disorders, schizophrenia, and attention-deficit hyperactivity disorder. The converse is also true: patients with mental illness diagnoses are twice as likely to have an addictive illness in addition to their mental illness.

Why is this? Is there a common factor underlying both types of disorders? Does one cause the other? For years, doctors and therapists have argued about this, and there are still no definite answers. However, why these diseases occur together isn’t as important to me as how to treat them most effectively.

We know patients get the best results when both diseases are treated at the same time, preferably under the same roof. That’s not always easy, but it’s the ideal.

To further complicate treatment, many times drug addiction causes the same symptoms as mental illness. For example, a person intoxicated on methamphetamine can look just like someone in the manic phase of bipolar disorder, or even schizophrenia. Another example can be seen in heavy drinkers, who are often depressed from the effects of alcohol, which is a depressant.

I rely on several methods to help me decide if drug use, abuse, or addiction is mimicking mental illness. First, I try to get information about what a patient was like during periods of abstinence from all drugs. If all of the mental illness symptoms went away during abstinence, it’s less likely that there’s an underlying mental illness. However, if the patient was still suffering with significant symptoms of mental illness even during a period of abstinence from drugs, the patient probably has a second diagnosis.

I ask about family history of mental illness, because if relatives have been diagnosed with these disorders, it’s more likely that the patient I’m treating will have mental illness in addition to addiction.

I ask my patient which started first, the symptoms of mental disorder or drug use? Often, symptoms of mental illness and drug use both started around the same time, at late adolescence/early adulthood, so that history often isn’t as helpful as I’d like.

Here’s an example of a case I saw recently: (identifying details have been changed):

A 24 year old female saw me in my office as a new patient. She wanted to be considered for my Suboxone program. She gave a history of illicit drug use for four years, and had used opioids daily for a year and a half, snorting up to 200mg of hydrocodone or oxycodone per day. She used marijuana three times a week, usually two cigarettes per day. She denied use of benzodiazepines or alcohol, and said her father was an alcoholic. She used cocaine heavily in the past, but stopped using it three years ago because of its expense. Besides, by that time, she preferred opioids. She acknowledged recent use of methamphetamine three or four days ago, and said she snorted methamphetamine when she couldn’t find any opioids, only to stave off withdrawal. Her answers about frequency and amount of methamphetamine used were vague and evasive, so I was unsure of her exact history.

When I asked about her mood, she said she was depressed because of all the bad things that were happening as a result of her addiction: she was broke, her boyfriend just broke up with her (he was her drug-using buddy) and her family wasn’t loaning her any money, so she was in withdrawal much of the time. She denied any period of abstinence from drugs since she started using drugs at age 15. Family history was significant for a maternal aunt with severe bipolar disorder, requiring psychiatric hospitalization on multiple occasions.

Her exam was worrisome for a very low body weight. At 5’6” she weighed 103lbs. (she denied any symptoms of eating disorders) She was tense, pleasant, intelligent, and well-spoken. She fidgeted in her chair to an extreme amount. She was in florid opioid withdrawal, with wide pupils that were briskly reactive, obvious runny nose, frequent yawning, sweating, and goose bumps visible on her upper arms.

Her mother, who paid for her treatment, came to the appointment with her. My patient gave me permission to talk with her mother, who had quite a bit to add to the story. Mom said her daughter often seemed paranoid, and last weekend she stayed awake all night on Saturday, peering out one window after another, and checking repeatedly to make sure they were locked. My patient’s weird behavior kept the family awake all night. My patient also claimed to be able to hear people talking just outside the windows, and was sure the government meant to take her from her family for a nefarious reason. The patient’s mother said this last weekend was the most severe paranoid behavior she had seen in her daughter, but she had seen similar conduct in the past.

At this point, I thought there was a good chance we were dealing with more than just addiction. I considered bipolar disorder with psychotic features to be the most likely diagnosis, or schizophrenia. I hoped her use of methamphetamine had caused these worrisome symptoms, since she shouldn’t have them once she stopped use of the drug and got out of opioid withdrawal.

With this new information, I changed my treatment recommendation, and thought an inpatient admission to a detoxification unit was most appropriate. Her psychiatric status could be closely observed, and she could be started on Suboxone. If the psychotic features resolved, great. If not, she could be started on appropriate medications, be stabilized and then come see me after she was discharged. I could maintain her on Suboxone after she was stabilized.

It was a great idea, but unworkable. The detoxification unit wanted a chunk of money up front, before admission, and she didn’t have that kind of money. It was also beyond her mother’s financial capability. This patient had no insurance and didn’t qualify for Medicaid.

The patient pleaded with me to start on Suboxone. She believed all would be well if only she could get out of opioid withdrawal. I had my doubts, but agreed to prescribe one week of medication with telephone contact. Her mother agreed to call me or take her daughter to the psychiatric emergency room if her mood or behavior deteriorated.

One week later, a calm, smiling young lady entered my office. She had gained seven pounds in one week, and was no longer restless. The change was remarkable. Her mom came with her and said she hadn’t seen any more paranoid behavior. Her mother started to cry, saying, “I have my daughter back.” I was thrilled at the improvement. I adjusted her Suboxone dose slightly, and made sure she had her first session with the addiction counselor in my office.

I’ve seen her every week for the past month. She goes to three Narcotics Anonymous meetings per week, which is fewer than I’d like, but at least she’s going. She’s met with the licensed addiction counselor in my office each week. She’s had negative urine drug screens for the past three weeks and continues to gain weight. She says her mood is good, and she just went back to work.

For now, I don’t see evidence on mental disorder, but I’ll keep watching for problems.

I have a sad update.

After about two years of doing extremely well in my office-based practice, this patient relapsed. She was taking Suboxone 8mg per day, and appeared to be enjoying a good recovery. She went to 12-step meetings, got a sponsor, worked the 12 steps of recovery, and did service work at her home group.

She also had some sessions with the therapist who works in my office, who is MINT certified and has LPC and LCAS certification. After the first six months, she didn’t see a need for this service, and I didn’t push the issue, since she appeared to be doing so well.

After nearly two years of recovery, she missed an office visit, without calling to re-schedule. When she came the next week, she was positive for opioids on her urine drug screen.

We talked about her relapse extensively. She said she was upset one day, and had taken a few pain pills her mom had around the house.

We talked about what this meant. She already talked to her sponsor and had picked up a white chip at her 12-step meeting. We talked about how relapse is often a part of a person’s recovery. Since she was fortunate enough to survive it, we needed to examine her relapse process in detail, to learn from it.

I was unsettled, since I thought she had been doing great. I could tell she was unsettled too, and I made her next visit in one week instead of our usual one month.

She missed that visit, and I was really worried.

When she did make it in to my office a few weeks later, she falsified her urine drug screen. I told her I was really worried, because that was so unlike her. She admitted to relapsing back to heavy pain pill use.

We discussed treatment options. I wanted her to go to an inpatient program, to become re-stabilized, and then come back into treatment with me. We also discussed transferring her temporarily to an opioid treatment program, where she can go each day to be dosed, and where there’s more accountability.

She refused both of these options, saying she couldn’t miss work, and both would interfere with her work schedule. She was sure she could pull herself out of this relapse, if only I would give her another chance.

She kept her appointment a week later, but she was still illicit opioids. She said she was filling my Suboxone prescription, but only used it if she couldn’t find anything else. She had stopped going to 12-step meetings. Her mom came with her to this visit, and I asked if we could include her mom in her session. My patient not only refused to allow her mom to be a part of the conversation about treatment options, she also revoked the release for me to disclose anything to her mom.

I told my patient it was no longer safe to treat her in an office-based setting. I gave her one more week’s prescription and told her she had one week to decide what option she preferred: inpatient medical detoxification followed by inpatient residential treatment, or transfer to an opioid treatment program. I gave her the number and address of the OTP, where I knew she could continue on buprenorphine while she regained her stability.

I never spoke to her again.

She didn’t keep her next appointment. Three weeks after this missed appointment, she went to an opioid treatment center (not the one I’d recommended), which only used methadone. After she took her first day’s dose, she took a handful of Xanax and died in her sleep that night.

I thought about those last sessions multiple times, and wished I’d handled them differently. I think I believed her when she said she could stop using heroin on her own, since she had done so well while in recovery. Surely, I thought, she doesn’t want to stay stuck in active addiction any longer. Surely she has the tools to get back on the right path.

But this is a deadly disease. Even two years of joyful recovery didn’t save this patient in the long run.

I’m sorry to end on such a somber thought. However, I need to remember the stakes are so very high for our patients, and all relapses are serious.


8 responses to this post.

  1. Posted by Theresa baxter on March 29, 2017 at 4:19 am

    I’m sorry for this loss… You mentioned you wish you would’ve handled her last few sessions different. What would you have done differently? What could you have actually done differently? Thank you.


  2. Posted by Alan Wartenberg MD on March 29, 2017 at 3:44 pm

    I am a bit concerned about the thrice weekly NA attendance, mainly as to whether you (or a counselor) discussed whether she would be told that her continued “addiction” to Suboxone constituted an ongoing relapse, which is the official NA position (according to Bulletin 29). I know that not all groups endorse this, and that there are some NA meetings in our area where people are considered “clean and sober” while on agonist therapies. However, most of the groups in my area will not allow people who admit they are on methadone or buprenorphine (and at least in a couple of cases, Naltrexone) to even speak at meetings, let alone get sobriety tokens. They are often encouraged to “stop taking that shit” by people at meetings and/or their own sponsors. I have always done a lot of pre-NA/AA counseling on my patients to make sure they understood the risks of self-disclosure, and if they chose that route, how to defend themselves from the disapproval and advice on people at meetings.

    I have had more than one patient tell me they stopped their agonist therapy because of pressure from NA/AA meetings. I have attempted, without success, to engage local NA
    area representatives to at least discuss Bulletin 29.

    I think many programs require their patients to go to 12 step meetings WITHOUT any discussion of the views of 12 step programs towards agonist therapy, and thus may be unwittingly, and with good intentions, sowing the seeds for later relapse, illness and death.


    • It was her choice to go to 12-step meetings. At the first patient visit, I always describe counseling options: once weekly sessions with the LPC/LCAS in my office, eventually moving to monthly sessions; attending a nearby SAIOP for six weeks; 12-step meetings; or any other reasonable options the patient may come up with. I tell them as long as it’s substance use disorder counseling, I’ll agree to it. Some patients already have a provider they know, and if they’re willing to sign a release, that’s fine with me. So I’m pretty loosy-goosy as to the type of counseling they do.
      This patient had exposure to 12-steps in the past, and preferred it to all other options, not least of which was because it didn’t cost her anything. We talked about the medication issue and she was fine with not mentioning it in the groups. She had a sponsor who, surprisingly, knew she was on suboxone, and was OK with it. In her area, there are a handful of patients on medication-assisted treatments who seemed to support each other as kind of a support group within a support group.
      I do hear what you are saying, though. Some of the patients at my OTP seem so ambivalent about being on MAT if they’ve spent time in 12-step meetings that I think it can get in the way of treatment.


      • Posted by Alan Wartenberg MD on March 30, 2017 at 2:57 pm

        Thanks, Jana. I always strongly urged my patients to NOT disclose, since it is health information, and they have every right to keep that private. I review the honesty issue with them and explore their concerns. I urge them to find a sponsor with whom they can be completely honest, and I actually had a list of more mature (in their sobriety) patients who are willing to take on, at least on a temporary basis, my newer patients

    • Posted by Maximilian Alexander on April 6, 2017 at 8:42 am

      I personally choose not to attend 12-step meetings whilst on Suboxone for this reason. There are other equally beneficial peer-support groups like SMART which are more open to pharmacotherapies.


      • Posted by Alan Wartenberg MD on April 6, 2017 at 7:21 pm

        There are a number of other mutual help groups in addition to 12 step programs, including SMART Recovery, LifeRing Secular Recovery and Women for Sobriety. Unfortunately, they do not have the group density that AA/NA has, so one has to look harder (and perhaps drive longer) to get to them. I have repeatedly tried to get that message out to my colleagues, that not only are 12 step programs not the only wheel in town, but that, at least for some patients, they may be inappropriate, ineffective and may even worsen their situation.

  3. Posted by Kim Comstock on April 23, 2017 at 9:52 pm

    Thanks for your blog Jana – I’ve been reading for almost a year and find every discussion beneficial and informative. At our clinics we work on what we call “internalized-stigma” with our pt’s in preparation for 12-step as well as exposure to just about everywhere. Family, peers, physicians, and especially SUD treatment providers are some of the worst sources of misinformation, including 12-step meetings. Coping with the external pressure to be “abstinent” can make or break a pt’s commitment to treatment, especially in regards to how that message is internalized. “Take what you need and leave the rest!”, is the best 12-step slogan for our population, I believe. All that said – there really are some excellent messages to be gotten from 12-step as well as the potential for a supportive and positive experience, if well prepared.


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