Archive for the ‘comorbidity’ Category

Insomnia

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Insomnia is defined as a sleep disorder which makes it difficult to get to sleep or stay asleep. Insomnia can come & go for periods of time, or can be a chronic problem. Not sleeping well can make us less able to handle the stresses of the next day, and can severely affect the quality of our lives.

Insomnia afflicts many patients in recovery, including those on medication assisted treatment with buprenorphine and methadone. Insomnia can occur for many reasons: the brain may be adjusting to life without the chemical ups & downs of addicted life, or because the patient had insomnia even before the addiction started. Physical health problems (chronic pain, thyroid disease, and menopause to name but a few) can cause insomnia or make it worse, as can mental illnesses like anxiety and mood disorders.

Active addiction can destroy normal sleep-wake cycles. Addictive chemicals disrupt the structure and function of the brain, and often people in active addiction become accustomed to passing out rather than falling asleep. It can be difficult to re-learn how to get to sleep naturally.

Many U.S. citizens, and not only addicts, have become “chemical copers.” We have the idea that every problem can and should be fixed with medication. But with insomnia, sleep hygiene is the best first option, and medication can be used if sleep hygiene doesn’t work.

Sleep hygiene, which sounds it means washing behind your ears at bedtime, really refers to habits that help us get satisfactory sleep. Most are common sense ideas, and they can really make a big difference. Here are some of these ideas:

1. Go to bed at the same time and wake at the same time every day, even on weekends.
If it’s at all possible, don’t go to bed later or sleep later on weekend days. Get your body into the habit of keeping a regular sleep/wake cycle. You will fall asleep more easily with a fixed bed time.
Besides making your feel better because you’ll get more regular sleep, this practice has other benefits. For example, people with migraine and tension headaches have fewer pain episodes with regular sleep/wake times. Keeping regular sleeping hours is also highly recommended for patients with bipolar disorder, as it can help with mood swings.

2. Avoid caffeine late in the day. For some people, drinking caffeine in the late afternoon can affect them up to six hours later. To be sure, cut off caffeine at least eight hours before you want to sleep. Caffeine doesn’t affect everyone to this degree, but unless you know for sure, try to limit late-day caffeine. If you consume energy drinks, consider cutting back or stopping them.

3. Make sure your bed is comfortable and your room as free from distractions as possible. Pets and rowdy bed partners may need to sleep in other areas. Make sure the room temperature is conducive to sleep and there’s no noise or light that may interrupt sleep. Keeping the television on for background noise isn’t a good idea and can prevent you from getting to the deeper levels of sleep.

4. Don’t set your alarm for earlier than you need to. Many of us like to do this so we can hit snooze a few times. However, the most beneficial sleep, REM sleep, comes at the end of the night, and we are depriving ourselves of REM sleep by hitting the snooze button a few times before getting out of bed for good.

5. Have a bedtime ritual. Have things you do each night before going to bed that relax you and put you in a mindset to sleep. This could be a series of ablutions like brushing your teeth, flossing, or taking a warm bath. Other people may prefer doing prayer or meditation to quiet the mind, or reading.

6. Don’t nap during the day to catch up on sleep. More than anything else, napping will keep you from sleeping at night.

This is a tough one for me, since napping has long been one of my hobbies. Because I think of a good nap as one of life’s great joys, on some days I’m willing to risk not being able to get to sleep at night and take the nap anyway.

7. Don’t use alcohol to help you sleep. While alcohol does cause faster sleep onset, it also shortens the sleep cycle, causing us to wake earlier, and robs us of the important REM sleep. Over long term, alcohol can greatly interfere with your sleep cycle.

8. Only use your bed for sleep. OK, for sex too. But don’t live in your bed so that you become accustomed to eating, watching television, and working on the computer in bed. Your mind should associate bed with sleep, and not these waking activities.

9. Exercise each day. More than most other suggestions, this one can help you more than you expect. Even a small amount of exercise can have surprisingly good benefits. Don’t exercise too close to bedtime, since exercise can have a stimulating effect.

Sometimes people in early recovery find they want to sleep more than usual. This can be part of your physical recovery, and I think it’s best to listen to your body and allow yourself extra sleep time without feeling guilty. However, some mood disorders also make people want to “take to the bed” during times of stress and negative emotion. This latter situation may need medication if it continues or interferes with your life.

If you try all these sleep hygiene measures and you still can’t sleep, talk to your doctor about a safe medication for sleep. I’ll write more about medications in a later blog.

Is Impotence on the Rise in Opioid Users?

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According to a recent study, long-acting opioids are nearly five times more likely to suppress testosterone levels than short-acting opioids.

Over the last few years, we’ve seen a surge in data that couples opioid use with lowered male testosterone levels. We know the use of opioids can lead to hypogonadism, a condition of lowered sex hormone production. In males, lowered testosterone levels can lead to fatigue, depression, and even osteoporosis and obesity. Some studies suggest this hypogonadism is also associated with lowered pain tolerance.

In previous studies, opioid users were lumped together, but this recent study compared the testosterone levels of patients taking long-acting opioids with patients taking short acting opioids.

Dr. Andrea Rubinstein presented data at the annual American Academy of Pain Medicine meeting. Her study compared 81 male patients taking opioids for at least three months. Those in the long-acting opioid group included patients prescribed methadone, buprenorphine (Subutex, Suboxone), sustained-release medications in patch form, such as morphine and fentanyl, and sustained-release medications like OxyContin (taken whole as intended with the coating not removed). These patients were compared with those on short acting opioid like immediate-release oxycodone and hydrocodone.

The patients on the long acting opioid were nearly five times more likely to have low testosterone levels than patients on the short acting opioids. The age of the patient and the total daily dose did not appear to affect the risk of low testosterone.

It’s possible that short acting opioids give more fluctuation in serum opioid levels, and thus less likely to suppress hormonal function.

This is not great news for those of us who treat opioid addiction. We use long-acting opioids like methadone and buprenorphine precisely because they are long-acting, and give a steady blood levels. Their long action in the body means they can be dosed once a day (usually) and still relieve all opioid withdrawal symptoms. The relief from opioid withdrawal frees the patient to focus on making important life changes. With short-acting opioids, most addicts feel a euphoric high, followed several hours later by withdrawal. This drives them to seek opioid drugs as often as every six hours. It’s hard to maintain a normal life when seeking pursuing opioids three or four times per day. Simply staying out of withdrawal becomes the opioid addict’s full time job. Short acting opioids may be better for my patients’ testosterone levels, but not good for their disease off addiction.

So what should I do with this data about hypogonadism in my practice?

I think I should be more diligent about monitoring my patients for symptoms of low libido. It’s important to ask male patients about sexual difficulties because sometimes they are embarrassed to mention them. If patients have no symptoms of hypogonadism, they probably don’t need further testing. If patients do have symptoms, I’ll ask them to see their family doctors for a work-up, because that’s something that can’t be treated at the opioid treatment programs where I work. Testosterone can be supplemented with gel or intramuscular injections, and testosterone levels need to be monitored, as well as cholesterol levels.

I’ve had previous patients who object to testosterone supplementation because they felt they were treating a side effect from one medication with a second medication. While this is true, the only other option is tapering off methadone or buprenorphine, or cutting down their dose. This also has risks, as opioid addiction is a life-threatening illness. If a patient wants completely off medication, he should have an inpatient treatment lined up as soon as his dose is low enough for admission.

What about women on medication-assisted treatments with low sex drive? Women weren’t included in this study, but yes, we know their hormones are also affected by opioids. Testosterone may help women recover their sex drive, but it has serious side effects and hasn’t been proven to be safe in the long term for women. For females who report sexual dysfunction on long-acting opioids, I will continue to refer them to their gynecologists.

As usual, the benefits of long-acting opioids must be balanced against their risks.

Opioid Use and Prostate Health

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I found an interesting article in a recently published issue of the Journal of Addiction Medicine, Vol 7 (1) pages 58-65. This article describes the effect of opioids on PSA (prostate specific antigen) scores.

PSA is an enzyme normally found in low levels in the blood of men with healthy prostates. It’s elevated in a variety of prostate diseases. Notably, it’s elevated in men with prostate cancer, but it can also be elevated from other ailments that cause inflammation of the prostate.

Routine screening of men through checking the PSA levels is controversial, and some experts say routine screening of PSA leads to unnecessary prostate biopsies. They also say screening doesn’t reduce deaths from prostate cancer. However, many men specifically ask for PSA screening, and many doctors still check the PSA levels as part of a routine physical. PSA levels can be followed after a patient has been treated for prostate cancer, and elevated levels can mean a recurrence of the cancer.

In this study of Iranian men, male opioid addicts had 28% lower PSA levels than subjects that didn’t use opioids.

We already know that opioid use is associated with lower serum testosterone levels, so the authors of the study postulated that lower testosterone levels lead to lower PSA levels, but this was not the case, at least in this group of men. There was no correlation between serum testosterone levels and PSA levels in this study, so it did not appear that testosterone levels caused the lowered PSA levels.

Since prostate biopsies are performed on men with elevated PSAs the study authors were concerned that in opioid addicts, their lower PSA levels will fall below the threshold for biopsy. This could mean cancers could be missed in opioid users that might be detected in non-opioid users. Therefore, prostate cancers may not be detected in opioid addicts until the cancer is more advanced.

Indeed, in this study, more the men on opioids who were diagnosed with prostate cancer during the study period had higher grade prostate cancer than the men not on opioids who were diagnosed with prostate cancer during the study period.

This study suggests that for men on long-term opioids, PSA cut-offs should be lowered when deciding if the patient needs an evaluation for possible prostate cancer.

Comorbidity

Today I had the pleasure of talking to a group of therapists and mental health professionals about my favorite topic in medicine: the treatment of opioid addiction with methadone and buprenorphine. I’ll blather on about that topic as long as anyone’s willing to listen.

 

Today’s listeners asked some great questions. They asked questions not only about opioid addiction, but also about the overlap between addiction and mental illness. These questions are crucial in the treatment of both disorders, because they occur together so frequently. When both types of disease occur in the same patient, we call this “comorbidity,” or “dual diagnosis,” or “co-occuring disorders.”

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 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, 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 may not be helpful.

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, 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 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 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.

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.

To learn more about the comorbidity of addiction and mental disorders, go to this free report:

http://drugabuse.gov/researchreports/comorbidity/