Depression, insomnia, Ambien—and cocaine

Co-occurring mental illness and substance abuse can be difficult to treat. Symptoms might be the result of either pathology or substance use, which complicates diagnosis, and almost all substances ultimately worsen the course of psychiatric disorders. I saw many cases of co-occurring disorders while working in a methadone clinic; a significant number of people who use heroin have histories of trauma and, as a result, suffer from comorbid depression, anxiety, PTSD, or other disorders.

For treatment to be most effective, practitioners need to understand both kinds of disorder and treatment teams should be unified. Unfortunately, in many cases treatment is fragmented. Since the methadone program where I worked didn't have an on-site psychiatrist, I had to coordinate treatment with outside practitioners, not all of whom understood the dynamics of addiction.

One particularly tragic case was that of Mrs. Peters, a guarded 72-year-old. We suspected she had psychiatric issues when her hygiene and grooming began to deteriorate. Legally, she wasn't obligated to let us confer with her psychiatrist as long as she brought in her medications for us to chart, so we could be sure there would be no harmful interactions with the methadone.

When she appeared at the clinic alive with bedbugs, however, she was given a choice: let the social worker speak to her psychiatrist or face administrative discharge—her dose reduced by 10 mg every three days until it reached zero. That is a very uncomfortable process, and Ms. Peters let me call Dr. Brown.

She warned him I'd be calling, so his first words to me were, “I know Ms. Peters is on methadone, and I know her dose is 80 mg. I've been treating her depression for more than 20 years.”

“Great,” I said. “Can you tell me what medications you're prescribing? She's having bedbugs and we're concerned.” Ms. Peters brought in her prescriptions sporadically. Even if she tested positive for a controlled substance, we wouldn't know the dose.

“Bedbugs? Really? I never saw any," he said. I stopped myself from offering to capture him a sample.

"Elavil for the depression, 100 mg,” he said. Elavil is one of the older antidepressants called tricyclics, and it's contraindicated with methadone because it can be sedating. Many newer medications incur fewer side effects. I wondered whether he was keeping up with current research. But I didn't say anything. Although I'm trained in the evidence-based practice of medication management, I've noticed not all psychiatrists appreciate social workers questioning their prescribing practices.

“Ambien for her insomnia, 10 mg,” Dr. Brown continued.

I had to say something to that. Adding Ambien to Elavil and methadone could be fatal. Moreover, ten mg of Ambien is twice the recommended dose for a woman her size.

“That seems like a lot of Ambien,” I said.

“Well, she has severe insomnia,” he replied pointedly. "I'm also prescribing 10 mg of Xanax." That is an enormous dose of a tranquilizer, especially for a 90-pound woman who's already taking elevated doses of Elavil and Ambien.

“Are you aware that she's using cocaine?” I asked. Methadone patients are drug-tested weekly or semiweekly, and her toxicology results were usually positive for cocaine. We suspected she was smoking crack, since it's a cheap, quick high, but she wouldn't concede anything.

I heard a sharp inhale. I didn't say anything. Finally, Dr. Brown admitted, “No, I did not know she was using cocaine.”

“Do you think her cocaine use might be related to her insomnia?” I asked, feeling like a courtroom attorney who knows the answer to every question posed.

He conceded that was possible.

Long-term cocaine use disrupts many of the body's natural systems, including the sleep-wake cycle. It's not uncommon for people using cocaine to stay up for hours or days at a time, then crash and sleep almost as long. Repeat the cycle often enough, and the body loses its ability to relax and fall asleep at the end of the day.

A person with a substance use disorder often looks for a pill—or another pill—to solve any problem. (As do many people who don't use substances.) Ms. Peters' doctor supplied her with powerful sedatives to treat her insomnia—a symptom of her cocaine abuse—instead of treating the cocaine abuse to bring the sleep-wake cycle back into balance.

In 20 years, Dr. Brown had run numerous blood tests for Ms. Peters, but never drug-tested her. Knowing about her cocaine use could have significantly changed the course of treatment. Unless you ask—or test—you won't know whether your patient is using. Then you consider whether their symptoms result from psychopathology or substance use, and address them holistically.

I almost wasn't surprised when Dr. Brown told me he was also prescribing blood pressure medication for Ms. Peters, the beta blocker propanolol.

"It's just until she can get to the cardiologist," he added hastily. "I check her vitals and her blood work regularly."

"How long have you been prescribing her propanolol?" I asked.

He waited an uncomfortably long pause before admitting, "About three years."

"I'll meet with her and try to make her an appointment with a cardiologist," I said. Unfortunately, unsurprisingly, Ms. Peters declined a referral. "Dr. Brown takes care of me," she said. He certainly had—two decades of cardiology, psychiatry, and sleep medicine.

Psychiatrists who see Medicaid patients aren't reimbursed very much. In one clinic where I worked, the psychiatrists' appointments lasted a total of 15 minutes once a month. I didn't know anything about this psychiatrist's practice, but he was prescribing outside his area of expertise and giving a tiny woman enough sedatives to fell an elephant.

I'm not sure what I could have done differently. I spoke to my supervisor. "Try to get her to accept a cardiology referral," she said; she didn't think a referral to Adult Protective Services would result in much help. Ms. Peters continued to refuse a cardiology referral. "I'm too old to get used to a new doctor." As far as we knew, Dr. Brown continued prescribing for her.

The clinic manager maintained we couldn't force her into anything, which was true. It's the conundrum of modern medicine and behavioral health: patient choice still reigns supreme, even if the choice risks harm or worse. I'm not arguing for that to change. For many decades, psychiatry warehoused people in state hospitals, people who were considered incapable of consenting to treatment or even participating in their own treatment plans. That was a tragic waste of human life potential.

Nowadays it's very difficult to compel "treatment over objection," or TOO, a cutesy acronym that can mask draconian efforts to treat an illness that a person doesn't recognize, or provide treatment that a person doesn't want to suffer.

I left the clinic a few months after my first meeting with Ms. Peters. I don't know what ultimately happened to her.