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Sunday, September 2, 2012

Less is MORE


Last week at the end of our session my patient told me, "I'm glad I found you". He had earlier seen an "addiction medicine" doctor who detoxed him off of opiates, i.e., 20+ Norco's per day. This doctor used a Suboxone taper with Tramadol and detoxed him over 5 days. The Suboxone was appropriate;  the Tramadol was not. My patient then stated that for 4 to 5 months he did not feel well. He couldn't sleep, he kept having racing thoughts, and he felt quite dazed. He was probably in a manic delirium exacerbated by his "successful" detox. My patient thought that he was still having drug withdrawal symptoms. I told him, "No, although your detox was successful this most likely triggered a bipolar mood cycle". It is not necessary to wait a year of sobriety to make this diagnosis. In fact my patient was so impaired during this time he almost lost his job.


I told my patient that this "addiction specialist" he saw was not trained to recognize why he was abusing prescription drugs in the first place. His attempt at self-medicating his unrecognized bipolar disorder was the problem. An internist or any other physician who does detox but is not a trained psychiatrist is going to drop the ball.  WHY?  It is a rare person who uses drugs in a vacuum. Usually there is some underlying issue that leads to the abuse or dependency. I applaud doctors who detox patients successfully. I can tolerate physicians who miss identifying Major Depression, Anxiety, Bipolar and ADHD disorders. But when they start taking the initiative to treat these disorders, I get mad as hell because it is dangerous! 

An addiction doctor I know put a patient on Lithium after his "successful detoxification". To make a long story short, he eventually came under my care after relapse. Lithium is a serious drug that has serious side effects. I discussed this with my patient and decided to discontinue Lithium. I evaluated him later and noticed continued hyperactivity and poor attention. After starting him on Stattera (Amoxetine) his ADHD is much better. We went from "bipolar disorder" to ADHD where my patient is now happy, functional and thriving.

The moral of the story? See a psychiatrist who can perform your detox AND who will not miss a serious underlying diagnosis that would prevent your optimal recovery and health. All psychiatrists who are recently trained can perform detox and treat psychiatric disorders. More so if they are board certified. Psychiatrists are the only medical doctors who are trained and certified in the biopsychosocial approach which aims at treating the whole person and not just parts like detox, withdrawal symptoms and maintenance. Psychosomatic medicine subspecialists like myself, practice this orientation for all types of diseases including drug abuse and dependence. The moral of the story? See a psychiatrist who can perform your detox AND who will not miss a serious underlying diagnosis that would prevent your optimal recovery and health.

The intersection of all 3 circles is health and well being.

Seriously?!?  Make it easy on yourself. Start with a psychiatrist and get it all done at one time. Why see several providers? As a board certified, subspecialized psychiatrist all of this is pretty easy for me to do. Less is MORE.

2 comments:

  1. Great article Soroya! The issue we face as primary care providers is that many insurances still refuse to provide adequate mental health coverage so patients come to us as. a last resort. I refer my patients with bipolar depression and ADHD to psychiatrist routinely and some are facing 100+ dollar specialty co-pays. I can not speak for internal medicine but in family medicine we are trained to recognize and treat depression, anxiety and ADHD.

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  2. This is such an important piece that's so often missing. Thanks for raising awareness -- great article!

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