Eric K. Mason
Obsessive-Compulsive Disorder, Opioid Addiction, and Treatment Issues
Introduction
Substance abuse and psychiatric disorders go hand in hand. In other words, if one suffers from a psychiatric disorder, one’s chances of becoming dependent upon drugs increases dramatically. The reverse is also true. That is, one who is dependent upon drugs is more likely to have a psychiatric disorder.
For example, in the U.S. there are some forty million people who suffer from mental illness, of which seven to ten million have a substance use disorder. Over Sixty-four percent of people who are treated for substance abuse have a co-occurring mental illness. Furthermore, mentally ill individuals are four times more likely than the general population to develop a drug abuse problem in their lifetime (Million, Blaney, & Davis, 1999).
Not surprisingly, there is often much debate as to which disorder appeared first. Did the substance abuse cause the psychiatric disorder, or did the psychiatric disorder lead one to abuse drugs? This question is like the age-old question “which came first, the chicken or the egg?” Those in the substance abuse treatment field tend to feel that if the substance abuse is “cured,” then the psychiatric disorder will likely be “cured,” as well. On the other hand, mental health professionals believe that substance abusers use drugs to self-medicate their psychiatric disorders, and that mental health treatment will help them inevitably recover from their substance abuse problems.
Unfortunately, sixty percent of people with co-occurring mental illness and substance use disorder receive no treatment at all. Twenty-three percent of those with co-occurring mental illness and substance use disorder receive only mental health care, while nine percent only receive care for their substance use disorder. A mere eight percent of those with a mental illness and a substance use disorder receive concurrent treatment for their mental illness and substance use disorder (Million, Blaney, & Davis, 1999).
In the following paper, I shall discuss the psychiatric disorder known as obsessive-compulsive disorder (OCD), as well as opioid addiction (a substance use disorder) and how these two disorders relate to one another. Some research seems to indicate that OCD is more prevalent in opioid addicts, than in the general population. This research hypothesizes that opioid use in opioid addicts may be caused by their OCD. The research does not proclaim that these individuals use opioids to self-medicate their OCD per se, but rather that the ritual use of opioids serves to satisfy the obsessive-compulsive tendencies of these individuals (Khazaal, 2006).
Obsessive-Compulsive Disorder
Anxiety disorders are the most prevalent mental disorders in the United States—reportedly affecting some 12.6% of the American population every year. Although patients suffering from an anxiety disorder may seek treatment, they usually seek out physicians to remedy physical complaints like dizziness, gastrointestinal problems, heart issues, and insomnia; however, such somatic symptoms are often common in those suffering from anxiety disorders. In fact, the somatic complaints are often caused by the patient’s anxiety (Maxmen & Ward, 1995).
Unfortunately, many primary physicians may choose to treat the physical symptoms, rather than recognizing the patient’s physical complaints as a manifestation of an anxiety disorder. About 30% of patients who visit primary-care physicians suffer from an anxiety disorder. Anxiety disorders are complex and come in many forms, such as panic disorder, phobia, generalized anxiety disorder, as well as the focus of this paper–obsessive-compulsive disorder (OCD) (Maxmen & Ward, 1995).
Being obsessive or compulsive in regards to some aspect of life is a far cry from suffering from OCD. While individuals my claim to be “obsessed with sports” or “compulsive with money,” these euphemism are used by the layperson to mean that they “really like sports” or have “poor money-management skills,” respectively (Wilhelm, 2004).
What differentiates such individuals from those who are truly obsessive-compulsive is the severity to which the obsessions and compulsions interfere with their daily life. Rarely, do sports fans’ obsessions with sports control his or her life. In contrast, OCD can be quite debilitating—interfering with social, occupational, and emotional aspects of life (Maxmen & Ward, 1995).
“Obsessions are persistent, disturbing, intrusive thoughts or impulses, which the patient finds illogical but irresistible” (Maxmen & Ward, 1995). They are differentiated from delusions in that the patient dislikes the thoughts, tries to resist them and views them as egodystonic (Maxmen & Ward, 1995). “Compulsions are obsessions expressed in action” (Maxmen & Ward, 1995). An OCD patient acts out his or her obsessions as a means of reducing anxiety. OCD occurs in about 3% of the total U.S. population (Maxmen & Ward, 1995).
OCD patients are typically categorized into five categories—washers, checkers, doubters and sinners, counters and arrangers, and hoarders (Maxmen & Ward,1995). The average age of onset for OCD is 27 (Wilhelm, 2004). Responses to treatment for OCD may vary depending on with which type of OCD a patient has been diagnosed (Seedat, 2002).
Opioid Addiction
Most often when one thinks of opioid addicts, heroin comes to mind. However, there are an estimated 3.5 million Americans who use prescription opioids illegally every month, while there are only 120,000 to 800,000 heroin users. Prescription opioids that have high abuse potential include hydrocodone, OxyContin, and cough syrups. Like heroin, they may be injected or snorted (though they are usually prescribed to be taken orally in pill form) (Inaba & Cohen, 2000). Children tend to be at higher risk for abusing prescription opioids than heroin. Between 1992 and 2003 the abuse of prescription opioids increased by 212% in those ages twelve to seventeen (Hyman, 2007).
Opioids work by decreasing one’s sensitivity to pain—both physical and emotional. (Inaba & Cohen, 2000) Opioids “act like the body’s endogenous…pain-killers (endorphins and enkephalins)” (Inaba & Cohen, 2000). Individuals who want to deaden real physical pain or bury undesirable emotions may be drawn to opioids. People who suffer from psychiatric disorders, therefore, may be at a greater risk for becoming dependant on opioids, because opioids may help them experience some relief from their disorder. In other words, people with psychiatric disorders may use opioids to self-medicate.
Obsessive-Compulsive Disorder and Opioid Addiction
According to Khazaal and colleagues, OCD occurs four times more frequently in opioid-dependant individuals than in the general population (2006). The nomenclature used in the DSM-IV-TR to described opioid dependence mirrors the symptoms of OCD in many ways. For example, the DSM-IV-TR states that “persons with Opioid Dependence tend to develop such regular patterns of compulsive drug use that daily activities are typically planned around obtaining and administering opioids” (2000).
OCD may be mistaken for opioid dependence, when in fact both disorders could be present. The habitual use of drugs is usually accompanied by certain rituals. Heroin users often have rituals associated with getting, preparing, and administering heroin. In addition, their drug seeking behaviors may be triggered psychologically, such as when they pass by a location where they would normally buy heroin (Prasant, 2006).
One study found that heroin users experienced an opioid-like rush simply by engaging in the rituals associated with their heroin use. Furthermore, the study found that heroin addicts demonstrated some physical signs associated with heroin use, such as constricted pupils, when they injected sterilized water. These findings suggest that the compulsive behaviors associated with opioid use may be part of the appeal for opioid addicts (Khazaal, 2006). In other words, the use of drugs may serve to satisfy the obsessive-compulsive tendencies in some opioid users (Friedman). One could, therefore, argue that the actual chemical effects of opioids were not used to self-medicate (as I mentioned may be the case for some people with psychiatric disorders), but rather the ritualistic and compulsive-like behaviors associated with opioid use were used–one could say–to “self-medicate” the OCD.
Although these findings may be relevant to some opioid addicts, the results of this study are surely not applicable to all opioid addicts. The reasons behind why people become addicted to opioids are as diverse and complex as people themselves. It is impossible to identify an all-encompassing explanation for opioid use.
Although some may argue that opioid addiction simply “mimics” OCD in some cases, OCD symptoms may persist or even worsen in some opioid users even after they have quit using opioids (Evans, 2001). For example, one study found that methadone tapering consistently worsened OCD symptoms in some individuals. That is, OCD symptoms became progressively worse as the methadone dose for these individuals was lowered (Khazaal, 2006). For example, the study reported that one
patient described ruminative doubts with the subjective experience of spontaneous uncertainty followed by compulsive behavior. These thoughts and actions were perceived as unrealistic, excessive and were experienced as highly distressing. The compulsive behaviors mainly consisted in ritualized washing, checking, and ordering, which the patient reported performing mainly to reduce tensions and anxiety associated with the egodystonic obsessions (Khazaal, 2006).
This patient clearly exhibited OCD symptoms, according to the DSM-IV-TR. One could, therefore, argue that the OCD symptoms existed independently of the opioid addiction and that the addiction was not simply “mimicking” the OCD symptoms (Khazaal, 2006). Perhaps, because the patient could no longer satisfy his obsessive-compulsive tendencies through rituals associated with his drug use, the patient’s OCD became more prevalent, as a result.
Treatment Issues
Providing treatment for the dually diagnosed is quite common for those in the counseling and mental health fields. As stated above, the likelihood that any given substance abuser will have a mental disorder (or vice versa, that those with a mental disorder will be substance abusers) is very high. In short, the dually diagnosed client is by no means rare (Evans, 2001).
Given that a dual diagnosis is more the norm than the exception, one would think that there would be an overabundance of research available to clinicians on providing treatment for the dually diagnoses. Unfortunately, this is not the case. As I mentioned above this is, perhaps, the result of a lack of agreement (on the origins of a dual diagnosis) between those who treat substance abuse and those who focus primarily on treating mental illness. In other words, those who primarily treat mental illness tend to believe that mental illness causes substance abuse, while those who treat primarily substance abuse contend that substance abuse causes mental illness (Evans, 2001). That being said, I will now focus on what we do now about treating the dually diagnosed—specifically those with OCD and opioid dependence.
Substance abuse is very common among those with anxiety disorders—effecting close to a third of those with OCD. In an attempt to escape their anxiety, many self-medicate with anti-anxiety drugs, opioids, and alcohol (Maxmen & Ward, 1995). People with co-occurring disorders (COD) are at a greater risk for relapse, as they will often see a spike in their anxiety when attempting to abstain from drugs. Therefore, a vicious cycle of anxiety followed by drug use followed by abstinence followed by anxiety followed by relapse and drug use is likely to ensue (Evans, 2001). It is generally recommended that people with COD abstain from drug use when seeking help for their mental disorders. It is thought that abstention from drugs goes along way in improving one’s mental condition—especially those with anxiety disorders (as it is important to break free of the vicious cycle mentioned above) (Maxmen & Ward, 1995).
However, this may not be possible for those with co-occurring OCD and opioid addiction. For example, opioid replacement therapies, such as methadone maintenance, are a common treatment for those addicted to opioids (regardless if they have co-occurring OCD or not). Methadone maintenance (the daily consumption of methadone, an opioid) is regarded as a long-term approach to the treatment of opioid addiction, which requires a sustained and high level of commitment by those receiving it. In order for methadone maintenance to be successful, it is essential that those involved do not abruptly stop using it for treatment (as relapse is extremely high for those who do so). People on methadone maintenance usually have their methadone dose stepped down gradually over a long period of time before they are able to abstain from methadone and other opioids completely (Khazaal, 2006).
Since abstaining from methadone would not be very plausible for people dually diagnosed with OCD and opioid dependence, those providing treatment to such individuals should remain aware that as these individuals reduce their methadone doses, their OCD symptoms may begin to worsen (as was the case in the study by Khazaal mentioned above) (Khazaal, 2006). The exacerbation of their OCD symptoms may, in turn, put them at greater risk for relapsing, as well. Therefore, it is critical to treat the OCD and opioid addiction simultaneously in order to increase the chances of a successful recovery from both disorders (Maxmen & Ward, 1995).
When providing treatment to one with co-occurring OCD and opioid addiction, mental health/substance abuse treatment professionals may choose to alternate between treatment approaches that have been shown to be successful for either OCD or opioid addiction. They may use an approach that has been proven for treating both OCD and opioid addiction (such as motivational interviewing). Lastly, they may combine different approaches according to their clients’ needs (Hyman, 2007; Miller, 2002).
Treatment approaches that show promise for improving OCD symptoms include medications (such SSRI’s), behavioral and cognitive-behavioral therapies, as well as motivational interviewing (Corey, 2001; Maxmen & Ward, 1995; Miller, 2002). Treatment for opioid addiction may include medications or opioid replacement therapies, person-centered therapy, reality therapy, as well as motivational interviewing (Corey, 2001; Khazaal, 2006; Miller, 2002). As I mentioned above, treatment professionals may choose an eclectic approach to treatment, in which they combine any number of therapy/treatment approaches according to their clients’ needs. A treatment approach that serves the clients’ needs, as well as focuses on treating both disorders simultaneously, is by far the most ideal treatment approach (Hester & Miller, 2003).
Conclusion
The co-morbidity of substance use and psychiatric disorders is extremely common. The debate as to which disorder appears first is likely to continue, but it is–perhaps–not the most important question to ask. Trying to tease apart which disorder came first may ultimately distract from giving an individual proper treatment for his or her disorder (Evans, 2001).
Nevertheless, I do feel that it is important for the clinician to keep in the back of his or her mind what led one to abuse substances or to develop a psychiatric disorder. I feel that this is important, because it should allow the clinician to treat both disorders simultaneously (rather than attempting to cure one disorder by curing the order disorder). Treating both disorders concurrently has been shown to be the most effective way to treat a dually-diagnosed individual (Evans, 2001).
Furthermore, clients’ psychiatric symptoms may become more pronounced when they are no longer using drugs, as may be the case with OCD. Clinicians should, therefore, keep in mind that during different stages of treatment either of their client’s disorders (i.e., either psychiatric or substance use) may be more prevalent than the other.
In regards to OCD, clinicians need to remain aware that the use of opioids may play a part in satisfying obsessive-compulsive tendencies in their clients (Khazaal, 2006). Helping such clients understand how the rituals associated with their drug use satisfies these obsessive-compulsive tendencies may help them to recover from their opioid addiction. Furthermore, treating these clients opioid addiction without addressing their OCD may be ineffective as well, since the two disorders are so intricately intertwined. Therefore, as I stated earlier, the most appropriate method of treating a dually-diagnosed client with OCD and opioid addiction is to treat both disorders simultaneously.
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