By Robert Matylewicz, DO, ABAM, Medical Director at Clarity Way
Anxiety and insomnia are common problems for people in treatment for substance use disorders. In many cases these issues were present prior to substance abuse, were masked during the addiction, and have now resurfaced in sobriety.
Substances like alcohol, opioids or benzodiazepines have an anxiety-relief component to them. These drugs are basically nervous system depressants and naturally calming. Some people were prescribed benzodiazepines to help with anxiety before they began abusing them. Other people may have been self-medicating their anxiety with alcohol. And in the case of opioid abuse, people may not have even realized that they were less anxious when they were using them until they stopped. Regardless of their drug of choice, many people complain early in treatment that they can’t sleep and are struggling with anxiety. This is because when we take away the chemical, their coping mechanism, they often get rebound anxiety and insomnia.
During drug detox, people may experience increased anxiety because the body gets restless without these substances or they’re experiencing that baseline anxiety again that they never dealt with in the first place. When clients come into treatment, we detox them from their drug of abuse with different protocols. For example, if someone is addicted to alcohol we may use a long-acting benzodiazepine or phenobarbital to help them through withdrawal. If they’re abusing Xanax (a short-acting benzodiazepine), we may prescribe phenobarbital or a long-acting medication like clonazepam to taper – getting them through the detoxification process safely.
For those withdrawing from opioids, we sometimes use a buprenorphine taper and some comfort medications short term. These methods can help ease some of the anxiety that comes up and other withdrawal symptoms. Detox protocols are individualized based on the client’s withdrawal symptoms, physical make-up, drug(s) of abuse and length of time they’ve abused drugs. Once clients move through detox, we have additional ways of addressing anxiety and insomnia.
It’s important to educate clients that the substances they were abusing were naturally suppressing their anxiety, and now it’s returning. They need to develop healthy coping skills to address the underlying issues that have been fueling their anxiety all along. Sometimes they may need help from medications to do this. However, medication needs to be used in tandem with therapies such as cognitive behavioral therapy (CBT), music/art therapy or psychodrama. If anxiety is significant or particularly impairing, we may prescribe a selective serotonin reuptake inhibitor (SSRI) like Lexapro, Zoloft or Paxil in addition to therapies. We may also prescribe gabapentin, a drug initially used as an anti-seizure medication but that has recently been found to have qualities that can help ease anxiety and mood disorders. We use this with caution.
Prescribing medications for anxiety can be tricky because many clients still want that immediate relief they got when active in their addiction, but they really need to work on coping skills. Sometimes they want a pill, and they want it now. My job is to not always give them that pill – not to feed into their compulsion – but help them understand there are other ways. It takes two minutes to okay a prescription but much longer to help them understand we know what they feel is real. It’s hard for a client to understand that no medication may be the best option at the moment. It makes us often unpopular at the time, but seeing the long-term outcome is worth it for all.
Therefore, we will work with clients to manage their anxiety and insomnia without medications. Some of the ways we do this include:
Cognitive behavioral therapy – This therapeutic approach helps clients identify unhealthy thought processes, beliefs and behaviors and work to change these with the help of assignments between therapy sessions and by putting skills learned in therapy into practice in real life. CBT can provide clients a sense of control over their lives and studies have shown it to be effective in treating anxiety disorders.
Neurofeedback – A noninvasive biofeedback technique, neurofeedback uses visual and auditory stimuli to train the brain to function more effectively and efficiently. It has been shown to decrease obsessive thoughts, which can help with anxiety and insomnia.
Mindfulness – Paying attention to the body and breath can have a calming effect and help people become less reactive and overstimulated. Mindfulness meditation has been shown to help people with generalized anxiety disorder.
Fitness – Exercise is a natural stress reliever and can help ease anxiety symptoms.
Education – It’s important that we educate clients that anxiety and insomnia can be a normal part of addiction recovery. We help clients understand that anxiety may have been an ongoing problem for them well before their addiction. It will take some time to correct now that they’re not using drugs or alcohol. Clients often come into treatment on safe medications for anxiety or depression and they want immediate changes. Helping them understand why these medications didn’t work or stopped working while they were actively using drugs is important. These medications need time to work while they’re sober. Time and sobriety are often the best choice. Accepting that requires education.
Good sleep hygiene – We encourage clients to practice good sleep hygiene to combat insomnia. This includes not using electronics close to bedtime, keeping a consistent sleep schedule, having a regular bedtime routine, having a supportive and calming sleep environment, exercising and avoiding caffeine.
Our medical staff and therapists work closely with clients to determine if they need to be prescribed medication versus just needing to understand that anxiety and insomnia are a natural part of the recovery process. Typically, we tell clients to give it four to six weeks using their new coping skills to help alleviate symptoms. That being said, if we find that after a few weeks a client is experiencing pretty significant distress due to anxiety, we will try to ease their symptoms with some of the previously mentioned SSRIs. We weigh that carefully with their progress though. Medications can change lives, but the body does have an innate ability to heal itself if given the opportunity. So, we consider many factors when deciding, and we listen most of all to the client.