AnneMarie Kelly is among the most impressive researchers I have met and I’ve met Nobel Prize winners like Arvid Carlsson and Julie Axelrod.
I have told the story in many venues how she, with no background in healthcare or university research, taught me things about the serotonin system that I, who have a PhD in this system, never knew. She is one of the heroes of Shipwreck of the Singular.
Her work led me to the idea that rather than have a 100 patients who cause a doctor’s heart to sink, when treated according to the guidelines they fail to get well, by listening to people who come to them and encouraging them to research problems, this might give doctors like me 100 free research assistants instead, making the job much more fun. See Relationship Based Medicine.
AnneMarie’s example prompted a ‘battle-cry’ – Motivation is worth more than Expertise.
Between versions on davidhealy.org Out of My Mind Driven to Drink and on RxISK Driven to Drink Antidepressants and Cravings, her story has been the most commented on with close to 500 comments, almost all endorsing exactly what she was saying 10 years ago. She has unquestionably saved lives and marriages and jobs – but there has been no recognition from the world.
Her efforts have done a lot to save others but her world was not easily put back together.
The world needs a prize for citizen researchers whose efforts save lives and pave the way to better treatments.
Is the World Catching Up?
It looks like AnneMarie’s work is beginning to be more appreciated. In recent weeks, medical colleagues have sent a host of articles my way and talked about their clinical experiences. (These colleagues come my way because they think it’s me who has recognized this link between SSRIs and alcohol abuse).
Several doctors have told me about people whose drinking only began after starting an SSRI or got much worse after starting the SSRI, who found their problem cleared completely once the doctor stopped the SSRI.
The issues are also broadening out to other triggering drugs and other substances triggered.
There is growing evidence that antipsychotics like quetiapine, olanzapine and Abilify can cause methamphetamine, cocaine, and cannabis addiction in addition to SSRIs causing alcohol problems and problems with drugs like methamphetamine.
Serotonergic Drugs and Alcohol
Ciraulo D, Barlow D, Gulliver S, Farchione T et al, The effects of venlafaxine and CBT alone and combined in the treatment of co-morbid alcohol use-anxiety disorders. Behavior Research and Therapy 51 (2013) 729 – 735.
Dundon W, Lynch K, Pettinati H, Lipkin C. Treatment Outcomes in Type A and B Alcohol Dependence 6 months after Serotonergic Pharmacotherapy. Alcohol Clin Exp Res. 2004; 28: 1065–1073.
Friedmann P, Rose J, Swift R, Stout R et al. Trazodone for Sleep Disturbance After Alcohol Detoxification: A Double-Blind, Placebo-Controlled Trial. Alcoholism: Clinical and Experimental Research 2008, 32, No. 9
Charney D, Heath L, Zikos E, Palacios-Boix J, Gill K. Poorer Drinking Outcomes with Citalopram Treatment for Alcohol Dependence: A Randomized, Double-Blind, Placebo-Controlled Trial. Alcohol Clin Exp Res, Vol 39, 2015: 1756–1765
Serotonergic Drugs and Drugs of Abuse
Shoptaw S, Huber A, Peck J, et al. Randomized, placebo-controlled trial of sertraline and contingency management for the treatment of methamphetamine dependence. Drug & Alc Dependence 85 (2006) 12–18
Antipsychotics and Drug Addiction
Samaha A-N. Can antipsychotic treatment contribute to drug addiction in schizophrenia? Progress in Neuropsychopharmacology and Biological Psychiatry 2014, 52, 9-16
Kampman K, Pettinati H, Lynch K, Sparkman T, O’Brien C. A pilot trial of olanzapine for the treatment of cocaine dependence. Drug and Alcohol Dependence 70 (2003) 265-273
Wiesbeck G, Weijers H, Lesch O et al. Flupenthixol Decanoate and relapse prevention in alcoholics: results from a placebo-controlled study. Alcohol and Alcoholism 2001, 36, 329-334.
Zorick T, Sugar C, Hellemann G, Shoptaw S, London E. Poor response to sertraline in methamphetamine dependence is associated with sustained craving for methamphetamine. Drug and Alcohol Dependence 118 (2011) 500– 503
Ziva D. Cooper R, Foltin C. Hart S, Vosburg S et al. A human laboratory study investigating the effects of quetiapine on marijuana withdrawal and relapse in daily marijuana smokers Addict Biol. 2013; 18: . doi:10.1111/j.1369-1600.2012.00461.x.
Levin F, Mariani J, Brooks D, Pavlicova M, et al. A randomized double-blind, placebo-controlled trial of venlafaxine-extended release for co-occurring cannabis dependence and depressive disorders. Addiction, 108, 1084–1094.
Haney M, Rubin E, Foltin R. Aripiprazole maintenance increases smoked cocaine self administration in humans. Psychopharmacology. 2011; 216: 379–387
Tiihonen J, Kuoppasalmi K, Fohr J, et al A Comparison of Aripiprazole, Methylphenidate, and Placebo for Amphetamine Dependence. Amer J Psychiatry 2007; 164:160-162
Craving, Contingencies or Dysphoria?
What’s going on? These problems might not all be the same and we need people who have had any problems like this to comment on what happened to make them drink.
For instance do SSRIs cause cravings in some people but not others. Or does the alcoholism stem from an emotional numbing and lack of anxiety as to the consequences?
The sertraline and methamphetamine paper above talks about Sertraline blocking contingency planning – this likely points to a degree of emotional numbing.
In the antipsychotic cases, one option is that these drugs cause what is sometimes called dysphoria and also called akathisia.
In a healthy volunteer study some years ago, with doctors and nursing staff as the volunteers, some subjects who got droperidol became intensely akathisic/dysphoric and found that alcohol, red wine in particular, was the best treatment for it – See The Immediate Effects of Droperidol.
This left me mentioning in the last 4 editions of Psychiatric Drugs Explained that we might in some cases be driving our patients to drink – and to other drugs especially stimulants (See Beware Doctors Bearing Gifts).
This is not typical craving. Its more like what happens when you take a drug torelieve the dysphoria of withdrawal – its driven by the relief the person gets from a drink. Its the relief that is craved rather than the drug.
There is a degree of puzzlement in standard clinical circles about this. They figure dopamine is the reward transmitter and antipsychotics block this and they should therefore prevent craving and prevent addiction. These observers miss the intense dysphoria these drugs can cause.
There is a lot more debate about these issues on forums like Bluelight where people affected by these issues have far more detailed discussions than clinicians have. Bluelight even has Prizes for people making breakthrough, which however important are unlikely to be recognized by a Nobel Prize committee.
Tackling the Problem
For anyone who has an addiction problem, or is living with or cares for someone with a problem, it is worth reviewing previous medicines. Did the substance misuse start after some drug was prescribed? If it did, it might be worth stopping what seems the most likely triggering drug to see what happens.
Taking these issues to your doctor may not be helpful. S/he will have been told that antidepressants prevent alcoholism (which they may do in some cases) and antipsychotics are routinely used in the management of substance misuse.
These issues get very tricky if the substance misuse is also leading to a psychosis. And tricky because most doctors do not have time to engage with these issues.
Better to do your own research first, build a case, and perhaps even take treatment into your own hands unless you have a regular doctor who listens.
I learned a lot from another impressive researcher, this time a man. He had OCD and needed some control over it in order to be able to work.
SSRIs, supplemented if need be by antipsychotics, are the standard treatment for this. This is what I gave him but he was not helped. Things got steadily worse.
Then he turned up one week clearly cured. He confessed to stopping all his drugs – but this was not what had cured him. He had gone back smoking, which he had stopped for several years.
I have mentioned his case in a medical forum where we are each asked to talk about a case that has shaped our thinking. The reaction from the doctors there was horror. It is the same in any medical circles. Doctors all but hold up a crucifix and garlic in front of me.
What they don’t realise is that my patient didn’t just go back smoking – he googled nicotine and OCD and found several studies showing benefits for OCD that other cholinomimetic drugs like donepezil also appear to have.
He didn’t know it but one of the studies he showed me involved Arvid Carlsson and colleagues – the same Carlsson who won a Nobel Prize for discovering the role of dopamine in the brain and who also made the first SSRI.
Who says citizen researchers can’t make breakthroughs to equal Nobel Prize winners?
Both AnneMarie and my OCD patient feature in Beware Doctors Bearing Gifts – a public facing lecture on some of the problems facing all of us – that many doctors have told me the public should never be made aware about.