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Ask the Experts

Question:

My son is 23 and has a history of substance abuse, mostly opiates (oxycontin). He has been on buprenorphine for a year now and going to therapy.

He suffers from anxiety, which has gotten worse over the past few years. Sometimes he has panic attacks for no good reason, and he feels all the physical symptoms of chest pain, dizziness, and so on.

We discussed getting a good evaluation because the therapy does not seem like enough, yet he feels that with his history of substance abuse, no physician will want to prescribe medication. I hate to see him suffer with anxiety, and fear he may self-medicate in the future if not properly diagnosed and treated.

Is this where dual diagnosis comes in and who would be the best physician to see?

Answered by: Gregory Sullivan

It is now well established from large studies of the population that substance use disorders and anxiety disorders often occur in the same individual. Although particular substances (and withdrawal from certain substances) may trigger anxiety symptoms that are not related to a co-occurring anxiety disorder, a thorough evaluation of history and pattern of anxiety symptoms is an essential part of determining presence of co-occurring conditions and development of a comprehensive treatment plan. When a co-occurring anxiety disorder is present, it is extremely important to address it with the best evidence-based treatments for that disorder. Co-occurring substance use disorder is not a contra-indication for medication treatment of an anxiety disorder; but avoidance of medication treatments that have potential for addiction is often prudent.

For evaluation of such a situation, a psychiatrist would be the best specialist, although there may be situations in which substance treatment is received from one physician and anxiety disorder treatment is received from another. Also, particular anxiety disorders can be well addressed by psychotherapies tailored to the particular disorder, such as cognitive-behavioral therapy for panic disorder.

When there is more than one clinician treating an individual, it is extremely important that they communicate with each other about the diagnoses and the comprehensive treatment that is administered.