Dr AXxxxx : Psychiatric Problems are
Very Common in the User / Addict Community

The main psychological problem with opioid (painkiller) type drugs is that they disturb the happiness mechanisms of the brain.

Users may develop  for example -  mood dysphoria. They feel flat or empty or not real or numb. There may be no normal enjoyment of life. They have difficulty feeling pleasure or satisfaction with normal activities. Even sex can become a lot more boring.

Many users develop a syndrome which we call depression. I think perhaps it is not really depression – but it is certainly a depression like group of symptoms. People feel down. People do not feel happy.

Another important psychological aspect post opioid use is anhedonia.
People who experience anhedonia have lost interest in activities they used to enjoy and have a decreased ability to feel pleasure. It’s a core symptom of significant depressive illnesses. It is a very common consequence of drug use – in fact all of opioids, amphetamines and even marijuana. Anhedonia can be social or physical.

Dr Xxxxx : Social anhedonia is a disinterest in social contact and a lack of pleasure in social situations. Physical anhedonia is an inability to feel tactile pleasures such as eating, touching, or sex.
The symptoms of anhedonia include:

• social withdrawal
• a lack of relationships or withdrawal from previous relationships
• negative feelings toward yourself and others
• reduced emotional abilities, including having less verbal or nonverbal expressions
• difficulty adjusting to social situations
• a tendency toward showing fake emotions, such as pretending you’re happy at a wedding
• a loss of libido or a lack of interest in physical intimacy
• persistent physical problems, such as being sick often

  Anhedonia : the image
Dr Xxxxx : Anhedonia is a serious problem because the user generally cannot anticipate feeling better and getting rid of the symptoms unless they take more of their drug. Unfortunately the more drug they take – the more symptoms they develop as the drug gets washed out from their body.
Brains often develop a cognitive dysfunction. Concentration fades. Memory can be impaired. People begin making mistakes at work – especially with chains of tasks (groups of activities that run in sequence) and with multiple tasks – often forgetting random tasks within a list. Forgetting to do things that they would previously have been able to do.
Users attend work but are essentially not really there – either not thinking about what they are doing or focusing only on their next hit.

It is not surprising that people’s ability to relate to others is seriously impaired when they have a substance use/addiction problem. They lose the ability to see themselves as others see them. They lose the ability to experience positive feelings from social interactions. They lose the ability to think about anything else except their drug use and their next hit. In short, they become very difficult people to live with. Not necessarily violent and angry although these behaviours do commonly occur. But definitely flattened, uncooperative, and unsociable.

Drugs may make users change their behaviour – engaging in risky sex, engaging in sex for money, and becoming promiscuous.

The final point to make is that these effects are very variable. Users will develop some of the symptoms, but only in extreme cases will they experience “all” of the symptoms. Drugs have their own particular patterns of altering behaviour. Marijuana in particular reduces long-term motivation and goal oriented achievement. Speed delivers a restless energy for a time, but then depression, flattened mood and poor motivation in the washout phase.

Passed out and lucky to be alive.
Dr Xxxxx : Opioids have a physical withdrawal syndrome lasting for several weeks up 2 months after the cessation. Amphetamines are said to have no withdrawal symptoms. However there is a definite “I am without my drug” symptom phase. Also when you learn to live with drugs, it becomes hard to establish a life or behaviour pattern without them. It is much akin to stopping smoking. For example, if you have a cigarette with coffee in the morning, having a cup of coffee in the morning automatically reminds you to have a cigarette.

Drug use can be mixed. Often heroin  is cut with GHB  or MDMA to give prolonged up and very prolonged “down” phases as the drug washes out, encouraging addiction. Amphetamines often are sold as small cellophane packets full of crystals. The process of crystallisation essentially purifies drugs. Crystals really form from the molecular packing of supersaturated solutions of chemicals and generally incorporate only single drugs in  their structure. It is easy enough though to mix the crystals going into a packet. You won’t see what you are not looking for. If all the crystals in packet are clear, but of different sizes or shapes, it may not be obvious to many that there is more than one drug in the packet -if you don’t understand what you need to look for.

The main resource that stops people using drugs is the people around them. These include family and significant others (FASOs). There are also important roles for psychologists, psychiatrists, dieticians, exercise physiologist physiotherapists, solicitors, and employers. Each of these people addresses a facet of a person’s life that is likely to have been affected by substance use/addiction.

Substance use/addiction is a complex chronic relapsing disorder. There is no one easy strategy or  solution. There are many problems which need to be addressed or managed.

Letter from Specialist : Psychiatrist

Erasmus :

Letter to Dr Xxxxx, Psychiatrist  
from Drug Subspecialty General Practitioner

Re-LittlePatient
Appointment 1st April 9 am, 2021.

Letter from referring practitioner:
LittlePatient has substance issues which he attributes to heroin but which probably include other substances such as MDMA – either mixed with the heroin by injection or as tablets. I would suggest you seek some clarification. The timescale of the symptoms experienced in use and withdrawal are not consistent with pure heroin usage.

LittlePatient has his substance use issues managed by government addiction specialty doctors at BIALA (RomaSt Brisbane). He is prescribed 24 mg Suboxone – daily dispensing with a take away dose on Sunday. My preference would be for this arrangement to continue, but perhaps with some input from you.  There are some new alternatives to daily oral Suboxone dispensing. Stronger ORT for craving suppression may be required.

The major issues requiring special attention include mood dysphoria.
LittlePatient complains of being amotivational, having little enjoyment from life and only receiving positive energy from illicit substances or his medications.

I believe some of the motivational issues relate to personality, post substance usage symptoms and longer term recovery from substance usage, plus possible injury affects from medications ingested or injected, as well as possibly depression.

The issue of possible depression has been a long-term one. He complains of not feeling well. He complains of a lack of motivation. He complains of a lack of enjoyment of many aspects of life. He is very morose in general.

Some of these depression issues are considerably exacerbated by his lack of routine for diet, exercise and ADL. He eats when he is hungry and not at routine times. Many of his other life activities are dictated by the same timetable, esp. inc. sleep. This does not help him to feel well most the time, I believe.

He is very afraid that he may NOT be able to cope with work without medication. Currently he is feeling that the Suboxone may be particularly impacting his motivation adversely and making him to some extent nihilistic.

Some consideration may be given to perhaps trialling the use of Subutex tablets versus Suboxone film. Some consideration may be given to altering his antidepressant therapy. I think a great deal of care must be taken not to exacerbate his symptoms or to cause deterioration in the amount of positivity or wellness he may feel. There may be some basis in truth to this attitude to Suboxone due to the amount of the Naloxone being absorbed from sublingual preparations. He will more likely take his medications than divert them, so Subutex may be a reasonable substitution in his case.

He is very adamant that he only feels better in regards to work when he’s taking Bupropion daily. He has done online research and has discovered that this drug alters dopamine brain chemistry.

During his work time prior to use of Bupropion he scored 1.5/5 on his performance review. During his work time after the use of Bupropion he scored 4.5 out of 5 on his performance review. His very reluctant to cease or reduce the regular use of this medication as result.

I have some concerns about other drugs apart from opioids being used (? MDMA). He experiences a medium energy high at time of usage. Occasional events of anxiety and panic during recovery. Some irritability in late recovery and then finally some long-term morose- ness --- as I suggested perhaps indicating a substance such as MDMA.

Some urinary drug screens may be useful in sorting this issue out. I think LittlePatient is unlikely to falsify such tests but may be fairly a-motivational in providing such tests.

Key issues are:
Management of motivation
Management of depression
Feeling well and positive.
You may wish to consider alternative antidepressants,
Altering his Opioid Replacement Therapy film>tabs,
Adjunctive motivational agents such as with dopaminergic action.

Yours sincerely
Dr Xxxxx

Adjunct from FASOs (family and significant others)
I/ my partner will pay the account in advance.
Any refunds to me / My Partner’s account: AAaaaa bbb bbbb bbbb
Any letters to MyHomeAddress, or my doctor only.
Please do not send any correspondence to CCCCCCCCCCCC.

Could you confirm all appointments beforehand by text or phone? Could you contact me if any appointments fail to be attended? I understand I will still be required to pay a cancellation/ non-attendance fee.

Yours sincerely
FASOs (family and significant others)

Dr. XXxxx, Psychiatrist
FRANZCP, MBBS BA Hons
City Specialists Clinic, Watkins Medical Centre
225 Wickham Terrace Spring Hill QLD 4000
P: 07 abcdefgh F: 07 abcdefgj Email: abcdefghij
Provider No 999999BB
1st April 2021
LittlePatient.
111 Suburbia St, Brisbane
City QLD 4000

Dear LittlePatient
RE: First appointment with
Dr. XXxxx

Thank you for making an appointment to see me. Please confirm the appointment at least two business days prior by calling P: abcd efgh. If you need to cancel, two days' notice gives us time to offer the appointment to someone else on the cancellation list.

About Psychiatrists
Psychiatrists are medical doctors who undergo specialized training in mental health. This means I am able to prescribe medications if appropriate, provide talk therapy, consider how medications and medical problems contribute to your mental health, and liaise with other medical specialists regarding your care. I can also refer for investigations, tests and other specialist input if necessary.

The first appointment, aka "Assessment"
The first time we meet is an opportunity for me to begin to get a comprehensive understanding of your difficulties. Sometimes this will require more than one assessment session. I aim to keep assessment sessions to no longer than 50 minutes. Most people have better outcomes with ongoing psychiatric care, and I try and offer ongoing support where possible.

Feedback
Normally I will provide a letter back to the referring GP summarizing my diagnosis and management recommendations. If for some reason you do not want this to occur, please let me know.

What to bring to the first appointment

• Medicare Card
• Doctor's referral letter (please note that you cannot receive the relevant Medicare rebate unless you have a valid referral from a doctor)
• Any medications you normally take, or an updated medications list, including any supplements

Payment

Accounts need to be settled on the day of the appointment. We accept cash, EFTPOS, Visa and MasterCard. Fees are based on those recommended by the Australian Medical Association. For an initial appointment, the fee is $435.00. Medicare will rebate you $227.10 of this amount, and this can be deposited back into your bank account on the day of the appointment. There are different fees for other appointments, depending on duration and purpose of the appointment.
(These fees are likely much higher in the USA.)
About the Medicare safety net
The Extended Medicare Safety Net means that Medicare will cover 80% of your out of pocket costs ("the gap") for all medical services out of hospital, after you meet a certain threshold. This reduces the cost of seeing me if you have ongoing treatment. More information on this is available at: https://www.humanservices.gov.au/individual services Medicare-safety-net.
If you have a family, please register with Medicare as a family, as your out of pocket costs are grouped together, and you may meet the threshold sooner.
Overseas Visitors Health Cover (OVHC)
If you are an international student, visitor, or on a work visa with overseas visitor's health cover, you may be covered for same of the fee for psychiatry outpatient clinic appointments. Some OVHC will pay for the equivalent of the Medicare fee for psychiatry. However not all OVHC provides cover. Please call your OVHC insurer and make sure you are clear on whether you are covered for psychiatry, and how much cover you have. IF YOU ARE NOT COVERED you may have the option of upgrading your cover, or you may want to shop around for cover that includes psychiatry clinic appointments. Please note there may be a waiting period.
Hospital care
Currently I do not provide hospital or inpatient care. I do have relationships with psychiatrists at most psychiatric hospitals who can take over care while you are an inpatient. I am able to take over care again when you leave hospital.
Missed appointments and last-minute cancellations
If you miss an appointment or cancel with less than 24-hours' notice, you will be charged a fee of $135 (inc. GST). Please note there is no Medicare rebate for this fee. I am unable to see patients who miss or cancel two or more appointments.
Parking  
There is a Public park at the rear of the building. There is also metered car parking in the area, although this can be difficult to find in the day time.
Public transport
Central Station is the closest railway station. The walk is a little steep up to the clinic. You may consider using the number 30 bus from Stop 57 on Queen Street, near the corner of Edward Street. This bus stops right in front of Watkins Medical Centre and leaves every 10 minutes on weekdays.
Finally
Seeing a psychiatrist is a big step for most people. Trusting a stranger with your private stresses is not easy. I chose this profession because I don't like to see people suffer, and because it gives me a real sense of satisfaction to be able to help people facing mental health difficulties. I look forward to working together with you.
Sincerely,
Dr. XXxxx
Psychiatrist

Erasmus : If you are unhappy with any part of your drug treatment, talk to your treatment team.
Counseling
Drug and alcohol clinics offer their clients one-on-one or group-based counseling. Other support agencies may also provide private counseling. These generally charge fees, but some offer people on a low income special rates that are more affordable.

Talk to your doctor or see the contact information at the back of this book about where to find counseling. For more information, you can also contact your local community health Centre or area health service. In Australia a Mental Health Care Plan done by your doctor can help you to obtain bulk billed psychology treatment.

Counseling can help you with treatment and other issues.
Where to go for support.
Supportive counseling services can help you with urgent issues, such as:
Welfare assistance: financial assistance
where to get legal advice
help with housing
pension benefits
systems with helpful social issues
Drug and alcohol counseling
Drug and alcohol counselors can help you understand the effects of your drug use, and provide information about how to reduce the harm that can result from drug use.

This includes helping you to:
Not to over dose
Not to catch blood-borne viruses such as hepatitis C or HIV
Changing your pattern of drug use
Managing cravings
Preventing cravings
Avoiding situations that might trigger drug use

The drug / heroin route of injecting drug use.

Kinkajou : Narcotics Anonymous

Narcotics Anonymous (NA) is a not-for-profit organization supporting people for whom drugs have become a major problem. The only requirement for membership is the desire to stop using.
Other types of counseling
Psychiatric or psychological counseling can help you address more in-depth issues (such as managing chronic anxiety or depression). To access these types of services you will normally require a referral from your doctor. If accessing a private service, you may want to ask if these services bulk bill.

This Sheet is Helping you with Medications Outside the ORT : Opioid Replacement Therapy Program.

Erasmus : Psychiatric problems are very common in the substance using population. Depressions and even feeling unwell are very important in maintaining a person’s need to use illegal opioids.

So it is very important to manage people’s symptoms ... in association with managing their opioid needs.

Opioids are not good medicines for depression, although they can help somewhat.

Opioids are not good medicines for amphetamine/crystal meth/ice use ... although some doctors have admitted that this can help somewhat.

Opioids are not good medicines to control anxiety or panic.

Opioids are not good medicines to control hallucinations, weird thoughts or ideas.

Opioids are not good medicines to assist with sleep, although they can help somewhat.

It is very important to work out what symptoms people have and to use a medication program which will assist the symptoms.

Erasmus : Psychiatric Assessments

These are most necessary for people who have psychiatric issues as well as Depression and Anxiety in addition to substance use / addiction issues.

A patient on significant doses of sedative medications will need to be referred for an opinion from a Psychiatrist regarding the use of of sedative medications, with a review of their usage for  many different reasons/ indications. The issue is to keep people stable medically but also to keep them safe. The other issue is of course - can we do it better - without upsetting people's health / stability or wellness?

A Psychiatrist can comprehensively review the clinical state of the patient as well as biological, psychological and social issues.

The Psychiatrist will advise if they have become aware that the patient would benefit from allied health therapy or other medical therapy in the course of the assessment. Suggestions are: Podiatry, Dietician advice, Exercise Physiology, Physiotherapy, Psychology. You can ask the Psychiatrist to undertake a single full and comprehensive assessment - and then allow your usual doctor or GP to follow up.