Let’s begin with a real example – a true story – of the devastating impact that substance addiction can bring to a person’s life when they have to deal with a severe mental health disorder as well – a medical condition known as dual diagnosis or co-occurring disorder.
“Imagine trying to live without air. Now imagine something worse.” – Amy Reed, U.S. writer/author of “Clean”
While this true story is told, this article will discuss the issues raised during the telling of it – from the unseen effects of trauma to the addictive nature and prevalence of opioid painkillers, the signs and symptoms of opioid substance abuse, through to how mental health disorders are diagnosed, and finally why so many opioid painkiller abusers move from an authorized prescription provided by a medical professional to purchasing other opioid substances, such as heroin, from shady drug dealers in the street.
Jessica’s Story: Part One
Please note: For the privacy and protection of the real “Jessica” and her family, that is not her real name, and it wasn’t a publishing firm she was going to work for. Otherwise, every word is sadly true.
This is Jessica’s story – the story of a young varsity graduate, looking forward to her first real job as a copywriter with a large publishing firm, and her slow and tragic descent into addiction following a supposedly short-term opioid prescription for a motor accident injury.
An unseen and so undiagnosed mental health disorder, not picked up by either the family physician or the hospital specialist her parents paid for, was to prove the “tipping point” – the invisible catalyst that turned the short-term prescription for opioid painkillers into something of a much longer duration – substance addiction, with the co-occurring presence of the mental health disorder.
Dual Diagnosis / Co-Occurring Disorder: The Facts
Unfortunately, it is exceptionally common for teenagers and adolescents to attempt to “self-medicate” when they are trying to cope with an undiagnosed mental health disorder, like anxiety, depression, or a personality disorder.
Some will try alcohol, some will try substances – marijuana, cocaine, ecstasy, and so on, some will try the prescription meds that they can steal from a parent’s or grandparent’s medicine cabinet, and some, equally desperate to control something they don’t understand, will try a combination of anything they can get their hands on.
For those with the appropriate genetics, and the appropriate family history, such substance abuse can lead straight to an addiction. The presence of both – a substance addiction and a mental health disorder – is known as dual diagnosis or co-occurring disorder.
Sometimes, it works the other way.
Substance abuse at a young age (and remember, the human brain doesn’t mature until around 25 years old) can lead to the development of a mental health disorder, such as the examples given above and others.
The result is the same – dual diagnosis or co-occurring disorder.
This dual medical condition requires a more complex form of treatment than normal, where both disorders are treated simultaneously. Failure to do so leads to the untreated one bringing the other disorder back, usually with a vengeance. Dual diagnosis treatment, as with any form of clinical treatment, works best and more successfully the sooner it is begun.
Dual Diagnosis: U.S. Statistics
According to data from the Substance Abuse & Mental Health Services Administration (SAMHSA), here are several concerning statistics that affect the U.S. as a whole:
- Approximately 1 in 10 Americans ages 12 or older are or will at some point in their lives suffer from either SUD or AUD
- Of those, 72% of those with SUD and 45% of people with AUD have at least one comorbid mental health disorder
- Only about 40% receive any treatment for either disorder, and
- Less than 5% receive treatment for both disorders
Mental Health in Idaho
Idaho has continued to struggle with rising mental health issues among its residents for many years, and, sadly, it continues to get worse. According to the National Alliance on Mental Illness (NAMI), nearly a quarter of Idahoans are living with a mental illness, higher per capita than the national average.
Jessica’s Story: Part Two
Jessica grew up in Idaho, got her schooling there, gained excellent grades at college, fell in love and fell out again, and went out-of-state to get her university education. Before she’d even made the long road back to her hometown to start to think about what she was going to do with the rest of her life (and thanks primarily to a few spoken words in the right businessman’s ear from one of her professors, and a large slice of luck), she landed a well-paid position as a copywriter for a well-branded publishing company.
Jessica’s future looked undoubtedly rosy. The new job started next month, and she was busy checking out apartments with her Mom. Her Dad was pleased she was finally becoming an adult, and at last putting her academic partying days behind her, as Jessica had a little bit of a reputation among her circle of friends for never refusing what was offered – a joint, a tablet, a drink. Jessica was a girl who just wanted to have fun.
Recreational “Party” Drugs: What Every Parent Should Know
Ever heard your sons or daughters mention “Molly” and you think it’s a new girl in their class? Or other things such as “baby food” or “magic mint” and you just put it down to the kid’s way of talking – just their street slang – they use these days?
If you do, you may be a little surprised, maybe even shocked.
Your kids are talking about drugs – illicit “party drugs” or “club drugs,” to get themselves high, so the party lasts a little longer, and so do they. However, all drugs, be they prescription, legal or illegal, can be dangerous if used incorrectly or if used at all. The trouble is – you never really know until you’ve tried them.
For example, “Molly” – the new girl in the class – is responsible for a number of deaths and ER admissions every year in the U.S. among unsuspecting teens and adolescents, primarily because it rapidly raises body temperature, resulting in organ failure, and, yes, death.
Hyperthermia and hyponatremia (low levels of sodium) are the most commonly reported immediate causes of death related to ecstasy. There are also reports of “ecstasy-induced depression,” which can result in suicide attempts and accidental deaths.
These substances are typically produced in illegal laboratories, using a variety of chemicals, and it’s difficult to predict their strength, what their specific effects will be, and whether they contain poisons – you’d be equally shocked to know what these drugs can sometimes be cut with. Sometimes, these drugs are simply dropped in an unattended drink at the club – the drink’s owner totally unaware of what awaits, including robbery, assault, and rape.
Here are the street names and slang associated with the most common recreational party drugs:
Ecstasy E, XTC, RAdam, Euphoria, “X”, MDMA, molly and Love Doves
Rohypnol* rophies, ruffies and roofies
Ketamine* Special K and baby food
GHB* Liquid Ecstasy and Liquid X
* reported and proven widespread use as a sedative in sexual assault cases
Here are the street names and slang associated with the most common hallucinogenic drugs or hallucinogens:
Psilocybin / Mushrooms magic mushrooms, shrooms and shroomies
LSD acid, blotter, cid, microdot and windowpane
Salvia Divinorum magic mint, SallyD, and salvia
Jimson Weed stinkweed, locoweed, Angel’s Trumpet, and Datura
Other hallucinogens include mescaline and PCP.
Jessica’s Story: Part Three
However, being the kind of thoughtful young woman she was, Jessica had already started wondering what was going to screw it all up well before an anonymous car jumped the lights at a city intersection, collided with another, and then careered straight into a young crowd gathered outside a club. Jessica was standing in that crowd, along with a small group of her friends.
Jessica went to the ER that night, red and blue lights flashing. Her friends, shocked but relieved, went home – something Jessica wouldn’t do for the best part of a couple of weeks. Her worst injury involved her left lung and her ribs on that side, and her recovery from that would never be fully complete.
When she did finally make it home, still in huge discomfort, she brought with her a hospital prescription for Percocet (a branded combination of oxycodone and acetaminophen), and the advice to see her doctor within a couple of weeks to see how her injuries were healing. The hospital physician, as in many cases no doubt, saw no foreseeable problems.
Jessica’s doctor was to prescribe a further course of Percocet, and then another after that. During this time, she saw a specialist, as her parents were deeply concerned about her pain level, her lack of any decent sleep or appetite, and her overall rehabilitation.
Percocet: Prescription-Only Opioid Painkillers
Percocet is a combination of oxycodone, a semi-synthetic opioid painkiller (similar to codeine and hydrocodone) used for treating moderate to severe pain, and acetaminophen, a less powerful pain reliever that increases the effects of the oxycodone. The abuse of any opioid painkiller can lead to addiction – opioid use disorder (OUD).
Available only on prescription, brand names for percocet in the U.S. include:
- Endocet, and
- Xartemis XR
Please note: Discontinued brand names include Xolox, Tylox, Oxycet, and Roxilox.
Just like the recreational party and hallucinogenic drugs described earlier, percocet has its own street names too – percs, perks, and hillbilly heroin. Common side effects of percocet abuse include:
- Slowed breathing
A percocet overdose carries the risks associated with all opioids, which include depressed breathing and heart rate. In additions to the abuse side effects listed above, signs and symptoms of a percocet overdose can include:
- Bluish nails and lips
- Extremely weak or stopped respiration
- Dangerously low blood pressure
- Slow heart rate
If you suspect a percocet overdose has occurred, it is imperative medical assistance is sought immediately.
Jessica’s Story: Part Four
Jessica told the physician she was having flashbacks to the accident during her waking hours, and nightmares if she finally found sleep. She was told it would take time, it had been a traumatic experience, to say the least, and her medication remained as it was, but at a slightly higher dosage.
No one mentioned (or apparently even considered) post-traumatic stress disorder – PTSD, until much, much later. Jessica was left alone to try and deal with her flashbacks, nightmares and constant anxiety herself, along with her sadness at losing her “rosy future” job offer.
PTSD & Other Mental Health Disorders in Idaho
As mentioned earlier, as many as a quarter of Idaho residents live with a mental health disorder, higher than the national average. Those who suffer from PTSD, anxiety and depression, to name but a few, face hefty challenges every single day of their life, regardless of the recent coronavirus lockdowns and enforced social isolation.
Mental health disorders are becoming increasingly more common too. According to non-profit Mental Health America’s 2019 State of Mental Health in America report:
- Over 44 million American adults (18.07%) have a mental health condition
- 12.2% (5.3 million) adults with mental illness remain uninsured, and
- 56.4% of adults (that’s over 24 million) with a mental illness received no treatment
NAMI lists the following most common mental health disorders in order of prevalence:
- Anxiety Disorders – 19%
- Depression – 7%
- Dual Diagnosis – 4%
- Post Traumatic Stress Disorder (PTSD) – 4%
- Bipolar Disorder – 3%
For those who turn to prescription opioid drugs as a way of self-medicating, any relief is temporary, with the symptoms of their mental health disorder returning more prevalently and potently than before. Using standard opioid epidemic statistics, this is how that pans out in practice here in Idaho:
- 21 – 29% of patients prescribed opioids for chronic pain will misuse them
- 8 – 12% will go on to develop an opioid use disorder
- 4 – 6% who misuse such opioids will transition to heroin
- In 2017, Idaho medical providers wrote 70.3 opioid prescriptions for every 100 persons – although this figure represents Idaho’s lowest prescribing rate in over 10 years, it is still considerably higher than the national average of 58.7 opioid prescriptions
Dual Diagnosis Case Study: Opioid Addiction and PTSD
The story we have been following throughout this article – opioid addiction (OUD) and post-traumatic stress disorder (PTSD) – has been found to be one of the most common cases of dual diagnosis, as a traumatic experience often involves physical injury and recurring pain, for which medication will be prescribed.
Year upon year, family physicians willingly handed out opioid painkillers, such as percocet, oxycodone, hydrocodone, and codeine, with, thanks to unscrupulous pharmaceutical companies like Purdue Pharma and Johnson & Johnson, little or no thought as to the addictive risks posed.
PTSD: Causes & Symptoms
Post-traumatic stress disorder (PTSD) is a mental health disorder, usually severe in nature, that occurs as a result of a major traumatic event in a person’s life. Common causes of PTSD include:
- Sexual abuse/assault
- Childhood abuse
- Natural disasters
- Military combat
During the time of the trauma, the sufferer feels utterly powerless, and this feeling of powerlessness often stays with them. When someone goes through such a traumatic event, PTSD can develop, and sufferers will experience symptoms including:
- Flashbacks of the traumatic experience
- Aggressive behavior
- Spontaneous outbursts of anger
- Repressed emotions – often the cause of clinical depression
- Severe anxietyAggressive behavior and angry outbursts
“The Effect of Trauma on the Brain & How it Affects Behaviors”
Presented by John Rigg (2015), TEDx – Augusta, GA.
Jessica’s Story: Part Five
Her parents had no real idea where she went at night, thinking she was just seeing local friends. A few months later, they still had no idea where she had gone on the night that she overdosed and died until a couple of policemen knocked on their door just short of midnight – the bearers of tragic news that no parent ever wants to hear.
The week before Jessica’s death from an opioid overdose, her parents, concerned for her mental health and the severe changes in her behavior, took her to see a psychologist – a family friend, in fact, who had known about the accident.
After the consultation, the psychologist spoke with Jessica’s parents about the existence of trauma and advised them to seek a professional clinical diagnosis and, more importantly, treatment for PTSD. Her parents booked an appropriate appointment for Jessica later that month.
An addiction to opioids and undiagnosed PTSD led her to the fatal fix, but no one knows (and probably no one ever will) what led the drug dealer’s supplier to start cutting his product with fentanyl, one of the strongest opioids available.
To give his clients a better buzz, a deeper, stronger high? Or simply to get those clients even more addicted to the heroin he was pushing?
The coroner’s report on Jessica’s death stated very clearly that fentanyl was in her system, but, of course, it didn’t say why. It never does.
Suicide in Idaho: The Sad Truth
The sad truth? Idaho is consistently among those states with the highest suicide rates, and has been for years. For example, in 2016, the state had the 8th highest suicide rate in the U.S. – a rate that was 50% higher than the national average. Furthermore, around 13% of Idaho adults who lack health insurance – that’s around 1 in 8 – have a serious mental illness, eg. schizophrenia or bipolar disorder.
Boise, where Northpoint Recovery has one of its addiction treatment centers, is the state capital of Idaho. Although the county of Ada, where Boise is also the county seat, is the state’s most populated county, its suicide rate is, fortunately, the lowest in the state (this is per capita, based on 2017 recorded data). In fact, the highest rates exist in Nampa and Twin Falls counties. However, that said, it’s 2017 suicide rate of 19.3 per capita is still much, much higher than the average rate across the U.S.
Lastly, looking at the prevalence of mental health disorders (and associated conditions, such as substance use disorders) within Boise, the figures reflect the rest of Idaho – again, much higher than the average rates for these disorders across the U.S.
Dual Diagnosis: Treatment & Recovery
Recovering from dual diagnosis, where a severe illness such as PTSD is the mental health disorder, is a complex and simultaneous professional treatment. An integrated dual diagnosis rehab program should incorporate:
- Expert professional counseling
- Peer support
- Medication (if required), and
- Relapse prevention strategies for both PTSD and substance abuse
Clinical therapies for the successful treatment of dual diagnosis include:
- Cognitive Behavioral Therapies (CBT)
- Dialectical Behavior Therapy (DBT)
- Interpersonal Therapy
- Family Therapy
Promise: Adult Mental Health Treatment
Ashwood Recovery, one of our family of addiction treatment centers and also located in Boise, ID, offers a professional adult mental health treatment program called “Promise.” Having an integrated care approach to substance use disorders, by tackling addiction from the core, ie. trauma, co-occurring disorders, etc., has led Ashwood Recovery to develop its own mental health program.
A Partial-Hospitalization Program (PHP), the Promise program, which incorporates all of the essential program elements and therapies listed above and more, is designed to treat the following mental health disorders:
- Panic disorder
- Obsessive-compulsive disorder (OCD)
- Post-traumatic stress disorder (PTSD)
- Social phobia (social anxiety disorder)
- Generalized anxiety disorder (GAD)
- Eating disorders, and
- Substance Use Disorder