How Prescription Medications Will Be Handled During Inpatient Rehab
Prescription Medications and Cornerstone of Recovery
Addressing the physical health needs, especially those that demand prescription medications, is a balancing act for the medical and psychiatric personnel at Cornerstone of Recovery.
As an abstinence-based drug and alcohol treatment center, there are a number of medications that patients who come to Cornerstone for help with an alcohol or drug problem won’t be able to continue — gabapentin (brand name: Neurontin), for example, as well as a number of opioids like Suboxone or hydrocodone. Each medication is evaluated on a case-by-case basis by the nursing and medical staff at Cornerstone of Recovery, however, and medications that pose a danger to a recovering individual’s sobriety are substituted for safer alternatives.
“The key is knowing about cross addiction, and how these drugs can very easily lead you back to abusing a substance, whether it’s that particular substance or alcohol,” says Travis Pyle, Director of Medical Services at Cornerstone of Recovery.
“Cross addiction” is a term used to describe the replacement of one addiction with another — in other words, many addicts and alcoholics may come to Cornerstone for help with a specific substance, but because of the addictive properties of their prescription medication, they may turn their addictive tendencies to that medication once treatment for the original substance is complete. For a medication like hydrocodone — a prescription opioid for pain — that’s often understandable; it is, after all, a narcotic that can often develop into a problem unto itself.
While there are, of course, legitimate pain needs on the part of some patients, Cornerstone of Recovery has specific pain management groups and works with Total Rehabilitation, which operates an outpatient clinic on the Cornerstone campus to treat chronic pain patients without the use of narcotics.
Other medications, like gabapentin, may seem innocuous enough, but they have a potential for abuse, and as of June 2020, four states — including Tennessee — designate gabapentin as a controlled substance.
“Gabapentin is used for neuropathic pain and back pain, and it’s also used for anxiety, but it is a controlled substance in Tennessee,” says Dr. Lane Cook, Chief of Psychiatric Services at Cornerstone. “Because we treat people from all over the country, it’s important for them to know that, because it differs by state, and sometimes patients come to us from different states where it’s not a controlled substance, and they don’t understand why we don’t continue it.”
“There are certain drugs, and gabapentin is one of them, that we have concerns about, because they’re highly abused,” adds Dr. Fred “Kip” Wenger, Chief of Medical Services at Cornerstone of Recovery. “I also work in emergency medicine, and I see people who come in all the time who have been snorting it or doing it in all different kinds of ways, so we have to be very cautious when it comes to that type of medication.”
Common medications that will be discontinued at Cornerstone of Recovery
- Opioids: Narcotic pain medication like hydrocodone, oxycodone and any other pain management opiates; opioid maintenance medication like Suboxone or methadone; and any other habit-forming pain medication like tramadol. During Medical Detox, those who have been prescribed and take this medication will be tapered off through a regimen of detox drugs that can include Subutex, Robaxin and/or Clonidine.
- Benzodiazepines: Xanax, Valium and other members of the benzo family will be discontinued due to the propensity for abuse and addiction. Anxiety will be treated through counseling and therapy, according to Pyle, and if a true need for medication is evaluated, Vistaril is the preferred substitute.
- Gabapentin: “It’s just not a safe medication for those in recovery, and there are better alternatives due to cross addiction,” Pyle says. “When you come to Cornerstone, we will taper you down off of gabapentin rapidly but comfortably.” Some of the replacement medications that can be substituted to treat the conditions for which gabapentin may have been originally prescribed, Pyle adds, include Amitriptyline and Cymbalta for anxiety and pain, and Vistaril for anxiety.
- Prescription stimulants typically used to treat ADHD and/or sleep apnea and narcolepsy: Vyvanse, Nuvigil, Adderall and Ritalin among them. Strattera, Pyle said, is the preferred replacement drug used by Cornerstone. A relatively new medication for narcolepsy known as Wakix has just been approved for use as well and is also not a controlled substance.
While there may be other medications, evaluated on a case-by-case basis, about which Cornerstone medical and psychiatric staff members have concerns, these are the most common ones patients are typically prescribed before seeking addiction treatment.
Streamlining patient care through recovery
It’s important to note, however, that while certain medications won’t be continued at Cornerstone of Recovery, that doesn’t mean that patients who take them before coming to treatment will be bereft of replacement care.
“We will always work with a patient to educate them about cross addiction and to find a suitable replacement,” Pyle says. “Every patient who comes to Cornerstone should plan to bring every medication that they’re currently taking. We will look at every medication they’re taking and continue it if it’s deemed an appropriate and safe medication for someone in recovery.”
Medication is collected from each patient during the Admissions process, and staff members will bring it with the patient to the Assessment and Orientation unit, where new arrivals undergo screenings to begin their continuum of care. Nursing staff members will go through each patient’s medication regimen, continue those medications that are deemed safe and medically necessary — for diabetes or hypertension, for example — and verify with the original prescriber of the medication to ensure that the patient has an adequate supply to last through their 28- to 35-day stay in residential inpatient treatment.
“We like for them to bring a 30-day supply, but sometimes that’s not possible,” Pyle says. “If they run out, Nursing will make sure their medications are refilled, and when they discharge, they’ll leave with their remaining medications as well as a refill called into their pharmacy of choice, so that way they have a month’s supply until they can set up an appointment with their primary care physician.”
Patients who come to Cornerstone for help with a drug and alcohol problem often discover that many of the medications they may be taking for other physical or mental health conditions can be adjusted as they get clean and sober. The physical and mental benefits of sobriety alone can help alleviate or lessen a number of ailments, Wenger and Cook point out.
“Now and again, I’ll see somebody who’s been on an anti-depressant, but it’s clear that their depression is secondary to their substance abuse,” Cook says. “I saw somebody this morning who, when they first filled out the PHQ-9 depression severity scale, scored a 26, which indicates severe depression. Now, after being in treatment and going through Medical Detox, she scored a 6, which is two points away from remission. So does she need to be on an anti-depressant? Of course not.
“It’s important for patients to understand that we don’t take anybody off of their psychiatric medications for no reason. They will get a psychiatric consult, and if we decide it’s the right medicine at the right dose, we’ll continue it. It’s always a case-by-case basis, and it isn’t one size fits all. There are six or seven SSRI anti-depressants, and a patient can try three of them that don’t work for their depression, but they’ll try the fourth one, and it works fine. It’s the key that fits the lock.”
Building a better you through sobriety
And sometimes, Wenger adds, getting clean and sober can help patients streamline their medication regimen. In some instances, patients may leave Cornerstone of Recovery with less medication than what they brought with them to Admissions.
“We start with a physical exam and a basic blood test, and what we often find is that many patients have fractionated health care — they’ve gone to an urgent care clinic one day, the emergency room on another day and their primary care doctor on another day, and they have three different prescriptions for the same problem, because there’s little coordination in their health care,” Wenger says. “We’ll do a review of their medication list, and it’s not unusual to see people on three different medications for the same problem when they only need one, or need one but increased. Having said that, we don’t want to alarm anyone and have them thinking we’re going to throw away their medications.”
If anything, the full continuum of care provided by Cornerstone of Recovery can be an added benefit of drug and alcohol treatment, especially for individuals who suffer from additional mental and physical health issues.
“You’re going to get a second and third opinion here about what you’ve been diagnosed with and treated for, and you’re going to have an expert evaluation about those things,” Cook says. “Sometimes, people leave here with less psychiatric medications. Sometimes they leave with more.”
And in each case, the decisions are made with input from the patient, as well as the patient’s primary care providers outside of Cornerstone of Recovery, according to Wenger.
“It’s about shared decision-making — that’s really what we do, because it’s not a dictatorship,” Wenger said. “Whether it’s your physical health or your mental health, we’re going to review what you’re taking, and we’re going to try and simplify things for you. If it’s working for you, and it’s not deleterious to you from your recovery standpoint, we’re not going to mess with it.”
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