Can You Let Him Suffer on the Couch?

Allies member ccomtl2014 is watching their long-time partner add a new drug to the usual mix: he's got ADHD meds and is blowing through a month's supply in 5 days. He blames all the behaviors on his underlying depression. How can ccomtl2014 be helpful here, without playing into their partner's victim mentality?

"What to do when long-time partner does not see that he is experiencing in part withdrawal or feeling poorly in relation to the substances?

Partner suffers from ADHD depression and anxiety, abuses marijuana alcohol and his ADHD medication (stimulants). Used to see and understand that using marijuana very heavily (for lengthy periods of time he is high morning to night, and heavy THC) affects his depression and anxiety negatively. He used to see that when he stops using, the anxiety and lack of motivation and overall feeling very down is part of withdrawal. He also used to see his lack of motivation as related to when he smokes too much.

He finally received treatment for his ADHD (already on meds for the depression and anxiety… but the medication did not work so well, because his ADHD was left untreated). Upon going on vyvanse, this was the only medication that helped his depressive, anxious, and ADHD symptoms. It was a HUGE change. Soon though, he began abusing the vyvanse. He will go through a months worth in 5 days max (I suspect he goes through it in more like 3-4 days depending). I was only able to put two and two together recently. When he abuses vyvanse he is awake for 4-5 days without sleep and does not eat, and when he runs out, it is the most horrific depressive crash. Since he started abusing vyvanse his behavior is more erratic, he is angry and has explosive fits of rage where he gets verbally aggressive, depression worse than ever, impulsive, agitated… and to deal with these symptoms he will be high 24/7.

Friends are on board now realizing this is problematic and recently stopped enabling him by lending him money after he lost his job. I am a mental health social worker and have been trying to embody the CRAFT approach, and hope to get him to look at SMART recovery stuff. At this point it is out of control, he is stealing from me and lying about it even in the face of obvious proof. On the couch day and night, completely let go of all of his responsibilities and becomes very angry at being asked for any accountability.

In his eyes, he sees all of this as part of his natural depression and anxiety. He feels the only reason he doesn't feel well when he is without substances, is because it is his natural level of depression. He does not see the stimulant withdrawal either, or that he becomes anxious when he is out of weed. He recognizes there is a problem, but will not consider much beyond this. Does not seem to feel bad about being caught stealing from and manipulating me, yells out why can't I let this go given he is suffering from depression and know that he is feeling bad enough… I do need to address that he tries to use his anger to throw me off and control the conversation.

Although he talks of feeling motivated to have the depression treated, he won't consider any intensive treatment for the depression as an "in". There is less and less change talk, when there actually used to be change talk and dips frequently. Since he started abusing vyvanse, maybe 6 months I figure… I see almost none.

He does not see any of the links between natural consequences and his choices. I fear that I am out of options and need to need to ask him to leave, if he is truly not willing to take actionable steps to any treatment. He frequently promises that he will, but quietly sabotages it.

How can I respond in a way that is helpful to this talk about all of the problem being depression and nothing linked to his choices or withdrawal, without preaching? He puts himself in a victim stance where everyone is expecting too much for someone who has depression and the substances have little to do with it aside from "treating" it."
 

Your partner uses alcohol and cannabis on top of depression and anxiety medication as a way to manage his mood. He recently began treatment of his ADHD and is now misusing the medication he has been prescribed for it. 

From your description, you have spoken to your partner repeatedly about the cannabis and alcohol. You are put back on your heels by his claim that the ADHD medication, 30 days-worth taken over 4-5 days or less, is not somehow responsible for the terrible emotional crash and the insomnia that happen when he runs out.

Your partner found a new drug of choice in the ADHD medication, and is now less forthcoming with talk of wanting to change (we call it Change Talk in the eLearning modules; a wish or a dip). He is unwilling to admit that the overuse of the ADHD medicine and the crushing withdrawals from it are anything more than his organic depression rearing its head.

BTW, you are right that heavy cannabis use also leads to anxiety, maybe worse anxiety than he would have if he didn’t use cannabis.

Your partner is now in a more serious situation; the ADHD medicine is flattening him mentally and physically for days after the drug runs out. I would guess he is turning to his other drugs for help to raise the bottom of these crashes. He is no longer talking of getting more intensive treatment for depression.

Your partner explains that the problem is not the drugs but the depression. There is nothing for him to do. He is depressed. 

Becoming addicted to ADHD drugs in not uncommon. They’re stimulants. When you misuse stimulant drugs, like cocaine, crack, methamphetamines and ADHD drugs, the landing is very, very rough, that is why you use until you run out, which, for your partner, happens in a matter of days after refilling his monthly prescription.

The ADHD drug must be thrilling to him. Stimulants raise dopamine far higher than do other drugs. Here’s a comparison of dopamine levels reached by different activities or drugs. 

Before your partner started to take the ADHD drug, your use of CRAFT techniques was starting to work. You were responding more strategically to him; he was talking about treating his depression more intensively. You were hearing wishes and dips. Now, nothing.

When asked, your partner claims the depression is the problem – full stop. You think he is not seeing what the new drug is doing to him. I somehow doubt this. Your partner fell upon a new drug that jacks up his system more than ever. He falls from higher up when the drug runs out, hence the couch for 4-5 days. He’s been tinkering with his neurobiological self, perhaps for decades. He is very well aware of the knobs to regulate it.

I would guess he uses a certain drug, alone or in combination, to reach specific outcomes. It looks chaotic to you but there is a pattern. Go to Module 3 and work through the questions there. The questions are meant to train you on what to look for. You’ll be prompted to answer questions about each drug individually and in combination. The new ADHD drug is one more knob your partner uses to tinker with his state of mind. You need to engage your practiced eye to identify moments he is high, moments he is about to use (like refill day), or moments he is coming down from using. This informs your responses to him. From your description of the situation, you are doing this with cannabis and alcohol.

It’s complicated with 3 drugs on board, used in various combinations. Module 3 helps you get the lay of the land.

Now you need to decide your strategy. You can:

(1) decide that the line between use and non-use is the use of any drug or alcohol above some low maintenance level, or

(2) aim to address just the ADHD drug, which has ramped up the problems with addiction.

When you talk to your partner, he says the withdrawals from the ADHD drug is depression. I don’t believe he is unaware of these withdrawals. Your partner is well versed in drug use. Having myself been on the couch, I can say with almost total assuredness that your partner knows the severe withdrawals are due to the stimulant drug.

Blaming depression is his way of getting you off his back.

If you choose to go with Option 1 (the line is between use and non-use of any drug/alcohol above some low maintenance level):

Here you clearly separate your response to the use of any drug, from your response to the non-use of all drugs. If he is constantly using something, then rather than non-use, look for “relatively sober,” just maintaining. This creates an environment around him that rewards relatively sober and gives him the big chill when he's using (which includes withdrawals from use). Let him feel the depression, let it hurt. You are helping to separate his world when he's okay from his world when he's massively depressed. You are helping to underline moments of massive depression by responding with the big chill.

If you choose to go with Option 2 (aim to address just the ADHD drug):

Another strategy is to do the same thing as described above, but only in response to the ADHD drug use. With this strategy you ignore the pot and alcohol use. He does what he can to overcome the withdrawals of the ADHD drug with the other two. Remember, couch time is active use, because it is withdrawals. You give him the big chill.

The Big Chill

Module 6 tells you “What to do when my Loved One is Using”

– remove rewards (no food in the fridge, no cooking, no holding his hand, no anything),

– remove yourself (you are now very scarce in his life for those 10 days),

– allow natural consequences (the crushing depression). 

In this strategy you ignore maintenance use of pot and alcohol all month, but you do respond just like I described when he is noticeably high on these two drugs.

Shifts in the cycle may not be totally clear to you or 100% correct, but you are describing the cycle pretty well already: 5 days of XXX + 5 days of withdrawals.

The new drug makes you want to leave him. The problem hasn’t changed though, rather, he’s added a new drug to the mix. He can point to the depression as the core problem, but you know better. It is pointless to try to convince him of anything else. He is defending his need to use drugs to address depression. 

Rather, see if you can find a couple of treatment options that treat co-occurring mental illness and Substance Use Disorder. Put them on paper. Have the list ready to present when he complains about his situation (dip) or expresses a wish to pull out of the depression (Module 8).

Take your time, let him twist and turn with the ADHD medication for a short while, maybe a couple months. Steer clear of him during these 10 days, while remaining neutral and still loving. Let him suffer on the couch alone and in silence. There is nothing inherently dangerous to the withdrawals of the stimulant. It may get worse before it gets better. Right now, the new drug is super exciting to him, a new level of high he hasn’t felt before or been able to reach with the cannabis and alcohol. He’s also experiencing new lows. I feel for your partner. He has stepped into a bigger, taller, more extreme rollercoaster.

Can you do this? What if I tell you the ADHD drug is good news? The harder drugs have serious consequences. Your partner is now spending days in withdrawals and in serious emotional pain. He is not functional for days after he runs out of the ADHD med. The depression is worse. Let him feel the lows, don’t step in with food, or talk of how things are going to be okay.

The world divides between maintenance levels of pot or alcohol, and being high from pot or alcohol or the ADHD medication. The mood extremes can speed up the process of getting your Loved One to accept more intensive treatment.

You can also call his prescriber and explain what is going on with the ADHD drug. (S)he can’t admit to even having your partner as a patient, but can listen to you explain what your partner is doing with the medication.

What if I go so far as to say the ADHD drug is a gift in disguise? It makes the depression more extreme. Let it be more extreme. At the top of the treatment list put a detox program. Is there one in your area that keeps someone longer than just the period of medical detoxification, or that has a protocol for transferring to more inpatient?

Your Loved One has been using drugs to address his mood problems for years. He is going to need a long period of treatment to get him clear of the drugs and to allow his depression and anxiety to land where they would organically. He needs to be under the care of someone who can follow him through this and can then assess what is needed to safely address the mood disorders and the ADHD.

Can you follow these suggestions? Can you let him suffer on the couch? Can you call in an EMT if you are worried? Can you wait until he says "help"? He will. He will ask for help with the depression before he asks for help with addiction. What does help look like? You may already have your list. Perhaps the conversation goes something like this:

I love you but you are in trouble and I no longer know what to do. The drugs may help your depression and ADHD but I see that the depression is getting worse. We need to back you out of all this. There is no way forward on your own. I want to help you but I can't see how I could do so. I worked up this list of ideas. Can we look at this together? Please consider pulling in more help. Your friends and I are very worried and will support you through all of this. [[[I want us to stay living together but I am out of ideas.]]]   [Can you say this last part? You will have to mean it.]

Your partner is very lucky to have you by his side. Many people give up. Before you do, let’s see if CRAFT can unblock the situation the drugs are causing and get your partner more help.