What is the treatment approach for anxiety and panic disorders with ongoing substance abuse?

Treatment of Anxiety and Panic Disorders with Ongoing Substance Abuse

Treat both the anxiety/panic disorder and substance use disorder simultaneously with integrated care—do not wait for abstinence before addressing the anxiety disorder, as integrated treatment produces superior outcomes for both conditions compared to treating substance use alone. 1

Critical First Principle: Integrated Treatment Approach

• Integrated behavioral treatments that address both anxiety/panic and substance use disorders simultaneously outperform substance-use-only treatment on both substance use and anxiety outcomes, with small to moderate effect sizes favoring integrated approaches. 1
• Rapid diagnosis and treatment initiation targeting both disorders are essential for successful outcomes in comorbid anxiety and substance abuse disorders. 2
• Treating anxiety disorders in isolation does not reliably improve substance abuse treatment outcomes unless the functional relationship between anxiety and substance use is directly addressed. 3

Initial Assessment Requirements

• Rule out substance-induced anxiety symptoms before diagnosing a primary anxiety disorder—evaluate for stimulant use, alcohol withdrawal, cannabis intoxication, and medical causes like hyperthyroidism. 4
• Assess the functional relationship between anxiety symptoms and substance use, particularly tension-reduction alcohol outcome expectancies (TR-AOEs), as this moderates treatment response. 3
• Evaluate severity using validated scales such as GAD-7 for generalized anxiety or HAM-A for panic disorder. 4
• Screen for immediate safety concerns including suicidal ideation, psychosis, or delirium requiring psychiatric referral. 4

First-Line Psychological Treatment

• Provide cognitive-behavioral therapy (CBT) adapted with motivational interviewing (MI) elements as the cornerstone of integrated treatment. 2, 1
• For panic disorder specifically, use CBT focused on eliminating catastrophic misinterpretations of physical sensations and breaking the cycle of anticipatory anxiety, panic, and avoidance. 5
• CBT combined with SSRI pharmacotherapy shows superior outcomes for panic disorder compared to either treatment alone. 6, 5
• Individual CBT is superior to group therapy for generalized anxiety disorder, with large effect sizes (Hedges g = 1.01). 4

Pharmacological Management: What TO Use

• Start with an SSRI—specifically sertraline (25-50 mg daily, titrate to 50-200 mg) or escitalopram (5-10 mg daily, titrate to 10-20 mg)—as first-line pharmacotherapy. 4, 5, 2
• Begin with subtherapeutic "test" doses and titrate slowly at 1-2 week intervals to minimize initial anxiety or agitation, as panic patients are hypersensitive to physical sensations. 5
• Allow 4-6 weeks for clinically significant improvement and up to 12 weeks for maximal therapeutic effect. 5
• If SSRIs fail or are not tolerated, switch to an SNRI (venlafaxine extended-release 75-225 mg/day). 4, 5
• Continue antidepressant treatment for 9-12 months after recovery to prevent relapse. 4, 5

Pharmacological Management: What NOT to Use

• Absolutely avoid benzodiazepines for ongoing treatment in patients with substance use disorders—they are reserved exclusively for acute crisis management only. 2, 7
• The VA/DoD strongly recommends against benzodiazepines for treatment of PTSD and related anxiety disorders. 4
• Do not use tricyclic antidepressants due to unfavorable risk-benefit profile, particularly cardiac toxicity. 4
• Do not recommend cannabis or cannabis-derived products. 4
• Exercise extreme caution with gabapentinoids (pregabalin/gabapentin) due to their abuse and dependence potential in substance use disorder populations, despite their second-line status for anxiety. 2

Acute Crisis Management Only

• For acute panic attacks or severe agitation requiring immediate intervention, use lorazepam 1 mg subcutaneously/intravenously (maximum 2 mg) or midazolam 2.5 mg subcutaneously/intravenously (maximum 5 mg). 8
• Limit benzodiazepine use to 2-4 weeks maximum to minimize dependence risk, then transition to definitive SSRI/SNRI treatment. 8
• Provide reassurance, ensure a calm environment, and administer oxygen 2-4 L/min if respiratory distress is present. 8

Treatment Algorithm for Non-Response

• After 8-12 weeks at therapeutic SSRI doses with inadequate response, switch to a different SSRI (e.g., from sertraline to escitalopram or vice versa). 4
• If the second SSRI fails after 6-8 weeks, switch to an SNRI (venlafaxine or duloxetine). 4, 5
• Ensure CBT is implemented if not already in place before escalating pharmacotherapy. 4
• Evaluate adherence and barriers to treatment before changing strategies. 4

Adjunctive Non-Pharmacological Strategies

• Teach diaphragmatic breathing, progressive muscle relaxation, and sensory anchoring techniques. 4
• Recommend regular cardiovascular exercise for its anxiolytic benefits. 4
• Provide sleep hygiene education and family psychoeducation on anxiety symptoms and treatment. 4

Common Pitfalls to Avoid

• Do not wait for abstinence before treating the anxiety disorder—this delays recovery and worsens outcomes for both conditions. 1
• Do not stop antidepressants before 9-12 months after recovery, as relapse is frequent. 5
• Do not taper SSRIs abruptly—gradual tapering prevents discontinuation syndrome (dizziness, fatigue, nausea, sensory disturbances, anxiety). 4, 5
• Do not escalate SSRI doses too quickly—allow 1-2 weeks between increments to assess tolerability. 4
• Do not use benzodiazepines for ongoing treatment in substance use disorder patients, as this creates iatrogenic dependence. 2, 7

Ongoing Monitoring

• Evaluate treatment response monthly using standardized anxiety scales (GAD-7, HAM-A). 4
• Monitor adherence to both psychological and pharmacological interventions. 4
• Assess for serotonin syndrome, behavioral activation/agitation, and hypomania/mania during SSRI initiation and dose adjustments. 5
• Track substance use outcomes alongside anxiety symptoms to ensure integrated treatment effectiveness. 1