Medication for Anxiety in Addiction Recovery
For patients in addiction recovery, prescribe SSRIs (escitalopram 10-20mg daily or sertraline 50-200mg daily) or SNRIs (venlafaxine XR 75-225mg daily or duloxetine 60-120mg daily) as first-line treatment, avoiding benzodiazepines entirely due to their abuse potential. 1, 2
First-Line Pharmacotherapy: SSRIs and SNRIs
SSRIs and SNRIs are the gold standard for anxiety treatment in patients with substance use history because they have no abuse potential, address both anxiety and depression simultaneously, and have robust efficacy evidence. 1, 3
Preferred SSRI Options:
- Escitalopram 10-20mg daily - Has the most favorable drug interaction profile with minimal CYP450 effects, making it safer in patients who may be on multiple medications for addiction recovery 1
- Sertraline 50-200mg daily - Extensively studied with lower risk of QTc prolongation and favorable tolerability 1, 2
SNRI Alternatives:
- Venlafaxine XR 75-225mg daily - Effective for generalized anxiety disorder, panic disorder, and social anxiety disorder, though requires blood pressure monitoring 1, 3
- Duloxetine 60-120mg daily - Additional benefits for patients with comorbid pain conditions 1
Critical Medications to AVOID
Never prescribe benzodiazepines to patients in addiction recovery. Despite FDA approval for anxiety, benzodiazepines carry high risks of dependence, tolerance, withdrawal, and cross-addiction potential that make them contraindicated in this population. 1, 3, 4
Second-Line Options (If SSRIs/SNRIs Fail)
Pregabalin or gabapentin can be considered when first-line treatments are ineffective, particularly for patients with comorbid pain conditions, though these also carry some abuse potential and require careful monitoring. 1, 5
Buspirone 20-60mg daily is another non-addictive option, though it has slower onset (2-4 weeks) and lower overall efficacy compared to SSRIs/SNRIs. 5, 4
Hydroxyzine 25-100mg as needed can be used for acute anxiety episodes without addiction risk, though it causes sedation and anticholinergic effects. 5, 4
Treatment Implementation Algorithm
Starting Treatment:
- Begin with escitalopram 10mg daily or sertraline 50mg daily 1
- Start at lower doses and titrate gradually over 1-2 weeks to minimize initial anxiety or agitation 1
- Warn patients that response follows a logarithmic pattern: statistically significant improvement by week 2, clinically significant improvement by week 6, maximal benefit by week 12 1
Monitoring Response:
- Assess using standardized anxiety scales (GAD-7 or HAM-A) every 2-4 weeks 1
- If inadequate response after 8-12 weeks at therapeutic doses, switch to a different SSRI or SNRI rather than adding benzodiazepines 1, 2
Combination with Psychotherapy:
Combining medication with cognitive behavioral therapy (CBT) provides superior outcomes compared to either treatment alone - this is particularly important in addiction recovery where addressing both neurobiological and psychological components is essential. 1, 2
Duration of Treatment
Continue effective medication for a minimum of 6-12 months after achieving remission to prevent relapse, with gradual tapering to avoid discontinuation symptoms. 2, 3
Common Pitfalls to Avoid
- Do not prescribe benzodiazepines "just for a few weeks" - even short-term use creates relapse risk in addiction recovery 3, 4
- Do not use beta-blockers (propranolol) as primary treatment - they are deprecated for chronic anxiety disorders and only have limited utility for acute performance anxiety 1
- Do not prescribe tricyclic antidepressants - unfavorable risk-benefit profile with cardiac toxicity concerns 1
- Do not abandon treatment prematurely - full response requires 12+ weeks, and switching medications before 8-12 weeks at therapeutic doses leads to missed opportunities for response 1