Episode 19 – Breaking Down Fentanyl
Dr. Ashish Bhatt ❘
It’s 100 times more potent than Morphine. Fentanyl has been involved in a large number of Opioid overdoses. Dr. Bhatt, MD explains why.
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The podcast and articles by Dr. Bhatt are intended to be strictly informative, and will not provide any diagnosis, treatment recommendation, or directed medical advice. Unfortunately, not all messages can be addressed, and no message is guaranteed a response. Information provided by Dr. Bhatt in articles and podcasts is intended to address common questions of general applicability, and may not apply to your unique situation. As a result, please do not use the advice or conclusions found in any articles and podcasts on this site as a substitute for professional personal medical advice. If you are looking for treatment, please call.
Hayley: Hi, my name is Hayley and this is Straight Talk With The Doc, a podcast on addiction, mental health, and treatment. I’m here with our medical director, addiction medicine specialist, Dr. Bhatt, and our content director Jeff. How are you doing?
Dr. Bhatt: Doing well Hayley, how are you guys doing?
Jeff: I’m doing well, I’m doing well today.
Hayley: I am too. Today we’re going to be talking about bipolar disorder. Which, I’m sure most people have heard of, but may not understand what it actually is. And we have a unique perspective today because Jeff was actually diagnosed with bipolar disorder, and he’s agreed to share with us about his experience with the disorder. So, Jeff, I’d like to ask you some questions about that, but first I want to start by explaining what the disorder is for those who don’t know. Dr. Bhatt, what does it mean to be bipolar?
Dr. Bhatt: Well, bipolar is essentially a mood disorder, and it’s classified as a mood disorder because it’s hallmarks are distinct periods of elevated moods or depressive moods. But depending on the type of bipolar disorder you have, you can have distinct periods where somebody is persistently elevated, where they’re expansive or irritable, where their mood is sustained that way for days at a time. I know when people hear bipolar disorder there’s an assumption that there is an up and down, and the down being a steady depressive component, but not necessarily in terms for the diagnostic criteria. So, many people with bipolar disorder have elevated periods where they are very high in terms of their energy level, the distractibility, their mood is often very euphoric, and they feel very grandiose. And during that time, they don’t need much sleep, they can start focusing on a specific task in an overzealous manner, they jump from topic to topic, and these are known as the manic or hypomanic phase. We can talk about this in more detail, but in essence it’s a period where you have a functional and mood shift from your normal baseline where you’re higher, more elevated than normal. And often times offset with depressive components depending on the individual.
Hayley: You mentioned different types, can you explain to me what the different types are?
Dr. Bhatt: Bipolar is a spectrum, but in general there’s a bipolar 1 disorder, a bipolar 2, there’s this thing called cyclothymia, and then there are these unspecified disorders. Bipolar 1, it’s basically classified by a period of mania, where during that period of mania, a person shifts their normal mood to this period of elevated or irritable expansive mood, plus they’re often very distracted or grandiose, plus they have these flight of ideas where they jump from idea to idea to topic to topic. They often speak in a very pressured manner, and you see them going on for days at a time like this. And this is not secondary to a substance or an abused agent, and that’s mania. Mania is often there for days at a time and it has to be in order to be diagnosed as a manic episode, and that’s the hallmark of bipolar 1. You have to have a manic episode. Bipolar 2 is where you have a hypomanic episode, so you have set of symptoms that last for days at a time, but they’re at a lower degree. In order to have bipolar 2 you have this hypo, or lower mania, and often you have to have a depressive episode, a major depressive episode, at some point in that cycle. And that distinguishes bipolar 1 from bipolar 2. Mania versus hypomania, then bipolar 2 it’s a hypomania with a major depressive episode at some point. The cyclothymia is actually when you cycle in those ups and baseline to some downs, depending on the individual. That is a brief description of the set of bipolar disorders.
Hayley: Are you born with bipolar disorder, or can something happen in life that triggers it?
Dr. Bhatt: There’s a lot of science and research that shows that bipolar has a genetic or heritable predisposition and we often don’t see it come about until later on in life. Most people don’t get discovered to be bipolar until their 20’s, and that’s often when the diagnosis takes place. An interesting part of bipolar disorder is often it’s hard for physicians and people to diagnose it, only because we have to tease out normal or non-normative behaviors. When you look back in retrospect, because of different comorbidities and sometimes mixing of substances, and the time it takes to enter out of different clinical venues or go to your doctors, it can take years before somebody is accurately diagnosed. But at the end of the day, there is a family history that often exists and so if you take that into consideration, looking at a family history and teasing out if this was an effect of substances or not, you can often be pointed in the direction that that this might be bipolar, when those manic episodes start to occur.
Hayley: Okay, so you mentioned most people get diagnosed in their 20’s. Is that because symptoms don’t present until then?
Dr. Bhatt: I want to explain that. I think from an epidemiological perspective, we do see it in later adulthood and early 20’s as when most common bipolar occurs, but the symptoms often start earlier in life. I think there was a swing where many people were probably misdiagnosed too early, and I think now people are starting to course correct a little bit, because depending on the decade that we were in, a lot of times bipolar became very I think popular, for lack of a better word. And many people used it so loosely, that people were misclassifying it and being misdiagnosed. The symptoms often are preexisting to diagnosis, and that has to happen in order for us accurately diagnosis, it’s often in retrospect. So, the symptoms are there often as early as adolescence, some in childhood, it’s rare to see children have it but it is there, but adolescence is often when we see the periods of mood swings and irritability where there’s these periods where somebody can look back and say wait a minute, this looked like it was mania or hypomania. And it often takes going into hospitals, or the behavior getting so out of hand that it ends up warranting seeking medical attention, but that’s often later in their lifetime, meaning in their early teens or later 20’s.
Hayley: With these mood swings and other symptoms, what kind of things in life does bipolar make it difficult to handle?
Dr. Bhatt: When somebody suffers with bipolar disorder, because the nature of the mania or hypomania can look like, it can really have difficulty in all aspects of someone’s life. From their occupation to their relationships to their education. Just to put it in perspective, when somebody has a full blown manic episode, these are people that you would notice the change. I think people again, I mentioned this before, use these terms “I’m manic” to just describe an accelerated phase in their life or when they’re doing things at a hectic pace, but to truly be manic these people have a sustained period of days in a row where they’re talking super fast, and they are doing reckless things, and they are spending money recklessly or engaging in activities that are reckless. Their speech is so off the wall and their behaviors are so off the wall and the level of their thinking, they often think things are somethings that they’re not. They have this sense of elevation, grandiosity, increased self-esteem, and it’s very, very distinct. It can affect every part of your life, and when it gets so extreme you can end up getting hospitalized, and that’s actually one of the criteria that if somebody ends up getting hospitalized because of that behavior, that would be considered a manic episode. Or, they have legal consequences, because of the, for lack of a better word, outlandish things that they do. Unfortunately, sometimes these episodes get so severe that they can become psychotic and delusional, where their reality testing is not intact and they’re often believing and thinking things that are not true, or acting upon things that are not real. And that’s the unfortunate side of those people who aren’t treated or have severe episodes.
Hayley: Jeff, I’d like to ask you a couple questions about your experiences. Can you tell me, when did you receive your diagnosis of bipolar disorder?
Jeff: I was first diagnosed when I was 28. That would’ve been about 6 years ago.
Hayley: How did receiving that diagnosis influence your outlook on life?
Jeff: It definitely changed it. In some ways, it was good because it kind of put a lot of things into perspective for me. It enabled me to be effectively treated for the first time in my life. I’d been misdiagnosed with other things, mainly depression and ADHD before and obviously the treatments weren’t very successful. It’s not a diagnosis that anyone wants, but overall, getting diagnosed and being able to be properly treated has overall improved my life.
Hayley: I wanted to ask you about that. Before you got the diagnosis and the right treatment, did you notice a big shift in your life before and after that period?
Jeff: I don’t think that the changes were very fast, I think the changes were more gradual over time, as I got to know myself better and got to know my cycles and my triggers, the things that would impact me. That was more gradual, it wasn’t an immediate overnight change.
Hayley: Have you experienced negative effects in your life due to being bipolar?
Jeff: Yes, very much so. It impacts at some point my relationship with pretty much everyone in my life. I’ve experienced the whole gambit of consequences as a result of bipolar disorder, but it is what it is.
Dr. Bhatt: I’d like to thank Jeff for sharing that perspective. I know it’s not easy often for people to speak about their personal experiences and reveal such an intimate part of themselves, so Jeff, thanks for speaking about that and sharing your experience.
Hayley: Dr. Bhatt, what’s treatment like for somebody with bipolar disorder?
Dr. Bhatt: Treatment is often with medication. I think when somebody’s in those manic phases of hypomanic phases where they’re so elevated and their symptoms are so significant, that medications are the hallmark for treatment there. We use this term mood stabilizers in essence because that’s what they do. They stabilize your mood. So, if you think about it as a straight line and a manic episode is the periods above that line, and depressive episodes being below that line, we want people to come back to that flat line and in the middle. These medications that are out there that have been around for years are used to help people become level. Again, I think people use this term bipolar or manic depression or mood swings loosely. But again, it’s a significant disorder, it’s a serious disorder and it has to be treated properly.
Hayley: Are there any physical effects or symptoms, or is it all mental symptoms?
Dr. Bhatt: When somebody is suffering with any mental health condition, it can have its effects on you physically. If somebody, for example, is in an elevated manic phase, where they are super accelerated, they start to become super focused in specific goal directed activities, they often don’t take care of themselves. They can start getting habitually reckless, they engage in inappropriate sexually activities, they often may not eat, they can be using illicit substances, and because of those things people can contract sexually transmitted diseases, they can have the negative effects of drugs or alcohol, they can neglect their nutrition, and they can obviously neglect their fundamental hygiene or their underlying medical co-occurring disorders that might be there, stop taking their other medications. So, because of those things they can affect you physically. There’s so much that happens when somebody is suffering with a hypomanic or manic episode, or the other side, the depressive episodes where often self-neglect is unfortunately a consequence. The physical consequences can be a result of that.
Dr. Bhatt: Imagine this, we all know that drugs or alcohol are not good for you. So, if you put something on top of a mental health or a physical condition, you’re just going to make it worse. The thing with bipolar disorder is that being that’s it’s a psychological and mental health condition. When you use drugs or abuse which affect your mental health and your mind and the way you think, this definitely complicates the whole thing. With bipolar, the difficult part is, is that due to those manic or hypomanic phases where there is so much risk taking and there are so much impulse control issues, when you add drugs or alcohol that alter the way you think, the amount of risk taking and the amount of consequences is exacerbated. Bipolarities often unfortunately associated with suicidality and suicide attempts, and so when you mix these drugs and alcohol with your mood being altered, people can even make major attempts at self-harm. Definitely, drugs and alcohol fixed with bipolar, it’s a perfect storm for a bad outcome.
Hayley: Because you mentioned the self-harm aspect, is there a link between having bipolar disorder and attempted suicides or self-harm?
Dr. Bhatt: Yeah, we do see this. We do see this in clinical practice and those who may be diagnosed with it or family members may have seen it of course on a personal level. But just the inherit nature of having that type of mood disorder and the impulsivity that goes along with it, often when you’re in a certain phase of the depression or even coming out of the depression into the steady state where you have the energy now or the hypomania that could be coming out, that impulse dysregulation renders people more susceptible to act out on their thoughts. And if their thoughts are negative, or there are suicidal thoughts happening at that time, unfortunately we do see a link between suicidal attempts and ideation and bipolarity.
Hayley: So, for someone who is receiving treatment for their disorder, will they have to receive treatment for the rest of their lives?
Dr. Bhatt: For most people, bipolar disorder is a life-long illness, and they should be under supervision and treatment for their entire lives. We do see some evolution in the course as people get older. Often, we see their ability to maybe anticipate symptoms and recognize behaviors earlier, so they can intervene and physicians can anticipate what course and what meds and what other type of therapeutics might need to implemented. But yes, unfortunately most patients are going to be dealing with it for the rest of their lives.
Hayley: And for someone who is struggling with bipolar disorder and an addiction at the same time, can they successfully be treated for both at the same time?
Dr. Bhatt: Yes. The good part is that bipolar is a treatable illness, and obviously when you’re mixing drugs and alcohol with any sort of physical or mental health condition, especially with mental health illnesses, drugs and alcohol mimic or exacerbate, or artificially relieve mental health symptoms. So, it’s important that treatment is received and that the appropriate diagnosis and assessment is taking place. Often times we try to address the addiction so that we can get to the root and underlying true self of a human being. It’s really important that both aspects are treated.
Hayley: For somebody who is struggling with both, if they’re seeking out help and a clinician tells them that they can’t treat both at the same time, should they seek out another opinion?
Dr. Bhatt: There are so many entities, practitioners, health care facilities, rehabs that have the capability to handle people, treat people, that do have both addiction and mental health bipolar diagnosis. I would try if I was a patient suffering from both, I would want to get both addressed. And I’m not saying that it’s not something that a person who is not in an episode, in an exacerbation and whose bipolar is somewhat relatively stable that they cannot get treatment just solely for their addiction at that time, so as long as that addiction provider or treatment facility is aware and able to recognize a triage and seek out that additional support or help, or bring in additional providers to make sure that in the event that the episode starts to exacerbate or occur that intervention can take place. I’m not necessarily saying that it has to occur in a place that provides dual diagnosis treatment, but it’s often good that whoever is treating their patient has that exit strategy or has the ability to bring in resources when they need it.
Hayley: Thank you Dr. Bhatt. Jeff, I have a few more questions for you. Have you ever felt or experienced any stigma around being bipolar?
Jeff: Yes and no. I mean, I’m pretty open about it. I know why a lot of people aren’t. I look at it as just a disability. If I was blind, people would probably be able to recognize that from my visual cues, or deaf. I have to tell people. Luckily, I get to disclose it when I want to, but I haven’t had really much direct stigma directed at me. Usually, frankly people are surprised when I tell them.
Hayley: Do you feel like it’s beneficial for you to disclose it?
Jeff: Yes, I do. First off, I’m not embarrassed about it, it’s just a part of who I am. Second off, eventually anyone who gets close enough to me will notice my mood changes anyway. So, I find it better just to explain it ahead of time.
Hayley: So, as somebody with obviously a first-hand experience with this, what do you think is the best way for people to offer support to their loved one whose bipolar?
Jeff: That kind of depends on the person. Like Dr. Bhatt was saying, there’s a real wide spectrum, and some people are frankly impacted much more than others. I am lucky, I lead a completely- not completely, but pretty normal life. I don’t really require much in the way of accommodation and everything. Many people do. I would say ask, the best way to do it is just ask. In general, I guess I would say educate yourself on the bipolar, and then be aware of when your loved one is experiencing symptoms and maybe change the way that you are acting around them, or thinking about their behavior, and maybe be more aware of why they might be acting a certain way and how the best way to respond to that would be.
Hayley: Is there anything else, Jeff, that you’d like to share on your experience that you think might be helpful to people?
Jeff: There is a lot of stigma around bipolar, I guess in general, even though I haven’t necessarily experienced much of it directly. I personally feel like I am not my condition, it’s just a part of me. General, more awareness would be nice. If you are bipolar, or have any mental condition for that matter, I just feel like it’s very important for you not to feel ashamed or embarrassed of that. It’s part of who you are and your treatment is your responsibility and that’s important, but help it out there and it will get better and you can lead a life that is satisfying to you, it’s possible.
Hayley: Well thank you, Jeff, for being open today about your experience. And Dr. Bhatt, thank you for breaking this down with us even further. You can check out more episodes on addictioncenter.com, Spotify, and Apple Podcasts. You can also write in your question to Dr. Bhatt on Addiction Center. Thanks for listening to another episode of Straight Talk With The Doc.
Dr. Ashish Bhatt
Addiction Center’s Medical Content Director, Dr. Ashish Bhatt, MD, MRO is an accomplished physician, addiction medicine specialist, and psychiatrist with over 20 years of medical and administrative leadership.