Understanding Addiction as Self Medication

58 Chapter 7
the speed became more difficult to obtain, and cocaine became more available, she
switched to cocaine, at first snorting and then after several years escalating to
intravenous use. The amount of cocaine increased dramatically to the point
where she was using a quarter of a million dollars’ worth a year. This was possible
because a close friend was high in the cocaine distribution chain—Betsy
purchased enough both to satisfy her habit and to sell, which gave her enough
money to afford her supply.
After her first appointment, agitated and discouraged, she despaired that
any help was forthcoming. As a result, she missed her next appointment, during
which she went on another “cocaine run.” It lasted over a week, but with the
firm insistence of her mother and a friend she conceded to another visit. On this
visit she had all the worst signs and symptoms of cocaine toxicity: She was grimacing,
literally gnashing and grinding her teeth, and digging at imagined
bugs crawling under her skin (referred to as “tactile hallucination”); she was
dirty, uncombed, and disheveled. Piecing together her past history, with the help
of her mother, the doctor ascertained that she suffered with ADHD and that she
had unconsciously self-medicated herself for it. Unfortunately, as so often happens,
she had rapidly become addicted. The doctor decided to treat her with Ritalin,
a treatment which to the doctor’s knowledge had not been tried; that is to
treat a person addicted to cocaine with a medically approved stimulant, but in
this case not to support the addiction but to treat the underlying condition. The
short and remarkable version of this case was that she immediately and beneficially
responded to the Ritalin medication. After her visit she took her prescribed
medication and took a “normal nap” (usually cocaine addicts “crash” into a comalike
sleep lasting up to several days and then are unable to sleep). When she
checked in by phone with the doctor later that day as asked, she said she had just
awoken from the nap and did not feel like she had any drug in her, but now felt
she had a choice whether to use or not. This patient has been followed regularly
for twenty-five years and has had no recurrence of her dependence on cocaine.
She has resumed a normal family life and started to work, after years of unemployability,
which she continues up to the present. This case was reported in the
psychiatric literature as an extreme case with marked improvement with Ritalin.
33 The encouraging results of this case were essentially ignored for almost
two decades, but in the context of a methamphetamine epidemic over the past
decade and a half, pioneering investigators have begun to scientifically demonstrate
the utility and benefit, in some cases, of medically substituting approved
stimulants for those used illegally by individuals addicted to cocaine and amphetamines.
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