What does medication management include?
Medication management at Ascend covers four prescribing domains, each grounded in FDA-approved indications and evidence-based protocols:
- Psychiatric medication for mood and anxiety disorders: SSRIs (sertraline, escitalopram, fluoxetine), SNRIs (venlafaxine, duloxetine), atypical antidepressants (bupropion, mirtazapine), and non-benzodiazepine anxiolytics (buspirone, hydroxyzine).
- Mood stabilizers and antipsychotics: Lamotrigine, lithium, valproate, and quetiapine for bipolar disorder. Aripiprazole, olanzapine, and risperidone when clinically indicated for severe mood or psychotic symptoms.
- FDA-approved MAT for opioid use disorder: Buprenorphine (Suboxone, Sublocade) and naltrexone (oral and Vivitrol extended-release injection). Buprenorphine reduces opioid overdose mortality by approximately 50% according to NIDA.
- FDA-approved MAT for alcohol use disorder: Naltrexone, acamprosate, and disulfiram. NIAAA confirms all three as first-line pharmacotherapies for AUD.
Every prescription includes baseline labs, ongoing monitoring (liver function for naltrexone, EKG when clinically indicated, urine drug screens for MAT), and documented informed consent.
How does psychiatric medication coordinate with MAT?
Co-prescribing psychiatric medication with MAT requires a single coordinating clinician — not separate prescribers — because of pharmacokinetic interactions and the bidirectional relationship between mental health and substance use:
- Buprenorphine and SSRIs: Both metabolize through CYP3A4. Dose adjustments and interaction monitoring are routine. Serotonin syndrome risk is low but documented; clinical surveillance is standard.
- Naltrexone and antidepressants: Naltrexone has no direct serotonergic activity and is compatible with SSRIs, SNRIs, and bupropion. Liver function monitoring is required for oral naltrexone.
- Mood stabilizers and MAT: Lamotrigine, lithium, and valproate are compatible with buprenorphine and naltrexone. Lithium requires renal monitoring; valproate requires liver and platelet monitoring.
- Avoiding benzodiazepines in SUD: Benzodiazepines combined with buprenorphine increase respiratory depression risk. Ascend prescribes non-addictive alternatives for anxiety in patients with SUD history per FDA black-box guidance.
This integration is why addiction psychiatry exists as a recognized subspecialty. Dr. Bishop coordinates psychiatric and MAT prescribing in the same clinical encounter, with the same medical record, under the same care plan.
Questions About How does psychiatric medication?
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Which psychiatric conditions are treated with medication?
Ascend prescribes for the psychiatric conditions most commonly co-occurring with substance use disorders. SAMHSA's 2022 NSDUH reports 21.5 million U.S. adults have co-occurring SUD and mental illness:
- Major depressive disorder: SSRIs and SNRIs are first-line. Bupropion is selected when sexual side effects or sedation are concerns. Mirtazapine helps when insomnia and appetite loss dominate.
- Generalized anxiety, panic, and social anxiety disorder: SSRIs, SNRIs, buspirone, and hydroxyzine. Benzodiazepines are avoided in patients with SUD history.
- PTSD: Sertraline and paroxetine carry FDA approval for PTSD. Prazosin reduces trauma-related nightmares. Topiramate is used off-label for hyperarousal.
- Bipolar disorder: Lamotrigine, lithium, valproate, and quetiapine. Antidepressant monotherapy is avoided due to manic switch risk.
- ADHD: Non-stimulant options — atomoxetine, bupropion, viloxazine, guanfacine, clonidine — are prioritized in patients with SUD. Stimulant medication is approached cautiously and only with documented clinical justification.
“Prescribing for someone with co-occurring psychiatric and substance use disorders is not the same as prescribing for either condition alone. We coordinate every psychiatric medication with MAT decisions, lab monitoring, and therapy progress — in one chart, with one clinician accountable.”
What does the medication evaluation process look like?
The initial psychiatric evaluation at Ascend follows a structured 60-to-90-minute clinical interview that meets ASAM and APA documentation standards:
- Psychiatric history: Past diagnoses, prior medication trials, response patterns, side effects, family psychiatric history, and current symptoms measured against DSM-5 criteria.
- Substance use history: Substances used, frequency, route, duration, prior treatment episodes, longest period of sobriety, and current withdrawal symptoms.
- Medical history and labs: Baseline CBC, comprehensive metabolic panel, liver function tests, TSH, urine drug screen, and pregnancy test when applicable. EKG when starting medications with QTc prolongation risk.
- Suicide and violence risk assessment: Columbia Suicide Severity Rating Scale or equivalent structured assessment, with safety planning when indicated.
- Shared decision-making and informed consent: Mechanism of action, expected benefits, common and serious side effects, monitoring schedule, and alternatives are documented before any prescription is issued.
Follow-up appointments occur weekly during PHP, every one to two weeks during IOP, and monthly during outpatient maintenance. Medication adjustments are made based on symptom rating scales, side-effect reports, and lab values.