Psychotropic Medication Management in Persons with Co-Occurring Psychiatric and Substance Use Disorders

Abstract

Persons presenting with concurrent psychiatric and substance problems present unique challenges for diagnosis and for effective and rational treatment planning. This is especially true for psychiatrists attempting to prescribe pharmacologic interventions which will promote recovery from both disorders and improve function. In order to be effective in this endeavor it is important to have a clear understanding of the dynamics of addiction as well as the particular issues and struggles related to mental illness which will affect an individual's attitude toward and use of medication. This article discusses some of the common problems related to diagnostic decision making and initiation of medication in persons with co-occurring disorders. An algorithm for guiding these decisions is presented. Common misconceptions held by these individuals regarding medication, as distinguished from "drugs," are considered. Unique psychodynamic issues that may lead these persons to actively seek medication as a solution to their problems, or which may, conversely, lead them to an outright rejection of medication as a part of their recovery, are discussed. Countertransferential issues influencing the physician's approach to prescribing for this population are also considered. The article concludes with recommendations for pharmacologic approaches to address specific psychiatric syndromes which may present in this population.

Adherence to Medication Regimens and Participation in Dual-Focus Self-Help Groups

“…Recovering persons who have dual diagnoses may be influenced by 12-steporiented treatment staff or self-help groups to avoid taking their medication (14). Substance users may decline medication because of denial of illness, preferring to ascribe their symptoms solely to substance misuse rather than to mental illness because the latter is more stigmatizing; medication, even if accepted initially, is used only temporarily (13,15).…”

“…Substance misuse can directly impair judgment about health behaviors (11,12). Substance abuse may function as self-medication, supplanting the use of psychiatric medications that may be perceived as less effective, slow to act, or having more side effects (13). Recovering persons who have dual diagnoses may be influenced by 12-steporiented treatment staff or self-help groups to avoid taking their medication (14).…”

Clinical Barriers to Effective Pharmacotherapy in Co-occurring Psychiatric and Substance Use Disorders

“…For example, there is significant disparity between official recommendations to avoid benzodiazepines in the treatment of co-occurring psychiatric and substance use disorders 9 and actual clinical practice where benzodiazepines are commonly prescribed. 10 Although several papers have been written about the challenges of prescribing to patients with co-occurring psychiatric and substance use disorders, 11,12 there seem to be ongoing biases that affect these prescribing practices. For example, a recent survey reported that psychiatrists underutilized psychological and psychoeducational measures when prescribing to patients with concurrent addiction and schizophrenia in contrast to schizophrenia alone.…”

“…The unsettling experience of feeling like he or she might be harming the patient or colluding with the patient's addictive pathology can contribute to significant anxiety about prescribing. One common response is to under-prescribe 11,12 in an effort to avoid feeling that one is harming the patient. 16 Additional factors that may contribute to under-prescribing are the sense of helplessness or betrayal that clinicians experience when confronted with the power of the addictive drugs in contrast to the "weak" prescribed medications.…”

“…16 Additional factors that may contribute to under-prescribing are the sense of helplessness or betrayal that clinicians experience when confronted with the power of the addictive drugs in contrast to the "weak" prescribed medications. 12 Finally, the compulsive self-sufficiency 17 and deficits in self-care 18 of patients with substance use disorders may make it easier for clinicians to distance themselves from the chaotic therapeutic encounter.…”