SCOTTSDALE, ARIZ. – Treating dual diagnosis patients–those with concurrent psychiatric and substance abuse disorders–requires a readiness to use a medication for the substance abuse, perhaps first and foremost, Dr. John W. Tsuang said at the annual meeting of the American Academy of Addiction Psychiatry.
For the substance abusing patient who may have some other psychiatric condition, it is best to wait until the patient is abstinent for some time before making a definitive diagnosis–but without proper treatment, few can get sober, said Dr. Tsuang, who is director of the dual diagnosis program at the Los Angeles County Harbor-UCLA Medical Center.
Dr. Tsuang described a study in which he was once involved to illustrate the conundrum and the difficulty in getting a handle on substance abuse in dual diagnosis patients.
In the study, the patients to be enrolled–presumably with schizophrenia–were actively seeking help and attending a program daily. They also needed to be abstinent for 6 weeks to be given a definitive diagnosis of schizophrenia. Of the candidates, 81% could not stay abstinent long enough, “despite our best intentions,” Dr. Tsuang said.
“I will use whatever I can to help a patient initiate and achieve abstinence,” Dr. Tsuang said in the workshop that he conducted with Dr. Timothy Fong, also with the University of California, Los Angeles.
Buprenorphine is an excellent medication for narcotics abusers, he said. For alcohol abusers, he mostly relies on disulfiram, but he acknowledges that what works and is appropriate for one patient is not necessarily right for everyone. “A lot of clinicians shy away from disulfiram,” he said.
Some drugs that can be used for the mental health diagnosis may also help with substance abuse. Some of the newer atypical antipsychotics, when used in patients with schizophrenia, may reduce drug-high cravings. Clozapine, for example, appears to reduce alcohol use and smoking. Theoretically, it may reduce craving for cocaine, though there is no evidence yet, said Dr. Tsuang.
“Clozapine is one of our best medications,” though it does require close monitoring in substance abusers and may interact badly with methamphetamine use, he said.
In an experiment, risperidone (Risperdal) was given to individuals who were using cocaine, and it was found to interfere with the high, Dr. Tsuang said
Since then, studies have shown that risperidone treatment reduced cravings and relapse in patients with either schizophrenia or bipolar disorder who used cocaine.
Risperidone, however, has been tried in primary cocaine abusers who did not have a dual-diagnosis, and it was not helpful, he said.
Quetiapine (Seroquel) is a popular medication in general, because it reportedly ameliorates anxiety and helps with sleep problems, two difficulties that substance abusers who become abstinent often have.
There have been suggestions that the drug may be of use in bipolar disorder patients who are cocaine dependent. However, there is less evidence of its efficacy than there is for some other drugs, and it has never been given a trial to see if it helped substance abusers with no second diagnosis, Dr. Tsuang pointed out.
Whatever medications are used, psychosocial substance-abuse treatment of some kind is essential for these patients, because no single drug is a panacea. In his experience, most patients will continue at least some substance abuse, Dr. Tsuang said.
Dr. Fong said that despite the conundrum faced by the clinician who has a patient who may have a dual diagnosis but cannot get sober long enough for symptoms to become clear, it is often necessary to make some primary diagnosis to initiate timely treatment.
Delay “may make them harder to treat over the long term,” he said. “Ongoing untreated psychosis is very bad for the brain. That's going to make it more difficult to treat the psychosis and to treat the substance abuse.”
At UCLA, said Dr. Fong, the solution is to take a meticulous history and try to establish a time line. The doctors ask patients if they had psychiatric symptoms or treatments before the substance use started. They also ask about symptoms during periods of abstinence. Finally, they ask about the patient's last use in relation to the most recent symptoms.