Clearly, case finding remains a priority if patients are to be offered any form of treatment aimed at reduction in substance use. Simply put, clinicians must take the initiative to identify patients who have substance use comorbidity. The first step requires screening and assessment. Most patients will not spontaneously assert that they are using substances. Thus, clinicians must actively seek out this information, with best results achieved by using nonjudgmental forms of inquiry such as "How often have you used...?" instead of "Do you use...?" Given the prevalence of substance use, a high index of suspicion is essential. Clinicians should routinely ask all patients about use of alcohol or other drugs and should continue to inquire on a periodic basis, especially with newer patients, who may be reluctant to discuss substance abuse with a new clinician. Because patients sometimes deny drug use when it is present, a multimodal strategy is optimal, including urine toxicology screens, interviews with collateral sources, records from recent hospitalizations, and consultation with other care providers or family if permitted by the patient.
Once a patient acknowledges using substances, a first step in treatment is to conduct a specialized assessment. In addition to the amount and frequency of substance use, it is critical that clinicians get an understanding of each patient's personal economy of substance use. What benefits and costs does he or she perceive to result from using substances? What are the patient's motivations and expectations? A detailed understanding of patients' perspectives on these questions is critical to engaging them in treatment and helping them to negotiate the phases of treatment to recovery.
Treatment for substance use by people with schizophrenia requires an integrated approach, given the extent to which these problems interact and are interconnected (Hellerstein et al. 2001). Although the deleterious effects of comorbid substance use on relapse rates are clear, the literature on interventions offers little guidance due to the paucity of controlled studies. In a recent article Bennett et al. (2001) noted that only seven studies available in the literature through 1998 employed experimental designs, five of which examined "inpatient care or intensive outpatient case management for serious mentally ill clients (primarily for homeless populations), and are not directly applicable to the treatment of the broader population of people with schizophrenia living in the community" (p. 164). In the remaining two controlled studies of outpatient treatment, one found decreased substance abuse and psychiatric severity among patients who began and remained in treatment over several months. The other semicontrolled study, comparing a 12-step program, behavioral skills training, and intensive case management, found that both skills training and case management were more effective than the 12-step program on several outcome measures, but had minimal effects on substance use. "Interestingly, the behavioral treatment was the most effective even though it was not designed specifically to address substance abuse problems and sessions were only held once per week" (p. 164).
More recent controlled studies of integrated dual-diagnosis treatment have demonstrated the efficacy of this approach. McHugo et al. (1999) showed that programs with high fidelity to dual-diagnosis treatment principles produced markedly greater rates of sobriety than other treatment strategies. After 36 months, patients in high-fidelity programs had a 55% rate of stable remission, whereas only about 15% of patients in low-fidelity programs were in stable remission. In Manchester, UK, Barrowclough et al. conducted a controlled 12-month study comparing outcomes in 18 patients with schizophrenia and substance use disorders employing an integrated approach of motivational interviewing, family interventions (including a family support worker), and cognitive behavior therapy, with outcomes from usual care (n =12) (Barrowclough et al. 2001). There was high retention in the integrated-care group (94%), with significant improvements compared with usual care on the Global Assessment of Functioning (GAF) scale, PANSS positive symptom scores, and relapse rates. The benefits of a combined, integrated approach, particularly with respect to retention, are also seen in the results of a randomized controlled study by the Combined Psychiatric and Addictive Disorders Program (COPAD) at Beth Israel Medical Center (New York). The components of the COPAD treatment approach include supportive group substance abuse counseling, a multifac-eted educational program (mental illness, psychiatric medications, alcohol and drug abuse, HIV), ongoing assessment of substance use via weekly urine toxicology, encouragement to attend self-help groups, monthly psychiatric medication visits, regular communication with other clinicians involved in the patient's care, and as-needed communication with family members (Hellerstein et al. 2001). After 8 months, 11 of 23 in the COPAD cohort remained in treatment, versus only 6 of 24 usual-care patients.
Bennett and colleagues delineated what they perceive as the necessary qualities of a dual-diagnosis program geared toward patients with schizophrenia in their description of the Behavioral Treatment for Substance Abuse in Schizophrenia (BTSAS) model (Bennett et al. 2001). The special requirements of an effective substance abuse treatment program for the schizophrenia population derive from the findings of low motivation for decreasing substance use (41%-60% depending on the substance[s] abused) in schizophrenia patients, and the cognitive deficits and social skills deficits present in schizophrenia. In creating the BTSAS program, the investigators relied on social skills training, "a behavioral approach for rehabilitation of schizophrenia patients that has been successfully employed for the past 25 years . . . that employs instruction, modeling, role-playing, and social reinforcement" (p. 165).
The components of BTSAS include monthly motivational interviews to discuss treatment goals; urinalysis, with rewards for abstinence; social skills training, which teaches patients how to refuse offers of drugs; education on the effects of drug use in schizophrenia; and problem-solving and relapse prevention training to help patients cope with urges and high-risk situations. Most skills groups meet twice per week, a similar frequency to the group counseling in COPAD. Recognizing the difficulty that schizophrenia patients have in changing behavior, and that many are abusing multiple substances, the program entails no mandated need to be abstinent or committed to total abstinence to participate; any decrement in use is seen "as a positive step that will reduce patients' overall level of harm" (p. 165) and bring the patient closer to their eventual goal.
Finally, in a discussion of implementing dual-diagnosis programs for substance-abusing patients with schizophrenia, Drake et al. (2001) listed several other critical components for integrated programs, including staged interventions for those at different stages of the recovery process, assertive outreach to engage clients (especially the homeless), the need to maintain a long-term perspective on the chronic and relapsing problems of substance use, and cultural sensitivity. They also noted the barriers that exist in implementing such integrated programs, including administrative issues (policy, programmatic barriers), clinician barriers due to lack of dual-diagnosis training, and consumer barriers due to denial or low motivation. Although the preceding models have not focused on intensive case management, the problems with medication noncompliance, housing, and psychosocial issues associated with substance use often warrant a case management approach, especially for those who are frequent utilizers of inpatient services.
As with all schizophrenia patients, antipsychotic medication is a fundamental aspect of treatment. Although medication-compliant substance users do relapse at higher rates than nonusers, the greatest risk for relapse is with medication-noncompliant substance users. In general, there are no absolute contraindications to the prescription of antipsychotics for schizophrenic patients who are currently using substances, apart from those who are medically compromised (e.g., hepatic disease, HIV), in whom dosage adjustment may be necessary. However, one must use reasonable caution in the use of the more sedating agents in patients abusing alcohol or other CNS depressants (e.g., opiates).
That antipsychotic medication will reduce the likelihood of psychotic relapse even in the presence of ongoing substance use is substantiated by data from the Australian 4-year prospective study (Hunt et al. 2002), yet there are recent studies indicating that the use of atypical antipsychotics might be associated with reductions in substance use. The data are most compelling for clozapine. One 3-year prospective study of 151 dual-diagnosis patients found that 79.0% of clozapine patients (n =36) achieved full remission from alcohol use for 6 months or longer, compared with 33.7% for clozapine nonrecipients (Drake et al. 2000). Another retrospective study of 45 dual-diagnosis patients prescribed clozapine noted that 85% decreased their substance use during the course of therapy, with the extent of decrease in abuse corresponding to symptomatic improvement (Zimmet et al. 2000). Promising data in prospective open-label trials have also been published related to risperidone (Smelson et al. 2002) and olan-zapine (Littrell et al. 2001) therapy. These agents appear to be safe in the substance-abusing schizophrenia population, as is clozapine, which is both sedating and associated with dose-dependent lowering of the seizure threshold. The approval of a long-acting, water-based injectable form of risperidone in many countries (although this form of risperidone has not yet been approved in the United States as of this writing) also means that the therapeutic advantages of an atypical antipsychotic can be provided to patients poorly compliant with oral medication.
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