Medication management for anxiety and substance abuse may also be necessary considerations. Psychotropic medication use may actually help patients with comorbid anxiety embrace and tolerate psychosocial and psychotherapeutic treatments.19 SSRIs are the first-line treatment for most anxiety disorders. Fortunately, there are few contraindications for the use of these agents in the acute or continuation phase of treatment, because they are generally well tolerated and have low abuse potential.
Recent work in animal models suggests a central role of the serotonin system in the onset and maintenance of substance abuse.20 While there have been few clinical trials of SSRIs for treatment of SUDs, early work signals more rapid maintenance of sobriety in marijuana-dependent individuals treated with buspirone(Drug information on buspirone).21
Research in animal models relevant to drug cessation also suggest the possibility of adjunctive pharmacotherapy approaches that alter glutamate or γ-aminobutyric acid (GABA) signaling to enhance extinction learning, a treatment also relevant to anxiety disorders.22 While such combined therapy and pharmacological treatments have yet to be studied in humans, medications targeting these transmitter systems are promising as treatments for SUDs.
Treatment with levetiracetam(Drug information on levetiracetam), an anticonvulsant that modulates glutamate and GABA, resulted in improvements in both anxiety and alcohol(Drug information on alcohol) dependence in 3 adults with comorbid anxiety and alcohol use disorders.23 A more substantial body of work suggests the utility of another anticonvulsant, topiramate(Drug information on topiramate), in the treatment of cocaine and alcohol use disorders.24
Because persons with comorbid anxiety have much higher rates of drug and alcohol relapse and treatment nonadherence, we advocate for aggressive concurrent treatment of SUDs and anxiety disorders because each is likely to perpetuate the other.25 By integrating SUD treatment with treatment for anxiety using an SSRI and a brief course of CBT, the long-term risk of relapse may be reduced. However, further studies of the mechanisms underlying the reciprocal relationship between comorbid symptoms and effective interventions are needed. The exact nature of these relationships is unknown for the many permutations of substance use and anxiety disorders (eg, alcohol dependence and panic disorder).
Current expert consensus supports concurrent psychosocial and psychopharmacological treatment of comorbid anxiety and SUDs in adults and adolescents.18 Ideally, this treatment should be delivered within a dedicated “co-occurring,” or “dual diagnosis,” substance use and mental disorder treatment program, by a team of experts that specializes in the treatment of both SUDs and mental illness (Figure). The goal of such targeted care would be improved efficiency in calibration of the frequency and intensity of treatment needed to break the cycle of mutually maintaining symptoms.
Despite recommendations for this intuitive dual treatment model, there is a surprising lack of evidence within the peer-reviewed literature to support simultaneous treatment of SUDs and comorbid psychiatric disorders.9,15,18,26-28 However, treatments designed for reducing psychiatric symptoms have been shown to be efficacious in individuals with SUDs and the corollary is also true—patients with comorbid disorders are helped by traditional treatment for psychiatric disorders.29 We propose that rather than avoiding or abandoning the dual treatment model, more research is needed to find mechanistic links and empirically tested combined treatments for various combinations of anxiety and SUDs.