Kenneth Minkoff, MD

All other clinicians either will receive a CME Attendance Certificate or may choose any of the types of CE credit being offered.

To goal of this activity is to provide a comprehensive, practical approach to working with individuals who are in active SUD crisis.

At the end of this CE activity, participants should be able to:

• Welcome individuals who present in crisis

• Develop guidelines for integrated longitudinal assessment

• Establish an environment of safety and stabilization

• Individualize disposition planning and continuity of care

This continuing medical education activity is intended for psychiatrists, psychologists, primary care physicians, physician assistants, nurse practitioners, and other health care professionals who seek to improve their care for patients with mental health disorders.

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Individuals with active substance use disorders (SUDs) who present to mental health crisis settings have often been regarded as “unwelcome visitors” who have come to the wrong place. Characterizations of at least some of these individuals (whether they present with substance use as the major complaint or with additional complaints such as suicidality, risk of violence, or active co-occurring psychiatric illness) by staff in many crisis settings are often negative.

Persons with active SUDs may not present in ways that fit our framework of how we can help. He or she may show up with symptoms or in situations that are clearly caused or exacerbated by substance use, but at the same time have no interest in receiving a referral for treatment. Another person may present with true desperation, but what he or she is asking for is not “psychiatric help,” but rather a place to stay, a medication, or something else that we cannot provide. Individuals with active substance use may state that they are suicidal without having serious intent, or they may have substance-related symptoms that exacerbate-or obscure-the presence of psychiatric illness. Finally, these individuals may not fit either addiction or psychiatric settings-our usual set of resources-and may be misunderstood and unwelcome.

Since the late 1990s, best practice recommendations emphasize that individuals in crisis with active SUDs, and particularly those with comorbid psychiatric and substance use disorders, should be considered not only as “welcome” but also treated on a priority basis.

Because of a number of factors, including the opioid epidemic, the need to re-think our prioritization of “who is in crisis” and “who needs our help the most” has become more urgent in the past few years. It is critical that the most effective engagement and clinical practice protocols are utilized, especially for patients who have co-occurring medical, psychiatric, cognitive, or significant social challenges (eg, homelessness). Rather than encountering barriers to access and unwelcoming attitudes, these individuals must be prioritized and provided with an organized and effective crisis response.

Implementing “welcoming practice” for individuals with active substance use requires clear policies and procedures that govern the expectations of behavior for all staff and requires monitoring and oversight by clinical and administrative leaders.

Staff need clear instructions about how to treat individuals who may be engaging in behaviors that generate negative reactions. First, the person who needs help is welcomed and our intention to help is explained. The help we provide is immediate as well as continuing. The person is made to feel safe, and over time we connect the person with services that will help him progress toward achieving meaningful life goals.

Welcoming includes never using disparaging or disrespectful language, even when the individual is not listening. It also includes the ability to empathize with the person who may be displaying challenging or difficult behavior. For example, this might include a person who has frequent episodes of intoxication but continually refuses referral to addiction treatment. He is living a desperate existence and may feel hopeless about being able to get sober. He is at his wit’s end and does not know how to get help. Or, it might be a person who has chronic pain, anxiety, depression, a history of trauma, and poorly managed opioid use presents with what might be considered “inappropriate” demands for pain medication. This individual is someone whose life is falling apart, is at high risk for a lethal outcome but who has no safe or easy way to ask for help other than by requesting medications for pain.

It is important to reframe our perceptions and change our approach. Incorporate a welcoming message in your routine instructions for preparing your patients for what to do when they are in crisis after hours. Let them know that they are always welcome to call for help (whether calling you directly or calling the crisis service that you use for back up), even if they have been using substances. For instance, you can say: “Call for help as soon as possible, so we can help you be safe and stable. It is helpful if you can call for help before you use substances, but substance use is never a barrier to calling for help. Our goal over time is to help you to develop the skills you need to manage these challenges successfully . . . but for right now, it is important that we meet you exactly where you are.”

Step two: Rapid integrated longitudinal assessment

Once the individual with active substance use is welcomed for care, we begin the assessment immediately and proceed with a thorough structured and integrated approach to learn best how to be helpful in the moment. Many crisis programs have adopted rules that automatically delay crisis assessment of anyone who is actively “under the influence,” often requiring that the blood alcohol level is below the legal limit of intoxication before crisis assessment can begin.

There is no rational clinical basis for having this rule. Under no circumstances should any provider of crisis services have a formal or informal policy that creates barriers to treatment for individuals with substance use.

 Note the following language in the current crisis management protocol utilized in Arizona.

Assessment begins at the point of clinical contact, regardless of the client’s [sic] clinical presentation. Initiation of assessment should not be made conditional on arbitrary criteria such as length [sic] of abstinence, non-intoxicated alcohol level, negative drug screen, absence of psychiatric medication, and so on.

The assessment of individuals in crisis needs to begin immediately. If the person is too intoxicated to communicate clearly, we still need to assess for any immediate risk to safety based on medical or behavioral lack of control (including risk of inadvertent falls or self-injury), as well as to rapidly access any available collateral information. The assessment of the individual begins with welcoming engagement and messages of safety and support while the person is intoxicated and proceeds to a more detailed discussion as soon as the person can carry on a conversation.

Some individuals will have their best and most honest conversations when their alcohol blood level is 0.2 (or when they are high on some other substance); some may not. That is part of the assessment. In addition, if the person presents with intoxication and complaints of suicidality, he is treated as potentially more at risk of self-harm than someone who is equally suicidal but sober; it is essential to evaluate the level of suicide risk when the person is intoxicated, not just hope that the person will “change his mind” when intoxication clears.

Guidelines for integrated longitudinal assessment

A frequent barrier to rapid and effective crisis intervention is the belief that assessment cannot proceed quickly because substance use may result in symptoms that mimic those of psychiatric illness. Although there are instances where this may occur, it should never delay beginning the assessment to quickly establish as much information as possible and proceed accordingly.

Guidelines for appropriate diagnostic assessment of individuals with an SUD in crisis have been described in the literature, and include the following:

 Identify the person’s goals and request for help, to establish connection and reinforce hope.

 (history of presenting illness), identify the person’s most recent stable baseline, before the current crisis. Gather information from the patient as well as collateral information from a partner/relative, previous treaters, and health records that include baseline mental status and mental health treatment, health status, SUD treatment efforts during the most recent period of abstinence or controlled use. Carefully describe-chronologically-the sequence of events proceeding from the last period of stability to the current presentation.

The Case Vignette illustrates an approach that rapidly provides information that identifies diagnosis, current baseline treatment, and recommended interventions, even though the patient may still be under the influence.

John has a long history of schizophrenia and alcohol use disorder. He lives in supported housing by himself, supported by his case management team who see him one to two times a week. At baseline he is managed on several medications, but even on his best day he has auditory hallucinations, and finds that using alcohol provides him with short-term relief. His team has been working hard to help him reduce or eliminate his alcohol use, and he recognizes that the short-term relief is often followed by exacerbations of voices.

John recently started on oral naltrexone and reports better control of craving. However, today he went out with some friends who offered him alcohol and an unknown substance described as “synthetic marijuana.” John reports that, “The alcohol didn’t do much for me, but the other stuff made me feel pretty good for a while. Then, all of a sudden, the voices got real loud and I started to panic.”

Alternatively, the same approach might yield a different story and imply a different solution. For example, John reports that he stopped his medication three weeks ago and has been responding to increased voices by trying to control them with more and more alcohol and drugs. He is very ambivalent about going back on medication but also knows that the alcohol and drugs are not working. He is scared and feels out of control.

In most cases, history (from multiple sources) will establish the probable diagnosis, baseline state during previous periods of abstinence, reasons for the immediate decompensation or crisis presentation, and recommended intervention. In some instances, assessment may need to be extended, either because more collateral information is needed and/or the person may not be initially coherent enough to provide accurate information.

 Be cautious about diagnostic assumptions. Many crisis settings utilize the diagnosis of “Substance-induced disorder” for almost every patient who presents with active substance use that has an impact on symptoms. This is very misleading. In most instances, persistent mental illness (which may be exacerbated, or at times masked, by substance use) can be identified by history. A diagnosis of “substance-induced psychiatric disorder” requires that the psychiatric symptoms were initiated only in response to significant substance use and clear up completely within 30 days after substance use is discontinued. Substance-induced psychiatric disorder therefore is a diagnosis of course-not cause-and should be utilized cautiously; whether the symptoms will in fact clear up quickly is often uncertain. Overuse of “substance induced disorder” may lead to underdiagnosis and undertreatment of persistent disorders that may be present already or that may be just beginning.

 Use urine screening judiciously as one piece of potentially corroborating information, along with self-report, collateral reports, and the person’s clinical presentation. Note that some substances (eg, synthetic cannabinoids, fentanyl) may not be detectable in the urine screen, and, conversely, urine screening may be positive without a commensurate understanding of quantity of use. Each crisis setting should be aware of what substances do not appear in its urine screen, as well as the threshold for a positive result, and what medications (including over the counter use) may lead to false positives.

 Identify any immediate risks due to intoxication, withdrawal, suicidality, violence, or exacerbation of mental illness/medical conditions that require emergent intervention.

 Once immediate safety is established, assess carefully to determine what is the best next step to engage the individual in ongoing services that will help him increase stability and make progress over time.

Step three: Establish immediate safety and stabilization

Each crisis setting must have clear protocols and medical/nursing resources for addressing intoxication and withdrawal. Note however that even programs with minimal medical support can still safely manage most episodes of intoxication safely. The level of withdrawal severity, measured by tools such as the CIWA-Ar (Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised) for alcohol or COWS (Clinical Opiate Withdrawal Scale) for opioids, determines intervention protocols in the behavioral health crisis setting.

 In more severe cases, the results help to clearly delineate referral to an emergency medical setting.

The determination of level of care for medical detoxification is based on assessment of the patient’s history and risk factors for withdrawal (previous history of seizures, DTs, etc) as well as withdrawal severity: What happened the last time you experienced withdrawal? How do you see this time as being the same or different as what happened before?

Many crisis settings assume that individuals who are intoxicated are inherently riskier in their behavior than those who are not. This is not true. While active substance use may lead people to be more impulsive in general, each person must be assessed and addressed based on individual need and presentation. Often, welcoming the individual with kindness, respect, and helping him feel safe and comfortable, in a place where the experience can be resolved with support will lead to resolution of the intoxication without escalation. By contrast, individuals who are actively intoxicated may become more belligerent if staff are being unduly confrontational or disrespectful.

Protocols for using medication for behavior management

Individuals who are displaying symptoms of psychosis or agitation when under the influence of substances, or withdrawing from substances, commonly respond to the same medications that can be used with individuals who are not using substances, with the following cautions.

Be alert for agitation due to early signs of withdrawal. For example, individuals may start to display alcohol withdrawal before their blood alcohol level is zero, and the consequent agitation may respond quickly to medication (eg, benzodiazepines) to alleviate those symptoms. Similarly, individuals with opioid use disorders may attempt to minimize their degree of addiction, but then become extremely uncomfortable as they go into withdrawal and require specific interventions.

Adopt and utilize established protocols for emergency management of agitation. The American Association for Emergency Psychiatry Guidelines for the Pharmacologic Treatment of Agitation provides simple guidance for responding to agitation that is substance related compared with nonsubstance related.

Managing and treating withdrawal symptoms that may emerge during a behavioral health crisis evaluation or crisis intervention (in any level of care) requires different protocols than the management of agitation per se. Each crisis program should therefore develop simple protocols for consistent management of alcohol withdrawal, sedative-hypnotic withdrawal, opioid withdrawal, and withdrawal from other categories of substances (cannabinoids, hallucinogens, stimulants, etc).

Do not automatically assume that all persons in withdrawal must be referred to a “detox” program. Most individuals with mild to moderate withdrawal (from any substance) can be managed successfully in a psychiatric crisis program that can prescribed medications. Even if a higher level of care is needed, withdrawal management should be initiated as soon as possible. While opioid withdrawal can be relieved with clonidine, it is recommended that crisis programs are permitted to provide buprenorphine and are able to perform buprenorphine inductions. Although withdrawal symptoms may not be as specific biologically for other substances, they can lead to significant discomfort and agitation and should be managed consistently and symptomatically.

Crisis settings are first responders and are increasingly likely to have exposure to individuals with life threatening overdose. In a psychiatric crisis setting, an individual may have hidden opioids and use them after admission or obtain opioids from a visitor (even with reasonable search protocols). All crisis settings must have naloxone available and capacity to administer naloxone in the event it is needed.

Step four: Individualized disposition planning and continuity of care

A common frustration of crisis providers is that individuals who present with significant substance use are routinely referred for abstinence-expected treatment (in a detoxification or addiction treatment program), even if that is not an appropriate match for what the individual wants, needs, or is ready for. This results in the person refusing the recommendation, being discharged to no service, and recidivism or accepting the referral and then not following through, leaving AMA (against medical advise), or being administratively discharged. These results are neither clinically appropriate nor a good use of resources.

Crisis standards of care developed by Balfour and colleagues

 include quality indicators that look at issues of repeated psychiatric crisis visits (including SUDs) as an improvement opportunity. The authors recommend that all crisis settings emphasize individually matched engagement and continuity of care (not just referral for an episode of sobriety) as markers of success. As with other chronic conditions, this approach is unlikely to achieve perfect remission, so much as to create the ability for engagement that will lead to improvement and stabilization over time.

The ASAM (American Society of Addiction Medicine) Criteria for patient placement -the gold standard for addiction service matching-helps connect individuals for whom typical addiction treatment programs are not appropriate to other levels of care including proactive community-based case management.

 These models have demonstrated success for high risk individuals who cannot or will not engage in more conventional services. Crisis services should establish the following guidelines for disposition planning.

Care should be individualized to each person’s crisis presentation and request for help, and should not involve referral for abstinence-expected services. The ASAM criteria can guide connection to levels of care that may include continuing community-based outreach. At the same time, it is important to remember that individuals who present with psychiatric issues (suicidality, psychosis) are at increased risk if there is comorbid substance use.

Tools such as the LOCUS (level of care utilization system) 20 reinforce that additional comorbidity for individuals who demonstrate safety risk can lead to a higher level of care than might be indicated for the MH presentation alone.

Prioritize engagement of high risk individuals

Individuals with substance use disorders (including those who present with frequent intoxication, requesting a place to stay or stating they are suicidal in order to get a bed), should be treated as high-risk and need to be engaged immediately. The crisis system should have a clearly demonstrated mechanism for providing crisis follow up for up to 90 days for these individuals. Intramuscular naltrexone is likely to be of benefit as well as crisis case management. Engaging individuals with severe alcohol use disorders in some level of community-based services may help them gain control even if at first they continue to use substances.

The importance of engaging high-risk opioid users

Individuals who present with unmanaged pain, requests for opioids or for higher dosages of opioid, or other indications of potentially risky or lethal opioid use should be prioritized for engagement. These individuals need crisis consultation and to be involved in some level of continuity of service, including initially with the crisis provider if necessary. A plan needs to be in place that helps them to manage pain and/or opioid use disorder with or without mental health and trauma issues, while minimizing risk of eventual overdose.

The crisis system must consider medication-assisted treatment for opioid use disorders (with or without co-occurring mental illness), including buprenorphine induction, initiation of naltrexone, and rapid connection to same day or next day methadone initiation. Around the country, state Medicaid agencies and Medicaid managed-care organizations are initiating 24-hour access to buprenorphine induction in the public crisis system.

Collaboration with addiction treatment providers

For persons who need and want a referral to abstinence-based addiction services, the crisis system maintains strong partnerships with the continuum of substance use disorders service providers, including provision of proactive consultation and welcoming offers of instant crisis response. This will encourage addiction treatment providers to be more willing to accept patients who may be psychiatrically or medically unstable, because they know the crisis provider will support them if something goes wrong and will be available to help with any patient who has an acute mental health crisis.

Articles

Patients with active addiction may not present in ways that "fit" our framework. The author provides four steps to an organized and effective crisis response.

Substance Use Disorders in Crisis Settings: Engagement, Assessment, and Intervention Approaches

CME credit for this article is now expired. It appears here for informational purposes only.

At the end of this article, readers should be able to:

1. Delineate evidence-based principles of successful assessment and treatment.

2. Translate these principles into applications for real-world practice.

3. Develop treatment strategies for patients who have comorbid mental illness and substance use disorder.

During the past 10 to 15 years, psychiatrists have increasingly recognized the importance of successfully engaging and treating individuals with comorbid psychiatric and substance use disorders. National epidemiological studies and surveys have clearly indicated that “co-occurring disorders are an expectation, not an exception.”

 In particular, data from the Epidemiology Catchment Area survey showed that of people living in the community, 55% of those with schizophrenia and 62% of those with bipolar disorder had a lifetime diagnosis of substance use disorder.

The National Comorbidity Survey replicated and expanded these results, and findings of high prevalence of comorbid mental illness and substance use disorders have been further demonstrated in more recent national epidemiological reports.

 Epidemiological studies have indicated higher odds ratios for comorbid substance use in adults and adolescents with nearly every psychiatric disorder, compared with those for the general population. Conversely, individuals (adults and adolescents) with diagnosed substance use dis­orders have higher odds of having a comorbid mental health condition than individuals with no substance use disorder. Furthermore, findings indicate a high prevalence of substance use disorders comorbid with trauma-related pathology.

In the past decade, there has been increasing research on evidence-based integrated treatment approaches for individuals with comorbid disorders. This research includes specific program models, such as Integrated Dual Disorder Treatment, as well as a range of integrated practices and approaches based on that model.

 These approaches have been condensed into instructions for integrated practice for clinicians and include an array of guidelines (eg, assessment, service planning, treatment).

 On the basis of this and other research, the Comprehensive, Continuous, Integrated System of Care incorporates universal integrated practice (termed “co-occurring capability”) as a fundamental system design feature and utilizes research-based principles that inform integrated practice.

There has also been a growing body of research on the effectiveness of psychotropic medication for mental illnesses in individuals with psychiatric disorders and co-occurring active substance use. Whereas active substance users were previously excluded from psychopharmacological research, resulting in limited data on the effectiveness of psychotropic medications in this population, current research makes it clear that active psychopharmacological intervention for mental illness produces significantly better treatment outcomes in these individuals, even when active substance use continues. It is now best practice for psychiatric prescribers to work within an integrated treatment framework, in which appropriately matched psychopharmacological and non-psychopharmacological interventions for both mental illness and substance use disorders are integrated into patient care.

In addition, as understanding of the “brain disorder of addiction” has increased, there has been a steady expansion of pharmacological options specific for treatment of substance use disorders.

 The previously limited armamentarium of psychopharmacology for addiction has been expanded to include an array of anticraving agents that directly intervene in the neurotransmitter mechanisms that support continuing addiction.

 In addition, opiate maintenance treatment, formerly restricted to licensed methadone programs, can now be provided more readily in office-based settings by practitioners who prescribe buprenorphine. Many common psychotropic medications are being shown to also have a potential direct effect on improving substance use disorders. For nicotine dependence, the most prevalent and most potentially lethal of comorbid substance use disorders, there are a range of psychopharmacological agents that have specific and potentially life­saving indications.

The psychopharmacological principles outlined in this article are based on 3 publications:

• The Centers for Mental Health Services (CMHS) Managed Care Initiative Report

 that includes treatment principles and practice guidelines (including psychopharmacology guidelines) for individuals with co-occurring psychiatric and substance use disorders

• An updated version of the CMHS Managed Care Initiative Report co-occurring disorder psychopharmacology practice guidelines that incorporates more current information

• An even more recent document issued by the Substance Abuse and Mental Health Services Administration that references and builds on the previous work

Because comorbidity is highly prevalent, all practicing psychiatrists are likely to see patients with co-occurring mental illness and substance use disorders, including patients with active use. The first principle of treatment is therefore to purposefully welcome these individuals-who are most likely to be at risk for poorer outcomes if not successfully engaged in care. A welcoming approach facilitates the creation of an empathic, hopeful relationship, screening for co-occurring substance use, building trust to allow the patient to share information, and working in partnership with the patient over time to make progress on both disorders.

Welcoming and engagement are the cornerstones of treatment success, yet some practitioners may find that their own attitudes make genuine welcoming difficult. Practice how you will welcome individuals with active co-occurring conditions:

Hi, there. As a person with both mental health symptoms and active substance use, you’re likely to be having a hard time. I know it’s difficult for you to come here, asking for help. Thank you for coming, and for sharing the information about your substance use. You are in the right place. I’m glad you’re here. My job is not to fix you or control you, but to get to know you, inspire you with hope, and work with you over time to help you address all of your issues in order to help you achieve your goals.

Successful psychopharmacological interventions for patients with comorbid psychiatric and substance use disorders are more likely to be successful when the clinician is a collaborator in the recovery process. Partnership and shared decision making about multiple issues are critical features of this type of relationship and facilitate the application of a range of non-medication evidence-based strategies (such as motivational engagement, skills training, and contingency management) in addition to identifying the best medication regimen for the individual. The clinician engages in continual assessment and re-assessment, and focuses on small steps of success and progress over time.

Research on patients with serious mental illness and co-occurring substance use disorders receiving Integrated Dual Disorder Treatment has shown that it commonly takes about 3 to 4 years for approximately half of the patients to achieve stable sobriety. Most of the rest are making significant progress in improving their lives, although they continue to abuse substances.

 Thus, it is important to work in the integrated relationship to take small steps forward for each issue, rather than feel frustrated that the patient is not sober after a few weeks or months.

The practice of delaying assessment of a patient pending a minimum duration of sobriety-usually 30 days-is incorrect. There should be no arbitrary barrier to the initiation of screening, psychiatric assessment, or psychopharmacological intervention based on substance levels or duration of sobriety.

Diagnostic assessment, whether for psychiatric disorders, substance use disorders, or both, primarily involves obtaining a good patient history. The assessment process I recommend is Integrated Longitudinal Strength-based Assessment.

 The first principle of this assessment process is that with a long-standing established psychiatric diagnosis, the diagnosis persists regardless of whether the person is using substances. Similarly, if the patient has substance dependence, that disorder persists over time regardless of the presence of comorbid mental health conditions or periods of being in or out of remission.

The second principle of the assessment process is a careful integrated and longitudinal (or chronologic) evaluation of persistent mental health conditions and substance use, looking at the overlap between both conditions at any point. The third principle is to pay particular attention to periods of 30 days or longer in the history when the patient was either abstinent or using substances below the threshold that would affect the symptoms. A careful analysis of baseline mental status, level of functioning, and previously successful medication response-during those periods of strength or success-helps in diagnostic decision making, because baseline persistence of mental health conditions during past periods of sobriety is predictive of current persistence. The integrated longitudinal strength-based assessment can begin immediately and will enable you to establish a provisional diagnosis of persistent mental illness (and initial treatment recommendations) based on history, even in individuals with current or recent substance use.

The integrated assessment process should attempt to distinguish persistent mental illness with associated disability at baseline from persistent mental illness without disability. Integrated assessment should also distinguish between substance use, abuse, and dependence (per DSM-IV-TR). Finally, a careful history can delineate which past mental health conditions may have been substance-induced, because they can be shown to have cleared up completely within 30 days of discontinuing use.

When mental illness and substance use disorders are comorbid, both disorders should be considered primary, and treatment of both should be integrated and simultaneous. Interventions, including medications if prescribed, should be specific to each disorder. In addition to being matched to diagnosis or problem, interventions must be matched to treatment readiness (often termed “stage of change”). Stage of change is issue-specific, not person-specific. Consequently, integrated interventions must be stage-matched for EACH issue. A common example is a patient in the action stage for a mental illness but in the contemplation stage for making changes regarding active substance use. In this case, an “integrated prescriber” might provide appropriately matched medication for the mental illness and use motivational interviewing strategies to help the patient think more clearly about decisions regarding substance use in relation to personal recovery goals.

During the action stage, interventions may include skill building for symptom or illness management or relapse prevention. In addition, providing patients with practical skills, such as refusing drugs from a dealer, can be very helpful in supporting small steps of progress. With practice, psychiatrists can learn to provide targeted integrated interventions within the context of the brief medication visit. Brief motivational interviewing and brief focused skill-building conversations are readily integrated into the short visit.

Contemplation: What is your current plan for using alcohol, and how is that plan working for you in relation to your goals?
OR
Action: Where are you having trouble in your efforts to not use sub­stances? Can we role-play one skill you can use in that situation?

Maintenance of necessary psychotropic and other medication

Integrated psychopharmacology begins by providing appropriate psychopharmacological interventions for each of the concurrent primary disorders, just as in any other type of comorbidity. The first step is simply to use the best medication (if any) for the patient for each disorder concurrently, being aware of potential medication interactions.

Next, be sure to initiate and maintain necessary (non-addictive) medication needed for stabilization and treatment of a known serious mental illness or medical condition even when the patient is actively using substances. Discontinuing necessary medication is associated with greater risk of symptom relapse and re-hospitalization than is continuing medication with closer monitoring.

This does not mean that abstinence from substances should not be recommended for individuals for whom psychotropic medication is being prescribed. It is important to discuss openly (and document) the recommendation of abstinence and that continuing substance use when taking a prescribed medication is associated with greater risks of adverse effects. However, if (as is likely) the patient chooses not to follow those recommendations, it is critical to continue necessary psychotropic medication treatment, to maintain an empathic and hopeful relationship, to monitor the patient closely, and to work in partnership with the patient to help the patient talk openly about his substance use and make better decisions regarding substance use over time.

Because comorbid disorders are to be expected, it is important for all prescribers to develop-and practice-artful approaches for working in partnership with patients who present challenges. In particular, it is important to be proactive in the prescribing relationship to avoid what might be termed an “unholy alliance,” which can emerge when patients approach prescribers with the goal of obtaining medications to “feel better,” and prescribers feel their job is to provide medications for that purpose. In that situation, we may feel that saying yes is inappropriate but do so to accommodate the patient, or we may say no and jeopardize the relationship. Either way, it feels like we lose. To avoid this, it is helpful to practice routine strategies and messages based on the expectation that these types of encounters will occur and on the desire to use these encounters purposefully to support positive engagement and progress.

When patients request (or demand) medications for symptom relief, it is important to take time to get a good integrated, longitudinal, strength-based history, not of the symptom, but of the person’s life: goals, current and past functioning, previous experiences with treatment, and evidence of disorders and syndromes beyond particular symptoms. It is important to be calm and in control of the assessment, letting the person know that you will get to know her well and will figure out the best medication strategy to help her in the context of what is actually happening in her life. The more that you can keep the conversation away from a focus on “symptoms” or “feelings” (which can often be exaggerated for the purpose of convincing you to prescribe), the more accurate will be your assessment. This will enable you to more clearly determine what aspects of the patient’s painful experiences are related to possible disorders that may respond to medication and what aspects of the patient’s pain relate to issues in her life (experiences of trauma, for example) that require other types of intervention.

Explain your medication decisions in relation to the likelihood (based on the assessment) that the diagnosis is a treatable psychiatric disorder, and the risks and benefits of medication in relation to that disorder. It is often difficult in any assessment (with or without comorbidity) to fully distinguish depression (for example) as a result of “life circumstances” from major depression; nevertheless, it is important to communicate any uncertainty accurately so that the patient has a clear idea of the potential benefits and limitations of medications.

It is helpful to point out clearly and empathically that medication is not intended to relieve normal painful feelings, so much as to correct any “biological imbalance” that may lead the patient to experience real feelings inaccurately. Consequently, it is important for the patient not to expect medications to simply make him feel “better” in the face of a painful life. The prescriber should simultaneously emphasize-very positively-the importance of receiving appropriate levels of empathic support and treatment (including residential addiction treatment if needed) to help the patient learn to manage painful feelings successfully, without using substances inappropriately, to achieve his recovery goals. This approach shifts the relationship from “withholding” to “offering the help that is truly needed.”

The appropriate use of benzodiazepines in patients with comorbid dis­orders is extremely controversial. This one issue created the greatest conflict in our CMHS Managed Care Initiative Panel project. After much debate, the group came up with the following recommended guidelines for prescribing benzodiazepines for anxiety disorders or opiates for chronic pain for individuals with known substance dependence.

For patients with known substance dependence (active or remitted), the routine continuation of prescriptions of benzodiazepines, addictive pain medications, or nonspecific sedative/hypnotics is not recommended, with or without comorbid psychiatric disorder. On the other hand, medications with addictive potential should not be automatically withheld for carefully selected patients with well-established abstinence who demonstrate specific beneficial responses to them without signs of misuse, merely because of a history of addiction.

However, consideration of continuing prescription of potentially addictive medications for consumers with diagnosed substance dependence is an indication for both (a) careful discussion of risks and benefits with the patient (and, when indicated, the family) and (b) documentation of expert consultation or peer review.

During the past decade, there has been detailed investigation of anticraving agents and other medications for treatment of substance use disorders, including in patients with co-occurring psychiatric disorders, as well as investigation of various psychopharmacological agents for the treatment of mental illness in individuals with comorbid active substance use disorders. Consequently, there is emerging knowledge that all prescribers should be aware of. Some of the new information is ahead of what has been formally approved and recognized by the FDA. The following is a selected list of tips regarding psychopharmacological practice with comorbid disorders.

More routine prescription of anticraving agents such as acamprosate or naltrexone for alcohol dependence (naltrexone-as an opiate blocker-is also an appropriate treatment for opiate dependence), and varenicline or bupropion for nicotine dependence is now being encouraged.

 Studies have demonstrated that both oral and long-acting injectable naltrexone are effective in reducing alcohol use, even in individuals who are actively using, including those with comorbid psychiatric disorders.

While the data are not fully clear, on average, naltrexone is probably more effective than acamprosate for alcohol use disorders, although some individuals respond better to the latter.

Varenicline has currently been recommended as a first-line treatment for nicotine dependence in individuals with comorbid schizophrenia and possibly bipolar disorder as well.

 Findings suggest better outcomes than with bupropion, and re-analysis indicates that prior concerns about symptom exacerbation is not well founded. Disulfiram continues to be viable for alcohol dependence in select motivated patients with comorbid psychiatric disorders (psychotic or nonpsychotic); it may also reduce cocaine craving as a result of dopamine beta hydroxylase inhibition, although it is not approved for the latter indication.

There are numerous reports of alcohol anticraving effect for anticonvulsant mood stabilizers such as valproate, topiramate, and gabapentin. In a recent study, gabapentin combined with naltrexone improved drinking outcomes compared with naltrexone alone.

These early findings are important to be aware of, although these anticonvulsant medications are not approved specifically for substance use disorders.

Emerging medications that may have anticraving potential for stimulants include baclofen, vigabatrin, and modafinil for cocaine and methamphetamine; tiagabine and topiramate for cocaine; and mirtazapine and bupropion for methamphetamine.

Clozapine has a differentially positive effect in reducing substance use in individuals with psychosis, beyond its direct effect in reducing positive and negative psychotic symptoms.

 For individuals with comorbid bipolar disorder and addiction, it is important to remember that lithium is still an important front-line treatment for bipolar I disorder, even though it is not effective for substance use. However, for many patients who have comorbid substance use and bipolar disorders, especially those with atypical or rapid cycling mood disorders, the anticonvulsant mood stabilizers such as valproate may have beneficial effects for both conditions.

Atomoxetine is currently recommended as a first-line treatment for clearly diagnosed ADHD in individuals who also have active substance dependence, for whom initial prescription of stimulants would usually not be advised. However, many patients with substance dependence in remission may be successfully and safely treated with long-acting stimulants for ADHD when atomoxetine is inadequate.

All types of antidepressants have been found to be effective for major depression with comorbid substance dependence. Recent findings indicate that with co-occurring alcohol use disorder and major depression, mirtaza­pine uniquely appears to improve depression and to function as an anticraving agent for the alcohol use disorder.

Finally, adolescents with comorbid mental health and substance use disorders have been shown to have better outcomes for their mental health disorders when treated with appropriate psychotropic medications, even with continuing active substance use, compared with those who were not so treated.

-acetylcysteine has been recently shown to have a positive effect in reducing marijuana abuse in adolescents.

Note: This article was originally published as a CME in the April 2013 issue of 

 Portions of it may have since been updated.

Kenneth Minkoff, MD, has no disclosures to report.

Mark J. Albanese, MD (peer/content reviewer), has no disclosures to report.

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All types of antidepressants have been found to be effective for major depression with comorbid substance dependence.

Kenneth Minkoff, MD

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