Magazine article Clinical Psychiatry News

Dual Diagnosis? Treat Substance Abuse First

Magazine article Clinical Psychiatry News

Dual Diagnosis? Treat Substance Abuse First

Article excerpt

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. …

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