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Clinical Aspects of Substance Abuse in Persons With Schizophrenia
Specific Pharmacotherapy Issues
Patients in treatment who have psychosis and who smoke tobacco or cannabis are exposed to the enzyme-induction properties of the smoke components and may experience an accelerated clearance of neuroleptic and antidepressant drugs (43). Therefore, the blood concentrations of these medications may not attain therapeutic levels at regular dosages. Conversely, they may increase rapidly following smoking cessation.
It is argued that neuroleptics with strong D2 receptor–binding affinity may contribute to perpetuating substance abuse in persons with schizophrenia. Such a pharmacologic property does lead to receptor upregulation and supersensitivity (44), thus enhancing drug reward and positive reinforcement, and causes more severe EPSEs—another incentive to use drugs. It is therefore recommended that schizophrenia sufferers with dual diagnosis be treated with atypical neuroleptics (44). Several clinical-outcome reports support this view (13,45,46).
The use of opiate receptor agonists such as buprenorphine and methadone (47,48) is considered to be safe and useful in both detoxification and narcotic maintenance therapies for opiate addiction in schizophrenia patients. No untoward effects have been reported to date. The same can be said for opiate antagonist therapy (that is, naltrexone) in cases of opiate addiction and alcoholism. Disulfiram must be used with caution in persons with schizophrenia, for in addition to its prime target, acetaldehyde dehydrogenase, it inhibits dopamine beta-hydroxylase, an enzyme involved in the conversion of dopamine and noradrenaline, and may thus increase delusional and hallucinatory activity (44). There is still not enough information on the performance of acamprosate in cases of comorbid alcoholism and schizophrenia and, in particular, on whether it has any negative interaction with antipsychotic therapy. This drug has undergone extensive trials in Europe and the US (49), but patients with psychosis appear to have been excluded from the samples studied so far. Bupropion and nicotine-replacement therapy (that is, the transdermal patch), used to achieve cessation of smoking, are apparently safe and effective in patients with chronic psychosis. Several trials have reported good results (50).
Another issue of considerable clinical importance is the decision to initiate a preventive course of pharmacotherapy in young people who have suffered brief, substance-induced psychotic episodes. Continuing neuroleptic treatment as a preventive measure has been recommended for persons who meet criteria for ultrahigh risk (51). It seems the right course if the brief psychotic outbreak occurs in a context of family history of schizophrenia and if the young person already presents other prodromal symptoms. However, other voices strongly advise caution, on the grounds that the reliability and specificity of the prodromal syndrome have not yet been satisfactorily established (52).
Psychotherapy Issues
Motivational interviewing, CBT, relapse-prevention skills training, and the 12-step mutual-help programs are the most widely used approaches in the psychotherapy of addiction. All have been tried in dual-disorder treatment programs, but it is clear that some specific modifications are required to adapt those interventions to the particular conditions of the patient with psychosis.
The Alcoholics Anonymous (AA) program is the most heavily subscribed treatment resource. It is a significant component in the therapy curriculum for the vast majority of addiction-treatment centres in North America. It offers a time-honoured contribution to treatment success—one that is supported by empirical evidence (53). Most dual-disorder treatment services encourage or require their clients to become involved in this program, but as Noordsy and others have found (54), schizophrenia patients experience significant difficulties adjusting to it: few attend, despite efforts by referring clinicians, although attendance is better for patients with fewer negative symptoms. Most resent confrontation and the dismissal of their justification for drinking (that is, mental symptoms) as an attempt to “deny” alcoholism. Many are uncomfortable in large groups, feeling watched, different, and out of place among people who do not suffer from psychosis. Some are embarrassed by their own restlessness and their inability to sit still through a long meeting. Most do not identify with the social loss stories of other group members (for example, loss of marriage, job, property, or driving permit), because they have seldom attained a similar status in life. Conversely, when self-help sessions are attended by peers and the experience of mental illness is part of the discussion agenda, patients with dual disorders appear to engage more readily and derive the expected benefits (55).
The main goal of motivational therapy is to help advance the process of change, to coach those who abuse substances into becoming more consciously aware of the nature and extent of the problems at hand, and to empower them to decide voluntarily to make the necessary effort and accept help. Such an approach is obviously more effective when the clients are able to recognize the costs and untoward consequences of not making the change, when they are capable of formulating goals for themselves, and when they can muster the necessary energy to pursue their goals. This is often not the case with persons who suffer chronic and severe mental illness. Dual-disorder motivational therapists must deal with individuals who often see nothing wrong with their drug practices and cannot perceive the advantage of quitting. Such patients have low levels of energy and a certain inability to become enthused with the idea of goal attainment (56). They may also be cognitively impaired. Despite all these limitations, evidence is accumulating to the effect that the motivation enhancement approach does yield positive results in this population and that it should be adopted (57,58).
Conclusions
Chronic schizophrenia and substance abuse are significantly associated in terms of risk for occurrence and underlying neuropathology. This clinical reality cannot be overlooked; for it is both neglectful and self-defeating to treat one of these disorders while ignoring the other. Emerging evidence points to the significant advantage of treating both disorders conjointly, in an integrated manner. Given that both illnesses follow a chronic and recurrent course, that their clinical management calls for a high level of psychiatric expertise, and that there is often a need to access hospital facilities within a continuing care model, integrated programs can be developed most adequately within psychiatric services that provide comprehensive and open-ended care.
Funding and Support
This paper includes data from research funded by the Canadian Psychiatric Research Foundation and Health Canada’s Health Research Development Program, in which the author was the coinvestigator.
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Author(s)
Manuscript received and accepted November 2002.
1. Professor of Psychiatry, McGill University, Montreal, Quebec; Senior Consultant, Montreal General Hospital Addictions Unit, Montreal, Quebec.
Address for correspondence: Dr JC Negrete, Montreal General Hospital, 1650 Cedar Avenue, Montreal, QC H3G 1A4
e-mail: jnegre1@po-box.mcgill.ca
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