Background
Individuals with co-occurring
psychiatric and substance disorders (COD) represent a challenging population
associated with poorer outcomes and higher costs in multiple domains. In addition, the prevalence of comorbidity is
sufficiently high that we can say that comorbidity is an expectation, not an
exception throughout the system of care.
Consequently, individuals with cod cannot be adequately served with only
a few specialized programs; rather, the expectation of comorbidity must be
addressed throughout the system of care.
The Comprehensive Continuous Integrated System of Care (CCISC) (Minkoff
& Cline, 2004) is a model for system design which permits any system to
address this problem in an organized manner within the context of existing
resources. The basic premise of this
model is that all programs become dual diagnosis programs meeting minimal
standards of Dual Diagnosis Capability, and all clinician (including
psychopharmacology prescribers) become dual diagnosis clinicians meeting
minimal standards of dual diagnosis competency, but each program and each
clinician has a different job. The job
of each program is based first on what it is already designed to be doing, and
the people with cod who are already being seen, but the goal is to organize the
infrastructure of the program to routinely provide matched services to those
individuals within the context of the program design, which in turn defines
specific clinical practices for clinicians working within that setting, that
define their competency requirements.
The service matching in this model is based on a set of evidence-based
principles in the context of an integrated philosophic model that makes sense
from the perspective of mental health and addiction treatment. These principles in turn have been utilized
to develop practice guidelines that define the process of assessment and
treatment matching at the clinical level, and outline the “job” of each program
in the system as well.
The most recent version of the
comprehensive CCISC practice guidelines were developed by Kenneth Minkoff, MD
in 2001, based on work of a consensus panel that led to a SAMHSA report in 1998
entitled: “Individuals with Co-occurring disorders in Managed Care Systems:
Standards of Care, Practice Guidelines, Workforce Competencies, and Training
Curricula” (Minkoff, 1998). The 2001
updated version of the practice guideline section of the report is being
utilized by the Behavioral Health Recovery Management Project in the State of
Illinois, and is available on line at
www.bhrm.org. The current document is an update of the
psychopharmacology section of that document. The need for this document is
based on the recognition that although there are psychopharmacology guidelines
that have been developed for the treatment of individuals with a variety of
mental illnesses OR substance disorders, most practitioners have neither
training, or experience, in an organized approach to the individuals who have
various combinations of mental health and substance conditions who commonly
present in clinical practice, particularly in public sector settings.
General Principles
The seven general principles of CCISC
are designed to provide a welcoming, accessible, integrated, continuous, and
comprehensive system of care to patients with CODs. These principles, and their application to
psychopharmacology, are listed below:
- Dual Diagnosis is an expectation, not an exception.
All psychiatrists need to develop comfort with the
likelihood that any patient requiring psychopharmacologic evaluation may also
have a substance use disorder, and be able to incorporate this expectation into
every clinical contact, beginning with assessment, and continuing throughout
the treatment process. Consequently, it
is necessary to have an organized evidence based approach to assessment and
treatment of individuals who present with co-occurring conditions of any type. In addition, given the expected complexity of
many patients with co-occurring disorders, it is helpful to routinely organize
access to peer consultation (defined below) as a valuable way for prescribers to obtain
help and guidance when treating patients with unusual or complicated clinical
situations.
- Successful treatment is based on empathic, hopeful,
integrated and continuing relationships.
Successful psychopharmacology is not an absolute science
governed by the application of rigid rules.
Rather, it is best performed in the context of an empathic, hopeful
relationship, which integrates ongoing attention to both psychiatric and
substance use issues. Emphasis needs to
be placed on an initial integrated (both mental health and substance use)
evaluation and continuous re-evaluation of diagnoses and treatment response.
Practitioners of psychopharmacology in mental health
settings should not underestimate the importance of ongoing inquiry regarding
co-occurring substance use, continued encouragement of healthy decision making
regarding substance use, and support to other caregivers who are engaged with
the patient and his or her family in addressing these issues.
- Treatment must be individualized utilizing a
structured approach to determine the best treatment. The national consensus “four quadrant”
model for categorizing individuals with co-occurring disorders can be a
first step to organizing treatment matching.
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Both High Severity
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MI Low Severity
SUD High Severity
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MI High Severity
SUD Low Severity
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Both Low Severity
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This model divides individuals throughout a service system
into four quadrants based on high and low severity of each disorder. Psychopharmacologic
strategies may need to be adjusted based on type and level of severity of each
illness in COD. In particular,
individuals with high severity mental illness are more likely to be considered
high priority mental health clients with Serious and Persistent Mental Illness
(SPMI) and associated disability, who are a high priority for continuing
engagement in psychopharmacologic treatment in the mental health system. Individuals with high severity substance use
disorders generally are those with active substance dependence (addiction), as
opposed to those with lower severity disorders, such as substance abuse. Pharmacologic strategies for either mental
illness or substance use disorder may vary, depending on the severity of the
mental illness and the diagnosis of dependence versus abuse (see below).
- Case management and clinical care (in which we
provide for individuals that which they cannot provide for themselves)
must be properly balanced with empathic detachment, opportunities for
empowerment and choice, contracting, and contingent learning.
As most individuals cannot legally prescribe their own
medication, the ability to receive medication for the treatment of CODs is a
vital aspect of the integrated treatment relationship. Given that treatment involves learning, the
psychopharmacologic treatment relationship needs to balance ongoing necessary
continuity of care (see below) with opportunities for contingent
learning (negotiation of type, quantity, and duration of treatment with any
medication) without threat of loss of the treatment relationship. This contingent learning may require a
“trial and error” process and several attempts before successful. Contingency plans are most effective in the
context of a good therapeutic alliance.
- When mental illness and substance use disorder
co-exist, each disorder is “primary”, requiring integrated, properly
matched, diagnosis specific treatment of adequate intensity.
Thus, in general, psychopharmacologic interventions are
designed to maximize outcome of two primary disorders, as follows:
a. For diagnosed
psychiatric illness, the individual receives the most clinically effective
psychopharmacologic strategy available, regardless of the status of the
comorbid substance disorder. (N.B.
Special considerations apply for utilization of addictive or potentially
addictive medications that may have psychiatric indications, such as
benzodiazepines and stimulants. See
below.)
b. For diagnosed
substance disorder, appropriate psychopharmacologic strategies (e.g.,
disulfiram, naltrexone, opiate maintenance) are used as ancillary treatments to
support a comprehensive program of recovery, regardless of the status of the
comorbid psychiatric disorder (although taking into account the individual's
cognitive capacity and disability).
Within the application of the above rules, there is some
evidence for improvement in certain addictive disorders reported with several
medications that also have common psychiatric indications (e.g., SSRIs, buproprion, topiramate) (See
below). Although there is little evidence to support selecting
one medication for any combination as a “magic bullet”, the prescriber may want
to consider the possible impact on a co-occurring substance use disorder when
choosing medication for a psychiatric disorder.
- Both serious mental illness and substance dependence
disorders are primary biopsychosocial disorders that can be treated in the
context of a “disease and recovery” model.
Treatment must be matched to the phase of recovery (acute
stabilization, engagement/motivational enhancement, active
treatment/prolonged stabilization, rehabilitation/recovery) and stage of
change or stage of treatment for each disorder.
Psychopharmacologic practice may vary depending on whether
the individual is requiring acute stabilization (e.g., detoxification) versus
relapse prevention or rehabilitation. In
addition, within the psychopharmacologic relationship, individuals may be
engaged in active treatment or prolonged stabilization of one disorder (usually
mental illness), which may provide an opportunity for the prescriber to
participate in provision of motivational strategies regarding other comorbid
conditions.
- There is no one correct approach (including
psychopharmacologic approach) to individuals with co-occurring
disorders. For each individual,
clinical intervention must be matched according to the need for engagement
in an integrated relationship, level of impairment or severity, specific
diagnoses, phase of recovery and stage of change.
This principle provides the framework for
practice guidelines and treatment matching generally, including the application
of the practice guidelines to psychopharmacologic practice.
Clinical Practice Guidelines
Utilizing
the principles as a foundation, the following clinical practice guidelines can
be developed. These guidelines include
both specific recommended or suggested practices, as well as providing a
suggested sequence for prioritization of clinical activities.
1. Welcoming: All psychopharmacologic practitioners should strive to welcome
individuals with co-occurring disorders into treatment as a high risk, high
priority population, and to engage them in empathic, hopeful, integrated and
continuing treatment relationships in which outcomes of psychopharmacologic
intervention can be optimally successful.
2. Access: Because of the importance of engaging individuals in treatment as
quickly as possible, and because (as will be noted below) initial diagnostic
evaluation is based significantly upon historical data, there should be no
arbitrary length of sobriety requirement for access to comorbid psychiatric
evaluation. Initial evaluations
should only require that the client be able to carry on a reasonable conversation,
and not require that alcohol or drug levels be below any arbitrary figure. Referral for psychopharmacologic evaluation
should occur as quickly as possible (based on triage of acuity and dangerous
risk factors). Maintaining existing non-addictive
psychotropic medication during detoxification and early recovery is
strongly recommended as substance abuse increases the risk of destabilization
of the mental illness.
3.
Safety: The first priority in the evaluation process is to
maintain safety, both for the patient and the treatment staff. Psychopharmacologic intervention can be vital
in this effort. In situations involving
acutely dangerous behavior, it may be necessary to utilize antipsychotics and
other sedatives (including benzodiazepines) to establish behavioral
control. In acute withdrawal situations
requiring medical detoxification, use of detoxification medications for
addicted psychiatric patients is no different than for patients with addiction only.
4. Integrated Assessment (ILSA): Assessment and diagnosis of individuals with CODs is based
on a process of integrated longitudinal strength based assessment
(ILSA) (See Center for Substance Abuse Treatment, Treatment Improvement
Protocol #42, 2005), which begins as soon as the patient is welcomed into care,
immediate safety established, and the capacity to obtain a history (from client
or collaterals) is present. This process
incorporates a careful chronological
description of both disorders; including emphasis on onset, interactions, effects of treatment, and
contributions to stability and relapse of either disorder. As with all psychiatric disorders, obtaining
information from family members and collateral caregivers can be extremely helpful. Particular attention to
assessing previous periods of sobriety or limited use for presence of
psychiatric symptoms, and history of medication responses with or without
sobriety can be useful.
Diagnosis of persistent psychiatric disorders in patients
with COD can be difficult given the overlap of symptoms with substance use
disorders. Information about the
presence of symptoms and need for continued psychiatric treatment either prior
to onset of substance use disorder, or during periods of abstinence or low substance
use of 30 days or longer can be vital in making a meaningful psychiatric
diagnosis. These periods of time can
occur at ANY TIME in the patient’s history after the onset of illness,
and do not have to be current.
Diagnostic and treatment decisions regarding psychiatric
illness are ideally made when the comorbid substance disorder is stabilized,
ideally for 30 days or longer.
Nonetheless, thorough assessment (as described above) can provide
reliable indications for diagnosis and immediate initiation or continuation
of psychopharmacologic treatment,
even for individuals who are actively
using. This is particularly true for
individuals with more serious and persistent mental illness and more severe
symptomatology, regardless of diagnosis.
Diagnostic and treatment decisions regarding substance
disorder are best made when the comorbid psychiatric disorder is at baseline.
Nonetheless, thorough assessment can provide reliable information about the course and severity
of substance disorder, even for an individual whose mental illness is
destabilized, and can provide reliable indications for diagnosis and immediate
initiation or continuation of psychopharmacologic treatment (e.g., opiate
maintenance).
Finally, integrated assessment during periods of
stabilization may also provide evidence that justify rescinding a previously
made diagnosis, and carefully discontinuing medication that may seem to have no
further indication, either because the condition for which treatment was
initiated has completely resolved (e.g., substance induced psychosis), or
because further evaluation indicates that justification for the diagnosis no longer
exists.
5. Continuity: Provision of necessary
non-addictive medication for treatment of psychotic illness and other known serious mental illness must be
initiated or maintained regardless of
continuing
substance use. Individuals whose substance use appears to be
significantly risky warrant closer monitoring or supervision, NOT treatment
discontinuation.
Peer consultation is indicated for cases in which the treating
psychiatrist is considering medication discontinuation due to ongoing substance
use for an individual with known or probable serious and persistent mental
illness, including persistent substance induced disorders.
In
patients with active substance dependence or substance dependent patients in early recovery, non-addictive medication for any
psychiatric disorders may be initiated or maintained,
provided reasonable historical evidence for the value/need for the medication is present.
Over
time, within the context of a continuing psychopharmacologic relationship,
continuing re-evaluation of diagnosis and psychopharmacologic regimes is
recommended, both to insure appropriate continuity of stabilizing medication for
established disorders, as well as to insure discontinuation of medication for
disorders that have resolved, discontinuation of medication that is not
effective, and cautious discontinuation of treatment for disorders whose
diagnosis appears to be no longer supported (while maintaining awareness that
there is always a risk of recurrence in discontinuing medication, even for
asymptomatic individuals)..
6. Consultation for Prescribers: It is highly
recommended that every system establish a mechanism for expert and/or peer
consultation to assist both psychopharmacology prescribers and other members of
the treatment team in making decisions regarding challenging patients. Consultation provides a framework for obtaining
clinical support, as well as for reviewing clinical decision making from a risk
management standpoint. Furthermore, work with people who have CODs can be both
frustrating and very rewarding, and the peer consultation process can be a
vehicle for both recognizing special effort by clinicians, as well as to
support the clinical team when dealing with particularly challenging cases. Examples of appropriate cases for expert or
peer consultation include (but are not limited to):
1. Continuation of treatment with benzodiazepines (beyond
detoxification) in patients with known substance dependence.
2. Discontinuation of psychiatric medications for a substance
using patient with a serious, persistent psychiatric illness.
3. Unilateral termination of clinical care for any patient
with CODs
7. Psychopharmacological Treatment Strategies
A. General principles: In patients with psychotic
presentations, with or without active substance dependence, initiation of
treatment for psychosis is generally urgent. In
patients with known active substance dependence and non-psychotic presentations,
it is recommended to utilize the integrated longitudinal assessment process
to determine the probability of a treatable mental health diagnosis
before medication is initiated. It can
be very difficult to make an accurate
diagnosis and effectively monitor treatment without this first step. It is understood that all diagnoses are
“presumptive” and subject to change as new information becomes available. If
there is uncertainty about diagnosis after reasonable history taking, evidence
for initial efforts to discontinue substance use may need to occur prior to
initiation of psychopharmacology, in order to establish a framework for further
diagnostic evaluation. However,
for high risk patients, with or without psychosis, developing a treatment
relationship is a priority, and there should not be an arbitrary length of time
required before treatment initiation takes place, nor should absolute
diagnostic certainty be required.
Individuals with reasonable probability of a treatable disorder can be
treated
Psychotropic medications, particularly for anxiety and
mood disorders, should be clearly directed to the treatment of known or probable psychiatric disorders, not to medicate
feelings. It is important to communicate
to patients with addiction that successful treatment of a comorbid anxiety or
mood disorder with medication is not intended to remove normal painful feelings
(such as normal anxiety or depressed feelings).
The medication is meant to help the patient feel his or her painful
feelings accurately, and to facilitate the process of developing healthy
capacities to cope with those feelings without using substances. If psychotropic medications are used for
mental illness in individuals with addiction, or if medication is used in the
treatment of the addiction itself, the following precepts may be helpful to
communicate to the patient:
“The
use of medication for either type of disorder does not imply that it is no
longer necessary for the patient to focus on
the importance of his/her own work in recovery from addiction. Consequently,
utilizing medication to help treat addiction should always
be considered as an ancillary tool to a full addiction recovery program.”
Addicts in early recovery have great difficulty regulating
medication; fixed dose regimes, not PRN's, are
recommended in the treatment of mood and anxiety disorders.
Just as in individuals with single disorders, and perhaps
more so, it is important to engage patients with co-occurring disorders as much
as possible in understanding the nature of the illness or illnesses for which
they are being treated, and to participating in partnership with prescribers in
determining the best course of treatment.
For this reason, most established medication algorithms (e.g. TMAP) and
practice guidelines recommend that medication education and peer support regarding
understanding the risks and benefits of medication use are incorporated into
standard treatment practice. This is
certainly true for individuals with co-occurring disorders, for whom
information provided by peers may be particularly helpful in making good
choices and decisions regarding both taking medication and reduction or elimination
of substance use.
B. Diagnosis specific psychopharmacological treatment for mental illness
1. Psychotic Disorders: Use the best psychotropic agent available for the
condition. Improving psychotic or negative symptoms may promote substance recovery. This
includes treatment of substance-induced psychoses, as well as psychosis
associated with conventional psychiatric disorders.
a. Atypical
neuroleptics: Consider olanzapine, risperidone, quetiapine, aripiprazole,
ziprasidone or clozapine. In addition,
it is well documented that clozapine has a direct effect on reducing substance
use in this population, beyond any improvement in psychotic symptoms, and
therefore may be specifically indicated for selected patients.
b. Typical
neuroleptics: Consider use in adjunct to the atypicals, especially in
situations of acute agitation, unresolved psychosis, and acute decompensation
c. Many individuals with cod will benefit from
depot antipsychotic medications. Both typical and atypical neuroleptics (e.g.,
risperidone) are available in depot form.
There have not been specific studies about the utilization of depot risperidone
in individuals with co-occurring substance use disorder, but there is no
apparent contraindication to its use.
2. Major Depression:
The relative safety profile of SSRI’s (and to a somewhat lesser extend SNRI’s
such as venlafaxine), other newer generation antidepressants and possibly
buproprion (though higher seizure risk must be considered) make their use
reasonable (risk-benefit assessment) in the treatment of individuals with
CODs. SSRI’s have been demonstrated to
be associated with lower alcohol use in a subset of alcohol dependent patients,
with or without depression. The use of
tricyclic antidepressants (TCAs) and MAO inhibitors (MAOIs) can be more
difficult and possibly more dangerous in the COD population if there is a risk
of active substance use..
3. Bipolar Disorder:
Use the best mood stabilizer or combination of mood stabilizers that match the
needs of the patient. Be aware that
rapid cycling and mixed states may be more common, hence consider valproate,
oxycarbamazepine, carbamazepine or olanzapine (and other atypicals), in
patients who may have these variants.
4. ADHD:
Initial treatment recommendations, in early sobriety, have included buproprion.
Recently, atomoxetine has been available, and may be a reasonable first choice,
though there have not been specific studies in co-occurring populations. In both adolescents and adults, there is
clear evidence that if stimulant medications are necessary to stabilize ADHD,
then these medications can be used safely, once addiction is adequately
stabilized and/or the patient is properly monitored, and will be associated
with better outcomes for both ADHD and substance use disorder.
5. Anxiety disorders: Consider SSRIs, venlafaxine, buspirone, clonidine and
possibly mood stabilizers such as valproate, carbamazepine, oxycarbamazepine,
gabapentin, and topiramate, as well as atypical neuroleptics. There is evidence
of effectiveness of topiramate for nightmares and flashbacks associated with
PTSD.
For patients with known substance dependence (active or remitted),
the continuation of prescriptions for of benzodiazepines,
addictive pain medications, or non- specific sedative/hypnotics is not
recommended, with or without comorbid psychiatric disorder. On the other hand,
medications with addiction potential should not be withheld for carefully
selected patients with well-established abstinence who
demonstrates 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, where indicated, the family) and (b) documentation of expert consultation or peer review.
Sleep disturbances are common in mental illness as well as substance use
disorders in early recovery. Use of non-addictive sedating medications (e.g.,
trazodone) may be used with a careful risk benefit assessment.
C.
Psychopharmacologic Strategies in the Treatment of Substance Use Disorders
There is an increasing repertoire of
medications available to treat substance use disorders, including medications
that appear to directly interrupt the core brain processes associated with lack
of control of use. All of these
medications have demonstrated effectiveness in populations who may also have
psychiatric disorders, including severe mental illnesses.
1. Disulfiram
A. Disulfiram
interferes with the metabolism of alcohol via alcohol dehydrogenase, so that
individuals who use alcohol will get ill to varying degrees when taking this
medication. This can be a valuable tool
in assisting individuals to resist impulsive drinking, but generally must be
combined with additional recovery programming and/or positive
contingencies. Disulfiram should NOT be
used to coerce sobriety in any patient.
B. As a dopamine
beta-hydroxylase inhibitor, disulfiram occasionally will exacerbate psychosis,
necessitating adjustment of antipsychotic medication
C. As a dopamine beta-hydroxylase inhibitor,
disulfiram has also been found to
reduce cocaine craving and cocaine usage in some studies.
2. Opiate
maintenance treatment
A. Methadone and LAAM are well
established treatments for opiate dependence, and have been found to be
successful in individuals with a wide range of psychiatric comorbidity, in the
context of methadone treatment programs..
Methadone dosing is now informed by the capacity to measure trough
levels. The prescriber must be aware
that there are enzymatic interactions that affect the interaction of methadone
with various psychotropics, the details of which are beyond the scope of these
guidelines, but which should be reviewed when such combinations are being
initiated.
B. Buprenorphine has been more
recently introduced for opiate maintenance, does not require participation in a
formal “program”, like methadone, and can be provided in office based settings
by physicians who have addiction specialization and/or who have had eight hours
of training. Oral buprenorphine is
provided combined with naloxone to prevent diversion for parenteral use. It is
a mixed m-opiate receptor agonist () and a k-receptor antagonist, that appears
to be easier to utilize, with fewer side effects, and less severe abuse or
withdrawal risk, than methadone.
Although not well studied in the co-occurring disordered population, all
indications in the literature indicate that it is effective. Again, there are a range of interactions that
may occur with enzymes that metabolize psychotropic medication, that need to be
reviewed when initiating treatment.
3. Naltrexone
A. Opiate
dependence: Naltrexone is a relatively long acting opiate blocker that can be
effective given three times weekly for opiate dependence, particularly when
combined with significant contingencies to support adherence.
B. Alcohol dependence: Naltrexone has been
demonstrated to be effective in reducing alcohol use through reducing craving
and loss of control, presumably by affecting endogenous opiate pathways that
are involved in the development of the brain disorder of alcohol
dependence. Naltrexone has been
demonstrated to be effective in individuals with schizophrenia and other mental
illnesses in preliminary studies.
4.
Acamprosate Available in Europe
for several years, acamprosate has recently been approved in the US. It reduces alcohol usage through an impact on
endogenous GABA pathways. The
combination of acamprosate plus naltrexone is reportedly more effective than
either alone.
5. Bupropion for nicotine dependence
appears to have an effect on reward pathways
associated with nicotine use. . Nicotine
replacement for nicotine dependence,
including nicotine patch, gum, and more recently, nasal spray, which
most closely mimics the effects of smoking in nicotine
delivery. Bupropion and nicotine replacement combined tend to result in better outcomes than either
alone
6. Topiramate
for alcohol dependence (one study) has some potential value through
its effect on GABA receptors
7. Desipramine
for cocaine craving has yielded very inconsistent findings.
8. Dopaminergic
agents for cocaine craving have also yielded inconsistent findings,
with risk of exacerbation of psychosis.
9. Serotoninergic agents (e.g., SSRIs) have
been found in some studies to have a beneficial effect in reducing alcohol
use in non-depressed alcoholics,
particularly in certain subtypes of alcohol dependence.
D.
General Strategies for Managing Interactive Effects of Substance Use on
Psychiatric Symptoms and Interventions
The
effects of various substances on psychiatric presentations and on psychiatric
treatment are quite variable. Discussion
of the effects of each type of substance on psychiatric symptoms and
medications are described in most textbooks, and are beyond the scope of these
guidelines. The prescriber should always keep in mind that the best way to
evaluate the effect of a particular pattern of substance use on a particular
client is to get a good history from that client and collaterals. Further, although there are unquestionably
unpredictable risks that may be attached to continuing substance use in
individuals receiving psychiatric care, the risks of poor outcome associated
with NOT TREATING a known mental illness appear to significantly outweigh the
risks of continuing treatment in an individual who is continuing to use
substances. Individuals who engage in
particularly risky behavior should be monitored more closely, not discontinued
from necessary psychiatric or medical treatment.
E.
Special Stage Specific Strategies
1.
Motivational
Interventions: In clinical situations where the
psychiatric diagnosis and/or severity of substance disorder
are unclear, psychotropic medications may be initiated if there is a reasonable
indication, and used as part of a strategy to facilitate
engagement in treatment and the creation of contingency contracts to promote abstinence.
2.
Contingency
Management Interventions: Within the context of a psychopharmacologic
relationship where necessary medication is provided, interventions that may be
considered optional or discretionary can be linked to incremental progress in
addressing substance use disorders. In
addition, in individuals receiving benzodiazepines, emergence of substance use
can be addressed by creating contingency plans that allow the individual to
maintain benzodiazepine dosage only if abstinence is maintained. Slow reduction
of dosage can offer multiple opportunities for the patient to regain the
original dosage by re-establishing abstinence.
Evidence of severe overuse or overdosage with benzodiazepines, however,
is usually an indication for discontinuation, often in a hospital setting.
8.
Continuing Evaluation and Re-evaluation
It is important not to expect that
diagnostic certainty can be obtained at the beginning of treatment. Individuals may begin on medication for a
presumed diagnosis during periods of substance use, and once they have stopped
using the presumed diagnosis may appear to clear up, necessitating the
discontinuation of medication.
Conversely, once individuals stop using, psychiatric disorders may
emerge or worsen, requiring the initiation of medication. It is important to maintain an open minded
stance, and to consider all possibilities.
Each patient must be considered as an individual, and continuity of care
provides an opportunity to become increasingly more accurate about diagnosis
and treatment over time.
