Section 4.9

Dual Diagnosis Medication Management


Psychiatric medication prescribing for individuals with dual diagnosis is already occurring in Orange County and nationwide. Use of psychiatric medications for individuals with dual diagnosis can be appropriate in many clinical situations.

When prescribing psychiatric medication for individuals with dual diagnosis, there is the additional ?adverse-effect? risk of unintentionally reinforcing the individual?s drug use/abuse. The reinforcement could occur if the individual perceives that:

  1. The psychiatric medication offers quick relief from a psychotic episode, or comforting sedation of an agitated state due to substance use/abuse,
  2. Their problem is "only" mental illness, not substance abuse, or
  3. They can substitute (albeit temporarily) a benzodiazepine or an anticholinergic medication for street drugs.

Unintentional reinforcement may represent an acceptable risk especially since there are additional factors that are not present in the private sector. County Mental Health Services are supposed to:

  1. Prescribe medication to relieve the patient?s symptoms/impairment, reduce dangerous-ness and avert hospitalization (even if abstinence cannot be assured for several months) and,
  2. Prescribe medication to provide patient safety, others? safety, residential stability and possible medical management of detoxification.

Because of all of the above aspects, new decisions on the treatment of dual diagnosis individuals may need to involve team consultation to avoid the high probability of team splitting.

Antipsychotic, Mood-Stabilizing and Antidepressant Medications


Antipsychotic, mood stabilizing and antidepressant medications may have the best benefit/ risk assessment for use with individuals with dual diagnosis because of the symptoms they can treat, versus the relatively low adverse effect risk.

Antipsychotic medications may be prescribed for Dual Diagnosis individuals who are psychotic due to 1) substance intoxication, 2) substance withdrawal, 3) substance induced psychotic disorder or 4) psychotic disorder with concomitant substance use.

Lithium/anticonvulsant mood stabilizers, and antidepressants may be prescribed for Dual Diagnosis individuals who have a diagnosis of a mental illness for which these medications are usually prescribed if substance use/abuse is eliminated as the sole cause of symptoms. If corroboration or longitudinal course validate that there are mental illness symptoms even when not intoxicated or withdrawing, then mood-stabilizing or antidepressant medications can be initiated even in the acute phase.

Antipsychotic medications, mood-stabilizing medications, and antidepressants are prescribed if the expected benefit of prescribing clearly outweighs the potential general risks of medication use and the additional risks of reinforcing drug using behaviors.

Examples of the expected benefit include treating psychotic, manic/impulse control or depressive/obsessive-compulsive symptoms that:

  1. Cause grave disability in utilizing food, clothing, or shelter to the point, or nearly the point, of involuntary hospitalization,
  2. Cause violence to be directed at self (or others),
  3. Allow the individual to participate in other mental health or substance abuse treatment components,
  4. Allow the individual to remain in their residence or otherwise averts hospitalization, or
  5. Cause other impairment in function.

Antipsychotic medications that are low-potency/high-dose have some physical additional risks in treatment of individuals with dual diagnosis, such as: 1) sedative/anticholinergic side effect exacerbation when used with substances of abuse, and 2) lowered seizure threshold during withdrawal. Using the high-potency antipsychotics may be safer.

Carbamazepine and valproic acid may also require more frequent monitoring of liver functions and CBC.

The tricyclic and trazodone medications have the potential of sedative/anticholinergic side effect exacerbation when used with substances of abuse. The MAOI medications have the potential risk of autonomic hyperactivity (including cardiac), with cocaine or amphetamine abuse. SSRI?s probably represent the safest alternative physiologically.

Side-effect Medications


The medications to treat the side effects are prescribed for Dual Diagnosis individuals who are taking or have just stopped taking antipsychotic medications. The anticholinergic medications have the potential to exacerbate delirium or cognitive deficits when used with substances of abuse. Amantadine or diphenhydramine probably represent the safest alternative physiologically.

Adjunctive Medications


Thyroid medications are generally prescribed for Dual Diagnosis individuals who are taking antidepressant medications. The antihypertensive medications are generally prescribed for Dual Diagnosis individuals for a variety of reasons, including but not limited to: 1) treating side-effects of psychiatric medications, 2) lessening impulsiveness, 3) treating narcotic withdrawal and 4) alcohol detoxification.

Disulfiram or naltrexone medications may be prescribed for Dual Diagnosis individuals who are not using drugs or alcohol, and who are willing to take these medications as part of an abstinence based treatment team plan. Again, the same concern applies of the unintentional reinforcing of the individual?s drug use.

Antianxiety Medications


Benzodiazepines may have the most difficult benefit/risk assessment for individuals with dual diagnosis because the symptoms they can treat may be related to the individual?s pattern of addiction.

Benzodiazepines may be prescribed for Dual Diagnosis individuals who have a diagnosis of a chronic anxiety disorder or other severe mental illness for which these medications are usually prescribed after corroboration or longitudinal course validate that anxiety symptoms are not due to intoxication or withdrawal. With dual diagnosis individuals, additional benzodiazepine precautions may include weekly or twice monthly refills of small amounts. Oxazepam may have many advantages over the other benzodiazepines.

Benzodiazepines may be prescribed even in the acute phase for Dual Diagnosis individuals who have severe insomnia, medical complications of withdrawal, or agitation as part of an abstinence based treatment team plan. In this case, the medication is prescribed for a short- term basis of a week or less. A significant other individual may be asked to participate in administering the benzodiazepine, and urine drug screens may be obtained to corroborate that the individual is complying with the detoxification plan. Examples of the expected benefit include treating insomnia, withdrawal, or agitation symptoms that:

  1. Allow the individual to remain in their residence or otherwise averts hospitalization,
  2. Helps establish relationship with clinic and abstinence program,
  3. Cause other impairment in function.

Buspirone, SSRI?s or hydroxyzine probably represent the safest options physiologically for treatment of the anxiety in individuals with dual diagnosis since the benzodiazepine medications have the potential of sedative side effect exacerbation when used with substances of abuse.

If benzodiazepines are used for detoxification, the treating psychiatrist may decide to refer for medical evaluation, or to obtain screening laboratory tests, vital sign measurements in the mental health setting and provide thiamine and multivitamin recommendations as part of acute management.

Psychostimulant Medications


Psychostimulants are drugs that have helped many individuals. Unfortunately, they also are the same or very similar to street drugs of abuse and as such are prescribed only with the use of a DEA triplicate prescription. These medications may be prescribed for Dual Diagnosis individuals who have a chronic Attention Deficit Disorder only after substance use/abuse is eliminated. Alternative pharmacological and non-pharmacological treatments for ADHD may be considered since the misuse of the psychostimulant or mixing of the prescription stimulant with drugs of abuse would diminish most of the benefits of these medications. Antidepressants have been used as safer alternatives, particularly in dual diagnosis.

If the decision is made to prescribe a psychostimulant, then additional precautions may include weekly or twice monthly refills of small amounts, with a significant other involved in the monitoring. The risks of side effects with psychostimulants in general are the same in treatment of individuals with dual diagnosis.