In addition to my practice, I sit on the advisory committee of a group interested in providing mental health services to the homeless, who often abuse alcohol and drugs. The intent of this program is to provide psychotropic medication as part of its treatment to these people. Is this a wise course of action? What are the consequences of concomitant use of these medications and street drugs?
I suggest you get hold of the August 1994 issue of Psychiatric Annals, which focuses on comorbid substance and psychiatric disorders. The article by Miller et al. specifically discusses many of the possible interactions between alcohol/drugs and antipsychotic agents. While the conventional wisdom, of course, is that every patient treated with a psychotropic agent should be clean and sober, this is often not practical in the real world, and may not always be essential for a response to the medication. For example, many individuals with chronic schizophrenia and substance abuse have been successfully treated with clozapine (Clozaril). The newsletter distributed by Sandoz (see Treatment Trends, vol. 3, no. 1, winter 1994) makes the following statement in response to the question, Does substance abuse rule out the use of Clozaril?
“Moderate substance abuse does not seem to have an adverse effect on the rate or extent of response to Clozaril. However, out-of-control substance abuse, especially among people who express no interest in trying to limit their abuse, creates serious, if not prohibitive, compliance problems.”
This is based on research done by Herbert Meltzer, MD; by inference, one would expect the same to apply to olanzapine (Zyprexa), but I have seen no studies done on this medication. Another interesting study, which has been misinterpreted by some, is that of McGrath et al in the March 1996 issue of Archives of General Psychiatry. They treated actively-drinking alcoholic outpatients with imipramine, and found it to be both safe and effective for the comorbid primary depression. They found fewer heavy drinking days among the imipramine responders, though no real improvement in overall sobriety. There are many methodological problems with this study, and I would advise you to read the authors’ own comments under study limitations.
I hope this will get the ball rolling for you. By the way, there are very few workers in this area who would sanction the use of benzodiazepines in this population, but the use of non-habit forming medications, such as buspirone, antipsychotics, and antidepressants should not, in my view, be automatically ruled out in individuals with episodic substance abuse. Obviously, one would like to monitor liver functions, do random urines, etc., if possible, and actively involve these individuals in a 12-step program as part of their care.