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Journal of Psychoactive Drugs Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/ujpd20
Psychotic Conditions and Substance Use: Prescribing Guidelines and Other Treatment Issues a
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Joan Ellen Zweben , David E. Smith & Pablo Stewart
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East Bay Community Recovery Project and The 14th Street Clinic and Medical Group , Oakland , California
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Haight-Ashbury Free Clinics, Inc. , San Francisco
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University of California School of Medicine , San Francisco Published online: 20 Jan 2012.
To cite this article: Joan Ellen Zweben , David E. Smith & Pablo Stewart (1991) Psychotic Conditions and Substance Use: Prescribing Guidelines and Other Treatment Issues, Journal of Psychoactive Drugs, 23:4, 387-395, DOI: 10.1080/02791072.1991.10471610 To link to this article: http://dx.doi.org/10.1080/02791072.1991.10471610
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Psychotic Conditions and Substance Use: Prescribing Guidelines and
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Other Treatment Issues" Joan Ellen Zweben, Ph.D. *; David E. Smith, M.D** & Pablo Stewart, M.D. *** Abstract - Th is article examines several circums tances in which psychotic symptoms coexist with substance abuse. It reviews psychotic states that may occur as a result of alcohol and other drug use, including intoxic ation, overdose and withdrawal, offering medication guidelines for managing these situations. It also examines psychiatric disturbances in which psychotic symptoms are recurrent featur es, explor ing patients' self-med ication practices and some strategi es to address them , as well as difficulties commonly encountered with prescription medications. It briefly discu sses other psychosocial int erventions that play a significant role in the treatment of the dual diagnosis patient. Keywords - dual diagnosis, prescrib ing guidelines, psychotic conditions, substance use, treatment
Increa sed awareness of the prevalence of substance abuse coexisting with psychiatric disorders is challenging the chemical dependency treatment system to adapt to the special needs of this population. More and more practitioners , asking how best to do this, find themselves facing major training tasks. Familiarization with the concepts and language of mental health practitioners is a key element in this endeavor, and nowhere is the challenge more ev -
ident than in situations where psychosis is a feature . Typic ally, chemical dependency treatment providers are most fearful of dealing with the population that manifests psychotic symptoms, whether acute or chronic. This article attempts to demystify psychotic conditions by offering a review of some common situations that arise and how they might be addressed, particularly from the perspective of appropriate and inappropriate use of prescription drug s. It presents an overview of psychotic states that may occur as a function of substance abuse, including intoxication , overdose, withdrawal , and in later stages of recovery. It then addresses more severe psychiatric disturbances in wh ich psychotic states are part of an enduring condition, in which they can be expected to recur. In addition, it con sider s both attempts to self-medicate by the patient and prescribing con siderations for the treating physician. A recent large-scale epidemiological study (Regier et aJ. 1990) documents the magnitude of the problem. Over 20,000 people were interviewed in the total community (i.e., both in and out of treatment) and institutional population of this study, which examined the problem from multiple perspectives. Among those with a mental disord er, the odds ratio of having some addictive disorder was 2.7, with a lifetime prevalence of 29% . Among those with an alcohol disorder, 37% had a comorbid mental disorder. Those with drug disorders manifested the highest mental-
tlbi s article is based on forums offered through the Primary Addiction Linkage Services (PALS) Training Project and the Train ing and Education Section of the Haight-Ashbury Free Clinics, Inc. PALS links substance abuse treatment and primary care providers, and provides linkages among a methadone maintenance clinic , adolescent substance abuse services, addiction med icine case consultation, and substance abuse tra ining through its multidisciplinary adjunct faculty. - Executive Director, East Bay Community Recovery Project and The 14th Street Clinic and Med ical Group, Oakland, California; Staff Psychologist, Substance Abuse Inpatient Unit, Veterans Affairs Medical Center, San Francisco, California. --Founder and Medical Director, Haight-Ashbury Free Clin ics, Inc., San Francisco; Research Director, Merritt Peralta Institute, Oakland, California; Associate Clinical Professor of Occupa tional Medicine and Clin ical Toxicology, University of California Medical School , San Franci sco. "-Chief, Substance Abuse Inpatient Unit, San Francisco Veterans Affairs Hospital; Chief, Psychiatric Serv ices, Haight-Ashbury Free Med ical Clin ics, Inc., San Francisco; Assistant Clinical Professor of Psychiatry, University of California School of Medicine, San Francisco. Journal ofPsy choactive Drugs
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addictive disorder comorbidity rate, with 53% having a mental disorder (odds ratio of 4.5). The data confirmed that individuals with multiple disorders have more incentives to seek treatment. Those treated in specialty mental health and addictive disorder clinical settings have significantly higher odds of having comorbid disorders. Among the institutional settings, comorbidity of addictive and severe mental disorders was highest in the prison population, particularly among those having antisocial personality disorder, schizophrenia, and bipolar disorders. The implications of such cornorbidity for the treatment provider arc far-reaching. The severity of psychiatric symptoms in persons seeking treatment for primary substance abuse is one of the best predictors of substance abuse outcome; more severe symptoms predict poorer outcome (McLellan 1986). Outcomes for psychiatric patients are typically poorer than for those without coexisting disorder. Osher and Kofoed (1989) noted that dually diagnosed patients demonstrate increased rates of hospitalization, utilization of acute care services, housing instability and homelessness, violent and criminal behavior, suicidal behavior, and poor medication compliance. This article first describes various phenomena characteristic of psychotic states, and then discusses appropriate medication strategies when substance abuse precipitates these symptoms. It then focuses on various medication and self-medication issues that commonly arise with severely disturbed patients.
siveness, or including irrelevant and extraneous details; (5) neologisms, new words that have private meanings; (6) perseveration, or an inability to change topics; (7) blocking, in which the flow of thoughts is stopped, often followed by a new and unrelated thought; (8) derailment, in which it is impossible to follow the logic of associations; and (9) echolalia, in which the patient repeats words back to the interviewer. These characteristics reflect the disordered structure or form of thinking. Goodwin and Guze also described ways in which thought content, what the patient thinks and talks about, is disturbed. These include hallucinations, delusions, obsessions, compulsions, phobias, and preoccupations deemed relevant to the psychiatric problem. They defined delusions as fixed false ideas not amenable to logic or social pressure, or incongruent with the patient's culture. These are distinguished from superstitions or other overvalued ideas in which the patient has a fixed idea that most people consider false, but which cannot be disproven or is not entirely unreasonable. Delusions can occur in a variety of psychiatric conditions, such as organic brain disorders, schizophrenia or affective disorders, as well as in intoxicated states and withdrawal from substances. Goodwin and Guze also described perceptual disturbances of thought content, including illusions (in which real stimuli arc mistaken for something else) and hallucinations (perceptions without an external stimulus). Hallucinations can be visual, auditory, olfactory, haptic (tactile), extracampine (seeing objects outside the sensory field), or atoscopic (visualizing oneself projected into space). Other perceptual distortions, also seen in a range of less severe conditions, include depersonalization (the feeling that one has changed in some bizarre way), derealization (the feeling the environment has changed), and deja vu (a sense of familiarity with a new perception). The ways in which these phenomena may appear in states of intoxication, withdrawal, or overdose are reviewed below.
CHARACTERISTICS OF PSYCHOTIC STATES The term "psychosis" has evolved over time and practitioners should be aware of differing and conflicting usage (Campbell 1989). Loosely used to indicate severe disorders, it has traditionally referred to organic brain syndromes, affective psychoses (such as manic depressive psychosis), paranoid states and psychotic depressive reactions. More narrowly defined (Goodwin & Guze 1989), it refers to the presence of persistent hallucinations, delusions, and/or disordered thoughts. Although addiction treatment professionals do not usually have the training to detect anything but an obvious thought disorder, it is important that they become familiar with what skilled diagnosticians mean by the term "thought disorder." Distinguishing thought disorder from subcultural variations in style and slang expressions can sometimes be difficult, but according to Goodwin and Guze 1989, a formal thought disorder includes the following: (1) association patterns that are "loose," tangential, circumstantial or incoherent; (2) flight of ideas, in which connections between ideas seem very tenuous (often accompanied by pressured speech); (3) clang associations, in which one word is used after another because they sound similar; (4) overincl uJOUTna/ of Psychoactive Drugs
SUBSTANCE USE CONDITIONS PRESENTING WITH THOUGHT DISORDER Good differential diagnosis in the emergency room is essential to avoid confusing toxic states with more enduring conditions. Psychotic symptoms may occur as a result of intoxication, withdrawal or overdose, and are indistinguishable from those occurring in the context of schizophrenic or major affective disorders. It is important to have sound procedures to help distinguish these conditions, not only to promote appropriate treatment but to avoid the sometimes devastating consequences to the patient, particularly an adolescent, of being incorrectly labeled as having a severe chronic disorder. An accurate diagnosis in the emergency room setting 388
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diazepines, the other major class of medications used in the acute situation. A different set of criteria should be applied when considering the clinical indication for this class of medications. Benzodiazepines are used to treat the withdrawal symptoms of alcohol and other minor tranquilizers (e.g ., benzodiazepines and barbiturates). Because withdrawal from these substances can lead to serious medical complications, the thoughtful clinician should not hesitate to use benzodiazepines in patients who are in withdrawal from minor tranquilizers. The patient experiencing severe withdrawal from minor tranquilizers or the mixed withdrawal/overdose patient who also manifests psychotic symptoms also presents a special situation. In these cases, the combination of an antipsychotic and a benzodiazepine is often clinically indicated and care should be taken to administer an adequate dose of bcnzodiazepines to treat withdrawal symptoms and to the lowest adequate dose of an antipsychotic to treat any psychotic symptoms. One example is the patient who has abused the common drug combination of alcohol and amphetamine, presenting with acute alcohol withdrawal and amphetamine hallucinosis (i.e., severe agitation, auditory hallucinosis, and paranoid ideation with ideas of reference). This patient would require a benzodiazepine to treat the alcohol withdrawal and an antipsychotic for other symptoms. In this situation, an antipsychotic is too often used alone, with the risk that the alcohol withdrawal remains untreated . This omission could result in the development of seizures or delirium tremens. Antipsychotic medications alone are not suitable for use in the treatment of minor tranquilizer withdrawal.
is difficult at best. It cannot be stressed enough that psychotic symptoms can be seen with an extremely wide range of medical and psychiatric conditions. In evaluating the emergency room patient who presents with psychotic symptoms, care must be taken to ensure that the patient is medically stable. The medical evaluation of the psychotic patient in the emergency room is beyond the scope of the present article (see Smith & Landry 1988 ; Slaby, Lieb & Tancredi 1985). Proper evaluation of the patient should include serum and/or urine toxicologies, as these provide the only definitive method of determining the presence of substances. This information is critical in making the differential diagnosis once the patient is found to "be medically stable. At this point in the evaluation, care should be taken to use psychotropic medication only if the clinical situation warrants. The presence of psychotic symptoms is not an automatic indication for the use of antipsychotic medication; careful use of medication helps prevent the confusion in the clinical picture that results from adding a drug to a drug. There are situations, however, when the use of medications in the acutely psychotic substance abusing patient is indicated - for example, the use of an antipsychotic to treat the severe paranoia and agitation often seen in stimulant overdose. As a general rule, it is preferable to use antipsychotics only if the patient is distressed by his or her symptoms. Recognizing a tox ic psychosis may also be essential to avoid precipitating a life-threatening medical emergency. A patient presenting with a stimulant psychosis may be indistinguishable from one with mania or agitated paranoid schizophrenia. Haloperidol (Haldol), often used in this situation, lowers the seizure threshold, as does cocaine; thus administering haloperidol to a stimulant-intoxicated patient amplifies the danger of seizures. In addition, use of neuroleptics to control a manic patient who is abusing stimulants may precipitate a hyperthermic crisis that can result in death unless appropriate measures are taken (Kosten & Kleber 1988, 1987). These and other potential medical complications do not necessarily contraindicate the use of antipsychotics in the patient who has ingested toxic substances. Rather, it is important to have an accurate diagnosis so that an adequate level of vigilance can be maintained to assure safe use in the crisis situation. It should be stressed that antipsychotic medication should be used to manage disruptive patients only when the patient is in a psychotic state, not merely for disruptive behavior itself. In this situation, the use of a high potency neuroleptic (haloperidol or droperidol) is recommended. Although short-acting benzodiazepines are gaining in popularity in the management of the disruptive patient, they should not be used when intoxication is suspected. The clinician should be alert to the possibility that benzodiazepines can worsen agitated patients by disinhibiting them . There are, however, appropriate indications for benzoJOIUNlI
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Intoxication Alcohol, stimulants, hallucinogens, phencyclidine and inhalants can all produce toxic psychoses. It is common for stimulants (cocaine, amphetamine) to manifest paranoid symptomatology indistinguishable from a paranoid schizophrenic disorder. These patients may appear for treatment carrying weapons and may attempt to use them against the medical staff during their suspicious confusion. Safety procedures are mandatory and practitioners should not attempt to manage these patients in the private practice setting. Tactile hallucinations (formication) are also characteristic. (An anecdotal report from the 1980s described a cocainesmoking patient who visited every parasitologist in the San Francisco area for help with the bugs under his skin and not one questioned him about his drug use .) As with other drug induced psychoses, toxicology screens are indispensable to clarify the diagnosis in the immediate situation and most toxic psychoses will clear within days to weeks. Patients may escalate their doses of anticholinergic drugs in an effort to enhance their intoxicating properties or they may present for emergency treatment in a psychotic state resulting from these drugs but easily mistaken for a 389
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reemergence ofpsychosis (faylor 1990). Anticholinergics areused to treat the parkinsonian symptoms associated with high potency neuroleptics. They can produce hallucinations, delirium, agitation, disorientation, short term memory loss, dizziness, elevated temperature, blurred vision, and dryness in the mouth and other mucous membranes. Evans and Sullivan (1990) noted that schizophrenics sometimes abuse these medications because of the "buzz" they provide and caution practitioners to be alert for patients who run out of their side effect medication before their antipsychotic medication, as they could be using or selling their anti cholinergic medication. The patient who presents with anticholinergic delirium is very difficult to distinguish from one with other clinical conditions. A history of ingestion of anticholinergic medication is obviously the best indicator, but rarely available to the clinician. The presence of visual hallucinations may point toward this type of intoxication but is not definitive. Also, certain cardiac fmdings may be present that would suggest a diagnosis of anticholinergic intoxication (i.e., widened QRS complex, prolonged QT interval and rapid heart rate). In the patient who presents with this symptom complex, the conservative way to proceed is to stabilize the patient med ically and observe without the addition of medications if possible . A high-potency medication like haloperidol could be used in low doses to help treat the agitation that often accompanies this fonn of delirium. When varying classes of intoxicating drugs are involved, differential diagnosis can be difficult in the dual diagnosis patient. For example, a patient with a prepsychotic condition who is functioning fairly well may take a potent hallucinogen, such as LSD, and precipitate a severe psychotic disorder. Another patient with a severe psychotic disorder may self-medicate by taking an opioid, such as heroin or methadone, that has an antipsychotic effeet, Yet another class of patients may fmd that the antipsy chotic drugs have numbing side effects producing sexual dysfunction and may use stimulants, such as amphetamines or cocaine, to counteract the side effects, but in the process aggravate the psychotic disorder. Detoxification from these self-administered drugs is necessary to distinguish between symptom generation from the intoxicant and symptom reemergence of the underlying psychotic disorder. As stated previously, psychosis is a symptom or set of symptoms that can be seen in a variety of conditions. There is no definitive method to tease out what substances may be involved. Toxicologies are helpful, as is obtaining a history from people who arc familiar with the patient. Once the patient is determined to be medically stable, the clinician has time to observe the patient, and if he or she is not distressed by the psychotic symptoms, the clinician should attempt to observe the patient off all medications. If the patient finds the symptoms bothersome, he or she Journal of Psychoa ct ive Drugs
should be placed on the lowest dose of an antipsychotic necessary to control thesymptoms, and then observed The resulting clinical course should be compared with that of previous treatment episodes. After a period of initial stabilization, the patient should be tapered off medication and the symptoms evaluated at that time. An accurate diagnosis can only be made with the benefit of time and observation. Withdrawal Psychotic presentations are not a usual part of the uncomplicated withdrawal syndrome. If the withdrawal is done adequately, with sufficient medications, then the occurrence of psychosis should be minimal. However, psychotic symptoms are occasionally seen in the course of routine withdrawal and usually indicate that the patient remains intoxicated, has an organic brain syndrome or has a preexisting psychiatric condition. The management of patients with these presentations is discussed elsewhere in this article. Overdose The patient who presents with an overdose of alcohol should be treated in a medical setting where life-support equipment is readily available. This is necessary to address the respiratory depressant effects of alcohol, especially problematic in patients who manifest a high tolerance to alcohol's sedating effects. Such a patient will present with extremely high blood alcohol levels but will be conscious or only minimally sedated because of the patient's high tolerance to the sedating effects of the drug. However, the patient will not have developed a tolerance to the respiratory depressant effects of alcohol, and the clinician must avoid a false sense of security that this patient can tolerate a minimally supervised detoxification. The addition of a benzodiazepine to the alcohol already present in the system may precipitate a state of respiratory depression. When a patient presents with high blood alcohol levels, care must be taken to avoid precipitating a respiratory crisis. A similar situation exists in patients with a high level of tolerance to other minor tranquilizers. Benzodiazepines are the most often abused drugs in this category, but barbiturates continue to be encountered frequently in the clinical situation. The risk of respiratory depression is a problem in the management of these patients. Those presenting with a sedative-hypnotic overdose should receive close medical supervision throughout all phases of treatment, including careful monitoring of vital signs, as this class of drugs depresses cardiorespiratory function. The patient who presents with an overdose of stimulants presents a variety of clinical challenges. Because stimulant abuse often obscures indications of other medical problems, these patients should receive a thorough medical evaluation, and because polydrug abuse is so common in this group, the clinician should consider that other substances may be contributing to the clinical picture. 390
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ications should be used only in the context of psychotic symptoms that are disturbing to the patient or causing violent acting out Medication with benzodiazepines has no role in the treaunent of hallucinogen overdose unless it is accompanied by minor tranquilizer withdrawal.
Stimulants and minor tranquilizers are popular drug combinations; patients often add a minor tranquilizer to their reg imen to attenuate the effects of stimulants. Thus they often present with a mixed stimulant and tranquilizer overdose. In the case of an uncomplicated stimulant overdose, the patient - once medically stabilized - should be handled in a psychiatric setting where physical restraints are available. These patients are often extremely psychotic and potentially violent. High-potency antipsychotics, such as droperidol and haloperidol, are both commonly used in this situation; however, droperidol has a powerful antipsychotic action in addition to being more strongly sedating. Extreme caution should be used in dealing with these patients because of the very real risk of violence. The safest procedure is to have the patient placed in restraints prior to the administration of medications. This accomplishes many things simultaneously. First and foremost, the safety of both patients and staff is assured. In addition, because of the risk of transmission of my disease, intramuscular administration of medications can be accomplished with minimal risk to staff. As with any use of antipsychotic medications , care should be taken to use the smallest amount of medication that is clinically effective, without being so conservative that the dose is insufficient and the patient is subjected to unpleasant symptoms longer than necessary. When the patient presents with a mixed stimulant and minor tranquilizer overdose, the risks of respiratory depression continue to be present but now the clinician faces a patient who can be extremely psychotic and potentially violent Benzodiazepines must now be added to the treatment approach. Ideally, this patient should be managed in a hospital psychiatric setting where life-support equipment is readily available. In addition to the use of haloperidolor droperidol to address the psychotic symptoms, a short-acting benzodiazepine, administered intramuscularly, is appropriate. One of the present authors (Stewart) has had good results using a combination of droperidol and lorazepam. The benzodiazepine should be used to control any withdrawal symptoms from the minor tranquilizers and not to address any behavioral manifestations of stimulant overdose. Hallucinogen or PCP overdose is another situation that is best handled in a psychiatric setting where staff is well versed in the use of physical restraints. The usual clinical manifestation is severe psychotic decompensation with the potential for violent acting out. As in the situations discussed previously, the patient should first be medically stabilized. Due to the extreme degree of disorganization and the potential for violence, these patients should be placed in physical restraints prior to any psychiatric intervention. The optimal situation is to keep the patient in a safe and protected environment while the offending agents work themselves out of the patient's system. Antipsychotic medJournal ofPsychoactive Drugs
ORGANIC BRAIN SYNDROMES PRESENTING WITH PSYCHOTIC SYMPTOMS AS A RESULT OF PROLONGED SUBSTANCE USE Two distinct clinical entities resulting from prolonged substance use are alcohol hallucinosis and organic delusional disorder secondary to amphetamine abuse. Both conditions present with a variety of psychotic symptoms that include but are not limited to auditory hallucinosis , paranoid ideation, ideas of reference as well as other irregularities of thought content and thought process. In both cases, these symptoms present in a patient who is neither intoxicated nor in withdrawal. In the case of alcohol hallucinosis, the symptoms usually appear in the fourth or fifth decade and have been preceded with heavy alcohol intake for a number of years. No exact amount of alcohol or time frame is required, though the patient will have been drinking heavily for years. The symptoms have an insidious onset, with the patient usually hearing buzzing or clicks that can develop into full-blown hallucinations. Concurrently, a variety of psychotic symptoms may appear, such as auditory hallucinations, paranoid ideation and ideas of reference. The patient may assume these are the result of drinking and even stop temporarily. For some, the symptoms decrease and eventually stop over a period of days to weeks if they do not drink. For others, the symptoms persist in the absence of alcohol intake and require treatment with antipsychotic medications. The situation with amphetamine-induced organic delusional disorder is quite similar. These patients have often experienced psychotic symptoms while intoxicated on amphetamines. In the case of organic delusional disorders, these symptoms will persist in the absence of amphetamine intoxication. These patients usually present with auditory hallucinations and paranoid ideation. They may also attempt to address their symptoms by discontinuing their drug use. Their symptoms may abate with abstinence, but a significant number will need antipsychotic medication for symptomatic relief. The exact time course of both disorders is unclear. Patients' symptoms tend to last days or weeks, but continued alcohol and other drug use as well as premature dropout from treatment makes the time parameters difficult to assess. One of the present authors (Stewart) has followed a patient with alcohol hallucinosis for more than two years, and other clinicians report protracted psychotic 391
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episodes, diminishing in frequency and duration, from chronic cocaine use (Clark 1991).
1990) have made significant contributions in the effort to understand complex relationships between subgroups of schizophrenics, their drug use preferences, and outcomes. They reviewed experimental and observed clinical effects of drug abuse in schizophrenic patients and explored the patients' stated reasons for use and subjective effects of intoxication. Acknowledging the abundance of evidence that drug abuse exacerbates psychotic symptoms, they noted that abused drugs may lead to transient symptom reduction in subgroups of schizophrenics. Noting that some patients described feeling less dysphoric or anxious and more energetic while intoxicated, they studied the characteristics of these subgroups, and offered some models for understanding the clinical phenomena. They examined the possibility that schizophrenic patients who abuse drugs may represent a subgroup of patients with better prognoses and less severe clinical characteristics of schizophrenia, but their drug abuse may adversely affect global outcome. The drug abusing schizophrenic patients showed less overall pathology than schizophrenic patients without drug abuse on measures of positive and negative symptoms at discharge. However, measures of global functioning were equivalent. Dixon and colleagues postulated that drug abuse may impair global functioning sufficiently to compromise any transient amelioration of pathology in drug abusing patients. Moreover, Dixon and colleagues reviewed some models that potentially aid in understanding why schizophrenic patients abuse drugs that can increase psychosis, but from which some apparently derive beneficial effects. The socializing effects model proposes that such drug use may be a socializing phenomenon, providing isolated, socially handicapped individuals with an identity and social group. However, their data also indicate that for many, drug abuse is a solitary phenomenon. The self-medication model emphasizes drug use as an attempt to ameliorate a wide range of distressing symptoms. It appears that some patients prefer drugs that counteract the negative symptoms of schizophrenia (apathy, withdrawal, unresponsiveness), while others are attempting to self-medicate the uncomfortable extrapyramidal symptoms (parkinsonlike symptoms, such as tremor and muscular rigidity, and the agitated pacing of akathisia) induced by the neuroleptics. They consider the anergia associated with the negative symptoms as a potentially important factor. However, they postulated that there is a "critical window" for the propensity to selfmedicate; patients with too few or too many negative symptoms may not effectively maintain a drug habit. The use of opioids to self-medicate in schizophrenia is an intriguing topic that warrants further exploration. It would appear that a small subgroup of the heroin-dependent population uses opioids to reduce the discomfort of psychotic states. Clinicians have long suggested that opioids have antipsychotic properties. O'Brien, Woody &
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GUIDELINES FOR DIAGNOSIS There is currently no substitute for observation over time to distinguish manifestations of alcohol and other drug use from symptoms of underlying pathology. Unfortunately, fiscal constraints have shaped a health care environment that disrupts the continuity of treatment and makes it difficult to get the kind of consistent information that produces accurate diagnosis. Ever briefer inpatient stays mean that the patient is discharged at or before the time needed for differentiating between the sequelae of substance use and more enduring conditions. In this environment, creating mechanisms for continuity of care is an important task of the health care provider. Adopting a longitudinal approach, with provisional diagnoses, is necessary to avoid labels that dictate inappropriate treatments. Practitioners have noted (e.g., Brown et al. 1989: 567) that " ... the interacting effects of substance use, psychological disorder, and escalating social disability cannot be unraveled in a single brief encounter." When possible, it is useful to obtain information from the patient, family members, significant others, and fellow users. Physical examinations yield clarification and toxicology screens are useful on admission and for ongoing surveillance for continuing substance use. Clinicians have noted that one barrier to using toxicology screens more routinely is the practice by mental health funding sources of disallowing payment if a toxicology screen reveals evidence of an addictive disorder. It is crucial for institutional leaders to mobilize to remove this and similar barriers to effective diagnosis and treatment. It is important to appreciate that the patient need not meet criteria for addiction in order for alcohol and other drugs to undermine functioning. Kosten and Kleber (1988) noted that schizophrenics are usually quite sensitive to the disorganizing effects and manifest substantial symptoms with even relatively small amounts of alcohol, marijuana or stimulants. However, opiate use is associated with a reduction of psychotic symptoms during periods of use (Kosten & Kleber 1988; Millman 1982; Comfort 1977), and with a worsening during withdrawal. Other drugs, notably alcohol, marijuana and cocaine, may result in a worsening of the global clinical picture, but actually provide some temporary relief from distressing symptoms during periods of intoxication.
SELF-MEDICATION IN SCHIZOPHRENICS Although substance use adversely affects the longterm picture, patients attempt to self-medicate with illegal drugs and describe benefits. Dixon and colleagues (1991, Journal of Psychoactive Drugs
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fects, which include disturbances of erection and ejaculation, changes in libido and priapism in men, and decreased libido, orgasmic dy sfunction and menstrual irregularities in women, are estimated to occur in 30% to 60% of persons taking the drugs . They offered some pharmacological interventions to address these problems, such as gradually reducing the dose, changing the medication or administering other medications that are known to improve sexual dysfunction . It is important to remember, however, that sexual dysfunction can also occur as a result of the disorder (e.g., fear of boundary loss, fear of intimacy, penetration). The physician can explore the possibility that the medication is the source of the problem by trying some of the adjustments suggested, but clinicians involved with the patient need to be attentive to the other issues involved. Thus it is important for the clinician to inquire carefully to understand the role of drug use in the total picture. All drug users tend to be more focused on the immediate effects of their drug use (e.g., short-term sedating and anxiolytic effects) and are less likely to connect adverse consequences that unfold over time. In the course of exploring the patient 's unique pattern and its underpinnings, the clinician can provide appropriate educational input along these lines. Schizophrenic patients especially need to understand that any drug use can undermine progress by exacerbating symptoms and decreasing compliance with the treatment regimen (Evans & Sullivan 1990a,b; Pristach & Smi th 1990; Drake et a1. 1990). Pr istach and Sm ith studied schizophrenic inpatients on an acute care ward in an effort to explore the interplay between sub stance use and noncompliance with prescribed medication and the role of each factor. They found that the majority of patients admitted drinking alcohol during the month preceding admission, and most of these patients discontinued their medication while drinking. There were no significant differences between the group defined as abusers and those who were not, and their behavior was not correlated with either the occurrence of any specific side effect or the total of side effects. Thus it appears that all patients are susceptible and should be cautioned about alcohol and drug use, whether or not they meet criteria for abuse or addiction or fall into a category of mod erate or social use. Evans and Sullivan (1990a) recommend working simultaneously on educating patients about the differences between medications (good) and drugs (bad). Simple, clear, repetitive focus on basic concepts is essential to discourage illicit drug use while encouraging the patient to take pre scribed medication. Inasmuch as schizophrenic patien ts have trouble integrating new information and translating it into behavior, Evans and Sull ivan work carefully with concrete tools, such as index cards, asking patients to list reason s why it is important to remain clean and sober on one card and why it is important to take their medication on another.
McLellan (1984) noted empirical studies that support this view by indicating relatively low rates of schizophrenia (compared to rates predicted for the same socioeconomic group) in the opioid-dependent population. Clinicians in methadone maintenance treatment settings are familiar with the phenomenon of thought disordered patients who appear to be calmed and stabilized by methadone; one such patient referred to methadone as his "sanity syrup." This group, who may refuse antipsychotic medication, often becomes disorganized when their methadone doses drop (Comfort 1977). Methadone maintenance treatment offers a stabilizing environment for these patients, who particularly benefit from the combination of frequent contact and relatively low psychological intrusiveness (Zweben 1991). Verebey (1982: xi) likens the clinically observed antipsychotic effects of opioids to "the anatomic distribution of opiate receptors and endorphins and to the biochemical and neurophysiological similarity between the effects of opiates and neuroleptic drugs." He recommended further study to confirm these findings and to identify diagnostic categories that may respond to opioid treatment. Verebey and others have noted the benefits of ident ifying an alternative that does not carry the risk of tardive dyskinesia and other serious complications resulting from the antipsychotic medications currently in widespread use . Efforts in this direction were reported by Brizer and colleagues (1985), who noted marked improvement in a small sample of chronic, severely ill patients given methadone as an adjunct to neuroleptics. As expected, the patients' agitation was dimin ished, but surprisingly, their thought disorders were also reduced. Possible explanations include a specific antipsychotic effect of methadone, an anxiolytic effect or a synergism between neuroleptics and methadone. In contrast to the heroin-dependent population, withdrawal from methadone in this sample resulted in no drug-seeking behavior, abstinence syndromes or related problems. Thus it appears that chronically opioid-dependent pat ients may be a biochemically distinct subgroup, suggesting it may be possible to extend the use of opioids in disturbed patients who do not fall into this group without creating long-term problems. Another dimension, rarely discussed, is the use of illicit drugs (e.g., stimulants, such as amphetamine or cocaine) to medicate sexual dysfunction occurring as a side effect of neuroleptics. Some patients on neuroleptics describe great reduction in sexual des ire and use stimulants to enhance sexual feelings and function . However, the stimulants may destabilize their psychosis. With careful questioning, many patients report sexual dysfunction, and often attribute it to their medication. Sullivan and Lukoff (1990) noted the absence of investigation and clinical attention to neuroleptic-induced sexual dysfunction and speculated about the role of discomfort with the notion that seriously mentally ill persons are sexual beings who are sexually active. They emphasized that sexual side efJournal a/Psychoactive Drugs
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ician. It is important to identify meetings in the community that are more likely to be tolerant of unusual behavior and the use of medication. An Alcoholics Anonymous (AA) (1984) publication, The AA Member - Medications and Other Drugs. Reportfrom a Group ofPhysicians in AA, makes it quite clear that medication appropriately prescribed by a physician familiar with the issues of recovering patients in no way disqualifies a patient from AA participation. Indeed, the pamphlet is quite emphatic that no AA member is to play doctor. Nonetheless it is quite common for other 12-Step program members to propose that drug use of any kind is incompatible with recovery, so in addition to providing this pamphlet (available from the AA central office) it is important to provide other support to the patient who goes to 12 -Step meetings. Simulations have been used to clarify for the patient what meetings are like and how to behave there. Role-play can also be used to prepare the patient to respond to members who are critical of medication use . In fostering 12-Step program participation, it is important to be aware of the fact that powerlessness is likely to be a very sensitive issue and it may be more useful to emphasize that the patient will gain power over his or her life through abstinence, rather than dwelling on the importance of the experience of powerlessness. Similarly, the Higher Power can be readily incorporated into a delusional system, and selecting a concrete, benevolent force (such as a person or activity) may be less hazardous. Several workbooks on 12-Step work for the dually disordered patient are now available. Each tailors its presentation to the characteristic limitations of the particular disorder. Evans and Sullivan (1 990b) offer handouts and specific guidelines for facilitators in their recent work.
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OTHER TREATMENT CONSIDERATIONS A comprehensive presentation of the treatment of severely disturbed patients who use alcohol and other drugs is beyond the scope of this article; however, some of the highlights will be reviewed. Although important, medication issues must be viewed in the context of a total treatment effort that addresses addictive disorders on psychosocial as well as medical levels. There are currently many impediments to effectively addressing the problems of dual diagnosi s patients (Wallen & Weiner 1989) and the task of the 1990s is to create a hybrid approach that meets the needs of these patients without subjecting them to the confusing and frustrating process of shuttling between the chemical dependency and mental health systems. The clinician working with severely disturbed patients needs to maintain realistic expectations while offering hope and direction to counteract the despair of the pati ent and family members. Isolated and homeless pa tients may require assertive outreach that is focused on providing help with their basic needs and giving support during a crisis to entice them into a treatment setting where they may then become engaged in a treatment pro cess (Osher & Kofoed 1989). Leverage obtained from engaging family members is helpful in improving retention, and the process of persuading the patient to cooperate in establishing abstinence may be a long one indeed. The questionable practice of terminating patients who do not readily comply with the treatment provider's expectation of a relatively unambivalent abstinence commitment (Wash ton & Stone-Wash ton 1990; Zweben 1989) make s even less sen se when dealing with a dual diagnosis pop ulation. Instead, painstaking and unhurried work geared to the information processing capability of the thought disordered patient is necessary to develop a foundation for an abstinence commitment. Osher and Kofoed (1989) noted that persuading these patients to accept long-term abstinence-oriented treatment is often difficult because these patients are typically unemployed and unaffiliated, and hence eseape many of the social pressures that make other patients more cooperative. Their impaired ability to process information, depressive cognition or organic brain syndromes make it difficult for staff to influence their denial. These patients need firm feedback to improve their reality testing within an overall context of support, despite their lapses. The aggressive exchanges considered therapeutic in many conventional chemical dependency treatment settings frequently precipitate regression in the schizophrenic patient.
CONCLUSION This paper has explored a range of issues that face the clinician who encounters psychotic conditions in the context of substance usc. As the gap between the mental health system and the chemical dependency treatment system narrows, clinicians in a wide variety of settings will prepare to meet the needs of this challenging group. Emergency room physicians, accustomed to psychotic patients , must maintain current knowledge of how prescribing guidelines change when substance abuse is a factor. Practitioners in a wide range of settings need to understand various patterns of self-medication; they must be especially sensitive to how the patient can accomplish his or her goal in ways that do not have the unintended and delayed consequences of abused drugs. Finally, clinicians in the chemical dependency treatment system need to apply their creativity to modifying and adapting treatment practices to meet the needs of this very challenging population.
TWELVE·STEP PROGRAM PARTICIPATION Encouraging appropriate 12-Step program participation requires careful preparation on the part of the clinJournal of Psychoactive Drugs
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REFERENCES ates: Clinical observations. In: Verehey, K. (Ed .) Opioids in Mt!ntal Illness: Theories, Clinical Observations, and Treatment Possibilities. Annals ofthi! New York Academy ofSciences. Vol. 398. New York: New York Academy of Sciences. O'Brien, e.P.; Woody, G.E. & McLel1an, A.T. 1984. Psychiatric disorders in opio id dependent patients . Journal of Clinical Psychiatry Vol. 45(12): 9-13 . Osher, EC. & Kofoed, LL. 1989. Treatment of patients with psychiatric and psychoactive substance use disorders. Hospital and COmmJUliJy Psychiatry Vol. 40(10): 1025 -1030. Pristach, C.A. & Smith, e.M. 1990. Medication compliance and substance use among schizophrenic patients. Hospital and Community Psychiatry Vol. 41(12): 1345-1348. Regier. D.A .; Farmer, M.E.; Rae, D.S.; Locke, B.Z.; Keith, S.J.; Judd, L.L. & Goodwin, EK. 1990. Comorbidity of mental disorders with alcohol and other drug abuse. Journal of the Amttrican Medical Association Vol. 264(19): 2511 -2518. Slaby, A.E.; Lieb, J. & Tancredi, L. 1985 . Handbook of Psychiatric Emergencies. 3d ed. New York : Medical Examination Publishing. Smith, D.E. & Landry, M . 1988. Substance use disorders : Drugs and alcohol. In: Goldman, H. (Ed .) Review of General Psychiatry. Los Altos, California: Lange Med ical . Stoffelmayr, B.E.; Benishek, L.A.; Humphreys, K.; Lee, J.A. & Mavis, B.E. 1989. Substance abuse prognosis with an additional psych iatric diagnosis: Understanding the relationship. Journal ofPsychoactive Drugs Vol. 21(2): 145 -152. Sullivan, G. & LukofJ, D. 1990. Sexual side effects of antipsychotic medication : Evaluation and interventions. Hosp ital and Community Psychiatry Vol. 41(11): 1238 -1241. Taylor, R. 1990. Distinguishing Psychologicalfrom Organic Disorders. New York: Springer. Verebey, K. 1982. Introduction. In: Verebey, K. (Ed .) Opioids in Mental Illness : Theories, Clinical Observations, and Treatment Poss ibilaies. Annals ofthe New York Academy ofSciences. Vol. 398 . New York: New York Academy of Sciences. Wallen , M.C. & Weiner, H.D . 1989. Impediments to effective treatment of the dual diagnosis patient. Journal ofPsy choactive Drugs Vol. 21( 2) : 161-168. Washton , A.M . & Stone-Washton, N. 1990. Abstinence and relapse in outpatient cocaine patients. Journal of Psychoactive Drugs Vol. 22(2): 135-148. Zweben , J .E. In press. Issues in the treatment of the dual diagnosis patient. In : Wallace, B. (Ed .) The Chemically Dependent : Phases of Treatment and Recovery. New York: Bruner Mazel. Zweben, J.E. 1991. Counseling issues in methadone maintenance treatment. Journal ofPsychoactive Drugs Vol. 23(2): 177-190. Zweben, J.E. 1989. Recovery oriented psychotherapy: Patient resistances and therapist dilemmas. Journal ofSubstance Abust! Treatment Vol. 6(2): 123-132. Zweben, J.E. & Smith. D.E. 1989. Considerations in using psychotropic medication with dual diagnosis patients in recovery. Journal of Psychoactive Drugs Vol. 21(2): 221-229.
Alcoholics Anonymous . 1984. TM AA Mt!mbt!r -Mt!dications and Other Drug s . Report from a Group ofPhysicians in AA . New York: Alcoholics Anonymous World Services. Berken, G .H .; Stone, M.M . & Stone, S.K. 1978 . Methadone in schizophrenic rage: A case study . Amuican Journal ofPsychiatry Vol. 132: 248-249. Brizer, D.A.; Hartman, N.; Sweeney, J.& Millman, R .B. 1985. Effect of methadone plu s neuroleptics on treatment-res istant chronic paranoid schizophrenia. Amttrican Journal of Psychiatry Vol. 142(9): 1106 -1107 . Brown, V.B .; Ridgely, M.S.; Pepper, B.; Levine, I.S. ; Ryglewicz, H. 1989. The dual crisis : Mental illne ss and substance abus e. Amttrican Psychologist Vol. 44(3): 565-569. Campbell, R .J . 1989. Psychiatric Dictionary. New York : Oxford University Press. Clark, H.W. 1991. Personal communication. Chief, Substance Abuse & Post -Traumatic Stress Disorder and Substance Abuse & HIV Programs, Substance Abase Service, Department of Psychiatry, San Francisco Veterans Affairs Medical Center. Comfort, A. 1977. Morphine as an antipsychotic. Lancet Vol. I: 443444. Dixon , L; Haas, G; Weiden , P.; Sweeney, J. & Frances, A. 1991. Drug abuse in schizophrenic patients: clin ical correlates and reasons for use. Amttrican Journal ofPsychiatry Vol. 148(2): 224-230 . Dixon, L; llaas, G.; Weiden, P.; Sweeney, 1. & Frances, A. 1990. Acute effects of drug abuse in schizophrenic patients : Clinical observations and patients ' self-reports. Schizophrenia Bullt!tin Vol. 16(1) : 69-79 . Drake, R.E.; Osher, Ee.; Noordsy, D.L.; Hurlbut, S.C.; Teague, G.B. & Beaudett, M.S . 1990. Diagnosis of alcohol use disorders in sch izophrenia . Sch izophrenia Bulletin Vol. 16(1) : 57-67. Evans, K. & Sullivan, J.M . 199Oa. Dual Diagnosis: Counseling the Mentally III Substance Abuser. New York: Guilford. Evans, K. & Sullivan, J.M. 1990b. Step study counseling with the dual disordered client. Center City, Minnesota : lIazelden. Goodwin, D.W. & Guze, S.B. 1989. Psy chiatric Diagnosis. New York: Oxford Un ive rsity Press. Kanas, N. 1988. Substance use disorders : Alcohol. In: Goldman , H. (Ed.) Review ofGeneral Psychiatry. Los Altos, Califomia: Lange Medical. Kaplan,II.S. 1983. The Evaluation ofSexual Disorders: Psychological and Medical Aspects. New York : Brunner/Mazel. Ko sten, T.R. & Kleber, H.D . 1988. Differential diagnosis of psychiatric comorbidity in substance abusers. Journal of Substance Abuse Treatment Vol. 5: 201-206. Kosten, T.R. & Kleber, H.D. 1987. Sudden death in cocaine abusers: Relation to neuroleptic malignancy syndrome. Lan cet Vol. I: 11981199. Lehman, A.E ; Meyers, M.A. & Cony, E. 1989 . Assessment and clas sif ication of patients with psychiatric and substance abuse syn dromes. Hospital and Community Psychiatry Vol. 40(10): 1025. Mclellan, A.T. 1986. Psychiatric severity as a prcdictorof outcome from substance abuse treatm ents . Psych opathology and Addict ive Disorders. New York: Guilford. Millman, R . 1982 . Introductory remarks . Antipsychotic effects of opi -
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Journal of Psychoactive Drugs Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/ujpd20
Psychotic Conditions and Substance Use: Prescribing Guidelines and Other Treatment Issues a
b
Joan Ellen Zweben , David E. Smith & Pablo Stewart
c
a
East Bay Community Recovery Project and The 14th Street Clinic and Medical Group , Oakland , California
b
Haight-Ashbury Free Clinics, Inc. , San Francisco
c
University of California School of Medicine , San Francisco Published online: 20 Jan 2012.
To cite this article: Joan Ellen Zweben , David E. Smith & Pablo Stewart (1991) Psychotic Conditions and Substance Use: Prescribing Guidelines and Other Treatment Issues, Journal of Psychoactive Drugs, 23:4, 387-395, DOI: 10.1080/02791072.1991.10471610 To link to this article: http://dx.doi.org/10.1080/02791072.1991.10471610
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Psychotic Conditions and Substance Use: Prescribing Guidelines and
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Other Treatment Issues" Joan Ellen Zweben, Ph.D. *; David E. Smith, M.D** & Pablo Stewart, M.D. *** Abstract - Th is article examines several circums tances in which psychotic symptoms coexist with substance abuse. It reviews psychotic states that may occur as a result of alcohol and other drug use, including intoxic ation, overdose and withdrawal, offering medication guidelines for managing these situations. It also examines psychiatric disturbances in which psychotic symptoms are recurrent featur es, explor ing patients' self-med ication practices and some strategi es to address them , as well as difficulties commonly encountered with prescription medications. It briefly discu sses other psychosocial int erventions that play a significant role in the treatment of the dual diagnosis patient. Keywords - dual diagnosis, prescrib ing guidelines, psychotic conditions, substance use, treatment
Increa sed awareness of the prevalence of substance abuse coexisting with psychiatric disorders is challenging the chemical dependency treatment system to adapt to the special needs of this population. More and more practitioners , asking how best to do this, find themselves facing major training tasks. Familiarization with the concepts and language of mental health practitioners is a key element in this endeavor, and nowhere is the challenge more ev -
ident than in situations where psychosis is a feature . Typic ally, chemical dependency treatment providers are most fearful of dealing with the population that manifests psychotic symptoms, whether acute or chronic. This article attempts to demystify psychotic conditions by offering a review of some common situations that arise and how they might be addressed, particularly from the perspective of appropriate and inappropriate use of prescription drug s. It presents an overview of psychotic states that may occur as a function of substance abuse, including intoxication , overdose, withdrawal , and in later stages of recovery. It then addresses more severe psychiatric disturbances in wh ich psychotic states are part of an enduring condition, in which they can be expected to recur. In addition, it con sider s both attempts to self-medicate by the patient and prescribing con siderations for the treating physician. A recent large-scale epidemiological study (Regier et aJ. 1990) documents the magnitude of the problem. Over 20,000 people were interviewed in the total community (i.e., both in and out of treatment) and institutional population of this study, which examined the problem from multiple perspectives. Among those with a mental disord er, the odds ratio of having some addictive disorder was 2.7, with a lifetime prevalence of 29% . Among those with an alcohol disorder, 37% had a comorbid mental disorder. Those with drug disorders manifested the highest mental-
tlbi s article is based on forums offered through the Primary Addiction Linkage Services (PALS) Training Project and the Train ing and Education Section of the Haight-Ashbury Free Clinics, Inc. PALS links substance abuse treatment and primary care providers, and provides linkages among a methadone maintenance clinic , adolescent substance abuse services, addiction med icine case consultation, and substance abuse tra ining through its multidisciplinary adjunct faculty. - Executive Director, East Bay Community Recovery Project and The 14th Street Clinic and Med ical Group, Oakland, California; Staff Psychologist, Substance Abuse Inpatient Unit, Veterans Affairs Medical Center, San Francisco, California. --Founder and Medical Director, Haight-Ashbury Free Clin ics, Inc., San Francisco; Research Director, Merritt Peralta Institute, Oakland, California; Associate Clinical Professor of Occupa tional Medicine and Clin ical Toxicology, University of California Medical School , San Franci sco. "-Chief, Substance Abuse Inpatient Unit, San Francisco Veterans Affairs Hospital; Chief, Psychiatric Serv ices, Haight-Ashbury Free Med ical Clin ics, Inc., San Francisco; Assistant Clinical Professor of Psychiatry, University of California School of Medicine, San Francisco. Journal ofPsy choactive Drugs
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addictive disorder comorbidity rate, with 53% having a mental disorder (odds ratio of 4.5). The data confirmed that individuals with multiple disorders have more incentives to seek treatment. Those treated in specialty mental health and addictive disorder clinical settings have significantly higher odds of having comorbid disorders. Among the institutional settings, comorbidity of addictive and severe mental disorders was highest in the prison population, particularly among those having antisocial personality disorder, schizophrenia, and bipolar disorders. The implications of such cornorbidity for the treatment provider arc far-reaching. The severity of psychiatric symptoms in persons seeking treatment for primary substance abuse is one of the best predictors of substance abuse outcome; more severe symptoms predict poorer outcome (McLellan 1986). Outcomes for psychiatric patients are typically poorer than for those without coexisting disorder. Osher and Kofoed (1989) noted that dually diagnosed patients demonstrate increased rates of hospitalization, utilization of acute care services, housing instability and homelessness, violent and criminal behavior, suicidal behavior, and poor medication compliance. This article first describes various phenomena characteristic of psychotic states, and then discusses appropriate medication strategies when substance abuse precipitates these symptoms. It then focuses on various medication and self-medication issues that commonly arise with severely disturbed patients.
siveness, or including irrelevant and extraneous details; (5) neologisms, new words that have private meanings; (6) perseveration, or an inability to change topics; (7) blocking, in which the flow of thoughts is stopped, often followed by a new and unrelated thought; (8) derailment, in which it is impossible to follow the logic of associations; and (9) echolalia, in which the patient repeats words back to the interviewer. These characteristics reflect the disordered structure or form of thinking. Goodwin and Guze also described ways in which thought content, what the patient thinks and talks about, is disturbed. These include hallucinations, delusions, obsessions, compulsions, phobias, and preoccupations deemed relevant to the psychiatric problem. They defined delusions as fixed false ideas not amenable to logic or social pressure, or incongruent with the patient's culture. These are distinguished from superstitions or other overvalued ideas in which the patient has a fixed idea that most people consider false, but which cannot be disproven or is not entirely unreasonable. Delusions can occur in a variety of psychiatric conditions, such as organic brain disorders, schizophrenia or affective disorders, as well as in intoxicated states and withdrawal from substances. Goodwin and Guze also described perceptual disturbances of thought content, including illusions (in which real stimuli arc mistaken for something else) and hallucinations (perceptions without an external stimulus). Hallucinations can be visual, auditory, olfactory, haptic (tactile), extracampine (seeing objects outside the sensory field), or atoscopic (visualizing oneself projected into space). Other perceptual distortions, also seen in a range of less severe conditions, include depersonalization (the feeling that one has changed in some bizarre way), derealization (the feeling the environment has changed), and deja vu (a sense of familiarity with a new perception). The ways in which these phenomena may appear in states of intoxication, withdrawal, or overdose are reviewed below.
CHARACTERISTICS OF PSYCHOTIC STATES The term "psychosis" has evolved over time and practitioners should be aware of differing and conflicting usage (Campbell 1989). Loosely used to indicate severe disorders, it has traditionally referred to organic brain syndromes, affective psychoses (such as manic depressive psychosis), paranoid states and psychotic depressive reactions. More narrowly defined (Goodwin & Guze 1989), it refers to the presence of persistent hallucinations, delusions, and/or disordered thoughts. Although addiction treatment professionals do not usually have the training to detect anything but an obvious thought disorder, it is important that they become familiar with what skilled diagnosticians mean by the term "thought disorder." Distinguishing thought disorder from subcultural variations in style and slang expressions can sometimes be difficult, but according to Goodwin and Guze 1989, a formal thought disorder includes the following: (1) association patterns that are "loose," tangential, circumstantial or incoherent; (2) flight of ideas, in which connections between ideas seem very tenuous (often accompanied by pressured speech); (3) clang associations, in which one word is used after another because they sound similar; (4) overincl uJOUTna/ of Psychoactive Drugs
SUBSTANCE USE CONDITIONS PRESENTING WITH THOUGHT DISORDER Good differential diagnosis in the emergency room is essential to avoid confusing toxic states with more enduring conditions. Psychotic symptoms may occur as a result of intoxication, withdrawal or overdose, and are indistinguishable from those occurring in the context of schizophrenic or major affective disorders. It is important to have sound procedures to help distinguish these conditions, not only to promote appropriate treatment but to avoid the sometimes devastating consequences to the patient, particularly an adolescent, of being incorrectly labeled as having a severe chronic disorder. An accurate diagnosis in the emergency room setting 388
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diazepines, the other major class of medications used in the acute situation. A different set of criteria should be applied when considering the clinical indication for this class of medications. Benzodiazepines are used to treat the withdrawal symptoms of alcohol and other minor tranquilizers (e.g ., benzodiazepines and barbiturates). Because withdrawal from these substances can lead to serious medical complications, the thoughtful clinician should not hesitate to use benzodiazepines in patients who are in withdrawal from minor tranquilizers. The patient experiencing severe withdrawal from minor tranquilizers or the mixed withdrawal/overdose patient who also manifests psychotic symptoms also presents a special situation. In these cases, the combination of an antipsychotic and a benzodiazepine is often clinically indicated and care should be taken to administer an adequate dose of bcnzodiazepines to treat withdrawal symptoms and to the lowest adequate dose of an antipsychotic to treat any psychotic symptoms. One example is the patient who has abused the common drug combination of alcohol and amphetamine, presenting with acute alcohol withdrawal and amphetamine hallucinosis (i.e., severe agitation, auditory hallucinosis, and paranoid ideation with ideas of reference). This patient would require a benzodiazepine to treat the alcohol withdrawal and an antipsychotic for other symptoms. In this situation, an antipsychotic is too often used alone, with the risk that the alcohol withdrawal remains untreated . This omission could result in the development of seizures or delirium tremens. Antipsychotic medications alone are not suitable for use in the treatment of minor tranquilizer withdrawal.
is difficult at best. It cannot be stressed enough that psychotic symptoms can be seen with an extremely wide range of medical and psychiatric conditions. In evaluating the emergency room patient who presents with psychotic symptoms, care must be taken to ensure that the patient is medically stable. The medical evaluation of the psychotic patient in the emergency room is beyond the scope of the present article (see Smith & Landry 1988 ; Slaby, Lieb & Tancredi 1985). Proper evaluation of the patient should include serum and/or urine toxicologies, as these provide the only definitive method of determining the presence of substances. This information is critical in making the differential diagnosis once the patient is found to "be medically stable. At this point in the evaluation, care should be taken to use psychotropic medication only if the clinical situation warrants. The presence of psychotic symptoms is not an automatic indication for the use of antipsychotic medication; careful use of medication helps prevent the confusion in the clinical picture that results from adding a drug to a drug. There are situations, however, when the use of medications in the acutely psychotic substance abusing patient is indicated - for example, the use of an antipsychotic to treat the severe paranoia and agitation often seen in stimulant overdose. As a general rule, it is preferable to use antipsychotics only if the patient is distressed by his or her symptoms. Recognizing a tox ic psychosis may also be essential to avoid precipitating a life-threatening medical emergency. A patient presenting with a stimulant psychosis may be indistinguishable from one with mania or agitated paranoid schizophrenia. Haloperidol (Haldol), often used in this situation, lowers the seizure threshold, as does cocaine; thus administering haloperidol to a stimulant-intoxicated patient amplifies the danger of seizures. In addition, use of neuroleptics to control a manic patient who is abusing stimulants may precipitate a hyperthermic crisis that can result in death unless appropriate measures are taken (Kosten & Kleber 1988, 1987). These and other potential medical complications do not necessarily contraindicate the use of antipsychotics in the patient who has ingested toxic substances. Rather, it is important to have an accurate diagnosis so that an adequate level of vigilance can be maintained to assure safe use in the crisis situation. It should be stressed that antipsychotic medication should be used to manage disruptive patients only when the patient is in a psychotic state, not merely for disruptive behavior itself. In this situation, the use of a high potency neuroleptic (haloperidol or droperidol) is recommended. Although short-acting benzodiazepines are gaining in popularity in the management of the disruptive patient, they should not be used when intoxication is suspected. The clinician should be alert to the possibility that benzodiazepines can worsen agitated patients by disinhibiting them . There are, however, appropriate indications for benzoJOIUNlI
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Intoxication Alcohol, stimulants, hallucinogens, phencyclidine and inhalants can all produce toxic psychoses. It is common for stimulants (cocaine, amphetamine) to manifest paranoid symptomatology indistinguishable from a paranoid schizophrenic disorder. These patients may appear for treatment carrying weapons and may attempt to use them against the medical staff during their suspicious confusion. Safety procedures are mandatory and practitioners should not attempt to manage these patients in the private practice setting. Tactile hallucinations (formication) are also characteristic. (An anecdotal report from the 1980s described a cocainesmoking patient who visited every parasitologist in the San Francisco area for help with the bugs under his skin and not one questioned him about his drug use .) As with other drug induced psychoses, toxicology screens are indispensable to clarify the diagnosis in the immediate situation and most toxic psychoses will clear within days to weeks. Patients may escalate their doses of anticholinergic drugs in an effort to enhance their intoxicating properties or they may present for emergency treatment in a psychotic state resulting from these drugs but easily mistaken for a 389
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reemergence ofpsychosis (faylor 1990). Anticholinergics areused to treat the parkinsonian symptoms associated with high potency neuroleptics. They can produce hallucinations, delirium, agitation, disorientation, short term memory loss, dizziness, elevated temperature, blurred vision, and dryness in the mouth and other mucous membranes. Evans and Sullivan (1990) noted that schizophrenics sometimes abuse these medications because of the "buzz" they provide and caution practitioners to be alert for patients who run out of their side effect medication before their antipsychotic medication, as they could be using or selling their anti cholinergic medication. The patient who presents with anticholinergic delirium is very difficult to distinguish from one with other clinical conditions. A history of ingestion of anticholinergic medication is obviously the best indicator, but rarely available to the clinician. The presence of visual hallucinations may point toward this type of intoxication but is not definitive. Also, certain cardiac fmdings may be present that would suggest a diagnosis of anticholinergic intoxication (i.e., widened QRS complex, prolonged QT interval and rapid heart rate). In the patient who presents with this symptom complex, the conservative way to proceed is to stabilize the patient med ically and observe without the addition of medications if possible . A high-potency medication like haloperidol could be used in low doses to help treat the agitation that often accompanies this fonn of delirium. When varying classes of intoxicating drugs are involved, differential diagnosis can be difficult in the dual diagnosis patient. For example, a patient with a prepsychotic condition who is functioning fairly well may take a potent hallucinogen, such as LSD, and precipitate a severe psychotic disorder. Another patient with a severe psychotic disorder may self-medicate by taking an opioid, such as heroin or methadone, that has an antipsychotic effeet, Yet another class of patients may fmd that the antipsy chotic drugs have numbing side effects producing sexual dysfunction and may use stimulants, such as amphetamines or cocaine, to counteract the side effects, but in the process aggravate the psychotic disorder. Detoxification from these self-administered drugs is necessary to distinguish between symptom generation from the intoxicant and symptom reemergence of the underlying psychotic disorder. As stated previously, psychosis is a symptom or set of symptoms that can be seen in a variety of conditions. There is no definitive method to tease out what substances may be involved. Toxicologies are helpful, as is obtaining a history from people who arc familiar with the patient. Once the patient is determined to be medically stable, the clinician has time to observe the patient, and if he or she is not distressed by the psychotic symptoms, the clinician should attempt to observe the patient off all medications. If the patient finds the symptoms bothersome, he or she Journal of Psychoa ct ive Drugs
should be placed on the lowest dose of an antipsychotic necessary to control thesymptoms, and then observed The resulting clinical course should be compared with that of previous treatment episodes. After a period of initial stabilization, the patient should be tapered off medication and the symptoms evaluated at that time. An accurate diagnosis can only be made with the benefit of time and observation. Withdrawal Psychotic presentations are not a usual part of the uncomplicated withdrawal syndrome. If the withdrawal is done adequately, with sufficient medications, then the occurrence of psychosis should be minimal. However, psychotic symptoms are occasionally seen in the course of routine withdrawal and usually indicate that the patient remains intoxicated, has an organic brain syndrome or has a preexisting psychiatric condition. The management of patients with these presentations is discussed elsewhere in this article. Overdose The patient who presents with an overdose of alcohol should be treated in a medical setting where life-support equipment is readily available. This is necessary to address the respiratory depressant effects of alcohol, especially problematic in patients who manifest a high tolerance to alcohol's sedating effects. Such a patient will present with extremely high blood alcohol levels but will be conscious or only minimally sedated because of the patient's high tolerance to the sedating effects of the drug. However, the patient will not have developed a tolerance to the respiratory depressant effects of alcohol, and the clinician must avoid a false sense of security that this patient can tolerate a minimally supervised detoxification. The addition of a benzodiazepine to the alcohol already present in the system may precipitate a state of respiratory depression. When a patient presents with high blood alcohol levels, care must be taken to avoid precipitating a respiratory crisis. A similar situation exists in patients with a high level of tolerance to other minor tranquilizers. Benzodiazepines are the most often abused drugs in this category, but barbiturates continue to be encountered frequently in the clinical situation. The risk of respiratory depression is a problem in the management of these patients. Those presenting with a sedative-hypnotic overdose should receive close medical supervision throughout all phases of treatment, including careful monitoring of vital signs, as this class of drugs depresses cardiorespiratory function. The patient who presents with an overdose of stimulants presents a variety of clinical challenges. Because stimulant abuse often obscures indications of other medical problems, these patients should receive a thorough medical evaluation, and because polydrug abuse is so common in this group, the clinician should consider that other substances may be contributing to the clinical picture. 390
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ications should be used only in the context of psychotic symptoms that are disturbing to the patient or causing violent acting out Medication with benzodiazepines has no role in the treaunent of hallucinogen overdose unless it is accompanied by minor tranquilizer withdrawal.
Stimulants and minor tranquilizers are popular drug combinations; patients often add a minor tranquilizer to their reg imen to attenuate the effects of stimulants. Thus they often present with a mixed stimulant and tranquilizer overdose. In the case of an uncomplicated stimulant overdose, the patient - once medically stabilized - should be handled in a psychiatric setting where physical restraints are available. These patients are often extremely psychotic and potentially violent. High-potency antipsychotics, such as droperidol and haloperidol, are both commonly used in this situation; however, droperidol has a powerful antipsychotic action in addition to being more strongly sedating. Extreme caution should be used in dealing with these patients because of the very real risk of violence. The safest procedure is to have the patient placed in restraints prior to the administration of medications. This accomplishes many things simultaneously. First and foremost, the safety of both patients and staff is assured. In addition, because of the risk of transmission of my disease, intramuscular administration of medications can be accomplished with minimal risk to staff. As with any use of antipsychotic medications , care should be taken to use the smallest amount of medication that is clinically effective, without being so conservative that the dose is insufficient and the patient is subjected to unpleasant symptoms longer than necessary. When the patient presents with a mixed stimulant and minor tranquilizer overdose, the risks of respiratory depression continue to be present but now the clinician faces a patient who can be extremely psychotic and potentially violent Benzodiazepines must now be added to the treatment approach. Ideally, this patient should be managed in a hospital psychiatric setting where life-support equipment is readily available. In addition to the use of haloperidolor droperidol to address the psychotic symptoms, a short-acting benzodiazepine, administered intramuscularly, is appropriate. One of the present authors (Stewart) has had good results using a combination of droperidol and lorazepam. The benzodiazepine should be used to control any withdrawal symptoms from the minor tranquilizers and not to address any behavioral manifestations of stimulant overdose. Hallucinogen or PCP overdose is another situation that is best handled in a psychiatric setting where staff is well versed in the use of physical restraints. The usual clinical manifestation is severe psychotic decompensation with the potential for violent acting out. As in the situations discussed previously, the patient should first be medically stabilized. Due to the extreme degree of disorganization and the potential for violence, these patients should be placed in physical restraints prior to any psychiatric intervention. The optimal situation is to keep the patient in a safe and protected environment while the offending agents work themselves out of the patient's system. Antipsychotic medJournal ofPsychoactive Drugs
ORGANIC BRAIN SYNDROMES PRESENTING WITH PSYCHOTIC SYMPTOMS AS A RESULT OF PROLONGED SUBSTANCE USE Two distinct clinical entities resulting from prolonged substance use are alcohol hallucinosis and organic delusional disorder secondary to amphetamine abuse. Both conditions present with a variety of psychotic symptoms that include but are not limited to auditory hallucinosis , paranoid ideation, ideas of reference as well as other irregularities of thought content and thought process. In both cases, these symptoms present in a patient who is neither intoxicated nor in withdrawal. In the case of alcohol hallucinosis, the symptoms usually appear in the fourth or fifth decade and have been preceded with heavy alcohol intake for a number of years. No exact amount of alcohol or time frame is required, though the patient will have been drinking heavily for years. The symptoms have an insidious onset, with the patient usually hearing buzzing or clicks that can develop into full-blown hallucinations. Concurrently, a variety of psychotic symptoms may appear, such as auditory hallucinations, paranoid ideation and ideas of reference. The patient may assume these are the result of drinking and even stop temporarily. For some, the symptoms decrease and eventually stop over a period of days to weeks if they do not drink. For others, the symptoms persist in the absence of alcohol intake and require treatment with antipsychotic medications. The situation with amphetamine-induced organic delusional disorder is quite similar. These patients have often experienced psychotic symptoms while intoxicated on amphetamines. In the case of organic delusional disorders, these symptoms will persist in the absence of amphetamine intoxication. These patients usually present with auditory hallucinations and paranoid ideation. They may also attempt to address their symptoms by discontinuing their drug use. Their symptoms may abate with abstinence, but a significant number will need antipsychotic medication for symptomatic relief. The exact time course of both disorders is unclear. Patients' symptoms tend to last days or weeks, but continued alcohol and other drug use as well as premature dropout from treatment makes the time parameters difficult to assess. One of the present authors (Stewart) has followed a patient with alcohol hallucinosis for more than two years, and other clinicians report protracted psychotic 391
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episodes, diminishing in frequency and duration, from chronic cocaine use (Clark 1991).
1990) have made significant contributions in the effort to understand complex relationships between subgroups of schizophrenics, their drug use preferences, and outcomes. They reviewed experimental and observed clinical effects of drug abuse in schizophrenic patients and explored the patients' stated reasons for use and subjective effects of intoxication. Acknowledging the abundance of evidence that drug abuse exacerbates psychotic symptoms, they noted that abused drugs may lead to transient symptom reduction in subgroups of schizophrenics. Noting that some patients described feeling less dysphoric or anxious and more energetic while intoxicated, they studied the characteristics of these subgroups, and offered some models for understanding the clinical phenomena. They examined the possibility that schizophrenic patients who abuse drugs may represent a subgroup of patients with better prognoses and less severe clinical characteristics of schizophrenia, but their drug abuse may adversely affect global outcome. The drug abusing schizophrenic patients showed less overall pathology than schizophrenic patients without drug abuse on measures of positive and negative symptoms at discharge. However, measures of global functioning were equivalent. Dixon and colleagues postulated that drug abuse may impair global functioning sufficiently to compromise any transient amelioration of pathology in drug abusing patients. Moreover, Dixon and colleagues reviewed some models that potentially aid in understanding why schizophrenic patients abuse drugs that can increase psychosis, but from which some apparently derive beneficial effects. The socializing effects model proposes that such drug use may be a socializing phenomenon, providing isolated, socially handicapped individuals with an identity and social group. However, their data also indicate that for many, drug abuse is a solitary phenomenon. The self-medication model emphasizes drug use as an attempt to ameliorate a wide range of distressing symptoms. It appears that some patients prefer drugs that counteract the negative symptoms of schizophrenia (apathy, withdrawal, unresponsiveness), while others are attempting to self-medicate the uncomfortable extrapyramidal symptoms (parkinsonlike symptoms, such as tremor and muscular rigidity, and the agitated pacing of akathisia) induced by the neuroleptics. They consider the anergia associated with the negative symptoms as a potentially important factor. However, they postulated that there is a "critical window" for the propensity to selfmedicate; patients with too few or too many negative symptoms may not effectively maintain a drug habit. The use of opioids to self-medicate in schizophrenia is an intriguing topic that warrants further exploration. It would appear that a small subgroup of the heroin-dependent population uses opioids to reduce the discomfort of psychotic states. Clinicians have long suggested that opioids have antipsychotic properties. O'Brien, Woody &
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GUIDELINES FOR DIAGNOSIS There is currently no substitute for observation over time to distinguish manifestations of alcohol and other drug use from symptoms of underlying pathology. Unfortunately, fiscal constraints have shaped a health care environment that disrupts the continuity of treatment and makes it difficult to get the kind of consistent information that produces accurate diagnosis. Ever briefer inpatient stays mean that the patient is discharged at or before the time needed for differentiating between the sequelae of substance use and more enduring conditions. In this environment, creating mechanisms for continuity of care is an important task of the health care provider. Adopting a longitudinal approach, with provisional diagnoses, is necessary to avoid labels that dictate inappropriate treatments. Practitioners have noted (e.g., Brown et al. 1989: 567) that " ... the interacting effects of substance use, psychological disorder, and escalating social disability cannot be unraveled in a single brief encounter." When possible, it is useful to obtain information from the patient, family members, significant others, and fellow users. Physical examinations yield clarification and toxicology screens are useful on admission and for ongoing surveillance for continuing substance use. Clinicians have noted that one barrier to using toxicology screens more routinely is the practice by mental health funding sources of disallowing payment if a toxicology screen reveals evidence of an addictive disorder. It is crucial for institutional leaders to mobilize to remove this and similar barriers to effective diagnosis and treatment. It is important to appreciate that the patient need not meet criteria for addiction in order for alcohol and other drugs to undermine functioning. Kosten and Kleber (1988) noted that schizophrenics are usually quite sensitive to the disorganizing effects and manifest substantial symptoms with even relatively small amounts of alcohol, marijuana or stimulants. However, opiate use is associated with a reduction of psychotic symptoms during periods of use (Kosten & Kleber 1988; Millman 1982; Comfort 1977), and with a worsening during withdrawal. Other drugs, notably alcohol, marijuana and cocaine, may result in a worsening of the global clinical picture, but actually provide some temporary relief from distressing symptoms during periods of intoxication.
SELF-MEDICATION IN SCHIZOPHRENICS Although substance use adversely affects the longterm picture, patients attempt to self-medicate with illegal drugs and describe benefits. Dixon and colleagues (1991, Journal of Psychoactive Drugs
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fects, which include disturbances of erection and ejaculation, changes in libido and priapism in men, and decreased libido, orgasmic dy sfunction and menstrual irregularities in women, are estimated to occur in 30% to 60% of persons taking the drugs . They offered some pharmacological interventions to address these problems, such as gradually reducing the dose, changing the medication or administering other medications that are known to improve sexual dysfunction . It is important to remember, however, that sexual dysfunction can also occur as a result of the disorder (e.g., fear of boundary loss, fear of intimacy, penetration). The physician can explore the possibility that the medication is the source of the problem by trying some of the adjustments suggested, but clinicians involved with the patient need to be attentive to the other issues involved. Thus it is important for the clinician to inquire carefully to understand the role of drug use in the total picture. All drug users tend to be more focused on the immediate effects of their drug use (e.g., short-term sedating and anxiolytic effects) and are less likely to connect adverse consequences that unfold over time. In the course of exploring the patient 's unique pattern and its underpinnings, the clinician can provide appropriate educational input along these lines. Schizophrenic patients especially need to understand that any drug use can undermine progress by exacerbating symptoms and decreasing compliance with the treatment regimen (Evans & Sullivan 1990a,b; Pristach & Smi th 1990; Drake et a1. 1990). Pr istach and Sm ith studied schizophrenic inpatients on an acute care ward in an effort to explore the interplay between sub stance use and noncompliance with prescribed medication and the role of each factor. They found that the majority of patients admitted drinking alcohol during the month preceding admission, and most of these patients discontinued their medication while drinking. There were no significant differences between the group defined as abusers and those who were not, and their behavior was not correlated with either the occurrence of any specific side effect or the total of side effects. Thus it appears that all patients are susceptible and should be cautioned about alcohol and drug use, whether or not they meet criteria for abuse or addiction or fall into a category of mod erate or social use. Evans and Sullivan (1990a) recommend working simultaneously on educating patients about the differences between medications (good) and drugs (bad). Simple, clear, repetitive focus on basic concepts is essential to discourage illicit drug use while encouraging the patient to take pre scribed medication. Inasmuch as schizophrenic patien ts have trouble integrating new information and translating it into behavior, Evans and Sull ivan work carefully with concrete tools, such as index cards, asking patients to list reason s why it is important to remain clean and sober on one card and why it is important to take their medication on another.
McLellan (1984) noted empirical studies that support this view by indicating relatively low rates of schizophrenia (compared to rates predicted for the same socioeconomic group) in the opioid-dependent population. Clinicians in methadone maintenance treatment settings are familiar with the phenomenon of thought disordered patients who appear to be calmed and stabilized by methadone; one such patient referred to methadone as his "sanity syrup." This group, who may refuse antipsychotic medication, often becomes disorganized when their methadone doses drop (Comfort 1977). Methadone maintenance treatment offers a stabilizing environment for these patients, who particularly benefit from the combination of frequent contact and relatively low psychological intrusiveness (Zweben 1991). Verebey (1982: xi) likens the clinically observed antipsychotic effects of opioids to "the anatomic distribution of opiate receptors and endorphins and to the biochemical and neurophysiological similarity between the effects of opiates and neuroleptic drugs." He recommended further study to confirm these findings and to identify diagnostic categories that may respond to opioid treatment. Verebey and others have noted the benefits of ident ifying an alternative that does not carry the risk of tardive dyskinesia and other serious complications resulting from the antipsychotic medications currently in widespread use . Efforts in this direction were reported by Brizer and colleagues (1985), who noted marked improvement in a small sample of chronic, severely ill patients given methadone as an adjunct to neuroleptics. As expected, the patients' agitation was dimin ished, but surprisingly, their thought disorders were also reduced. Possible explanations include a specific antipsychotic effect of methadone, an anxiolytic effect or a synergism between neuroleptics and methadone. In contrast to the heroin-dependent population, withdrawal from methadone in this sample resulted in no drug-seeking behavior, abstinence syndromes or related problems. Thus it appears that chronically opioid-dependent pat ients may be a biochemically distinct subgroup, suggesting it may be possible to extend the use of opioids in disturbed patients who do not fall into this group without creating long-term problems. Another dimension, rarely discussed, is the use of illicit drugs (e.g., stimulants, such as amphetamine or cocaine) to medicate sexual dysfunction occurring as a side effect of neuroleptics. Some patients on neuroleptics describe great reduction in sexual des ire and use stimulants to enhance sexual feelings and function . However, the stimulants may destabilize their psychosis. With careful questioning, many patients report sexual dysfunction, and often attribute it to their medication. Sullivan and Lukoff (1990) noted the absence of investigation and clinical attention to neuroleptic-induced sexual dysfunction and speculated about the role of discomfort with the notion that seriously mentally ill persons are sexual beings who are sexually active. They emphasized that sexual side efJournal a/Psychoactive Drugs
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ician. It is important to identify meetings in the community that are more likely to be tolerant of unusual behavior and the use of medication. An Alcoholics Anonymous (AA) (1984) publication, The AA Member - Medications and Other Drugs. Reportfrom a Group ofPhysicians in AA, makes it quite clear that medication appropriately prescribed by a physician familiar with the issues of recovering patients in no way disqualifies a patient from AA participation. Indeed, the pamphlet is quite emphatic that no AA member is to play doctor. Nonetheless it is quite common for other 12-Step program members to propose that drug use of any kind is incompatible with recovery, so in addition to providing this pamphlet (available from the AA central office) it is important to provide other support to the patient who goes to 12 -Step meetings. Simulations have been used to clarify for the patient what meetings are like and how to behave there. Role-play can also be used to prepare the patient to respond to members who are critical of medication use . In fostering 12-Step program participation, it is important to be aware of the fact that powerlessness is likely to be a very sensitive issue and it may be more useful to emphasize that the patient will gain power over his or her life through abstinence, rather than dwelling on the importance of the experience of powerlessness. Similarly, the Higher Power can be readily incorporated into a delusional system, and selecting a concrete, benevolent force (such as a person or activity) may be less hazardous. Several workbooks on 12-Step work for the dually disordered patient are now available. Each tailors its presentation to the characteristic limitations of the particular disorder. Evans and Sullivan (1 990b) offer handouts and specific guidelines for facilitators in their recent work.
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OTHER TREATMENT CONSIDERATIONS A comprehensive presentation of the treatment of severely disturbed patients who use alcohol and other drugs is beyond the scope of this article; however, some of the highlights will be reviewed. Although important, medication issues must be viewed in the context of a total treatment effort that addresses addictive disorders on psychosocial as well as medical levels. There are currently many impediments to effectively addressing the problems of dual diagnosi s patients (Wallen & Weiner 1989) and the task of the 1990s is to create a hybrid approach that meets the needs of these patients without subjecting them to the confusing and frustrating process of shuttling between the chemical dependency and mental health systems. The clinician working with severely disturbed patients needs to maintain realistic expectations while offering hope and direction to counteract the despair of the pati ent and family members. Isolated and homeless pa tients may require assertive outreach that is focused on providing help with their basic needs and giving support during a crisis to entice them into a treatment setting where they may then become engaged in a treatment pro cess (Osher & Kofoed 1989). Leverage obtained from engaging family members is helpful in improving retention, and the process of persuading the patient to cooperate in establishing abstinence may be a long one indeed. The questionable practice of terminating patients who do not readily comply with the treatment provider's expectation of a relatively unambivalent abstinence commitment (Wash ton & Stone-Wash ton 1990; Zweben 1989) make s even less sen se when dealing with a dual diagnosis pop ulation. Instead, painstaking and unhurried work geared to the information processing capability of the thought disordered patient is necessary to develop a foundation for an abstinence commitment. Osher and Kofoed (1989) noted that persuading these patients to accept long-term abstinence-oriented treatment is often difficult because these patients are typically unemployed and unaffiliated, and hence eseape many of the social pressures that make other patients more cooperative. Their impaired ability to process information, depressive cognition or organic brain syndromes make it difficult for staff to influence their denial. These patients need firm feedback to improve their reality testing within an overall context of support, despite their lapses. The aggressive exchanges considered therapeutic in many conventional chemical dependency treatment settings frequently precipitate regression in the schizophrenic patient.
CONCLUSION This paper has explored a range of issues that face the clinician who encounters psychotic conditions in the context of substance usc. As the gap between the mental health system and the chemical dependency treatment system narrows, clinicians in a wide variety of settings will prepare to meet the needs of this challenging group. Emergency room physicians, accustomed to psychotic patients , must maintain current knowledge of how prescribing guidelines change when substance abuse is a factor. Practitioners in a wide range of settings need to understand various patterns of self-medication; they must be especially sensitive to how the patient can accomplish his or her goal in ways that do not have the unintended and delayed consequences of abused drugs. Finally, clinicians in the chemical dependency treatment system need to apply their creativity to modifying and adapting treatment practices to meet the needs of this very challenging population.
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