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7. Clinical Features Influencing Treatment

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Consider whether the plan of treatment needs to be modified on the basis of individual patient characteristics described in Table 3.

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Table 3. Individual Patient Characteristics That May Influence Treatment

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Table Reference Number
Table 3. Individual Patient Characteristics That May Influence Treatment

Show sensitivity to cultural differences and incorporate cultural beliefs about healing and recovery to improve outcomes in ethnic minority groups.

Recognize that use of multiple substances is common and can complicate assessment and treatment.

  • Signs and symptoms of intoxication or withdrawal may be an amalgamation of effects from two or more substances.

  • The time courses of withdrawal syndromes resulting from two or more substances may overlap.

  • Detoxification from two or more substances may be needed simultaneously.

  • Pharmacological treatments for one substance use disorder may result in drug interactions with another substance of abuse.

  • Treatment plans should incorporate specific therapies to address each individual substance use disorder as well as consider whether integrative treatment approaches are indicated.

Consider whether the treatment plan requires modification on the basis of co-occurring general medical conditions.

  • Be alert for signs and symptoms of medical conditions that may be associated with specific substance use disorders (see Table 4).

  • Recognize that nicotine replacement therapies (NRTs) and bupropion appear to be safe and effective when used to treat nicotine dependence in patients with co-occurring general medical conditions.

  • Check for potential interactions between abused substances and prescribed medications to treat co-occurring conditions (e.g., effects of smoking on metabolism of drugs via cytochrome P450 1A2, metronidazole, and alcohol use).

  • Check for potential interactions between medications used to treat substance use disorders and those used to treat co-occurring conditions (e.g., naltrexone and opioid treatment of pain).

  • Recognize that pain from general medical conditions is often inadequately treated in individuals with substance use disorders.

  • Address issues such as lack of health care access and a chaotic lifestyle that may limit the capability of individuals with substance use disorders to receive appropriate treatment for co-occurring medical disorders.

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Table 4. Medical Disorders Associated With Specific Substances

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Table Reference Number
Table 4. Medical Disorders Associated With Specific Substances

Consider the benefits and risks for the individual patient when choosing medications to treat co-occurring disorders.

  • Consider the recommended treatment for the co-occurring disorder in the absence of a substance use disorder.

  • Consider the safety, tolerability, and abuse potential of each medication.

  • Determine whether modifications in medication or dose are needed because of potential drug-drug interactions.

  • Review additional considerations as described in Table 5.

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Table 5. Treatments for Other Co-occurring Psychiatric Disorders in Patients With Substance Use Disorders

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Table Reference Number
Table 5. Treatments for Other Co-occurring Psychiatric Disorders in Patients With Substance Use Disorders

Modify the plan of substance use disorder treatment to address other aspects of co-occurring psychiatric disorders.

  • Address the augmented risk for suicidal and aggressive behaviors during substance intoxication or withdrawal in individuals with other co-occurring psychiatric disorders.

  • Incorporate indicated psychosocial as well as pharmacological therapies to address each disorder.

  • Integrate psychosocial and pharmacological treatments of substance use disorders and co-occurring psychiatric disorders.

  • Consider whether early stages of treatment may need to be more intensive than when treating individuals with substance use disorders alone (e.g., earlier use of nicotine replacement, supplemental use of nicotine patch with other nicotine replacement therapies or group or individual behavioral therapy with smoking cessation).

  • Consider the potential effects of substance cessation on the symptoms of the co-occurring psychiatric disorder when timing treatment efforts.

  • Attend to insomnia, which is common and may predict relapse; although evidence is limited, CBT or sedating psychotropic medications (e.g., trazodone, gabapentin) may be considered.

  • Address factors that may be more likely to influence treatment adherence in individuals with co-occurring disorders (e.g., concern about medication interactions, cognitive impairment, limited motivation, lack of peer and social support).

  • Consider whether treatment could be enhanced through approaches such as assertive community treatment, stage-based motivational models, social skills or money management training, contingency techniques, and recovery-oriented perspectives.

  • Encourage attendance at 12-step groups that support appropriate use of psychotropic medications.

Consider the possibility of pregnancy in women of childbearing age as part of the treatment planning process.

  • Use a therapeutic approach that is supportive and maintains patient confidentiality.

  • To women who request it, provide education and counseling to help them make an informed decision about continuing or terminating a pregnancy.

Modify the treatment of pregnant women to optimize the well-being of the patient and the fetus.

  • Encourage abstinence from substance use.

  • Ensure adequacy of maternal nutrition.

  • Encourage participation in prenatal care.

  • Work with the patient'€™s obstetrician to reduce the risk of obstetrical complications (e.g., low birth weight with nicotine dependence; effects on fetal growth and later behavioral, cognitive, or academic deficits with marijuana dependence; fetal alcohol spectrum disorder with alcohol use disorders; placental blood flow abnormalities, neonatal abstinence syndrome, and premature labor and delivery with cocaine use disorders; miscarriage, preeclampsia, low birth weight, premature labor and delivery, stillbirth, and neonatal abstinence syndrome with opioid use disorders).

  • Motivate the patient to remain in treatment and use aggressive relapse prevention strategies after delivery to decrease relapse risk.

  • Counsel women who are likely to return to a substance-abusing milieu about long-term community treatment options and harm-reduction behaviors.

  • Arrange for appropriate postnatal care when necessary.

  • Consider referring the patient for education in parenting skills.

Choose treatments in pregnant women based on consideration of the risks and benefits of treatments for the fetus as well as the patient.

  • Psychosocial treatments are generally considered initially in treating pregnant women.

  • Agonist therapy (e.g., nicotine replacement therapy in smokers, methadone or buprenorphine in opioid-dependent women) is preferable and likely to be associated with fewer risks to the fetus than continued substance use.

  • Compared with continued heroin use, methadone maintenance is still considered the treatment of choice for women who are unable to remain substance-free, because it has a long history of use and improves infant outcomes. Buprenorphine may also be useful in treating pregnant women with opioid dependence and may be less likely to cause neonatal abstinence syndrome.

  • Narcotic antagonist therapy (e.g., naloxone, naltrexone) is not recommended, because it can contribute to spontaneous abortion, premature labor, and stillbirth.

Table Reference Number
Table 3. Individual Patient Characteristics That May Influence Treatment
Table Reference Number
Table 4. Medical Disorders Associated With Specific Substances
Table Reference Number
Table 5. Treatments for Other Co-occurring Psychiatric Disorders in Patients With Substance Use Disorders

References

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Manual of Clinical Psychopharmacology, 7th Edition > Chapter 1.  >
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Manual of Clinical Psychopharmacology, 7th Edition > Chapter 4.  >
Manual of Clinical Psychopharmacology, 7th Edition > Chapter 6.  >
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