Substance Use and Medication Treatment

To the Editor: I commend Kenneth Minkoff, M.D., for his useful column in the May issue on developing standards of care for persons with dual disorders (1). However, I disagree with one of the principles he listed for professionals to follow: "Medication for known serious mental illness should never be discontinued on the grounds that the patient is using substances."

Like many other clinicians, I like to look the other way if I know that a patient taking a prescribed psychotropic medication has had a can of beer during the weekend or a glass of wine at a family festivity. However, a clinician should be cautious about continuing to prescribe medication for a serious mental illness if the type and quantity of substances used by the patient is of concern.

My argument is based on several questions: Shouldn't the patient be advised to seek substance abuse treatment if he or she is using substances? Are we not sending the wrong message to the patient, his or her family, our colleagues and associates, and the media if we say that it is acceptable to use substances during psychiatric treatment? Won't substance use alter the effectiveness of the psychotropic medications we prescribe? Can't the interaction of substances with medications seriously increase the side effects of both? Is what Dr. Minkoff advises acceptable within the perspective of clinical, ethical, and legal standards of care?