For the CoOccurring Psychiatric Disorder Has Abuse Potential

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As evidenced in numerous studies, treating a co-occurring psychiatric disorder can often have positive outcomes in both reducing substance use and helping the specific psychiatric disorder for which it is prescribed. However, what if the pharmacological treatment has the potential to worsen or create a new SUD? This dilemma is often considered in treating patients who suffer with SUDs and co-occurring anxiety disorders or ADHD, when clinicians ask themselves, "Is it safe to prescribe stimulants/benzodiazepines for this patient?"

Pharmacotherapies that do not have abuse potential should be considered first-line treatments before prescribing stimulants or benzodiazepines in these populations (Ciraulo &Nace, 2000; Levin et al., 1999), and it is important that patients receive adequate trials (i.e., dose and duration) of these medications before they are abandoned. Psychosocial treatments with demonstrated efficacy should also be tried before prescribing an abusable medication. For example, CBT has demonstrated efficacy for anxiety disorders (Beck et al., 1993) and should be explored before prescribing a benzodiazepine. If these first-line treatments fail to improve the anxiety or ADHD symptoms adequately, then the following guidelines are suggested when prescribing stimulants or benzodiazepines in these patient populations (Ciraulo & Nace, 2000; Levin et al., 1999):

• Select preparations that limit the potential for abuse. Medications with longer half-lives or sustained-release preparations have lower abuse potential and are therefore preferable in these populations. Select as low a dose as possible. For benzodiazepines, avoid as-needed-basis prescribing in lieu of a fixed dosing schedule. Limit the number of pills given with each prescription, and keep a log of the pills prescribed. Frequent patient contact can help the clinician assess whether the medication is helpful, as well as whether it is being overused.

• Use objective measures to document improvements. For example, using a standardized assessment such as the Adult Behavior Checklist (Murphy & Barkley, 1996) or the Beck Anxiety Inventory (Beck, Epstein, Brown, & Steer, 1988) can help document improvements (or lack thereof).

• Monitor substance use. Patients should be asked about alcohol and drug use, and other sources of information (urine screens, collateral information from family members) should be strongly considered.

• Enlist family members in supporting and monitoring the patient. Verify the efficacy and appropriate use of the medication with family members.

• Patients should safeguard medications. While the patient may not abuse the medication, family members may.

• Monitor prescriptions. Keep careful track of the number of pills you prescribe, and beware of warning signs of abuse, such as premature requests for refills or "lost prescriptions." These usually indicate overuse of the medication.

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