Text adapted in 2021 from The Fundamentals of Addiction in The Primary Care Addiction Toolkit (online only). A complete list of Toolkit authors, editors and contributors is available here.
These general principles can guide treatment for patients with concurrent substance use and mental health disorders:
Try to address the substance use problem first. When patients with alcohol or other substance use disorders exhibit symptoms of mental health problems, such as depression, anxiety or psychosis, assume that the substance is a part of the problem. Abstinence may be the ideal option for most patients with concurrent disorders; however, it is important that patients decide on their goals for treatment.
When in doubt, refer the patient to a psychiatrist. When patients have a past history of primary mental health problems, taking a close history will commonly reveal that these disorders underlie their substance use problems. Treatment of the psychiatric disorder may help to facilitate the treatment of a substance use disorder.
Patients with concurrent disorders need comprehensive case management and an integrated treatment approach that involves both substance use and mental health treatment.
Phase 1: Getting Started
Goals include medical withdrawal management, comprehensive assessment and stabilization of the mental illness. The focus is on engagement and motivation.
Phase 2: Substance Use Treatment
Goals include counselling, education, group therapy, mutual aid (e.g., Alcoholics Anonymous), family counselling, life skills and behavioural treatments.
Phase 3: Relapse Prevention
Goals include mutual aid, substance use disorder aftercare and concurrent mental health case management for long-term follow-up and support.
Pharmacotherapy: General Principles
Patients with milder mood or anxiety disorders who are able to achieve abstinence should be monitored for four to 12 weeks. If the disorder persists or worsens over this period, consider pharmacotherapy. However, the psychiatric diagnosis may remain unclear until the patient has abstained for three to six months.
If symptoms are severe or you strongly suspect that the patient has a primary psychiatric disorder, consider beginning pharmacotherapy earlier than four to 12 weeks.
If the patient cannot achieve abstinence and you suspect a primary psychiatric disorder, consider pharmacotherapy.
If possible, avoid benzodiazepines and opioids. Exceptions are:
- benzodiazepines to treat acute alcohol withdrawal
- appropriate opioids to treat significant acute pain.
Benzodiazepines should not be used in the long-term management of primary anxiety disorders in patients with alcohol dependence.
In Fundamentals of Addiction:
- Defining Addiction
- Key Concepts in Addiction
- Implications for Clinical Practice
- Intoxication & Driving
- Identifying Concurrent Disorders
- Motivation and change