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Active Substance Use Disorders David N. Osser, MD Associate Professor of Psychiatry Harvard Medical School Brockton Division of the VA Boston Healthcare System General Editor - Psychopharmacology Algorithm Project Harvard South Shore Residency Training Program

50-70 % of patients with schizophrenia Substance use disorder at some point Kirchner, J. E.,et al . (2006). Diagnosis and management of substance use disorders among inpatients with schizophrenia. Psychiatric Services. Kerfoot, K. E.,& CATIE Investigators. (2011). Substance use and schizophrenia: adverse correlates in the CATIE study sample. Schizophrenia research, 132(2), 177-182.

Active substance abuse Poorer outcome Depression Quality of life Psychosis Active substance abuse Kirchner, J. E.,et al . (2006). Diagnosis and management of substance use disorders among inpatients with schizophrenia. Psychiatric Services. Kerfoot, K. E.,& CATIE Investigators. (2011). Substance use and schizophrenia: adverse correlates in the CATIE study sample. Schizophrenia research, 132(2), 177-182.

Pharmacotherapy evidence Patients who are not using substances

Proceed with antipsychotic treatment Try to treat substance use disorder first Hospital detoxification Proceed with antipsychotic treatment

Proceed with antipsychotic treatment Try to treat substance use disorder first Hospital detoxification Proceed with antipsychotic treatment

Selected specific considerations

Clozapine interactions Monitor levels when treating smokers When patients start or stop smoking: Make appropriate changes Clozapine interactions Naltrexone for alcohol-using patients May be effective Alcohol Bupropion and varenicline for smoking cessation Smoking cessation Phansalkar, S., & Osser, D. N. (2009). Optimizing clozapine treatment: part I. Psychopharm Review, 44(2), 9-15.

Clozapine interactions Monitor levels when treating smokers When patients start or stop smoking: Make appropriate changes Clozapine interactions Effective for alcohol abusing schizophrenia patients Naltrexone Effective for smoking cessation Bupropion and varenicline Petrakis, I. L., et al (2004). Naltrexone augmentation of neuroleptic treatment in alcohol abusing patients with schizophrenia. Psychopharmacology, 172(3), 291-297.

Clozapine interactions Monitor levels when treating smokers When patients start or stop smoking: Make appropriate changes Clozapine interactions Effective for alcohol abusing schizophrenia patients Naltrexone Effective for smoking cessation Bupropion and varenicline Tsoi, D. T. Y., et al (2010). Efficacy and safety of bupropion for smoking cessation and reduction in schizophrenia: systematic review and meta-analysis. The British Journal of Psychiatry, 196(5), 346-353. Weiner, E., et al. (2011). Varenicline for smoking cessation in people with schizophrenia: a double blind randomized pilot study. Schizophrenia research, 129(1), 94.

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