Patients With Significant
Psychiatric Comorbidity


 Better to light a candle than to curse the darkness. 

The association of psychopathology and opioid addiction is well established. Psychiatric symptoms and disorders may be drug-induced, independent, or interrelated. Substance use and addiction can mimic, exacerbate, or precipitate psychiatric symptoms and disorders. Most substances of abuse produce moderate-to-severe psychiatric symptoms, and there is a complex association between substance use and psychiatric status.

A study of rates of psychiatric disorders among 716 patients addicted to opioids seeking treatment with methadone (Brooner et al. 1997), found a lifetime rate of 47 percent, and a current rate of 39 percent. Of note, patients in this study were stabilized in treatment for 1 month before the psychiatric evaluation. Other, earlier studies have reported higher rates of depression, antisocial personality characteristics, schizophrenia or schizotypal features, manic symptomatology, and alcoholism in opioid-addicted patients. For example, in a study of 533 opioid-addicted patients in treatment for their drug problems, Rounsaville and colleagues (1982) found that 86.9 percent met diagnostic criteria for some psychiatric disorder (including personality disorders) in their lifetimes, and 70.3 percent met criteria for a current psychiatric disorder. It should be noted, however, that, although the rates of major depressive disorder, alcoholism, antisocial personality, minor mood disorders, and anxiety disorders in this group exceeded those found in the general population, the rates of schizophrenia and mania did not.

Although the etiological significance of psychiatric disorders in the genesis of opioid addiction is not established, it is known that treatment for both conditions is necessary for substance abuse treatment to be effective. Therefore, the presence and severity of comorbid psychiatric conditions must be assessed in patients who are opioid addicted before, or while, initiating buprenorphine treatment, and a determination must be made whether referral to specialized behavioral health services is indicated.

Untreated or inadequately treated psychiatric disorders can interfere with the effective treatment of addiction. Polysubstance use and psychiatric problems are both associated with negative treatment outcomes unless they are identified and treated appropriately. For example, patients with major depression or dysthymia are more likely to use illicit drugs during treatment than patients who do not suffer from depression. Assessment is critical to determine whether psychiatric symptoms represent primary psychiatric disorders or substance-induced conditions. Primary psychiatric disorders may improve but do not dissipate with abstinence or maintenance therapies, and these disorders may require additional treatment.

The psychiatric disorders most commonly encountered in patients who are opioid addicted are other substance abuse disorders, depressive disorders, posttraumatic stress disorder, substance-induced psychiatric disorders, and antisocial and borderline personality disorders.

The presence of comorbid psychiatric disorders should not exclude patients from admission to opioid addiction treatment. Diagnosis of psychiatric disorders is critical to matching patients to appropriate treatment services.

    In first encounters with patients, it is essential to evaluate for the presence of suicidal or homicidal ideations, signs or symptoms of acute psychosis, and other acute or chronic psychiatric problems that may render patients unstable. Initiation of antidepressant therapy, in conjunction with treatment for opioid addiction, may be considered in patients presenting with signs or symptoms of depression. If manic behavior is present, attempts should be made to determine whether it is substance induced or whether the etiology is a primary mood disorder.

When psychiatric symptoms are severe or unstable, hospitalization for protection and containment may be appropriate to ensure the safety of the patient and others. Patients who are considered actively suicidal should not receive buprenorphine on an outpatient, prescription basis. Rather, they should be referred immediately for appropriate treatment, which may include psychiatric hospitalization. Those who are not currently suicidal but who have a history of suicidal ideation or attempts should be monitored closely in terms of medication supply and follow up.

Psychiatrically stable patients can be readily accepted into treatment and stabilized on buprenorphine; subsequently they may receive additional psychiatric assessment to identify conditions requiring treatment. Patients who present with
depression during the maintenance phase of buprenorphine treatment require continued assessment and should be treated appropriately.

Polysubstance Abuse

The abuse of multiple drugs (polysubstance abuse) among individuals addicted to opioids is common. Although polysubstance abuse or dependence may be identified during assessment, physicians should remain alert to their presence throughout the course of addiction treatment.

Pharmacotherapy with buprenorphine for opioid addiction will not necessarily have a beneficial effect on an individual's use of other drugs. It is essential that patients be referred for treatment of addiction to other types of drugs when indicated.

In addition, care must be exercised in the prescribing of buprenorphine for patients who abuse alcohol and for those who abuse sedative/hypnotic drugs (especially benzodiazapines) because of the documented potential for fatal interactions.

References:   (1) Clinical Guidelines For The Use Of Buprenorphine In The
                                   Treatment of Opioid Addiction (TIP 40)  Chapter 5 pp. 72-74

Written and Compiled By:  Deborah Shrira        Dated:  12 June 2007