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2. 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

3. 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),

4. 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),

5. Pharmacotherapy evidence
Patients who are not using substances

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

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

8. Selected specific considerations

9. 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.

10. 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),

11. 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),
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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