As with depression, much of the anxiety exhibited by clients entering AOD treatment will subside following a period of abstinence and stabilisation without the need for any direct attention [866–868], but some may require further treatment. Research relating to co-occurring anxiety and AOD use is sparse [1158, 1167]; however, there are several options available for the treatment of anxiety disorders as single disorders, including psychotherapy, pharmacotherapy, e-health interventions, physical activity, and complementary and alternative therapies (e.g., dietary supplements). The evidence base surrounding these treatments in relation to each of the different anxiety disorders is discussed below.
Broadly speaking, the RANZCP clinical practice guidelines for the treatment of GAD, panic disorder, and SAD recommend an approach that begins with psychoeducation and lifestyle advice, followed by CBT, pharmacotherapy (SSRIs or SNRIs) augmented with graded exposure, or a combination of CBT and pharmacotherapy [1158].
There is also growing evidence suggesting that integrated treatment approaches may be effective at reducing symptoms of anxiety [669, 1168, 1169], depression, stress [1168], and AOD use [669, 1168–1171], as well as improving quality of life [669], among people with co-occurring anxiety and AOD use; but the evidence is mixed.
If the anxiety is acute and disabling and interfering with a response to AOD treatment, then consideration should be given to pharmacotherapy, either for the substance use (in the case of alcohol – naltrexone, acamprosate, or disulfiram), the anxiety, or both. Although research examining the treatment of co-occurring anxiety and AOD use is scarce [1172], it would be reasonable to draw similar conclusions for these co-occurring groups as for those experiencing co-occurring depression and AOD use – namely, use of a medication such as an SSRI (which has anxiolytic properties), with a good side-effect profile, proven efficacy in the mental health disorder and minimal negative interactions with the substance of abuse [1110, 1173]. Commonly prescribed anti-anxiety medications include some of the SSRIs (and other antidepressants, e.g., venlafaxine) listed in Table 47, and those listed in Table 49.
Despite their proven effectiveness in relieving anxiety, the use of benzodiazepines is not recommended due to their abuse liability [1158, 1174, 1175]. Benzodiazepines should only be prescribed among patients with a history of problematic AOD use if there is a compelling reason to use them, there is no good alternative (i.e., other psychological and medication options have failed), close follow-up and supervision is provided, and monitoring for misuse is in place. If benzodiazepines are used, the client should only be prescribed the lowest possible dose for only a short period of time (no more than one month [1110]).