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In general, there is relatively little research to guide treatment for comorbid personality and AOD use disorders. The first line of treatment for those with comorbid BPD and AOD use should be psychotherapy, with several interventions having been specifically developed for this group. Similarly, psychological interventions should be the first line of treatment for those with comorbid ASPD and AOD use, although the evidence is less well-developed.

Without evidentiary support, pharmacological intervention is not recommended for the treatment of either comorbid BPD and AOD use, or ASPD and AOD use, highlighting the need for further well-conducted studies to be undertaken in this area.

Box 21 illustrates the continuation of case study H, following Luke’s story after the AOD worker consulted with a forensic psychologist. As illustrated, it may be necessary to involve multiple services in the delivery of care to a person with comorbid personality and AOD use disorders.

Box 21: Case study I: Treating comorbid ASPD and AOD use: Luke’s story continued

Luke’s AOD worker liaised with a forensic psychologist and Luke was comprehensively assessed. The forensic psychologist reported that Luke met criteria for a diagnosis of ASPD. His AOD worker had also arranged for Luke to undergo a physical health assessment, and Luke was found to have hepatitis C.

Over several meetings, Luke developed a reasonable relationship with the psychologist and indicated that he had reached a point where he ‘needed to turn things around’. In consultation with his AOD worker, Luke decided to begin suboxone treatment for his heroin dependence, while at the same time receiving psychological treatment for his ASPD. The AOD worker contacted housing services in an attempt to help find Luke stable accommodation, and Luke began treatment for his hepatitis C.

Luke’s treatment plan also included his attendance at a group program for people with ASPD which was based on cognitive behavioural principles. Most of the others in this group also had histories of problematic AOD use. The treatment plan emphasised the need for long–term contact with Luke and his family. After three months, Luke had reached a stable dose of suboxone, was regularly attending his group cognitive behavioural sessions, as well as individual CBT sessions with his psychologist and AOD worker. The AOD worker arranged for treatment to continue and provided a report to the court with favourable recommendations.

The long–term treatment plan emphasised the need for continued multi-agency cooperation and preparing to deal with factors that could jeopardise long–term stability. These included plans to address life and relationship stressors, and manage the several occasions when Luke failed to attend for appointments.

Key points

  • Where the ASPD is associated with AOD use, both sets of problems should be addressed concurrently and the approaches carefully coordinated.
  • The need for multi-agency cooperation and information sharing is important and, in the case of comorbidity, interventions need to be planned over months and years rather than weeks.