Although somewhat dated, current Australian and international guidelines on the management of BPD suggest pharmacotherapies only be used as an adjunct to psychotherapy [555, 1517–1519]. Pharmacotherapies that support a reduction in, or the cessation of, AOD use (e.g., naltrexone and disulfiram) in particular may be helpful in facilitating stabilisation that will allow the client to make further gains in psychotherapy [121, 1532]. Concerns have been raised with regard to the potential for dangerous interaction effects of medications and AOD use in the context of impulsivity and self-harming behaviours [1240]. As such, although disulfiram has been found to be safe and effective among people with BPD and alcohol use disorders [1532], caution is advised due to the potential risk [1515].
No pharmacotherapies have been approved for the treatment of BPD as a single disorder, and there is little evidence to support their efficacy in the context of BPD as a single disorder, and none in the context of co-occurring AOD use disorders [162]. Nonetheless, off label prescribing of antidepressants, mood stabilisers, antipsychotics and anticonvulsants to address primary or secondary symptoms of BPD is common, with medications often chosen to target specific symptoms such as affect dysregulation or impulsivity [1240, 1533]. This targeted approach to prescribing has been the subject of considerable debate and concerns have been raised regarding the use of polypharmacy. There is consensus in the literature, however, that prescribing should be kept to a minimum [1240] and polypharmacy avoided whenever possible [1515, 1533, 1534].