Pharmacotherapy

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Despite the high rates of comorbid AOD use among people with psychosis, most trials of pharmacotherapy for psychotic spectrum disorders have excluded individuals with AOD use disorders [524]. The UK NICE Guidelines for comorbid psychosis and AOD use recommend the use of antipsychotics, in line with the UK NICE Guidelines on schizophrenia [536] or bipolar disorder [537], due to the lack of evidence of any differential benefit for one antipsychotic over another for people with this comorbidity. Table 33 lists the names of some of the more common antipsychotics.

It has been theorised that the increased AOD use found amongst those with psychotic disorders relates to dopamine dysfunction which is better addressed by the newer (atypical) antipsychotic agents than the older (typical) agents [538]. There has been considerable research on the effects of clozapine on AOD use, with generally positive outcomes [539]. Results for other newer antipsychotics in terms of impact on AOD use have been equivocal [540].

There are several reasons why pharmacological interventions for the comorbid AOD use disorder may prove more effective for this group than psychosocial treatments. Problems associated with negative symptoms such as amotivation and cognitive impairment may restrict involvement and outcomes in psychosocial interventions. On the other hand, greater tolerance of medication regimes may render clients with this comorbidity more amenable to pharmacotherapy for AOD use. Caution should be taken when selecting pharmacotherapies for AOD use and some are contraindicated in individuals with psychotic disorders as they may exacerbate symptoms (e.g., disulfiram).

Table 33: Antipsychotic medications

Newer (atypical) antipsychotics
Drug name Brand names
Clozapine Clozaril, Clopine
Olanzapine Zyprexa
Quetiapine Seroquel
Risperidone Risperdal
Amisulpride Solian, Sulprix
Aripiprazole Abilify
Ziprasadone Zeldox
Paliperidone Invega
Sodium valporate Epilim, Valpro
Carbamazepine Tegretol, Teril
Lithium Lithicarb
Asenapine Saphris
Trifluoperazine hydrochloride Stelazine
Traditional (typical) antipsychotics
Drug name Brand names
Chlorpromazine Largactil
Droperidol Droleptan
Fluphenazine Anatensol, Modecate
Flupenthixol Fluanxol
Haloperidol Haldol, Serenace
Pericyazine Neulactil
Zuclopenthixol Clopixol
Prochlorperazine Stemzine

Adapted from the Australian Government Department of Health [541]. For a full list of generic brands available, see the Therapeutic Goods Administration website (https://www.tga.gov.au/).