Pharmacological treatment of schizophrenia with comorbid substance use disorder

ABSTRACT

Introduction: While antipsychotics remain the cornerstone of treatment for schizophrenic patients with comorbid substance use disorder (SUD), such treatment is nonetheless complicated by frequent medical comorbidity and poor adherence to medication. Areas covered: Randomised controlled trials (RCTs) on the efficacy of antipsychotics for the treatment of schizophrenic patients with comorbid SUD are reviewed and analysed on the basis of a systematic literature search (PubMed) ranging from 1985 to 2015. On the same basis, findings from RCTs on the efficacy of psychotropic and other medications used for primary SUD are summarised, and the main issues liable to influence treatment choice are discussed, including pharmacodynamic as well as pharmacokinetic interactions, adherence, medical comorbidity and the impact on brain structure. Expert opinion: As far as the treatment of schizophrenic patients with SUD is concerned, direct and indirect evidence tends to stand in favour of the use of second-generation antipsychotics (SGAs), and particularly those with lower metabolic, cardiovascular and extrapyramidal side effects, as well as those with a depot formulation. A few of the usual medications for the treatment of primary SUD, such as naltrexone and disulfiram for alcohol use and bupropion for tobacco cessation, can also be safely and efficiently administered to schizophrenic patients with SUD.

KEYWORDS:

• Antipsychotics
• co-occurring disorder
• pharmacotherapy
• schizophrenia
• substance use disorder

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Corrigendum

Article highlights

• Comorbid substance use is frequent among schizophrenic patients

• It is associated with poor adherence to treatment, high rates of medical comorbidity and may impact brain structures.

• There is a paucity of well-designed controlled studies for the treatment of schizophrenic symptoms in these patients.

• Randomised placebo-controlled trials are more frequent for the treatment of craving and substance intake.

• Concerning antipsychotics, given the poor adherence to medication, we recommend LAIs as a first-line option, especially risperidone and derived from studies with the oral application form aripiprazole.

• Regarding anticraving agents, the best evidence is for naltrexone and disulfiram in alcohol use, and bupropion for tobacco cessation.

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Acknowledgements

The authors would like to than Katherine Depax, Aix-Marseille University, and Justine Buand, Aix-Marseille University, for their assistance in the English language editing of this manuscript.

Declaration of interest

JM Azorin has received research support from, acted as a consultant for or been on the speaker’s bureau for Bristol-Meyers Squibb, Janssen Pharmaceuticals, Eli Lilly, Otsuka, Takeda, Novartis, Pfizer, AstraZeneca, Servier and Sanofi-Aventis. N Simon has received consulting fees from Lundbeck, Reckitt Benckiser Pharma, Merck/Serono and Ethypharm. M Adida has received research grants from Eli Lilly and Servier. R Belzeaux has received honoraria for conferences from AstraZeneca and Janssen. The authors have no other relevant affiliations or financial involvement with any organisation or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.