psychotropic medications and substance use

psychotropic medications and substance use Dually diagnosed or mentally ill chemically abusing (MICA) students, who
have both substance abuse and psychiatric problems, present a special challenge
for colleges and college mental health programs. Many students are less
than completely forthcoming when discussing substance use or abuse with
clinicians. As a rule, clinicians should have a high index of suspicion for substance
use when students present with rapidly fl uctuating states, have atypical
presentations, or have unexplained symptoms or rapid deterioration. Drug
abuse should also be kept in mind in the diff erential of psychotic symptoms,
since drug use, which can precipitate psychosis, is more prevalent in this age group than is functional psychosis (SAMHSA, 2004). In many cases, it is diffi cult to discern whether drugs are exacerbating an
underlying problem or are a separate and independent problem. In the best
of circumstances, when students admit to drug use and accept the possibility
that their use is exacerbating their problems, they may agree to stop or
curb drug use so that psychiatric status can be assessed without substances
muddying the presentation. If the student does succeed in cutting back or
stopping drugs, a proper assessment can be made. If the student is unable
to decrease use (or feels worse upon trying to stop), discussion should then
focus on the severity of the substance problem. A referral for alcohol or drug
treatment, and possibly inpatient detoxifi cation or rehabilitation, might then
be necessary.
When a patient denies suspected substance use, it may be worth asking
if the student will agree to a toxicology screen. Few agree or comply. At this
point, it may be necessary to begin medication treatment, proceeding slowly
and carefully with frequent follow-up visits. Th e psychiatrist should continue
asking about substance use but avoid antagonizing and turning away the student.
It is oft en useful to invite the student’s participation in the treatment
with the reminder that the withholding of information about substance use
can lead to getting the wrong kind of help.
Th ere are no absolute contraindications against using most psychiatric
medications in the context of surreptitious substance use. (One exception is
the MAOIs, which should, in any case, be prescribed only for patients who
are highly responsible and compliant with care.) Nevertheless, substance use
may interfere with proper response to medication and prompt the psychiatrist
to augment or change medicines unnecessarily or unhelpfully. It has also
been my clinical impression that some students have intensifi ed responses to
marijuana when they are on SSRIs, and so warnings are in order about mixing
these medications with marijuana or any of the hallucinogens. For further
information on substance abuse in college students, visit the National Institute
of Drug Abuse website at www.nida.nih.gov.