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Substance use decreases medication adherence, increases relapse

the front cover of a crosscurrents magazine- the main image is a vase with bold coloured flowers


By Shelagh Ross

Winter 2004-05, Vol 8 No 2


It’s the long weekend and it’s Anthony’s birthday, so he plans to celebrate. He has been doing well on the antipsychotic medication he started taking six months ago for schizophrenia, but he decides it won’t do any harm to skip his meds for three days. After all it’s safer that way – his psychiatrist has warned him not to mix alcohol with his medication. As the weekend winds down, Anthony begins to feel agitated and disoriented. After three days of no medication, he takes his regular dose, then collapses on the floor.

As this scenario illustrates, substance use increases the likelihood of medication non-adherence, which in turn increases relapse risk. Approximately 50 per cent of people prescribed antipsychotics are non-adherent, according to a 2004 report published in the American Journal of Psychiatry. Denial, disorganization, complicated medication regimens, poor communication, lack of education around medication use and interactions between prescription drugs and substance use are some of the factors that decrease compliance.

Substance use, in particular, is a major barrier. Studies have found that individuals with schizophrenia who use substances are up to 13 times more likely than their non-using counterparts to be non-adherent. A 2002 study published in Schizophrenia Research found that the highest rates of relapse and hospital re-admission were among individuals with concurrent mental health and substance use issues who were non-compliant.

There are various reasons why substance use may decrease compliance. Candice Traynor, a registered nurse with Archway, a community-based outpatient program in Toronto, explains that substances may be preferable to medication for dealing with a mental health issue: “Self-medicating can be much more gratifying because alcohol and other drugs provide an immediate effect: The client self-medicates, feels better and then uses more substances. It’s a vicious, destructive cycle, and a very challenging concept to communicate to someone who’s in the midst of it.”

Wende Wood, a psychiatric pharmacist at the Centre for Addiction and Mental Health in Toronto, agrees, adding that clients may not be properly educated. “For example, they may not realize that their antidepressant may take up to two months to kick in,” says Wood. “A joint makes them feel better now.”

The litany of unpleasant side-effects also makes antipsychotics less than appealing for people used to self-medicating. Dr. Patricia Cavanagh, a psychiatrist at Toronto Western Hospital, says, “Imagine a young person being told about this double trouble they’re in for, responding that they’ll happily take medication for the rest of their lives, accept the limitations without complaint, not get distressed about the serious side-effects?”

Dr. Eva Styrsky, a psychiatrist with Humber River Regional Hospital in Toronto, offers another reason for non-adherence. She says there is a lot of confusion among health care workers about medication-drug interactions, so many practitioners simply tell their clients to quit the substance, an approach often met with resistance and failure. Similarly, clients may quit taking medication, themselves believing it may interact with the substance. “Many professionals and clients think it’s a black and white issue – either medication or substance, not both. It’s the wrong way to approach it,” says Styrsky.

For clients with serious substance use issues, such advice may interfere with treatment. Clients who are advised not to drink alcohol may stop medication so they can drink. Similarly, some medications counteract the effects of substances, so the user doesn’t experience the desired high and may go off the medication to regain that high. “For example, antidepressants may blunt the effect of ecstasy,” says Wood. “If someone has had very pleasurable experiences on ecstasy but isn’t any longer because of medication, they may stop the meds, thinking ‘I’d rather take the ecstasy and have fun.’”

Interactions aside, stopping medications abruptly and resuming several days later can be counter-therapeutic or even dangerous. Wood explains that since some antidepressants clear out of the system quickly, withdrawal symptoms and anxiety can appear after as little as two days. Ceasing antipsychotic medication can have a similar effect: “For people with schizophrenia who go off clozapine abruptly, their psychotic symptoms can return after two or three days,” says Wood. “Suddenly resuming the full dose can have serious consequences, including fainting and seizures.”

Improving compliance begins with helping clients understand why medication is so important. “They think their ‘medication’ is better,” says Styrsky.“You have to see it from their perspective, work with them, don’t give up.”

Cavanagh stresses that a caring, empathetic long-term relationship is necessary to establish a workable treatment plan and promote adherence. Wood agrees: “A good therapeutic alliance makes people more comfortable about disclosing their drug use so the doctor can help them. Disclosing about non-compliance is something nobody wants to tell their doctor.”

Experts generally agree that a multidisciplinary approach – integrating psychiatric and substance abuse treatment – is the best way to deal with concurrent disorders. Harm reduction approaches are also important. But most health care professionals worry that condoning mixing medications and substances puts them in a legally difficult position. “But it may be unrealistic to say ‘just don’t do it,’” explains Wood. “Yes, there is risk involved in combining substances, but what’s often less talked about is the risk of not treating a disorder and not addressing substance use. Risk-benefit–wise, for some individuals, it may be smarter to use antidepressants and drink than stop antidepressants and drink. It’s a poor coping mechanism, but then, as a therapist, that’s your opportunity to address the issue with the client. ‘No you can’t do it’ closes off a lot of discussion.”


Cocktails: Facts for Youth about Mixing Medicine, Booze and Street Drugs is a comprehensive clinical reference that outlines 105 medications and their interactions with alcohol, tobacco, caffeine and street drugs. It is published by the Children’s and Women’s Health Centre of British Columbia. The guide targets youth, but is relevant to people of all ages.