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Concurrent disorders

Addiction is rarely a stand-alone problem. As research and clinical reality demonstrate, concurrent addiction, mental health and other medical problems are quite common.

Due to the stigma associated with substance use issues, there is often a focus on substances such as cocaine, cannabis and opiates. However, substance use issues involving sedatives, various pain medications and other over-the-counter and prescription drugs are often seen in the primary care setting. Primary care practitioners also likely see many clients who use tobacco, alcohol and caffeine, but client use of these substances often remains unexplored. Due to the potential interaction of these substances with other medications, the possible impact on clients' work and school performance and the biological effects of using substances, primary care practitioners should look for substance use problems as a normal part of general assessment and in a way that begins to lift the stigma around such problems.

This website uses the term concurrent disorder, as defined by the Canadian Centre on Substance Abuse ([CCSA], 2009), to refer to the co-ccurrence of mental health and substance use problems.
 
Concurrent disorders can include various combinations of mental health and substance use problems, such as:
 
  • anxiety disorder and alcohol use problems
  • schizophrenia and cannabis use
  • depression and benzodiazepine abuse
  • borderline personality disorder and oxycodone dependence
  • eating disorder and cocaine use
  • problem gambling and depression
  • attention-deficit/hyperactivity disorder and stimulant abuse.
 
Adding further complexity, people who have concurrent disorders may have more than just one mental health problem and may be using more than one substance at a given time. In addition, people with concurrent disorders can experience different levels of severity of their substance use and mental health problems.
 
Practitioners must take special considerations and precautions based on each client's specific needs and situation to decide on the best approaches to pharmacotherapeutic interventions, as well as to refer clients to specialized services when appropriate.
 
Substance Abuse in Canada: Concurrent Disorders (CCSA, 2009), has identified the five most common subgroups of concurrent disorders:
 
  1. stress, trauma and substance use problems
  2. anxiety disorders and substance use problems
  3. impulsivity and substance use problems
  4. mood disorders (including bipolar disorders) and substance use problems
  5. psychosis and substance use problems. 

Skinner (2010) outlined the role of primary care for people with concurrent disorders using the acronym I–SEE:

 

Assessment

A comprehensive assessment includes an assessment of the client's:
  • substance use problems
  • mental health problems
  • understanding of the relationship between these problems
  • motivation to change
  • psychosocial functioning.

Treatment

Treatment for concurrent disorders is still a fairly new field. There are some evidence-based practices, but they have been developed for targeted populations and have been tested mainly within specialty addictions and mental health treatment settings. Nonetheless, these evidence-based practices provide valuable information that may be of help to primary care practitioners. While there are specific evidence-based interventions and best practices that are recommended for particular types of concurrent disorders, the overall philosophy is applicable to all types of concurrent disorders.
 
The following overarching elements of treatment for concurrent disorders offer primary care practitioners a framework from which to work (Minkoff, 2000).
 
Practitioners should:
  • be empathic and hopeful
  • provide integrated and co-ordinated care
  • recognize that this work will involve multiple treatment sessions

Conditions