Low cost substance use is very common amongst those with schizophrenia although opiate use is rare.   Drug use symptoms may mimic schizophrenic like symptoms in a number of situations:
- Amphetamine intoxication or withdrawal (hallucinations, paranoid delusions)
- Withdrawal from alcohol ('alcoholic hallucinosis')
- Chronic use of cannabis (paranoid behaviour)

Because schizophrenia is commonly treated with anti-psychotic drugs, the drug-related goal of intervention is often abstinence. However, the reality is that many will go on to continue to use substances despite best efforts.  Therefore, harm reduction strategies should always form a key component of any treatment plan.

Identifying the functional aspects of substance use and developing alternatives will improve outcomes.

It is also helpful to have an understanding of the clients prescribed medications, particularly possible side effects.  With permission from the client, side effects or other prescribed drug use issues should be referred to the client's doctor. The client should never be encouraged to reduce or discontinue prescribed medication without first consulting the medical practitioner who prescribed the medication.

Incidence and Aetiology

Early Signs

Symptoms

Treatment

Non-specific treatments
Referral
Drug therapy
Counselling
Family Involvement
Support groups

Incidence and Aetiology

Of those with a primary diagnosis of schizophrenia, a third to a half or more may have clinically relevant substance use problems. Of those with a primary diagnosis of substance use problems only 1- 4% have schizophrenia as a co-existing disorder although many more have drug-related schizophrenia-like symptoms.

Aetiology

While a range of theories have been used to explain the aetiology of schizophrenia, common hypothesis point to multiple causative factors such as:

- Genetic factors
- Social stressors such as crisis, migration or separation (which may be compounded by substance use)
- Dopamine hypothesis - an imbalance within the neurotransmitters which is exacerbated by Dopamine stimulating substances such as alcohol, marijuana, amphetamine or LSD where this predisposition exists.

Early Signs

Becoming socially withdrawn
Focus on bizarre and abstract topics (cosmos, conspiracy..)
Blocking or cut off conversation
Over suspiciousness
Abandoned life goals and plans
Blackouts or other 'spells'

Symptoms

Inappropriate behaviour
Grimacing, ritualistic behaviour, withdrawn or inactive, negative change in social habits such as poor hygiene

Affect (mood & emotions)
Blunted, ambivalence or inappropriate emotional responses

Thought and speech disorders
Thoughts may jump around, be stunted, illogical and hard to follow. Client may make up words, over-use symbols, use rhyming sentences or may be mute

Associated symptoms can include non-compliance, inappropriate expression of aggression, anxiety, regressive behaviour, threatened suicide, impulsiveness, manipulation, alterations in self-esteem and overall social decline.

Schizophrenia within the family is commonly experienced as a high stress event.

Treatment

Referral
Psychiatric assessment is nearly always indicated if psychotic symptoms are present.  Even if the diagnosis is not schizophrenia, anti-chaotic mediation may still be helpful in the short-term.

Hospitalisation
Hospitalisation is indicated if:
a. Symptoms present potential hazard to self, family, community members or other staff (eg threatening hallucinations).
b. Social situation is particularly poor or negative (supported accommodation only may be indicated)
c. More intensive observation is required during stabilisation on anti-psychotic drugs

Drug therapy
Anti-psychotics reduce psychotic symptoms, reduce the 'emotional push' behind delusional thoughts and reduce impulsive acts.
They also increase the client's availability to counselling. Adherence to prescribed drugs is actively sought through a range of motivational and support methods.  Monitoring of side-effects not only reduces discomfort and possible complications, it also improves adherence.

The nature of possible interactions with non-prescribed and prescribed substances should be investigated with medical or pharmacy staff and subsequently discussed with the client.

Counselling
Counselling aims to help the client deal with daily issues, support relationship building, manage anxiety and teach strategies to cope with stress.

Behavioural approaches are useful to identify triggers and reinforcements for bizarre or disruptive behaviour and managed  through stimulus control and alterations to reinforcement contingencies.  Cognitive approaches are generally inappropriate.

Identification of the functional aspects of drug use and developing positive alternatives as well as dealing with drug use and related problems are all indicated.

While abstinence is generally the option of choice, ultimately, it is the client who will make the final decision between controlled use or abstinence.  Even if the client chooses abstinence, harm reduction information should be made available in light of the high incidence of relapse.

Family Involvement
Family members may require support as clients in their own right.  They may also play a key role as an extension of the therapy team.  Where children are involved, a careful assessment of child safety is required, generally by someone specifically trained in this area such as a child protection worker.

After care and rehabilitation
Assertive after-care procedures are normally indicated to monitor the effectiveness of treatment including medications, as well as to provide ongoing supports to enhance maintenance.

Rehabilitation services may be required to improve living skills, provide vocational retraining or integrate into a half-way house..

Support groups

Support groups exist for those with schizophrenia, drug use problems. Separate support groups also exist  for those with both mental illness and substance use problems. Support groups also exist for family and friends of those with mental illness and/or drug use problems.