Indodo

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I have a young patient who drinks regularly and is on clozapine. I am in a community clinic and inherited this young man. He has parental involvement but lives alone and likes to "get zonked" and drinks "one bottle of wine" a day. I think he is fairly honest is isn't drinking more but how concerned should I be and should I use another medication.

Labs are normal for except for WBC that is slightly low, 4.something.
 

whopper

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I think the big concern is his compliance. If he gets drunk, how likely is he going to be compliant? As you likely already know, you just can't stop a dosage of Clozaril unless it's the starting dosage for a few days and then resume it.

How concerned should you be? Well the above problem is fairly dangerous if someone misses a few days of Clozapine then suddenly just restarts it.. Aside from this Clozapine increases the risk of seizure and so too does drikning.

But if he's noncompliant, how bad is he when psychotic? That too is a consideration.

You'll have to weight the risks of him being off the med vs. being on it and go from there. Anyone on Clozapine is supposed to be told the risks of it's use and his responsibilities. Document that you did this. Further, try to treat his drinking.
 
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Indodo

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I think the big concern is his compliance. If he gets drunk, how likely is he going to be compliant? As you likely already know, you just can't stop a dosage of Clozaril unless it's the starting dosage for a few days and then resume it.

How concerned should you be? Well the above problem is fairly dangerous if someone misses a few days of Clozapine then suddenly just restarts it.. Aside from this Clozapine increases the risk of seizure and so too does drikning.

But if he's noncompliant, how bad is he when psychotic? That too is a consideration.

You'll have to weight the risks of him being off the med vs. being on it and go from there. Anyone on Clozapine is supposed to be told the risks of it's use and his responsibilities. Document that you did this. Further, try to treat his drinking.

I should have mentioned that compliance isn't a big problem because his parents go to his apartment daily to make sure that he takes the meds. He is not psychotic but he has been on zyprexa, risperdal and seroquel in the past. 2 notes, 2 years apart from that time found on zyprexa shows that he was well controlled for about 3 years on zyprexa.

He is not interested in stopping the alcohol. This is all I discuss with him and he is not the least bit interested. At least he is not asking for a medical marijuana card anymore. Luckily he is an introvert, otherwise I would suspect he would become a very serious drug user. He very openly talks about how much he likes to "get zonked."
 

whopper

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There's too many factors here for me to give specific advice but in a situation like this, in general either you can't do anything because the patient's own poor insight and lack of desire for treatment, in which case you can try motivational interviewing but not much more,

Or you can have the parents apply for guardianship but this will only work if there's enough argument stating he doesn't know what he's doing to himself.
 
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Indodo

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He fully understands what is being said to him. There is no way he could be called incompetent.

My question really is would you keep the guy on clozaril or switch. I am going to start discussing a switch at his next visit but I just wanted some input on what other psychiatrists might try.
 

Fastball32

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Hi,
If medicine compliance is not an issue, then you shouldn't be more concerned about your patient being on Clozapine compared to other antipsychotics.
I would want to know if his psychosis is controlled with Clozapine, this should be more of an indicator of whether to continue it or not.

In fact, there's evidence to support that Clozapine helps reduce substance use for patients with psychosis.
http://www.dartmouth.edu/~dcare/pdfs/fp/GreenAlan-AlcoholandCannabisUseInSchizophrenia.pdf
http://psycnet.apa.org/journals/szb/26/2/441/
http://journals.lww.com/psychopharmacology/Abstract/2000/02000/Effects_of_Clozapine_on_Substance_Use_in_Patients.16.aspx


This knowledge is becoming a standard. The idea that Clozapine may help with substance use disorders has actually appeared in last year's Resident PRITE exams.
 

whopper

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There are a lot of broad issues here where a doc has to know the specifics. If a patient has treatment resistant psychosis where nothing else worked except Clozapine, of course they have to be on it unless that person's psychosis is not that bad (unlikely), or they are not healthy enough to take it.

The standard on paper is two antipsychotics needed to be tried and failed. I think that standard should be changed given how many newer antipsychotics we now have.

Another view is several patients on Clozaril do better on it (as measured in CATIE) vs other atypicals to the degree where some notables in psychiatry have argued that perhaps we should be considering it earlier. While that is not my own view, I see where they're coming from, and fully acknowledge I might be wrong about this.

I have treated dozens of patients on Clozaril. Unless you've done long-term or forensic psychiatric units, your'e likely not in a position where you've seen several patients who need it. Most doctors I've seen in settings other than long-term or forensic only see Clozapine patients rarely and get scared when dealing with them. Further, IMHO, the data regarding it is rather user unfriendly, having to read several documents then piece together what to do.

A colleague of mine made a very cohesive, easy to understand, and user-friendly state manual for the use of Clozapine within a treatment setting for the Ohio Dept. of Mental Health that incorporates very useful data often not found in textbooks. If you give me your e mail, and I got the time, I could scan it and email it to you. Please be aware that I'm up to my eyeballs in work, having worked 7 days a week for the past few weeks because I'm working on a private forensic case on top of my usual job and I got to fish for this manual that may be difficult for me to find.
 
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Indodo

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I am not comfortable treating addiction with clozapine.
 

whopper

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I don't think the issue is treating addiction with Clozapine, but that psychotic patients with an addiction problem do better if their psychosis is under control. Clozapine may actually have some direct benefit in treating alcoholism, but I wouldn't give it for that reason. I would, however, have no fear in giving it to someone who needs it anyway, it's medically justified, and if it creates an added benefit for alcohol dependence or abuse, that's even better.
 
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