There are no data regarding whether to treat the substance addiction or OCD first or to treat both simultaneously. Effective treatment for OCD may differ substantially from treatment for a substance addiction. Although different treatments are involved, in our clinical experience with patients with OCD and substance addictions, we recommend that both conditions be treated simultaneously.

Medication options

It is well established that the pharmacological first-line treatment of choice for OCD is a serotonin reuptake inhibitor (SRI) (for example, clomipramine, fluvoxamine, fluoxetine).

The data regarding the efficacy of SRIs in the treatment of addiction are largely unimpressive except when targeting co-occurring disorders or symptoms.

A range of treatment modalities are available for substance abusers and different modalities are appropriate at different phases of recovery.

Detoxification is the first phase of recovery and medications are often required to reduce symptoms of withdrawal. Longer acting benzodiazepines are typically used in alcohol withdrawal. Opioid withdrawal can be effectively managed using methadone, clonidine, naltrexone, or buprenorphine; specialist input is advised.

The second phase of recovery is active treatment provided in settings ranging from weekly outpatient counseling to ambulatory day programs to residential treatment. The content of these treatments tends to be multimodal, often using a disease or twelve step orientation supplemented with cognitive and behavioral strategies. Naltrexone, acamprosate, and disulfiram are medications approved by the Food and Drug Administration (FDA) (and agencies in countries besides the United States) for treating alcohol dependent patients. Ondansetron has been shown to be effective in treating early-onset (predominantly male) alcoholism.

Methadone, naltrexone, and buprenorphine are pharmacological options for maintenance treatment of opioid dependence.

A variety of medications have been evaluated for cocaine dependence, and n-acetylcysteine, disulfiram, and baclofen have demonstrated early promise in randomized controlled trials. These medications can generally be used safely with SRIs when treating substance addictions in OCD patients (except possibly fluvoxamine when used in methadone patients due to causing increased levels of methadone and potential toxicity).

N-acetylcysteine has also shown benefit for the treatment of cannabis dependence. There are limited data supporting effective medications for the treatment of anxiolytic and sedative, hallucinogens and other stimulant dependence.

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