For the OCD patient with alcohol addiction, naltrexone plus an SRI may be a useful combination as some evidence suggests naltrexone helps with cognitive inflexibility, a deficit that is likely to contribute to perseverative behaviors in OCD.

For OCD patients with cocaine or marijuana addiction, the addition of n-acetylcysteine to an SRI may be helpful as there is growing evidence that this type of agent (a glutamate modulator) may help with OCD as well.

The third phase of recovery is the maintenance phase. For some individuals, highly structured environments, such as halfway houses, are helpful in promoting long-term success. These structured living situations should be recommended cautiously, however, in the case of OCD patients who may find that these environments trigger and worsen OCD (e.g., living with many people with HIV or hepatitis C in a person with OCD contamination obsessions). These living situations may worsen OCD and thereby lead to relapse.

For others, some type of ongoing focus on recovery is important in the maintenance phase. Although the exposure ritual prevention therapy (ERP) form of cognitive behavioral therapy has shown clear benefit for OCD, when a substance addiction co-occurs with OCD, the therapy may also need to focus on relapse prevention forms of cognitive behavioral therapy. Attendance at twelve step programs such as Alcoholics Anonymous, Narcotic Anonymous, and Cocaine Anonymous is associated with better outcomes in numerous correlational studies. Alternative mutual support groups with less focus on the spiritual aspect of recovery, such as Women for Sobriety, SMART Recovery, and Rational Recovery are increasingly available across North America, with similar/equivalent groups available in other countries. These interventions can be used simultaneously with ERP for OCD.

Key References

• Blom RM, Koeter M, van den Brink W, de Graaf R, Ten Have M, Denys D. Co-occurrence of obsessive compulsive disorder and substance use disorder in the general population. Addiction. 2011 Dec;106(12):2178-85.

Fontenelle LF, Oostermeijer S, Harrison BJ, Pantelis C, Yucel M. Obsessive compulsive disorder, impulse control disorders and drug addiction: common features and potential treatments. Drugs. 2011 May 7;71(7):827-40.

Gentil AF, de Mathis MA, Torresan RC, Diniz JB, Alvarenga P, do Rosario MC, Cordioli AV, Torres AR, Miguel EC. Alcohol use disorders in patients with obsessive compulsive disorder: the importance of appropriate dual-diagnosis. Drug Alcohol Depend. 2009 Feb 1;100(1-2):173-7.

Mancebo MC, Grant JE, Pinto A, Eisen JL, Rasmussen SA. Substance use disorders in an obsessive compulsive disorder clinical sample. J Anxiety Disord. 2009 May;23(4):429-35.

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