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Table 4 WHO Recommendations- the management of tobacco use, substance use disorders in people with severe mental disorders

From: Gaps and challenges: WHO treatment recommendations for tobacco cessation and management of substance use disorders in people with severe mental illness

Question Recommendation Strength of recommendation
For people with SMD who use tobacco, are pharmacological (including nicotine replacement therapy, bupropion, varenicline) and/or nonpharmacological interventions effective to support tobacco cessation? In people with severe mental disorders, combined pharmacological and non-pharmacological interventions may be considered in accordance with the WHO training package (Strengthening health systems for treating tobacco dependence in primary care. Building capacity for tobacco control: training package) (http://www.who.int/tobacco/publications/building_capacity/training_package/treatingtobaccodependence/en/). Conditional; quality of evidence- very low
  In people with severe mental disorders, a directive and supportive behavioural intervention programme may be considered and should be tailored to the needs of the population. Conditional; quality of evidence- very low
  In people with severe mental disorders, varenicline, bupropion and nicotine replacement therapy may be considered for tobacco cessation. Conditional; quality of evidence- very low
Best practice recommendation Prescribers should take into account potential interactions between buproprion and varenicline with psychotropic medications as well as possible contra-indications.  
For people with SMD and substance (drug and/or alcohol) use disorder, are pharmacological and/or non-pharmacological interventions for substance use disorder effective to support reduction in substance use-related outcomes? For people with severe mental disorders and comorbid substance use disorders (drug and/or alcohol) interventions should be considered in accordance with the WHO mhGAP guidelines. Conditional; quality of evidence- low
  Non-pharmacological interventions (e.g. motivational interviewing) may be considered and tailored to the needs of people with severe mental disorders and substance use disorders. Conditional; quality of evidence- very low
Best practice recommendation Prescribers should take into account the potential for drug-drug interactions between medicines used for treatment of substance use disorders and severe mental disorders.  
  Additional considerations:
• There was some non-consistent evidence to indicate effectiveness of motivational interviewing in reducing cannabis and alcohol use in dual diagnoses populations in terms of level of consumption, frequency of use, and abstinence.
• Findings from one study identified from reviews indicated that contingency management for substance use may be beneficial in terms of frequency of use (stimulants and alcohol) and non-abstinence (stimulants)
• In populations with depression and comorbid alcohol use disorders there is some indication that antidepressants may be more effective than placebo in reducing number of drinks on drinking days or increasing the number of people abstinent.
• The GDG also highlighted that, for injecting drug users, testing for Hepatitis B and C and vaccination for Hepatitis A and B should be considered.