Transcript Substance Abuse: Assessment and Treatment

Substance Abuse and PTSD in
the Veteran Population:
Overview and Treatment
Lisa T. Arciniega Ph.D.
and Jennifer Klosterman Rielage Ph.D.
NMVAHCS
Feb. 6, 2008
Objectives
• Background substance use disorders (SUD):
assessment and treatment
• Address: the relationship between substance
use disorders (SUD) and posttraumatic stress
disorder (PTSD)
• Introduction to Seeking Safety
• References / Resources for further information
Substance Abuse
DSM-IV TR
A. Maladaptive pattern of substance use leading to clinically significant impairment or distress, as
manifested by one or more of the following, occurring within a 12-month period:
• Failure to fulfill major role obligations at work, school or home
• Recurrent use when physically hazardous
Recurrent legal problems
• Continued use despite recurrent social or interpersonal problems
B. The symptoms have never met the criteria for Substance Dependence for this class of substance
Substance Dependence
A. Maladaptive pattern of substance use leading to clinically significant impairment or distress, as
manifested by three or more of the following, occurring at anytime within a 12-month period:
• Tolerance
• Withdrawal
• Taken in greater amounts or over longer time course than intended
• Desire or unsuccessful attempts to cut down or control use
• Great deal of time spent obtaining, using, or recovering from drug
• Social, occupational, or recreational activities given up or reduced
• Continued use despite knowledge of physical or psychological sequelae
(Diagnostic and Statistical Manual of Mental Disorders: Fourth Edition (DSM-IV-TR), (2000). American Psychiatric Association)
Addiction: definition
“Addiction has a specific definition: you are unable to stop when you
want to , despite [being] aware of the adverse consequences. It
permeates your life; you spend more and more time satisfying [your
craving].” (N. Volkow, Director NIDA)
“Addiction is a chronic and relapsing brain disease characterized by
uncontrollable drug-seeking behavior and use. It persists even with
the knowledge of negative health and social consequences. “ (S.
Lukas, Mclean Hospital )
Lemonick, M. (2007). The Science of Addiction. Time (July 16,2007), 42-48.
Background: The State of the Art in Drug
Addiction Treatment
• Treatment is effective (reduces by 40-60%)
• Treatment reduces undesirable consequences whether or not
patients achieve complete abstinence
• Mesa Grande findings:
(Miller,W.R, Wilbourne, P.L. Mesa Grande: A methodological
analysis of clinical trials of treatments for alcohol use disorders. Addiction, 97(3): 265-277. 2002).
brief interventions
social skills training
CRA,
behavior contracting,
behavioral marital therapy
case management.
Two pharmacotherapies: opiate antagonists (naltrexone,
nalmefene) and acamprosate
SUD in Veteran Population
• SUD is a significant problem in the veteran
population
• Data from a VHA report for 2003 showed 22%
veterans with SUD diagnosis (Improving the
Quality of Health Care for Mental and
Substance-Use Conditions: Quality Chasm
Series(2006))
• NMVAHCS population: CY 2007, 3500 unique
veterans were treated by the SUD clinic (primary
substances of use alcohol, cannabis, cocaine,
stimulants, opiates)
Case Examples*
• 20 yr old male National Guardsman who came home from Iraq and
partied with his friends for 6 months. Is now interested in buckling
down and going back to school.
• 24 yr old female OIF/OEF veteran who had to respond to a bad
convoy accident & help rescue. She has flashbacks and nightmares
and feels angry all the time. She begins using alcohol to cope.
• 60 yr old male veteran of the Army who met criteria for Alcohol
Dependence after his TOD in Vietnam. Has been doing well but
recently deployed to Iraq.
*Important Note: All case examples provided have had demographic
characteristics and details altered in order to protect the identity of clients.
Assessment: Screening
Screening (Primary Clinic, ER, Specialty clinic as referral sources)
• Patients should be routinely screened for SUD (MAST,
DAST, CAGE, AUDIT)
• Patients should be routinely screened for PTSD
(TSQ, PC-PTSD)
Refer for specialized treatment as needed
SUD Clinic Initial Assessment
• Biopsychosocial assessment (MHA, ASI)
• Assess for Medical / Psychiatric stability and/or intervention
(SI/HI; detox; withdrawal; anticraving medications)
• Motivational Intervention emphasizing building
motivation for change
Blocking the Cascade of Alcohol Dependence
(Collins, G. et. al. (2006). Drug adjuncts for treating alcohol dependence. Cleveland Clinic Journal of Medicine, 73:7, 641-649)_
Physiological Process
And Behavior
Drugs that May
Block the Cascade
Desire for alcohol,
Positive craving
Acute drinking
Naltrexone, nalmefene
“Pleasure center”
Dopamine release
Ondansetron
Chronic Drinking
Central nerbous system
Hyperexcitability
Topiramate
Withdrawal, negative craving
During abstinence
Acamprosate
Relapse
Disulfiram
Medications for Drug Abuse
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Opioid (heroin, morphine) Addiction:
Methadone and buprenorphine - medications that block the drug's effects,
suppress withdrawal symptoms, and relieve craving for the drug
Buprenorphine (Subutex or, in combination with naloxone, Suboxone) : This is a
relatively new and important treatment medication. Development of
medication and the passing of the Drug Addiction Treatment Act (DATA
2000), permitting opiate treatment in a medical setting rather than limiting it
to specialized drug treatment clinics.
•
Ttobacco (nicotine) addiction – Chantrix and Zyban (wellbutrin)
•
stimulant (cocaine, methamphetamine) and cannabis (marijuana)
medications are still under development.
Evidence Based Treatment
(NIAAA COMBINE CBI Intervention)
• Variety of well-supported treatment methods merged into an
integrated approach.
• Phase 1: motivation for change / MET feedback
• Phase 2: Functional analysis, psychosocial functioning, survey of
strengths and resources, SSO involvement to be used in treatment
planning
• Phase 3: Nine CB skill training modules (assertiveness,
communication, coping with craving and urges, drink refusal and
social pressure, job finding, mood management, mutual-help group
facilitation, social and recreational counseling and social support for
sobriety)
• Phase 4: maintenance checkups
• Pull-Out procedures: sobriety sampling, raising therapist’s concerns,
implementing case management, handling resumed drinking,
supporting medication adherence, responding to a missed
appointment, telephone consultation and crisis intervention)
PTSD Diagnostic Criteria
• Criterion A: The person has been exposed to a traumatic event in
which BOTH of the following were present:
– Experience/witness/confronted /w actual or threatened death or
serious harm
– Response included intense fear/helplessness/horror
• Criterion B: Persistent Re-experience Trauma
• Criterion C: Persistent Avoidance
• Criterion D: Persistent Hyperarousal
• Criterion E: Symptoms > 1month
• Criterion F: Clinically significant distress or impairment in work,
family, etc.
Complex Relationship between
PTSD and SUD
• Alcohol and drugs may be abused in an attempt to control
PTSD symptoms
• SUD may increase risk of development of PTSD by
increasing likelihood of exposure to certain types of trauma
• A third variable may be related to the development of both
PTSD and SUD following a trauma exposure, e.g. poor
coping skills
Used with permission by R. Walser Ph.D., National Center for PTSD
Prevalence Rates of Veterans with
SUD and PTSD
• PTSD and substance abuse co-occur at a relatively high rate
• Estimates of substance use disorders and PTSD
– Rate among patients in SUD treatment ranges from 12%59% 1
– 58% of veterans in SUD programs have lifetime PTSD2
– 73% of male Vietnam veterans who met diagnostic criteria for
PTSD also qualified for lifetime SUD disorders3
• The odds of drug use disorders are 3 times greater in individuals
with versus without PTSD4
• Presence of either disorder alone increases the risk for the
development of the other5
Used with permission by R. Walser Ph.D., National Center for PTSD
30% of Returnees in VA Care Receive Mental
Health Diagnoses – Substance Use Disorders
are among the Most Common Problems
15%
13%
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Used with permission by R. Walser Ph.D., National Center for PTSD
Treatment Considerations
PTSD/SUD Patients
• Parallel SUD / PTSD Treatment: separate but
concurrent treatment in different clinics by different
providers
• Sequential: separate with one treatment following the
other. Usual order is typically SUD treatment followed
by PTSD treatment
• Integrated: newer approach (Seeking Safety)
Used with permission by R. Walser Ph.D., National Center for PTSD
Treatment Considerations
PTSD/SUD Patients
• PTSD, unlike other disorders, may worsen in the early stages of
abstinence creating a challenging treatment environment
• Exposure therapy may trigger substance abuse relapse
• Aspects of 12-Step groups are difficult for some trauma patients
– Powerlessness
– Higher Power
– Locating appropriate groups
– Issues of forgiveness
Used with permission by R. Walser Ph.D., National Center for PTSD
Treatment Considerations
NMVAHCS Treatment
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Intensive Treatment (MITP)
Family Involvement (CRAFT)
Community Involvement (CRA)
Residential Treatment (STARR; DRRTP)
12-step programs encouragement (AA,NA,CA)
Mindfulness
Seeking Safety
PTSD Symptom Model
HYPERAROUSAL
RE-EXPERIENCING
AVOIDANCE
Herman’s Trauma Recovery Model
Step 3: Re-Integration
Step 2: Mourning
Step 1: Safety
Herman, J. (1997). Trauma and Recovery: The aftermath of
violence—from domestic abuse to political terror. Basic.
Seeking Safety: Basic Principles
• Most urgent clinical need is to establish
safety
– Stop using substances
– Reduce suicidal and parasuicidal behaviors
– Curb risky behaviors (unprotected sex, driving
fast, etc.)
– End dangerous relationships
• Continuous treatment of BOTH SUD &
PTSD
Seeking Safety: Overview
• Goal of treatment is safety, including
replacing unsafe coping (e.g., binge
drinking) with safer coping
• 25 topics in cognitive, interpersonal, &
behavioral realms
• Importance of session format
• Focus on case management
References:
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Collins, G. et. al. (2006). Drug adjuncts for treating alcohol dependence. Cleveland Clinic Journal of Medicine,
73:7, 641-649.
•
American Psychiatric Association (APA) (2000). Diagnostic and Statistical Manual of Mental Disorders:
Fourth Edition (DSM-IV-TR).
•
Herman, J. (1997). Trauma and Recovery: The aftermath of violence—from domestic abuse to political terror.
Basic.
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Lemonick, M. (2007). The Science of Addiction. Time (July 16,2007), 42-48.
Marlatt, A. and Gordon (1985). Relapse Prevention Model and the Relapse Prevention Group. Seattle VAMC
WATC.
Miller, W.R. et.al. (2004). Combined Behavioral Intervention Manual: A clinical research guide for therapists
treating people with alcohol abuse and dependence. U.S. Department of Health and Human Services: NIH;
NIAAA.
Meyers, R.J., and Smith, J.E. (1995) clinical guide to Alcohol Treatment: The Community Reinforcement
Approach. New York: guilford Press, 1995.
Miller, W.R. and Rollnick, S. (1991). Motivational Interviewing: Preparing People for Change. New York: guilford
Press, 1991.
Miller,W.R, Wilbourne, P.L. Mesa Grande: A methodological analysis of clinical trials of treatments for alcohol use
disorders. Addiction, 97(3): 265-277. 2002
Najavits, L.M. (2002). Seeking Safety: A treatment manual for PTSD and substance abuse. New York: Guilford.
Principles of Drug Addiction Treatment: A Research-based Guide (NCADI publication BKD347
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Additional Resources:
National Institute on Alcohol Abuse and Alcoholism (http://www.niaaa.nih.gov)
National Institute on Drug Abuse (http://www.nida.nih.gov)
National Center on PTSD (http://www.ncptsd.va.gov)
National Clearinghouse on Alcohol and Drug Information (http:/www.health.gov).
The End
Questions?
Comments?
COMBINE Treatment
Phase 2:
• Functional analysis
• a review of the client’s psychosocial functioning
• survey of the client’s strengths and resources
• SSO involvement
• Community support involvement (12-step)
• Treatment planning
COMBINE Treatment
Phase 3: Menu of nine CB skill training modules
• Assertiveness
• Communication
• coping with craving and urges
• drink refusal and social pressure
• job finding
• mood management
• mutual-help group facilitation
• social and recreational counseling
• social support for sobriety
NMVAHCS SUD Treatment
Inpatient vs Outpatient
Inpatient (Gallup, DOM, STARR, other)
Outpatient
MITP (Mini Intensive Treatment Program)
EOP (Evening Outpatient Program)
Seeking Safety
Mindfulness Class
Continuing Care Treatment
CRAFT (Community Reinforcement and Family Training)
Relapse Prevention
Dual Diagnosis
Gambling Program
Older Veteran Program
Individual Treatment
Case Management
Medication Management / Consultation
Background: Thirteen Principles of Effective
Drug Addiction Treatment
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No single treatment is appropriate for all individuals.
Treatment needs to be readily available.
Effective treatment attends to multiple needs of the individual, not just his or her drug use.
Treatment needs to be flexible and to provide ongoing assessments of patients’ needs.
Remaining in treatment for an adequate period of time is critical for treatment effectiveness. (For
most, the threshold of significant improvement is reached at about 3 months)
Individual and/or group counseling and other behavioral therapies are critical components of
effective treatment for addiction.
Medications are an important element of treatment for many patients, especially when combined
with counseling and other behavioral therapies.
Addicted or drug-abusing individuals with coexisting mental disorder should have both disorders
treated in an integrated way.
Medical detoxification is only the first stage of addiction treatment and by itself does little to
change long-term drug use.
Treatment does not need to be voluntary to be effective.
Possible drug use during treatment must be monitored continuously.
Treatment programs should provide assessment for HIV/AIDS, hepatitis B and C, tuberculosis and
other infectious diseases and counseling to help patients modify or change behaviors that place
them or other at risk of infection.
Recovery from drug addiction can be a long-term process and frequently requires multiple
episodes of treatment.
(Principles of Drug Addiction Treatment: A Research-based Guide (NCADI publication BKD347)