Transcript No Slide Title

Prevention and
Co-Occurring Disorders
Douglas Ziedonis, MD, MPH
Professor & Director, Addiction Psychiatry
UMDNJ - Robert Wood Johnson Medical
School
April 7, 2005
Agenda
• Define prevention
• Systems-Oriented versus Client-Oriented
Prevention Strategies and Programs
• Identify windows of opportunity to prevent a
secondary mental illness or addiction disorder
– Adolescents
– College students
– Older adults
• Promote Wellness and Reduce Morbidity amongst
individuals with COD
– Tobacco Dependence
– Obesity
• Treatment and Prevention Continuum
– Example: Addressing Tobacco
Prevention is Critical
• Handbook on Drug
Abuse Prevention
– Coombs and Ziedonis
(1995)
• Co-Occurring
Disorders
• Alcohol, Tobacco, and
Other Drugs
Defining Prevention
• Keeping something bad from happening
• Helping individuals, families, and communities to be
healthy, safe, and productive
• Promote constructive healthy lifestyles in all stages of
life
• Prevention is pro-recovery, pro-holistic health care,
and pro-wellness
• Prevention goals focus on:
– reducing morbidity and mortality
– prevent the initial onset of a disorder
– prevent co-morbidity, relapse, disability, and the
consequences of the illnesses on individuals, families, and
the community (NIMH, 1998)
Prevention Classifications
• Traditional public health distinguished
primary, secondary, and tertiary prevention
– Agent, Environment, Vector, Host
• IOM labeled MH prevention in terms of three
core activities: prevention, treatment, and
maintenance
• Current most common SA and MH
Prevention classification: Universal,
Selective, and Indicated Interventions.
Effective Prevention Strategies
• Prevention programs must be comprehensive,
family-focused, and include appropriate cultural,
developmental and gender perspectives.
• They need to focus on risk and protective factors
that are both identifiable and modifiable.
• Many mental health and addiction problems, share
common risk factors for initial onset and so
targeting those factors should result in reduced
illness and healthier lives
Universal, Selective, and Indicated
Interventions
• Universal - target the general public or a
whole population that has no known risk
factors.
• Selective - are targeted to groups at greater
than average risk of illness than the rest of the
population.
• Indicated - are provided to high-risk
individuals, their families, and to people
experiencing early symptoms of a disorder.
Primary prevention goals related to
co-occurring disorders
• (1) Promote healthy lifestyles to improve lives
and also reduce the likelihood of a mental
illness or substance abuse disorder from
occurring.
• (2) Promote healthy lifestyles amongst
individuals who have co-occurring disorders so
as to reduce morbidity and mortality of common
medical diseases and traumas, including
reducing the severity and preventing relapse of
one or both disorders.
Window of Opportunity
• In many cases either the mental illness or
the addiction develops first
• There is a window of opportunity until the
next disorder develops
• Adolescence, College Students, Adults, and
Older Adults
• Epidemiology Data – few targeted studies
COD Prevention Programs Should . . .
.
Reduce Risk Factors
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ineffective parenting
chaotic home environment
lack of mutual attachments/nurturing
inappropriate behavior in the classroom
failure in school performance
poor social coping skills
affiliations with deviant peers
perceptions of approval of drug-using behaviors in
the school, peer, and community environments
COD Prevention Programs Should . . .
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Enhance Protective Factors
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strong family bonds
parental monitoring
parental involvement
success in school performance
prosocial institutions (e.g. such as
family, school, and religious
organizations)
conventional norms about drug use
SA Prevention Programs Should . .
Include Interactive Skills-Based
Training
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Resist drugs
Strengthen personal commitments
against drug use
Increase social competency
Reinforce attitudes against drug use
Prevention Programs Should be . . .
Family-Focused
Provides greater impact than parent-only
or child-only programs
Include at each stage of development
Involve effective parenting skills
Prevention Programs Should . . . .
Involve Communities and Schools
Media campaigns and policy changes
Strengthen norms against drug use
Address specific nature of local drug
problem
Key targets for reducing morbidity and
mortality
• reducing obesity
• increasing physical activity
• reduce risky behaviors leading to
HIV/AIDS
• eliminating tobacco use
• preventing birth defects
• prevent injury
• Prevent suicide
Clinical Prevention Targets
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Cancer
Heart and Vascular Diseases
Lipid Disorders
Infectious Diseases
Injury and Violence
Mental Health Conditions and Substance
Abuse
• Obesity in Adults and Children
Barriers to Clinical Prevention
• CLINICIANS
– Lack of training in prevention
– Limited appreciation of how their work can be reframed as
prevention
– Competing demands and not enough time to provide basic
services
• PATIENTS
– unaware of the benefits or availability of services
– unmotivated to pursue
– Deterred by inconvenience and expense of preventive care
• PROGRAM
– Inadequate reimbursement for these services
– Lack system for integrating services into regular care
– Patients often change programs
Put Prevention Into Practice Program
• U.S. Preventive Services Task Force (USPSTF)
• Found much support for clinical prevention
efforts in primary care
• The Agency for Healthcare Research and
Quality's PPIP program for primary care
– A Step-by-Step Guide to Delivering Clinical
Preventive Services: A Systems Approach
Steps to deliver clinical preventive services
• Establish preventive care protocols.
• Define staff roles for delivering and monitoring
preventive care.
• Determine patient and material flow.
• Audit your delivery of preventive care
continually
• Readjust and refine your delivery system and
standards
Tobacco dependence treatment is cancer
and cardiac disease prevention.
• 44% of all the cigarettes in the US are
consumed by individuals with mental disorders
• Clinical interventions:
– Assessment
– Treatment planning
– Integrating treatment (medications and therapy) into
existing treatment interventions
– Referring to services such as State Quit Lines, Quit
Internet sites, or Quit Treatment Centers.
HIV/AIDS, Hepatitis and Other
Infectious Diseases
Drug treatment is disease prevention
Drug treatment reduces likelihood of HIV infection
by 6 fold in injecting drug users
Drug treatment presents opportunities for
screening, counseling, and referral
HIV prevention
• Not just about changing individual behavior
• Other Factors: relationships with family and friends,
community norms, access to health care and local
laws
• Addressing factors through multiple approaches:
individual, couple/family, community, medical and
legal.
• HIV prevention programs for injecting drug users
(IDUs):
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intensive street outreach to educate IDUs
drug treatment
syringe exchange
community-building and empowerment efforts
Adherence programs for HIV+ IDUs.
Addressing Tobacco with both
Prevention and Treatment
• Prevention and Treatment are
both necessary to reduce tobacco
dependence
• Targeting smokers with addiction
or mental illness is very
important for both groups
Now is the time to address tobacco
 Remember when we had:
 Drug versus Alcohol Treatment Programs
 Mental Health versus Addiction Treatment Programs
 SAMHSA’s definition of co-occurring disorders
includes tobacco dependence
 Model MH & Addiction Treatment programs are
better addressing tobacco with integrated treatment
 Recent Robert Wood Johnson Foundation Initiative
 Example: UMDNJ State-Wide Program
 DHSS, DMH, and DAS initiatives
 July 2003 issue of Psychiatric Annals
 www.tobaccoprogram.org
Tobacco is part of “Multiple Drug
Addictions” AND “Dual Diagnosis”
• Need Comprehensive Treatment and
prevention Services integrated at all levels of
care
• Motivation Based Treatment Approach
• Recovery-oriented long-term Treatment
Perspective
• Shared Decision Making
Tobacco Control / Prevention experts
• Done a tremendous job at reducing tobacco
use in the general population
• But not amongst individuals with either
mental illness or substance use disorders
• Need these experts to become more aware
of this high risk target population and to
develop new strategies that target this group
in particular.
Diseases Caused by Tobacco Use
Cigarette smoking increases the risk of:
 Coronary heart disease
 Atherosclerotic peripheral vascular disease
 Cerebrovascular disease
 Cancers of the lung, larynx, mouth, esophagus, bladder,
pancreas,
kidney, and cervix
 Chronic obstructive pulmonary disease
 Intrauterine growth retardation, premature rupture of membranes
 Low-birthweight babies, perinatal mortality
 Cataract, macular degeneration; hip fracture
 Peptic ulcer disease
 Possibly liver, stomach, and colorectal cancers and acute
myelocytic leukemia
Disease Caused by Tobacco Use
Involuntary smoking (environmental tobacco smoke) is a
cause of:
 Lung cancer and coronary heart disease in nonsmokers
 Respiratory infections and symptoms in the children of
parents who smoke
Smokeless tobacco causes:
 Oral Cancer
 Oral leukoplakia
 Dental caries (possibly)
Cigars cause:
 Cancers of the mouth, larynx, and lung
 Coronary heart disease
 COPD
Stages of Initiation (Flay)
Preparatory stage
Never smokes
Trying stage
No longer smokes
Experimental stage
No longer smokes
Regular use
Quits smoking
Addiction/Dependent smoker
Tobacco Control
Model
of Nicotine Addiction
Tobacco Products
Agent
Environment
Familial, Social,
Cultural, Political,
Economic, Historical,
Media
Vector
Tobacco Product
Manufacturers;
Other Users
Source: Orleans & Slade, 1993
Host
Smoker/Chewer
Incidental Host
Involuntary Smoker
Paradigm for Tobacco Control
Educational Activities
 Treatment activities
 Regulatory Efforts
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- Advertising and Promotion
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- Product Regulation / Price
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- Clean indoor air
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- Minor’s Access to Tobacco
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- Litigation
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- Advertising
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Treating Tobacco in Addiction and
Mental Health Settings
• Treatment can Work:
– 5 NRT options, Bupropion, Nortriptyline
– Brief counseling, MET, and Behavioral therapy
• Fewer Studies of Nicotine Dependence and either
Mental Illness or other Addictions
• Abstinence versus Harm Reduction
• Motivation Based Treatment Approach – total
abstinence may not be immediately achievable
Barriers to Tobacco Dependence Treatment
• Lack of staff training
• “not my role” – go to primary care
• Staff fear that patient’s will misuse NRT or smoke
while taking NRT
• Staff who smoke – normalize smoking, staff may
help patient’s access cigarettes, program may sell
cigarettes
• Restrictive formulary or insurance coverage of the
cost of medications
• Limited income and cannot afford OTC medications
Rationale for Treating Alcohol and
Tobacco Dependence Simultaneously
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Closely related behaviors
Eliminates a cue to drink
Serious cause of morbidity/mortality
Protected milieu
Common message
Apply same treatment philosophy
Postponing means potentially never
Program Level Changes to Address
Tobacco (1st)
• Acknowledge the challenge
• Establish a leadership group and commitment to
change
• Create a Change Plan and Implementation
timeline
• Start with the Easier System Changes
• Conduct staff training
• Provide Treatment and Recovery Assistance for
interested nicotine dependent staff
• Document Assessment and Treatment Planning
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Program Level Changes to Address
nd)
Tobacco
(2
Incorporate tobacco issues into patient education
curriculum
Provide Medications for Nicotine Dependence
Treatment and Required Abstinence Periods
Integrate Motivation-Based Treatments throughout
system
Develop onsite Nicotine Anonymous meetings and
establish ongoing communication with 12-Step
Recovery groups, professional colleagues, and referral
sources about system change
Develop Addressing Tobacco Policies and clear
consequences
Clinical Program changes
• Develop no-smoking policies
• Require assessment of tobacco use and
dependence
• Require treatment planning to include tobacco
dependence
• Creating a motivation-based treatment model
to address all smokers
• Not allow staff to smoke with patients
• Provide appropriate medications for use in
treatment of withdrawal
APA Nicotine Dependence Treatment
Guidelines
• Establish a therapeutic alliance
• Treatment setting
– TX best occurs in a setting that encourages cessation
• Initial interventions
• Education about nicotine dependence and its
treatment
• Timing of cessation attempt
• Abrupt vs. Gradual cessation
• Advise about alcohol & caffeine use
• Follow-up visits
• Dealing with slips and relapses