Transcript No Slide Title

Co-Occurring Disorders: Overview of
Latest Research and Clinical Implications
- including Prevention and Tobacco
Douglas Ziedonis, M.D., MPH
Professor & Director, Division of Addiction Psychiatry
Robert Wood Johnson Medical School
732-235-4341
[email protected]
Big Year for COD
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SAMHSA’s Report To Congress
President’s New Freedom Commission on MH
SAMHSA’s TIPS on COD (new version)
CO-MAP: Medication Algorithm for COD
RWJF Addressing Tobacco in MH & Addictions
NIH grant requests
RWJF & RAND COD Initiative
ASAM PPC II – DD Capable & DD Enhanced
APA SA Treatment Guidelines Update www.psych.org
National Training Center on COD
SYSTEM ISSUES
Treatment Models for Different
Settings
Clinical, Program, & System Issues
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Mental Health, Addiction, & Primary Care
What are the remaining Barriers?
What are the innovations?
How do we continue to change the field to
better address co-occurring disorders?
– Clinical - screen, assessment, treatment
– Program - training, QI, program integrity
– System - collaboration, networks, financial
Mentally Ill Chemical Abuser (MICA)
vs Chemical Abuser with Mental Illness
(CAMI)
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Type & Severity of Psychiatric Disorders
Type & Severity of Substance Use Disorders
Motivation to Stop Using Substances
Role of Physician & Prescribing Medications
Routine Mental Status Exam & Urine Testing
MICA vs CAMI (II)
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Continuum of Care
Outreach & Case Management
Residential Services: Rules & Medications
HIV / Medical Services Linkage
Family, Spouse, & SO involvement
System Models to Address Co-occurring
Mental Illness and Addiction
• Quadrant Model
• Program Development Stages:
– Seek Consultation
– Coordinate treatment across systems
– Develop Integrated Services
• Sequential, Parallel, and Integrated Services
• Fully versus Consultant Integrated
MH System Models: Motivation
Based Dual Diagnosis Treatment
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Engagement & Empathy
Match Goals and Techniques to 5 Stages
Integrated MH & SA approaches
Comprehensive Services (all levels of care)
Services matched to motivational levels
– “healthy living groups”
– contemplation vs action phase groups /
programs
– Dual Recovery Anonymous
Addiction System Models:
Differences in Service Components
• “Consultant added” vs “All staff” Integrated
• Addiction Medicine / Psychiatrist Time
• Psychological Testing Availability
• Role of Addiction Treatment Staff
• Therapy Approach
• Motivational Enhancement Therapy
• Involvement of Family, Spouse, & S.O.
• Staff Training
Fully Integrated (Experimental Model)
• Psychiatrist on-site two days per week with 5 day
on-call availability
• Psychological testing available on site
• Addiction Staff address addiction & mental health
• Basic and Advanced training and supervision
• Use of Motivational Enhancement Therapy
• Dual Recovery Therapy for Co-occurring Disorders
• Enhanced Family, Spouse, and SO Services
Comparison / Treatment As Usual Model
(Consultant Integrated)
• Consultant integrated 2 half days per week (MD,
PhD, MSW-CADC) & Improved Access to MDs
• No Psychological testing on site
• Addiction staff treatment as usual
• Basic training and supervision
• Limited Motivational Enhancement Therapy
• Standard Addiction Counseling & Support
• Standard family, spouse, and SO services
Get Publication: Strategies for Developing
Treatment Programs for People with COD
• Collection of COD Training Materials
• Strategies and tools that public purchasers
use to build integrated care systems
• Core competencies
• SAMHSA.gov (with NCCBH & SAAS)
• 2003 publication
Program Implementation
• Acknowledge the challenge
• Establish a leadership group and commitment to change
– Create the vision and adopt a COD treatment model
• Create a Change Plan and Implementation timeline
– Can the program afford medical services (MD, APRN)?
– What COD subtypes will we treat?
– Do we have staff who are trained?
– Do we need program consultation or PT consultants?
– Start with the Easier System Changes
• Conduct staff training
• Enhance COD Assessment and Treatment Planning
Program Implementation - continued
• Incorporate COD issues into patient education
curriculum
• Provide Medications for Mental Health and Addiction
• Integrate Motivation-Based Treatments throughout
system
• Develop onsite Dual Recovery Anonymous meetings
and establish ongoing communication with 12-Step
Recovery groups, professional colleagues, and referral
sources about system change
• Later steps: Prevention Opportunities and Address
Tobacco
Relatively Easier Program Changes
• Obtain Program Change Manual: CSAT
web page
• Change forms to include MH, Tobacco,
and Prevention
• Provide educational materials to patients
and family
• Encourage the development of Nic A on
site
SPECIFIC INTERVENTIONS
• By Subtype
• Medications
• Psychosocial interventions
– Motivational Enhancement Therapy
– Dual Recovery Therapies – for sub-types
TIPS: Principles of COD Treatment
• COD treatment is different – Depends on
Setting
• Integrate and modify mental health and
addiction treatment approaches
• Match treatment approaches to recovery
stage and motivational level
• Provide comprehensive dual diagnosis
services across the continuum
• Consider a long-term treatment perspective
Dual Recovery Therapy (DRT)
• Integrate and modify the best of mental health and
addiction approaches
• Consider the impact of each disorder on the individual
and traditional treatments
• Consider the patient’s stage of recovery for both
illnesses and their motivation to change: Motivation
Based Dual Diagnosis Treatment Model
• Recognizes the need for hope, acceptance, and
empowerment
• Encourage Medication Compliance
Dual Recovery Therapy Blends
and Modifies
• Core addiction therapy approaches
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Motivational Enhancement Therapy
Relapse Prevention
12-step Facilitation
NCADI: 1-800-SAY NO TO; www.health.org
• Core mental health therapy approaches
– Varies according to MICA / CAMI – specific
mental health disorders or problems
– More case management & outreach
Dual Recovery Therapy (DRT)
Dual Recovery Therapy
Comprehensive Assessment
MET - 4 Sessions
Feedback
Change Plan
Mental Health Tx
Disorder Specific
Medications
Addiction
Relapse Prevention
12-Step Facilitation
Other Related Problems
Case Management
MET = MI + Feedback
• Motivational Interviewing (Style)
– Empathy, Client-Centered, Respects readiness to
change, embraces ambivalence
– Directive – one problem focused (needs
adaptation for poly-drug & COD)
• Personalized Feedback (Content)
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Assessment
Personalized Feedback
Values / Decisional Balance: Pros & Cons
Change Plan & Menu of Options
Assessing Motivation to Change
• Formal: SOCRATES & URICA
• Informal:
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Importance, Readiness, & Confidence
DARN-C
Decisional Balance
Time-line / Quit Date
Counter-transference & Non-verbal cues
Key Consideration: What do you
Feedback?
• What type of feedback is important and will
have an impact to do what?
• How does motivational level effect what
type of feedback?
• How does specificity of substance matter?
– Alcohol – you are not a social drinker
– Drugs – you are like drug users in treatment
Modifying MET for COD
• More Problems to Address
– Longer Engagement Period
– Lower Self-Efficacy (link with recovery / hope)
• Assess MH, SA, & Meds (can one be consistent?)
• Modify Feedback & Change Plans - dual
• Address Cognitive Limitations
– Higher therapist activity & behavioral strategies
– Briefer, More Concrete, Repetitions, Follow Alertness
• Integrate with Mental Health Treatments
Modify MET for COD
• Poly-Drug issues
• Multiple Mental Illnesses & medications
• Assessing Motivation to Change for Each issue
on the Problem List
– HOW BLEND MULTIPLE TREATMENT
STYLES: Motivational & Action (RP, 12-Step,
etc)
– HOW TRANSITION from MET/MI & Action
Oriented Treatments
• Engage the Patient in picking the priority list
and what to address when
Poly-drug Abuse
• Variety of combinations are common:
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Alcohol, cocaine, and benzodiazepines
Heroin and cocaine, sedatives, and alcohol
Marijuana and tobacco
Tobacco and any other drug
Multiple Club drugs, prescription (opioids, stimulants,
sedatives, steroids, etc), street drugs (inhalants, hallucinogens,
formaldehyde, PCP, K-7 and other internet sold substances,
etc)
• Variety of severity of substance use disorders
• Variety of motivation to stop each specific substance
• Variety of COD and interest to address mental health
problem or health risks and to take medication
Tobacco & Schizophrenia:
Personalized feedback
• CO monitoring – their immediate
health
• Tobacco caused medical disorders
• Costs
• Recovery
• Children’s health
• “Personalized message”
Problems & Disorders NOT to
Forget
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Sub-threshold Depression &Anxiety Disorders
PTSD
Adult ADHD & Learning Disability
Social Anxiety Disorder
Eating Disorders
Axis II
Anger
Compulsive Behaviors (sex, gambling,
codependence, work, food, spending, etc)
Specific Psychosocial Treatments For
COD with Other Psychiatric Disorders
• PTSD: Behavioral Therapies - Seeking
Safety – Lisa Najavitz
• Bipolar: Family / Psychoeducation Roger Weiss
• Schizophrenia: Social Skills Training,
Case Management / ACT
• Social Anxiety Disorder – Behavioral
Therapy
Integrating Spirituality into
Treatment (Miller W.APA, 1999)
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Mindfulness and Meditation
Prayer
Values, Spirituality, and Therapy
Spiritual Surrender
Acceptance and Forgiveness
Evoking Hope
Serenity
Complementary Approaches
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Acupuncture
Hypnosis
Herbs
Meditation
Qi-Gong: Meditation, Deep Breathing, Yoga
The Arts: art and music
– Drumming, NAF
• ETC
Medications for COD Treatment
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Detoxification
Protracted Abstinence
Harm Reduction / Opioid Agonists
Co-occurring Psychiatric Disorders
– AA Brochure: The AA Member:
Medications and Other Drugs, 1984
Addressing Tobacco in Dual
Recovery and Mental Illness
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44% of all cigarettes consumed in the US
$256 Billion Dollars on Cigarettes
75% of those with mental illness
Most smoke and die due to smoking caused diseases
Nicotine use is a trigger for other substance use
Treatment can Work: NRT, Atypicals, MET, and
Behavioral therapy improves outcomes
• Social support and reduction of tobacco triggers is
helpful
Smoker’s Bill of Rights
• Right to smoke (it is legal)
• Right to concern and compassion from non-smoker
• Right to have their children protected from illegal
tobacco sales
• Right to learn the truth from tobacco companies about
the ingredients in tobacco products
• Right to learn the truth about the components of tobacco
smoke
• Rights to learn from the tobacco companies about what
health risks they have learned about
• Right to sue tobacco companies
• Right to have medical health coverage when they desire
to quit - Medication and Psychosocial treatments
Objectives
 Why Address Tobacco in Addiction Treatment
Settings?
 It’s a Clinical Issue
 a Health Issue
 a Recovery Issue
 an Environmental Tobacco Smoke Issue
 Changing the Culture of any program includes
 Vision, leadership, and written implementation plan
 staff training
 providing staff EAP options
 Environmental changes and Clinical Services
 Developing new policies & enforcement
Tobacco Dependence Treatment
Clinical Issues: Assessment, Treatment
Planning, and Treatment
Psychosocial
Medications
Clinical questions
Timing of tobacco dependence treatment
Only drug with a “quit date”
Pharmacology: FDA and beyond
13mgs per cigarette – about 2 mgs absorbed into
the body per cigarette
Blending Psychosocial Treatments
Only 3% of the time is psychosocial treatment
offered to those smokers who get help to quit
Mood Management Training
To Prevent Relapse
• Sharon Hall and colleagues at UCSF
• Skills can be developed through instruction,
modeling, and homework practice
• Cognitive Therapy
– Learn to identify and anticipate external and
internal cues - thought patterns that lead to
negative moods
– Learn to avoid or cope with cues
– Learn to modify their thought patterns so as to
avoid or reduce the likelihood of negative affect
Drug-Free is Nicotine-Free
• A Manual for Chemical
Dependency Treatment Programs
• 732-235-8222
• www.tobaccoprogram.org
Treating Tobacco Use and Dependence
– PHS Clinical Practice Guideline
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AHCPR: 800-358-9295
CDC: 800-CDC-1311
NCI: 800-4-CANCER
www.surgeongeneral.gov/tobacco/default.htm
Prevention of a Secondary Disorder
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Prevention Opportunities
By Age of Onset of Disorder
By Age Group
By MH versus Addiction Treatment System
How do we get clinicians to consider
prevention??
Internet Resources
• Mental Health: www.mentalhealth.org
• Addiction: www.health.org (1-800-say-no-to)
– NCADI: ask for catalog, TIPS # 9 – new update
next month
• American Psychiatric Association Treatment
Guidelines: www.psych.org
• Nicotine: www.tobaccoprogram.org