Transcript Brazil workshop - California Society of Addiction Medicine

Integrating Dual Recovery Therapy and
Medications for Co-occurring Disorders
Douglas Ziedonis, M.D., MPH
Professor & Director, Division of Addiction Psychiatry
Robert Wood Johnson Medical School
732-235-4341
[email protected]
Today’s Goals Include
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Increase awareness of the SAMHSA TIP on COD
(www.health.org)
Learn Dual Recovery Therapy & related assessment
issues
Learn how to modify MET for poly-drug, COD, HIV risk
behavior
Learn how to improve medication adherence and better
integrate medications into psychosocial treatments
Addressing Tobacco – an opportunity to learn MET
CASE STUDIES
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
General Treatment Issues for COD
• Empathy and the therapeutic alliance
• Family Involvement
• Brief Interventions: Feedback, Advice, Choices,
Optimism, Responsibility, and Follow-up
• Managing Resistance
• Monitoring for relapse / relapse prevention
• Detoxification
• Recovery Tools: treatment plan & contract, selfhelp groups, medications, & therapy
Excellent Resource: Strategies for Developing
Treatment Programs for People with COD
• SAMHSA.gov (with NCCBH & SAAS)
• 2003 publication – available through NCADI
and National Mental Health Information
Center
• Collection of COD Training Materials
• Strategies and tools that public purchasers use
to build integrated care systems
• Core competencies
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
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
Stages of Dual Recovery
* Blending Mental Health and Addiction
Perspectives
* Motivation Based Treatment:
Prochaska & DiClemente Stages of Change:
Precontemplation, Contemplation,
Preparation, Action, and Maintenance
* MICA model: Acute Stabilization,
Engagement, Active Treatment, Relapse
Prevention, & Recovery
DRT for
Addiction
Settings
Professional Development of Staff
• What is their Identity – Role?
• How improve their Training?
• Do they have the Credentials to see this
group of patients and in what capacity?
• EX: CSAT’s COD Model Program
Evaluation Studies
– Fully-Integrated vs Consultant-Integrated
ASAM PPC: 6 Dimensions
Dual Diagnosis Capable vs Enhanced
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SEVERITY GRID / Integrated programs
Acute Intoxication / Withdrawal
Biomedical Conditions or Complications
Emotional / Behavioral Conditions or
Complications
• Treatment Acceptance / Resistance
• Relapse / Continued Use Potential
• Recovery Environment
Basic Mental Health Training
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Organized around six sections
Focused on concrete skill acquisition
Style is didactic, with discussion
Includes articles and fact sheets that complement
content areas
Basic Mental Health Training Manual
• Six sections addressing diagnostic issues and
clinical presentations
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Assessment
Anxiety disorders
Mood disorders
Personality disorders
Suicide, violence and sleep problems
Medications and role of counselor in supporting
compliance
• Internet resources for each section
• Clinical vignettes for each section
• Documentation suggestions
Advanced Mental Health and Dual
Recovery Therapy Training
• Organized around major content areas
• Includes articles and fact sheets that
complement content areas
• Focused on concrete skill acquisition
• Style is didactic and experiential
• Includes role plays and demonstrations
• Includes consultants for family, couples and
spirituality components
COD Assessment Issues
• Symptoms versus Diagnosis
– anxiety, depression, mania, & psychosis
– intoxication, withdrawal, & chronic use
– personality factors
– symptom scales and diagnostic tools
• Primary versus Secondary ?
• Self-Medication ?
Assessment Strategies
–Time-line (prior history)
–Prior mental health, addiction, & dual
diagnosis treatment
–Information from Significant Others
–Family History
–Changes while in Treatment
Dual Recovery Status Exam
• Assess Both Psychiatric and Addiction
Issues, including motivation
• Cravings / Thoughts
• Last substance use
• 12-Step & Treatment Involvement
• Current Mental status
• Medication Compliance
Suicide Assessment
• Current suicidal thoughts, intent, and plan
• History of suicide attempts (eg, lethality of method,
circumstances)
• Family history of suicide
• History of violence (eg, weapon use, circumstances)
• Intensity of current depressive symptoms
• Current treatment regimen and response
• Recent life stressors (eg, marital separation, job loss)
• Alcohol and drug use patterns
• Psychotic symptoms
• Current living situation (eg, social supports, availability of
weapon)
SAD PERSONS: a mnemonic for
assessing suicide risk
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Sex (male)
Age (elderly or adolescent)
Depression
Previous suicide attempts
Ethanol abuse
Rational thinking loss (psychosis)
Social supports lacking
Organized plan to commit suicide
No spouse (divorced > widowed > single)
Sickness (physical illness)
Motivation to Change
• Motivation to address substance abuse, take
medications and acknowledge mental illness
• Internal versus External Motivation
• Decisional Balance, Change Ruler, Quit Date, etc
– Motivationalinterviewing.org
• Stages of Change (Prochaska & DiClemente):
– Precontemplation, Contemplation, Preparation, Action,
Maintenance
• Motivation varies by substance and setting
– Alcohol, Cocaine, Marijuana, Nicotine
– Inpatient, ER, and Outreach
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)
Treatment Planning
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How organize? disorders, sub-threshold / problems, etc
By individual treatment needs & program menu of options
Motivational Level? Client Preference? Level of Care?
Include ongoing assessment / monitoring, medication options,
and therapy options
Co-occurring issues – mental illness, medical problems,
prevention (HIV, COD, other)
Couple/SO & Family involvement
Follow-up / Referrals
HOW INVOLVE client and family in the treatment planning
process? (MET Change Plan)
Example
• Major Depression
– Ongoing assessments (BDI, others)
• Ongoing assessment of SI
• Follow-up for addiction, anxiety, Axis II problems
– Medications
• Reviewed Options – interest in taking a med (motivational
level)
– Therapy (program level and modalities and specific
type of therapy)
• Ex. Low intensity Treatment – group therapy once per
week; individual therapy
• Couples / Family
Teaching Mental Illness Treatment
Issues to Substance Abuse Counselors
• Concrete Tools versus Style
• Mood Management
– Thought Diary (STEP work)
– Assertiveness / Role Play
– Practical Self-Help Skills / Behavioral Shaping
• Counter-transference management
• MET – easier to do with MI or Tobacco
• Couples / Family interventions
• Psychiatric medications, MD teamwork, & med compliance
Limitations of depression:
modifying addiction treatment
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Lower self-efficacy
Lower motivation and inertia
Difficulties managing mood / affect
Worsening Coping Skills
Cognitive Distortions
Maladaptive Interpersonal Skills
– avoidance or antagonism
Integrated Treatment for Mood and
Substance Use Disorders (2003)
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Westermeyer J, Weiss R, and Ziedonis D
John Hopkins University Press
Hardcover (0-8018-7199-9)
$39.95 ($31.96 with 20% discount –
mention code NAF)
• www.jhupbooks.com
• 1-800-537-5487
Psychosocial Treatments For
Depression``
• Cognitive Therapy
– Feeling Good by Burns
• Behavioral Therapy
• Interpersonal Therapy
• Psychodynamic Therapy
Dual Recovery Therapy:
CBT STEP Worksheet
• Based on CBT principles of self-monitoring and
cognitive restructuring
• Should be used to target problematic emotional
responses
• Should be reviewed thoroughly in session
• Give clear rationale for assignment
• Client should complete at home after an
upsetting incident and bring to next session
Dual Recovery Therapy: CBT STEP
Worksheet
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Situation
• Thought
• Emotion
• Persuasive reply
Dual Recovery Therapy: CBT STEP
Worksheet
Situation:
• What was the external event?
• Who else was there?
• When did it happen?
• Where did it happen?
Dual Recovery Therapy: CBT STEP
Worksheet
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Thought – what was the client’s self-talk?
• Should be a complete sentence
• Distinguish between thoughts and
feelings
• Can guess if not recalled precisely
Dual Recovery Therapy: CBT STEP
Worksheet
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Emotion
• Usually a single feeling word
• Not an evaluation or attribution
• Ask client to elaborate and
describe feeling
Dual Recovery Therapy: CBT STEP
Worksheet
Persuasive reply - what could client say in
response to thought? Should be:
• Realistic in content
• Reassuring in tone
• Concise
• Personally meaningful
Anger Management for Substance
Abuse and Mental Health Clients
• SAMHSA pub: SMA 02-3756
• Events >> Cues >> Strategies
• Anger Control Plans (timeout – formal or informal, talk to
friend, conflict resolution, exercise, 12-Step meetings, explore
primary feeling beneath anger)
• The Aggression Cycle: Escalation>Explosion>Violence>Post
• Anger and the Family: How Past Learning Can Influence
Present Behavior
• Relaxation Interventions (breathing, muscle relaxation, exercise,
meditation, music, etc)
Anger Management (continued)
• Cognitive Restructuring: ABCD Model and
Thought Stopping
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Activating event
Belief System
Consequences (feelings)
Dispute (examine your beliefs and expectations and are
they unrealistic or irrational?
• Assertiveness Training & Conflict Resolution Model
– Communication Skills Interventions
– ID problem, feelings, impact of the problem, decide
whether to resolve conflict, work for resolution)
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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
Couples and Family Therapy
• Intervention Request
• Assessment of interactions & changes with usage
status (wet, damp, and dry)
• Couples and Family Treatment
• Enhancing Treatment Compliance
• Alanon / 12-Step Meetings
• ACOA, Co-dependence, Sex Addiction, role in
family of origin
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
Schizophrenia and Addiction
Keep medicating the psychosis
Adapt to Features of Disorders:
Example of Schizophrenia
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Heterogeneous group
Positive and Negative Symptoms
Therapeutic Alliance
Cognitive Deficits
Low Motivation
Low Self-Efficacy
Limited Interpersonal Skills
More Cravings during Withdrawal
More complications with co-occurring addiction
and mental illness
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Greater fluctuations in mental status
Increased suicide risk
Worse medication compliance
Questionable reports on substance use
Increased episodic homelessness
Greater chance of doing violence and
being the victim of traumatic events
• Greater incidence of illegal activities
Assertive Community Treatment
• Team structure with integration of clinical and
case management roles, team responsibility
• Staff : patient ratio
• Regular contact
• Direct interventions to maintain concrete services
• After hours service with an on-call team
• Occupational rehabilitation with job placement
• Provision for Appropriate Housing
Relapse Prevention – Good one to
blend with MH CBT approaches
• LIKE Identifying cues / triggers for substance use or
cravings / thoughts === ID early warning signs of
mental illness recurrence
• Goal to improve self-efficacy to handle specific
people, places, things, moods
• Examples:
– Drug refusal skills
– Seemingly irrelevant decisions
– Managing moods / thoughts
– Stimulus control
• Medication & Treatment adherence / compliance
Social Skills Training – CBT
example used in Schizophrenia
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Liberman, Bellack, and other models
Problem Solving and Communication Skills
Behavioral Learning Principles
Symptom and Medication Management
Asking others for help and exploring new interests
Identifying healthy and unhealthy relationships
Discussion of family relationships
The Use of Role Plays:
Behavioral Learning
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Setting up the Role Play (discreetly)
Problem to Solve
Non-verbal and Verbal Communication
“Modeling” by peers
“Coaching” by therapist
All provide Positive Feedback Sandwich
Homework is to try to do learned approach
outside of treatment
Dual Recovery Anonymous: modifying 12Step for COD
• Dual Recovery Anonymous: Modified 12-Step
• Recovery concepts supports increased sense of hope and
connection to others
• Shared Experience (experience, strength, and hope)
• Recovery is not cure, but rather a way of living a
meaningful life within the limitations of schizophrenia,
depression, addiction, or any combination
• Recovery is a process of restoring self-esteem and a
symbol of a personal commitment to growth, discovery,
and transformation
Working a 12-Step Program
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Abstinence goal assumed
Working the Steps
Sponsor, mentor or guide
Group support and involvement
Spirituality & Spiritual Guides
Daily Reading and Reflections
Self-Evaluation
Time to Celebrate
Health Care (when address tobacco?)
Integrate Complementary Approaches
MET and Psychiatric Disorders –
Clinical Applications
•Transition from inpatient to outpatient
treatment
• Treatment adherence
• Enhancing motivation for MH and SA
disorders
• Enhancing medication compliance
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
Motivational Enhancement Therapy
• Brief Therapy - 4 Sessions in Project MATCH
• Blends MI and Feedback Tools
• Tools: Personalized Feedback & Change Plan with
Menu of Options
• Focused Heavily on Developing Discrepancy
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Use of decisional balance (pros / cons)
engaging a SO
Eliciting Change Talk
Provide feedback and promote self-efficacy
MBDDT: Matching Stages of
Change with MET
• Precontemplation: Eliciting Self-Motivational Statements,
Empathy, Managing Resistance, Presenting Personal Feedback /
Use of Assessments, Involve Significant Other
• Contemplation: Affirm Ambivalence, Decisional Balance,
Explore Goals
• Preparation: Recognize Change Readiness, Discuss a Change
Plan, Freedom of Choice, Review Consequences, Ask For
Commitment
Elements of Effective Brief Interventions
FRAMES:
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Feedback
Responsibility
Advice
Menu
Empathy
Self-Efficacy
Motivational Interviewing
• As much a matter of fundamental attitudes and
assumptions as of techniques
• Attitudes:
– Respect, patience, empathy, and willingness to listen
• Assumptions:
– Client is assumed to be ambivalent rather than resistant;
client has fundamental responsibility to change
• Technique:
– Active approach with Socratic questioning and guided
reflection
MI Four Core Principles:
• Express Empathy
• Develop Discrepancy
• Roll with Resistance
• Support Self-Efficacy
Opening Strategies
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Ask open ended questions
Listen reflectively *** (50% of time)
Summarize
Affirm
Elicit change talk
MI Core Strategies of Engagement
MI Mantra
• OARS
–Open Ended Questions
–Affirmations
–Reflective Listening **
–Summarize
Change Talk:
Commitment to Change
Types of self-motivational statements:
– Problem recognition
– Concern
– Intention to change
– Optimism
DARN-C
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Desire to Change
Ability to Change
Readiness to Change (REASONS)
Need to Change
Commitment to Change **
Latest research: Commitment to Change largest
predictor of who will change
Eliciting Change Talk
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Ask open ended questions
Ask for elaboration
DO Change Rulers (DARN-C or ICR)
Explore pros/cons of change
Imagining extremes
Looking forward (“where do you see
yourself?”)
• Looking backward
• Other’s concerns
Advice-Giving
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Assume continued ambivalence
Unwelcome advice elicits resistance
Advice must match readiness to change
Knowing what to do does not guarantee
behavior change
Elicit - Provide - Elicit
ELICIT client’s ideas
 Goals, strategies, skills
PROVIDE advice, instruction
– Ask permission
– Offer short menu
– Just the facts
• 3rd person tense
ELICIT client’s reactions
 Credibility: “Does this make sense?”
 Self-efficacy: “Could you do this?”
Feedback - MET
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Personalized, normative, objective
Deliver in non-judgmental manner
Involve significant other
What has the biggest impact?
Normative data
– General population, addicts, sub-groups of COD
Feedback – Change Mechanisms
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Informational / Educational
Motivational / Inspirational
Changing Attitudes and Beliefs
Providing Support / Helping Relationships
Offering Social norms and comparisons
Increasing Active information processing
Providing information about risks, skills, strengths
Values Clarification
Pros and Cons
• Values
• Decisional Balance
– Pros & Cons of Use
– Pros & Cons of Quitting / Adhering, etc
Change Plan:
First part – the client describes
• The Changes I want to make are . . . .
• The most important reasons why I want to
make these changes are . . . .
• I will know that my plan is working if . . . .
• Some things that could interfere with my
plan are . . . .
• Things to think about and options to
consider are . . . . .
MET Change Plan: Menu of Options
(Treatment Planning led by Clinician)
• Identify disorders and problems
• Ask Patient to prioritize the list
• Create Plan that includes bio-psycho-socialspiritual approachs – consider menu of
options
• Consider Role of: motivation (document),
medications, therapies, level of care, SO, &
vocational, housing, legal, medical, etc
Poly-Drug Addiction and Co-Occurring
Mental Illness, HIV, and Tobacco
• Poly-Drug Abuse is the norm – especially when
you include tobacco dependence
• COD, HIV high risk behavior, and Tobacco are
very common with poly-drug addiction
• Match treatment approaches to recovery stage
and motivational level
• Provide comprehensive services
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 using each specific substance
• Variety of COD and interest to address mental health problem or
health risks / problems and to take medication
Poly-Drug Abuse Issues
• Possibility of sedation and respiratory depression is greater
• Alcohol and Cocaine combo can increase toxicity with the
formation of cocaethylene
• Speedballs (heroin and cocaine) increase the seizure risk
• Many combinations have not been studied
– cigarettes dipped into formaldehyde
– Marijuana and PCP
– ecstasy, ketamine, and GHB
• Be alert for new drugs, new combinations, and new routes of
administration
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
MET and HIV – Clinical Applications
•Needle sharing
•Needle cleaning and safe injection practices
•Safer sex practices
• Medication noncompliance
MET and HIV – Medication noncompliance
• Highrates of noncompliance (10-60%)
• (DiIorio et. al., 1993) MET subjects more likely than
control subjects to self-report medication adherence and
less likely to miss doses
• (Safren, 2001) MI + CBT/Problem solving vs. selfmonitoring:
• MI/CBT showed faster improvement in compliance
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Depression a strong predictor of
noncompliance
MET and HIV – Safer Sex
• Picciano et. al., 2001 – telephone based,
single session MI intervention
• MI vs delayed treatment control
• MI group less likely to have unprotected sex,
less ambivalent about practicing safer sex and
expressed greater intention to use condoms in
the future
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
Medication Management Issues
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Provide hope and realistic expectations
Educate about & monitor for side effects
Start low and go slow
Family help with monitoring
Psychology of taking medications among
abusers: no magic bullets
• Benzodiazepines issue
• Treat chronic mental illness & use
Protracted Abstinence / Withdrawal
Syndromes
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Alcohol and benzodiazepines
Physiologic and mood changes
Resolve spontaneously – up to 1 year
Increases vulnerability to addiction relapse
Education and reassurance
Behavioral therapy approaches to mood, anxiety,
and sleep management
• Medications might be needed
Protracted Abstinence/
Withdrawal Syndromes
• Physiological Changes in
– sleep latency and awakening
– increased respiratory rate, temperature, blood
pressure and pulse
– decrease in cold-stress response
– persistence of tolerance to sedatives
– tremor
Protracted Abstinence/
Withdrawal Syndromes
• Mood changes
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Irritability
Depressed mood
Frustration
Reduced problem solving
Anxiety
Monitor Psych Symptoms over time
• Structured tools – baseline and follow-ups
• MSE - routine
• SO / Family – baseline and follow-ups
Principles of Pharmacology for COD
• Resources: CO-MAP & TIPS & APA guidelines
• Treat diagnoses & sometimes sub-threshold disorders
• Choose psychiatric medications that help addictions if
possible
• Avoid sedating, addicting medications and those that
potentiate the effects of illicit drugs whenever possible
• Simplify dosing strategies
• Stress education and compliance
• Minimize refills
Principles of Pharmacology for COD
• Consider specificity of psychiatric disorder
• All medications are not created equal with regard to
abuse liability
• Avoid psychiatric medications with abuse liability,
overdose risk, causing seizure, sedation, liver toxicity
EX: Medications for Schizophrenia &
Addiction
• Primary Antipsychotic Medication
– Atypicals are best
– Increased side effects with traditionals (EPS)
• start low, go slow
– Consider DEPO
• Issues: seizure risk, cardiac QTC, liver, sedation,
weight gain, sexual dysfunction
• Controversial role of benzodiazepines
• Consider also Addiction Treatment Medications:
– Maintenance, Detoxification, & Protracted Withdrawal Phase
EX: Medications for Depression & Addiction
• Primary Antidepressant Medication
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SSRIs & Wellbutrin – most common
Avoid MAOs (interaction with stimulants)
start low, go slow
Consider DEPO
• Choices often made due to considering SE issues –
especially “calming / sedating” aspects of medication –
also sexual dysfunction, GI
• Controversial role of benzodiazepines
• Consider also Addiction Treatment Medications:
– Maintenance, Detoxification, & Protracted Withdrawal Phase
Medications for Alcohol Dependence
• Detoxification: Benzodiazepines and
Barbituates
• Protracted Abstinence: Disulfiram and
Naltrexone
• Experimental: Acamprosate, Nalmafene,
Tiapride, Ondansetron, Serotonergic drugs
Medications for Cocaine
Dependence
• Detoxification: Symptom Relief
• Protracted Abstinence: None are FDA
approved
• Experimental: Amantadine, Desipramine,
Antabuse
Medications for Opiate
Dependence
• Detoxification: Methadone, Clonidine,
Clonidine/Naltrexone, Buprenorphine
• Protracted Abstinence: Naltrexone
• Harm Reduction/ Maintenance: Methadone,
LAAM, Buprenorphine
Medications for Tobacco Dependence
Nicotine Replacement Treatment (20 – 25%)
gum (appropriate administration key)
Nicotine patch
Nasal spray
Inhaler
Lozenge
Buproprion (25-30%)
Buproprion & patch – 30-35%
50% increase in mediation treatment outcome with the
addition of behavior therapy – but only 3% do both
Addressing Tobacco in Addiction
and Dual Recovery
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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
Key Considerations
 Setting & Staff Readiness
 Patient Assessment and Treatment Planning
Timing of tobacco dependence treatment
Pharmacological Considerations
Blending Psychosocial Treatments
Characteristics of Tobacco
Dependence with COD Patients
•
•
•
•
•
•
Heavier smokers - more cigarettes per day
More Effective and Efficient
High Fagerstrom Scores
Complain of Withdrawal Symptoms
Use and withdrawal effects psych symptoms
Have made attempts to quit in the past but few and
short periods of abstinence
• Mental Health settings offer little help to quit or
reduce environmental triggers
• Tobacco changes medication blood levels
• Increased morbidity and mortality
Tobacco and Other Drug Craving
• Imagery scripts eliciting tobacco craving
• Cravings for other drugs occurred along
with tobacco cravings
– Implication that tobacco dependence should be
addressed in addictions treatment along with
the drug problem prompting treatment
– Finding a mirror image of the clinical wisdom
in tobacco dependence treatment
– Taylor, Harris, Singleton, Moolchan, Heishman.
Exptl Clin Psychopharm. 2000; 8:75-87.
UMDNJ Tobacco Program
• Tobaccoprogram.org
• 732-235-8222
• Addressing Tobacco in Mental Health and
Addiction Settings: July Issue of the
Psychiatric Annals 2003
American Psychiatric Association Practice
Guidelines
• For
– specific Mental Illnesses
– Substance Use Disorders
– Nicotine Dependence
• www.psych.org
• call APPI press: 1-800-368-5777
• Published in the American Journal of Psychiatry
– Nicotine Dependence Guidelines in November 1996 AJP
Personalized feedback about healthrelated indices
•
•
•
•
•
•
CO monitoring – their immediate health
Tobacco caused medical disorders
Costs
Recovery
Children’s health
“Personalized message”
Setting a Target Quit Date
• For those who are motivated to quit
• Provides time and target date to mobilize
resources for quitting’
• Date should allow for sufficient time to
acquire skills for quitting
Tobacco Smoking Effects Some
Psychiatric Medication Blood Levels
• Smoking increases the metabolism of some medications
• Smoking induces the hepatic microsomal enzymes P450 system
• Specifically the 1A2 isoenzyme is increased secondary to
polynuclear aromatice hydrocarbons
• Nicotine does not change medication blood levels
• NRT doesn’t effect medication blood levels
• Nicotine may modulate side effects of psychiatric medications
and psychiatric symptoms
Abstinence Increases Some Medication
Blood Levels
• Tobacco effects the P450 / 1A2 liver enzymes
• Antidepressants: desipramine, doxepin, imipramine
• Antipsychotics: clozapine, haloperidol, fluphenazine,
olanzapine
• Antianxiety medications: clomipramine,
desmethyldiazepam (valium), oxazepam
• Other meds: caffeine, acetaminophen, propranolol,
theophylline
Buproprion SR
Contrindications:
Hx of seizures
Hx of eating disorders
Consider:
Insomnia
Mild agitation (extra cup of coffee)
Dry mouth
Dosage:
150 mg every morning for 3 – 7* days, then
150 mg twice daily
Begin tx 1-2 weeks pre-quit date
Duration:
3 months – also clinicians use for 6 – 12 months
Availability/Cost:
Prescription: $3.33/day
Nicotine Gum / Lozenge
Consider:
Mouth soreness
Dyspepsia
People with dental work may not want to use it
Some people don’t like gum
Absorption of nicotine affected by food/beverages
Blister packs hard to open
Dosage:
1-24 cig/d: 2mg gum up to 24 pieces/day (.8mg)
>25 cig/d: 4mg gum up to 24 pieces/day (1.5mg)
Duration:
Up to 12 weeks
Availability/Cost:
OTC only / $6.25 for 10 2-mg pieces
$6.87 for 10 4-mg pieces
Nicotine Inhaler
Consider:
local irritation of the mouth and throat
absorption in mouth & throat (not nose)
Cartridge is temperature sensitive (warm
for best nicotine delivery)
Dosage:
6-16 cartridges/d (2mg/cartridge)
*Give license to use more than they’ll ever
use (I.e., Rx-15-20 cartridges a day)
Duration:
Up to 6 months
Availability/Cost:
Prescription/ $10.94 for 10
cartridges
Nicotine Nasal Spray
Consider:
Nasal irritation
Spray up into nose
Dosage:
8-40 doses/day
(.25mg each nostril=.5mg tot)
Duration:
3-6 months
Availability/Cost: Prescription/ $5.40 for 12 doses
Nicotine Patch
Consider:
may cause local skin irritation (adhesive)
may come off in water or from sweat
may cause sleep disturbance (Nic@nite)
Dosage/Duration:
21mg/24 hr
14mg/24 hr
7 mg/24 hr
15mg/16hr
Availability/Cost:
Prescription & OTC/ $4.22* or $4.51#
4 weeks*
2 weeks
2 weeks
8 weeks#
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
Other Resources
• Motivational Groups for Community Substance
Abuse Programs
– www.mid-attc.org
– 804-828-9910
• Co-Occurring Disorder Series: Foundations
Associates (888-869-9230; www.dualdiagnosis.org)
– How Medicine Can Help You
– Making Medication Part of Your Life