Transcript Addressing Military Sexual Trauma in an Integrated Care

Current Issues in Substance Abuse
Joan E. Zweben, Ph.D.
Executive Director, East Bay Community Recovery Project
Clinical Professor of Psychiatry, UCSF
Psychiatry Grand Rounds – Herrick Hospital
January 7, 2013
The Substance Abuse Treatment
System: Finding Good Care
Comprehensive Assessment
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Current alcohol & other drug use
AOD history
Substance induced symptoms
History and current treatment of other
mental disorders
SUDS treatment efforts
Recovery support system & activities
Are addiction meds appropriate?
Substance-Induced
Symptoms
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AOD USE CAN PRODUCE SYMPTOMS
CHARACTERISTIC OF OTHER DISORDERS:
Alcohol: impulse control problems (violence,
suicide, unsafe sex, other high risk behavior);
anxiety, depression, psychosis, dementia
Stimulants: impulse control problems, mania,
panic disorder, depression, anxiety, psychosis
Opioids: mood disturbances, sexual dysfunction
Psychotic Symptoms
Hallucinations, paranoia:
 alcohol intoxication, withdrawal, overdose
 stimulant intoxication, overdose
 depressant intoxication, overdose
 hallucinogen intoxication, overdose
 phencyclidine intoxication, overdose
Distinguishing Substance Abuse
from Other Mental Disorders
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wait until withdrawal phenomena have
subsided (usually by 4 weeks)
physical exam, toxicology screens
history from significant others
longitudinal observations over time
inquiry about quality of life during drug
free periods
Look for Evidence-Based
Principles & Practices
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Evidence-based principles and practices
guide system development
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Example: care that is appropriately
comprehensive and continuous over time will
produce better outcomes
Evidence-based treatment interventions
are important elements in the overall
picture. They are not a substitute for
overall adequate care.
Translating EBTs into the Real
World
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Distinguish between efficacy and
effectiveness studies
Huge gaps in the research literature (e.g.,
group interventions, therapist variables)
Achieving fidelity is expensive, must be
ongoing
Infrastructure for ongoing evaluation is
often inadequate
ASAM Patient Placement
Criteria PPC-2R
DIMENSIONAL CRITERIA:
1. Acute intoxication and/or withdrawal
2. Biomedical conditions/complications
3. Emotional/behavioral/cognitive conditions and
complications
4. Readiness to change
5. Continued problem potential
6. Living environment
ASAM Levels of Care
Level 0.5: early intervention
 Level I: outpatient services
 Level II: intensive OP/partial hospitalization
 Level III: residential/inpatient services
 Level IV: medically managed intensive IP
Opioid maintenance therapy
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Marketing
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Impostors
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Distinguishing evidence from marketing
Presenting multiple anecdotes with no
comparison or control groups as “proof”
Medications
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Options are good, but…..
Beware the new drug “darling”
Working Effectively with
Returning Military
Members
Updated Roster of OEF, OIF, and
OND Veterans Who Have Left Active
Duty
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1,318,510 OEF, OIF, and OND Veterans have
left active duty and become eligible
for VA health care since FY 2002
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712,089 (~54%)* Former Active Duty troops
606,421 (~46%) Reserve and National Guard
*Percentages reported are approximate due to rounding.
Cumulative from 1st Quarter FY
2002 through 2nd Quarter FY
2011
John Straznikas, MD
OEF/OIF Data
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24% of OEF/OIF veterans responded
positively to “used alcohol more than they
meant to.”
21% OIF/ 18% OEF responded affirmatively
that they “wanted or needed to cut down.”
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Hoge 2004
12% of OEF/OIF soldiers endorsed alcohol
misuse.
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Milliken, Hoge 2007
(John Straznikas, MD)
2005 Survey of Health Related Behaviors
from DOD
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Rates of Heavy Drinking – 5+ drinks/day:
 26-55 yr olds –
9.7% Soldiers/9.5% Civilians
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18-25 yr olds –
Soldiers 25%/Civilians 17%
(John Straznikas, MD)
OEF/OIF/OND SUD Data
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Greater than a third of Army prosecutions
are alcohol or drug related charges.
90% of military sexual crimes involve
alcohol
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NY Times March 13, 2007
30% in rate of binge drinking from 2002
until 2005.
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Pentagon report 1/07
(John Straznikas, MD)
PTSD and SUDs in OEF/OIF Veterans
Rand Study – Dec 2008
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Binge Alcohol:
50% (2x community)
Tobacco Smoking: 50% (2x community)
Opiate Abuse:
09% (3x community)
Other Drugs:
Marijuana, Sedatives, etc.
Slide from: Kosten, Thomas, Treating PTSD
and Addiction, 2009 Presentation
Military Culture Take-home
Points
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Make an effort to ask and learn about what
the military was like for your patient.
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Have them teach you
Know basic language
Identify what is your patient’s view of their
military/veteran status
Examine your own biases
Assess for weapons
Basic Military History
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Which Branch did they serve in?
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Active Duty, National Guard or Reserves
What was their job?
Involved with combat?
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They are NOT the same!
Peace-time or war-time service?
Fire-fights, “being shot at”, mortars.
Cooks and truck-drivers saw combat
Unwanted sexual advances?
Not all veterans view their
military service the same
Individual differences
Cultural differences – VN vs. OEF/OIF
Viewing the Military as a culture
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Cultural values
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Honor
Respect
Leave no brother behind
Protect yourself - weapons
Chain of command
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Follow orders
Challenging ways veterans present
to community-based programs
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Conformity – devalues the military and
emphasizes the civilian life
Dissonance – ambivalent about the two
‘cultures’
Immersion/Resistance – Idealization of the
military and denigration of the civilian
culture
Using this Model to facilitate
treatment engagement
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The ‘conforming’ veteran
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The ‘dissonant’ veteran
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Don’t challenge the devaluing
Don’t actively join the devaluing
Use Motivational Interviewing techniques to
explore the ‘yes-but’ communications
The ‘immersion/resistance’ veteran
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Don’t challenge the devaluing
Focus on the present problem and solution
Examine your own biases
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Your view of war
Your view of the soldier
Your view of perpetrators of violence
Your view of perpetrators of atrocities
Weapon assessment
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Assume they have a weapon
Assume their weapon is an important part
of their identity
Ask specific questions about how they
store the weapon and the bullets
If lethality is active, negotiate storing
bullets with a friend or getting a trigger
lock.
Special Issues with Traumatized
Veterans
SUD/PTSD
Take Home Points for SUD/PTSD
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Complex and Confusing and Crisis-prone
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Expect an erratic therapeutic alliance
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Don’t blame them or yourself
May take multiple treatment contacts
Expect more crisis management, relapse
and need for intensification of treatment
structure
Therapeutic Alliance is the
primary treatment goal
Reduces distress /discouragement with poor
outcomes.
More difficult to treat and worse
outcomes with SUD/PTSD pts
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Fewer clinical improvements, more crises
Uneasy alliance, negative counter-tranfx
Poorer compliance with Aftercare tx
Shorter time to relapse post treatment
Drink more on drinking days
Increased medical and interpersonal problems
Increased homelessness
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Druley and Pashko 1988, Nace 1988, Brown and Wolfe 1994,
Saladin et. al. 1995, Breslau et. al. 1997, Ouimette et. al. 1999,
Najavits 1998
PREP: Prevention and Recovery
for Early Psychosis
Alameda County Collaboration
Adolescent Substance Use
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Critical time for onset of SUDS
Experimentation is prevalent; most do not
develop SUDS
Prevalence rates in higher risk samples is approx
24% or higher
Social factors, esp peer influence, are strongest
determinants of initiation of use.
Psychological factors and effects of the
substances more closely linked to abuse.
(Millin & Walker, 2011)
Adolescent Substance Abuse
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Adolescent brain more is susceptible to alcohol
and other drugs
Marijuana is the most prevalent, then alcohol.
Polydrug use is the norm
Tobacco: most smokers initiate during
adolescence
Prescription drug abuse is rising
Prevention efforts target salient risk and
protective factors
Marijuana
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Impact on developing brain
Distortions of self-concept due to disturbances of
attention and concentration
Conclude they are not intelligent, don’t like
school; seek peer group with negative attitudes
and behaviors
Increased risk of psychotic illness
Possible interference with medications
(Zweben & Martin, 2009)
PREP Collaborative:
Alameda County
EBCRP – Lead Agency
- Administration of PREP Program
- Administration of PREP Services
FSASF
• Community-based
treatment;
• Innovative funding
options.
• Training structure
and capacity to
document client
outcomes
MHA-AC
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Outreach
Marketing
Stigma Reduction
Community
Education
UCSF
• Training in
evidence-based
practices
• Diagnosis
• Program
evaluation and
research.
ACBHCS
- Transition Age
Youth System of
Care
- Issued initial RFP
for TAY early
psychosis funding
Treatment as Usual vs. PREP
• Case management
(if severe enough)
• 15-minute medication
management, every 2-3
months
• ?psychotherapy? –
maybe “supportive”
• Care management for
everyone
• Algorithm-based
medication management,
monthly visits+
• Cognitive Behavioral
Therapy (CBT)
• Little family involvement • Multi-Family Group
• No specific vocational/
• Individualized vocational/
educational treatment
educational support (IPS)
Treatment as Usual vs. PREP
• No treatment for
cognitive symptoms
• Referred out for
substance use treatment
• Computerized cognitive
remediation
• Harm reduction approach
embedded throughout
• Frequent hospitalization • Hospitalization minimized
• Assumption of eventual
housing/disability care
• Focus on active recovery
and return to full
functioning
Before and After PREP
Hospitalizations Reduced by Half
Symptom Change
Real - World Functioning
Medication Use at PREP: Outcomes
• 23 clients whose medications were primarily
managed by PREP:
• 4 were not prescribed antipsychotic medication
• 19 were prescribed antipsychotic medication
• 5 switched from 2 or 3 antipsychotic agents to 1
• The average antipsychotic dose prescribed by PREP
was 35% less than the World Health Organization’s
defined daily dose*
*http://www.whocc.no/atc_ddd_index/
Conclusions: PREP Works!
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Improves symptoms (depression), distress
Reduces hospitalization and arrest rates
While clients are taking the minimum medication
dosages necessary
Real-World Impact: Improves social functioning and
functioning in school/work participation
Referrals: 888-535- PREP (7737),
Facilitating the Use of
Mutual Help Groups
Abstinence from Alcohol &
Participation in AA
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Greater # meetings in 9-12 months, higher
abstinence rates
Weekly mtg attendance, higher abstinence
rates at 2 years
Sustained attendance, high abstinence
rates (1-10+ yrs)
(Kaskutas, L.A. 2009)
12 Steps: Parallels to Therapy
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understanding the negative consequences
of AOD use
understanding efforts to control use have
not worked
willingness to accept help
taking inventory
sharing with others
12 Steps, Cont.
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becoming willing to change
identifying those harmed
making amends
ongoing awareness and effort to change
behavior
integrating changes into all aspects of
behavior
CBT and Other Concepts Embodied
in 12-Step Programs
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community reinforcement
social learning theory; use of social role models
social support and recognition
cognitive reframing
social comparisons, use of social norms
reference group theory
catharsis
cognitive control tools
culture that embodies the values of recovery
(John Wallace, Ph.D. 9/99)
12-Step Programs
Resistances to Participation
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Stranger Anxiety
Discomfort at being the outsider
“I’m not an alcoholic/addict
Fear of being engulfed
“That religious stuff”
Social isolation
Facilitating the Use of
12-Step Programs
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Elicit picture of what meetings are like
Explore charged issues
Give permission to be ambivalent
Stress “Take what you need and leave the
rest”
Surrender and empowerment
Provide a place to talk about what is
happening to them on a regular basis
Preparing Psychiatric Patients for
12-Step Meetings
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medication is compatible with recovery, but
meetings are best selected carefully
some meetings are more tolerant than others of
medication or eccentric behavior
schizophrenics benefit from coaching on how to
behave in meetings
12-step structure often beneficial; non-intrusive
and stable
References
Kaskutas, Lee Ann. (2009). Alcoholics Anonymous
Effectiveness: Faith Meets Science. Journal of Addictive
Diseases, 28, 145-157.
Acknowledgments:
John Straznickas, MD (slides)
Rachel Loewy, Ph.D. (slides)
Resources
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www.ebcrp.org
https://askprep.org/