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Co-Occurring Disorders: Overview of Latest Research and Clinical Implications
- including Prevention and Tobacco
Co-Occurring Disorders: Overview of Latest Research and Clinical Implications
- including Prevention and Tobacco
Douglas Ziedonis, M.D., MPHProfessor & Director, Division of Addiction Psychiatry
Robert Wood Johnson Medical School
732-235-4341
Douglas Ziedonis, M.D., MPHProfessor & Director, Division of Addiction Psychiatry
Robert Wood Johnson Medical School
732-235-4341
Big Year for COD• 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
Clinical, Program, & System Issues
• 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)• 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)
• 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 MH System Models: Motivation Based Dual Diagnosis Treatment
• 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
• 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– 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)
D u a l R ecovery Th erap y
M en ta l H ea lth TxD isord er S p ec ific
M ed ica tion s
A d d ic tionR e lap se P reven tion1 2 -S tep F ac ilita t ion
O th er R e la ted P rob lem sC ase M an ag em en t
C om p reh en s ive A ssessm en tM E T - 4 S ess ion s
F eed b ackC h an g e P lan
MET = MI + FeedbackMET = 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)– Assessment– Personalized Feedback – Values / Decisional Balance: Pros & Cons– Change Plan & Menu of Options
• 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)– Assessment– Personalized Feedback – Values / Decisional Balance: Pros & Cons– Change Plan & Menu of Options
Assessing Motivation to Change
• Formal: SOCRATES & URICA
• Informal:– 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:
– 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
• 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)
• Mindfulness and Meditation• Prayer• Values, Spirituality, and Therapy• Spiritual Surrender• Acceptance and Forgiveness• Evoking Hope• Serenity
Complementary Approaches• Acupuncture
• Hypnosis
• Herbs
• Meditation
• Qi-Gong: Meditation, Deep Breathing, Yoga
• The Arts: art and music– Drumming, NAF
• ETC
Medications for COD Treatment
• 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
• 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 PsychosocialMedications
Clinical questionsTiming 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 TreatmentsOnly 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
• AHCPR: 800-358-9295
• CDC: 800-CDC-1311
• NCI: 800-4-CANCER
• www.surgeongeneral.gov/tobacco/default.htm
Prevention of a Secondary Disorder
• 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