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NationalInstituteonDrugAbuse(NIDA)
CommonComorbiditieswithSubstanceUseDisorders
LastUpdatedFebruary2018
https://www.drugabuse.gov
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TableofContents
CommonComorbiditieswithSubstanceUseDisorders
Introduction
Part1:TheConnectionBetweenSubstanceUseDisordersandMentalIllness
Whyistherecomorbiditybetweensubstanceusedisordersandmentalillnesses?
Whataresomeapproachestodiagnosis?
Whatarethetreatmentsforcomorbidsubstanceusedisorderandmentalhealthconditions?
Part2:Co-occurringSubstanceUseDisorderandPhysicalComorbidities
Part3:TheConnectionbetweenSubstanceUseDisordersandHIV
WhyisHIVscreeningimportant?
WhataresomemethodsforHIVpreventionandtreatmentforindividualswithsubstanceusedisorders?
HowcanweachieveanAIDS-freegeneration?
Part4:BarrierstoComprehensiveTreatmentforIndividualswithCo-OccurringDisorders
WherecanIgetmorescientificinformationoncomorbidsubstanceusedisorder,mentalillness,andmedicalconditions?
References
3
Introduction
Whentwodisordersorillnessesoccurinthesameperson,simultaneouslyorsequentially,theyaredescribedascomorbid. Comorbidityalsoimpliesthattheillnessesinteract,affectingthecourseandprognosisofboth. Thisresearchreportprovidesinformationonthestateofthescienceinthecomorbidityofsubstanceusedisorderswithmentalillnessandphysicalhealthconditions
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Part1:TheConnectionBetweenSubstanceUseDisordersandMentalIllness
Manyindividualswhodevelopsubstanceusedisorders(SUD)arealsodiagnosedwithmentaldisorders,andviceversa.Multiplenationalpopulationsurveyshavefoundthatabouthalfofthosewhoexperienceamentalillnessduringtheirliveswillalsoexperienceasubstanceusedisorderandviceversa. Althoughtherearefewerstudiesoncomorbidityamongyouth,researchsuggeststhatadolescentswithsubstanceusedisordersalsohavehighratesofco-occurringmentalillness;over60percentofadolescentsincommunity-basedsubstanceusedisordertreatmentprogramsalsomeetdiagnosticcriteriaforanothermentalillness.
Datashowhighratesofcomorbidsubstanceusedisordersandanxietydisorders—whichincludegeneralizedanxietydisorder,panicdisorder,andpost-traumaticstressdisorder. Substanceusedisordersalsoco-occurathighprevalencewithmentaldisorders,suchasdepressionandbipolardisorder,attention-deficithyperactivitydisorder(ADHD), psychoticillness,
borderlinepersonalitydisorder, andantisocialpersonalitydisorder.Patientswithschizophreniahavehigherratesofalcohol,tobacco,anddrugusedisordersthanthegeneralpopulation. AsFigure1shows,theoverlapisespeciallypronouncedwithseriousmentalillness(SMI).Seriousmentalillnessamongpeopleages18andolderisdefinedatthefederallevelashaving,atanytimeduringthepastyear,adiagnosablemental,behavior,oremotionaldisorderthatcausesseriousfunctionalimpairmentthatsubstantiallyinterfereswithorlimitsoneormoremajorlifeactivities.Seriousmentalillnessesincludemajordepression,schizophrenia,andbipolardisorder,andothermentaldisordersthatcauseseriousimpairment. Around1in4individualswithSMIalsohaveanSUD.
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Figure1:Co-OccurringSubstanceUseDisorderandSeriousMentalIllnessinPastYearamongPersonsAged18orOlder
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Datafromalargenationallyrepresentativesamplesuggestedthatpeoplewithmental,personality,andsubstanceusedisorderswereatincreasedriskfornonmedicaluseofprescriptionopioids. Researchindicatesthat43percentofpeopleinSUDtreatmentfornonmedicaluseofprescriptionpainkillershaveadiagnosisorsymptomsofmentalhealthdisorders,particularlydepressionandanxiety.
Youth—AVulnerableTime
Althoughdruguseandaddictioncanhappenatanytimeduringaperson’slife,drugusetypicallystartsinadolescence,aperiodwhenthefirstsignsofmentalillnesscommonlyappear.Comorbiddisorderscanalsobeseenamongyouth. Duringthetransitiontoyoungadulthood(age18to25years),peoplewithcomorbiddisordersneedcoordinatedsupporttohelpthemnavigatepotentiallystressfulchangesineducation,work,andrelationships.
DrugUseandMentalHealthDisordersinChildhoodorAdolescenceIncreasesLaterRisk
Thebraincontinuestodevelopthroughadolescence.Circuitsthatcontrol
Source:SAMHSA,CenterforBehavioralHealthStatisticsandQuality,NationalSurveyonDrugUseandHealth,MentalHealth,DetailedTables.Availableat:https://www.samhsa.gov/data/population-data-nsduh
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executivefunctionssuchasdecisionmakingandimpulsecontrolareamongthelasttomature,whichenhancesvulnerabilitytodruguseandthedevelopmentofasubstanceusedisorder. Earlydruguseisastrongriskfactorforlaterdevelopmentofsubstanceusedisorders, anditmayalsobeariskfactorforthelateroccurrenceofothermentalillnesses.However,thislinkisnotnecessarilycausativeandmayreflectsharedriskfactorsincludinggeneticvulnerability,psychosocialexperiences,and/orgeneralenvironmentalinfluences.Forexample,frequentmarijuanauseduringadolescencecanincreasetheriskofpsychosisinadulthood,specificallyinindividualswhocarryaparticulargenevariant.
Itisalsotruethathavingamentaldisorderinchildhoodoradolescencecanincreasetheriskoflaterdruguseandthedevelopmentofasubstanceusedisorder.Someresearchhasfoundthatmentalillnessmayprecedeasubstanceusedisorder,suggestingthatbetterdiagnosisofyouthmentalillnessmayhelpreducecomorbidity.Onestudyfoundthatadolescent-onsetbipolardisorderconfersagreaterriskofsubsequentsubstanceusedisordercomparedtoadult-onsetbipolardisorder. Similarly,otherresearchsuggeststhatyouthdevelopinternalizingdisorders,includingdepressionandanxiety,priortodevelopingsubstanceusedisorders.
UntreatedChildhoodADHDCanIncreaseLaterRiskofDrugProblems
NumerousstudieshavedocumentedanincreasedriskforsubstanceusedisordersinyouthwithuntreatedADHD, althoughsomestudiessuggestthatonlythosewithcomorbidconductdisordershavegreateroddsoflaterdevelopingasubstanceusedisorder. Giventhislinkage,itisimportanttodeterminewhethereffectivetreatmentofADHDcouldpreventsubsequentdruguseandaddiction.TreatmentofchildhoodADHDwithstimulantmedicationssuchasmethylphenidateoramphetaminereducestheimpulsivebehavior,fidgeting,andinabilitytoconcentratethatcharacterizeADHD.
ThatriskpresentsachallengewhentreatingchildrenwithADHD,sinceeffectivetreatmentofteninvolvesprescribingstimulantmedicationswithaddictivepotential.Althoughtheresearchisnotyetconclusive,many
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studiessuggestthatADHDmedicationsdonotincreasetheriskofsubstanceusedisorderamongchildrenwiththiscondition. ItisimportanttocombinestimulantmedicationforADHDwithappropriatefamilyandchildeducationandbehavioralinterventions,includingcounselingonthechronicnatureofADHDandriskforsubstanceusedisorder.
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Whyistherecomorbiditybetweensubstanceusedisordersandmentalillnesses?
Thehighprevalenceofcomorbiditybetweensubstanceusedisordersandothermentalillnessesdoesnotnecessarilymeanthatonecausedtheother,evenifoneappearedfirst.Establishingcausalityordirectionalityisdifficultforseveralreasons.Forexample,behavioraloremotionalproblemsmaynotbesevereenoughforadiagnosis(calledsubclinicalsymptoms),butsubclinicalmentalhealthissuesmaypromptdruguse.Also,people’srecollectionsofwhendruguseoraddictionstartedmaybeimperfect,makingitdifficulttodeterminewhetherthesubstanceuseormentalhealthissuescamefirst.
Threemainpathwayscancontributetothecomorbiditybetweensubstanceusedisordersandmentalillnesses:
1. Commonriskfactorscancontributetobothmentalillnessandsubstanceuseandaddiction.
2. Mentalillnessmaycontributetosubstanceuseandaddiction.
3. Substanceuseandaddictioncancontributetothedevelopmentofmentalillness.
1.Commonriskfactorscancontributetobothmentalillnessandsubstanceuseandaddiction.
Bothsubstanceusedisordersandothermentalillnessesarecausedbyoverlappingfactorssuchasgeneticandepigeneticvulnerabilities,issueswithsimilarareasofthebrain, andenvironmentalinfluencessuchasearlyexposuretostressortrauma.
GeneticVulnerabilities
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Itisestimatedthat40–60percentofanindividual’svulnerabilitytosubstanceusedisordersisattributabletogenetics. Anactiveareaofcomorbidityresearchinvolvesthesearchforthatmightpredisposeindividualstodevelopbothasubstanceusedisorderandothermentalillnesses,ortohaveagreaterriskofaseconddisorderoccurringafterthefirstappears. Mostofthisvulnerabilityarisesfromcomplexinteractionsamongmultiplegenesandgeneticinteractionswithenvironmentalinfluences. Forexample,frequentmarijuanauseduringadolescenceisassociatedwithincreasedriskofpsychosisinadulthood,specificallyamongindividualswhocarryaparticulargenevariant.
Insomeinstances,ageneproductmayactdirectly,aswhenaproteininfluenceshowapersonrespondstoadrug(e.g.,whetherthedrugexperienceispleasurableornot)orhowlongadrugremainsinthebody.Specificgeneticfactorshavebeenidentifiedthatpredisposeanindividualtoalcoholdependenceandcigarettesmoking,andresearchisstartingtouncoverthelinkbetweengeneticsequencesandahigherriskofcocainedependence,heavyopioiduse,andcannabiscravingandwithdrawal. Butgenescanalsoactindirectlybyalteringhowanindividualrespondstostress orbyincreasingthelikelihoodofrisk-takingandnovelty-seekingbehaviors, whichcouldinfluencetheinitiationofsubstanceuseaswellasthedevelopmentofsubstanceusedisordersandothermentalillnesses.Researchsuggeststhattherearemanygenesthatmaycontributetotheriskforbothmentaldisordersandaddiction,includingthosethatinfluencetheactionofneurotransmitters—chemicalsthatcarrymessagesfromoneneurontoanother—thatareaffectedbydrugsandcommonlydysregulatedinmentalillness,suchasdopamineandserotonin.
EpigeneticInfluences
Scientistsarealsobeginningtounderstandtheverypowerfulwaysthatgeneticandenvironmentalfactorsinteractatthemolecularlevel. Epigeneticsreferstothestudyofchangesintheregulationofgeneactivityandexpressionthatarenotdependentongenesequence;thatis,changesthataffecthowgeneticinformationisreadandactedonbycellsinthebody.Environmentalfactorssuchaschronicstress,trauma,ordrugexposurecaninducestablechangesingeneexpression,whichcanalterfunctioninginneuralcircuitsandultimatelyimpactbehavior. Formoreinformationonepigenetics,seeGeneticsand
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EpigeneticsofAddictionDrugFacts.
Throughepigeneticmechanisms,theenvironmentcancauselong-termgeneticadaptations—influencingthepatternofgenesthatareactiveorsilentinencodingproteins—withoutalteringtheDNAsequence.Thesemodificationscansometimesevenbepasseddowntothenextgeneration. Thereisalsoevidencethattheycanbereversedwithinterventionsorenvironmentalalteration.
Theepigeneticimpactofenvironmentishighlydependentondevelopmentalstage. Studiessuggestthatenvironmentalfactorsinteractwithgeneticvulnerabilityduringparticulardevelopmentalperiodstoincreasetheriskformentalillnesses andaddiction. Forexample,animalstudiesindicatethatamaternaldiethighinfatduringpregnancycaninfluencelevelsofkeyproteinsinvolvedinneurotransmissioninthebrain’srewardpathway. Otheranimalresearchhasshownthatpoorqualitymaternalcarediminishedtheabilityofoffspringtorespondtostressthroughepigeneticmechanisms. Researchersareusinganimalmodelstoexploretheepigeneticchangesinducedbychronicstressordrugadministration,andhowthesechangescontributetodepression-andaddiction-relatedbehaviors. Abetterunderstandingofthebiologicalmechanismsthatunderliethegeneticandbiologicalinteractionsthatcontributetothedevelopmentofthesedisorderswillinformthedesignofimprovedtreatmentstrategies.
BrainRegionInvolvement
Manyareasofthebrainareaffectedbybothsubstanceusedisordersandothermentalillnesses.Forexample,thecircuitsinthebrainthatmediatereward,decisionmaking,impulsecontrol,andemotionsmaybeaffectedbyaddictivesubstancesanddisruptedinsubstanceusedisorders,depression,schizophrenia,andotherpsychiatricdisorders. Inaddition,multipleneurotransmittersystemshavebeenimplicatedinbothsubstanceusedisordersandothermentaldisordersincluding,butnotlimitedto,dopamine,serotonin, glutamate, GABA, andnorepinephrine.
EnvironmentalInfluences
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Manyenvironmentalfactorsareassociatedwithanincreasedriskforbothsubstanceusedisordersandmentalillnessincludingchronicstress,trauma,andadversechildhoodexperiences,amongothers.Manyofthesefactorsaremodifiableand;thus,preventioninterventionswilloftenresultinreductionsinbothsubstanceusedisordersandmentalillness,asdiscussedintheSurgeonGeneral’sreportonalcohol,drugs,andhealth.
Stress
Stressisaknownriskfactorforarangeofmentaldisordersandthereforeprovidesonelikelycommonneurobiologicallinkbetweenthediseaseprocessesofsubstanceusedisordersandmentaldisorders. Exposuretostressorsisalsoamajorriskfactorforrelapsetodruguseafterperiodsofrecovery.Stressresponsesaremediatedthroughthehypothalamic-pituitary-adrenal(HPA)axis,whichinturncaninfluencebraincircuitsthatcontrolmotivation.Higherlevelsofstresshavebeenshowntoreduceactivityintheprefrontalcortexandincreaseresponsivityinthestriatum,whichleadstodecreasedbehavioralcontrolandincreasedimpulsivity. Earlylifestressandchronicstresscancauselong-termalterationsintheHPAaxis,whichaffectslimbicbraincircuitsthatareinvolvedinmotivation,learning,andadaptation,andareimpairedinindividualswithsubstanceusedisordersandothermentalillnesses.
Importantly,dopaminepathwayshavebeenimplicatedinthewayinwhichstresscanincreasevulnerabilitytosubstanceusedisorders.HPAaxishyperactivityhasbeenshowntoalterdopaminesignaling,whichmayenhancethereinforcingpropertiesofdrugs. Inturn,substanceusecauseschangestomanyneurotransmittersystemsthatareinvolvedinresponsestostress.Theseneurobiologicalchangesarethoughttounderliethelinkbetweenstressandescalationofdruguseaswellasrelapse.Treatmentsthattargetstress,suchasmindfulness-basedstressreduction,havebeenshowntobebeneficialforreducingdepression,anxiety,andsubstanceuse.
TraumaandAdverseChildhoodExperiences
Physicallyoremotionallytraumatizedpeopleareatmuchhigherriskfordrug
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useandSUDs. andtheco-occurrenceofthesedisordersisassociatedwithinferiortreatmentoutcomes. PeoplewithPTSDmayusesubstancesinanattempttoreducetheiranxietyandtoavoiddealingwithtraumaanditsconsequences.
ThelinkbetweensubstanceusedisorderandPTSDisofparticularconcernforservicemembersreturningfromtoursofdutyinIraqandAfghanistan.Between2004and2010,approximately16percentofveteranshadanuntreatedsubstanceusedisorder,and8percentneededtreatmentforseriouspsychologicaldistress(SPD). Datafromasurveythatusedacontemporary,nationalsampleofveteransestimatedthattherateoflifetimePTSDwas8percent,whileapproximately5percentreportedcurrentPTSD. Approximately1in5veteranswithPTSDalsohasaco-occurringsubstanceusedisorder.
2.Mentalillnessescancontributetodruguseandaddiction.
Certainmentaldisordersareestablishedriskfactorsfordevelopingasubstanceusedisorder. Itiscommonlyhypothesizedthatindividualswithsevere,mild,orevensubclinicalmentaldisordersmayusedrugsasaformofself-medication. Althoughsomedrugsmaytemporarilyreducesymptomsofamentalillness,theycanalsoexacerbatesymptoms,bothacutelyandinthelongrun.Forexample,evidencesuggeststhatperiodsofcocaineusemayworsenthesymptomsofbipolardisorderandcontributetoprogressionofthisillness.
Whenanindividualdevelopsamentalillness,associatedchangesinbrainactivitymayincreasethevulnerabilityforproblematicuseofsubstancesbyenhancingtheirrewardingeffects,reducingawarenessoftheirnegativeeffects,oralleviatingtheunpleasantsymptomsofthementaldisorderorthesideeffectsofthemedicationusedtotreatit. Forexample,neuroimagingsuggeststhatADHDisassociatedwithneurobiologicalchangesinbraincircuitsthatarealsoassociatedwithdrugcravings,perhapspartiallyexplainingwhypatientswithsubstanceusedisordersreportgreatercravingswhentheyhavecomorbidADHD.
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3.Substanceuseandaddictioncancontributetothedevelopmentofmentalillness.
Substanceusecanleadtochangesinsomeofthesamebrainareasthataredisruptedinothermentaldisorders,suchasschizophrenia,anxiety,mood,orimpulse-controldisorders. Drugusethatprecedesthefirstsymptomsofamentalillnessmayproducechangesinbrainstructureandfunctionthatkindleanunderlyingpredispositiontodevelopthatmentalillness.
TheComorbidityBetweenMentalIllnessandTobaccoUse—HighlightonSchizophrenia
Basedonnationallyrepresentativesurveydatafrom2016,30.5percentofrespondentswhohaveamentalillnesssmokedcigarettesinthepastmonth,whichisabout66percenthigherthantherateamongthosewithnomentalillness.Thereisastrongassociationbetweenmentalillness,particularlydepressionandschizophrenia,anduseoftobaccoproducts.Peoplewithschizophreniahavethehighestprevalenceofsmoking(70
to80percent) —withratesupto5timeshigherthanthegeneralpopulation.
Smokingmayreduceorhelpindividualscopewiththesymptomsoftheseillnesses,suchaspoorconcentration,lowmood,andstress. Suchalleviationofsymptomsmayexplainwhypeoplewithmentalillnessesarelesslikelytoquitsmokingcomparedwiththoseinthegeneralpopulation. Unfortunately,highratesofsmokinganddifficultyquittingamongpeoplewithschizophreniamaycontributetotheirgreaterprevalenceofcardiovasculardiseaseandshorterlifeexpectancy.
ResearchonSchizophreniaandNicotine
Researchonhowbothnicotineandschizophreniaaffectthebrainhasgeneratedotherpossibleexplanationsforthehighrateofsmokingamongpeoplewithschizophrenia. Thepresenceofabnormalitiesinparticularcircuitsofthebrainmaypredisposeindividualstoschizophreniaand
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increasetherewardingeffectsofdrugslikenicotine,and/orreduceanindividual’sabilitytoquitsmoking. Thesemechanismsareconsistentwiththeobservationthatbothnicotineandthemedicationclozapine(whichalsoactsatnicotinicacetylcholinereceptors,amongothers)areeffectiveintreatingindividualswithschizophrenia, andcanserveasreplacementsforthenicotineobtainedthroughcigarettesmoking,thusmakingiteasiertoquitsmoking.
Thedorsalanteriorcingulatecortex(dACC)isinvolvedindecision-makingandplanning,focusingattention,andcontrollingimpulsesandemotions.Researchershavefoundthatconnectionsbetweenthisregionandseveralotherbrainareas—includingsomeinvolvedinmemory,emotion,andreward—areweakeramongpatientswithschizophreniacomparedwiththosewithoutthedisorder.Thiscircuitwasimpairedamongpeoplewithschizophreniaregardlessofwhethertheysmokedornot,aswellasamongthecloserelativesofpeoplewithschizophrenia.Severaloftheseneuralcircuitswerealsolessactiveamongindividualswithseverenicotineusedisorder,suggestingthatthisbraincircuitisimpairedinbothschizophreniaandnicotinedependence.
Alowerlevelofnicotinicacetylcholinereceptorsisaneurobiologicalhallmarkofschizophrenia.Thesereceptors,whichareinvolvedincognitionandmemory, arenaturallyactivatedbytheneurotransmitteracetylcholine—buttheycanalsobeactivatedbynicotine.Researchersareworkingtodevelopmedicationsthatstimulatethesespecificreceptors,whichcancounterthecognitiveimpairmentsassociatedwithschizophreniawithouttheaddictivepotentialofnicotineorthenegativehealthconsequencesofsmoking. Understandinghowandwhypatientswithschizophreniausenicotinemayhelpinformthedevelopmentofnewtreatmentsforbothschizophreniaandnicotinedependence.
Althoughthereisagreatneedfornewtreatmentsforbothschizophreniaandnicotinedependence,peoplewiththesecomorbiddisorderscanquitwithoutworseningtheirmentalhealthwhentheyhaveappropriatesupport. Forexample,bupropionincreasessmokingabstinenceratesinpeoplewithschizophrenia,withnoapparentworseningofpsychoticsymptoms. Addingmotivationalincentives(rewardingpatientsfor
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biologicallyverifiedabstinence)tobupropionmedicationmayhelppreventrelapseduringtheinitialphaseofsmokingcessation. Vareniclinemayalsoimprovesmokingcessationratesinschizophrenia,butthismedicationmayworsenpsychiatricsymptomsandrequiresadditionalresearch.
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Whataresomeapproachestodiagnosis?
Thehighrateofcomorbiditybetweendrugusedisordersandothermentalillnesseshighlightstheneedforanintegratedapproachtointerventionthatidentifiesandevaluateseachdisorderconcurrentlyandprovidestreatmentasappropriateforeachpatient’sparticularconstellationofdisorders.Enhancedunderstandingofthecommongenetic,neural,andenvironmentalsubstratesofthesedisorderscanleadtoimprovedtreatmentsforindividualswithcomorbiditiesandmayhelpdiminishthesocialstigmathatmakessomepatientsreluctanttoseekthetreatmenttheyneed.
Thediagnosisandtreatmentofcomorbidsubstanceusedisordersandmentalillnessarecomplex,becauseitisoftendifficulttodisentangleoverlappingsymptoms. Comprehensiveassessmenttoolsshouldbeusedtoreducethechanceofamisseddiagnosis. Patientswhohavebothadrugusedisorderandanothermentalillnessoftenexhibitsymptomsthataremorepersistent,severe,andresistanttotreatmentcomparedwithpatientswhohaveeitherdisorderalone.
Patientsenteringtreatmentforpsychiatricillnessesshouldbescreenedforsubstanceusedisordersandviceversa.Accuratediagnosisiscomplicated,however,bythesimilaritiesbetweendrug-relatedsymptoms,suchaswithdrawal,andthoseofpotentiallycomorbidmentaldisorders.Thus,whenpeoplewhousedrugsentertreatment,itmaybenecessarytoobservethemafteraperiodofabstinencetodistinguishbetweentheeffectsofsubstanceintoxicationorwithdrawalandthesymptomsofcomorbidmentaldisorders.Thispracticeresultsinmoreaccuratediagnosesandallowsforbetter-targetedtreatment.
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PolysubstanceUseandComorbidSubstanceUseDisorders
Polysubstanceuseiscommon,andmanypeopledevelopmultiplecomorbidsubstanceusedisorders(Table1).Forexample,amongpeoplewithaheroinusedisorderover66percentaredependentonnicotine,nearly25percenthaveanalcoholusedisorder,andover20percenthaveacocaineusedisorder.Amongpeoplewithacocaineusedisordernearly60percenthaveanalcoholusedisorder,approximately48percentaredependentonnicotine,andover21percenthaveamarijuanausedisorder.Aswithsingle-substanceusedisorders,thediagnosisandtreatmentofcomorbidsubstanceusedisordersandmentalillnessarecomplex.Theuseofmultiplesubstancescanfurthercomplicatediagnosisandtreatment.
Fullsizetable
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Whatarethetreatmentsforcomorbidsubstanceusedisorderandmentalhealthconditions?
Integratedtreatmentforcomorbiddrugusedisorderandmentalillnesshasbeenfoundtobeconsistentlysuperiorcomparedwithseparatetreatmentofeachdiagnosis. Integratedtreatmentofco-occurringdisordersofteninvolvesusingcognitivebehavioraltherapystrategiestoboostinterpersonalandcopingskillsandusingapproachesthatsupportmotivationandfunctionalrecovery.
Patientswithcomorbiddisordersdemonstratepoorertreatmentadherenceandhigherratesoftreatmentdropout thanthosewithoutmentalillness,whichnegativelyaffectsoutcomes.Nevertheless,steadyprogressisbeingmadethroughresearchonnewandexistingtreatmentoptionsforcomorbidity. Inaddition,researchonimplementationofappropriatescreeningandtreatmentwithinavarietyofsettings,includingcriminaljusticesystems,canincreaseaccesstoappropriatetreatmentforcomorbiddisorders.
Treatmentofcomorbidityofteninvolvescollaborationbetweenclinicalprovidersandorganizationsthatprovidesupportiveservicestoaddressissuessuchashomelessness,physicalhealth,vocationalskills,andlegalproblems.Communicationiscriticalforsupportingthisintegrationofservices.Strategiestofacilitateeffectivecommunicationmayincludeco-location,sharedtreatmentplansandrecords,andcasereviewmeetings. Supportandincentivesforcollaborationmaybeneeded,aswellaseducationforstaffonco-occurringsubstanceuseandmentalhealthdisorders.
TreatmentforYouth
Asmentionedpreviously,theonsetofmentalillnessandsubstanceusedisordersoftenoccursduringadolescence,andpeoplewhodevelop
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problemsearliertypicallyhaveagreaterriskforsevereproblemsasadults.GiventhehighprevalenceofcomorbidmentaldisordersandtheiradverseimpactonSUDtreatmentoutcomes,SUDprogramsforadolescentsshouldscreenforcomorbidmentaldisordersandprovidetreatmentasappropriate.
Researchindicatesthatsomemental,emotional,andbehavioralproblemsamongyouthcanbepreventedorsignificantlymitigatedbyevidence-basedpreventioninterventions. Theseinterventionscanhelpreducetheimpactofriskfactorsforsubstanceusedisordersandothermentalillnesses,includingparentalunemployment,maternaldepression,childabuseandneglect,poorparentalsupervision,deviantpeers,deprivation,poorschools,trauma,limitedhealthcare,andunsafeandstressfulenvironments.Implementationofpolicies,programs,andpracticesthatdecreaseriskfactorsandincreaseresiliencecanhelpreducebothsubstanceusedisordersandothermentalillnesses,potentiallysavingbillionsofdollarsinassociatedcostsrelatedtohealthcareandincarceration.
Otherevidence-basedinterventionsemphasizestrengtheningprotectivefactorstoenhanceyoungpeople’swell-beingandprovidethetoolstoprocessemotionsandavoidbehaviorswithnegativeconsequences.Keyprotectivefactorsincludesupportivefamily,school,andcommunityenvironments.
Inadditiontothetreatmentoptionsdiscussedinthisresearchreport,thefollowingtreatmentshavebeenshowntobeeffectiveforchildrenandadolescents:
MultisystemicTherapy(MST).MSTtargetskeyfactorsthatareassociatedwithseriousantisocialbehaviorinchildrenandadolescentswithsubstanceusedisorders,suchasattitudes,family,peerpressure,schoolandneighborhoodculture.
BriefStrategicFamilyTherapy(BSFT).BSFTtargetsfamilyinteractionsthatarethoughttomaintainorexacerbateadolescentsubstanceusedisorderandotherco-occurringproblembehaviors
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suchasconductproblems,oppositionalbehavior,delinquency,associatingwithantisocialpeers,aggressiveandviolentbehavior,andriskysexualbehaviors.
MultidimensionalFamilyTherapy(MDFT).MDFT,acomprehensiveinterventionforadolescents,focusesonmultipleandinteractingriskfactorsforsubstanceusedisordersandrelatedcomorbidconditions.Thistherapyaddressesadolescents’interpersonalandrelationshipissues,parentalbehaviors,andthefamilyenvironment.Familiesreceiveassistancewithnavigatingschoolandsocialservicesystems,aswellasthejuvenilejusticesystemifneeded.Treatmentincludesindividualandfamilysessions.
Medications
Effectivemedicationsexistfortreatingopioid,alcohol,andnicotineusedisordersandforalleviatingthesymptomsofmanyotherdisorders.Whilemosthavenotbeenwellstudiedincomorbidpopulations,somemedicationsmayhelptreatmultipleproblems.Forexample,bupropionisapprovedfortreatingdepressionandnicotinedependence.Formoreinformation,seethetablebelow.
ViewTable:PharmacotherapiesUsedtoTreatAlcohol,Nicotine,andOpioidUseDisorders
BehavioralTherapies
Behavioraltreatment(aloneorincombinationwithmedications)isacornerstonetosuccessfullong-termoutcomesformanyindividualswithdrugusedisordersorothermentalillnesses. Severalstrategieshaveshownpromisefortreatingspecificcomorbidconditions.
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CognitiveBehavioralTherapy(CBT)CBTisdesignedtomodifyharmfulbeliefsandmaladaptivebehaviorsandshowsstrongefficacyforindividualswithsubstanceusedisorders.CBTisthemosteffectivepsychotherapyforchildrenandadolescentswithanxietyandmooddisorders.
DialecticalBehaviorTherapy(DBT)DBTisdesignedspecificallytoreduceself-harmbehaviorsincludingsuicidalattempts,thoughts,orurges;cutting;anddruguse.Itisoneofthefewtreatmentseffectiveforindividualswhomeetthecriteriaforborderlinepersonalitydisorder.
AssertiveCommunityTreatment(ACT)ACTprogramsintegratebehavioraltreatmentsforseverementalillnessessuchasschizophreniaandco-occurringsubstanceusedisorders.ACTisdifferentiatedfromotherapproachestocasemanagementthroughfactorssuchasasmallercaseloadsize,teammanagement,outreachemphasis,ahighlyindividualizedapproach,andanassertiveapproachtomaintainingcontactwithpatients.
TherapeuticCommunities(TCs)TCsareacommonformoflong-termresidentialtreatmentforsubstanceusedisorders.Theyfocusonthe“resocialization”oftheindividual,oftenusingbroad-basedcommunityprogramsasactivecomponentsoftreatment.TCsareappropriateforpopulationswithahighprevalenceofco-occurringdisorderssuchascriminaljustice-involvedpersons,individualswithvocationaldeficits,vulnerableorneglectedyouth,andhomelessindividuals. Inaddition,someevidencesuggeststhatTCsmaybehelpfulforadolescentswhohavereceivedtreatmentforsubstanceuseandaddiction.
ContingencyManagement(CM)orMotivationalIncentives(MI)CM/MIisusedasanadjuncttotreatment.Voucherorprize-basedsystemsrewardpatientswhopracticehealthybehaviorsandreduceunhealthybehaviors,includingsmokinganddruguse.Incentive-basedtreatmentsareeffectiveforimprovingtreatmentcomplianceandreducingtobaccoandotherdruguse,andcanbeintegratedintobehavioralhealthtreatmentprogramsforpeoplewithco-occurringdisorders.
ExposureTherapy
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Exposuretherapyisabehavioraltreatmentforsomeanxietydisorders(phobiasandPTSD)thatinvolvesrepeatedexposuretoafearedsituation,object,traumaticevent,ormemory.Thisexposurecanbereal,visualized,orsimulated,andisalwayscontainedinacontrolledtherapeuticenvironment.Thegoalistodesensitizepatientstothetriggeringstimuliandhelpthemdevelopcopingmechanisms,eventuallyreducingoreveneliminatingsymptoms.SeveralstudiessuggestthatexposuretherapymaybehelpfulforindividualswithcomorbidPTSDandcocaineusedisorder,althoughretentionintreatmentisachallenge.
IntegratedGroupTherapy(IGT)IGTisatreatmentdevelopedspecificallyforpatientswithbipolardisorderandsubstanceusedisorder,designedtoaddressbothproblemssimultaneously. ThistherapyislargelybasedonCBTprinciplesandisusuallyanadjuncttomedication.TheIGTapproachemphasizeshelpingpatientsunderstandtherelationshipbetweenthetwodisorders,aswellasthelinkbetweenthoughtsandbehaviors,andhowtheycontributetorecoveryandrelapse.
SeekingSafety(SS)SeekingSafetyisapresent-focusedtherapyaimedattreatingtrauma-relatedproblems(includingPTSD)andsubstanceusedisordersimultaneously.Patientslearnbehavioralskillsforcopingwithtrauma/post-traumaticstressdisorderandsubstanceusedisorder.
MobileMedicalApplicationIn2017,theFoodandDrugAdministrationapprovedthefirstmobilemedicalapplicationtohelptreatsubstanceusedisorders.Theintentionisforpatientstouseitwithoutpatienttherapytotreatalcohol,cocaine,marijuana,andstimulantusedisorders;itisnotintendedtotreatopioiddependence.ThedevicedeliversCBTtopatientstoteachskillsthataidinthetreatmentinsubstanceusedisordersandincreaseretentioninoutpatienttherapyprograms.
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Part2:Co-occurringSubstanceUseDisorderandPhysicalComorbidities
Peoplewithsubstanceusedisordersalsooftenexperiencecomorbidchronicphysicalhealthconditions,includingchronicpain, cancer,andheartdisease. Theuseofvarioussubstances—includingalcohol,heroin,prescriptionstimulants,methamphetamine,andcocaine—isindependentlyassociatedwithincreasedriskforcardiovascularandheartdisease.
ChronicPain
Chronicpainisaphysicalproblemthathasacomplexrelationshipwithsubstanceusedisorders,particularlyopioidmisuseandaddiction. Anestimated10percentofchronicpainpatientsmisuseprescriptionopioids.Chronicpainandassociatedemotionaldistressarethoughttodysregulatethebrain’sstressandrewardcircuitry,increasingtheriskforopioidusedisorder.Opioidmisuseandaddictionareseriouspublichealthproblemsthatledtomorethan42,000deathsin2016alone. Highratesofopioidmisuseandaddictionamongpatientswithchronicpainhighlighttheneedforcarefulpre-treatmentscreeningandeducationaswellasongoingmonitoringforsafetyandeffectivenesswhenopioidmedicationsareusedtotreatpain.
TobaccoUse
Oneofthelargestdriversofphysicalhealthcomorbiditiesiscigarettesmoking.ItislinkedtomanymajorhealthconditionsandremainstheleadingpreventablecauseofprematurediseaseanddeathintheUnitedStates. Forexample,themajorityoflungcancerandapproximatelyone-thirdofallcancerdeathsareattributabletosmoking. Smokingisknowntocontributetoage-relatedmaculardegeneration,diabetes,colorectalcancer,livercancer,adversehealthoutcomesincancerpatientsandsurvivors,tuberculosis,erectiledysfunction,rheumatoidarthritis,inflammation,andimpairedimmunefunction. Smokingisalsoanimportantcomorbidityamongpeoplewithotherdrugusedisordersandcontributestotheirphysicalhealthproblems.An
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estimated77–93percentofpeopleintreatmentforsubstanceusedisordersusetobacco.
MentalIllness
Physicalillnessesnotonlyaffectthebodyanddailyfunctioning,buttheycanalsoincreasetheriskformentalillnessessuchasdepression andanxiety.Depressionhasanegativeimpactonindividualswithchronicphysicalconditions,reducingaperson’squalityoflifeandabilitytomanagetheirhealth. Comorbidmentalillnessesareassociatedwithgreaterfunctionalimpairmentsandmortalityratesrelatedtophysicalillnesses. Olderpeoplewithchronicphysicalillnessesorimpairmentsmayfeelisolatedandincreasesubstanceuse. Furthermore,asdiscussedinPart1,mentalillnessmayleadtosubstanceusedisordersandviceversa,thus,SUDsmayplayaroleinlinkingmentalillnessandphysicalhealth.
TreatmentAdherence
Inadditiontothedirecteffects,substanceusedisorderscanhaveanindirectnegativeimpactonthemanagementofmedicalconditions.Forexample,peoplewithsubstanceusedisordersarelesslikelytoadherewiththeirtreatmentplansortotakemedicationregularly, whichworsensthecourseoftheirillnesses.Inaddition,substanceusecandiminishtheeffectivenessofmedicationsforphysicalconditions.
InfectiousDiseaseTransmission
Substanceusealsoincreasestheriskofinfectiousdiseasetransmission,includingHIV andthehepatitisCvirus(HCV). Thisincreasedriskisrelatedtoinjectiondruguseandincreasedriskysexualbehaviorsassociatedwithdruguse. FormoreinformationabouttheconnectionbetweensubstanceuseandHIVpleasegotoPart3("TheConnectionbetweenSubstanceUseDisordersandHIV").
ImplicationsforHealthCareDelivery
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Comorbidchronicphysicalandbehavioralhealthconditions(mentalandsubstanceusedisorders)areassociatedwithgreaterfunctionalimpairmentandincreasedhealthcarecosts.Aswithcomorbidmentalillness,integratedcareiscriticalforaddressingphysicalhealthcomorbidities. AsdiscussedinPart4("BarrierstoComprehensiveTreatmentforIndividualswithCo-OccurringDisorders"),recentdeliverysysteminnovationmodelsprovideincentivestoshifthealthcaretowardsintegratedcaremodels.Integratedcareoffersgreateropportunitiesforprimarycareproviders,physicianspecialists,andbehavioralhealthspecialiststoworktogethertoreducetheimpactofmentalandphysicalhealthcomorbiditiesonsubstanceusedisorder,andviceversa,toimproveoverallhealthoutcomes.
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Part3:TheConnectionbetweenSubstanceUseDisordersandHIV
Morethan1.2millionpeopleintheUnitedStatesarelivingwithhumanimmunodeficiencyvirus(HIV),thevirusthatcausesacquiredimmunedeficiencysyndrome(AIDS). HIVistransmittedthroughcontactwithinfectedbloodandbodilyfluids.Suchcontactcanoccurthroughunprotectedsex,throughsharingneedlesorotherdruginjectionequipment,throughmother-to-childtransmissionduringpregnancyorbreastfeeding,andthroughinfectedbloodtransfusionsandplasmaproducts.Whileeffectiveantiretroviraltherapy(ART)isavailable,thereiscurrentlynocureforHIV/AIDS. However,theprovisionofARTreducesviralload—ultimatelydecreasingHIVtransmissioninthelargercommunity.
ThisnationalpublichealthissueandtheongoingglobalHIV/AIDSpandemicareexacerbatedbysubstanceuse,whichservesasapowerfulcofactorateverystage,includingtransmission,diagnosis,illnesstrajectories,andtreatment.Sincethebeginningoftheepidemicinthe1980s,druguseandHIVhavebeeninextricablylinked.Today,illicitdruguseisanimportantdriverofHIVacrosstheglobe. Intravenousdruguseinparticularcontinuestobeariskfactorfortransmissionofthevirus, accountingforapproximately6percentofHIVdiagnosesin2015.
Inaddition,druguseplaysamoregeneralroleinthespreadofHIVbyincreasingthelikelihoodofhigh-risksexwithinfectedpartners. Theintoxicatingeffectsofmanydrugscanalterjudgmentandinhibition,andleadpeopletoengageinimpulsiveandunsafebehaviors.Additionally,peoplewhoareaddictedtodrugsmayengageinriskysexualbehaviorstoobtaindrugsormoneytobuythem.
DruguseandaddictioncanalsohastentheprogressionofHIVanditsconsequences,especiallyinthebrain.Clinicalresearchindicatesthatdruguseandaddictionmayincreaseviralload,acceleratediseaseprogression,andworsenAIDS-relatedmortalityevenamongpatientswhofollowARTregimens. Inaddition,peoplewithsubstanceusedisordersarelesslikelyto
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takelife-savingHIVmedicationregularly, whichworsensthecourseoftheirillness.
AlthoughitisunclearwhetherHIVinfectioncontributestodruguseandaddictioninhumanpatients, animalstudiessuggestthatbothtypesofbraincells—neuronsandglia—canbeinfectedbyHIV,causingneurobiologicaldisruptionstobraincircuitsthatareeffectedbydruguseandaddiction.
DrugscanmakeiteasierforHIVtoenterthebrainandtriggeranimmuneresponseandthereleaseofneurotoxins,whichcancausechronicneuroinflammation. HIV-inducedinflammationinthebrainunderliestheneurocognitivedisorders,alsocalledNeuroHIV,thatareacomplicationofHIVinfection. Around50percentofindividualswithHIVandAIDSsufferfromHIV-relatedneurocognitivedisorders. NeuroHIVischallengingtodiagnoseandtreat,sinceotherfactors—suchasaging,druguse,addiction,andpsychiatricillnesses—arecommonandcanproducesimilarcognitivesymptoms. ThereisanongoingneedfornewtherapeuticapproachestotheneurologicalcomplicationsofHIV,asclinicaltrialsofneuroprotectiveoranti-inflammatorymedicationshavebeenunsuccessful.
BecausepeoplewithHIVarelivinglongerduetoeffectivetreatments,theinfluenceofthevirusontheagingbrainandneurocognitionisagrowingconcern.AroundhalfofallHIV-infectedpersonsare50yearsoldorover.NeuroimagingresearchconductedpriortoeffectivetreatmentoronuntreatedindividualssuggeststhatHIVacceleratesagingofthebrain.ComorbidsubstanceusedisordermayexacerbateneurologicalagingamongpeoplewithHIV.
TestingforandtreatingHIVincriminaljusticesettingsbenefitsboththehealthofinmatesandoverallpublichealth.PeoplewithHIVinfectionareoverrepresentedinprisons;in2010,therewere20,093inmateswithHIV/AIDSinstateandfederalprisons. MostincarceratedindividualswithHIVacquireditinthecommunitypriortoincarceration. IndividualswithHIVoftenbegintreatmentwhileincarcerated,buttheyexperienceadisruptionofcarewhentheyreturntothecommunity,inadditiontofacingchallengescopingwithsubstanceuseandmentalhealthproblems. Thereforeitisparticularly
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importanttolinkpeoplewhohaveHIVandahistoryofsubstanceusetocommunityHIVservices,substanceabusetreatment,mentalhealthservices,andotherwraparoundservicesintheircommunitytoreducerecidivism,improvetheirhealth,reducethespreadoftheinfectiontoothers,andpreventrelapsetosubstanceabuse.129–131
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WhyisHIVscreeningimportant?
TheriskofHIVtransmissionislowerwhenpeoplewhoareinfectedwithHIVreceiveARTtosuppresstheirviralload.DespiteCDC’srecommendationsandeffortstoincreaseHIVtesting. Onesurveyfoundthatonlyabout19percentofpeopleaged15to44weretestedforHIVduringthepastyear. ThismeansthatpeoplewhomayhaveHIVareunawareoftheirstatusand,thus,arenotreceivingART,whichincreasesthetransmissionratenation-wide.
BecauseHIV,druguse,andaddictionareinextricablylinked,onestrategyforreducingincidenceistoimplementHIVtestingatSUDtreatmentfacilities. AnanalysisofnationallyrepresentativedatafromprivatelyfundedSUDtreatmentprogramsfoundthatmostprogramsprovidededucationandpreventionservices.Whiletheproportionofprogramsofferingon-siteHIVtestingandthepercentageofpatientswhoreceivedtestingincreasedinrecentyears, fewerthanone-thirdofprogramsofferedon-sitetesting.Inthoseprograms,fewerthanone-thirdofpatientsreceivedtesting.
NIDAiscollaboratingwiththeSubstanceAbuseandMentalHealthServicesAdministration(SAMHSA)andotherstoexpandrapidHIVtestingtodrugtreatmentfacilitiestobetteridentifyHIVinfectionsandengagepatientsmoreefficientlyincomprehensivetreatmentforbothsubstanceusedisorderandHIVinfection.ManyhealthinsuranceproviderscoverHIVtestingwithoutaco-payordeductible. TofindalocalHIVtestingcentervisit:https://www.cdc.gov/hiv/.
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WhataresomemethodsforHIVpreventionandtreatmentforindividualswithsubstanceusedisorders?
ResearchindicatesthatSUDtreatment, sterilesyringeprograms,community-basedoutreach,testing,andlinkagetocomprehensivecareforHIVandotherinfections arethemosteffectivewaystoreducetransmissionamongindividualswhousedrugs.Becausetheseindividualsoftenfacebarrierstotesting,treatment,andadheringtoART,uniquesupportsareneededforpreventionandtreatmentwithinthispopulation.
Pre-exposureprophylaxis(PrEP)
PrEPisanimportantcomponentofHIVprevention.Inthisapproach,peoplewhoareatsignificantriskbutnotinfectedwithHIVtakeadailyoraldoseofmedicationtopreventthemfromcontractingthevirus. TheWorldHealthOrganizationrecommendsPrEPasonecomponentofpreventionforindividualsathighriskforHIV. Aswithallmedications,adherenceiscriticaltoeffectiveness. TherehavebeensomepromisingresultsofPrEPamongpeoplewhoinjectdrugs,withoneclinicaltrialfindingthatitdecreasedtheriskofHIVinfectionbyasmuchas84percentforthosewhowerehighlyadherent,butonlyabout50percentoverall. MoreresearchisneededonoptimizingPrEPadherenceandthebestwaystointegrateitintoSUDtreatment.DespiteresearchindicatingthatPrEPisgenerallysafeandeffectiveforthosewhoareatsignificantriskofHIVinfection, strategiestoincreaseaccesstoPrEPamonginjectiondrugusersshouldbeexplored.
TheSeek,Test,Treat,andRetain(STTR)ModelofCare
PeoplecontinuetobeinfectedbyHIVthroughunsafecontactwithotherswhoareeitherunawarethattheyhavethevirusorhaveinadequatelysuppressedtheirviralload. TheSTTRmodelofcareisspecificallydesignedtoaddress
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thesetwodriversofnewHIVinfections,particularlyconsideringthewell-documenteddelaysintestingandtreatmentexperiencedbyindividualswithsubstanceusedisorders. Thisapproachinvolvesreachingouttohigh-risk,hard-to-reachdrug-usingpopulationswhohavenotrecentlybeentestedforHIV(seeking);engagingtheminHIVtesting(testing);initiating,monitoring,andmaintainingARTforthosetestingpositive(treating);andretainingpatientsincare(retaining).
Incorporatingrapidon-siteHIVtestingintoSUDtreatmentisanimportantcomponentofeffortstoidentifythosewhoareinfected,initiatecareearlier,andreducetransmission. However,treatmentprogramsmaynothavesufficientresourcestoprovideHIVtesting.Reducingbarriersbyprovidingstart-upcostsandstafftrainingonhowtosupportindividualswhotestpositive,andaddressingstaffingneedsarecrucialtoestablishingandmaintainingrapidon-siteHIVtestinginSUDtreatmentfacilities. ResearchersestimatethattestingpeoplewhoinjectdrugsforHIVevery6monthsiscosteffective,comparedwithannualtesting,at$133,200inincrementalcostsperquality-adjustedlifeyeargained.
ARThasimprovedthesurvivalofpeoplewithHIV,includingthosewhoinjectdrugs,sothattheynowtendtoliveaslongasthosewhoarenotinfectedwiththevirus. Mostpatients,regardlessofinjectiondrugusehistory,canachieveviralsuppressionwithART, whichcansignificantlyreducetransmissionofHIVtoothers. Thisapproach,calledTreatmentasPrevention,isacrucialpartofeffortstoreducethespreadofthevirusandakeycomponentoftheSTTRstrategy.TheTreatmentasPreventionapproachreliesonidentifyingundiagnosedindividuals,linkingthemtotreatmentwithART,andretainingthemincare. Retentionintreatmentiskeytoachievingfullviralsuppression(i.e.,virusisbelowdetectablelevels)andpreventingtransmissionofHIV.CDCestimatesthat49percentofpeoplewithHIVintheUnitedStateshadfullviralsuppressionin2014. Datafrom2011showedthatamongpeoplewhoseviralloadwasnotsuppressed,20percenthadneverbeendiagnosedwithHIV,66percentwerediagnosedbutnotengagedinmedicalcareforHIV,4percentwereengagedinHIVmedicalcarebutnotprescribedART,and10percentwereprescribedARTbuthadnotachievedviralsuppression.
SubstanceUseDisorderTreatment
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StudiesfindthatbehavioraltreatmentssuchascognitivebehavioraltherapyandmotivationalinterviewingnotonlyreducedrugusebutalsoimproveadherencetoARTregimens andmedicationsforHCV. Amongmenwhohavesexwithmen(MSM),SUDtreatmentisassociatedwithreduceddruguseandriskysexualbehavior,andthosewithHIVreportimprovementsinviralload. AddictionpharmacotherapiesalsoreducetheriskforHIV.Pooledresultsfrommultiplestudiesindicatethatmethadoneorbuprenorphinetreatmentforopioidusedisorderisassociatedwitha54percentreductioninriskofHIVinfectionamongpeoplewhoinjectdrugs. HIV-infectedpeoplewhoinjectdrugsaremorelikelytoinitiateARTwhenengagedinmethadonetreatment. Becausepeoplewhoinjectdrugsalsohavearelativelyhighprevalenceofmentalillness,researchsuggeststhatfullyintegratedaddiction,psychiatric,andHIVcaremightincreasethelikelihoodofARTadherenceandimprovehealthoutcomes.
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HowcanweachieveanAIDS-freegeneration?
Althoughmoreresearchisneeded,thescientificandmedicalcommunitiescontinuetodevelopanddisseminateeffectiveHIVpreventionandtreatmentapproaches.ThreekeyprinciplesunderlieNIDA’sstrategy:(1)substanceusedisorderandHIVarelinkedinwaysthatextendbeyondinjectiondruguse;(2)substanceusedisorderandHIVremainintertwinedepidemicsintheUnitedStatesandaroundtheworld—therefore,SUDtreatmentisHIVprevention;and(3)theSTTRapproach,especiallywhenimplementedinhigh-riskpopulationsorsettings,candecreaseviralloadandHIVincidenceatapopulationlevel,improvingoutcomesforall.Implementingtheseevidence-basedstrategieswillbringtheUnitedStatesclosertothegoalofan"AIDS-freegeneration."
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Part4:BarrierstoComprehensiveTreatmentforIndividualswithCo-OccurringDisorders
Althoughevidenceindicatestheneedforcomprehensiveandintegratedtherapytoaddresscomorbidity, researchshowsthatonlyabout18percentofSUDtreatmentprogramsand9percentofmentalhealthtreatmentorganizationshavethecapacitytoserveduallydiagnosedpatients.Provisionofsuchtreatmentcanbeproblematicforseveralreasons:
IntheUnitedStates,SUDtreatmentisoftensiloedfromthegeneralhealthcaresystem. Primarycarephysiciansaremostoftenthefrontlineoftreatmentformentaldisorders.Thespecialtymentalhealthtreatmentsystemtypicallyaddressesonlyseverementalillness,whiledrugtreatmentistypicallyprovidedbyaseparateSUDtreatmentsystem.Typically,noneofthesesystemshavesufficientlybroadexpertisetoaddressthefullrangeofproblemspresentedbyduallydiagnosedpatients.
AlingeringbiasremainsinsomeSUDtreatmentcentersagainstusinganymedications,includingthosenecessarytotreatseriousmentalillnessesincludingdepression,althoughthisisslowlychanging. Additionally,manySUDtreatmentprogramsdonotemployclinicianswhocanprescribe,dispense,andmonitormedications.
Manyindividualswhowouldbenefitfromtreatmentareinthecriminaljusticesystem.Itisestimatedthatabout45percentofindividualsinstateandlocalprisonsandjailshaveamentalhealthproblemcomorbidwithsubstanceuseoraddiction. However,adequatetreatmentservicesforbothdrugusedisordersandothermentalillnessesareoftennotavailablewithinthesesettings.Treatmentofcomorbiddisorderscanreducenotonlymedicalcomorbidities,butalsonegativesocialoutcomesbymitigatingagainstareturntocriminalbehaviorandre-incarceration.
Whilethesebarriersloomlarge,changestotheU.S.healthcaresystemcanhelpimprovecareforpeoplewithcomorbidities. TheMentalHealthParity
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andAddictionEquityActof2008(alsoknownastheParityAct)andthePatientProtectionandAffordableCareActof2010(alsoknownastheAffordableCareActorACA)haveincreasedthenumberofpeoplewithinsurancethatcoversaddictionandmentalhealthtreatment.TheParityActmandatesthathealthcareplansthatcoverbehavioralhealthtreatmentsdosotothesameextentastreatmentsforphysicalhealthconditions. TheACArequiresthataddictionandmentalhealthtreatmentbecoveredasoneofthetenEssentialBenefitcategories.Withhealthcarereform’sotherprovisionstoincreasethequalityofcare,cliniciansnowhavegreatersupportandincentivestoimplementevidence-basedpractices andtocollaborateinteamsthatprovideintegratedcareforphysicalandmentaldisorders.
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WherecanIgetmorescientificinformationoncomorbidsubstanceusedisorder,mentalillness,andmedicalconditions?
Tolearnmoreaboutsubstanceusedisordersandothermentalillnesses,ortoordermaterialsonthesetopicsfreeofchargeinEnglishorSpanish,visittheNIDAwebsiteatwww.drugabuse.govorcontacttheDrugPubsResearchDisseminationCenterat877-NIDA-NIH(877-643-2644;TTY/TDD:240-645-0228).
NIDA'swebsiteincludes:
Informationondrugsofuseandmisuseandrelatedhealthconsequences
NIDApublications,news,andevents
Resourcesforhealthcareprofessionals,educators,andpatientsandfamilies
InformationonNIDAresearchstudiesandclinicaltrials
Fundinginformation(includingprogramannouncementsanddeadlines)
Internationalactivities
Linkstorelatedwebsites(accesstowebsitesofmanyotherorganizationsinthefield)
InformationinSpanish(enespañol)
NIDAwebsitesandwebpages
drugabuse.gov/related-topics/comorbidity
drugabuse.gov/publications/drugfacts/comorbidity-addiction-other-mental-
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disorders
drugabuse.gov
teens.drugabuse.gov
easyread.drugabuse.gov
researchstudies.drugabuse.gov
irp.drugabuse.gov
Forphysicianinformation
NIDAMED:drugabuse.gov/nidamed
Otherwebsites
Informationonmentalillnesses,substanceuse,andsubstanceusedisorderisalsoavailablethroughtheseotherwebsites:
NationalInstituteofMentalHealth
SubstanceUseandMentalHealth
HIV/AIDSandMentalHealth
NationalInstituteonAlcoholAbuseandAlcoholism
OtherPsychiatricDisorders
OtherSubstanceAbuse
SubstanceAbuseandMentalHealthServicesAdministrationHealthInformationNetwork
CommonComorbidities
Co-occuringDisorders
PublicationsandResources
CentersforDiseaseControlandPrevention—CopingWithaDisasteror
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TraumaticEvent
HIV/AIDS
HIV.gov
OfficeofHIV/AIDSandInfectiousDiseasePolicy(OHAIDP)
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