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

ziedondm@umdnj.edu

Douglas Ziedonis, M.D., MPHProfessor & Director, Division of Addiction Psychiatry

Robert Wood Johnson Medical School

732-235-4341

ziedondm@umdnj.edu

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

SYSTEM ISSUESTreatment Models for Different

Settings

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