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WHAT PSYCHOLOGISTS NEED TO KNOW ABOUT CO-OCCURRING SUBSTANCE USE

AND MENTAL HEALTH DISORDERS

Margaret King, PsyD

INTRODUCTION

▪ Nearly ½ of all individuals diagnosed with a mental illness will also meet criteria for a substance use disorder in their lifetime (Ross & Peselow, 2012; Kelly, T. M., & Daley, D. C., 2013).

▪ Mood and anxiety disorders greatly increase the likelihood of developing a SUD (Conway, et al. 2006).

▪ Therapists fail to diagnosis and/or treat addictive issues in nearly ½ of cases with active addictive issues (Liese & Reis, 2016; Mitchell, Meader, Bird, & Rizzo, 2012) due to prohibitive beliefs and limited knowledge about addictive behaviors.

▪ The APA has no requirement for training in substance use disorders (APA, 2015)

▪ Less than 1/3 of clinical psychology programs offer specialized training in addiction (Dimoff,

Sayette, Norcross, 2017).

▪ In the clinical and counseling psychology programs that offered addiction courses, only half had an addiction course as a requirement (Corib, Gottdiener, Sirikantraporn, Armstrong, & Probber, 2013).

APA DIVISION 50 - SOCIETY OF

ADDICTION PSYCHOLOGY

(SOAP)

▪ Historically, there was an examination and certificate to recognize proficiency in addition

▪APA currently recognizes addiction psychology as a “proficiency” not a “specialization.”▪Understand the biopsychosocial underpinnings, risk factors, and results addictions

▪Training and experience in evidenced based prevention and treatment

▪Master Addiction Counselor (MAC) from the National Association of Alcohol and Drug Abuse Counselors

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MYTHS AND MISCONCEPTIONS

“Addiction is a moral failing”

“Addicts are unemployed and/or

homeless.”

“They could quit if they really wanted to.” –

“Just say no”

“Prescription drugs and alcohol aren’t as

dangerous as illegal drugs.”

“Marijuana isn’t harmful.”

“I can accurately diagnose a mental

health disorder without taking a comprehensive substance use history.”

“I need to refer clients that have an addiction

history or who are currently using.”

TRENDS OF DRUG USE IN

THE US: OPIOIDS

▪ The U.S. is 4.6% of world population and are consuming 80% of the world’s opioids (Express scripts, 2014)

▪ Reduction in opioid prescriptions, especially in high doses, in the recent years

▪ 21-29% of people prescribed opioids for chronic pain misuse the medication

▪ 2018 Monitoring the Future Research (Johnston, Miech, O'Malley,

Bachman, Schulenberg, & Patrick, 2019)

▪ Lifetime prevalence rates of use of illicit drugs other than

marijuana decreased (19% in 2018; 43% 1981)

▪ Misuse of prescription opioids continue to decline

▪ “Narcotics other than heroin” 3.4% of 12th graders used in the past year

▪ Heroin was 0.4% of 12th graders, 0.2% of 10th 0.3% of 8th in

past year.

TRENDS OF DRUG USE IN THE US: OPIOIDS

▪ First time heroin users were aged 18 to 25 (52.7%), male (59%), non-Hispanic white (79.3%), lived in metropolitan areas (84.5%), and previously used non-medical prescription pain relievers (48.2%) (Muhuri, Gfroerer,

& Davies, 2013)

▪ Nearly 80% of Americans using heroin reported misusing prescription opioids prior to using heroin (Muhuri, Gfroerer, & Davies, 2013)

▪ First heroin use was 19x higher among those who reported prior abuse of non-medical use of prescription pain reliever within the last12 months

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TRENDS OF DRUG USE IN THE US: OPIOIDS

▪ In 2017, among 70,237 drug overdose deaths, 47,600 (67.8%) involved opioids (Scholl, et al 2019)

▪ Drug overdoses in 2016 were nearly 3x that of overdoses in 1999(Hedegaard, Warner & Miniño, 2017)

▪ PA’s drug overdose deaths were among the highest & higher than the national average. ▪ Drug overdose deaths that involved synthetic opioids doubled from 2015 to 2016. ▪ Accidental overdose is leading cause of death for people under 50 years old (CDC)

▪ Synthetic opioids were involved in nearly 50% (19,413) of opioid-related deaths in 2016 which is up from 14% (3,007) in 2010 (Jones, Einstein, & Compton, 2018)

▪ Fentanyl is 50 times more potent than heroin and 100x more potent than morphine & Carfentanil is 10,000x more potent than morphine

▪ Relapse rates (70-91%) after detox (59% in one week)

TRENDS OF DRUG USE IN

THE US: MARIJUANA

▪Map of Marijuana Legality by State

▪THC (Delta 9 Tetrahydrocannabinol) is the psychoactive ingredient in marijuana

▪Average potency rates 2.5-9.2% (1993-2003) to 12.0-29.3% (2004-2008) (Mehmedic, et. Al, 2015)

▪Cannabidiol (CBD) – non-psychoactive ingredient of marijuana

▪Potency is decreasing in illicit marijuana (ElSohly, et. Al 2016)

▪Marijuana Extracts – THC-rich resins that are known for having extremely high THC levels (40%-99%)

Trending Methods of Use:

▪Dabbing/Vaping – ingesting marijuana extracts via electronic cigarette or vaporizer

▪Higher tolerance and withdrawal (Loflin & Earleywine, 2014)

▪Edibles – brownies, cookies, candy, or tea infused with marijuana extracts

TRENDS OF DRUG USE IN

THE US: MARIJUANA

▪Probability estimate of transition to dependence 8.9% for cannabis users (Lopez-

Quintero, et al, 2011)

▪Adolescents (ages 12-18) who use marijuana are four to seven times more likely to develop a marijuana use disorder than people who first use between ages 22-26 (Winters & Lee, 2007)

▪44.7% of individuals with lifetime cannabis use progressed to other illicit drug use at some time in their lives (Secades-Villa, et. Al, 2015)

▪Co-occurring mental health issues increased this risk

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TRENDS OF DRUG USE IN THE US: ALCOHOL

▪ NIAAA & SAMHSA define binge drinking as 4 drinks for women and 5 drinks for men—in about 2 hours. (blood alcohol concentration (BAC) levels to 0.08 g/dL)

▪ Low-risk drinking - no more than 3 drinks on any single day and no more than 7 drinks per week for

women and healthy older adults & no more than 4 drinks on any single day and no more than 14 drinks per week for men.

▪ The global adult per-capita consumption is increasing while lifetime abstainers are decreasing (Manthey, Shield, Rylett, Hasan, Probst, & Rehm, 2019)

▪ In 2017, 20% of adults were heavy episodic drinkers

▪ It is estimated that 22.7% of people will transition from first use to dependence(Lopez-Quintero, et al, 2011)

▪ Onset of alcohol use at 14, 16, 17, and 18, were more likely to develop an alcohol use

disorder than people who first use between ages 22-26 (Winters & Lee, 2007)

TRENDS OF DRUG USE IN THE US: ALCOHOL

17.5% of 12th graders were intoxicated in the past 30 days (26% 2013) (Johnston, Miech, O'Malley, Bachman, Schulenberg, & Patrick, 2019).

20% of college students meet criteria for an Alcohol Use Disorder (Blanco, et al., 2008).

20.6% of practicing lawyers were positive on the AUDIT; and 36.4% were positive AUDIT-C (Krill, Johnson, & Albert, 2016).

11.8% of highly educated workforce were positive on AUDIT (Matano, Koopman, Wanat, Whhitsell, Borggrefe, & Westrup, 2003)

15% of physicians and surgeons were positive on the AUDIT-C (Oreskovich, et al., 2012)

Service workers “surface acting” at work correlated to heavy drinking (Grandey, Frone, Melloy, & Sayre, 2019)

one-time encounter with customer; generally more impulsive; low self-control jobs

TRENDS OF DRUG USE IN THE US: NICOTINE

▪Probability estimate of transition to dependence was 67.5% for nicotine users(Lopez-Quintero, et al, 2011)

▪Cigarette smoking for all adults was 22.0% (USDHHS, 2014)

▪86.9% of adult users had first cigarette before age 18

▪61.9% of adult current cigarette smokers were daily smokers

▪In 2018, 37.3% of 12th graders reporting “any vaping” in the past 12 months (27.8 percent in 2017); 26.7% within the last 30days (11% in 2017); 21.7% of 10th graders and 10.4% of 8th graders reported “any vaping” in the last month (Johnston, et al., 2019).

▪3.6% of 12th graders smoke daily (peak of 22.4% in 1998)

▪Adolescent brain is more sensitive to the immediate and chronic impact of nicotine leading to quicker addiction.

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REVIEW OF MAJOR DRUGS’ EFFECTS ON MENTAL HEALTH

OPIOIDS

Acute Intoxication

▪ Euphoria

▪ Mental and physical sluggishness

▪ Salience attribution to opioids

▪ Inability to inhibit impulses related to use

▪Delusion thinking about death

▪ limited pleasure from natural release of dopamine (Neglect of personal responsibility/hygiene)

Withdrawal ▪ Anhedonia

▪ Sleep disturbances

▪ Anxiety/depressive symptoms

▪ Impairment in episodic memory, concentration, problem solving

▪ Intense cravings

Possible permanent cognitive impairments can occur in long-term use ▪ Attention, concertation, memory, learning, visuospatial and visuomotor activities

MARIJUANA

▪ Acute intoxication▪ Euphoriant, psychostimulant, hallucinogen effects▪ Emotional reactivity/disinhibition, time disorientation, impaired

memory, hallucinations, impaired selective and divided attention, slowed visual processing (Lezak, Howieson, Bigler, & Tranel, 2012)

▪ Dose dependent relationship

▪ Effects of short-term use (Volkow, Baler, Compton, & Weiss, 2014)

▪ Impaired short-term memory▪ Impaired motor coordination▪ Altered judgment▪ In high doses, paranoia and psychosis

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MARIJUANA

▪Effects of long-term or heavy use (Volkow, Baler, Compton, & Weiss, 2014)

▪ Altered brain development

▪ Poor educational outcome, with increased likelihood of dropping out of school

▪ Cognitive impairment (lower IQ)▪ Some studies have not found long-term effects on cognition (Lezak, Howieson, Bigler, & Tranel, 2012)

▪ Diminished life satisfaction and achievement

▪ Increased risk of chronic psychosis disorders, anxiety, depression

▪ Accelerate trajectory of mental illness

▪ Cannabis Withdrawal

Syndrome (Bonnet, & Preuss, 2017):

▪ Irritability

▪ Nervousness/anxiety

▪ Sleep difficulty

▪ Depressed mood

▪ Decreased appetite or weight loss

▪ one of the following: abdominal

pain, shakiness/tremors, sweating,

fever, chills, or headache

ALCOHOL

▪Central nervous system depressant (Lezak, Howieson, Bigler, & Tranel, 2012)

▪ Social drinkers - mild cognitive impairment, mostly in short-term memory, mental flexibility, and mild perseverative tendencies. (not supported in other studies)

▪ Chronic users- Impaired color vision; impaired visual search/scanning; visuospatial functions intact but slowed on visual organization and integration; reduced psychomotor speed ▪ subtle short-term memory & learning that are more apparent as task difficulty increases,

▪ well established abilities and skills such as arithmetic and language & remote memory should be unimpaired

▪ Executive functioning impairment – decreased flexibility, simplistic problem solving, motor inhibition, perseverations, impaired ability to organize perceptomotor responses, impaired theory of mind, processing speed, attentional control, working memory

▪ Binge drinkers – impaired inhibition, attentional deficits, depressive symptoms, decrease life satisfaction, decreased abstract thinking

ALCOHOL▪ Withdraw can be deadly (Delirium Tremens DTs) (Lezak, Howieson, Bigler, & Tranel, 2012)

▪ First two weeks of abstained, global neuropsychological deficits are likely (even in well learned information)

Most return to baseline occurs in first week; then levels off around 3-6 weeks; gains can be seen 1-5 years of abstinence

Recovery is much slower for older patients

Cigarette smoking can impede this recovery

▪ Social drinkers are typically within normal limits within two weeks of abstinence

▪ Alcohol induced brain atrophy – Excessive alcohol consumptions – atrophy of the cerebral cortex, reduced white matter, enlarged ventricles, atrophy of subcortical structures

▪ Wernicke-Korskoff syndrome – memory impairment, confusion, disordered eye and limb movements

Nutritional deficit (thiamine)– can be treated

Neuronal loss, microhemorrhages, and change of glial cells

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NICOTINE

▪Stimulant effects (Lezak, Howieson, Bigler, & Tranel, 2012)

▪Acute – enhances cognitive performance, learning, memory, and attention (Lezak, Howieson, Bigler, &

Tranel, 2012)

▪Chronic consumption decreases cognitive performance (Lezak, Howieson, Bigler, & Tranel, 2012)

▪Significant health consequences, including death

▪ lower psychomotor speed and cognitive flexibility (Goriounova, & Mansvelder, 2012).

▪Adolescents

▪Acute - disturbances in working memory and attention Goriounova, & Mansvelder, 2012).

▪Chronic -- increases the risk of developing psychiatric disorders and cognitive impairment in later life.*

▪Withdrawal – within 1-2 days after discontinued use; lasts 2-4 weeks▪Drowsiness, confusion, impaired concentration, low frustration tolerance, and irritability

▪ Intense cravings

PSYCHOSOCIAL RISK FACTORS AND NEUROBIOLOGY OF ADDICTION

POPULATIONS AT HIGH RISK

▪Adverse childhood experiences (ACEs)

▪ ½ - 2/3 of serious drug problems stem from ACEs (Dube, et. al, 2003)

▪ ACEs score of ≥ 5 were 7- to 10 times more likely to report illicit drug use problems, addiction to illicit drugs, and non-oral drug use. (Dube, et. al, 2003)

▪ Dose dependent relationship

▪ 4+ ACE = 11x more likely to use IV drugs (Dube, et. al, 2003)

▪ All individual ACEs except physical neglect increased the risk of ever using alcohol (Dube,

et. al, 2006)

▪ ACE score had dose dependent relationship with alcohol use during early and mid adolescence (Dube, et. al, 2006)

▪ The likelihood of heavy drinking, self-reported alcoholism, and marrying an alcoholic were increased 2-4 times with the presence of multiple ACEs (Dube, et. al, 2002)

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POPULATIONS AT HIGH RISK

▪Patients diagnosed with PTSD are estimated to be 2 to 4 times more likely to meet criteria for a SUD (Kessler, et al, 2005).

▪Nearly half (46.4%) of individuals with PTSD also met criteria for SUD (Pietrzak, Goldstein, Southwick, & Grant, 2011)

▪Trends of substance abuse in people diagnosed with PTSD (Mills, et al. 2012):

27% opiates

25% stimulants

20% marijuana

16% benzodiazepines

12% alcohol

Prevalence and degree substance use did not change after participation in PTSD treatment alone

• 50% Adults presenting for SUD Outpatient treatment also met criteria for PTSD (Ford & Smith, 2009)

Use of substances increased risk of

additional trauma

Use Substances to decrease

distress

PTSD & Complex

PTSD Symptoms

POPULATIONS AT HIGH RISK

▪ Increased risk of use/abuse transitioning to dependence among individuals from minorities or those with psychiatric or other substance use disorders (Lopez-

Quintero, et al, 2011)

▪Heritability has been demonstrated for large cohorts of twins (Ducci, & Goldman, 2012)

▪ lowest for hallucinogens (0.39) and highest for cocaine (0.72).

▪A number of genes have been associated with substance use disorders

▪ MAOA, SLC6A4, COMT, ALDH2, ADH1B, & OPRM1

▪Social status and social support is correlated with D2/3receptor binding (Martinez, et al, 2010)

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WHAT IS ADDICTION?

▪ A chronic and progressive brain disease.

▪ Three primary symptoms of addiction

1) Desensitization of the reward circuits of the brain

2) Increased conditioned responses related to the substance an individual is dependent upon

3) Declining function of brain regions that facilitate decision making and self-regulation.

OVERVIEW OF NEUROBIOLOGY OF ADDICTION

American Society of Addition Medicine’s short definition of addiction (asam.org):

“Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.”

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OVERVIEW OF NEUROBIOLOGY OF ADDICTION

Nora Volkow MD, Director of the National Institute on Drug Abuse (NIDA) at the National Institutes of Health (NIH) --https://www.youtube.com/watch?v=M2uNoeB7AsA

OVERVIEW OF NEUROBIOLOGY OF ADDICTION

ALL drugs of abuse cause adaptation in dopamine reward pathway that is

out of proportion to natural rewards

Addict brain adapts to experience

Changes in receptors and neurotransmitters

Dopamine receptors are reduced

The brain becomes numb to natural rewards

Brain changes persist with abstinence

Non addict brains have no persisting brain

changes when taking substances

NON ADDICT VS. ADDICT

Non Addict When Using

At First:

> Pleasurable feeling

> Inhibitions go down

Increased:

> Feels out of control

> Feels confused

> Feels disconnected

> Feels tired

> Feels foggy

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NON-ADDICT BRAIN RESPONSE TO DRUG

No persisting brain changes

Baseline = Normal

NON ADDICT VS. ADDICT

Non Addict When Using

At First:

> Pleasurable feeling

> Inhibitions go down

Increased:

> Feels out of control

> Feels confused

> Feels disconnected

> Feels tired

> Feels foggy

Addict When Using

At First:

> Immediately crave more

Increased:

> Feels in control

> Feels empowered

> Feels connected

> Feels normal

> Feels content

Baseline = Normal

Misery

Pleasure

Below

normal

ADDICTED BRAIN RESPONSE

•Brain chemistry is changing

•Brain is rewiring itself

•Craving/desire for drug occurs

The addicted person once

used for pleasure, now uses

out of desperation just to

feel normal.

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Baseline = Normal

BRAIN HEALING - RECOVERY

CHRONIC DISEASE MANAGEMENT

I. Assessment and

Diagnosis

II. Withdrawal Management

III. Treatment Planning

IV. Treatment Management

V. Care Transition &

Care Coordination

VI. Continuing

Care Management

The Standard of Care for Addiction Specialist Physicians (ASAM):

COMMON PSYCHOLOGIST INVOLVEMENT

PreventionI. Assessment and Diagnosis

II. Withdrawal Management

III. Treatment Planning

IV. Treatment Management

V. Care Transition &

Care Coordination

VI. Continuing Care

Management

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PREVENTION, ASSESSMENT, AND TREATMENT

PREVENTION AND TREATMENT

PrimaryAltering Risk Factors

SecondaryScreening/Assessment

Referral to appropriate level of care

Tertiary Medication Assisted Treatment

SBIRT (NIAAA, 2004 & 2005)

Screening — In any healthcare setting, assesses a patient for risky substance use behaviors using standardized screening tools. At least yearly for adults with unhealthy alcohol or drug use

Brief Intervention — Provide brief intervention for patients who are engaging in risky substance use behaviors by providing psychoeducation, brief motivational interviewing, providing feedback and advice --- impact to relevant health conditionsCan occur at every visit unless/until accepting of referral to more specialized care

Set goal

Referral to Treatment — Make a referral to therapy or appropriate treatment/additional services

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SCREENERS – AUDIT (WHO)

Alcohol Use Disorder Identification Test (AUDIT)▪https://www.drugabuse.gov/sites/default/files/files/AUDIT.pdf

▪0-7 - Alcohol Education

▪8-15 - Advice Regarding Safer Alcohol Consumption

▪16 - 19 - brief counseling and continued monitoring.

▪20 + - further diagnostic evaluation for alcohol dependence.

AUDIT – C – first 3 questions of AUDIT

AUDIT – C- Plus - includes questions about marijuana▪ https://www.nationalcouncildocs.net/wp-content/uploads/2018/02/AUDIT-C-Plus-2-Screening-

Questionnaire.pdf

SCREENERS – CAGE (EWING, 1984)

1. Have you ever felt you should Cut down on your drinking?

2. Have people Annoyed you by criticizing your drinking?

3. Have you ever felt bad or Guilty about your drinking?

4. Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (Eye-opener)?

SCREENERS – CAGE-AID (BROWN, 1995)

1. Have you ever felt you should Cut down on your drinking or drug use?

2. Have people Annoyed you by criticizing your drinking or drug use?

3. Have you ever felt bad or Guilty about your drinking or drug use?

4. Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover (Eye-opener)?

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SCREENERS – DAST(SKINNER,1982)

Drug Abuse Screen Test (DAST-10)

Adults – self or clinician administered

https://www.bu.edu/bniart/files/2012/04/DAST-10_Institute.pdf

Drug Abuse Screen Test (DAST-20: Adolescent version)*Adolescent -- self or clinician administered

https://www.nams.sg/helpseekers/drug-use/Documents/DAST-A.pdf

SCREENERS –CRAFT (KNIGHT, 1999)

1. Have you ever ridden in a CAR driven by someone (including yourself) who was “high” or had been using alcohol or drugs?

2. Do you ever use alcohol or drugs to RELAX, feel better about yourself, or fit in?

3. Do you ever use alcohol or drugs while you are by yourself, or ALONE?

4. Do you ever FORGET things you did while using alcohol or drugs?

5. Do your FAMILY or FRIENDS ever tell you that you should cut down on your drinking or drug use?

6. Have you ever gotten into TROUBLE while

you were using alcohol or drugs?

DSM-V CRITERIA (APA, 2015)

1. Substance is often taken in larger amounts and/or over a longer period than the

patient intended.

2. Persistent attempts or one or more unsuccessful efforts made to cut down or control

substance use.

3. A great deal of time is spent in activities necessary to obtain the substance, use the

substance, or recover from effects.

4. Craving or strong desire or urge to use the substance

5. Recurrent substance use resulting in a failure to fulfill major role obligations at work,

school, or home.

6. Continued substance use despite having persistent or recurrent social or interpersonal

problem caused or exacerbated by the effects of the substance.

7. Important social, occupational or recreational activities given up or reduced because

of substance use.

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DSM-V DIAGNOSTIC CRITERIA (APA, 2015)8. Recurrent substance use in situations in which it is physically hazardous.

9. Substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.

10. Tolerance, as defined by either of the following:a. Markedly increased amounts of the substance in order to achieve intoxication or desired

effect;b. Markedly diminished effect with continued use of the same amount;

11. Withdrawal, as manifested by either of the following:a. The characteristic withdrawal syndrome for the substance;

b. The same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms;

DSM-V DIAGNOSTIC SEVERITY (APA, 2015)

Mild = 2-3

symptoms present

Moderate = 4-5

symptoms present

Severe = 6+

symptoms present

ASAM MULTIDIMENSIONAL ASSESSMENT (ASAM, 2013)

Intoxication and withdrawal potentialDimension 1

Biomedical Conditions and ComplicationsDimension 2

Emotional/Behavioral/Cognitive Conditions & ComplicationsDimension 3

Readiness to ChangeDimension 4

Relapse, Continued Use, or Continued Problem PotentialDimension 5

Recovery and Living EnvironmentDimension 6

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DIMENSION 4:

STAGES OF CHANGE (DICLEMENTE

&PROCHASKA)

Precontemplation

• “I don’t have a problem. I just like weed.”

Contemplation

• “My wife thinks I have a drinking problem; she might be right.”

Determination: Commitment to Action

• “I OD’d yesterday. I need to go to rehab.”

Action: Implementing the Plan

• At meeting, “I’m Sam and I’m an alcoholic.”

Maintenance

• Maintains changes in person, place, and things

ASAM OUTPATIENT PLACEMENT (ASAM, 2013)

No/minimal risk for severe withdrawalDimension 1

None or very stableDimension 2

None or very stable; concurrent MH monitoring/txDimension 3

Ready for recovery but needs encouragementDimension 4

Able to abstain or control use Dimension 5

Environment is supportive/pt. has skills to copeDimension 6

ASAM IOP PLACEMENT (ASAM, 2013)

Minimal risk for severe withdrawal -- *minimal withdrawal or at risk for withdrawal *

Dimension 1

None or not a distraction (manageable)Dimension 2

Mild with potential to distract/needs monitoring --- *low risk for harm; mild interference/impairment*

Dimension 3

Variable engagement in tx; lack of insight of SUD or MH --- *requires close monitoring; no desire for assistance*Dimension 4

Intensity of use/MH = high risk for relapse ---- *significant risk; poor

prevention skills* Dimension 5

Not supportive/with structure/support, pt can cope -- *environment impeding recovery*

Dimension 6

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ASAM RESIDENTIAL PLACEMENT (ASAM, 2013)

Stable withdrawal --- *mild-moderate; not need med management*Dimension 1

Stable with concurrent medical monitoringDimension 2

Mild-moderate; co-occurring enhanced programing *moderate – stable risk of harm*

Dimension 3

Little awareness & needs residential interventions -- *needs intensive motivating strategies *

Dimension 4

Little awareness & needs residential interventions -- *unable to control use/behaviors & serious impairment*

Dimension 5

Environment is dangerous/pt. lacks skillsDimension 6

INTEGRATIVE TREATMENT

FOR CO-OCCURRING

DISORDERS

Mental health treatment

Medical treatment

Addiction focused evidenced based treatment

MENTAL HEALTH TREATMENT

➢Motivational Enhancement Techniques

➢Contingency management

➢Mindfulness/Meditation

➢Skills development

➢Family Therapy

➢Education & Encourage a recovery program

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CBT4CBT http://www.cbt4cbt.com/demo/

MANAGEMENT OF PSYCHOTROPIC MEDICATION

Find a ASAM provider: https://findtreatment.samhsa.gov/

Avoidance of psychotropic medications that have an addiction potential

Ex – Benzodiazepines, Stimulants, Vistaril, sleep medications

In some cases/settings – Wellbutrin and Seroquel

ADDICTION AS A FAMILY DISEASE

Family Education❖Regarding the nature of addiction

Family and/or Marriage Therapy❖Emotional wounds caused by the disease

❖Establishing healthy boundaries and responsibilities

❖Supporting vs. Enabling

Support group❖Al-Anon – 12 Step Philosophy

❖Alateen – 12 Step Philosophy

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EVIDENCED BASED

TREATMENT FOR ADDICTION

12-step-facilitation

Smart Recovery

Refuge Recovery

Medication Assisted Treatment

ALCOHOLICS/NARCOTICS ANONYMOUS

12-STEP-FACILITATION

A.A./N.A. meetings

✓mutual-help organizations

✓Peer-led

✓Anonymity

✓Book is an instruction manual

✓Strong research support

12-Step Facilitation

✓Acceptance

✓Higher Power

✓Powerlessness

✓Amends

✓Moral inventory

✓Fellowship

12 STEPS1. We admitted we were powerless over alcohol—that our lives had become unmanageable.

2. Came to believe that a Power greater than ourselves could restore us to sanity.

3. Made a decision to turn our will and our lives over to the care of God as we understood Him.

4. Made a searching and fearless moral inventory of ourselves.

5. Admitted to God, to ourselves, and to another human being the exact nature of our wrongs.

6. Were entirely ready to have God remove all these defects of character.

7. Humbly asked Him to remove our shortcomings.

8. Made a list of all persons we had harmed, and became willing to make amends to them all.

9. Made direct amends to such people wherever possible, except when to do so would injure them or others.

10. Continued to take personal inventory and when we were wrong promptly admitted it.

11. Sought through prayer and meditation to improve our conscious contact with God, as we understood Him, praying only for knowledge of His will for us and the power to carry that out.

12. Having had a spiritual awakening as the result of these Steps, we tried to carry this message to alcoholics, and to practice these principles in all our affairs.

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SMART RECOVERY

HTTPS://WWW.SMARTRECOVERY.ORG/

In persons and online “interactive, conversational and educational” meetings

✓Some facilitators complete a 30-hour training course others have little formal training.

✓Action-oriented & focused on the present and future.

Program Principles:

1) Enhance and Maintain Motivation to Abstain

2) Cope with Urges

3) Problem Solve (manage thoughts, feelings, and behaviors)

4) Achieve a Balanced Lifestyle.

REFUGE RECOVERY (REFUGERECOVERY.ORG)

Eight-fold path1. Understanding2. Intention3. Communication/Community4. Action5. Livelihood/Service6. Effort7. Mindfulness/Meditations8. Concentration/Meditations

In person and online meetings✓ Peer led

✓ Abstinence based

Core principles✓ Mindfulness

✓ Compassion

✓ Forgiveness

✓ Generosity

MEDICATION ASSISTED TREATMENT

Standard of Care in Medicine▪Reduces Opioids overdose deaths and relapses

Common MAT for Opioids:▪Naltrexone (Vivitrol)

▪Full Antagonist

▪Methadone

▪Full Agonist

▪Buprenorphine (Suboxone = Bupe & Naloxone)

▪Partial Agonist

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MEDICATION ASSISTED TREATMENT

MAT for Alcohol:

▪Detox – Librium

▪Naltrexone

▪Acamprosate

▪Many side effects

▪Antabuse

▪Unpleasant symptoms when taken with alcohol

MAT for Nicotine:

▪Nicotine replacement – Lozenges or patch

▪Bupropion & Chantix

RATING SYSTEMS COMING…..

Shatterproof National Treatment Quality Initiative

❖Rating system to describe quality of drug treatment facilities -https://www.shatterproof.org/rating

American Society of Addiction Medicine (ASAM) and CARF International (CARF)

❖Independent, Comprehensive Assessment of Addiction Treatment Facilities’ Ability to Deliver Care Consistent with The ASAM Criteria

KEY QUESTIONS TO ASK A SUBSTANCE USE DISORDER FACILITY

• Does the facility use evidence-based addiction treatment ?

• What is the philosophy on treating an individual who has co-occurring mental health issues?

• How does the facility help the patient/family transition back home/next level of care?

Philosophy:

• What mental health providers do you have on staff?

• Master’s Level Clinicians –Do they have training/certification in working with individuals who have addiction AND mental health issues?

Staffing:

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KEY QUESTIONS TO ASK A SUBSTANCE USE DISORDER FACILITY

▪How often are patients seen by the

psychologist, psychiatrist, MH-trained

therapist?

▪Philosophy on the use of medications vs.

psychotherapy to treat mental health

symptoms?

▪Do you have a system or treatment

structure in place to manage problem

behavior?

▪How are psychiatric crises managed?

▪How is progress in treatment tracked?

▪How and to what extent is the family

involved in treatment?

▪Treatment:

LEGAL AND ETHICAL CONSIDERATIONS

Competence -- Assessment and Therapy

Privacy and ConfidentialityCFR-42

Free webinar -- https://elearning.asam.org/42CFRPart2

https://www.ecfr.gov/cgi-bin/text-idx?SID=f4fcd6cea165e0b02cc7ff17a6091ca5&mc=true&tpl=/ecfrbrowse/Title42/42cfrv1_02.tpl#0

▪Childline reporting

Mandatory confronting/reporting impaired colleagues

“SAFETY SENSITIVE” PROFESSIONS

Illness vs. impairment

Public health

“fitness for duty”

Monitoring programs

Some professionals cannot be on MAT

Better outcomes with cohort treatment

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RESOURCES

American Society of Addiction Medicine: https://www.asam.org/

National Institute on Drug Addiction - https://www.drugabuse.gov/

https://www.samhsa.gov/ https://www.samhsa.gov/sbirt

https://attcnetwork.org/

https://www.apa.org/ed/graduate/specialize/alcohol

https://addictionpsychology.org/education-training/certification

https://www.addictionpsychology.org/education-training/podcasts

National Institute on Alcohol Abuse and Alcoholism -- https://www.niaaa.nih.gov/

Dr. John Kelly -- https://www.recoveryanswers.org

Narcan Training (ACT 139) - https://www.pavtn.net/act-139-training

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