Co-Occurring Disorders: Overview of Latest Research and Clinical Implications - including Prevention and Tobacco

1. Co-Occurring Disorders: Overview of Latest Research and Clinical Implications- including Prevention and Tobacco Douglas Ziedonis, M.D., MPH Professor & Director, Division of Addiction Psychiatry Robert Wood Johnson Medical School 732-235-4341 ziedondm@umdnj.edu

2. 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

3. SYSTEM ISSUESTreatment Models for Different Settings

4. 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

5. 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

6. MICA vs CAMI (II) • Continuum of Care • Outreach & Case Management • Residential Services: Rules & Medications • HIV / Medical Services Linkage • Family, Spouse, & SO involvement

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. SPECIFIC INTERVENTIONS • By Subtype • Medications • Psychosocial interventions • Motivational Enhancement Therapy • Dual Recovery Therapies – for sub-types

17. 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

18. 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

19. 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

20. Dual Recovery Therapy (DRT)

21. MET = 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

22. Assessing Motivation to Change • Formal: SOCRATES & URICA • Informal: • Importance, Readiness, & Confidence • DARN-C • Decisional Balance • Time-line / Quit Date • Counter-transference & Non-verbal cues

23. 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

24. 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

25. 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

26. 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

27. Tobacco & Schizophrenia: Personalized feedback • CO monitoring – their immediate health • Tobacco caused medical disorders • Costs • Recovery • Children’s health • “Personalized message”

28. 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)

29. 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

30. Integrating Spirituality into Treatment (Miller W.APA, 1999) • Mindfulness and Meditation • Prayer • Values, Spirituality, and Therapy • Spiritual Surrender • Acceptance and Forgiveness • Evoking Hope • Serenity

31. Complementary Approaches • Acupuncture • Hypnosis • Herbs • Meditation • Qi-Gong: Meditation, Deep Breathing, Yoga • The Arts: art and music • Drumming, NAF • ETC

32. 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

33. 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

34. 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

35. 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

36. Tobacco Dependence Treatment • Clinical Issues: Assessment, Treatment Planning, and Treatment • Psychosocial • Medications

37. Clinical questions • Timing 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 Treatments • Only 3% of the time is psychosocial treatment offered to those smokers who get help to quit

38. 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

39. Drug-Free is Nicotine-Free • A Manual for Chemical Dependency Treatment Programs • 732-235-8222 • www.tobaccoprogram.org

40. 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

41. 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??

42. 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