Treatment for Substance Use Disorders and Co-Occurring MH Disorders: New Initiatives in the VA

1. Treatment for Substance Use Disorders and Co-Occurring MH Disorders:New Initiatives in the VA James R. McKay, Ph.D. Professor of Psychology in Psychiatry University of Pennsylvania Center of Excellence in Substance Abuse Treatment and Education Philadelphia VA CESATE

2. Outline of the Presentation • Treatment for substance use disorders (SUD) in the VA • Practice guidelines • Evidence-based behavioral and pharmacological treatments • Treatment for co-occurring SUD and PTSD • Numbers • Practice guidelines • Most recent research • Treatment for co-occurring SUD and depression • New initiatives to reorganize MH treatment in VA • Examples of major rollouts of EBT for SUD in VA

3. Treatment

4. Uniform Services Handbookand Practice Guidelines

5. Purpose of the Handbook • Describe levels of care within VA system • Specify SUD treatments that VA programs must be able to offer veterans • Define the required features of programs at different levels in the continuum, including staffing, duration of care, and case loads • Define standards for access

6. Practice Guidelines • Provide step-by-step directions, presented in clinical algorithms, for every type of SUD treatment • Detoxifiation • Assessment and treatment planning • Residential treatment • Outpatient treatment • pharmacotherapy

7. MH screening in the VA • All patients are screened once per year for alcohol problems, PTSD, and depression • Vets who come up positive are supposed to be referred to either a brief intervention or to SUD/MH specialty care • In practice, less than 50% of vets with a positive alcohol screen are referred • Referral rates are higher for those with positive PTSD or depression screen

8. Evidence-Based Treatments for SUD:Large-Scale Training Initiatives in the VA

9. Cognitive-Behavioral Therapy(CBT) • CBT focuses on changing cognitions and behaviors thought to increase vulnerability to relapse • Cognitions: • All or nothing thinking • Catastrophic thinking • Attributional biases • Behaviors: • Spending time with other substance users • Going to “high risk” locations • Interpersonal conflict • Unstructured time

10. Contingency Management • Provides rewards for drug negative urine samples or attendance at sessions • Requires patient to provide urine samples 2-3x/week, and rapid analysis of samples • Amount of reward can escalate with serial success and reset to lower amounts if substance use occurs • Probably our most effective treatment for stimulant dependence

11. Motivational Enhancement Therapy • Many individuals with SUD are not ready for abstinence oriented treatment • MET is designed to help people with SUD who are relatively unmotivated • Techniques • Compare patient’s substance use to normative data • Roll with resistance (non-confrontational) • Open ended questions combined with reflective listening • Express Empathy • Develop Discrepancies between behavior and goals • Usually done in 3-4 sessions

12. Medications for the Treatment of SUD

13. Medications Approved in the US to Treat Alcohol Dependence • Disulfiram (Antabuse): 1949 • Naltrexone (ReVia): 1994 • Acamprosate (Campral): 2004 • Long-acting Naltrexone (Vivitrol): 2006

14. Opiate Addiction • Two agonist medications are effective for opiate dependence: • Methadone (dispensed daily in programs) • Buprenorphine (can be dispensed by private physician in office) • The antagonist medication naltrexone is highly effective, but very underused • All must be used as long-term, maintenance medications in order to be effective

15. Are these meds used in the VA? • Medications to reduce alcohol use: • Less than 10% of patients who might benefit from these meds receive them • Reasons for low rate are being explored in a number of research studies • Medications to treat opiate use disorders • VA provides both methadone and buprenorphine

16. Treatment of Co-Occurring PTSD and SUD

17. Epidemiology

18. Fiscal Year (FY) 2008 Prevalence of Co-Occurring Conditions in Veterans Seeking Treatment in Veterans Health Administration (VHA) PTSD N=351,708 Major Depressive Disorder SUD N=387,807 MDD & SUD 23% PTSD & SUD 23% N=80,588 Schizophrenia Bipolar Sch & SUD 26% BP & SUD 33%

19. Fiscal Year (FY) 2013 Prevalence of Co-Occurring Conditions in Veterans Seeking Treatment in Veterans Health Administration (VHA) PTSD N=535,506 (up 52%) Major Depressive Disorder (MDD) SUD N=516,095 (up 33%) PTSD & SUD 26.5% N=142,163 (up 76%) Schizophrenia Bipolar(BP)

20. Mental Disorders1 among Veterans2 Returning from DeploymentCumulative from 1st Quarter FY 2002 through 1st Quarter FY 2014 1 Includes provisional and confirmed diagnoses. http://www.publichealth.va.gov/epidemiology/reports/oefoifond/health-care-utilization/ 2 These are cumulative administrative data since FY 2002. 3 A total of 572,569 unique patients received one or more diagnoses of a possible mental disorder.

21. VHA Trends in Diagnoses by Drug for Veterans with PTSD and SUD

22. PTSD-SUD Treatment in the VA

23. Summary of VA/DoD PTSD Guideline Recommendations for Co-occurring SUD 1. All patients diagnosed with PTSD should receive comprehensive assessment for SUD, including nicotine dependence 2. Recommend and offer cessation treatment to patients with nicotine dependence 3. Patients with SUD and PTSD should be educated about the relationships between PTSD and substance abuse. The patient’s prior treatment experience and preference should be considered since no single intervention approach for the co-morbidity has yet emerged as the treatment of choice.

24. Summary of VA/DoD PTSD Guideline Recommendations for Co-occurring SUD 4. Treat other concurrent substance use disorders consistent with VA/DoD clinical practice guidelines for SUD including concurrent pharmacotherapy: a. Addiction-focused pharmacotherapy should be discussed, considered, available and offered, if indicated, for all patients with alcohol dependence and/or opioid dependence b. Once initiated, addiction-focused pharmacotherapy should be monitored for adherence and treatment response. Ravelski, Olivera-Figueroa & Petrakis (2014). PTSD and comorbid AUD: a review of pharmacological and alternative treatment options. Substance Abuse and Rehabilitation, 5, 25-36 http://dx.doi.org/10.2147/SAR.S37399

25. Summary of VA/DoD PTSD Guideline Recommendations for Co-occurring SUD 5. Provide multiple services in the most accessible setting to promote engagement and coordination of care for both conditions. 6. Reassess response to treatment for SUD periodically and systematically, using standardized and valid self report instrument(s) and laboratory tests. Indicators of SUD treatment response include ongoing substance use, craving, side effects of medication, emerging symptoms, etc. 7. There is insufficient evidence to recommend for or against any specific psychosocial approach to addressing PTSD that is co-morbid with SUD.

26. Recent Research Findings

27. Cochrane Report on PTSD/SUD Treatment- Roberts, Roberts, Jones, Bisson Roberts NP, Roberts PA, Jones N, Bisson JI. Psychological interventions for post-traumatic stress disorder and comorbid substance use disorder. Cochrane Database of Systematic Reviews 2014, Issue 2. Art. No.: CD010204. DOI: 10.1002/14651858.CD010204.pub2. Submitted for publication • Searched up to Jan 10, 2014 • RCT’s of individual or group psychotherapy with PTSD/SUD participants, compared with waiting list, usual care, or other psychotherapy • 14 studies included • Meta-analysis with over 1400 participants total

28. Cochrane Review Results • Main comparison was CBT with trauma processing v. CBT without trauma focus (coping skills) • Overall quality of evidence was low to very low • i.e., future research very likely to change estimate of effect

29. Results: Individual Trauma Focused Interventionsw/Concurrent or Integrated SUD Treatment • PTSD symptoms • More effective than TAU or minimal intervention in reduction in symptoms at post-treatment and follow-up • Substance use • No effects at post-treatment, but more effective than comparison conditions at 5-7 month follow-up • Higher drop out rate than TAU

30. Results: Non-Trauma Focused Interventions • Most studies looked at group-based interventions • No positive effect on PTSD symptoms or SUD compared to TAU • Full course Seeking Safety more effective at end of treatment than TAU, but not at follow-up • Drop out rate comparable to TAU

31. Other Findings • High drop out rate across all studies • Review based on small number of studies, some small or poorly designed • Need for further study given low to very low quality of research • Need to interpret results with caution

33. Results • Naltrexone produced better alcohol use outcomes than placebo (mean difference = -7.93 % days drinking) • No significant effect for either naltrexone or prolonged exposure on PTSD outcomes • Authors note that PE did not worsen drinking outcomes • Low PTSD severity <10 on PSS (exploratory analysis) • 70% PE + nalrexone • 55% PE + placebo • 44% supportive + naltrexone • 37% supportive + placebo

34. Considerations • Excluded substance dependence except for nicotine and cannabis • Excluded for opiate use in past month prior to study entry • Required abstinence prior to study participation

36. Design and Results • Design • COPE (PE + CBT/RP) compared to TAU • 103 participants with PTSD and SUD dx • Followed for 9 months • Results • COPE produced greater reductions in PTSD symptom severity than TAU (mean difference -16.1) • No differences in substance use outcomes

37. Considerations • Most participants polysubstance users • Median = 4 substances in past month • The most common main drugs of concern were heroin (21%), cannabis (19%), amphetamines (17%), benzodiazepines (15%), alcohol (11%), cocaine (6%) • Only 54% of COPE-assigned participants attended sessions with exposure • Most who did only attended one or two sessions • Treatment took close to a year for some participants

39. Kaysen et al., 2014 • Method • Chart review of 536 Veterans receiving at least one session of Cognitive Processing Therapy (CPT) • 90% male • Looked at outcomes in three groups: • Current AUD (11% of sample) • Lifetime but not current AUD (39% of sample) • No AUD (50% of sample)

40. Results • Comparable drop out rates in all 3 groups (m = 9 CPT sessions attended) • Comparable symptom improvement in all 3 groups • Decrease in PTSD symptoms by all groups • Decrease in MDD symptoms by all groups

41. Considerations • Chart review • No randomization • No alcohol use outcomes • No follow up • But… • First study showing CPT works as well in those with AUD as in those without AUD

42. Where Are We Now? • Nothing to contradict PTSD Clinical Practice Guideline recommendations • Treatment for alcohol use disorder or other SUD together with PTSD treatment • Trauma focused (evidence based) PTSD treatments are tolerable and perform as well or better than other treatments

43. What do Vets Want? • Pilot study by Back et al. (2014) looked at the treatment preferences of 35 veterans with SUD and PTSD • Perceptions of SUD and PTSD • 94% perceived a relationship between SUD and PTSD symptoms • 85% perceived that increased PTSD symptoms led to increased SUD • 62% believed that improvement led to decrease in substance use • Preferred sequence of treatments: • Integrated SUD/PTSD treatment: 66% • Treat SUD first: 20% • Treat PTSD first: 9%

44. Treatment of Co-Occurring SUD and Depression

45. New CBT-Based Interventions • Building Recovery by Improving Goals, Habits, and Thoughts (BRIGHT) • Group based CBT for SUD patients with depression • Delivered by SUD counselors, with little or no formal training in mental health care • Well-suited to the VA, given reliance on group counseling

46. Initial Research • Watkins et al. (2012) • Quasi-experimental study compared residential TX to same plus BRIGHT groups • Participants had SUD + major depression • Results: • 3 months: Positive effect for BRIGHT over TAU on BDI (p< .01) and SF-12 (p< .05) • 6 months: Positive effect for BRIGHT over TAU on BDI (p= .08) and SF-12 (p< .05) • Also, fewer days of substance use problems in BRIGHT, but no effect on alcohol use

47. Training Counselors to Provide BRIGHT • VA Study (G. Curran, PI) • Developed a web-based, interactive training program plus weekly telephone supervision • If successful, could replace more costly and time consuming in-person training protocols • Pilot study produced very encouraging results • Three training products are now available on TMS, and are being used by providers

48. Reorganization of VA SUD Services

49. Where services are provided • Specialty SUD programs • Drug free • Opiate maintenance • Behavioral Health Integrated Programs (BHIP)– panel model • Primary care-based integrated teams

50. Where all this is going • Greater management of SUD patients in BHIP or primary care programs • Referral to SUD specialty care for more severe patients and those who keep relapsing • Idea is to stabilize patient in SUD specialty care, and refer back to BHIP or primary care team.