Richard Saitz MD, MPH, FACP, FASAM Clinical Addiction Research and Education Unit

1. Co-occurring Disorders:The “Z-axis”Complexities of Co-Occurring Conditions ConferenceJune 2004Washington, DC Richard Saitz MD, MPH, FACP, FASAM Clinical Addiction Research and Education Unit Section of General Internal Medicine Center to Prevent Alcohol Problems Among Young People Boston University and Boston Medical Center

2. Outline • What we mean by comorbidity • Conceptual framework • Risk for co-occurring disorders • Services not currently coordinated • MH/SA impact care for chronic medical conditions • Models of care for patients with co-occurring disorders • Research directions

3. Comorbidity

4. Case #1 • A 40 year old man is transferred from a group home to the general medical hospital with diabetic ketoacidosis; he stopped taking his antipsychotic. He refuses insulin because he believes it will harm him. After initial treatment he stabilizes but cannot return to his home because he won’t take insulin. He is too medically complex for the psychiatric hospital and is declined by addictions treatment programs. He remains in the medical hospital where consultation for MH conditions is available.

5. Case #2 • A 54 year old man with Type 2 diabetes has alcohol dependence. He has poor glycemic control and severe hypertriglyceridemia. His alcohol use limits medication choices; he is on maximal doses of oral agents. He takes his lipid lowering medication once instead of twice a day to avoid drinking and taking medication. He declines alcoholism treatment.

6. Outline • What we mean by comorbidity • Conceptual framework • Risk for co-occurring disorders • Services not currently coordinated • MH/SA impact care for chronic medical conditions • Models of care for patients with co-occurring disorders • Research directions

7. Service Coordination by Severity Integration Alcohol, Tobacco & Other Drug Severity Collaboration Consultation Mental Illness Severity Adapted from SAMHSA 2002 Report to Congress on the Prevention and Treatment of Co-occurring Substance Abuse and Mental Disorders

8. Service Coordination by Severity Integration Hospital, ED Alcohol, Tobacco & Other Drug Severity Collaboration Primary Health Consultation Mental Illness Severity The “Z-axis” Medical Severity Medical Specialty

9. Outline • What we mean by comorbidity • Conceptual framework • Risk for co-occurring disorders • Services not currently coordinated • MH/SA impact care for chronic medical conditions • Models of care for patients with co-occurring disorders • Research directions

10. Alcohol-related Emergency and Hospital Utilization, US • Emergency • 29 visits/1000 persons each year • 8% of all ED visits • Hospital • 7.4% of acute admissions to short-stay, non-Federal general hospitals • 1.8 million hospitalizations per year McDonald AJ et al. Arch Intern Med 2004; 164: 531 - 537. Smothers BA et al. Arch Intern Med 2003; 163: 713 - 719.

11. Alcohol-related Diagnoses, AAFs<1 Pulmonary and other respiratory tuberculosis 0.25 Malignant neoplasm of lip, oral cavity, and pharynx 0.50 Malignant neoplasm of esophagus 0.75 Malignant neoplasm of stomach 0.20 Malignant neoplasm of liver and intrahepatic bile ducts0.15 Malignant neoplasm of larynx 0.50 Diabetes mellitus 0.05 Essential hypertension 0.076 Cerebrovascular disease 0.065 Pneumonia and influenza 0.05 Diseases of esophagus, stomach, and duodenum 0.10 Cirrhosis of liver without mention of alcohol 0.50 Biliary cirrhosis 0.50 Acute pancreatitis 0.42 Chronic pancreatitis 0.60

12. Medical Disorders More Common in Patients with Substance Use Disorder, Psychotic Disorder, and Both • Diabetes • Hypertension • Heart Disease* • Asthma* • Gastrointestinal Disorders* • Skin Infections* • Malignant Neoplasms • Acute Respiratory Disorders* *highest risk in those with both Dickey B et al. Psych Services 2002;53(7):861-7.

13. Comorbidity in a Detoxification Sample • 470 adults with no primary medical care in a short-term residential detoxification unit, mean age 36 • 47% had chronic medical illness • 90% had CES-D score >16 • 70% reported moderate to severe pain at least intermittently during 2 years of follow-up • Intermittent pain associated with relapse (OR 2.0) • Persistent pain associated with relapse (OR 5.2) DeAlba I et al. Am J Addictions 2004;13:33-45. Larson MJ et al. CPDD Abstract 2004. Saitz R et al. HSR 2004;39(3):587-606.

14. Mertens JR et al. Arch Intern Med 2003; 163: 2511 - 2517.

15. Outline • What we mean by comorbidity • Conceptual framework • Risk for co-occurring disorders • Services not currently coordinated • MH/SA impact care for chronic medical conditions • Models of care for patients with co-occurring disorders • Research directions

16. Patients in Addiction Treatment not Receiving Medical Care, and Vice Versa • Of 5,824 adults entering addiction treatment in Massachusetts, 41% had no physician • Prior substance abuse treatment or mental health treatment were not associated with having a physician • Of those with a primary care physician, 45% reported the physician unaware of their addiction Saitz R et al. Substance Abuse 1997;18:187-195. Saitz R et al. Am J Drug Alcohol Abuse 1997;23:343-354.

17. Patients with Severe Mental IllnessWhere are they? Medical Care Bosworth HB et al. Psych Services 2004 June;55:708-10.

18. Outline • What we mean by comorbidity • Conceptual framework • Risk for co-occurring disorders • Services not currently coordinated • MH/SA impact care for chronic medical conditions • Models of care for patients with co-occurring disorders • Research directions

19. Quality of Diabetes Care Desai MM et al. Am J Psychiatry 2002;159(9): 1584-90.

20. Alcohol Use and Incident Diabetic Retinopathy Howard AA et al. Ann Intern Med. 2004;140(3):211–219.

21. Catheterization and Revascularization after Myocardial Infarction Druss BG et al. JAMA 2000; 283: 506 - 511.

22. Influence of Mental Health and Addictions on Hepatitis C Therapy • 154 patients with HIV, alcohol abuse, hepatitis C • 81 (53%) had contraindications to interferon • 52 heavy drinking • 15 had CD4<100 • 14 IDU with needle sharing • 14 decompensated liver disease • 13 recent suicidal ideation • 54 (35%) had lesser contraindications to interferon • 47 had significant depressive symptoms • 8 Had CD4 100-200 • 7 were drinking alcohol (“moderate amounts”) • 7 IDU Nunes et al. Abstract at CPDD 2004

23. Substance use, Depressive symptoms, and HIV Outcomes • Prospective cohort study of 350 adults with HIV and alcohol problems • Depressive symptoms and substance use were associated with worse adherence • Substance use was associated with less HIV viral load suppression • Substance abuse treatment • reduced the odds of ED utilization (AOR 0.5) • increased the odds of HAART for HIV (AOR 1.70) • not associated with 30-day HAART adherence or HIV viral load suppression Palepu A et al. J Subst Abuse Treat 2003;25:37-42 and Palepu et al. Addiction 2004;99:361-8

24. Major Depression in Patients with Myocardial Infarction Frasure-Smith N et al. JAMA 1993;270(15):1819-1825

25. Treating Major Depression in Patients with Myocardial Infarction • Randomized, clinical trial • 2,481 men and women hospitalized with MI and depression (75%) or lower perceived social support (25%) • CBT and group therapy for 6 months • Results: • Improvements in depressive symptoms and perceived social support • No difference in 24% death or recurrent MI

26. Outline • What we mean by comorbidity • Conceptual framework • Risk for co-occurring disorders • Services not currently coordinated • MH/SA impact care for chronic medical conditions • Models of care for patients with co-occurring disorders • Research directions

27. The “teachable moment” • Definition: naturally occurring health events thought to motivate individuals to spontaneously adopt risk-reducing health behaviors • Smoking cessation • Pregnancy, hospitalization and disease diagnosis, high (10-78%) • Clinic visits (2-10%) consistently lower McBride CM et al. Health Educ Res 2003;18(2):156-70

28. Integrated Primary Care and Addiction Treatment • Overall sample: trend towards higher costs and no difference in abstinence • Subgroup with substance abuse-related medical or psychiatric conditions • --More likely to be abstinent in integrated care • group (69% vs. 55%, p=0.006) Weisner C et al. JAMA 2001;286:1715-23.

29. Integrated Medical and Alcoholism Care • Randomized trial of a thorough multidisciplinary evaluation, and care plan (N=101) • Monthly primary care visits to review drinking and medical problems • Mental health, social services and more intensive alcohol treatment on site • 2-year results: • 30-day abstinence increased from 47% to 74% • Mortality decreased from 30% to 19% Willenbring ML & Olson DH. Arch Intern Med 1999;159:1946-52 Willenbring ML et al. J Stud Alcohol. 1995;56:337-343

30. Potential Impact of Buprenorphine Treatment in Primary Care • Initial experience with 37 patients (30 max. at any one time). Median age 31. • 68% had no previous primary medical care • 59% had medical comorbidity • 43% had Hepatitis C (a quarter of these diagnosed at entry) • 54% had psychiatric comorbidity (80% with no psychiatric care) • 86% retained in care 4 months Alford DP et al. SGIM Abstract 2004.

31. What is Primary Care? • Integrated and accessible health services provided by primary care clinicians (generally MD, NP, PA) • Addresses the majority of health care needs • Sustained personal relationship between patient and clinician • Does not consider mental health separately from physical health • Intrinsic to PC are opportunities to promote health and prevent disease Institute of Medicine. Primary Care: America’s Health in a New Era. National Academy Press, Washington, DC. 1996.

32. Receipt of Primary Care Improves Addiction Severity Saitz et al. Submitted.

33. Care for People with Drug Abuse or Dependence Laine C et al. JAMA, May 2001; 285: 2355 - 2362.

34. Chronic Disease Management • 1,801 older adults with depression or dysthymia in 18 primary care clinics • Mean 3 chronic conditions • 20 minute educational video, booklet, visit with nurse or psychologist case manager in primary care, with medical and psychiatric consultation as needed • Results: Significant reduction in depressive symptoms, functional impairment, and arthritis pain and functional outcomes (for the 1001 with arthritis) Lin EHB et al. JAMA 2003; 290: 2428 - 2429 Unützer J et al. JAMA 2002; 288: 2836 - 2845

35. Outline • What we mean by comorbidity • Conceptual framework • Risk for co-occurring disorders • Services not currently coordinated • MH/SA impact care for chronic medical conditions • Models of care for patients with co-occurring disorders • Research directions

36. Research Agenda • Prevalence of co-occurring MH/SA disorders and medical disorders • Impact of one medical/MH/SA disorder on the incidence, severity, quality of care and health outcomes of others • Development and testing of new models of care that • bring needed care to the patient with “triple diagnosis” • can address comorbidity in the face of varied levels of severity of comorbidities • Identify and overcome barriers to implementation

37. Thank You for Your Attention

38. Extra Slides

39. Alcohol-related diagnosesAAFs=1 Alcoholic psychoses Alcohol dependence syndrome Nondependent abuse of alcohol Alcoholic polyneuropathy Alcoholic cardiomyopathy Alcoholic gastritis Alcoholic fatty liver Acute alcoholic hepatitis Alcoholic cirrhosis of liver Alcoholic liver damage, unspecified Excessive blood level of alcohol Accidental poisoning by ethyl alcohol, not elsewhere specified

40. Cardiac Catheterization after Myocardial Infarction Druss BG et al. JAMA 2000; 283: 506 - 511.

41. Revascularization after Myocardial Infarction

42. Preventive Care: Mammography • Older women with schizophrenia • 62% in past 2 years • Age-matched controls • 86% in past 2 years Dickerson FB et al. Psych Services 2002;53:882-4.

43. Alcohol Use and Diabetes • Incident diabetes • 18 prospective cohort studies: U-shaped relationship • Glycemic control • 6 experimental studies of up to 6 drinks given to 5-20 subjects with diabetes • 3 found decreases in serum glucose • 3 found no difference each • Diabetes medications • In 2 studies, immediate glycemic response to 3-drink challenge did not differ • 23 subjects taking troglitazone or placebo • 50 subjects before and after sulfonylurea Howard AA et al. Ann Intern Med. 2004;140(3):211–219.