Prevention and Co-Occurring Disorders

1. Prevention and Co-Occurring Disorders Douglas Ziedonis, MD, MPH Professor & Director, Addiction Psychiatry UMDNJ - Robert Wood Johnson Medical School April 7, 2005

2. Agenda • Define prevention • Systems-Oriented versus Client-Oriented Prevention Strategies and Programs • Identify windows of opportunity to prevent a secondary mental illness or addiction disorder • Adolescents • College students • Older adults • Promote Wellness and Reduce Morbidity amongst individuals with COD • Tobacco Dependence • Obesity • Treatment and Prevention Continuum • Example: Addressing Tobacco

3. Prevention is Critical • Handbook on Drug Abuse Prevention • Coombs and Ziedonis (1995) • Co-Occurring Disorders • Alcohol, Tobacco, and Other Drugs

4. Defining Prevention • Keeping something bad from happening • Helping individuals, families, and communities to be healthy, safe, and productive • Promote constructive healthy lifestyles in all stages of life • Prevention is pro-recovery, pro-holistic health care, and pro-wellness • Prevention goals focus on: • reducing morbidity and mortality • prevent the initial onset of a disorder • prevent co-morbidity, relapse, disability, and the consequences of the illnesses on individuals, families, and the community (NIMH, 1998)

5. Prevention Classifications • Traditional public health distinguished primary, secondary, and tertiary prevention • Agent, Environment, Vector, Host • IOM labeled MH prevention in terms of three core activities: prevention, treatment, and maintenance • Current most common SA and MH Prevention classification: Universal, Selective, and Indicated Interventions.

6. Effective Prevention Strategies • Prevention programs must be comprehensive, family-focused, and include appropriate cultural, developmental and gender perspectives. • They need to focus on risk and protective factors that are both identifiable and modifiable. • Many mental health and addiction problems, share common risk factors for initial onset and so targeting those factors should result in reduced illness and healthier lives

8. Universal, Selective, and Indicated Interventions • Universal - target the general public or a whole population that has no known risk factors. • Selective- are targeted to groups at greater than average risk of illness than the rest of the population. • Indicated - are provided to high-risk individuals, their families, and to people experiencing early symptoms of a disorder.

9. Primary prevention goals related to co-occurring disorders • (1) Promote healthy lifestyles to improve lives and also reduce the likelihood of a mental illness or substance abuse disorder from occurring. • (2) Promote healthy lifestyles amongst individuals who have co-occurring disorders so as to reduce morbidity and mortality of common medical diseases and traumas, including reducing the severity and preventing relapse of one or both disorders.

10. Window of Opportunity • In many cases either the mental illness or the addiction develops first • There is a window of opportunity until the next disorder develops • Adolescence, College Students, Adults, and Older Adults • Epidemiology Data – few targeted studies

11. COD Prevention Programs Should . . . . Reduce Risk Factors • ineffective parenting • chaotic home environment • lack of mutual attachments/nurturing • inappropriate behavior in the classroom • failure in school performance • poor social coping skills • affiliations with deviant peers • perceptions of approval of drug-using behaviors in the school, peer, and community environments

12. COD Prevention Programs Should . . . . Enhance Protective Factors • strong family bonds • parental monitoring • parental involvement • success in school performance • prosocial institutions (e.g. such as family, school, and religious organizations) • conventional norms about drug use

13. SA Prevention Programs Should . . Include Interactive Skills-Based Training • Resist drugs • Strengthen personal commitments against drug use • Increase social competency • Reinforce attitudes against drug use

14. Prevention Programs Should be . . . Family-Focused • Provides greater impact than parent-only or child-only programs • Include at each stage of development • Involve effective parenting skills

15. Prevention Programs Should . . . . Involve Communities and Schools • Media campaigns and policy changes • Strengthen norms against drug use • Address specific nature of local drug problem

16. Key targets for reducing morbidity and mortality • reducing obesity • increasing physical activity • reduce risky behaviors leading to HIV/AIDS • eliminating tobacco use • preventing birth defects • prevent injury • Prevent suicide

17. Clinical Prevention Targets • Cancer • Heart and Vascular Diseases • Lipid Disorders • Infectious Diseases • Injury and Violence • Mental Health Conditions and Substance Abuse • Obesity in Adults and Children

18. Barriers to Clinical Prevention • CLINICIANS • Lack of training in prevention • Limited appreciation of how their work can be reframed as prevention • Competing demands and not enough time to provide basic services • PATIENTS • unaware of the benefits or availability of services • unmotivated to pursue • Deterred by inconvenience and expense of preventive care • PROGRAM • Inadequate reimbursement for these services • Lack system for integrating services into regular care • Patients often change programs

19. Put Prevention Into Practice Program • U.S. Preventive Services Task Force (USPSTF) • Found much support for clinical prevention efforts in primary care • The Agency for Healthcare Research and Quality's PPIP program for primary care • A Step-by-Step Guide to Delivering Clinical Preventive Services: A Systems Approach

20. Steps to deliver clinical preventive services • Establish preventive care protocols. • Define staff roles for delivering and monitoring preventive care. • Determine patient and material flow. • Audit your delivery of preventive care continually • Readjust and refine your delivery system and standards

21. Tobacco dependence treatment is cancer and cardiac disease prevention. • 44% of all the cigarettes in the US are consumed by individuals with mental disorders • Clinical interventions: • Assessment • Treatment planning • Integrating treatment (medications and therapy) into existing treatment interventions • Referring to services such as State Quit Lines, Quit Internet sites, or Quit Treatment Centers.

22. HIV/AIDS, Hepatitis and Other Infectious Diseases • Drug treatment is disease prevention • Drug treatment reduces likelihood of HIV infection by 6 fold in injecting drug users • Drug treatment presents opportunities for screening, counseling, and referral

23. HIV prevention • Not just about changing individual behavior • Other Factors: relationships with family and friends, community norms, access to health care and local laws • Addressing factors through multiple approaches: individual, couple/family, community, medical and legal. • HIV prevention programs for injecting drug users (IDUs): • intensive street outreach to educate IDUs • drug treatment • syringe exchange • community-building and empowerment efforts • Adherence programs for HIV+ IDUs.

24. Addressing Tobacco with both Prevention and Treatment • Prevention and Treatment are both necessary to reduce tobacco dependence • Targeting smokers with addiction or mental illness is very important for both groups

25. Now is the time to address tobacco • Remember when we had: • Drug versus Alcohol Treatment Programs • Mental Health versus Addiction Treatment Programs • SAMHSA’s definition of co-occurring disorders includes tobacco dependence • Model MH & Addiction Treatment programs are better addressing tobacco with integrated treatment • Recent Robert Wood Johnson Foundation Initiative • Example: UMDNJ State-Wide Program • DHSS, DMH, and DAS initiatives • July 2003 issue of Psychiatric Annals • www.tobaccoprogram.org

26. Tobacco is part of “Multiple Drug Addictions” AND “Dual Diagnosis” • Need Comprehensive Treatment and prevention Services integrated at all levels of care • Motivation Based Treatment Approach • Recovery-oriented long-term Treatment Perspective • Shared Decision Making

27. Tobacco Control / Prevention experts • Done a tremendous job at reducing tobacco use in the general population • But not amongst individuals with either mental illness or substance use disorders • Need these experts to become more aware of this high risk target population and to develop new strategies that target this group in particular.

28. Diseases Caused by Tobacco Use Cigarette smoking increases the risk of:  Coronary heart disease  Atherosclerotic peripheral vascular disease  Cerebrovascular disease  Cancers of the lung, larynx, mouth, esophagus, bladder, pancreas, kidney, and cervix  Chronic obstructive pulmonary disease  Intrauterine growth retardation, premature rupture of membranes  Low-birthweight babies, perinatal mortality  Cataract, macular degeneration; hip fracture  Peptic ulcer disease  Possibly liver, stomach, and colorectal cancers and acute myelocytic leukemia

29. Disease Caused by Tobacco Use Involuntary smoking (environmental tobacco smoke) is a cause of:  Lung cancer and coronary heart disease in nonsmokers  Respiratory infections and symptoms in the children of parents who smoke Smokeless tobacco causes: Oral Cancer  Oral leukoplakia  Dental caries (possibly) Cigars cause: Cancers of the mouth, larynx, and lung  Coronary heart disease  COPD

30. Preparatory stage Never smokes Trying stage No longer smokes Experimental stage No longer smokes Regular use Quits smoking Addiction/Dependent smoker Stages of Initiation (Flay)

31. Tobacco Control Model of Nicotine Addiction Tobacco Products Agent Environment Familial, Social, Cultural, Political, Economic, Historical, Media Host Vector Smoker/Chewer Tobacco Product Manufacturers; Other Users Incidental Host Involuntary Smoker Source: Orleans & Slade, 1993

32. Paradigm for Tobacco Control • Educational Activities • Treatment activities • Regulatory Efforts • - Advertising and Promotion • - Product Regulation / Price • - Clean indoor air • - Minor’s Access to Tobacco • - Litigation • - Advertising

33. Treating Tobacco in Addiction and Mental Health Settings • Treatment can Work: • 5 NRT options, Bupropion, Nortriptyline • Brief counseling, MET, and Behavioral therapy • Fewer Studies of Nicotine Dependence and either Mental Illness or other Addictions • Abstinence versus Harm Reduction • Motivation Based Treatment Approach – total abstinence may not be immediately achievable

34. Barriers to Tobacco Dependence Treatment • Lack of staff training • “not my role” – go to primary care • Staff fear that patient’s will misuse NRT or smoke while taking NRT • Staff who smoke – normalize smoking, staff may help patient’s access cigarettes, program may sell cigarettes • Restrictive formulary or insurance coverage of the cost of medications • Limited income and cannot afford OTC medications

35. Rationale for Treating Alcohol and Tobacco Dependence Simultaneously • Closely related behaviors • Eliminates a cue to drink • Serious cause of morbidity/mortality • Protected milieu • Common message • Apply same treatment philosophy • Postponing means potentially never

36. Program Level Changes to Address Tobacco (1st) • Acknowledge the challenge • Establish a leadership group and commitment to change • Create a Change Plan and Implementation timeline • Start with the Easier System Changes • Conduct staff training • Provide Treatment and Recovery Assistance for interested nicotine dependent staff • Document Assessment and Treatment Planning

37. Program Level Changes to Address Tobacco (2nd) • Incorporate tobacco issues into patient education curriculum • Provide Medications for Nicotine Dependence Treatment and Required Abstinence Periods • Integrate Motivation-Based Treatments throughout system • Develop onsite Nicotine Anonymous meetings and establish ongoing communication with 12-Step Recovery groups, professional colleagues, and referral sources about system change • Develop Addressing Tobacco Policies and clear consequences

38. Clinical Program changes • Develop no-smoking policies • Require assessment of tobacco use and dependence • Require treatment planning to include tobacco dependence • Creating a motivation-based treatment model to address all smokers • Not allow staff to smoke with patients • Provide appropriate medications for use in treatment of withdrawal

39. APA Nicotine Dependence Treatment Guidelines • Establish a therapeutic alliance • Treatment setting • TX best occurs in a setting that encourages cessation • Initial interventions • Education about nicotine dependence and its treatment • Timing of cessation attempt • Abrupt vs. Gradual cessation • Advise about alcohol & caffeine use • Follow-up visits • Dealing with slips and relapses