Current Issues in Substance Abuse

1. Current Issues in Substance Abuse Joan E. Zweben, Ph.D. Executive Director, East Bay Community Recovery Project Clinical Professor of Psychiatry, UCSF Psychiatry Grand Rounds – Herrick Hospital January 7, 2013

2. The Substance Abuse Treatment System: Finding Good Care

3. Comprehensive Assessment • Current alcohol & other drug use • AOD history • Substance induced symptoms • History and current treatment of other mental disorders • SUDS treatment efforts • Recovery support system & activities • Are addiction meds appropriate?

4. Substance-Induced Symptoms AOD USE CAN PRODUCE SYMPTOMS CHARACTERISTIC OF OTHER DISORDERS: • Alcohol: impulse control problems (violence, suicide, unsafe sex, other high risk behavior); anxiety, depression, psychosis, dementia • Stimulants: impulse control problems, mania, panic disorder, depression, anxiety, psychosis • Opioids: mood disturbances, sexual dysfunction

5. Psychotic Symptoms Hallucinations, paranoia: • alcohol intoxication, withdrawal, overdose • stimulant intoxication, overdose • depressant intoxication, overdose • hallucinogen intoxication, overdose • phencyclidine intoxication, overdose

6. Distinguishing Substance Abuse from Other Mental Disorders • wait until withdrawal phenomena have subsided (usually by 4 weeks) • physical exam, toxicology screens • history from significant others • longitudinal observations over time • inquiry about quality of life during drug free periods

7. Look for Evidence-Based Principles & Practices • Evidence-based principles and practices guide system development • Example: care that is appropriately comprehensive and continuous over time will produce better outcomes • Evidence-based treatment interventions are important elements in the overall picture. They are not a substitute for overall adequate care.

8. Translating EBTs into the Real World • Distinguish between efficacy and effectiveness studies • Huge gaps in the research literature (e.g., group interventions, therapist variables) • Achieving fidelity is expensive, must be ongoing • Infrastructure for ongoing evaluation is often inadequate

9. ASAM Patient Placement Criteria PPC-2R DIMENSIONAL CRITERIA: 1. Acute intoxication and/or withdrawal 2. Biomedical conditions/complications 3. Emotional/behavioral/cognitive conditions and complications 4. Readiness to change 5. Continued problem potential 6. Living environment

10. ASAM Levels of Care • Level 0.5: early intervention • Level I: outpatient services • Level II: intensive OP/partial hospitalization • Level III: residential/inpatient services • Level IV: medically managed intensive IP Opioid maintenance therapy

11. Marketing • Impostors • Distinguishing evidence from marketing • Presenting multiple anecdotes with no comparison or control groups as “proof” • Medications • Options are good, but….. • Beware the new drug “darling”

12. Working Effectively with Returning Military Members

13. Updated Roster of OEF, OIF, and OND Veterans Who Have Left Active Duty • 1,318,510 OEF, OIF, and OND Veterans have left active duty and become eligible for VA health care since FY 2002 • 712,089 (~54%)* Former Active Duty troops • 606,421 (~46%) Reserve and National Guard *Percentages reported are approximate due to rounding. Cumulative from 1st Quarter FY 2002 through 2nd Quarter FY 2011

14. OEF/OIF Data • 24% of OEF/OIF veterans responded positively to “used alcohol more than they meant to.” • 21% OIF/ 18% OEF responded affirmatively that they “wanted or needed to cut down.” • Hoge 2004 • 12% of OEF/OIF soldiers endorsed alcohol misuse. • Milliken, Hoge 2007 (John Straznikas, MD)

15. 2005 Survey of Health Related Behaviors from DOD • Rates of Heavy Drinking – 5+ drinks/day: • 26-55 yr olds – 9.7% Soldiers/9.5% Civilians • 18-25 yr olds – Soldiers 25%/Civilians 17% (John Straznikas, MD)

16. OEF/OIF/OND SUD Data • Greater than a third of Army prosecutions are alcohol or drug related charges. • 90% of military sexual crimes involve alcohol • NY Times March 13, 2007 • 30% in rate of binge drinking from 2002 until 2005. • Pentagon report 1/07 (John Straznikas, MD)

17. PTSD and SUDs in OEF/OIF Veterans Rand Study – Dec 2008 • Binge Alcohol: 50% (2x community) • Tobacco Smoking: 50% (2x community) • Opiate Abuse: 09% (3x community) • Other Drugs: Marijuana, Sedatives, etc. Slide from: Kosten, Thomas, Treating PTSD and Addiction, 2009 Presentation

18. Military Culture Take-home Points • Make an effort to ask and learn about what the military was like for your patient. • Have them teach you • Know basic language • Identify what is your patient’s view of their military/veteran status • Examine your own biases • Assess for weapons

19. Basic Military History • Which Branch did they serve in? • They are NOT the same! • Peace-time or war-time service? • Active Duty, National Guard or Reserves • What was their job? • Involved with combat? • Fire-fights, “being shot at”, mortars. • Cooks and truck-drivers saw combat • Unwanted sexual advances?

20. Not all veterans view their military service the same Individual differences Cultural differences – VN vs. OEF/OIF

21. Viewing the Military as a culture • Cultural values • Honor • Respect • Leave no brother behind • Protect yourself - weapons • Chain of command • Follow orders

22. Challenging ways veterans present to community-based programs • Conformity – devalues the military and emphasizes the civilian life • Dissonance – ambivalent about the two ‘cultures’ • Immersion/Resistance – Idealization of the military and denigration of the civilian culture

23. Using this Model to facilitate treatment engagement • The ‘conforming’ veteran • Don’t challenge the devaluing • Don’t actively join the devaluing • The ‘dissonant’ veteran • Use Motivational Interviewing techniques to explore the ‘yes-but’ communications • The ‘immersion/resistance’ veteran • Don’t challenge the devaluing • Focus on the present problem and solution

24. Examine your own biases • Your view of war • Your view of the soldier • Your view of perpetrators of violence • Your view of perpetrators of atrocities

25. Weapon assessment • Assume they have a weapon • Assume their weapon is an important part of their identity • Ask specific questions about how they store the weapon and the bullets • If lethality is active, negotiate storing bullets with a friend or getting a trigger lock.

26. Special Issues with Traumatized Veterans SUD/PTSD

27. Take Home Points for SUD/PTSD • Complex and Confusing and Crisis-prone • Don’t blame them or yourself • Expect an erratic therapeutic alliance • May take multiple treatment contacts • Expect more crisis management, relapse and need for intensification of treatment structure

28. Therapeutic Alliance is the primary treatment goal Reduces distress /discouragement with poor outcomes.

29. More difficult to treat and worse outcomes with SUD/PTSD pts • Fewer clinical improvements, more crises • Uneasy alliance, negative counter-tranfx • Poorer compliance with Aftercare tx • Shorter time to relapse post treatment • Drink more on drinking days • Increased medical and interpersonal problems • Increased homelessness • Druley and Pashko 1988, Nace 1988, Brown and Wolfe 1994, Saladin et. al. 1995, Breslau et. al. 1997, Ouimette et. al. 1999, Najavits 1998

30. PREP: Prevention and Recovery for Early Psychosis Alameda County Collaboration

31. Adolescent Substance Use • Critical time for onset of SUDS • Experimentation is prevalent; most do not develop SUDS • Prevalence rates in higher risk samples is approx 24% or higher • Social factors, esp peer influence, are strongest determinants of initiation of use. • Psychological factors and effects of the substances more closely linked to abuse. (Millin & Walker, 2011)

32. Adolescent Substance Abuse • Adolescent brain more is susceptible to alcohol and other drugs • Marijuana is the most prevalent, then alcohol. Polydrug use is the norm • Tobacco: most smokers initiate during adolescence • Prescription drug abuse is rising • Prevention efforts target salient risk and protective factors

33. Marijuana • Impact on developing brain • Distortions of self-concept due to disturbances of attention and concentration • Conclude they are not intelligent, don’t like school; seek peer group with negative attitudes and behaviors • Increased risk of psychotic illness • Possible interference with medications (Zweben & Martin, 2009)

34. PREP Collaborative: Alameda County EBCRP – Lead Agency • Administration of PREP Program • Administration of PREP Services FSASF MHA-AC UCSF ACBHCS • Community-based treatment; • Innovative funding options. • Training structure and capacity to document client outcomes • Outreach • Marketing • Stigma Reduction • Community Education • Training in evidence-based practices • Diagnosis • Program evaluation and research. • Transition Age Youth System of Care • Issued initial RFP for TAY early psychosis funding

35. Treatment as Usual vs. PREP • Case management (if severe enough) • 15-minute medication management, every 2-3 months • ?psychotherapy? – maybe “supportive” • Little family involvement • No specific vocational/ educational treatment • Care management for everyone • Algorithm-based medication management, monthly visits+ • Cognitive Behavioral Therapy (CBT) • Multi-Family Group • Individualized vocational/ educational support (IPS)

36. Treatment as Usual vs. PREP • No treatment for cognitive symptoms • Referred out for substance use treatment • Frequent hospitalization • Assumption of eventual housing/disability care • Computerized cognitive remediation • Harm reduction approach embedded throughout • Hospitalization minimized • Focus on active recovery and return to full functioning

37. Before and After PREP

38. Hospitalizations Reduced by Half

39. Symptom Change

40. Real - World Functioning

41. Medication Use at PREP: Outcomes • 23 clients whose medications were primarily managed by PREP: • 4 were not prescribed antipsychotic medication • 19 were prescribed antipsychotic medication • 5 switched from 2 or 3 antipsychotic agents to 1 • The average antipsychotic dose prescribed by PREP was 35% less than the World Health Organization’s defined daily dose* *http://www.whocc.no/atc_ddd_index/

42. Conclusions: PREP Works! • Improves symptoms (depression), distress • Reduces hospitalization and arrest rates • While clients are taking the minimum medication dosages necessary • Real-World Impact: Improves social functioning and functioning in school/work participation Referrals: 888-535- PREP (7737), 

43. Facilitating the Use of Mutual Help Groups

44. Abstinence from Alcohol & Participation in AA • Greater # meetings in 9-12 months, higher abstinence rates • Weekly mtg attendance, higher abstinence rates at 2 years • Sustained attendance, high abstinence rates (1-10+ yrs) (Kaskutas, L.A. 2009)

45. 12 Steps: Parallels to Therapy • understanding the negative consequences of AOD use • understanding efforts to control use have not worked • willingness to accept help • taking inventory • sharing with others

46. 12 Steps, Cont. • becoming willing to change • identifying those harmed • making amends • ongoing awareness and effort to change behavior • integrating changes into all aspects of behavior

47. CBT and Other Concepts Embodied in 12-Step Programs • community reinforcement • social learning theory; use of social role models • social support and recognition • cognitive reframing • social comparisons, use of social norms • reference group theory • catharsis • cognitive control tools • culture that embodies the values of recovery (John Wallace, Ph.D. 9/99)

48. 12-Step ProgramsResistances to Participation • Stranger Anxiety • Discomfort at being the outsider • “I’m not an alcoholic/addict • Fear of being engulfed • “That religious stuff” • Social isolation

49. Facilitating the Use of 12-Step Programs • Elicit picture of what meetings are like • Explore charged issues • Give permission to be ambivalent • Stress “Take what you need and leave the rest” • Surrender and empowerment • Provide a place to talk about what is happening to them on a regular basis

50. Preparing Psychiatric Patients for 12-Step Meetings • medication is compatible with recovery, but meetings are best selected carefully • some meetings are more tolerant than others of medication or eccentric behavior • schizophrenics benefit from coaching on how to behave in meetings • 12-step structure often beneficial; non-intrusive and stable