Dual Addictions Kathleen M Carroll PhD Yale University School of Medicine

1. Dual AddictionsKathleen M Carroll PhDYale University School of Medicine

3. Overview • Definitions and terms • Epidemiology: Rates and risks • Onset: Gateways and destinations • Treatments: Everything we don’t know

5. Terms Comorbidity: Co-occurrence of two conditions or disorders Dual diagnosis: Co-occurrence of alcohol/drug use disorder and another psychiatric disorder (heterotypic comorbidity) Homotypic comorbidity: Co-occurrence of disorders within a diagnostic grouping (e.g., substance use disorders)

6. Major US epidemiologic surveys

7. National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) • Previous surveys in US, Canada, Australia confirm probabilities of alcohol use disorder rise with drug use disorder visa versa • Only NESARC diagnosis specific (multiple types of drugs rather than ‘lumping’) • Includes data on help seeking • Focus on 12-month (current), rather than lifetime disorders • Oversampling of African Americans and Hispanics

8. DSM-IV Substance Dependence Maladaptive use leading to clinically significant impairment or distress, shown by 3+ of the following in the same 12-month period: • Use of the substance more or longer than intended • Persistent desire or unsuccessful efforts to cut down or stop • A great deal of time spent on use of the substance or getting over its effects • Important activities given up or reduced because of use • Continued use despite knowledge of a serious physical or psychological problem • Tolerance • Withdrawal, or use to avoid withdrawal

10. DSM-IV Substance Abuse Not dependent, and maladaptive use leading to clinically significant impairment or distress, shown by 1 + of the following: • Continued use despite social/interpersonal problems • Hazardous use (e.g., driving when impaired by alcohol) • Frequent use leading to failure to function in major roles • Legal problems

12. NESARC: 12-month prevalence rates Stinson et al, (2005) DAD

13. 12-month prevalence: Drug use disorders Stinson et al, (2005) DAD

14. Demographics: Users of alcohol + drugs more likely to be: • Male (74%) • Younger (18-29) (65%) • Never married (63%) • Similar to drug-only with respect to education, ethnicity, income

16. Rates of alcohol use disorders among those with specific drug use disorders: NESARC

17. Alcohol use among those with specific drug use disorders and visa-versa

18. Comorbidity: NESARC Stinson et al, (2005) DAD

19. 12-month prevalence treatment seeking by disorder: NESARC Stinson et al, (2005) DAD

20. 12-month prevalence treatment seeking by disorder: NESARC

21. Factors associated with multiple substance use • Retention of use through gateway progression • Pharmacologic effects of combinations, including modulation, treatment of withdrawal and uncomfortable effects • Genetic evidence of common mechanisms, vulnerability in some families • Availability, market trends

22. Gateway pattern of drug initiation: Kandel et al Cigarettes Alcohol Cannabis NCS-R: Only 5.2% Violate this pattern Other illicit

23. Risk of developing disorder, given use Anthony et al. 1994, Comparative epidemiology, NCS

24. NESARC: Hazard rates for alcohol and drug use disorders Hasin et al., 2007 Arch Gen Psychiatry Compton et al. 2007 Arch Gen Psychiatry

26. Drug-alcohol comorbidity associated with: • Earlier onset • Higher severity • Higher psychiatric comorbidity • Higher rates of treatment seeking • Higher rates of dropout once in treatment • Less socioeconomic support • Poorer treatment outcome

28. Limited research on treatment of homotypic comorbidity Users of multiple substances usually excluded from treatment research: • Difficulty in meeting needs of heterogeneous populations in single trial • Complexity of assessment (time frame, availability of biologic indicators, time) • Complexity of targeting multiple substances simultaneously (licit, illicit)Safety and compliance concerns, especially in pharmacologic trials • Pharmacologic specificity Rounsaville et al, 2003

30. Available pharmacotherapies for substance use disorders

31. Emerging pharmacologic strategies for homotypic comorbidity

33. Original rationale for disulfiram as treatment for cocaine users • Clinical observation of high levels of concurrent alcohol-cocaine use (60-70% of patients) • Rationale: Reducing alcohol use may reduce concurrent cocaine use • Better ability to utilize coping skills (Marlatt et al) • Alcohol powerful conditioned cue (Higgins et al) • Cocaethylene (Jatlow, McCance)

34. Open outpatient study, cocaine-alcohol users: % attaining 3+ weeks abstinence Carroll et al., 1998

35. Double blind trial of disulfiram for cocaine dependence in methadone maintenance N=67 Petrakis et al 2000

36. Randomized outpatient clinical trial: Disulfiram, CBT, and IPT, N=121 Carroll et al., 2004

37. Cocaine outcomes for those who did NOT meet criteria for alcohol abuse or dependence (n=58)

38. Behavioral therapy studies of alcohol-drug users

39. Behavioral therapies tend to be effective across types of substance use

40. Clinical Trials Network:17 Current Nodes, >200 CTPs

41. Clinical Trials Network: MET Trials Participant Characteristics • Mean age 35 • 29% female (<MI) • 42% Caucasian (<MI) • 12 years of education • 28% mandated or legal referral • Primary substance use problem: • Alcohol: 29 % (<MI) • Marijuana: 16% • Cocaine: 23% (>MI) • Methamphetamine: 4% (<MI) • Opioids: 9% • Benzodiazepenes: 1% Ball et al., 2007

42. CTN MET/MI studies: Design

43. CTN: MET longitudinal outcomes Ball et al.., 2007

44. CTN MET/MI studies: Outcomes for alcohol subgroups

45. ‘CBT 4 CBT’Computer Based Therapy/CBT • 6 modules, ~1 hour each, high flexibility • Highly user friendly, no text to read, linear navigation • Video examples of characters struggling real life situations • Multimedia presentation of skills • Repeat movie with character using skills to change ‘ending’ • Interactive exercises, quizzes • Multiple examples of ‘homework’

46. Computer-based training in CBT: CBT4CBT “All comers”: few restriction on participation, only require some drug use in past 30 days • 43% female • 45% African American, 12% Hispanic • 23% employed • 37% on probation/parole • 59% primary cocaine problem, 18% alcohol, 16% opioids, 7% marijuana • 79% users of more than one drug or alcohol Carroll et al., in press, Am J Psychiatry

47. Primary outcomes, 8 weeksCBT+TAU versus TAU Carroll et al., in press, Am J Psychiatry

49. Treatment of Dual Addictions:General strategies • Target, treat most severe disorder and any requiring detoxification first • Utilize pharmacotherapies when available • Attend to psychiatric and medical comorbidity • Frequent monitoring, chronic care model • Sequential targeting may be important for some treatments (eg. contingency management)

50. “I wonder why we’re not getting any new converts.”