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General Approach – Many Small Actions

Substance Abuse Services in Psychiatric Settings Best Practice Recommendations Joseph Parks, MD 2005 Hospital Summit. General Approach – Many Small Actions. Presentations of published literature Analysis of hospital data Building alliances with Substance Abuse Treatment Community

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General Approach – Many Small Actions

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  1. Substance Abuse Services in Psychiatric SettingsBest Practice RecommendationsJoseph Parks, MD2005 Hospital Summit

  2. General Approach – Many Small Actions • Presentations of published literature • Analysis of hospital data • Building alliances with Substance Abuse Treatment Community • Building consensus • Writing a guideline came last

  3. Messages • Substance Abuse/Dependence is a major cause of program admissions • Our programs aren’t assessing and managing it well or at least could do better • It’s our job to do it well as long as they are with us • Here’s how

  4. National CoMorbidity Survey 1991 Random sample of 8089 persons aged 15 yr. – 54 yr • Lifetime prevalence – Addictive Disorders 26.6% Psychiatric Disorders 21.4% Both Simultaneously 13.7% • 12 month prevalence with both 2.7%

  5. CoMorbidity SurveyMost Severely Impaired Persons Have Multiple Disorders # Psychiatric or Addiction Disorders % of Population None 52% Any 48% One 21% Two or More 27% Three or More 14% 53.9% of the total psychiatric and addiction disorders occur in the 14% with three or more disorders.

  6. Epidemiologic Catchment Area Study Among Persons with Mental Disorder • 29% have an addictive disorder 22% alcohol disorder 15% other drug disorder • 2.7 times more likely than general population Among Persons with Addictive Disorders • alcohol disorders 36.6% have mental disorder 2.3 times more likely • Other drug disorders 53% have mental disorder 4.5 times more likely

  7. CoMorbidity in Psychiatric Setting % with Substance DiagnosisAbuse Disorder Depression 30% Bipolar 50% Schizophrenia 50% Anxiety 30% Phobia 23% Antisocial Personality 80%

  8. Compared to Non-Addicted Psychiatric PatientsAddicted Psychiatric Patients Have • Earlier on-set of psychiatric illness • More severe symptoms • More social impairment

  9. CoMorbidity in Substance Abuse Setting % with Psychiatric Syndrome Alcohol Treatment 10 – 70% Drug Treatment 40-70% Lower rates are from studies attempting to exclude substance-induced psychiatric syndromes

  10. Increased Risk Lifetime Relative to Substance Prevalence of any General AbusedMental DisorderPopulation Alcohol 36.6% 2.3 Cocaine 76.1% 11.3 Opiates 62.5% 6.7 Sedatives 74.7% 10.8 Hallucinogens 69.2% 8.0 Lifetime Risk of Psychiatric Disorder by Substance Abused (ECA)

  11. Compared to Non-Depressed Alcoholics Depressed Alcoholics Have • Earlier 1st episode of outpatient treatment • Earlier 1st episode of hospitalization • More hospitalizations, longer lengths of stay inpatient • More blackouts • More legal problems • More polysubstance abuse • The same relapse rate Psychiatric Clinics of N. Am. Vol. 13 #4 pp. 613-633 Dec 1990

  12. MacArthur Foundation Research on Mental Illness and Violence Study Design • 1136 men and women age 18-40discharged from psychiatric hospital • Follow up interview of person and collateral every 10 weeks for 1 year • Comparison group of non-hospitalized persons from same neighborhood • 3 sites: Kansas City, Missouri Worchester, Massachusetts Pittsburg, Pennsylvania

  13. MacArthur Foundation Research on Mental Illness and Violence Continuum of Violence Overall Non-MI/Non-SA = MI/Non-SA <Non-Mi/SA < MI/SA

  14. CPS/ADA OVERLAPby Program Episode File ADA Clients CPS Clients in CPS in ADA One Day 5% 11% One Year 10% 14% Ever 24% 31% Diagnosed 13% 10%

  15. FIRST ADMISSION TO ADULT ACUTE INPATIENT SERVICE FY97Top Discharge Diagnoses Axis 1-1

  16. FY01Facility Summary

  17. CONCLUSION All mental health (and Substance Abuse) Programs are Dual Diagnosis Programs… Some are just in denial.

  18. Missouri Best Practice Initiatives on Co-Occurring SA/MI • Screening (3 times) • Acute Psychiatric Hospital • Long Term Inpatient • Community

  19. Hospital Task Force Charge • Conduct survey and analysis needs • Review current programming • Review research and expert opinion to identify best practices • Recommend changes

  20. Hospital Task Force Membership • Co-chairs, Psychiatrist (MH) and SA Psychologist • 2-3 staff from each hospital • ADA division treatment head • 2 SA community providers • Multi-disciplinary – MD, PhD, RN, MSW, SA Counselors

  21. Chart Review - Method • 3 Acute Hospitals • 40 charts at each • 20 primary diagnosis SA • 20 secondary diagnosis SA • Jointly reviewed by General Adult Psychiatrist and Psychologist specializing in Substance Abuse.

  22. Chart Review - Results • Admissions were appropriate • LOS was often longer than necessary • Assessment of current SA and history was inadequate • Diagnosis was sloppy

  23. Chart Review Results • Persons admitted were beyond the capabilities of SA treatment programs to manage • Substance abuse interventions were inadequate • Assessment and intervention for trauma and abuse was inadequate.

  24. Staff attitude was major obstacle “It’s not our mission” “It’s not my job”

  25. Public Sector Mission To Care for Persons whose behavior is so dangerous or socially unacceptable that their communities cannot tolerate their presence and no other entity can or will work with

  26. Public Sector Admission Criteria The facility or program is the least inappropriate currently available.

  27. Role of Acute Psychiatric Hospital • Universal screening for substance use disorder of all persons presenting • For persons admitted, assessment of substance use disorders sufficient to plan and provide for initial management and referral. • Modified medical detox. • Brief focused interventions to increase motivation, to accept referral and continue to treatment. • Appropriate referral to ongoing treatment in the community.

  28. Best Practice Recommendations for Substance Use Disorder Services Acute Psychiatric Hospitals All persons presenting for evaluation should be screened for substance use disorder risk using the CAGE questionnaire while in the emergency room admitting area.

  29. Best Practice Recommendations for Substance Use Disorder Services Acute Psychiatric Hospitals All persons presenting should be screened for alcohol use or intoxication using hand-held breathalyzer while in the emergency room admitting area.

  30. Best Practice Recommendations for Substance Use Disorder Services Acute Psychiatric Hospitals All persons admitted should receive substance abuser assessment covering the content from the ASI substance use history module.

  31. Best Practice Recommendations for Substance Use Disorder Services Acute Psychiatric Hospitals All persons admitted should have urine screening for drugs of abuse. (In recent published research, 20% of patients who deny substance abuse are found to have positive urine screens and of these, half of the physicians evaluating them did not suspect it.

  32. Best Practice Recommendations for Substance Use Disorder Services Acute Psychiatric Hospitals All acute inpatients should have access and be encouraged to attend a substance abuse prevention group education • Increased risk of persons with mental illness for developing substance use disorders • The impact of substance use disorders on the course of common mental illnesses • The addictive potential of various drugs of abuse • Refusal skills training.

  33. Best Practice Recommendations for Substance Use Disorder Services Acute Psychiatric Hospitals Persons with a substance use disorder should receive individual substance abuse counseling • once a day • 15 to 30 minutes • use motivational interviewing techniques • done by a qualified substance abuse counselor.

  34. Best Practice Recommendations for Substance Use Disorder Services Acute Psychiatric Hospitals Persons with substance use disorders should have access to and be encouraged to attend 2 group interventions a day.

  35. Best Practice Recommendations for Substance Use Disorder Services Acute Psychiatric Hospitals Information group • Done by any trained staff • Topics • What is addiction • What is abuse and dependence • How mental illness effects addiction • What are the medical consequences of addiction

  36. Best Practice Recommendations for Substance Use Disorder Services Acute Psychiatric Hospitals Process group • Done by • A qualified substance abuse counselor • Use a motivation enhancement therapy • Topics • Triggers to relapse • Relapse prevention • Coping skills • Refusal skills and other social skills

  37. Best Practice Recommendations for Substance Use Disorder Services Acute Psychiatric Hospitals Detox practice guidelines should be developed and adopted for alcohol, opiates, and for stimulant use.

  38. Best Practice Recommendations for Substance Use Disorder Services Acute Psychiatric Hospitals A chart quality assurance review protocol should be used at each facility • Adequate assessment • Accurate Diagnosis using DSM • Appropriate referral

  39. Best Practice Recommendations for Substance Use Disorder Services Acute Psychiatric Hospitals CPS acute facilities should meet the ADA certification guidelines for modified medical detox.

  40. Best Practice Recommendations for Substance Use Disorder Services Acute Psychiatric Hospitals CPS acute facility staff should receive additional training and education on the assessment and management of substance use disorders and dual diagnosis

  41. Best Practice Recommendations for Substance Use Disorder Services Acute Psychiatric Hospitals The divisions of ADA and CPS in DMH should require by contract that their community treatment programs provide immediate access to substance abuse treatment services for people referred from CPS acute facilities and should make appropriate dual diagnosis programming available.

  42. Training • Diagnosis of Abuse and Dependence • Models of Addiction • Dual Diagnosis • Motivational Interviewing • 12 Step Model • S A interview techniques • Efficacy of S A Treatment

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