Truman Medical Center Behavioral Health

1. Truman Medical CenterBehavioral Health Evidence Based Practices Integrated Dual Disorder Treatment (IDDT)

2. Treatment Models • Sequential: The first and historically most common model of dual disorder is sequential. The client is treated by one system and then the other. • Parallel: The simultaneous involvement of the client in both mental health and addiction treatment settings

3. Treatment Models • Integrated: Combines elements of both mental health and addiction treatment into unified and comprehensive treatment program for clients with dual disorders. • Integrated Dual Disorder Treatment (IDDT): An evidenced based practice that is successful in treating Co-Occurring disorders.

4. Treatment Models • Treatment for clients with mental health issues that showed positive outcomes in multiple research studies. • SAMHSA has provided six practices that demonstrate strong evidence base: • Standardized pharmacological treatment • Illness management and recovery skills • Supported employment • Family psychoeducation • Assertive community treatment • Integrated Dual Disorder Treatment (IDDT)

5. IDDT • Multidisciplinary Team • Integrated Substance Abuse Specialist • Stage Wise Treatment • Access for clients to comprehensive DD services • Time-unlimited • Outreach • Motivational Interventions

6. IDDT • Substance Abuse Counseling • Group DD Treatment • Family Psychoeducation on DD • Participation in alcohol and drug self help groups • Pharmacological treatment • Interventions to promote health • Secondary interventions for substance abuse non-responders Source: IDDT toolkit

7. IDDT • Stage Wise Interventions: interventions based on the client’s level of treatment and change (persuasion vs. active treatment; pre-contemplation; contemplation; action; etc) • Time-unlimited: No end to services; all based on client’s level of motivation; change and needs.

8. IDDT • Multidisciplinary team: CSW’s; Psychiatrist; RN; QMHP’s; SAC’s; Vocational specialist • Integrated Substance Abuse Specialist: works with the team not only to provide counseling but train the other team members.

9. IDDT • Outreach: meet client where they are; services are in vivo; in the community; ED; homes; immediate access to services. • Very important to engaging clients in services; most often in a state of crisis; needs support and immediate access to services.

10. IDDT • Motivational Interventions: most effective with substance abuse populations: change comes from the client; instills self efficacy; hope. Avoid arguments; resistance; identify stage of change.

11. Stages of Change • Pre-contemplation-not yet considering a change • Contemplation-acknowledges concerns; consider possible change; uncertain and ambivalent

12. Stages of Change • Preparation-committed to making the change; planning to make changes in the near future. • Action-Actively taking steps to change but has not reached a stable state. • Maintenance-Achieves initial goals and is now working to maintain the goals.

13. Motivational Interviewing • Motivational Interviewing • Reflection (Simple; Amplified; Double-sided) • Rolling with Resistance • Reframing • Avoid Arguments • Express Emphathy • Developing Discrepancy • Labeling is Unnecessary

14. IDDT • Interventions to Promote Health: preventative care; identification of high risk situations; physical health • Interventions for non-responders: inpatient treatment; family intervention; hospitalization.

15. Trends • Trends : • 10 million Americans are affected by a dual disorder each year. • 56% of individuals with a bipolar disorder, (Manic depressive illness) abuse substances • 47% of individuals with a schizophrenic disorder, abuse substances • 32% of individuals with a mood disorder other than bipolar, abuse substances • 27% of individuals with an anxiety

16. Goals of Medication Tx in Addictions • Pharmacological Treatment • Abstinence (or Reduction) • Treat or prevent withdrawal symptoms • Reduces urges/cravings • Diminish “the high” / make it less worthwhile • Minimize relapses time and intensity • Treat comorbid disorders

17. Medication Strategies • Agonist • Substitute effects of drug • Antagonist • Block the effects of drug • Deterrent Medications (aversive) • Reduce Drug Intake • Target cravings, reinforcement

18. Medication for the treatment of Addictive Disorders and their Mechanism of Action

19. Alcohol Dependence • Disulfiram (Antabuse) • Naltrexone (Revia) • Acamprosate (Campral) • Naltrexone IM ( Vivitrol IM)

20. Antabuse • FDA Approved 1954 • MOA: Inhibits aldehyde dehydrogenase, increasing acetaldehyde. • Evidence: So-so • Most likely to benefit: • highly motivated patients, directly observed patients,

22. Naltrexone (Revia) • FDA Approved 1994 • Mechanism of Action : Opiate Antagonist • decrease positive, reinforcing effects • increase negative aspects • decrease craving from first dose (prime) • decrease craving from cues

23. Naltrexone • Starting: 50 mg daily (start half dosage to decrease GI discomfort ) • SE: dysphoria, nausea, headaches , tirdness increased LFTs • MOA: Antagonist at Opioid receptor –blocking euphoria from alcohol • Costly • Helps in reducing alcohol consumption and frequency ,Increase time to relapse

24. Acamprosate (Campral) • FDA approved Sept 2004 • Mechanism of Action : Made from taurine ; NMDA receptors in the glutamate system – partial agonist • Not much action on GABA • Dose: 333mg TID – 333mg ii TID (1,998 mg) • Notes: • European data – 4500 patients, • Relapse Prevention, and asbtinennce • targets “negative reinforcement” • SE: Diarrhea, Asthenia and Nausea

25. Vivitrol Naltrexone for extended release Injectable suspension • The margin of Separation between apparently safe dose of Naltrexone and the dose causing hepatic injury appears to only five fold or less • Contra indicated patient receiving or dependent on Opioids • Positive urine test for opioid • Has to refrain from Alcohol use for at least one week • Psychosocial involvement • Dosage : 380 mg IM every four weeks ( needs to be refrigerated and mixed prior to injection) • Side Effects : Nausea ( transient ) headaches and Fatigue

26. Other Medication of Interest • Topiramate: Recent study in Unvi. Of Virginia • Wellbutrin Receptor modulation • Varenicillin Paritial Agonist • Nicotine replacement • Boprenorphine: Partial Agonist • For Stimulant: Abilify; Modafinil; Topiramate • Rimonabant: Cannabinoid CB 1 Receptor Antagonist originally developed for obesity has been in phase III trial and also smoking cessation.

27. Triple Diagnosis • Patients with “triple diagnosis” Mental Health; Substance Abuse and HIV or Hepatitis infection face daunting problems and need integrated treatment for the first two before starting antiviral therapy • As impulsivity; cognitive impairment and hypersexuality can increase HIV and Hepatitis risk and compliance. MI SA Hep. C HIV

29. Conclusion • IDDT decreases • Duration; frequency and intensity of mental and substance use disorder symptoms • Hospitalizations • Arrests and incarceration • Duplication of services • Treatment drop out • Utilization of high cost services

30. Conclusion • IDDT increases • Abstinence from alcohol and drugs • Continuity of care • Improved relationships • Client quality of life • Stable housing • Independent living

31. References • IDDT Evidenced Based Manual, SAMHSA resource kit 2003. • Motivational Interviewing; Preparing People to Change Addictive Behavior, William Miller and Stephen Rollnick 1991. • Focus-Journal of Lifelong Learning in Psychiatry. Spring 2007 Vol. V; No. 2. • Joseph Parks, MD in conjunction with 7 other states; “Mentally ill die 25 year earlier.”