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2. www.centerforepb.case.edu

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4. Opiate Addiction and the Dually Diagnosed Consumer: Organizational Capability Presented by: Christina Delos Reyes, MD Patrick Boyle, LISW-S, LICDC The Center for Evidence Based Practices Case Western Reserve University Cleveland, Ohio the CEBP is a partnership between the Mandel School of Applied Social Sciences and the Department of Psychiatry, CWRU School of Medicine, Case Western Reserve University in collaboration with the Ohio Departments of Mental Health and Alcohol Dependence and Addiction Services

5. Learning objectives • Describe interacting symptoms of typical co-morbid diagnoses • Describe the essential components for organizational capability in the delivery of integrated co-occurring disorders • Identify one’s organizational stage of development for essential components

6. Substance abuse is common in people with mental illness • Over 50% of people with schizophrenia, bipolar disorder and other severe mood disorders have a substance use disorder at some time in their life • About one third of people with anxiety and depressive disorders have a substance use disorder at some time in their life

7. Prevalence and Incidence of Dual Disorders • In 2010, an estimated 4.9 million adult Americans met criteria for both severe mental illness (SMI) and substance dependence or abuse in the prior year • 25-35% of people with SMI have an active substance abuse problem. • Substance abuse among people with SMI has greater than three times the incidence as those in the general population • About 50% of the people with severe mental illness will have a lifetime substance abuse disorder • Substance Abuse and Mental Health Services Administration. (2012). Overview of the findings from National Household Survey on Drug Use and Health. (Office of Applied Studies, NSDUH Series H-27, DHHS Publication No. 05-4061). Rockville, MD.

8. Mental illness is common in individuals with drug dependence • Many studies lump “all illicit drugs” into 1 category, so it is often very difficult to isolate just “opiate dependence” • Compton et al. (2000) studied 425 individuals with drug dependence (excluding alcohol and tobacco): • 64% had alcohol dependence • 44% had antisocial personality • 39% had phobic disorders • 24% had major depression • 12% had dysthymia • 10% had generalized anxiety disorder

9. Opiate Dependence and Comorbidity • Benningfield et al 2010: studied mental illness in pregnant women with opiate dependence (n=174) • 64.6% screened + for 1 or more psych disorders (48.6% mood symptoms, 40.0% anxiety symptoms, and 12.6% suicidal thinking) within the last 30 days • Jaffe et al 1998: studied OA (opiate addiction) in a SPMI (severe and persistent mental illness) population • 43 patients had both OA/SPMI and 297 had SPMI only • significantly fewer opiate-addicted patients were diagnosed with schizophrenia (26% vs. 52%)

10. Additional Information from SAMHSA • 73 % of persons with a drug dependence disorder in substance abuse treatment had a co-occurring mental disorder at some point during their lifetime • In substance abuse settings, very common to see: • Antisocial personality disorder • Major Depressive Disorder (and other mood disorders) • Post-Traumatic Stress Disorder • SOURCE: “The Epidemiology of Co-Occurring Substance Use and Mental Disorders.” COCE Overview Paper 8. DHHS Publication No. (SMA) 07-4308. Rockville, MD: Substance Abuse and Mental Health Services Administration, and Center for Mental Health Services, 2007.

11. Additional Information from NIDA • Both drug use disorders and other mental illnesses are caused by overlapping factors such as underlying brain deficits, genetic vulnerabilities, and/or early exposure to stress or trauma. • Early drug use increases later risk (for BOTH mental illness and substance use disorders). • Mood and anxiety disorder rates are doubled in those with drug use disorders • SOURCE: NIDA Research Reports: Comorbidity: Addiction and Other Mental Illnesses; NIH Pub Number: 10-5771; Published: December 2008; Revised: September 2010

12. Quadrant Model for Co-Occurring Disorders

13. Traditional Treatment • Treat each disorder separately May be parallel or sequential • Parallel • Treating the disorders at the same time however in different organizations, departments, or with different clinicians • Sequential • Treating the disorders one at a time – based on ? Separate treatment is less effective

14. Traditional Treatment • People with MI often lack genuine access to AOD programs Not admitted Prematurely discharged • People with AOD issues lack genuine access to MH programs Not screened, assessed or diagnosed properly Implication that the consumer fails, not the treatment

15. Problems With Separate Mental Illness And Substance Abuse Treatments • Different eligibility requirements • Trouble accessing both services • Primary/secondary distinction • Different treatment approaches • Variable clinical expertise and focus • Lack of integration

16. Integrated Care Strategies Dual Disorder Capability for Addiction Treatment DDCAT Index http://www.centerforebp.case.edu/practices/sami/ddc Dual Disorder Capability for Mental Health Treatment DDCMHT Index Integrated Dual Disorder Treatment/IDDT IDDT Fidelity Scales

17. Dual Diagnosis Capability Index Development Practical program level policy, practice and workforce benchmarks Based on scientific literature and expert consensus Observational methodology Staff interviews; milieu observation; Document review (clinical record, policies, curricula) Iterative process of measure refinement: Field testing and psychometric analyses Materials Index, manual, toolkit & Excel workbook for scoring and graphic profiles

18. The Basic Change Paradigm • Why change? • What is in it for me as a stakeholder? • How to change? • How is the practice implemented? • How to sustain the practice? • What structures need to be modified?

19. Exploring Program Capability • What client needs are important for organizations and systems to address over the next 1-5 years in order to become co-occurring capable? • Discussion • What outcomes do you want to improve? • Discussion • Challenges, barriers, facilitators, resources, processes? • Discussion

20. 1. Pre-Contemplation 6. Relapse 2. Contemplation 5. Maintenance 3. Preparation 4. Action STAGES OF CHANGE Adapted from Prochaska & DiClemente (1982), “Transtheoretical therapy: Toward a more integrative model of change.” Psychotherapy: Theory, Research, and Practice, 19: 276-288.

21. Where Are You in Your Professional Behavior Change? 1. Pre-Contemplation 6. Relapse 2. Contemplation 5. Maintenance 3. Preparation 4. Action Adapted from Prochaska & DiClemente (1982), “Transtheoretical therapy: Toward a more integrative model of change.” Psychotherapy: Theory, Research, and Practice, 19: 276-288.

22. Where Do You See Your Agency/Dept? 1. Pre-Contemplation 6. Relapse 2. Contemplation 5. Maintenance 3. Preparation 4. Action Adapted from Prochaska & DiClemente (1982), “Transtheoretical therapy: Toward a more integrative model of change.” Psychotherapy: Theory, Research, and Practice, 19: 276-288.

23. DDCAT/MHT Specific Objectives • To objectively determine the dual diagnosis capability of addiction treatment and/or mental health services. • To develop practical operational benchmarks or guidelines for enhancing dual diagnosis capability. • To provide a useful quality improvement tool for organizational change pertinent to co-occurring disorders (COD).

24. DDCAT/CMHT Index • 7 domains • Subdivided into 35 Program elements • Utilizes taxonomy of Patient Placement Criteria Second Edition Revised outlined by American Society of Addiction Medicine (ASAM)

25. DDCAT/CMHT Index Measures • Presence or absence of benchmark • Relative frequency Variable vs. Routine, systematic and standardized “Percentage of…”

26. Continuum of Co-occurring Capability • Addiction Only Services/Mental Health Only Services • Dual Diagnosis Capable • Dual Diagnosis Enhanced 1 2 3 4 5

27. Addiction Only Services (AOS)Mental Health Only Services (MHOS) AOS reflects programs whose mission and treatment focus are primarily services to individuals with substance-related disorders. MHOS reflects programs whose mission and treatment focus are primarily services to individuals with mental health-related disorders.

28. Dual Diagnosis Capable (DDC) DDCAT Programs that have some capacity to provide services for both disorders, however there is greater capacity to serve individuals with substance-related disorders. DDCMHT Programs that have some capacity to provide services for both disorders, however there is greater capacity to serve individuals with mental health-related disorders.

29. Dual Diagnosis Enhanced (DDE) Programs that: • Are capable of providing services to any individual with substance-related and mental health-related disorders. • Can be responsive to both types of disorders fully and equally.

30. Dual Diagnosis Capability – Index Domains • Program Structure • Program Milieu • Clinical Process: Assessment • Clinical Process: Treatment • Continuity of Care • Staffing • Training

31. DDCAT/MHT Content

32. Stage-based Approach to Organizational Change

33. I. Program Structure A. Mission statement Programs that offer treatment for individuals with co-occurring disorders (COD) should have this philosophy reflected in their Mission Statement B. Certification and licensure Allows for unrestricted service delivery without barriers that have traditionally divided MH/AOD services

34. Barriers & Facilitators 1. What are the next steps towards achieving this standard? 2. Who is responsible for this next step? 3. When will we accomplish this next step?

35. I. Program Structure C. Coordination/collaboration with MH/AOD services Staged advances in service systems: Minimal coordination Consultation Collaboration Integration

36. I. Program Structure D. Financial incentives Programs that accommodate billing strategies for both services have greater capacity to provide integrated services

37. Barriers & Facilitators 1. What are the next steps towards achieving this standard? 2. Who is responsible for this next step? 3. When will we accomplish this next step?

38. II. Program Milieu A. Routine expectation and welcome to treatment for both disorders • Program communicates this in policy, protocol, and literature (handouts, curricula, brochures, etc.) • Program does not discharge individuals for having the symptoms of their illness B. Display and distribution of literature and client/family education materials includes content for both MH and AOD

39. Barriers & Facilitators 1. What are the next steps towards achieving this standard? 2. Who is responsible for this next step? 3. When will we accomplish this next step?

40. III. Clinical Process: Assessment A. Screening Methods • Routine and systematic for both MH and AOD disorders • Standardized, reliable and validated • Incorporated into comprehensive evaluation process B. Assessment • Routine and systematic assessment for both disorders • Standardized and integrated • Essential component in directing an individuals care

41. Barriers & Facilitators 1. What are the next steps towards achieving this standard? 2. Who is responsible for this next step? 3. When will we accomplish this next step?

42. III. Clinical Process: Assessment C. Psychiatric and Substance Use Diagnoses • Initial vs. Ongoing: Establishing diagnosis • Routine, systematic and documented diagnoses are made for both disorders • Appropriately licensed, trained and supervised clinicians demonstrate core assessment competencies inclusive of both disorders

43. Barriers & Facilitators 1. What are the next steps towards achieving this standard? 2. Who is responsible for this next step? 3. When will we accomplish this next step?

44. III. Clinical Process: Assessment D. Psychiatric and Substance Use history is documented in the medical record • Interaction of both disorders is reflected in assessment documentation • Routine QI and supervisory review of assessment insures accurate, comprehensive and integrated documentation E. Program Acceptance – Symptom Acuity • Mild, moderate, severe • Policy and protocol reflects program parameters

45. Barriers & Facilitators 1. What are the next steps towards achieving this standard? 2. Who is responsible for this next step? 3. When will we accomplish this next step?

46. III. Clinical Process: Assessment F. Program Acceptance – Symptom Severity • Mild: Few symptoms in excess of those required to diagnose and otherwise minor functional impairment • Moderate: “Symptoms or functional impairment between Mild and Severe are present” • Severe: many symptoms in excess of those required to make the diagnosis or several symptoms that are particularly severe are present or marked functional impairment

47. III. Clinical Process: Assessment G. Stage-wise Assessment • Initial and ongoing • Essential component in directing an individuals care • Helps assess motivation across identified areas of need • Helps more strategically and efficiently match the individual to appropriate service intensity Service intensity vs. treatment readiness

48. Barriers & Facilitators 1. What are the next steps towards achieving this standard? 2. Who is responsible for this next step? 3. When will we accomplish this next step?

49. IV. Clinical Process: Treatment A. Treatment Plans (Recovery Plans) • Both disorders addressed B. Assess and Monitor Interactive Courses of Disorders • Routine client interaction • “How does your marijuana use affect your mood?” • Curriculum • Case consultation • Routinely Documented

50. Barriers & Facilitators 1. What are the next steps towards achieving this standard? 2. Who is responsible for this next step? 3. When will we accomplish this next step?