Co-occurring Substance Use And Mental Disorders: Clinical .

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Co-occurring Substance Use and MentalDisorders: Clinical Issues in Diagnosis,Treatment and PharmacotherapyDavid Mee-Lee, M.D. DML Training & Consultingdavidmeelee@gmail.com davidmeelee.com tipsntopics.comTerminologyCo-occurring Mental and Substance-Related DisordersIn “A Report to Congress on the Prevention and Treatment of Co-occurringSubstance Abuse Disorders and Mental Disorders,” SAMHSA defines peoplewith co-occurring disorders as “individuals who have at least one mental disorderas well as an alcohol or drug use disorder. While these disorders may interactdifferently in any one person at least one disorder of each type can be diagnosedindependently of the other.” The report also states, “Co-occurring disorders mayinclude any combination of two or more substance abuse disorders and mentaldisorders identified in the Diagnostic and Statistical Manual of Mental DisordersIV (DSM-IV). There are no specific combinations of disorders that are defineduniquely as co-occurring loads/2014/10/Behavioral Health-Primary CoOccurringRTC.pdf)“Co-occurring Disorders refer to substance use disorders and mental disorders.”“Integrated interventions are specific treatment strategies or therapeutictechniques in which interventions for both disorders are combined in asingle session or interaction, or in a series of interactions or multiple sessions.Integrated interventions can include a wide range of techniques.”(Center for Substance Abuse Treatment. Substance Abuse Treatment for Persons With Co-OccurringDisorders. Treatment Improvement Protocol (TIP) Series 42. DHHS Publication No. (SMA) 05-3992.Rockville, MD: Substance Abuse and Mental Health Services Administration, 2005, page 27, 29)“The key to effective treatment for clients with dual disorders is the seamlessintegration of psychiatric and substance abuse interventions in order to form acohesive, unitary system of care.” 2020 The Change Companies It is illegal to duplicate this page in any manner. 1

“The integration of services represents the organizational dimension of treatment: Servicesfor both mental illness and substance abuse need to be provided simultaneously by the sameclinicians within the same organization, in order to avoid gaps in service deliver and to ensurethat both types of disorders are treated effectively.”(Mueser KT, Noordsy DL, Drake RE, Fox L (2003): “Integrated Treatment for Dual Disorders – A Guide to EffectivePractice” The Guilford Press, NY. page xvi, 19)“Integrated treatment is the interaction between the mental health and/or substance abuse clinician(s)and the individual, which addresses the substance and mental health needs of the individual.”(From page vi in “A Report to Congress on the Prevention and Treatment of Co-Occurring Substance Abuse Disorders andMental Disorders” 2002, from the Substance Abuse and Mental Health Services Administration (SAMHSA). s/2014/10/Behavioral Health-Primary CoOccurringRTC.pdf)One Team, One Plan for One PersonCultural Clashes in the Behavioral Health FieldPolarized Perspectives About Presenting Problems3 Ps3 Ds1Deadly Disease2Denial3DetachmentConsider addiction in differential diagnosis,ask questions to screen, diagnoseConscious lying, amnesia of blackouts,unconscious survival mechanismHealthy distance, don’t pin your professionalself-esteem to client’s success1Psychiatric Disorders2Psychopharmacology3ProcessNot all mental health problems aresymptoms of addiction and withdrawalMedications often necessary, can preventpsychiatric and addiction relapseOften no quick, easy answer to decideaddiction versus psychiatric versus CODDifferent Theoretical Perspectives, Different Treatment MethodologiesAddiction System versus Mental Health System 3 Ds and 3 Ps - implications for medication, staff credentials, attitudes towards physicians,role of staff and team, programsIntegrated Treatment versus Parallel or Sequential Treatment Hybrid programs - staffing difficulties, numbers of patients and variability, butone-stop treatment Parallel programs - use of existing programs and staff, but more difficult tomanage cases2 It is illegal to duplicate this page in any manner. 2020 The Change Companies

Care versus Confrontation Mental health - care, support, understanding, passivity Addiction - accountability, behavior changeAbstinence-oriented versus Abstinence-mandated Treatment as a process, not an event Respective roles in both approachesDeinstitutionalization versus Recovery and Rehabilitation Role of “least restrictive” setting Role for individualized treatment with continuum of careWhy Diagnostic Confusion?Diagnostic Confusion Due to:Alcohol/drugs can cause psychiatric symptoms in anyone (acute toxicity)Prolonged alcohol/drug use can cause short or long-term psychiatric illnessAlcohol/drug use can escalate in episodes of psychiatric illnessPsychiatric symptoms and alcohol/drug use can occur in other psychiatric disordersIndependent addiction and psychiatric illnesses (co-occurring disorders)(Marc A. Schuckit: Am. J. Psychiatry, 143:2, 1986. p.141 - modified)Decision Tree for “Addiction versus Psychiatric Diagnoses: Either or Both?”Take a good history.A definitive psychiatric diagnosis by history requires the psychiatric symptoms to have occurredduring drug-free periods of time.Observe the client for a sufficient time drug-free. Shorter time for objective, psychotic symptoms Longer for subjective, affective symptoms Non-drug ways of copingAddiction is a biopsychosocial disorder, so encourage active involvement in a recovery program.Incorporate meetings, tools, techniques and a wide variety of non-drug coping responses to helpclient deal with the stresses of everyday living. Diagnosis is a process, not an event. 2020 The Change Companies It is illegal to duplicate this page in any manner. 3

DECISION TREEfor Addiction vs. Other Psychiatric Diagnoses: Either or Both?TAKE A GOOD HISTORYPerson presents with psychiatric signs andsymptoms and question of substance use hasbeen raised.Was person using substances at thetime of, or not long before, the acutepresenting psychiatric problem (e.g.,suicidal attempt, hallucinations)?Acute toxic reaction, substance-inducedor addiction diagnosis likely and needsfurther assessment.YESNODid person first start having addiction problemsbefore a significant history of psychiatricsymptoms developed?NOYESAddiction diagnosis needs further assessment.YESDid person have difficulty staying drug-free?Has person had significant period drug free?YESNOIs there an addictive pattern of substance use(as in DSM)?YESExplore for addictiondiagnosis and, ifpresent, treat first,before any otherpsychiatric diagnosis.NOOBSERVE PERSON’SBEHAVIORS IF DIAGNOSISUNCLEARInitiate treatment of non-addiction psychiatricdiagnosis, but monitor substance use.Do the psychiatric symptoms improve with thepsychiatric treatment?NODid psychiatricsymptoms persistduring drug-freeperiod?YESYESNon-addictionpsychiatric diagnosisis confirmed.Explore further for apsychiatric diagnosisother than addiction.NOInitiate diagnostic trial of helping theperson to be drug-free via outpatient orinpatient treatment.YESNODid person have trouble staying drug-free?Did psychiatric symptoms persistduring drug-free period?NOYESNEEDED AFTERADDICTION TREATMENTNOInitiate primary addiction treatment beforepursuing other psychiatric treatment.Once person is drug free for significant period,do psychiatric symptoms and non-addictionpsychiatric diagnoses persist?NOAddiction diagnosis isconfirmed.YESInitiate additional psychiatric treatment fornon-addiction diagnosis.4 It is illegal to duplicate this page in any manner. 2020 The Change Companies

Integrated Treatment Approach: Person-centeredAssessment and TreatmentBiopsychosocial Perspective of Addiction and Mental DisordersA common view allows a common language of assessment and treatment for all involved.Addiction illness and many psychiatric disorders are chronic, potentially relapsing illnesses, oftenneeding an ongoing process of treatment, rehabilitation and recovery, with brief episodes ofacute care and stabilization.Feedback Informed Treatment - Measurement-based PracticeA diagnosis is a necessary but not sufficient determinant of treatment. A client is matchedto services based on multidimensional needs and the focus of treatment, not placed in a setprogram based only on having met diagnostic criteria.PARTICIPANT ASSESSMENTData from allBIOPSYCHOSOCIALDimensionsPROGRESSPROBLEMS or PRIORITIESTreatment Response:Clinical functioning, psychological,social/interpersonal LOFProximal Outcomes e.g., SessionRating Scale; Outcome Rating ScaleBuild engagement and alliance workingwith multidimensional obstacles inhibitingthe client from getting what they want.What will client do?PLANBIOPSYCHOSOCIAL TreatmentIntensity of Service (IS) Modalities and Levelsof Service 2020 The Change Companies It is illegal to duplicate this page in any manner. 5

Multidimensional Assessment - ASAM Assessment Dimensions(The ASAM Criteria 2013, pp 43-53)The common language of the six assessment dimensions can be used to determine multidimensional assessment ofobstacles, needs and strengths1. Acute intoxication and/or withdrawal potential2. Biomedical conditions and complications3. Emotional/behavioral/cognitive conditions and complications4. Readiness to change5. Relapse/continued use/continued problem potential6. Recovery environmentBiopsychosocial Treatment - Overview: 5 Ms5 M's1Motivate2Manage3MedicationDual diagnosis clients can have ambivalence about and lack of interest in changing theiraddiction and mental health problems. Deal with readiness to change at a pace thatkeeps the patient engaged in treatment. Family and healthcare workers may also need“motivating” to deal with both addiction and psychiatric issues equally (Dimension 4).Because co-occurring disordered clients easily present to both addiction and mentalhealth programs, treatment requires more case management across the addiction andmental health treatment systems, social welfare, legal, family systems and significantothers than individual therapy. Case management is especially important for high risk,multiproblem and chronic relapsing clients. Take a total systems approach. To improveoutcomes, alternative services may be necessary (e.g., educational or vocationalservices, child care and parenting training, financial counseling, coping with feelings anddual relapse groups, daily living skills, tutoring or mentoring services, transportation)(Dimensions 1 - 6).For a diagnosed co-morbid psychiatric disorder (but only after sufficient assessmentstrategies exclude addiction mimicking). also for withdrawal management if necessary,educate clients about their medication and interaction with alcohol/drugs. Prepare themon how to deal with conflicts about medication at AA/NA meetings. Anti-addictionmedication (MAT): naltrexone (Vivitrol), acamprosate (Campral); disulfiram (Antabuse);methadone; buprenorphine; opioid antagonists (Dimensions 1, 2, 3, 5).6 It is illegal to duplicate this page in any manner. 2020 The Change Companies

4Meetings5MonitorMainstream into AA and NA as much as possible, but prepare clients on how to notalienate themselves (e.g., too readily discussing medication and mental health issuesunless with an understanding member or group). Help clients deal with their “dualidentity.“ Help identify appropriate meetings in the area and locate or develop specialsupport groups for those unable to be “mainstreamed.” Other self/mutual help groupsinclude SMART Recovery, Dual Diagnosis Anonymous, Emotions Anonymous, DoubleTrouble in Recovery, Schizophrenia Anonymous (Dimensions 3, 4, 5, 6).To ensure continuity of care, be alert to missed appointments, hospitalizations andprofessionals unfamiliar with dual diagnosis and the treatment goals (e.g., drug-freediagnostic trial). Promote accountability for an ongoing treatment plan rather thanfragmented responses to crises. Recognize treatment as a process, not an event(Dimensions 1 - 6).Treatment Levels of Service - ASAM Levels of Care/Service to MatchSeverity of ProblemsOutpatient ServicesIntensive Outpatient/Partial Hospitalization ServicesResidential/Inpatient ServicesMedically-managed Intensive Inpatient Services(The ASAM Criteria 2013, pp 106-107) 2020 The Change Companies It is illegal to duplicate this page in any manner. 7

Medication Treatment Adherence Problems:Differential Diagnosis and What to Do About ItIt is important to diagnose why the person does not adhere to medication. Otherwise,the strategy may be counterproductive:Cognitive Client had a bad side effect or felt meds have not worked before and so won’ttake medication anymore. Treat the fear of side effects and/or the lack ofconfidence in medication. Readiness to change issues: client not ready to accept medication as necessaryfor an illness which they may accept or be ambivalent about (motivationalenhancement, stages of change work) Wants to use natural substances rather than psychotropic medication.Cultural Believes the medication is dangerous from a cultural perspective (get a bi-culturaloutreach worker)Unconsciously non-adherent Somatic complaint Sick role, characterological The more the therapist is involved, the more it shows they care and the more thesick role pays off (Assertive Community Treatment (ACT) for example, because themore you go to their home to count pills, the more they are non-compliant to keepyou coming back)Drug addicted person Overusing pills due to addictionPsychotic Delusional Maintain the relationship and don’t struggle over the diagnosis (ACT is appropriatein such situations)Malingering External incentives for the behavior (e.g., keep getting workers compensation)Recovery environment problems Insufficient funds to pay for medication and/or transportation and/or childcare tokeep appointments for medication monitoring8 It is illegal to duplicate this page in any manner. 2020 The Change Companies

Literature References and ResourcesCenter for Substance Abuse Treatment. “Substance Abuse Treatment for Persons With Co-Occurring Disorders” TreatmentImprovement Protocol (TIP) Series 42. DHHS Publication No. (SMA) 05-3992. Rockville, MD: Substance Abuse and MentalHealth Services Administration, 2005(TIP 42 available online at Health Services/Technology Assessment Text (HSTAT) section of National Library of MedicineWeb site at rders/SMA13-3992McKillip, R. (2004): “The Basics – A Curriculum for Co-Occurring Psychiatric and Substance Disorders” Volumes I and II,Second EditionMee-Lee, D., Shulman G.D., Fishman, M.J, Gastfriend, D.R., & Miller, M.M eds. (2013). The ASAM Criteria: TreatmentCriteria for Addictive, Substance-Related, and Co-Occurring Conditions. Third Edition. Carson City, NV: The ChangeCompanies.Mee-Lee, D. (2001): “Treatment Planning for Dual Disorders”. Psychiatric Rehabilitation Skills Vol.5. No.1, 52-79.Mee-Lee, D., & Harrison, J.E. (2010): “Tips and Topics: Opening the Toolbox for Transforming Services and Systems”. TheChange Companies, Carson City, NVMiller, W.R., & Mee-Lee, D. (2010): “Self-management: A Guide to Your Feelings, Motivations and Positive Mental Health”Addiction Treatment Edition.Miller, W.R., & Mee-Lee, D. (2012): “Self-management: A Guide to Your Feelings, Motivations and Positive Mental Health”Mueser, K.T., Noordsy, D.L, Drake, R.E., & Fox, L. (2003): “Integrated Treatment for Dual Disorders – A Guide to EffectivePractice” The Guilford Press, NY.Schuckit, M.A. (1986): “Genetic and clinical implications of alcoholism and affective disorder” Am J Psychiatry 143(2): 140147, Feb 1986.Resources from SAMHSA1. In 2002, the Substance Abuse and Mental Health Services Administration (SAMHSA) presented “A Report to Congresson the Prevention and Treatment of Co-Occurring Substance Abuse Disorders and Mental Disorders”. It provides asummary of practices for preventing substance use disorders among individuals who have mental illness and also asummary of evidence-based practices for treating co-occurring disorders. /2014/10/Behavioral Health-Primary CoOccurringRTC.pdf2. Substance Abuse and Mental Health Services Administration. Integrated Treatment for Co-Occurring Disorders: TheEvidence. DHHS Pub. No. SMA-08-4366, Rockville, MD: Center for Mental Health Services, Substance Abuse and MentalHealth Services Administration, U.S. Department of Health and Human Services, ence-itc.pdf3. Center for Substance Abuse Treatment. “Substance Abuse Treatment for Persons With Co-Occurring Disorders”Treatment Improvement Protocol (TIP) Series 42. DHHS Publication No. (SMA) 05-3992. Rockville, MD: Substance Abuseand Mental Health Services Administration, 2005 (TIP 42 is available online at the Health Services/Technology AssessmentText (HSTAT) section of the National Library of Medicine Web site at the following: rders/SMA13-3992 2020 The Change Companies It is illegal to duplicate this page in any manner. 9

Notes:10 It is illegal to duplicate this page in any manner. 2020 The Change Companies

Notes: 2020 The Change Companies It is illegal to duplicate this page in any manner. 11

ASAM eLearning ModulesThe ASAM eLearning modules introduce The ASAM Criteria andprovides opportunities to practice multidimensional assessment,service planning and level of care placement.Module 1: Multidimensional AssessmentModule 2: From Assessment to Service Planning and Level of CareModule 3: Introduction to The ASAM Criteriawww.changecompanies.net/etraining/The ASAM CriteriaThe ASAM Criteria, Third Edition, is the most comprehensive set of guidelines forassessment, service planning, placement, continued stay and transfer/discharge ofindividuals with addiction and co-occurring conditions.www.changecompanies.net/asamInteractive Journaling : An Evidence-based SolutionHow does a facility deliver individualized care and maintainconsistent service delivery, all while keeping programparticipants engaged and focused on their change goals? Theevidence-based approach of Interactive Journaling can help.Used by over 25 million people in 5,000 agencies nationwide,Interactive Journaling is a structured and experiential writingapproach that motivates and guides participants towardpositive life change.Interactive Journals have underpinnings in motivationalinterviewing, cognitive-behavioral therapy, expressive writingand the transtheoretical model of behavior change. TheChange Companies ' curricula are used in many behaviorchange fields, including substance use treatment, justiceservices, healthcare, mental health and impaired driving.Free Monthly NewsletterTips and Topics includes three sections: Savvy,Skills and Soul. At times, Dr. Mee-Lee includesadditional sections: Stump the Shrink; SuccessStories and Sharing Solutions.Sign up at tipsntopics.com.Learn more: www.changecompanies.net(888) 889-8866

“Co-occurring Disorders refer to substance use disorders and mental disorders.” . “The key to effective treatment for clients with dual disorders is the seamless . (2003): “Integrated Treatment for Dual Disorders – A Guide to Effective Practice” The Guilford Press, NY. page xvi, 19)

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