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Dual diagnosis:
An Integrated Model for the Treatment of
People with Co-occurring Psychiatric and
Substance Disorders
Kenneth Minkoff, M.D.
[email protected]
781-932-8792x311
“Co-occurring Psychiatric & Substance Disorders in
Managed Care Systems: Standards of Care, Practice
Guidelines, Workforce Competencies & Training
Curricula”
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American Association of
Community Psychiatrists
• PRINCIPLES OF TREATMENT FOR
INDIVIDUALS WITH CO-OCCURRING
PSYCHIATRIC AND SUBSTANCE
DISORDERS
• www.comm.psych.pitt.edu
FIVE SECTIONS OF
PANEL REPORT
• I. CONSUMER/FAMILY STANDARDS
• II. SYSTEM STANDARDS/PROGRAM
COMPETENCIES
• III. PRACTICE GUIDELINES
• IV. WORKFORCE COMPETENCIES
• V. TRAINING CURRICULA
CONSUMER/FAMILY
SYSTEM STANDARDS
WELCOMING
• ACCESSIBLE
• INTEGRATED
• CONTINUOUS
• COMPREHENSIVE
TRENDS LEADING TO
COMORBIDITY
• DEINSTITUTIONALIZATION
• CHANGED PATTERNS OF
SUBSTANCE ABUSE/DEPENDENCE
• DECADE OF THE BRAIN:
INCREASED KNOWLEDGE RE
BRAIN DISORDERS
Beyond the self-medication
hypothesis
• People with serious mental illness use
substances:
• To alleviate general feelings of isolation,
loneliness, boredom, and despair,
• To facilitate peer interaction/socialization
• To create a sense of well-being, and
escape from bleak life experience
Vulnerabilities to substance use
disorders for SPMI
• 1. Greater extent of dysphonic feelings
and sense of despair
• 2. Fewer alternative, healthier coping
resources
• 3. Increased brain vulnerability to
harmful effects of substances
• 4. Mental illness may inhibit learning
from results of adverse drug experience
AREAS OF POOR
OUTCOME
•
•
•
•
•
•
•
•
RELAPSE & REHOSPITALIZATION
SUICIDALITY AND VIOLENCE
MEDICAL INVOLVEMENT (HIV/STD)
CRIMINAL INVOLVEMENT
HOMELESSNESS
TRAUMA VULNERABILITY
FAMILY DISRUPTION/ABUSE
HIGH SERVICE UTILIZATION
SAME FACES
DIFFERENT PLACES
• Comorbidity is highly prevalent in all systems of
care:
• Mental health
• Substance treatment
• Criminal Justice
• Homeless
• Primary care
• Victim/trauma services
• Family protective services
SYSTEM MISFITS
in all places
• SYSTEM LEVEL
• PROGRAM LEVEL
• CLINICIAN LEVEL
RESEARCH-BASED
TREATMENT MODELS FOR
DUAL DISORDERS
Integrated Intensive Case Mgt Teams
Continuous Treatment Team (CTT)- Drake &
Mueser
Integrated ACT/PACT Team
Modified Addiction Residential Programs
Modified Therapeutic Community (TC) –
Sachs/DeLeon
Parenting Women Programs
The most significant predictor of treatment
success is...
the ability of a program or intervention to provide...
through an individual clinician, team of clinicians, or a
community of recovering peers and clinicians...
an empathic, hopeful, continuous treatment
relationship, which provides integrated
treatment and coordination of care through the
course of multiple treatment episodes.
EMPATHY MANTRA
• When individuals with mental illness and
substance disorder are not following
recommendations, they are doing their job.
• It is our job to understand their job, to join them in
it, and help them to do it better.
• Their job involves coming to terms with the
painful reality of having both mental illness and
substance disorder, wanting neither one, yet
having to build an identity that involves rx for
both.
HOPE
1.
2.
3.
4.
• FOUR STEP PROCESS
Empathize with reality of despair.
Establish legitimacy of need to ASK for
extensive help.
Identify meaningful, attainable
measures of successful progress.
Emphasize a hopeful vision of pride and
dignity to counter self-stigmatization.
INTEGRATED TREATMENT
• Integrated treatment refers to any of a
number of mechanisms by which
established diagnosis-specific and stagespecific treatments for each disorder are
combined into a person-centered
coherent whole at the level of the
consumer, and each rx can be modified
as needed to accommodate issues related
to the other disorder.
CONTINUITY
• Course of treatment for individuals with
chronic co-morbid conditions ideally
combines continuous integrated
relationships which are unconditional,
with multiple episodic interventions or
programmatic episodes of care which
have expectations, conditions, and/or
time limits.
SUB-GROUPS OF PEOPLE WITH
COEXISTING DISORDERS
Patients with “Dual Diagnosis” - combined psychiatric and substance abuse
problems - who are eligible for services fall into four major quadrants
PSYCH. HIGH
SUBSTANCE HIGH
PSYCH. LOW
SUBSTANCE HIGH
Serious & Persistent
Psychiatrically Complicated
Mental Illness with QUAD Substance Dependence
Substance Dependence: IV QUADRANT III
PSYCH. HIGH
SUBSTANCE LOW
PSYCH. LOW
SUBSTANCE LOW
Serious & Persistent
Mild Psychopathology with
Mental Illness with
Substance Abuse
Substance Abuse QUAD II QUADRANT i
PSYCH HIGH / SUBSTANCE LOW
SERIOUS & PERSISTENT
MENTAL ILLNESS
WITH SUBSTANCE ABUSE
QUADRANT II
• Patients with serious and persistent mental illness
(e.g. Schizophrenia, Major Affective Disorders with
Psychosis, Serious PTSD) which is complicated by
substance abuse, whether or not the patient sees
substances as a problem.
PSYCH HIGH / SUBSTANCE HIGH
SERIOUS & PERSISTENT
MENTAL ILLNESS
WITH SUBSTANCE DEPENDENCE
QUADRANT IVA
• Patients with serious and persistent mental illness,
who also have alcoholism and or drug addiction, and
who need treatment for addiction, for mental illness,
or for both. This may include sober individuals who
may benefit from psychiatric treatment in a setting
which also provides sobriety support and Twelve-step
Programs.
PSYCH LOW / SUBSTANCE HIGH
PSYCHIATRICALLY COMPLICATED
SUBSTANCE DEPENDENCE
QUAD III (mild-mod); QUAD IVB (severe)
• Patients with alcoholism and/or drug addiction who
have significant psychiatric symptomatology and /or
disability but who do NOT have serious and
persistent mental illness.
• Includes both substance-induced psychiatric
disorders and substance-exacerbated psychiatric
disorders.
• Includes the following psychiatric syndromes:
–
–
–
–
–
Anxiety/Panic Disorder
- Suicidality
Depression/Hypomania
- Violence
Psychosis/Confusion
- PTSD Symptoms
Symptoms Secondary to Misuse/Abuse of Psychotropic Medication
Personality Traits/Disorder
PSYCH LOW / SUBSTANCE LOW
MILD PSYCHOPATHOLOGY
WITH SUBSTANCE ABUSE
QUADRANT I
• Patients who usually present in outpatient setting with
various combinations of psychiatric symptoms (e.g.
anxiety, depression, family conflict) and patterns of
substance misuse and abuse, but not clear cut
substance dependence.
DSM III-R Diagnostic Criteria
PSYCHOACTIVE SUBSTANCE
ABUSE
• A maladaptive pattern of psychoactive substance use
indicated by at least one of the following:
• Continued substance use despite having persistent or recurrent social,
occupational, psychological, or physical problems caused or
exacerbated by the effects of the substance use
• Recurrent substance use in situations in which it is physically
hazardous
• Recurrent substance-related legal problems
• Some symptoms of the disturbance have lasted for at least
one month, or have occurred repeatedly over a longer
period of time.
• The symptoms have never met the criteria for Substance
Dependence for this class of substance.
DSM IV Diagnostic Criteria
PSYCHOACTIVE SUBSTANCE
DEPENDENCE
• A maladaptive pattern of substance use, leading to
clinically significant impairment or distress, as manifested
by three (or more) of the following, occurring any time in
the same 12-month period:
– Tolerance, as defined by either of the following:
•
•
A need for markedly increased amounts of substance to achieve intoxication or desired effect
Markedly diminished effect with continued use of the same amount of the substance
– Withdrawal, as manifested by either of the following:
•
•
The characteristic withdrawal syndrome for the substance
The same (or closely related) substance is taken to relieve or avoid withdrawal symptoms
• The substance is often taken in larger amounts or over a longer
period than was intended
• There is a persistent desire or unsuccessful efforts to cut down
or control substance use
(Continued)
DSM IV Diagnostic Criteria
PSYCHOACTIVE SUBSTANCE
DEPENDENCE
(Continued)
• A great deal of time spent in activities necessary to obtain the
substance, use the substance, or recover from its effects
• Important social, occupation, or recreational activities are given
up or reduced because of substance use
• Continued use despite knowledge of having a persistent or
recurrent physical or psychological problem that is likely to have
been caused or exacerbated by the substance
NOTE: The following items may not apply to cannabis,
hallucinogens, or phencyclidine (PCP)
• Characteristic withdrawal symptoms
• Substance often taken to relieve or avoid withdrawal symptoms
Individuals with Co-occurring Disorders
Treatment Rules
•
All good treatment proceeds from empathic, hopeful, clinical relationship.
•
Consequently, promote opportunities to initiate and maintain
integrated, continuing, empathic, hopeful relationships whenever
possible.
•
Specifically, remove arbitrary barriers to initial mental health assessment
and evaluation, including initial psychopharmacology evaluation (e.g.,
length of sobriety, alcohol level, etc.)
Similarly, never deny access to substance disorder evaluation and/or
treatment because a patient is on a prescribed non-addictive psychotropic
medication.
•
•
•
Moreover, never discontinue medication for a known serious mental
illness because a patient is using substances.
In fact, when mental illness and substance disorder co-exist, both disorders
require specific and appropriately intensive primary treatment.
There are no rules! The specific content of dual primary treatment for each
person must be individualized according to diagnosis, phase of treatment,
level of functioning and/or disability, and assessment of level of care based
on acuity, severity, medical safety, motivation, and availability of recovery
support.
PRINCIPLES
Dual Diagnosis is an expectation,
not an exception.
Philosophical & Clinical
BARRIERS TO INTEGRATED
TREATMENT
Addiction System
Mental Health System
Peer Counseling model
vs.
Medical/Professional model
Spiritual Recovery
vs.
Scientific treatment
Self Help
vs.
Medication
Confrontation and expectation
vs.
Individualized support and
flexibility
Detachment/empowerment
vs.
Case management/care
Episodic treatment
vs.
Continuity of Responsibility
Recovery ideology
vs.
Deinstitutionalization ideology
Psychopathology is secondary vs.
to addiction
Substance use is secondary
to psychopathology
PRINCIPLES
Within the context of the empathic, hopeful,
continuous, integrated relationship,
case management/care and
empathic detachment/confrontation
are appropriately balanced
at each point in time.
PRINCIPLES
When both Mental Illness and Substance
Disorder coexist, both diagnoses should be
considered primary.
PRINCIPLES
Both Major Mental Illness and Substance
Dependence are examples of primary,
chronic, biologic mental illnesses which fit
into a disease and recovery model of
treatment.
PARALLELS
Alcoholism/Addiction
Major Mental Illness
1.
2.
3.
4.
5.
1.
2.
3.
4.
5.
A biological illness
Hereditary (in part)
Chronicity
Incurability
Leads to lack of control of
behavior and emotions
6. Positive and negative
symptoms
7. Affects the whole family
8. Progression of the disease
without treatment
9. Symptoms can be controlled
with proper treatment
A biological illness
Hereditary (in part)
Chronicity
Incurability
Leads to lack of control of
behavior and emotions
6. Positive and negative
symptoms
7. Affects the whole family
8. Progression of the disease
without treatment
9. Symptoms can be controlled
with proper treatment
(Continued)
PARALLELS
(Continued)
Alcoholism/Addiction
10. Disease of denial, relates to
both disease & chronicity of
disease
11. Facing the disease can lead
to depression and despair
12. Disease is often seen as a
“moral issue”, due to
personal weakness rather
than biological causes
13. Feelings of guilt & failure
14. Feelings of shame & stigma
15. Physical, mental and
spiritual disease
Major Mental Illness
10. Disease of denial, relates to
both disease & chronicity of
disease
11. Facing the disease can lead
to depression and despair
12. Disease is often seen as a
“moral issue”, due to
personal weakness rather
than biological causes
13. Feelings of guilt & failure
14. Feelings of shame & stigma
15. Physical, mental and
spiritual disease
PARALLELS
PROCESS OF RECOVERY
• PHASE 1: Stabilization
- Stabilization of active substance use or acute psychiatric
symptoms
• PHASE 2: Engagement/
Motivational Enhancement
- Engagement in treatment
- Contemplation, Preparation, Persuasion
• PHASE 3: Prolonged Stabilization
- Active treatment, Maintenance, Relapse Prevention
• PHASE 4: Recovery & Rehabilitation
- Continued sobriety and stability
- One year - ongoing
PROCESS OF RECOVERY
PHASE 1: Stabilization
Stabilize Acute
Psychiatric Illness
Detoxification
•
•
•
•
•
Often inpatient, may be
involuntary
Usually need medication
3-5 days (alcohol) to 2-3 weeks
(opiates, benzos)
Includes assessment for other
diagnoses
Stabilization can occur at any
level of care (ASAM)
•
•
•
•
•
Often inpatient, may be involuntary
Usually need medication
2 days to 6 months
Includes assessment for effects of
substances, and for addiction
Stabilization may occur at any level
of care (LOCUS)
Level of Care Assessment
ASAM ASSESSMENT
DIMENSIONS
1. Intoxication,
withdrawal
2. Biomedical complic.
3. Emotional/behavior
4. Accept/resistance
5. Relapse potential
6. Recovery env’t
1.
2.
3.
4.
5.
6.
LOCUS
ASSESSMENT
DIMENSIONS
Risk of harm
Functional status
Comorbidity
Recovery env’t
Treatment History
Adherence/motiv.
PROCESS OF RECOVERY
PHASE 2: Engagement/Motivational
Enhancement
Addiction Treatment
•
•
•
•
Engagement in ongoing treatment is
crucial for recovery to proceed
Begins with empathy and proceeds
through phases of education and
empathic confrontation, before
patient commits to ongoing active
treatment
Motivational interviewing techniques
Education about substance use,
abuse, and dependence & empathic
confrontation of adverse
consequences are tools to
overcome denial. Patient accepts
powerlessness to control drug
without help
Psychiatric Treatment
•
•
•
•
Engagement in ongoing treatment is
crucial for recovery to proceed
Begins with empathy and proceeds
through phases of education and
empathic confrontation, before
patient commits to ongoing active
treatment
Motivational interviewing techniques
Education about mental illness and
the adverse consequences of
treatment non-compliance are tools
to overcome denial. Patient accepts
powerlessness to control symptoms
without help
(Continued)
PROCESS OF RECOVERY
PHASE 2: Engagement/Motivational
Enhancement
(Continued)
Addiction Treatment
•
•
•
•
Education of the family, & involving
them in interviews to promote
motivation
Engagement may take place in a
variety of treatment settings…may
need extended inpatient or day
treatment rehabilitation (2-12
weeks)
Engagement may be initially
coerced
Multiple cycles of relapse usually
occur before engagement in
ongoing treatment is successful
(revolving door)
Psychiatric Treatment
•
•
•
•
Education of the family, & involving
them in setting limits on noncompliance
Engagement may take place in a
variety of treatment settings…may
need extended inpatient or day
treatment rehabilitation (1-6 months)
Engagement may be initially
coerced
Multiple cycles of relapse usually
occur before engagement in
ongoing treatment is successful
(revolving door)
STAGES OF CHANGE
Prochaska & DiClemente (1992)
• PRECONTEMPLATION
• CONTEMPLATION
• PREPARATION
• ACTION
• MAINTENANCE
STAGES OF TREATMENT
Osher & Kofoed (1989)
McHugo et al (1995)
1. Pre-engagement
ENGAGEMENT
2. Engagement
3. Early Persuasion
PERSUASION
4. Late Persuasion
5. Early Active Rx
ACTIVE TREATMENT
6. Late Active Rx
7. Relapse Prevention
RELAPSE PREVENTION 8. Remission
PROCESS OF RECOVERY
PHASE 3: Prolonged Stabilization
Continued Abstinence
•
•
•
•
•
•
One-Year
Patient consistently attends
abstinence support programs
Usually voluntary, but ongoing
compliance may be coerced or
mandated
Ongoing education about addiction,
recovery and skills to maintain
abstinence
Focus on asking for help to cope
with urges to use substances and
drop out of treatment
Must learn to accept the illness and
deal with shame, stigma, guilt, and
despair
Continued Medication
Compliance
•
•
•
•
•
•
One-Year
Patient consistently takes
medication and attends treatment
sessions regularly
Usually voluntary, but may be
coerced or mandated
Ongoing education about mental
illness, recovery and skills to
prevent relapse
Focus on asking for help to cope
with continuing symptoms and
urges to discontinue treatment
Must learn to accept the illness and
deal with shame , stigma, guilt, and
despair
(Continued)
PROCESS OF RECOVERY
PHASE 3: Prolonged Stabilization
(Continued)
Continued Abstinence
•
•
•
•
•
Must learn to cope with “negative
symptoms”: social, affective,
cognitive, and personality
development
Family needs ongoing involvement
in its own program of recovery to
learn empathic detachment and
how to set caring limits
May need intensive outpatient
treatment and/or 6-12 months
residential placement
Continuing assessment
Risk of relapse continues
Continued Medication
Compliance
•
•
•
•
•
Must learn to cope with “negative
symptoms”: impaired cognition,
affect, social skills, and lack of
motivation/energy
Family needs ongoing involvement
in its own program of recovery to
learn empathic detachment and how
to set caring limits
May need extended hospital, day
treatment and/or residential
placement
Continuing assessment
Risk of relapse continues
PROCESS OF RECOVERY
PHASE 4: Recovery & Rehabilitation
Continued Sobriety
•
•
•
•
•
Continued Stability
Voluntary, active involvement in
treatment
Stability precedes growth; no
growth is possible unless sobriety
is fairly secure. Growth occurs
slowly (One Day at a Time)
Continued work in the AA program,
on growing, changing, dealing with
feelings
•
Thinking begins to clear
New skills for dealing with feelings,
situations
•
•
•
•
Voluntary, active involvement in
treatment
Stability precedes growth; no growth
is possible unless stabilization of
illness is fairly solid. Growth occurs
slowly (One Day at a Time)
Continued medication, but reduction
to lowest level needed for
maintenance. Continued work in
treatment program
Thinking begins to clear
New skills dealing with feelings,
situations
(Continued)
PROCESS OF RECOVERY
PHASE 4: Recovery & Rehabilitation
(Continued)
Continued Sobriety
•
•
•
•
Increasing responsibility for illness,
and recovery program brings
increasing control of one’s life
Increasing capacity to work and to
have relationships
Recovery is never “complete”,
always ongoing
Eventual goal is peace of mind and
serenity (Serenity Prayer)
Continued Stability
•
•
•
•
Increasing responsibility for illness,
and recovery programs brings
increasing control of one’s life
Increasing capacity to work and
relate (voc rehab, clubhouse)
Recovery is never “complete”,
always ongoing
Eventual goal is peace of mind and
serenity (Serenity Prayer)
SERENITY PRAYER
“Grant me the serenity to accept the
things I can not change,
the courage to change the things I can,
and the wisdom to know the difference.”
Individuals with Co-occurring Disorders
PRINCIPLES OF SUCCESSFUL
TREATMENT:
Dual diagnosis is an expectation,
not an exception. This expectation must
be incorporated in a welcoming manner
into all clinical contact.
• The Four Quadrant Model is a viable
mechanism for categorizing individuals
with co-occurring disorders for purpose
of service planning and system
responsibility.
Treatment success derives from the
implementation of an empathic, hopeful,
continuous treatment relationship, which
provides integrated treatment and coordination
of care through the course of multiple
treatment episodes.
Within the context of the empathic, hopeful,
continuous, integrated relationship,
case management/care
(based on level of impairment) and
empathic detachment/confrontation
(based on strengths and contingencies)
are appropriately balanced
at each point in time.
When substance disorder and psychiatric
disorder co-exist, each disorder should be
considered primary, and integrated dual
primary treatment is recommended,
where each disorder receives appropriately
intensive diagnosis-specific treatment.
Both substance dependence and serious
mental illness are examples of primary,
chronic, biologic mental illnesses, which
can be understood using a disease and
recovery model, with parallel phases of
recovery.
There is no one type of dual diagnosis
program or intervention.
For each person, the correct treatment
intervention must be individualized
according to subtype of dual disorder, and
diagnosis, phase of recovery, stage of
treatment, level of functioning, skills, and/or
disability, plus goals, problems, and
contingencies, associated with each
disorder.
In a managed care system, individualized
treatment matching also requires
multidimensional level of care assessment
involving acuity, dangerousness,
motivation, capacity for treatment
adherence, and availability of continuing
empathic treatment relationships and other
recovery supports.
Individuals with Co-occurring Disorders
Principles of Successful Treatment
•
Co morbidity is an expectation, NOT an exception. Four Quadrant Model.
•
Treatment success derives from the implementation of an empathic, hopeful,
continuous treatment relationship, which provides integrated treatment and coordination
of care through the course of multiple treatment episodes.
•
Within the context of the empathic, hopeful, continuous, integrated relationship, case
management/care and empathic detachment/ confrontation are appropriately
balanced at each point in time.
•
When substance disorder and psychiatric disorder co-exist, each disorder should be
considered primary, and integrated dual primary treatment is recommended, where
each disorder receives appropriately intensive diagnosis-specific treatment.
•
Both major mental illness and substance dependence are examples of primary mental
illnesses which can be understood using a disease and recovery model, with parallel
phases of recovery, each requiring phase-specific treatment.
There is no one type of dual diagnosis program or intervention. For each person,
the correct treatment intervention must be individualized according to diagnosis, phase
of recovery/treatment, level of functioning and/or disability associated with each disorder,
and level of acuity, dangerousness, motivation, capacity for treatment adherence,
and availability of continuing empathic treatment relationships and other recovery
supports.
•
ASSESSMENT OF
INDIVIDUALS WITH COOCCURRING DISORDERS
• Detachment
• Detection
• Diagnosis and Disability
• Determination of treatment needs
• Detailed Description of Situation,
Supports, Skills, and Cultural Context
Detachment
• Empathic detachment facilitates
gathering accurate information
• Proactively communicate detachment
and acceptance of consumer choice
• Use detachment mantra
Detection
• High index of welcoming and expectation
• Gather data from multiple sources, expecting
information discrepancies.
• Initial screening: do (did) you have a problem?
• Screening tools: CAGE, MAST, DALI ,
RAFFT (SA); MIDAS
(www.ohiosamiccoe.cwru.edu/clinical)
• BSI, MINI, Project Return MH Screening
Form (www.asapnys.org/resources) (MH)
• Use urine/saliva/hair screens selectively
Diagnosis
• Integrated, longitudinal, strength-based history
• Utilize mental status and medication response
data from past periods of abstinence or limited
use
• Low threshold for MH consult in SA setting
• Identify patterns of dependence (vs. abuse) by
assessing for awareness of lack of control in the
face of serious harm; tolerance and withdrawal
are not required.
Description
• Ask more questions to obtain more details about the
problems you know least about
• Identify external problem areas and supports (ASI),
and explore opportunities for contingencies
• Obtain detailed information about mh symptoms :
duration, content, control, perception of cause, factors
which exacerbate/lessen, mh disease mgt skills
• Obtained detailed information about substance use:
factors which promote/inhibit use, situations of use,
cost of use, substance using peers, efforts to control use,
substance use mgt skills
• Obtain detailed cultural context information: (peer,
traditional, mh system, addiction recovery cultures)
Determination of Treatment
Needs
• Assessment of individualized treatment goals
using motivational interviewing
• Determination of stage of change/ stage of
treatment:
–
–
–
–
Substance Abuse Treatment Scale (McHugo et al)
SOCRATES (Miller et al);
URICA (DiClemente et al)
Readiness to Change Questionnaire (Rollnick et al)
Treatment Matching Example
Quadrant IVA
•
•
•
•
•
Continuity
Acute Stabilization
Motivational Enhancement
Active Treatment
Relapse Prevention/Rehabilitation
PSYCHOPHARMACOLOGY
PRACTICE GUIDELINES
• I. GENERAL PRINCIPLES
• Not an absolute science
• Ongoing, empathic, integrated
relationship
• Continuous re-evaluation of dx and rx
• Balance case management and care with
contingency management and contracts
• Strategies to promote dual recovery
PSYCHOPHARMACOLOGY
PRACTICE GUIDELINES
• II. ACCESS AND ASSESSMENT
• Promotion of access and continuity of
relationship is the first priority
• No arbitrary barriers to psychopharm
assessment in any setting based on length of
sobriety or drug/alcohol levels
• No arbitrary barriers to substance assessment
based on psychopharm regimen
PSYCHOPHARMACOLOGY
PRACTICE GUIDELINES
• III. DUAL PRIMARY TREATMENT
• Diagnosis-specific treatment for each disorder
simultaneously
• Distinguish abuse and dependence
• Specific psychopharm strategies for addictive
disorders are appropriate for individuals with
comorbidity
• For a known or presumed psychiatric disorder,
continue use of best non-addictive medication
for that disorder, regardless of status of SUD.
PSYCHOPHARMACOLOGY
PRACTICE GUIDELINES
• III. DUAL PRIMARY TREATMENT
• ADDICTION PSYCHOPHARM
• Disulfiram
• Naltrexone
• Opiate Maintenance Treatment
• Others?
PSYCHOPHARMACOLOGY
PRACTICE GUIDELINES
• III. DUAL PRIMARY TREATMENT
• PSYCHOPHARM FOR MI
• Atypicals and clozapine for psychosis
• LiCO3 vs newer generation mood stabilizers
• Any non-tricyclic antidepressant
• Anxiolytics: clonidine, SSRIs, venlafaxine,
nefazodone, topiramate, other mood stabilizers,
atypicals, (buspirone not first line)
• ADHD: Bupropion, then clonidine, SSRIs,
tricyclics, then stimulants
PSYCHOPHARMACOLOGY
PRACTICE GUIDELINES
• IV. DECISION PRIORITIES
• SAFETY
• STABILIZE ESTABLISHED OR
SERIOUS MI
• SOBRIETY
• IDENTIFY AND STABILIZE MORE
SUBTLE DISORDERS
SAFETY
• Acute medical detoxification should follow same
established protocols as for individuals with
addiction only.
• Maintain reasonable non-addictive psychotropics
during detoxification
• For acute behavioral stabilization, use whatever
medications are necessary (including
benzodiazepines) to prevent harm.
STABILIZATION OF SMI
• NECESSARY NON ADDICTIVE
MEDICATION FOR ESTABLISHED
AND/OR SERIOUS MENTAL ILLNESS
MUST BE INITIATED AND MAINTAINED
REGARDLESS OF CONTINUING
SUBSTANCE USE
• More risky behavior requires closer
monitoring, not treatment extrusion
• Be alert for subtle symptoms that are substance
exacerbated, but still require medication at
baseline.
STRATEGIES FOR SOBRIETY
• Medication for addiction is presented as ancillary to a full
recovery program that requires work independent of
medication. Individuals on proper medication must work
as hard as those with addiction only.
• Distinguish normal feelings from disorders with similar
names (anxiety, depression)
• Psychiatric medications are directed to known or probable
disorders, not to medicate feelings
• Proper medication for mental illness does not take away
normal feelings, but permits patients to feel their feelings
more accurately.
• Use fixed dosage regimes, not prn meds.
More Strategies for Sobriety
• Avoid use of benzodiazepines or other generic
potentially addictive sedative/hypnotics in patients
with known substance dependence
• Continued BZD prescription should be an
indication for consultation, peer review
• Use contingency contracting to engage individuals
who are already on BZDs.
• If indicated, withdrawal from prescribed BZDs
using carbamazepine (or VPA, gabapentin), plus
phenobarbital taper (1mg clonazepam = 30 mg pb)
• Be alert for prolonged BZD withdrawal syndrome
More Strategies for Sobriety
• Pain Management should occur in collaboration
with a prescribing physician who is fully informed
about the status of substance use disorder
• Individuals addicted to opiates for non-specific
neck, back, etc. conditions can be informed that
continued use of opiates worsens perceived pain.
Full withdrawal plus alternative pain management
strategies can actually improve pain in the long
run.
CHANGING THE WORLD
Developing
Comprehensive, Continuous, Integrated
Systems of Care (CCISC)
For
Individuals with Co-occurring
Psychiatric and Substance
Disorders
CCISC CHARACTERISTICS
• 1. SYSTEM LEVEL CHANGE
• 2. USE OF EXISTING RESOURCES
• 3. BEST PRACTICES UTILIZATION
• 4. INTEGRATED TREATMENT
PHILOSOPHY
CHANGING THE WORLD
• A. SYSTEMS
• B. PROGRAM
• C. CLINICAL PRACTICE
• D. CLINICIAN
12 STEPS OF IMPLEMENTATION
•
•
•
•
1. INTEGRATED SYSTEM PLANNING
2. CONSENSUS ON CCISC MODEL
3. CONSENSUS ON FUNDING PLAN
4. IDENTIFICATION OF PRIORITY
POPULATIONS WITH 4 BOX MODEL
• 5. DDC/DDE PROGRAM STANDARDS
• 6. INTERSYSTEM CARE
COORDINATION
12 STEPS OF IMPLEMENTATION
• 7. PRACTICE GUIDELINES
• 8. IDENTIFICATION, WELCOMING,
ACCESSIBILITY: NO WRONG DOOR
• 9. SCOPE OF PRACTICE FOR
INTEGRATED TREATMENT
• 10. DDC CLINICIAN COMPETENCIES
• 11. SYSTEM WIDE TRAINING PLAN
12 STEPS OF IMPLEMENTATION
• 12. PLAN FOR COMPREHENSIVE
PROGRAM ARRAY
– A. EVIDENCE-BASED BEST PRACTICE
– B. PEER DUAL RECOVERY SUPPORT
– C. RESIDENTIAL ARRAY: WET, DAMP,
DRY, MODIFIED TC
– D. CONTINUUM OF LEVELS OF CARE
IN MANAGED CARE SYSTEM: ASAM2R, LOCUS 2.0
A. SYSTEMS CHANGE
• 1. Empower structure to manage change
• 2. Consensus building on principles
• 3. Regulatory Change
– A. Licensure/certification
– B. Reimbursement/funding
– C. Program standards/Practice Guidelines
– D. Clinician competency/certification
4. Quality Management/Outcome Evaluation
B. PROGRAM CHANGE
• 1. STRUCURED PLAN FOR
PROGRAMMATIC INTERFACE
• 2. COMPREHENSIVE PROGRAM
ARRAY
– A. Horizontal integration/ MH and SA
– B. Vertical integration/ managed care
B1. PROGRAM INTERFACE
• A. Formal interagency care coordination
• B. Mechanisms for administrative and clinical
dispute resolution
• C. Longitudinal continuity: interface with
episodes of care
• D. Vertical continuity/integration: front door
meets back door
• E. MH support to CD system: Emergency/meds
• F. CD continuity of connection: MH&CD
B2. COMPREHENSIVE
PROGRAM ARRAY
• PROGRAM CATEGORIES
• Addiction System (ASAM PPC2R)
• DDC-CD
• DDE-CD
• AOS
• Mental Health System (Minkoff)
• DDC-MH
• DDE-MH
• Peer Involvement/Cultural Competency
Dual Diagnosis Capable:
DDC-CD
• Routinely accepts dual patients, provided:
• Low MH symptom acuity and/or disability,
that do not seriously interfere with CD Rx
• Policies and procedures present re: dual
assessment, rx and d/c planning, meds
• Groups address comorbidity openly
• Staff cross-trained in basic competencies
• Routine access to MH/MD consultation/coord.
• Standard addiction program staffing level/cost
Dual Diagnosis Enhanced:
DDE-CD
• Meets criteria for DDC-CD, plus:
• Accepts moderate MH symptomatology or
disability, that would affect usual rx.
• Higher staff/patient ratio; higher cost
• Braided/blended funding needed
• More flexible expectations re:group work
• Programming addresses mh as well as dual
• Staff more cross-trained/ senior mh supervision
• More consistent on site psychiatry/ psych RN
• More continuity if patient slips
Addiction Only Services:
AOS
•
•
•
•
Not standard for addiction services
Does not meet DDC criteria
Dual diagnosis accepted irregularly
Dual diagnosis not routinely addressed in
treatment, nor documented
• Appropriate for a narrowing group of
clients
Dual Diagnosis Capable:
DDC-MH
• Welcomes people with active substance use
• Policies and procedures address dual
assessment, rx & d/c planning
• Assessment includes integrated mh/sa hx,
substance diagnosis, phase-specific needs
• Rx plan: 2 primary problems/goals
• D/c plan identifies substance specific skills
• Staff competencies: assessment, motiv.enh., rx
planning, continuity of engagement
• Continuous integrated case mgt/ phase-specific
groups provided: standard staffing levels
Dual Diagnosis Enhanced
DDE-MH
• Meets all criteria for DDC-MH, plus:
• Supervisors and staff: advanced competencies
• Standard staffing; specialized programming:
a. Intensive addiction programming in
psychiatrically managed setting (dual inpt unit; dry
dual dx housing, supported sober house)
b. Range of phase-specific rx options in ongoing care setting:
dual dx day treatment; damp dual dx housing
c. Intensive case mgt outreach/motiv. enh.: CTT, wet
housing, payeeship management
DUAL DIAGNOSIS CAPABLE
ROUTINELY ACCEPTS DUAL DIAGNOSIS PATIENT
WELCOMING ATTITUDES TO COMORBIDITY
CD PROGRAM: MH CONDITION STABLE AND
PATIENT CAN PARTICIPATE IN TREATMENT
MH PROGRAM: COORDINATES PHASE-SPECIFIC
INTERVENTIONS FOR ANY SUBSTANCE DX.
POLICIES AND PROCEDURES ROUTINELY LOOK
AT COMORBIDITY IN ASSESSMENT, RX PLAN,
DX PLAN, PROGRAMMING
CARE COORDINATION RE MEDS (CD)
DUAL DIAGNOSIS
ENHANCED (DDE)
MEETS DDC CRITERIA PLUS:
CD: MODIFICATION TO ACCOMMODATE MH
ACUITY OR DISABILITY
MH SPECIFIC PROGRAMMING, STAFF, AND
COMPETENCIES, INCLUDING MD
FLEXIBLE EXPECTATIONS; CONTINUITY
MH; ADDICTION TREATMENT IN PSYCH
MANAGED SETTINGS (DUAL DX INPT UNIT) OR
INTENSIVE CASE MGT/OUTREACH TO
MOST SERIOUSLY MI AND ADDICTED PEOPLE
B. PROGRAM
COMPETENCIES
•
•
•
•
•
•
•
•
•
1. CLINICAL CASE MANAGEMENT
2. EMERGENCY SERVICES
3. CRISIS STABILIZATION
4. DETOXIFICATION
5. PSYCH INPATIENT
6. PSYCHIATRIC PARTIAL HOSP/ DAY RX
7. ADDICTION DAY RX/ INTENSIVE OP
8. ADDICTION RESIDENTIAL RX
9. PSYCHIATRIC RESIDENCE PROGRAMS
1. Case Management
(DDC/DDE)
• Integrated, continuous care coordination
• High, medium, and low intensity
• Incorporated into existing front-line case
management for SPMI
• Developed for high utilizers who are nonSPMI as well as SPMI
• Mechanism for supportive administrative
case coordination
2. Emergency Services (DDC)
• Mission defined as welcoming into
appropriate treatment for MH and CD
• Barrier-free access-assessment begins
when client able to participate
• Diagnostic and level of care assessment
for both MH and substance disorder
• Capacity to engage in ongoing crisis
intervention and motivational strategies
3. Crisis Stabilization (DDC)
• Routine acceptance of substance-using patients
who do not need medical detoxification
• Stabilizes substance exacerbated psychiatric
symptoms, with meds if necessary
• Utilizes motivational and active treatment
strategies to address substance use
• Participates with primary case coordination
team in implementation of treatment contracts
• May provide access to intensive outpatient
addiction treatment (DDC or DDE)
4A. Detoxification (DDC)
• Provides detoxification for
psychiatrically stable individuals with
mental illness who are not severely
disabled
• Meets ASAM PPC2R defined criteria for
DDC programs
4B. Psychiatrically-Enhanced
Detoxification (DDE)
• Provides ASAM Level III detoxification for
psychiatrically impaired or unstable (e.g.,
suicidal) individuals who are voluntary and can
contract for safety
• Medical monitoring provided by psychiatrist or
psychiatric nurse
• Psychopharmacologic adjustment provided
• Space, staffing, and staff training permit closer
monitoring
• Meets ASAM PPC2R DDE criteria
5A.Inpatient Psych Unit (DDC)
• Program standards address dual diagnosis
competency
• Required basic staff and MD competencies,
included in job description
• Welcoming staff attitudes
• Competence in detox protocols
• Demonstrated assessment competency
• Documentation of substance disorder
interventions in treatment planning/notes
• Daily substance related group programming
• Competent substance disorder d/c planning
5B.Inpatient Dual Unit (DDE)
• Meets all DDC criteria, plus
• Staff routinely have expertise in both psych and
addiction
• Full addiction program, incorporating dual dx
groups
• Routine access to 12-step programs
• Provides addiction rx for patients with severe
psychiatric acuity and instability
• Specialized expertise in dual diagnosis
assessment and psychopharmacology
6. Psychiatric Day Treatment
and Partial Hosp. (DDC-MH)
• Acute Partial: Same as DDC inpatient, except
for detox, plus specific policies to address
substance use while in treatment
• Intermediate/long-term Day Treatment:
routine assessment and rx planning; phasespecific groups, including motivational
interventions for non-abstinent patients. No
reject for substance use. Specific policies to
address substance use in rx.
6B: Dual Diagnosis Partial
Hosp and Day Rx (DDE)
• Acute Partial: Similar to DDE inpatient;
abstinence-oriented, with strict limits on use in
program
• Intermediate/Long-Term Day Rx: Program
may be abstinence-oriented, or may provide
intensive motivational/harm reduction groups
for long-term clients who are still using, OR
BOTH (2 tracks). Extensive addiction/dual
programming. Specific policies on substance
use which promote continuity even if pt.
discharged.; Dual dx specialist supervisors.
7A. Addiction Residential
Treatment (DDC)
• Sober environment for episode of addiction
treatment. DDC program meets all standard
criteria for DDC-CD.
• Relapses not tolerated, but in long-term
programs, first-offense may not result in
discharge
• Discharge is an opportunity for learning;
individual welcome to return
• Discharge coordinated with mh provider and
criteria for readmission established
• Collaborative relationship with mh system re:
7B. Psychiatrically Enhanced
Addiction Residential Rx(DDE)
• DDE Program meets all DDC-CD residential
criteria, plus all DDE-CD criteria.
• Residential addiction rx for individuals (SMI
and non-SMI) with moderate psychiatric acuity
and/or disability
• Dual Diagnosis Acute Residential Treatment
(DDART) is a short-term (10-14 day) DDE
program in Mass.
• Modified Therapeutic Community (Sacks,
DeLeon) is an example of a long-term DDE
program
8. Psychiatric Residential
Programs
• Primarily HOUSING programs for people with
psychiatric disabilities
• All programs designed to be DDC
• Programs must accommodate a range of ability
and willingness to address substance use: WET,
DAMP, DRY
• DRY (DDE) Housing for individuals with dual
disorder who want sober support. Multiple (but
finite) slips permitted, with intervention plan
• DAMP (DDC) Abstinence recommended, not
required. Substance use addressed if safety
Psych Residential (cont’d)
• WET: Consumer choice housing; no
requirement to limit use to have housing
support. Pathways to Housing (NYC) Usually
supported housing model
• Case Managed Supported Sober Housing:
Combines Oxford House concept with MH
supported housing concept. Inexpensive
method to create sober housing
C. CLINICAL PRACTICE
STANDARDS I
• 1. WELCOMING PHILOSOPHY
• 2. ACCESS TO BARRIER-FREE
ASSESSMENT: “NO WRONG DOOR”
• 3. SCREENING & ASSESSMENT:
INCENTIVES FOR IDENTIFICATION
• 4. LEVEL OF CARE ASSESSMENT: ASAM
PPC2R, LOCUS,CHOICE-DUAL
• 5. SCOPE OF PRACTICE/SERVICE CODE
C. CLINICAL PRACTICE
STANDARDS II
• 6. CONTINUITY OF CARE: MH & CD
• 7. PHASE-SPECIFIC RX MATCHING
• 8. PSYCHOPHARM GUIDELINES:
CONTINUITY, QUALITY, BENZOS
• 9. CONSISTENT RX MANUALS
• 10. OUTCOME MEASURES:
UTILIZATION, HARM, STAGE OF
CHANGE, ABSTINENCE/USE
SCOPE OF PRACTICE FOR INTEGRATED
TREATMENT
•
•
•
•
•
•
1. WELCOMING, EMPATHY, DUAL RECOVERY
2. SCREENING FOR COMORBIDITY
3. ASSESS ACUTE MH/DETOX RISK
4. OBTAIN ASSESSMENT OF COMORBIDITY
5. AWARENESS OF DIAGNOSIS AND RX PLAN
6. SUPPORT TREATMENT ADHERENCE/ MED
COMPLIANCE
• 7. IDENTIFY STAGE OF CHANGE FOR EACH DX
• 8. 1-1 & GROUP INTERVENTIONS FOR
EDUCATION & MOTIVATION ENHANCEMENT
SCOPE OF PRACTICE (continued)
• 9. SPECIFIC SKILLS TRAINING TO REDUCE USE
• 10. MANAGE FEELINGS AND SYMPTOMS
WITHOUT USING
• 11. HELP CLIENT ADVOCATE WITH OTHER
PROVIDERS REGARDING MH NEEDS
• 12. HELP CLIENT ADVOCATE RE: CD NEEDS
13. COLLABORATE WITH OTHER PROVIDERS.
14. EDUCATE CLIENT RE: MEDS AND 12 STEP
15. MODIFY SKILLS TRAINING RE: DISABILITY
16. PROMOTE DUAL RECOVERY MEETING USE
D. CLINICIAN STANDARDS
• 1. COMPETENCY/CERTIFICATION
• A. Required basic competencies:
Attitudes, values, knowledge, and skill
Competency Assessment Tools
• B. Place/train: job descriptions
• C. Certifications for career ladders
• D. Advanced competencies for trainers and
supervisors.
D. CLINICIAN STANDARDS
•
•
•
•
•
•
• 2. TRAINING
A. System wide training plan
B. Training program guidelines
C. Train trainers for each site
D. Curriculum guideline dissemination
E. On-site case based continuing training
F. Experiential learning/ staff exchange
CHANGING THE WORLD:
• DEVELOPING AN INTEGRATED
SYSTEM OF CARE
IN A
STATE MENTAL HOSPITAL
SYSTEMS LEVEL CHANGE
1. Develop a structure to manage change
A. Integrated Team of discipline/dept.
heads.
B. Continuous Quality Improvement
1. Defines bidirectional, multilevel
process
2. Identifies measurable outcomes
3. Meets JCAHO requirements
SYSTEMS LEVEL CHANGE
2. Build Consensus on Principles
A. Use TDMHMR Principles to start
B. Include “firestarters”
C. Begin with management team
D. All staff involved, emphasize
attitudes
E. Measure consensus (outcome)
SYSTEMS LEVEL CHANGE
3. Establish Standards
A. Program Competency Standards
B. Practice Guidelines: Assessment,
continuity, discharge planning, rx plan
psychopharm (algorithm project)
C. Program Plan for service matching
D. Clinician Competencies
SYSTEMS LEVEL CHANGE
4. Identify Outcomes
A. Structure
1. Consensus, standards established
2. Program elements in place
B. Process
1. Screening tools used
2. Consumers identified and treated
C. Outcome: Satisfaction, stage of change,
skill, relapse prevention, community linkage
PROGRAM LEVEL
CHANGES
1. Develop program array based on needs
assessment
2. Implement general program standards
hospital wide
3. Develop content and protocols for specialized
interventions
4. Implement hospital wide mechanisms to
monitor program interface
5. Implement strategies for managing
community interface & promoting continuity
Program Array
1. Needs assessment based on categories:
a. Severe mh impairment vs. non-severe
b. Substance Abuse vs. Dependence
c. Stage of change/Phase of Recovery
d. Long stay vs. short stay
2. Program matching categories
a. Detox
b. Motivational Enhancement (mh hi vs. lo)
c. Active Rx/Relapse Prevention: SubstancAbuse
d. Specialized Addiction Rx (mh hi vs. lo)
Program Standards/DDC
1. Uniform screening and assessment
2. Assessment includes abuse/dep, stage of
change, recovery skills and supports
3. Document diagnosis, formulation using
treatment matching algorithm
4. Problem-specific rx plan and d/c plan
5. Stage-specific groups with range of
educational materials
Specialized Program
Model/DDE
1. Addiction group program with mh
modifications (high vs low disability)
2. Policies defining behavioral
expectations and consequences
3. Dual competent clinical leadership
4. In vivo skills training and role playing
5. Contingent learning interventions
6. Plans to promote community continuity
Intrahospital Program
Interface
1. Clinical Review Committee
a. Chaired by Medical Director/Clin Dir
b. Conferences complex cases
c. Reviews policies & contingency plans
d. Addresses interprogram disputes
2. Program Admission/D/C Criteria
a. Seamless b. Incentives/sanctions
Hospital-Community Interface
1. Interagency care coordination
a. Admission/readmission criteria
b. Contingency based transitions
c. Skills training for community setting
d. Case conferences
2. Consistent hospital/community manuals
3. Recovery program (AA, DRA) linkage
CLINICAL STANDARDS
1.
2.
3.
4.
Welcoming attitudes
Accessible admission/readmission
Standard screening and assessment tools
Multi dimensional assessment including
CIWA, diagnosis, description, stage of
change, recovery skills and supports
5. Detox and urine screening protocols
6. Behavioral criteria for pass or discharge
7. Psychopharmacology guidelines (TMAP)/
Peer review
Behavioral Criteria
1. Pass Skills (for pts w/ identified issue)
a. I have a problem
b. I want to change
c. I am at risk on pass
d. I agree to a risk plan
e. I will demonstrate skills to not use
f. I will agree to monitoring and incentives.
Behavioral Criteria
2. Specialized program criteria
a. Positive incentives for entry and
success
b. Point or token system
c. Consequences for non-compliance
and/or use, including ultimate time
limited transfer to more restricted
setting.
CLINICIAN COMPETENCY
1. Consensus basic competency related to job
descriptions
a. Amend HR policy, and evaluation tool
b. Self-learning workbook and exam
2. Training and supervision plan
a. Assign supervisory resource to each unit.
b. Combine didactics with on the job
learning.
c. Community internships and staff exchange