Download substance use disorders - Drug Abuse Alternatives Center

Treating the Whole Person:
Integrating Care for Persons
with Co-Occurring Disorders
Thomas E. Freese, Ph.D.
Beth A. Rutkowski, M.P.H.
UCLA ISAP/Pacific Southwest ATTC
www.uclaisap.org
www.psattc.org
Ice Breaker
• In pairs, discuss a consumer who has
experienced both mental health and
substance use disorders.
• How is this consumer unique from other
mental health consumers?
• How does the consumer present? What
behaviors does he/she exhibit that are
different from a consumer with mental illness
only?
Introduction:
What we will cover
• Overview of the evolving field of
Co-Occurring Disorders
• What is happening in the brain?
• Using motivational interviewing with this
population—why and how
• Importance of conducting effective screening
and assessment for COD
• Conducting a brief intervention for
consumers with COD
• Ways in which trauma and HIV impact COD
Co-Occurring Disorders
Co-occurring disorders
• Refers to co-occurring substance use (abuse or
dependence) and mental disorders
In other words…
consumers with co-occurring disorders have:
• one or more disorders relating to the use of alcohol
and/or other drugs of abuse and one or more
mental disorders
Co-Occurring Disorders
Diagnosis of COD occurs when:
• at least one disorder of each type can be
established independent of the other and
• is not simply a cluster of symptoms resulting from
the one disorder
Clinicians knowledge of
both mental health and substance abuse
is essential, but challenging to achieve
So, all of that is well and
good, but…
…is dealing with drug abuse
REALLY important to my job?
Prevalence of COD
• In 2006, 5.6 million adults (2.5% of persons aged
18+) met the criteria for both serious psychological
distress (SPD) and substance dependence and
abuse (i.e., substance use disorder, SUD)
• In 2006, 15.8 million adults (7.2% of persons aged
18+) had at least one major depressive episode
(MDE) in the past year
– Adults with MDE in the past year were more
likely than those without MDE to have used an
illicit drug in the past year (27.7 vs. 12.9 percent)
SOURCE: 2006 National Survey on Drug Use and Health, SAMHSA.
Past Year Treatment of Adults with
Both Serious Psychological
Distress (SPD) and SUD (2006)
39.60
Tx for MH Problems
Tx for SUD Only
Tx for SPD and SUD
No Tx
2.8
49.2
8.4
5.6 Million adults with co-occurring SPD
and substance use disorder.
SOURCE: 2007 National Survey on
Drug Use and Health, SAMHSA.
Past Year Treatment of Adults with
Both MDE and AUD
48.6
Tx for MDE only
Tx for Alcohol Only
Tx for MDE and Alcohol
No Tx
40.7
1.9
8.8
SOURCE: 2007 National Survey on Drug Use and Health, SAMHSA.
Percentage of Adults with Past
Year MDE and AUD by Age Group
SOURCE: 2007 National Survey on Drug Use and Health, SAMHSA.
Substance Use and Depression
among Adults
SOURCE: 2006 National Survey on Drug Use and Health, SAMHSA.
Substance Use and Depression
among Adolescents
*Aged 12-17
SOURCE: 2006 National Survey on Drug Use and Health, SAMHSA.
Adolescents with
Substance Use Disorders...
• Are largely undiagnosed
• Are distributed across diverse health and
social service systems
• Are more likely to be involved in the
juvenile justice system
• Have higher rates of child abuse (neglect,
physical and sexual abuse
• Have high co-morbidity with psychiatric
conditions
Data from LA County DMH, 2007
• 61,739 new episodes opened in DMH
Directly Operated Programs:
– 17,647 (29%) dual code field was empty (i.e.,
neither presence nor absence of substance use
noted);
– 44,092 episodes where dual field was
completed:
• 31,187 (71%) indicated NO substance abuse issues
• 12,905 (29%) indicated substance abuse issues.
Prevalence and Other Data
Data now show:
• COD are common in general adult population.
• Increased prevalence of people with COD and
programs for people with COD
• People with COD are more likely to be
hospitalized and the rate may be increasing
• Rates of mental disorders increase as the
number of substance use disorders increase
• If we treat the SUD, we also address mental
health symptoms
So, the answer is…
Yes, this really IS
important to your job!
We must address SUD
in order to increase the
effectiveness of
mental health treatment
One Client’s Perspective
…and to complicate the
picture even more…
Substance Use and Trauma
• The co-occurrence of PTSD and substance use among
those in treatment is 12-34%; for women it is 30-59%.
• Up to two-thirds of men and women in substance abuse
treatment report childhood abuse or neglect.
• People with PTSD and substance abuse are vulnerable to
repeated traumas.
• Becoming abstinent from substances does not resolve
PTSD; some symptoms may become worse with
abstinence.
• Treatment outcomes for those with PTSD and substance
abuse are worse than for those with substance abuse
alone.
Substance Use and HIV
• By 2010, HIV/AIDS will have caused more deaths
than any disease outbreak in history.
• “HIV is spread by unsafe behaviors that mental
health care providers are often in the best position
to identify and address.” **
• Individuals with Severe Mental Illness (SMI) are
disproportionately affected by HIV/AIDS.
• Persons with HIV/AIDS and who have a mental
illness have special needs.
**McKinnon, K. 1999. Psychiatric Services, 50 (9) 1225-1228.
So, How Do We Treat COD?
TIP 42
Guiding Principles
and Recommendations
Six Guiding Principles
(SAMHSA, TIP 42)
• Employ a recovery perspective
• Develop a phased approach to treatment
• Address specific real-life problems early in
treatment
• Plan for cognitive and functional
impairments
Delivery of Services
(SAMHSA, TIP 42)
•
•
•
•
Provide access
Complete a full assessment
Provide appropriate level of care
Achieve integrated treatment
- Treatment Planning and Review
- Psychopharmacology
• Provide comprehensive services
• Ensure continuity of care
Vision of Fully
Integrated Treatment
• One program that provides treatment
for both disorders
• Mental and substance use disorders are
treated by the same clinicians
• The clinicians are trained in
psychopathology, assessment, and
treatment strategies for both disorders
Vision of Fully
Integrated Treatment (continued)
• Treatment is characterized by a slow pace
and a long-term perspective
• Providers offer motivational counseling
• 12-Step groups are available to those who
choose to participate
• Pharmacotherapies are utilized according
to consumers’ psychiatric and other medical
needs
• Sensitivity to issues of trauma, culture,
gender, and sexual orientation
Consumer Improvement Strategies
• Increase the focus on consumer satisfaction
and consumer perception of care
• Increase the use of behavioral enhancement
techniques (use of positive reinforcement
techniques).
• Increase the use to strategies to increase
consumer access to care and appreciation of
care (eg. NIATx)
• Increase measurement of service effectiveness
and greater provider accountability
30
Provider/practice barriers
• Differing practice styles
• Differing practice cultures and language
• Difficulty in matching provider skills with patient
needs
• Heavy reliance on physician services
• Tension between direct patient care services
(reimbursable) and integrative (non-reimbursable)
services
31
Provider/practice barriers
• Lack of recognition of provider limitations
• Lack of MH knowledge in PC providers and lack
of health knowledge in BH providers
• Lack of clinical competence in integrated service
models (MH/SU and BH/PC) and selection of
proper integration model based on practice
context
• Differing coding and billing systems
• Provider resistance
32
Addiction: A Brain Disease
Putting Drug Use into Context with
other Mental Disorders
Onset of Mental Health
Disorders
•
•
•
•
•
•
Oppositional Defiance: 5yo
Attention Deficit Disorder-ADHD: 1.3-2.4 yo
Anxiety Disorders: 3.8 yo
Conduct Disorder: 5.6 yo
Depression: 10.1 yo
Schizophrenia-affective disorders:
mid-teens to mid-thirties
Typical Progression of Use
FAS---Substance use in-uterus
No
Social
Use
Experimentation Use
Use
Abuse
Dependence
----------------------------------------------------------------------------------------------0-2 3-5 6-8 9-10 11-12 13-14 15-16 17+
Infant Child Pre- Adolescent
adol
Mental Health Disorder’s onset----------------------------------
What are we talking about?
Alcoholism/Addiction
Major Mental Disorders
Both heredity and environment play a role
Characterized by chronicity and “denial”
Affects the whole family
Progresses without treatment
Feelings of shame and guilt
Inability to control behavior and emotions
Often seen as a moral issue
Leads to feelings of despair and failure
Biological, psychological, social and spiritual components
Collision of Symptomology
• Differential Diagnosis is essential for accurate
assessment. Is the presenting problem affected by a
medical condition or substance?
– Is it depression or alcohol, prescription pain killer,
heroin use?
– Is it ADHD or is it methamphetamine,
cocaine use?
– Is it bipolar disorder or cocaine use?
– Is it schizophrenia or methamphetamine use?
– Is it PTSD or polysubstance use?
A Major Reason People
Take a Drug is They Like
What It Does to Their Brains
Initially, A Person Takes A Drug
Hoping to Change their Mood,
Perception, or Emotional State
Translation--…Hoping to Change their Brain
The Brain Undergoes Tremendous
Changes During Development
Increase of brain activity that accompanies
the growth of the brain, in the same patient,
from the age of 1 to 12 months.
Information taken from NIDA’s Science of Addiction http://www.drugabuse.gov/ScienceofAddiction/
43
Continuing Brain Development
During Adolescence
 Strengthening the Circuitry
Synaptic connections are strengthened
 Pruning Unused Connections
- Adolescent brain is in a unique state of flux
- Neurons are eliminated, pruned and shaped
- This process is influenced by interactions with the outside
world (Seeman, 1999)
- Pruning occurs from back to front so frontal lobes mature
the last.
 Other brain areas are also growing during adolescence
(e.g., sub-cortical areas, receptors)
44
Continuing Brain Development
Early in development, synapses are rapidly created and then
pruned back. Children’s brains have twice as many synapses as
the brains of adults.
(Shore, 1997)
45
Brain Development
Ages 5-20 years
 MRI scans of healthy children and teens compressing
15 years of brain development (ages 5–20).
 Red indicates more gray matter, blue less gray matter.
 Neural connections are pruned back-to-front.
 The prefrontal cortex ("executive" functions), is last to mature.
Information taken from NIDA’s Science of Addiction
http://www.drugabuse.gov/ScienceofAddiction/
Gagtay, N., et
46 al.
PNAS, 101, 8174-8179
The interaction between the developing
nervous system and drugs of abuse leads to:
 Difficulty in decision making
 Difficulty understanding the consequences of behavior
 Increased vulnerability to memory and attention
problems
This can lead to:
 Increased experimentation
 Substance addiction
(Fiellin, 2008)
47
Young Brains Are Different
from Older Brains
 Alcohol and drugs affect the brains of
adolescents and young adults differently than
they do adult brains
– Adolescent rats are more sensitive to the
memory and learning problems than adults*
– Conversely, they are less susceptible to
intoxication (motor impairment and
sedation) from alcohol*
 These factors may lead to higher rates of
dependence in these groups
(Hiller-Sturmhöfel and Swartzwelder, 2004)
48
Triggers and Cravings
Human Brain
Triggers and Cravings
Ivan Petrovich Pavlov
Triggers and Cravings
Pavlov’s Dog
Classical Conditioning:
Addiction
•
Over time, drug or alcohol use is paired with cues
such as money, paraphernalia, particular places,
people, time of day, emotions
•
Through classical conditioning these cues are
paired with pleasurable effects of the drug (“high”).
•
Eventually, exposure to cues alone produces
drug or alcohol cravings or urges that are often
followed by substance abuse
Development of Craving Response
Entering Using
Site
Use of AODs
AOD Effects
 Heart
 Blood Pressure
 Energy
Development of Craving Response
Entering Using
Site
Mild Physiological
Response
 Heart Rate
 Breathing Rate
 Energy
 Adrenaline Effects
Use of AODs
AOD Effects
 Heart
 Blood Pressure
 Energy
Development of Craving Response
Entering Using
Site
Powerful Physiological
Response
 Heart Rate
 Breathing Rate
 Energy
 Adrenaline
Use of AODs
AOD Effects
 Heart
 Blood Pressure
 Energy
Development of Craving Response
Entering Using
Site
Powerful Physiological
Response
 Heart Rate
 Breathing Rate
 Energy
 Adrenaline
Thinking
of Using
Use of AODs
AOD Effects
 Heart
 Blood Pressure
 Energy
Development of Craving Response
Thinking of
Using
AOD Effects
 Heart
 Blood Pressure
 Energy
Cognitive Process During Addiction
Relief From
Relief
From Fatigue
Depression
Mania
Relief
From Stress AOD
Anxiety
Relief
From Depression
Insomnia
“Voices”
Euphoria
Increased Energy
Increased Social Confidence
Increased School/Work Output
Increased Thinking Ability
Weight Loss/Gain
May Be Illegal
May BeParanoia
Expensive
Hangover/Feeling
Loss of FamilyIll
May Miss Work/School
Seizures
Severe Depression
Psychosis
Unemployment
Bankruptcy
Effecting Change
through the Use of
Motivational Interviewing
How can MI be helpful for us in working
with our consumers/patients?
• The successful MI therapist is able to inspire
people to want to change
• Use of MI can help engage and retain
consumers in treatment
• Using MI can help increase participation and
involvement in treatment (thereby improving
outcomes)
What Causes a Person to be
Judged “Motivated”
• The person agrees with us
• Is willing to comply with our
recommendations and treatment
prescriptions
• States desire for help
• Shows distress, acknowledges helplessness
• Has a successful outcome
Definition of Motivation
The probability that a person
will enter into, continue,
and comply with
change-directed behavior
A patient-centered directive method for enhancing
intrinsic motivation to change by exploring and
resolving ambivalence.
Enhancing Motivation for Change Inservice Training
Based Treatment Improvement Protocol (TIP) 35
Published by the Center for Substance Abuse Treatment
www.samhsa.gov
Where do I start?
• What you do depends on where the
consumer is in the process of changing
• The first step is to be able to identify where
the consumer is coming from
Stages of Change
Prochaska & DiClemente
Helping People Change
• Motivational Interviewing is the process of
helping people move through the stages of
change
1. Precontemplation
Definition:
Not yet considering change or
is unwilling or unable to change.
6. Recurrence
Definition:
Primary Task:
Raising Awareness
2. Contemplation
Definition:
Experienced a recurrence
of the symptoms.
Sees the possibility of change but
is ambivalent and uncertain.
Primary Task:
Primary Task:
Cope with consequences and
determine what to do next
Resolving ambivalence/
Helping to choose change
5. Maintenance
Stages of Change:
Primary Tasks
3. Determination
Definition:
Definition:
Has achieved the goals and is
working to maintain change.
Committed to changing.
Still considering what to do.
Primary Task:
Primary Task:
Develop new skills for
maintaining recovery
4. Action
Definition:
Taking steps toward change but
hasn’t stabilized in the process.
Primary Task:
Help implement change strategies
and learn to eliminate
potential relapses
Help identify appropriate
change strategies
Building Motivation OARS
(the microskills)
• Open-ended questioning
• Affirming
• Reflective listening
• Summarizing
The goal is to elicit and reinforce
self-motivational statements (Change Talk)
Use the Microskills of MI to:
Express Empathy
• Acceptance facilitates change
• Skillful reflective listening is fundamental
• Ambivalence is normal
Use the Microskills of MI to:
Develop Discrepancy
• Discrepancy between present behaviors
and important goals or values motivates
change
• Awareness of consequences is important
• Goal is to have the PERSON present
reasons for change
Decisional Balance
The good
things
about
______
The notso-good
things
about ____
The good
things
about
changing
The not-sogood things
about
changing
Use the Microskills of MI to:
Avoid Argumentation
•
•
•
•
Resistance is signal to change strategies
Labeling is unnecessary
Shift perceptions
Peoples’ attitudes are shaped by their
words, not yours
Use the Microskills of MI to:
Support Self-Efficacy
• Belief that change is possible is an
important motivator
• Person is responsible for choosing and
carrying out actions to change
• There is hope in the range of alternative
approaches available
Providing Feedback
• Elicit (ask for permission)
• Give feedback or advice
• Elicit again (the person’s view of how
the advice will work for him/her)
Screening and Assessing
for COD
What can be determined through the
screening and assessment process?
• The interplay between the substance use
and the mental health problem
• The degree to which each disorder interferes
with functioning and is situational or social
• The frequency, intensity and duration of use
and associated diagnosis (i.e., substance
abuse or dependence)
THESE DETERMINATIONS TAKE TIME
‘The Secret in the Pocket’
• Please write down one personal experience, that you
have determined to keep to yourself. This can be an
experience or character flaw that you are NOT proud of.
YOUR SECRET.
• A word or phrase that will help identify this experience to
you and you alone.
YOU WILL NOT BE ASKED TO SHARE THIS OR
SHOW THIS TO ANYONE.
Appreciating the ‘difficult to tell….’
Before we begin to ask questions, we need to:
• understand and appreciate the DIFFICULT process
of sharing what is considered personal and private
• understand the processes whereby individuals communicate
‘family secrets’ and information to strangers
We need to review what we see as
healthy, intrapersonal non-disclosure versus
unhealthy, self destructive secret-keeping
Tasks of Addiction Counselor
and/or Mental Health Clinician:
• Our responsibility is to provide the best, most comprehensive
assessment and treatment for clients
• This requires a complete and thorough assessment
• Balance timeframes between completing necessary forms and
paperwork and providing Best Practice
• Those who struggle with COD need an ally who has a complete
understanding of the problem
• Services must move at the pace set by the client
When do I bring up ‘the topic’
• Ensure that sufficient rapport has been established with the
client
• Embed questions about substance use and mental health
into the overall assessment
• Completing paperwork and broaching specific topics may be
two different events
“Tips for Communicating”
“Talking with clients about their
medication”
What for?
• Prevent/warn Pt about interactions W/
foods, alcohol and other drugs,
medications, pregnancy, etc.
• Inform about the need for lab tests for
some medications
• What to expect: positive outcomes &
potential side effects
What for?
• Stress reducer (control, knows what to
expect, understands the importance of:
– Taking medication
– Avoid interactions
– Schedules
– Combinations of medication
– etc.
Why?
• Untreated psychiatric problems are a
common cause for treatment failure in
substance abuse and mental health
treatment programs
• Supporting clients with mental illness in
continuing to take their psychiatric
medications can significantly improve
substance abuse treatment outcomes
Talking with Clients about their
Medication
• 5-10 minutes every few sessions:
– Taking care of their mental health will help
prevent relapse
Talking with Clients about their
Medication
• 5-10 minutes every few sessions:
– How their psychiatric medication is helpful?
Talking with Clients about their
Medication
• “How many doses have you missed?”
• Have you felt or acted different on days
when you missed your medication?
• Was missing the medication related to any
substance use relapse?
• “Why did you miss the medication? Did
you forget, or did you choose not to take it
at that time?” Without judgment
Medication Adherence: Common
Reasons for Missing Doses
• 5-10 minutes every few sessions:
– Taking a pill every day is a hassle
Medication Adherence: Common
Reasons for Missing Doses
• 5-10 minutes every few sessions:
– Everybody on medication misses taking
it sometimes
Medication Adherence: Common
Reasons for Missing Doses
• For clients who forgot:
– Keep medication where it cannot be missed
Medication Adherence: Common
Reasons for Missing Doses
• For clients who forgot:
– Alarm Clock
Medication Adherence: Common
Reasons for Missing Doses
• For clients who forgot:
– Mediset
Talking with Clients about their
Medication
• For clients who admit to choosing NOT to take
their medication:
– Acknowledge they have a right to choose NOT to
use any medication
– They owe it to themselves to make sure their
decision is well thought out
– They need to discuss it with their prescribing
physician
– What is the reason for choosing not to take the
medication?
– Don’t accept “I just don’t like pills”. Tell them you are
sure they wouldn’t make such an important decision
without having a reason
Medication Adherence: Common
Reasons for Missing Doses
• Don’t believe they ever needed it; never
were mentally ill
Medication Adherence: Common
Reasons for Missing Doses
• Don’t believe they need it anymore; cured
Medication Adherence: Common
Reasons for Missing Doses
• Don’t like the side effects
Medication Adherence: Common
Reasons for Missing Doses
• Fear the medication will harm them
Medication Adherence: Common
Reasons for Missing Doses
• Struggle with objections or ridicule of friends
and family members
Medication Adherence: Common
Reasons for Missing Doses
• Feel taking medication means they’re not
personally in control
Talking with Clients about
their Medication
• Explore the triggers or cues that led to the
undesired behavior
Talking with Clients about
their Medication
• Why the undesired behavior seemed like a
good idea at the time?
Talking with Clients about
their Medication
• Review the actual outcome resulting from
their choice
• Did their choice get them what they were
seeking?
Talking with Clients about their
Medication
Strategize with clients about what they
could do differently in the future
Activity
Review the “Talking with Clients about their
Medication” slides. Choose one of the
common reasons why clients do not take
their medications.
In groups of 3 (counselor, client, observer),
role play a client who is non-adherent and a
counselor working with the patient to
explore reasons and strategize solutions.
The observer should watch the dynamics
and the client’s responses to the counselors
use of the guidelines, and provide the
counselor with feedback.
Assessing Risk Factors
Factors affecting risk for
involvement with substance use
Assessing
Individual Risk Factors
• Favorable attitudes towards the use of
substances
• Early age of onset of substance use
• Gender: Males more likely to abuse substances
than females
• Genetics: Family history of substance abuse
• History of sexual/physical abuse
• Trauma/displacement
Assessing
Psychological Risk Factors
•
•
•
•
•
•
•
•
Impulsivity
Novelty-seeking
Childhood ADHD or conduct disorder
Antisocial Personality Disorder
Failure to complete high school
Poor occupational achievement
Low frustration tolerance
Internalized racism/sexism/heterosexism
Assessing
Sociocultural Risk Factors
•
•
•
•
•
•
Social network
Friends/coworkers that use
Alcohol/drug use integrated into family culture
Socioeconomic Status (SES)
High crime rate/ “culture of violence”
Degree of acculturation
Assessing HIV Risk Behaviors
• Two broad categories:
– Sexual risk behaviors
• How comfortable are you asking questions about
explicit sexual behaviors that are high risk for
transmission/infection with HIV and other STI’s?
– Injection drug use
• Much higher risk of HIV & hepatitis among injection
users – highlights the importance of assessing route
of administration of drug use
Understanding the impact of age…
• It is often difficult for us to approach people
who are different in age (much younger or
much older)
• Not all young people act out and not all old
people are depressed.
• Age often brings out our assumptions and
biases
– “She looks like my grandma, she couldn’t be
using drugs.”
– “He’s only 10, substance abuse cannot be an
issue.”
Contact Your Trainers
www.uclaisap.org and www.psattc.org
Thomas E. Freese, Ph.D.
[email protected]
Beth A. Rutkowski, M.P.H.
[email protected]
Thank you for your time!