Download Substance Abuse

Quick Guide
For Clinicians
Based on TIP 9
Assessment and Treatment of
Patients With Coexisting Mental
Illness and Alcohol and Other Drug
Abuse
What is a TIP?
• The TIP series provides the substance abuse
treatment and related fields with consensus-based,
field-reviewed guidelines on substance abuse
treatment topics of vital current interest.
• This presentation is based on TIP 9 Assessment
and Treatment of Patients With Coexisting Mental
Illness and Alcohol and Other Drug Abuse (see last
slide for ordering information).
• For more detailed information, readers are referred
by page number to the publication mentioned
above.
Introduction
• Treatment needs of patients who have a psychiatric
disorder in combination with a substance abuse
disorder differ significantly from the treatment needs
of patient with either a substance abuse disorder or
a psychiatric disorder by itself.
• Clinicians must discriminate between psychiatry and
substance abuse disorders by obtaining a thorough
history of symptoms and disorders.
See TIP 9, pp.1-3.
Dual Disorders
Concepts and Definitions
For more information, see TIP 9, pp.3-7.
Relationships: Substance Abuse and
Psychiatric Symptoms and Disorders
• Substance abuse may mask psychiatric
symptoms, complicating the diagnostic process.
• Terminology of dual disorders:
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MICA: mentally ill chemical abusers
MISA: mentally ill substance abuser
CAMI: chemical abuse and mental illness
SAMI substance abuse and mental illness
Relationships
• Patients with mental disorders have an
increased risk for substance abuse disorders,
and
• Patients with substance abuse disorders have
an increased risk for mental disorders.
Signs & Symptoms of Dependency/Addiction
• Pathologic, often progressive and chronic process.
• Compulsion and preoccupation with obtaining a
drug or drugs.
• Loss of control over use or substance abuseinduced behavior.
• Continued use despite adverse consequences.
• Tendency for relapse after period of abstinence.
• Increased tolerance and characteristic withdrawal.
Components of Drug Dependence1
• Psychologic dependence: centers on the user’s
need of a drug to reach a level of functioning or
feeling or well-being.
• Physical dependence: refers to the issues of
physiologic dependence, establishment of tolerance,
and evidence of an abstinence syndrome, or
withdrawal upon cessation of substance abuse.
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American Society of Addiction Medicine.
Symptoms: Substance Abuse
• Significant impairment or distress resulting from
use.
• Failure to fulfill roles at work, home, or school.
• Persistent use in physically hazardous
situations.
• Recurrent legal problems related to use.
• Continued use despite interpersonal problems.
Medication Misuse
• Describes the use of prescription medications
outside of medical supervision or advice.
• Not an abuse problem, it is a high-risk behavior.
• May or may not involve or lead to substance abuse.
• May promote the reemergence of psychiatric
symptoms.
• May cause toxic effects and psychiatric symptoms if
it involved overdose.
Mental Health and Addiction Treatment
Systems
For more information, see TIP 9, pp.9-17.
Similarities of Mental Health and Addiction
Treatment Systems
• Variety of treatment settings and program
types.
• Public and private settings.
• Multiple levels of care.
• Biopsychosocial models.
• Increasing use of case and care
management.
Mental Health and Addiction Treatment
Systems
• Potential pitfall is prescribing psychoactive
medications to psychiatric patient without
first determining if the individual has a
substance abuse disorder.
• In treating dual disorders, a balance must
be made between behavioral interventions
and psychiatric medications as needed for
the recovery process.
Treatment Models
• Sequential: patient is treated by one system
(addiction or mental health) and then by the
other.
• Parallel: simultaneous involvement of the patient
in both mental health and addiction treatment
settings.
• Integrated: combines elements of both mental
health and addiction treatment into a unified
program for patients with dual disorders.
Critical Treatment Issues for Dual Disorder
Treatment
• Treatment engagement: initiating and sustaining
patient’s participation.
• Treatment continuity: between treatment
programs and treatment components.
• Comprehensiveness: includes collaborative
integrated programs.
• Treatment phases: detoxification, subacute
stabilization, and long-term stabilization.
• Continual reassessment and rediagnosis:
involves collaboration across multiple systems.
Mood Disorders
For more information, see TIP 9, pp.30-42.
Mood Disorders
• Most common psychiatric diagnosis among
patients with a substance abuse disorder.
• More prevalent among patients using
methadone and heroin.
• Depression is common over the first months of
sobriety whose symptoms may fade over time.
• Mood disorder symptoms may be related to
acute withdrawal symptoms from substances;
adequate time should lapse prior to diagnosis of
an independent mood disorder.
Substances That Precipitate or Mimic Mood
Disorders
• Depression and Dysthymia
– During use (intoxication): alcohol,
benzodiazepines, opioids, barbituates,
cannabis, steroids (chronic), stimulants
(chronic).
– After use (withdrawal): alcohol,
benzodiazepines, barbituates, opiates,
steriods (chronic), stimulants (chronic).
Substances That Precipitate or Mimic Mood
Disorders
• Mania and Cyclothymia
– During use (intoxication): stimulants, alcohol,
hallucinogens, inhalants (organic solvents),
steroids (chronic, acute).
– After use (withdrawal): alcohol,
benzodiazepines, barbituates, opiates,
steroids (chronic).
Stages of Assessment
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Assessing danger to self or others
Medical assessment
Initial addiction assessment
Social assessment
Violence towards others
Assessing mood symptomatology
Medical assessment
Psychiatric and addiction screening
Assessment instruments
Psychosocial assessment
Acute Treatment Strategies
• Management of intoxication and
withdrawal
• Medical treatment
• Psychiatric treatment
Subacute Treatment Issues
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Matching patients and treatment
Psychiatric medications
Case management
Counseling and psychotherapy for depression
Levels of care
Family involvement in treatment settings
Professional and vocational planning
AIDS and HIV risk reduction
Long-Term Treatment Goals
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Addiction treatment
Psychiatric treatment
Long-term treatment needs
Family issues
Eating disorders and gambling
Anxiety Disorders
For more information, see TIP 9, pp.46-50.
Substance-Induced
• Never assume anxiety symptoms or
depersonalization are related to substance
abuse.
• Substance-induced conditions:
– Panic
– Phobias
– Posttraumatic stress disorder
– Obsessive-compulsive disorder
Anxiety
• Most common symptom of people with
substance abuse disorders.
• Treatment of mild anxiety can be
postponed to see if it resolves as addiction
treatment progresses.
Long-Term Treatment
• Medications are not a substitute for addiction
treatment.
• Cognitive-behavioral techniques are often as
effective as medications, but generally take
longer to achieve an equivalent response in the
treatment of anxiety disorders.
• For dual diagnosis patients, psychotherapy has
significant advantages over substance abuse
counseling alone, and can be incorporated into
the substance abuse treatment.
Anxiety Treatment
• Can be postponed unless anxiety interferes
with substance abuse treatment.
• Anxiety symptoms may resolve with
abstinence and substance abuse treatment.
• Affect-liberating therapies should be
postponed until the patient is stable.
• Psychotherapy, when required, should be
recovery oriented.
Anxiety Treatment
• Nonpsychoactive medications should be
used when medications are needed.
• Antianxiety treatments such as relaxation
techniques can be used with and without
medications.
• A healthy diet, aerobic exercise, and
avoiding caffeine can reduce anxiety.
Personality Disorders
For more information, see TIP 9, pp.53-73.
Personality Disorders
• Rigid, inflexible, and maladaptive behavior
patterns of sufficient severity to cause significant
impairment in functioning or internal stress.
• If a personality disorder coexists with substance
abuse, only the personality disorder will remain
during abstinence.
• Substance use often relates to the disorder to
diminish symptoms, to enhance low self-esteem,
to decrease feelings of guilt, and to amplify
feelings of diminished individuality.
Most Challenging to Treat
• Antisocial personality disorder, which involves a history
of chronic antisocial behavior that begins before the age
of 15 and continues into adulthood.
• Borderline personality disorder, which is characterized
by unstable mood and self-image, and unstable intense,
interpersonal relationships.
• Narcissistic personality disorder, which describes a
pervasive pattern of grandiosity, lack of empathy, and
hypersensitivity to evaluation by others.
• Passive-aggressive personality disorder, which involves
covertly hostile but dependent relationships.
Key Issues and Concerns
• Patient contracting may involve a patient’s promise to
avoid certain self-harm or high-risk behavior.
• Transference and countertransference both rely on the
mechanism of projection, a combination of personal past
experiences along with feelings experienced during the
course of therapy.
• Clear boundaries are ethical and practical ground rules
that help a therapist to be therapeutically helpful to
patients.
Key Issues and Concerns
• Changing roles of people with personality disorders may
include: the victim, the persecutor, and the rescuer.
• Resistance involves patients with personality disorders
who often exhibit acting-out behaviors that were
developed as psychological defenses and survival
techniques.
• Subacute withdrawal may include mood swings,
irritability, impairment in cognitive functioning, short- and
long-term memory problems, and intense craving for
substances.
Key Issues and Concerns
• Symptom substitutions are compulsive behaviors that
includes eating disorders, compulsive spending,
gambling, and sex.
• Somatic complaints: therapists should watch for use of
prescription and over-the-counter drugs and for drugseeking behaviors.
• Therapist well-being can be compromised when working
with patients with personality disorders. Therapists
should join or develop support systems with others in the
field.
Borderline Personality Disorder
• Therapist should engage patient by
acknowledging/joining the patient’s need for safety.
• Assessment should include: history of substance abuse
and mental health treatment, suicidal planning,
dissociative experiences, psychosocial history, history of
sexual abuse, and a history of psychotic thinking. Could
require a neurological examination.
• Avoid psychodynamic confrontations with patient.
• Long-term care may include individual counseling, group
therapy, 12-step participation, and the continuum of care.
Antisocial Personality
• In engaging the patient, it is useful to join with the
patient’s world view.
• Assessment should include a thorough family history,
including a sexual history that includes questions about
animals and objects. Other topics should be bonding,
parasitic relationships, head injuries, fighting, and being
hit.
• Avoid angry confrontations since patients may engage in
dangerous physical behavior to avoid unpleasant
situations or activities.
• Long-term care includes individual counseling, group
therapy, and the continuum of care.
Narcissistic Personality Disorder
• To engage, therapeutically address patient traits such as
hypersensitivity, need for control, rage, and depression.
• Assessment should include survival skills/self-care, monitor
use of OTC drugs, treatment provider history, psychosocial
and substance abuse history, medication evaluations for
antidepressants, and identification of typical passiveaggressive maneuvers of patient.
• Several issues, such as responses to abusive relationships,
obtaining safe housing, and receiving emergency
psychiatric admissions for suicidal crises must be managed
by the therapist.
• Long-term care may include individual counseling, group
therapy, 12-step participation, and the continuum of care.
Coordination of Care
• Maintaining ongoing contacts is essential for all
patients with personality disorders.
• Issues to remember in coordination of care:
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Primary case manager
Legal issues
Managed care
Funding issues
Staffing and cross-training
Medical issues
Integration into 12-step self-help groups
Psychotic Disorders
For more information, see TIP 9, pp.76-85.
Psychotic Disorders
• Stimulant-Induced Symptoms
– Acute stimulant intoxication (chronic) can cause symptoms of
psychosis. Included are: delirium, delusions, prominent hallucinations,
incoherence, and loosening of associations. Stimulant delirium often
includes formication (a tactile hallucination of bugs crawling on or under
the skin).
• Depressant-Induced Symptoms
– Acute withdrawal from alcohol, barbiturates, and benzodiazepines can
produce a withdrawal delirium, especially with heavy use and high
tolerance due to a concomitant physical illness.
• Psychedelic- and Hallucinogen-Induced Symptoms
– Psychotic symptoms are possible in chronic, high-dose patterns due to
virtue of drugs’ stimulant properties. Can cause hallucinogenic
hallucinosis, characterized by perceptual distortions, maladaptive
behavioral changes and impaired judgment.
Engaging the Chronically Psychotic Patient
• Noncoercive Engagement Techniques
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Assistance obtaining food, shelter, and clothing
Assistance obtaining entitlements and social services
Drop-in centers as entry to treatment
Recreational activities
Low-stress, nonconfrontational approaches
Outreach to patient’s community
• Coercive Engagement Techniques
– Involuntary commitment
– Mandated medications
– Representative payee strategies
Pharmacological Management
For more information, see TIP 9, pp.91-97.
Pharmacologic effects
• Therapeutic effects include indicated
purposes and desired outcomes such as a
decrease in the frequency and severity of
episodes of depression produced by
antidepressants.
• Detrimental effects include unwanted side
effects, such as dry mouth or constipation
resulting from antidepressant use.
Dual Disorder Patients
• Special attention should be given to
detrimental effects, in terms of:
– Medication compliance
– Abuse and addiction potential
– Substance abuse disorder relapse
– Psychiatric disorder relapse
Pharmacologic Risk Factors
• Psychoactive Potential
– Not all psychiatric medications are psychoactive.
– Psychoactive medications can cause acute psychomotor effects and a
relatively rapid change in mood or thought.
• Reinforcement Potential
– Some drugs promote reinforcement or increased likelihood of repeated
use.
– Can occur by either the removal of negative symptoms or conditions, or
the amplification of positive symptoms or states.
– Involves strengthening that a certain behavior will be repeated for
reward and satisfaction, as with drug-induced euphoria.
• Tolerance and Withdrawal Potential
– Long-term or chronic use can cause tolerance to therapeutic effects and
dosage increases to recreate desired effects.
– Drugs that promote tolerance and withdrawal generally have higher
risks for abuse and addiction.
Prescribing Medication
• High-risk patients should include a benefit
analysis that considers:
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The risk of medication abuse.
The risk of undertreating a psychiatric problem.
The type and severity of the psychiatric problem.
The relationship between the psychiatric disorder and
the substance abuse disorder for the individual
patient.
– The therapeutic benefits of resolving the psychiatric
and substance abuse problems.
Nonpharmacologic Approaches
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Psychotherapy
Cognitive therapy
Behavioral therapy
Relaxation skills
Meditation
Biofeedback
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Acupuncture
Hypnotherapy
Self-help groups
Support groups
exercise
• Education
Antihistamines
• Frequently prescribed for mild anxiety and
insomnia.
• Exert mild anxiolytic and hypnotic effects, lack
euphoric properties, and do not promote
physical dependence.
• High doses can cause acute delirium, alter
mood, or cause morning-after depression.
• Patients in recovery should be discouraged from
purchasing and using OTC antihistamines.
Antidepressants
• Effective for treatment of depression, anxiety disorders,
including generalized anxiety disorder, phobias, and
panic disorder.
• They are not euphorigenic and do not cause acute mood
alterations.
• Some exert a mild sedating effect, while others exert a
mild stimulating effect.
• Anticholinergic effects include: dry mouth, blurred vision,
constipation, urinary hesitancy, and toxic-confusional
states.
• Adrenergic activation symptoms may include: tremor,
excitement, palpitation, orthostatic hypotension, and
weight gain.
β-Blockers
• Used to treat hypertension, cardiac arrhythmias,
and angina pectoris.
• Can’t be used for extended periods of time due
to the rapid tolerance of anti-panic effects.
• These drugs are consistent with a psychoactivedrug-free philosophy, does not compromise
recovery from addiction, and can be important
adjunct to anxiety management.
Benodiazepines
• Promote sedation, central nervous system
depression, and muscle relaxation.
• Effective for anxiety reduction and short-term
management of insomnia.
• Use of these drugs after the medical
management of withdrawal is not consistent with
a psychoactive-drug-free philosophy and may
compromise recovery from addiction.
• However, they can be used in the management
of acute and severe withdrawal, panic, and
psychosis.
Buspirone
• Useful for generalized anxiety disorder, chronic
anxiety symptoms, anxiety with depressive
features, and anxiety among elderly patients.
• Is not psychoactive, mood altering, or
euphorigenic.
• Is consistent with a psychoactive-drug-free
philosophy, and does not compromise recovery
from addiction.
• Enhances recovery from anxiety disorders.
Clonidine
• Used for treatment of symptoms of hypertension,
including hypertensive symptoms that occur
during withdrawal of depressant drugs,
especially opioids.
• May be useful for short-term use in the treatment
of refractory anxiety with panic.
• This drug is consistent with a psychoactive-drugfree philosophy and does not compromise
recovery from addiction.
• May be an adjunct in the treatment of anxiety
symptoms.
Neuroleptic (Antipsychotic) Medications
• Most effective in suppressing the positive symptoms of
psychosis such as hallucinations, delusions, and
incoherence.
• May help reduce disturbances of arousal, affect,
psychomotor activity, thought content, and social
adjustment.
• Many can cause sedation as a side effect, but adaptation
develops within days or weeks.
• These drugs allow patients who often experience
significant biopsychosocial problems to engage in
problem-solving and recovery-oriented interpersonal
activities.
Lithium
• Initial symptoms managed by Lithium include
increased psychomotor activity, pressured
speech, and insomnia.
• Later it diminishes the symptoms of expansive
mood, grandiosity, and intrusiveness.
• Common adverse effects include thirst, urinary
frequency, tremor, and gastrointestinal distress.
• Allows patients who may have seriously
disabling symptoms to engage in problemsolving and recovery-oriented interpersonal
activities.
Anticonvulsants
• Have a role in the management of bipolar
disorders, mania, schizoaffective disorder, and
alcohol and benzodiazepine withdrawal.
• Typical side effects such as sedation and
nausea may emerge as treatment is initiated.
• These medications are consistent with a
psychoactive drug-free philosophy, and may
enhance the abilities of those who need them to
participate in the recovery process.
Ordering Information
• TIP 9 related products:
– TIP 9 Assessment and Treatment of Patients With Coexisting
Mental Illness and Alcohol and Other Drug Abuse
– KAP Keys for Clinicians based on TIP 9
– Quick Guide for Clinicians based on TIP 9
• To obtain free copies:
– Call SAMHSA’s National Clearinghouse for Alcohol and Drug
Information (NCADI) at 800-729-6686, TDD (hearing impaired)
800-487-4889
– Visit CSAT’s Web site at www.csat.samhsa.gov
Disclaimer
Do not reproduce or distribute this presentation for a fee without
specific, written authorization from the Office of Communications,
Substance Abuse and Mental Health Services Administration, U.S.
Department of Health and Human Services.