advances in integrated dual disorders treatment fadaa/fccm—annual conference 2013 troy pulas, md...
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Advances in Integrated Dual Disorders Treatment
FADAA/FCCM—Annual Conference 2013
Troy Pulas, MDAddiction Psychiatrist
Judy Magnon, RN-BCBS,CAC1
Disclosure• Neither we nor any member of our immediate
families have a financial relationship or interest with any proprietary entity producing health care goods or services related to the content of this CEU activity.
• Our content will not include discussion/reference to commercial products or services.
• We do not intend to discuss an unapproved/investigative use of commercial products/devices. 2
Affiliations• Troy Pulas is an addiction psychiatrist and
medical director for WestBridge South in Brooksville, FL. He was formerly an instructor of psychiatry at Boston University Medical Center.
• Judy Magnon is a board certified psychiatric/mental health nurse and a Florida Certified Addiction Counselor. She is the Program director for WestBridge South in Brooksville, FL.
3
Co-Occurring Disorders
Psychiatric Disorders and Substance Abuse are both Brain Disorders.
Both effect Dopamine and Serotonin functioning in the nerve cells. 4
Co-Occurring Disorders
Impaired brain chemistry effects the metabolism of substances, resulting in loss of control, abuse, and/or dependence. Dopamine receptors are effected by alcohol/drug use and this is the same area effected by psychotropic medication. (and Caffeine & Nicotine)
HELP
5
6
SUBSTANCE ABUSE/DEPENDENCE IS A
DISEASE
1. It has symptoms(Warning Signs)
2. There is progression(How things get worse)
3. There is a Prognosis(An outcome based on the usual course of the disease)
Rationale for Integrated TreatmentAny Sub. Use Dis.
Any Alcohol use Dis.
Any Drug use Dis.
Psychiatric DX: % % %General Population
16.7 13.5 6.1
Schizophrenia 47% 33.7% 27.5%Bipolar Disorder
56.1% 43.6% 33.6%
Major Depression
27.2 16.5 18
OCD 32.8 24 18.4Phobia 22.9 17.3 11.2Panic Disorder 35.8 28.7 16.7
7
Rationale for Integrated Treatment
• Dual disorders orders have worse outcomes:
• Greater symptom relapse and worse adherence to treatment
• More likely to be violent or a victim of violence • Higher rates of homelessness• Higher hospitalization rates and ER utilization• More likely to be incarcerated• More medical problems including HIV and hepatitis
Green 2007 AJP, Drake 2008 JSAT
8
Rationale for Integrated Treatment
• Programs that integrate treatment of both illnesses have been shown to be more effective
Think--- 2 broken legs• Parallel treatment has a high
dropout rate, few get both services, poor communication between providers
Green 2007 AJP, Drake 2008 JSAT
9
Higher Rates of Psychiatric Relapse For People with Dual Disorders Who Use Substances
10
More relapses over time using “pot”
PARALLELS: Psychosis and Addiction
By Dr. Ken MinkoffAddiction Disease• 1. A biological illness• 2. Hereditary
(In part)• 3. Chronicity• 4. Incurable• 5. Leads to lack of
control of behavior & emotions
• 6. Affects the whole family
Major MI Disease• 1. A biological illness• 2. Hereditary
(In part)• 3. Chronicity• 4. Incurable• 5. Leads to lack of
control of behavior & emotions
• 6. Affects the whole family
11
PARALLELS: Psychosis and Addiction
By Dr. Ken MinkoffAddiction Disease• 7. Symptoms can be
controlled with proper treatment
• 8. Progression of the disease without treatment
• 9. Disease of denial• 10. Facing the disease
can lead to depression and despair
Major MI Disease• 7. Symptoms can be
controlled with proper treatment
• 8. Progression of the disease without treatment
• 9. Disease of denial• 10. Facing the disease
can lead to depression and despair 12
PARALLELS: Psychosis and Addiction
By Dr. Ken MinkoffAddiction Disease• 11. Disease is often
seen as a “Moral” issue, due to personal weakness rather than biological causes
• 12. Feelings of guilt and failure
• 13. Feelings of shame and stigma
• Physical, mental, and spiritual disease
Major MI Disease• 11. Disease is often
seen as a “Moral” issue, due to personal weakness rather than biological causes
• 12. Feelings of guilt and failure
• 13. Feelings of shame and stigma
• Physical, mental, and spiritual disease
13
Parallels--Recovery
• 1. First phase is acute stabilization with medication (Detox/antipsychotic)
• 2. First phase often requires hospitalization
• 3. Following acute stabilization, next phases are prolonged stabilization and rehabilitation.
14
Parallels--Recovery
• 4. a. A prerequisite for rehabilitation is
maintaining stabilization by following a long term program:• “Don’t drink”…, Go to meetings,
read literature, etc.• Take meds, attend groups, see
CM/Dr., etc.15
Parallels--Recovery
• 4. b. Once stabilization has been maintained
long enough (usually 1 year) growth and rehabilitation can occur.
• 5. Person must overcome Denial/Disbelief.
• 6. Person must acknowledge powerlessness over the disease
16
Parallels--Recovery
• 7. Person must ask for help from a power greater than themselves to control symptoms (Higher Power, AA/NA, Therapist, Meds, etc.)
• 8. Recovery proceeds one day at a time through increasing acceptance of one’s illness and gradually learns better coping skills to cope with
daily reality. 17
Parallels--Recovery
• 9. Recovery is never “complete”, but slow, gradual progress can be made.
• 10.Risk of relapse is always present—need help over time.
• 11.Family must also be involved in a program to get help dealing
with the disease. 18
Parallels--Recovery
• 12.Education about the disease is an important component.
• 13.Treatment must focus on feelings about the disease, and feeling good about oneself with a
disease.• 14.Ultimately, recovery is a physical,
mental, and spiritual process. 19
IDDT Development
• 1980s: Identification/description of model• Based on PACT Model of Care
• 1990s: Development of integrated treatments• Research started in NH and spread through out
the world• 2000s: Implementation of evidenced based
practices in IDDT• IDDT Manual published by Dartmouth
Psychiatric Research Center—Dr. Robert Drake and team.
Drake 2008 JSAT 20
Integrated vs. Non-Integrated Treatments
*** If current & subsequent points = 1 then the current score = 1Assessment Points Baseline 6 mo. 12 mo. 18 mo. 24 mo. 30 mo. 36 mo.Hi-Fidelity 0 19.67 26.23 29.51 37.7 42.62 55.74Low-Fidelity 0 3.85 3.85 7.69 7.69 15.38 15.38
Figure 1. Percent of Participants in Stable Remission for High-Fidelity ACT Programs (E; n=61) vs. Low-Fidelity ACT Programs (G; n=26).
0
10
20
30
40
50
60
Baseline 6 mo. 12 mo. 18 mo. 24 mo. 30 mo. 36 mo.
Assessment Point
Pe
rce
nt in
Re
mis
sio
n
McHugo 1999 Psych Serv
21
Principles of IDDT
• Administered by a multidisciplinary team• Counseling is less confrontational and more
supportive• Comprehensive services• Case management• Residential treatment• Stage-wise interventions
Brunette 2006 J Clin Psychiatry22
Principles of IDDT (continued)
• Supported employment (EBP)• Social support• Rehabilitation or skills training• Flexibility• Long-term perspective• Interventions for non-responders• Assertive Community Treatment (ACT) (EBP)
Brunette 2006 J Clin Psychiatry 23
Stage-wise Treatment
Stage of change Stage of Treatment
Strategies
PrecontemplationContemplationPreparation
Engagement and persuasion
Outreach, Engagement activities (i.e. addressing basic needs)Crisis interventionMotivational interviewingPsychiatric StabilizationMedication, StructureEducation about MH & SAEducation about wellness-nutrition, exercise, smoking, sleepEncourage self help with staff after education and reframing for stageIndividual and Ed. Groups 24
Stage-wise Treatment
25
Action Active treatment Self-monitoring, Self-helpSocial skills trainingGroups, CM, CBT programsBuild sober networkContinue to address wellness —nutrition, exercise, sleep, tobacco cessation
Maintenance Relapse prevention
Formulate a plan for relapseExpand recovery to other areas of their lives, use sober networkContinue to address wellness —nutrition, exercise, sleep, tobacco cessation
Assertive Community Treatment and IDDT
• ACT is an evidence-based treatment started in the 1970s to provide treatment and rehabilitation for SMI in Wisconsin
• Multidisciplinary team approach
• Integration of intensive services individualized to each person
• Assertive outreach in the community and to families
• Medication management
• Prescribers meet regularly with the team in a leadership role
• Continuity of care over time
• The ACT model has been adapted successfully for IDDT
Bond 2001 Dis Manage Health Outcomes
26
27
IDDTACTIntegrated Dual Disorders Treatment
Assertive
Community Treatment
OVERLAP OF THE MODELS
Focus is on developing motivation for treatment using Stage Wise interventions VS on SX Management & everyday problems;
Based on: Recovery thinking, individual choice, shared decision making, and the individual drives TX.
ACT & IDDT equals addressing all areas.
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Four Quadrant Model
MI High
SA High
MI Low
SA High
High
S
A
M I Low
Q IV Q III
Q II Q1
LOW
MI High
SA Low
MI Low
SA Low
Severity
S
E
V
E
R
I
T
Y
High
K. Minkoff
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STAFF-- NEEDED ABILITIES
• To be able to NOT take person’s anger personally
• To not join/align with the illness(s) and enable client to use
• To advocate with them to take the medications (Or unable to participate in TX offered)
• To understand Stages of Change/Motivational Interviewing
30
STAFF-- NEEDED ABILITIES• To use Baker Act, Marchman Act,
Payeeship, guardianship and any other tools as needed to ensure care
• To develop a long term relationship• Work with families, S/O,
Partners,police, guardians, lawyers, physicians, etc.
• To understand the consequences of person’s use of substances
31
STAFF-- NEEDED ABILITIES
• To understand:• Recovery is a slow process with ups and
downs• Recovery is not an event• Treatment is like Insulin—without it, the
illness returns and progression is faster with worse physical and mental damage
• The Family is not to blame and neither is the Participant. We do not blame for Cancer.
32
STAFF-- NEEDED ABILITIES
• To have compassion for the illness
• Have a commitment to this Population
• Have knowledge of:• MI & SA, Sexual Abuse issues, medical issues, PTSD, Personality Disorders, medications, documentation, etc.
33
STAFF-- NEEDED ABILITIES
• Ability to be a team player• Able to communicate effectively to all
team members, especially with the participant & family
• Able to partner with person in treatment, instead of as the “expert”
• Able to carry the hope for the person, until they are ready to take it back.
34
BASED ON: Recovery Thinking
The person’s illness(s) is not all they are.
(EXAMPLE—Judy is a person who experiences Schizophrenia instead of Judy is Schizophrenic.) (Just like experiencing Diabetes)
35
BASED ON:Recovery Thinking (Continued)
The person is a partner in the treatment process and
The provider is a guide with knowledge and clinical experience to share, discuss, educate, explore, coach, advise, assist, encourage, negotiate, role model, validate, etc.
36
BASED ON:Recovery Thinking (Continued)EXPECT THEY WILL IMPROVE/RECOVER!!!!!!!!!!!
Celebrate the successes, no matter how small,
Use positive language in meetings and in day to day job tasks to practice the recovery way of thinking,
EMPOWERMENT: Offer choices, clarify they have the power to make choices/decisions,
You are offering tools, and they can choose to use them or not. You hope they will, but you respect their choice to not be ready yet.
37
BASED ON:Recovery Thinking (Continued)
No matter what level of illness—Expect that they can participate at some point in “Meaningful Day time Activity”
WORK is Therapy!!!!!!
They do not have to be sober to work. (Clinical evidence shows that some people will stop using to keep a job!)
38
PREDICTOR OF SUCCESS (Ken Minkoff)
“The most significant predictor of treatment success for people with Co-occurring Disorders is the presence of an empathic, hopeful, continuous, treatment relationship in which integrated treatment and coordination of care can take place through multiple treatment episodes”.
Conclusions30 years of dual disorder research shows:
• Integrated Dual Disorders Treatment is effective
• The model works well for severe mental illness
• Certain interventions may be integrated to enhance substance use reduction and encourage addiction recovery
• IDDT can be individualized using stage-wise treatment, flexibility, comprehensive services, the assertive community treatment model, and a long-term perspective.
39
WestBridge Integrated Dual Disorders Treatment Model
40
• IDDT Program based on stage-based treatment model developed by Robert Drake, MD , PhD at Dartmouth PRC
• Multiple levels of care to allow for seamless transitions (residential-community)
• Private, non-profit organization with programs in Boston, New Hampshire, and Florida.
• Family-founded and family-centered, designed to rapidly implement evidence-based therapies
• No patients or clients, just participants & families
41
Evidence-based practices @ WestBridge
• Evidence-based therapies:• Assertive community treatment • Supportive employment • Pharmacotherapy and medication monitoring• Cognitive-behavioral therapy• Behavioral family therapy/family education• Motivational interviewing• Contingency management/voucher systems• Regular urine toxicology screening• Twelve-step facilitation with mentor program• Mindfulness training 42
Advances in Integrated Dual Disorders Treatment:Opioid Dependence, Sleep Disorders, and Smoking
Cessation
FADAA/FCCM—Annual Conference 2013
Troy Pulas, MD
Medical Director, WestBridge Community Services, Brooksville, FL campus
43
Objectives• Discuss a new integrated treatment model of opioid
dependence in a co-occurring disorder population
• Discuss the rationale for increased awareness, diagnosis, and treatment of sleep disorders in a co-occurring disorder population
• Discuss rationale for integration of smoking cessation treatment in a co-occurring disorder population
44
Adapted by CESARFAX 1/30/12 from Centers for Disease Control and Prevention (CDC), National Center for Injury Prevention and Control (NCIPC), Drug Poisoning Deaths in the United States, 1980-2008, 2011.
45
Prescription Opioids and Mental Illness
46
Rate of Chronic Past Year Nonmedical Use of Prescription Drugs
Adapted by CESARFAX 7/16/12 from Jones, C.M., “Frequency of Prescription Pain Reliever Nonmedical Use: 2002-2003 and 2009-2010”, Archives of Internal Medicine, 2012.
While overall nonmedical use of prescription pain relievers did not increase from 2002-2003 to 2009-2010, Chronic nonmedical use—use on 200 or more days in the past year—increased significantly, from a rate of 2.2 to 3.8 per 1,000 people.
47
Admissions reporting primary prescription opioid abuse, by age: 1998 and 2008
Source: SAMHSA Treatment Episode Data Set (TEDS), 1998 and 2008
48
Buprenorphine for Prescription Opioid Dependence--POATS
Adapted by CESARFAX 12/5/11 from Weiss, R.D., et. al., “Adjunctive Counseling During Brief and Extended Buprenorphine-Naloxone Treatment for Prescription Opioid Dependence,” Archives of General Psychiatry, 2011.
49
Buprenorphine Treatment Models• Outpatient-Based Opioid Treatment1
• Primary care/medical management2
• Collaborative care with nurse care managers3
• Adjunctive counseling (group/individual)4
• Private-pay physician or psychiatrist
• Practice-based Opioid Treatment (France)• Pharmacist-engaged5
• Clinic-Based Opioid Treatment (Australia)• Regular observed administration6
• Assertive Community Opioid Treatment Model
1Gunderson, Fiellin. 2008 CNS Drugs; 22 (2): 99-1112Barry D, et al. 2007. J Gen Int Med;22:242–245.3Alford D, et al. 2011. Arch Intern Med;171(5):425-431
4Weiss RD, et al. 2011. Arch of Gen Psych.
5Vignau, et al. 2001. JSAT.6Lintzeris, et al. 2004 Am J Add;13 Suppl 1:S29-41.
50
Buprenorphine in primary care
Fiellin, et al. 2008. AJA, 17: 116–120.
51
3 6 9 12
Months after intake
Prop
orti
on r
etai
ned
in O
BO
T tr
eatm
ent
Age groupings18-2526-3031-4041-5051+
Age and Retention in B/N Collaborative Care OBOT Treatment
Schuman-Olivier, et al 2013
52
18-25 year olds
Why do emerging adults do so poorly in Buprenorphine treatment?• Could it be the same reasons that emerging adults
do poorly in other forms of substance abuse treatment?
• Not ready to stop (lack of consequences)
• Developmental challenges
• Difficulty giving up co-morbid substance abuse
• Poor self-help attendance
• Neurobiology
• Psychiatric co-morbidity
• Lack of integration of treatment
53
Case:• 21 year old male with Obsessive Compulsive Disorder,
Major Depressive Disorder, Opioid Dependence• Living in Boston, attending college. Parents find out he has
been using intranasal heroin for 3 months after 9 months of daily prescription opioid use (~240mg/day of oxycodone).
• Drinking alcohol, using benzodiazepines, and regular marijuana use. History of overdose on alcohol and heroin.
• Contemplative about heroin, but does not want to stop alcohol or marijuana.
• Living with roommate who is also using heroin, dealing prescription opioids, and benzodiazepines, parents not aware of this.
54
WB risk calculator for buprenorphine/naloxone treatment for
people with co-occurring disorders
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Assertive Community Opioid Treatment Model, Integrated Services
• Risk Level 3 Services:• Daily care manager and/or substance abuse counselor meetings
=>Motivational Interviewing, engagement, supportive counseling, ACT, active treatment, education
• Twice weekly urine toxicology (M/Th, T/F) => Stage-wise treatment (work with relapse/continued use),
motivational interviewing , engagement• Weekly buprenorphine prescription, dispensed daily from lockbox by care
manager=> Multidisciplinary team, community outreach, flexible approach
• Weekly to twice monthly meetings with psychiatrist => Multidisciplinary team, psychiatric stabilization, education
• Alcohol or benzodiazepine detoxification when necessary=> Residential treatment, multidisciplinary team
• Sign treatment contract=> Non-confrontational, supportive
• Regular attendance to self-help meetings or group treatment=> Community integration, social support
56
Assertive Community Opioid Treatment Model, Integrated Services
Risk Level 3: Encouraged (but not required) Services:
• Contingency contracting with daily money rationing or other forms of contingency management.
=>Structure, flexibility, case management
• Provide housing support when necessary
=>Case management, community outreach
• Disulfiram for alcohol dependence if indicated=>Multidisciplinary team, medication management
57
ACT Team: Diversion Prevention
• Lockboxes• Urine testing• Pill checks• Short prescriptions • In-office inductions• Observed administration
58
Conclusions1. Opioid dependence is a dangerous problem, and
prescription opioid abuse is at crisis levels among emerging adults.
2. Dual diagnosis is very common among emerging adults with opioid dependence, and must be addressed in treatment models.
3. Buprenorphine/naloxone treatment improves retention and reduces opioid use; however, standard treatment models are poor at retaining emerging adults and those with co-occurring disorders.
4. An integrated dual disorder assertive community treatment team approach may offer promise for improving clinical outcomes, increasing safety and preventing diversion.
59
Integrating Sleep Disorder Treatment
andDual Disorder
Treatment60
Brain Burden of Addiction and Sleep Disorders: $
SOURCE: Neuroinsights, Office of Nat’l Drug Policy, Nat’l Institute of Diabetes, Alz Assoc., Duke University, American Psych. Association, Harvard, Nat’l Sleep Found., American Stroke Assoc., Prevent Blindness America, CDC, Journal of Clinical Psych, Epilepsy Foundation, Cost of Brain Disorders Europe ( Lynch, Science Progress 2007)
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Outcomes of co-morbidity
• Dual Disorders and Sleep Disorders • Worse outcomes• Altered course of illness• Poor coping• Adverse drug reactions• Cognitive deficits
Horn and Sateia, J Dual Diagnosis, 2012 ; Hofstetter, et al BMC Psych 2005; Ritsner, et al Qual of Life Res 2004; Yang and Winkelman Schiz Res 2006; Krystal, Thakur, & Roth, Sleep 2008
62
Sleep Stages• Non REM
• Stage 1: Fast Theta Waves, light sleep• Stage 2: Sleep Spindles, K complexes• Stage 3 & 4: Slow Delta Waves
• REM• Rapid Eye Movements, voluntary
muscles inactive
Penelope A. Bryant, John Trinder and Nigel CurtisNature Reviews Immunology 4, 457-467 (June 2004)
63
Sleep and Addiction• Alcohol
• Insomnia: 36-75% while drinking or in withdrawal. Varies depending on many factors with sobriety.
• Time to fall asleep increases with drinking—tolerance to sedating effects (takes 5-9 months of abstinence to normalize).
• Total sleep time decreases with drinking (takes 1-2 years)• REM sleep % decreases during alcohol use (takes 3months-3 years )• REM occurs earlier in the night with drinking.• Sleep fragmentation, (takes 1-2 years)• Obstructive Sleep Apnea exacerbation
Brower et al Sleep Med Rev 2001. Brower Alcohol Res Health. 2001; 25(2): 110–125.Remmers Am Rev Resp Dis 1984. Stein et al J Subst Ab Treat 2004.
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Sleep and AddictionOpioids
• Insomnia: 84% • Central Sleep Apnea: 30-75% of people on methadone• Associated with Obstructive Sleep Apnea• Longterm consequence; chronic insomnia
Cocaine: • Increased wakefulness, suppressed REM sleep
Benzodiazepines:• Inhibit Stage 3&4 (slow wave sleep)
Marijuana• Reduced REM sleep, increased stage 4 sleep• Withdrawal: REM rebound, strange dreams
Nicotine• Association with Obstructive Sleep Apnea• Shorter sleep time, longer time to fall asleep, more leg movements
Brower et al Sleep Med Rev 2001; Jaehne A. Sleep Med 2012. Remmers Am Rev Resp Dis 1984; Stein et al J Subst Ab Treat 2004. Brower Alcohol Res Health. 2001; 25(2): 110–125
65
Sleep disorders and Schizophrenia
• Schizophrenia presents with co-occurring substance use disorder 47-65% of the time!
Sleep disorders in schizophrenia:• Effects of antipsychotics on sleep are common (positive
and negative)• Obstructive Sleep Apnea: 48% • Periodic Limb Movement Disorder: 14-21%
(Ancoli-Israel, Biol Psych 1999; Lieberman, “CATIE” NEJM 2005; Bola et al Sleep 2008; Wang et al Chest 2005), Cohrs S, CNS Drugs 2008.
66
Diagnosis and Intervention
Diagnosis:
• Sleep habits
• Sleep log
• Screening measures:
• Epworth Sleepiness scale
• Pittsburgh Quality Index
• Sleep study
Intervention:
• Sleep Hygiene
• Cognitive Behavioral Treatment
• Sleep Mentors
• Continuous Positive Airway Pressure (CPAP)
• Medications
67
Sleep habits (staff assessment)• Note weight/ BMI
• 35
• Diet: timing of meals, content• No breakfast, chocolate bar at lunch, heavy dinner prior to bed
• Exercise/physical activity patterns• Walk 15 min/day
• Substance use and relationship with sleep (including smoking, coffee)• 2 cups of coffee at evening AA meeting; cigarettes prior to bed and
several times a night
• Day –time sleep• Wakes up at noon, 2 hour nap in the afternoon 68
Sleep Diary (self-report)
• What time did you go to bed last night? 10 pm (stayed awake due to hallucinations)
• What time you think you fell asleep? 4 am
• What time did you get up? 12 noon
• Did you wake up during your sleep time? no
• Overall, how tired did you feel yesterday, scale of 1 to 5 (Very tired = 5) ? 3
• How unusual or stressful was your day yesterday, scale of 1 to 5? (Very unusual or stressful = 5) 2
• How tired do you feel, scale of 1 to 5? (Very tired = 5) 569
Interventions
• Basic Sleep hygiene• Sleep at night• Bed use only for sleep, sex or sickness• Avoid caffeine • End psychosis engagement earlier
• Light therapy• CBT
• Progressive Muscle Relaxation• CBT for psychosis• Progressive desensitization of CPAP (claustrophobia)
• Sleep mentors/coaches• Personalized sleep plan 70
Medications• Evaluate underlying disorder• Antidepressants: Mirtazapine, Trazodone• Sedating antipsychotics if psychosis/bipolar disorder• Mood stabilizers (Carbamazepine in BZD/ ETOH
withdrawal)• Miscellaneous:
• Non-addicting medications• Hydroxyzine (Vistaril)• Melatonin• Clonidine• Gabapentin
71
Conclusions: Sleep Improvement Tools
Sleep Log, Sleep Habits
Formal ScreeningSleep Hygiene
Personalized sleep plan
Light therapy
CBT
Sleep mentors
Sleep Study
CPAP 72
SMOKING CESSATION FOR PEOPLE WITH CO-
OCCURRING DISORDERS
73
OVERVIEW
• Prevalence and consequences of nicotine dependence in people with co-occurring disorders
• Brief review of evidence for treatment in people with severe mental illnesses
• Stage-based treatment approach with behavioral and pharmacologic interventions 74
NicotineThe number one addictive substance
used by people who experience mental health and addictive disorders!
Smokers die 25 years earlier than general public!
75
Ferron, et al 2011 Psych Serv
76
Toxins in smoke cause heart disease, cancer, lung disease, diabetes
77
PREMATURE MORTALITY BY HEART AND OTHER TOBACCO-RELATED ILLNESSES
05
101520253035
Percentage of deaths
Heart
Dise
ase
Cance
rCVDRes
pAcc
iden
tsDia
bete
s
Flu/
Pneum
onia
Suicid
e
Data from Oklahoma 1996-2000; Colton et al, 2006 CDC
OTHER STATES LOOK THE SAME78
Combined cessation treatments improve outcomes in smokers with severe mental illnesses (15+studies)
• Abstinence after treatment in VA patients with co-occurring disorders
Review: Effect sizes in Schizophrenia 0.62-0.83 (Ferron 2009; Tsoi 2010)
6-12 wk group +/- NRT or buproprion in VA setting
Gershon-Grand, 2007 J Clin Psych79
SYMPTOMS REMAIN STABLE DURING CESSATION TREATMENT
Scale for the Assessment of Negative Symptoms
Positive and Negative Symptom Scale
Evins, 2007 J Clin Psychopharm
80
BRIEF MOTIVATIONAL INTERVENTIONS IMPROVE TREATMENT ENGAGEMENT
Higher percentage of people initiated cessation treatment after an electronic decision support-system
Brunette et al, 2011 Psychiatric Serv
81
MODELS OF INTEGRATED TREATMENT
• Medical management
• Brief meetings, support use of medications and coping (Williams et al, 2010 JSAT)
• Cognitive behavioral therapy (Individual or group)
• Teach self monitoring of urges and triggers
• Teach coping with urges and triggers
• Planning for quit day – other activities
• Group support (Cather, Gottlieb, Evins et al, 2010 SRNT)
• Contingency management
82
Alternatives to Tobacco
• E-Cigarettes: • Does not address the habits associated with
smoking• Designed and sold by the tobacco companies to
reduce loss of income• Inhaling a substance which has unknown
consequences• If it is anything other than oxygen, the lungs do
not like it.
83
MEDICATION FOR SMOKING CESSATION
• Nicotine Treatment• Gum• Patch• Lozenge
• Zyban/Wellbutrin• Chantix (varenicline)• Combination treatment
84
WESTBRIDGE STAGE OF CHANGE APPROACH
• Precontemplation - Engagement – develop treatment relationship, assess nicotine use on treatment entry, monthly CO monitoring and brief intervention.
• Contemplation/Preparation - Persuasion – re-assess, provide education, motivational counseling - quarterly• Review pros and cons of tobacco use (financial, health, social)• Provide peer models for quitting to increase social norms• Increase self efficacy – teach skills, try medications• Practice replacement activities• Trials of NRT, periods of abstinence
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WESTBRIDGE STAGE OF CHANGE APPROACH• Action - Active treatment - Provide
medication and behavioral cessation treatment; support for long periods of time
• Relapse prevention – ongoing medication and relapse prevention training, peer support for abstinence
86
Conclusions
87
• Integrated Dual Disorder Treatment is an effective way to address co-occurring disorders.
• IDDT concepts can be used system-wide or in a targeted manner.
• IDDT can be modified to address opioid dependence, sleep disorders, and smoking cessation.
QUESTIONS
88
Contact Information:Feel free to contact us:
7300 Grove RoadBrooksville, FL 34613
Toll Free: 1-877-461-7711FL # 1-352-678-5553 89
90
References:• Allness, D. J., & Knoedler, W. H. (1998). The PACT
model of community-based treatment for persons with severe and persistent mental illness: A manual for PACT start up.(2nd ed) Arlington, VA: NAMI
• Mueser, K. T., Noordsy, D. L., Drake, R. E., Fox, L (2003). Integrated treatment for dual disorders: A guide for effective practice. New York: Guilford Press.
• Multiple articles available from NH-Dartmouth Psychiatric Research Center: Contact for resources.
91
References:• Miller, W. R., & Rolnick, S. (2002) Motivational
Interviewing (2nd ed.): Preparing People for Change. New York: Guilford Press.
• Prochaska, J. O., Norcross, J. C., & DiClemente, C. C. (1994) Changing for Good. New York: Avon Books. [Stages of Change]
• Woods, Mary & Armstrong, Katherine (2012) When The Door Opened. Manchester, NH: WestBridge 1361 Elm St. Manchester, NH 03101. www.westbridge.org
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References:• TIPS (SAMHSA)
• #35 Enhancing Motivation for Change in SA TX
• #42 SA TX for Persons With Co- Occurring Disorders
• http://store.samhsa.gov/product/TIP-35-Enhancing-Motivation-for-Change-in-Substance-Abuse-Treatment/SMA12-4212
• http://store.samhsa.gov/product/TIP-42-Substance-Abuse-Treatment-for-Persons-With-Co-Occurring-Disorders/SMA12-3992
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References:• WEB SITES:
• WWW.COCE.samhsa.gov• WWW.Homeless.samhsa.gov• WWW.ATTCnetwork.org
• (The Addiction Technology Transfer Center Network)
• WWW.nimh.nih.gov