Advances in Integrated Dual Disorders Treatment

1. Advances in Integrated Dual Disorders Treatment FADAA/FCCM—Annual Conference 2013 Judy Magnon, RN-BC BS,CAC Troy Pulas, MD Addiction Psychiatrist

2. 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.

3. 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.

4. Co-Occurring Disorders Psychiatric Disorders and Substance Abuse are both Brain Disorders. Both effect Dopamine and Serotonin functioning in the nerve cells.

5. Co-Occurring Disorders Impaired brain chemistry effects the metabolism of substances, resulting in loss of control, abuse, and/or dependence. HELP Dopamine receptors are effected by alcohol/drug use and this is the same area effected by psychotropic medication. (and Caffeine & Nicotine)

6. SUBSTANCE ABUSE/DEPENDENCE IS A DISEASE • It has symptoms (Warning Signs) • There is progression (How things get worse) 3.There is a Prognosis (An outcome based on the usual course of the disease)

7. Rationale for Integrated Treatment

8. 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

9. 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

10. Higher Rates of Psychiatric Relapse For People with Dual Disorders Who Use Substances More relapses over time using “pot”

11. PARALLELS: Psychosis and AddictionBy Dr. Ken Minkoff Addiction 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

12. PARALLELS: Psychosis and AddictionBy Dr. Ken Minkoff Addiction 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

13. PARALLELS: Psychosis and AddictionBy Dr. Ken Minkoff Addiction 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

14. 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.

15. 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.

16. 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

17. 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.

18. 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.

19. 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.

20. 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

21. Integrated vs. Non-Integrated Treatments McHugo 1999 Psych Serv

22. 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 Psychiatry

23. 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

24. Stage-wise Treatment

25. Stage-wise Treatment

26. 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

27. OVERLAP OF THE MODELS IDDT ACT Integrated Dual Disorders Treatment 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. Assertive Community Treatment ACT & IDDT equals addressing all areas.

28. Four Quadrant Model K. Minkoff High MIHigh SAHigh Q IV MILow SA High Q III S E V E R I T Y S A Q II Q1 MI Low SA Low MI High SA Low LOW Low High M I Severity

29. 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 ofJudy 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, treatmentrelationship in which integrated treatment and coordination of care can take place through multiple treatment episodes”.

39. Conclusions 30 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.

40. WestBridge Integrated Dual Disorders Treatment Model

41. 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

42. 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

43. 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

44. 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

45. 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.

46. Prescription Opioids and Mental Illness

47. Rate of Chronic Past Year Nonmedical Use of Prescription Drugs 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. 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.

48. Admissions reporting primary prescription opioid abuse, by age: 1998 and 2008 Source: SAMHSA Treatment Episode Data Set (TEDS), 1998 and 2008

49. 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.

50. 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): 99-111 2Barry 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.