1 / 50

Dual Addictions Kathleen M Carroll PhD Yale University School of Medicine

Dual Addictions Kathleen M Carroll PhD Yale University School of Medicine. Overview. Definitions and terms Epidemiology: Rates and risks Onset: Gateways and destinations Treatments: Everything we don’t know. Terms. Comorbidity: Co-occurrence of two conditions or disorders

galeno
Download Presentation

Dual Addictions Kathleen M Carroll PhD Yale University School of Medicine

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Dual AddictionsKathleen M Carroll PhDYale University School of Medicine

  2. Overview • Definitions and terms • Epidemiology: Rates and risks • Onset: Gateways and destinations • Treatments: Everything we don’t know

  3. Terms Comorbidity: Co-occurrence of two conditions or disorders Dual diagnosis: Co-occurrence of alcohol/drug use disorder and another psychiatric disorder (heterotypic comorbidity) Homotypic comorbidity: Co-occurrence of disorders within a diagnostic grouping (e.g., substance use disorders)

  4. Major US epidemiologic surveys

  5. National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) • Previous surveys in US, Canada, Australia confirm probabilities of alcohol use disorder rise with drug use disorder visa versa • Only NESARC diagnosis specific (multiple types of drugs rather than ‘lumping’) • Includes data on help seeking • Focus on 12-month (current), rather than lifetime disorders • Oversampling of African Americans and Hispanics

  6. DSM-IV Substance Dependence Maladaptive use leading to clinically significant impairment or distress, shown by 3+ of the following in the same 12-month period: • Use of the substance more or longer than intended • Persistent desire or unsuccessful efforts to cut down or stop • A great deal of time spent on use of the substance or getting over its effects • Important activities given up or reduced because of use • Continued use despite knowledge of a serious physical or psychological problem • Tolerance • Withdrawal, or use to avoid withdrawal

  7. DSM-IV Substance Abuse Not dependent, and maladaptive use leading to clinically significant impairment or distress, shown by 1 + of the following: • Continued use despite social/interpersonal problems • Hazardous use (e.g., driving when impaired by alcohol) • Frequent use leading to failure to function in major roles • Legal problems

  8. NESARC: 12-month prevalence rates Stinson et al, (2005) DAD

  9. 12-month prevalence: Drug use disorders Stinson et al, (2005) DAD

  10. Demographics: Users of alcohol + drugs more likely to be: • Male (74%) • Younger (18-29) (65%) • Never married (63%) • Similar to drug-only with respect to education, ethnicity, income

  11. Rates of alcohol use disorders among those with specific drug use disorders: NESARC

  12. Alcohol use among those with specific drug use disorders and visa-versa

  13. Comorbidity: NESARC Stinson et al, (2005) DAD

  14. 12-month prevalence treatment seeking by disorder: NESARC Stinson et al, (2005) DAD

  15. 12-month prevalence treatment seeking by disorder: NESARC

  16. Factors associated with multiple substance use • Retention of use through gateway progression • Pharmacologic effects of combinations, including modulation, treatment of withdrawal and uncomfortable effects • Genetic evidence of common mechanisms, vulnerability in some families • Availability, market trends

  17. Gateway pattern of drug initiation: Kandel et al Cigarettes Alcohol Cannabis NCS-R: Only 5.2% Violate this pattern Other illicit

  18. Risk of developing disorder, given use Anthony et al. 1994, Comparative epidemiology, NCS

  19. NESARC: Hazard rates for alcohol and drug use disorders Hasin et al., 2007 Arch Gen Psychiatry Compton et al. 2007 Arch Gen Psychiatry

  20. Drug-alcohol comorbidity associated with: • Earlier onset • Higher severity • Higher psychiatric comorbidity • Higher rates of treatment seeking • Higher rates of dropout once in treatment • Less socioeconomic support • Poorer treatment outcome

  21. Limited research on treatment of homotypic comorbidity Users of multiple substances usually excluded from treatment research: • Difficulty in meeting needs of heterogeneous populations in single trial • Complexity of assessment (time frame, availability of biologic indicators, time) • Complexity of targeting multiple substances simultaneously (licit, illicit)Safety and compliance concerns, especially in pharmacologic trials • Pharmacologic specificity Rounsaville et al, 2003

  22. Available pharmacotherapies for substance use disorders

  23. Emerging pharmacologic strategies for homotypic comorbidity

  24. Original rationale for disulfiram as treatment for cocaine users • Clinical observation of high levels of concurrent alcohol-cocaine use (60-70% of patients) • Rationale: Reducing alcohol use may reduce concurrent cocaine use • Better ability to utilize coping skills (Marlatt et al) • Alcohol powerful conditioned cue (Higgins et al) • Cocaethylene (Jatlow, McCance)

  25. Open outpatient study, cocaine-alcohol users: % attaining 3+ weeks abstinence Carroll et al., 1998

  26. Double blind trial of disulfiram for cocaine dependence in methadone maintenance N=67 Petrakis et al 2000

  27. Randomized outpatient clinical trial: Disulfiram, CBT, and IPT, N=121 Carroll et al., 2004

  28. Cocaine outcomes for those who did NOT meet criteria for alcohol abuse or dependence (n=58)

  29. Behavioral therapy studies of alcohol-drug users

  30. Behavioral therapies tend to be effective across types of substance use

  31. Clinical Trials Network:17 Current Nodes, >200 CTPs

  32. Clinical Trials Network: MET Trials Participant Characteristics • Mean age 35 • 29% female (<MI) • 42% Caucasian (<MI) • 12 years of education • 28% mandated or legal referral • Primary substance use problem: • Alcohol: 29 % (<MI) • Marijuana: 16% • Cocaine: 23% (>MI) • Methamphetamine: 4% (<MI) • Opioids: 9% • Benzodiazepenes: 1% Ball et al., 2007

  33. CTN MET/MI studies: Design

  34. CTN: MET longitudinal outcomes Ball et al.., 2007

  35. CTN MET/MI studies: Outcomes for alcohol subgroups

  36. ‘CBT 4 CBT’Computer Based Therapy/CBT • 6 modules, ~1 hour each, high flexibility • Highly user friendly, no text to read, linear navigation • Video examples of characters struggling real life situations • Multimedia presentation of skills • Repeat movie with character using skills to change ‘ending’ • Interactive exercises, quizzes • Multiple examples of ‘homework’

  37. Computer-based training in CBT: CBT4CBT “All comers”: few restriction on participation, only require some drug use in past 30 days • 43% female • 45% African American, 12% Hispanic • 23% employed • 37% on probation/parole • 59% primary cocaine problem, 18% alcohol, 16% opioids, 7% marijuana • 79% users of more than one drug or alcohol Carroll et al., in press, Am J Psychiatry

  38. Primary outcomes, 8 weeksCBT+TAU versus TAU Carroll et al., in press, Am J Psychiatry

  39. Treatment of Dual Addictions:General strategies • Target, treat most severe disorder and any requiring detoxification first • Utilize pharmacotherapies when available • Attend to psychiatric and medical comorbidity • Frequent monitoring, chronic care model • Sequential targeting may be important for some treatments (eg. contingency management)

  40. “I wonder why we’re not getting any new converts.”

More Related