Topics In Addictions and Mental Health: Concurrent disorders and Community resources. Laurence Bosley, MD, FRCPC

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1 Topics In Addictions and Mental Health: Concurrent disorders and Community resources Laurence Bosley, MD, FRCPC

2 Overview Understanding concurrent disorders. Developing approaches to treatment

3 Definitions Dual Disorders; SPMI; Quadrant 4 A heterogeneous group.

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5 Rates of lifetime substance use disorder (SUD) among recently admitted psychiatric inpatients (n=325; Mueser et al., 2000) % of clients with SUD Schizo schizoaff. bipolar maj. Depr.

6 Chronic Pain Prevalence In Persons with Addictive Disorders MMT patients 61.3% (Jamison 2000) 80% (Rosenblum, Joseph 2003) -37% severe Substance abuse treatment inpatients 78% (Rosenblum, Joseph 2003)

7 Theories to explain high rates of cooccurring disorders: Berkson s Fallacy (a kind of sampling bias) Self-medication Super-sensitivity to effects of substances Socialization motives Precipitation of psychosis and other conditions from substance use Underlying common genetic factors

8 Severe mental illness co-morbid with substance abuse: Higher rates of: Relapse, hospitalization, violence, incarceration, homelessness, victimization, medical complications (eg, HIV, Hep C, hepatic disease). Worse clinical course, treatment outcome and prognosis for each problem. Other common factors: Poverty/deprivation; neurocognitive impairment; conduct d/o, antisocial and other personality disorders.

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10 Addiction: A Biopsychosocial Illness Psychology Environment Availability & Milieu Neurobiology Genetics Acquired * Drug *Manifestation of the disease of addiction Reinforcement Adapted from JD Haddox, DDS, MD.

11 Components of Comprehensive Drug Addiction Treatment

12 DSM - drawbacks Poor specificity in context of co-occurring problems, particularly with conditions such as anxiety, mood disorders, chronic pain. Substance-induced mood disorder time frame Pay attention to all 5 axes (diagnosis must be made in the context of medical/psychiatric history)

13 Normal Cocaine Abuser (10 da ) Cocaine Abuser (100 da )

14 Drug related symptoms mimicking depression or mania: Bipolar symptoms Euphoria Energy Appetite Grandiosity paranoia Depression symptoms Anhedonia Apathy Depressed mood suicidality

15 Diagnoses to consider: Acute intoxication Acute withdrawal sub-acute or prolonged withdrawal Substance induced mood disorder Pre-existing mood disorder Combination Further complexity when considering more subtle forms (eg. Dysthymia, cyclothymia)

16 Concurrent Disorders Treatment Models Serial Parallel Integrated

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19 SA and Mood and Anxiety Disorders Best Practice Recommendation An integrated approach to treatment/support(see Section 2.3 for discussion of program and system integration) is recommended. With the exception of post-traumatic stress syndrome (PTSD), and in the context of this integrated approach, a sequencing of the specific intervention (beginning with the substance abuse) is recommended, accompanied by ongoing assessment and adjustment of the treatment/support plan if the mood and anxiety disorder does not improve following an improvement in the substance use disorder. For post-traumatic stress syndrome an integrated treatment approach that deals with both the post-traumatic stress syndrome and substance abuse at the same time is recommended. The best current evidence for the treatment of concurrent substance use and mood and anxiety disorders, including post-traumatic stress syndrome, is cognitive-behavioural treatment.

20 SA and Severe and Persistent Mental Illness Best Practice Recommendation An integrated approach to treatment/support (see Section 2.3 for discussion of program and system integration) is recommended. Within this integrated approach, it is recommended that interventions for substance abuse and severe mental illness be planned and implemented concurrently. The best current evidence is for a range of services, including a staged approach to engagement and service delivery; outpatient setting; motivational interviewing and cognitive behavioural treatment; harm reduction and comprehensive psychosocial rehabilitation supports, to name a few program/system components.

21 ASAM placement criteria Dimension 1: Acute Intoxication/Withdrawal Potential Dimension 2: Biomedical Conditions and Complications Dimension 3: Emotional, Behavioral, or Cognitive Conditions and Complications Dimension 4: Readiness to Change Dimension 5: Relapse, Continued Use or Continued Problem Potential Dimension 6: Recovery/Living Environment

22 ASAM placement criteria Level.05 Early Intervention Level I Outpatient Treatment Level II Intensive Outpatient/Partial Hospitalization Level III Residential/Inpatient Treatment Level IV Medically Managed Inpatient Treatment

23 Range of treatment Self-Help Support Groups Outpatient Counselling Services & Day Programs Detoxification Centres Support Recovery Houses Residential Treatment Centres Inpatient care Specific Concurrent Disorders Programs

24 Medications to treat chemical dependency / mental illness Antabuse Naltrexone Acamprosate Topiramate Ondansetron Benzodiazepines Barbiturates Carbamazepine Valproate Methadone Buprenorphine Antidepressants Anxiolytics Mood Stabilizers Antipsychotics

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26 Principles of Pharmacotherapy for Concurrent Disorders Treatment of major psychiatric disorders in context of ongoing substance use: Medications treatments directed towards diagnosis and symptom profile Benzodiazepines relatively contraindicated. Maintaining non-addictive medications maybe useful when historical evidence of effectiveness present and Initiating medications controversial

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