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1 Dual Dagnoss Omar S. Manejwala, M.D. Hazelden Medcal Drector Twtter.com/DrManejwala Overvew Medcal Illnesses Sucde Prevalence of Dual Dagnoss Dagnostc Dffcultes Barrers to Recovery n Dual Dagnoss Broad Prncples 2 The AA member- medcatons and other drugs pamphlet "It becomes clear that just as t s wrong to enable or support any alcoholc to become re-addcted to any drug, t's equally wrong to deprve any alcoholc of medcaton whch can allevate or control other dsablng physcal and/or emotonal problems." 3 1

2 Narcotcs Anonymous Fellowshp Servces states "The queston of prescrpton medcaton should be decded between the member, ther doctor, and the member's Hgher Power. Our pamphlet "In Tmes Of Illness" and our 10th Tradton,, make ths abundantly clear. We strongly recommend tellng our doctors about our hstory so that when prescrpton medcaton s absolutely necessary * they can prescrbe t knowng that we are recoverng addcts." 4 State of the evdence Meta analyss (Nunes & Levn) of depresson treatment n patents wth substance use dsorders 300 trals between Only 44 were placebo controlled Only 14 met ncluson crtera for rgor (randomzed, etc) 8 studes focused on EtOH In 4 of those studes, patents were drnkng at the tme of the study The only clear fndngs were that antdepressants worked better for depresson f patents were sober and they ddn t mprove abstnence rates 5 COMBINE TRIAL Among the largest PharmaRx addcton trals Patents were not excluded for cannabs dependence Patents were not tested for cannabs use durng study Vsts ncluded GGT, CDT, LFT, Renal Functon but not a urne drug screen Outcomes were measured by % days abstnent or tme to heavy drnkng, rather than contnuous abstnence. 6 2

3 Overvew Medcal llnesses Sucde Prevalence of Dual Dagnoss Dagnostc Dffcultes Barrers to Recovery n Dual Dagnoss Treatment Prncples: Medcatons, Therapy, 12-step approaches 7 Medcal Illnesses wth common depresson comorbdtes: Eplepsy Huntngton s dsease Infectons (HIV, neurosyphlls) Mgranes MS Narcolepsy Cancer Wlson s dsease Parknson s Dsease Cushng s dsease Menses-related Post-partum Parathyrod dsorders and thyrod dsorders SLE Immune/nflammatory dsorders Certan medcatons 8 Overvew Specfc Depressve Dsorders Sucde Prevalence of Dual Dagnoss Dagnostc Dffcultes Barrers to Recovery n Dual Dagnoss Treatment Prncples: Medcatons, Therapy, 12-step approaches 9 3

4 Sucde Patents wth an EtOH use dsorder 20x more lkely to complete sucde than general populaton. Between 18% and 66% of sucde d vctms have alcohol n ther blood at the tme of death (Rozen 1988; Welte et al. 1988, Coller et al. 1986, Berkelman et al. 1985). 10 Sucde Rsk Sucde Factors Rsk Factors Prevous sucde attempts Hstory of mental dsorders, partcularly depresson Hstory of alcohol and substance abuse Famly hstory of sucde Famly hstory of chld maltreatment Feelngs of hopelessness Impulsve or aggressve tendences Barrers to accessng mental health treatment Loss (relatonal, socal, work, or fnancal) 11 Sucde Protectve Factors Effectve clncal care for mental, physcal, and substance abuse dsorders Easy access to a varety of clncal nterventons and support for help seekng Famly and communty support Support from ongong medcal and mental health care relatonshps Sklls n problem solvng, conflct resoluton, and nonvolent handlng of dsputes Cultural and relgous belefs that dscourage sucde and support self-preservaton nstncts 12 4

5 Overvew Medcal Illnesses Sucde Prevalence of Dual Dagnoss Dagnostc Dffcultes Barrers to Recovery n Dual Dagnoss Broad Prncples 13 Prevalence One estmate ndcates that n a gven year, 10 mllon US resdents have both a substance use dsorder and mental health dagnoss The prevalence of depressve d/o among treatment seekng alcoholcs ranges from 15-67% dependng on the study The largest studes to address prevalence are ECA and NCS 14 What conclusons about prevalence can be drawn? Data are conflctng d/t falure to exclude substance nduced llnesses, study desgn, etc. All affectve dsorders are common n SUD patents, and Bpolar d/o has the hghest rate of SUD of any psychatrc llness Depresson and dysthyma are more common n opate dep and alcohol dep. 15 5

6 Overvew Medcal Illnesses Sucde Prevalence of Dual Dagnoss Dagnostc Dffcultes Barrers to Recovery n Dual Dagnoss Broad Prncples 16 Dagnostc Dffcultes Whch came frst may not help you dstngush. Perods of abstnence, whle extremely helpful n clarfyng dagnoss are Often naccurately reported Sometmes never present or too short to be useful Occasonally characterzed by exposure to prescrpton medcatons that further complcate dagnoss 17 Dagnostc Confuson Mana s generally easer to dagnose than depresson n people wth a SUD Manc symptoms nduced by substance use tend to resolve n days; depressve symptoms can take weeks or n some cases, months Methamphetamne and hallucnogens can be the excepton to ths rule, as substance-nduced mana wth these agents can persst for weeks. 18 6

7 When to dagnose? The best way to clarfy dagnoss s through observaton durng a perod of abstnence Dagnosng too early can lead to overtreatment and msmatchng and possbly poorer outcomes. Dagnosng too late can lead to hgher rsk of relapse, poorer outcomes, and sucde. What clncal features predct comorbdty rather than substance-nduced affectve d/o? 19 Dfferentatng Illnesses Affectve symptoms that predate onset of substance use d/o Affectve symptoms durng extended perods of abstnence Strong famly h/o affectve d/o Postve h/o response to affectve d/o treatment hedgng your bets 20 Dfferentatng Illnesses The luxury of beng a purst We don t have t. RCTs for antdepressants exclude current or recent substance use or substance use dsorders. The dually dagnosed are heterogeneous wth respect to severty of substance use dsorder, substances used, perods of abstnence, trauma hstory, type of affectve llness 21 7

8 Do treatment centers actually use medcatons? J. Cln. Psychopharm 2006; 26 supplement From Natonal Treatment Center Study 22 Intoxcant-based treatment remans wdely acceptable Natonal Treatment Center Study 2004 Perceved Acceptablty NTCS 8

9 Buprenorphne Wrtng off a generaton Ant-buprenorphne vs Wake up State of the evdence Cogntve mparment (Soyka et al J. Cln Psychopharm 12/2008) Buprenorphne Abuse SAMHSA monograph Buprenorphne Abuse The most common pattern of abuse nvolves crushng the sublngual tablets and njectng the resultng extract (Ccero & Incard, 2005). When njected ntravenously, addcts have descrbed the clncal effects of buprenorphne as smlar to equpotent doses of morphne or heron (Sporer, 2004). Investgators have found that the blockade effcacy of Suboxone s dose-related, and that doses of up to 32/8 mg of buprenorphne/naloxone provde only partal blockade when subjects receve a hgh dose of an opod agonst (Stran, Walsh et al, 2002). Under expermental condtons, buprenorphne has been found to be as effectve as methadone n producng renforcng and subjectve effects (Alho, Snclar et al., 2006). Based on follow-up ntervews wth study subjects, researchers have hypotheszed that, by suppressng wthdrawal symptoms, the buprenorphne provdes both postve and negatve renforcement by smultaneously producng euphorc effects and allevatng wthdrawal (Comer, Sullvan et al., 2005a). Buprenorphne dverson and abuse have been reported worldwde wherever the drug has been used for addcton treatment and, to a more lmted extent, n the management of pan (Maxwell, 2006; Yeo, Chan et al., 2006; Chua & Lee, 2006; Jenknson, Clark et al., 2005; Auracombe, Fatseas et al., 2004). In a study reported at the 2006 Australan Natonal Drug Trends Conference, one percent of 914 respondents (all of whom were njecton drug users) cted buprenorphne as ther drug of choce, and sx percent sad t was the drug they had njected most often n the precedng month. Those who had njected Suboxone reported that they used t to allevate wthdrawal, to acheve ntoxcaton, and out of curosty (Maxwell, 2006). From 12 studes cted n thesamhsa monograph Overvew Medcal Illnesses Sucde Prevalence of Dual Dagnoss Dagnostc Dffcultes Barrers to Recovery n Dual Dagnoss Broad Prncples 27 9

10 Barrers to 12-step approaches Increased level of socal solaton Low energy Impared concentraton Sucdalty Anxety 12-step approaches are heavly socally drven 28 The 12-step program member and medcatons Patents are told they are not dfferent, then fnd that they are (e.g. dual dagnoss vs. termnal unqueness) Patents are told by peers and even sponsors to dscontnue medcatons or to seek multple medcal opnons untl they fnd the one that states they can go wthout medcatons. Peers wthn 12-step communtes have themselves been msdagnosed as havng prmary affectve llness and therefore mstrust doctors and ther capacty to make the dagnoss. 29 AA member atttudes towards usng medcatons to prevent relapse Good dea or maybe Shouldn't take 17% Advse others not to take 12% Other/no opnon Journal of Studes on Alcohol. 61(1):134-8, 2000 Jan 10

11 Among the 29% who felt pressure to stop Actually stopped 31% Ddn't Stop 69% Journal of Studes on Alcohol. 61(1):134-8, 2000 Jan Overvew Medcal Illnesses Sucde Prevalence of Dual Dagnoss Dagnostc Dffcultes Barrers to Recovery n Dual Dagnoss Broad Prncples 32 Broad Prncples Where possble start low, go slow Combne meds and use hgh doses when necessary Use the evdence, not the label Avod / Lmt PRN s Re-evaluate evaluate frequently 33 11

12 Broad Prncples Teach your patents: They are NOT unque wth respect to ther addcton Pseudomedcal advce s dangerous Don t dose-adjust or manage your own meds How to handle scenaros that challenge the DD patent 34 Broad Prncples Use therapy and medcatons Assess ego strength carefully before usng any ntense psychodynamc approaches, especally wth PTSD Attend to alexthyma Use but don t rely on psychologcal testng, delay when clncally approprate 35 Broad prncples Hedge bets Prescrbe treatment when hgh ndex of suspcon exsts Clearly communcate dagnoss vs. ndex of suspcon 12

13 Broad Prncples There are no psychatrc condtons for whch medcaton monotherapy s approprate Prescrbng therapy as a generc recommendaton can be largely worthless Be specfc about why therapy for ths ndvdual, what modaltes mght be helpful and why, what mght be markers of mprovement, and what the goals are. The goal of therapy s termnaton Dual Dagnoss Omar S. Manejwala, M.D., MBA, FAPA, CPE Medcal Drector twtter: drmanejwala 13