Dual Diagnosis. Steven Shoptaw, PhD UCLA Center for Behavioral and Addiction Medicine Department of Family Medicine

Transcription

1 Dual Diagnosis Steven Shoptaw, PhD UCLA Center for Behavioral and Addiction Medicine Department of Family Medicine July 14, 2013

2 Acknowledgments NIDA support R01 DA029804; R01 DA030577; T32 DA026400; P50 DA Disclosures: Clinical supplies from Medicinova (ibudilast) Pfizer (varenicline) Gilead (tenofovir + emtricitibine)

3 Overview Definitions and Concepts Epidemiology Treatment Strategies

4 Addiction DEFINITIONS

5 Identical Presentations Mania and intoxication from amphetamines, cocaine Depression and withdrawal from stimulants Addiction on opiates (street and prescribed) and opioid control of chronic, non-cancer pain Paranoid schizophrenia and heavy use of amphetamines Social anxiety and cannabis dependence Suicide

6 Substances Sedative/barbs ALCOHOL, benzodiazepines, GHB Stimulants cocaine, speed, NICOTINE, Ecstasy (MDMA) Opiates heroin, percodan, dilaudid, vicodin Hallucinogens LSD, mescaline, peyote Tranquilizers/anesthetics ketamine, PCP Cannabinoids POT, hash Inhalants poppers, solvents

7 DSM-5 Definition: Substance Use Disorder Maladaptive pattern of use, clinically significant impairment or distress and 2+ of the following in the same 12-month period: 1. Tolerance 2. Withdrawal 3. Used for longer periods than intended 4. Can t cut down or quit 5. Time spent getting, using or recovering 6. Give up social, work or fun activities 7. Craving or a strong desire or urge to use a substance 8. Continued use despite knowledge of negative consequences 9. Failure to fulfill major role obligations 10. Use in physically hazardous situations 11. Continued use despite social and interpersonal problems

8 Drug Use in America is Normative In 2011, 20.6 million (8.0% of adults aged 12 and over) met criteria for substance abuse or dependence not including tobacco dependence (National Survey on Drug Use and Health, 2012). Alcohol abuse and dependence represents the majority (14.1 million or 68.4% of those with abuse or dependence) remainder splits between drug disorders only and comorbid illicit drug use and alcohol use disorders. NSDUH, 2012

9 The Prevailing Model: Bio-Psycho-Social IMPLICATIONS FOR TREATMENT Bio: Individual differences (genetics, gender) that represent risk factors for addiction Physiologic changes from chronic drug exposure Physiologic changes from withdrawal or sustained abstinence Individual responses to treatment medications Psycho: Psychological, cognitive and emotional factors that contribute to impulsive drug seeking Social: Environmental, social, cultural and political effects that protect from and promote drug use

10 Addiction Dual Disorders Developmental Considerations EPIDEMIOLOGY

11 Substance Use Prevalence, 2011 Substance Δ from 2010 % Current Cigarette Smokers % Alcohol Use (any in past month) % Heavy Alcohol Drink (5+ drinks, 5+ days past month) 6.2% Marijuana Use (past month) 5.8% in % Prescription Drug Misuse (past month) 2.4% Heroin Use (past month) % Cocaine Use (past month) % Methamphetamine Use (past month) 0.2% NSDUH,

12 Incidence: Drug Abuse and Dependence For the first time, prevalence of drug abuse, dependence continues as cohort ages up: Gen X (30-44) did not show reductions in prevalence of abuse and dependence. N=~43,000 Compton W, et al., Arch Gen Psych, 2007, 64:

13 Marijuana

14 Brain Development Frances Jensen and David Urion

15 Substances and Incident Schizophrenia No Substance Use Cannabis Cannabis + AMP Age at Onset Replication of this finding from large cohort [N=785] of Dutch patients (Dekker et al., 2012) In 63.5% of cannabis using patients, most intense period of use preceded incident break by 1+ years. Cannabis+Coc+AMP Effect not as consistent for depression disorders (Manrique-Garcia et al., BMC Psychiatry 2012 Power BD et al., Aust N Z J Psychiatry. 47:51-8. [N=167]

16 Substances and Incident Bipolar In 118 Australian first episode psychotic mania, substance use (cannabis) and forensic issues were predictive for males; sexual abuse trauma for females (Cotton et al. BMC Psychiatry Mar 13:82) Lagerberg et al., 2011, Eur Arch Psychiatry Clin Neurosci. 261:

17 Incident Drug Use and Mood Disorders - NESARC At Time 1, Incident drug use was predicted by childhood adversity, family history of addiction. At Follow-up (3 years) new onset drug use was predicted by: Pre-existing mood disorder (AOR 1.31, 95% CI: ) Personality disorder (AOR 1.82, 95% CI: ) Nicotine dependence (AOR 1.41, 95% CI: ) Alcohol abuse/dependence (AOR 1.96, 95% CI: ) Harrington M et al Can J Psychiatry. 56:

18 Prospective Considerations When comparing clinical high risk (CHR) late adolescents (n=101) to healthy controls (n=59), cannabis use did not predict incident psychosis Cannabis using CHR youth had significantly higher social functioning than non-using CHR youth May indicate better social functioning OR cannabis use may mediate prodromal symptoms Auther AM et al., Psychol Med. 42(12):

19 Personality Disorders and SUD Hasin D. et al Arch Gen Psych 68:

20 Cigarette Smoking and Mood Disorders - NESARC Social phobia (OR 1.69, 95% CI: ) Specific phobia (OR 1.69, 95% CI: ) Major Depression Disorder (OR 1.65, 95% CI: ) Bipolar Disorder (OR 2.38, 95% CI: ) Goodwin RD Am J Addict. 21:416-23

21 Pharmacotherapies TREATMENT STRATEGIES

22 Addiction Treatment? Only 10% of adults with abuse get treatment; 30% of adults with dependence get treatment ~2/3 seek primary care, but less than 10% of MDs refer drug users to Rx Compton W et al., Arch Gen Psych. 64:

23 Pharmacotherapy Targets and Treatments Pharmacological Targets Substitution (agonists) Relieve withdrawal symptoms (craving) Block relapse (antagonists) Mixed approaches (partial agonists) None of these targets imply cure The palette of medications approved for use: Smoking (NRT, bupropion, varenicline) Opioids (methadone, Suboxone, naltrexone) Alcohol (naltrexone, acamprosate, disulfiram) Signal for bupropion for methamphetamine

24 Addiction Medicine in Los Angeles County Drug and Alcohol Treatment Public Private Methadone Suboxone Naltrexone NRT + Bupropion Varenicline Naltrexone (inject/tablets) Acamprosate + 2 weeks of NRT available from LAC: NOBUTTS

25 Behavioral Therapies TREATMENT STRATEGIES

26 Psychology of Addiction Disorder of impulse inhibition Cognitive and behavioral brakes are shot Key factor is ambivalence It s never resolved Lots of comorbidities, but when do you treat? Easiest when considering pharmacotherapies Many of the behavior therapies are similar and will have direct crossover Skills for managing historical issues How do you know when your patient is lying? Essential to use biomarkers

27 Efficacious Behavioral Therapies Targets for Behavioral Therapy Instilling of abstinence Prevention of relapse Improve mood and cognition Reduce craving Behavioral therapy models with efficacy Cognitive Behavioral Therapy Contingency Management Motivational Interviewing Community Reinforcement Approach

28 Depth Psychotherapy Despite elegant constructions of drug use in depth psychotherapy, outcome studies do not support this technique for addictions Good rule of thumb is to begin psychotherapy within 3-6 months after drug discontinuation

29 Behavioral Treatments in Los Angeles County Drug and Alcohol Treatment Public Private Cog-B Therapy Contingency Mgmt Mot Interviewing Comm Reinf App 12-Step Groups 1 Social Model 1,2 Milieu Therapy 1,2 1 No efficacy studies; 2 Inpatient/residential modalities only

30 Self-Help Brief Interventions Behavioral Therapies BEHAVIORAL INTERVENTIONS

31 Self-Help Approaches 12-Step Programs are effective, despite lack of efficacy data Application to many addictions SMART Recovery Enhance motivation; cope with urges; manage harmful behavior; establish lifestyle balance.

32 Knock it Off! Works Remits Needs Intervention Babor et al., 2005

33 Brief Intervention 5 A s Ask Advise Assess Assist Arrange Implement an officewide system that ensures that, for every meth using MSM at every clinic visit, meth use status is queried and documented In a clear, strong, and personalized manner, urge every patient to quit Ask every meth using MSM if he is willing to make a quit attempt now (next 30 days) Help the patient plan, provide practical counseling, recommend meds, be supportive Provide for follow-up support, phone calls Adapted from Fiore et al., 2008, Clinical Practice Guidelines for Smoking Cessation

34 Evidence for SBIRT NIDA Med Assist: rugabuse.gov /nmassist Madras et al Drug Alc Dep, 99:

35 Motivational Interviewing: Basic Assumptions People change thinking and behavior along a series of stages Individuals may enter treatment at different stages of change The natural change process can be changed using MI techniques MI engages individuals in longer term treatment and promotes specific behavior changes Confrontation of denial is counterproductive and may be harmful

36 Cognitive Behavioral Therapy: Key Concepts Encourage and reinforce behavior change Situation-thought-feeling links Recognize and avoid high risk settings Behavioral planning (scheduling) Skills for coping with conditioned triggers Understand and deal with craving Abstinence violation effect getting back on the wagon Understanding basic psychopharmacology principles Self-efficacy

37 Contingency Management Providing vouchers of increasing value or chances to draw from a lottery for consecutive biological samples documenting substance abstinence Evidence of efficacy for use with opioids, nicotine, cocaine, methamphetamine Effective as treatment, but has variable effects implemented with non-treatment seekers Strona et al., 2006 Menza et al., 2011; Corsi et al., 2012

38 Summary ACA is going to change landscape for providers and for patients People living with diagnoses of mental illness and addictions need treatment for both conditions Some medications and many behavioral therapies for both sets of disorders Few with capacity to treat both at the same time Both types of disorders are chronic and disorganizing, so start treatments when needed

39 UCLA Department of Family Medicine Thank You! Advancing the prevention and treatment of chronic illnesses