Integrating the Treatment of Substance Use Disorders and Co-occurring Psychiatric Disorders in Adolescents

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1 Integrating the Treatment of Substance Use Disorders and Co-occurring Psychiatric Disorders in Adolescents Paula Riggs, M.D. University of Colorado School of Medicine Denver, CO Disclosures Source Consultant Advisory Board Stock of Equity >$, Speakers Bureau Research Support Honorarium for this talk or meeting Expenses Related to This talk or meeting Other Honorarium AACAP McNeil NIDA Shire Learning Objectives At the conclusion of this presentation participants should be able to: Recognize the prevalence, developmental risk factors, and bidirectional impact of co-occurring psychiatric and substance use disorders (SUD) in adolescents; Identify evidence-based treatment for adolescent SUD, conduct disorder, ADHD, depression and anxiety disorders; Describe current research supporting integrated treatment of co-occurring disorders; and Understand the clinical implications and applications of research. 1

2 Background and Significance 6-8% adolescents with substance use disorders have co-occurring psychiatric disorder Co-occurring disorders associated with poorer treatment outcomes Clinical and research consensus supporting integrated treatment Systemic barriers and research gaps have impeded progress with implementation Whitmore, E., Riggs, P. Developmentally Informed Diagnostic and Treatment Considerations in Comorbid Condition. In: H.A., C. L Rowe (Eds) Adolescent Substance Abuse: Research and Clinical Advances. Cambridge University Press, 26. Background and Significance No empirically-supported model to guide clinical implementation Psychiatric research historically excluded adolescents w/ SUD Addiction treatment research has generally ignored or excluded co-morbidity Clinicians reluctant to treat psychiatric problems in adolescents with SUD Developmental Pathways to Adolescent Mental Health, Substance Use Problems Childhood Psychiatric Disorders Conduct Disorders (general pop % vs. 5 6%) ADHD (general pop 8% vs. 3 5%) Depression (general pop 5 9% vs. 15 4%) Family SUD Abuse, Neglect Parental Monitoring INDIVIDUAL Peers Drug-using Gangs Anti-social School Truancy Failure Dropout Chan, Y-F, Y Dennis, M.L., Funk, R.R., Prevalence and comorbidity of major internalizing and externalizing problems among adolescents ents and adults presenting to substance abuse treatment, J Subst Abuse Treat 28 January; 34(1):14-24 Whitmore, E.A. and Riggs, P.D. Developmentally Informed Diagnostic and Treatment Considerations in Comorbid Conditions Chapter 13 In : H.A. Liddle,, C.L. Rowe (Eds( Eds) Adolescent Substance Abuse: Research and Clinical Advances,, Cambridge University Press, 26 2

3 Evidence Based Treatment Substance Use Disorders and Common Co-Occurring Disorders Conduct Disorder ADHD Major Depression Anxiety Evidence-Based Treatment Modalities for Adolescents Psychiatric Disorders Conduct Disorder Family-Based Intervention Parent Management Training Functional Family Therapy, Multi- Dimensional Family Therapy, Multisystematic Therapy, Individual Therapy Cognitive Behavioral Therapy/Behavioral Therapy/Skills Training ADHD Psychostimulants Non-stimulants Depression, Anxiety Disorders Cognitive Behavioral Therapy Interpersonal Pharmacotherapy/SSRIs Substance Use Disorders Family-Based Interventions Functional Family Therapy (FFT) Multidimensional Family Therapy (MDFT) Multisystemic Therapy (MST) Behavioral Interventions Contingency management Motivational incentives Cognitive Behavioral Therapy (CBT) Motivational Enhancement Therapy (MET) Addiction as a Chronic Medical Illness Pre Treatment Symptoms During Treatment Post Treatment* *6-8% relapse first year post-treatment Complete absence of primary disorder symptoms is high expectation for chronic disorders Cornelius JR, et al. Rapid Relapse Generally Follows Treatment for Substance Use Disorders Among Adolescents, Addictive Behaviors, Vol 28, Issue 2, March 23. 3

4 Research Support for Integrated Treatment of Co-occurring Disorders in Adolescents Randomized Controlled Trial Fluoxetine vs Placebo + 16 weeks CBT 328 Telephone Pre-Screen Calls Adolescents (13-19) 143 Assessed for Eligibility met DSM Criteria for: 13 Not Meeting Inclusion Criteria Major Depressive Disorder (MDD) + 4 Admitted to Residential Treatment 17 Excluded Substance Use Disorder (SUD) 126 Randomized Conduct Disorder (CD) Fluoxetine + CBT N = 63 Placebo + CBT N = 63 Withdrawals:: Withdrawals: 4 Went to Jail/Detention 1 Went to Jail/Detention 3 Went to Residential Treatment at a 3 Lost to Follow-up Facility Unable to Continue Study 3 Moved Out of Area 3 Lost to Follow-up + 2 Withdrew Consent 9 Participants Withdrawn + 1 Moved Out of Area 11 Participants Withdrawn 84% tx completion: >85% adherence weekly medication visits; >7 % adherence with CBT 16 week completers N=52 16 week completers N = 54 Riggs P et al., Randomized Controlled Trial of Fluoxetine With CBT in Adolescents with Major Depressive Disorder, Behavior Problems, and Substance Use Disorders, Archives of Pediatric and Adolescent Medicine, 161(11)1-9, 27 Change in Depression Change in Depression (CDRS R) Week 1 Week 5 Week 9 Week 13 Week 17 Fluoxetine + CBT (n=63) Placebo + CBT (n=63) Remission v Non-remission (CDRS<29)* % 52% 2 P<.5 Fluoxetine + CBT (n=63) Placebo + CBT (n=63) flx v placebo = NS Pre-post change in depression P<.1 both flx/pbo *High rates of depression remission in both fluoxetine and placebo treatment groups strongly support that CBT as an active ingredient in the treatment of depression 4

5 Change in Drug Use Fluoxetine vs Placebo=NS 12 # days Past 8 Month 6 Drug 4 Use 5 2 Week 1 Week 4 Week 8 Week 12 Week Remitters vs Non-remitters Non-remitters PNR FNR FR Remitters Week Week 4 Week 8 Week 12 Week 16 Week o Fluoxetine..Placebo PR Fluoxetine + CBT (n=63) Placebo + CBT (n=63) Results: Significant pre-post change in both fluoxetine and placebo (P=<.1); no difference between groups Remitters significantly reduced drug use Non-remitters drug use did not decrease Change in Conduct Disorder Symptoms Fluoxetine vs Placebo = NS Week 1 Week 4 Week 8 Week 12 Week Remitters vs Non-Remitters = P=.4 PNR FNR FR Week Week 4 Week 8 Week 12 Week 16 PR Fluoxetine + CBT (n=63) Placebo + CBT (n=63) Week o Results: Pre post decrease in CD symptoms fluoxetine and placebo; P=.1; NS difference between groups Remitters > Non-remitters P=.5 Conclusions and Clinical Implications Fluoxetine RCT Empirical Support For Integrated T Depression outcomes as good or better than controlled studies in depressed teens without SUD Substance treatment outcomes as good or better than other evidence-based drug treatment modalities despite severity of co-occurring psychopathology Can integrated treatment be implemented in real world treatment settings with comparable outcomes? Riggs P et al., Randomized Controlled Trial of Fluoxetine With CBT in Adolescents with Major Depressive Disorder, Behavior Problems, and Substance Use Disorders, Archives of Pediatric and Adolescent Medicine, 161(11)1-9, 27 5

6 NID A NATIONAL INSTITUTE ON DRUG ABUSE National Drug Abuse Treatment Clinical Trials Network NIDA-CTN-28 Randomized Controlled Trial Osmotic-Release Methylphenidate (OROS-MPH) with CBT in Adolescents with Attention Deficit Hyperactivity Disorder and Substance Use Disorders Paula Riggs, M.D., Principal Investigator Efficacy Study vs CTN 28 Efficacy CTN % CBT MED visit Medication Treatment Compliance Completion N= 25/3 Randomized 11 sites Implications of CTN 28 for Clinical Practice and Integrated Treatment Feasible implementation of comprehensive, structured diagnostic evaluation and integrated treatment of psychiatric and substance use disorders in real world adolescent treatment programs Comparable preliminary treatment outcomes to the efficacy study 6

7 Encompass TM Integrated Treatment for Adolescents and Young Adults Assessment of Co-morbid Disorders Comprehensive Structured Diagnostic Interview (e.g., K-SADS) to identify important symptoms Lifetime Timeline to Longitudinally Map Clinically Relevant Developmental History Onset and Progression of Psychiatric Symptoms Onset and Progression of Substance Use Assessment Outcomes: Helps clinicians differentiate between actual psychiatric disorders and substance induced states Strengthens therapeutic alliance given the initial focus not on psychopathology but rather on normal development. Initial Evaluation First meeting with adolescent and parent/guardian (if available) hours Integrate information from KSADS and Lifetime Timeline for meaningful clinical/diagnostic formulation and treatment planning Discussion of diagnostic formulation, treatment plan, expectations, next steps with adolescent and parent/guardian 7

8 14 Year Old Male Brought to Clinic for Evaluation of Mood Swings, Irritability, and Aggression Increase in behavior problem at school, high truancy rate, falling grades; expelled for marijuana possession at school Parents divorced; moved to NM with father /stepmother age 6 Increased irritability; moodiness, aggression toward peers; sleep disturbance Physical Abuse by stepmother 6-12 Flashbacks, nightmares, sleep disturbance, intrusive thoughts irritability, aggression, difficulty concentrating Daily Marijuana Use Meets criteria for cannabis dependence, Marijuana Experimentation conduct disorder, PTSD S M T W T F S School Dance THC EtoH THC EtoH THC? ø THC THC Visit Day Use of the time line follow back (TLFB) anchored with a calendar to monitor change in drug use Overcoming Roadblocks to Obtaining Valid Clinical History Normalize experience and avoid pathologizing clinical jargon Educate about symptoms Concrete examples of symptoms and severity Do you often lose or misplace things, like your cell phone, keys, Alexithymia purse, shoes, ipod, etc.? Capture presence and severity of symptoms by asking more often than your friends/peers? Disorders with Early Onset ADHD Initially ask about symptoms in terms of how the environment would have responded to patient if symptoms had been present. Depression Use 1- likert scale for mood Anchor with clear examples of severity 8

9 Evidence-Based Treatment of Co-occurring Disorders in Adolescents Cognitive Behavioral Therapy with Motivational Enhancement Substance Abuse Psychiatric Co-morbidity Motivational Incentives to Reinforce Specific Target Behaviors Family involvement Pharmacotherapy Principles Empirical support for safety, efficacy Lower abuse /diversion Monotherapy > polypharmacy Monitor Target symptom response Depression (CDRS R) ADHD (DSM IV checklist) Substance Use (TLFB)* Adverse side effects Ongoing drug use Potential interactions with drugs of abuse Evidence-Based Treatment of Co-occurring Disorders in Adolescents Engage in positively reinforcing activity incompatible with drug use Build and maintain internalized motivation Facilitate association with prosocial peers, adults Augment paucity of continuing care resources, relapse prevention Periodically Re-evaluate Treatment goals and clinical progress External supports, resources, barriers, high risk situations Self-management and lifestyle changes to maintain treatment gains Develop Plan Re-intensify treatment if relapse/clinical deterioration Continuing Care Summary and Conclusion Additional research is needed to broaden our understanding of more effective integrative treatment Research advances have helped guide development of integrated treatment principles 9

10 Thank You Please click continue to proceed to the next section or click the main menu button above to return to the main menu. Continue

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