The Complex Client in the Community: A New Standard of Care Addictions & Mental Health Ontario Community of Practice Meetings November 9 th, 2015 (8:30 9:30 am) Dr. Peter Selby, MBBS, CCFP, FCFP, MHSc, dip ABAM Professor, DFCM & Psychiatry and the Dalla Lana School of Public Health, University of Toronto Director of Medical Education and Clinician Scientist, Addictions, CAMH @psquitsmoking 1
Disclosures Grants/Research Support: CAMH, Health Canada, OMOH, CTCRI, CIHR Alberta Health Services, Pfizer Inc./Canada, OLA, ECHO, NIDA, CCS, CCO, OICR, Ontario Brain Institute, McLaughlin Centre, AHSC/AFP, WSIB, NIH, AFMC, Mt Sinai Hospital Shoppers Drug Mart Speakers Bureau/Honoraria: Pfizer Inc. Canada, Pfizer Global, ABBVie Consulting Fees: Pfizer Inc./Canada, Pfizer Global, NABI Pharmaceuticals, V-CC Systems Inc. (ehealth Behaviour Change Software Co.) NO TOBACCO or ALCOHOL or FOOD INDUSTRY FUNDING 2
Learning Objectives 1. Understand the definition of concurrent disorders. 2. Reflect on the patient, clinician, and system barriers in the assessment and treatment of patients with concurrent disorders. 3. Describe an approach to people with concurrent disorders 4. Analyze the pharmacotherapeutic options for patients with concurrent disorders. 3
What are Concurrent Disorders? Co-occurring mental illness and SUDS Dual diagnosis Axis 1 disorders Axis 2 disorders 4
The 5 Facts About CD & Treatment Under-recognized, but common Complex, but understandable Challenging, but treatable More than a clinical problem Integration of services are key 5
Rates of Co-occurrence Presence of psychiatric illness increases likelihood of a substance use disorder by 2.7 times Presence of substance use disorder increases likelihood of psychiatric disorder: if alcohol, by 2.3 time if other drugs, by 4.5 times Kofeod et al. 1991 6
Prevalence & Marginalization Street youth Chronically homeless IDU HIV+ Dual diagnosis --> Triple diagnosis Forensic Personality disorders Head injury 7
Prevalence & Marginalization CD prevalence rates are high among clients of substance abuse and mental health services Co-occurring disorders negatively affect treatment Clients with CD are at higher risk for: Suicide Family violence HIV infection Incarceration Re-hospitalization Individual, family, and societal costs are extremely high 8
Barriers in Assessment and Treatment Co-occurring addictive and other psychiatric illnesses have similar symptoms but are treated differently at different systems of care Memory problems Impaired thinking Mood disturbances Unpredictable behavior Substance Abuse Mental Illness Cindy McGlynn, CAMH 2005 9
Patient-Level Barriers Interferes with ability to adhere to treatments Risk of mental illness increases with severity of the substance use disorder Influences behavior may lead to riskier behavior Do not seek help due to higher healthcare costs and unsatisfactory treatment CCSA 2014, Rush et al 2008 10
Clinician-Level Barriers Lack of familiarity with evidence-based practice Lack of belief or confidence in collaboration Lack of preparation through education and training Attitudes, stigma, and discrimination Lack of incentives for change Lack of access to key services Fear of change CCSA 2014 11
System-Level Barriers Historic separation between substance use and mental health sectors Emphasis on either substance use or mental health at the cost of the other Strained work environment Unanticipated costs and delays CCSA 2013 12
+ Contrasting Historical Features: A Tale of Two Tribes Substance use Mental health Psychosocial and self-help models Community support base Counsellors who are in recovery Abstinence from all psychoactive substances Medical model Institutional treatment base Professionally trained staff Use of drug therapy 13
Typical Treatment Assessment Withdrawal/Stabilization Motivation Treatment Aftercare Biopsychosocial Multidisciplinary 14
Whole person care: Concurrent disorders within a context It is time to create a new standard of care! 16
Glass et al., 2006 17
Approach to Diagnosis Establish the presence of a concurrent diagnosis? Screeners? Self medication? Temporal relationship Which accounts for presenting problem? Prospective observation: Effect of abstinence/reduction 18
Determinants of CD 19
A Dimensional Model of Concurrent Disorders Hallucinogens Stimulants Mental Health Depressants 20
A Dimensional Model of Concurrent Disorders Anxiety Mood Substance Use Psychosis Impulsivity 21
Dimensional Approach to CD Behaviour Dimension Mental Health Diagnoses (Eg) AXIS 1 AXIS 2 Substance Use (Eg) H/D/Weird Talk Psychosis (Thoughts) Schizophrenia Paranoid, Schizotypal Cocaine Induced Psychosis Sad/Manic Mood (Feelings) Bipolar All PDs Alcohol Induced Depression Fearful Anxiety (Inhibition) Panic, GAD Dependent Cannabis Induced Anxiety Acting Out, Aggressive Impulsivity (Disinhibition) Alcohol Dependence, Abuse BPD Amphetamine Induced Sexual Disorder 22
Why work with co-occurring disorders? Working better with existing clients Creating a more receptive climate for reaching & engaging excluded populations Developing more collaborative and consultative relationships with other care providers The next step towards a holistic model of care (Bio- Psycho-Social-Spiritual) Creating a true system of care that people affected by addiction & mental health problems value 23
Building Holistic Perspectives Housing Income Consumer Groups & Organizations Addiction & Mental Health Services PERSON Education Family & Friends Community Groups & Services Work (From Trainor et al, 2000) 24
The Quadrant Model High A/Low MI High A/High MI Low A/Low MI Low A/High MI Low High Severity of Mental Illness 25
Level 1: Capacities & Competencies Level 1 Capacities (Systems Level) To offer effective care to clients with a primary mental health or addiction problem who also present with co-occurring addiction or mental health problems Level 1 Competencies (Practitioner Level) Staff teams in all addiction and mental health programs will be skilled in the following areas regarding concurrent disorders: identification assessment treatment planning referral provision of level one treatment interventions case management and supportive care 26
Level 2: Capacities & Competencies Level 2 Capacities (Systems Level) To provide assessment and treatment services for clients with co-occurring addiction and mental health problems who require care in specialized treatment programs with a single, integrated, multidisciplinary team; and to provide expert consultation and training to Level 1 programs Level 2 Competencies (Practitioner Level) Staff working in Level II Programs (e.g., Concurrent Disorders Service) would be skilled in the following areas: -all Level I competencies, plus: -specialized assessment methods and procedures -delivering specialized treatment programs and modules -providing specialized consultation to Level I staff -providing clinical training and education in the -assessment and treatment of concurrent disorders -collaborating and conducting clinical research in concurrent disorders 27
Approach to Treatment Which accounts for the presenting problem Which is more acute? Rule of thumb Treat SUDs first Detox does wonders Treat underlying psychiatric problems Encourage psychosocial treatments 28
Goals of Pharmacotherapy Cure? Induction of remission Prevention of relapse 29
Goals of Pharmacotherapy Addicted Brain 30
Pharmacotherapeutic Options Name of Drug Disulfiram (Antabuse) Use in Addiction Treatment Aversive effects when drinking alcohol Naltrexone (ReVia) Decreased craving and reinforcement of drinking, increased headache and nausea Acamprosate (Campral) Methadone Buprenorphine Reduces alcohol cravings and prevents relapse Treatment for opiate withdrawal and replacement Detoxification and maintenance treatment of opioids Doweiko 2002, Garbutt 2005, Keltner & Folks 2005 31
Pharmacotherapeutic Options Name of Drug Nicotine Replacement Therapy (NRT) Use in Addiction Treatment Patch, gum, nasal spray, inhaler, lozenges Increase success of initially quitting smoking by 50% - 70% Mostly skin irritations Bupropion (Zyban) Reduces nicotine cravings and withdrawal symptoms Approximately doubles the chances of quitting smoking after 3 months Insomnia, headaches, seizures, nausea, and contraindications Varenicline (Champix) One of the most effective medications for smoking cessation More effective than bupropion and NRT Depression, suicide, associated with cardiovascular disease Stead 2012, Wu 2006, Jorenby 2006, Mills 2009 32
Final Principle, and Starting Point Concurrent disorders treatment is not about a willingness to work with people because their complex and challenging problems, but a commitment to working with people because of the complexity and difficulty of their problems Wayne Skinner, CAMH 2005 33
Resources Collaboration for Addiction and Mental Health Care: Best Care http://www.ccsa.ca/resource%20library/ccsa- Collaboration-Addiction-Mental-Health-Best-Advice- Report-2014-en.pdf Systems Approach Workbook: Integrating Substance Use and Mental Health Systems http://www.ccsa.ca/resource%20library/nts-systemsapproach-integrating-substance-use-and-mentalhealth-systems-en.pdf 34
Acknowledgements 35
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