Presentation on theme: "Dual Diagnosis - Handout"— Presentation transcript:
1Dual Diagnosis - Handout Dual diagnosis: An Integrated Model for the Treatment of People with Co-occurring Psychiatric and Substance DisordersKenneth Minkoff, M.D.x311Kenneth Minkoff, MD
2“Co-occurring Psychiatric & Substance Disorders in Managed Care Systems: Standards of Care, Practice Guidelines, Workforce Competencies & Training Curricula”click on: Publications & Presentationsclick on: Managed Care(215) Cost: $20.00
3American Association of Community Psychiatrists PRINCIPLES OF TREATMENT FOR INDIVIDUALS WITH CO-OCCURRING PSYCHIATRIC AND SUBSTANCE DISORDERS
4FIVE SECTIONS OF PANEL REPORT I. CONSUMER/FAMILY STANDARDSII. SYSTEM STANDARDS/PROGRAM COMPETENCIESIII. PRACTICE GUIDELINESIV. WORKFORCE COMPETENCIESV. TRAINING CURRICULA
5CONSUMER/FAMILY SYSTEM STANDARDS WELCOMINGACCESSIBLEINTEGRATEDCONTINUOUSCOMPREHENSIVE
6TRENDS LEADING TO COMORBIDITY DEINSTITUTIONALIZATIONCHANGED PATTERNS OF SUBSTANCE ABUSE/DEPENDENCEDECADE OF THE BRAIN: INCREASED KNOWLEDGE RE BRAIN DISORDERS
7Beyond the self-medication hypothesis People with serious mental illness use substances:To alleviate general feelings of isolation, loneliness, boredom, and despair,To facilitate peer interaction/socializationTo create a sense of well-being, and escape from bleak life experience
8Vulnerabilities to substance use disorders for SPMI 1. Greater extent of dysphonic feelings and sense of despair2. Fewer alternative, healthier coping resources3. Increased brain vulnerability to harmful effects of substances4. Mental illness may inhibit learning from results of adverse drug experience
9AREAS OF POOR OUTCOME RELAPSE & REHOSPITALIZATION SUICIDALITY AND VIOLENCEMEDICAL INVOLVEMENT (HIV/STD)CRIMINAL INVOLVEMENTHOMELESSNESSTRAUMA VULNERABILITYFAMILY DISRUPTION/ABUSEHIGH SERVICE UTILIZATION
10SAME FACES DIFFERENT PLACES Comorbidity is highly prevalent in all systems of care:Mental healthSubstance treatmentCriminal JusticeHomelessPrimary careVictim/trauma servicesFamily protective services
11SYSTEM MISFITS in all places SYSTEM LEVELPROGRAM LEVELCLINICIAN LEVEL
12RESEARCH-BASED TREATMENT MODELS FOR DUAL DISORDERS Integrated Intensive Case Mgt TeamsContinuous Treatment Team (CTT)- Drake & MueserIntegrated ACT/PACT TeamModified Addiction Residential ProgramsModified Therapeutic Community (TC) – Sachs/DeLeonParenting Women Programs
13Dual Diagnosis - Handout The most significant predictor of treatment success is... the ability of a program or intervention to provide... through an individual clinician, team of clinicians, or a community of recovering peers and clinicians... an empathic, hopeful, continuous treatment relationship, which provides integrated treatment and coordination of care through the course of multiple treatment episodes.Kenneth Minkoff, MD
14EMPATHY MANTRAWhen individuals with mental illness and substance disorder are not following recommendations, they are doing their job.It is our job to understand their job, to join them in it, and help them to do it better.Their job involves coming to terms with the painful reality of having both mental illness and substance disorder, wanting neither one, yet having to build an identity that involves rx for both.
15HOPE FOUR STEP PROCESS Empathize with reality of despair. Establish legitimacy of need to ASK for extensive help.3. Identify meaningful, attainable measures of successful progress.4. Emphasize a hopeful vision of pride and dignity to counter self-stigmatization.
16INTEGRATED TREATMENTIntegrated treatment refers to any of a number of mechanisms by which established diagnosis-specific and stage-specific treatments for each disorder are combined into a person-centered coherent whole at the level of the consumer, and each rx can be modified as needed to accommodate issues related to the other disorder.
17CONTINUITYCourse of treatment for individuals with chronic co-morbid conditions ideally combines continuous integrated relationships which are unconditional, with multiple episodic interventions or programmatic episodes of care which have expectations, conditions, and/or time limits.
18SUB-GROUPS OF PEOPLE WITH COEXISTING DISORDERS Patients with “Dual Diagnosis” - combined psychiatric and substance abuse problems - who are eligible for services fall into four major quadrants
19Dual Diagnosis - Handout PSYCH HIGH / SUBSTANCE LOW SERIOUS & PERSISTENT MENTAL ILLNESS WITH SUBSTANCE ABUSE QUADRANT IIPatients with serious and persistent mental illness (e.g. Schizophrenia, Major Affective Disorders with Psychosis, Serious PTSD) which is complicated by substance abuse, whether or not the patient sees substances as a problem.Kenneth Minkoff, MD
20Dual Diagnosis - Handout PSYCH HIGH / SUBSTANCE HIGH SERIOUS & PERSISTENT MENTAL ILLNESS WITH SUBSTANCE DEPENDENCE QUADRANT IVAPatients with serious and persistent mental illness, who also have alcoholism and or drug addiction, and who need treatment for addiction, for mental illness, or for both. This may include sober individuals who may benefit from psychiatric treatment in a setting which also provides sobriety support and Twelve-step Programs.Kenneth Minkoff, MD
21Dual Diagnosis - Handout PSYCH LOW / SUBSTANCE HIGH PSYCHIATRICALLY COMPLICATED SUBSTANCE DEPENDENCE QUAD III (mild-mod); QUAD IVB (severe)Patients with alcoholism and/or drug addiction who have significant psychiatric symptomatology and /or disability but who do NOT have serious and persistent mental illness.Includes both substance-induced psychiatric disorders and substance-exacerbated psychiatric disorders.Includes the following psychiatric syndromes:Anxiety/Panic Disorder - SuicidalityDepression/Hypomania - ViolencePsychosis/Confusion - PTSD SymptomsSymptoms Secondary to Misuse/Abuse of Psychotropic MedicationPersonality Traits/DisorderKenneth Minkoff, MD
22Dual Diagnosis - Handout PSYCH LOW / SUBSTANCE LOW MILD PSYCHOPATHOLOGY WITH SUBSTANCE ABUSE QUADRANT IPatients who usually present in outpatient setting with various combinations of psychiatric symptoms (e.g. anxiety, depression, family conflict) and patterns of substance misuse and abuse, but not clear cut substance dependence.Kenneth Minkoff, MD
23DSM III-R Diagnostic Criteria PSYCHOACTIVE SUBSTANCE ABUSE Dual Diagnosis - HandoutDSM III-R Diagnostic Criteria PSYCHOACTIVE SUBSTANCE ABUSEA maladaptive pattern of psychoactive substance use indicated by at least one of the following:Continued substance use despite having persistent or recurrent social, occupational, psychological, or physical problems caused or exacerbated by the effects of the substance useRecurrent substance use in situations in which it is physically hazardousRecurrent substance-related legal problemsSome symptoms of the disturbance have lasted for at least one month, or have occurred repeatedly over a longer period of time.The symptoms have never met the criteria for Substance Dependence for this class of substance.Kenneth Minkoff, MD
24DSM IV Diagnostic Criteria PSYCHOACTIVE SUBSTANCE DEPENDENCE Dual Diagnosis - HandoutDSM IV Diagnostic Criteria PSYCHOACTIVE SUBSTANCE DEPENDENCEA maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring any time in the same 12-month period:Tolerance, as defined by either of the following:A need for markedly increased amounts of substance to achieve intoxication or desired effectMarkedly diminished effect with continued use of the same amount of the substanceWithdrawal, as manifested by either of the following:The characteristic withdrawal syndrome for the substanceThe same (or closely related) substance is taken to relieve or avoid withdrawal symptomsThe substance is often taken in larger amounts or over a longer period than was intendedThere is a persistent desire or unsuccessful efforts to cut down or control substance use(Continued)Kenneth Minkoff, MD
25Dual Diagnosis - Handout DSM IV Diagnostic Criteria PSYCHOACTIVE SUBSTANCE DEPENDENCE (Continued)A great deal of time spent in activities necessary to obtain the substance, use the substance, or recover from its effectsImportant social, occupation, or recreational activities are given up or reduced because of substance useContinued use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance NOTE: The following items may not apply to cannabis, hallucinogens, or phencyclidine (PCP)Characteristic withdrawal symptomsSubstance often taken to relieve or avoid withdrawal symptomsKenneth Minkoff, MD
26Individuals with Co-occurring Disorders Treatment Rules Dual Diagnosis - HandoutIndividuals with Co-occurring Disorders Treatment RulesAll good treatment proceeds from empathic, hopeful, clinical relationship.Consequently, promote opportunities to initiate and maintain integrated, continuing, empathic, hopeful relationships whenever possible.Specifically, remove arbitrary barriers to initial mental health assessment and evaluation, including initial psychopharmacology evaluation (e.g., length of sobriety, alcohol level, etc.)Similarly, never deny access to substance disorder evaluation and/or treatment because a patient is on a prescribed non-addictive psychotropic medication.Moreover, never discontinue medication for a known serious mental illness because a patient is using substances.In fact, when mental illness and substance disorder co-exist, both disorders require specific and appropriately intensive primary treatment.There are no rules! The specific content of dual primary treatment for each person must be individualized according to diagnosis, phase of treatment, level of functioning and/or disability, and assessment of level of care based on acuity, severity, medical safety, motivation, and availability of recovery support.Kenneth Minkoff, MD
27PRINCIPLES Dual Diagnosis is an expectation, not an exception. Dual Diagnosis - HandoutPRINCIPLES Dual Diagnosis is an expectation, not an exception.Kenneth Minkoff, MD
28Philosophical & Clinical BARRIERS TO INTEGRATED TREATMENT Addiction System Mental Health SystemPeer Counseling model vs. Medical/Professional modelSpiritual Recovery vs. Scientific treatmentSelf Help vs. MedicationConfrontation and expectation vs. Individualized support and flexibilityDetachment/empowerment vs. Case management/careEpisodic treatment vs. Continuity of ResponsibilityRecovery ideology vs. Deinstitutionalization ideologyPsychopathology is secondary vs. Substance use is secondaryto addiction to psychopathology
29Dual Diagnosis - Handout PRINCIPLES Within the context of the empathic, hopeful, continuous, integrated relationship, case management/care and empathic detachment/confrontation are appropriately balanced at each point in time.Kenneth Minkoff, MD
30Dual Diagnosis - Handout PRINCIPLES When both Mental Illness and Substance Disorder coexist, both diagnoses should be considered primary.Kenneth Minkoff, MD
31Dual Diagnosis - Handout PRINCIPLES Both Major Mental Illness and Substance Dependence are examples of primary, chronic, biologic mental illnesses which fit into a disease and recovery model of treatment.Kenneth Minkoff, MD
32Dual Diagnosis - Handout PARALLELSAlcoholism/Addiction1. A biological illness2. Hereditary (in part)3. Chronicity4. Incurability5. Leads to lack of control of behavior and emotions6. Positive and negative symptoms7. Affects the whole family8. Progression of the disease without treatment9. Symptoms can be controlled with proper treatmentMajor Mental Illness1. A biological illness2. Hereditary (in part)3. Chronicity4. Incurability5. Leads to lack of control of behavior and emotions6. Positive and negative symptoms7. Affects the whole family8. Progression of the disease without treatment9. Symptoms can be controlled with proper treatment(Continued)Kenneth Minkoff, MD
33PARALLELS (Continued) Dual Diagnosis - HandoutPARALLELS (Continued)Alcoholism/Addiction10. Disease of denial, relates to both disease & chronicity of disease11. Facing the disease can lead to depression and despair12. Disease is often seen as a “moral issue”, due to personal weakness rather than biological causes13. Feelings of guilt & failure14. Feelings of shame & stigma15. Physical, mental and spiritual diseaseMajor Mental Illness10. Disease of denial, relates to both disease & chronicity of disease11. Facing the disease can lead to depression and despair12. Disease is often seen as a “moral issue”, due to personal weakness rather than biological causes13. Feelings of guilt & failure14. Feelings of shame & stigma15. Physical, mental and spiritual diseaseKenneth Minkoff, MD
34PARALLELS PROCESS OF RECOVERY Dual Diagnosis - HandoutPARALLELS PROCESS OF RECOVERYPHASE 1: Stabilization- Stabilization of active substance use or acute psychiatric symptomsPHASE 2: Engagement/ Motivational Enhancement- Engagement in treatment- Contemplation, Preparation, PersuasionPHASE 3: Prolonged Stabilization- Active treatment, Maintenance, Relapse PreventionPHASE 4: Recovery & Rehabilitation- Continued sobriety and stability- One year - ongoingKenneth Minkoff, MD
35PROCESS OF RECOVERY PHASE 1: Stabilization DetoxificationOften inpatient, may be involuntaryUsually need medication3-5 days (alcohol) to 2-3 weeks (opiates, benzos)Includes assessment for other diagnosesStabilization can occur at any level of care (ASAM)Stabilize AcutePsychiatric IllnessOften inpatient, may be involuntaryUsually need medication2 days to 6 monthsIncludes assessment for effects of substances, and for addictionStabilization may occur at any level of care (LOCUS)
36Level of Care Assessment ASAM ASSESSMENT DIMENSIONSIntoxication, withdrawalBiomedical complic.Emotional/behaviorAccept/resistanceRelapse potentialRecovery env’tLOCUS ASSESSMENTDIMENSIONSRisk of harmFunctional statusComorbidityRecovery env’tTreatment HistoryAdherence/motiv.
37PROCESS OF RECOVERY PHASE 2: Engagement/Motivational Enhancement Addiction TreatmentEngagement in ongoing treatment is crucial for recovery to proceedBegins with empathy and proceeds through phases of education and empathic confrontation, before patient commits to ongoing active treatmentMotivational interviewing techniquesEducation about substance use, abuse, and dependence & empathic confrontation of adverse consequences are tools to overcome denial. Patient accepts powerlessness to control drug without helpPsychiatric TreatmentEngagement in ongoing treatment is crucial for recovery to proceedBegins with empathy and proceeds through phases of education and empathic confrontation, before patient commits to ongoing active treatmentMotivational interviewing techniquesEducation about mental illness and the adverse consequences of treatment non-compliance are tools to overcome denial. Patient accepts powerlessness to control symptoms without help(Continued)
38PROCESS OF RECOVERY PHASE 2: Engagement/Motivational Enhancement (Continued) Addiction TreatmentEducation of the family, & involving them in interviews to promote motivationEngagement may take place in a variety of treatment settings…may need extended inpatient or day treatment rehabilitation (2-12 weeks)Engagement may be initially coercedMultiple cycles of relapse usually occur before engagement in ongoing treatment is successful (revolving door)Psychiatric TreatmentEducation of the family, & involving them in setting limits on non-complianceEngagement may take place in a variety of treatment settings…may need extended inpatient or day treatment rehabilitation (1-6 months)Engagement may be initially coercedMultiple cycles of relapse usually occur before engagement in ongoing treatment is successful (revolving door)
39STAGES OF CHANGE Prochaska & DiClemente (1992) PRECONTEMPLATIONCONTEMPLATIONPREPARATIONACTIONMAINTENANCE
40STAGES OF TREATMENT Osher & Kofoed (1989) McHugo et al (1995) 1. Pre-engagementENGAGEMENT Engagement3. Early PersuasionPERSUASION Late Persuasion5. Early Active RxACTIVE TREATMENT Late Active Rx7. Relapse PreventionRELAPSE PREVENTION 8. Remission
41PROCESS OF RECOVERY PHASE 3: Prolonged Stabilization Continued AbstinenceOne-YearPatient consistently attends abstinence support programsUsually voluntary, but ongoing compliance may be coerced or mandatedOngoing education about addiction, recovery and skills to maintain abstinenceFocus on asking for help to cope with urges to use substances and drop out of treatmentMust learn to accept the illness and deal with shame, stigma, guilt, and despairContinued Medication ComplianceOne-YearPatient consistently takes medication and attends treatment sessions regularlyUsually voluntary, but may be coerced or mandatedOngoing education about mental illness, recovery and skills to prevent relapseFocus on asking for help to cope with continuing symptoms and urges to discontinue treatmentMust learn to accept the illness and deal with shame , stigma, guilt, and despair (Continued)
42PROCESS OF RECOVERY PHASE 3: Prolonged Stabilization (Continued) Continued AbstinenceMust learn to cope with “negative symptoms”: social, affective, cognitive, and personality developmentFamily needs ongoing involvement in its own program of recovery to learn empathic detachment and how to set caring limitsMay need intensive outpatient treatment and/or 6-12 months residential placementContinuing assessmentRisk of relapse continuesContinued Medication ComplianceMust learn to cope with “negative symptoms”: impaired cognition, affect, social skills, and lack of motivation/energyFamily needs ongoing involvement in its own program of recovery to learn empathic detachment and how to set caring limitsMay need extended hospital, day treatment and/or residential placementContinuing assessmentRisk of relapse continues
43PROCESS OF RECOVERY PHASE 4: Recovery & Rehabilitation Continued SobrietyVoluntary, active involvement in treatmentStability precedes growth; no growth is possible unless sobriety is fairly secure. Growth occurs slowly (One Day at a Time)Continued work in the AA program, on growing, changing, dealing with feelingsThinking begins to clearNew skills for dealing with feelings, situationsContinued StabilityVoluntary, active involvement in treatmentStability precedes growth; no growth is possible unless stabilization of illness is fairly solid. Growth occurs slowly (One Day at a Time)Continued medication, but reduction to lowest level needed for maintenance. Continued work in treatment programThinking begins to clearNew skills dealing with feelings, situations(Continued)
44PROCESS OF RECOVERY PHASE 4: Recovery & Rehabilitation (Continued) Continued SobrietyIncreasing responsibility for illness, and recovery program brings increasing control of one’s lifeIncreasing capacity to work and to have relationshipsRecovery is never “complete”, always ongoingEventual goal is peace of mind and serenity (Serenity Prayer)Continued StabilityIncreasing responsibility for illness, and recovery programs brings increasing control of one’s lifeIncreasing capacity to work and relate (voc rehab, clubhouse)Recovery is never “complete”, always ongoingEventual goal is peace of mind and serenity (Serenity Prayer)
45SERENITY PRAYER“Grant me the serenity to accept the things I can not change,the courage to change the things I can,and the wisdom to know the difference.”
46Individuals with Co-occurring Disorders PRINCIPLES OF SUCCESSFUL TREATMENT:
47Dual Diagnosis - Handout Dual diagnosis is an expectation, not an exception. This expectation must be incorporated in a welcoming manner into all clinical contact.Kenneth Minkoff, MD
48The Four Quadrant Model is a viable mechanism for categorizing individuals with co-occurring disorders for purpose of service planning and system responsibility.
49Dual Diagnosis - Handout Treatment success derives from the implementation of an empathic, hopeful, continuous treatment relationship, which provides integrated treatment and coordination of care through the course of multiple treatment episodes.Kenneth Minkoff, MD
50Dual Diagnosis - Handout Within the context of the empathic, hopeful, continuous, integrated relationship, case management/care (based on level of impairment) and empathic detachment/confrontation (based on strengths and contingencies) are appropriately balanced at each point in time.Kenneth Minkoff, MD
51Dual Diagnosis - Handout When substance disorder and psychiatric disorder co-exist, each disorder should be considered primary, and integrated dual primary treatment is recommended, where each disorder receives appropriately intensive diagnosis-specific treatment.Kenneth Minkoff, MD
52Dual Diagnosis - Handout Both substance dependence and serious mental illness are examples of primary, chronic, biologic mental illnesses, which can be understood using a disease and recovery model, with parallel phases of recovery.Kenneth Minkoff, MD
53Dual Diagnosis - Handout There is no one type of dual diagnosis program or intervention.For each person, the correct treatment intervention must be individualized according to subtype of dual disorder, and diagnosis, phase of recovery, stage of treatment, level of functioning, skills, and/or disability, plus goals, problems, and contingencies, associated with each disorder.Kenneth Minkoff, MD
54Dual Diagnosis - Handout In a managed care system, individualized treatment matching also requires multidimensional level of care assessment involving acuity, dangerousness, motivation, capacity for treatment adherence, and availability of continuing empathic treatment relationships and other recovery supports.Kenneth Minkoff, MD
55Dual Diagnosis - Handout Individuals with Co-occurring Disorders Principles of Successful TreatmentCo morbidity is an expectation, NOT an exception. Four Quadrant Model.Treatment success derives from the implementation of an empathic, hopeful, continuous treatment relationship, which provides integrated treatment and coordination of care through the course of multiple treatment episodes.Within the context of the empathic, hopeful, continuous, integrated relationship, case management/care and empathic detachment/ confrontation are appropriately balanced at each point in time.When substance disorder and psychiatric disorder co-exist, each disorder should be considered primary, and integrated dual primary treatment is recommended, where each disorder receives appropriately intensive diagnosis-specific treatment.Both major mental illness and substance dependence are examples of primary mental illnesses which can be understood using a disease and recovery model, with parallel phases of recovery, each requiring phase-specific treatment.There is no one type of dual diagnosis program or intervention. For each person, the correct treatment intervention must be individualized according to diagnosis, phase of recovery/treatment, level of functioning and/or disability associated with each disorder, and level of acuity, dangerousness, motivation, capacity for treatment adherence, and availability of continuing empathic treatment relationships and other recovery supports.Kenneth Minkoff, MD
56ASSESSMENT OF INDIVIDUALS WITH CO-OCCURRING DISORDERS DetachmentDetectionDiagnosis and DisabilityDetermination of treatment needsDetailed Description of Situation, Supports, Skills, and Cultural Context
57DetachmentEmpathic detachment facilitates gathering accurate informationProactively communicate detachment and acceptance of consumer choiceUse detachment mantra
58Detection High index of welcoming and expectation Gather data from multiple sources, expecting information discrepancies.Initial screening: do (did) you have a problem?Screening tools: CAGE, MAST, DALI , RAFFT (SA); MIDAS (www.ohiosamiccoe.cwru.edu/clinical)BSI, MINI, Project Return MH Screening Form (www.asapnys.org/resources) (MH)Use urine/saliva/hair screens selectively
59Diagnosis Integrated, longitudinal, strength-based history Utilize mental status and medication response data from past periods of abstinence or limited useLow threshold for MH consult in SA settingIdentify patterns of dependence (vs. abuse) by assessing for awareness of lack of control in the face of serious harm; tolerance and withdrawal are not required.
60DescriptionAsk more questions to obtain more details about the problems you know least aboutIdentify external problem areas and supports (ASI), and explore opportunities for contingenciesObtain detailed information about mh symptoms : duration, content, control, perception of cause, factors which exacerbate/lessen, mh disease mgt skillsObtained detailed information about substance use: factors which promote/inhibit use, situations of use, cost of use, substance using peers, efforts to control use, substance use mgt skillsObtain detailed cultural context information: (peer, traditional, mh system, addiction recovery cultures)
61Determination of Treatment Needs Assessment of individualized treatment goals using motivational interviewingDetermination of stage of change/ stage of treatment:Substance Abuse Treatment Scale (McHugo et al)SOCRATES (Miller et al);URICA (DiClemente et al)Readiness to Change Questionnaire (Rollnick et al)
62Treatment Matching Example Quadrant IVA ContinuityAcute StabilizationMotivational EnhancementActive TreatmentRelapse Prevention/Rehabilitation
63PSYCHOPHARMACOLOGY PRACTICE GUIDELINES I. GENERAL PRINCIPLESNot an absolute scienceOngoing, empathic, integrated relationshipContinuous re-evaluation of dx and rxBalance case management and care with contingency management and contractsStrategies to promote dual recovery
64PSYCHOPHARMACOLOGY PRACTICE GUIDELINES II. ACCESS AND ASSESSMENTPromotion of access and continuity of relationship is the first priorityNo arbitrary barriers to psychopharm assessment in any setting based on length of sobriety or drug/alcohol levelsNo arbitrary barriers to substance assessment based on psychopharm regimen
65PSYCHOPHARMACOLOGY PRACTICE GUIDELINES III. DUAL PRIMARY TREATMENTDiagnosis-specific treatment for each disorder simultaneouslyDistinguish abuse and dependenceSpecific psychopharm strategies for addictive disorders are appropriate for individuals with comorbidityFor a known or presumed psychiatric disorder, continue use of best non-addictive medication for that disorder, regardless of status of SUD.
66PSYCHOPHARMACOLOGY PRACTICE GUIDELINES III. DUAL PRIMARY TREATMENTADDICTION PSYCHOPHARMDisulfiramNaltrexoneOpiate Maintenance TreatmentOthers?
67PSYCHOPHARMACOLOGY PRACTICE GUIDELINES III. DUAL PRIMARY TREATMENTPSYCHOPHARM FOR MIAtypicals and clozapine for psychosisLiCO3 vs newer generation mood stabilizersAny non-tricyclic antidepressantAnxiolytics: clonidine, SSRIs, venlafaxine, nefazodone, topiramate, other mood stabilizers, atypicals, (buspirone not first line)ADHD: Bupropion, then clonidine, SSRIs, tricyclics, then stimulants
68PSYCHOPHARMACOLOGY PRACTICE GUIDELINES IV. DECISION PRIORITIESSAFETYSTABILIZE ESTABLISHED OR SERIOUS MISOBRIETYIDENTIFY AND STABILIZE MORE SUBTLE DISORDERS
69SAFETYAcute medical detoxification should follow same established protocols as for individuals with addiction only.Maintain reasonable non-addictive psychotropics during detoxificationFor acute behavioral stabilization, use whatever medications are necessary (including benzodiazepines) to prevent harm.
70STABILIZATION OF SMINECESSARY NON ADDICTIVE MEDICATION FOR ESTABLISHED AND/OR SERIOUS MENTAL ILLNESS MUST BE INITIATED AND MAINTAINED REGARDLESS OF CONTINUING SUBSTANCE USEMore risky behavior requires closer monitoring, not treatment extrusionBe alert for subtle symptoms that are substance exacerbated, but still require medication at baseline.
71STRATEGIES FOR SOBRIETY Medication for addiction is presented as ancillary to a full recovery program that requires work independent of medication. Individuals on proper medication must work as hard as those with addiction only.Distinguish normal feelings from disorders with similar names (anxiety, depression)Psychiatric medications are directed to known or probable disorders, not to medicate feelingsProper medication for mental illness does not take away normal feelings, but permits patients to feel their feelings more accurately.Use fixed dosage regimes, not prn meds.
72More Strategies for Sobriety Avoid use of benzodiazepines or other generic potentially addictive sedative/hypnotics in patients with known substance dependenceContinued BZD prescription should be an indication for consultation, peer reviewUse contingency contracting to engage individuals who are already on BZDs.If indicated, withdrawal from prescribed BZDs using carbamazepine (or VPA, gabapentin), plus phenobarbital taper (1mg clonazepam = 30 mg pb)Be alert for prolonged BZD withdrawal syndrome
73More Strategies for Sobriety Pain Management should occur in collaboration with a prescribing physician who is fully informed about the status of substance use disorderIndividuals addicted to opiates for non-specific neck, back, etc. conditions can be informed that continued use of opiates worsens perceived pain. Full withdrawal plus alternative pain management strategies can actually improve pain in the long run.
74CHANGING THE WORLD Developing Comprehensive, Continuous, Integrated Systems of Care (CCISC)ForIndividuals with Co-occurringPsychiatric and SubstanceDisorders
75CCISC CHARACTERISTICS 1. SYSTEM LEVEL CHANGE2. USE OF EXISTING RESOURCES3. BEST PRACTICES UTILIZATION4. INTEGRATED TREATMENT PHILOSOPHY
76CHANGING THE WORLD A. SYSTEMS B. PROGRAM C. CLINICAL PRACTICE D. CLINICIAN
7712 STEPS OF IMPLEMENTATION 1. INTEGRATED SYSTEM PLANNING2. CONSENSUS ON CCISC MODEL3. CONSENSUS ON FUNDING PLAN4. IDENTIFICATION OF PRIORITY POPULATIONS WITH 4 BOX MODEL5. DDC/DDE PROGRAM STANDARDS6. INTERSYSTEM CARE COORDINATION
7812 STEPS OF IMPLEMENTATION 7. PRACTICE GUIDELINES8. IDENTIFICATION, WELCOMING, ACCESSIBILITY: NO WRONG DOOR9. SCOPE OF PRACTICE FOR INTEGRATED TREATMENT10. DDC CLINICIAN COMPETENCIES11. SYSTEM WIDE TRAINING PLAN
7912 STEPS OF IMPLEMENTATION 12. PLAN FOR COMPREHENSIVE PROGRAM ARRAYA. EVIDENCE-BASED BEST PRACTICEB. PEER DUAL RECOVERY SUPPORTC. RESIDENTIAL ARRAY: WET, DAMP, DRY, MODIFIED TCD. CONTINUUM OF LEVELS OF CARE IN MANAGED CARE SYSTEM: ASAM-2R, LOCUS 2.0
80A. SYSTEMS CHANGE 1. Empower structure to manage change 2. Consensus building on principles3. Regulatory ChangeA. Licensure/certificationB. Reimbursement/fundingC. Program standards/Practice GuidelinesD. Clinician competency/certification4. Quality Management/Outcome Evaluation
81B. PROGRAM CHANGE 1. STRUCURED PLAN FOR PROGRAMMATIC INTERFACE 2. COMPREHENSIVE PROGRAM ARRAYA. Horizontal integration/ MH and SAB. Vertical integration/ managed care
82B1. PROGRAM INTERFACE A. Formal interagency care coordination B. Mechanisms for administrative and clinical dispute resolutionC. Longitudinal continuity: interface with episodes of careD. Vertical continuity/integration: front door meets back doorE. MH support to CD system: Emergency/medsF. CD continuity of connection: MH&CD
83B2. COMPREHENSIVE PROGRAM ARRAY PROGRAM CATEGORIESAddiction System (ASAM PPC2R)DDC-CDDDE-CDAOSMental Health System (Minkoff)DDC-MHDDE-MHPeer Involvement/Cultural Competency
84Dual Diagnosis Capable: DDC-CD Routinely accepts dual patients, provided:Low MH symptom acuity and/or disability, that do not seriously interfere with CD RxPolicies and procedures present re: dual assessment, rx and d/c planning, medsGroups address comorbidity openlyStaff cross-trained in basic competenciesRoutine access to MH/MD consultation/coord.Standard addiction program staffing level/cost
85Dual Diagnosis Enhanced: DDE-CD Meets criteria for DDC-CD, plus:Accepts moderate MH symptomatology or disability, that would affect usual rx.Higher staff/patient ratio; higher costBraided/blended funding neededMore flexible expectations re:group workProgramming addresses mh as well as dualStaff more cross-trained/ senior mh supervisionMore consistent on site psychiatry/ psych RNMore continuity if patient slips
86Addiction Only Services: AOS Not standard for addiction servicesDoes not meet DDC criteriaDual diagnosis accepted irregularlyDual diagnosis not routinely addressed in treatment, nor documentedAppropriate for a narrowing group of clients
87Dual Diagnosis Capable: DDC-MH Welcomes people with active substance usePolicies and procedures address dual assessment, rx & d/c planningAssessment includes integrated mh/sa hx, substance diagnosis, phase-specific needsRx plan: 2 primary problems/goalsD/c plan identifies substance specific skillsStaff competencies: assessment, motiv.enh., rx planning, continuity of engagementContinuous integrated case mgt/ phase-specific groups provided: standard staffing levels
88Dual Diagnosis Enhanced DDE-MH Meets all criteria for DDC-MH, plus:Supervisors and staff: advanced competenciesStandard staffing; specialized programming:a. Intensive addiction programming in psychiatrically managed setting (dual inpt unit; dry dual dx housing, supported sober house)b. Range of phase-specific rx options in ongoing care setting: dual dx day treatment; damp dual dx housingc. Intensive case mgt outreach/motiv. enh.: CTT, wet housing, payeeship management
89DUAL DIAGNOSIS CAPABLE ROUTINELY ACCEPTS DUAL DIAGNOSIS PATIENTWELCOMING ATTITUDES TO COMORBIDITYCD PROGRAM: MH CONDITION STABLE AND PATIENT CAN PARTICIPATE IN TREATMENTMH PROGRAM: COORDINATES PHASE-SPECIFIC INTERVENTIONS FOR ANY SUBSTANCE DX.POLICIES AND PROCEDURES ROUTINELY LOOK AT COMORBIDITY IN ASSESSMENT, RX PLAN, DX PLAN, PROGRAMMINGCARE COORDINATION RE MEDS (CD)
90DUAL DIAGNOSIS ENHANCED (DDE) MEETS DDC CRITERIA PLUS:CD: MODIFICATION TO ACCOMMODATE MH ACUITY OR DISABILITYMH SPECIFIC PROGRAMMING, STAFF, AND COMPETENCIES, INCLUDING MDFLEXIBLE EXPECTATIONS; CONTINUITYMH; ADDICTION TREATMENT IN PSYCH MANAGED SETTINGS (DUAL DX INPT UNIT) ORINTENSIVE CASE MGT/OUTREACH TO MOST SERIOUSLY MI AND ADDICTED PEOPLE
91B. PROGRAM COMPETENCIES 1. CLINICAL CASE MANAGEMENT2. EMERGENCY SERVICES3. CRISIS STABILIZATION4. DETOXIFICATION5. PSYCH INPATIENT6. PSYCHIATRIC PARTIAL HOSP/ DAY RX7. ADDICTION DAY RX/ INTENSIVE OP8. ADDICTION RESIDENTIAL RX9. PSYCHIATRIC RESIDENCE PROGRAMS
921. Case Management (DDC/DDE) Integrated, continuous care coordinationHigh, medium, and low intensityIncorporated into existing front-line case management for SPMIDeveloped for high utilizers who are non-SPMI as well as SPMIMechanism for supportive administrative case coordination
932. Emergency Services (DDC) Mission defined as welcoming into appropriate treatment for MH and CDBarrier-free access-assessment begins when client able to participateDiagnostic and level of care assessment for both MH and substance disorderCapacity to engage in ongoing crisis intervention and motivational strategies
943. Crisis Stabilization (DDC) Routine acceptance of substance-using patients who do not need medical detoxificationStabilizes substance exacerbated psychiatric symptoms, with meds if necessaryUtilizes motivational and active treatment strategies to address substance useParticipates with primary case coordination team in implementation of treatment contractsMay provide access to intensive outpatient addiction treatment (DDC or DDE)
954A. Detoxification (DDC) Provides detoxification for psychiatrically stable individuals with mental illness who are not severely disabledMeets ASAM PPC2R defined criteria for DDC programs
964B. Psychiatrically-Enhanced Detoxification (DDE) Provides ASAM Level III detoxification for psychiatrically impaired or unstable (e.g., suicidal) individuals who are voluntary and can contract for safetyMedical monitoring provided by psychiatrist or psychiatric nursePsychopharmacologic adjustment providedSpace, staffing, and staff training permit closer monitoringMeets ASAM PPC2R DDE criteria
975A.Inpatient Psych Unit (DDC) Program standards address dual diagnosis competencyRequired basic staff and MD competencies, included in job descriptionWelcoming staff attitudesCompetence in detox protocolsDemonstrated assessment competencyDocumentation of substance disorder interventions in treatment planning/notesDaily substance related group programmingCompetent substance disorder d/c planning
985B.Inpatient Dual Unit (DDE) Meets all DDC criteria, plusStaff routinely have expertise in both psych and addictionFull addiction program, incorporating dual dx groupsRoutine access to 12-step programsProvides addiction rx for patients with severe psychiatric acuity and instabilitySpecialized expertise in dual diagnosis assessment and psychopharmacology
996. Psychiatric Day Treatment and Partial Hosp. (DDC-MH) Acute Partial: Same as DDC inpatient, except for detox, plus specific policies to address substance use while in treatmentIntermediate/long-term Day Treatment: routine assessment and rx planning; phase-specific groups, including motivational interventions for non-abstinent patients. No reject for substance use. Specific policies to address substance use in rx.
1006B: Dual Diagnosis Partial Hosp and Day Rx (DDE) Acute Partial: Similar to DDE inpatient; abstinence-oriented, with strict limits on use in programIntermediate/Long-Term Day Rx: Program may be abstinence-oriented, or may provide intensive motivational/harm reduction groups for long-term clients who are still using, OR BOTH (2 tracks). Extensive addiction/dual programming. Specific policies on substance use which promote continuity even if pt. discharged.; Dual dx specialist supervisors.
1017A. Addiction Residential Treatment (DDC) Sober environment for episode of addiction treatment. DDC program meets all standard criteria for DDC-CD.Relapses not tolerated, but in long-term programs, first-offense may not result in dischargeDischarge is an opportunity for learning; individual welcome to returnDischarge coordinated with mh provider and criteria for readmission establishedCollaborative relationship with mh system re: acute crisis intervention
1027B. Psychiatrically Enhanced Addiction Residential Rx(DDE) DDE Program meets all DDC-CD residential criteria, plus all DDE-CD criteria.Residential addiction rx for individuals (SMI and non-SMI) with moderate psychiatric acuity and/or disabilityDual Diagnosis Acute Residential Treatment (DDART) is a short-term (10-14 day) DDE program in Mass.Modified Therapeutic Community (Sacks, DeLeon) is an example of a long-term DDE program
1038. Psychiatric Residential Programs Primarily HOUSING programs for people with psychiatric disabilitiesAll programs designed to be DDCPrograms must accommodate a range of ability and willingness to address substance use: WET, DAMP, DRYDRY (DDE) Housing for individuals with dual disorder who want sober support. Multiple (but finite) slips permitted, with intervention planDAMP (DDC) Abstinence recommended, not required. Substance use addressed if safety issues emerge.
104Psych Residential (cont’d) WET: Consumer choice housing; no requirement to limit use to have housing support. Pathways to Housing (NYC) Usually supported housing modelCase Managed Supported Sober Housing: Combines Oxford House concept with MH supported housing concept. Inexpensive method to create sober housing
105C. CLINICAL PRACTICE STANDARDS I 1. WELCOMING PHILOSOPHY2. ACCESS TO BARRIER-FREE ASSESSMENT: “NO WRONG DOOR”3. SCREENING & ASSESSMENT: INCENTIVES FOR IDENTIFICATION4. LEVEL OF CARE ASSESSMENT: ASAM PPC2R, LOCUS,CHOICE-DUAL5. SCOPE OF PRACTICE/SERVICE CODE
106C. CLINICAL PRACTICE STANDARDS II 6. CONTINUITY OF CARE: MH & CD7. PHASE-SPECIFIC RX MATCHING8. PSYCHOPHARM GUIDELINES: CONTINUITY, QUALITY, BENZOS9. CONSISTENT RX MANUALS10. OUTCOME MEASURES: UTILIZATION, HARM, STAGE OF CHANGE, ABSTINENCE/USE
107SCOPE OF PRACTICE FOR INTEGRATED TREATMENT 1. WELCOMING, EMPATHY, DUAL RECOVERY2. SCREENING FOR COMORBIDITY3. ASSESS ACUTE MH/DETOX RISK4. OBTAIN ASSESSMENT OF COMORBIDITY5. AWARENESS OF DIAGNOSIS AND RX PLAN6. SUPPORT TREATMENT ADHERENCE/ MED COMPLIANCE7. IDENTIFY STAGE OF CHANGE FOR EACH DX& GROUP INTERVENTIONS FOR EDUCATION & MOTIVATION ENHANCEMENT
108SCOPE OF PRACTICE (continued) 9. SPECIFIC SKILLS TRAINING TO REDUCE USE10. MANAGE FEELINGS AND SYMPTOMS WITHOUT USING11. HELP CLIENT ADVOCATE WITH OTHER PROVIDERS REGARDING MH NEEDS12. HELP CLIENT ADVOCATE RE: CD NEEDS13. COLLABORATE WITH OTHER PROVIDERS.14. EDUCATE CLIENT RE: MEDS AND 12 STEP15. MODIFY SKILLS TRAINING RE: DISABILITY16. PROMOTE DUAL RECOVERY MEETING USE
1091. COMPETENCY/CERTIFICATION D. CLINICIAN STANDARDS1. COMPETENCY/CERTIFICATIONA. Required basic competencies:Attitudes, values, knowledge, and skillCompetency Assessment ToolsB. Place/train: job descriptionsC. Certifications for career laddersD. Advanced competencies for trainers and supervisors.
110D. CLINICIAN STANDARDS 2. TRAINING A. System wide training plan B. Training program guidelinesC. Train trainers for each siteD. Curriculum guideline disseminationE. On-site case based continuing trainingF. Experiential learning/ staff exchange
111DEVELOPING AN INTEGRATED CHANGING THE WORLD:DEVELOPING AN INTEGRATEDSYSTEM OF CAREIN ASTATE MENTAL HOSPITAL
112SYSTEMS LEVEL CHANGE Develop a structure to manage change A. Integrated Team of discipline/dept. heads.B. Continuous Quality Improvement1. Defines bidirectional, multilevel process2. Identifies measurable outcomes3. Meets JCAHO requirements
113SYSTEMS LEVEL CHANGE Build Consensus on Principles A. Use TDMHMR Principles to startB. Include “firestarters”C. Begin with management teamD. All staff involved, emphasize attitudesE. Measure consensus (outcome)
114SYSTEMS LEVEL CHANGE Establish Standards A. Program Competency StandardsB. Practice Guidelines: Assessment, continuity, discharge planning, rx plan psychopharm (algorithm project)C. Program Plan for service matchingD. Clinician Competencies
115SYSTEMS LEVEL CHANGE Identify Outcomes A. Structure 1. Consensus, standards established2. Program elements in placeB. Process1. Screening tools used2. Consumers identified and treatedC. Outcome: Satisfaction, stage of change, skill, relapse prevention, community linkage
116PROGRAM LEVEL CHANGES Develop program array based on needs assessment Implement general program standards hospital wideDevelop content and protocols for specialized interventionsImplement hospital wide mechanisms to monitor program interfaceImplement strategies for managing community interface & promoting continuity
117Program Array Needs assessment based on categories: a. Severe mh impairment vs. non-severeb. Substance Abuse vs. Dependencec. Stage of change/Phase of Recoveryd. Long stay vs. short stayProgram matching categoriesa. Detoxb. Motivational Enhancement (mh hi vs. lo)c. Active Rx/Relapse Prevention: SubstancAbused. Specialized Addiction Rx (mh hi vs. lo)
118Program Standards/DDC Uniform screening and assessmentAssessment includes abuse/dep, stage of change, recovery skills and supportsDocument diagnosis, formulation using treatment matching algorithmProblem-specific rx plan and d/c planStage-specific groups with range of educational materials
119Specialized Program Model/DDE Addiction group program with mh modifications (high vs low disability)Policies defining behavioral expectations and consequencesDual competent clinical leadershipIn vivo skills training and role playingContingent learning interventionsPlans to promote community continuity
120Intrahospital Program Interface Clinical Review Committeea. Chaired by Medical Director/Clin Dirb. Conferences complex casesc. Reviews policies & contingency plansd. Addresses interprogram disputesProgram Admission/D/C Criteriaa. Seamless b. Incentives/sanctions
121Hospital-Community Interface Interagency care coordinationa. Admission/readmission criteriab. Contingency based transitionsc. Skills training for community settingd. Case conferencesConsistent hospital/community manuals3. Recovery program (AA, DRA) linkage
122CLINICAL STANDARDS Welcoming attitudes Accessible admission/readmissionStandard screening and assessment toolsMulti dimensional assessment including CIWA, diagnosis, description, stage of change, recovery skills and supportsDetox and urine screening protocolsBehavioral criteria for pass or dischargePsychopharmacology guidelines (TMAP)/ Peer review
123Behavioral Criteria Pass Skills (for pts w/ identified issue) a. I have a problemb. I want to changec. I am at risk on passd. I agree to a risk plane. I will demonstrate skills to not usef. I will agree to monitoring and incentives.
124Behavioral Criteria Specialized program criteria a. Positive incentives for entry and successb. Point or token systemc. Consequences for non-compliance and/or use, including ultimate time limited transfer to more restricted setting.
125CLINICIAN COMPETENCYConsensus basic competency related to job descriptionsa. Amend HR policy, and evaluation toolb. Self-learning workbook and examTraining and supervision plana. Assign supervisory resource to each unit.b. Combine didactics with on the job learning.c. Community internships and staff exchange