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Co-Occurring Disorders Expected rather than the Exception Tribal Justice & Safety – One OJP Tribal Training and Technical Assistance – Session III Shelton,

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Presentation on theme: "Co-Occurring Disorders Expected rather than the Exception Tribal Justice & Safety – One OJP Tribal Training and Technical Assistance – Session III Shelton,"— Presentation transcript:

1 Co-Occurring Disorders Expected rather than the Exception Tribal Justice & Safety – One OJP Tribal Training and Technical Assistance – Session III Shelton, WA June 5, 2007 Elizabeth I. Lopez, Ph.D. US Department of Health and Humans Services Substance Abuse and Mental Health Services Administration

2 Presentation Overview Definition of Co-Occurring Disorders Epidemiology of Co-Occurring Disorders Overview of SAMHSA Co-Occurring Activities SAMHSA Targeted Co-Occurring Programs –COSIG –COCE –National Policy Academy on Co-Occurring Disorders Upcoming AI/AN Policy Academy Discussion

3 Definition: Co-occurring Disorders The term refers to co-occurring substance use (abuse or dependence) and mental disorders. Clients said to have co-occurring disorders have one or more mental disorders as well as one or more disorders relating to the use of alcohol and/or other drugs. A diagnosis of a co-occurring disorder (COD) occurs when at least one disorder of each type can be established independently of the other and is not simply a cluster of symptoms resulting from a single disorder.

4 Co-Occurring Disorders Epidemiology What do we know about Co-Occurring Disorders?

5 Co-Occurring Disorders We know that co-occurring disorders are increasing becoming the expectation rather than the exception.

6 6 Co-Occurrence of SMI and Substance Use Disorders among Adults Aged 18 or Older: Million 15.4 Million Co-Occurring Disorders Substance Use Disorder Only SMI Only 4.2 Million * NSDUH 2003

7 Co-Occurrence of SPD and Substance Use Disorder in the Past Year among Adults Aged 18 or Older: Million 19.4 Million Co-Occurring SUD and SPD Substance Use Disorder (SUD) Only Serious Psychological Distress (SPD) Only 5.2 Million Up by 1 million in 2 years

8 Substance Use among Adults Aged 18 or Older, by Major Depressive Episode in the Past Year: 2005

9 Substance Use among Youths Aged 12 to 17, by Major Depressive Episode in the Past Year: 2005 Percent Using Substance Past Year Illicit Drug Use Daily Cigarette Use in Past Month Past Month Heavy Alcohol Use Past Year Marijuana Use Past Year Psycho- therapeutics Use

10 Co-Occurring Psychiatric Problems Source: CSAT AT Outcome Data Set (n=9,276 adolescents)

11 Co-Occurring Disorders Expected rather than the Exception We know that individuals with a co-occurring disorder are less likely to receive treatment for BOTH disorders.

12 Past Year Treatment among Adults Aged 18 or Older with Both Serious Psychological Distress and a Substance Use Disorder: 2005 Substance Use Treatment Only 5.2 Million Adults with Co-Occurring SPD and Substance Use Disorder Treatment for Both Mental Health and Substance Use Problems No Treatment 34.3% 53.0% 8.5% 4.1% Treatment Only for Mental Health Problems Note: Due to rounding, these percentages do not add to 100 percent.

13 Mean Age for Past Year Initiates, by Illicit Drug: 2004 Age Marijuana Heroin Pain Relievers Cocaine LSD TranquilizersPCP EcstasyInhalants Stimulants Sedatives NSDUH, 2004

14 Past Month Illicit Drug Use among Persons Aged 12 or Older, by Age: 2004 Percent Using in Past Month Age in Years

15 Co-Occurring Disorders Expected rather than the Exception American Indian/Alaskan Native Communities face unique challenges with co-occurring substance abuse and psychological conditions Historical trauma Stigma / Discrimination Preserving cultural healing traditions Multiple funding streams / delivery systems for behavioral health services

16 Substance Use and AI/AN Rates of past year use disorders were higher among American Indians and Alaska Natives than members of other racial groups for alcohol, illicit drug use, marijuana, cocaine, and hallucinogen use disorders. Although in the past year American Indians and Alaska Natives were less likely than persons of other racial backgrounds to have used alcohol (60.8% vs. 65.8%), they were more likely to have an alcohol use disorder (10.7% vs. 7.6%). For illicit drug use in the past year, American Indians and Alaska Natives were more likely than persons of other racial backgrounds both to have used an illicit drug (18.4% vs. 14.6%) and to have an illicit drug use disorder (5.0% vs. 2.9%). NSDUH 2005

17 Substance Abuse/Dependence & MDE or SPD by AI/AN and Non- AI/AN % with Co-Occurring Conditions AI/AN=American Indian/Alaska Native; MDE=Major Depressive Episode; SPD= Serious Psychological Distress; ID= Illicit Drugs; Alc=Alcohol Source: NSDUH 2004 & 2005

18 Current Use of Illicit Drugs among Persons Aged 12 or Older, by Race: Percent Using in Past Month NSDUH

19 Current Use of Illicit Drugs among Youth Aged 12 to 17, by Race: Percent Using in Past Month NDSUH

20 Current Use of Illicit Drugs among Persons Aged 26 or Older, by Race: Percent Using in Past Month National Survey on Drug Use and Health 2004

21 Current Use of Alcohol among Persons Aged 12 or Older, by Race: Percent Using in Past Month National Survey on Drug Use and Health 2004

22 Heavy Use of Alcohol among Persons Aged 12 or Older, by Race: Percent Using in Past Month National Survey on Drug Use and Health 2004

23 Received Substance Use Treatment in the Past Year among Persons Aged 12 or Older, by Race: 2004 Percentage

24 Substance Dependence or Abuse in the Past Year among Persons Aged 12 or Older, by Race: 2004 Percentage

25 Substance Abuse Individuals with alcohol and drug problems Prevalence rates for current alcohol abuse and/or dependence among Northern Plains and Southwestern Vietnam veterans have been estimated to be as high as 70% compared to % of their white, black, and Japanese American counterparts. The estimated rate of alcohol-related deaths for AI/AN is much higher than for the general population.

26 Mental health Exposure to trauma The rate of violent victimization of AI/AN is more than twice the national average Higher rate of traumatic exposure - 22% rate of PTSD for AI/AN, compared to 8% in the general U.S. population

27 Mental health Availability of Mental Health Services Approximately 101 AI/AN mental health professionals are available per 100,000 AI/AN, compared to 173 per 100,000 for whites. In 1996, only about 29 psychiatrists in the U.S. were of AI/AN heritage.

28 Mental health Access to Mental Health Services The Indian Health Service (IHS) is the Federal agency responsible for providing health care to Native populations 20% of AI/AN report access to IHS clinics, which are located mainly on reservations

29 Mental health Medicaid is the primary insurer for 25% of AI/AN Approximately 50% of AI/AN have employer- based insurance coverage, compared to 72% of whites 24% of AI/AN have no health insurance, compared to 16% of the U.S. population

30 Risk and Protective Factors for Substance Use among American Indian or Alaska Native Youths American Indian or Alaska Native youths were more likely to perceive moderate to no risk of substance use A larger percentage of American Indian or Alaska Native youths did not perceive strong parental disapproval of youth substance use than youths in other racial/ethnic groups American Indian or Alaska Native youths were more likely to believe that all or most of the students in their school get drunk at least once a week NSDUH

31 SAMHSA Response to address the Co-occurring Disorders

32 SAMHSA Co-Occurring Initiatives Report To Congress (2002) Federal Leadership Cross Agency Matrix Action Plan Co-occurring State Incentive Grants Co-occurring Center for Excellence Key publications: TIP 42/COD Toolkits Co-occurring Policy Academies

33 Congress called on SAMHSA to prepare a report outlining the scope of the problem of co- occurring disorders, current treatment approaches, best practice models, and prevention efforts. This report was mandated to include: · a summary of the manner in which individuals with co-occurring disorders are receiving treatment, · a summary of practices for preventing substance abuse disorders among individuals who have a mental illness and are at risk of having or acquiring a substance abuse disorder; · a summary of evidence-based practices for treating individuals with co-occurring disorders and recommendations for implementing such practices; and · a summary of improvements necessary to ensure that individuals with co-occurring disorders receive the services they need.

34 Released November 2002 Raised the awareness of Co-occurring Disorders Included a Five-Year Blueprint for Action SAMHSA adopted road map to address Co- occurring Disorders Report to Congress on the Prevention and Treatment of Co-Occurring Substance Abuse Disorders and Mental Disorders

35

36 Co-Occurring Matrix Workgroup Chair and Membership A. Kathryn Power. M.Ed. Director Center for Mental Health Service (CMHS) H. Westley Clark, M.D., J.D. M.P.H Director Center for Substance Abuse Treatment (CSAT) SAMHSA Workgroup representation: Center for Mental Health ServicesOffice of the Administrator Center for Substance Abuse TreatmentOffice of Applied Studies Center for Substance Abuse PreventionOffice of Communications Office of Policy, Planning & Budget

37 “No Wrong Door” Policy Each provider should be aware that he/she has the responsibility to address the range of client needs… wherever a client presents for care whenever a client presents for care properly refer clients for appropriate care as needed follow-up on referrals to ensure clients received proper care

38 SAMHSA Co-occurring Matrix Action Plan FY 2006/2007: Purpose To expand and improve prevention, appropriate treatment and other supportive services to individuals with and/or at risk for co-occurring disorders. Approximately 5.2 million individuals in the United States are estimated to be affected by co- occurring mental and substance abuse disorders. However, only a small percentage of these individuals receive treatment that addresses both disorders.

39 SAMHSA Co-Occurring Matrix Action Plan Long Term Measures Increase the percentage of persons with co-occurring disorders who receive appropriate treatment services that address both disorders. Increase the percentage of adolescents aged 12 – 17 who receive appropriate prevention services that address substance abuse and mental health. Increase the percentage of persons who experience reduced impairment from their co-occurring disorders following appropriate treatment.

40 SAMHSA Co-Occurring Matrix Action Plan: Outcome / Annual Measures Increased percent of prevention and treatment settings that: –screen for co-occurring disorders –assess for co-occurring disorders –provide treatment to clients through collaborative, consultative and integrated models of care

41 SAMHSA Co-Occurring Matrix Action Plan: Outcome / Annual Measures Increase the number of grantees (States, Tribes, communities, and providers) measuring and reporting on co-occurring programs, practices, and models of treatment (accountability) Increase the number of States and Tribes with State or Tribal-Level actions plans for improving access to mainstream and specialty services for individuals with co- occurring disorders(capacity) Increase the number of people trained to implement appropriate co-occurring prevention and integrated treatments among States, communities, providers and consumers (effectiveness)

42 SAMHSA Co-Occurring Action Plan: FY Key Activities Ensure that co-occurring disorders are a significant focus in the following major grant programs, as appropriate: Mental Health Systems Transformation SIG, Access to Recovery, and the Strategic Prevention Framework SIG Monitor the extent to which the Co-Occurring State Incentive Grant (COSIG) addresses those populations prioritized on the SAMHSA Matrix that are appropriate and relevant to the programs within the matrix area Create and disseminate a nationally accepted framework for developing, implementing, and sustaining co-occurring disorders prevention and treatment service systems.

43 SAMHSA Co-Occurring Matrix Action Plan: FY Key Activities -continued Increase the number of candidate programs addressing co-occurring disorders that apply for review to the National Registry of Evidence-based Programs and Practices (NREPP) addressing co-occurring disorders Hold a policy academy for Tribal organizations, tribal communities, and tribal governments to assist in developing and sustaining service systems for the unique needs of AI/AN with and at risk for co-occurring disorders and for interested States who have not participate in a policy academy to date.

44 SAMHSA Strategic Plan for Co- Occurring Disorders Mission To expand and improve prevention, appropriate treatment and other supportive services to individuals with and/or at risk for co-occurring disorders Key Drivers Report to Congress Presidents New Freedom Initiative SAMHSA Co- Occurring Action Plan SAMHSA Matrix IOM Report Target Population Adult and Youth with Co-Occurring Disorders Adult and Youth at risk for Co-Occurring Disorders States, Tribes, Local Communities Mechanisms COSIG Specialized TA (COCE/Policy Academy) Training Curriculum/Publication (TIP 42/Tool Kits) Outcomes Individual Increase access to appropriate prevention & treatment services Provider Increase number of people trained to implement appropriate COD treatment Community/System Increase number of States, Tribes, Communities with comprehensive action plans

45 National Outcome Measures (NOMS) Domains Abstinence from Drug / Alcohol Use / Reduced Morbidity Employment / Education  Crime and Criminal Justice  Family and Living Conditions  Access / Capacity  Retention  Social Connectedness Perception of Care Cost Effectiveness Use of Evidence-Based Practices

46 Co-Occurring Disorders Expected rather than the Exception Linking Co-Occurring Disorders with key SAMHSA Matrix Areas Mental Health System Transformation Substance Abuse Treatment Capacity Strategic Prevention Framework

47 Treatment Implications of Comorbidity Between Alcohol and/or Drug Use Disorders and Other Psychiatric Disorders Adolescents and adults with co-occurring disorders are not treated Increased severity, disability and impairment in social/occupational functioning Resistance to pharmacologic treatment Lower probability of recovery Increased suicidality Increased economic burden of each comorbid condition

48 Co-Occurring Disorders Expected rather than the Exception Areas of Focus for the Treatment of COD Innovative Models of Integrated Treatment Sharing Lessons Learned across programs Workforce Development Working with Tribal, Rural Communities Child, Adolescent, Family and Older Adults Cultural Competency Training for Local Providers

49 Co-Occurring Disorders Expected rather than the Exception Co-Occurring Programs Co-Occurring State Incentive Grant (COSIG)

50 Co-occurring State Incentive Grants (COSIG) Supports grantees in overcoming service delivery barriers Supports grantees in systems change and infrastructure development Enhancing service coordination, networks and linkages to support quality care Improving financial incentives for integrated care Information sharing among stakeholders 17 grantees

51 Co-occurring State Incentive Grants (COSIG) Key Program Accomplishments  Implemented first COD program within CJ System  Redesigned and implemented a website to transfer information between local practitioners and States  Implemented a voucher system to acquire ancillary services needed by COD clients  Established Statewide common data warehouse about persons within the MH and SA systems

52 History of COSIG Funding Grants Awarded (annually in September) Year Number Awarded States Receiving AwardFunding Agency 20037AR, PA, HI, MO, TX, AK, LA Jointly by CSAT and CMHS 20044OK, VA, AZ, NMCMHS 20054CT, DC, ME, VTCMHS 20062MN, SCCSAT

53 Co-occurring State Incentive Grants (COSIG) Lessons Learned  Involve Senior State/Tribal Leadership  Family/Consumer Participation  Engage provider community in COSIG planning  Program accountability  Measures of success – Linking outcomes Evaluation Update

54 Co-Occurring Disorders Expected rather than the Exception SAMHSA Co-Occurring Center for Excellence (COCE)

55 Funded through SAMHSA, is a leading national resource for the field of co-occurring mental and substance use disorders Consists of national and regional experts who join service recipients in shaping COCE’s mission, guiding principles, and approaches Accomplishes its mission through technical assistance and training, delivered through multiple vehicles COCE

56 COCE Mission To receive and transmit advances in treatment for all levels of COD severity To guide enhancements in the infrastructure and clinical capacities of service systems To foster the infusion and adoption of evidence- and consensus-based COD treatment and program innovations into clinical practice.

57 COCE Targeted Populations States / Tribes receiving COSIG funding States / Tribes not yet receiving COSIG funding, including Co-Occurring Policy Academy States and all other States / Tribes AI/AN tribes and organizations, clinical providers, other providers, agencies and systems through which clients might enter the COD treatment system

58 Key Focus of COCE Program COSIG TA Policy Academy TA Community TA COCE Web site COCE Training / Material Development

59 Co-Occurring Disorders Expected rather than the Exception Prevention & Co-Occurring Disorders Operationalizing the Role of Prevention

60 Prevention Strategies for Co-Occurring Disorders Develop evidence based strategies, programs, and practices that target risk/protective factors of at risk kids Develop individual and family-based case management systems that target families of addicted and/or those presenting w/ mental health disorders to clinics, hospitals etc. Develop programs across the life span

61 Tip 42: Substance Abuse Treatment for Persons with Co-Occurring Disorders This TIP revises TIP 9, Assessment and Treatment of Patients With Coexisting Mental Illness and Alcohol and Other Drug Abuse. 1 st printing of Tip 42 —27,000 2 nd printing of Tip 42 —50,000

62 Co-Occurring Disorders: Expected rather than the Exception National Policy Academy on Co-Occurring Disorders

63 The purpose of the National Policy Academy on Co- Occurring Mental and Substance Abuse Disorders is to enhance the provision of co-occurring services in States, Tribes and communities. The Policy Academy brings together Teams comprised of individuals with policy-making influence in conjunction with nationally recognized faculty and facilitators who assist the Teams to develop a comprehensive Action Plan to enhance the provision of, and expand access to, effective prevention, treatment, and related services for co-occurring disorders within their jurisdiction.

64 National Policy Academy on Co-Occurring Disorders The overarching goal of SAMHSA’s National Policy on Co-Occurring Substance Use and Mental Disorders is to enhance the provision of co-occurring services in States, Tribes and communities. This goal is supported by four objectives of the Policy Academy.

65 National Policy Academy on Co-Occurring Disorders Objectives To assist States, Tribes and local policymakers in the development of an Action Plan intended to improve access to appropriate services for people with co-occurring substance use and mental disorders; To create and/or reinforce relationships among the Governor’s office, Legislators, Government and local program administrators, and stakeholders from the public and private sectors; To provide an environment conducive to the process of strategic decision-making within the context of co-occurring disorders; and To assist State, Tribal and local policymakers in identifying issues or areas of concern that may result in a formal request for technical assistance.

66 National Policy Academy on Co-Occurring Disorders The Policy Academy model sequential process: 1.Pre-meeting work, a technical assistance site visit, and SWOT (Strengths, Weaknesses, Opportunities, Threats) analysis 2.Formal Academy meeting (on-site “live” technical assistance) 3.Post-meeting technical assistance and follow-up 4.Ongoing implementation (on-site technical assistance)

67 National Policy Academy on Co-Occurring Disorders Strategic / specialized technical assistance approach Not a grant program - no new funding for services Focus on improving services for people with co-occurring disorders Innovation in health care reimbursement Focus on prevention / recovery Evidence of partnership with substance abuse and mental health treatment systems

68 National Policy Academy on Co-Occurring Disorders Desired Outcomes Operationalize “No Wrong Door” for all people with co-occurring disorders Culturally relevant and appropriate service systems Building partnership across mental health and and substance abuse prevention services & treatment systems Identify institutionalized barriers and develop strategies to overcome

69 National Policy Academy on Co-Occurring Disorders Cohort I (April 2004)—Alabama; Arizona; Connecticut; Hawaii; Louisiana; Maine; Michigan; Missouri; North Carolina; South Dakota Cohort II (Jan 2005)—California; Georgia; Illinois; Iowa; New Mexico; Oklahoma; Texas; Virginia; Washington Cohort III (Sept. 2005)—Delaware; Indiana; Kansas; Maryland; Montana; New York; Ohio; Rhode Island; Tribal Policy Academy (Sept. 2007)

70 National Policy Academy on Co-Occurring Disorders Key Program Accomplishments Much of the success of the Policy Academy is that it transcends a typical strategic planning retreat or a conference, in that it seeds a process of cross-agency collaboration and systems change. The design facilitates leaders, policy makers and advocates from each Team to build on its strengths, develop policy strategies and implement action plans for transforming practice before, during, and after the Academy meeting.

71 National Policy Academy on Co-Occurring Disorders Key Program Accomplishments (cont.) Locally defined shared vision Innovative financing strategies and leverage existing resources Culturally relevant approach Cross sector policy makers / providers / stakeholders working together

72 National Policy Academy on Co-Occurring Disorders – AI/AN Planning Underway for tentatively scheduled academy - September 2007 Invitation released May 2007 – applications due June 15, 2007.

73 National Policy Academy on Co-Occurring Disorders Key review factors that will shape eligibility criteria: Capacity/Readiness Outline Need Current Health/ Behavioral Health Delivery Approach Multi-level commitment Current Health / Behavioral Health Financing Structures Willingness to collaborate / partner with other entities delivering behavioral health delivery services Interest and willingness to share lessons learned from the policy academy with other communities

74 The National Policy Academy on Co-Occurring Substance Use and Mental Disorders: A Schematic Overview The Policy Academy Model: A Multi-Stage Process Selection ProcessAcademy OrientationFormal Academy Meeting Post-Academy Technical Assistance Applicants responded to a Letter of Invitation specifying formal eligibility criteria clearly defined problem high-level commitment breadth, depth, and authority of proposed Tribal team Peer review selection process of participating teams/delegations Conference calls, SAMHSA communications introduce Tribes to Academy process Pre-Academy site visits: provide Academy orientation enhance understanding of Academy model develop common vision, priorities, strategies, and draft S.W.O.T. analysis initiate identification of technical assistance needs formalizes team leadership and decision- making process Facilitates delivery of technical assistance and action plan development across multiple formats (i.e., plenaries, presentations, Team working sessions) Teams present vision statements and Tribal-related key issues and efforts Formal presentations on systems change, evidence- based practices, prevention, funding, resources, and other co-occurring curriculum areas Policy Teams: continue developing action plans and identifying technical assistance needs receive feedback and technical assistance from faculty and peers report out on action plan, priorities, next steps, and technical assistance needs Policy teams finalize strategies (short-and long- range) and specific action steps submit revised action plan for SAMHSA review/feedback prioritize and coordinate technical assistance with COCE and other TA implement action plans submit semi-annual progress reports to SAMHSA Enhances the Provision of Co-Occurring Services in Communities

75 Next Steps for SAMHSA Co-occurring Portfolio Institutionalizing “No Wrong Door” Unique needs of special populations –(Children, rural, AI/AN) Core Co-Occurring Competencies Supporting Integrated System Sustainability Evidence-based COD programs Disparate Funding Streams/Reimbursement Licensing/Certification Cultural Competent/Relevant Service System

76 Co-Occurring Disorders Expected rather than the Exception For more information: (TDD) Publication Ordering and Funding Information

77 Co-Occurring Disorders Expected rather than the Exception Thank you! Elizabeth I. Lopez, Ph.D. US Department of Health & Human Services Substance Abuse and Mental Health Services Administration Office of Policy, Planning & Budget (voice) (fax)

78 Co-Occurring Disorders Expected rather than the Exception Discussion Recommendations Questions Thoughts


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