1. Truman Medical Center Behavioral Health Evidence Based Practices Integrated Dual Disorder Treatment (IDDT)

2. Treatment Models Sequential: The first and historically most common model of dual disorder is sequential. The client is treated by one system and then the other. Parallel: The simultaneous involvement of the client in both mental health and addiction treatment settings

3. Treatment Models Integrated: Combines elements of both mental health and addiction treatment into unified and comprehensive treatment program for clients with dual disorders. Integrated Dual Disorder Treatment (IDDT): An evidenced based practice that is successful in treating Co-Occurring disorders.

4. Treatment Models Treatment for clients with mental health issues that showed positive outcomes in multiple research studies. SAMHSA has provided six practices that demonstrate strong evidence base: –Standardized pharmacological treatment –Illness management and recovery skills –Supported employment –Family psychoeducation –Assertive community treatment –Integrated Dual Disorder Treatment (IDDT )

5. IDDT Multidisciplinary Team Integrated Substance Abuse Specialist Stage Wise Treatment Access for clients to comprehensive DD services Time-unlimited Outreach Motivational Interventions

6. IDDT Substance Abuse Counseling Group DD Treatment Family Psychoeducation on DD Participation in alcohol and drug self help groups Pharmacological treatment Interventions to promote health Secondary interventions for substance abuse non-responders Source: IDDT toolkit

7. IDDT Stage Wise Interventions: interventions based on the client’s level of treatment and change (persuasion vs. active treatment; pre-contemplation; contemplation; action; etc) Time-unlimited: No end to services; all based on client’s level of motivation; change and needs.

8. IDDT Multidisciplinary team: CSW’s; Psychiatrist; RN; QMHP’s; SAC’s; Vocational specialist Integrated Substance Abuse Specialist: works with the team not only to provide counseling but train the other team members.

9. IDDT Outreach: meet client where they are; services are in vivo; in the community; ED; homes; immediate access to services. –Very important to engaging clients in services; most often in a state of crisis; needs support and immediate access to services.

10. IDDT Motivational Interventions: most effective with substance abuse populations: change comes from the client; instills self efficacy; hope. Avoid arguments; resistance; identify stage of change.

11. Stages of Change –Pre-contemplation-not yet considering a change –Contemplation-acknowledges concerns; consider possible change; uncertain and ambivalent

12. Stages of Change –Preparation-committed to making the change; planning to make changes in the near future. –Action-Actively taking steps to change but has not reached a stable state. –Maintenance-Achieves initial goals and is now working to maintain the goals.

13. Motivational Interviewing –Reflection (Simple; Amplified; Double-sided) –Rolling with Resistance –Reframing –Avoid Arguments –Express Emphathy –Developing Discrepancy –Labeling is Unnecessary

14. IDDT Interventions to Promote Health: preventative care; identification of high risk situations; physical health Interventions for non-responders: inpatient treatment; family intervention; hospitalization.

15. Trends Trends : 10 million Americans are affected by a dual disorder each year. 56% of individuals with a bipolar disorder, (Manic depressive illness) abuse substances 47% of individuals with a schizophrenic disorder, abuse substances 32% of individuals with a mood disorder other than bipolar, abuse substances 27% of individuals with an anxiety

16. Goals of Medication Tx in Addictions Pharmacological Treatment –Abstinence (or Reduction) – Treat or prevent withdrawal symptoms – Reduces urges/cravings – Diminish “the high” / make it less worthwhile – Minimize relapses time and intensity – Treat comorbid disorders

17. Medication Strategies Agonist –Substitute effects of drug Antagonist –Block the effects of drug Deterrent Medications (aversive) Reduce Drug Intake –Target cravings, reinforcement

18. Medication for the treatment of Addictive Disorders and their Mechanism of Action TobaccoOpioidsAlcoholStimulants Partial Agonist VernicilineBuprenorphine?Aripiprazole Full Agonist Nicotine Replacement Methodone Receptor Modulator BupropironNaltrexoneNaltrexone; Acompasate; Topiramate Modafanil; Topriamate; Disulfiram

19. Alcohol Dependence Disulfiram (Antabuse) Naltrexone (Revia) Acamprosate (Campral) Naltrexone IM ( Vivitrol IM)

20. Antabuse FDA Approved 1954 MOA: Inhibits aldehyde dehydrogenase, increasing acetaldehyde. Evidence: So-so Most likely to benefit: highly motivated patients, directly observed patients,

22. Naltrexone (Revia) FDA Approved 1994 Mechanism of Action : Opiate Antagonist decrease positive, reinforcing effects increase negative aspects decrease craving from first dose (prime) decrease craving from cues

23. Naltrexone Starting: 50 mg daily (start half dosage to decrease GI discomfort ) SE: dysphoria, nausea, headaches, tirdness increased LFTs MOA: Antagonist at Opioid receptor –blocking euphoria from alcohol Costly Helps in reducing alcohol consumption and frequency,Increase time to relapse

24. Acamprosate (Campral) FDA approved Sept 2004 Mechanism of Action : Made from taurine ; NMDA receptors in the glutamate system – partial agonist Not much action on GABA Dose: 333mg TID – 333mg ii TID (1,998 mg) Notes: European data – 4500 patients, Relapse Prevention, and asbtinennce targets “negative reinforcement” SE: Diarrhea, Asthenia and Nausea

25. The margin of Separation between apparently safe dose of Naltrexone and the dose causing hepatic injury appears to only five fold or less Contra indicated patient receiving or dependent on Opioids Positive urine test for opioid Has to refrain from Alcohol use for at least one week Psychosocial involvement Dosage : 380 mg IM every four weeks ( needs to be refrigerated and mixed prior to injection) Side Effects : Nausea ( transient ) headaches and Fatigue Vivitrol Naltrexone for extended release Injectable suspension

26. Other Medication of Interest Topiramate: Recent study in Unvi. Of Virginia Wellbutrin Receptor modulation Varenicillin Paritial Agonist Nicotine replacement Boprenorphine: Partial Agonist For Stimulant: Abilify; Modafinil; Topiramate Rimonabant: Cannabinoid CB 1 Receptor Antagonist originally developed for obesity has been in phase III trial and also smoking cessation.

27. Triple Diagnosis Patients with “triple diagnosis” Mental Health; Substance Abuse and HIV or Hepatitis infection face daunting problems and need integrated treatment for the first two before starting antiviral therapy As impulsivity; cognitive impairment and hypersexuality can increase HIV and Hepatitis risk and compliance. MI SA Hep. C HIV

29. Conclusion IDDT decreases –Duration; frequency and intensity of mental and substance use disorder symptoms –Hospitalizations –Arrests and incarceration –Duplication of services –Treatment drop out –Utilization of high cost services

30. Conclusion IDDT increases –Abstinence from alcohol and drugs –Continuity of care –Improved relationships –Client quality of life –Stable housing –Independent living

31. References IDDT Evidenced Based Manual, SAMHSA resource kit 2003. Motivational Interviewing; Preparing People to Change Addictive Behavior, William Miller and Stephen Rollnick 1991. Focus-Journal of Lifelong Learning in Psychiatry. Spring 2007 Vol. V; No. 2. Joseph Parks, MD in conjunction with 7 other states; “Mentally ill die 25 year earlier.”