integrating dual recovery therapy and medications for co-occurring disorders douglas ziedonis, m.d.,...

Integrating Dual Recovery Therapy and Medications for Co-occurring Disorders

Douglas Ziedonis, M.D., MPHProfessor & Director, Division of Addiction Psychiatry

Robert Wood Johnson Medical School

732-235-4341

[email protected]

Today’s Goals Include• Increase awareness of the SAMHSA TIP on COD (

www.health.org) • Learn Dual Recovery Therapy & related assessment

issues • Learn how to modify MET for poly-drug, COD, HIV risk

behavior• Learn how to improve medication adherence and better

integrate medications into psychosocial treatments • Addressing Tobacco – an opportunity to learn MET • CASE STUDIES

http://www.health.org/

Principles of COD Treatment

• COD treatment is different – Depends on Setting

• Integrate and modify mental health and addiction treatment approaches

• Match treatment approaches to recovery stage and motivational level

• Provide comprehensive dual diagnosis services across the continuum

• Consider a long-term treatment perspective

General Treatment Issues for COD

• Empathy and the therapeutic alliance

• Family Involvement

• Brief Interventions: Feedback, Advice, Choices, Optimism, Responsibility, and Follow-up

• Managing Resistance

• Monitoring for relapse / relapse prevention

• Detoxification

• Recovery Tools: treatment plan & contract, self-help groups, medications, & therapy

Excellent Resource: Strategies for Developing Treatment Programs for People with COD

• SAMHSA.gov (with NCCBH & SAAS)

• 2003 publication – available through NCADI and National Mental Health Information Center

• Collection of COD Training Materials

• Strategies and tools that public purchasers use to build integrated care systems

• Core competencies

Mentally Ill Chemical Abuser (MICA) vs Chemical Abuser with Mental Illness (CAMI)

• Type & Severity of Psychiatric Disorders

• Type & Severity of Substance Use Disorders

• Motivation to Stop Using Substances

• Role of Physician & Prescribing Medications

• Routine Mental Status Exam & Urine Testing

MICA vs CAMI (II)

• Continuum of Care

• Outreach & Case Management

• Residential Services: Rules & Medications

• HIV / Medical Services Linkage

• Family, Spouse, & SO involvement

Dual Recovery Therapy (DRT)

• Integrate and modify the best of mental health and addiction approaches

• Consider the impact of each disorder on the individual and traditional treatments

• Consider the patient’s stage of recovery for both illnesses and their motivation to change: Motivation Based Dual Diagnosis Treatment Model

• Recognizes the need for hope, acceptance, and empowerment• Encourage Medication Compliance

Dual Recovery Therapy Blends and Modifies

• Core addiction therapy approaches– Motivational Enhancement Therapy– Relapse Prevention– 12-step Facilitation– NCADI: 1-800-SAY NO TO; www.health.org

• Core mental health therapy approaches – Varies according to MICA / CAMI – specific mental

health disorders or problems– More case management & outreach

Dual Recovery Therapy (DRT)

D u a l R ecovery Th erap y

M en ta l H ea lth TxD isord er S p ec ific

M ed ica tion s

A d d ic tionR e lap se P reven tion1 2 -S tep F ac ilita t ion

O th er R e la ted P rob lem sC ase M an ag em en t

C om p reh en s ive A ssessm en tM E T - 4 S ess ion s

F eed b ackC h an g e P lan

MET = MI + FeedbackMET = MI + Feedback

• Motivational Interviewing (Style)– Empathy, Client-Centered, Respects readiness to

change, embraces ambivalence– Directive – one problem focused (needs

adaptation for poly-drug & COD)

• Personalized Feedback (Content)– Assessment– Personalized Feedback – Values / Decisional Balance: Pros & Cons– Change Plan & Menu of Options





Stages of Dual Recovery

* Blending Mental Health and Addiction Perspectives

* Motivation Based Treatment:

Prochaska & DiClemente Stages of Change: Precontemplation, Contemplation, Preparation, Action, and Maintenance

* MICA model: Acute Stabilization, Engagement, Active Treatment, Relapse Prevention, & Recovery

DRT for Addiction Settings

DRT for Addiction Settings

Professional Development of Staff

• What is their Identity – Role?• How improve their Training?• Do they have the Credentials to see this

group of patients and in what capacity?• EX: CSAT’s COD Model Program

Evaluation Studies– Fully-Integrated vs Consultant-Integrated

ASAM PPC: 6 DimensionsDual Diagnosis Capable vs Enhanced

• SEVERITY GRID / Integrated programs

• Acute Intoxication / Withdrawal

• Biomedical Conditions or Complications

• Emotional / Behavioral Conditions or Complications

• Treatment Acceptance / Resistance

• Relapse / Continued Use Potential

• Recovery Environment

Basic Mental Health Training

• Organized around six sections• Focused on concrete skill acquisition• Style is didactic, with discussion• Includes articles and fact sheets that complement

content areas

Basic Mental Health Training Manual• Six sections addressing diagnostic issues and clinical

presentations– Assessment– Anxiety disorders– Mood disorders– Personality disorders– Suicide, violence and sleep problems– Medications and role of counselor in supporting compliance

• Internet resources for each section• Clinical vignettes for each section• Documentation suggestions

Advanced Mental Health and Dual Recovery Therapy Training

• Organized around major content areas• Includes articles and fact sheets that

complement content areas• Focused on concrete skill acquisition• Style is didactic and experiential• Includes role plays and demonstrations• Includes consultants for family, couples and

spirituality components

COD Assessment Issues• Symptoms versus Diagnosis

– anxiety, depression, mania, & psychosis

– intoxication, withdrawal, & chronic use

– personality factors

– symptom scales and diagnostic tools

• Primary versus Secondary ?

• Self-Medication ?

Assessment Strategies

–Time-line (prior history)

–Prior mental health, addiction, & dual diagnosis treatment

–Information from Significant Others

–Family History

–Changes while in Treatment

Dual Recovery Status Exam• Assess Both Psychiatric and Addiction

Issues, including motivation• Cravings / Thoughts• Last substance use• 12-Step & Treatment Involvement• Current Mental status • Medication Compliance

Suicide Assessment• Current suicidal thoughts, intent, and plan • History of suicide attempts (eg, lethality of method,

circumstances) • Family history of suicide • History of violence (eg, weapon use, circumstances) • Intensity of current depressive symptoms • Current treatment regimen and response • Recent life stressors (eg, marital separation, job loss) • Alcohol and drug use patterns • Psychotic symptoms • Current living situation (eg, social supports, availability of

weapon)

SAD PERSONS: a mnemonic for assessing suicide risk

• Sex (male) • Age (elderly or adolescent) • Depression• Previous suicide attempts • Ethanol abuse • Rational thinking loss (psychosis) • Social supports lacking • Organized plan to commit suicide • No spouse (divorced > widowed > single)• Sickness (physical illness)

Motivation to Change• Motivation to address substance abuse, take

medications and acknowledge mental illness• Internal versus External Motivation • Decisional Balance, Change Ruler, Quit Date, etc

– Motivationalinterviewing.org

• Stages of Change (Prochaska & DiClemente): – Precontemplation, Contemplation, Preparation, Action,

Maintenance

• Motivation varies by substance and setting– Alcohol, Cocaine, Marijuana, Nicotine– Inpatient, ER, and Outreach

Problems & Disorders NOT to Forget

• Sub-threshold Depression &Anxiety Disorders

• PTSD

• Adult ADHD & Learning Disability

• Social Anxiety Disorder

• Eating Disorders

• Axis II

• Anger

• Compulsive Behaviors (sex, gambling, codependence, work, food, spending, etc)

Treatment Planning• How organize? disorders, sub-threshold / problems, etc• By individual treatment needs & program menu of options• Motivational Level? Client Preference? Level of Care?• Include ongoing assessment / monitoring, medication options,

and therapy options• Co-occurring issues – mental illness, medical problems,

prevention (HIV, COD, other)• Couple/SO & Family involvement• Follow-up / Referrals• HOW INVOLVE client and family in the treatment planning

process? (MET Change Plan)

Example

• Major Depression– Ongoing assessments (BDI, others)

• Ongoing assessment of SI• Follow-up for addiction, anxiety, Axis II problems

– Medications• Reviewed Options – interest in taking a med (motivational

level)

– Therapy (program level and modalities and specific type of therapy)

• Ex. Low intensity Treatment – group therapy once per week; individual therapy

• Couples / Family

Teaching Mental Illness Treatment Issues to Substance Abuse Counselors

• Concrete Tools versus Style• Mood Management

– Thought Diary (STEP work)– Assertiveness / Role Play– Practical Self-Help Skills / Behavioral Shaping

• Counter-transference management• MET – easier to do with MI or Tobacco• Couples / Family interventions• Psychiatric medications, MD teamwork, & med compliance

Limitations of depression: modifying addiction treatment

• Lower self-efficacy

• Lower motivation and inertia

• Difficulties managing mood / affect

• Worsening Coping Skills

• Cognitive Distortions

• Maladaptive Interpersonal Skills– avoidance or antagonism

Integrated Treatment for Mood and Substance Use Disorders (2003)

• Westermeyer J, Weiss R, and Ziedonis D

• John Hopkins University Press

• Hardcover (0-8018-7199-9)

• $39.95 ($31.96 with 20% discount – mention code NAF)

• www.jhupbooks.com

• 1-800-537-5487

http://www.jhupbooks.com/

Psychosocial Treatments For Depression``

• Cognitive Therapy– Feeling Good by Burns

• Behavioral Therapy

• Interpersonal Therapy

• Psychodynamic Therapy

Dual Recovery Therapy:

CBT STEP Worksheet

• Based on CBT principles of self-monitoring and cognitive restructuring

• Should be used to target problematic emotional responses

• Should be reviewed thoroughly in session

• Give clear rationale for assignment

• Client should complete at home after an upsetting incident and bring to next session

Dual Recovery Therapy: CBT STEP Worksheet

• Situation

• Thought

• Emotion

• Persuasive reply


Situation::

• What was the external event?

• Who else was there?

• When did it happen?

• Where did it happen?


• Thought – what was the client’s self-talk?

• Should be a complete sentence

• Distinguish between thoughts and feelings

• Can guess if not recalled precisely


• Emotion

• Usually a single feeling word

• Not an evaluation or attribution

• Ask client to elaborate and describe feeling


Persuasive reply - what could client say in response to thought? Should be:

• Realistic in content

• Reassuring in tone

• Concise

• Personally meaningful

Anger Management for Substance Abuse and Mental Health Clients

• SAMHSA pub: SMA 02-3756• Events >> Cues >> Strategies• Anger Control Plans (timeout – formal or informal, talk to

friend, conflict resolution, exercise, 12-Step meetings, explore primary feeling beneath anger)

• The Aggression Cycle: Escalation>Explosion>Violence>Post• Anger and the Family: How Past Learning Can Influence

Present Behavior• Relaxation Interventions (breathing, muscle relaxation, exercise,

meditation, music, etc)

Anger Management (continued)• Cognitive Restructuring: ABCD Model and

Thought Stopping– Activating event– Belief System– Consequences (feelings)– Dispute (examine your beliefs and expectations and are

they unrealistic or irrational?

• Assertiveness Training & Conflict Resolution Model– Communication Skills Interventions– ID problem, feelings, impact of the problem, decide

whether to resolve conflict, work for resolution)

Specific Psychosocial Treatments For COD with Other Psychiatric Disorders

• PTSD: Behavioral Therapies - Seeking Safety – Lisa Najavitz

• Bipolar: Family / Psychoeducation - Roger Weiss

• Schizophrenia: Social Skills Training, Case Management / ACT

• Social Anxiety Disorder – Behavioral Therapy

Couples and Family Therapy

• Intervention Request

• Assessment of interactions & changes with usage status (wet, damp, and dry)

• Couples and Family Treatment

• Enhancing Treatment Compliance

• Alanon / 12-Step Meetings

• ACOA, Co-dependence, Sex Addiction, role in family of origin

Integrating Spirituality into Treatment (Miller W.APA, 1999)

• Mindfulness and Meditation• Prayer• Values, Spirituality, and Therapy• Spiritual Surrender• Acceptance and Forgiveness• Evoking Hope• Serenity

Complementary Approaches• Acupuncture

• Hypnosis

• Herbs

• Meditation

• Qi-Gong: Meditation, Deep Breathing, Yoga

• The Arts: art and music– Drumming, NAF

• ETC

Schizophrenia and Addiction

Keep medicating the psychosis

Adapt to Features of Disorders: Example of Schizophrenia

• Heterogeneous group• Positive and Negative Symptoms• Therapeutic Alliance• Cognitive Deficits• Low Motivation• Low Self-Efficacy• Limited Interpersonal Skills• More Cravings during Withdrawal

More complications with co-occurring addiction and mental illness

• Greater fluctuations in mental status• Increased suicide risk• Worse medication compliance• Questionable reports on substance use• Increased episodic homelessness• Greater chance of doing violence and

being the victim of traumatic events• Greater incidence of illegal activities

Assertive Community Treatment• Team structure with integration of clinical and

case management roles, team responsibility • Staff : patient ratio• Regular contact• Direct interventions to maintain concrete services• After hours service with an on-call team• Occupational rehabilitation with job placement• Provision for Appropriate Housing

Relapse Prevention – Good one to blend with MH CBT approaches

• LIKE Identifying cues / triggers for substance use or cravings / thoughts === ID early warning signs of mental illness recurrence

• Goal to improve self-efficacy to handle specific people, places, things, moods

• Examples: – Drug refusal skills– Seemingly irrelevant decisions– Managing moods / thoughts– Stimulus control

• Medication & Treatment adherence / compliance

Social Skills Training – CBT example used in Schizophrenia

• Liberman, Bellack, and other models

• Problem Solving and Communication Skills

• Behavioral Learning Principles

• Symptom and Medication Management

• Asking others for help and exploring new interests

• Identifying healthy and unhealthy relationships

• Discussion of family relationships

The Use of Role Plays: Behavioral Learning

• Setting up the Role Play (discreetly)

• Problem to Solve

• Non-verbal and Verbal Communication

• “Modeling” by peers

• “Coaching” by therapist

• All provide Positive Feedback Sandwich

• Homework is to try to do learned approach outside of treatment

Dual Recovery Anonymous: modifying 12-Step for COD

• Dual Recovery Anonymous: Modified 12-Step

• Recovery concepts supports increased sense of hope and connection to others

• Shared Experience (experience, strength, and hope)

• Recovery is not cure, but rather a way of living a meaningful life within the limitations of schizophrenia, depression, addiction, or any combination

• Recovery is a process of restoring self-esteem and a symbol of a personal commitment to growth, discovery, and transformation

Working a 12-Step Program• Abstinence goal assumed

• Working the Steps

• Sponsor, mentor or guide

• Group support and involvement

• Spirituality & Spiritual Guides

• Daily Reading and Reflections

• Self-Evaluation

• Time to Celebrate

• Health Care (when address tobacco?)

• Integrate Complementary Approaches

MET and Psychiatric Disorders – Clinical Applications

•Transition from inpatient to outpatient treatment

• Treatment adherence

• Enhancing motivation for MH and SA disorders

• Enhancing medication compliance

MET = MI + FeedbackMET = MI + Feedback









Motivational Enhancement Therapy • Brief Therapy - 4 Sessions in Project MATCH

• Blends MI and Feedback Tools

• Tools: Personalized Feedback & Change Plan with Menu of Options

• Focused Heavily on Developing Discrepancy– Use of decisional balance (pros / cons)– engaging a SO– Eliciting Change Talk– Provide feedback and promote self-efficacy

MBDDT: Matching Stages of Change with MET

• Precontemplation: Eliciting Self-Motivational Statements, Empathy, Managing Resistance, Presenting Personal Feedback / Use of Assessments, Involve Significant Other

• Contemplation: Affirm Ambivalence, Decisional Balance, Explore Goals

• Preparation: Recognize Change Readiness, Discuss a Change Plan, Freedom of Choice, Review Consequences, Ask For Commitment

Elements of Effective Brief Interventions FRAMES:

• Feedback• Responsibility• Advice• Menu• Empathy• Self-Efficacy

Motivational Interviewing• As much a matter of fundamental attitudes and

assumptions as of techniques

• Attitudes: – Respect, patience, empathy, and willingness to listen

• Assumptions: – Client is assumed to be ambivalent rather than resistant;

client has fundamental responsibility to change

• Technique: – Active approach with Socratic questioning and guided

reflection

MI Four Core Principles:

• Express Empathy

• Develop Discrepancy

• Roll with Resistance

• Support Self-Efficacy

Opening Strategies1. Ask open ended questions

2. Listen reflectively *** (50% of time)

3. Summarize

4. Affirm

5. Elicit change talk

MI Core Strategies of EngagementMI Mantra

• OARS

–Open Ended Questions

–Affirmations

–Reflective Listening **

–Summarize

Types of self-motivational statements:

– Problem recognition

– Concern

– Intention to change

– Optimism

Change Talk: Commitment to Change

DARN-C

• Desire to Change

• Ability to Change

• Readiness to Change (REASONS)

• Need to Change

• Commitment to Change **

Latest research: Commitment to Change largest predictor of who will change

• Ask open ended questions• Ask for elaboration• DO Change Rulers (DARN-C or ICR)• Explore pros/cons of change• Imagining extremes• Looking forward (“where do you see

yourself?”)• Looking backward • Other’s concerns

Eliciting Change Talk

Advice-Giving

• Assume continued ambivalence• Unwelcome advice elicits resistance• Advice must match readiness to change• Knowing what to do does not guarantee

behavior change

Elicit - Provide - Elicit

ELICIT client’s ideas Goals, strategies, skills

PROVIDE advice, instruction– Ask permission – Offer short menu – Just the facts

• 3rd person tense

ELICIT client’s reactions Credibility: “Does this make sense?” Self-efficacy: “Could you do this?”

Feedback - MET• Personalized, normative, objective

• Deliver in non-judgmental manner

• Involve significant other

• What has the biggest impact?Normative data– General population, addicts, sub-groups of COD

Feedback – Change Mechanisms

• Informational / Educational

• Motivational / Inspirational

• Changing Attitudes and Beliefs

• Providing Support / Helping Relationships

• Offering Social norms and comparisons

• Increasing Active information processing

• Providing information about risks, skills, strengths

Values ClarificationPros and Cons

• Values

• Decisional Balance– Pros & Cons of Use– Pros & Cons of Quitting / Adhering, etc

Change Plan:First part – the client describes

• The Changes I want to make are . . . .• The most important reasons why I want to

make these changes are . . . .• I will know that my plan is working if . . . .• Some things that could interfere with my

plan are . . . . • Things to think about and options to

consider are . . . . .

MET Change Plan: Menu of Options(Treatment Planning led by Clinician)

• Identify disorders and problems• Ask Patient to prioritize the list• Create Plan that includes bio-psycho-social-

spiritual approachs – consider menu of options

• Consider Role of: motivation (document), medications, therapies, level of care, SO, & vocational, housing, legal, medical, etc

Poly-Drug Addiction and Co-Occurring Mental Illness, HIV, and Tobacco

• Poly-Drug Abuse is the norm – especially when you include tobacco dependence

• COD, HIV high risk behavior, and Tobacco are very common with poly-drug addiction

• Match treatment approaches to recovery stage and motivational level

• Provide comprehensive services

Modifying MET for COD

• More Problems to Address – Longer Engagement Period

– Lower Self-Efficacy (link with recovery / hope)

• Assess MH, SA, & Meds (can one be consistent?)

• Modify Feedback & Change Plans - dual

• Address Cognitive Limitations– Higher therapist activity & behavioral strategies

– Briefer, More Concrete, Repetitions, Follow Alertness

• Integrate with Mental Health Treatments

Modify MET for COD• Poly-Drug issues• Multiple Mental Illnesses & medications• Assessing Motivation to Change for Each issue on the

Problem List– HOW BLEND MULTIPLE TREATMENT STYLES:

Motivational & Action (RP, 12-Step, etc)– HOW TRANSITION from MET/MI & Action Oriented

Treatments

• Engage the Patient in picking the priority list and what to address when

Poly-drug Abuse • Variety of combinations are common:

– Alcohol, cocaine, and benzodiazepines

– Heroin and cocaine, sedatives, and alcohol

– Marijuana and tobacco

– Tobacco and any other drug

– Multiple Club drugs, prescription (opioids, stimulants, sedatives, steroids, etc), street drugs (inhalants, hallucinogens, formaldehyde, PCP, K-7 and other internet sold substances, etc)

• Variety of severity of substance use disorders• Variety of motivation to stop using each specific substance• Variety of COD and interest to address mental health problem or

health risks / problems and to take medication

Poly-Drug Abuse Issues

• Possibility of sedation and respiratory depression is greater• Alcohol and Cocaine combo can increase toxicity with the

formation of cocaethylene • Speedballs (heroin and cocaine) increase the seizure risk• Many combinations have not been studied

– cigarettes dipped into formaldehyde– Marijuana and PCP– ecstasy, ketamine, and GHB

• Be alert for new drugs, new combinations, and new routes of administration

Key Consideration: What do you Feedback?

• What type of feedback is important and will have an impact to do what?

• How does motivational level effect what type of feedback?

• How does specificity of substance matter?– Alcohol – you are not a social drinker– Drugs – you are like drug users in treatment

MET and HIV – Clinical Applications

•Needle sharing

•Needle cleaning and safe injection practices

•Safer sex practices

• Medication noncompliance

MET and HIV – Medication noncompliance• Highrates of noncompliance (10-60%)

• (DiIorio et. al., 1993) MET subjects more likely than control subjects to self-report medication adherence and less likely to miss doses

• (Safren, 2001) MI + CBT/Problem solving vs. self-monitoring:

• MI/CBT showed faster improvement in compliance

• Depression a strong predictor of noncompliance

MET and HIV – Safer Sex

• Picciano et. al., 2001 – telephone based, single session MI intervention• MI vs delayed treatment control• MI group less likely to have unprotected sex, less ambivalent about practicing safer sex and expressed greater intention to use condoms in the future

Medications for COD Treatment

• Detoxification

• Protracted Abstinence

• Harm Reduction / Opioid Agonists

• Co-occurring Psychiatric Disorders– AA Brochure: The AA Member:

Medications and Other Drugs, 1984

Medication Management Issues • Provide hope and realistic expectations

• Educate about & monitor for side effects

• Start low and go slow

• Family help with monitoring

• Psychology of taking medications among abusers: no magic bullets

• Benzodiazepines issue

• Treat chronic mental illness & use

Protracted Abstinence / Withdrawal Syndromes

• Alcohol and benzodiazepines• Physiologic and mood changes• Resolve spontaneously – up to 1 year• Increases vulnerability to addiction relapse• Education and reassurance• Behavioral therapy approaches to mood, anxiety,

and sleep management• Medications might be needed

Protracted Abstinence/ Withdrawal Syndromes

• Physiological Changes in – sleep latency and awakening– increased respiratory rate, temperature, blood

pressure and pulse – decrease in cold-stress response– persistence of tolerance to sedatives – tremor

Protracted Abstinence/ Withdrawal Syndromes

• Mood changes– Irritability– Depressed mood– Frustration– Reduced problem solving– Anxiety

Monitor Psych Symptoms over time

• Structured tools – baseline and follow-ups

• MSE - routine

• SO / Family – baseline and follow-ups

Principles of Pharmacology for COD

• Resources: CO-MAP & TIPS & APA guidelines• Treat diagnoses & sometimes sub-threshold disorders• Choose psychiatric medications that help addictions if

possible• Avoid sedating, addicting medications and those that

potentiate the effects of illicit drugs whenever possible• Simplify dosing strategies• Stress education and compliance• Minimize refills

Principles of Pharmacology for COD

• Consider specificity of psychiatric disorder

• All medications are not created equal with regard to abuse liability

• Avoid psychiatric medications with abuse liability, overdose risk, causing seizure, sedation, liver toxicity

EX: Medications for Schizophrenia & Addiction

• Primary Antipsychotic Medication– Atypicals are best – Increased side effects with traditionals (EPS)

• start low, go slow

– Consider DEPO

• Issues: seizure risk, cardiac QTC, liver, sedation, weight gain, sexual dysfunction

• Controversial role of benzodiazepines • Consider also Addiction Treatment Medications:

– Maintenance, Detoxification, & Protracted Withdrawal Phase

EX: Medications for Depression & Addiction

• Primary Antidepressant Medication– SSRIs & Wellbutrin – most common

– Avoid MAOs (interaction with stimulants)

– start low, go slow

– Consider DEPO

• Choices often made due to considering SE issues – especially “calming / sedating” aspects of medication – also sexual dysfunction, GI

• Controversial role of benzodiazepines • Consider also Addiction Treatment Medications:

– Maintenance, Detoxification, & Protracted Withdrawal Phase

Medications for Alcohol Dependence

• Detoxification: Benzodiazepines and Barbituates

• Protracted Abstinence: Disulfiram and Naltrexone

• Experimental: Acamprosate, Nalmafene, Tiapride, Ondansetron, Serotonergic drugs

Medications for Cocaine Dependence

• Detoxification: Symptom Relief

• Protracted Abstinence: None are FDA approved

• Experimental: Amantadine, Desipramine, Antabuse

Medications for Opiate Dependence

• Detoxification: Methadone, Clonidine, Clonidine/Naltrexone, Buprenorphine

• Protracted Abstinence: Naltrexone

• Harm Reduction/ Maintenance: Methadone, LAAM, Buprenorphine

Medications for Tobacco Dependence

Nicotine Replacement Treatment (20 – 25%)gum (appropriate administration key)Nicotine patch Nasal spray Inhaler Lozenge

Buproprion (25-30%)Buproprion & patch – 30-35%

50% increase in mediation treatment outcome with the addition of behavior therapy – but only 3% do both

Addressing Tobacco in Addiction and Dual Recovery

• 44% of all cigarettes consumed in the US

• $256 Billion Dollars on Cigarettes

• 75% of those with mental illness

• Most smoke and die due to smoking caused diseases

• Nicotine use is a trigger for other substance use

• Treatment can Work: NRT, Atypicals, MET, and Behavioral therapy improves outcomes

• Social support and reduction of tobacco triggers is helpful

Key Considerations Setting & Staff Readiness Patient Assessment and Treatment Planning

Timing of tobacco dependence treatmentPharmacological ConsiderationsBlending Psychosocial Treatments

Characteristics of Tobacco Dependence with COD Patients

• Heavier smokers - more cigarettes per day• More Effective and Efficient• High Fagerstrom Scores• Complain of Withdrawal Symptoms• Use and withdrawal effects psych symptoms• Have made attempts to quit in the past but few and

short periods of abstinence• Mental Health settings offer little help to quit or reduce

environmental triggers• Tobacco changes medication blood levels• Increased morbidity and mortality

Tobacco and Other Drug Craving• Imagery scripts eliciting tobacco craving

• Cravings for other drugs occurred along with tobacco cravings– Implication that tobacco dependence should be

addressed in addictions treatment along with the drug problem prompting treatment

– Finding a mirror image of the clinical wisdom in tobacco dependence treatment

– Taylor, Harris, Singleton, Moolchan, Heishman. Exptl Clin Psychopharm. 2000; 8:75-87.

UMDNJ Tobacco Program

• Tobaccoprogram.org

• 732-235-8222

• Addressing Tobacco in Mental Health and Addiction Settings: July Issue of the Psychiatric Annals 2003

American Psychiatric Association Practice Guidelines

• For – specific Mental Illnesses– Substance Use Disorders– Nicotine Dependence

• www.psych.org

• call APPI press: 1-800-368-5777

• Published in the American Journal of Psychiatry – Nicotine Dependence Guidelines in November 1996 AJP

Personalized feedback about health-related indices

• CO monitoring – their immediate health

• Tobacco caused medical disorders

• Costs

• Recovery

• Children’s health

• “Personalized message”

Setting a Target Quit Date

• For those who are motivated to quit

• Provides time and target date to mobilize resources for quitting’

• Date should allow for sufficient time to acquire skills for quitting

Tobacco Smoking Effects Some Psychiatric Medication Blood Levels

• Smoking increases the metabolism of some medications• Smoking induces the hepatic microsomal enzymes P450 system• Specifically the 1A2 isoenzyme is increased secondary to

polynuclear aromatice hydrocarbons• Nicotine does not change medication blood levels• NRT doesn’t effect medication blood levels • Nicotine may modulate side effects of psychiatric medications

and psychiatric symptoms

Abstinence Increases Some Medication Blood Levels

• Tobacco effects the P450 / 1A2 liver enzymes• Antidepressants: desipramine, doxepin, imipramine• Antipsychotics: clozapine, haloperidol, fluphenazine,

olanzapine• Antianxiety medications: clomipramine,

desmethyldiazepam (valium), oxazepam• Other meds: caffeine, acetaminophen, propranolol,

theophylline

Buproprion SRContrindications: Hx of seizures

Hx of eating disorders

Consider: InsomniaMild agitation (extra cup of coffee)Dry mouth

Dosage: 150 mg every morning for 3 – 7* days, then 150 mg twice daily Begin tx 1-2 weeks pre-quit date

Duration: 3 months – also clinicians use for 6 – 12 months

Availability/Cost: Prescription: $3.33/day

Nicotine Gum / Lozenge

Consider: Mouth sorenessDyspepsiaPeople with dental work may not want to use itSome people don’t like gumAbsorption of nicotine affected by food/beveragesBlister packs hard to open

Dosage: 1-24 cig/d: 2mg gum up to 24 pieces/day (.8mg)>25 cig/d: 4mg gum up to 24 pieces/day (1.5mg)

Duration: Up to 12 weeks

Availability/Cost: OTC only / $6.25 for 10 2-mg pieces $6.87 for 10 4-mg pieces

Nicotine InhalerConsider: local irritation of the mouth and throat

absorption in mouth & throat (not nose)Cartridge is temperature sensitive (warm

for best nicotine delivery)

Dosage: 6-16 cartridges/d (2mg/cartridge)*Give license to use more than they’ll ever use (I.e., Rx-15-20 cartridges a day)

Duration: Up to 6 months

Availability/Cost: Prescription/ $10.94 for 10cartridges

Nicotine Nasal Spray

Consider: Nasal irritation

Spray up into nose

Dosage: 8-40 doses/day

(.25mg each nostril=.5mg tot)

Duration: 3-6 months

Availability/Cost: Prescription/ $5.40 for 12 doses

Nicotine PatchConsider: may cause local skin irritation (adhesive)

may come off in water or from sweatmay cause sleep disturbance (Nic@nite)

Dosage/Duration: 21mg/24 hr 4 weeks*14mg/24 hr 2 weeks7 mg/24 hr 2 weeks15mg/16hr 8 weeks#

Availability/Cost: Prescription & OTC/ $4.22* or $4.51#

mailto:Nic@nite

Mood Management Training To Prevent Relapse

• Sharon Hall and colleagues at UCSF • Skills can be developed through instruction, modeling, and

homework practice• Cognitive Therapy

– Learn to identify and anticipate external and internal cues - thought patterns that lead to negative moods

– Learn to avoid or cope with cues– Learn to modify their thought patterns so as to avoid or

reduce the likelihood of negative affect

Other Resources

• Motivational Groups for Community Substance Abuse Programs– www.mid-attc.org– 804-828-9910

• Co-Occurring Disorder Series: Foundations Associates (888-869-9230; www.dualdiagnosis.org) – How Medicine Can Help You– Making Medication Part of Your Life

http://www.mid-attc.org/

http://www.dualdiagnosis.org/

integrating dual recovery therapy and medications for co-occurring disorders douglas ziedonis, m.d.,...

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