Dual Addictions

Kathleen M Carroll PhDKathleen M Carroll PhDYale University School of Yale University School of

MedicineMedicine

Overview

• Definitions and terms

• Epidemiology: Rates and risks

• Onset: Gateways and destinations

• Treatments: Everything we don’t know

Terms

Comorbidity: Co-occurrence of two conditions or disorders

Dual diagnosis: Co-occurrence of alcohol/drug use disorder and another psychiatric disorder (heterotypic comorbidity)

Homotypic comorbidity: Co-occurrence of disorders within a diagnostic grouping (e.g., substance use disorders)

Major US epidemiologic surveysEpidemiologic Catchment Area Study (ECA)

1980-1984

N=20291 adults 18+

DSM-III

(DIS)

Regier et al., 1990

National Comorbidity Survey (NCS)

1990-1992

N=8098

15-54

DSM-III-R

(CIDI)

Kessler et al. 1994

NCS-R 2001-2002

N=9282 adults

DSM-IV

(CIDI)

Kessler et al.

2005

**NESARC 2001-2002

N=43093

adults

DSM-IV Grant et al., 2004

National Epidemiologic Survey on Alcohol and Related Conditions

(NESARC)• Previous surveys in US, Canada, Australia

confirm probabilities of alcohol use disorder rise with drug use disorder visa versa

• Only NESARC diagnosis specific (multiple types of drugs rather than ‘lumping’)

• Includes data on help seeking• Focus on 12-month (current), rather than lifetime

disorders• Oversampling of African Americans and Hispanics

DSM-IV Substance Dependence

Maladaptive use leading to clinically significant impairment or distress, shown by 3+ of the following in the same 12-month period:

1. Use of the substance more or longer than intended2. Persistent desire or unsuccessful efforts to cut down or

stop3. A great deal of time spent on use of the substance or

getting over its effects4. Important activities given up or reduced because of use5. Continued use despite knowledge of a serious physical or

psychological problem6. Tolerance7. Withdrawal, or use to avoid withdrawal

DSM-IV Substance Abuse

Not dependent, and maladaptive use leading to clinically significant impairment or distress, shown by 1 + of the following:

1. Continued use despite social/interpersonal problems

2. Hazardous use (e.g., driving when impaired by alcohol)

3. Frequent use leading to failure to function in major roles

4. Legal problems

NESARC: 12-month prevalence rates

Disorder 12-month prevalence

Population estimate (thous)

Any alcohol use disorder 8.5 17580

Any alcohol use only 7.4 15285

Any drug use disorder 2.0 4159

Any alcohol use + drug use disorder 1.1 2295

Any drug use disorder only 0.9 1864

Any drug abuse 1.4 2858

Any drug dependence 0.6 1301

Stinson et al, (2005) DAD

12-month prevalence: Drug use disorders

Disorder % abuse % dependence Pop est (thou)

Cannabis 1.13 0.32 3016

Opioid .24 .11 737

Cocaine .13 .13 557

Amphetamine .09 .07 342

Sedative .09 .07 333

Hallucinogen .12 .02 291

Tranquilizer .08 .05 260

Solvent/ inhalant

.02 - 49

Stinson et al, (2005) DAD

Demographics:

Users of alcohol + drugs more likely to be:

• Male (74%)

• Younger (18-29) (65%)

• Never married (63%)

• Similar to drug-only with respect to education, ethnicity, income

Disorder Prevalence (%)

Any drug dependence 67.7

Any drug abuse 49.5

Cocaine 79.5

Hallucinogen 79.2

Amphetamine 62.8

Solvent /inhalant abuse 59.9

Opioids 57.5

Cannabis 57.6

Tranquilizers 57.5

Sedatives 39.8

Rates of alcohol use disorders among those with specific drug use disorders: NESARC

% alcohol use disorder, given drug use

% drug use disorder, given alcohol use

Any drug dependence 67.7 5.01

Any drug use 49.5 8.04

Cocaine 79.5 2.51

Hallucinogen 79.2 1.31

Amphetamine 62.8 1.22

Solvent /inhalant 59.9 0.17

Opioids 57.5 2.41

Cannabis 57.6 9.89

Tranquilizers 57.5 0.85

Sedatives 39.8 0.75

Alcohol use among those with specific drug use disorders and visa-versa

Comorbidity: NESARC

Disorder No alcohol or drug

Alcohol only

Drug only

Alcohol + any drug

Any personality disorder

13.2 25.3 44.0 50.8

Any mood disorder, past yr

8.1 16.4 27.5 35.3

Any anxiety disorder, past yr

10.4 15.6 24.0 26.5

Stinson et al, (2005) DAD

12-month prevalence treatment seeking by disorder: NESARC

0

5

10

15

20

25

Alcohol only Drug only Alcohol and anydrug

Stinson et al, (2005) DAD

12-month prevalence treatment seeking by disorder: NESARC

0102030405060708090

100

Alcohol only Drug only Alcohol and anydrug

Factors associated with multiple substance use

• Retention of use through gateway progression

• Pharmacologic effects of combinations, including modulation, treatment of withdrawal and uncomfortable effects

• Genetic evidence of common mechanisms, vulnerability in some families

• Availability, market trends

Gateway pattern of drug initiation: Kandel et al

Cigarettes

Alcohol

Cannabis

Other illicit

NCS-R: Only 5.2%Violate this pattern

Risk of developing disorder, given use

0

5

10

15

20

25

30

35

Tobacco Alcohol Heroin Cocaine Cannabis Tranqul.

Anthony et al. 1994, Comparative epidemiology, NCS

NESARC: Hazard rates for alcohol and drug use disorders

Hasin et al., 2007Arch Gen Psychiatry

Compton et al. 2007Arch Gen Psychiatry

Drug-alcohol comorbidity associated with:

• Earlier onset

• Higher severity

• Higher psychiatric comorbidity

• Higher rates of treatment seeking

• Higher rates of dropout once in treatment

• Less socioeconomic support

• Poorer treatment outcome

Limited research on treatment of homotypic comorbidity

Users of multiple substances usually excluded from treatment research:

• Difficulty in meeting needs of heterogeneous populations in single trial

• Complexity of assessment (time frame, availability of biologic indicators, time)

• Complexity of targeting multiple substances simultaneously (licit, illicit)Safety and compliance concerns, especially in pharmacologic trials

• Pharmacologic specificity

Rounsaville et al, 2003

Available pharmacotherapies for substance use disorders

Alcohol Opioids Cocaine Marijuana

Detoxification X x - -

Maintenance X

Antagonist X

Aversive, reduce craving

X

Treat co-existing psychiatric disorders

X X X X

Emerging pharmacologic strategies for homotypic comorbidity

Type Medication Reference

Opioid alcohol Naltrexone Volpicelli et al (1992)

O’Malley et al (1992)

Alcohol cocaine Disulfiram Carroll et al. (2004)

Original rationale for disulfiram as treatment for cocaine users

• Clinical observation of high levels of concurrent alcohol-cocaine use (60-70% of patients)

• Rationale: Reducing alcohol use may reduce concurrent cocaine use

1. Better ability to utilize coping skills (Marlatt et al)

2. Alcohol powerful conditioned cue (Higgins et al)3. Cocaethylene (Jatlow, McCance)

Open outpatient study, cocaine-alcohol users: % attaining 3+

weeks abstinence

0

10

20

30

40

50

60

70

TSF CBT CM/DISULF TSF/DISULF CBT/DISULF

Carroll et al., 1998

Double blind trial of disulfiram for cocaine dependence in methadone

maintenance N=67

0

10

20

30

40

50

60

70

Disulfiram Placebo

% cocaine neg urines% days coc. abst

Petrakis et al 2000

Randomized outpatient clinical trial: Disulfiram, CBT, and IPT, N=121

Frequency of cocaine use by treatment week

0

0.5

1

1.5

2

2.5

3

3.5

0 1 2 3 4 5 6 7 8 9 10 11 12

Treatment week

Day

s of

use

CBT/Disulfiram

IPT/Disulfiram

CBT/Placebo

IPT/Placebo

Carroll et al., 2004

z p

Time -7.15 .00

Disulfiram x time -2.10 .04

CBT x time -2.33 .03

Disulfiram x CBT x time

-1.97 .05

Cocaine outcomes for those who did NOT Cocaine outcomes for those who did NOT meet criteria for alcohol abuse or meet criteria for alcohol abuse or dependence (n=58) dependence (n=58)

Behavioral therapy studies of alcohol-drug users

Behavioral therapies tend to be effective across types of substance use

Alcohol Opioids Cocaine Marijuana Mixed

Motivational interviewing

X (X) (X) X (X)

Contingency management

X X X X X*

Cognitive behavioral therapies

X X X X X

Behavioral couples, family therapies

X X X X X

Clinical Trials Network:17 Current Nodes, >200

CTPs

Clinical Trials Network: MET Trials Participant Characteristics

• Mean age 35• 29% female (<MI)• 42% Caucasian (<MI)• 12 years of education• 28% mandated or legal referral

• Primary substance use problem:• Alcohol: 29 % (<MI)• Marijuana: 16%• Cocaine: 23% (>MI)• Methamphetamine: 4% (<MI)• Opioids: 9%• Benzodiazepenes: 1%

Ball et al., 2007

CTN MET/MI studies: Design

Individual presents for treatment at clinicScreened for studyInformed consent

Baseline assessment Randomization

Standard individual treatment @ CTP

3 sessions

3 sessionsWith MET

Posttreatment assessment28 days after randomization

84-day (3 month) follow-up

CTN: MET longitudinal outcomes

0.00

0.50

1.00

1.50

2.00

2.50

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

CAU MET

Days of Use - all sites

Ball et al.., 2007

CTN MET/MI studies: Outcomes for alcohol subgroups

Engagement Substance use outcomes

Alcohol use only subgroup

MI (1 session)

Carroll et al. (2007)

+ - +

MET (3 sessions)

Ball et al. (2007)

- (+) +

MET-Spanish

(3 sessions)

Under review

- - +

‘CBT 4 CBT’Computer Based Therapy/CBT

• 6 modules, ~1 hour each, high flexibility• Highly user friendly, no text to read, linear navigation• Video examples of characters struggling real life

situations• Multimedia presentation of skills• Repeat movie with character using skills to change ‘ending’• Interactive exercises, quizzes • Multiple examples of ‘homework’

Computer-based training in CBT: CBT4CBT

“All comers”: few restriction on participation, only require some drug use in past 30 days

• 43% female• 45% African American, 12% Hispanic • 23% employed• 37% on probation/parole• 59% primary cocaine problem, 18% alcohol,

16% opioids, 7% marijuana• 79% users of more than one drug or alcohol

Carroll et al., in press, Am J Psychiatry

Primary outcomes, 8 weeksCBT+TAU versus TAU

34

53

0

10

20

30

40

50

60

70

80

% drug positive urines

CBT4CBT + TAUTAU

Carroll et al., in press, Am J Psychiatry

Treatment of Dual Addictions:General strategies

• Target, treat most severe disorder and any requiring detoxification first

• Utilize pharmacotherapies when available

• Attend to psychiatric and medical comorbidity

• Frequent monitoring, chronic care model

• Sequential targeting may be important for some treatments (eg. contingency management)

“I wonder why we’re not getting any new converts.”