The Evolving Field of COD: Overview and Treatment Options

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The Evolving Field of COD Overview and Treatment
Options
Sherry Larkins, Ph.D. UCLA Integrated Substance
Abuse Programs
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IntroductionWhat we will cover

• Overview of the evolving field of Co-Occurring
  Disorders
• Addiction and Mental Health Disorders
• Treating COD
• Cognitive-Behavioral Skills
• Motivational Interviewing Skill

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Ice Breaker

• In pairs, discuss a consumer who has experienced
  both mental health and substance use disorders.
• How is this consumer unique from other mental
  health consumers?
• How does the consumer present? What behaviors
  does he/she exhibit that are different from a
  consumer with mental illness only?

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Co-Occurring Disorders

• Co-occurring disorders
• Refers to co-occurring substance use (abuse or
  dependence) and mental disorders
• In other words
• consumers with co-occurring disorders have
• one or more disorders relating to the use of
  alcohol and/or other drugs of abuse and one or
  more mental disorders

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Co-Occurring Disorders

• Diagnosis of COD occurs when
• at least one disorder of each type can be
  established independent of the other and
• is not simply a cluster of symptoms resulting
  from the one disorder
• Clinicians knowledge of
• both mental health and substance abuse
• is essential, but challenging to achieve

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So, all of that is well and good, but

• is dealing with drug abuse REALLY important to
  my job?

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Prevalence of COD

• In 2006, 5.6 million adults (2.5 of persons aged
  18) met the criteria for both serious
  psychological distress (SPD) and substance
  dependence and abuse (i.e., substance use
  disorder, SUD)
• In 2006, 15.8 million adults (7.2 of persons
  aged 18) had at least one major depressive
  episode (MDE) in the past year
• Adults with MDE in the past year were more likely
  than those without MDE to have used an illicit
  drug in the past year (27.7 vs. 12.9 percent)

SOURCE 2006 National Survey on Drug Use and
Health, SAMHSA.
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Past Year Treatment of Adults with Both Serious
Psychological Distress (SPD) and SUD (2006)
5.6 Million adults with co-occurring SPD and
substance use disorder.
SOURCE 2007 National Survey on Drug Use and
Health, SAMHSA.
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Percentage of Adults with Past Year MDE and AUD
by Age Group

• SOURCE 2007 National Survey on Drug Use and
  Health, SAMHSA.

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Substance Use and Depression among Adults
SOURCE 2006 National Survey on Drug Use and
Health, SAMHSA.
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COD and Juvenile Justice

• Nearly two-thirds of incarcerated youth with
  substance use disorders have at least one other
  mental health disorder
• As many as 50 of substance abusing juvenile
  offenders have ADHD
• About 30 of incarcerated youth with substance
  use disorders have a mood or anxiety disorder
• Those exposed to high levels of traumatic
  violence might experience symptoms of
  posttraumatic stress as well as increased rates
  of substance abuse

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Data from LA County DMH, 2007

• 61,739 new episodes opened in DMH Directly
  Operated Programs
• 44,092 episodes where dual field was completed
• 31,187 (71) indicated NO substance abuse issues
• 12,905 (29) indicated substance abuse issues.
• 17,647 (29) dual code field was empty (i.e.,
  neither presence nor absence of substance use
  noted)

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Prevalence and Other Data

• Data now show
• COD are common in general adult population.
• Increased prevalence of people with COD and
  programs for people with COD
• People with COD are more likely to be
  hospitalized and the rate may be increasing
• Rates of mental disorders increase as the number
  of substance use disorders increase
• If we treat the SUD, we also address mental
  health symptoms

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So, the answer is

• YES this REALLY is important to my job?
• We must address SUD in order to increase the
  effectiveness of mental health treatment

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So, How Do We Treat COD?

• TIP 42
• Guiding Principles and Recommendations

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Six Guiding Principles (SAMHSA, TIP 42)

• Employ a recovery perspective
• Develop a phased approach to treatment
• Address specific real-life problems early in
  treatment
• Plan for cognitive and functional impairments

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Delivery of Services (SAMHSA, TIP 42)

• Provide access
• Complete a full assessment
• Provide appropriate level of care
• Achieve integrated treatment
• - Treatment Planning and Review
• - Psychopharmacology
• Provide comprehensive services
• Ensure continuity of care

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Vision of Fully Integrated Treatment

• One program that provides treatment for both
  disorders
• Mental and substance use disorders are treated
  by the same clinicians
• The clinicians are trained in psychopathology,
  assessment, and treatment strategies for both
  disorders

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Vision of Fully Integrated Treatment (continued)

• Treatment is characterized by a slow pace and a
  long-term perspective
• Providers offer motivational counseling
• 12-Step groups are available to those who
  choose to participate
• Pharmacotherapies are utilized according to
  consumers psychiatric and other medical needs
• Sensitivity to issues of trauma, culture,
  gender, and sexual orientation

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Quick Exercise Levels of Program Capacity
Advanced Addiction COD Enhanced
Beginning Addiction Only Treatment
Intermediate Addiction COD Capable
Fully Integrated COD Integrated
Intermediate Mental Health COD Capable
Beginning Mental Health Only Treatment

• What challenges have you encountered in moving
  toward the center?
• What have you done to overcome these challenges?

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Addiction A Brain Disease

• Putting Drug Use into Context with other Mental
  Disorders

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Onset of Mental Health Disorders

• Oppositional Defiance 5yo
• Attention Deficit Disorder-ADHD 1.3-2.4 yo
• Anxiety Disorders 3.8 yo
• Conduct Disorder 5.6 yo
• Depression 10.1 yo
• Schizophrenia-affective disorders mid-teens to
  mid-thirties

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Typical Progression of Use

• FAS---Substance use in-uterus
• No Social
• Use Experimentation Use Use
  Abuse Dependence
• --------------------------------------------------
  ---------------------------------------------
• 0-2 3-5 6-8 9-10 11-12 13-14 15-16 17
• Infant Child Pre- Adolescent
• adol
• Mental Health Disorders
  onset----------------------------------

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What are we talking about?

• Alcoholism/Addiction Major Mental
  Disorders
• Both heredity and environment play a role
• Characterized by chronicity and denial
• Affects the whole family
• Progresses without treatment
• Feelings of shame and guilt
• Inability to control behavior and emotions
• Often seen as a moral issue
• Leads to feelings of despair and failure
• Biological, psychological, social and spiritual
  components

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Collision of Symptomology

• Differential Diagnosis is essential for accurate
  assessment. Is the presenting problem affected by
  a medical condition or substance?
• Is it depression or alcohol, prescription pain
  killer, heroin use?
• Is it ADHD or is it methamphetamine, cocaine
  use?
• Is it bipolar disorder or cocaine use?
• Is it schizophrenia or methamphetamine use?
• Is it PTSD or polysubstance use?

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A Major Reason People Take a Drug is They Like
What It Does to Their Brains
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Initially, A Person Takes A Drug Hoping to
Change their Mood, Perception, or Emotional State
Translation---
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Dopamine and the Brain
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But Then
After A Person Uses Drugs For A While, Why Cant
They Just Stop?
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Because
Their Brains have been Re-Wired
by Drug Use
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Prolonged Drug Use Changesthe Brain In
Fundamentaland Long-Lasting Ways
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Dopamine Transporter Loss AfterHeavy
Methamphetamine Use
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• Cognitive and
• Memory Effects

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Control gt MA
4
3
2
1
0
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MA gt Control
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Addiction Is A Brain Disease Expressed As
Compulsive Behavior
Both Developing and Recovering From It Depend
on Behavior and Social Context
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Thats Why Addicts Cant Just Quit!
Thats Why Treatment Is Essential!
Thats Why It is Critical to Help with Both
Skills Motivation for Change!
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Treatments for Co-Occurring Disorders
Cognitive Behavioral Tools Motivational Tools
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What is CBT and how is it used in addiction
treatment?

• CBT is a form of talk therapy that is used to
  teach, encourage, and support individuals about
  how to reduce / stop their harmful drug use.
• CBT provides skills that are valuable in
  assisting people in gaining initial abstinence
  from drugs (or in reducing their drug use).
• CBT also provides skills to help people sustain
  abstinence (relapse prevention)

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Why is CBT useful?

• CBT is a counseling-teaching approach well-suited
  to the resource capabilities of most clinical
  programs
• CBT has been extensively evaluated in rigorous
  clinical trials and has solid empirical support
• CBT is structured, goal-oriented, and focused on
  the immediate problems faced by substance abusers
  entering treatment who are struggling to control
  their use

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Important concepts in CBT

• CBT attempts to help clients
• Follow a planned schedule of low-risk activities
  
• Recognize drug use (high-risk) situations and
  avoid these situations
• Cope more effectively with a range of problems
  and problematic behaviors associated with using

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Important concepts in CBT

• As CBT treatment continues into later phases of
  recovery, more emphasis is given to the
  cognitive part of CBT. This includes
• Teaching clients knowledge about addiction
• Teaching clients about conditioning, triggers,
  and craving
• Teaching clients cognitive skills (thought
  stopping and urge surfing)
• Focusing on relapse prevention

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The 5 Ws

• People addicted to drugs do not use them at
  random. It is important to know
• The time periods when the client uses drugs
• The places where the client uses and buys drugs
• The external cues and internal emotional states
  that can trigger drug craving (why)
• The people with whom the client uses drugs or the
  people from whom she or he buys drugs
• The effects the client receives from the drugs -
  the psychological and physical benefits (what
  happened)

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Triggers Cravings
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CBT Techniques for Addiction Treatment
High-Risk Low-Risk Situations
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High- and low-risk situations

• Situations that involve triggers and have been
  highly associated with drug use are referred to
  as high-risk situations.
• Other places, people, and situations that have
  never been associated with drug use are referred
  to as low-risk situations.

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High- and low-risk situations

• An important CBT concept is to teach clients to
  decrease their time in high-risk situations and
  increase their time in low-risk situations.

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Triggers cravings
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Strategies to cope with craving

• Coping with Craving
• Engage in non-drug-related activity
• Talk about craving
• Surf the craving
• Thought stopping
• Contact a drug-free friend or counsellor
• Pray

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Methods for Using Cognitive Behavioural
Strategies
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The role of the clinician in CBT

• The CBT clinician has to strike a balance
  between
• Being a good listener and asking good questions
  in order to understand the client
• Teaching new information and skills
• Providing direction and creating expectations
• Reinforcing small steps of progress and providing
  support and hope in cases of relapse

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The role of the clinician in CBT

• The CBT clinician also has to balance
• The need of the client to discuss issues in his
  or her life that are important.
• The need of the clinician to teach new material
  and review homework.
• The clinician has to be flexible to discuss
  crises as they arise, but not allow every session
  to be a crisis management session.

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The role of the clinician in CBT

• The clinician is one of the most important
  sources of positive reinforcement for the client
  during treatment. It is essential for the
  clinician to maintain a non-judgemental and
  non-critical stance.
• Motivational interviewing skills are extremely
  valuable in the delivery of CBT.

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Effecting Change through the Use of
Motivational Interviewing
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How can MI be helpful for us in working with our
consumers/patients?

• The successful MI therapist is able to inspire
  people to want to change
• Use of MI can help engage and retain consumers in
  treatment
• Using MI can help increase participation and
  involvement in treatment (thereby improving
  outcomes)

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Definition of Motivation
The probability that a person will enter into,
continue, and comply with change-directed
behavior
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Motivational Interviewing
Elicit behavior change
Respect autonomy
A patient-centered directive method for enhancing
intrinsic motivation to change by exploring and
resolving ambivalence.

Tolerate patient ambivalence
Explore consequences
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Where do I start?

• What you do depends on where the consumer is in
  the process of changing
• The first step is to be able to identify where
  the consumer is coming from

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Stages of ChangeProchaska DiClemente
Precontem- plation
Contemplation
Recurrence
Preparation
Maintenance
Action
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Helping People Change

• Motivational Interviewing is the process of
  helping people move through the stages of change

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1. Precontemplation Definition Not yet
considering change or is unwilling or unable to
change. Primary Task Raising Awareness
6. Recurrence Definition Experienced a
recurrence of the symptoms. Primary Task Cope
with consequences and determine what to do next
2. Contemplation Definition Sees the
possibility of change but is ambivalent and
uncertain. Primary Task Resolving
ambivalence/ Helping to choose change
Stages of ChangePrimary Tasks
5. Maintenance Definition Has achieved the
goals and is working to maintain
change. Primary Task Develop new skills for
maintaining recovery
3. Determination Definition Committed to
changing. Still considering what to do. Primary
Task Help identify appropriate change strategies
4. Action Definition Taking steps toward
change but hasnt stabilized in the
process. Primary Task Help implement change
strategies and learn to eliminate potential
relapses
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Building Motivation OARS(the microskills)

• Open-ended questioning
• Affirming
• Reflective listening
• Summarizing

The goal is to elicit and reinforce
self-motivational statements (Change Talk)
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Four Principles ofMotivational Interviewing
1. Express empathy 2. Develop discrepancy 3. Avoi
d argumentation 4. Support self-efficacy
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Use the Microskills of MI to

• Express Empathy
• Acceptance facilitates change
• Skillful reflective listening is fundamental
• Ambivalence is normal

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Use the Microskills of MI to

• Develop Discrepancy
• Discrepancy between present behaviors and
  important goals or values motivates change
• Awareness of consequences is important
• Goal is to have the PERSON present reasons for
  change

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Decisional Balance
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Use the Microskills of MI to

• Avoid Argumentation
• Resistance is signal to change strategies
• Labeling is unnecessary
• Shift perceptions
• Peoples attitudes are shaped by their words, not
  yours

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Use the Microskills of MI to

• Support Self-Efficacy
• Belief that change is possible is an important
  motivator
• Person is responsible for choosing and carrying
  out actions to change
• There is hope in the range of alternative
  approaches available

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Change Talk

• Recognizing the problem
• Expressing concern
• Stating intention to change
• Being optimistic about change

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Signs of Readiness to Change

• Less resistance
• Fewer questions about the
  problems
• More questions about change
• Self-motivational statements
• Resolve
• Looking ahead
• Experimenting with change

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Change Talk is Happening When the Consumer Makes
Statements that Indicate
Recognition of a problem A concern about the
problem Statements indicating an intention to
change Expressions of optimism about change
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How Do I Finish?

• Develop a Change Plan with the consumer by
• Offering a menu of change options
• Developing a behavior contract
• Lowering barriers to action
• Enlisting social support
• Educating the consumer about treatment

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You Are Using MI If You

• Talk less than your consumer does
• Offer one refection for every
  three questions
• Reflect with complex reflections more than half
  the time
• Ask mostly open-ended questions
• Avoid getting ahead of your consumers stage of
  readiness (warning, confronting, giving unwelcome
  advice, taking good side of the argument)