Integrating Co-occurring Disorders

1
Integrating Co-occurring Disorders

• What Every Clinician Needs to Know
• By
• John Roberts, MD
• Medical Director
• Addiction Psychiatrist

2
Prevalence

• Approximately 5 million US Adults have a serious
  mental illness and a co-occurring substance use
  disorder (SAMHSA,2006)
• Mental health settings reveal 20-50 of their
  clients have a lifetime co-occurring substance
  use disorder (Sacks, et al., 1997)
• Substance abuse agencies reveal 50-75 of their
  clients have a lifetime co-occurring mental
  disorder (Compton et al.,2000)

3

• ECA Study 45 of individuals with ETOH use
  disorders and 72 of individuals with drug abuse
  disorders have have at least one co-occurring
  psychiatric disorder (Reiger et al., 1990)
• NCS 78 ETOH dependent males and 86 of ETOH
  dependent females have another lifetime
  psychiatric disorder, including drug dependence
  (Kessler et al., 1994)

4

• CODs are the expectation rather than the
  exception

5
Relevance

• Dual Services
• Poor Outcomes
• Non-compliance
• Increase suicide Risk
• Medications May Be Discouraged

6
Diagnosing COD

• Time Line
• Longest Period of Sobriety
• Observe During Abstinence
• Distinguish Withdrawal vs. Psychiatric Symptoms
• Screening Tools (Alcohol Use Identification Test,
  Michigan Alcohol Screening Test and Drug Abuse
  Screening Test, The Patient Health Questionnaire,
  CAGE, CRAFFT, Psychiatric Research Interview for
  Substance and Mental Disorders
• Labs- UDS, CDT, dCDT, GGT, EtG, MCV
• Family History

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Carbohydrate Deficient Transferrin (CDT or dCDT)

• Abnormal liver transferrin
• Serum blood Test
• Detects heavy drinking (5-6 STD/day) over the
  preceding several weeks (4-5 heavy days per week)
• Severe liver disease might invalidate the test
• Decreases with abstinence and increases with
  relapse drinking
• Measures drinking occurring at unhealthy levels

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How Well Does dCDT Work?

• In heavy drinking (at least 5 drinks per day on
  average for at least several weeks) the positive
  rate is about 60-80.
• So. That means 2-4 out of 10 people with heavy
  alcohol use/abuse will not be detected
• The false positive (error) rate is about 2.
• So. That means that 2 out of 100 people might
  have a high value not caused by heavy alcohol
  consumption

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How Do You Interpret CDT?

• If elevated there would be a strong suspicion
  of heavy alcohol consumption. If there is other
  reason to believe that heavy consumption is
  occurring then certainty approaches 100.
• If not elevated this does not mean that heavy
  alcohol consumption is not occurring. If strong
  suspicion remains consider other data, clinical
  evaluation, and potentially other lab tests (GGT,
  ethylglucuronide, Peth)
• Repeat testing after abstinence, antabuse, etc.
  is always an option

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What We Now Know About CDT

• It is 50-80 sensitive in chronic alcoholics and
  is gt 95-97 specific - but assay dependent.
• Sensitivity is conditional on time since last
  heavy drinking day.
• Sex does not seem to make a difference in cut-off
  with newer assays (except pregnancy?).
• Severe liver disease and a few genetic variants
  might interfere with interpretation.
• dCDT will go down with abstinence and up with
  relapse drinking.
• Its use is cost-effective based on published
  studies.

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Hazeldens COD Series

• MDD
• BPAD
• Anxiety disorders
• Borderline personality disorder
• DID
• Workbooks, DVD, CD-ROM
• 1-800-328-9000

12
Medications for Substance Abuse

• Disulfuram (Antabuse)
• Acamprosate (Campral)
• Naltrexone (Revia, Vivitrol)
• Topiramate (Topamax)
• Baclofen
• Buprenorphine (Suboxone)
• Methadone
• Modafinil (Provigil)

13
Depression

• Prevalence 16.5 had ETOH USE Disorders(ECA)
  18.5 had Drug Use
  Disorders (Reiger et al)
• TCAs Imipramine, Desipramine, Doxepine
• SSRIS(prozac, zoloft, paxil, lexapro, celexa)
• Lamotrigine(Lamictal)
• Nefazodone(Serzone)
• Buproprione(Wellbutrin)
• Venlafaxine(Effexor)

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Therapy

• CBT
• Group therapy
• 12 step programs
• Family involvement
• Emergency Planning

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Bipolar Affective Disorder

• Prevalence 56 had a SUD (ECA)
• Most common disorder with COD (ECA,NCS)
• More episodes of mixed mania and rapid cycling
• Kindling (Neuronal Sensitization)
• Poor Prognosis
• More frequent hospitalizations
• Earlier onset
• More depression

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Valproate

• Two studies support safety and efficacy( no
  change in WBC, platelet counts, transaminase
  levels)
• Valproate plus normal treatment VS. placebo
  suggested higher levels of ETOH use in placebo
  group
• Valproate plus normal treatment vs. placebo
  revealed lower proportion of heavy drinking days
• Valproate plus naltrexone vs. valproate only had
  better outcomes in substance use, depression,
  mania
• Valproate had better compliance and tolerance vs.
  lithium in COD
• Recent reports suggest that valproate can be
  safely used in patients with hepatitis C virus

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Carbamazepine

• Reduced cocaine use in patients with cocaine
  dependence and BPAD

18
Oxcarbazepine

• Less drug interactions
• No oxidative metabolism
• Liver impairment will not effect metabolism
• Associated with hyponatremia

19
Lamotrigine

• Improved Mood
• Lower cocaine craving
• No effect on drug use

20
Second Generation Antipsychotics

• Olanzapine(Zyprexa)-reduced substance use,
  cravings
• Quetiapine(Seroquel)- mixed results effective
  with BPAD and cocaine dependence, did not help
  decrease ETOH in BPAD with ETOH Dependence

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Antidepressants

• Greater risk of mania secondary to antidepressant
  use

22
Lithium

• Less effective in COD patients

23
Therapy

• Abstinence
• Relapse prevention
• Medication compliance
• Treatment team relationship
• Family involvement
• Monitor moods Normal feeling vs. BPAD Sxs
• Warning signs
• Structure and routine
• 12 steps
• Prepare for emergencies

24
BPAD Summary

• Anticonvulsants and second-generation
  antipsychotics may be more useful than lithium or
  first generation antipsychotics
• Supportive therapy, education
• ACT Assertive community program

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Schizophrenia

• Prevalence 47-70 have substance use disorders
  and exceeds 80 when nicotine is included
• Poor compliance
• Poor outcomes
• More frequent hospitalizations
• Increased suicidality
• Higher levels of cocaine craving

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First vs. Second Generation Antipsychotics

• Haldol vs. Olanzapine(Zyprexa)
• Olanzapine group had less craving, fewer
• () drug screens and improved PANSS
• One study with no difference
• Risperidone(Risperdal) vs. class of FGA
• Risperidone group had less craving, fewer
  relapses and improved negative symptoms

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• Risperidone(Risperdal) and ziprazidone(Geodon)
  groups stayed in treatment longer than than those
  on olanzapine(Zyprexa) and FGA
• Large VA study found no difference between groups
  in substance abuse-related outcomes

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Second Generation Antipsychotics Compared

• Olanzapine(Zyprexa) had reduced positive cocaine
  drug screens compared to risperidone(Risperdal)(bo
  th groups positive drug screens reduced over
  time)
• Clozapine(Clozaril) had higher abstinence rates
  than risperidone in patients with ETOH and
  cannabis abuse

29
Specific Second Generation Antipsychotics

• Risperidone(Risperdal) in open label study had
  improved CGI ratings, less craving, 88 retention
  in cocaine abusing patients
• Olanzapine(Zyprexa) in open label study suggested
  70 achieved early partial remission
• Quetiapine(Seroquel) in open label study improved
  substance use outcomes and symptoms
• Aripiprazole(Abilify) in open label or switch
  studies showed less craving, and fewer () UDS,
  and improved psychosis

30

• Clozapine open label and retrospective reviews
  revealed decrease in ETOH and Substance use
• Long acting injectable risperidone(Risperdal
  Consta) open label suggests it is more
  efficacious than long acting first generation
  antipsychotics

31
FDA-Approved Medications For The Treatment of
SUD

• Disulfiram(Antabuse) no psychiatric
  complications and 64 1 year remission and 30 2
  year remission
• Disulfiram and or naltrexone more weeks of
  abstinence and less craving
• Naltrexone(ReVia)- fewer drinking days and less
  craving
• Methadone/buprenorphine- both appear safe

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Considerations for Treating COD With
Schizophrenia

• Adherence may be more important than efficacy so
  focus on patient preference
• Encourage compliance with medication even if the
  patient relapses
• Consider long-acting injectable medications
• Consider side effects such as EPS, lipid profile
• General consensus favors SGA over FGA
• Caution with benzodiazepines and anticholinergics

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• ACT (Assertive community program)
• Supportive therapy
• Living skills
• Family education
• Vocational Rehab
• Therapeutic community (CooperRiis 800-957-5155)

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Panic Disorder

• Prevalence 36 had co-occurring SUD
• 5-42 alcoholics had
  panic
• 1.7-13 with SUD had
  panic
• Panic symptoms can be seen during withdrawal or
  intoxication

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Medications Used In Panic Disorder

• SSRIS
• TCAs(Imipramine, Desipramine, Nortriptyline)
• MAOIs(Nardil, Parnate)
• Benzodiazepines(klonopin, ativan, xanax)
• Anticonvulsants(neurontin, gabitril, lyrica)
• Beta blockers(Inderal,propanolol,metoprolol)
• Baclofen

36
Considerations for Treating COD With Panic
Disorder

• Activation from SSRIs, TCAs, SNRIs
• Discontinuation Syndrome from SSRIS, SNRs
• Latency of onset with SSRIs, TCAs, SNRIs
• Risk of abuse with benzodiazepines

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Therapy

• CBT
• Relaxation training
• Diaphragmatic breathing
• Exposure therapy graduated exposure, imaginal
  exposure
• Explore interaction between anxiety and addiction
• 12 step program

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Generalized Anxiety Disorder

• Prevalence 8-21 with SUD had GAD
• 8-52.6 of alcoholics
  had GAD
• Difficult to differentiate GAD symptoms from
  withdrawal
• Excessive worry may help with diagnosis

39
Medications Used In GAD

• SSRIs
• SNRIs
• TCAs
• Buspirone (Buspar) less anxiety, fewer drinking
  days/ mixed results
• Anticonvulsants- tiagibine(Gabitril)
• Baclofen
• Second generation antipsychotics
• Benzodiazepines

40
Therapy

• CBT
• AIR
• Scheduled worry time
• 12 step program

41
Social Anxiety Disorder

• Prevalence 8-56 have co-morbid social
  phobia and alcohol use
• disorders
• - 13.9 cocaine
  dependent patients had social phobia
• - 5.9 methadone
• maintained patients
  had
• social phobia
• SAD usually precedes SUD
• SAD interferes with ability to engage in
  treatment

42
Medications Used In SAD

• SSRIs(Paxil)
• SNRIs
• MAOIs
• Benzodiazepines
• Anticonvulsants- pregabalin(Lyrica)
• Beta blockers- specific subtype
• Ondansetron(Zofran)

43
Therapy

• CBT
• Exposure
• 12 step program
• Explore interaction with addiction and treatment
• Managing Social Anxiety- Client Workbook a CBT
  Approach Debra Hope

44
Benzodiazepines In COD

• Assessing the Risks and Benefits of
  Benzodiazepines for Anxiety disorders in Patients
  with a History of Substance Abuse or Dependence
• Posternak et al,. American Journal on Addictions
  1048-68,2001

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• Risk for abuse in general population is low,
  perhaps less than 1
• Vast majority of patients take fewer BZDs than
  prescribed and take sub-therapeutic doses
• Few patients experience tolerance for anxiolytic
  properties
• Few patients increase their dose with time
• Differentiate dependence vs. abuse

46

• BZD abuse rarely occurs in isolation
• 90 of BZD abusers do so with other substances
• Drug abusers appear more likely to abuse BZD than
  patients with ETOH abuse
• There is little evidence for abuse of BZD in
  former drug abusers
• 5 large scale studies comprising over 16,000 BZD
  users do not support concerns that BZD will
  induce relapse in former substance abusers

47

• There is some evidence that BZDs reduce ETOH
  over time
• Use with caution especially in patients with
  antisocial personality
• Contraindication in former substance abusers
  lacks empirical justification
• BZDs may be indicated in certain patients with
  anxiety disorders and former SUD

48
Obsessive Compulsive Disorder

• Prevalence 3-12 of alcoholics had OCD
• Individuals using cocaine and marijuana had 5.6
  times the risk of developing OCD

49
Medications Used In OCD

• SSRIs
• Clomipramine(Anafranil)
• SNRIs
• Buspirone(Buspar)
• Second Generation Antipsychotics
• Topiramate(Topamax)
• Dopamine Agonists(Bromocriptine)
• Memantine HCL (Namenda)
• N-acetylcysteine(NAC)

50
Therapy

• CBT
• 12 step program

51
Post Traumatic Stress Disorder

• Prevalence Lifetime prevalence of 36-50 and
  current prevalence of 25-42 in patients with SUD
• Rate of PTSD was 10 times higher in SUD

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• Reexperiencing- dreams, intrusive thoughts,,
  flashbacks
• Avoidance- numbing, avoidance of thoughts or
  activities
• Hyperarousal- Sleep, hypervigilance
• Flashbacks and numbing are unique to PTSD

53
PTSD and ETOH Dependence

• Improvement in PTSD had greater affect on ETOH
  abuse than improvement in ETOH abuse had on PTSD
• Improvement in hyperarousal associated with
  improvement in ETOH abuse
• Try to address PTSD and ETOH abuse concurrently

54
Medications Used In PTSD

• SSRIs
• Anticonvulsants-lamotrigine, carbamazepine
• Prazosin
• Second Generation Antipsychotics
• Beta-blockers
• Clonidine
• Lithium
• Baclofen

55
Medications For Nightmares

• Prazosin
• Trazodone
• Atypical antipsychotics- Seroquel
• Topamax
• Low dose cortisol
• Gabapentin
• Phenelzine
• Triazolam
• Nitrazepam
• Cyproheptadine
• TCAs

56
Prazosin

• Alpha 1 adrenergic antagonist
• 1-10mg more effective than placebo in treating
• Nightmares
• Sleep
• Reexperiencing
• Avoidance
• Numbing
• Hyperarousal

57
Prazosin vs. Seroquel

• Similar for nightmares in the short term
• Superior in the long term
• Less side effects
• More likely to continue treatment
• Less expensive

58
Common Sleep Medications Used In PTSD

• Trazodone-improved sleep and decreased nightmares
• Neurontin- improved sleep and decreased
  nightmares
• Seroquel- improved sleep and decreased nightmares
• Remeron- improved sleep and decreased nightmares.
  Less side effects in PTSD vs. MDD

59
Benzodiazepines

• Less affective then other medications and may
  exacerbate PTSD symptoms
• Risk of abuse, disinhibition, memory
• Anger seen with withdrawal
• Try to avoid benzodiazepines in PTSD
• One study revealed no adverse outcomes in COD
  patients with PTSD

60
PTSD and ETOH Dependence

• Natrexone and Disulfiram had better outcomes than
  placebo
• Overall PTSD symptoms improved
• Safe in PTSD and ETOH dependence
• Disulfiram- beta hydroxylase inhibition
• Promising in PTSD and ETOH, cocaine dependence
• May help with craving and PTSD symptoms
• Topamax- Improves craving for ETOH and cocaine
• Improves PTSD symptoms
• Needs research

61
Preventative Medications In PTSD

• Inderal(propanolol)
• Morphine in wounded soldiers
• Restoril 5 day treatment

62
Other Treatment Options In PTSD

• CBT
• Exposure therapy
• EMDR
• Seeking safety
• TMS- decreased depression but no improvement in
  PTSD

63
Cognitive Behavioral Therapy

• Relaxation training
• Cognitive reframing
• Exposure therapy

64

• Triggers
• Physical response
• Cognitive response
• Behaviors

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Relaxation Techniques

• Breathing techniques
• Diaphragmatic breathing
• Progressive muscle relaxation
• Yoga
• Meditation

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Cognitive Therapy

• Monitor precipitating factors
• Monitor catastrophic thoughts
• Monitor overestimations
• Challenge evidence for catastrophic thoughts
• Replace with more accurate thoughts
• Challenge inaccurate thoughts

67

• AIR
• Awareness of thoughts
• Interrupt negative thoughts
• Replace thoughts

68

• Panic diary
• Anxiety diary
• Exposure therapy

69

• CBT
• Relapse prevention therapy
• Patients can incorporate CBT into existing
  relapse prevention techniques
• 12 steps meetings can assist with exposure
• 12 steps can be adapted to address anxiety

70
Eating Disorders

• Prevalence-
• 0-6 of patients with anorexia had ETOH Abuse
• 5-19 of patients with anorexia had SUD
• 14-49 of patients with bulimia nervosa had ETOH
  abuse
• 8-36 of patients with bulimia nervosa had SUD
• 1/3 of Patients with ETOH abuse had eating
  disorders

71
Medications Used In Eating Disorders

• SSRIs
• Topiramate
• Naltrexone

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Therapy

• CBT
• OA
• Explore interaction with addiction

73
Attention Deficit/Hyperactive Disorder

• Prevalence 33 of adults with ADHD have
  histories of alcohol use disorders and 20 have
  SUD
• 17-50 of alcoholics have ADHD
• 17-45 of SUD adults have ADHD

74
Medications Used In ADHD

• Stimulants(Adderall, Ritalin, Vyvanse, Daytrana)
• Atomoxetine(Strattera)
• Buproprione(Wellbutrin)- mixed results
• Desipramine
• Modafinil(Provigil)
• Clonidine
• Guanfacine(Tenex, Intuniv)
• Dopamine agonists
• Donepezil (Aricept)

75
Stimulants

• Methylphenidate(Ritalin) improved ADHD and
  decreased cocaine use
• Methylphenidate improved ADHD, but showed no
  change in drug use
• SR methylphenidate showed improvement in ADHD,
  but no change from placebo/ decreased probability
  for () cocaine UDS/responders had a better
  outcome than non responders
• Mariani, JJ, Levine FR Stimulant Pharmacotherapy
  in ADHD in Patients with Co-occurring Substance
  Use Disorders. Advances in ADHD 20061(2)47-52.

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Stimulants

• Use with caution
• Use delayed release formulas
• Lisdexamphetamine (Vyanse)
• Adderall XR
• Concerta
• Daytrana
• No abuse of stimulants or increase cravings for
  cocaine were reported

77

• Mariani, JJ, Levine FR Stimulant Pharmacotherapy
  in ADHD in Patients with Co-occurring Substance
  Use Disorders. Advances in ADHD 20061(2)47-52.

78

• CBT
• Organization skills
• Life coach
• Twelve Steps A key to living with ADD
  Friends in Recovery - RPI Publishing, Inc.- San
  Diego

79
Borderline Personality Disorder (BPD)

• Hazelden- Understanding BPD and Addiction
• 12 step program
• DBT
• Address thinking errors
• BPD group
• Education
• Safety plan
• SSRIs, SGAs, anticonvulsants

80
Pregnancy

• Methadone
• Buprenorphine (Suboxone)

81
Chronic Pain

• Methadone
• Buprenorphine (suboxone)
• Anticonvulsants
• SNRIs(Cymbalta, Pristiq, effexor)
• Fentanyl Patch
• Morphine Pump
• Dorsal Column Stimulator
• NSAIDs
• Acetaminophen

82
Self Mutilation

• Naltrexone

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Memory

• Memantine HCL (Namenda)
• Donepezil (Aricept)

84
Insomnia

• Trazadone
• Mirtazepine (Remeron)
• Ramelteon (Rozerem)
• Anticonvulsants
• Eszopiclone (Lunesta)
• Second Generation Antipsychotics

85
Dual Recovery Anonymous (DRA)

• World Services Central Office
• PO Box 8107
• Prairie Village, Kansas 66208
• 877-883-2332

86

• John Roberts, MD
• Medical Director
• Addiction Psychiatrist
• Pavillon
• www.pavillon.org
• [phone] Mill Spring, NC
• [phone] Greenville, SC