Truman Medical CenterBehavioral Health

Evidence Based Practices

Integrated Dual Disorder Treatment (IDDT)

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

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.

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)

IDDT

• Multidisciplinary Team• Integrated Substance Abuse Specialist• Stage Wise Treatment• Access for clients to comprehensive DD

services• Time-unlimited• Outreach• Motivational Interventions

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

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.

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.

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.

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.

Stages of Change

– Pre-contemplation-not yet considering a change

– Contemplation-acknowledges concerns; consider possible change; uncertain and ambivalent

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.

Motivational Interviewing

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

IDDT

• Interventions to Promote Health: preventative care; identification of high risk situations; physical health

• Interventions for non-responders: inpatient treatment; family intervention; hospitalization.

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

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

Medication Strategies

• Agonist– Substitute effects of drug

• Antagonist– Block the effects of drug

• Deterrent Medications (aversive)

• Reduce Drug Intake– Target cravings, reinforcement

Medication for the treatment of Addictive

Disorders and their Mechanism of Action

Tobacco Opioids Alcohol Stimulants

Partial Agonist

Verniciline Buprenorphine ?Aripiprazole

Full Agonist

Nicotine Replacement

Methodone

Receptor Modulator

Bupropiron Naltrexone Naltrexone; Acompasate; Topiramate

Modafanil; Topriamate; Disulfiram

Alcohol Dependence

• Disulfiram (Antabuse)

• Naltrexone (Revia)

• Acamprosate (Campral)

• Naltrexone IM ( Vivitrol IM)

Antabuse

• FDA Approved 1954

• MOA: Inhibits aldehyde dehydrogenase, increasing acetaldehyde.

• Evidence: So-so

• Most likely to benefit:

• highly motivated patients, directly observed patients,

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

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

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

• 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

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.

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 SAHep. C

HIV

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

Conclusion

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

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.”