Cooccurring Disorders: The Zaxis Complexities of CoOccurring Conditions Conference June 2004 Washing

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Co-occurring DisordersThe Z-axisComplexities
of Co-Occurring Conditions ConferenceJune
2004Washington, DC

• Richard Saitz MD, MPH, FACP, FASAM
• Clinical Addiction Research and Education Unit
• Section of General Internal Medicine
• Center to Prevent Alcohol Problems Among Young
  People
• Boston University and Boston Medical Center

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Outline

• What we mean by comorbidity
• Conceptual framework
• Risk for co-occurring disorders
• Services not currently coordinated
• MH/SA impact care for chronic medical conditions
• Models of care for patients with co-occurring
  disorders
• Research directions

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Comorbidity
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Case 1

• A 40 year old man is transferred from a group
  home to the general medical hospital with
  diabetic ketoacidosis he stopped taking his
  antipsychotic. He refuses insulin because he
  believes it will harm him. After initial
  treatment he stabilizes but cannot return to his
  home because he wont take insulin. He is too
  medically complex for the psychiatric hospital
  and is declined by addictions treatment programs.
  He remains in the medical hospital where
  consultation for MH conditions is available.

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Case 2

• A 54 year old man with Type 2 diabetes has
  alcohol dependence. He has poor glycemic control
  and severe hypertriglyceridemia. His alcohol use
  limits medication choices he is on maximal doses
  of oral agents. He takes his lipid lowering
  medication once instead of twice a day to avoid
  drinking and taking medication. He declines
  alcoholism treatment.

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Outline

• What we mean by comorbidity
• Conceptual framework
• Risk for co-occurring disorders
• Services not currently coordinated
• MH/SA impact care for chronic medical conditions
• Models of care for patients with co-occurring
  disorders
• Research directions

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Service Coordination by Severity
Integration
Alcohol, Tobacco Other Drug Severity
Collaboration
Consultation
Mental Illness Severity
Adapted from SAMHSA 2002 Report to Congress on
the Prevention and Treatment of Co-occurring
Substance Abuse and Mental Disorders
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Service Coordination by Severity
Integration Hospital, ED
Alcohol, Tobacco Other Drug Severity
Collaboration
Primary Health
Consultation
Mental Illness Severity
The Z-axis
Medical Severity
Medical Specialty
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Outline

• What we mean by comorbidity
• Conceptual framework
• Risk for co-occurring disorders
• Services not currently coordinated
• MH/SA impact care for chronic medical conditions
• Models of care for patients with co-occurring
  disorders
• Research directions

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Alcohol-related Emergency and Hospital
Utilization, US

• Emergency
• 29 visits/1000 persons each year
• 8 of all ED visits
• Hospital
• 7.4 of acute admissions to short-stay,
  non-Federal general hospitals
• 1.8 million hospitalizations per year

McDonald AJ et al. Arch Intern Med 2004 164 531
- 537. Smothers BA et al. Arch Intern Med 2003
163 713 - 719.
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Alcohol-related Diagnoses, AAFsPulmonary and other respiratory tuberculosis
0.25 Malignant neoplasm of lip, oral cavity,
and pharynx 0.50 Malignant neoplasm of
esophagus 0.75 Malignant neoplasm of stomach
0.20 Malignant neoplasm of liver and
intrahepatic bile ducts0.15 Malignant neoplasm
of larynx 0.50 Diabetes mellitus
0.05 Essential hypertension 0.076
Cerebrovascular disease 0.065 Pneumonia
and influenza 0.05 Diseases of esophagus,
stomach, and duodenum 0.10 Cirrhosis of liver
without mention of alcohol 0.50 Biliary
cirrhosis 0.50 Acute pancreatitis
0.42 Chronic pancreatitis 0.60
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Medical Disorders More Common in Patients with
Substance Use Disorder, Psychotic Disorder, and
Both

• Diabetes
• Hypertension
• Heart Disease
• Asthma
• Gastrointestinal Disorders
• Skin Infections
• Malignant Neoplasms
• Acute Respiratory Disorders

highest risk in those with both Dickey B et al.
Psych Services 200253(7)861-7.
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Comorbidity in a Detoxification Sample

• 470 adults with no primary medical care in a
  short-term residential detoxification unit, mean
  age 36
• 47 had chronic medical illness
• 90 had CES-D score 16
• 70 reported moderate to severe pain at least
  intermittently during 2 years of follow-up
• Intermittent pain associated with relapse (OR
  2.0)
• Persistent pain associated with relapse (OR 5.2)

DeAlba I et al. Am J Addictions
20041333-45. Larson MJ et al. CPDD Abstract
2004. Saitz R et al. HSR 200439(3)587-606.
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Mertens JR et al. Arch Intern Med 2003 163 2511
- 2517.
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Outline

• What we mean by comorbidity
• Conceptual framework
• Risk for co-occurring disorders
• Services not currently coordinated
• MH/SA impact care for chronic medical conditions
• Models of care for patients with co-occurring
  disorders
• Research directions

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Patients in Addiction Treatment not Receiving
Medical Care, and Vice Versa

• Of 5,824 adults entering addiction treatment in
  Massachusetts, 41 had no physician
• Prior substance abuse treatment or mental health
  treatment were not associated with having a
  physician
• Of those with a primary care physician, 45
  reported the physician unaware of their addiction

Saitz R et al. Substance Abuse
199718187-195. Saitz R et al. Am J Drug Alcohol
Abuse 199723343-354.
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Patients with Severe Mental IllnessWhere are
they? Medical Care
Bosworth HB et al. Psych Services 2004
June55708-10.
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Outline

• What we mean by comorbidity
• Conceptual framework
• Risk for co-occurring disorders
• Services not currently coordinated
• MH/SA impact care for chronic medical conditions
• Models of care for patients with co-occurring
  disorders
• Research directions

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Quality of Diabetes Care
Desai MM et al. Am J Psychiatry 2002159(9)
1584-90.
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Alcohol Use and Incident Diabetic Retinopathy
Howard AA et al. Ann Intern Med.
2004140(3)211219.
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Catheterization and Revascularization after
Myocardial Infarction
Druss BG et al. JAMA 2000 283 506 - 511.
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Influence of Mental Health and Addictions on
Hepatitis C Therapy

• 154 patients with HIV, alcohol abuse, hepatitis C
• 81 (53) had contraindications to interferon
• 52 heavy drinking
• 15 had CD4
• 14 IDU with needle sharing
• 14 decompensated liver disease
• 13 recent suicidal ideation
• 54 (35) had lesser contraindications to
  interferon
• 47 had significant depressive symptoms
• 8 Had CD4 100-200
• 7 were drinking alcohol (moderate amounts)
• 7 IDU

Nunes et al. Abstract at CPDD 2004
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Substance use, Depressive symptoms, and HIV
Outcomes

• Prospective cohort study of 350 adults with HIV
  and alcohol problems
• Depressive symptoms and substance use were
  associated with worse adherence
• Substance use was associated with less HIV viral
  load suppression
• Substance abuse treatment
• reduced the odds of ED utilization (AOR 0.5)
• increased the odds of HAART for HIV (AOR 1.70)
• not associated with 30-day HAART adherence or HIV
  viral load suppression

Palepu A et al. J Subst Abuse Treat
20032537-42 and Palepu et al. Addiction
200499361-8
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Major Depression in Patients with Myocardial
Infarction
Frasure-Smith N et al. JAMA 1993270(15)1819-1825

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Treating Major Depression in Patients with
Myocardial Infarction

• Randomized, clinical trial
• 2,481 men and women hospitalized with MI and
  depression (75) or lower perceived social
  support (25)
• CBT and group therapy for 6 months
• Results
• Improvements in depressive symptoms and perceived
  social support
• No difference in 24 death or recurrent MI

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Outline

• What we mean by comorbidity
• Conceptual framework
• Risk for co-occurring disorders
• Services not currently coordinated
• MH/SA impact care for chronic medical conditions
• Models of care for patients with co-occurring
  disorders
• Research directions

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The teachable moment

• Definition naturally occurring health events
  thought to motivate individuals to spontaneously
  adopt risk-reducing health behaviors
• Smoking cessation
• Pregnancy, hospitalization and disease diagnosis,
  high (10-78)
• Clinic visits (2-10) consistently lower

McBride CM et al. Health Educ Res
200318(2)156-70
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Integrated Primary Care and Addiction Treatment

• Overall sample trend towards higher costs and no
  difference in abstinence
• Subgroup with substance abuse-related medical or
  psychiatric conditions
• --More likely to be abstinent in integrated care
• group (69 vs. 55, p0.006)

Weisner C et al. JAMA 20012861715-23.
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Integrated Medical and Alcoholism Care

• Randomized trial of a thorough multidisciplinary
  evaluation, and care plan (N101)
• Monthly primary care visits to review drinking
  and medical problems
• Mental health, social services and more intensive
  alcohol treatment on site
• 2-year results
• 30-day abstinence increased from 47 to 74
• Mortality decreased from 30 to 19

Willenbring ML Olson DH. Arch Intern Med
19991591946-52 Willenbring ML et al. J Stud
Alcohol. 199556337-343
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Potential Impact of Buprenorphine Treatment in
Primary Care

• Initial experience with 37 patients (30 max. at
  any one time). Median age 31.
• 68 had no previous primary medical care
• 59 had medical comorbidity
• 43 had Hepatitis C (a quarter of these diagnosed
  at entry)
• 54 had psychiatric comorbidity (80 with no
  psychiatric care)
• 86 retained in care 4 months

Alford DP et al. SGIM Abstract 2004.
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What is Primary Care?

• Integrated and accessible health services
  provided by primary care clinicians (generally
  MD, NP, PA)
• Addresses the majority of health care needs
• Sustained personal relationship between patient
  and clinician
• Does not consider mental health separately from
  physical health
• Intrinsic to PC are opportunities to promote
  health and prevent disease

Institute of Medicine. Primary Care Americas
Health in a New Era. National Academy Press,
Washington, DC. 1996.
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Receipt of Primary Care Improves Addiction
Severity
Saitz et al. Submitted.
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Care for People with Drug Abuse or Dependence
Laine C et al. JAMA, May 2001 285 2355 - 2362.
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Chronic Disease Management

• 1,801 older adults with depression or dysthymia
  in 18 primary care clinics
• Mean 3 chronic conditions
• 20 minute educational video, booklet, visit with
  nurse or psychologist case manager in primary
  care, with medical and psychiatric consultation
  as needed
• Results Significant reduction in depressive
  symptoms, functional impairment, and arthritis
  pain and functional outcomes (for the 1001 with
  arthritis)

Lin EHB et al. JAMA 2003 290 2428 - 2429
Unützer J et al. JAMA 2002 288 2836 - 2845
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Outline

• What we mean by comorbidity
• Conceptual framework
• Risk for co-occurring disorders
• Services not currently coordinated
• MH/SA impact care for chronic medical conditions
• Models of care for patients with co-occurring
  disorders
• Research directions

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Research Agenda

• Prevalence of co-occurring MH/SA disorders and
  medical disorders
• Impact of one medical/MH/SA disorder on the
  incidence, severity, quality of care and health
  outcomes of others
• Development and testing of new models of care
  that
• bring needed care to the patient with triple
  diagnosis
• can address comorbidity in the face of varied
  levels of severity of comorbidities
• Identify and overcome barriers to implementation

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Thank You for Your Attention
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Extra Slides
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Alcohol-related diagnosesAAFs1
Alcoholic psychoses Alcohol dependence syndrome
Nondependent abuse of alcohol Alcoholic
polyneuropathy Alcoholic cardiomyopathy
Alcoholic gastritis Alcoholic fatty liver
Acute alcoholic hepatitis Alcoholic cirrhosis
of liver Alcoholic liver damage, unspecified
Excessive blood level of alcohol Accidental
poisoning by ethyl alcohol, not elsewhere
specified
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Cardiac Catheterization after Myocardial
Infarction
Druss BG et al. JAMA 2000 283 506 - 511.
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Revascularization after Myocardial Infarction
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Preventive Care Mammography

• Older women with schizophrenia
• 62 in past 2 years
• Age-matched controls
• 86 in past 2 years

Dickerson FB et al. Psych Services 200253882-4.
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Alcohol Use and Diabetes

• Incident diabetes
• 18 prospective cohort studies U-shaped
  relationship
• Glycemic control
• 6 experimental studies of up to 6 drinks given to
  5-20 subjects with diabetes
• 3 found decreases in serum glucose
• 3 found no difference each
• Diabetes medications
• In 2 studies, immediate glycemic response to
  3-drink challenge did not differ
• 23 subjects taking troglitazone or placebo
• 50 subjects before and after sulfonylurea

Howard AA et al. Ann Intern Med.
2004140(3)211219.