General Addiction Assessment and Treatment Special Populations Centre for Addiction and Mental Healt

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Presentation to Pharmacy Students November 11,
2004 Overview of Addiction Concurrent Disorders
Treatment Presenter Andrea Tsanos Advanced
Practice Clinician Concurrent Disorders Service,
CAMH
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Presentation Overview

• Broad overview of non-pharmacological treatment
  programs available for clients with addiction
  problems
• II. Overview of various sub-populations in
  concurrent disorders, and the various treatment
  modalities used
• III. Treatment Philosophy and clinical issues
  encountered in treating clients with concurrent
  disorders

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I. Addictions Program Org Structure

• CAMH ADDICTIONS PROGRAM INCLUDES
• (1) General Assessment Brief Treatment Program
  (Assessment Service, Guided Self Change Program,
  Structured Relapse prevention program, Evening
  Health Program)
• (2) Special Populations Program (Women Service,
  Rainbow Service, Cocaine Service, Aboriginal
  Service, Older Persons)
• (3) Addiction Medicine Program (Addiction
  Medicine Clinic, Opiate Clinic, Nicotine
  Dependence Clinic, 501 Withdrawal Management
  Service, Medical W.M. Unit)
• (4) Concurrent Disorders Program

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Referral Procedure Wait Lists

• Self-referrals or referrals from health
  professionals.
• Intake Assessment first (1.5 2 hr assessment)
• (Wait time is 2 weeks from calling)
• (3) Recommendations collaboration on treatment
  disposition
• (4) E.g. Referral to the Concurrent Disorders
  Service Wait is 2 weeks or longer for 1st appt.
•          -Psychiatric assessment OR assessment
  with a Therapist/Psychologist
•          -Clients case is reviewed by the
  Team
•          -A treatment recommendation is
  developed
• -Treatment plan is negotiated with the client
  (and with others involved in the clients
  care).

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Substance Use Continuum of Care

• Most intensive to least
• Inpatient/residential program (21 days)
• Inpatient withdrawal management (3-7 days)
• -medical withdrawal management
• -T.L.C. (non-medical) withdrawal management
• Day Treatment (attend 9-4 p.m. for 21 days)
• Outpatient day withdrawal management
• Outpatient program (attend 1-2 x week)
• Informal drop-in contacts
• note
  Aftercare is important

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II. CDS Who we are Who We Serve...

• We are an outpatient service
• 53 staff(soft-funded staff trainees)
• Multi-disciplinary, team approach
• We serve clients with substance use problems who
  are also suffering from
• Mood disorders (such as major depression)
• Anxiety disorders (such as panic disorder or
  social phobia)
• Psychotic disorders(such as schizophrenia)
• Eating disorders (such as anorexia)
• Personality disorders (e.g. Borderline
  Personality)
• Anger problems
• Treatment duration is 6 months to 1 year

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Concurrent Disorders Service Organizational Chart
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CDS Client Characteristics Primary Problem
Substance Use
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Primary Psychiatric Diagnoses by Class
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of Psychiatric Diagnoses
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of Substance Use Diagnoses
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III. CD Treatment Philosophy

• Based on bio-psycho-social-spiritual-spiritual
  model
• Client-centred care
• Importance of working as a Team
• Integrated treatment approach (Add MH system
  links or program integration Program is
  optimal)
• Stepped-care approach
• MI Ability to work with the client where he/she
  is at
• MI Value in being collaborative, not
  prescriptive
• Belief in a Harm-Reduction approach
• Flexibility of Goal-Choice
• Goal of continued engagement

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Substance Use Treatment Goals
(1) Abstinence -cold-turkey -tapering
down -medically-assisted (e.g. Valium,
Clonadine) -outpatient vs. inpatient (2)
Reduction goal (e.g. Controlled drinking-not
everyone is a candidate!) Low-Risk Drinking
Guidelines -frequency alternate drinking
days with abstinent days -have one hour in
between alcoholic drinks -Quantity No more
than 2 standard drinks (SDs) on any one
day Men no more than 14 SDs per week
Women no more than 9 SDs per
week (3) The no-change goal Agreement to
monitor and discuss substance use Remember
goals are not static and neither is motivation
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TREATMENT MODALITIES

• Individual Therapy/Brief Frequent Contact
• Case Management
• Group Therapy (decreases isolation stigma
  gives sense of
• kinship
  belonging, power of group influence
  support--not just more cost- effective)
• Family/Couples Therapy
• Pharmacotherapy

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FAMILY MATTERS

• (1) CD Family Support Group (Research Study)
• A Concurrent Disorders Family Support Group was
  designed to meet the needs of family members of
  people with concurrent disorders.
• Randomized to a 12-session Support Group OR
  receiving a psycho-educational manual.
• (2) Family Support Groups offered in the DBT
  Clinic
• for people with Borderline Personality Disorder
  
• (1) is for clients receiving treatment in the DBT
  Clinic who can bring their family
  member/significant other to the group with them
• (2) This 2nd group is only for family members
  themselves (this is an 8-week psycho-educational
  group).

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SPECIFIC TREATMENT APPROACHES

• Self-Help/12-Step Approach
• Psycho-Education
• Motivational Interviewing (MI)
• Psycho-Education
• Structured Relapse Prevention (SRP)
• Cognitive-Behavior Therapy (CBT)
• Interactional Group Therapy (IGT)
• Social Skills Training
• Assertive Community Outreach (ACT)

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Treatment GoalsWhat can we hope for?

• Achieve goal with respect to substance use
  (reduction/abstinence)
• Reduce/eliminate the frequency and intensity of
  mental health symptoms (less re-hospitalization/c
  rises)
• Increase tolerance for negative emotions
• Increase self-care behavior
• Increase independent living
• Increase overall self-esteem, self-efficacy
• Enhance relationships (family, friends)
• Increase the overall level of functioning

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Questions?