Quick Guide

1
Quick Guide

• For Clinicians
• Based on TIP 9Assessment and Treatment of
  Patients With Coexisting Mental Illness and
  Alcohol and Other Drug Abuse

2
What is a TIP?

• The TIP series provides the substance abuse
  treatment and related fields with
  consensus-based, field-reviewed guidelines on
  substance abuse treatment topics of vital current
  interest.
• This presentation is based on TIP 9 Assessment
  and Treatment of Patients With Coexisting Mental
  Illness and Alcohol and Other Drug Abuse (see
  last slide for ordering information).
• For more detailed information, readers are
  referred by page number to the publication
  mentioned above.

3
Introduction

• Treatment needs of patients who have a
  psychiatric disorder in combination with a
  substance abuse disorder differ significantly
  from the treatment needs of patient with either a
  substance abuse disorder or a psychiatric
  disorder by itself.
• Clinicians must discriminate between psychiatry
  and substance abuse disorders by obtaining a
  thorough history of symptoms and disorders.
• See TIP 9, pp.1-3.

4
Dual Disorders

• Concepts and Definitions
• For more information, see TIP 9, pp.3-7.

5
Relationships Substance Abuse and Psychiatric
Symptoms and Disorders

• Substance abuse may mask psychiatric symptoms,
  complicating the diagnostic process.
• Terminology of dual disorders
• MICA mentally ill chemical abusers
• MISA mentally ill substance abuser
• CAMI chemical abuse and mental illness
• SAMI substance abuse and mental illness

6
Relationships

• Patients with mental disorders have an increased
  risk for substance abuse disorders, and
• Patients with substance abuse disorders have an
  increased risk for mental disorders.

7
Signs Symptoms of Dependency/Addiction

• Pathologic, often progressive and chronic
  process.
• Compulsion and preoccupation with obtaining a
  drug or drugs.
• Loss of control over use or substance
  abuse-induced behavior.
• Continued use despite adverse consequences.
• Tendency for relapse after period of abstinence.
• Increased tolerance and characteristic
  withdrawal.

8
Components of Drug Dependence1

• Psychologic dependence centers on the users
  need of a drug to reach a level of functioning or
  feeling or well-being.
• Physical dependence refers to the issues of
  physiologic dependence, establishment of
  tolerance, and evidence of an abstinence
  syndrome, or withdrawal upon cessation of
  substance abuse.
• 1 American Society of Addiction Medicine.

9
Symptoms Substance Abuse

• Significant impairment or distress resulting from
  use.
• Failure to fulfill roles at work, home, or
  school.
• Persistent use in physically hazardous
  situations.
• Recurrent legal problems related to use.
• Continued use despite interpersonal problems.

10
Medication Misuse

• Describes the use of prescription medications
  outside of medical supervision or advice.
• Not an abuse problem, it is a high-risk behavior.
• May or may not involve or lead to substance
  abuse.
• May promote the reemergence of psychiatric
  symptoms.
• May cause toxic effects and psychiatric symptoms
  if it involved overdose.

11
Mental Health and Addiction Treatment Systems

• For more information, see TIP 9, pp.9-17.

12
Similarities of Mental Health and Addiction
Treatment Systems

• Variety of treatment settings and program types.
• Public and private settings.
• Multiple levels of care.
• Biopsychosocial models.
• Increasing use of case and care management.

13
Mental Health and Addiction Treatment Systems

• Potential pitfall is prescribing psychoactive
  medications to psychiatric patient without first
  determining if the individual has a substance
  abuse disorder.
• In treating dual disorders, a balance must be
  made between behavioral interventions and
  psychiatric medications as needed for the
  recovery process.

14
Treatment Models

• Sequential patient is treated by one system
  (addiction or mental health) and then by the
  other.
• Parallel simultaneous involvement of the patient
  in both mental health and addiction treatment
  settings.
• Integrated combines elements of both mental
  health and addiction treatment into a unified
  program for patients with dual disorders.

15
Critical Treatment Issues for Dual Disorder
Treatment

• Treatment engagement initiating and sustaining
  patients participation.
• Treatment continuity between treatment programs
  and treatment components.
• Comprehensiveness includes collaborative
  integrated programs.
• Treatment phases detoxification, subacute
  stabilization, and long-term stabilization.
• Continual reassessment and rediagnosis involves
  collaboration across multiple systems.

16
Mood Disorders

• For more information, see TIP 9, pp.30-42.

17
Mood Disorders

• Most common psychiatric diagnosis among patients
  with a substance abuse disorder.
• More prevalent among patients using methadone and
  heroin.
• Depression is common over the first months of
  sobriety whose symptoms may fade over time.
• Mood disorder symptoms may be related to acute
  withdrawal symptoms from substances adequate
  time should lapse prior to diagnosis of an
  independent mood disorder.

18
Substances That Precipitate or Mimic Mood
Disorders

• Depression and Dysthymia
• During use (intoxication) alcohol,
  benzodiazepines, opioids, barbituates, cannabis,
  steroids (chronic), stimulants (chronic).
• After use (withdrawal) alcohol, benzodiazepines,
  barbituates, opiates, steriods (chronic),
  stimulants (chronic).

19
Substances That Precipitate or Mimic Mood
Disorders

• Mania and Cyclothymia
• During use (intoxication) stimulants, alcohol,
  hallucinogens, inhalants (organic solvents),
  steroids (chronic, acute).
• After use (withdrawal) alcohol, benzodiazepines,
  barbituates, opiates, steroids (chronic).

20
Stages of Assessment

• Assessing danger to self or others
• Medical assessment
• Initial addiction assessment
• Social assessment
• Violence towards others
• Assessing mood symptomatology
• Medical assessment
• Psychiatric and addiction screening
• Assessment instruments
• Psychosocial assessment

21
Acute Treatment Strategies

• Management of intoxication and withdrawal
• Medical treatment
• Psychiatric treatment

22
Subacute Treatment Issues

• Matching patients and treatment
• Psychiatric medications
• Case management
• Counseling and psychotherapy for depression
• Levels of care
• Family involvement in treatment settings
• Professional and vocational planning
• AIDS and HIV risk reduction

23
Long-Term Treatment Goals

• Addiction treatment
• Psychiatric treatment
• Long-term treatment needs
• Family issues
• Eating disorders and gambling

24
Anxiety Disorders

• For more information, see TIP 9, pp.46-50.

25
Substance-Induced

• Never assume anxiety symptoms or
  depersonalization are related to substance abuse.
• Substance-induced conditions
• Panic
• Phobias
• Posttraumatic stress disorder
• Obsessive-compulsive disorder

26
Anxiety

• Most common symptom of people with substance
  abuse disorders.
• Treatment of mild anxiety can be postponed to see
  if it resolves as addiction treatment progresses.

27
Long-Term Treatment

• Medications are not a substitute for addiction
  treatment.
• Cognitive-behavioral techniques are often as
  effective as medications, but generally take
  longer to achieve an equivalent response in the
  treatment of anxiety disorders.
• For dual diagnosis patients, psychotherapy has
  significant advantages over substance abuse
  counseling alone, and can be incorporated into
  the substance abuse treatment.

28
Anxiety Treatment

• Can be postponed unless anxiety interferes with
  substance abuse treatment.
• Anxiety symptoms may resolve with abstinence and
  substance abuse treatment.
• Affect-liberating therapies should be postponed
  until the patient is stable.
• Psychotherapy, when required, should be recovery
  oriented.

29
Anxiety Treatment

• Nonpsychoactive medications should be used when
  medications are needed.
• Antianxiety treatments such as relaxation
  techniques can be used with and without
  medications.
• A healthy diet, aerobic exercise, and avoiding
  caffeine can reduce anxiety.

30
Personality Disorders

• For more information, see TIP 9, pp.53-73.

31
Personality Disorders

• Rigid, inflexible, and maladaptive behavior
  patterns of sufficient severity to cause
  significant impairment in functioning or internal
  stress.
• If a personality disorder coexists with substance
  abuse, only the personality disorder will remain
  during abstinence.
• Substance use often relates to the disorder to
  diminish symptoms, to enhance low self-esteem, to
  decrease feelings of guilt, and to amplify
  feelings of diminished individuality.

32
Most Challenging to Treat

• Antisocial personality disorder, which involves a
  history of chronic antisocial behavior that
  begins before the age of 15 and continues into
  adulthood.
• Borderline personality disorder, which is
  characterized by unstable mood and self-image,
  and unstable intense, interpersonal
  relationships.
• Narcissistic personality disorder, which
  describes a pervasive pattern of grandiosity,
  lack of empathy, and hypersensitivity to
  evaluation by others.
• Passive-aggressive personality disorder, which
  involves covertly hostile but dependent
  relationships.

33
Key Issues and Concerns

• Patient contracting may involve a patients
  promise to avoid certain self-harm or high-risk
  behavior.
• Transference and countertransference both rely on
  the mechanism of projection, a combination of
  personal past experiences along with feelings
  experienced during the course of therapy.
• Clear boundaries are ethical and practical ground
  rules that help a therapist to be therapeutically
  helpful to patients.

34
Key Issues and Concerns

• Changing roles of people with personality
  disorders may include the victim, the
  persecutor, and the rescuer.
• Resistance involves patients with personality
  disorders who often exhibit acting-out behaviors
  that were developed as psychological defenses and
  survival techniques.
• Subacute withdrawal may include mood swings,
  irritability, impairment in cognitive
  functioning, short- and long-term memory
  problems, and intense craving for substances.

35
Key Issues and Concerns

• Symptom substitutions are compulsive behaviors
  that includes eating disorders, compulsive
  spending, gambling, and sex.
• Somatic complaints therapists should watch for
  use of prescription and over-the-counter drugs
  and for drug-seeking behaviors.
• Therapist well-being can be compromised when
  working with patients with personality disorders.
  Therapists should join or develop support
  systems with others in the field.

36
Borderline Personality Disorder

• Therapist should engage patient by
  acknowledging/joining the patients need for
  safety.
• Assessment should include history of substance
  abuse and mental health treatment, suicidal
  planning, dissociative experiences, psychosocial
  history, history of sexual abuse, and a history
  of psychotic thinking. Could require a
  neurological examination.
• Avoid psychodynamic confrontations with patient.
• Long-term care may include individual counseling,
  group therapy, 12-step participation, and the
  continuum of care.

37
Antisocial Personality

• In engaging the patient, it is useful to join
  with the patients world view.
• Assessment should include a thorough family
  history, including a sexual history that includes
  questions about animals and objects. Other topics
  should be bonding, parasitic relationships, head
  injuries, fighting, and being hit.
• Avoid angry confrontations since patients may
  engage in dangerous physical behavior to avoid
  unpleasant situations or activities.
• Long-term care includes individual counseling,
  group therapy, and the continuum of care.

38
Narcissistic Personality Disorder

• To engage, therapeutically address patient traits
  such as hypersensitivity, need for control, rage,
  and depression.
• Assessment should include survival
  skills/self-care, monitor use of OTC drugs,
  treatment provider history, psychosocial and
  substance abuse history, medication evaluations
  for antidepressants, and identification of
  typical passive-aggressive maneuvers of patient.
• Several issues, such as responses to abusive
  relationships, obtaining safe housing, and
  receiving emergency psychiatric admissions for
  suicidal crises must be managed by the therapist.
• Long-term care may include individual counseling,
  group therapy, 12-step participation, and the
  continuum of care.

39
Coordination of Care

• Maintaining ongoing contacts is essential for all
  patients with personality disorders.
• Issues to remember in coordination of care
• Primary case manager
• Legal issues
• Managed care
• Funding issues
• Staffing and cross-training
• Medical issues
• Integration into 12-step self-help groups

40
Psychotic Disorders

• For more information, see TIP 9, pp.76-85.

41
Psychotic Disorders

• Stimulant-Induced Symptoms
• Acute stimulant intoxication (chronic) can cause
  symptoms of psychosis. Included are delirium,
  delusions, prominent hallucinations, incoherence,
  and loosening of associations. Stimulant
  delirium often includes formication (a tactile
  hallucination of bugs crawling on or under the
  skin).
• Depressant-Induced Symptoms
• Acute withdrawal from alcohol, barbiturates, and
  benzodiazepines can produce a withdrawal
  delirium, especially with heavy use and high
  tolerance due to a concomitant physical illness.
• Psychedelic- and Hallucinogen-Induced Symptoms
• Psychotic symptoms are possible in chronic,
  high-dose patterns due to virtue of drugs
  stimulant properties. Can cause hallucinogenic
  hallucinosis, characterized by perceptual
  distortions, maladaptive behavioral changes and
  impaired judgment.

42
Engaging the Chronically Psychotic Patient

• Noncoercive Engagement Techniques
• Assistance obtaining food, shelter, and clothing
• Assistance obtaining entitlements and social
  services
• Drop-in centers as entry to treatment
• Recreational activities
• Low-stress, nonconfrontational approaches
• Outreach to patients community
• Coercive Engagement Techniques
• Involuntary commitment
• Mandated medications
• Representative payee strategies

43
Pharmacological Management

• For more information, see TIP 9, pp.91-97.

44
Pharmacologic effects

• Therapeutic effects include indicated purposes
  and desired outcomes such as a decrease in the
  frequency and severity of episodes of depression
  produced by antidepressants.
• Detrimental effects include unwanted side
  effects, such as dry mouth or constipation
  resulting from antidepressant use.

45
Dual Disorder Patients

• Special attention should be given to detrimental
  effects, in terms of
• Medication compliance
• Abuse and addiction potential
• Substance abuse disorder relapse
• Psychiatric disorder relapse

46
Pharmacologic Risk Factors

• Psychoactive Potential
• Not all psychiatric medications are psychoactive.
• Psychoactive medications can cause acute
  psychomotor effects and a relatively rapid change
  in mood or thought.
• Reinforcement Potential
• Some drugs promote reinforcement or increased
  likelihood of repeated use.
• Can occur by either the removal of negative
  symptoms or conditions, or the amplification of
  positive symptoms or states.
• Involves strengthening that a certain behavior
  will be repeated for reward and satisfaction, as
  with drug-induced euphoria.
• Tolerance and Withdrawal Potential
• Long-term or chronic use can cause tolerance to
  therapeutic effects and dosage increases to
  recreate desired effects.
• Drugs that promote tolerance and withdrawal
  generally have higher risks for abuse and
  addiction.

47
Prescribing Medication

• High-risk patients should include a benefit
  analysis that considers
• The risk of medication abuse.
• The risk of undertreating a psychiatric problem.
• The type and severity of the psychiatric problem.
• The relationship between the psychiatric disorder
  and the substance abuse disorder for the
  individual patient.
• The therapeutic benefits of resolving the
  psychiatric and substance abuse problems.

48
Nonpharmacologic Approaches

• Psychotherapy
• Cognitive therapy
• Behavioral therapy
• Relaxation skills
• Meditation
• Biofeedback

• Acupuncture
• Hypnotherapy
• Self-help groups
• Support groups exercise
• Education

49
Antihistamines

• Frequently prescribed for mild anxiety and
  insomnia.
• Exert mild anxiolytic and hypnotic effects, lack
  euphoric properties, and do not promote physical
  dependence.
• High doses can cause acute delirium, alter mood,
  or cause morning-after depression.
• Patients in recovery should be discouraged from
  purchasing and using OTC antihistamines.

50
Antidepressants

• Effective for treatment of depression, anxiety
  disorders, including generalized anxiety
  disorder, phobias, and panic disorder.
• They are not euphorigenic and do not cause acute
  mood alterations.
• Some exert a mild sedating effect, while others
  exert a mild stimulating effect.
• Anticholinergic effects include dry mouth,
  blurred vision, constipation, urinary hesitancy,
  and toxic-confusional states.
• Adrenergic activation symptoms may include
  tremor, excitement, palpitation, orthostatic
  hypotension, and weight gain.

51
ß-Blockers

• Used to treat hypertension, cardiac arrhythmias,
  and angina pectoris.
• Cant be used for extended periods of time due to
  the rapid tolerance of anti-panic effects.
• These drugs are consistent with a
  psychoactive-drug-free philosophy, does not
  compromise recovery from addiction, and can be
  important adjunct to anxiety management.

52
Benodiazepines

• Promote sedation, central nervous system
  depression, and muscle relaxation.
• Effective for anxiety reduction and short-term
  management of insomnia.
• Use of these drugs after the medical management
  of withdrawal is not consistent with a
  psychoactive-drug-free philosophy and may
  compromise recovery from addiction.
• However, they can be used in the management of
  acute and severe withdrawal, panic, and psychosis.

53
Buspirone

• Useful for generalized anxiety disorder, chronic
  anxiety symptoms, anxiety with depressive
  features, and anxiety among elderly patients.
• Is not psychoactive, mood altering, or
  euphorigenic.
• Is consistent with a psychoactive-drug-free
  philosophy, and does not compromise recovery from
  addiction.
• Enhances recovery from anxiety disorders.

54
Clonidine

• Used for treatment of symptoms of hypertension,
  including hypertensive symptoms that occur during
  withdrawal of depressant drugs, especially
  opioids.
• May be useful for short-term use in the treatment
  of refractory anxiety with panic.
• This drug is consistent with a psychoactive-drug-f
  ree philosophy and does not compromise recovery
  from addiction.
• May be an adjunct in the treatment of anxiety
  symptoms.

55
Neuroleptic (Antipsychotic) Medications

• Most effective in suppressing the positive
  symptoms of psychosis such as hallucinations,
  delusions, and incoherence.
• May help reduce disturbances of arousal, affect,
  psychomotor activity, thought content, and social
  adjustment.
• Many can cause sedation as a side effect, but
  adaptation develops within days or weeks.
• These drugs allow patients who often experience
  significant biopsychosocial problems to engage in
  problem-solving and recovery-oriented
  interpersonal activities.

56
Lithium

• Initial symptoms managed by Lithium include
  increased psychomotor activity, pressured speech,
  and insomnia.
• Later it diminishes the symptoms of expansive
  mood, grandiosity, and intrusiveness.
• Common adverse effects include thirst, urinary
  frequency, tremor, and gastrointestinal distress.
• Allows patients who may have seriously disabling
  symptoms to engage in problem-solving and
  recovery-oriented interpersonal activities.

57
Anticonvulsants

• Have a role in the management of bipolar
  disorders, mania, schizoaffective disorder, and
  alcohol and benzodiazepine withdrawal.
• Typical side effects such as sedation and nausea
  may emerge as treatment is initiated.
• These medications are consistent with a
  psychoactive drug-free philosophy, and may
  enhance the abilities of those who need them to
  participate in the recovery process.

58
Ordering Information

• TIP 9 related products
• TIP 9 Assessment and Treatment of Patients With
  Coexisting Mental Illness and Alcohol and Other
  Drug Abuse
• KAP Keys for Clinicians based on TIP 9
• Quick Guide for Clinicians based on TIP 9
• To obtain free copies
• Call SAMHSAs National Clearinghouse for Alcohol
  and Drug Information (NCADI) at 800-729-6686, TDD
  (hearing impaired) 800-487-4889
• Visit CSATs Web site at www.csat.samhsa.gov

59
Disclaimer

• Do not reproduce or distribute this presentation
  for a fee without specific, written authorization
  from the Office of Communications, Substance
  Abuse and Mental Health Services Administration,
  U.S. Department of Health and Human Services.