New visions in community mental health: Substance abuse treatment in the community

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New visions in community mental healthSubstance
abuse treatment in the community

• University of Nebraska Medical Center
• 11/11/04
• Bert Pepper, MD

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Treating tobacco, alcohol, drug abuse, and mental
health problems in the community

• Avoiding trans-institutionalization from mental
  hospitals to jails and prisons

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Greeting to workers injails prisons

• Congratulations!!
• You now work in a
• Mental Hospital
• Full of
• Drug Addicts

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The Life Cycle
BeginHere
ImmatureYoungAdult
EarlyAlcohol/Substance Abuse
Poor SocialVocation Skills Cognitive
BehavioralProblem
Child(Un-Parented)
Next Generation
The AdultCycle
ImpulsivityViolentPsychosis
CommunityReturn
Doing Time LittleTreatmentContinued S.A., ALC
In The CriminalJustice System
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Recent cocaine use among female juvenile
detainees, N132

• 14 admitted to ever using
• 9 admitted to use in past 90 days
• 6 admitted to use in past 3 days
• 8 had urine positive 3 day window
• 32 had hair positive 90 day window

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D.C. Juvenile Arrestees and Drug use, by age,
May, 1995

• Below 13 42
• 14..52
• 15..60
• 16..74
• 17. 75

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Three Approaches to Substance Abusers and the
Justice System

• Diversion before incarceration at
• arrest
• arraignment
• sentencing
• Treatment during incarceration
• Treatment and supervision after release

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What drugs endanger the community?

• Tobacco disables and kills the most
• Alcohol comes next
• Marihuana is next, especially for adolescents
• Ecstasy and heroin are growing in importance
• Cocaine is diminishing
• Inhalant abuse, in selected populations, is
  devastating

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Untreated emotional disorders in children and
youth greatly increase the risk of secondary
substance abuse developing. Co-occurring
disorders are more disabling and harder to treat
than either one alone.
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Public policy

• Children are the future of our society
• We should have policies in place to nurture and
  protect them, while supporting traditional and
  non-traditional families

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A Common SequenceTroubled Adolescents

• 1.Trauma (physical, sexual, psychological,
  emotional) or neglect in childhood
• 2. Early emotional problems
• 3. Personality immaturity or disorder
• 4. Self-medication with AOD
• 5. School family problems
• 6. Criminal justice involvement

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What adolescents in residential SA Tx say

• I had many troubles, but after I was sent to
  inpatient,
• No one asked my opinion about my treatment
• My mental health emotional problems were
  ignored
• My family was left out of my treatment

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What adolescents in residential SA Tx say

• But I had emotional problems before I had a drug
  problem.
• Ten focus groups, 110 adolescents recently in
  residential SA TX. Federation of Families

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The changed state of childhood 1960-90

• Kids born to unmarried moms 5...28
• Kids under 3 with one parent 7..27
• Parents divorced before 18 1..50
• Mom working with kid lt1 1753
• Married mom works, kidslt6 1960

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Individuals Living as Couples Without Being
Married

• 1970one million
• 1997-eight million
• Step-parents are likelier to abuse children than
  biological parents, and
• Unmarried couples are less likely to stay together

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Childhood physical abuse and adult drug use,
Iowa, 1993

• 13 who abused no drugs were physically abused
  before age 18
• 26 of those who abused one drug were abused
• 55 of those who abused two drugs were abused
• 90 of those who abused three or more drugs were
  physically abused before 19

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U.S. youth are the target market, because the
worlds drug wholesalers see them as Willie
Sutton saw the banksWhy do you rob banks?
Because thats where the money is
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Why focus on dual disorders?

• Because the commonest cause of psychiatric
  relapse is substance use/abuse
• And
• The commonest cause of relapse to drugs and
  alcohol is untreated depression, mood disorder,
  panic/anxiety, and psychosis

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Chronic pot use can cause psychosis

• Swedish researchers studied drugs of abuse, not
  including cocaine. Marijuana stood out
• A small percentage of young pot smokers developed
  schizophrenia
• There was a linear correlation with dosage
• Some recovered with abstinence, some did not

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Marijuana use in youth in 2000

• Data from the National Household Survey on DA
• Over 3 M youth between 1217 used at least once
• This is 13 of 23M
• 1825 24
• 26 5

• Whites more often than black, Hispanic, or Asian
• Youth averaging D or less 4x likelier than those
  with A average

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Pot use increases risk of depression

• Re-interviews of 2,000 ECA subjects in 96
• Pot smoker were 4 times as likely to be depressed
  on follow-up, compared to non- smokers
• They were also likely to be anhedonic and
  suicidal
• Am. J. Psychiatry G. Bovasso, PhD 12/2001

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Maternal smoking during pregnancyNegative
effects on children

• Marked gender differencesIf a women smokes 10 or
  more cigarettes/ day during pregnancy
• Girls risk for adolescent drug abuse
• increased by more than 500
• Boys risk of conduct disorder increased by more
  than 400
• Research at Harvard/Mass. GeneralHospital found
  an association betweenprenatal smoking and ADHD.

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Genetics of Alcohol Dependence

• Genetic factors account for 4060 of risk
  remainder is socialenvironmental
• No single gene controls
• Adoption studies strongly indicate a genetic
  factor among males Risk is 2.6 times greater
  for boys with a family history

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Genetics of Alcohol Dependence

• 5 of 5 studies of boys agree
• Situation less clear for girls, but higher risk
  probable
• In contrast, 40 of sons of dependent fathers
  had lower biological and subjective reactions to
  first drink, compared to
• 10 of sons of non-dependent fathers

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One thing leads to another

• Caffeine to tobacco to alcohol to marijuana to
  ecstasy to heroin to cocaine
• The longer we delay the beginning use of any of
  these substances, the better the chance of
  preventing abusive use of any/all of them later on

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More alcoholics die from tobaccothan from alcohol

• Mayo Clinic followed 845 alcoholics for 10-20
  years after inpatient care. 75 smoked
• Death rate was 200 of the expected rate
• 34 died of alcohol-related illnesses.
• 51 died of smoking-related illnesses.
• Can we ignore tobacco in SA prevention
• and treatment?

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Continuum of Abuse

• experimentation
• recreational use
• habitual use
• abuse
• dependence
• and the younger one starts at the top, the
  quicker one gets to the bottom.

Dose
Frequency
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Cerebral Atrophy, Age Years of Problem Drinking,
and Age of Onset of Problem Drinking in 50
Patients
From Alcoholism and Cerebral Atrophy A study of
50 Patients with CT Scan and Psychological
Testing by John Luisin, M.D., Sheldon Zimberg,
M.D., Alcoholism Clinical and Experimental
Research, Vol 4., No, 4. (October) 1980
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Six Effects of Drugs on the Brain and on the Mind

• SubIntoxication
• Intoxication
• Post-Intoxication recovery
• Residual effects on brain function
• Brain damage
• Impact on personality development.

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S.A. treatment began with AA

• Historically, psychiatry regarded alcohol abuse
  as a symptom of a character disorder that
  required psychotherapy. Ineffective.
• 1930s AA began Self-help. Anonymous because of
  stigma. Abstinence required.
• Other addictions followed with their own 12
  Step programs NA, OA, GA, SA.

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When did funded SA Tx begin?

• Not until the 1980s, when poly-substance abuse
  became a problem for each state thats when
  state government reorganizations began.
• But new funding streams - federal and state- were
  hard to come by competition with other, already
  established human services was fierce. And stigma
  continues.

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What Tx formats developed?

• Detox Medical and social. Medical almost gone
• Residential rehab- 28 days- Hazelden- almost gone
• Partial and outpatient of various intensities
• Case management
• Therapeutic community

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What are the conflicts in philosophies in SA Tx?

• Drug free v. medicated (e.g., methadone)
• Abstinence v. Harm Reduction
• Professional, trained staff using evidenced-based
  treatments v. staff in recovery helping from
  their own recovery experience.

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Goals of Substance Abuse Treatment Harm
reduction perspective

• Reduction or elimination of use
• Participation in the legitimate economy
• Improved personal, family relationships
• Reduction or elimination of illegal activities
• Reduced frequency of slips, relapses
• When possible, eventually, abstinence

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Harm reduction and stages of recovery

• (Prochaska and di Clementi)
• Pre-contemplation
• Contemplation
• Action
• Relapse prevention
• N.B. Get ahead of the clients stage, and you
  lose them unless tx is involuntary

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National Co-morbidity Survey -1990 Ron
Kesslerand Preventing Substance Abuse

• Stratified sample of U.S. population
• 8, 000 individuals interviewed, 15-55
• CIDI, modified, WHO approved, used
• All positives were re-interviewed
• The gold standard of epi studies of MH-SA
• Replicated and expanded in 2000-2001
• New data due in 2004 U.S. and world

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National Co-morbidity Survey-1990- Kessler

• 48 of respondents reported at least one lifetime
  disorder29.5 had at least one past year
  disorder.
• Major depressive episode10 an episode in the
  past year.17 lifetime. Women gt men.
• Lifetime alcohol abuse 14.Past year7 Men gt
  women
• Lifetime, at least one anxiety disorder25
• Past year17. Simple and social phobias were
  commonest.

Source February, 1994 Kessler, et al. in
Archives of General Psychiatry
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NCS

• Between 8-11 million have at least 1 mental
  health and 1 substance-related disorder
• 89 developed mental illness first-
• 9 developed substance abuse first
• Median age of onset
• Mental Illness - 11
• Substance Abuse - 17-21

Source February, 1994 Kessler, et al. in
Archives of General Psychiatry
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The take home prevention message There is a
Window of opportunity

• for preventing substance abuse, by focusing on a
  high risk group kids with anxiety, depression,
  ADHD, and conduct disorder.
• But if we dont help them as children, we will
  meet them in jail as adolescents with
  co-occurring disorders

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NCS

• 79 of all lifetime disorders occurred among
  persons reporting two or more disorders

Source February, 1994 Kessler, et al. in
Archives of General Psychiatry
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NCS

• 14 of respondents had 3 or more lifetime
  disorders. They collected
• 54 of all lifetime disorders,
• 59 of all past year disorders, and
• 89.5 of all past year severe disorders

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The take home prevention message

• If you have no disorder, thats great!
• With one disorder, if you stay in treatment and
  recovery, you can have a life

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The take home prevention message

• With two disorders, its hard to keep life going
  on an even keel
• With three or more disorders a high likelihood
  of being disabled, unemployed, and labeled SMI

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Ten Common Personality Immaturities (Pepper)

• Low frustration tolerance
• Cant wait for a deferred goal
• Lying to avoid punishment, guilt
• Conflict between autonomy and dependency,
  resulting in hostile dependency

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Ten Common Personality Immaturities P. 2

•  Limit testing
• Dualistic, no contextual judgments, leading to
  all or none. No moderation
•  Present tense only behavior not based on past
  experience or future expectations
• Denial a. Of unpleasant but necessary duties
  b. Time to stop playing, having fun

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Ten Common Personality Immaturities, P.3

• Rejection sensitive a, Cant say no b. Seeks
  approval by promising too much
• Alexithymia

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Alexithymia

• A without
• Lex words, language for
• Thymia feelings (from the Latin)
• Described by Peter Sifneos in 1972, it refers to
  difficulty knowing, expressing ones
  feelings/emotions.
• More common in men may cause acting out

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Alexithymia P. 2

• Interferes with self-soothing
• Makes it difficult to ask for help
• Can lead to violence against self or others

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Alexithymia Antidote
Blissful
Demure
Distasteful
Hurt
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A Model for Personality Development The Maze
Conflict or Problem
More mature, Competent person
Gravity
It is the RESOLUTIONof problems and
conflictsthat leads to maturationof personality
drug intoxication
Evasion Loop
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A SociogramIntensities of Relationships
1
2
3
4
5
6
6. Strangers5. Acquaintances4. Casual
friends3. Good friends 2. Circle of intimacy1.
Private self
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The NIDA Principles of Drug Addiction Treatment

• No single treatment is appropriate for all
  individuals.
• Treatment needs to be readily available.
• Effective treatment attends to multiple needs of
  the individual, not just his or her drug use.
• An individuals treatment and services plan must
  be assessed continually and modified as necessary
  to ensure that the plan meets the persons
  changing needs.
• Remaining in treatment for an adequate period of
  time is critical for treatment effectiveness

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The NIDA Principles of Drug Addiction Treatment

• 6. Counseling (individual and/or group) and other
  behavioral therapies are critical components of
  effective treatment for addiction.
• 7. Medications are an important element of
  treatment for many patients, especially when
  combined with counseling and other behavioral
  therapies,
• 8. Addicted or drug-abusing individuals with
  coexisting mental disorders should have both
  disorders treated in an integrated way.
• 9. Medical detoxification is only the first stage
  of addiction treatment and by itself does little
  to change long-term drug use.

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The NIDA Principles of Drug Addiction Treatment

• Treatment does not need to be voluntary to be
  effective.
• Possible drug use during treatment must be
  monitored continuously.
• Treatment programs should provide assessment for
  HIV/AIDS, hepatitis B and C, tuberculosis and
  other infectious diseases, and counseling to help
  patients modify or change behaviors that place
  themselves or others at risk of infection.
• Recovery from drug addiction can be a long-term
  process and frequently requires multiple episodes
  of treatment.

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Treatment approaches to interactive co-occurring
disorders

• No treatment worst!
• Treat one disorder bad!
• Sequential treatment bad!
• Parallel treatment not as bad
• Collaborative treatment better
• Integrated treatment Best!

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A definition ofIntegrated Treatment (I.T.)

• The design and provision of a long-term,
  time-phased treatment plan using a planned
  sequence of of techniques
• They are
• Titrated in intensity,
• Responsive to the many changing symptoms and
  disorders of the patient.
• May be provided by a cross-trained clinician or
  team

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Public Health Levels of Prevention

• Primary Prevention Keep the first disorder from
  developing e.g., vaccination
• Secondary Prevention Acute treatment, to prevent
  chronicity and disability
• Tertiary Prevention Long-term treatment and
  support for chronic, often disabling disorders

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The costs of prevention levels

• Primary prevention cheapest per person
• Secondary prevention Expensive short-term per
  person, but can avoid long-term costs
• Tertiary prevention (Care of the chronic,
  disabled patient) Most expensive

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Vertical Horizontal Service Integration