CoOccurring Disorders Center for Excellence COCE

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SAMHSAs Co-Occurring Center for Excellence (COCE)
Co-Occurring DisordersMental Illness and
Substance Use Disorders2007 IHS/SAMHSA National
Behavioral Health Conference
Anthony J. Ernst, Ph.D. Director of Technology
Transfer CDM Group, Inc. SAMHSA's Co-Occurring
Center for Excellence [phone]
aj.ernst_at_cdmgroup.com www.coce.samhsa.gov/
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Prevalence Epidemiology
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The Beginning Onset of Brain Disorders (Deidre
Roach, M.D., NIAAA presentation, March, 2006)
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Addictive DisordersOften Co-Exist WithMental
Disorders
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Co-Occurrence of Serious Psychological Distress
(SPD) and Substance Use Disorders (SUD) Among
Adults Aged 18 or Older (2005 National Survey on
Drug Use and Health)
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Odds of an Alcohol-Dependent Individual Having a
Co-occurring Disorder (General Population)
DSM-IV 12-month Prevalence
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Underage Substance Abuse Emergency Department
Data Drug Abuse Warning Network (DAWN) Report,
January, 2006

• 42 ED visits for drugs and alcohol were ages
  12-20
• 18-20 year olds had 3X more Alcohol ED visits
  than 12-17

500-- 400-- 300-- 200-- 100-- 0--
12-17
461
18-20
Rate per 100,00 population
208
160
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Alcohol with Other drug(s)
Alcohol alone
http//dawninfo.samhsa.gov/files/TNDR02_underage_d
rinking_final.pdf
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Consequences of Underage Drinking NSDUH 2006

• 90 of rapes on college campuses
• 95 of violent crime on college campuses
• Potential brain impairment
• Increased risk of alcohol use disorder
• Unprotected sex
• Academic, medical, and social problems
• Alcohol related motor vehicle crashes are the
  greatest single mortality risk for underage
  drinkers. Half of drunk driving deaths involve
  drivers under 21.
• DHHS SAMHSA, A Comprehensive plan for preventing
  and reducing underage drinking, 1/2006
• http//www.stopalcoholabuse.gov/media/underagedrin
  king/pdf/underagerpttocongress.pdf

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Prevalence of Mental Illness and Substance Abuse
in American Indian Populations

• Beals et al. (2005) study of 3,084 tribal members
  (1,446 in a Southwest tribe and 1,638 in a
  Northern Plains tribe) age 15 54 years living
  on or near their home reservations
• Found both American Indian samples were at
  heightened risk for PTSD and alcohol dependence,
  but at a lower risk for major depressive episode,
  compared with the National Comorbidity Survey
  data conducted in 1990-1992
• Beals, J.et al. (2005). Prevalence of DSM-IV
  Disorders and Attendant Help-Seeking in 2
  American Indian Reservation Populations. Archives
  of General Psychiatry, 62 (1) 99-108.

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Traumatic Events and Alcohol Use Among American
Indian Adolescents and Young Adults

• Boyd-Ball et. al study (2006) interviewed 432
  adolescents and young adults who were enrolled
  tribal members. Results indicated that severe
  trauma increased the odds of alcohol use
  disorders.
• Boyd-Ball, Manson, Noonan Beals (2006).
  Traumatic events and alcohol use disorders among
  American Indian adolescents and young adults.
  Journal of Traumatic Stress, 19 (6), 937-947.
• Koss et al. study (2003) interviewed 1660
  individuals from 7 Native American tribes. High
  prevalence rates of alcohol dependence were
  associated with one or more types of adverse
  childhood experiences. For men, combined physical
  and sexual abuse. For women, sexual abuse.
• Koss, Yuan, Dightman, Prince, Polazza, Sanderson
  Goldman (2003). Adverse childhood exposures and
  alcohol dependence among seven Native American
  tribes. American Journal of Preventive Medicine,
  25 (3), 238-244.

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Alaska Native Alcohol-Related Deaths

• Existing data indicate that Alaska Native
  alcohol-related deaths are almost 9 times the
  national average, and approximately 7 of all
  Alaska Native deaths are alcohol related.
• Seale, J, Shellenberger, S. Spence, J. (2006).
  Alcohol Problems in Alaska Natives Lessons from
  the Inuit. American Indian and Alaska Native
  Mental HElath Reserach The Journal of the
  National Center, Volume 13, Number 1, 2006.
• http//aianp.uchsc.edu/ncaianmhr/journal/pdf_files
  /13(1).pdf

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The National Survey on Drug Use and Health
Report Substance Use and Substance Use
Disorders among American Indians and Alaska
Natives (January 19, 2007)

• NSDUH asks persons age 12 and older to report on
  their use of alcohol and Illicit drugs during the
  past year (N271,978 14,518 of whom were Native
  American or Alaska Native)
• In 2002-2005, American Indians and Alaska Natives
  were more likely than members of other racial
  groups to have a past year alcohol use disorder
  (10.7 vs. 7.6) as well as a past year illicit
  drug use disorder (5 vs. 2.9)
• Rates were higher among American Indians and
  Alaska Natives than among members of other racial
  groups for past year marijuana (13.5 vs.10.6),
  cocaine (3.5 vs. 2.4), and hallucinogen use
  (2.7 vs. 1.7) disorders .
• http//oas.samhsa.gov/2k7/AmIndian
  s/AmIndians.pdf

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American Indians and Suicide

• Published studies indicate that American Indians
  experience the highest rate of suicide of all
  ethnic groups in the United States.
• Olson, L Wahab, S (2006). American Indians and
  Suicide. A neglected area of research. Trauma,
  Violence Abuse, 7 (1), 19-33.
• Senate Approves Dorgan Bill (S 398) in May, 2007
  to Combat Youth Suicide, Curb Child Abuse. 
•   

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Ideal Medical Model
Identify Describe Clinical Syndrome
Understand Cause
then
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What is treatment?
Persons Attributes
Program Services (Treatment)
Program Attributes
Treatment Outcomes
Positive or Negative
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What are a persons attributes?
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Challenges to Treating Co-Occurring Disorders
Effective treatment should attend to multiple
needs of the individual.Principles of Drug
Addiction Treatment, NIDA, www.drugabuse.gov
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Whats different today about treating
co-occurring disorders?

• Rapid advances in neuroscience, evidence-based
  practices (i.e., IDDT), and medications
  development.
• Data regarding the long-term high costs
  associated with untreated mental illnesses and
  substance use disorders.
• Seminal resources such as TIP 42 and reports
  including the recent Institute of Medicine report
  on improving quality in the treatment of mental
  and substance use disorders (Nov. 2005) and the
  report on mental health from the Presidents New
  Freedom Commission (July, 2003).
• Increased recognition of cultural competence
  standards in service delivery.

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Leading to No Wrong Door Mainstream Services
Outreach Referral
Screening Assessment
Treatment
Continuing Care in the Community
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SAMHSAs Co-Occurring Center for Excellence
(COCE)

• Meetings and Conferences
• Informational Products
• Collaborative Workgroups
• Pilot Evaluation of the Performance Partnership
  Grant (PPG) Measures
• Technical Assistance and Training
• COCE Web Site WWW.COCE.SAMHSA.GOV

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Technical Assistance Categories for Constructing
a Co-Occurring Treatment System
Infrastructure
Clinical Capacity
Evaluation and Monitoring
Information Sharing
Certification and Licensure
Evidence and Consensus- Based Practices
Workforce Development and Training
Financing Mechanisms
Systems Integration
Screening, Assessment, Treatment Planning
Definitions, Terminology, Classification
Services Integration
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• Definitions

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Integrated Treatment

• Integrated treatment refers broadly to any
  mechanism by which treatment interventions for
  COD are combined within the context of a primary
  treatment or service setting.
• Integrated treatment is a means of coordinating
  substance abuse and mental health interventions
  to treat the whole person more effectively.

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Six Guiding Principles for Integrated Treatment

• Employ a recovery perspective
• Adopt a multi-problem viewpoint
• Develop a phased approach to treatment

(samhsa, 2005) NEATTC Adolescent Training Manual
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Stages of Treatment Stages of Change
Engagement Pre-Contemplation Persuasion Conte
mplation Preparation Active
Treatment Action Relapse Prevention Maintenance
Mueser, et al (2003)
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Six Guiding Principles for Integrated Treatment
(cont.)

• Address specific real-life problems early in
  treatment
• Plan for cognitive and functional impairments
• Use support systems to maintain and extend
  treatment effectiveness

(samhsa, 2005) NEATTC Adolescent Training Manual
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• Screening, Assessment Treatment Planning

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The Clinical Planning Process

• Screening

Assessment
Diagnosis
Person
Treatment Services (referral or provision)
Individualized Treatment Plan
Developing Treatment Resources
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Screening Instruments for COD COSIG Workgroup
Findings

• Mental Health
• Mental Health Screening Form-III (MHSF)-III
• Mini International Neuropsychiatric Interview
  (MINI) Screen - Modified
• Substance Abuse
• Simple Screening Instrument for Substance Abuse
  (SSI-SA)
• Dartmouth Assessment of Lifestyle (DALI) -
  Modified
• Both
• Global Appraisal of Individual Needs
  (GAIN)Combination of above especially MINI and
  DALI

(MHSF)-III user friendly in SA settings MINI
Screen Modified-best with SMI and low motivation,
important validation studies completed
SSI-SA-better with strong rapport and/or strong
desire to look at AOD use DALI-modified form
best as MH screener in SA settings GAIN-good for
both SA and MH screening and in settings that can
streamline data collection - i.e., screening,
assessment, treatment planning, outcome
evaluation.
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The Four Quadrants
III Less severe mental disorder/more
severe substance abuse disorder
IV More severe mental disorder/more
severe substance abuse disorder
High Severity
Alcohol and other drug abuse
I Less severe mental disorder/less
severe substance abuse disorder
II More severe mental disorder/less
severe substance abuse disorder
Mental Illness
High Severity
Low Severity
Adapted from Substance Abuse Treatment for
Persons With Co-Occurring Disorders, TIP 42 (2005)
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• Workforce Development Training

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Clinical Practice and the Community
Treatment Strategies
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Key Issues Providers Face inDeveloping a
Workforce

• The attitudes and values providers must have to
  work successfully with these clients.
• Essential competencies for clinicians (basic,
  intermediate, and advanced).
• Opportunities for continuing professional
  development.
• Ways to avoid burnout and reduce turnovercommon
  problems for any substance abuse treatment
  provider, but particularly so for those who work
  with clients who have COD.

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Retaining Members of the Workforce

• Factors influencing turnover
• Job autonomy
• Good communication within the program
• Recognition and rewards for performance
• Augment existing sources of satisfaction
• Onsite training builds skills and enhances
  morale
• Streamline paperwork

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• Evidence and Consensus-Based Practices

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What is an Evidence-Based Practice?

• The use of current and best research evidence in
  making clinical and programmatic decisions about
  the care of clients.
• Research evidence can be described in terms of
  levels, that reflect ranking of the strength of
  that research evidence.

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Pyramid of Evidence Based Practices in COD Type
of Design
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Center for Substance Abuse Treatment. (2005c)
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Table of Consensus- and Evidence-Based Practices
for COD
1 Also applicable to populations with
co-occurring disorders. 2 Based on Drake, R.,
ONeal, E.L., Wallach, M.A. A systematic review
of research on interventions for people with
co-occurring severe mental and substance use
disorders. Journal of Substance Abuse Treatment,
(in press).

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• Evaluation and Monitoring

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Evaluation

• Five elements are needed to design an evaluation
  process for an outpatient program that can
  provide useful feedback to program staff and
  administrators on the effectiveness or outcome of
  treatment for persons with COD. These important
  data can be used to improve programs.
• Define the operational goals of the program in
  terms of the client behaviors for which change is
  sought. Programs may define their goals for
  client change narrowly in terms of reductions in
  alcohol and drug use and crime only or more
  broadly, to include reductions in psychological
  symptoms, homelessness, unemployment, and so on.
• Decide who the study clients will be and devise a
  plan for selecting or sampling those clients.
  Depending on the rate of client entry into a
  program and the number of clients sought for the
  outcome study (typically at least 35), a program
  may select every client presenting to treatment
  over the course of a designated time period or
  may sample systematically (e.g., taking every
  third client) or randomly (e.g., using a coin
  toss). It is important to use a system that
  avoids bias (i.e., avoids the selection of
  clients who, for one reason or another, are
  believed to be more likely to respond
  particularly well or particularly poorly to the
  treatment program).

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Evaluation continued

• Locate and/or develop instruments that can be
  used to assess client functioning in the areas of
  concern for outcome. Include areas about which
  the program staff feels information is needed
  (e.g., demographic characteristics and background
  variables such as source of referral, drug use
  and criminal justice histories, education or
  employment histories, prior drug treatment,
  social support, physical and mental health
  histories, etc.). For studies generally, and for
  in-treatment studies in particular, it is also
  important to gather information about client
  retention. Indeed, a number of studies now
  suggest that length of retention is a useful
  proxy measure for understanding post-treatment
  outcomes, and that retention to 3 months in
  outpatient programs is critical for clients to
  achieve meaningful behavior change.
• Develop a plan for data collection. Information
  on client functioning can be gathered using
  selected instruments at the time of entry into
  treatment (baseline) and at intervals of 1 or
  more months from time of entry while the
  individual is in treatment. Data gathered may be
  restricted to self-report or may include
  biological markers such as urinalysis and/or data
  gathered from others knowledgeable about the
  clients functioning (e.g., family or school
  personnel). Outcome studies frequently involve
  continuing assessment after the client leaves
  treatment, then again at designated intervals
  typically, assessments at 6- to 12-month
  intervals.
• Develop a plan for data analysis and reporting.
  Data analysis may be comparatively simple,
  describing client functioning at baseline in the
  areas of concern (e.g., drug use) and client
  functioning in those same areas at times of
  assessment or follow-up alternatively, it may be
  complex, comparing client functioning in the
  areas of concern at multiple points in time and
  controlling for variables that might affect that
  functioning (e.g., prior treatment history). The
  findings obtained through data analysis are
  communicated through written and oral reporting
  to interested parties, particularly program staff
  who can use this information on program
  effectiveness to its greatest advantage (i.e., to
  improve the programs capacity to facilitate
  client change). Both the National Institute for
  Drug Abuse (NIDA) and CSAT have developed manuals
  for outcome studies designed to be conducted by
  treatment program staff. NIDAs document (1993)
  is titled How Good Is Your Drug Abuse Treatment
  Program? A Guide to Evaluation. CSATs document
  (1997b) is titled Demystifying Evaluation A
  Manual for Evaluating Your Substance Abuse
  Treatment Program.

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• Services Integration

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Services Integration

• Services integration refers to both
• The process of merging previously separate
  clinical services into a seamless and harmonious
  framework of practices at the level of the
  individual and
• The delivery of integrated treatment for clients
  with co-occurring disorders (COD) utilizing
  various techniques.

Source Adapted from Rosenthal, R. 2005.
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• Systems Integration

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Systems Integration

• Systems Integration facilitates an integrated
  response to client needs through the development
  of educational, fiscal, and regulatory
  infrastructures within States and sub-state
  entities that support integrated services for
  COD.
• Systems integration infrastructure integration,
  for example, deals with
• Clinician education
• Licensure of clinicians and programs
• Service settings
• Funding sources

Source Adapted from Rosenthal, R. 2005.
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A Vision of Fully Integrated Treatment for COD
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Ways of Achieving Integrated Care

• Differing mechanisms can be used to achieve
  integration. For example
• One clinician delivers a variety of needed
  services.
• Two or more clinicians work together to provide
  needed services
• A clinician may consult with other specialties
  and then integrate that consultation into the
  care provided.
• A clinician may coordinate a variety of efforts
  in an individualized treatment plan that
  integrates the needed services. For example, if
  someone with housing needs was not accepted at
  certain facilities, the clinician might work with
  a State-level community-housing program to find
  the transitional or supported housing the client
  needs.
• One program can provide integrated care.
• Multiple agencies can join together to create a
  program that will serve a specific population.
  For example, a mental health center, a local
  housing authority, a foundation, a county
  government funding agency, a drug and alcohol
  treatment program, and a neighborhood association
  could join together to establish a treatment
  center to serve women and children with
  co-occurring disorders.

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• Financing Mechanisms

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Funding Principles
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Funding Principles (continued)

• Plan To Purchase Together. It has been found that
  in most successful demonstration programs for
  people with co-occurring disorders, the State
  mental health agency and the State alcohol and
  drug abuse agency jointly planned and purchased
  services.
• Define the Population. Individuals with COD may
  fall into any of the four quadrants. Program
  services must target populations based on the
  severity of their mental health and substance use
  disorders, among other considerations.
• Secure Financing. The following section of this
  chapter will provide some suggestions on this
  admittedly challenging and often complex task.
• Purchase Effective Services. It is important to
  purchase services that research has shown to be
  effective. Unfortunately, COD research tends to
  focus on those with serious mental disorders. As
  a result, guidance on which strategies are most
  cost-effective in treating persons with less
  serious mental disorders and co-occurring
  substance use disorders is not readily available.
• Purchase Performance. NASMHPD NASADAD strongly
  recommend performance-based contracts that focus
  on outcomes. A programs effectiveness should be
  judged not only by how many people it serves or
  units of service it delivers, but rather by the
  level of real change it helps bring about in the
  lives of consumers who have co-occurring mental
  health and substance abuse disorders.
• Evaluate and Improve. It is essential to evaluate
  performance. Findings help providers revise
  protocols to get better results and give them a
  vital two-way channel for communicating with key
  stakeholders.

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Certification and Licensure
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Licensure and Certification of Professionals
Key Definitions

• Licensure A license is a property right of an
  individual and as a property right a license is
  backed by the laws of the State in which it is
  granted. (Shimberg Roederer, 1994) it is
  illegal for a person to practice a profession
  without meeting standards imposed by the State.
  (Schoon Smith, 2000)

Source Adapted from Kaplan, L. 2005.
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Licensure and Certification of Professionals
Key Definitions

• Certification A process established by a private
  sector body that defines standards for
  professional practice. It may prohibit the use of
  a title or designation but often does not
  restrict someone from practicing a
  profession.(Schoon Smith 2000)

Source Adapted from Kaplan, L. 2005.
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Licensure and Certification of Professionals
Key Definitions

• Difference between licensure and certification is
  that certification is voluntary, not overseen by
  a governmental body and usually does not prohibit
  someone from practicing.
• Some states use the term certified to indicate a
  license-e.g. certified independent social
  worker instead of licensed independent social
  worker.

Source Adapted from Kaplan, L. 2005.
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Information Sharing
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Overview

• For three decades the Federal government has
  required substance abuse treatment programs that
  treat patients with co-occurring disorders (COD)
  to comply with a complex set of rules that govern
  how programs can use and disclose information
  about patients.
• These rules are commonly known as
  Confidentiality Regulations.
• To govern the same activities, the Federal
  government in more recent years has enacted new
  legislation commonly called the Health Insurance
  Portability and Accountability Act (HIPAA)
  Regulations or the Privacy Rule.
• Today, many programs must comply with both sets
  of rules and in some cases State laws that
  protect the confidentiality of patient
  information.
• Programs subject to HIPAA Regulations also must
  establish and implement new written policies and
  procedures and recognize federally protected
  patients rights.

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In Closing, Co-Occurring Center of Excellence
Services (COCE)
Type
Higher Intensity Technical Assistance
Definitions, Terminology, Nosology
Approach
Main Outcome
comprehensivecollaborativeproactive
longitudinalorganizational
Services Systems Change
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Technical Assistance Available to Tribes

• On-site Technical Assistance (TA)
• Off-site TA
• COCE Products/TA Reports
• COCE Web Site Information and Resources

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COCE Website
http//coce.samhsa.gov/
Please direct TA requests to samhsacoce_at_cdmgroup.c
om Phone inquiries may be directed to the COCE
at 301-951-3369
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Other COD Resources

• Co-Occurring Dialogues Discussion List
  Membership is free and unrestricted and can be
  done by sending an e-mail to dualdx_at_treatment.org.
  
• SAMHSA Funding Opportunities www.samhsa.gov

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COCE Contact Information

• Jill Hensley, M.A., COCE Project Director
• The CDM Group, Inc.
• 7500 Old Georgetown Road
• 9th Floor
• Bethesda, MD 20814
• (p) 301-654-6740
• (f) 301-656-4012
• jill.hensley_at_cdmgroup.com
• Anthony Ernst, Ph.D., Director of Technology
  Transfer
• The CDM Group, Inc.
• 7500 Old Georgetown Road
• 9th Floor
• Bethesda, MD 20814
• (p) 301-654-6740
• (f) 301-656-4012
• aj.ernst_at_cdmgroup.com

• John Challis, COCE/NDRI Project Director Center
  for the Integration for Research Practice
  (CIRP)National Development Research
  Institutes, Inc. (NDRI)71 W 23rd Street, 8th
  FloorNew York, NY 10010(p) 212-845-4513
• (f) 212-845-4650challis_at_ndri.org
• JoAnn Y. Sacks, Ph.D., Deputy DirectorCenter for
  the Integration for Research Practice
  (CIRP)National Development Research
  Institutes, Inc. (NDRI)71 W 23rd Street, 8th
  FloorNew York, NY 10010(p) 212-845-4648
• (f) 212-845-4650
• jysacks_at_mac.com