Adolescent Substance Abuse New Strategies

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Adolescent Substance Abuse New Strategies Powered By Docstoc
					Co-occurring Psychiatric and
 Substance Use Disorders:
The Concept of Comorbidity
               Ricardo Restrepo, MD; MPH
              The Addiction Institute of NY
               St. Luke’s-Roosevelt Hospitals

VI Simpósio Internacional de Alcoologia e Outras Drogas
                   Vila Serena Bahia
 Epidemiology

 Neurobiology

 Overview of comorbidity

 Theories

 Dual diagnosis principles

 Comorbid treatment: Anxiety Disorders, Affective Disorders,
  Psychotic Disorders, and Personality Disorders

 Conclusions
            Which came first?
Psychiatric Symptoms or Substance Abuse

 In the ECA study an estimated 45 % of individuals with alcohol use disorders
 and 72% of individuals with drug use disorders had at least one co-occurring
                             psychiatric disorder
 ECA Odds Ratios of SUD’s in persons with
             Mental Illness
Mental disorder                              Odds ratio
                                (Risk for Substance Abuse Increase)
   Bipolar Disorder                                           6.6
   Schizophrenia                                              4.6
   Panic Disorder                                             2.9
   Major Depression                                           1.9
   Anxiety Disorder                                           1.7

  Epidemiologic Catchment Area (ECA) Study (Regier 1990) Regier, D. A., Farmer,
    M. E., Rae, D. S., Locke, B. Z., Keith, S. J., Judd, L. L., & Goodwin, F. K.
    (1990). Comorbidity of mental disorders with alcohol and other drug abuse:
    Results from the Epidemiologic Catchment Area (ECA) study. Journal of the
    American Medical Association, 264, 2511–2518.
 Comorbidity: Other biological factors
      contribute to Addiction

Conway KP, Compton W, Stinson FS, Grant BF. J Clin Psychiatry. 2006;67(2):247.
Reward Pathway: Comorbid activation
  from mesolimbic to mesocortical

    Prefrontal cortex
                Nucleus     tegmental
                accumbens   area
     Role of Dopamine: Comorbidity
 Psychoactive substances may 1) increase DA
  release, 2)inhibit reuptake, 3) act as DA agonist
 Acute increases in DA in both mesolimbic and
  mesocortical pathways are thought to be essential
  to the initial liking and reinforcement of drug
  taking (The Reward Pathway)
 Chronic use      Global decrease in DA
     Role of Dopamine: Comorbidity
 Corticotropin Releasing Factor (CRF) and the
  hypothalamic-pituitary-adrenal (HPA) axis (stress
 In response to drug use and more precisely, activation of
  the mesolimbic DA system, CRF and the HPA axis are
 In acute withdrawal this leads to physiological and
  psychological withdrawal
 However, increases in cortisol, CRF, NE in addition to
  neuropeptide Y, nociceptin, vasopressin are thought to
  persist weeks/months into sobriety leading to anxiety
  dysphoria that is called protracted withdrawal
Why Do Drug Abuse and Mental
Disorders Commonly Co-occur?

  Overlapping genetic vulnerabilities
  Overlapping environmental triggers
  Involvement of similar brain regions
  Drug abuse and mental illness are
   developmental disorders
 How Can Comorbidity Be Diagnosed
           and Treated?
 The health care systems in place to treat substance abuse and
  mental illness are typically disconnected, hence inefficient.
  Physicians tend to treat patients with mental illnesses, whereas
  a mix of clinicians with varying backgrounds deliver drug abuse

 Some substance abuse treatment centers are biased against
  using any medications, including those necessary to treat
  patients with severe mental disorders.

 Clinicians and researchers generally agree that broad-spectrum
  diagnosis and concurrent therapy (pharmacological and
  behavioral) will lead to better outcomes for patients with
  comorbid disorders.
Psychosocial treatment for comorbid
disorders and substance use disorders
 Single: treating the primary d/o resolved the
  other one
 Sequential: treating the primary d/o initially,
  followed by treating the other disorder
 Parallel: treating both disorders at the same time
  but in different settings
 Integrated: simultaneously treating both disorders
   What is Comorbidity and What Are Its
 When two or more disorders or illnesses occur simultaneously in
  the same person, they are called comorbid. Surveys show that
  drug abuse and other mental illnesses are often comorbid. They
  can occur at the same time or one after the other

 Three scenarios that we should consider:
   Drug abuse can cause a mental illness (Causal Effect)

   Mental illness can lead to drug abuse (Self-medication)

   Drug abuse and mental disorders are both caused by other
    common risk factors (Common or correlated causes)
Hypothesis 1: Alcohol and drug abuse can
   cause mental illness (Causal Effect)
 Galanter et al. (1988): Drug & ETOH abuse: 1/3 of patients
  receiving acute psychiatric services
 Kosten and Kleber (1988): Specific drugs/alcohol may result
  in tendency for the development of mental d/o’s
 National Institute of Drug Abuse –NIDA- (1991): Prolonged
  abuse of specific drug combinations : direct causal role/
  hasten development of psychiatric d/o’s
 Miller and Gold (1991): acute & chronic actions of alcohol &
  drugs can produce symptoms similar to psychiatric disorders
  (ie. depression, anxiety, personality disorders & psychosis)
  Hypothesis 1: Alcohol and drug abuse can
     cause mental illness (Causal Effect)
 Stimulants & cocaine: dose dependent agitation, anxiety, panic & psychosis
  during acute intoxication; depression post-withdrawal

 Hallucinogens & cannabis: psychotic symptoms

 Adverse psychiatric reactions to marijuana/THC: panic attacks, anxiety
  reactions, severe MDD, psychosis

 Chronic opiate administration: high rates of major & minor depressions

 Lysergic acid diethylamide (LSD): severe panic & anxiety reactions, bipolar
  manic disorders, schizoaffective disorders & MDD

 Irritability & anger attacks, depressed mood, and decreased social interaction
  may be seen in patients taking BZ or drinking alcohol.
  Hypothesis 2: Mental illness can cause
 alcohol and drug abuse (Self-medication)
- Drug of choice: interaction between psychopharmacologic
actions of the drug & dominant painful feelings
- Opioid abuse: powerful muting action of opioids on the
disorganizing & threatening affects of rage & aggression
- cocaine: relieves distress from depression, hypomania &
- psychopathology can alter course of any addictive disorder
- most support based on clinical experience
                                         McLellan and Druley (1977)
Case Presentation….what to do?
(Common or correlated causes)
 ID: Ms. B; 32 y/o, single, female student from Salvador.

 CC: I am depressed and hopeless after terminating my
  relationship and since I’ve not been able to find a job.
  “sometimes I cut my self to relieve the pain when I am high”

 HPI: Depressed, reports use of alcohol and other drugs including
  cocaine and heroin to relieve the depressed mood. Patient
  describes self cutting behavior since age 15 during stressful

  Past Psych Hx: 2 hospitalizations for depression and suicidal

  Past SA Hx: ETOH use since age 13, THC use since age 15,
  cocaine and heroin use since age 20
   Treating a Biobehavioral Disorder Must
    Go Beyond Just Fixing the Chemistry
                     We Need to Treat the Person
Pharmacological Treatment                    Behavioral Therapies


                Medical Services       Social Services
            Dual Diagnosis Principles
 Dual Diagnosis is an expectation, not an exception

 Successful treatment is based on empathic, hopeful, integrated
  and continuing relationships.

 Treatment must be individualized utilizing a structured
  approach to determine the best treatment. The consensus
  “four quadrant” model for categorizing individuals with co-
  occurring disorders can be a first step to organizing treatment
             Dual Diagnosis Principles
Both High Severity       Mental Illness Low Severity
                         Substance use disorder High

MI High Severity         Both Low Severity
SUD Low Severity
        Determining Level of Care
 Level I: Outpatient treatment
 Level II: Intensive outpatient treatment, including
  partial hospitalization
 Level III: Residential/medically monitored
  intensive inpatient treatment
 Level IV: Medically managed intensive inpatient
         Dual Diagnosis Principles
 Case management and clinical care (in which we
  provide for individuals that which they cannot
  provide for themselves) must be properly
  balanced with empathic detachment,
  opportunities for empowerment and choice,
  contracting, and contingent learning.
 When mental illness and substance use disorder
  co-exist, each disorder is “primary”, requiring
  integrated, properly matched, diagnosis specific
  treatment of adequate intensity.
         Dual Diagnosis Principles
 Both serious mental illness and substance
  dependence disorders are primary biopsychosocial
  disorders that can be treated in the context of a
  “disease and recovery” model. Treatment must
  be matched to the phase of recovery (acute
  stabilization, engagement/motivational
  enhancement, active treatment/prolonged
  stabilization, rehabilitation/recovery) and stage
  of change or stage of treatment for each disorder.
         Dual Diagnosis Principles
 There is no one correct approach (including
  psychopharmacologic approach) to individuals
  with co-occurring disorders. For each individual,
  clinical intervention must be matched according
  to the need for engagement in an integrated
  relationship, level of impairment or severity,
  specific diagnoses, phase of recovery and stage of
         Case Presentation part 2
 Patient and clinicians agree with an Integrated
  treating program where simultaneously both
  disorders (Comorbid treatment program) are
- Pharmacotherapy
- Psychotherapy (Intensive outpatient treatment)
- DBT, Dual dx group among others
  Pharmacotherapy and Psychotherapy in
    comorbid psychiatric disorder and
       substance abuse disorders

 Double Blind Controlled Trial Data IS ALMOST NON-EXISTENT
How do I determine if my addiction patient
  has a co-morbid psychiatric disorder?
  History of symptoms (current history may not be as
   important as past history)
  Family history
  No blood tests, physical exam, imaging studies are
  Must conduct a clinical interview
  (remember that a ‘mental status examination’ is a present-
    state assessment; the key is to get the longitudinal
    course, the natural history of the condition)
    Comorbid Psychiatric Disorder and
        Substance Use Disorder
 The following scenarios suggest an independent
  psychiatric disorder:
 - Psychiatric disturbance precedes substance use
 - Psychiatric disturbance persists following prolonged
 - Psychiatric disturbance occur in excess of those
 typically seen considering the quantity and frequency
 of substance consumption
            Comorbid Anxiety and Substance Use
 Patients with an anxiety disorder
     36% alcohol or illicit drug abuse

     26% of substance dependent pt’s: PTSD *

 Exposure to Traumatic Events Puts People at Higher Risk of Substance Use
  Disorders. Recent epidemiological studies suggest that as many as half of
  all veterans diagnosed with PTSD also have a co-occurring substance use
  disorder (SUD)
 Primary vs. secondary
          * substance use → anxiety
          * substance withdrawal → anxiety
          * anxiety → symptom relief w/ substance use
•Merikangas KR, Whitaker A, et al. Comorbidity and boundaries of affective disorders with anxiety disorders and substance misuse; results of
an international task force. Br J Psychiatry 1996; 168 (Suppl 30): 58-67
12-Month prevalence rates of drug and alcohol dependence
   in patients with anxiety disorder compared with the
                    general population

    NESARC: National Epidemiological Survey on Alcohol and Related Conditions 2004
 Treatment of Anxiety & Substance abuse
      SSRIs are the first-line therapy for anxiety disorders with Psychotherapy (CBT)
      Use of nonaddictive medications, with the exception of treating withdrawal
      Other antianxiety medications to consider in patients being treated for
       comorbid SUD: hydroxyzine, gabapentin, quetiapine
      Cravings or preoccupation w/ ETOH: naltrexone, acamprosate and disulfiram
    - popular “mainstay” of treatment, but…
    - highest abuse potential (40% of substance abusers seeking treatment)
    - concern for prescribers (abuse risk vs. trigger for relapse vs. disinhibition)
Resource : Harvard Psychopharmacology Algorithm Project Osser DN, Renner JA & Bayog (1999)
          Comorbid Mood Disorders and
            Substance Use Disorder
 Patients with an affective disorder
   32% alcohol or illicit drug abuse

 Prevalence rate of 20.5% of major depressive disorder in patients
  with alcohol dependence

 Among all Axis I conditions, bipolar disorder has the highest
  prevalence of comorbid substance use. Prevalence rates of alcohol
  or drug abuse in patients with bipolar disorder have been estimated
  to range from 21% to 58% (Brady and Lydiard 1992).
           Treatment of Mood disorders and
                     Substance abuse disorder
 SRI (Serotonin Reuptake Inhibitors) are the pharmacotherapeutic
  intervention of alcohol dependence and major depression
 Several studies have identified substance abuse as a predictor of
  poor response to lithium
 Bipolar patients with concomitant substance use disorders appear
  to have more mixed and/or rapid cycling bipolar disorder than
  patients with bipolar disorder who do not abuse substances.
  Therefore, substance-abusing bipolar patients may respond
  better to anticonvulsant medications (for example, valproate)
  than to lithium therapy.
 The optimal management of patients with comorbid
  schizophrenia and SA involves both psychopharmacology and
Principles of Addiction Medicine, 3rd Edition
Results of studies of antidepressant use in patients
with comorbid depression and alcohol dependence
                                                   Outcomes (med vs. placebo)
STUDY (N)          Medication    Average daily    Depression     Drinking
                                 dose (no wks)
Mason (28)         Desipramine   200 mg (24)      Med< plac      Med < plac
McGrath (69)       Imipramine    260 mg (12)      Med < plac     Med = plac
Cornelliuos (51)   Fluoxetine    20-40 mg (12)    Med < plac     Med < plac
Roy (36)           Sertraline    100 mg (6)       Med < plac     Med = plac
Roy-Byrne (64)     Nefazodone    460 mg (12)      Med < plac     Med = plac
Pettinati (29)     Sertraline    170 mg (14)      Med = plac     Med = plac
Moak (82)          Sertraline    186 mg (12)      Med < plac     Med = plac
Hernandez-Avila Nefazadone       413 mg (10)      Med = plac     Med < plac
Kranzler (345)     Sertraline    50-100 mg (10)   Med = plac     Med = Plac
                        New treatment strategy

Study (N)         Medication       Average daily    Depression       Drinking
                                   dose (no.wks)                     abstinence
Pettinati (170)   Sertraline and   200 mg (14)      Med              Med combination <
                  Naltrexone                        combination <    Single medication <
                                   100 mg (14)      Single           placebo
                  Single                            medication <
                  Medication                        placebo


(Double blind, placebo-controlled trial combining sertraline and naltrexone for treating co-
                      occurring depression and alcohol dependence)

Implication: Combining a medication to treat alcohol dependence (eg, naltrexone)
 with an antidepressant (eg, sertraline) with some basic psychosocial support and
 advice for both disorders can provide an aggressive approach to treating patients
               with co-occuring depression and alcohol dependence
    Comorbid Psychotic Disorder and
       Substance Use Disorder
 Patients seeking treatment for schizophrenia
   50% alcohol or illicit drug abuse
   70-90% are nicotine dependent

 Symptomatic relief
   Combat hallucinations/paranoia
   Decrease negative symptoms
   Ameliorate adverse effects of medication

 The optimal management of patients with comorbid
  schizophrenia and SA involves both psychopharmacology and
     Comorbid Psychotic Disorder and
        Substance Use Disorder

           schizophreniform disorder at
                  Percent with

                     age 26

                                          COMT genotype

Casp A, Moffitt TE, Cannon M, et al., Biol Psychiatry, May 2005
                          Cannabis and psychosis risk
                             Hypotheses linking cannabis and psychosis

Hypothesis                          Strenght of Evidence for                                                           Evidence
                                    evidence                                                                           against
Cannabis worsens                    Strong               •Cannabis is associated with                                  Cannabidiol
existing psychotic                                       increased symptoms, relapse, and                              and Δ9-THC
disorders                                                treatment nonadherence among                                  improve
                                                         those with schizophrenia                                      symptoms
                                                                                                                       in some
                                                         •Patients with schizophrenia are                              patients
                                                         more vulnerable to cannabis-                                  with
                                                         induced psychosis under                                       schizophren
                                                         experimental conditions                                       ia

Zammit S, Moore TH, Lingford-Hughes A, et al. Effects of cannabis use on outcomes of psychotic disorders: systematic review. Br J
Psychiatry. 2008;193(5):357–363 .
                          Cannabis and psychosis risk
                            Hypotheses linking cannabis and psychosis

Hypothesis                        Strenght of Evidence for                                                       Evidence
                                  evidence                                                                       against
Cannabis increases                Strong                •For patients with schizophrenia,                        Cannabis use
the risk of chronic                                     a history of cannabis use is                             is not always
psychosis among                                         associated with illness onset 2 to                       a risk factor
vulnerable                                              3 years earlier compared with                            for conversion
individuals                                             non-users.                                               to psychosis
                                                                                                                 in studies of
                                                        •Cannabis use is a risk factor for                       prodromal
                                                        conversion to psychosis in some                          schizophrenia
                                                        studies of prodromal
Large M, Sharma S, Compton MT, et al. Cannabis use and earlier onset of psychosis: a systematic meta-analysis. Arch Gen
Psychiatry. 2011;68(6):555–561
        Treatment: Comorbid Psychotic
     Disorder and Substance Use Disorder
 There are few controlled trials on the use of specific antipsychotics
  on people with psychoses and SUD, although it appears that clozapine
  (Buckley, Thompson,Way, & Meltzer, 1994) and olanzapine (Conley,
  Kelly, & Gale, 1998) have approximately equal effectiveness in
  treatment-resistant patients with and without substance abuse.

 Since people taking standard antipsychotic medication have an
  increased risk of tardive dyskinesia if they misuse alcohol, cannabis
  (Olivera, Kiefer, & Manley, 1990; Salyers & Mueser, 2001; Zaretsky et
  al., 1993) and perhaps nicotine (Yassa, Lal, Korpassy, & Ally, 1987), it
  may be especially important for these patients to be given
  medications with a lower risk of this side-effect.
      Comorbid Personality disorder and
          Substance Use Disorder
 About 40% to 50% of individuals with a substance use disorder meet
  the criteria for antisocial personality disorder (ASPD) and
  approximately 90% of individuals diagnosed with ASPD also have a
  co‐occurring substance use disorder (Messina, Wish, & Nemes, 1999).

 People with comorbid personality disorder and substance use:
   Have more problematic symptoms of substance use than those without a
    personality disorder.
   Are more likely to participate in risky substance-injecting practices that
    predispose them to blood borne viruses.
   Are more likely to engage in risky sexual practices and other disinhibited
   May have difficulty staying in treatment programs and complying with
    treatment plans.
   Treatment: Comorbid Personality
 disorder and Substance Use Disorder
 Treatment for substance use in people with personality
  disorders is associated with a reduction in substance use.

 Treatment for substance use is also associated with a reduction
  in the likelihood of being arrested, suggesting a reduction in
  criminal activity.

 Psychotherapy is the treatment of choice for personality
  disorders but be aware of pharmacological agents available to
  help with comorbidity
            Evidence-Based Practices
 Motivational Enhancement Therapy (MET)- Initiate and maintain
 Cognitive Behavioral Therapy (CBT)- make and identify the cause and
  consequences of changes
 Dialectic Behavioral Therapy (DBT) (Borderline Personality d/o)
 Exposure Therapy (anxiety d/o-Phobia and PTSD)
 Integrated Group Therapy (IGT) (Bipolar d/o and SA)
 Twelve Step Facilitation (TSF)- help to sustain changes
 Other considerations:
   Managing Medications
   Involving the Family
   Encouraging participation in group/individual therapy
  Avoid These group of Medications for
Treatment of Substance Abuse disorders
Choosing a pharmacological agent include paying particular
  attention to potential toxic interaction of the medication with
  drugs and alcohol


 Opiates

 Barbiturates

 Stimulants

 Short Acting BZDs

 Tricyclics (metabolism, cardiac conduction)
   When to consider Pharmacotherapy
Consider Precipitant To Treatment And Severity of Associated
  Medical/Psychiatric/Psychosocial Problems

     Family
     Employment
     Financial
     Medical
     Legal
     Psychiatric comorbidity (including risk for harm to self or others)
     Relapse Potential

 The higher the acuity or severity; greater need for use of
  medication treatment (if there is an appropriate
  medication intervention available)
      When to consider Pharmacotherapy
Indications: To treat psychiatric disorders and minimize potential relapse to
    substance use.
   Any Primary/Endogenous Psychiatric Disorder
   Any Psychosis or mood disorder irrespective of whether drug-induced or
    primary (e.g., antipsychotics, mood stabilizers, antidepressants)
   Secondary anxiety or mood disorders - If there has been clear, lasting, and
    severe past episodes that led to impaired function.
   Psychiatric Disorders that last more than 4 weeks after drug/alcohol use
    *May need detoxification to ascertain psychiatric diagnosis
   Can use psychopharmacotherapy with other medications used to
    promote/maintain abstinence (e.g., methadone, acamprosate)
Pharmacology Treatment (Medications)
 Pharmacotherapies that benefit multiple problems:
   Bupropion -----depression and nicotine dependence, might also help
    reduce craving and use of the drug methamphetamine

 Pharmacotherapies for Nicotine Dependence:
   Nicotine Substitution (Agonist Therapy): Nicotine
    polacrilex gum, Transdermal nicotine patch, Nicotine
    nasal spray

   Bupropion

   Varenicline (nicotine partial agonist)
Pharmacology Treatment (Medications)

 Pharmacotherapies for Alcohol dependence (Relapse
   Naltrexone (oral and injectable)
   Disulfiram
   Acamprosate

 Pharmacotherapies for Opiate Addiction
   Methadone (Can’t use outside of a registered narcotic treatment
   Buprenorphine
   Naltrexone
    Pharmacology Treatment (Medications)
            Alcohol Typologies
                                                  • Abstinence rates during a
                                                    14-week treatment trial
                                                    with sertraline 200 mg

                                                  • Sertraline helped Type A
                                                    (Late-Onset) alcoholics
                                                    stay abstinent (P=0.004),
                                                    but not Type B (Early-
Adapted from: Pettinati HM, Volpicelli JR, Kranzler HR, Luck G, Rukstalis MR, Cnaan, A: Sertraline
treatment for alcohol dependence: Interactive effects of medication alcoholic subtype. Alcohol Clin
Exp Res 24:1041-1049, 2000
 TIP 42 Substance Abuse Treatment For Persons With Co-
  Occurring Disorders Inservice Training based on Treatment
  Improvement Protocol (TIP) 42 Substance Abuse Treatment
  For Persons With Co-

 NIDA (National Institute of Drug

 SAMHSA (Substance Abuse & Mental Health Services
 Identify the need of your patients to get treatment

 Addiction and psychiatric disorders are treatable brain diseases

 Research is edifying the biological mechanisms involved

 Increased understanding of neurobiology is allowing for the
  development of effective, targeted pharmacotherapies and

 Comorbidity disorders are multifactorial, be ready for relapses

 Pharmacotherapy and psychotherapy modalities are effective and
  scientifically based approaches

 Prevention is based on screening and early Intervention
THANKS! Gracias! Obrigado!

  Questions? Comments?

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