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									Substance Abuse Services in
    Psychiatric Settings
       Best Practice
    Recommendations

    Joseph Parks, MD
   2005 Hospital Summit
    General Approach – Many Small
               Actions

   Presentations of published literature
   Analysis of hospital data
   Building alliances with Substance
    Abuse Treatment Community
   Building consensus
   Writing a guideline came last
               Messages
1.   Substance Abuse/Dependence is a
     major cause of program admissions
2.   Our programs aren’t assessing and
     managing it well or at least could
     do better
3.   It’s our job to do it well as long as
     they are with us
4.   Here’s how
        National CoMorbidity Survey
                        1991

Random sample of 8089 persons aged 15 yr. – 54 yr

   Lifetime prevalence –
    Addictive Disorders   26.6%
    Psychiatric Disorders 21.4%
    Both Simultaneously 13.7%

   12 month prevalence with both   2.7%
                CoMorbidity Survey
Most Severely Impaired Persons Have Multiple Disorders


# Psychiatric or
Addiction Disorders                  % of Population

     None                                  52%
     Any                                   48%
     One                                   21%
  Two or More                              27%
  Three or More                            14%

  53.9% of the total psychiatric and addiction
  disorders occur in the 14% with three or more
  disorders.
  Epidemiologic Catchment Area Study

Among Persons with Mental Disorder
       29% have an addictive disorder
        22% alcohol disorder
        15% other drug disorder
       2.7 times more likely than general population


Among Persons with Addictive Disorders
       alcohol disorders    36.6% have mental disorde
                             2.3 times more likely
       Other drug disorders 53% have mental disorder
                             4.5 times more likely
    CoMorbidity in Psychiatric
            Setting
                         % with
                         Substance
Diagnosis                Abuse Disorder

Depression                   30%
Bipolar                      50%
Schizophrenia                50%
Anxiety                      30%
Phobia                       23%
Antisocial Personality       80%
      Compared to Non-Addicted Psychiatric
                   Patients
       Addicted Psychiatric Patients Have


   Earlier on-set of psychiatric illness

   More severe symptoms

   More social impairment
           CoMorbidity in
       Substance Abuse Setting

                              % with
                          Psychiatric Syndrome

Alcohol Treatment         10 – 70%
Drug Treatment            40-70%

Lower rates are from studies attempting to exclude
  substance-induced psychiatric syndromes
  Lifetime Risk of Psychiatric
Disorder by Substance Abused
             (ECA)
                                     Increased Risk
                     Lifetime         Relative to
Substance       Prevalence of any      General
Abused               Mental Disorder   Population

Alcohol             36.6%                 2.3
Cocaine             76.1%                11.3
Opiates             62.5%                 6.7
Sedatives           74.7%                10.8
Hallucinogens       69.2%                 8.0
     Compared to Non-Depressed
 Alcoholics Depressed Alcoholics Have

   Earlier 1st episode of outpatient treatment
   Earlier 1st episode of hospitalization
   More hospitalizations, longer lengths of
    stay inpatient
   More blackouts
   More legal problems
   More polysubstance abuse
   The same relapse rate
Psychiatric Clinics of N. Am. Vol. 13 #4 pp. 613-633 Dec 1990
    MacArthur Foundation Research
    on Mental Illness and Violence
Study Design
   1136 men and women age 18-40 discharged
    from psychiatric hospital
   Follow up interview of person and collateral every
    10 weeks for 1 year
   Comparison group of non-hospitalized persons
    from same neighborhood
   3 sites: Kansas City, Missouri
             Worchester, Massachusetts
             Pittsburg, Pennsylvania
  MacArthur Foundation Research
   on Mental Illness and Violence


  Continuum of Violence Overall

Non-MI/Non-SA = MI/Non-SA <Non-Mi/SA < MI/SA
            CPS/ADA OVERLAP
        by Program Episode File
             ADA Clients   CPS Clients
              in CPS        in ADA

One Day          5%           11%
One Year        10%           14%
Ever            24%           31%
Diagnosed       13%           10%
           FIRST ADMISSION TO ADULT ACUTE
                INPATIENT SERVICE FY97
                      Top Discharge Diagnoses Axis 1-1
SEMMHC                  MMMHC                 MSLPC                    WMMHC

Major Depression        Major Depression      Schizophrenia            Major Depression
(100)                   (118)                 (178)                    & Bipolar (136)
Adjustment              Alcohol Related       Major Depression         Alcohol Related
Disorder (77)           Problems (103)        (108)                    Problems (107)
Bipolar Disorder        Substance Abuse       Substance Abuse          Substance Abuse
(65)                    (91)                  (103)                    (87)
Alcohol/Substance       Adjustment            Alcohol Related          Adjustment Disorders
Abuse (48)              Disorders (85)        Problems (100)           (78)

Psychotic Disorders     Bipolar Disorders     Bipolar disorders (97)   Schizophrenia
(45)                    (78)                                           (67)
Schizophrenia           Schizophrenia         Psychotic Disorders      Substance Dependence
(39)                    (30)                  (84)                     (57)

Alcohol Induced         Psychotic Disorders   Adjustment disorders     Psychotic Disorders
Psychosis (39)          (26)                  (59)                     (37)

Mood Disorders          Anxiety, OCD and      Anxiety, OCD and         Drug Induced
NOS                     Dysthymic Disorders   Dysthymic Disorders      Psychosis (28)
                        (17)                  (21)
                             FY01
                      Facility Summary
Diagnosis                      Discharges   % of Total   Days of Care   % of Total
                                            Discharges                  Days


Mental Illness Only              3,815         45.8         56,577         51.4
                                                          (155 beds)
Substance Abuse Only             1,824         21.9        14,201          12.9
                                                         (38.9 beds)
Primary Substance Abuse           539          6.5          4,003          3.6
and Secondary Mental Illness                              (11 beds)


Primary Mental Illness and       1,474         17.7        16,403          14.9
Secondary Substance Abuse                                (44.9 beds)


No Axis I Diagnosis               136          1.6          1,477          1.3
                                                          (4.1 beds)
No Discharge Diagnosis            548          6.6         17,466          15.8
Available                                                (47.9 beds)
        CONCLUSION

All mental health (and Substance
Abuse) Programs are Dual Diagnosis
Programs…

Some are just in denial.
Missouri Best Practice Initiatives on
       Co-Occurring SA/MI

   Screening (3 times)

   Acute Psychiatric Hospital

   Long Term Inpatient

   Community
    Hospital Task Force Charge

   Conduct survey and analysis needs
   Review current programming
   Review research and expert opinion
    to identify best practices
   Recommend changes
    Hospital Task Force Membership


   Co-chairs, Psychiatrist (MH) and SA
    Psychologist
   2-3 staff from each hospital
   ADA division treatment head
   2 SA community providers
   Multi-disciplinary – MD, PhD, RN,
    MSW, SA Counselors
        Chart Review - Method

   3 Acute Hospitals
   40 charts at each
    • 20 primary diagnosis SA
    • 20 secondary diagnosis SA
   Jointly reviewed by General Adult
    Psychiatrist and Psychologist specializing
    in Substance Abuse.
       Chart Review - Results

   Admissions were appropriate
   LOS was often longer than necessary
   Assessment of current SA and
    history was inadequate
   Diagnosis was sloppy
        Chart Review Results

   Persons admitted were beyond the
    capabilities of SA treatment
    programs to manage
   Substance abuse interventions were
    inadequate
   Assessment and intervention for
    trauma and abuse was inadequate.
Staff attitude was major obstacle


        “It’s not our mission”

          “It’s not my job”
    Public Sector Mission

To Care for Persons whose behavior
is so dangerous or socially
unacceptable that their communities
cannot tolerate their presence and
no other entity can or will work with
       Public Sector
     Admission Criteria

The facility or program is the
least inappropriate currently
available.
 Role of Acute Psychiatric Hospital
1.   Universal screening for substance use
     disorder of all persons presenting
2.   For persons admitted, assessment of
     substance use disorders sufficient to plan
     and provide for initial management and
     referral.
3.   Modified medical detox.
4.   Brief focused interventions to increase
     motivation, to accept referral and
     continue to treatment.
5.   Appropriate referral to ongoing
     treatment in the community.
 Best Practice Recommendations for
Substance Use Disorder Services Acute
        Psychiatric Hospitals


All persons presenting for evaluation
should be screened for substance
use disorder risk using the CAGE
questionnaire while in the emergency
room admitting area.
 Best Practice Recommendations for
Substance Use Disorder Services Acute
        Psychiatric Hospitals


All persons presenting should be
screened for alcohol use or
intoxication using hand-held
breathalyzer while in the emergency
room admitting area.
 Best Practice Recommendations for
Substance Use Disorder Services Acute
        Psychiatric Hospitals




All persons admitted should receive
substance abuser assessment
covering the content from the ASI
substance use history module.
 Best Practice Recommendations for
Substance Use Disorder Services Acute
        Psychiatric Hospitals

All persons admitted should have urine
screening for drugs of abuse.

(In recent published research, 20% of patients
who deny substance abuse are found to have
positive urine screens and of these, half of the
physicians evaluating them did not suspect it.
 Best Practice Recommendations for
Substance Use Disorder Services Acute
        Psychiatric Hospitals

All acute inpatients should have access
and be encouraged to attend a substance
abuse prevention group education
 • Increased risk of persons with mental illness for
   developing substance use disorders
 • The impact of substance use disorders on the course of
   common mental illnesses
 • The addictive potential of various drugs of abuse
 • Refusal skills training.
 Best Practice Recommendations for
Substance Use Disorder Services Acute
        Psychiatric Hospitals

Persons with a substance use disorder
should receive individual substance abuse
counseling
 • once a day
 • 15 to 30 minutes
 • use motivational interviewing techniques
 • done by a qualified substance abuse counselor.
 Best Practice Recommendations for
Substance Use Disorder Services Acute
        Psychiatric Hospitals



   Persons with substance use
   disorders should have access to
   and be encouraged to attend 2 group
   interventions a day.
   Best Practice Recommendations for
 Substance Use Disorder Services Acute
          Psychiatric Hospitals
         Information group
 Done by any trained staff

 Topics

  • What is addiction
  • What is abuse and dependence
  • How mental illness effects addiction
  • What are the medical consequences of
    addiction
   Best Practice Recommendations for
 Substance Use Disorder Services Acute
          Psychiatric Hospitals
              Process group
 Done by
    • A qualified substance abuse counselor
   Use a motivation enhancement therapy
   Topics
    •   Triggers to relapse
    •   Relapse prevention
    •   Coping skills
    •   Refusal skills and other social skills
 Best Practice Recommendations for
Substance Use Disorder Services Acute
        Psychiatric Hospitals



Detox practice guidelines should be
developed and adopted for alcohol,
opiates, and for stimulant use.
 Best Practice Recommendations for
Substance Use Disorder Services Acute
        Psychiatric Hospitals

A chart quality assurance review protocol
should be used at each facility

 • Adequate assessment
 • Accurate Diagnosis using DSM
 • Appropriate referral
 Best Practice Recommendations for
Substance Use Disorder Services Acute
        Psychiatric Hospitals



CPS acute facilities should meet the ADA
certification guidelines for modified
medical detox.
 Best Practice Recommendations for
Substance Use Disorder Services Acute
        Psychiatric Hospitals



CPS acute facility staff should receive
additional training and education on the
assessment and management of
substance use disorders and dual
diagnosis
 Best Practice Recommendations for
Substance Use Disorder Services Acute
        Psychiatric Hospitals

The divisions of ADA and CPS in DMH
should require by contract that their
community treatment programs provide
immediate access to substance abuse
treatment services for people referred
from CPS acute facilities and should make
appropriate dual diagnosis programming
available.
              Training
   Diagnosis of Abuse and Dependence
   Models of Addiction
   Dual Diagnosis
   Motivational Interviewing
   12 Step Model
   S A interview techniques
   Efficacy of S A Treatment
      Other Supporting Actions

   Sponsor American Association of
    Addiction Psychiatry Review Courses
   Funded Addiction Psychiatry
    Fellowship
   Proposed budget request for SA
    counselors
    Screening Best Practices
A. Defined minimum acceptable
   screening questions for:
  • SA in MI treatment settings
  • MI in SA treatment settings
B. May be an independent triage prior
   to assessment or embedded in the
   assessment process
C. Mandated content – not a particular
   form or format
Principles for Treatment
          Programs

     MI or SA
Accept that in
practice you treat
Dual Diagnosis
Resolve Do It Well
           How to Do it Well
   Identify the degree to which “the
    other” disorder interferes with good
    outcomes in your clients

   If “the other” program isn’t available
    or not doing a good job, learn to do
    it in-house as long as they are in
    house
                Introduction
   Within the DMH system of the future,
    there will be no specialized "Dual
    Diagnosis Programs" or "Co-Occurring
    Disorders Programs." Given our
    population, all CPS and ADA programs
    must be prepared to effectively treat this
    population.

   The goal, therefore, is to enhance existing
    programs and services to better meet the
    needs of persons with co-occurring
    disorders and persons who are survivors
    of trauma.
         DMH Vision
All state-funded mental health and
substance abuse programs and
services will include co-occurring
substance abuse and mental
disorders as an expectation in
program design, development of
program standards, and monitoring
of clinical outcomes and quality
indicators. Specifically:
         DMH Vision (cont’d)
1.   Psychiatric facilities, programs,
     and services for the seriously and
     persistently mentally ill will include
     staff trained in the treatment of
     substance abuse disorders along
     with appropriate individual, group,
     and family counseling and
     education directed at substance
     abuse issues.
         DMH Vision (cont’d)
2.   Mainstream substance abuse
     programs and services will
     include qualified mental health
     diagnosticians, cross-trained
     clinicians, and appropriate
     medications for persons with less
     severe mental illness whose
     chances of successful treatment
     and recovery are significantly
     enhanced by access to
     psychotherapy and medication
     management.
            Implementation
   Establish Standards of Care
   Obtain Support for Enhanced
    Programming
   Enhance Staff Skills
   Enhance Programs
        Standards of Care
      DMH Practice Guidelines
PRACTICE GUIDELINES FO RTHE TREATMENT OF ADULTS WITH CO-
            OCCURRING SUBSTANCE USE DISORDERS
                   AND MENTAL ILLNESS




                        September, 2002

  http://www.dmh.mo.gov/homeinfo/pracguid/trngcodisorders.pdf
                                          Standards of Care
               High                        Quadrant Model
              Severity


                                                    IV
                               III
                                             Locus of Care:
                         Locus of Care:
                                           Joint alcohol/drug
Substance Use Disorder

                            Alcohol/
                                              and mental
                          drug system
                                             health systems




                                I                 II
                         Locus of Care:     Locus of Care:
                         Primary health     Mental health
                          care settings        system



               Low                                               High
              Severity                                          Severity
                              Mental Illness
Standards of Care – Quadrant 4

      Inpatient Hospital
      Concurrent Medical Management of
       Intoxication or Withdrawal along
       with Stabilization of Mental
       Disorder
      Suicide Precautions
      Management of Violent or
       Aggressive Behaviors
      Screen & Assess All Clients for
       Substance Related and Mental
Standards of Care – Quadrant 3
   Alcohol and Drug Residential and
    Outpatient Programs
   Screen all Clients for Mental
    Disorders
   Assess Clients when Appropriate by
    QMHP
   Common Mental Disorders – Trauma,
    PTSD, Depression, Anxiety,
    Personality Disorders
   Medication Management (by
    appropriate staff) of Symptoms
Standards of Care – Quadrant 3
   Services Described in Substance Abuse
    Treatment for Persons with Co-Occurring
    Disorders, TIP XX.. The guiding principles
    in this approach are:
    • Develop a therapeutic alliance to engage the
      client in treatment
    • Motivational Enhancement consistent with
      client’s stage of change
    • Use culturally appropriate methods
    • Use cognitive-behavioral techniques
    • Use relapse prevention [DMH prefers Marlatt’s
      model]
    • Facilitate client participation in self-help
      groups.
Standards of Care – Quadrant 2
   CPS and other Outpatient Programs
   Screen all Clients for Substance-
    Related Disorders
   Assess Clients when Appropriate by
    QSAC
   Medication Management (by
    appropriate staff) of Symptoms
Standards of Care – Quadrant 2
   Services as Described in Co-Occurring Disorders:
    Integrated Dual Disorders Treatment
    Implementation Resource Kit. Many of the
    practices are described in Drake, Goldman, Leff,
    et al, (2001) and Torrey, Drake, Dixon, et
    al,(2001).
    • Welcoming Attitude
    • Staged Interventions
    • Assertive Outreach
    • Motivational Interventions
    • Individual and Group Substance Abuse Education &
      Counseling
    • Culturally Appropriate Methods
    • Social Support
    • Self-Help Group Facilitation
Standards of Care – Quadrant 1
   Outpatient Primary Care Settings
   Screen for Substance-Related
    Disorders and Mental Disorders
   Medication Management
   Brief Interventions
   Referral to Appropriate Care Settings
       Obtain Support for New or
        Enhanced Programming
   Appropriations Requests
   New Block Grant Funding
   Grants
    • COSIG
      Develop Consensus on Co-
         occurring Services
   Developed Co-Occurring Practice
    Guidelines for State Hospitals (1992-
    1995)
   Spring & Fall Conference Agenda
    Items since 1998
   Developed Practice Guideline on Co-
    Occurring Disorders (1999-2002)
     Develop Consensus on Co-
        occurring Services
   Developed Core Rules
         Add ADA Experience to QMHP
         Change Definition of Primary Dx
   Added Medication Services to ADA
    Programs
   Add ADA Services to CPRC
         Enhance Staff Skills
   Provide Training at every opportunity
   Clinical Skills
    • Screening & Assessment
    • Motivational Enhancement
    • Recovery Perspective
    • Self-Help Facilitation
    • Cognitive-Behavioral Techniques
    • Helping vs. Enabling
   Co-Occurring Programming
       Enhance Programming
   As resources become available,
    enhance programs and services in all
    quadrants
   Every program cannot provide every
    Quadrant
   Support agencies as they make
    resources available internally
                            More Information
   DMH Web Site
    http://www.dmh.mo.gov/
   Joseph Parks
     joe.parks@dmh.mo.gov
   Andrew L. Homer
    mzhomea@mail.dmh.state.mo.us
   Practice Guidelines
    http://www.dmh.mo.gov/homeinfo/pracguid/index.htm

								
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