1. Copyright Alcohol Medical Scholars Program 1 Integrated Treatment of Co-Occurring Mental Illness (MI) and Substance Use Disorders (SUD) Krishna Balachandra, M.D., FRCPC Concurrent Disorders Program University of Western Ontario University of Western Ontario

2. Copyright Alcohol Medical Scholars Program2 Co-Occurring Disorders (COD) ~50% Serious disorders have SUD ~50% Serious disorders have SUD Physicians inadequately trained in SUD Physicians inadequately trained in SUD Pts with COD  suboptimal care Pts with COD  suboptimal care Pts with COD at  risk Pts with COD at  risk

3. Copyright Alcohol Medical Scholars Program3 Definitions Mental disorders Mental disorders Substance abuse ≥ 1 of Substance abuse ≥ 1 of Obligations Obligations Hazardous use Hazardous use Legal Legal Interpersonal problems Interpersonal problems Substance dependence ≥ 3 of Substance dependence ≥ 3 of Tolerance Tolerance Withdrawal Withdrawal Amounts/time Amounts/time Cut Cut Time Time Activities Activities Physical/psychological problems Physical/psychological problems

4. Copyright Alcohol Medical Scholars Program4 Co-Occurring Disorders Mental Illness Substance Use Disorder COD

5. Copyright Alcohol Medical Scholars Program5 This Lecture Reviews Epidemiology Epidemiology Etiology Etiology Treatment overall Treatment overall Relevance of integrated treatment Relevance of integrated treatment

6. Copyright Alcohol Medical Scholars Program6 Epidemiology of COD SUDAUDDUD 17

7. Copyright Alcohol Medical Scholars Program7 SUD Epidemiology of COD Bipolar 3-5 X’s AUDDUD 17 56

8. Copyright Alcohol Medical Scholars Program8 Epidemiology of COD ASPD 5-7 X’s SUDAUDDUD 17 56 83

9. Copyright Alcohol Medical Scholars Program9 Etiology of COD Common Vulnerability Common genes Common genes Twin study of AUD + Depression Twin study of AUD + Depression ASPD ASPD Common physiology in both Common physiology in both HPA axis HPA axis Hippocampus/frontal cortex Hippocampus/frontal cortex Cannabinoid, dopamine receptors Cannabinoid, dopamine receptors

10. Copyright Alcohol Medical Scholars Program10 Etiology of COD SUD as Response to MI  Symptoms  Symptoms  Social skills  Social skills  Medication side effects  Medication side effects Mental Illness Substance Use Disorder

11. Copyright Alcohol Medical Scholars Program11 Etiology of COD MI as Response to SUD Cannabis use  ↑ rates of psychosis Cannabis use  ↑ rates of psychosis Meta-analysis supports ↑ risk Meta-analysis supports ↑ risk Possible genetic mechanism Possible genetic mechanism Mental Illness Substance Use Disorder

12. Copyright Alcohol Medical Scholars Program12 We Have Reviewed Epidemiology  Epidemiology  Etiology  Etiology  Treatment overall Treatment overall Relevance of integrated treatment Relevance of integrated treatment

13. Copyright Alcohol Medical Scholars Program13 Treatment Strategies AdvantagesDisadvantages Sequential Rx ++++++ Parallel Rx ++ ++++ Integrated Rx +++ ++

14. Copyright Alcohol Medical Scholars Program14 Integrated Treatment Simultaneous treatment Simultaneous treatment Consistency of location and providers Consistency of location and providers Advantages Advantages Disadvantages Disadvantages

15. Copyright Alcohol Medical Scholars Program15 Integrated Rx: Clinical Case 27 M, Bipolar, Alc dep 27 M, Bipolar, Alc dep ++ ER visits ++ ER visits No show appts No show appts Frustrated docs Frustrated docs Legal charges Legal charges Homeless Homeless

16. Copyright Alcohol Medical Scholars Program16 Principles of Integrated Rx “No wrong door” “No wrong door” Shared decision making Shared decision making Comprehensiveness Comprehensiveness Assertiveness Assertiveness

17. Copyright Alcohol Medical Scholars Program17 Principles of Integrated Rx  Negative consequences  Negative consequences Time unlimited Time unlimited Multiple therapies Multiple therapies Cultural sensitivity Cultural sensitivity

18. Copyright Alcohol Medical Scholars Program18 Principles of Integrated Rx Motivation based treatment Motivation based treatment Engagement Engagement Persuasion Persuasion Active treatment Active treatment Maintenance/Relapse prevention Maintenance/Relapse prevention

19. Copyright Alcohol Medical Scholars Program19 Integrated Treatment Engagement Goal: Establish working relationship Goal: Establish working relationship Outreach Outreach Practical assistance Practical assistance E.g. housing E.g. housing Crisis intervention Crisis intervention

20. Copyright Alcohol Medical Scholars Program20 Integrated Treatment Engagement Support + assistance to social network Support + assistance to social network Stabilize medical/psychiatric illness Stabilize medical/psychiatric illness Address legal issues Address legal issues Family visits Family visits Close monitoring Close monitoring

21. Copyright Alcohol Medical Scholars Program21 Integrated Treatment Persuasion Goal:  awareness of problem Goal:  awareness of problem Individual + family education Individual + family education Groups to discuss pros/cons of using Groups to discuss pros/cons of using Non substance social skills Non substance social skills

22. Copyright Alcohol Medical Scholars Program22 Integrated Treatment Persuasion Structured activity Structured activity E.g. supported employment E.g. supported employment Social + rec activities Social + rec activities “Damp” housing “Damp” housing Psychiatric stabilization Psychiatric stabilization

23. Copyright Alcohol Medical Scholars Program23 Integrated Rx: Clinical Case 27 M, Bipolar, Alc dep 27 M, Bipolar, Alc dep  ER visits  ER visits Keeps appts Keeps appts Happier docs Happier docs Legal assistance Legal assistance Housing Housing Alcohol use continues Alcohol use continues

24. Copyright Alcohol Medical Scholars Program24 Integrated Treatment Active Rx Goal:  substance use Goal:  substance use Strategies to  substance use Strategies to  substance use Social skills Social skills E.g. refusal skills E.g. refusal skills Self help groups Self help groups E.g. “Double Trouble” E.g. “Double Trouble”

25. Copyright Alcohol Medical Scholars Program25 Integrated Treatment Active Rx Individual psychotherapy Individual psychotherapy Substitute activities Substitute activities Meds Meds  Substance use (e.g. disulfiram, naltrexone)  Substance use (e.g. disulfiram, naltrexone) “Dry” housing “Dry” housing Stress/coping skills Stress/coping skills

26. Copyright Alcohol Medical Scholars Program26 Goal: maintain and extend recovery Goal: maintain and extend recovery Social skills Social skills E.g. interpersonal relationships E.g. interpersonal relationships Problem solving Problem solving E.g. new ways to cope E.g. new ways to cope Integrated Treatment Maintenance/Relapse Prevention

27. Copyright Alcohol Medical Scholars Program27 Lifestyle improvement Lifestyle improvement E.g. smoking cessation E.g. smoking cessation Independent housing Independent housing Role modeling Role modeling E.g. leading groups E.g. leading groups Integrated Treatment Maintenance/Relapse Prevention

28. Copyright Alcohol Medical Scholars Program28 Hank’s 12 step program

29. Copyright Alcohol Medical Scholars Program29 Efficacy of Integrated Rx  Retention  Retention 55% Integrated Rx > 35% usual Rx 55% Integrated Rx > 35% usual Rx  Substance use  Substance use 40% Abstinence post Rx vs 2% baseline 40% Abstinence post Rx vs 2% baseline 60% Negative urine integrated Rx > 25% usual Rx 60% Negative urine integrated Rx > 25% usual Rx

30. Copyright Alcohol Medical Scholars Program30 Efficacy of Integrated Rx  Financial stress  Financial stress 40% Employed vs 5% baseline 40% Employed vs 5% baseline 60% Housing vs 50% baseline 60% Housing vs 50% baseline 70% $ For basic needs > 45% usual Rx 70% $ For basic needs > 45% usual Rx 6000 $/pt Criminal justice cost savings 6000 $/pt Criminal justice cost savings

31. Copyright Alcohol Medical Scholars Program31 Efficacy of Integrated Rx  Hospitalization  Hospitalization 7% Post-integrated Rx vs 30% pre Rx 7% Post-integrated Rx vs 30% pre Rx  Rates of arrest  Rates of arrest 13% Post-integrated Rx vs 30% pre Rx 13% Post-integrated Rx vs 30% pre Rx

32. Copyright Alcohol Medical Scholars Program32 We Have Reviewed Epidemiology  Epidemiology  Etiology  Etiology  Treatment overall  Treatment overall  Relevance of integrated treatment  Relevance of integrated treatment 