Strategies for Strategies for Psychopharmacology with Psychopharmacology with Persons who have Persons who have Co-Occurring DisordersCo-Occurring Disorders

Kenneth Minkoff, M.D.Kenneth Minkoff, M.D.

Kminkov@aol.com

617-435-5919617-435-5919

Individuals with Co-occurring DisordersIndividuals with Co-occurring DisordersPrinciples of Successful TreatmentPrinciples of Successful Treatment

• Co morbidity is an Co morbidity is an expectationexpectation, NOT an exception. , NOT an exception. Welcoming, access, and integrated screeningWelcoming, access, and integrated screening

• Empathic, hopeful, integrated, strength-based Empathic, hopeful, integrated, strength-based partnership is the essence of success.partnership is the essence of success.

Integrated longitudinal strength-based Integrated longitudinal strength-based assessment (ILSA). assessment (ILSA).

Integrated, strength-based community based Integrated, strength-based community based learning for each issue in small steps over timelearning for each issue in small steps over time

• Four Quadrant ModelFour Quadrant Model

Distinguish abuse from dependence, Distinguish abuse from dependence, and and SPMI SPMI from other persistent MI, from transient from other persistent MI, from transient disorders from painful feelingsdisorders from painful feelings

Individuals with Co-occurring DisordersIndividuals with Co-occurring DisordersPrinciples of Successful TreatmentPrinciples of Successful Treatment

• When substance disorder and psychiatric disorder When substance disorder and psychiatric disorder co-exist, each disorder is co-exist, each disorder is primary.primary.

Integrated primary disorder specific treatment.Integrated primary disorder specific treatment.

• Parallel process of recovery for each condition.Parallel process of recovery for each condition.

Integrated stage-matched interventionsIntegrated stage-matched interventions

• Adequately supported, adequately rewarded, skill-Adequately supported, adequately rewarded, skill-based learning for each conditionbased learning for each condition

Skill teaching with rounds of applause for small Skill teaching with rounds of applause for small steps of progress, balancing care and steps of progress, balancing care and contingencies for each condition. contingencies for each condition.

Individuals with Co-occurring DisordersIndividuals with Co-occurring DisordersPrinciples of Successful TreatmentPrinciples of Successful Treatment

• There is no one correct program or intervention There is no one correct program or intervention for people with co-occurring conditionsfor people with co-occurring conditions. . Interventions must be individualized according Interventions must be individualized according to specific disorders, quadrant, hopeful goals, to specific disorders, quadrant, hopeful goals, strengths and disabilities, stage of change, strengths and disabilities, stage of change, phase of recovery (acuity), skills, supports, and phase of recovery (acuity), skills, supports, and contingencies for each condition.contingencies for each condition.

THE FOUR QUADRANT MODEL FOR THE FOUR QUADRANT MODEL FOR SYSTEM MAPPINGSYSTEM MAPPING

For children and adolescents, use SED instead of SPMIFor children and adolescents, use SED instead of SPMI

PSYCH. HIGH SUBSTANCE HIGH

Serious & Persistent Mental Illness with QUAD Substance Dependence: IV

PSYCH. LOW SUBSTANCE HIGH

Psychiatrically Complicated Substance Dependence QUADRANT III

PSYCH. HIGH SUBSTANCE LOW

Serious & Persistent Mental Illness with Substance Abuse QUAD II

PSYCH. LOW SUBSTANCE LOW

Mild Psychopathology with Substance Abuse QUADRANT i

ASSESSMENT OF INDIVIDUALS WITH ASSESSMENT OF INDIVIDUALS WITH CO-OCCURRING DISORDERS (ILSA)CO-OCCURRING DISORDERS (ILSA)

• Welcoming and HopeWelcoming and Hope• EmpathyEmpathy

• Chronologic StoryChronologic Story• Screening for problems and riskScreening for problems and risk• Periods of Strength and SuccessPeriods of Strength and Success

• Diagnosis DeterminationDiagnosis Determination• Stages of ChangeStages of Change

• Skills and SupportsSkills and Supports

DetectionDetection

• High index of welcoming and expectationHigh index of welcoming and expectation• Gather data from multiple sources, Gather data from multiple sources,

expecting information discrepancies.expecting information discrepancies.• Initial screening: do (did) you have a Initial screening: do (did) you have a

problem?problem?• Screening tools: ASSIST, MIDAS, DALI, Screening tools: ASSIST, MIDAS, DALI,

ASII, SSI, CRAFFTASII, SSI, CRAFFT• MH Screening Form III MH Screening Form III

(www.asapnys.org/resources) , MINI and (www.asapnys.org/resources) , MINI and MINI-PlusMINI-Plus

• Use urine/saliva/hair screens selectively, Use urine/saliva/hair screens selectively, and in a welcoming mannerand in a welcoming manner

DiagnosisDiagnosis

• Integrated, longitudinal, strength-based Integrated, longitudinal, strength-based historyhistory

• No period of sobriety needed to establish No period of sobriety needed to establish diagnosis by historydiagnosis by history

• For MH Diagnosis: Utilize mental status and For MH Diagnosis: Utilize mental status and medication response data from medication response data from pastpast periods of periods of abstinence or limited useabstinence or limited use

• For SUD Diagnosis: Identify patterns of For SUD Diagnosis: Identify patterns of dependence (vs. abuse) by assessing for dependence (vs. abuse) by assessing for awareness of lack of control in the face of awareness of lack of control in the face of serious harm; tolerance and withdrawal are serious harm; tolerance and withdrawal are not required.not required.

Trajectory of Trajectory of Substance-Induced DisorderSubstance-Induced Disorder

• See Next Slide for explanation of A, B, C, D, ESee Next Slide for explanation of A, B, C, D, E

A

B

C

D

E

Trajectory ofTrajectory ofSubstance-Induced DisorderSubstance-Induced Disorder

Part 2Part 2

• A: A: During period A, no target symptomsDuring period A, no target symptoms

• B: B: During period B (should be slanted), During period B (should be slanted), substance use begins that can cause the target substance use begins that can cause the target symptoms we are looking atsymptoms we are looking at

• C: C: During period C, symptoms emergeDuring period C, symptoms emerge

• D: D: During period D, substance use stops or During period D, substance use stops or goes below threshold to affect symptomsgoes below threshold to affect symptoms

• E: E: By period E (30 days later), symptoms in By period E (30 days later), symptoms in question have gone away. question have gone away.

Trajectory of Trajectory of Substance-Induced DisorderSubstance-Induced Disorder

Part 3Part 3

• If symptoms are already present, and get worse with If symptoms are already present, and get worse with substance use, than they are “substance-exacerbated” and substance use, than they are “substance-exacerbated” and may return to baseline (but will not go away) when may return to baseline (but will not go away) when substance use stops.substance use stops.

• If symptoms are not present at baseline, emerge during If symptoms are not present at baseline, emerge during substance use, and DO NOT FULLY REMIT within 30 days substance use, and DO NOT FULLY REMIT within 30 days once substance use stops, they represent the onset of a once substance use stops, they represent the onset of a “persistent” (though not necessarily permanent) MH “persistent” (though not necessarily permanent) MH disorder. disorder.

• Note that it is COMMON that some mental health symptoms Note that it is COMMON that some mental health symptoms GET WORSE (or emerge for the first time) when substance GET WORSE (or emerge for the first time) when substance use STOPS! Ex: trauma symptoms like flashbacks; anxiety or use STOPS! Ex: trauma symptoms like flashbacks; anxiety or emotional lability that is suppressed, then rebounds emotional lability that is suppressed, then rebounds

PSYCHOPHARMACOLOGY PSYCHOPHARMACOLOGY PRACTICE GUIDELINESPRACTICE GUIDELINES

• I. GENERAL PRINCIPLESI. GENERAL PRINCIPLES

• Not an absolute scienceNot an absolute science• Ongoing, empathic, integrated relationshipOngoing, empathic, integrated relationship• Continuous re-evaluation of dx and rxContinuous re-evaluation of dx and rx• Strategies to promote Strategies to promote dualdual recovery recovery• Stage-matched interventions for each dxStage-matched interventions for each dx• Strength-based, skill-based learning.Strength-based, skill-based learning.• Balance necessary medical care and support Balance necessary medical care and support

with opportunities for reward based with opportunities for reward based contracting and contingent learning.contracting and contingent learning.

PSYCHOPHARMACOLOGY PSYCHOPHARMACOLOGY PRACTICE GUIDELINESPRACTICE GUIDELINES

• II. ACCESS AND ASSESSMENTII. ACCESS AND ASSESSMENT• Promotion of access and continuity of Promotion of access and continuity of

relationship is the first priorityrelationship is the first priority• No arbitrary barriers to psychopharm No arbitrary barriers to psychopharm

assessment in any setting based on assessment in any setting based on length of sobriety or drug/alcohol length of sobriety or drug/alcohol levelslevels

• No arbitrary barriers to substance No arbitrary barriers to substance assessment based on psychopharm assessment based on psychopharm regimen regimen

PSYCHOPHARMACOLOGY PSYCHOPHARMACOLOGY PRACTICE GUIDELINESPRACTICE GUIDELINES

• III. DUAL PRIMARY TREATMENTIII. DUAL PRIMARY TREATMENT• Diagnosis-specific treatment for each Diagnosis-specific treatment for each

disorder simultaneouslydisorder simultaneously• Distinguish abuse and dependenceDistinguish abuse and dependence• Specific psychopharm strategies for Specific psychopharm strategies for

addictive disorders are appropriate for addictive disorders are appropriate for individuals with comorbidityindividuals with comorbidity

• For a known or presumed psychiatric For a known or presumed psychiatric disorder, continue use of best non-disorder, continue use of best non-addictive medication for that disorder, addictive medication for that disorder, regardless of status of SUD. regardless of status of SUD.

PSYCHOPHARMACOLOGY PSYCHOPHARMACOLOGY PRACTICE GUIDELINESPRACTICE GUIDELINES

• III. DUAL PRIMARY TREATMENTIII. DUAL PRIMARY TREATMENT• ADDICTION PSYCHOPHARMADDICTION PSYCHOPHARM

• DisulfiramDisulfiram• NaltrexoneNaltrexone

• AcamprosateAcamprosate• Bupropion, VareniclineBupropion, Varenicline• Opiate Maintenance Opiate Maintenance

• Mood stabilizers?Mood stabilizers?• Others? (Baclofen, etc.)Others? (Baclofen, etc.)

PSYCHOPHARMACOLOGY PSYCHOPHARMACOLOGY PRACTICE GUIDELINESPRACTICE GUIDELINES

• III. DUAL PRIMARY TREATMENTIII. DUAL PRIMARY TREATMENT• PSYCHOPHARM FOR MIPSYCHOPHARM FOR MI

• Atypicals (?) and clozapine for Atypicals (?) and clozapine for psychosispsychosis

• LiCO3 vs newer generation mood LiCO3 vs newer generation mood stabilizersstabilizers

• Any non-tricyclic antidepressant, Any non-tricyclic antidepressant, particularly SSRI, SNRIparticularly SSRI, SNRI

PSYCHOPHARMACOLOGY PSYCHOPHARMACOLOGY PRACTICE GUIDELINESPRACTICE GUIDELINES

• III. DUAL PRIMARY TREATMENTIII. DUAL PRIMARY TREATMENT• PSYCHOPHARM FOR MIPSYCHOPHARM FOR MI

• Anxiolytics: clonidine, SSRIs, SNRIs, Anxiolytics: clonidine, SSRIs, SNRIs, topiramate, other mood stabilizers, topiramate, other mood stabilizers,

atypicals (short-term), atypicals (short-term), buspirone – usually takes longerbuspirone – usually takes longer

• ADHD: Atomoxetine is probably first ADHD: Atomoxetine is probably first line. Bupropion, clonidine, SSRIs, line. Bupropion, clonidine, SSRIs, tricyclics, then sustained release tricyclics, then sustained release

stimulants. stimulants.

PSYCHOPHARMACOLOGY PSYCHOPHARMACOLOGY PRACTICE GUIDELINESPRACTICE GUIDELINES

• IV. DECISION PRIORITIESIV. DECISION PRIORITIES• SAFETYSAFETY

• STABILIZE ESTABLISHED OR STABILIZE ESTABLISHED OR SERIOUS MISERIOUS MI

• SOBRIETYSOBRIETY• IDENTIFY AND STABILIZE MORE IDENTIFY AND STABILIZE MORE

SUBTLE DISORDERSSUBTLE DISORDERS

SAFETYSAFETY

• Acute medical detoxification should Acute medical detoxification should follow same established protocols as for follow same established protocols as for individuals with addiction only.individuals with addiction only.

• Maintain reasonable non-addictive Maintain reasonable non-addictive psychotropics during detoxificationpsychotropics during detoxification

• For acute behavioral stabilization, use For acute behavioral stabilization, use whatever medications are necessary whatever medications are necessary (including benzodiazepines) to prevent (including benzodiazepines) to prevent harm.harm.

STABILIZATION OF SMISTABILIZATION OF SMI

• NECESSARY NON ADDICTIVE NECESSARY NON ADDICTIVE MEDICATION FOR ESTABLISHED MEDICATION FOR ESTABLISHED AND/OR SERIOUS MENTAL ILLNESS AND/OR SERIOUS MENTAL ILLNESS MUST BE INITIATED AND MAINTAINED MUST BE INITIATED AND MAINTAINED REGARDLESS OF CONTINUING REGARDLESS OF CONTINUING SUBSTANCE USESUBSTANCE USE

• More risky behavior requires closer More risky behavior requires closer monitoring, not treatment extrusionmonitoring, not treatment extrusion

• Be alert for subtle symptoms that are Be alert for subtle symptoms that are substance exacerbated, but still substance exacerbated, but still require medication at baseline.require medication at baseline.

STRATEGIES FOR STRATEGIES FOR SOBRIETYSOBRIETY

• Medication for addiction is presented as Medication for addiction is presented as ancillary to a full recovery program that ancillary to a full recovery program that requires work independent of medication. requires work independent of medication. Individuals on proper medication must work as Individuals on proper medication must work as hard as those with addiction only.hard as those with addiction only.

• Distinguish normal feelings from disorders with Distinguish normal feelings from disorders with similar names (anxiety, depression)similar names (anxiety, depression)

• Psychiatric medications are directed to known Psychiatric medications are directed to known or probable disorders, not to medicate feelingsor probable disorders, not to medicate feelings

STRATEGIES FOR STRATEGIES FOR SOBRIETYSOBRIETY

• Proper medication for mental illness does not Proper medication for mental illness does not take away normal feelings, but permits take away normal feelings, but permits patients to feel their feelings more accurately.patients to feel their feelings more accurately.

• Use fixed dosage regimes, not prn meds, for Use fixed dosage regimes, not prn meds, for disorders or conditions where symptoms and disorders or conditions where symptoms and feelings might be easily confused. feelings might be easily confused.

More Strategies for More Strategies for SobrietySobriety

• Avoid use of benzodiazepines or other Avoid use of benzodiazepines or other generic potentially addictive generic potentially addictive sedative/hypnotics in patients with sedative/hypnotics in patients with known substance dependenceknown substance dependence

• Continued BZD prescription should be Continued BZD prescription should be an indication for consultation, peer an indication for consultation, peer reviewreview

• Use contingency contracting to engage Use contingency contracting to engage individuals with SUD who are already on individuals with SUD who are already on BZDs.BZDs.

More Strategies for More Strategies for SobrietySobriety

• If indicated, withdrawal from prescribed If indicated, withdrawal from prescribed BZDs using carbamazepine (or VPA, BZDs using carbamazepine (or VPA, gabapentin), plus phenobarbital taper gabapentin), plus phenobarbital taper (1mg clonazepam = 30 mg pb)(1mg clonazepam = 30 mg pb)

• Be alert for prolonged BZD withdrawal Be alert for prolonged BZD withdrawal syndrome syndrome

More Strategies for More Strategies for SobrietySobriety

• Pain Management should occur in collaboration with a Pain Management should occur in collaboration with a prescribing physician who is fully informed about the status of prescribing physician who is fully informed about the status of substance use disorder.substance use disorder.

• Individuals with stable substance dependence should not be Individuals with stable substance dependence should not be routinely denied access to opiates for pain management if routinely denied access to opiates for pain management if otherwise appropriateotherwise appropriate

• Individuals addicted to or escalating dosage of opiates for Individuals addicted to or escalating dosage of opiates for non-specific neck, back, etc. conditions can be informed that non-specific neck, back, etc. conditions can be informed that continued use of opiates continued use of opiates worsens perceived pain. worsens perceived pain. Full Full withdrawal plus alternative pain management strategies can withdrawal plus alternative pain management strategies can actually improve pain in the long run.actually improve pain in the long run.

• Buprenorphine and methadone are both viable strategies for Buprenorphine and methadone are both viable strategies for high risk opiate using individuals with severe chronic pain high risk opiate using individuals with severe chronic pain problems.problems.