Advances in Integrated Dual Disorders Treatment FADAAFCCMAnnual Conference

Advances in Integrated Dual Disorders Treatment FADAA/FCCM—Annual Conference 2013 Troy Pulas, MD Addiction Psychiatrist Judy Magnon, RN-BC BS, CAC 1

Disclosure • Neither we nor any member of our immediate families have a financial relationship or interest with any proprietary entity producing health care goods or services related to the content of this CEU activity. • Our content will not include discussion/ reference to commercial products or services. • We do not intend to discuss an unapproved/ investigative use of commercial products/devices. 2

Affiliations • Troy Pulas is an addiction psychiatrist and medical director for West. Bridge South in Brooksville, FL. He was formerly an instructor of psychiatry at Boston University Medical Center. • Judy Magnon is a board certified psychiatric/mental health nurse and a Florida Certified Addiction Counselor. She is the Program director for West. Bridge South in Brooksville, FL. 3

Co-Occurring Disorders Psychiatric Disorders and Substance Abuse are both Brain Disorders. Both effect Dopamine and Serotonin functioning in the nerve cells. 4

Co-Occurring Disorders Impaired brain chemistry effects the metabolism of substances, resulting in loss of control, abuse, and/or dependence. HELP Dopamine receptors are effected by alcohol/drug use and this is the same area effected by psychotropic medication. (and Caffeine & Nicotine) 5

1. It has symptoms (Warning Signs) 2. There is progression (How things get worse) 3. There is a Prognosis (An outcome based on the usual course of the disease) 6 SUBSTANCE ABUSE/DEPENDENCE IS A DISEASE

Rationale for Integrated Treatment Psychiatric DX: General Population Schizophrenia Bipolar Disorder Major Depression OCD Phobia Panic Disorder Any Sub. Use Dis. Any Alcohol use Dis. Any Drug use Dis. % 16. 7 47% 56. 1% 27. 2 32. 8 22. 9 35. 8 % 13. 5 33. 7% 43. 6% 16. 5 24 17. 3 28. 7 % 6. 1 27. 5% 33. 6% 18 18. 4 11. 2 16. 7 7

Rationale for Integrated Treatment • Dual disorders have worse outcomes: • Greater symptom relapse and worse adherence to treatment • More likely to be violent or a victim of violence • Higher rates of homelessness • Higher hospitalization rates and ER utilization • More likely to be incarcerated • More medical problems including HIV and hepatitis 8 Green 2007 AJP, Drake 2008 JSAT

Rationale for Integrated Treatment • Programs that integrate treatment of both illnesses have been shown to be more effective Think--- 2 broken legs • Parallel treatment has a high dropout rate, few get both services, poor communication between providers Green 2007 AJP, Drake 2008 JSAT 9

Higher Rates of Psychiatric Relapse For People with Dual Disorders Who Use Substances More relapses over time using “pot” 10

PARALLELS: Psychosis and Addiction By Dr. Ken Minkoff Addiction Disease Major MI Disease • 1. A biological illness • 2. Hereditary (In part) • 3. Chronicity • 4. Incurable • 5. Leads to lack of control of behavior & emotions • 6. Affects the whole family 11

PARALLELS: Psychosis and Addiction By Dr. Ken Minkoff Addiction Disease Major MI Disease • 7. Symptoms can be controlled with proper treatment • 8. Progression of the disease without treatment • 9. Disease of denial • 10. Facing the disease can lead to depression and despair 12

PARALLELS: Psychosis and Addiction By Dr. Ken Minkoff Addiction Disease Major MI Disease • 11. Disease is often seen as a “Moral” issue, due to personal weakness rather than biological causes • 12. Feelings of guilt and failure • 13. Feelings of shame and stigma • Physical, mental, and spiritual disease 13

Parallels--Recovery First phase is acute stabilization with medication (Detox/antipsychotic) • 2. First phase often requires hospitalization • 3. Following acute stabilization, next phases are prolonged stabilization and rehabilitation. • 1. 14

Parallels--Recovery • 4. a. A prerequisite for rehabilitation is maintaining stabilization by following a long term program: • “Don’t drink”…, Go to meetings, read literature, etc. • Take meds, attend groups, see CM/Dr. , etc. 15

Parallels--Recovery • 4. b. Once stabilization has been maintained long enough (usually 1 year) growth and rehabilitation can occur. • 5. Person must overcome Denial/Disbelief. • 6. Person must acknowledge powerlessness over the disease 16

Parallels--Recovery • 7. Person must ask for help from a power greater than themselves to control symptoms (Higher Power, AA/NA, Therapist, Meds, etc. ) • 8. Recovery proceeds one day at a time through increasing acceptance of one’s illness and gradually learns better coping skills to cope with daily reality. 17

Parallels--Recovery • 9. Recovery is never “complete”, but slow, gradual progress can be made. • 10. Risk of relapse is always present—need help over time. • 11. Family must also be involved in a program to get help dealing with the disease. 18

Parallels--Recovery • 12. Education about the disease is an important component. • 13. Treatment must focus on feelings about the disease, and feeling good about oneself with a disease. • 14. Ultimately, recovery is a physical, mental, and spiritual process. 19

IDDT Development • 1980 s: Identification/description of model • Based on PACT Model of Care • 1990 s: Development of integrated treatments • Research started in NH and spread through out the world • 2000 s: Implementation of evidenced based practices in IDDT • IDDT Manual published by Dartmouth Psychiatric Research Center—Dr. Robert Drake and team. Drake 2008 JSAT 20

Integrated vs. Non-Integrated Treatments 21 Mc. Hugo 1999 Psych Serv

Principles of IDDT • Administered by a multidisciplinary team • Counseling is less confrontational and more supportive • Comprehensive services • Case management • Residential treatment • Stage-wise interventions 22 Brunette 2006 J Clin Psychiatry

Principles of IDDT (continued) • Supported employment (EBP) • Social support • Rehabilitation or skills training • Flexibility • Long-term perspective • Interventions for non-responders • Assertive Community Treatment (ACT) (EBP) Brunette 2006 J Clin Psychiatry 23

Stage-wise Treatment Stage of change Stage of Treatment Strategies Precontemplation Contemplation Preparation Engagement and persuasion Outreach, Engagement activities (i. e. addressing basic needs) Crisis intervention Motivational interviewing Psychiatric Stabilization Medication, Structure Education about MH & SA Education about wellnessnutrition, exercise, smoking, sleep Encourage self help with staff after education and reframing for stage Individual and Ed. Groups 24

Stage-wise Treatment Action Active treatment Self-monitoring, Self-help Social skills training Groups, CM, CBT programs Build sober network Continue to address wellness — nutrition, exercise, sleep, tobacco cessation Maintenance Relapse prevention Formulate a plan for relapse Expand recovery to other areas of their lives, use sober network Continue to address wellness — nutrition, exercise, sleep, tobacco cessation 25

Assertive Community Treatment and IDDT • ACT is an evidence-based treatment started in the 1970 s to provide treatment and rehabilitation for SMI in Wisconsin • Multidisciplinary team approach • Integration of intensive services individualized to each person • Assertive outreach in the community and to families • Medication management • Prescribers meet regularly with the team in a leadership role • Continuity of care over time • The ACT model has been adapted successfully for IDDT 26 Bond 2001 Dis Manage Health Outcomes

ACT IDDT Integrated Dual Disorders Treatment Focus is on developing motivation for treatment using Stage Wise interventions Assertive VS on SX Management & everyday Community problems; Treatment Based on: Recovery thinking, individual choice, shared decision making, and the individual drives TX. ACT & IDDT equals addressing all areas. 27 OVERLAP OF THE MODELS

High MI High Q IV S E R A I T Y SA LOW High Q III SA High MI MI Low 28 Four Quadrant Model K. Minkoff Q II High MI Low Q 1 SA Low MI Severity Low

• To be able to NOT take person’s anger personally • To not join/align with the illness(s) and enable client to use • To advocate with them to take the medications (Or unable to participate in TX offered) • To understand Stages of Change/Motivational Interviewing 29 STAFF-- NEEDED ABILITIES

• To use Baker Act, Marchman Act, Payeeship, guardianship and any other tools as needed to ensure care • To develop a long term relationship • Work with families, S/O, Partners, police, guardians, lawyers, physicians, etc. • To understand the consequences of person’s use of substances 30 STAFF-- NEEDED ABILITIES

• To understand: • Recovery is a slow process with ups and downs • Recovery is not an event • Treatment is like Insulin—without it, the illness returns and progression is faster with worse physical and mental damage • The Family is not to blame and neither is the Participant. We do not blame for Cancer. 31 STAFF-- NEEDED ABILITIES

• To have compassion for the illness • Have a commitment to this Population • Have knowledge of: • MI & SA, Sexual Abuse issues, medical issues, PTSD, Personality Disorders, medications, documentation, etc. 32 STAFF-- NEEDED ABILITIES

• Ability to be a team player • Able to communicate effectively to all team members, especially with the participant & family • Able to partner with person in treatment, instead of as the “expert” • Able to carry the hope for the person, until they are ready to take it back. 33 STAFF-- NEEDED ABILITIES

The person’s illness(s) is not all they are. (EXAMPLE— Judy is a person who experiences Schizophrenia instead of Judy is Schizophrenic. ) (Just like experiencing Diabetes) 34 BASED ON: Recovery Thinking

BASED ON: Recovery Thinking The person is a partner in the treatment process and The provider is a guide with knowledge and clinical experience to share, discuss, educate, explore, coach, advise, assist, encourage, negotiate, role model, validate, etc. 35 (Continued)

BASED ON: Recovery Thinking (Continued) EXPECT THEY WILL IMPROVE/RECOVER!!!!!! Celebrate the successes, no matter how small, 36 Use positive language in meetings and in day to day job tasks to practice the recovery way of thinking, EMPOWERMENT: Offer choices, clarify they have the power to make choices/decisions, You are offering tools, and they can choose to use them or not. You hope they will, but you respect their choice to not be ready yet.

(Continued) No matter what level of illness—Expect that they can participate at some point in “Meaningful Day time Activity” WORK is Therapy!!!!!! They do not have to be sober to work. (Clinical evidence shows that some people will stop using to keep a job!) 37 BASED ON: Recovery Thinking

PREDICTOR OF SUCCESS (Ken “The most significant predictor of treatment success for people with Co-occurring Disorders is the presence of an empathic, hopeful, continuous, treatment relationship in which integrated treatment and coordination of care can take place through multiple treatment episodes”. 38 Minkoff)

Conclusions 30 years of dual disorder research shows: • Integrated Dual Disorders Treatment is effective • The model works well for severe mental illness • Certain interventions may be integrated to enhance substance use reduction and encourage addiction recovery • IDDT can be individualized using stage-wise treatment, flexibility, comprehensive services, the assertive community treatment model, and a long-term perspective. 39

West. Bridge Integrated Dual Disorders Treatment Model 40

• IDDT Program based on stage-based treatment model developed by Robert Drake, MD , Ph. D at Dartmouth PRC • Multiple levels of care to allow for seamless transitions (residential-community) • Private, non-profit organization with programs in Boston, New Hampshire, and Florida. • Family-founded and family-centered, designed to rapidly implement evidence-based therapies • No patients or clients, just participants & families 41

Evidence-based practices @ West. Bridge • Evidence-based therapies: • Assertive community treatment • Supportive employment • Pharmacotherapy and medication monitoring • Cognitive-behavioral therapy • Behavioral family therapy/family education • Motivational interviewing • Contingency management/voucher systems • Regular urine toxicology screening • Twelve-step facilitation with mentor program • Mindfulness training 42

Advances in Integrated Dual Disorders Treatment: Opioid Dependence, Sleep Disorders, and Smoking Cessation FADAA/FCCM—Annual Conference 2013 Troy Pulas, MD Medical Director, West. Bridge Community Services, Brooksville, FL campus 43

Objectives • Discuss a new integrated treatment model of opioid dependence in a co-occurring disorder population • Discuss the rationale for increased awareness, diagnosis, and treatment of sleep disorders in a co-occurring disorder population • Discuss rationale for integration of smoking cessation treatment in a co-occurring disorder population 44

45 Adapted by CESARFAX 1/30/12 from Centers for Disease Control and Prevention (CDC), National Center for Injury Prevention and Control (NCIPC), Drug Poisoning Deaths in the United States, 1980 -2008, 2011.

Prescription Opioids and Mental Illness 46

Rate of Chronic Past Year Nonmedical Use of Prescription Drugs While overall nonmedical use of prescription pain relievers did not increase from 2002 -2003 to 2009 -2010, Chronic nonmedical use—use on 200 or more days in the past year— increased significantly, from a rate of 2. 2 to 3. 8 per 1, 000 people. Adapted by CESARFAX 7/16/12 from Jones, C. M. , “Frequency of Prescription Pain Reliever Nonmedical Use: 2002 -2003 and 2009 -2010”, Archives of Internal Medicine, 2012. 47

Admissions reporting primary prescription opioid abuse, by age: 1998 and 2008 48 Source: SAMHSA Treatment Episode Data Set (TEDS), 1998 and 2008

Buprenorphine for Prescription Opioid Dependence--POATS Adapted by CESARFAX 12/5/11 from Weiss, R. D. , et. al. , “Adjunctive Counseling During Brief and Extended Buprenorphine-Naloxone Treatment for Prescription Opioid Dependence, ” Archives of General Psychiatry, 2011. 49

Buprenorphine Treatment Models • Outpatient-Based Opioid Treatment 1 • • Primary care/medical management 2 Collaborative care with nurse care managers 3 Adjunctive counseling (group/individual)4 Private-pay physician or psychiatrist • Practice-based Opioid Treatment (France) • Pharmacist-engaged 5 • Clinic-Based Opioid Treatment (Australia) • Regular observed administration 6 • Assertive Community Opioid Treatment Model 50 Fiellin. 2008 CNS Drugs; 22 (2): 99 -111 4 Weiss RD, et al. 2011. Arch of Gen Psych. 5 Vignau, et al. 2001. JSAT. 2 Barry D, et al. 2007. J Gen Int Med; 22: 242– 245. 3 Alford D, et al. 2011. Arch Intern Med; 171(5): 425 -431 6 Lintzeris, et al. 2004 Am J Add; 13 Suppl 1: S 29 -41. 1 Gunderson,

Buprenorphine in primary care 51 Fiellin, et al. 2008. AJA, 17: 116– 120.

Age and Retention in B/N Collaborative Care OBOT Treatment Proportion retained in OBOT treatment Age groupings 18 -25 26 -30 31 -40 41 -50 51+ 18 -25 year olds 3 6 9 12 Months after intake Schuman-Olivier, et al 2013 52

Why do emerging adults do so poorly in Buprenorphine treatment? • Could it be the same reasons that emerging adults do poorly in other forms of substance abuse treatment? • Not ready to stop (lack of consequences) • Developmental challenges • Difficulty giving up co-morbid substance abuse • Poor self-help attendance • Neurobiology • Psychiatric co-morbidity • Lack of integration of treatment 53

Case: • 21 year old male with Obsessive Compulsive Disorder, Major Depressive Disorder, Opioid Dependence • Living in Boston, attending college. Parents find out he has been using intranasal heroin for 3 months after 9 months of daily prescription opioid use (~240 mg/day of oxycodone). • Drinking alcohol, using benzodiazepines, and regular marijuana use. History of overdose on alcohol and heroin. • Contemplative about heroin, but does not want to stop alcohol or marijuana. • Living with roommate who is also using heroin, dealing prescription opioids, and benzodiazepines, parents not aware of this. 54

WB risk calculator for buprenorphine/naloxone treatment for people with co-occurring disorders 55

Assertive Community Opioid Treatment Model, Integrated Services • Risk Level 3 Services: • Daily care manager and/or substance abuse counselor meetings =>Motivational Interviewing, engagement, supportive counseling, ACT, active treatment, education • Twice weekly urine toxicology (M/Th, T/F) => Stage-wise treatment (work with relapse/continued use), motivational interviewing , engagement • Weekly buprenorphine prescription, dispensed daily from lockbox by care manager => Multidisciplinary team, community outreach, flexible approach • Weekly to twice monthly meetings with psychiatrist => Multidisciplinary team, psychiatric stabilization, education • Alcohol or benzodiazepine detoxification when necessary => Residential treatment, multidisciplinary team • Sign treatment contract => Non-confrontational, supportive • Regular attendance to self-help meetings or group treatment => Community integration, social support 56

Assertive Community Opioid Treatment Model, Integrated Services Risk Level 3: Encouraged (but not required) Services: • Contingency contracting with daily money rationing or other forms of contingency management. =>Structure, flexibility, case management • Provide housing support when necessary =>Case management, community outreach • Disulfiram for alcohol dependence if indicated =>Multidisciplinary team, medication management 57

ACT Team: Diversion Prevention • • • Lockboxes Urine testing Pill checks Short prescriptions In-office inductions Observed administration 58

Conclusions 1. Opioid dependence is a dangerous problem, and prescription opioid abuse is at crisis levels among emerging adults. 2. Dual diagnosis is very common among emerging adults with opioid dependence, and must be addressed in treatment models. 3. Buprenorphine/naloxone treatment improves retention and reduces opioid use; however, standard treatment models are poor at retaining emerging adults and those with co-occurring disorders. 4. An integrated dual disorder assertive community treatment team approach may offer promise for improving clinical outcomes, increasing safety and preventing diversion. 59

Integrating Sleep Disorder Treatment and Dual Disorder Treatment 60

Brain Burden of Addiction and Sleep Disorders: $ SOURCE: Neuroinsights, Office of Nat’l Drug Policy, Nat’l Institute of Diabetes, Alz Assoc. , Duke University, American Psych. Association, Harvard, Nat’l Sleep Found. , American Stroke Assoc. , Prevent Blindness America, CDC, Journal of Clinical Psych, Epilepsy Foundation, Cost of Brain Disorders Europe ( Lynch, Science Progress 2007) 61

Outcomes of co-morbidity • Dual Disorders and Sleep Disorders • • • Worse outcomes Altered course of illness Poor coping Adverse drug reactions Cognitive deficits Horn and Sateia, J Dual Diagnosis, 2012 ; Hofstetter, et al BMC Psych 2005; Ritsner, et al Qual of Life Res 2004; Yang and Winkelman Schiz Res 2006; Krystal, Thakur, & Roth, Sleep 2008 62

Sleep Stages • Non REM • Stage 1: Fast Theta Waves, light sleep • Stage 2: Sleep Spindles, K complexes • Stage 3 & 4: Slow Delta Waves • REM • Rapid Eye Movements, voluntary muscles inactive Penelope A. Bryant, John Trinder and Nigel Curtis Nature Reviews Immunology 4, 457 -467 (June 2004) 63

Sleep and Addiction • Alcohol • Insomnia: 36 -75% while drinking or in withdrawal. Varies depending on many factors with sobriety. • Time to fall asleep increases with drinking—tolerance to sedating effects (takes 5 -9 months of abstinence to normalize). • Total sleep time decreases with drinking (takes 1 -2 years) • REM sleep % decreases during alcohol use (takes 3 months-3 years ) • REM occurs earlier in the night with drinking. • Sleep fragmentation, (takes 1 -2 years) • Obstructive Sleep Apnea exacerbation Brower et al Sleep Med Rev 2001. Brower Alcohol Res Health. 2001; 25(2): 110– 125. Remmers Am Rev Resp Dis 1984. Stein et al J Subst Ab Treat 2004. 64

Sleep and Addiction Opioids • Insomnia: 84% • Central Sleep Apnea: 30 -75% of people on methadone • Associated with Obstructive Sleep Apnea • Longterm consequence; chronic insomnia Cocaine: • Increased wakefulness, suppressed REM sleep Benzodiazepines: • Inhibit Stage 3&4 (slow wave sleep) Marijuana • Reduced REM sleep, increased stage 4 sleep • Withdrawal: REM rebound, strange dreams Nicotine • Association with Obstructive Sleep Apnea • Shorter sleep time, longer time to fall asleep, more leg movements 65

Sleep disorders and Schizophrenia • Schizophrenia presents with co-occurring substance use disorder 47 -65% of the time! Sleep disorders in schizophrenia: • Effects of antipsychotics on sleep are common (positive and negative) • Obstructive Sleep Apnea: 48% • Periodic Limb Movement Disorder: 14 -21% 66 (Ancoli-Israel, Biol Psych 1999; Lieberman, “CATIE” NEJM 2005; Bola et al Sleep 2008; Wang et al Chest 2005), Cohrs S, CNS Drugs 2008.

Diagnosis and Intervention Diagnosis: Intervention: • Sleep habits • Sleep Hygiene • Sleep log • Cognitive Behavioral Treatment • Screening measures: • Sleep Mentors • Epworth Sleepiness scale • Pittsburgh Quality Index • Sleep study • Continuous Positive Airway Pressure (CPAP) • Medications 67

Sleep habits (staff assessment) • Note weight/ BMI • 35 • Diet: timing of meals, content • No breakfast, chocolate bar at lunch, heavy dinner prior to bed • Exercise/physical activity patterns • Walk 15 min/day • Substance use and relationship with sleep (including smoking, coffee) • 2 cups of coffee at evening AA meeting; cigarettes prior to bed and several times a night • Day –time sleep • Wakes up at noon, 2 hour nap in the afternoon 68

Sleep Diary (self-report) • What time did you go to bed last night? 10 pm (stayed awake due to hallucinations) • What time you think you fell asleep? 4 am • What time did you get up? 12 noon • Did you wake up during your sleep time? no • Overall, how tired did you feel yesterday, scale of 1 to 5 (Very tired = 5) ? 3 • How unusual or stressful was your day yesterday, scale of 1 to 5? (Very unusual or stressful = 5) 2 • How tired do you feel, scale of 1 to 5? (Very tired = 5) 5 69

Interventions • Basic Sleep hygiene • • Sleep at night Bed use only for sleep, sex or sickness Avoid caffeine End psychosis engagement earlier • Light therapy • CBT • Progressive Muscle Relaxation • CBT for psychosis • Progressive desensitization of CPAP (claustrophobia) • Sleep mentors/coaches • Personalized sleep plan 70

Medications Evaluate underlying disorder Antidepressants: Mirtazapine, Trazodone Sedating antipsychotics if psychosis/bipolar disorder Mood stabilizers (Carbamazepine in BZD/ ETOH withdrawal) • Miscellaneous: • • • Non-addicting medications Hydroxyzine (Vistaril) Melatonin Clonidine Gabapentin 71

Conclusions: Sleep Improvement Tools Sleep Log, Sleep Habits Formal Screening Sleep Hygiene Light therapy Personalized sleep plan CBT Sleep mentors Sleep Study CPAP 72

SMOKING CESSATION FOR PEOPLE WITH COOCCURRING DISORDERS 73

OVERVIEW • Prevalence and consequences of nicotine dependence in people with co-occurring disorders • Brief review of evidence for treatment in people with severe mental illnesses • Stage-based treatment approach with behavioral and pharmacologic interventions 74

Nicotine The number one addictive substance used by people who experience mental health and addictive disorders! Smokers die 25 years earlier than general public! 75

76 Ferron, et al 2011 Psych Serv

Toxins in smoke cause heart disease, cancer, lung disease, diabetes 77

PREMATURE MORTALITY BY HEART AND OTHER TOBACCO-RELATED ILLNESSES Data from Oklahoma 1996 -2000; Colton et al, 2006 CDC OTHER STATES LOOK THE SAME 78

Combined cessation treatments improve outcomes in smokers with severe mental illnesses (15+studies) Review: Effect sizes in Schizophrenia 0. 62 -0. 83 (Ferron 2009; Tsoi 2010) • Abstinence after treatment in VA patients with co-occurring disorders 6 -12 wk group +/- NRT or buproprion in VA setting 79 Gershon-Grand, 2007 J Clin Psych

SYMPTOMS REMAIN STABLE DURING CESSATION TREATMENT Scale for the Assessment of Negative Symptoms Positive and Negative Symptom Scale 80 Evins, 2007 J Clin Psychopharm

BRIEF MOTIVATIONAL INTERVENTIONS IMPROVE TREATMENT ENGAGEMENT Higher percentage of people initiated cessation treatment after an electronic decision support-system Brunette et al, 2011 Psychiatric Serv 81

MODELS OF INTEGRATED TREATMENT • Medical management • Brief meetings, support use of medications and coping (Williams et al, 2010 JSAT) • Cognitive behavioral therapy (Individual or group) • Teach self monitoring of urges and triggers • Teach coping with urges and triggers • Planning for quit day – other activities • Group support (Cather, Gottlieb, Evins et al, 2010 SRNT) • Contingency management 82

Alternatives to Tobacco • E-Cigarettes: • Does not address the habits associated with smoking • Designed and sold by the tobacco companies to reduce loss of income • Inhaling a substance which has unknown consequences • If it is anything other than oxygen, the lungs do not like it. 83

MEDICATION FOR SMOKING CESSATION • Nicotine Treatment • Gum • Patch • Lozenge • Zyban/Wellbutrin • Chantix (varenicline) • Combination treatment 84

WESTBRIDGE STAGE OF CHANGE APPROACH • Precontemplation - Engagement – develop treatment relationship, assess nicotine use on treatment entry, monthly CO monitoring and brief intervention. • Contemplation/Preparation - Persuasion – reassess, provide education, motivational counseling quarterly • • • Review pros and cons of tobacco use (financial, health, social) Provide peer models for quitting to increase social norms Increase self efficacy – teach skills, try medications Practice replacement activities Trials of NRT, periods of abstinence 85

WESTBRIDGE STAGE OF CHANGE APPROACH • Action - Active treatment - Provide medication and behavioral cessation treatment; support for long periods of time • Relapse prevention – ongoing medication and relapse prevention training, peer support for abstinence 86

Conclusions • Integrated Dual Disorder Treatment is an effective way to address cooccurring disorders. • IDDT concepts can be used systemwide or in a targeted manner. • IDDT can be modified to address opioid dependence, sleep disorders, and smoking cessation. 87

QUESTIONS 88

Contact Information: Feel free to contact us: tpulas@westbridge. org jmagnon@westbridge. org 7300 Grove Road Brooksville, FL 34613 Toll Free: FL # 1 -877 -461 -7711 1 -352 -678 -5553 89

• Allness, D. J. , & Knoedler, W. H. (1998). The PACT model of community-based treatment for persons with severe and persistent mental illness: A manual for PACT start up. (2 nd ed) Arlington, VA: NAMI • Mueser, K. T. , Noordsy, D. L. , Drake, R. E. , Fox, L (2003). Integrated treatment for dual disorders: A guide for effective practice. New York: Guilford Press. • Multiple articles available from NH-Dartmouth Psychiatric Research Center: Contact for resources. 90 References:

• Miller, W. R. , & Rolnick, S. (2002) Motivational Interviewing (2 nd ed. ): Preparing People for Change. New York: Guilford Press. • Prochaska, J. O. , Norcross, J. C. , & Di. Clemente, C. C. (1994) Changing for Good. New York: Avon Books. [Stages of Change] • Woods, Mary & Armstrong, Katherine (2012) When The Door Opened. Manchester, NH: West. Bridge 1361 Elm St. Manchester, NH 03101. www. westbridge. org 91 References:

References: • #35 Enhancing Motivation for Change in SA TX • #42 SA TX for Persons With Co- Occurring Disorders • http: //store. samhsa. gov/product/TIP-35 -Enhancing. Motivation-for-Change-in-Substance-Abuse. Treatment/SMA 12 -4212 • http: //store. samhsa. gov/product/TIP-42 -Substance-Abuse. Treatment-for-Persons-With-Co-Occurring. Disorders/SMA 12 -3992 92 • TIPS (SAMHSA)

References: • WWW. COCE. samhsa. gov • WWW. Homeless. samhsa. gov • WWW. ATTCnetwork. org • (The Addiction Technology Transfer Center Network) • WWW. nimh. nih. gov 93 • WEB SITES: