# Presentation: 046587

## Methamphetamine Crisis:  Addiction and Mental Health Opportunity?

**Kathleen Masis M.D.**
** ****Billings Area Behavioral Health Conference**
**August 22, 2006**

## Tragedies 

**People with co-occurring MH and Addictive Disorders often seen in emergency rooms, jails, homeless shelters, on the streets, and in the obituaries.**

## What is necessary is to have reasonable expectations!

**A patient who has continuous low grade hallucinations will not continue to come to group sessions that he can’t understand.**
**A client with memory and cognitive disabilities won’t remember to keep her appointments.**
** ****Often meth is more accessible than services that are compatible with the person’s needs.**

## Methamphetamine causes severe mental illness (DSM-IV)

**Amphetamine-Induced Psychotic Disorder, with Delusions**
**Amphetamine-Induced Mood Disorder**
**Amphetamine-Induced Anxiety Disorder**
**Amphetamine-Induced Sleep Disorder**
**Amphetamine-Induced Psychotic Disorder, with Hallucinations**

## Methamphetamine causes psychiatric symptoms

**Amphetamine intoxication with perceptual disturbances**
**Amphetamine withdrawal**

## How can we deal with this epidemic?

**Our CD recovery programs were not designed to treat addiction to methamphetamine, heroin, and prescription drugs.**
**Our mental health programs are overwhelmed and often limited to crisis intervention only.**

## Now that everything is changing, is it not up to us to change ourselves?             Rilke 

## Co-occurring MH and Addictions

**27 yo male in ER**
**Brought by police**
**Combative, hallucinating**
**Intact reality testing**
**Treated with Haldol and Ativan**
**Calms down **
**Drug screen + meth and morphine**

## Co-Occurring Mental Health and Addictive Disorders

**42 yo female**
**Discharged from acute psych hospital**
**3 days after suicide attempt**
**Drug screen was positive for methamphetamine**

## Sound Familiar?

**Male from the ER is referred to the CD/Addiction counselor**
**Doesn’t keep appointment**

**Female from psych hospital is seen in follow up by the mental health provider**
**She is referred to the CD Program**
**Doesn’t keep appointment**

## Characteristics of Co-Occurring

**Clients don’t keep appointments**
**They have many treatment and living situation needs**
**Their treatment providers fail to communicate**
**It’s easy for them to fall through the cracks**
**They don’t have a lot of success**
**They tend to get blamed for not doing well**

## No single therapist, health care provider, or counselor can successfully treat clients with both severe mental illness and addiction.

## Integrated Treatment Model for Methamphetamine Dependence

## Stages of Treatment compared to Stages of Change

_**Patient’s stage of change**_**:      **_**Our role**_**:**
**Precontemplation               Engagement**
**Contemplation,                   Motivation**
**     ****Preparation                                                            **
**Action                                  Active Treatment       **
**Maintenance                       Relapse Prevention    **
-                                         Mueser, 2003

## Engagement: Strategies

**26 yo male with paraplegia, depression, and methamphetamine dependence**
**Stage:  Not engaged in treatment**
**Goal:  Establish working alliance with client**
**Interventions:  Outreach, practical assistance, crisis intervention**
-                                           adapted from Mueser, 1999

## Engaging the meth user in treatment

**Ambivalence is expected**
**Make treatment accessible**
**Provide support for being in treatment (food vouchers, transportation, onsite child care)**
**Respond quickly and positively when user makes contact with program**
**Convey empathic concern**
-                                      CSAT, 1999

##  Motivation

**14 yo  female came in for pregnancy test, has needle marks.  Mother is in clinic waiting room.**
**Stage: Not aware that substance abuse is a problem for her.  She is interested in the question of pregnancy, tho.**
**Goal: Assess, motivate towards change**
**Intervention: Urine drug test, (and pregnancy test,) interview mother. **
**Referral made to BH/CD. Worker meets pt and mother**
**Arrange for follow up with primary care doc/NP!**
**Motivational intervention.**

## Active Treatment Stage

**46 yo male with Hepatitis C, one month off meth, depressed**
**Stage: Motivated to reduce substance use**
**Goals: Help client develop plan for abstinence. Instill hope.**
**Interventions: Working relationship between MH, CD program  is evident to client.  Therapists and counselors are confident in ability to assist him.**

## Stages in Methamphetamine Treatment

**1.  Get started**
**2.  Get clean**
**3.  Stay clean**
**4.  Stay Healthy (Long-term abstinence support plan)**
-                                      adapted from CSAT, 1999

## Getting Started: what client/family need to know

**  **
**Feel “yucky”: **
** ****depression, fatigue, poor memory, trouble concentrating, irritability, craving for drug,**
**     ****sometimes paranoia**
**Lasts 10 days-2 weeks**
-                                                                                    CSAT, 1999

## Getting Started: what we need to do:

**Frequent, brief, supportive visits**
**Urine drug testing: mandatory, vigilant, frequent, and record of results protected by  42CFR regulations**
**Client is not kicked out of treatment for positive drug test**
**Instead, they are rewarded for clean urines (vouchers, etc.)**
**Assess co-occurring mental health disorders**
**Initiate treatment of MH disorders, including meds if needed**
**                                            ****CSAT, 1999**

## Get Started: Look for co-occurring disorders

**Multidimensional assessment needed**
**Look for safety/lethality issues**
**Environmental/Medical/Cognitive**
**If present, patient needs to go to Stabilization Placement immediately**
** **
**                                    **ASAM 2001

## First Face to Face Assessment

**Questions to answer: immediate**
**    ****stabilization placement, or F/U appt?**
**Danger to self or others?**
**Psychotic/paranoid?**
**Home is dangerous ?**
**Unstable medical condition?**

## Assess Barriers to Outpatient Treatment

**Malnourishment**
**Dental Deterioration**
**Pregnancy**
**Acute cognitive problems**
**Psychosis**
**Stage of readiness**
**Withdrawal symptoms (fatigue, depression)**
**                                          **ASAM 2001

## Motivational Intervention to remove barriers to treatment

**Address barriers to engagement in outpatient treatment**
**Provide Motivational, low-intensity services**
**Inpatient or outpatient**
**High structure/high frequency services**
**Family engagement**
**Medical**
**Dental**
**Psychiatric care**
-                                                  ASAM 2001

## Behavioral Health and Primary Care

**Depression/fatigue is a powerful motivation to resume use**
**Joining with the client to address these issues is treatment— not “enabling!”**
**BH treatment plan can include referral to Primary Care for evaluation and treatment of depression—meet and discuss your needs/expectations beforehand**
**CD and Clinic need to ask client for consent to discuss their case (sign release forms)**

## Getting Clean

**45 yo male with Hep C**
**One month off meth, has fewer cravings, mental status is clearing**
**Is depressed**
**Referred to MH from CD**
**Integrated treatment plan**
**Patient and family education on what to expect in recovery process**
**Recovery community can be immense help.**

## Getting Clean: Evidence-based Interventions

**Case-Management**
**Contingency Management**
**Matrix Model**
**Drug Court**
**Exercise, Nutrition**
**Couples Counseling**
**18 months of services**

## “Stay Clean”What patient/family need 

**Support, encouragement, support!**
**Dealing with relationships**
**Individualized services**
**Assessment of cognitive recovery**
**Assistance with life issues:**
**    ****Legal, child custody**

## “Stay Healthy” Relapse Prevention Stage

**35 yo female with diagnosis of amphetamine-induced psychosis with delusions**
**Stable on meds at home**
**Last use of meth was six months ago**
**Stage:  Relapse prevention**
**Goal: Extend recovery to other areas of life. Maintain awareness that relapse can happen. Stay on meds.**
**Interventions: Cultural/traditional resources, case management, stress management**

## MH and CD programs: engage each other

**Outreach—visit each other’s programs**
**In-services—offer to teach each other**
**Support—Ask clients for consent to consult with the other program whenever they are going to both programs**
**Speak the same language—bring trainers in, go to the same training.  **
**Doesn’t matter exactly what language you speak, as long as you understand each other!**

##   Agree that every client is unique.     Agree on terminology to describe client’s current status.   Get permission from client to consult about his/her case. Meet and/or discuss the case.  Support each other.  This is hard work.

## You are the experts:Your community’s treatment model is in your hands.

## Summary

**Our systems weren’t designed for today’s **
**    ****drug problems.**
**Our clients are sicker and have more psychiatric problems than ever before.**
**Evidence shows that integrated treatment is necessary for co-occurring MH and Addictions**
**We are starting with simple, (not easy) steps **
**   ****to integrate treatment for clients with co-occurring mental health and addictions.**

## References:

- American Psychiatric Association, DSM IV, 1994
- American Society of Addiction Medicine ( 2001)
-      _Patient Placement Criteria for the Treatment of Substance-Related Disorders_ (ASAM PPC 2R)
- Consensus Panel on Treatment of Stimulant Use Disorders, Center for Substance Abuse Treatment, SAMHSA, 1999
- Fox K.  Noordsy D.  Drake R  Fox L(2003) _Integrated Treatment for Dual Disorders,_ Dartmouth Psychiatric Research Center. New York: Guilford Press
- Rawson RA, Gonzales R, Brethen P (2002) Treatment of methamphetamine use disorders: an  update. _Journal of Substance_ _Abuse Treatment_ 23(2): 145-150