# Presentation: 189319

## Welcome

## Training CurriculumBased on TIP 43: Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs

- Module 11: TIP Chapter 12

## Course Goals

- The goals of this training are to...
- Familiarize you with the content of TIP 43; and
- Increase your awareness of issues related to medication-assisted treatment of opioid addiction.

## Module 11:Treatment of Co-Occurring Disorders

- During this module, you will:
- Identify common co-occurring disorders among patients who are opioid addicted;
- Study screening procedures for co-occurring disorders;
- List guidelines for diagnosis of co-occurring disorders;
- Identify factors affecting prognosis; and
- Investigate treatment issues.

## What Is a Co-Occurring Disorder?

- A mental disorder that coexists with at least one substance use disorder.
- Patients with co-occurring disorders often exhibit behaviors or feelings that interfere with treatment.
- Rapid, accurate identification of co-occurring disorders and immediate interventions improve MAT outcomes.
- Other types of disorders occur, such as cognitive and medical disorders and physical disabilities.
- These require individualized treatment approaches.

## Exhibit 12-1:Common Co-Occurring Disorders

- Axis I Categories.
- Mood disorders:  major depressive disorder, dysthymic disorder, bipolar disorder.
- Anxiety disorders:  generalized anxiety disorder, posttraumatic stress disorder (PTSD), social phobia, obsessive-compulsive disorder, panic disorders.
- Attention deficit/hyperactivity disorder (AD/HD).
- Schizophrenia and other psychotic disorders.
- Cognitive disorders.
- Eating disorders.
- Impulse control disorders.
- Sleep disorders.

## Exhibit 12-1:Common Co-Occurring Disorders

- Axis II Categories.
- Personality disorders:  antisocial personality disorder (APD), borderline personality disorder, narcissistic personality disorder.
- Studies comparing patients in MAT with the general population have confirmed higher rates of co-occurring Axis I and II disorders.

## Prevalence of Co-Occurring Disorders

- Some factors increase prevalence of co-occurring disorders among people with substance use disorders, including
- Older age;
- Lower socioeconomic status;
- Residence in urban areas;
- Homelessness; and
- Incarceration.
- Mental disorders and some affective and anxiety disorders are more prevalent among persons with substance use disorders than in the general population.

## Gender Differences inCo-Occurring Disorders

- Rates of co-occurring disorders differ between men and women.
- More women have affective and anxiety disorders.
- More men have APD and are dependent on alcohol.
- Women are more likely than men to have Axis I diagnoses and/or borderline personality disorders, and less likely to be diagnosed with APD or manifest problems with other substances.
- Female patients receiving methadone are more likely to have psychotic and affective disorders, and PTSD.

## Etiology of Co-Occurring Disorders

- Four common models explain the relationship between co-occurring and substance use disorders.
- Primary substance use disorder and secondary co-occurring disorder:  holds that substance use disorders cause most co-occurring disorders.
- Primary co-occurring disorder and secondary substance use disorder:  argues that preexisting mental disorders are a significant cause of substance use disorders.

## Etiology of Co-Occurring Disorders

- Common pathway:  shared genetic or environmental factors may cause both substance use and co-occurring disorders.
- Bidirectional model:  emphasizes socioenvironmental and interpersonal factors that contribute to both substance use and co-occurring disorders through interaction between environment and genetic susceptibility.

## Screening Procedures

- Admission and ongoing assessment routinely should incorporate screening for co-occurring disorders; a positive result should trigger detailed assessment.
- OTPs should establish specific screening procedures for co-occurring disorders.
- When possible, screening for co-occurring disorders should be linked with other assessments.

## Specific Screening Procedures

- Screening for co-occurring disorders usually entails determining:
- An applicant’s immediate safety and self-control;
- Previous diagnosis, treatment, or hospitalization for a mental disorder;
- Current co-occurring disorder symptomatology based on DSM-IV-TR criteria;
- Trauma history;
- History of mental disorder-related symptoms among immediate relatives; and
- Unusual aspects of an applicant’s appearance, behavior, and cognition.

## Screening for Cognitive Impairment

- Accuracy of screening instruments for co-occurring disorders may be compromised if administered to patients with cognitive impairments.
- Brief preexamination of cognitive functioning during mental status examination is recommended for individuals who are disoriented, have memory problems, or have difficulty understanding information in their first language.

## Screening Tools

- Important considerations in selecting a screening tool for co-occurring disorders include its psychometric properties and cultural appropriateness and, if the test is self-administered, the literacy level required.

## Diagnosing Co-Occurring Disorders

- After a possible co-occurring disorder is identified, an experienced, licensed mental health clinician should perform additional evaluation to make or confirm a diagnosis.
- The most widely used systems to classify mental and substance use disorders are provided in DSM-IV-TR and the International Classification of Diseases, 10th Edition (ICD-10).
- Both systems present diagnosis criteria accepted by national (DSM-IV-TR) or international (ICD-10) experts.

## DSM-IV-TR Criteria

- The DSM-IV-TR divides substance-related disorders into two types: substance use disorders and substance-induced co-occurring disorders.
- _Substance use disorders_.  DSM-IV-TR divides substance use disorders into abuse and dependence. It also makes distinctions pertaining to early or sustained remission; differences in programs; and treatment in a controlled environment.

## DSM-IV-TR Criteria

- _Substance-induced co-occurring disorders_.
- Substance-induced co-occurring disorders:  associated with intoxication, withdrawal, and the persistent effects of substances of abuse.
- Substance-induced *persisting* disorders: substance-related symptoms continue long after a person stops using a drug. Different drugs have been associated with different types of co-occurring disorders; some (such as opioids) have relatively few or no reported psychotoxic effects, whereas others have many.

## Interview Formatsfor Psychiatric Diagnoses

- Many instruments are available to determine DSM-IV or ICD-10 diagnoses. These include:
- Structured Clinical Interview for DSM-IV Axis I and II Disorders, Clinical Versions;
- Composite International Diagnostic Interview, Core Version 2.1;
- Psychiatric Research Interview for Substance Abuse and Mental Health Disorders;
- Diagnostic Interview Schedule, Version 4; and
- Alcohol Use Disorder and Associated Disabilities Interview Schedule.

## Differential Diagnosis

- Careful assessment is critical to determine whether symptoms indicate independent co-occurring disorders, disorders induced by substance use, or a general medical or neurological condition.
- Substance use can magnify symptoms of many co-occurring disorders, or increase the risk of suicide, violence, and impulsive behaviors among individuals with antisocial or borderline personality disorders.

## Differential Diagnosis

- Independent disorders tend to follow a typical course for each diagnosis and require specific, long-term treatment.
- Substance-induced disorders tend to follow the course of the substance use disorder itself and to dissipate with abstinence.

## Differential Diagnosis:  Timing

- Accurate diagnosis is difficult during the early phases of MAT.
- Definitive diagnosis often must wait until a patient is stabilized for a minimum of 5 to 7 days (but preferably 2 to 4 weeks) and substance use is eliminated.
- Symptoms of severe co-occurring disorders (e.g., suicidality, psychotic reaction) need prompt attention.

## Differential Diagnosis:  Guidelines

- To assist with a differential diagnosis, the following information should be collected and reviewed:
- Previous history of mental disorders and treatment, esp. substance use and response to previous treatment;
- Type, quantity or frequency, and time of last use of illicit substances or prescribed psychotropic drugs; and
- Family history of mental disorders.

## Differential Diagnosis:Primary or Secondary Disorders?

- DSM-IV-TR offers procedures to ascertain whether a co-occurring disorder is primary or secondary.
- Primary (not substance induced) if symptoms:
- Developed before substance use disorder;
- Persist during 30 days or more of abstinence;
- Inconsistent with or exceed those produced by the abused substance at the dosage used; and
- Are not better accounted for by substance use or another medical disorder.

## Differential Diagnosis:Primary or Secondary Disorders?

- Secondary (substance induced) if:
- Symptoms developed during periods of active substance use or within 1 month of intoxication or withdrawal;
- Symptoms consistent with intoxication or withdrawal from substances used;
- Other features atypical for primary co-occurring disorder; and
- Another co-occurring or medical disorder does not account better for symptoms.

## Diagnosing Co-Occurring Disorders:  What Have We Learned?

** **

## Treatment Outcomes

## Treatment Issues

- Co-occurring disorders should not exclude people with opioid addiction from admission to an OTP.
- The best strategy is to stabilize these patients’ opioid addiction while assessing their co-occurring disorder symptoms and choosing the most appropriate treatment course.

## Treatment Issues

- Six principles are essential to manage patients with co-occurring disorders in an OTP.
- Treatment should be integrated or closely coordinated.
- Staff members should be knowledgeable about treatments for both disorders.
- Psychotropic medications should be prescribed only after patients are stabilized on treatment medication, unless an independent co-occurring disorder is evident.

## Treatment Issues

- All medications should be monitored carefully. Physicians should be careful about prescribing substances with abuse potential.
- Patients should be assured that a psychiatric diagnosis can aid in treatment.
- Therapy for patients with co-occurring disorders should be more intensive. Primary goal is abstinence from substances; remission of co-occurring-disorder symptoms is secondary.

## Treatment Issues:  Group Research

## Resources and Review

- Exhibits 12-3 and 12-4, found on pages 203 and 204 in TIP 43, respectively, provide resources and topics for mutual-help groups
- What are some of the benefits of identifying and treating co-occurring disorders among patients who are addicted to opiates?

## Training CurriculumBased on TIP 43: Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs

- Module 11: TIP Chapter 12