Pacific Southwest Addiction Technology Transfer Center UCLA Integrated Substance Abuse Programs

1. COD 101: A Clinical Look at Co-occurring Mental Health, Substance Use, and Physical Health Disorders Pacific Southwest Addiction Technology Transfer Center UCLA Integrated Substance Abuse Programs Dept. of Psychiatry & Biobehavioral Sciences, David Geffen School of Medicine at UCLA www.psattc.orgwww.uclaisap.org/dmhcod

2. UCLA ISAP Trainers: Thomas E. Freese, PhD (tfreese@mednet.ucla.edu) Albert Hasson, MSW (alhasson@ucla.edu) Grant Hovik, MA (ghovik@ucla.edu) Andrew Kurtz, MA, MFT (askurtz@mednet.ucla.edu) James Peck, PsyD(jpeck@mednet.ucla.edu) Beth Rutkowski, MPH (brutkowski@mednet.ucla.edu)

3. Working with communities to address the opioid crisis. • SAMHSA’s State Targeted Response Technical Assistance (STR-TA) Consortium assists STR grantees and other organizations, by providing the resources and technical assistance needed to address the opioid crisis. • Technical assistance is available to support the evidence-based prevention, treatment, and recovery of opioid use disorders. Funding for this initiative was made possible (in part) by grant no. 1H79TI080816-01 from SAMHSA. The views expressed in written conference materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services; nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.

4. Working with communities to address the opioid crisis. • The STR-TA Consortium provides local expertise to communities and organizations to help address the opioid public health crisis. • The STR-TA Consortium accepts requests for education and training resources. • Each state/territory has a designated team, led by a regional Technology Transfer Specialist (TTS) who is an expert in implementing evidence-based practices. Funding for this initiative was made possible (in part) by grant no. 1H79TI080816-01 from SAMHSA. The views expressed in written conference materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services; nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.

5. Contact the STR-TA Consortium • To ask questions or submit a technical assistance request: • Visit www.getSTR-TA.org • Email str-ta@aaap.org • Call 401-270-5900 Funding for this initiative was made possible (in part) by grant no. 1H79TI080816-01 from SAMHSA. The views expressed in written conference materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services; nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.

6. Acknowledgements This training was developed by the Pacific Southwest Addiction Technology Transfer Center, University of California, Los Angeles (UCLA) Integrated Substance Abuse Programs, Department of Psychiatry & Biobehavioral Sciences, David Geffen School of Medicine at UCLA.

7. Disclaimer The UCLA, its employees, contractors, and affiliates shall not be liable for any damages, claims, liabilities, costs, or obligations arising from the use or misuse of materials or information contained in this presentation.

8. Suggested Citation University of California, Los Angeles’ Integrated Substance Abuse Programs. (2016). Cognitive-behavioral therapy and relapse prevention strategies [PowerPoint slides]. Retrieved from http://www.uclaisap.org/

9. What We’ll Cover Today • Prevalence of co-occurring mental health, substance use, and physical health disorders • Review of drug categories • How drugs affect your brain and body • Strategies for working with clients with COD’s • Tips to accommodate cognitive deficits • Behavioral health interventions for medical conditions • Introduction to CBT for COD’s

10. RedefiningCo-Occurring Disorders

11. Co-Occurring Disorders and Your Clients • How do these individuals present? • What conditions are common? • What are the challenges of working with them?

12. Co-Occurring Disorders Are Common Druss, B.G., and Walker, E.R. (2011). SAMHSA (2018)

13. COD Prevalence Among Individuals with past-12 month SUD Any Substance Use Disorder Substance Dependence Grant et al., 2006; from National Epidemiologic Survey on Alcohol & Related Conditions

14. Past Year Substance Use and Severity of Mental Illness SAMHSA, NSDUH 2013

15. COD Prevalence Schizophrenia Over half of individuals with schizophrenia have tobacco use disorder and smoke regularly (DSM-V, 2013) Worldwide, estimates of co-occurring substance use range from 17%-90% (Chakraborty et al, 2014) Co-occurring SUD & schizophrenia associated with poorer outcomes and increased morbidity and mortality (Rosen et al, 2008)

16. COD Prevalence Schizophrenia • Nicotine, cannabis, and alcohol are the most frequently used substances • Neural mechanisms may be responsible • Deficits in GABA neurotransmitter (causes anxiety) • Most antipsychotic meds block transmission of dopamine • Can cause depressed mood, loss of interest & pleasure, and cognitive impairment • Substances can compensate for these deficits (Volkow, 2009)

17. COD Prevalence Schizophrenia Cannabis – also frequently used • A basic function of the endocannabinoid system in the human brain is to regulate emotional responses to stress • In part because of the deficit of GABA, individuals with schizophrenia may have difficulty coping with stressful situations • By stimulating the endocannabinoid system, cannabis may compensate for that deficit • It also likely alleviates dysphoria • Unfortunately, loss of gray matter appears to proceed twice as fast in cannabis-using schizophrenia patients (Volkow, 2009)

18. COD PrevalencePTSD Nearly 90% of women participating in substance abuse treatment report lifetime exposure to trauma (Reynolds et al., 2011) From 30% to 60% of these women present with current co-occurring PTSD and substance use disorders (Morgan-Lopez et al., 2013) There is a strong association between childhood experiences of trauma and adult psychopathology (Blanco et al., 2013)

19. COD PrevalencePTSD • Compared to individuals with PTSD only, individuals with PTSD and co-occurring alcohol dependence: • Meet more PTSD diagnostic criteria (severity) • Had earlier onset of PTSD • Are more likely to use alcohol & drugs to relieve their PTSD symptoms • Have difficulty expressing emotion • Have higher rates of impulsivity

20. COD PrevalenceADHD (International Collaboration on ADHD & Substance Abuse Research Group, 2013) • Recent study conducted in 10 countries • 1,205 patients at addiction treatment centers • 14% had adult ADHD • Those with ADHD, compared to those w/out ADHD: • More likely to report stimulants and cannabis as drug of choice • 75% had at least one co-occurring disorder in addition to SUD • 15% current hypomania • 30% Major Depressive Disorder • 31% Borderline PD

21. The Challenge of COD’s • Common disease treatments can make comorbid MH or medical problems worse • Antipsychotics & other psych meds can lead to weight gain, type 2 diabetes, and cardiovascular diseases. • Some meds for medical conditions have psych side effects or exacerbate MH symptoms • e.g., diuretics can cause anxiety and depressive symptoms • MH/SU symptoms can affect physical health • Paranoia can reduce usage of services • Disorganized thinking makes following medical treatments difficult • Impairs self-care Druss, B.G., and Walker, E.R. (February 2011).

22. How Expensive are COD’s? • Need more complex and expensive care • Higher rates of relapse • Higher rates of re-hospitalization • More frequent ER visits • Violence, suicide, homelessness, trauma • Increased morbidity and mortality • Broad scope of problems (medical, legal, social, interpersonal, homelessness, etc.) • Co-occurring disorders are the expectation, not the exception.

23. Adverse Effects of COD’s 1Brady et al., 1996. 2Ziedonis et al., 2005 3 DiClemente, Nidecker, & Bellack, 2008 • Behavior change more complex because clients often in different stages of change for each disorder1. • Poorer medication and treatment adherence compared to those with SMI alone2. • Motivational Interviewing can improve client engagement in psychosocial and medical treatment, including medication adherence. • Motivational Interviewing can be used for any behavior change

24. Why Are We Focusing on This? In the USA and Canada, mental health disorders account for 25% of all years of life lost to disability and premature mortality1 Among those who die by suicide, more than 90%have a diagnosable disorder4. In 2008, suicide was the tenth leading cause of death in the USA6. People with serious mental illness die about 25 years earlier (on average) than the general population.

25. Conceptualizing Co-Occurring Disorders

26. Mental Health, Substance Use, and Physical Health are Interconnected • Pathways/causes are complex and multi-directional • Substance use can cause symptoms similar to mental health disorders • Mental health disorders can lead to substance use • Medical disorders can lead to MH & SU disorders (and vice versa) • Having one type of disorder is a risk factor for developing another Druss, B.G., and Walker, E.R. (February 2011)

27. How Do We Conceptualize the Development of COD? Substance Use Mental Health ? 3 primary pathways in development of COD have been suggested:

28. Mental Disorder Substance Use Review of empirical literature found that anxiety disorders precede SUD in at least 75% of cases (Kushner et al., 2008) Stimulant treatment of ADHD was linked to a reduced risk for substance use disorders compared with no stimulant treatment, even after controlling for CD and ODD (Groenman et al., 2013) Improvements in PTSD symptoms have a greater impact on improving alcohol dependence than improving alcohol dependence has on reducing PTSD symptoms (Back et al., 2006) In some cases, treating the mental health disorder improves substance use

29. Substance Use Mental Health Problems Drug abuse changes the brain in fundamental, long-lasting ways Marijuana use increases risk of psychotic disorder in individuals with predisposition(Volkow ND et al., 2014) Abusers of MA have abnormalities in brain regions implicated in mood disorders (London, et al., 2004) More difficult to determine causality, but substance use certainly impacts mental health

30. Shared Risk Factors Involved • Both substance use disorders and other mental illnesses are caused by overlapping factors • Underlying brain deficits • Genetic vulnerabilities • Environmental triggers • Early exposure to stress or trauma • Drug use disorders and other mental illnesses are developmental disorders NIDA, 2011

31. Mental Health, Substance Use, and Physical Health are Interconnected Mental Health & Substance Use Druss, B.G., and Walker, E.R. (February 2011).

32. Conceptualization So where does of this leave us? Regardless of how they develop, Substance Use Disorders and other Mood or Anxiety Disorders become “functionally intertwined” in the maintenance of the co-occurring disorders such that each perpetuates the other What are the treatment implications of this?

33. Conceptualization of Treatment Common strategy in treatment of co-occurring disorders was to treat them sequentially, usually requiring substance abstinence before initiating treatment for the co-occurring disorder If the mood or anxiety disorder is in fact helping to maintain/perpetuate the SUD, this may be difficult if not impossible May be particularly challenging for people with PTSD to achieve sobriety before starting trauma-focused work

34. Vision of Fully Integrated Treatment • One program that provides treatment for both disorders • Mental and substance use disorders are treated by the same clinicians • The clinicians are trained in psychopathology, assessment, and treatment strategies for both disorders

35. Vision of Fully Integrated Treatment (cont’d) • The focus is on preventing anxiety rather than breaking through denial • Emphasis is placed on trust, understanding, and learning • Treatment is characterized by a slow pace and a long-term perspective • Providers offer motivational counseling

36. Vision of Fully Integrated Treatment (cont’d) • 12-Step groups are available to those who choose to participate and can benefit from participation • Pharmacotherapies are indicated according to clients’ psychiatric and other medical needs

37. Providers need to be knowledgeable about mental illness assessment and treatment Providers need to be knowledgeable about SUD assessment and treatment

38. Overview of Psychoactive Drugs

39. Why do people use drugs? Key Motivators & Conditioning Factors • Psychiatric disorders • Forget (stress / pain amelioration) • Functional (purposeful) • Fun (pleasure) • Social / educational disadvantages Also, initiation starts through: • Experimental use • Peer pressure

40. Classification • Drug effects depend on: • AMOUNT • FREQUENCY • DURATION of use • Make up of the user • Setting • Reactions to psychoactive substances can vary radically from person to person and situation to situation

41. Classifying psychoactive drugs

42. CNS Depressants (“Downers”) Opiates/Sedatives/Alcohol • Opium, morphine, heroin • Oxycodone/hydrocodone • Benzodiazapines/Xanax/Klonopin/Ambien Physical Effects • Depress CNS • Slow HR; reduce pain • Induce sleep • Perceptual impairment (dulls senses)

43. CNS Stimulants (“Uppers”) Stimulants • Cocaine (freebase; crack) • Amphetamines (crystal, speed, Adderall, Ritalin) • Plant-based (Khat) • Caffeine, Nicotine Physical Effects • Excessive CNS stimulation • Enhanced wakefulness; increased HR & BP • Euphoria; decreased appetite

44. Substances with Mixed Effects Hallucinogens/Psychedelics • Ecstasy • LSD • PCP • Mushrooms • Mescaline/Peyote Physical Effects • Distortion of perceptions • Alters sensory experiences • Elevated BP

45. Spice vs. “Spice”

46. Synthetic Drugs • Not really “Spice,” “Bath Salts,” or “Incense” • Chemically-based; not plant derived • Complex chemistry • Constantly changing to “stay legal” • Need to prove “intended to use” to convict in some areas

47. Short-Term Effects of Synthetic Marijuana • Loss of control • Lack of pain response • Increased agitation • Pale skin • Seizures • Vomiting • Profuse sweating • Uncontrolled spastic body movements • Elevated blood pressure • Elevated heart rate • Heart palpitations In addition to physical signs of use, users may experience severe paranoia, delusions, and hallucinations. SOURCE: Join Together Online, December 4, 2012.

48. Bath Salts vs. “Bath Salts”

49. Synthetic Cathinones:“Bath Salts” • Could be MDPV, 4-MMC, mephedrone, or methylone • Sold on-line with little info on ingredients, dosage, etc. • Advertised as legal highs, legal meth, cocaine, or ecstasy • Taken orally or by inhaling • Serious side effects include tachycardia, hypertension, confusion or psychosis, nausea, convulsions • Labeled “not for human consumption” to get around laws prohibiting sales or possession SOURCE: Wood & Dargan. (2012). Therapeutic Drug Monitoring, 34, 363-367.