Co-Occurring Treatment: Latest Trends The Circle Program at CMHIP: Fully Integrated Dual-Diagnosis Inpatient Treatment

1. Co-Occurring Treatment: Latest TrendsThe Circle Program at CMHIP:Fully Integrated Dual-Diagnosis Inpatient Treatment Elizabeth ‘Libby’ Stuyt, MD Medical Director, Circle Program Colorado Mental Health Institute at Pueblo 2012 Colorado Behavioral Healthcare Council Annual Training Conference September 28, 2012

2. Circle ProgramMission Statement To help persons with co-occurring mental illness and substance dependence learn how to maintain sobriety, psychiatric stability, medication compliance, social responsibility and personal integrity outside the hospital setting.

3. Circle Program • 20 bed, 90-day inpatient treatment program • Men and women, 18 - 65 • Dual diagnosis – substance abuse and mental illness • Abstinence based (no addictive medications) • Totally tobacco free since 2000 • Funded by the State of Colorado • Treating people who have failed everything else • 40 hours of group per week • Lots of written work

4. Treatment Team The treatment team consists of a board certified addiction psychiatrist, a psychologist, a social worker, a team leader, a recreational therapist, 6 registered nurses, 2 licensed psychiatric technicians, and 4 mental health workers, all of whom are at some level of Certified Addiction Counselors. Treatment team is also supported by chaplain services, registered dietitians, physical therapists, vocational therapists, occupational therapists, teachers for GED services and medical, surgical, and dental services to meet individual treatment needs.

5. Addiction is a disease of the learning and memory part of the brain • Treatment involves stopping the substances, allowing the brain to heal, and re-wiring the brain – enabling new learning • Cognitive/Behavioral Treatment • Dialectical Behavioral Therapy (DBT) • Strategies for Self-Improvement and Change (SSIC) • Relapse Prevention • Cue Exposure • Creating a society with societal rules that need to be followed (Behavioral Awareness)

6. People often start using and continue using substances as a way to cope with stress • Treatment also needs to teach people how to manage stress without using addictive substances • Stress Management Techniques • NADA acudetox – 5 point ear acupuncture • Other meridian therapies – TAT, EFT, TFT • Mindful Meditation, Yoga, Tai Chi, exercise • Biofeedback – Heartmath ® - based on heart rate variability - Cardiac Coherence

7. Patient Population • Patients come from all over the state of Colorado – 60% from the Denver-metro area • Patients are referred by mental health centers, DSS, ADAD, probation/parole officers, public defenders, judges • The program is voluntary and doors are not locked • 75% have legal problems and treatment is a condition of probation, parole or diversion

8. Application Process • Application and patient agreement must be complete and signed by the patient, we also need: • Current psychiatric assessment documenting mental illness diagnosis and current treatment • Documentation of previous substance abuse treatment, either inpatient or outpatient (DUI classes or detox don’t count) • Standardized Offender Assessment and/or resolution of pending charges if legal problems are present

9. What is the Circle Program? • Very intense, cognitive/behavioral program • 40 hours of group per week, 18 different groups, some meet once a week, some occur several times a week • Homework assignments from every group • Many rules – patients are expected to report themselves and peers for rule violations • Level system – based on Stages of Change

10. Groups – Based on Four Treatment Cornerstones • Relapse Prevention • Behavioral Change • Education • Origin of Issues

11. Relapse Preventionlearning to manage cravings and stress that lead to relapse • Resolutions (cue exposure response prevention) • Re-entry (recovery plan) • Recreational Therapy (voluntary exercise) • Support Groups (AA, DTR, voluntary 12-step group) • 5-point NADA ear acupuncture (voluntary) • Biofeedback training - Heartmath® • Thought Field Therapy (voluntary) • Yoga, Tai Chi, pool therapy, physical therapy (pain management)

12. Restorative Yoga

13. Not so restorative Yoga

14. Behavioral Change • HOPE group (Behavioral Awareness) • Gift system • Teaching tools • Peer coordinators • Strategies for Self-Improvement and Change (SSC 1) • Thinking reports • Addressing criminal thoughts and behaviors • Dialectical Behavioral Therapy (DBT)

15. Educational Groups • Recovery Education – how drugs and alcohol affect the body, how medications work, how different therapies work • Symptoms Management – signs and symptoms of mental illness • Discovery Group • Talk with the Doc

16. Origin of Issues Groups • Parenting • Men’s and Women’s Trauma/Process Group • Men’s and Women’s Anger Group

17. Individual Work • On admission – Plan of Care Formulation – given goals to work on for first month • Substance abuse • Mental health – diagnostic exploration worksheets • Physical problems – chronic pain management • Plan of Care Review – treatment team reviews work from previous month and assigns new work for the next month • Brain Synchronization Therapy

18. Successful Completion • Remaining the full recommended time in treatment • Completing all program components ex: parenting, SSC 1, re-entry, resolutions • Completing all written assignments from groups and on plan of care, including recovery plan • Not engaging in major rule violations • No continuous pattern of minor rule violations • Moving up in the level system

19. Level System • Developed to reflect “stages of change” model • All patients start out at level • Precontemplation • Staff determine levels on a weekly basis based on progress made on POC and homework, group attendance, documented major and minor rule violations

20. Levels • Precontemplation • Minimal compliance, not ready to make changes • Contemplation • Increasing but inconsistent compliance, thinking about change • Action • Decision to change, actively changing behavior • Ownership • Consistently demonstrating change and appropriate behavior

21. Effects of Creating Tobacco Free Treatment • Comparison of all patients treated in the six months before going tobacco free on January 1, 2000 and the years after going tobacco free. • In the six months before – patients allowed to go outside to smoke. • After going tobacco free patients are expected to completely refrain from tobacco use during the three months of treatment. • All patients are given a great deal of education regarding tobacco use and encouraged to quit. Tobacco is full integrated into every aspect of treatment.

22. Patient’s decision regarding tobacco use before and after program is tobacco free

23. So What Happens after Treatment? • Current Outcome study – following patients for one year after completing 3 months inpatient treatment in a tobacco free environment • Self-report, probation officer, family member • 231 consecutive admissions and discharges from January 1, 2009 – December 31, 2011 • 80% successfully completed program (n=185) • Of those eligible (179), 86% enrolled to participate in outcome study (n=154) • By December 31, 2011, 68% completed the one year follow-up (n=105)

24. Demographics of 231 patients admitted and discharged 2009-2011 • 55% male • 78% Caucasian, 15% Hispanic, 6% African American, 1% Asian • Age = 35 ± 11 years (18 – 65) • Primary Drug Dependence • 33% Alcohol • 31% Polysubstance • 15% Methamphetamine • 10% Cocaine • 7% Opiates • 4% Cannabis • Nicotine Dependence – 88%

25. Psychiatric Diagnoses • Primary Psychiatric Diagnoses • 29% PTSD • 22% Depression • 17% Bipolar • 12% Anxiety • 10% Schizophrenia/Schizoaffective • 6% Substance Induced psych symptoms • 4% Other • 79% have an Axis II diagnosis • 34% Borderline Personality disorder • 16% Antisocial Personality disorder

26. What determines program completion? • No difference by gender (p=.4104) • No difference by race (p=.3402) • No difference by age (p=.1258) • No difference by primary psychiatric diagnosis (p=.4834) • No difference by primary drug dependence (p=.4898) • No difference by number of previous treatment programs attended (p=.8792) • No difference by tobacco use on admission (p=.08) • Mean LOS for completers = 87 ± 7 days • Mean LOS for non-completers = 40 ± 22 days

27. Presence of Axis II diagnosis affects program completion • 98% of those with no personality disorder diagnosis completed the program • 87% of those with Borderline Personality completed the program • 59% of those with Antisocial Personality) completed the program • p<.0001

28. Attitude regarding tobacco predicts program completion • 67% of those who used tobacco while in treatment versus 83% of those who did not use tobacco completed the program (p=0.02) • 48% of those planning to use tobacco ASAP after discharge, completed the program versus 93% who were planning to attempt to stay quit or expressed ambivalence regarding tobacco use (p<.0001)

29. Other factors aiding in program completion • Having a probation officer and accountability • 85% on probation completed • 71% of the voluntary patients completed • 53% of civil commitments completed • p=.0013 • NADA acudetox appears to help with program completion • Those completing had 12 ± 9 acudetox sessions • Those not completing had 5 ± 5 sessions • p<.0001

30. Patients using tobacco were more likely to use NADA acudetox and were more likely to remain in treatment longer the more sessions they had. p=.2616 p<.0001

31. p=.2714 p=.001 p=.2879 p=.4896

32. Attitude about Tobacco Use as a predictor of outcome

33. 86% of the 58 patients with Borderline PD completed treatment and they remained significantly longer in treatment the more acudetox sessions they had (averaging 13 ± 9 sessions) p=.0454

34. 98% of the 44 patients with no Axis II diagnosis completed treatment and averaged 13 ± 9 acudetox sessions p=.2007

35. Preliminary Data – as of January 2012 • 105 patients have completed one year follow-up after discharge from the program. Information obtained on 101 for full year, 4 were lost to follow-up • 54% sober and doing well at end of year • 30% continuously abstinent • 16% relapsed but got back on track • 7% one or more slips but back on track • 22% continuing to relapse • 19% re-offended and incarcerated • 4% deceased • 2% relapsed and back in treatment

36. There was no difference between status at the end of the year and: • Gender (p=.6837) • Race (p=.4738) • Primary drug dependence (p=.7149) • Primary psych diagnosis (p=.8409) • Tobacco use prior to admission (p=.7068) • Legal status (p=.2617) • Presence of Axis II diagnosis (p=.0518)

37. Tobacco use was significantly correlated with relapse • Non-tobacco use increased from 12% to 25% at the end of the year. • Those using tobacco were much more likely to relapse. (p=.012) • Those continuously abstinent were more likely to not be using tobacco. (p=.0326) • For those who relapsed to drugs or alcohol • 9 ± 4 months to first relapse for non-tobacco user • 6 ± 5 months to first relapse for tobacco user (p=.0117)

38. Cost Benefits of Program • First 40 patients in outcome study who were referred to Circle as a condition of probation • 21 (52%) sober and doing well at the end of the year. 9 (23%) relapsed but still on probation successfully, 8 (20%) re-offended and incarcerated, 2 (5%) deceased. (January 2011) • All 40 were looking at a 2-6 year term in DOC if not successful in Circle • Average of 3 previous inpatient treatment programs prior to Circle without benefit • Most had already spent considerable time in and out of jail/prison proving just incarceration doesn’t work

39. How Circle Saves the State of Colorado Money • Cost of three months at Circle - $36,000 • Cost one year general population DOC $36,000 • Cost of one year DOC-TC - $73,000 • 40 X 72,000 (2yrs DOC-GP) = $2,880,000 • 40 X 36,000 (1 yr DOC-GP) + 40 X 73,000 (1 yr DOC-TC) = $4,360,000 • 40 X 36,000 (Circle 3 mos) = $1,440,000 • 40 X 36,000 (Circle 3 mos) + 8 X 72,000 (20% recidivism – 2 yrs DOC-GP) = $2,016,000 • 2,880,000 – 2,016,000 = $ 864,000 • 4,360,000 – 2,016,000 = $ 2, 3440,000