Dual Diagnosis describes the co-occurring problems of mental illness and substance misuse. However, the term 'dual' is something of a misnomer - the needs of this client group are often highly complex and extend beyond the relatively simplistic scenario implied by the term 'dual diagnosis'. This course uses realistic scenarios to enable participants to look at the reasons why mentally ill clients are so prone to drug and alcohol problems, the potential consequences of dual diagnosis, and current assessment and treatment approaches Duration: half-day. one day, or two day options Experience: None required This course is suitable for: all staff currently working within health and social care settings in the United Kingdom. The course is designed to meet the training needs of domiciliary care agencies, care home or hospital settings and all staff. The course is also ideal for carers. Number of Trainees: 15 maximum Course Standard: Certificate of attendance Equipment Needed: Hand-outs will be provided Candidates will cover: •Definitions of dual diagnosis and co-morbidity. •Possible reasons for substance misuse in those with mental health difficulties •Effects of substance misuse on those with mental health difficulties By the end of the course Candidates will be able to: •Discuss the relationship between substance misuse and mental health problems •Describe the risk factors associated with these behaviours •Understand the skills that are necessary to effectively work with clients who have dual diagnosis

1. 1-day
Working with Mental Illness and Harmful
Substance Abuse
Cambian Fountains
March 2nd 2016
Tutor: Patrick Doyle
Last updated: 27.09.15 1

2. Learning objectives
To gain an understanding of what dual diagnosis means
To become more familiar with the multiple factors that
may contribute to substance/drugs use in this client group
To establish facts and myths surrounding the links and
relationships between drug/substance use/misuse and
mental health
Reflect on your own use of legal drugs/substances
To be aware of the approaches/interventions that may
best help this client group
2

3. Thinking about you own use of
legal drugs/substances
• Do you enjoy a drink of beer, wine or spirits?
• Do you smoke?
• Do you like caffeinated drinks such as tea and
coffee?
• Does your own use of the above drugs/substances
ever exceed ‘healthy limits?’
• Would you be willing to give up these ‘pleasures’ if
someone else told you to? Why?
3

4. Definitions
• Dual Diagnosis
• Combined mental health and substance use
problems
• More than “dual problems”- likely to have
complex health and social needs
• Wide range of people with varying degrees of
need
• need individualised treatment
4

5. NICE Definition
substance misuse is defined as
intoxication by – or
regular excessive consumption of and/or
dependence on – psychoactive substances,
leading to social, psychological, physical or
legal problems. It includes problematic use of
both legal and illegal drugs (including alcohol
when used in combination with other
substances).
5

6. Policy Drivers and related Documents
• Dual Diagnosis Good Practice Guide (2002)
• Inpatient Dual Diagnosis Guidance (2006)
• Standards for Better Health
• NIMHE Suicide Toolkit
• NSF 5 Years On
• Health Care Commission
• Themed review in dual diagnosis
• The management of Dual Diagnosis in prisons (2009)
6

7. Substance Abuse
A maladaptive pattern of use leading to impairment, in
at least one of the following, occurring within a 12-
month period:
• recurrent substance use resulting in a failure to
fulfill major role obligations at work, school, or
home
• recurrent substance use in situations in which it is
physically hazardous
• recurrent substance-related legal problems
• continued substance use despite having persistent
or recurrent social or interpersonal problems
caused or exacerbated by the effects of the
substance
DSM-V
7

8. Substance Dependence
A maladaptive pattern of use, leading to impairment as manifested by
three (or more) of the following, occurring at any time in the same 12-
month period:
• tolerance
• withdrawal
• the substance is often taken in larger amounts or over a longer
period than was intended
• there is a persistent desire or unsuccessful efforts to cut down
or control substance use
• a great deal of time is spent in activities necessary to obtain the
substance, use the substance, or recover from its effects
• important social, occupational, or recreational activities are
given up or reduced because of substance use
• the substance use is continued despite knowledge of having a
persistent or recurrent physical or psychological problem that is
likely to have been caused or exacerbated by the substance
DSM-V
8

9. Substance-Related Disorders
• 2 Groups:
– Substance Use Disorders
• Previously split into abuse or dependence
• Involves: impaired control, social impairment, risky use,
and pharmacological criteria
– Substance-Induced Disorders & Pre-existing
Disorders exacerbated by substance misuse:
– Drug abuse, including alcohol and prescription drugs,
can induce symptomatology which resembles mental
illness, which can make it difficult to differentiate
between substance induced psychiatric syndromes
and pre-existing mental health problems.
9

10. Substance-Induced
• Intoxication
• Withdrawal
• Psychotic Disorder
• Bipolar Disorder
• Depressive Disorder
• Anxiety Disorder
• Sleep Disorder
• Delirium
• Neurocognitive
• Sexual Dysfunction
10

11. Severity
• Severity
– Depends on # of symptom criteria endorsed
– Mild: 2-3 symptoms
– Moderate: 4-5 symptoms
– Severe: 6 or more symptoms
11

12. Withdrawal
• Substance-specific syndrome problematic
behavioral change due to stopping or
reducing prolonged use
• Physiological & cognitive components
• Significant distress in social, occupational
or other important areas of functioning
• Not due to another medical condition or
mental disorder
• No withdrawal: PCP; other hallucinogens;
inhalants
12

13. Tolerance
• Need to use an increased amount of a
substance in order to achieve the desired
effect
OR
• Markedly diminished effect with continued
use of the same amount of the substance
13

14. Dual Diagnosis Good practice Guide 2002
• Mainstreaming
• Doesn’t advocate a separate DD services, but advocates
services that can support mainstreaming
• Mental health services should take primary responsibility
for those with serious mental health problems (like
schizophrenia) and substance use
• AOT likely to provide care for those with dual diagnosis
as typically hard to engage and chaotic users of services
• Substance use services should take primary
responsibility for those with primary substance problems
and common mental health problems (anxiety,
depression)
• However mental health and substance use services
should work together and support each other
14

15. Examples of Dual Disorders:
• MENTAL DISORDERS
– Schizophrenia
– Bi-polar
– Schizoaffective
– Major Depression
– Borderline
Personality
– Post Traumatic
Stress
– Social Phobia
– others
• ADDICTION
DISORDERS
– Alcohol
Abuse/Depen.
– Cocaine/ Amphet
– Opiates
– Marijuana
– Polysubstance
combinations
– Prescription drugs
15

16. Dual Disorders for Everyone?
• If applied to all cases, Term has no meaning
– (eg Spider phobia and “Running Addiction”)
• Both Mental and Addiction Disorders need to be over
threshold
• Personality Disorders, other than Borderline not usually
counted
• Substance Induced Disorders cause diagnostic confusion
16

17. Consequences of Dual Diagnosis
• Increased likelihood of self-harm and violence
• Poor physical health (including HIV, hep B and C)
• Frequent relapse and re-hospitalisation
• Higher rates compulsory detention
• Forensic mental health care and criminal justice system
• Higher overall risk of untoward incidents
• Difficulty getting access to appropriate aftercare
• Poor medication adherence
• Family problems
• Homelessness
• Higher overall service costs
• Higher levels of social exclusion
17

18. The Four Quadrant Framework for
Co-Occurring Disorders
A four-quadrant
conceptual framework
to guide systems
integration and
resource allocation in
treating individuals with
co-occurring disorders
(NASMHPD,NASADAD,
1998; NY State; Ries,
1993; SAMHSA Report
to Congress, 2002)
Not intended to be used
to classify individuals
(SAMHSA, 2002),
but . . .
Less severe
mental disorder/
less severe
substance
abuse disorder
More severe
mental disorder/
less severe
substance
abuse disorder
More severe
mental disorder/
more severe
substance
abuse disorder
Less severe
mental disorder/
more severe
substance
abuse disorder
High
severity
High
severity
Low
severity
18

19. What is ‘dual diagnosis?’
• ‘The co-existence of psychiatric disorder
and substance misuse’ (Crome et al. 2004)
• ‘…a broad spectrum of mental health
and substance misuse problems that an
individual might experience concurrently’
(DOH 2002).
• ‘Dual diagnosis is a label they give you,
but even at my most buoyant I think I’ve
got more than two problems’ (Quote from a
Service user taken from Rethink 2007)
19

20. Is the term ‘dual diagnosis’ helpful?
Some points to consider
• A professional term.
• A broad term, at best, promotes an understanding
of two interwoven complex conditions.
• Provides a conceptualisation of the phenomenon of
substance misuse and mental health
• Too narrow a focus? More than just 2 problems?
• Medicalised?
• Misleading?
• A vague and yet stigmatising label?
20

21. Common MH Problems in
DD
Depressive disorders
– Depression
– Bipolar disorder
Anxiety disorders
– Generalised anxiety
disorder
– Panic disorder
– OCD
– Phobias
Other psychiatric disorders,
– Schizophrenia
– Personality disorders
– ADHD,PTSD
Common Addictions in DD
Substance Addictions
- Alcoholism
- Street drug addiction
- Prescribed drug
addiction
Behavioural Addictions
- Gambling addiction
- Sex addiction
- Food addiction
21

22. How common is ‘dual diagnosis?’
• ‘Substance misuse is usual rather than exceptional
amongst people with mental health problems’ (DOH
2002)
• May affect between 30 to 70% of those presenting to
health and social care settings (Crome et al. 2009).
• At the same time, approximately 50% of patients in
drug & alcohol services have a mental health problem
(Rethink 2007).
• First-episode psychosis: A sample of 168 young
people showed that 37% of the sample reported drug
use, drug misuse and alcohol misuse (Cantwell et al.
1999).
22

23. Why do people with mental health problems
use or misuse drugs/substances? (1)
• As varied as the individuals themselves
• Socially excluded, may find a sense of belonging and
community with other drug users
• Counteract the unpleasant side-effects of prescribed
psychiatric medication such as limb stiffness, involuntary
movements, sexual dysfunction.
• Increase energy levels and motivation by stimulating
nervous system
• Numb or mask painful thoughts and feelings
• Alleviate intensity and distress from auditory
hallucinations
• Aid sleep
23

24. Why do people with mental health problems
use or misuse drugs/substances? (2)
• Shorted-lived sense of euphoria and confidence
• Vulnerability: may be a ‘soft’ target for drug
dealers
• Boredom/unemployment
• ‘Anti-depressants not always enough’
• ‘Living on the streets-to keep a lid on it’
• Enjoyment
• Availability-
• Peer pressure
• To reduce marked periods of mania/excitability
24

25. Do substances/drugs cause mental
health problems?
• There remains on-going debate about the extent to which
substance/drug use causes mental health problems?
• More agreement reached that drug/substance misuse can
‘enhance’, ‘exacerbate’ or ‘trigger’ in individuals who are
pre-disposed to mental health problems.
• Substance/drug use can also mask a mental health
problem which is later revealed when use is ceased.
• Earlier age of onset of first-episode psychosis is proposed in
young people with a vulnerability to schizophrenia and who
misuse substances (Addington & Addington 1998). May
act as a trigger.
25

26. What ‘dual diagnosis’ may mean for
services & carers/families
• Pessimistic attitudes and values: could be viewed
as ‘criminal’, ‘manipulative’, ‘aggressive’, ‘intoxicated’,
‘bringing it on themselves’.
• May be viewed by services as ‘problematic’ or
‘revolving door’.
• Preoccupations with ‘what came first’- whose
responsibility is it?
• Restrictive ‘gate-keeping’ practices
• In a climate of finite resources, may be removed from
caseload list for poor or non-engagement with
appointments
26

27. What may dual diagnosis mean for
service users?
• ‘ I was pushed around like a tennis ball. The
alcohol people said I had a mental illness and
the mental illness group said I had a drink
problem. Neither of them did very much for
me’ (Rorstad & Chesinski 1996).
• ‘Passing the book’
• May not be ready to address their substance misuse
problems, when their carers and professionals believe
they should.
• May perceive their issues differently and may not view
their substance use or mental ill-health as a problem
• Previous contact with services may have been negative
and consequently, there may be poor engagement or
mistrust.
27

28. Assessment of Dual Diagnosis
The possible relationships
between addictions
and psychiatric symptoms or
disorders
are the following:
(according to McDowell & Spitz, 1999):
28

29. 1. Primary Mental Illness
Many psychiatric disorders can lead to symptoms
associated with many addictions.
Example:
Depression Alcoholism
Pathways: Self-soothing, self-medicating, self-
damage
29

30. 2. Primary Addiction, including Withdrawal
Symptoms:
Many addictions can lead to symptoms associated
with almost any psychiatric disorder.
Example: Alcoholism Depression
30

31. 3.Simultaneous and independent conditions.
One disorder may prompt the emergence of the
other, or the two disorders may exist independently.
Example:
History of Depression (inc. family)
History of Alcoholism (inc. family)
31

32. Alcohol
–What % admission have alcohol or
drugs associated
–What % of all hospital deaths
–21bn per year in health care costs
(Alcohol Concern)
–Ax up 37% in last 10 year
–Alcohol 61% more affordable than in
1980
32

33. Theories
• Find out the different explanations or
models of dual diagnosis
• What is the Aetiology of Dual Diagnosis
33

34. Etiology
• Multiple interacting factors influence using
behavior and loss of decisional flexibility
• Not all who become dependent experience
it same way or motivated by same factors
• Different factors may be more or less
important at different stages (drug
availability, social acceptance, peer
pressure VS personality and biology)
34

35. Etiology
• “Brain Disease” – changes in structure and
neurochemistry transform voluntary drug-
using becomes compulsive
• Changes proven but necessary/sufficient?
(drug-dependent person changes behavior
in response to positive reinforcers)
• Psychodynamic: disturbed ego function
(inability to deal with reality)
35

36. Etiology
• Self-medication
– panic; opioids -anger; amphetamine -
depression
• Genetic (well-established with alcohol)
• Conditioning: behavior maintained by its
consequences
– Terminate aversive state (pain, anxiety, w/d)
– Special status
– Euphoria
– Secondary reinforcers (ex. Paraphernalia)
36

37. Learning and Physiological Basis for
Dependence
• After drug or abstinence – leads to a
depleted state resulting in dysphoria
and/or cravings to use, reinforcing the
use of more drug.
• Response of brain cells is to down
regulate receptors and/or decrease
production of neurotransmitters that are
in excess of normal levels.
37

38. Drug Induced Psychopathology
Drug States
• Withdrawal
– Acute
– Protracted
• Intoxication
• Chronic Use
Symptom Groups
• Depression
• Anxiety
• Psychosis
• Mania
• Rounsaville ‘90
38

39. Comorbidity
• Up to 50% of addicts have comorbid
psychiatric disorder
– Antisocial PD
– Depression
– Suicide
39

40. Exercise
• What has made you angry, sad, happy,
distressed, frustrated, stressed recently?
• How did you react/ cope?
40

41. Four guiding principles to aid engagement
• Known as R.U.L.E ( Rollnick, Miller &
Butler 2008).
• Resist the Righting Reflex
• Understanding the Service User’s
Motivations
• Listen to the Service User
• Empower the Service User
41

42. Ask the service user
• Best way to detect substance use/misuse is to ask
users in an open and frank way
• Ask sympathetically and reassure that negative
consequences will not automatically follow
• Might be important to initially consider asking service
users on their own (although don’t wholly exclude
families, carers or friends).
• Slang terms can vary across the country- Be clear
about misunderstandings or misuse of drug-using
terminology.
42

43. Interventions
• Establishing a therapeutic alliance
• Focus on ‘engaging’ with the service user – be flexible
in your approach
• Maintain an holistic focus
• Consider that ‘reduction’ may be more realistic than
‘abstinence’
• Provide advice and information
• Accept that ‘setbacks’ can occur- that drug/substance
reduction does not always move along in an linear
mode
43

44. Who is at Risk?
44

45. NON- severely mentally ill co-occurring
patients?
• Like in Addiction Treatment settings
• Like in Criminal Justice settings
• Like in Primary Care Settings
• Like in ER’s, especially with suicidal pts
• The new TIP will bring more focus on
these populations
45

46. Forensic Units
• Studies have shown prevalence of use toward upper end of range in
both medium and high security patients (Steele et al, 2003; Da Silva
et al, 2003, Madden et al, 1999; Beck et al 2002)
• Isherwood et al (2001) found 57% of consecutive referrals to a
forensic psychiatric service in London had an ICD 10 diagnosis of
substance misuse
• In a national review of MSU’s, Melzer et al (2000) found that 58% of
patients had social or health problems related to substance misuse
46

47. Young people at risk
• those whose family members misuse
substances
• those with behavioural, mental health or
social problems
• those excluded from school and truants
• young offenders
47

48. Young people at risk
• looked after children
• those who are homeless
• those involved in commercial sex
work
• those from some black and minority
ethnic groups.
• Recent increase in human trafficking
48

49. Likelihood of a Suicide Attempt
Risk Factor
• Cocaine use
• Major Depression
• Alcohol use
• Separation or Divorce
NIMH/NIDA
Increased Odds Of
Attempting Suicide
62 times more likely
41 times more likely
8 times more likely
11 times more likely
ECA EVALUATION
49

50. Clues to Primary Problem
(not always clear)
• Began before serious secondary problem
• Persists during remission periods of
secondary problem
• Severity of symptoms in relation to
moderate levels of secondary problem
• Chronic, acute, uniqueness of symptoms
• Family history
50

51. It may not be that the med(s) stopped
working, but……
• The patient stopped the med
• The patient stopped the med AND used drugs
and/or alcohol…...
• OR lowered the med and used…
• OR used on top of the med….
• OR used twice the dose on one day and
nothing the next….
• Stimulants ( cocaine/amphets) are most MSE
destructive.
51

52. RISKS OF NON-DETECTION
• Misdiagnosis
• Inadequate treatment planning
- Suboptimal pharmacological treatment for both
- Neglect of interventions for substance misuse
- Inappropriate referrals
• Poor treatment outcomes
e.g. - relapse
- rehospitalisations
• Economic/service costs
• Poor experience of services
52

53. Drugs
53

54. Substance Classes
• Alcohol
• Caffeine
• Cannabis
• Hallucinogens
– PCP
– others
• Inhalants
Gambling
• Opioids
• Sedatives, hypnotics,
and anxiolytics
• Stimulants
• Tobacco/ Nicotine
• Other
54

55. Alcohol
55

56. ALCOHOL: Effect on mental health and some interactions with
commonly used psychotropic medications:
Alcohol is a central nervous system (CNS) depressant.
• Exacerbates depression
• Disinhibiting effect, suicide attempts more likely (15% people with serious
drinking problems kill themselves and most who do so are depressed)
• Sedative effects of antidepressants exacerbated and action impaired
• Exacerbates mania – increases likelihood and level of disinhibited behaviour
• Increases sedative effects of anti-psychotic medication
• Psychotic symptoms common as part of alcohol withdrawal syndrome
Long term delusional disorders and dementias noted
with prolonged and heavy use
Georgiou (1999)
56

57. ALCOHOL- CNS depressant
• Intoxication
 Blood Alcohol Level -
0.08g/dl
 Progress from mood
lability, impaired
judgment, and poor
coordination to
increasing level of
neurologic impairment
(severe dysarthria,
amnesia, ataxia,
obtundation)
 Can be fatal (loss of
airway protective
reflexes, pulmonary
aspiration, profound CNS
depression)
57

58. Alcohol Withdrawal
• Early
– anxiety, irritability, tremor, insomnia, nausea,
tachycardia, hyperthermia, hyperactive reflexes
• Seizures
– generally seen 24-48 hours
– most often Grand mal
• Withdrawal Delirium (DTs)
– generally between 48-72 hours
– altered mental status, hallucinations, marked
autonomic instability
– life-threatening
58

59. Alcohol Withdrawal (cont.)
• Benzodiazepines
– GABA agonist - cross-tolerant with alcohol
– reduce risk of seizures; provide comfort/sedation
• Anticonvulsants
– reduce risk of seizures and may reduce kindling
– helpful for protracted withdrawal
– Carbamazepine or Valproic acid
• Thiamine supplementation
– Risk thiamine deficiency (Wernicke/Korsakoff)
59

60. Alcohol treatment
• Outpatient CD treatment:
– support, education, skills training, psychiatric
and psychological treatment, AA
• Medications:
– Disulfiram
– Naltrexone
– Acamprosate
60

61. Medications - Alcohol Use Disorder
• Disulfiram (antabuse) 250mg-500mg po daily
– Inhibits aldehyde dehydrogenase and dopamine beta
hydroxylase
– Aversive reaction when alcohol ingested- vasodilatation,
flushing, N/V, hypotenstion/ HTN, coma / death
– Hepatotoxicity - check LFT's and h/o hep C
– Neurologic with polyneuropathy / paresthesias that slowly
increase over time and increased risk with higher doses
– Psychiatric side effects - psychosis, depression, confusion,
anxiety
– Dermatologic rashes and itching
– Watch out for disguised forms of alcohol - cologne, sauces,
mouth wash, OTC cough meds, alcohol based hand sanitizers,
etc
61

62. Medications - Alcohol Use Disorder
• Naltrexone 50mg po daily
– Opioid antagonist thought to block mu receptors
reducing intoxication euphoria and cravings
– Hepatotoxicity at high doses so check LFT's
• Acamprosate(Campral) 666mg po tid
– Unknown MOA but thought to stabilize neuron
excitation and inhibition - may interact with GABA and
Glutamate receptor - cleared renally (check kidney
function)
62

63. Depressants
• Barbiturates, Benzodiazepines, GHB, Rohypnol,
Quaalude
• How Consumed: swallowed, injected
• Effects: reduced anxiety, feeling of well-being, lowered
inhibitions, slowed pulse and breathing, lowered blood
pressure, poor concentration
• Consequences: fatigue, confusion, impaired
coordination, memory, judgment, respiratory depression
and arrest, death
63

64. Benzodiazepine( BZD)/
Barbiturates
64

65. Benzodiazepine( BZD)/ Barbiturates
• Intoxication
– similar to alcohol but less cognitive/motor
impairment
– variable rate of absorption (lipophilia) and
onset of action and duration in CNS
– the more lipophilic and shorter the duration of
action, the more "addicting" they can be
– all can by addicting
65

66. Benzodiazepine
• Withdrawal
– Similar to alcohol with anxiety, irritability, insomnia, fatigue, HA,
tremor, sweating, poor concentration - time frame depends on
half life
– Common detox mistake is tapering too fast; symptoms worse at
end of taper
– Convert short elimination BZD to longer elimination half life drug
and then slowly taper
– Outpatient taper- decrease dose every 1-2 weeks and not more
than 5 mg Diazepam dose equivalent
• 5 diazepam = 0.5 alprazolam = 25 chlordiazepoxide = 0.25 clonazepam = 1
lorazepam
– May consider carbamazepine or valproic acid especially if doing
rapid taper
66

67. Benzodiazapines
• Alprazolam (Xanax) t 1/2 6-20 hrs
• *Oxazepam (Serax) t 1/2 8-12 hrs
• *Temazepam (Restoril) t 1/2 8-20 hrs
• Clonazepam (Klonopin) t 1/2 18-50 hrs
• *Lorazepam (Ativan) t1/2 10-20 hrs
• Chlordiazepoxide (Librium) t1/2 30-100 hrs
• Diazepam (Valium) t ½ 30-100 hrs
67

68. Opoids
68

69. Opiods
• Codeine, heroin, morphine, opium,
Oxycodone, Hydrocodone
• How Consumed: injected, swallowed,
smoked, snorted
• Effects: pain relief, euphoria, drowsiness
• Consequences: nausea, constipation,
confusion, sedation, respiratory
depression and arrest, unconsciousness,
coma, death
69

70. OPIOIDS
Bind to the mu receptors in the CNS to modulate pain
• Intoxication- pinpoint pupils, sedation, constipation,
bradycardia, hypotension and decreased respiratory rate
• Withdrawal- not life threatening unless severe medical
illness but extremely uncomfortable. s/s dilated pupils
lacrimation, goosebumps, n/v, diarrhea, myalgias,
arthralgias, dysphoria or agitation
70

71. Treatment - Opiate Use Disorder
• Treatment
– support, education, skills building, psychiatric and psychological
treatment, Narcotics Anonymous (NA)
• Medications
– Methadone (opioid substitution)
– Naltrexone
– Buprenorphine (opioid substitution)
71

72. Treatment - Opiate Use Disorder
• Naltrexone
– Opioid blocker, mu antagonist
– 50mg po daily
• Methadone
– Mu agonist
– Start at 20-40mg and titrate up until not craving or using illicit opioids
– Average dose 80-100mg daily
– Needs to be enrolled in a certified opiate substitution program
• Buprenorphine
– Partial mu partial agonist with a ceiling effect
– Any physician can Rx after taking certified ASAM course
– Helpful for highly motivated people who do not need high doses
72

73. Stimulants
73

74. Stimulants
• Amphetamine, cocaine, MDMA, methamphetamine,
nicotine, Ritalin
• How Consumed: injected, smoked, snorted, swallowed
• Effects: increased heart rate, blood pressure,
metabolism, feelings of exhilaration, energy, increased
mental alertness
• Consequences: rapid or irregular heart beat, reduced
appetite, weight loss, heart failure, nervousness,
insomnia
74

75. COCAINE/CRACK COCAINE & AMPHETAMINES:
Effect on mental health and some interactions with commonly used
psychotropic medications:
• These drugs are CNS stimulants.
• Exacerbates psychotic symptoms for those with diagnosed psychosis
• Drug precipitated/induced psychosis
• Opposes action of anti-psychotic medication
• Will initially induce euphoria/lift mood but mood will lower following use of
drug: use will exacerbate depression
• Will exaggerate delusional elements of mania and
hypomania
Georgiou (1999) ISDN (1999)
75

76. STIMULANTS
• Intoxication (acute)
– psychological and physical signs
– euphoria, enhanced vigor, gregariousness,
hyperactivity, restlessness, interpersonal sensitivity,
anxiety, tension, anger, impaired judgment, paranoia
– tachycardia, papillary dilation, hypertension, nausea
and vomiting, sweating, chills, weight loss, chest pain,
cardiac arrhythmias, confusion, seizures, coma
76

77. STIMULANTS
(cont.)
• Chronic intoxication
– affective blunting, fatigue, sadness, social
withdrawal, hypotension, bradycardia, muscle
weakness
• Withdrawal
– not severe but have exhaustion with sleep
(crash)
– treat with rest and support
77

78. Treatment - Stimulant Use Disorder
(cocaine)
• Treatment including support, education,
skills, Cocaine Anonymous (CA)
• Pharmacotherapy
– No medications approved for treatment
– If medication used, also need a psychosocial
treatment component
78

79. Amphetamines
• Similar intoxication syndrome to cocaine but
usually longer
• Route - oral, IV, nasally, smoked
• No vaso-constrictive effect
• Risk of permanent amphetamine psychosis with
continued use
• Treatment similar as for cocaine but no known
substances to reduce cravings
• Neuroadaptation
– inhibit reuptake of DA, NE, SE - greatest effect on DA
receptors
79

80. Treatment – Stimulant Use Disorder
(amphetamine)
• Treatment: including support, education,
skills, Cocaine Anonymous (CA)
• No specific medications have been found
helpful in treatment although some early
promising research using atypical
antipsychotics (methamphetamine)
80

81. Tobacco
81

82. Tobacco
• Most important preventable cause of death /
disease in UK
• 25%- current smokers, 25% ex smokers
• 45% of smokers die of tobacco induced disorder
• Second hand smoke causes death / morbidity
• Psychiatric pts at risk for Nicotine dependence-
75%-90 % of Schizophrenia pts smoke
82

83. Tobacco (cont.)
• Drug Interactions
– induces CYP1A2 - watch for interactions when start
or stop (ex. Olanzapine)
• No intoxication diagnosis
– initial use associated with dizziness, HA, nausea
• Neuroadaptation
– nicotine acetylcholine receptors on DA neurons in
ventral tegmental area release DA in nucleus
accumbens
• Tolerance
– rapid
• Withdrawal
– dysphoria, irritability, anxiety, decreased
concentration, insomnia, increased appetite
83

84. Treatment – Tobacco Use
Disorder
• Cognitive Behavioral Therapy
• Agonist substitution therapy
– nicotine gum or lozenge, transdermal patch,
nasal spray
• Medication
– bupropion (Zyban) 150mg po bid,
– varenicline (Chantix) 1mg po bid
84

85. Hallucinogens
85

86. Hallucinogens
• LSD, Mescaline, Mushrooms
• How Consumed: swallowed, smoked
• Effects: increased body temperature, heart rate, blood
pressure, loss of appetite, sleeplessness, numbness,
weakness, tremors, altered states of perception and
feeling, nausea
• Consequences: persisting perception disorder
(flashbacks)
86

87. HALLUCINOGENS
• Naturally occurring - Peyote cactus (mescaline);
magic mushroom(Psilocybin) - oral
• Synthetic agents – LSD (lysergic acid
diethyamide) - oral
• DMT (dimethyltryptamine) - smoked, snuffed, IV
• STP (2,5-dimethoxy-4-methylamphetamine) –
oral
• MDMA (3,4-methyl-enedioxymethamphetamine)
ecstasy – oral
87

88. MDMA (XTC or Ecstacy)
• Designer club drug
• Enhanced empathy, personal insight, euphoria,
increased energy
• 3-6 hour duration
• Intoxication- illusions, hyperacusis, sensitivity
of touch, taste/ smell altered, "oneness with the
world", tearfulness, euphoria, panic, paranoia,
impairment judgment
• Tolerance develops quickly and unpleasant side
effects with continued use (teeth grinding) so
dependence less likely
88

89. MDMA (XTC or Ecstacy)cont.
• Neuroadaptation- affects serotonin (5HT), DA,
NE but predominantly 5HT2 receptor agonists
• Psychosis
– Hallucinations generally mild
– Paranoid psychosis associated with chronic use
– Serotonin neural injury associated with panic, anxiety,
depression, flashbacks, psychosis, cognitive
changes.
• Withdrawal – unclear syndrome (maybe similar
to mild stimulants-sleepiness
and depression due to 5HT depletion)
89

90. Cannabis
90

91. CANNABIS: Effect on mental health and some interactions with
commonly used psychotropic medications:
Cannabis is an hallucinogenic and all rounder.
• THC (Tetrahydrocannabinols) effects some dopamine receptors; therefore heavy
use has been shown to increase frequency and severity of relapse for those with
psychosis.
• Disorientates to time and space, Impaired cognition Slowed reaction time/ motor
speed
• Colors/ sounds/ tastes are clearer
• Exacerbates paranoid delusions
• Depression/A motivational syndrome noted
• Cannabis use is an independent risk factor for more psychotic relapses and
aggravation of psychotic and disorganization symptoms (D Linszel et al 2004)
91

92. CANNABIS (cont.)
• Can increase anxiety levels and be a trigger for panic
attacks leading to an increase/complications for people
with depression
• In mania, paranoia can manifest as grandiosity Georgiou
(1999)
• Appetite and thirst increase
• Increased confidence and euphoria
• Increased libido
• Tachycardia, dry mouth,
• Cough, frequent respiratory infections,
• Withdrawal - insomnia, irritability, anxiety, poor appetite,
depression, physical discomfort
92

93. CANNABIS (cont.)
• Treatment
-Detox and rehab
-Behavioral model
-No pharmacological treatment but may
treat other psychiatric symptoms
93

94. Dissociative Anesthetics
• Ketamine, PCP
• How Consumed: Injected, swallowed, smoked, snorted
• Effects: increased heart rate and blood pressure,
impaired motor function, delirium, panic, aggression
• Consequences: memory loss, numbness,
nausea/vomiting, depression
94

95. PCP
95

96. PHENACYCLIDINE ( PCP)
"Angel Dust"
• Dissociative anesthetic
• Similar to Ketamine used in anesthesia
• Intoxication: severe dissociative reactions – paranoid
delusions, hallucinations, can become very agitated/
violent with decreased awareness of pain.
• Cerebellar symptoms - ataxia, dysarthria, nystagmus
(vertical and horizontal)
• With severe OD - mute, catatonic, muscle rigidity, HTN,
hyperthermia, rhabdomyolsis, seizures, coma and death
96

97. PCP cont.
• Treatment
– antipsychotic drugs or BZD if required
– Low stimulation environment
– acidify urine if severe toxicity/coma
• Neuroadaptation
– opiate receptor effects
– allosteric modulator of glutamate NMDA receptor
• No tolerance or withdrawal
97

98. Long Term Methamphetamine Use
98

99. Long term Meth
99

100. Other
• Steroid
– Injected, swallowed, applied to skin
– no intoxication effect
– hypertension, blood clotting and cholesterol changes, liver cysts and cancer, kidney cancer,
hostility and aggression, acne
• in adolescents - premature stoppage of growth
• in males - prostate cancer, reduced sperm production, shrunken testicles, breast
enlargement
• in females - menstrual irregularities, development of beard and other masculine
characteristics
• Dextromethorphan
– swallowed
– Dissociative effects, distorted visual perceptions to complete dissociative effects
– memory loss; numbness; nausea/vomiting
• Inhalants
– Inhaled through nose or mouth
– stimulation, loss of inhibition; headache; nausea or vomiting; slurred speech, loss of motor
coordination; wheezing
– unconsciousness, cramps, weight loss, muscle weakness, depression, memory impairment,
damage to cardiovascular and nervous systems, sudden death
100

101. Mixing Drugs
101

102. Treatment
• Manage Intoxication & Withdrawal
– Intoxication
• Ranges: euphoria to life-threatening emergency
– Detoxification
• outpatient: "social detox” program
• inpatient: close medical care
• preparation for ongoing treatment
102

103. Treatment
• Behavioral Interventions (target internal and
external reinforcers)
Abstinence vs. harm reduction
Motivation to change (MI)
Group Therapy
Individual Therapy
Contingency Management
Self-Help Recovery Groups (AA)
Therapeutic Communities
Aversion Therapies
Family Involvement/Therapy
Twelve-Step Facilitation
Relapse Prevention
103

104. Treatment
• Pharmacologic Intervention
• Treat Co-Occurring Psychiatric Disorders
– 50% will have another psychiatric disorder
• Treat Associated Medical Conditions
cardiovascular, cancer, endocrine, hepatic,
hematologic, infectious, neurologic,
nutritional, GI, pulmonary, renal,
musculoskeletal
104

105. Achievement of Integrated treatment in
mainstream mental health teams.
• Service users
• No Fall Between
services
• Not duplicating
Assessment
• Complex needs
addressed concurrently.
• Enhanced engagement
and retention in
treatment
• Access to interventions
for cannabis use
• Teams
• Enhanced skills
• Consistency
• Ownership of client
group
• Clearly identified
roles/responsibilities
• Support to deliver
structured interventions
• Comprehensive
services.
• Consistent approach.
105

106. Thoughts
Emotions Behaviour
Physiology
CBT Symptom Cycle
106

107. TYPES OF DISTORTED
THINKING
1. All-or-nothing thinking: You look at things in absolute,
black-and-white categories.
2. Overgeneralization: You view a negative event as a never-
ending pattern of defeat.
3. Mental filter: You dwell on the negatives and ignore the
positives.
4. Discounting the positives: You insist that your
accomplishments or positive qualities "don't count.“
5. Jumping to conclusions: (A) Mind reading: you assume
that people are reacting negatively to you when there is no
definite evidence for this; (B) Fortune-telling: you arbitrarily
predict that things will turn out badly.
107

108. 6. Magnification or minimization: You blow things up way out of
proportion, or you shrink their importance inappropriately.
7. Emotional reasoning: You reason from how you feel: "I feel
like an idiot, so I really must be one." Or "I don't feel like doing
this, so I'll put it off.“
8. Should statements: You criticize yourself or other people with
"shoulds" etc.
9. Labeling: You identify with your shortcomings. Instead of
saying, "I made a mistake," you tell yourself, "I'm an idiot," or "a
fool," or "a loser.“
10. Personalization and blame: You blame yourself for something
you aren't entirely responsible for, or you blame other people and
overlook ways that your own attitudes and behavior might be
contributing to a problem.
108

109. Cycle of Change
109

110. Motivational Interviewing
-Explore desire to stop drinking/using vs
perceived benefits of ongoing use
-Gentle confrontation with education (risks
to health) / therapeutic alliance
-Involve family and friends for support
-Education about substance dependence
and need for rehabilitation plan
110

111. Assessment
• Open-ended questions
• Obtain releases for all other providers
• Maintain active communication with
providers
• Observations
111

112. Relapse
• IT’S PROBABLY GOING TO HAPPEN!
• 2/3 relapse rate
• Before picking up
– Post-Acute Withdrawal Syndrome
– Return To Denial – “everything’s alright”
– Avoidance And Defensive Behavior
– Starting To Crisis Build
– Feeling Immobilized (Stuck)
– Becoming Depressed
– Compulsive And/Or Impulsive Behaviors (Loss Of Control)
– Urges And Cravings (Thinking About Drinking/Using)
112

113. Action Plan.
• What areas of your practice do you need
to focus on and how will you implement
changes?
• What new ways can you interact with the
patient in your care?
• Are there any practices that need to
change?
113

114. Thank you
Any further questions?
Feedback
114

115. Any Questions?
115

116. • Please take some time to complete the
course evaluation - Thank you…
• patrickdoyle@traininginnovations.co.uk
• Twitter: @Traininnovate
• Facebook: Training Innovations Ltd
• http://www.slideshare.net/TInnovations
116

117. Thankyou!
117