This document discusses a web conference on treating co-occurring disorders. It defines co-occurring disorders as the simultaneous existence of substance use disorders and mental health disorders. Approximately 50-75% of those with substance use disorders also have a mental health disorder. The document contrasts traditional treatment models with integrated treatment and argues that integrated treatment, which addresses both disorders simultaneously with one treatment team, has benefits over other models. It provides information on screening and assessment tools, levels of care, and evidence-based therapies for treating co-occurring disorders.

1. Integrating Treatment for Co-Occurring Disorders Brought to you by:

2. Presented By

3. TODAY’S PRESENTERS Cynthia Moreno Tuohy Executive Director NAADAC, The Association for Addiction Professionals Misti Storie Education and Training Consultant NAADAC, The Association for Addiction Professionals

4. TODAY’S PRESENTERS Tim Sheehan, Ph.D. Director of Institutional Effectiveness Hazelden Graduate School of Addiction Studies Mary Woods, RNC, LADC, MSHS Chief Executive Officer Westbridge Community Services

5. WEB CONFERENCE OBJECTIVES Discuss the prevalence of co-occurring disorders in substance abuse treatment programs

6. WEB CONFERENCE OBJECTIVES Discuss the prevalence of co-occurring disorders in substance abuse treatment programs Contrast co-occurring treatment with traditional addiction treatment

7. WEB CONFERENCE OBJECTIVES Discuss the prevalence of co-occurring disorders in substance abuse treatment programs Contrast co-occurring treatment with traditional addiction treatment Give a rationale for integrated treatment

8. WEB CONFERENCE OBJECTIVES Discuss the prevalence of co-occurring disorders in substance abuse treatment programs Contrast co-occurring treatment with traditional addiction treatment Give a rationale for integrated treatment List instruments helpful for screening

9. WEB CONFERENCE OBJECTIVES Discuss the prevalence of co-occurring disorders in substance abuse treatment programs Contrast co-occurring treatment with traditional addiction treatment Give a rationale for integrated treatment List instruments helpful for screening Describe evidence-based therapies helpful in treating co-occurring disorders

10. WEB CONFERENCE OBJECTIVES Discuss the prevalence of co-occurring disorders in substance abuse treatment programs Contrast co-occurring treatment with traditional addiction treatment Give a rationale for integrated treatment List instruments helpful for screening Describe evidence-based therapies helpful in treating co-occurring disorders Access new training programs available through NAADAC and Hazelden

11. Part One: Introduction to Co-occurring Disorders

12. SCOPE OF PRACTICE An Addiction Professional’s scope of practice varies with education, training and state requirements. With over 300 people on line today, each practitioner should keep his or her scope of practice in mind as we conduct this presentation.

13. DEFINING CO-OCCURRING DISORDERS 50 to 75% of all clients who are receiving treatment for a substance use disorder also have another diagnosable mental health disorder . Further, of all psychiatric clients with a mental health disorder, 25 to 50% of them also currently have or had a substance use disorder at some point in their lives.

14. Co-morbidity of Substance Use and Psychiatric Disorders Among a sample of about 10,000 adults: 13.5% had an alcohol use disorder. Of those, 36.6% also had a psychiatric disorder. 6.1% had a drug use disorder. Of those, 53.1% also had a psychiatric disorder. 22.5% had a psychiatric disorder. Of those, 28.9% also had an alcohol or drug use disorder. DEFINING CO-OCCURRING DISORDERS Source: Regier et al. 1990

15. Psychiatric Disorders in Addiction Treatment Two studies of Prevalence rates in addiction treatment settings had similar findings. Persons with substance use disorders are also like to have mood and anxiety disorders. DEFINING CO-OCCURRING DISORDERS Source: Cacciola et al, 2001; Ross, Glaser and Germanson 1988

16. DEFINING CO-OCCURRING DISORDERS Addiction Treatment Provider Estimates by Psychiatric Disorder

17. Mental health disorder (MHD) : significant and chronic disturbances with “feelings, thinking, functioning and/or relationships that are not due to drug or alcohol use and are not the result of a medical illness” 22 DEFINING CO-OCCURRING DISORDERS Bipolar disorder Major depressive disorder Schizophrenia Obsessive-compulsive disorder Social phobia Borderline personality disorder Posttraumatic stress disorder

18. Substance use disorder (SUD) : a behavioral pattern of continual psychoactive substance use that can be diagnosed as either substance abuse or substance dependence DEFINING CO-OCCURRING DISORDERS

19. Co-occurring disorders (COD) : the simultaneous existence of “one or more disorders relating to the use of alcohol and/or other drugs of abuse as well as one or more mental [health] disorders.” 18 DEFINING CO-OCCURRING DISORDERS

20. SEVERITY OF CO-OCCURRING DISORDERS Co-occurring mental health disorders are often placed on a continuum of severity. Non-severe: early in the continuum and can include mood disorders, anxiety disorders, adjustment disorders and personality disorders. Severe: include schizophrenia, bipolar disorder, schizoaffective disorder and major depressive disorder.

21. SEVERITY OF CO-OCCURRING DISORDERS The classification of “severe and non-severe” is based on a specific diagnosis and by state criteria for Medicaid qualification but can vary significantly based on severity of the disability and the duration of the disorder.

22. QUADRANTS OF CARE

23. Part Two: What is Co-occurring Treatment and How is It Different from Traditional Addiction Treatment?

24. MODELS OF TREATMENT Clients with co-occurring disorders have historically received substance abuse treatment services in isolation from mental health treatment services. As more research on co-occurring disorders began to be conducted, the many limitations this approach places on the client and his or her success in treatment began to surface.

25. MODELS OF TREATMENT A twenty-eight year-old-woman named Anita entered an addiction treatment center where she was assessed as having alcohol dependence. Six months earlier, Anita had been diagnosed with major depressive disorder and was prescribed medication by her family doctor. At the treatment facility, it was recommended that Anita be re-assessed and treated, if necessary, at a mental health clinic, located nearby in town. What model of treatment does this scenario represent? single model of treatment sequential model of treatment parallel model of treatment integrated model of treatment

26. Single model of care - It was believed that once the “primary disorder" was treated effectively, the client’s substance use problem would resolve itself because drugs and/or alcohol were no longer needed to cope. Sequential model of treatment - acknowledges the presence of co-occurring disorders but treats them one at a time. Parallel model of treatment - mental health disorders are treated at the same time as co-occurring substance use disorders, only by separate treatment professionals and often at separate treatment facilities. MODELS OF TREATMENT

27. INTEGRATED MODEL OF TREATMENT Integrated model of treatment an approach to treating co-occurring disorders that utilizes one competent treatment team at the same facility to recognize and address all mental health and substance use disorders at the same time.

28. INTEGRATED MODEL OF TREATMENT The integrated model of treatment can best be defined by following seven components: Integration

29. INTEGRATED MODEL OF TREATMENT The integrated model of treatment can best be defined by following seven components: Integration Comprehensiveness

30. INTEGRATED MODEL OF TREATMENT The integrated model of treatment can best be defined by following seven components: Integration Comprehensiveness Assertiveness

31. INTEGRATED MODEL OF TREATMENT The integrated model of treatment can best be defined by following seven components: Integration Comprehensiveness Assertiveness Reduction of negative consequences

32. INTEGRATED MODEL OF TREATMENT The integrated model of treatment can best be defined by following seven components: Integration Comprehensiveness Assertiveness Reduction of negative consequences Long-term perspective

33. INTEGRATED MODEL OF TREATMENT The integrated model of treatment can best be defined by following seven components: Integration Comprehensiveness Assertiveness Reduction of negative consequences Long-term perspective Motivation-based treatment

34. INTEGRATED MODEL OF TREATMENT The integrated model of treatment can best be defined by following seven components: Integration Comprehensiveness Assertiveness Reduction of negative consequences Long-term perspective Motivation-based treatment Multiple psychotherapeutic modalities

35. BENEFITS OF AN INTEGRATED MODEL OF CARE Benefits of an Integrated Model of Care Reduced need for coordination

36. BENEFITS OF AN INTEGRATED MODEL OF CARE Benefits of an Integrated Model of Care Reduced need for coordination Reduced frustration for clients

37. BENEFITS OF AN INTEGRATED MODEL OF CARE Benefits of an Integrated Model of Care Reduced need for coordination Reduced frustration for clients Shared decision-making responsibilities

38. BENEFITS OF AN INTEGRATED MODEL OF CARE Benefits of an Integrated Model of Care Reduced need for coordination Reduced frustration for clients Shared decision-making responsibilities Families and significant others are included

39. BENEFITS OF AN INTEGRATED MODEL OF CARE Benefits of an Integrated Model of Care Reduced need for coordination Reduced frustration for clients Shared decision-making responsibilities Families and significant others are included Transparent practices help everyone involved share responsibility

40. BENEFITS OF AN INTEGRATED MODEL OF CARE Benefits of an Integrated Model of Care Reduced need for coordination Reduced frustration for clients Shared decision-making responsibilities Families and significant others are included Transparent practices help everyone involved share responsibility Clients are empowered to treat their own illness and manage their own recovery

41. BENEFITS OF AN INTEGRATED MODEL OF CARE Benefits of an Integrated Model of Care Reduced need for coordination Reduced frustration for clients Shared decision-making responsibilities Families and significant others are included Transparent practices help everyone involved share responsibility Clients are empowered to treat their own illness and manage their own recovery The client and his/her family has more choice in treatment, more ability for self-management, and a higher satisfaction with care

42. One disorder does not necessarily present as “primary.” There isn’t necessarily a causal relationship between co-occurring disorders. These are co-occurring brain diseases that need to be treated simultaneously . CO-OCCURRING DISORDERS INTERACTIONS An integrated model of care assumes that:

43. SCREENING AND ASSESSMENT Screening : The first phase of evaluation where the potential client is interviewed to determine if he or she is appropriate for that specific treatment facility and to determine the possible presence or absence of a substance use or mental health problem.

44. SCREENING AND ASSESSMENT Assessment: The second phase of evaluation where a systematic interview is necessary to verify the potential presence of a mental health or substance use disorder detected during the screening process.

45. SCREENING AND ASSESSMENT Intoxication Withdrawal Substance-induced disorders Motivational factors Feelings, symptoms, and disorders Complexities of Screening and Assessment

46. CO-OCCURRING DISORDERS INTERACTIONS Substances and Negative Emotions

47. SCREENING AND ASSESSMENT The choice of screening measures depends on: The skill of the screening professional The cost of the screening materials How simple the scale is to interpret and use across disciplines Psychometric qualities The relevance of screening to prevalent disorders Movement from very sensitive (generic) measures to more specific measures

48. Integrated Assessment Process – 12 Steps Engage the Client SCREENING AND ASSESSMENT

49. Integrated Assessment Process – 12 Steps Engage the Client Identify and Contact Collaterals SCREENING AND ASSESSMENT

50. Integrated Assessment Process – 12 Steps Engage the Client Identify and Contact Collaterals Screen for and Detect Co-occurring Disorders SCREENING AND ASSESSMENT

51. Integrated Assessment Process – 12 Steps Engage the Client Identify and Contact Collaterals Screen for and Detect Co-occurring Disorders Determine Quadrant and Locus of Responsibility SCREENING AND ASSESSMENT

52. Integrated Assessment Process – 12 Steps Engage the Client Identify and Contact Collaterals Screen for and Detect Co-occurring Disorders Determine Quadrant and Locus of Responsibility Determine Level of Care SCREENING AND ASSESSMENT

53. Integrated Assessment Process – 12 Steps Engage the Client Identify and Contact Collaterals Screen for and Detect Co-occurring Disorders Determine Quadrant and Locus of Responsibility Determine Level of Care Determine Diagnosis SCREENING AND ASSESSMENT

54. Integrated Assessment Process – 12 Steps Determine Disability and Functional Impairment SCREENING AND ASSESSMENT

55. Integrated Assessment Process – 12 Steps Determine Disability and Functional Impairment Identify Strengths and Supports SCREENING AND ASSESSMENT

56. Integrated Assessment Process – 12 Steps Determine Disability and Functional Impairment Identify Strengths and Supports Identify Cultural and Linguistic Needs and Supports SCREENING AND ASSESSMENT

57. Integrated Assessment Process – 12 Steps Determine Disability and Functional Impairment Identify Strengths and Supports Identify Cultural and Linguistic Needs and Supports Identify Problem Domains SCREENING AND ASSESSMENT

58. Integrated Assessment Process – 12 Steps Determine Disability and Functional Impairment Identify Strengths and Supports Identify Cultural and Linguistic Needs and Supports Identify Problem Domains Determine Stage of Change SCREENING AND ASSESSMENT

59. Integrated Assessment Process – 12 Steps Determine Disability and Functional Impairment Identify Strengths and Supports Identify Cultural and Linguistic Needs and Supports Identify Problem Domains Determine Stage of Change Plan Treatment SCREENING AND ASSESSMENT

60. American Society of Addiction Medicine Patient Placement Criteria – 2 nd Edition Revised (ASAM PPC-2R) dimensions of care Dimension 1: Acute Intoxication and/or Withdrawal Potential Dimension 2: Biomedical Conditions and Complications Dimension 3: Emotional, Behavioral or Cognitive Conditions and Complications Dimension 4: Readiness to Change Dimension 5: Relapse, Continued Use or Continued Problem Potential Dimension 6: Recovery/Living Environment DETERMINING LEVEL OF CARE

61. Level I: Outpatient treatment. Level II: Intensive outpatient treatment, including partial hospitalization. Level III: Residential/medically monitored intensive inpatient treatment. Level IV: Medically managed intensive inpatient treatment. DETERMINING LEVEL OF CARE

62. EVIDENCE-BASED PRACTICES In most treatment addiction centers, the three primary evidence-based practices used are: motivational enhancement therapy (MET) cognitive-behavioral therapy (CBT) twelve step facilitation (TSF) All of these treatment models are widely used – often without formal training – by addiction professionals around the country and can be easily applied to clients suffering from co-occurring disorders.

63. EVIDENCE-BASED PRACTICES The Integrated Combined Therapies model combines these three EBPs (Evidence-Based Practices) into a stage-wise treatment plan whereby: motivational enhancement therapy is first utilized to initiate change and engage the client in the therapeutic process; cognitive-behavioral therapy is then used to help make change within the client; and twelve step facilitation is essential to helping maintain and sustain changes .

64. STAGES OF CHANGE/ STAGES OF TREATMENT

65. STAGES OF CHANGE/ STAGES OF TREATMENT STAGES OF CHANGE/ STAGES OF TREATMENT

66. STAGES OF CHANGE/ STAGES OF TREATMENT

67. STAGES OF CHANGE/ STAGES OF TREATMENT

68. OTHER CONSIDERATIONS Managing Medications Involving the Family Encouraging Participation in Peer-Support Recovery Programs

69. Collaboration with the prescriber Even though the prescriber is ultimately responsible for ensuring safety and effectiveness of pharmacotherapies, addiction professionals can also help in this effort. Since addiction professionals tend to see the client more often, they are well-positioned to: recognize danger signs (including recent psychoactive substance use) recognize abnormal side effects monitor and support medication compliance

70. MANAGING MEDICATIONS Pharmacotherapy can only work if medications are taken as prescribed. Some clients with co-occurring disorders are required to manage a regimen of multiple medications each day. Clients often have difficulty strictly adhering to a dosing schedule, making them more prone to relapse and hospitalization. Clinicians can help prepare clients to manage their medications.

71. INVOLVING THE CLIENT’S FAMILY It is a myth that people with co-occurring disorders are disconnected from their families. Research has shown that outcomes for substance use and mental health disorders are improved, including fewer relapses, when families are actively engaged in the treatment process. Unfortunately, family members of a client who has co-occurring disorders often experience considerable stress, heartbreak, and confusion. Involving families in treatment

72. INVOLVING THE CLIENT’S FAMILY Involving families in treatment Encourage family member involvement and develop a collaborative relationship as early as possible in the treatment process Use an evidence-based practice for family treatment Encourage families to attend self-help groups such as Al-Anon and NAMI

73. Double Trouble in Recovery Mental Illness Anonymous Dual Disorders Anonymous Dual Recovery Anonymous Dual Diagnosis Anonymous DUAL-RECOVERY MUTUAL SELF-HELP Specific dual-recovery groups can provide essential peer support:

74. GUIDING PRINCIPLES OF RECOVERY There are many pathways to recovery. Recovery is self-directed and empowering, involving personal recognition of the need for change and transformation. Recovery exists on a continuum of improved health and wellness. Recovery involves addressing discrimination and transcending shame and stigma. Recovery is supported by peers and allies, and involves joining and rebuilding a life in the community. Recovery is a reality. (from CSAT ’ s Regional Recovery Meetings, May 2008)

75. Part Three Resources and Training Opportunities

76. CO-OCCURRING DISORDERS PROGRAM from Dartmouth/Hazelden Written by the faculty from the Dartmouth Medical School, CDP provides practical tools for implementing evidence-based, integrated treatment practices.

77. CO-OCCURRING DISORDERS PROGRAM from Dartmouth/Hazelden Clinical Administrator ’ s Guide Curriculum 1: Screening and Assessment Curriculum 2: Integrating Combined Therapies Curriculum 3: Cognitive-Behavioral Therapy Curriculum 4: Medication Management Curriculum 5: Family Program DVD A Guide for Living with Co-occurring Disorders Components of CDP include: Training and technical assistance is available for all components: Call 1-800-328-9000, ext. 4672 or e-mail training@hazelden.org

78. NAADAC/HAZELDEN COURSE Integrating Treatment for Co-occurring Disorders: An Introduction to What Every Addiction Counselor Needs to Know … is a skill-based training program that will help addiction counselors improve their ability to assist clients who have co-occurring disorders, within their scope of practice.

79. NAADAC/HAZELDEN COURSE Through case studies, video presentations, interactive exercises and extensive written resources, participants learn: the many myths related to mental illness treatment barriers to assessing and treating co-occurring disorders relevant research and prevalence data commonly encountered mental disorders applicable screening and assessment instruments issues surrounding medication management coordinating with other mental health professionals the integrated model of mental health and addiction treatment services

80. NAADAC is now conducting the Lifelong Learning Program: Integrating Treatment for Co-occurring Disorders: An Introduction to What Every Addiction Counselor Needs To Know Check the NAADAC website for trainings coming to your area at www.naadac.org NAADAC/HAZELDEN COURSE Interested in hosting a training? Contact: Diana Kamp dkamp@naadac.org Cynthia Moreno Tuohy moreno@naadac.org

81. Now available as a distance learning program! Integrating Treatment for Co-Occurring Co-occurring Disorders: An Introduction to What Every Addiction Counselor Needs to Know. Learn at your own pace through presentations, videos, case studies, and interactive exercises. Available 24/7. $180.00 18 CEs from NAADAC; 6 CEs from APA NAADAC/HAZELDEN COURSE

82. LEADERSHIP IN CO-OCCURRING DISORDERS Announcing the Focus on Integrated Recovery! A collaboration between: Dartmouth Psychiatric Research Center Hazelden NAADAC, the Association for Addiction Professionals NAATP, the National Association of Addiction Treatment Providers The National Council for Community Behavioral Healthcare SAMHSA, the Substance Abuse and Mental Health Services Administration, and WestBridge Community Services Active discussions with other leaders

83. FOCUS ON INTEGRATED RECOVERY Co-Occurring Leadership What you can expect from Focus on Integrated Recovery Practical, evidence-based resources to aid in the integration of the substance use and mental health disorders professions Centralized source for consistent messaging about co-occurring disorders Ongoing mechanism to capture the learning and experiences from partners and constituents across the behavioral health spectrum Opportunities for in-person and distance education on co-occurring disorders Support for the September 2011 Recovery Month Collaboration on new initiatives: evidence-based scopes of practice, outcome measurement, workforce development

84. FOCUS ON INTEGRATED RECOVERY Co-Occurring Leadership Where to find the Focus on Integrated Recovery Communications begin during September, 2011 Recovery Month National Public Relations efforts E-mail campaigns Focus on Integrated Recovery Website Links on the partners’ websites Recovery Month materials Let us know what you think and how we can help! contact Jon Hartman - jhartman@hazelden.org

85. August 18, 2011 - Strategies for Successful Test Taking September 15, 2011 - Your Voice Counts: Advocacy and the NAADAC Political Action Committee October 13, 2011 - Conflict Resolution for Clients and Professionals November 17, 2011 - What's Next in Your Career? Recap and Highlights from the NAADAC Workforce Conference December 15, 2011 - Clinical Supervision: Keys to Success Register at: www.naadac.org/education or www.myaccucare.com/webinars UPCOMING WEBINARS 2011

86. Alcohol SBIRT: Integrating Evidence-based Practice Into Your Practice Medication Assisted Recovery: What Every Addiction Professional Needs to Know Build Your Business With the Department of Transportation Substance Abuse Professional (SAP) Qualification Working with NAADAC to Express Your Professional Identity Screening, Brief Intervention and Referral to Treatment (SBIRT) Medicaid Expansion 2014 and Preparing to Bill for Medicaid Understanding NAADAC’s Code of Ethics Staying Informed: Trends of the Addiction Profession Archived webinars located at: www.naadac.org/education or www.myaccucare.com/webinars ARCHIVED WEBINARS

87. Time for discussion! www.naadac.org www.bhevolution.org www.hazelden.org www.westbridge.org

88. Providing solutions to improve the quality of life for communities by helping addictions professionals excel in their field through the use of information technology. Visit us today! Call: (800) 324-7966 Click: www.MyAccuCare.com Clinical Administrative Outcome Reporting Billing

89. The education delivered in this webinar is FREE to all professionals. 2 CEs are FREE to NAADAC members and AccuCare subscribers who attend this webinar. Non-members of NAADAC or non-subscribers of AccuCare receive 2 CEs for $25. If you wish to receive CE credit, you MUST download, complete and submit the “CE Quiz” that is located at: www.myaccucare.com/webinars www.naadac.org/education A CE certificate will be emailed to you within 30 days. Successfully passing the “CE Quiz” is the ONLY way to receive a CE certificate. OBTAINING CE CREDIT

90. Thank you for participating! www.naadac.org www.bhevolution.org www.hazelden.org www.westbridge.org www.myaccucare.com Misti - misti@naadac.org Emily - ehaverty@orionhealthcare.com