national institute on drug abuse (nida) common ... · 1 national institute on drug abuse (nida)...
TRANSCRIPT
1
NationalInstituteonDrugAbuse(NIDA)
CommonComorbiditieswithSubstanceUseDisorders
LastUpdatedFebruary2018
https://www.drugabuse.gov
2
TableofContents
CommonComorbiditieswithSubstanceUseDisorders
Introduction
Part1:TheConnectionBetweenSubstanceUseDisordersandMentalIllness
Whyistherecomorbiditybetweensubstanceusedisordersandmentalillnesses?
Whataresomeapproachestodiagnosis?
Whatarethetreatmentsforcomorbidsubstanceusedisorderandmentalhealthconditions?
Part2:Co-occurringSubstanceUseDisorderandPhysicalComorbidities
Part3:TheConnectionbetweenSubstanceUseDisordersandHIV
WhyisHIVscreeningimportant?
WhataresomemethodsforHIVpreventionandtreatmentforindividualswithsubstanceusedisorders?
HowcanweachieveanAIDS-freegeneration?
Part4:BarrierstoComprehensiveTreatmentforIndividualswithCo-OccurringDisorders
WherecanIgetmorescientificinformationoncomorbidsubstanceusedisorder,mentalillness,andmedicalconditions?
References
3
Introduction
Whentwodisordersorillnessesoccurinthesameperson,simultaneouslyorsequentially,theyaredescribedascomorbid. Comorbidityalsoimpliesthattheillnessesinteract,affectingthecourseandprognosisofboth. Thisresearchreportprovidesinformationonthestateofthescienceinthecomorbidityofsubstanceusedisorderswithmentalillnessandphysicalhealthconditions
1
1,2
4
Part1:TheConnectionBetweenSubstanceUseDisordersandMentalIllness
Manyindividualswhodevelopsubstanceusedisorders(SUD)arealsodiagnosedwithmentaldisorders,andviceversa.Multiplenationalpopulationsurveyshavefoundthatabouthalfofthosewhoexperienceamentalillnessduringtheirliveswillalsoexperienceasubstanceusedisorderandviceversa. Althoughtherearefewerstudiesoncomorbidityamongyouth,researchsuggeststhatadolescentswithsubstanceusedisordersalsohavehighratesofco-occurringmentalillness;over60percentofadolescentsincommunity-basedsubstanceusedisordertreatmentprogramsalsomeetdiagnosticcriteriaforanothermentalillness.
Datashowhighratesofcomorbidsubstanceusedisordersandanxietydisorders—whichincludegeneralizedanxietydisorder,panicdisorder,andpost-traumaticstressdisorder. Substanceusedisordersalsoco-occurathighprevalencewithmentaldisorders,suchasdepressionandbipolardisorder,attention-deficithyperactivitydisorder(ADHD), psychoticillness,
borderlinepersonalitydisorder, andantisocialpersonalitydisorder.Patientswithschizophreniahavehigherratesofalcohol,tobacco,anddrugusedisordersthanthegeneralpopulation. AsFigure1shows,theoverlapisespeciallypronouncedwithseriousmentalillness(SMI).Seriousmentalillnessamongpeopleages18andolderisdefinedatthefederallevelashaving,atanytimeduringthepastyear,adiagnosablemental,behavior,oremotionaldisorderthatcausesseriousfunctionalimpairmentthatsubstantiallyinterfereswithorlimitsoneormoremajorlifeactivities.Seriousmentalillnessesincludemajordepression,schizophrenia,andbipolardisorder,andothermentaldisordersthatcauseseriousimpairment. Around1in4individualswithSMIalsohaveanSUD.
2,3
4
5–9
6,9–
11 12,13 14,15
16 10,15
17
18
Figure1:Co-OccurringSubstanceUseDisorderandSeriousMentalIllnessinPastYearamongPersonsAged18orOlder
5
Datafromalargenationallyrepresentativesamplesuggestedthatpeoplewithmental,personality,andsubstanceusedisorderswereatincreasedriskfornonmedicaluseofprescriptionopioids. Researchindicatesthat43percentofpeopleinSUDtreatmentfornonmedicaluseofprescriptionpainkillershaveadiagnosisorsymptomsofmentalhealthdisorders,particularlydepressionandanxiety.
Youth—AVulnerableTime
Althoughdruguseandaddictioncanhappenatanytimeduringaperson’slife,drugusetypicallystartsinadolescence,aperiodwhenthefirstsignsofmentalillnesscommonlyappear.Comorbiddisorderscanalsobeseenamongyouth. Duringthetransitiontoyoungadulthood(age18to25years),peoplewithcomorbiddisordersneedcoordinatedsupporttohelpthemnavigatepotentiallystressfulchangesineducation,work,andrelationships.
DrugUseandMentalHealthDisordersinChildhoodorAdolescenceIncreasesLaterRisk
Thebraincontinuestodevelopthroughadolescence.Circuitsthatcontrol
Source:SAMHSA,CenterforBehavioralHealthStatisticsandQuality,NationalSurveyonDrugUseandHealth,MentalHealth,DetailedTables.Availableat:https://www.samhsa.gov/data/population-data-nsduh
19
20
21–23
21
6
executivefunctionssuchasdecisionmakingandimpulsecontrolareamongthelasttomature,whichenhancesvulnerabilitytodruguseandthedevelopmentofasubstanceusedisorder. Earlydruguseisastrongriskfactorforlaterdevelopmentofsubstanceusedisorders, anditmayalsobeariskfactorforthelateroccurrenceofothermentalillnesses.However,thislinkisnotnecessarilycausativeandmayreflectsharedriskfactorsincludinggeneticvulnerability,psychosocialexperiences,and/orgeneralenvironmentalinfluences.Forexample,frequentmarijuanauseduringadolescencecanincreasetheriskofpsychosisinadulthood,specificallyinindividualswhocarryaparticulargenevariant.
Itisalsotruethathavingamentaldisorderinchildhoodoradolescencecanincreasetheriskoflaterdruguseandthedevelopmentofasubstanceusedisorder.Someresearchhasfoundthatmentalillnessmayprecedeasubstanceusedisorder,suggestingthatbetterdiagnosisofyouthmentalillnessmayhelpreducecomorbidity.Onestudyfoundthatadolescent-onsetbipolardisorderconfersagreaterriskofsubsequentsubstanceusedisordercomparedtoadult-onsetbipolardisorder. Similarly,otherresearchsuggeststhatyouthdevelopinternalizingdisorders,includingdepressionandanxiety,priortodevelopingsubstanceusedisorders.
UntreatedChildhoodADHDCanIncreaseLaterRiskofDrugProblems
NumerousstudieshavedocumentedanincreasedriskforsubstanceusedisordersinyouthwithuntreatedADHD, althoughsomestudiessuggestthatonlythosewithcomorbidconductdisordershavegreateroddsoflaterdevelopingasubstanceusedisorder. Giventhislinkage,itisimportanttodeterminewhethereffectivetreatmentofADHDcouldpreventsubsequentdruguseandaddiction.TreatmentofchildhoodADHDwithstimulantmedicationssuchasmethylphenidateoramphetaminereducestheimpulsivebehavior,fidgeting,andinabilitytoconcentratethatcharacterizeADHD.
ThatriskpresentsachallengewhentreatingchildrenwithADHD,sinceeffectivetreatmentofteninvolvesprescribingstimulantmedicationswithaddictivepotential.Althoughtheresearchisnotyetconclusive,many
3,24
24
25,26
26,27
28
29
13,30
30,31
32
7
studiessuggestthatADHDmedicationsdonotincreasetheriskofsubstanceusedisorderamongchildrenwiththiscondition. ItisimportanttocombinestimulantmedicationforADHDwithappropriatefamilyandchildeducationandbehavioralinterventions,includingcounselingonthechronicnatureofADHDandriskforsubstanceusedisorder.
31,32
13,32
8
Whyistherecomorbiditybetweensubstanceusedisordersandmentalillnesses?
Thehighprevalenceofcomorbiditybetweensubstanceusedisordersandothermentalillnessesdoesnotnecessarilymeanthatonecausedtheother,evenifoneappearedfirst.Establishingcausalityordirectionalityisdifficultforseveralreasons.Forexample,behavioraloremotionalproblemsmaynotbesevereenoughforadiagnosis(calledsubclinicalsymptoms),butsubclinicalmentalhealthissuesmaypromptdruguse.Also,people’srecollectionsofwhendruguseoraddictionstartedmaybeimperfect,makingitdifficulttodeterminewhetherthesubstanceuseormentalhealthissuescamefirst.
Threemainpathwayscancontributetothecomorbiditybetweensubstanceusedisordersandmentalillnesses:
1. Commonriskfactorscancontributetobothmentalillnessandsubstanceuseandaddiction.
2. Mentalillnessmaycontributetosubstanceuseandaddiction.
3. Substanceuseandaddictioncancontributetothedevelopmentofmentalillness.
1.Commonriskfactorscancontributetobothmentalillnessandsubstanceuseandaddiction.
Bothsubstanceusedisordersandothermentalillnessesarecausedbyoverlappingfactorssuchasgeneticandepigeneticvulnerabilities,issueswithsimilarareasofthebrain, andenvironmentalinfluencessuchasearlyexposuretostressortrauma.
GeneticVulnerabilities
1
27,33–35
2,3,36
3,27
9
Itisestimatedthat40–60percentofanindividual’svulnerabilitytosubstanceusedisordersisattributabletogenetics. Anactiveareaofcomorbidityresearchinvolvesthesearchforthatmightpredisposeindividualstodevelopbothasubstanceusedisorderandothermentalillnesses,ortohaveagreaterriskofaseconddisorderoccurringafterthefirstappears. Mostofthisvulnerabilityarisesfromcomplexinteractionsamongmultiplegenesandgeneticinteractionswithenvironmentalinfluences. Forexample,frequentmarijuanauseduringadolescenceisassociatedwithincreasedriskofpsychosisinadulthood,specificallyamongindividualswhocarryaparticulargenevariant.
Insomeinstances,ageneproductmayactdirectly,aswhenaproteininfluenceshowapersonrespondstoadrug(e.g.,whetherthedrugexperienceispleasurableornot)orhowlongadrugremainsinthebody.Specificgeneticfactorshavebeenidentifiedthatpredisposeanindividualtoalcoholdependenceandcigarettesmoking,andresearchisstartingtouncoverthelinkbetweengeneticsequencesandahigherriskofcocainedependence,heavyopioiduse,andcannabiscravingandwithdrawal. Butgenescanalsoactindirectlybyalteringhowanindividualrespondstostress orbyincreasingthelikelihoodofrisk-takingandnovelty-seekingbehaviors, whichcouldinfluencetheinitiationofsubstanceuseaswellasthedevelopmentofsubstanceusedisordersandothermentalillnesses.Researchsuggeststhattherearemanygenesthatmaycontributetotheriskforbothmentaldisordersandaddiction,includingthosethatinfluencetheactionofneurotransmitters—chemicalsthatcarrymessagesfromoneneurontoanother—thatareaffectedbydrugsandcommonlydysregulatedinmentalillness,suchasdopamineandserotonin.
EpigeneticInfluences
Scientistsarealsobeginningtounderstandtheverypowerfulwaysthatgeneticandenvironmentalfactorsinteractatthemolecularlevel. Epigeneticsreferstothestudyofchangesintheregulationofgeneactivityandexpressionthatarenotdependentongenesequence;thatis,changesthataffecthowgeneticinformationisreadandactedonbycellsinthebody.Environmentalfactorssuchaschronicstress,trauma,ordrugexposurecaninducestablechangesingeneexpression,whichcanalterfunctioninginneuralcircuitsandultimatelyimpactbehavior. Formoreinformationonepigenetics,seeGeneticsand
37
27,33,34
33,38
25–27
37
38
3
33,39
40,41
42
10
EpigeneticsofAddictionDrugFacts.
Throughepigeneticmechanisms,theenvironmentcancauselong-termgeneticadaptations—influencingthepatternofgenesthatareactiveorsilentinencodingproteins—withoutalteringtheDNAsequence.Thesemodificationscansometimesevenbepasseddowntothenextgeneration. Thereisalsoevidencethattheycanbereversedwithinterventionsorenvironmentalalteration.
Theepigeneticimpactofenvironmentishighlydependentondevelopmentalstage. Studiessuggestthatenvironmentalfactorsinteractwithgeneticvulnerabilityduringparticulardevelopmentalperiodstoincreasetheriskformentalillnesses andaddiction. Forexample,animalstudiesindicatethatamaternaldiethighinfatduringpregnancycaninfluencelevelsofkeyproteinsinvolvedinneurotransmissioninthebrain’srewardpathway. Otheranimalresearchhasshownthatpoorqualitymaternalcarediminishedtheabilityofoffspringtorespondtostressthroughepigeneticmechanisms. Researchersareusinganimalmodelstoexploretheepigeneticchangesinducedbychronicstressordrugadministration,andhowthesechangescontributetodepression-andaddiction-relatedbehaviors. Abetterunderstandingofthebiologicalmechanismsthatunderliethegeneticandbiologicalinteractionsthatcontributetothedevelopmentofthesedisorderswillinformthedesignofimprovedtreatmentstrategies.
BrainRegionInvolvement
Manyareasofthebrainareaffectedbybothsubstanceusedisordersandothermentalillnesses.Forexample,thecircuitsinthebrainthatmediatereward,decisionmaking,impulsecontrol,andemotionsmaybeaffectedbyaddictivesubstancesanddisruptedinsubstanceusedisorders,depression,schizophrenia,andotherpsychiatricdisorders. Inaddition,multipleneurotransmittersystemshavebeenimplicatedinbothsubstanceusedisordersandothermentaldisordersincluding,butnotlimitedto,dopamine,serotonin, glutamate, GABA, andnorepinephrine.
EnvironmentalInfluences
35
41
42
42 35
41
41
40
40,42
2,3,34,43
44–46
47,48 49,50 51 46,52,53
11
Manyenvironmentalfactorsareassociatedwithanincreasedriskforbothsubstanceusedisordersandmentalillnessincludingchronicstress,trauma,andadversechildhoodexperiences,amongothers.Manyofthesefactorsaremodifiableand;thus,preventioninterventionswilloftenresultinreductionsinbothsubstanceusedisordersandmentalillness,asdiscussedintheSurgeonGeneral’sreportonalcohol,drugs,andhealth.
Stress
Stressisaknownriskfactorforarangeofmentaldisordersandthereforeprovidesonelikelycommonneurobiologicallinkbetweenthediseaseprocessesofsubstanceusedisordersandmentaldisorders. Exposuretostressorsisalsoamajorriskfactorforrelapsetodruguseafterperiodsofrecovery.Stressresponsesaremediatedthroughthehypothalamic-pituitary-adrenal(HPA)axis,whichinturncaninfluencebraincircuitsthatcontrolmotivation.Higherlevelsofstresshavebeenshowntoreduceactivityintheprefrontalcortexandincreaseresponsivityinthestriatum,whichleadstodecreasedbehavioralcontrolandincreasedimpulsivity. Earlylifestressandchronicstresscancauselong-termalterationsintheHPAaxis,whichaffectslimbicbraincircuitsthatareinvolvedinmotivation,learning,andadaptation,andareimpairedinindividualswithsubstanceusedisordersandothermentalillnesses.
Importantly,dopaminepathwayshavebeenimplicatedinthewayinwhichstresscanincreasevulnerabilitytosubstanceusedisorders.HPAaxishyperactivityhasbeenshowntoalterdopaminesignaling,whichmayenhancethereinforcingpropertiesofdrugs. Inturn,substanceusecauseschangestomanyneurotransmittersystemsthatareinvolvedinresponsestostress.Theseneurobiologicalchangesarethoughttounderliethelinkbetweenstressandescalationofdruguseaswellasrelapse.Treatmentsthattargetstress,suchasmindfulness-basedstressreduction,havebeenshowntobebeneficialforreducingdepression,anxiety,andsubstanceuse.
TraumaandAdverseChildhoodExperiences
Physicallyoremotionallytraumatizedpeopleareatmuchhigherriskfordrug
3,38,54
55
2,3,34,43
38,54,55
56
57
12
useandSUDs. andtheco-occurrenceofthesedisordersisassociatedwithinferiortreatmentoutcomes. PeoplewithPTSDmayusesubstancesinanattempttoreducetheiranxietyandtoavoiddealingwithtraumaanditsconsequences.
ThelinkbetweensubstanceusedisorderandPTSDisofparticularconcernforservicemembersreturningfromtoursofdutyinIraqandAfghanistan.Between2004and2010,approximately16percentofveteranshadanuntreatedsubstanceusedisorder,and8percentneededtreatmentforseriouspsychologicaldistress(SPD). Datafromasurveythatusedacontemporary,nationalsampleofveteransestimatedthattherateoflifetimePTSDwas8percent,whileapproximately5percentreportedcurrentPTSD. Approximately1in5veteranswithPTSDalsohasaco-occurringsubstanceusedisorder.
2.Mentalillnessescancontributetodruguseandaddiction.
Certainmentaldisordersareestablishedriskfactorsfordevelopingasubstanceusedisorder. Itiscommonlyhypothesizedthatindividualswithsevere,mild,orevensubclinicalmentaldisordersmayusedrugsasaformofself-medication. Althoughsomedrugsmaytemporarilyreducesymptomsofamentalillness,theycanalsoexacerbatesymptoms,bothacutelyandinthelongrun.Forexample,evidencesuggeststhatperiodsofcocaineusemayworsenthesymptomsofbipolardisorderandcontributetoprogressionofthisillness.
Whenanindividualdevelopsamentalillness,associatedchangesinbrainactivitymayincreasethevulnerabilityforproblematicuseofsubstancesbyenhancingtheirrewardingeffects,reducingawarenessoftheirnegativeeffects,oralleviatingtheunpleasantsymptomsofthementaldisorderorthesideeffectsofthemedicationusedtotreatit. Forexample,neuroimagingsuggeststhatADHDisassociatedwithneurobiologicalchangesinbraincircuitsthatarealsoassociatedwithdrugcravings,perhapspartiallyexplainingwhypatientswithsubstanceusedisordersreportgreatercravingswhentheyhavecomorbidADHD.
57
57
58
59
60
61
62
1,28
63
1
64–66
13
3.Substanceuseandaddictioncancontributetothedevelopmentofmentalillness.
Substanceusecanleadtochangesinsomeofthesamebrainareasthataredisruptedinothermentaldisorders,suchasschizophrenia,anxiety,mood,orimpulse-controldisorders. Drugusethatprecedesthefirstsymptomsofamentalillnessmayproducechangesinbrainstructureandfunctionthatkindleanunderlyingpredispositiontodevelopthatmentalillness.
TheComorbidityBetweenMentalIllnessandTobaccoUse—HighlightonSchizophrenia
Basedonnationallyrepresentativesurveydatafrom2016,30.5percentofrespondentswhohaveamentalillnesssmokedcigarettesinthepastmonth,whichisabout66percenthigherthantherateamongthosewithnomentalillness.Thereisastrongassociationbetweenmentalillness,particularlydepressionandschizophrenia,anduseoftobaccoproducts.Peoplewithschizophreniahavethehighestprevalenceofsmoking(70
to80percent) —withratesupto5timeshigherthanthegeneralpopulation.
Smokingmayreduceorhelpindividualscopewiththesymptomsoftheseillnesses,suchaspoorconcentration,lowmood,andstress. Suchalleviationofsymptomsmayexplainwhypeoplewithmentalillnessesarelesslikelytoquitsmokingcomparedwiththoseinthegeneralpopulation. Unfortunately,highratesofsmokinganddifficultyquittingamongpeoplewithschizophreniamaycontributetotheirgreaterprevalenceofcardiovasculardiseaseandshorterlifeexpectancy.
ResearchonSchizophreniaandNicotine
Researchonhowbothnicotineandschizophreniaaffectthebrainhasgeneratedotherpossibleexplanationsforthehighrateofsmokingamongpeoplewithschizophrenia. Thepresenceofabnormalitiesinparticularcircuitsofthebrainmaypredisposeindividualstoschizophreniaand
2,36
67–
69
70
68
43,67,68
68,71,72
68
43
14
increasetherewardingeffectsofdrugslikenicotine,and/orreduceanindividual’sabilitytoquitsmoking. Thesemechanismsareconsistentwiththeobservationthatbothnicotineandthemedicationclozapine(whichalsoactsatnicotinicacetylcholinereceptors,amongothers)areeffectiveintreatingindividualswithschizophrenia, andcanserveasreplacementsforthenicotineobtainedthroughcigarettesmoking,thusmakingiteasiertoquitsmoking.
Thedorsalanteriorcingulatecortex(dACC)isinvolvedindecision-makingandplanning,focusingattention,andcontrollingimpulsesandemotions.Researchershavefoundthatconnectionsbetweenthisregionandseveralotherbrainareas—includingsomeinvolvedinmemory,emotion,andreward—areweakeramongpatientswithschizophreniacomparedwiththosewithoutthedisorder.Thiscircuitwasimpairedamongpeoplewithschizophreniaregardlessofwhethertheysmokedornot,aswellasamongthecloserelativesofpeoplewithschizophrenia.Severaloftheseneuralcircuitswerealsolessactiveamongindividualswithseverenicotineusedisorder,suggestingthatthisbraincircuitisimpairedinbothschizophreniaandnicotinedependence.
Alowerlevelofnicotinicacetylcholinereceptorsisaneurobiologicalhallmarkofschizophrenia.Thesereceptors,whichareinvolvedincognitionandmemory, arenaturallyactivatedbytheneurotransmitteracetylcholine—buttheycanalsobeactivatedbynicotine.Researchersareworkingtodevelopmedicationsthatstimulatethesespecificreceptors,whichcancounterthecognitiveimpairmentsassociatedwithschizophreniawithouttheaddictivepotentialofnicotineorthenegativehealthconsequencesofsmoking. Understandinghowandwhypatientswithschizophreniausenicotinemayhelpinformthedevelopmentofnewtreatmentsforbothschizophreniaandnicotinedependence.
Althoughthereisagreatneedfornewtreatmentsforbothschizophreniaandnicotinedependence,peoplewiththesecomorbiddisorderscanquitwithoutworseningtheirmentalhealthwhentheyhaveappropriatesupport. Forexample,bupropionincreasessmokingabstinenceratesinpeoplewithschizophrenia,withnoapparentworseningofpsychoticsymptoms. Addingmotivationalincentives(rewardingpatientsfor
43,73
17,74
74
73
75
75
67,76
77,78
15
biologicallyverifiedabstinence)tobupropionmedicationmayhelppreventrelapseduringtheinitialphaseofsmokingcessation. Vareniclinemayalsoimprovesmokingcessationratesinschizophrenia,butthismedicationmayworsenpsychiatricsymptomsandrequiresadditionalresearch.
78
78,79
16
Whataresomeapproachestodiagnosis?
Thehighrateofcomorbiditybetweendrugusedisordersandothermentalillnesseshighlightstheneedforanintegratedapproachtointerventionthatidentifiesandevaluateseachdisorderconcurrentlyandprovidestreatmentasappropriateforeachpatient’sparticularconstellationofdisorders.Enhancedunderstandingofthecommongenetic,neural,andenvironmentalsubstratesofthesedisorderscanleadtoimprovedtreatmentsforindividualswithcomorbiditiesandmayhelpdiminishthesocialstigmathatmakessomepatientsreluctanttoseekthetreatmenttheyneed.
Thediagnosisandtreatmentofcomorbidsubstanceusedisordersandmentalillnessarecomplex,becauseitisoftendifficulttodisentangleoverlappingsymptoms. Comprehensiveassessmenttoolsshouldbeusedtoreducethechanceofamisseddiagnosis. Patientswhohavebothadrugusedisorderandanothermentalillnessoftenexhibitsymptomsthataremorepersistent,severe,andresistanttotreatmentcomparedwithpatientswhohaveeitherdisorderalone.
Patientsenteringtreatmentforpsychiatricillnessesshouldbescreenedforsubstanceusedisordersandviceversa.Accuratediagnosisiscomplicated,however,bythesimilaritiesbetweendrug-relatedsymptoms,suchaswithdrawal,andthoseofpotentiallycomorbidmentaldisorders.Thus,whenpeoplewhousedrugsentertreatment,itmaybenecessarytoobservethemafteraperiodofabstinencetodistinguishbetweentheeffectsofsubstanceintoxicationorwithdrawalandthesymptomsofcomorbidmentaldisorders.Thispracticeresultsinmoreaccuratediagnosesandallowsforbetter-targetedtreatment.
80,81
2,80,81
81
3,82
80,81
17
PolysubstanceUseandComorbidSubstanceUseDisorders
Polysubstanceuseiscommon,andmanypeopledevelopmultiplecomorbidsubstanceusedisorders(Table1).Forexample,amongpeoplewithaheroinusedisorderover66percentaredependentonnicotine,nearly25percenthaveanalcoholusedisorder,andover20percenthaveacocaineusedisorder.Amongpeoplewithacocaineusedisordernearly60percenthaveanalcoholusedisorder,approximately48percentaredependentonnicotine,andover21percenthaveamarijuanausedisorder.Aswithsingle-substanceusedisorders,thediagnosisandtreatmentofcomorbidsubstanceusedisordersandmentalillnessarecomplex.Theuseofmultiplesubstancescanfurthercomplicatediagnosisandtreatment.
Fullsizetable
18
Whatarethetreatmentsforcomorbidsubstanceusedisorderandmentalhealthconditions?
Integratedtreatmentforcomorbiddrugusedisorderandmentalillnesshasbeenfoundtobeconsistentlysuperiorcomparedwithseparatetreatmentofeachdiagnosis. Integratedtreatmentofco-occurringdisordersofteninvolvesusingcognitivebehavioraltherapystrategiestoboostinterpersonalandcopingskillsandusingapproachesthatsupportmotivationandfunctionalrecovery.
Patientswithcomorbiddisordersdemonstratepoorertreatmentadherenceandhigherratesoftreatmentdropout thanthosewithoutmentalillness,whichnegativelyaffectsoutcomes.Nevertheless,steadyprogressisbeingmadethroughresearchonnewandexistingtreatmentoptionsforcomorbidity. Inaddition,researchonimplementationofappropriatescreeningandtreatmentwithinavarietyofsettings,includingcriminaljusticesystems,canincreaseaccesstoappropriatetreatmentforcomorbiddisorders.
Treatmentofcomorbidityofteninvolvescollaborationbetweenclinicalprovidersandorganizationsthatprovidesupportiveservicestoaddressissuessuchashomelessness,physicalhealth,vocationalskills,andlegalproblems.Communicationiscriticalforsupportingthisintegrationofservices.Strategiestofacilitateeffectivecommunicationmayincludeco-location,sharedtreatmentplansandrecords,andcasereviewmeetings. Supportandincentivesforcollaborationmaybeneeded,aswellaseducationforstaffonco-occurringsubstanceuseandmentalhealthdisorders.
TreatmentforYouth
Asmentionedpreviously,theonsetofmentalillnessandsubstanceusedisordersoftenoccursduringadolescence,andpeoplewhodevelop
3,81–83
81
84
3,82
74,81–83,85
86
87
87
19
problemsearliertypicallyhaveagreaterriskforsevereproblemsasadults.GiventhehighprevalenceofcomorbidmentaldisordersandtheiradverseimpactonSUDtreatmentoutcomes,SUDprogramsforadolescentsshouldscreenforcomorbidmentaldisordersandprovidetreatmentasappropriate.
Researchindicatesthatsomemental,emotional,andbehavioralproblemsamongyouthcanbepreventedorsignificantlymitigatedbyevidence-basedpreventioninterventions. Theseinterventionscanhelpreducetheimpactofriskfactorsforsubstanceusedisordersandothermentalillnesses,includingparentalunemployment,maternaldepression,childabuseandneglect,poorparentalsupervision,deviantpeers,deprivation,poorschools,trauma,limitedhealthcare,andunsafeandstressfulenvironments.Implementationofpolicies,programs,andpracticesthatdecreaseriskfactorsandincreaseresiliencecanhelpreducebothsubstanceusedisordersandothermentalillnesses,potentiallysavingbillionsofdollarsinassociatedcostsrelatedtohealthcareandincarceration.
Otherevidence-basedinterventionsemphasizestrengtheningprotectivefactorstoenhanceyoungpeople’swell-beingandprovidethetoolstoprocessemotionsandavoidbehaviorswithnegativeconsequences.Keyprotectivefactorsincludesupportivefamily,school,andcommunityenvironments.
Inadditiontothetreatmentoptionsdiscussedinthisresearchreport,thefollowingtreatmentshavebeenshowntobeeffectiveforchildrenandadolescents:
MultisystemicTherapy(MST).MSTtargetskeyfactorsthatareassociatedwithseriousantisocialbehaviorinchildrenandadolescentswithsubstanceusedisorders,suchasattitudes,family,peerpressure,schoolandneighborhoodculture.
BriefStrategicFamilyTherapy(BSFT).BSFTtargetsfamilyinteractionsthatarethoughttomaintainorexacerbateadolescentsubstanceusedisorderandotherco-occurringproblembehaviors
21,23,88
89
89
22,24
20
suchasconductproblems,oppositionalbehavior,delinquency,associatingwithantisocialpeers,aggressiveandviolentbehavior,andriskysexualbehaviors.
MultidimensionalFamilyTherapy(MDFT).MDFT,acomprehensiveinterventionforadolescents,focusesonmultipleandinteractingriskfactorsforsubstanceusedisordersandrelatedcomorbidconditions.Thistherapyaddressesadolescents’interpersonalandrelationshipissues,parentalbehaviors,andthefamilyenvironment.Familiesreceiveassistancewithnavigatingschoolandsocialservicesystems,aswellasthejuvenilejusticesystemifneeded.Treatmentincludesindividualandfamilysessions.
Medications
Effectivemedicationsexistfortreatingopioid,alcohol,andnicotineusedisordersandforalleviatingthesymptomsofmanyotherdisorders.Whilemosthavenotbeenwellstudiedincomorbidpopulations,somemedicationsmayhelptreatmultipleproblems.Forexample,bupropionisapprovedfortreatingdepressionandnicotinedependence.Formoreinformation,seethetablebelow.
ViewTable:PharmacotherapiesUsedtoTreatAlcohol,Nicotine,andOpioidUseDisorders
BehavioralTherapies
Behavioraltreatment(aloneorincombinationwithmedications)isacornerstonetosuccessfullong-termoutcomesformanyindividualswithdrugusedisordersorothermentalillnesses. Severalstrategieshaveshownpromisefortreatingspecificcomorbidconditions.
90
91
62,74,83
3,81–83,85
21
CognitiveBehavioralTherapy(CBT)CBTisdesignedtomodifyharmfulbeliefsandmaladaptivebehaviorsandshowsstrongefficacyforindividualswithsubstanceusedisorders.CBTisthemosteffectivepsychotherapyforchildrenandadolescentswithanxietyandmooddisorders.
DialecticalBehaviorTherapy(DBT)DBTisdesignedspecificallytoreduceself-harmbehaviorsincludingsuicidalattempts,thoughts,orurges;cutting;anddruguse.Itisoneofthefewtreatmentseffectiveforindividualswhomeetthecriteriaforborderlinepersonalitydisorder.
AssertiveCommunityTreatment(ACT)ACTprogramsintegratebehavioraltreatmentsforseverementalillnessessuchasschizophreniaandco-occurringsubstanceusedisorders.ACTisdifferentiatedfromotherapproachestocasemanagementthroughfactorssuchasasmallercaseloadsize,teammanagement,outreachemphasis,ahighlyindividualizedapproach,andanassertiveapproachtomaintainingcontactwithpatients.
TherapeuticCommunities(TCs)TCsareacommonformoflong-termresidentialtreatmentforsubstanceusedisorders.Theyfocusonthe“resocialization”oftheindividual,oftenusingbroad-basedcommunityprogramsasactivecomponentsoftreatment.TCsareappropriateforpopulationswithahighprevalenceofco-occurringdisorderssuchascriminaljustice-involvedpersons,individualswithvocationaldeficits,vulnerableorneglectedyouth,andhomelessindividuals. Inaddition,someevidencesuggeststhatTCsmaybehelpfulforadolescentswhohavereceivedtreatmentforsubstanceuseandaddiction.
ContingencyManagement(CM)orMotivationalIncentives(MI)CM/MIisusedasanadjuncttotreatment.Voucherorprize-basedsystemsrewardpatientswhopracticehealthybehaviorsandreduceunhealthybehaviors,includingsmokinganddruguse.Incentive-basedtreatmentsareeffectiveforimprovingtreatmentcomplianceandreducingtobaccoandotherdruguse,andcanbeintegratedintobehavioralhealthtreatmentprogramsforpeoplewithco-occurringdisorders.
ExposureTherapy
22,24,88
92
93
86
94
95
22
Exposuretherapyisabehavioraltreatmentforsomeanxietydisorders(phobiasandPTSD)thatinvolvesrepeatedexposuretoafearedsituation,object,traumaticevent,ormemory.Thisexposurecanbereal,visualized,orsimulated,andisalwayscontainedinacontrolledtherapeuticenvironment.Thegoalistodesensitizepatientstothetriggeringstimuliandhelpthemdevelopcopingmechanisms,eventuallyreducingoreveneliminatingsymptoms.SeveralstudiessuggestthatexposuretherapymaybehelpfulforindividualswithcomorbidPTSDandcocaineusedisorder,althoughretentionintreatmentisachallenge.
IntegratedGroupTherapy(IGT)IGTisatreatmentdevelopedspecificallyforpatientswithbipolardisorderandsubstanceusedisorder,designedtoaddressbothproblemssimultaneously. ThistherapyislargelybasedonCBTprinciplesandisusuallyanadjuncttomedication.TheIGTapproachemphasizeshelpingpatientsunderstandtherelationshipbetweenthetwodisorders,aswellasthelinkbetweenthoughtsandbehaviors,andhowtheycontributetorecoveryandrelapse.
SeekingSafety(SS)SeekingSafetyisapresent-focusedtherapyaimedattreatingtrauma-relatedproblems(includingPTSD)andsubstanceusedisordersimultaneously.Patientslearnbehavioralskillsforcopingwithtrauma/post-traumaticstressdisorderandsubstanceusedisorder.
MobileMedicalApplicationIn2017,theFoodandDrugAdministrationapprovedthefirstmobilemedicalapplicationtohelptreatsubstanceusedisorders.Theintentionisforpatientstouseitwithoutpatienttherapytotreatalcohol,cocaine,marijuana,andstimulantusedisorders;itisnotintendedtotreatopioiddependence.ThedevicedeliversCBTtopatientstoteachskillsthataidinthetreatmentinsubstanceusedisordersandincreaseretentioninoutpatienttherapyprograms.
57
96
96
97
98
23
Part2:Co-occurringSubstanceUseDisorderandPhysicalComorbidities
Peoplewithsubstanceusedisordersalsooftenexperiencecomorbidchronicphysicalhealthconditions,includingchronicpain, cancer,andheartdisease. Theuseofvarioussubstances—includingalcohol,heroin,prescriptionstimulants,methamphetamine,andcocaine—isindependentlyassociatedwithincreasedriskforcardiovascularandheartdisease.
ChronicPain
Chronicpainisaphysicalproblemthathasacomplexrelationshipwithsubstanceusedisorders,particularlyopioidmisuseandaddiction. Anestimated10percentofchronicpainpatientsmisuseprescriptionopioids.Chronicpainandassociatedemotionaldistressarethoughttodysregulatethebrain’sstressandrewardcircuitry,increasingtheriskforopioidusedisorder.Opioidmisuseandaddictionareseriouspublichealthproblemsthatledtomorethan42,000deathsin2016alone. Highratesofopioidmisuseandaddictionamongpatientswithchronicpainhighlighttheneedforcarefulpre-treatmentscreeningandeducationaswellasongoingmonitoringforsafetyandeffectivenesswhenopioidmedicationsareusedtotreatpain.
TobaccoUse
Oneofthelargestdriversofphysicalhealthcomorbiditiesiscigarettesmoking.ItislinkedtomanymajorhealthconditionsandremainstheleadingpreventablecauseofprematurediseaseanddeathintheUnitedStates. Forexample,themajorityoflungcancerandapproximatelyone-thirdofallcancerdeathsareattributabletosmoking. Smokingisknowntocontributetoage-relatedmaculardegeneration,diabetes,colorectalcancer,livercancer,adversehealthoutcomesincancerpatientsandsurvivors,tuberculosis,erectiledysfunction,rheumatoidarthritis,inflammation,andimpairedimmunefunction. Smokingisalsoanimportantcomorbidityamongpeoplewithotherdrugusedisordersandcontributestotheirphysicalhealthproblems.An
99
100
100
99
99
99
101
102,103
104
104
104
24
estimated77–93percentofpeopleintreatmentforsubstanceusedisordersusetobacco.
MentalIllness
Physicalillnessesnotonlyaffectthebodyanddailyfunctioning,buttheycanalsoincreasetheriskformentalillnessessuchasdepression andanxiety.Depressionhasanegativeimpactonindividualswithchronicphysicalconditions,reducingaperson’squalityoflifeandabilitytomanagetheirhealth. Comorbidmentalillnessesareassociatedwithgreaterfunctionalimpairmentsandmortalityratesrelatedtophysicalillnesses. Olderpeoplewithchronicphysicalillnessesorimpairmentsmayfeelisolatedandincreasesubstanceuse. Furthermore,asdiscussedinPart1,mentalillnessmayleadtosubstanceusedisordersandviceversa,thus,SUDsmayplayaroleinlinkingmentalillnessandphysicalhealth.
TreatmentAdherence
Inadditiontothedirecteffects,substanceusedisorderscanhaveanindirectnegativeimpactonthemanagementofmedicalconditions.Forexample,peoplewithsubstanceusedisordersarelesslikelytoadherewiththeirtreatmentplansortotakemedicationregularly, whichworsensthecourseoftheirillnesses.Inaddition,substanceusecandiminishtheeffectivenessofmedicationsforphysicalconditions.
InfectiousDiseaseTransmission
Substanceusealsoincreasestheriskofinfectiousdiseasetransmission,includingHIV andthehepatitisCvirus(HCV). Thisincreasedriskisrelatedtoinjectiondruguseandincreasedriskysexualbehaviorsassociatedwithdruguse. FormoreinformationabouttheconnectionbetweensubstanceuseandHIVpleasegotoPart3("TheConnectionbetweenSubstanceUseDisordersandHIV").
ImplicationsforHealthCareDelivery
100
105 106
105,106
105
100
107,108
100,109
110 111
110,111
25
Comorbidchronicphysicalandbehavioralhealthconditions(mentalandsubstanceusedisorders)areassociatedwithgreaterfunctionalimpairmentandincreasedhealthcarecosts.Aswithcomorbidmentalillness,integratedcareiscriticalforaddressingphysicalhealthcomorbidities. AsdiscussedinPart4("BarrierstoComprehensiveTreatmentforIndividualswithCo-OccurringDisorders"),recentdeliverysysteminnovationmodelsprovideincentivestoshifthealthcaretowardsintegratedcaremodels.Integratedcareoffersgreateropportunitiesforprimarycareproviders,physicianspecialists,andbehavioralhealthspecialiststoworktogethertoreducetheimpactofmentalandphysicalhealthcomorbiditiesonsubstanceusedisorder,andviceversa,toimproveoverallhealthoutcomes.
112
113
26
Part3:TheConnectionbetweenSubstanceUseDisordersandHIV
Morethan1.2millionpeopleintheUnitedStatesarelivingwithhumanimmunodeficiencyvirus(HIV),thevirusthatcausesacquiredimmunedeficiencysyndrome(AIDS). HIVistransmittedthroughcontactwithinfectedbloodandbodilyfluids.Suchcontactcanoccurthroughunprotectedsex,throughsharingneedlesorotherdruginjectionequipment,throughmother-to-childtransmissionduringpregnancyorbreastfeeding,andthroughinfectedbloodtransfusionsandplasmaproducts.Whileeffectiveantiretroviraltherapy(ART)isavailable,thereiscurrentlynocureforHIV/AIDS. However,theprovisionofARTreducesviralload—ultimatelydecreasingHIVtransmissioninthelargercommunity.
ThisnationalpublichealthissueandtheongoingglobalHIV/AIDSpandemicareexacerbatedbysubstanceuse,whichservesasapowerfulcofactorateverystage,includingtransmission,diagnosis,illnesstrajectories,andtreatment.Sincethebeginningoftheepidemicinthe1980s,druguseandHIVhavebeeninextricablylinked.Today,illicitdruguseisanimportantdriverofHIVacrosstheglobe. Intravenousdruguseinparticularcontinuestobeariskfactorfortransmissionofthevirus, accountingforapproximately6percentofHIVdiagnosesin2015.
Inaddition,druguseplaysamoregeneralroleinthespreadofHIVbyincreasingthelikelihoodofhigh-risksexwithinfectedpartners. Theintoxicatingeffectsofmanydrugscanalterjudgmentandinhibition,andleadpeopletoengageinimpulsiveandunsafebehaviors.Additionally,peoplewhoareaddictedtodrugsmayengageinriskysexualbehaviorstoobtaindrugsormoneytobuythem.
DruguseandaddictioncanalsohastentheprogressionofHIVanditsconsequences,especiallyinthebrain.Clinicalresearchindicatesthatdruguseandaddictionmayincreaseviralload,acceleratediseaseprogression,andworsenAIDS-relatedmortalityevenamongpatientswhofollowARTregimens. Inaddition,peoplewithsubstanceusedisordersarelesslikelyto
114
115,116
117
118
118,119
120
119
119
121
107
27
takelife-savingHIVmedicationregularly, whichworsensthecourseoftheirillness.
AlthoughitisunclearwhetherHIVinfectioncontributestodruguseandaddictioninhumanpatients, animalstudiessuggestthatbothtypesofbraincells—neuronsandglia—canbeinfectedbyHIV,causingneurobiologicaldisruptionstobraincircuitsthatareeffectedbydruguseandaddiction.
DrugscanmakeiteasierforHIVtoenterthebrainandtriggeranimmuneresponseandthereleaseofneurotoxins,whichcancausechronicneuroinflammation. HIV-inducedinflammationinthebrainunderliestheneurocognitivedisorders,alsocalledNeuroHIV,thatareacomplicationofHIVinfection. Around50percentofindividualswithHIVandAIDSsufferfromHIV-relatedneurocognitivedisorders. NeuroHIVischallengingtodiagnoseandtreat,sinceotherfactors—suchasaging,druguse,addiction,andpsychiatricillnesses—arecommonandcanproducesimilarcognitivesymptoms. ThereisanongoingneedfornewtherapeuticapproachestotheneurologicalcomplicationsofHIV,asclinicaltrialsofneuroprotectiveoranti-inflammatorymedicationshavebeenunsuccessful.
BecausepeoplewithHIVarelivinglongerduetoeffectivetreatments,theinfluenceofthevirusontheagingbrainandneurocognitionisagrowingconcern.AroundhalfofallHIV-infectedpersonsare50yearsoldorover.NeuroimagingresearchconductedpriortoeffectivetreatmentoronuntreatedindividualssuggeststhatHIVacceleratesagingofthebrain.ComorbidsubstanceusedisordermayexacerbateneurologicalagingamongpeoplewithHIV.
TestingforandtreatingHIVincriminaljusticesettingsbenefitsboththehealthofinmatesandoverallpublichealth.PeoplewithHIVinfectionareoverrepresentedinprisons;in2010,therewere20,093inmateswithHIV/AIDSinstateandfederalprisons. MostincarceratedindividualswithHIVacquireditinthecommunitypriortoincarceration. IndividualswithHIVoftenbegintreatmentwhileincarcerated,buttheyexperienceadisruptionofcarewhentheyreturntothecommunity,inadditiontofacingchallengescopingwithsubstanceuseandmentalhealthproblems. Thereforeitisparticularly
107
121
122
123
124
125
126
126
127
127
128
129
130
28
importanttolinkpeoplewhohaveHIVandahistoryofsubstanceusetocommunityHIVservices,substanceabusetreatment,mentalhealthservices,andotherwraparoundservicesintheircommunitytoreducerecidivism,improvetheirhealth,reducethespreadoftheinfectiontoothers,andpreventrelapsetosubstanceabuse.129–131
29
WhyisHIVscreeningimportant?
TheriskofHIVtransmissionislowerwhenpeoplewhoareinfectedwithHIVreceiveARTtosuppresstheirviralload.DespiteCDC’srecommendationsandeffortstoincreaseHIVtesting. Onesurveyfoundthatonlyabout19percentofpeopleaged15to44weretestedforHIVduringthepastyear. ThismeansthatpeoplewhomayhaveHIVareunawareoftheirstatusand,thus,arenotreceivingART,whichincreasesthetransmissionratenation-wide.
BecauseHIV,druguse,andaddictionareinextricablylinked,onestrategyforreducingincidenceistoimplementHIVtestingatSUDtreatmentfacilities. AnanalysisofnationallyrepresentativedatafromprivatelyfundedSUDtreatmentprogramsfoundthatmostprogramsprovidededucationandpreventionservices.Whiletheproportionofprogramsofferingon-siteHIVtestingandthepercentageofpatientswhoreceivedtestingincreasedinrecentyears, fewerthanone-thirdofprogramsofferedon-sitetesting.Inthoseprograms,fewerthanone-thirdofpatientsreceivedtesting.
NIDAiscollaboratingwiththeSubstanceAbuseandMentalHealthServicesAdministration(SAMHSA)andotherstoexpandrapidHIVtestingtodrugtreatmentfacilitiestobetteridentifyHIVinfectionsandengagepatientsmoreefficientlyincomprehensivetreatmentforbothsubstanceusedisorderandHIVinfection.ManyhealthinsuranceproviderscoverHIVtestingwithoutaco-payordeductible. TofindalocalHIVtestingcentervisit:https://www.cdc.gov/hiv/.
132
133
134
134
134
135
30
WhataresomemethodsforHIVpreventionandtreatmentforindividualswithsubstanceusedisorders?
ResearchindicatesthatSUDtreatment, sterilesyringeprograms,community-basedoutreach,testing,andlinkagetocomprehensivecareforHIVandotherinfections arethemosteffectivewaystoreducetransmissionamongindividualswhousedrugs.Becausetheseindividualsoftenfacebarrierstotesting,treatment,andadheringtoART,uniquesupportsareneededforpreventionandtreatmentwithinthispopulation.
Pre-exposureprophylaxis(PrEP)
PrEPisanimportantcomponentofHIVprevention.Inthisapproach,peoplewhoareatsignificantriskbutnotinfectedwithHIVtakeadailyoraldoseofmedicationtopreventthemfromcontractingthevirus. TheWorldHealthOrganizationrecommendsPrEPasonecomponentofpreventionforindividualsathighriskforHIV. Aswithallmedications,adherenceiscriticaltoeffectiveness. TherehavebeensomepromisingresultsofPrEPamongpeoplewhoinjectdrugs,withoneclinicaltrialfindingthatitdecreasedtheriskofHIVinfectionbyasmuchas84percentforthosewhowerehighlyadherent,butonlyabout50percentoverall. MoreresearchisneededonoptimizingPrEPadherenceandthebestwaystointegrateitintoSUDtreatment.DespiteresearchindicatingthatPrEPisgenerallysafeandeffectiveforthosewhoareatsignificantriskofHIVinfection, strategiestoincreaseaccesstoPrEPamonginjectiondrugusersshouldbeexplored.
TheSeek,Test,Treat,andRetain(STTR)ModelofCare
PeoplecontinuetobeinfectedbyHIVthroughunsafecontactwithotherswhoareeitherunawarethattheyhavethevirusorhaveinadequatelysuppressedtheirviralload. TheSTTRmodelofcareisspecificallydesignedtoaddress
136 137
138–140
107
141
142
143,144
145
146
107
143,14
148
31
thesetwodriversofnewHIVinfections,particularlyconsideringthewell-documenteddelaysintestingandtreatmentexperiencedbyindividualswithsubstanceusedisorders. Thisapproachinvolvesreachingouttohigh-risk,hard-to-reachdrug-usingpopulationswhohavenotrecentlybeentestedforHIV(seeking);engagingtheminHIVtesting(testing);initiating,monitoring,andmaintainingARTforthosetestingpositive(treating);andretainingpatientsincare(retaining).
Incorporatingrapidon-siteHIVtestingintoSUDtreatmentisanimportantcomponentofeffortstoidentifythosewhoareinfected,initiatecareearlier,andreducetransmission. However,treatmentprogramsmaynothavesufficientresourcestoprovideHIVtesting.Reducingbarriersbyprovidingstart-upcostsandstafftrainingonhowtosupportindividualswhotestpositive,andaddressingstaffingneedsarecrucialtoestablishingandmaintainingrapidon-siteHIVtestinginSUDtreatmentfacilities. ResearchersestimatethattestingpeoplewhoinjectdrugsforHIVevery6monthsiscosteffective,comparedwithannualtesting,at$133,200inincrementalcostsperquality-adjustedlifeyeargained.
ARThasimprovedthesurvivalofpeoplewithHIV,includingthosewhoinjectdrugs,sothattheynowtendtoliveaslongasthosewhoarenotinfectedwiththevirus. Mostpatients,regardlessofinjectiondrugusehistory,canachieveviralsuppressionwithART, whichcansignificantlyreducetransmissionofHIVtoothers. Thisapproach,calledTreatmentasPrevention,isacrucialpartofeffortstoreducethespreadofthevirusandakeycomponentoftheSTTRstrategy.TheTreatmentasPreventionapproachreliesonidentifyingundiagnosedindividuals,linkingthemtotreatmentwithART,andretainingthemincare. Retentionintreatmentiskeytoachievingfullviralsuppression(i.e.,virusisbelowdetectablelevels)andpreventingtransmissionofHIV.CDCestimatesthat49percentofpeoplewithHIVintheUnitedStateshadfullviralsuppressionin2014. Datafrom2011showedthatamongpeoplewhoseviralloadwasnotsuppressed,20percenthadneverbeendiagnosedwithHIV,66percentwerediagnosedbutnotengagedinmedicalcareforHIV,4percentwereengagedinHIVmedicalcarebutnotprescribedART,and10percentwereprescribedARTbuthadnotachievedviralsuppression.
SubstanceUseDisorderTreatment
149
150
150
151
152
153
138
138
154
155
32
StudiesfindthatbehavioraltreatmentssuchascognitivebehavioraltherapyandmotivationalinterviewingnotonlyreducedrugusebutalsoimproveadherencetoARTregimens andmedicationsforHCV. Amongmenwhohavesexwithmen(MSM),SUDtreatmentisassociatedwithreduceddruguseandriskysexualbehavior,andthosewithHIVreportimprovementsinviralload. AddictionpharmacotherapiesalsoreducetheriskforHIV.Pooledresultsfrommultiplestudiesindicatethatmethadoneorbuprenorphinetreatmentforopioidusedisorderisassociatedwitha54percentreductioninriskofHIVinfectionamongpeoplewhoinjectdrugs. HIV-infectedpeoplewhoinjectdrugsaremorelikelytoinitiateARTwhenengagedinmethadonetreatment. Becausepeoplewhoinjectdrugsalsohavearelativelyhighprevalenceofmentalillness,researchsuggeststhatfullyintegratedaddiction,psychiatric,andHIVcaremightincreasethelikelihoodofARTadherenceandimprovehealthoutcomes.
156 157
158
136
159
160,161
33
HowcanweachieveanAIDS-freegeneration?
Althoughmoreresearchisneeded,thescientificandmedicalcommunitiescontinuetodevelopanddisseminateeffectiveHIVpreventionandtreatmentapproaches.ThreekeyprinciplesunderlieNIDA’sstrategy:(1)substanceusedisorderandHIVarelinkedinwaysthatextendbeyondinjectiondruguse;(2)substanceusedisorderandHIVremainintertwinedepidemicsintheUnitedStatesandaroundtheworld—therefore,SUDtreatmentisHIVprevention;and(3)theSTTRapproach,especiallywhenimplementedinhigh-riskpopulationsorsettings,candecreaseviralloadandHIVincidenceatapopulationlevel,improvingoutcomesforall.Implementingtheseevidence-basedstrategieswillbringtheUnitedStatesclosertothegoalofan"AIDS-freegeneration."
34
Part4:BarrierstoComprehensiveTreatmentforIndividualswithCo-OccurringDisorders
Althoughevidenceindicatestheneedforcomprehensiveandintegratedtherapytoaddresscomorbidity, researchshowsthatonlyabout18percentofSUDtreatmentprogramsand9percentofmentalhealthtreatmentorganizationshavethecapacitytoserveduallydiagnosedpatients.Provisionofsuchtreatmentcanbeproblematicforseveralreasons:
IntheUnitedStates,SUDtreatmentisoftensiloedfromthegeneralhealthcaresystem. Primarycarephysiciansaremostoftenthefrontlineoftreatmentformentaldisorders.Thespecialtymentalhealthtreatmentsystemtypicallyaddressesonlyseverementalillness,whiledrugtreatmentistypicallyprovidedbyaseparateSUDtreatmentsystem.Typically,noneofthesesystemshavesufficientlybroadexpertisetoaddressthefullrangeofproblemspresentedbyduallydiagnosedpatients.
AlingeringbiasremainsinsomeSUDtreatmentcentersagainstusinganymedications,includingthosenecessarytotreatseriousmentalillnessesincludingdepression,althoughthisisslowlychanging. Additionally,manySUDtreatmentprogramsdonotemployclinicianswhocanprescribe,dispense,andmonitormedications.
Manyindividualswhowouldbenefitfromtreatmentareinthecriminaljusticesystem.Itisestimatedthatabout45percentofindividualsinstateandlocalprisonsandjailshaveamentalhealthproblemcomorbidwithsubstanceuseoraddiction. However,adequatetreatmentservicesforbothdrugusedisordersandothermentalillnessesareoftennotavailablewithinthesesettings.Treatmentofcomorbiddisorderscanreducenotonlymedicalcomorbidities,butalsonegativesocialoutcomesbymitigatingagainstareturntocriminalbehaviorandre-incarceration.
Whilethesebarriersloomlarge,changestotheU.S.healthcaresystemcanhelpimprovecareforpeoplewithcomorbidities. TheMentalHealthParity
3,22,82,83
162
23,163
164
162
165
166
167
35
andAddictionEquityActof2008(alsoknownastheParityAct)andthePatientProtectionandAffordableCareActof2010(alsoknownastheAffordableCareActorACA)haveincreasedthenumberofpeoplewithinsurancethatcoversaddictionandmentalhealthtreatment.TheParityActmandatesthathealthcareplansthatcoverbehavioralhealthtreatmentsdosotothesameextentastreatmentsforphysicalhealthconditions. TheACArequiresthataddictionandmentalhealthtreatmentbecoveredasoneofthetenEssentialBenefitcategories.Withhealthcarereform’sotherprovisionstoincreasethequalityofcare,cliniciansnowhavegreatersupportandincentivestoimplementevidence-basedpractices andtocollaborateinteamsthatprovideintegratedcareforphysicalandmentaldisorders.
168
23,169
23,163,168,169
36
WherecanIgetmorescientificinformationoncomorbidsubstanceusedisorder,mentalillness,andmedicalconditions?
Tolearnmoreaboutsubstanceusedisordersandothermentalillnesses,ortoordermaterialsonthesetopicsfreeofchargeinEnglishorSpanish,visittheNIDAwebsiteatwww.drugabuse.govorcontacttheDrugPubsResearchDisseminationCenterat877-NIDA-NIH(877-643-2644;TTY/TDD:240-645-0228).
NIDA'swebsiteincludes:
Informationondrugsofuseandmisuseandrelatedhealthconsequences
NIDApublications,news,andevents
Resourcesforhealthcareprofessionals,educators,andpatientsandfamilies
InformationonNIDAresearchstudiesandclinicaltrials
Fundinginformation(includingprogramannouncementsanddeadlines)
Internationalactivities
Linkstorelatedwebsites(accesstowebsitesofmanyotherorganizationsinthefield)
InformationinSpanish(enespañol)
NIDAwebsitesandwebpages
drugabuse.gov/related-topics/comorbidity
drugabuse.gov/publications/drugfacts/comorbidity-addiction-other-mental-
37
disorders
drugabuse.gov
teens.drugabuse.gov
easyread.drugabuse.gov
researchstudies.drugabuse.gov
irp.drugabuse.gov
Forphysicianinformation
NIDAMED:drugabuse.gov/nidamed
Otherwebsites
Informationonmentalillnesses,substanceuse,andsubstanceusedisorderisalsoavailablethroughtheseotherwebsites:
NationalInstituteofMentalHealth
SubstanceUseandMentalHealth
HIV/AIDSandMentalHealth
NationalInstituteonAlcoholAbuseandAlcoholism
OtherPsychiatricDisorders
OtherSubstanceAbuse
SubstanceAbuseandMentalHealthServicesAdministrationHealthInformationNetwork
CommonComorbidities
Co-occuringDisorders
PublicationsandResources
CentersforDiseaseControlandPrevention—CopingWithaDisasteror
38
TraumaticEvent
HIV/AIDS
HIV.gov
OfficeofHIV/AIDSandInfectiousDiseasePolicy(OHAIDP)
39
References
1. SantucciK.Psychiatricdiseaseanddrugabuse.CurrOpinPediatr.2012;24(2):233-237.doi:10.1097/MOP.0b013e3283504fbf.
2. RossS,PeselowE.Co-occurringpsychoticandaddictivedisorders:neurobiologyanddiagnosis.ClinNeuropharmacol.2012;35(5):235-243.doi:10.1097/WNF.0b013e318261e193.
3. KellyTM,DaleyDC.IntegratedTreatmentofSubstanceUseandPsychiatricDisorders.SocWorkPublicHealth.2013;28(0):388-406.doi:10.1080/19371918.2013.774673.
4. HserYI,GrellaCE,HubbardRL,etal.Anevaluationofdrugtreatmentsforadolescentsin4UScities.ArchGenPsychiatry.2001;58(7):689-695.
5. MagidsonJF,LiuS-M,LejuezCW,BlancoC.ComparisonoftheCourseofSubstanceUseDisordersamongIndividualsWithandWithoutGeneralizedAnxietyDisorderinaNationallyRepresentativeSample.JPsychiatrRes.2012;46(5):659-666.doi:10.1016/j.jpsychires.2012.02.011.
6. ConwayKP,ComptonW,StinsonFS,GrantBF.LifetimecomorbidityofDSM-IVmoodandanxietydisordersandspecificdrugusedisorders:resultsfromtheNationalEpidemiologicSurveyonAlcoholandRelatedConditions.JClinPsychiatry.2006;67(2):247-257.
7. BradyKT,HaynesLF,HartwellKJ,KilleenTK.Substanceusedisordersandanxiety:atreatmentchallengeforsocialworkers.SocWorkPublicHealth.2013;28(3-4):407-423.doi:10.1080/19371918.2013.774675.
8. Wolitzky-TaylorK,OperskalskiJT,RiesR,CraskeMG,Roy-ByrneP.Understandingandtreatingcomorbidanxietydisordersinsubstanceusers:reviewandfuturedirections.JAddictMed.2011;5(4):233-247.doi:10.1097/ADM.0b013e31823276d7.
9. TorrensM,GilchristG,Domingo-SalvanyA,psyCoBarcelonaGroup.Psychiatriccomorbidityinillicitdrugusers:substance-inducedversusindependentdisorders.DrugAlcoholDepend.2011;113(2-3):147-156.doi:10.1016/j.drugalcdep.2010.07.013.
10. ComptonWM,ThomasYF,StinsonFS,GrantBF.Prevalence,correlates,
40
disability,andcomorbidityofDSM-IVdrugabuseanddependenceintheUnitedStates:resultsfromthenationalepidemiologicsurveyonalcoholandrelatedconditions.ArchGenPsychiatry.2007;64(5):566-576.doi:10.1001/archpsyc.64.5.566.
11. PettinatiHM,O’BrienCP,DundonWD.CurrentStatusofCo-OccurringMoodandSubstanceUseDisorders:ANewTherapeuticTarget.AmJPsychiatry.2013;170(1):23-30.doi:10.1176/appi.ajp.2012.12010112.
12. DeAlwisD,LynskeyMT,ReiersenAM,AgrawalA.Attention-deficit/hyperactivitydisordersubtypesandsubstanceuseandusedisordersinNESARC.AddictBehav.2014;39(8):1278-1285.doi:10.1016/j.addbeh.2014.04.003.
13. HarstadE,LevyS,AbuseConS.Attention-Deficit/HyperactivityDisorderandSubstanceAbuse.Pediatrics.2014;134(1):e293-e301.doi:10.1542/peds.2014-0992.
14. HartzSM,PatoCN,MedeirosH,etal.Comorbidityofseverepsychoticdisorderswithmeasuresofsubstanceuse.JAMAPsychiatry.2014;71(3):248-254.doi:10.1001/jamapsychiatry.2013.3726.
15. Flórez-SalamancaL,Secades-VillaR,BudneyAJ,García-RodríguezO,WangS,BlancoC.Probabilityandpredictorsofcannabisusedisordersrelapse:ResultsoftheNationalEpidemiologicSurveyonAlcoholandRelatedConditions(NESARC).DrugAlcoholDepend.2013;132(0):127-133.doi:10.1016/j.drugalcdep.2013.01.013.
16. PennayA,CameronJ,ReichertT,etal.Asystematicreviewofinterventionsforco-occurringsubstanceusedisorderandborderlinepersonalitydisorder.JSubstAbuseTreat.2011;41(4):363-373.doi:10.1016/j.jsat.2011.05.004.
17. LubmanDI,KingJA,CastleDJ.Treatingcomorbidsubstanceusedisordersinschizophrenia.IntRevPsychiatryAbingdonEngl.2010;22(2):191-201.doi:10.3109/09540261003689958.
18. SubstanceAbuseandMentalHealthServicesAdministration(SAHMSA).MentalandSubstanceUseDisorders.https://www.samhsa.gov/disorders.PublishedJune20,2014.AccessedFebruary21,2018.
19. KatzC,El-GabalawyR,KeyesKM,MartinsSS,SareenJ.Riskfactorsforincidentnonmedicalprescriptionopioiduseandabuseanddependence:
41
resultsfromalongitudinalnationallyrepresentativesample.DrugAlcoholDepend.2013;132(1-2):107-113.doi:10.1016/j.drugalcdep.2013.01.010.
20. GoldnerEM,LustedA,RoereckeM,RehmJ,FischerB.PrevalenceofAxis-1psychiatric(withfocusondepressionandanxiety)disorderandsymptomatologyamongnon-medicalprescriptionopioidusersinsubstanceusetreatment:systematicreviewandmeta-analyses.AddictBehav.2014;39(3):520-531.doi:10.1016/j.addbeh.2013.11.022.
21. SheidowAJ,McCartM,ZajacK,DavisM.Prevalenceandimpactofsubstanceuseamongemergingadultswithseriousmentalhealthconditions.PsychiatrRehabilJ.2012;35(3):235-243.doi:10.2975/35.3.2012.235.243.
22. BuksteinOG,HornerMS.Managementoftheadolescentwithsubstanceusedisordersandcomorbidpsychopathology.ChildAdolescPsychiatrClinNAm.2010;19(3):609-623.doi:10.1016/j.chc.2010.03.011.
23. SterlingS,WeisnerC,HinmanA,ParthasarathyS.AccesstoTreatmentforAdolescentsWithSubstanceUseandCo-OccurringDisorders:ChallengesandOpportunities.JAmAcadChildAdolescPsychiatry.2010;49(7):637-726.doi:10.1016/j.jaac.2010.03.019.
24. WintersKC,Tanner-SmithEE,BresaniE,MeyersK.Currentadvancesinthetreatmentofadolescentdruguse.AdolescHealthMedTher.2014;5:199-210.doi:10.2147/AHMT.S48053.
25. BarkusE,MurrayRM.Substanceuseinadolescenceandpsychosis:clarifyingtherelationship.AnnuRevClinPsychol.2010;6:365-389.doi:10.1146/annurev.clinpsy.121208.131220.
26. ParakhP,BasuD.Cannabisandpsychosis:havewefoundthemissinglinks?AsianJPsychiatry.2013;6(4):281-287.doi:10.1016/j.ajp.2013.03.012.
27. Pelayo-TeránJM,Suárez-PinillaP,ChadiN,Crespo-FacorroB.Gene-environmentinteractionsunderlyingtheeffectofcannabisinfirstepisodepsychosis.CurrPharmDes.2012;18(32):5024-5035.
28. GoldsteinBI,BuksteinOG.Comorbidsubstanceusedisordersamongyouthwithbipolardisorder:opportunitiesforearlyidentificationandprevention.JClinPsychiatry.2010;71(3):348-358.doi:10.4088/JCP.09r05222gry.
42
29. O’NeilKA,ConnerBT,KendallPC.Internalizingdisordersandsubstanceusedisordersinyouth:comorbidity,risk,temporalorder,andimplicationsforintervention.ClinPsycholRev.2011;31(1):104-112.doi:10.1016/j.cpr.2010.08.002.
30. WilensTE,MartelonM,JoshiG,etal.DoesADHDpredictsubstance-usedisorders?A10-yearfollow-upstudyofyoungadultswithADHD.JAmAcadChildAdolescPsychiatry.2011;50(6):543-553.doi:10.1016/j.jaac.2011.01.021.
31. ZulaufCA,SprichSE,SafrenSA,WilensTE.Thecomplicatedrelationshipbetweenattentiondeficit/hyperactivitydisorderandsubstanceusedisorders.CurrPsychiatryRep.2014;16(3):436.doi:10.1007/s11920-013-0436-6.
32. NelsonA,GalonP.ExploringtherelationshipamongADHD,stimulants,andsubstanceabuse.JChildAdolescPsychiatrNursOffPublAssocChildAdolescPsychiatrNursesInc.2012;25(3):113-118.doi:10.1111/j.1744-6171.2012.00322.x.
33. CerdáM,SagdeoA,JohnsonJ,GaleaS.Geneticandenvironmentalinfluencesonpsychiatriccomorbidity:asystematicreview.JAffectDisord.2010;126(1-2):14-38.doi:10.1016/j.jad.2009.11.006.
34. TsuangMT,FrancisT,MinorK,ThomasA,StoneWS.Geneticsofsmokinganddepression.HumGenet.2012;131(6):905-915.doi:10.1007/s00439-012-1170-6.
35. NestlerEJ.Epigeneticmechanismsofdrugaddiction.Neuropharmacology.2014;76PtB:259-268.doi:10.1016/j.neuropharm.2013.04.004.
36. FontenelleLF,OostermeijerS,HarrisonBJ,PantelisC,YücelM.Obsessive-compulsivedisorder,impulsecontroldisordersanddrugaddiction:commonfeaturesandpotentialtreatments.Drugs.2011;71(7):827-840.doi:10.2165/11591790-000000000-00000.
37. WangJ-C,KapoorM,GoateAM.Thegeneticsofsubstancedependence.AnnuRevGenomicsHumGenet.2012;13:241-261.doi:10.1146/annurev-genom-090711-163844.
38. EnochM-A.Theinfluenceofgene-environmentinteractionsonthedevelopmentofalcoholismanddrugdependence.CurrPsychiatryRep.
43
2012;14(2):150-158.doi:10.1007/s11920-011-0252-9.
39. HartzSM,BierutLJ.Geneticsofaddictions.PsychiatrClinNorthAm.2010;33(1):107-124.doi:10.1016/j.psc.2009.10.003.
40. MahgoubM,MonteggiaLM.Epigeneticsandpsychiatry.NeurotherJAmSocExpNeurother.2013;10(4):734-741.doi:10.1007/s13311-013-0213-6.
41. GuintivanoJ,KaminskyZA.Roleofepigeneticfactorsinthedevelopmentofmentalillnessthroughoutlife.NeurosciRes.2016;102:56-66.doi:10.1016/j.neures.2014.08.003.
42. PeñaCJ,BagotRC,LabontéB,NestlerEJ.Epigeneticsignalinginpsychiatricdisorders.JMolBiol.2014;426(20):3389-3412.doi:10.1016/j.jmb.2014.03.016.
43. WingVC,WassCE,SohDW,GeorgeTP.Areviewofneurobiologicalvulnerabilityfactorsandtreatmentimplicationsforcomorbidtobaccodependenceinschizophrenia.AnnNYAcadSci.2012;1248:89-106.doi:10.1111/j.1749-6632.2011.06261.x.
44. HowesOD,Fusar-PoliP,BloomfieldM,SelvarajS,McGuireP.Fromtheprodrometochronicschizophrenia:theneurobiologyunderlyingpsychoticsymptomsandcognitiveimpairments.CurrPharmDes.2012;18(4):459-465.
45. VolkowND,FowlerJS,WangG-J,SwansonJM,TelangF.DopamineinDrugAbuseandAddiction:ResultsofImagingStudiesandTreatmentImplications.ArchNeurol.2007;64(11):1575-1579.doi:10.1001/archneur.64.11.1575.
46. XingB,LiY-C,GaoW-J.NorepinephrineversusDopamineandtheirInteractioninModulatingSynapticFunctioninthePrefrontalCortex.BrainRes.2016;1641(PtB):217-233.doi:10.1016/j.brainres.2016.01.005.
47. MarazzitiD.Understandingtheroleofserotonininpsychiatricdiseases.F1000Research.2017;6.doi:10.12688/f1000research.10094.1.
48. MüllerCP,HombergJR.Theroleofserotoninindruguseandaddiction.BehavBrainRes.2015;277:146-192.doi:10.1016/j.bbr.2014.04.007.
49. TsapakisEM,TravisMJ.Glutamateandpsychiatricdisorders.AdvPsychiatrTreat.2002;8(3):189-197.doi:10.1192/apt.8.3.189.
44
50. TzschentkeTM,SchmidtWJ.Glutamatergicmechanismsinaddiction.MolPsychiatry.2003;8(4):373-382.doi:10.1038/sj.mp.4001269.
51. KumarK,SharmaS,KumarP,DeshmukhR.TherapeuticpotentialofGABABreceptorligandsindrugaddiction,anxiety,depressionandotherCNSdisorders.PharmacolBiochemBehav.2013;110:174-184.doi:10.1016/j.pbb.2013.07.003.
52. Aston-JonesG,KalivasPW.Brainnorepinephrinerediscoveredinaddictionresearch.BiolPsychiatry.2008;63(11):1005-1006.doi:10.1016/j.biopsych.2008.03.016.
53. LangerSZ.2-Adrenoceptorsinthetreatmentofmajorneuropsychiatricdisorders.TrendsPharmacolSci.2015;36(4):196-202.doi:10.1016/j.tips.2015.02.006.
54. NormanSB,MyersUS,WilkinsKC,etal.ReviewofbiologicalmechanismsandpharmacologicaltreatmentsofcomorbidPTSDandsubstanceusedisorder.Neuropharmacology.2012;62(2):542-551.doi:10.1016/j.neuropharm.2011.04.032.
55. SinhaR.ChronicStress,DrugUse,andVulnerabilitytoAddiction.AnnNYAcadSci.2008;1141:105-130.doi:10.1196/annals.1441.030.
56. BrewerJA,BowenS,SmithJT,MarlattGA,PotenzaMN.Mindfulness-BasedTreatmentsforCo-OccurringDepressionandSubstanceUseDisorders:WhatCanWeLearnfromtheBrain?AddictAbingdonEngl.2010;105(10):1698-1706.doi:10.1111/j.1360-0443.2009.02890.x.
57. BerenzEC,CoffeySF.TreatmentofCo-occurringPosttraumaticStressDisorderandSubstanceUseDisorders.CurrPsychiatryRep.2012;14(5):469-477.doi:10.1007/s11920-012-0300-0.
58. BodenMT,KimerlingR,KulkarniM,Bonn-MillerMO,WeaverC,TraftonJ.CopingamongmilitaryveteranswithPTSDinsubstanceusedisordertreatment.JSubstAbuseTreat.2014;47(2):160-167.doi:10.1016/j.jsat.2014.03.006.
59. GolubA,VazanP,BennettAS,LibertyHJ.Unmetneedfortreatmentofsubstanceusedisordersandseriouspsychologicaldistressamongveterans:anationwideanalysisusingtheNSDUH.MilMed.2013;178(1):107-114.
45
60. WiscoBE,MarxBP,WolfEJ,MillerMW,SouthwickSM,PietrzakRH.PosttraumaticstressdisorderintheUSveteranpopulation:resultsfromtheNationalHealthandResilienceinVeteransStudy.JClinPsychiatry.2014;75(12):1338-1346.doi:10.4088/JCP.14m09328.
61. VAHealthCare,NationalCenterforPTSD.UnderstandingPTSDandSubstanceAbuse.NationalCenterforPosttraumaticStressDisorder;2011.http://www.narbha.org/includes/media/docs/sudptsdflyer.pdf.
62. BaigentM.Managingpatientswithdualdiagnosisinpsychiatricpractice.CurrOpinPsychiatry.2012;25(3):201-205.doi:10.1097/YCO.0b013e3283523d3d.
63. PostRM,KalivasP.Bipolardisorderandsubstancemisuse:pathologicalandtherapeuticimplicationsoftheircomorbidityandcross-sensitisation.BrJPsychiatryJMentSci.2013;202(3):172-176.doi:10.1192/bjp.bp.112.116855.
64. PérezdeLosCobosJ,SiñolN,PuertaC,CantillanoV,LópezZuritaC,TrujolsJ.Featuresandprevalenceofpatientswithprobableadultattentiondeficithyperactivitydisorderwhorequesttreatmentforcocaineusedisorders.PsychiatryRes.2011;185(1-2):205-210.doi:10.1016/j.psychres.2009.03.019.
65. BerlinI,HuM-C,CoveyLS,WinhusenT.Attention-deficit/hyperactivitydisorder(ADHD)symptoms,cravingtosmoke,andtobaccowithdrawalsymptomsinadultsmokerswithADHD.DrugAlcoholDepend.2012;124(3):268-273.doi:10.1016/j.drugalcdep.2012.01.019.
66. SeitzA,WappM,BurrenY,StutzS,SchläfliK,MoggiF.Associationbetweencravingandattentiondeficit/hyperactivitydisordersymptomsamongpatientswithalcoholusedisorders.AmJAddict.2013;22(3):292-296.doi:10.1111/j.1521-0391.2012.12000.x.
67. AubinH-J,RollemaH,SvenssonTH,WintererG.Smoking,quitting,andpsychiatricdisease:areview.NeurosciBiobehavRev.2012;36(1):271-284.doi:10.1016/j.neubiorev.2011.06.007.
68. MinichinoA,BersaniFS,CalòWK,etal.Smokingbehaviourandmentalhealthdisorders--mutualinfluencesandimplicationsfortherapy.IntJEnvironResPublicHealth.2013;10(10):4790-4811.doi:10.3390/ijerph10104790.
46
69. CenterforBehavioralHealthStatisticsandQuality.Resultsfromthe2016NationalSurveyonDrugUseandHealth:DetailedTables.Rockville,MD:SubstanceAbuseandMentalHealthServicesAdministration;2017.
70. WintererG.Whydopatientswithschizophreniasmoke?CurrOpinPsychiatry.2010;23(2):112-119.doi:10.1097/YCO.0b013e3283366643.
71. DonaldS,ChartrandH,BoltonJM.Therelationshipbetweennicotinecessationandmentaldisordersinanationallyrepresentativesample.JPsychiatrRes.2013;47(11):1673-1679.doi:10.1016/j.jpsychires.2013.05.011.
72. MackowickKM,LynchM-J,WeinbergerAH,GeorgeTP.Treatmentoftobaccodependenceinpeoplewithmentalhealthandaddictivedisorders.CurrPsychiatryRep.2012;14(5):478-485.doi:10.1007/s11920-012-0299-2.
73. MoranLV,SampathH,KochunovP,HongLE.Braincircuitsthatlinkschizophreniatohighriskofcigarettesmoking.SchizophrBull.2013;39(6):1373-1381.doi:10.1093/schbul/sbs149.
74. MurthyP,ChandP.Treatmentofdualdiagnosisdisorders.CurrOpinPsychiatry.2012;25(3):194-200.doi:10.1097/YCO.0b013e328351a3e0.
75. DineleyKT,PandyaAA,YakelJL.NicotinicAChreceptorsastherapeutictargetsinCNSdisorders.TrendsPharmacolSci.2015;36(2):96-108.doi:10.1016/j.tips.2014.12.002.
76. RaggM,GordonR,AhmedT,AllanJ.Theimpactofsmokingcessationonschizophreniaandmajordepression.AustralasPsychiatryBullRAustNZCollPsychiatr.2013;21(3):238-245.doi:10.1177/1039856213486213.
77. TsoiDT,PorwalM,WebsterAC.Efficacyandsafetyofbupropionforsmokingcessationandreductioninschizophrenia:systematicreviewandmeta-analysis.BrJPsychiatryJMentSci.2010;196(5):346-353.doi:10.1192/bjp.bp.109.066019.
78. TsoiDT,PorwalM,WebsterAC.Interventionsforsmokingcessationandreductioninindividualswithschizophrenia.CochraneDatabaseSystRev.2013;(2):CD007253.doi:10.1002/14651858.CD007253.pub3.
79. CerimeleJM,DurangoA.Doesvareniclineworsenpsychiatricsymptomsinpatientswithschizophreniaorschizoaffectivedisorder?Areviewof
47
publishedstudies.JClinPsychiatry.2012;73(8):e1039-1047.doi:10.4088/JCP.11r07410.
80. MorojeleNK,SabanA,SeedatS.Clinicalpresentationsanddiagnosticissuesindualdiagnosisdisorders.CurrOpinPsychiatry.2012;25(3):181-186.doi:10.1097/YCO.0b013e328351a429.
81. MueserKT,GingerichS.Treatmentofco-occurringpsychoticandsubstanceusedisorders.SocWorkPublicHealth.2013;28(3-4):424-439.doi:10.1080/19371918.2013.774676.
82. TorrensM,RossiPC,Martinez-RieraR,Martinez-SanvisensD,BulbenaA.Psychiatricco-morbidityandsubstanceusedisorders:treatmentinparallelsystemsorinoneintegratedsystem?SubstUseMisuse.2012;47(8-9):1005-1014.doi:10.3109/10826084.2012.663296.
83. KellyTM,DaleyDC,DouaihyAB.Treatmentofsubstanceabusingpatientswithcomorbidpsychiatricdisorders.AddictBehav.2012;37(1):11-24.doi:10.1016/j.addbeh.2011.09.010.
84. DeMarceJM,LashSJ,StephensRS,GrambowSC,BurdenJL.Promotingcontinuingcareadherenceamongsubstanceabuserswithco-occurringpsychiatricdisordersfollowingresidentialtreatment.AddictBehav.2008;33(9):1104-1112.doi:10.1016/j.addbeh.2008.02.008.
85. HuntGE,SiegfriedN,MorleyK,SitharthanT,ClearyM.PsychosocialInterventionsforPeopleWithBothSevereMentalIllnessandSubstanceMisuse.SchizophrBull.2014;40(1):18-20.doi:10.1093/schbul/sbt160.
86. SacksS,SacksJ.Researchontheeffectivenessofthemodifiedtherapeuticcommunityforpersonswithco-occurringsubstanceuseandmentaldisorders.TherCommunities.2010;31:176-211.
87. LeeSJ,CrowtherE,KeatingC,KulkarniJ.Whatisneededtodelivercollaborativecaretoaddresscomorbiditymoreeffectivelyforadultswithaseverementalillness?AustNZJPsychiatry.2013;47(4):333-346.doi:10.1177/0004867412463975.
88. MacgowanMJ,EngleB.Evidenceforoptimism:behaviortherapiesandmotivationalinterviewinginadolescentsubstanceabusetreatment.ChildAdolescPsychiatrClinNAm.2010;19(3):527-545.doi:10.1016/j.chc.2010.03.006.
48
89. NationalResearchCouncil(US)andInstituteofMedicine(US)CommitteeonthePreventionofMentalDisordersandSubstanceAbuseAmongChildren,Youth,andYoungAdults:ResearchAdvancesandPromisingInterventions.PreventingMental,Emotional,andBehavioralDisordersAmongYoungPeople:ProgressandPossibilities.(O’ConnellME,BoatT,WarnerKE,eds.).Washington(DC):NationalAcademiesPress(US);2009.http://www.ncbi.nlm.nih.gov/books/NBK32775/.AccessedAugust22,2017..
90. SzapocznikJ,ZarateM,DuffJ,MuirJ.Briefstrategicfamilytherapy:engagingdrugusing/problembehavioradolescentsandtheirfamiliesintreatment.SocWorkPublicHealth.2013;28(3-4):206-223.doi:10.1080/19371918.2013.774666.
91. RoweCL.Multidimensionalfamilytherapy:addressingco-occurringsubstanceabuseandotherproblemsamongadolescentswithcomprehensivefamily-basedtreatment.ChildAdolescPsychiatrClinNAm.2010;19(3):563-576.doi:10.1016/j.chc.2010.03.008.
92. AxelrodSR,PerepletchikovaF,HoltzmanK,SinhaR.Emotionregulationandsubstanceusefrequencyinwomenwithsubstancedependenceandborderlinepersonalitydisorderreceivingdialecticalbehaviortherapy.AmJDrugAlcoholAbuse.2011;37(1):37-42.doi:10.3109/00952990.2010.535582.
93. FriesHP,RosenMI.Theefficacyofassertivecommunitytreatmenttotreatsubstanceuse.JAmPsychiatrNursesAssoc.2011;17(1):45-50.doi:10.1177/1078390310393509.
94. JainchillN,HawkeJ,MessinaM.Post-TreatmentOutcomesAmongAdjudicatedAdolescentMalesandFemalesinModifiedTherapeuticCommunityTreatment.SubstUseMisuse.2005;40(7):975-996.doi:10.1081/JA-200058857.
95. TideyJW.Usingincentivestoreducesubstanceuseandotherhealthriskbehaviorsamongpeoplewithseriousmentalillness.PrevMed.2012;55Suppl:S54-60.doi:10.1016/j.ypmed.2011.11.010.
96. FarrenCK,HillKP,WeissRD.Bipolardisorderandalcoholusedisorder:areview.CurrPsychiatryRep.2012;14(6):659-666.doi:10.1007/s11920-012-0320-9.
97. NajavitsLM,HienD.Helpingvulnerablepopulations:acomprehensive
49
reviewofthetreatmentoutcomeliteratureonsubstanceusedisorderandPTSD.JClinPsychol.2013;69(5):433-479.doi:10.1002/jclp.21980.
98. FDApermitsmarketingofmobilemedicalapplicationforsubstanceusedisorder[FDANewsRelease].FoodandDrugAdministration(FDA).https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm576087.htm.PublishedSeptember14,2017.AccessedFebruary8,2018.
99. GarlandEL,FroeligerB,ZeidanF,PartinK,HowardMO.TheDownwardSpiralofChronicPain,PrescriptionOpioidMisuse,andAddiction:Cognitive,Affective,andNeuropsychopharmacologicPathways.NeurosciBiobehavRev.2013;37(1002):2597-2607.doi:10.1016/j.neubiorev.2013.08.006.
100. SchulteMT,HserY-I.SubstanceUseandAssociatedHealthConditionsthroughouttheLifespan.PublicHealthRev.2014;35(2).
101. CentersforDiseaseControlandPrevention(CDC).DataBrief294.DrugOverdoseDeathsintheUnitedStates,1999–2016.NationalCenterforHealthStatisticshttps://www.cdc.gov/nchs/data/databriefs/db294_table.pdf#page=4.
102. BerlandD,RodgersP.Rationaluseofopioidsformanagementofchronicnonterminalpain.AmFamPhysician.2012;86(3):252-258.
103. SehgalN,ManchikantiL,SmithHS.Prescriptionopioidabuseinchronicpain:areviewofopioidabusepredictorsandstrategiestocurbopioidabuse.PainPhysician.2012;15(3Suppl):ES67-92.
104. U.S.DepartmentofHealthandHumanServices.TheHealthConsequencesofSmoking—50YearsofProgress.AReportoftheSurgeonGeneral.Atlanta,GA:U.S.DepartmentofHealthandHumanServices,CentersforDiseaseControlandPrevention,NationalCenterforChronicDiseasePreventionandHealthPromotion,OfficeonSmokingandHealth;2014.
105. KangH-J,KimS-Y,BaeK-Y,etal.ComorbidityofDepressionwithPhysicalDisorders:ResearchandClinicalImplications.ChonnamMedJ.2015;51(1):8-18.doi:10.4068/cmj.2015.51.1.8.
106. DeJeanD,GiacominiM,VanstoneM,BrundisiniF.Patientexperiencesofdepressionandanxietywithchronicdisease:asystematicreviewandqualitativemeta-synthesis.OntHealthTechnolAssessSer.2013;13(16):1-
50
33.
107. CampbellANC,TrossS,CaslynDA.SubstanceUseDisordersandHIV/AIDSPreventionandTreatmentIntervention:ResearchandPracticeConsiderations.SocWorkPublicHealth.2013;28(0):333-348.doi:10.1080/19371918.2013.774665.
108. MaguraS,RosenblumA,FongC.Factorsassociatedwithmedicationadherenceamongpsychiatricoutpatientsatsubstanceabuserisk.OpenAddictJ.2011;4:58-64.doi:10.2174/1874941001104010058.
109. BidellMR,McLaughlinM,FaragonJ,MorseC,PatelN.DesirableCharacteristicsofHepatitisCTreatmentRegimens:AReviewofWhatWeHaveandWhatWeNeed.InfectDisTher.2016;5(3):299-312.doi:10.1007/s40121-016-0118-x.
110. El-BasselN,ShawSA,DasguptaA,StrathdeeSA.DruguseasadriverofHIVrisks:re-emergingandemergingissues.CurrOpinHIVAIDS.2014;9(2):150-155.doi:10.1097/COH.0000000000000035.
111. KlevensRM,HuDJ,JilesR,HolmbergSD.EvolvingepidemiologyofhepatitisCvirusintheUnitedStates.ClinInfectDisOffPublInfectDisSocAm.2012;55Suppl1:S3-9.doi:10.1093/cid/cis393.
112. YoungJQ,Kline-SimonAH,MordecaiDJ,WeisnerC.Prevalenceofbehavioralhealthdisordersandassociatedchronicdiseaseburdeninacommerciallyinsuredhealthsystem:findingsofacase-controlstudy.GenHospPsychiatry.2015;37(2):101-108.doi:10.1016/j.genhosppsych.2014.12.005.
113. ShimRS,KoplanC,LangheimFJP,etal.Healthcarereformandintegratedcare:agoldenopportunityforpreventivepsychiatry.PsychiatrServWashDC.2012;63(12):1231-1233.doi:10.1176/appi.ps.201200072.
114. CentersforDiseaseControlandPrevention(CDC).HIVintheUnitedStates:AtAGlance.;2017.https://www.cdc.gov/hiv/statistics/overview/ataglance.html.AccessedFebruary8,2018.
115. ArchinNM,MargolisDM.EmergingstrategiestodepletetheHIVreservoir.CurrOpinInfectDis.2014;27(1):29-35.doi:10.1097/QCO.0000000000000026.
51
116. BartonKM,BurchBD,Soriano-SarabiaN,MargolisDM.ProspectsfortreatmentoflatentHIV.ClinPharmacolTher.2013;93(1):46-56.doi:10.1038/clpt.2012.202.
117. MontanerJSG,LimaVD,BarriosR,etal.Associationofhighlyactiveantiretroviraltherapycoverage,populationviralload,andyearlynewHIVdiagnosesinBritishColumbia,Canada:apopulation-basedstudy.LancetLondEngl.2010;376(9740):532-539.doi:10.1016/S0140-6736(10)60936-1.
118. DegenhardtL,WhitefordHA,FerrariAJ,etal.Globalburdenofdiseaseattributabletoillicitdruguseanddependence:findingsfromtheGlobalBurdenofDiseaseStudy2010.LancetLondEngl.2013;382(9904):1564-1574.doi:10.1016/S0140-6736(13)61530-5.
119. VolkowND,BalerRD,NormandJL.TheunrealizedpotentialofaddictionscienceincurbingtheHIVepidemic.CurrHIVRes.2011;9(6):393-395.
120. CentersforDiseaseControlandPrevention(CDC).HIVandInjectionDrugUse.;2017.https://www.cdc.gov/hiv/risk/idu.html.AccessedFebruary8,2018.
121. DashS,BalasubramaniamM,VillaltaF,DashC,PandhareJ.ImpactofcocaineabuseonHIVpathogenesis.FrontMicrobiol.2015;6.doi:10.3389/fmicb.2015.01111.
122. HauserKF,KnappPE.InteractionsofHIVanddrugsofabuse:theimportanceofglia,neuralprogenitors,andhostgeneticfactors.IntRevNeurobiol.2014;118:231-313.doi:10.1016/B978-0-12-801284-0.00009-9.
123. DahalS,ChittiSVP,NairMPN,SaxenaSK.InteractiveeffectsofcocaineonHIVinfection:implicationinHIV-associatedneurocognitivedisorderandneuroAIDS.FrontMicrobiol.2015;6:931.doi:10.3389/fmicb.2015.00931.
124. ChangSL,ConnaghanKP,WeiY,LiMD.NeuroHIVanduseofaddictivesubstances.IntRevNeurobiol.2014;118:403-440.doi:10.1016/B978-0-12-801284-0.00013-0.
125. NasiM,PintiM,DeBiasiS,etal.AgingwithHIVinfection:ajourneytothecenterofinflammAIDS,immunosenescenceandneuroHIV.ImmunolLett.2014;162(1PtB):329-333.doi:10.1016/j.imlet.2014.06.012.
126. AlfahadTB,NathA.UpdateonHIV-associatedneurocognitivedisorders.
52
CurrNeurolNeurosciRep.2013;13(10):387.doi:10.1007/s11910-013-0387-7.
127. HoltJL,Kraft-TerrySD,ChangL.NeuroimagingstudiesoftheagingHIV-1-infectedbrain.JNeurovirol.2012;18(4):291-302.doi:10.1007/s13365-012-0114-1.
128. LauraM.Maruschak.HIVinPrisons,2001-2010.U.S.DepartmentofJustice;2012.https://www.bjs.gov/content/pub/pdf/hivp10.pdf.
129. BeckwithCG,ZallerND,FuJJ,MontagueBT,RichJD.Opportunitiestodiagnose,treat,andpreventHIVinthecriminaljusticesystem.JAcquirImmuneDeficSyndr1999.2010;55Suppl1:S49-55.doi:10.1097/QAI.0b013e3181f9c0f7.
130. MontagueBT,RosenDL,SolomonL,etal.TrackinglinkagetoHIVcareforformerprisoners.Virulence.2012;3(3):319-324.doi:10.4161/viru.20432.
131. IrohPA,MayoH,NijhawanAE.TheHIVCareCascadeBefore,During,andAfterIncarceration:ASystematicReviewandDataSynthesis.AmJPublicHealth.2015;105(7):e5-16.doi:10.2105/AJPH.2015.302635.
132. NationalCenterforHealthStatistics.EarlyReleaseofSelectedEstimatesBasedonDatafromTheNationalHealthInterviewSurvey.Atlanta,GA:CentersforDiseaseControlandPrevention;2015.https://www.cdc.gov/nchs/data/nhis/earlyrelease/earlyrelease201506_10.pdf.
133. CopenCE,ChandraA,Febo-VazquezI.HIVTestinginthePastYearAmongtheU.S.HouseholdPopulationAged15-44:2011-2013.NCHSDataBrief.2015;(202):1-8.
134. AletrarisL,RomanPM.ProvisionofonsiteHIVServicesinSubstanceUseDisorderTreatmentPrograms:ALongitudinalAnalysis.JSubstAbuseTreat.2015;57:1-8.doi:10.1016/j.jsat.2015.04.005.
135. TheWhiteHouse.NationalHIV/AIDSStrategyfortheUnitedStates:Updatedto2020.;2015.https://www.hiv.gov/federal-response/national-hiv-aids-strategy/overview.
136. MacArthurGJ,MinozziS,MartinN,etal.OpiatesubstitutiontreatmentandHIVtransmissioninpeoplewhoinjectdrugs:systematicreviewandmeta-analysis.BMJ.2012;345:e5945.
53
137. FriedmanSR,DowningMJ,SmyrnovP,etal.Socially-integratedtransdisciplinaryHIVprevention.AIDSBehav.2014;18(10):1821-1834.doi:10.1007/s10461-013-0643-5.
138. HullMW,WuZ,MontanerJSG.Optimizingtheengagementofcarecascade:acriticalsteptomaximizetheimpactofHIVtreatmentasprevention.CurrOpinHIVAIDS.2012;7(6):579-586.doi:10.1097/COH.0b013e3283590617.
139. MainaG,MillJ,Chaw-KantJ,CaineV.AsystematicreviewofbestpracticesinHIVcare.JHIVAIDSSocServ.2016;15(1):114-126.
140. MontanerJSG.Treatmentasprevention:towardanAIDS-freegeneration.TopAntivirMed.2013;21(3):110-114.
141. CastelAD,MagnusM,GreenbergAE.Pre-exposureprophylaxisforhumanimmunodeficiencyvirus:thepast,present,andfuture.InfectDisClinNorthAm.2014;28(4):563-583.doi:10.1016/j.idc.2014.08.001.
142. WorldHealthOrganization.GuidelineonWhentoStartAntiretroviralTherapyandonPre-ExposureProphylaxisforHIV.WorldHealthOrganization;2015.http://www.who.int/hiv/pub/guidelines/earlyrelease-arv/en/.
143. BaetenJ,GrantR.UseofAntiretroviralsforHIVPrevention:WhatDoWeKnowandWhatDon’tWeKnow?CurrHIV/AIDSRep.2013;10(2):142-151.doi:10.1007/s11904-013-0157-9.
144. BlumenthalJ,HaubrichR.Pre-exposureProphylaxis(PrEP)forHIVInfection:HowAntiretroviralPharmacologyhelpstoMonitorandImproveAdherence.ExpertOpinPharmacother.2013;14(13):1777-1785.doi:10.1517/14656566.2013.812072.
145. MartinM,VanichseniS,SuntharasamaiP,etal.TheimpactofadherencetopreexposureprophylaxisontheriskofHIVinfectionamongpeoplewhoinjectdrugs.AIDSLondEngl.2015;29(7):819-824.doi:10.1097/QAD.0000000000000613.
146. EscuderoDJ,LurieMN,KerrT,HoweCJ,MarshallBDL.HIVpre-exposureprophylaxisforpeoplewhoinjectdrugs:areviewofcurrentresultsandanagendaforfutureresearch.JIntAIDSSoc.2014;17:18899.
147. BurnsDN,GrossmanC,TurpinJ,ElharrarV,VeroneseF.Roleoforalpre-
54
exposureprophylaxis(PrEP)incurrentandfutureHIVpreventionstrategies.CurrHIV/AIDSRep.2014;11(4):393-403.doi:10.1007/s11904-014-0234-8.
148. GwadzM,ClelandCM,HaganH,etal.StrategiestouncoverundiagnosedHIVinfectionamongheterosexualsathighriskandlinkthemtoHIVcarewithhighretention:a“seek,test,treat,andretain”study.BMCPublicHealth.2015;15:481.doi:10.1186/s12889-015-1816-0.
149. MeyerJP,AlthoffAL,AlticeFL.OptimizingcareforHIV-infectedpeoplewhousedrugs:evidence-basedapproachestoovercominghealthcaredisparities.ClinInfectDisOffPublInfectDisSocAm.2013;57(9):1309-1317.doi:10.1093/cid/cit427.
150. HoodKB,RobertsonAA,Baird-ThomasC.Implementingsolutionstobarrierstoon-siteHIVtestinginsubstanceabusetreatment:ataleofthreefacilities.EvalProgramPlann.2015;49:1-9.doi:10.1016/j.evalprogplan.2014.11.001.
151. HutchinsonAB,FarnhamPG,SansomSL,YaylaliE,MerminJH.Cost-EffectivenessofFrequentHIVTestingofHigh-RiskPopulationsintheUnitedStates.JAcquirImmuneDeficSyndr1999.2016;71(3):323-330.doi:10.1097/QAI.0000000000000838.
152. MugaR,LangohrK,TorJ,etal.SurvivalofHIV-infectedinjectiondrugusers(IDUs)inthehighlyactiveantiretroviraltherapyera,relativetosex-andage-specificsurvivalofHIV-uninfectedIDUs.ClinInfectDisOffPublInfectDisSocAm.2007;45(3):370-376.doi:10.1086/519385.
153. LimaVD,NosykB,WoodE,etal.AssessingtheeffectivenessofantiretroviralregimensincohortstudiesinvolvingHiv-positiveinjectiondrugusers.Aids.2012;26(12):1491-1500.doi:10.1097/QAD.0b013e3283550b68.
154. CentersforDiseaseControlandPrevention(CDC).MorepeoplewithHIVhavethevirusundercontrol[pressrelease].NCHHSTPNewsroom.https://www.cdc.gov/nchhstp/newsroom/2017/2017-HIV-Continuum-Press-Release.html.PublishedJuly27,2017.AccessedFebruary8,2018.
155. BradleyH,HallHI,WolitskiRJ,etal.VitalSigns:HIVDiagnosis,Care,andTreatmentAmongPersonsLivingwithHIV—UnitedStates,2011.CentersforDiseaseControlandPrevention(CDC);2014.https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6347a5.htm#fig2.
55
AccessedFebruary8,2018.
156. DurvasulaR,MillerTR.SubstanceabusetreatmentinpersonswithHIV/AIDS:challengesinmanagingtriplediagnosis.BehavMedWashDC.2014;40(2):43-52.doi:10.1080/08964289.2013.866540.
157. DimovaRB,ZeremskiM,JacobsonIM,HaganH,DesJarlaisDC,TalalAH.DeterminantsofhepatitisCvirustreatmentcompletionandefficacyindrugusersassessedbymeta-analysis.ClinInfectDisOffPublInfectDisSocAm.2013;56(6):806-816.doi:10.1093/cid/cis1007.
158. CarricoAW,FlentjeA,GruberVA,etal.Community-BasedHarmReductionSubstanceAbuseTreatmentwithMethamphetamine-UsingMenWhoHaveSexwithMen.JUrbanHealth.2014;91(3):555-567.doi:10.1007/s11524-014-9870-y.
159. JosephB,WoodE,HayashiK,etal.FactorsassociatedwithinitiationofantiretroviraltherapyamongHIV-positivepeoplewhouseinjectiondrugsinaCanadiansetting.AIDSLondEngl.2016;30(6):925-932.doi:10.1097/QAD.0000000000000989.
160. BuckinghamE,SchrageE,CournosF.WhytheTreatmentofMentalDisordersIsanImportantComponentofHIVPreventionamongPeopleWhoInjectDrugs.AdvPrevMed.2013;2013:690386.doi:10.1155/2013/690386.
161. KamarulzamanA,AlticeFL.TheChallengesinManagingHIVinPeopleWhoUseDrugs.CurrOpinInfectDis.2015;28(1):10-16.doi:10.1097/QCO.0000000000000125.
162. McGovernMP,Lambert-HarrisC,GothamHJ,ClausRE,XieH.Dualdiagnosiscapabilityinmentalhealthandaddictiontreatmentservices:Anassessmentofprogramsacrossmultiplestatesystems.AdmPolicyMentHealth.2014;41(2):205-214.doi:10.1007/s10488-012-0449-1.
163. CroftB,ParishSL.CareIntegrationinthePatientProtectionandAffordableCareAct:ImplicationsforBehavioralHealth.AdmPolicyMentHealth.2013;40(4).doi:10.1007/s10488-012-0405-0.
164. PerfasFB,SprossS.Whytheconcept-basedtherapeuticcommunitycannolongerbecalleddrug-free.JPsychoactiveDrugs.2007;39(1):69-79.doi:10.1080/02791072.2007.10399866.
56
165. JamesDJ,GlazeLE.MentalHealthProblemsofPrisonandJailInmates.;2006.
166. BaillargeonJ,PennJV,KnightK,HarzkeAJ,BaillargeonG,BeckerEA.Riskofreincarcerationamongprisonerswithco-occurringseverementalillnessandsubstanceusedisorders.AdmPolicyMentHealth.2010;37(4):367-374.doi:10.1007/s10488-009-0252-9.
167. PatingDR,MillerMM,GoplerudE,MartinJ,ZiedonisDM.Newsystemsofcareforsubstanceusedisorders:treatment,finance,andtechnologyunderhealthcarereform.PsychiatrClinNorthAm.2012;35(2):327-356.doi:10.1016/j.psc.2012.03.004.
168. MechanicD.SeizingopportunitiesundertheAffordableCareActfortransformingthementalandbehavioralhealthsystem.HealthAffProjHope.2012;31(2):376-382.doi:10.1377/hlthaff.2011.0623.
169. DrussBG,MauerBJ.Healthcarereformandcareatthebehavioralhealth—primarycareinterface.PsychiatrServWashDC.2010;61(11):1087-1092.doi:10.1176/ps.2010.61.11.1087.