Presentation to Pharmacy Students

November 11, 2004

Overview of Addiction & Concurrent Disorders

Treatment Presenter: Andrea Tsanos

Advanced Practice Clinician

Concurrent Disorders Service, CAMH

Presentation Overview

I. Broad overview of non-pharmacological treatment programs available for clients with addiction problems

II. Overview of various sub-populations in

concurrent disorders, and the various treatment modalities used

III. Treatment Philosophy; and clinical issues encountered in treating clients with concurrent disorders

I. Addictions Program Org Structure

CAMH “ADDICTIONS PROGRAM” INCLUDES:

(1) General Assessment & Brief Treatment Program (Assessment Service, Guided Self Change Program, Structured Relapse prevention program, Evening Health Program)

(2) Special Populations Program (Women’ Service, Rainbow Service, Cocaine Service, Aboriginal Service, Older Person’s)

(3) Addiction Medicine Program (Addiction Medicine Clinic, Opiate Clinic, Nicotine Dependence Clinic, 501 Withdrawal Management Service, Medical W.M. Unit)

(4) *Concurrent Disorders Program

Referral Procedure & Wait Lists

(1) Self-referrals or referrals from health professionals. (2) Intake Assessment first (1.5 – 2 hr assessment)

(Wait time is 2 weeks from calling)(3) Recommendations & collaboration on treatment

disposition(4) E.g.: Referral to the Concurrent Disorders Service: Wait

is 2 weeks or longer for 1st appt.          -Psychiatric assessment OR assessment with a

Therapist/Psychologist          -Client’s case is reviewed by the Team         -A treatment recommendation is developed

-Treatment plan is negotiated with the client (and with others involved in the client’s care).

Substance Use Continuum of Care

Most intensive to least:• Inpatient/residential program (21 days)• Inpatient withdrawal management (3-7 days)

-”medical” withdrawal management-”T.L.C.” (non-medical) withdrawal

management• Day Treatment (attend 9-4 p.m. for 21 days)• Outpatient “day” withdrawal management• Outpatient program (attend 1-2 x week)• Informal drop-in contacts note: Aftercare is important

II. CDS: Who we are & Who We Serve...

• We are an outpatient service• 53 staff(soft-funded staff & trainees)

• Multi-disciplinary, team approach

• We serve clients with substance use problems who are also suffering from:

Mood disorders (such as major depression) Anxiety disorders (such as panic disorder or social phobia) Psychotic disorders(such as schizophrenia) Eating disorders (such as anorexia) Personality disorders (e.g. Borderline Personality) Anger problems

• Treatment duration is 6 months to 1 year+

Concurrent Disorders Service Organizational

Chart

I ndividual T herapy

A nx iety & A ddict ionGroup

Psychiatr ic S uppor t Groups

CD Consultat ion

CO RE PRO GRA M

Plus I ndividualT herapy

W eekly S kills Group

DI A LECT I CA L BEH A VI O R

T H ERA PY CLI N I C

Plus I ndividualT herapy

W eekly S kills Group

EA T I N G DI S O RDERS

& A DDI CT I O N CLI N I C

Plus I ndividualT herapy

W eekly S kills Group

A N GER & A DDI CT I O N

CLI N I C

CD Youth Group

CD Psycho- Ed Group

T rauma & A ddict ionGroup

A ction Group

A ction Group:A lcohol & A bst inence Goal

I N T EGRA T I VE GRO UPPS YCH O T H ERA PY CLI N I C

Concurrent Disorders S ervice

CDS Client Characteristics: Primary Problem Substance

Use

Cocaine & Other Stimulants

26%

Cannabis10%

Heroin & Other Opioids

10% Benzodiazepines3%

Other3%

Alcohol48%

Primary Psychiatric Diagnoses by Class

Personality Disorders

15%

Schizophrenic Disorders

13%

Other (e.g ADHD)11%

Bipolar Disorder9%

Anxiety Disorders20%

Depressive Mood Disorders

32%

# of Psychiatric Diagnoses

8.91%

5.94%

22.77%

0.00%

20.00%

40.00%

60.00%

80.00%

100.00%

% o

f dia

gnos

ed c

lient

s

3 or more

2

1

0

62.38%

# of Substance Use Diagnoses

49.5

32.67

17.82

0

20

40

60

80

100

% d

iag

no

sed

cli

en

ts

3 or more

2

1

III. CD Treatment Philosophy

• Based on bio-psycho-social-spiritual-spiritual model• Client-centred care• Importance of working as a Team• “Integrated treatment” approach (“Add & MH system

links” or “program” integration: Program is optimal)

• “Stepped-care” approach• MI: Ability to work with the client where he/she is at• MI: Value in being collaborative, not prescriptive• Belief in a Harm-Reduction approach• Flexibility of Goal-Choice• Goal of continued engagement

Substance Use Treatment Goals

(1) Abstinence: -cold-turkey-tapering down-medically-assisted (e.g. Valium, Clonadine)-outpatient vs. inpatient

(2) Reduction goal (e.g. Controlled drinking-not everyone is a candidate!) “Low-Risk Drinking Guidelines”:

-frequency: alternate drinking days with abstinent days -have one hour in between alcoholic drinks-Quantity: No more than 2 standard drinks (SD’s) on any

one dayMen: no more than 14 SD’s per week

Women: no more than 9 SD’s per week

(3) The no-change goal: Agreement to monitor and discuss substance use*Remember: goals are not static and neither is motivation…

TREATMENT MODALITIES

• Individual Therapy/Brief & Frequent Contact• Case Management• Group Therapy (decreases isolation & stigma; gives sense

of kinship & belonging, power of group

influence & support--not just more cost- effective)

• Family/Couples Therapy• Pharmacotherapy

FAMILY MATTERS(1) CD Family Support Group (Research Study):• A ‘Concurrent Disorders Family Support Group’ was designed

to meet the needs of family members of people with concurrent disorders.

• Randomized to a 12-session Support Group OR receiving a psycho-educational manual.

(2) Family Support Groups offered in the DBT Clinic:• for people with Borderline Personality Disorder: • (1) is for clients receiving treatment in the DBT Clinic who

can bring their family member/significant other to the group with them

• (2) This 2nd group is only for family members themselves (this is an 8-week psycho-educational group).

SPECIFIC TREATMENT APPROACHES

• Self-Help/12-Step Approach• Psycho-Education• Motivational Interviewing (MI)• Psycho-Education• Structured Relapse Prevention (SRP)• Cognitive-Behavior Therapy (CBT)• Interactional Group Therapy (IGT)• Social Skills Training• Assertive Community Outreach (ACT)

Treatment Goals:What can we hope for?

*Achieve goal with respect to substance use (reduction/abstinence)

*Reduce/eliminate the frequency and intensity of mental health symptoms (less re-hospitalization/crises)

*Increase tolerance for negative emotions

*Increase self-care behavior*Increase independent living*Increase overall self-esteem, self-efficacy*Enhance relationships (family, friends)*Increase the overall level of functioning

Questions?