MANAGING PARTICIPANTS WITH PSYCHIATRIC AND CO-OCCURRING DISORDERS IN ALTERNATIVE TO DISCIPLINE PROGRAMS
NOAP MARCH 28, 2018
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GINNY MATTHEWSRN, BSN, MBA
MAXIMUS
CALIFORNIA DIVERSION PROGRAM
PHOTO
PLACEHOLDER
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REVIEW OF COMMON PSYCHIATRIC AND CO-OCCURRING
DISORDERS
THEIR IMPACT ON HEALTHCARE PRACTICE
RECOVERY AGREEMENT TERMS WITH MENTAL HEALTH FOCUS
TOPICS OF DISCUSSION
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� IDENTIFY COMMON PSYCHIATRIC DISORDERS
� IDENTIFY THE IMPACT OF PSYCHIATRIC DISORDERS ON HEALTHCARE
PRACTICE
� RECOGNIZE CO-OCCURRING DISORDERS
� DEVELOP RECOVERY AGREEMENT TERMS TO ACCOMMODATE MENTAL
HEALTH ISSUES
LEARNING OBJECTIVES
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IDENTIFICATION OF THE NATURE OF THE DISORDER LEADS TO
�APPROPRIATE INTERVENTION
�APPROPRIATE TREATMENT
�DEVELOPMENT OF A MEANINGFUL RECOVERY AGREEMENT
�RETURN TO SAFE PRACTICE WITH APPROPRIATE LEVEL OF OVERSIGHT
ASSESSMENT: CO-OCCURRING DISORDER,
SUBSTANCE-RELATED, OR MENTAL ILLNESS?
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� The disorder shows the same distinct symptoms of a mental disorder
� Symptoms stop within days or weeks after drug or medication was last used
� Prior health history/exam/lab results demonstrate the following:
�Began during or within 1 month of intoxication or withdrawal
�Substance or medication that was used is known to cause the disorder
� Determine the disorder is due to a separate mental D/O dx (not substance-
related) with evidence of the following:
�Symptoms started before the severe intoxication, withdrawal or exposure
�Full D/O lasted at least 1 month after the severe exposure ended
� Not part of a delirium (confusion, reduced attention) caused by intoxication
� Disorder causes temporary distress and problems with social, work or daily
functions
SUBSTANCE-RELATED PSYCHIATRIC
DISORDERS
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Substance or medication Psychiatric symptoms
Sedating substances:
sedative, hypnotics,
alcohol, marijuana
Psychotic symptoms, depression, sleep disorders,
sexual dysfunction
Withdrawal can lead to panic and anxiety
Stimulants: cocaine,
amphetamines
Psychotic symptoms, manic symptoms, anxiety, sleep
disorders
Anesthetics,
antihistamines,
antihypertensives,
gabapentin
Neurocognitive problems: forgetfulness, memory
impairment, confusion, disorganization
Cardiovascular
medications, steroids
Psychotic symptoms
SUBSTANCE-RELATED PSYCHIATRIC
DISORDERS
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� Co-occurring disorders must be expected when evaluating any person, and
clinical services should incorporate this assumption into all screening,
assessment, and treatment planning
ASSESSMENT: CO-OCCURRING DISORDER,
SUBSTANCE-RELATED, OR MENTAL ILLNESS?
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� As many as 6 in 10 substance abusers also have at least one other mental
disorder. (NIDA)
� Co-occurring disorders were previously referred to as dual diagnoses. According
to SAMHSA’s 2014 National Survey on Drug Use and Health (NSDUH) (PDF | 3.4
MB), approximately 7.9 million adults in the United States had co-occurring
disorders in 2014. (SAMHSA)
� Co-occurring disorders, such as post-traumatic stress disorder (PTSD) and
substance use, is prevalent among veterans and the military community.
According to the Veterans Affairs Department (VA), approximately one-third of veterans seeking treatment for substance use disorders also met the criteria for
PTSD. (SAMHSA)
ASSESSMENT: CO-OCCURRING DISORDER,
SUBSTANCE-RELATED, OR MENTAL ILLNESS?
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� For persons with COD, symptoms of either disorder may vary over time. It is
possible for the person to be effectively managing one set of symptoms while the
other set causes significant impairment. The interactive nature of COD requires
each disorder to be continually assessed and treatment plans adjusted
accordingly
� Within the treatment context, both co-occurring disorders are considered primary
ASSESSMENT: CO-OCCURRING DISORDER,
SUBSTANCE-RELATED, OR MENTAL ILLNESS?
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CO-OCCURRING DISORDERSSUBSTANCE USE DISORDER AND PSYCHIATRIC DISORDERFEATURES
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CO-OCCURRING DISORDERSSUBSTANCE USE DISORDER AND PSYCHIATRIC DISORDER
IMPACT ON HEALTHCARE PRACTICE
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NEURODEVELOPMENTAL DISORDERS
SYMPTOMS
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NEURODEVELOPMENTAL DISORDERS
IMPACT ON HEALTHCARE PRACTICE
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PSYCHOTIC DISORDERSSchizophrenia; Schizoaffective D/O; Delusional D/O
SYMPTOMS
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PSYCHOTIC DISORDERS
IMPACT ON HEALTHCARE PRACTICE
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BIPOLAR DISORDERS
DEFINITIONS
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BIPOLAR DISORDERS
SYMPTOMS
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BIPOLAR DISORDERS
IMPACT ON HEALTHCARE PRACTICE
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DEPRESSIVE DISORDERS
SYMPTOMS
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DEPRESSIVE DISORDERS
IMPACT ON HEALTHCARE PRACTICE
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ANXIETY DISORDERS
SYMPTOMS
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ANXIETY DISORDERS
IMPACT ON HEALTHCARE PRACTICE
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TRAUMA AND STRESS DISORDERS
PTSD, CHILDHOOD TRAUMA, ACUTE STRESS
DISORDERSYMPTOMS
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TRAUMA AND STRESS DISORDERS
PTSD, CHILDHOOD TRAUMA, ACUTE STRESS
DISORDERSYMPTOMS
A diagnosis of PTSD requires exposure to an
upsetting traumatic event. However, exposure
could be indirect rather than first hand. For
example, PTSD could occur in an individual
who learns that a close family member or friend
has died accidentally or violently.
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TRAUMA AND STRESS DISORDERS
SYMPTOMS
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TRAUMA AND STRESS DISORDERS
IMPACT ON HEALTHCARE PRACTICE
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NEUROCOGNITIVE, DEMENTIA AND MEMORY DISORDERSSYMPTOMS
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NEUROCOGNITIVE, DEMENTIA AND MEMORY DISORDERSIMPACT ON HEALTHCARE PRACTICE
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CLUSTER A-marked by odd or eccentric
thoughts, feelings or behaviors
PARANOID
SCHIZOID
SCHIZOTYPAL
CLUSTER B-appear dramatic, emotional
or erratic. Extreme shifts in feelings,
frequent changes in behavior
ANTISOCIAL
BORDERLINE
HISTRIONIC
NARCISSISTIC
CLUSTER C-anxious or fearful, marked
by fear or worry
AVOIDANT
DEPENDENT
OBSESSIVE-COMPULSIVE
PERSONALITY DISORDERS
BY DSM-5 CLUSTERS
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PERSONALITY DISORDERS
SYMPTOMS/FEATURES
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PERSONALITY DISORDERS
IMPACT ON HEALTHCARE PRACTICE
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ELIGIBILITY AND ASSESSMENT
•Baseline Poly-drug Urine Screen
•Based on history, consider hair test for longer window of detection
•Report from current treating psychiatrist with Comprehensive or
DSM-5 Diagnosis
•Safety Assessment: Suicidality, Homicidality, Medical
complications, Risk of withdrawal
•Therapeutic drug levels (if available)
•Clinical assessment by MD psychiatrist, psychologist, psychiatric
RN, LCSW, MFT
RECOVERY AGREEMENT
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ADMISSION CRITERIA
•PARTICIPANT ACKNOWLEDGES THAT A PROBLEM EXISTS
•PARTICIPANT WILLING TO FOLLOW REHABILITATION PLAN
•PARTICIPANT VOLUNTARILY REQUESTS TO ENTER PROGRAM
•PARTICIPANT SIGNS RELEASE OF INFORMATION
SPECIFICALLY FOR PSYCHIATRIC RECORDS
•PARTICIPANT AGREES TO ABSTAIN FROM ALCOHOL OR
OTHER DRUGS NOT PRESCRIBED
RECOVERY AGREEMENT
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Four-Quadrant Model of Care for Co-occurring DisordersI
Psychiatric
Disorder
LOW
Severity
Substance Use
Disorder
LOW
Severity
II
Psychiatric
Disorder
HIGH
Severity
Substance Use
Disorder
LOW
Severity
III
Psychiatric
Disorder
LOW
Severity
Substance Use
Disorder
HIGH
Severity
IV
Psychiatric
Disorder
HIGH
Severity
Substance Use
Disorder
HIGH
Severity
LOC: Client served by primary care
clinic
LOC: Client served by mental
health center/clinic
LOC: Client served by SUD treatment
program
LOC: Client served by mental
health center integrated Co-
occurring disorders program
Source: National Advisory Council, Substance Abuse and Mental Health Services Administration: Improving Services for Individuals at Risk of, or With co-occurring Substance-Related and Mental Health Disorders. Rockville, MD, SAMHSA, 1997.
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TREATMENT
•INITIAL TREATMENT AT LEAST RESTRICTIVE LEVEL OF CARE
•ONGOING TREATMENT AND MEDICATION MANAGEMENT WITH
TREATMENT PROVIDER WHO AGREES TO SUBMIT MONTHLY OR QUARTERLY REPORTS, INCLUDING:
•COMPLIANCE WITH TREATMENT & MEDICATION MANAGEMENT
REGIMEN
•NOTIFICATION TO PROGRAM OF ANY CHANGES TO TX PLAN
•PARTICIPANT AGREES TO ABSTAIN FROM ALCOHOL OR OTHER DRUGS NOT PRESCRIBED
•IMMEDIATE REPORT OF ANY ESCALATION OR CHANGE IN
SYMPTOMS
RECOVERY AGREEMENT
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PHARMACOLOGICAL TREATMENT
RECOVERY AGREEMENT
DIAGNOSIS COMMON TREATMENT SAFER WITH SUD
ANXIETY BENZODIAZEPINES SSRI, GABAPENTIN
ADHD AMPHETAMINE SALTS ATOMOXETINE (Strattera)
PTSD CANNABIS SERTRALINE, NALTREXONE, DISULFIRAM
PSYCHOTIC SX 2ND GEN ANTIPSYCHOTICS(Clozapine)
2ND GEN ANTIPSYCHOTICS(Clozapine)
BIPOLAR D/O TOPIRAMATE, LITHIUM,
GABAPENTIN, VALPROIC ACID, LAMICTAL
TOPIRAMATE, LITHIUM,
GABAPENTIN, VALPROIC ACID, LAMICTAL
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SELF-HELP /COMMUNITY SUPPORT GROUPS
• DBSA-Depression and Bipolar Support Alliance (Live and Online) www.dbsalliance.org
• ADAA-Anxiety and Depression Association of America (Live, chat, online) www.adaa.org/supportgroups#
• NAMI-National Alliance for the Mentally Ill NAMI Connection
www.nami.org
• EA-Emotions Anonymous (Live, chat, skype and phone) www.emotionsanonymous.org
• RI-Recovery International (Live, chat, phone, online)
www.Recoveryinternational.org/meetings/
RECOVERY AGREEMENT
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NURSE/HEALTH PROFESSIONAL PEER SUPPORT GROUPS
� REMOVE FROM GROUPS IF DISRUPTIVE OR UNABLE TO HANDLE THE SITUATION
�DISCUSSION WITH FACILITATOR BEFORE PARTICIPANT JOINS GROUP
� PEER SUPPORT HELPS TO NAVIGATE PROGRAM REQUIREMENTS
� PEER SUPPORT HELPS TO GIVE PARTICIPANT FEEDBACK ON BEHAVIORS
� FACILITATOR AND GROUP PROVIDE EARLY DETECTION OF CHANGES IN
THOUGHT PROCESSES OR BEHAVIORS
�NEED TO MAINTAIN EXPECTATION OF CONSISTENT ATTENDANCE-NOT
SPECIAL TREATMENT
RECOVERY AGREEMENT
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DRUG TESTING COMPONENTS
Continue random drug testing on a limited basis
To ensure participant is not engaged in “self-medicating”
To ensure participant is not presenting with a missed
co-occurring substance use disorder
Consider limited or varied test panel
RECOVERY AGREEMENT
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WORK RESTRICTIONS
•PRIOR TO RELEASE TO WORK, OBTAIN TREATMENT PROVIDER REPORT
FROM PSYCHIATRIST OR THERAPIST, SPECIFICALLY
•STABILITY ON MEDICATION
•JUDGEMENT
•LOGICAL THOUGHT PROCESSES
•ABILITY TO WORK UNDER STRESS
•ABILITY TO FOLLOW DIRECTIONS
•INTERACTIONS WITH OTHERS
•RECOMMENDATION TO RETURN TO PRACTICE
RECOVERY AGREEMENT
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WORK RESTRICTIONS
•Gradual return to practice to ensure stress of work schedule and responsibilities are not overwhelming
•Start with non-direct patient care or in position with limited clinical decision-making (advice nurse, blood donations, dialysis, utilization management, case management, insurance reviews)
•Consider restriction on work hours, less than full time
•Limit overtime, night shift, home-based positions, Home Health, Registry or traveler positions, Float, or unstable shift schedule
•Each case must be considered individually, for participant’s ability to practice safely
•If not co-occurring disorder, may return to medication privileges sooner
RECOVERY AGREEMENT
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CRITERIA FOR UNSUCCESSFUL COMPLETION
•FAILURE TO RESPOND TO TREATMENT PLAN
•FAILURE TO ACHIEVE A LEVEL OF STABILITY
•INABILITY TO MAINTAIN SUCCESSFUL EMPLOYMENT
•DEMONSTRATED FAILURE TO DERIVE BENEFIT DUE TO
•CHRONIC AND SERIOUS NATURE OF THE DISEASE
PROCESS
•INABILITY TO COMPLY WITH PROGRAM REQUIREMENTS
RECOVERY AGREEMENT
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CRITERIA FOR SUCCESSFUL COMPLETION
•2 YEARS OF GOOD COMPLIANCE, INCLUDING:
•MAINTAIN THERAPEUTIC REGIMEN AS PRESCRIBED BY TREATMENT PROVIDER
•TAKING MEDICATIONS AS PRESCRIBED
•SUBMISSION OF LETTERS OF SUPPORT FOR SUCCESSFUL
COMPLETION FROM TREATMENT PROVIDERS, SPONSOR OR
“BUDDY”, SPOUSE/S.O./GROUP FACILITATOR
•NEGATIVE RANDOM DRUG TESTS OF NON-PRSECRIBED
MEDICATIONS OR ALCOHOL
RECOVERY AGREEMENT
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CRITERIA FOR SUCCESSFUL COMPLETION
•DEMONSTRATED STABIILTY IN DAILY LIVING CHARACTERIZED BY:
•ABILITY TO RECOGNIZE ESCALATION OF SYMPTOMS
•ABILITY TO EXPRESS SELF-AWARENESS OF MENTAL HEALTH
AND DIAGNOSIS
•NO EVIDENCE OF PSYCHIATRIC SYMPTOMS
•IF SYMPTOMS ARE IDENTIFIED, SEEKS PROMPT,
APPROPRIATE TREATMENT
RECOVERY AGREEMENT
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Neurodevelop-
mental D/OPsychotic D/O BiPolar D/O;
Depressive D/OAnxiety D/O Trauma and
Stress D/ODementia and Memory D/O
Personality D/O
IMPACT
Judgement
Distraction
Relationships
IMPACT
Judgement
Distraction
Relationships
Thought disorder
Safety
IMPACT
Judgement
Distraction
Relationships
Labile
IMPACT
Judgement
Distraction
Relationships
Avoidance
Labile
IMPACT
Judgement
Distraction
Relationships
Avoidance
Labile
IMPACT
Judgement
Distraction
Relationships
Errors
IMPACT
Judgement
Distraction
Relationships
Labile
AGREEMENT TERMS
Work Monitor
Peer support group
Psych assessment
and reporting
Basic drug testing
AGREEMENT TERMS
Work Monitor
May not be appropriate for
peer support group
Psych assessment
and reporting
Basic drug testing, higher risk of self-
medicating
AGREEMENT TERMS
Work Monitor
Peer support group
Psych assessment
and reporting
Basic drug testing,
higher risk of self-medicating
AGREEMENT TERMS
Work Monitor
Peer support group
Psych assessment
and reporting
Basic drug testing,
higher risk of self-medicating
AGREEMENT TERMS
Work Monitor
Peer support group
Psych assessment
and reporting
Basic drug testing,
higher risk of self-
medicating
Ensure Pt/WSM notifies program of
workplace risks
AGREEMENT TERMS
Work Monitor
May not be appropriate for
peer support group
Psych assessment
and reporting
Basic drug testing
Consider if progressive, may
not be appropriate to return to work
AGREEMENT TERMS
Work Monitor
May be disruptive in peer support
group
Psych assessment
and reporting
Basic drug testing, higher risk of self-
medicating
SUMMARY