Douglas Ziedonis, MD, MPHProfessor & Chair

Department of PsychiatryUniversity of Massachusetts Medical School & UMass

Memorial Health Care

UMass Medical School / UMass Memorial HealthcareUMass Medical School / UMass Memorial Healthcare

High rates in-treatment & community Many Subtypes (MI & SUD/Process)– Setting Context – Selection BiasSetting Context – Selection Bias

Cravings, withdrawal, cognitive & sleep impairment, mood & other symptoms– cause, worsen, & maintain both disorders

Poor response to traditional treatments Integrated Treatment, Programs, and Systems is key

Substance Use Disorders– Tobacco Use Disorders

Process Addictions / Compulsive Behaviors – Gambling, Internet, Sex / Paraphilias, – Food (obesity through the addiction lens), – Work, Spending, etc

Multiple addictions & switching addictions

Mental Illness– Mood & Anxiety– Personality Disorders

Medical Illnesses

Increased fluctuation in mental status– Increased suicide risk & cognitive impairment

Multiple Addictions

Increased episodic violence, victimization / trauma, illegal activities (& homelessness)

Increased morbidity & mortality – HIV, HepC

– Tobacco caused / worsened disorders

Worse medication compliance

Reward,

Memory/Learning,

Motivation, &

Inhibitory Control/ Executive Function Areas to consider in developing new treatments

• Psychiatric and addiction neurobiology

• Substance- Substance interactions (ATOD)

• Psychiatric and addictions medications

• Medical Consequences-Substance-Medication

alcohol

BioNeuro

MedsNic

social

Meds

psychSA

Garavan H, et al. Am J Psychiatry 2000;157:1789-1798.

IFG

Ant. Cing.

Cingulate

Sig

nal I

nten

sity

(A

U)

Cocaine FilmErotic Film

Controls Cocaine Users

Dopamine

Dendritic Spines

Adapted from Nestler EJ. NIDA Science & Practice Perspectives, 3(1) 2005.

Symptoms versus Diagnosis ?– anxiety, depression, mania, & psychosis– intoxication, withdrawal, & chronic use– personality factors

– symptom scales and diagnostic tools

Primary versus Secondary ?– timeline review, past treatments

Self-Medication ?– FH, significant other, pros / cons, attributions

Changes in treatment ?Changes in treatment ?– How long wait ??? How long wait ???

Dual Recovery Status Exam

Blend 3 Addiction Psychosocial TreatmentsBlend 3 Addiction Psychosocial Treatments– Motivational Enhancement TherapyMotivational Enhancement Therapy– Relapse PreventionRelapse Prevention– 12-Step Facilitation12-Step Facilitation

Blend Evidence Based Treatments for specific psychiatric Blend Evidence Based Treatments for specific psychiatric disordersdisorders– CBT, Social Skills Training, etcCBT, Social Skills Training, etc

Recovery Orientation: recognize the need for hope, Recovery Orientation: recognize the need for hope, acceptance, and empowermentacceptance, and empowerment

DetoxificationDetoxification Protracted abstinenceProtracted abstinence Harm reduction / opioid agonistsHarm reduction / opioid agonists Co-occurring psychiatric disordersCo-occurring psychiatric disorders– Consider medication abuse liability, safety, & interaction

with substances

The AA Member: Medications and Other DrugsThe AA Member: Medications and Other Drugs, , 19841984

12

““Pills Fix Problems”Pills Fix Problems”

Soothing – Quick Soothing – Quick

Switch / Add an addiction in vulnerable individualSwitch / Add an addiction in vulnerable individual

How does it fit in working my program?How does it fit in working my program?

Manage aversion to taking medications once in Manage aversion to taking medications once in recovery for addictionrecovery for addiction

Substances alter impact of MedicationsSubstances alter impact of Medications

Complete Wellness:Mental & Physical Health

CompleteWellness

HealthyFood Choices

DailyPhysicalActivity

Stress Management* Mindfulness & Spirituality

Address Addictive Behaviors* Smoking cessation

RegularCheckups

MentalHealth &RecoveryPlan

Co-occurring disorders are the norm and integrated care and systems get best outcomes

Psychosocial Treatment is still the cornerstone in addiction treatment; however medications can be helpful – especially in co-occurring disorders

Programs need to better address tobacco and promote wellness as part of recovery

SAMHSA’s TIPS #42 on COD – www.health.org

SAMHSA Pharmacotherapy Principles (2012)SAMHSA Pharmacotherapy Principles (2012)

COCE: National Training Center on COD www.coce.org

SAMHSA’s Report To Congress

President’s New Freedom Commission on MH

ASAM PPC II – DD Capable & DD Enhanced

APA SA Treatment Guidelines Update

– www.psych.org (Updated May 2006)

Parallel, Consultant Model, Fully-Integrated Integrated Dual Diagnosis Treatment (IDDT) - ACT

teams, housing, etc– www.mentalhealth.samhsa.gov/cmhs/communitysup

port/toolkits/cooccurring/ COSIG National Program – 17 States Addressing Tobacco Through Organizational Change

(ATTOC) in MH / SA settings

– http://www.umassmed.edu/psychiatry/ATTOC.aspx

UMass Addressing Tobacco Through Organizational Change– http://www.umassmed.edu/psychiatry/attoc.aspx

NASMHPD’s Tool Kit– www.nasmhpd.org

NY State Tobacco Dependence Resource Center– www.tobaccodependence.org/

Toolkit from The Alliance for the Prevention and Treatment of Nicotine Addiction (APTNA) – www.aptna.org/APTNA_Prov_Toolkits.html

Treating Tobacco Use and Dependence - Public Health Service Clinical Practice Guideline (2008)– http://www.surgeongeneral.gov/tobacco/treating_tobacco_use08.pdf

American Psychiatric Association’s Substance Use Disorder Treatment Guidelines (2006) www.psych.org