Integrated Treatment for Substance Use Disorders  Research studies indicate that most adolescents with substance abuse (SA) disorders also qualify for diagnosis of one or more mental illnesses, including mood disorders, behavioral disorders, eating disorders, and psychosis (Shrier, Harris, Kurland, & Knight, 2003). Professionals refer to the co-occurrence of SA disorders and mental illness as comorbidity (i.e., dual diagnosis).  Prior to the 1970s, SA treatment was provided in mental health institutions. Since that time, treatment for SA has become increasingly separate from the mental health system. The treatment is usually provided at SA treatment centers or through the alcoholics anonymous (AA) twelve-step programs.  This separation has been a problem for people with dual diagnosis. When an individual presents with both SA disorder and mental illness, SA treatment facilities tend to refer the individual to mental health providers. Likewise, psychological services are not well equipped to handle substance-related issues and tend to refer those individuals back to SA treatment facilities. In other words, treatment providers do not address both issues at the same time. Most psychological service providers require individuals to resolve their addictions before beginning mental health treatment, and most SA treatment providers require the individuals to be psychiatrically stable before beginning SA recovery treatment.  In recent years, however, there has been a movement toward integrated treatment of SA disorders and mental illnesses or the treatment of both at the same time by the same service provider (Riggs, 2003; Sterling, Chi, & Hinman, 2011).  For this assignment, drawing upon the week’s information and ancillary research, address the following:  Discuss the integrated treatment for adolescents who have both SA disorder and mental illness. Do you support the existing model of treating one disorder first, then treating the other, or do you support the newer model of treating both at the same time? Provide at least three reasons for your position and support your argument using information from at least two academic sources and cite those sources using APA format. Create a description of a fictional adolescent struggling with both types of disorders (SA and a mental illness). Be specific in your identification of which substance-related disorder and which mental illness diagnosis the adolescent has been given; provide details about the adolescent’s symptoms; and make a recommendation for the adolescent’s treatment. Describe your recommendation, specifically mentioning whether it should be integrated or not. Provide a fictional description of the progress the adolescent makes in that treatment as a way to illustrate how and why the chosen method of treatment is effective. References:  Riggs, P. D. (2003). Treating adolescents for substance abuse and comorbid psychiatric disorders. Science and Practice Perspectives, 2(1), 18–29. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2851046/ pdf/spp-02-1-18.pdf Shrier, L. A., Harris, S. K., Kurland, M., & Knight, J. R. (2003). Substance use problems and associated psychiatric symptoms among adolescents in primary care. Pediatrics, 111(6), e699–e705. Retrieved from http:// www.pediatricsdigest.mobi/content/111/6/e699.full.pdf+html Sterling, S., Chi, F., & Hinman, A. (2011). Integrating care for people with co-occurring alcohol and other drug, medical, and mental health conditions. Alcohol Research and Health, 33(4), 338–349.

chapter covered:

• Elimination Disorders Substance Use Disorders Feeding and Eating Disorders
  10:55
• Fanti, K. A. (2007). Trajectories of pure and co-occurring internalizing and externalizing problems from age 2 to age 12: Findings from the NICHD study of early child care. Available from ProQuest Dissertations and Theses database. (Order No. 3260558) Jensen, C. D., Cushing, C. C., Aylward, B. S., Craig, J. T., Sorell, D. M., & Steele, R. G. (2011). Effectiveness of motivational interviewing interventions for adolescent substance use behavior change: A meta-analytic review. Journal of Consulting and Clinical Psychology, 79(4), 433–440. Younis, M. S., & Ali, L. D. (2012). Adolescent male with anorexia nervosa: A case report from Iraq. Child & Adolescent Psychiatry & Mental Health, 6(5) 1–5.
  10:55
• this is the text book I’m using, please add the reference also. Mash, E. & Wolfe, D. (2015). Abnormal Child Psychology (6th Ed.). Cengage Learning. (IBSN: 9781305105423)

Comorbid Psychiatrie and Substance Abuse Disorders: Recent Treatment Research

Paula Riggs, MD Frances Levin, MD Alan L Green, MD Frank Vocci, PhD

ABSTRACT. Psychiatric comorbidity is defined as the co-occurretice of a psychiatric disorder iti a patient with a substance use disorder. Psychiatric disorders in substance abuse patients can antedate the substance use disorder or be a consequence of the substance abuse. There is etTierging evidence that drug use in adolescence may alter the onset of certain psychiatric disorders in vulnerable individuals. Patients with coticurrent comorbid disorders present special challetiges for the substance abuse treatment system in terms of diagnosis atid management because each disorder has the capability of exacerbating the other.

This tnanuscript is a sunitnary of an ISAM sytnposium that featured three speakers who discussed the following topics:

1. Etiology and treatment of comorbid psychiatric and substance use disorders in adolescents; 2. Treatment of ADHD and substance use disorders in adults; 3. Effects of substance abuse on the onset, severity, and treatment of schizophrenia.

Recotiimendations for further research will be presented.

KEYWORDS. Adolescence, cottiorbidity, depression, attention deficit hyperactivity disorder, schizophrenia

Paula Riggs is affiliated with the Department of Psychiatry, University of Colorado Health Science Center, Denver, CO 80224.

Frances Levin is affiliated with the Department of Psychiatry, Colutnbia University Medical Center/New York State Psychiatric Institute, Division of Substance Abuse, New York, NY 10032.

Alan I. Green is affiliated with the Departtnent of Psychiatry, Dartmouth Medical School, One Medical Center Drive, Lebanon, NH 03756.

Frank Vocci is affiliated with the National Institute on Drug Abuse, NIH, DHHS. Address correspondence to: Frank Vocci, PhD, National Institute on Drug Abuse, National Institutes of

Health, Department of Health and Human Services, 6001 Executive Boulevard, Room 4133, Bethesda, MD 20892 (E-mail: [email protected]).

Dr. Green is supported in part by NIH grants DA-13196, AA-014644, MH-62197, and R21 DA-019215. Dr. Green reports grant support, honoraria, or advisory board service for Eli Lilly, Janssen, Bristol Myers, Forest, and AstraZeneca. Dr. Levin is supported in part by NIH grant DA K0200465. Dr. Riggs is supported byNIDAROl DA 13176 and NIDA U lO-DA-1-3716 and also receives hotioraria from Shire as a consultant and advisory board member.

Drs. Green, Levin, and Riggs presented at a symposium, chaired by Dr. Vocci, on comorbidity and substance abuse disorders at the VIII International Society of Addiction Medicine Annual Meeting atid Scientific Conference, Oporto, Portugal. Each author contributed equally to the development of the article. Dr. Vocci’s contribution was part of his official duties.

Substance Abuse, Vol. 29(3) 2008 Available online at http://suba.haworthpress.com

© 2008 by The Haworth Press. All rights reserved. doi: 10.1080/08897070802218794 5/

52 SUBSTANCE ABUSE

EPIDEMIOLOGY OF COMORBID SUBSTANCE ABUSE AND

PSYCHIATRIC DISORDERS

Experimentation with alcohol and drugs of- ten begins in adolescence and carries significant prognostic features if it progresses to a substance use disorder (SUD) during adolescence. Early onset of substance abuse is associated with a higher risk of progression to substance depen- dence and continuation in adulthood (1,2), in- creased psychiatric comorbidity (3) and an in- creased number of suicide attempts (4).

Psychiatric comorbidity is the rule rather than the exception among adolescents with substance use disorders, ranging from 60 to 85% in clini- cal samples (see Waxmonsky and Wilens (5) for a detailed review) and epidemiological surveys (3) and the Oregon Adolescent Depression Project (OADP) (6). Kandel et al. (3) analyzed a subset of 401 adolescents, aged 14-17 years old, and reported on drug use patterns and comor- bidity of the disorders and psychiatric disorders. Rates of psychiatric disorders (affective or dis- ruptive disorders) among adolescents with a cur- rent substance abuse disorder were three times higher than for adolescents without a substance abuse disorder. In the OADP, adolescents with a lifetime substance abuse disorder had more that twice the rate of anxiety, depression, or a dis- ruptive behavioral disorder. Tlie rates of comor- bidity reported by Kandel et al. (3) were higher in the nontreatment group for conduct disorders (68%) and depression (32%) than those noted in an adolescent treatment sample: 55 and 9%, respectively (7).

Rates of comorbidity have also been esti- mated from a convenience sample of patients treated at a hospital-based adolescent medicine clinic (8). In this study, 538 adolescents, aged 14-18, receiving routine medical care were screened for substance abuse problems using the Problem Oriented Screening Instrument for Teenagers (POSIT) Substance Use/Abuse scale and the Adolescent Diagnostic Interview of the Diagnostic and Statistical Manual (DSM)-IV (23). Eighteen percent of the group was diag- nosed with substance use problems and another 16 percent with a substance use disorder. Psychi- atric symptomatology was compared across the

non-users, users, and dependent subgroups. Sig- nificant increases in depression, mania, eating disorders, attention deficit disorder, and conduct disorders were noted in the drug using groups.

ETIOLOGY AND TREATMENT OF COMORBID PSYCHIATRIC AND

SUBSTANCE USE DISORDERS IN ADOLESCENTS

Genetic and neurobiological vulnerabili- ties (e.g., difficult temperament) coupled with chronic environmental adversities throughout development put children at risk for develop- ment of psychiatric disorders and substance use disorders (SUD) in adolescence (9). Biologi- cal vulnerabilities include genetic risk factors that may influence development of “difficult temperament” or neurobehavioral disinhibition in early childhood, characterized by poor at- tention and persistence, impulsivity, executive function deficits, hyperactivity, aggression, and poor frustration tolerance (10,11). Children with such temperaments are at higher risk for devel- oping academic problems and childhood onset psychiatric disorders such as oppositional defi- ant disorder (ODD), attention deficit hyperactiv- ity disorder (ADHD), learning disorders (LD), conduct disorder (CD), and affective disorders (9,11). Family risk factors, such as abuse, ne- glect, and parental or sibling substance abuse are also important. These problems synergistically contribute to increasing social marginalization, association with deviant peers, as well as early experimentation with drugs of abuse, often with rapid progression to SUD during adolescence.

By the time such youths enter drug treat- ment, psychiatric comorbidity is the rule rather than the exception (9,12). Research shows that commonly co-occurring psychiatric disor- ders, such as ADHD and depression, often go untreated in community drug treatment pro- grams, which may contribute to poorer substance treatment outcomes compared to non-comorbid adolescents with SUD (13). Although a num- ber of family-based, behavioral, and cognitive- behavioral interventions have been shown to have efficacy in the treatment of adolescent SUD, there is a paucity of controlled treatment

Riggs et al. 53

outcome research evaluating the effectiveness of combined or integrated treatment of psychiatric comorbidity and SUD (14).

To our knowledge, only 3 controlled trials have been conducted to date evaluating the safety and efficacy of pharmacotherapy targeting a co- occurring psychiatric disorder in adolescents with SUD. One small study (n = 22) supported the safety and efficacy of lithium carbonate for bipolar disorder in adolescents with concurrent SUD ( 15). Another controlled trial evaluated the safety and efficacy of pemoline (a schedule-IV psyciiostimulant) for attention deficit hyperac- tivity disorder (ADHD) in 69 out-of-treatment adolescents with active SUD (16). (Diagnostic criteria and treatment studies of ADHD in adults are presented in the section following the discus- sion on adolescents.) Results showed that pemo- line had a good safety profile and a comparable effect size to that reported for ADHD in ado- lescents without SUD despite non-abstitience in most study participants. However, in the absence of specific behavioral treatment for SUD, phar- macotherapy for ADHD had no impact on drug use, which did not significantly decrease in either tieatment group (16).

Another recently completed controlled trial evaluated the safety and efficacy of fluoxetine vs. placebo in 126 adolescents with DSM-IV diag- noses of major depressive disorder (MDD), CD, and SUD (17,18). Adolescents in both medica- tion groups received weekly, individual, manu- alized CBT for their SUD during the 16-week trial (18). Thus, the study also evaluated the impact of pharmacotherapy for depression on change in drug use, substance treatment compli- ance, and retention. Results showed that fluoxe- tine had a good safety profile and demonstrated superior efficacy (.78 effect size) to placebo for depression, despite non-abstinence in the major- ity of study participants. Most adolescents also decreased their drug use, about 5-7 days per month on average. However, only about 10% of the sample (n = 12/126) achieved sustained ab- stinence of at least 1 month and there was no difference between fluoxetine and placebo treat- ment in change in drug use. Since rates of depres- sion remission were unexpectedly high in both the ñuoxetine -I- CBT (75%) and the placebo + CBT (64%) treatment groups but rates of ab-

stinence were relatively low, researchers con- cluded that most depressions did not remit due to abstinence. However, the limitations of the study design did not allow more definitive con- clusions to be drawn about the temporal rela- tionships or directionality of change in depres- sion and change in substance use. Researchers also speculated that CBT most likely contributed to the higher than expected depression response rates despite its pritnary focus on the treat- ment of SUD. More definitive conclusions about the contribution of CBT to depression response rates cannot be made because all study partic- ipants received the manualized CBT as outpa- tient treatment for SUD during the medication trial. Post hoc analyses indicated that remission of depression was a stronger predictor of change in drug use than medication treatment. Those whose depressions remitted, regardless of med- ication assigntnent, significantly decreased their drug use, whereas non-remitters’ drug use did tiot decrease from baseline levels of use despite similar rates of treatment compliance and re- tention. If replicated, the clinical implications of this study indicate that co-occurring depres- sion in substance-abusing adolescents may remit without antidepressant pharmacotherapy or ab- stinence, in the context of individual outpatient CBT for SUD. However, if depression does not remit, their drug use may not decrease even if they continue with substance treatment. Thus, in dually diagnosed adolescents, if depression does not appear to be improving early in the course of substance treattnent (e.g., within the first month of treatment) it appears to be safe, efficacious, and clinically prudent to initiate flu- oxetine, with careful monitoring, even if not yet abstinent, because ongoing depression may im- pede abstinence achievement.

Taken together, preliminary results of these adolescent studies indicate that some medi- cations for common co-occurring psychiatric disorders such as ADHD and deptession in ado- lescents with SUD may be safe and effective even if non-abstinent, but treatment of psychi- atric comorbidity alone is not likely to impact drug use without concutTent and specific be- havioral therapy for SUD. Results must be in- terpreted with caution due to the small number of controlled trials conducted to date and their

54 SUBSTANCE ABUSE

limitations. For example, studies conducted to date lack sufficient sample size to detect the full range of clinically significant effects of ADHD or depression treatment on substance use or other clinical outcomes. Existing studies have not yet been able to address the separate and combined influences of pharmacotherapy and behavioral interventions for comorbid psychi- atric and substance use disorders. More research is clearly needed in larger samples with ap- propriate design before definitive conclusions can be drawn that may guide development of clinical practice parameters in dually diagnosed adolescents.

ATTENTION DEFICIT HYPERACTIVITY DISORDER

AND SUBSTANCE ABUSE DISORDERS IN ADULTS

Attention-deficit/hyperactivity disorder (AD- HD) is characterized by inattention, hyperactiv- ity and impulsivity. ADHD imposes a substantial individual and public burden. It has been es- timated that the excess U.S. health care and work-related costs for individuals with ADHD and their family exceeds $32 billion/year (19). Although it was once believed that children “outgrew” ADHD when they reached adult- hood, recently conducted community surveys estimate that up to 60% of children with ADHD continue to have symptoms into adolescence and adulthood (20,21).

In the National Comorbidity Survey Repli- cation (NCS-R), ADHD was found to occur in 4.4% adults (22). Further, the individuals with ADHD had significantly higher rates of comor- bid substance use disorders compared to those without ADHD (15.2% versus 5.6%). Similarly, in samples of individuals seeking treatment for substance abuse, the rates of adult ADHD us- ing DSM-IV-TR criteria (23) are substantially higher than what would be expected based on population estimates, with rates ranging from 10 to 25%. Importantly, substance abusers with ADHD may progress less well or may be more likely to drop out of treatment compared to those without ADHD (24-26). These data indi-

cate that ADHD commonly co-occurs with sub- stance use disorders and impacts the outcome of treatment.

While the exact cause of ADHD is un- known, there is converging evidence from ge- netic and imaging studies that genes and brain regions associated with dopaminergic transmis- sion are altered in individuals with ADHD (27, 28). Repeatedly, medications that increase dopamine, such as stimulants, have been shown to improve ADHD symptoms, suggesting a key role of dopamine in the pathophysiology of ADHD. Given that ADHD is overrepresented in substance-abusing populations, and may neg- atively impact on treatment, it is incumbent on clinicians to learn how to diagnosis and treat ADHD.

According to DSM-IV-TR, an individual with ADHD can be diagnosed with inattentive type, impulsive-hyperactive, or combined type de- pending on the number of symptoms (see APA (23) for a description of diagnostic criteria). Because the diagnosis of ADHD in adults of- ten depends on obtaining symptomatology from childhood, it can be challenging to garner ade- quate information in substance-abusing popula- tions, particularly those who may have cognitive difficulties as a direct result of their alcohol or drug abuse. There are common factors that may lead to both under-diagnosis and over-diagnosis of ADHD in substance abusers. Common rea- sons that lead to under-diagnosis include: (1) inability to recall symptoms prior to the age of 7, (2) assuming that the presence of other psychiatric disorders (e.g., hypomania, depres- sion) preclude the diagnosis of ADHD, (3) un- structured clinical interviews that depend on the clinician querying about ADHD symptoms, and (4) not recognizing that ADHD symptoms may be fewer, less obvious, or be compensated for in adulthood. DSM-IV requires that individu- als with ADHD have symptoms prior to the age of 7. This is problematic when evaluating adults who may not recall how they behaved in first or second grade and there may not be any older family members available to provide historical information. Increasingly, experienced clinicians have questioned the validity of the “before age 7” criterion (29,30). An individ- ual who otherwise meets criteria for ADHD

Riggs et al. 55

but does not recall whether his symptoms be- gan before the age of 7 may be diagnosed with ADHD, NOS (not otherwise specified); how- ever, clinicians may unfortunately forgo mak- ing the diagnosis since the individual does not meet full ADHD criteria and not commence with treatment. Also, there are numerous reasons for over-diagnosis. These include (1) not obtaining an adequate longitudinal history, (2) relying on screening instruments alone, (3) not ensuring that symptoms occur in more than one setting, (4) not ensuring that the symptoms cause impair- ment, and (5) the potential for secondary gain on being diagnosed with ADHD such as special consideration with test-taking or stimulant med- ication prescriptions. While these possibilities should not be ignored, overwhelmingly, in sub- stance abuse treatment settings, under-diagnosis is much more common.

It still remains controversial regarding how to best treat co-occurring ADHD individuals with SUD. To date, there are few empirical data to guide treatment. Although there have been numerous open trials suggesting that both nonstimulants and stimulants may reduce ADHD symptoms and substance use (31,32), there are only a few double-blind controlled trials in individuals with active substance abuse with ADHD. To date, the data are mixed. Two studies suggest that ADHD may be improved with either methylphenidate (adults) (33) or pemoline (adolescents, aforementioned) even if non-abstinent (16). Two other adult studies did not demonstrate a greater improvement in ADHD symptoms in methadone mainte- nance patients receiving methylphenidate or bupropion or cocaine-dependent patients with ADHD (34,35). For those cocaine-dependent individuals who had an improvement in ADHD symptoms based on clinician ratings, the methylphenidate group was more likely to show a reduction in cocaine use over time compared to placebo. Even in placebo subjects with reduction of ADHD symptoms, cocaine use did not remit. However, none of these studies found that active medication was superior to placebo in reducing substance use on primary outcome measures. Thus, the hypothesis that reduction in ADHD symptoms would lead to reduction in drug use has not been substantiated. It should

be noted that the lack of a difference between medication and placebo groups does not allow for a conclusion regarding a specific mediated effect of medication in the latter studies. Larger studies, which presumably would show differ- ences between medications and placebo groups on ADHD symptoms, are needed to determine whether medications for ADHD in adults have a salutary effect on concurrent substance abuse.

There has been some evidence that direct ag- onist treatment with amphetamines may reduce cocaine use (36,37), but to date only one of the studies with ADHD cocaine abusers has found some evidence on a secondary outcome mea- sure that methylphenidate reduces cocaine use over time. Because of the relatively small sam- ple sizes of these trials, high dropout rates, and high placebo response rates, it is difficult to draw firm conclusions from these findings. However, it may be that ADHD medication works best for those who are able to achieve a period of absti- nence, when greater diagnostic clarity is better attained and the acute toxicity of psychoactive substances is reduced (38).

Although there are few empirical data to guide the treatment of co-occurring substance use dis- orders with ADHD, clinical experience suggests that stimulants can be used effectively under closely monitored conditions. While it is prudent to first try medications with a low abuse and di- version liability such as atomoxetine (which is an FDA-approved treatment for ADHD) or bupro- pion (which does not have an FDA itidication for ADHD), this should not necessarily preclude the use of stimulants if these agents are not effec- tive. Prior to initiating a trial of stimulants, cer- tain questions need to be asked: (1) Have other nonstimulant medications been tried or are there specific reasons why stimulants make sense as a first-line treatment? (2) Is the patient a cur- rent or past substance abuser? (3) Has the pa- tient had an established period of abstinence?

(4) If the patient is a current substance abuser, is he in ongoing substance abuse treatment? (5) Is there a history of amphetamine or other stimulant abuse? (6) If the individual abused stimulants, what were the reasons for taking nonprescribed stimulants in the past?to get work done or to get high?

56 SUBSTANCE ABUSE

In general, it a reasonable to first try a med- ication with little abuse potential, such as ato- moxetine or bupropion. However, data suggest that these medications have lower effect sizes in their efficacy in treating ADHD compared to stimulant medication (39). Thus there are cer- tain clinical circumstances when implementing a stimulant may be a rational first choice. For example, a patient who has been in remission from alcohol dependence for 10 years, with no other intervening drug use, might be reasonably initiated on a long-acting stitnulant. However, other important questions to consider prior to starting a stimulant in a patient with a current or past history of substance abuse include: (1 ) Is the patient reliable? (2) Are there family members who can be involved in the treatment plan? (3) Has the patient and/or family been adequately informed of the potential risks involved in using stimulants? Although the research conducted in cocaine-dependent individuals with and without ADHD have shown little evidence of abuse of prescribed stimulants (34,36,37,40,41), misuse of prescribed medication is a significant public health problem (42-44) and a certain percentage of individuals with ADHD, particularly adoles- cents, will report giving or selling their medi- cation to others or will report getting high from their medication (44,45).

Since the long-acting formulations are more difficult to tamper with, it is less likely that in- dividuals will take these formulations in non- prescribed routes (e.g., intranasally or intra- venously). Further, long-acting stimulants may be associated with less abuse potential than short-acting stimulants (46,47). Thus, in most circumstances, long-acting stimulant formula- tions should be chosen rather than immediate- release preparations.

Modafinil is a stimulant medication with some abuse potential. It has been established that 200 mg of modafinil given to ADHD patients under controlled conditions improved work- ing memory, visual memory, spatial planning, and stop-signal reaction time (48). The spa- tial planning accuracy was accompanied by increased response latency, suggesting that modafinil increases reflective cognition. Addi- tionally, modafinil increased sustained attention in the ADHD patients. Such data provide a ratio-

nale for extending the study to comorbid ADHD substance abuse populations.

Although the emphasis has been on the use of medications to treat ADHD, there is a grow- ing literature on the potential utility of non- pharmacologic interventions such as cognitive remediation (49) and other cognitive behavioral approaches (50) to treat ADHD. Whether these interventions are effective alone in adult sub- stance abusers with ADHD or are best when combined with medication requires further eval- uation. However, at present, medications remain the mainstay of treatment for adult ADHD. Al- though various classes of medications may prove effective in reducing ADHD symptoms and psy- choactive substance use in ADHD adults with comorbid substance abuse, many questions re- main, such as when to initiate treatment, what is the optimal dosing, under what circumstances are stimulants a reasonable choice, and un- der what circumstances should stimulants be avoided. Future research should help address these issues.

SUBSTANCE ABUSE AND THE ONSET, SEVERITY, AND TREATMENT

OF SCHIZOPHRENIA: PHARMACOTHERAPEUTIC

INTERVENTION

Schizophrenia, characterized by both positive (e.g., hallucinations) and negative (e.g., anhe- donia) symptoms, as well as cognitive deficits, occurs in about 1 % of the population. The symp- toms of schizophrenia tend to present initially in late adolescence or early adulthood. Modem approaches to treatment emphasize effective in- tervention at the earliest stages of the illness in an attempt to limit the long-term disability that is often associated with schizophrenia.

Substance use disorder (SUD) is very com- mon in patients with schizophrenia and dra- matically worsens their outcome (51). The Epi- demiological Catchment Area study suggested that nearly 50% of patients with schizophrenia have a lifetime history of SUD, a rate approx- imately 3 times that seen in the general popu- lation (52). An elevated rate of SUD is seen in

Riggs et al. 57

both chronic and first episode patients. SUD is known to complicate the course of schizophrenia and is associated with increased levels of symp- toms, noncompliance with treatment, hospital- izations, violence, suicidality, victimization, and medical costs (53). Alcohol and cannabis ap- pear to be the 2 most commonly used substances in these patients; cannabis is more common in first episode patients and some investigators have suggested that cannabis use may trigger the on- set of psychosis in vulnerable individuals (54). A number of studies have suggested that cannabis use is associated with an early age of onset of schizophrenia (54).

The basis of substance use in these patients has been addressed by a number of inves- tigators. Various authors have suggested that their substance use is related to an attempt to self-medicate positive or negative symptoms of schizophrenia (55) or to decrease neurologi- cal side effects of the antipsychotic medica- tions used to treat the patients (56). Studies that have assessed this, however, have been unable to substantiate the causal association of the self- medication hypothesis (57). We and others have proposed an alternative but not totally contra- dictory theory—that of a brain reward circuitry dysfunction in patients with schizophrenia that underlies their substance use (57-59).

The pathophysiology of schizophrenia is thought to involve dysfunctional mesocortico- limbic pathways mediated by the neurotransmit- ter dopamine. These pathways also comprise a component of the brain reward circuit. We have proposed, based on a series of animal studies (60), that use of substances (all of which re- lease dopamitie in the nucleus accumbens, part of the reward circuit) serves to transiently im- prove functioning of the reward circuitry, even as it makes the course of schizophrenia worse (57). Studies in our laboratory and elsewhere are underway in an attempt to provide evidence to confirm this theory.

The use of functional magnetic imaging is one way to study the brain reward circuit. Us- ing monetary gambling procedures, investiga- tors have demonstrated the ability to activate the ventral striatum and the cortex, key components of the brain reward circuit (61). Interestingly, re- ports from 2 investigators in recent years (62,63)

have demonstrated abnormal brain reward cir- cuitry in patients with schizophrenia. Studies in our laboratory (53) are underway to confirm and extend these findings.

Treatment of patients with schizophrenia and co-occurring SUD optimally involves a hybrid treatment system, in which one treatment team delivers medication management, as well as sub- stance abuse and psychosocial services (54,64). One such treatment program, known as inte- grated dual diagnosis treatment (IDDT), has been demonstrated to be useful for such patients (54,64,65). Integrated or hybrid programs should involve services that are consistent with the indi- vidual’s motivation for change, and they must be given with recognition that successful treatment requires a long-term perspective.

Antipsychotic medications are the mainstay for pharmacological treatment of schizophre- nia, as they have been since the 1950s. Stud- ies over many years have suggested, however, that although the first-generation (or typical) antipsychotic medications are effective in pa- tients with schizophrenia, they are not particu- larly helpful in such patients if they also have a co-occurring SUD (53). In fact, some reports suggest that substance use may increase in pa- tients given these first-generation antipsychotics (66). There is some evidence, however, that the newer, second-generation (or atypical) antipsy- chotics, e.g., clozapine and the medications in- troduced after clozapine, may be more effective in patients with schizophrenia and co-occuiTÍng SUDs (67).

Clozapine is generally considered the most effective antipsychotic for the treatment of schizophrenia (68). Unfortunately, it is also the most toxic, with important side effects that generally limit its use to patients known to be refractory to treatment with other antipsy- chotics. Interestingly, however, data from a num- ber of investigators have begun to suggest that clozapine may be highly efficacious in patients with schizophrenia and co-occurring SUDs and may limit substance use in these patients (53,54,67,69). These data, obtained from a num- ber of studies, while still preliminary (in the ab- sence to this point of a rigorous, adequately pow- ered randomized controlled trial), consistently demonstrate this. For example, case reports have

58 SUBSTANCE ABUSE

suggested clozapine’s ability to decrease cocaine use and tobacco smoking, retrospective studies have demonstrated an ability to decrease alco- hol and cannabis use, and a naturalistic study indicated that clozapine use was associated with decreases in alcohol and cannabis abuse at a rate greater than typical antipsychotics (53).

The data are even more preliminary, and seemingly less consistent, with regard to the other second-generation, atypical antipsychotic medications. A recent review has summarized the current data regarding these agents (53). The most accurate statement that can be made at this time about these non-clozapine second- generation agents in this population is as follows: while clinicians tend to use second-generation antipsychotics for patients with co-occurring disorders (perhaps because they are thought to potentially have somewhat greater efficacy for negative symptoms), data to support this clinical practice is only beginning to be ac- quired. Nonetheless, given the reports that first- generation antipsychotics appear to be of lim- ited value in these patients, even the modest data about the newer agents suggest their appropriate preferential use in this population (70). Clini- cians, however, must be aware of the metabolic side effects of many of these second-generation antipsychotics and need to weigh their potential benefits against the likelihood that such side ef- fects may develop. Clearly, further research is needed to adequately clarify the optimal use of clozapine and other second-generation antipsy- chotics in patients with schizophrenia and co- occurring SUD.

Our group has proposed a neurobiological hy- pothesis to explain clozapine’s apparent ability to limit alcohol, cannabis, and potentially co- caine use in patients with schizophrenia (57). We have suggested that clozapine’s broad spectrum of effects, particularly its weak blockade of dopamine D2 receptors, its potent blockade of norepinephrine alpha 2 receptors, as well as its ability to release norepinephrine in brain and plasma, may allow this medication to ameliorate the brain reward circuit deficit in patients with schizophrenia that underlies their substance use (57). Preclinical studies in alcohol-drinking ani- mals as well as clinical neuroimaging studies are underway to substantiate this hypothesis.

Beyond the antipsychotic medications them- selves, other adjunctive agents are also beginning to be tested in this population. Nal- trexone, for example, which is approved for use in the treatment of alcoholism, has been re- cently shown to also limit alcohol use in patients with schizophrenia, although liver toxicity from this medication is a potential worry in these pa- tients (53,72,73). In addition, disulfiram appears to also limit alcohol use in this population, al- though it must be used with caution because of its potential to increase psychosis and produce liver toxicity (53,65,71). Other medications have been tried in patients with alcoholism (such as acamprosate), although they have yet to be tested in patients with schizophrenia. Lastly, bupropion has been shown to help decrease cigarette smok- ing in patients with schizophrenia (74), topira- mate has been demonstrated in 2 case reports to limit alcohol use in this population (75), and tricyclic antidepressants have been reported to potentially limit cocaine use in patients with schizophrenia (76). Clearly, all of these reports are quite preliminary and more studies need to be done before a clear recommendation can be given regarding the optimal adjunctive treatment approaches for these patients.

Schizophrenia, a serious mental illness that usually presents in late adolescence and early adulthood, is worsened by co-occurring substance abuse. Alcohol and cannabis are the 2 most often used substances in schizophrenic patients. The use of these agents as self- medication for positive or negative symptoms or to counteract dysphoric effects of antipsychotic medication has been proposed by a number of investigators. An alternate to these notions is that a reward deficiency/imbalance exists in the mesolimbic and mesocortical dopamine-linked circuits. Patients abusing drugs or alcohol are thought to be attempting to compensate for the reward deficiency, even if it worsens the disease pathology. Clozapine, a second-generation an- tipsychotic, has been reported to reduce alcohol and cannabis use in schizophrenic patients (53). More rigorous clinical trials of this agent and other agents such as topiramate and naltrexone are necessary to develop definitive evidence that could establish new treatment guidelines for schizophrenic patients with co-occurring

Riggs et al. 59

substance abuse disorders. Also needed are mechanistic studies utilizing noninvasive imag- ing techniques to confirm the hypothesized derangements and their amelioration by second- generation antipsychotic medications.

While it is clear that the optimal pharmaco- logical approach to these co-occurring patients is still developing, the field is quickly recogniz- ing that limiting substance use in patients with schizophrenia, particularly those in the early phase of the disorder, is crucial if we are to achieve the goal of improving the course of this severe psychiatric disorder. Moreover, the field further recognizes that any new pharmacologi- cal agent, to be used in any phase of the disor- der, will optimally be given in conjunction with an active psychosocial intervention program to achieve maximal therapeutic benefit.

SUMMARY AND CONCLUSIONS

Important advances in research have clearly increased our knowledge and understanding of the complex etiology of genetic, neuro- biological, and environmental vulnerabilities and adversities that put children at risk for developing substance use disorders (SUDs) and psychiatric comorbidity. Research advances have also deepened our appreciation of the importance of understanding the onset and progression of addiction from a developmental perspective. We have learned that many child- hood psychiatric disorders increase the risk of drug abuse during adolescence; that the onset of drug abuse in adolescence increases the risk of developing psychiatric comorbidity; and that the majority of substance-dependent adults began experimenting with substances of abuse during adolescence, progressing to more serious SUD, psychosocial problems, and comorbidity into adulthood. We have also learned that a severe psychiatric disorder, schizophrenia, which has an onset in late adolescence or early adulthood, is commonly associated with substance use disorders and that use of substances worsens the course of schizophrenia. Research advances in these areas have sparked a growing interest to further our understanding of the impact of treatment for psychiatric comorbidity on substance abuse and treatment outcomes.

The 3 presentations in this workshop have highlighted the results of key studies that have advanced research in the field, focusing on those that have evaluated the safety and efficacy of various pharmacotherapies for comorbid depres- sion, ADHD, and schizophrenia and the impact of such treatment on substance abuse. Prelimi- nary conclusions from the studies presented in- dicate that some medications may be safe and efficacious for comorbid disorders even in pa- tients who have not yet achieved abstinence from substances of abuse. Although results must be interpreted with caution, there is some indica- tion that adolescents with comorbid depression or ADHD may be somewhat more responsive to medications for co-occurring disorders com- pared to adults with more chronic and severe his- tories of substance dependence. Taken together, results of current research indicate that pharma- cotherapy for a co-occurring psychiatric comor- bidity alone does little or nothing to reduce drug use in the absence of specific behavioral therapy for SUD. And it is not yet clear that concur- rent treatment of psychiatric comorbidity and SUD improve outcomes for both disorders. Fac- tors related to patient age, comorbidity, chronic- ity, severity, and predominant type of substance abused are all likely to have influenced study out- comes and interpretation of the mixed research findings to date. These factors coupled with the methodological limitations of current research have not yet produced sufficiently clear and con- vergent results to enable derivation of generaliz- able clinical implications. Important directions for future research include:

1. Research, with appropriate design method- ology, is needed to enhance our under- standing of the separate and combined effects of behavioral interventions and pharmacotherapy for SUD and comorbid- ity in adolescents and adults.

2. Research is needed to identify similar- ities of symptoms and neurobiology of common co-occurring disorders and ad- diction. Understanding cotnmon features/ overlapping neurobiological similarities/ symptoms could help guide medication de- velopment of pharmacotherapies to poten- tially target not one but both SUD and comorbidity (see below).

60 SUBSTANCE ABUSE

3. We need to develop and test medications that have the potential to directly tar- get both SUD and comorbidity through amelioration of the presumed underly- ing neurobiological (e.g., brain reward) dysfunction. We also need to conduct larger controlled trials of medications al- ready showing promise, including:

a. Clozapine—an atypical antipsy- chotic with the seeming ability to decrease alcohol and other substance abuse in patients with schizophrenia.

b. Bupropion—an antidepressant that is therapeutically helpful for ma- jor depressive disorder, ADHD, and nicotine dependence, as well as potentially reducing metam- phetamine/cocaine (77) use and craving, or cannabis craving.

4. We need medication development to aug- ment psychosocial treatment outcomes and bolster relapse prevention efforts. Consid- erations in medication development for adolescents with SUD include:

a. New medications are needed that can target both SUD and one or more psychiatric comorbidities (e.g., be- yond bupropion and clozapine).

b. Existing and new medications should be evaluated for use in pa- tients with cannabis use disorder, the most common SUD bringing teenagers into treatment.

5. Research is needed to evaluate neuro- biological/HPA axis, neuroimaging, or other relevant biomarker responses to both pharmacotherapy and behavioral/ psychotherapy treatment modalities.

a. Does treatment impact your brain re- ward system?

b. Is internalized motivation that allows for sustained abstinence able to mod- ify brain reward dysfunction? Know- ing this will allow us to determine what types of interventions may be most helpful therapeutically.

6. Research is needed to develop sophisti- cated study design methods and innova- tive biostatistical approaches to data to disentangle the directionality and/or tem- poral relationships between change in drug use and change in depression or symptoms from other psychiatric comorbidities.

7. Research is needed to refine assessment instruments evaluating withdrawal/craving and symptoms of common co-occurring psychiatric conditions.

8. Research is needed to establish the utility of managing adult ADHD patients with co- occurring substance abuse disorders. New psychostimulants and new formulations of old psychostimulants should be evaluated for their ability to improve symptoms of ADHD and also to reduce substance abuse in patients with ADHD.

9. Mechanistic studies should be carried out in substance abusing patients with ADHD to establish pharmacological effects on cognition as a function of dose and time.

10. More research is needed on the effect of second-generation antipsychotic med- ications on the management of substance abuse in patients with schizophrenia, par- ticularly those in the early phase of illness. Special emphasis should be given to cloza- pine.

11. More research is needed in schizophrenic patients on ancillary medications such as naltrexone and topiramate for their possi- ble ability to reduce substance abuse.

12. Mechanistic research is needed to vali- date the hypothesis of an imbalance in dopaminergic systems in patients with schizophrenia and its possible ameliora- tion by medications.

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Integrating Care for People With Co-Occurring Alcohol and

Other Drug, Medical, and Mental Health Conditions

Stacy Sterling, M.P.H., M.S.W.; Felicia Chi, M.P.H.; and Agatha Hinman

Most people with alcohol and other drug (AOD) use disorders suffer from co-occurring disorders (CODs), including mental health and medical problems, which complicate treatment and may contribute to poorer outcomes. However, care for the patients’ AOD, mental health, and medical problems primarily is provided in separate treatment systems, and integrated care addressing all of a patient’s CODs in a coordinated fashion is the exception in most settings. A variety of barriers impede further integration of care for patients with CODs. These include differences in education and training of providers in the different fields, organizational factors, existing financing mechanisms, and the stigma still often associated with AOD use disorders and CODs. However, many programs are recognizing the disadvantages of separate treatment systems and are attempting to increase integrative approaches. Although few studies have been done in this field, findings suggest that patients receiving integrated treatment may have improved outcomes. However, the optimal degree of integration to ensure that patients with all types and degrees of severity of CODs receive appropriate care still remains to be determined, and barriers to the implementation of integrative models, such as one proposed by the Institute of Medicine, remain. KEY WORDS: Alcohol and other drug use (AODU) disorders; comorbidity; co-occurring disorders; mental health; health care; treatment; treatment outcomes; integrated treatment; combined treatment

It is widely recognized that themajority of patients with alcoholuse problems also suffer from co-occurring mental health and medical problems. Co-occurring disorders (CODs) complicate the treatment process and, in many cases, contribute to poorer outcomes (Drake et al. 1996; Rosenthal and Westreich 1999) as well as higher service utilization and costs over time (Curran et al. 2008; Lennox et al. 1993). In the past, clinicians within each treatment setting—alcohol treatment, mental health, and general medicine—frequently treated COD patients as they would patients with only one of these disorders; however, such treatment is not well suited to the special needs of patients with CODs (Rosenthal and Westreich 1999).

Extensive research has documented the need to treat all conditions from which patients suffer and has identified many key components of the best practices for achieving this goal (Goldman et al. 2000; Minkoff 1991; Minkoff and Ajilore 1998; Osher 1996). Moreover, a growing body of research suggests that integrated approaches to treatment may improve the outcomes of patients with alcohol problems (Craig et al. 2008; Drake et al. 2004, 2008; Goldman et al. 2000; Minkoff and Ajilore 1998; Osher 1996). Although optimally integrated care still is the exception in most treatment settings, interest in this approach is mounting, and many pro- grams are attempting to incorporate integrated models of care.

This articles draws from the frame- work established in the Institute of Medicine (IOM) (2006) report, Improving the Quality of Health Care for Mental and Substance-Use Conditions, and other literature to consider the state of integrated care for people with alcohol problems and CODs. It examines how integrated approaches can make treatment more attractive to patients and contribute to higher retention rates and better

STACY STERLING, M.P.H., M.S.W., is a group leader; FELICIA CHI, M.P.H., is a senior analyst, and AGATHA HINMAN is a research associate at the Division of Research, Kaiser Permanente Medical Care Program, Oakland, California.

338 Alcohol Research & Health

Integrating Care for People with Co-Occurring Conditions

outcomes, and discusses strategies and mechanisms that facilitate greater integration. It also considers barriers that impede optimal coordination of care for CODs, including organizational fragmentation; stigma; financing mechanisms; and the complex issues of confidentiality, patient safety, and the free flow of information necessary to implement integrated treatment approaches. Throughout the article, the term “disorder” refers to alcohol or other drug (AOD) use problems that meet the criteria set forth in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM–IV) for abuse or dependence. The term “unhealthy use” describes less severe but problematical AOD use. The term “problems” encompasses the entire spectrum of severity.

Scope of the Problem

Prevalence of Co-Occurring AOD and Mental Health Problems The high prevalence of co-occurring AOD problems and mental health conditions has been well documented in the addiction and psychiatric liter- atures. There are several excellent reviews of the epidemiologic research (Cornelius et al. 2003; Kessler 2004), and many studies of clinical samples (Compton et al. 2000; Flynn et al. 1996; Jainchill 1994; Sacks et al. 1997), as well as large national (Grant et al. 2004; Hasin et al. 2007; Kessler et al. 2005) and international (Kessler et al. 2007) population surveys, have been published. Lifetime prevalence of CODs among those seeking treatment for AOD disorders has been estimated at anywhere from one-quarter to well over one-half. For example, the National Comorbidity Survey, a general population survey of adults, found that 51.4 percent of those surveyed with a lifetime AOD disorder also reported a lifetime mental health disorder, whereas 50.9 percent of those with a mental health disorder reported having had an AOD disorder (Kessler 2004). The co-occurrence of AOD problems with mood and anxiety

disorders is especially high. In a general population sample, the 2001–2002 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) found that of those with at least one AOD disorder, 20 percent suffered from a mood disorder and 18 percent from an anxiety disorder in the same period.

Many studies determine the preva- lence of CODs by examining clinical DSM–IV diagnoses or by assessing patients’ scores on research instruments that are well validated and which typically assess type and severity of problems consistent with the criteria used to make DSM–IV diagnoses. The true prevalence of co-occurring AOD and mental health problems, however, probably is much higher than that documented in the literature, particularly when including lower- severity, subdiagnostic threshold cases. In addition, co-occurrence of AOD use and more than one mental disorder is not unusual (Jainchill 1994; Kessler et al. 2005).

Chronology and Etiology of Co-Occurring AOD and Mental Health Problems The chronology and etiology of CODs also are complex issues and often a contentious subject in the AOD treat- ment and psychiatry fields, because many of the factors that predispose patients to develop AOD use problems also are related to mental health problems. For example, on the one hand, AOD problems can stem from self-medication for mental health problems; on the other hand, they also can catalyze or exacerbate certain mental health problems (e.g., depres- sion). The differences in how profes- sional disciplines have perceived and addressed these complexities have contributed to the historical lack of treatment integration.

Regardless of the origin or order of problem development, however, the co-occurrence of AOD and mental health problems usually complicates the treatment process. In studies of treatment populations, psychiatric status has proven an important predic-

tor of the course of AOD problems; in fact, it is one of the more salient and well-replicated variables associated with treatment seeking and lack of improvement (Haller et al. 1993; Hesselbrock 1991; McLellan et al. 1993; Rounsaville et al. 1987, 1991). In longitudinal population studies, psychiatric problem severity predicts increases in alcohol consumption and adverse consequences of drinking over time (Schutte et al. 1994). In addition to having poorer outcomes, AOD patients with psychiatric problems are at heightened risk of readmission (Booth et al. 1991; Moos et al. 1994a,b; Ornstein and Cherepon 1985).

Prevalence of Co-Occurring AOD Problems and Medical Conditions Co-occurring AOD problems and general medical conditions have been less studied than co-occurring AOD and mental health problems. However, the literature suggests that people with AOD problems have a higher prevalence of health problems in general and of many specific conditions in particular, including HIV disease, infection with hepatitis B and C viruses, hypertension, asthma, chronic obstructive pulmonary disorder (COPD), arthritis, headache, acid- related disorders, and many pain conditions (Cargiulo 2007; Carlsson et al. 2005; Corrao et al. 2000; Mertens et al. 2003). The AOD field has begun to develop a framework for examining the specific AOD abuse–related medical conditions that could be targeted for integrated inter- ventions (Mertens et al. 2003). For example, COPD, depression, or hypertension patients could be targeted for alcohol screening (and brief treatment if appropriate) in primary- care or disease-management programs.

People with AOD disorders are at increased risk for many chronic medi- cal conditions (Dickey et al. 2002; Mannelli and Pae 2007). As with mental health problems, clear etio- logic relationships are not easy to establish. Thus, unhealthy alcohol use is implicated in the development of some conditions (e.g., cirrhosis),

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increased exposure to some diseases (e.g., HIV, hepatitis), or exacerbation of existing medical problems (e.g., diabetes). Conversely, alcohol use also may result from attempting to cope with overwhelming medical problems (e.g., chronic pain). In addition, it is clear that medical conditions and their sequelae frequently interfere with the alcohol treatment process (e.g., doctor’s appointments may conflict with treatment program schedules or pain conditions may make it impossible to attend treatment) and impede recovery. Similarly, unhealthy AOD use can thwart medical treatments. For example, patients’ AOD use may impede their ability to comply with treatment regimens. In addition, AOD use is contraindicated with many medications and can inhibit immune system functioning.

Integrating the Treatment of Co-Occurring AOD and Other Health Problems

Co-Occurring AOD and Mental Health Problems Although AOD treatment today occurs mainly in a separate system, it historically was located within the larger mental health treatment system. Until well into the 20th century, patients with alcohol problems—if they received treatment at all—received care from institutions and organizations charged with mental health care, such as asylums and sanatoria. (More often, alcohol problems were addressed within the criminal justice and, to a lesser extent, the social welfare systems.) The latter part of the 20th century saw the alcohol treatment field begin to separate from the mental health system in a variety of ways. Thus, programs were designed to specifically treat alcohol (and other drug) problems; the “disease model” of addictions and the attendant proliferation of the 12- step and self-help movements became more prominent, and research insti- tutions dedicated to the formal study of AOD use problems, such as the National Institute on Alcohol Abuse

and Alcoholism (NIAAA) and the National Institute of Drug Abuse (NIDA), were established. Many researchers and clinicians in the addictions field welcomed the separa- tion because of concern that AOD problems had been given short shrift under the mental health system. The two separate public systems of care became largely funded by the Federal Government via separate block grants, further reinforcing the separation of services. Unfortunately, however, the separation also created a system in which most programs and providers do not have the resources, training, or inclination to treat patients with CODs and instead reinforced differ- ences in provider attitudes toward specific disorders and in overall treat- ment philosophy. Regrettably, this often resulted in patients being referred to another agency for treatment of the other disorder before they were eligible to be seen for their presenting problem, or in ignoring the co-occurring problem entirely.

Differences between the mental health and AOD fields in clinician beliefs, training, behavior, and ideology pose significant barriers to the effec- tive treatment of COD patients. On the mental health side it often has been argued that AOD problems are symptoms of deeper psychological distress and that when those other disorders are properly treated, AOD problems will lessen or subside. This conceptualization reinforces a hierarchy in which AOD disorders and their treatment are seen as less legitimate and less deserving of attention and resources. At the same time, the AOD treatment field frequently is ideology driven, and its disagreements with the mental health field on appropriate diagnosis and treatment often have been contentious.

Although AOD treatment programs may vary in other ways, the great majority have been influenced by the Alcoholics Anonymous (AA) tradition, and the major treatment model cur- rently used in the United States, the “Minnesota Model” (IOM 1990; Kaskutas 1998; Room 1998), is based on the same 12-step principles.

Although AA and AA-influenced pro- grams have given much to the field (see below), they have had a pervasive unitary influence, resistant to com- peting treatment models (IOM 1990; NIAAA 1997), even in the case of CODs. These programs traditionally have emphasized more confrontational approaches than mental health pro- grams, which have emphasized more supportive techniques (or have simply not treated patients until they are “clean and sober”). Many AOD treat- ment providers themselves are in recovery and graduates of AA and AA-influenced programs and adhere to a philosophy of abstinence. These treatment providers often frown on medications such as methadone or naltrexone for their patients, whereas medications are commonplace in mental health programs for psychiatric problems. This has significantly slowed the adoption of pharmacotherapeutic interventions for COD patients in many AOD treatment settings.

Screening and referral practices also differ. Historically, mental health providers have not routinely assessed patients for AOD misuse, and, by the same token, AOD treatment providers have not systematically screened for mental health problems. The reasons are many and in some cases may simply signify lack of training. However, too often assessment and diagnosis of CODs are ignored or delayed because the provider conceptualizes either the AOD or the mental health problem as “primary” and needing to be addressed before dealing with any other problems. Conversely, some clinicians may not feel equipped to treat patients with complex CODs, and prefer to refer them out to another agency for treatment. Both practices contribute to COD patients receiving suboptimal treatment.

Mental health and AOD treatment also have differed in their use of self- help groups. Whereas AOD treatment has a long tradition of relying on self-help, particularly 12-step–oriented groups, as a key therapeutic ingredient, they are much less commonly used in the psychiatric setting (Timko et al. 2005). Although the literature is mixed

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on whether COD patients are more or less likely than others to participate in 12-step meetings (Bogenschutz 2007; Chi et al. 2006a; Jordan et al. 2002; Kelly et al. 2003), evidence increasingly shows that when they do participate, they benefit from 12-step participation as much or more than other patients (Chi et al. 2006a; Magura et al. 2008; Timko and Sempel 2004). In the past two decades, self-help groups that are rooted in traditional 12-step programs but have been adapted to meet the special needs of people with CODs have been growing in number, and evaluations point to positive direct and indirect effects on several key components of recovery for COD patients (Magura 2008).

Clearly, reaching a consensus on treatment strategies that work for COD patients remains a challenge. However, this may be an opportune time to experiment with new treatment approaches. AOD treatment providers who see patients with CODs are becoming more open to trying new interventions (e.g., medications) for AOD disorders, as evidence for the effectiveness of these interventions is accumulating rapidly.

Co-Occurring AOD Problems and Medical Conditions Historically, alcohol and general medical services have been even less integrated than AOD treatment and psychiatry. Except for medically supervised detoxification, medical and AOD treatment providers continue to operate separately, although recent evidence suggests that integration would con- tribute to better outcomes (Friedmann et al. 2003; Grazier et al. 2003; Mertens et al. 2008; Weisner et al. 2001), and provide opportunities to intervene with patients who might benefit from AOD treatment (Aertgeerts et al. 2001; Bethell et al. 2001; Friedman et al. 1990; Singer et al. 1987).

For a variety of reasons—including discomfort with or insufficient knowl- edge about AOD problems, inade- quate clinical tools, time constraints, ignorance of treatment resources, and issues of professional jurisdiction—

many primary-care providers rarely screen for or discuss AOD use with their patients (Friedmann et al. 2000b; Spandorfer et al. 1999). Moreover, general medical practitioners only treat a small proportion of their patients’ AOD use problems.1 Stigma and societal attitudes about addictions affect physicians as well as the general public. Accordingly, many treatment providers are uncomfortable about discussing AOD use with their patients, and few are trained in assessment and treatment. The proliferation of “carve-outs”—arrangements whereby health plans contract with managed behavioral health care companies to provide AOD and mental health care services rather than reimbursing the providers—has reduced financial incentives for providers to treat patients rather than referring them (IOM 2006). As a result of all these factors, general medical practitioners are not commonly considered the appropriate health care professional to handle treatment for AOD use problems.

The role of general medicine in AOD treatment may be changing, however, because of increased interest in moving identification and brief treatment for AOD problems into medical settings in general, and primary care in particular. Evidence supporting the effectiveness of such interventions (Babor et al. 2005; Bertholet et al. 2005; D’Onofrio and Degutis 2002; Kanouse et al. 1995) is growing; more- over, several factors have been identi- fied that can make such integrative practices more likely to succeed. These factors include the adoption of the drug and alcohol problem identification and treatment initiation measures set forth in the Healthcare Effectiveness Data and Information Set (HEDIS) of the National Committee for Quality Assurance (NCQA); the development of Current Procedural Technology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes that permit Medicare and Medicaid reimbursement for brief AOD treatments in medical settings; and NIAAA’s Assessing Alcohol Problems: A Guide for Clinicians and Researchers,

Second Edition (2003) with accompany- ing evidence-based screening questions.

The growing evidence supporting the efficacy and effectiveness of medi- cations for AOD problems also may encourage physicians to treat such problems, although studies suggest that pharmacotherapies for treatment of AOD disorders are adopted more slowly than for other medical condi- tions (Thomas et al. 2003). The extent of adoption of medications for AOD disorders also may be context related and depend on organizational policies and capacities (Fuller et al. 2005; Roman and Johnson 2002). For example, adoption of a new medication is more likely in settings where other AOD medications already are being prescribed (Knudsen et al. 2007); therefore, AOD medications are more likely to be adopted in AOD treat- ment programs than in primary care.

Barriers to Integrating Care for Patients with CODs

AOD, mental health, and general medicine providers differ widely in education and training. Providers in medicine generally are physicians or advanced-practice nurses and mental health clinicians who typically hold doctoral- or master’s-level degrees. In contrast, the education and training among addiction treatment providers is more varied, ranging from medical or doctoral degrees to non-degreed peer counselors.

Organizational factors also pose significant barriers to the integration of care for patients with CODs. According to Ridgely and colleagues (1990, p.126), “The system problems are at least as intractable as the chronic illnesses themselves.” Most research indicates that people with CODs do not readily fit into either medical or traditional AOD treatment or psychi- atry programs and that like patients with other chronic conditions they need ongoing services, possibly over

1 However, treatment may occur more often than reported, because physicians may code their patients’ alcohol disorders as somatic complaints for which they can be reimbursed.

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several years (Mercer et al. 1998). This need for long-term services also is related to the issue of financing mechanisms for chronic-care patients (Tessler and Goldman 1992). On the whole, financing mechanisms cur- rently are geared to acute rather than long-term treatment (Drake et al. 1996). Inclusion of reimbursement for long-term disease management of CODs might help lower hospitalization costs and improve outcomes. Related questions that should be addressed are whether treatment patterns and costs differ for different CODs and whether more coherent treatment policies could increase appropriate utilization of different treatment settings (i.e., primary care versus emergency departments versus inpatient care) and reduce costs.

Because of these complex organiza- tional constraints, patients often are forced to navigate separate systems of care (sometimes both public and private), contacting different agencies or departments within large organiza- tions (e.g., a health plan) and seeing multiple providers. Too often patients must coordinate their own care, even when appropriate linkages between providers and organizations are lacking. This can be especially challenging for patients experiencing cognitive and/or functional impairments related to their CODs, and, not surprisingly, many fail to follow through with one or more of their treatment regimens. Because of the stigma attached to co-occurring problems, many patients also experience considerable prejudice not only from society but from treat- ment providers, their own families, and even from themselves. Under these circumstances, it is difficult for patients to assume the role of proactive consumers, empowered to demand the highest quality, coordinated health care. As a result, many patients fall through the cracks in these fragmented systems of care, and treatment initia- tion, engagement and retention rates in this population are notoriously low (Chi et al. 2006b).

Models of Treatment for Patients With CODs

Many programs now recognize the downside of separate systems for COD patients and are attempting to add integrative elements into their curricula. Currently, treatment models for patients with AOD problems and CODs broadly fall into four categories:

• Serial treatment—care is received in sequential treatment episodes, in separate systems of care;

• Simultaneous/parallel—care is received for both/all disorders simultaneously, but in separate, noncoordinated systems;

• Coordinated/parallel—care for both/all disorders is received simul- taneously in separate but well- coordinated and closely linked systems, with established and formalized collaborative agreements; and

• Integrated care—care for both/all disorders is provided by the same cross-trained clinicians and in the same program, resulting in clinical integration of services.

Unfortunately, the evidence base for recommending one type or model of treatment over another is small. Controlled studies on integrated pro- grams and services have been few, and the methodological challenges many, including small sample sizes (Ley et al. 2000). Moreover, most studies have focused on treatment for co-occurring AOD and mental health disorders, focusing particularly on patients with severe mental illness (Cleary et al. 2008; Drake et al. 2004; Dumaine 2003). A recent review of randomized clinical trials of psychosocial inter- ventions to reduce AOD problems of severely mentally ill patients found no compelling evidence to recom- mend one type or model of treatment delivery over another (Cleary et al. 2008), partly because none of the models have been studied extensively (Cochrane 1999; Donald et al. 2005; Ley et al. 2008). The review by Ley

and colleagues (2000) did not detect strong effects of different treatments on AOD outcomes. Only a few studies (Friedmann et al. 2003; Weisner et al. 2001) have examined the integration of medical care and AOD treatment.

Nevertheless, recent research has provided some evidence that integrat- ed treatment may improve posttreat- ment outcomes (Drake et al. 2008; Godley et al. 1994; Meisler et al. 1997) or produce favorable outcomes compared with other types of services (Blankertz and Cnaan 1994; Drake et al. 1997; Herman et al. 2000) (also see the textbox). One study of AOD treatment patients with CODs (Grella and Stein 2006) found that patients in programs with more services for CODs (e.g., more “dual diagnosis” groups, higher percentages of clinicians with training or certification in COD treatment, or a higher number of psychological services) more frequently used psychological services and had better psychological and AOD use outcomes at 6 months. Another study (Craig et al. 2008) examined the impact on patient outcomes of training psychiatric clinicians in the treatment of CODs, including comprehensive assessment, motivational interviewing, and relapse prevention techniques. These investigators found that patients assigned to COD-trained clinicians had significantly better mental health outcomes at 18 months than did those who received usual mental health services. Other study findings have suggested that treatment components which increase integration of services for CODs may be beneficial. However, because many of these studies were of small samples, with most patients uninsured (often homeless) or on Medicaid, more research is needed “to compare outcome for non-homeless clinical patients in well-defined and monitored examples of integrated treatment and parallel treatment” (RachBeisel et al. 1999, p.1432).

Fully Integrated Treatment: Is That the Goal? In response to the growing evidence base for integrated care, one could

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argue that, ideally, all AOD treatment and mental health and medical pro- grams should be fully clinically integrated—that is, all services should be provided simultaneously within the same organizations, by the same providers—and capable of treating patients with CODs. However, complete clinical integration does not seem feasible for most programs in the short term, if only for logistical reasons, particularly with regard to integrating medical care and AOD treatment. A recent survey estimates that only half of AOD programs nationwide offer dual AOD and mental health treatment (Mojtabai 2004), and even fewer offer integrated medical services. There is no evidence

in the literature that mental health programs are more likely to coordinate services for patients with CODs. In fact, a survey of AOD and psychiatric treatment programs found that AOD programs were more likely to provide services for CODs than were psychiatric programs (Timko et al. 2005). Another strategy would be to incorporate specialty AOD and mental health services into general medical settings such as primary care. This approach could potentially reach far more patients in less stigmatized health care settings.

Another question is whether com- plete integration would even be desirable. For example, Minkoff (1997) suggested that full integration within programs actually might threaten choice, flexi-

bility, and quality of treatment. Because COD patients are highly heteroge- neous in their specific diagnoses and acuity, it is conceivable that integration and coordination of care across pro- grams might be preferable to within- program clinical integration. History suggests that in fully integrated pro- grams, patients with AOD and severe co-occurring mental health disorders are likely to receive the most attention, whereas patients with single disorders or with sub-diagnostic comorbidities are more likely to be excluded from treatment or their co-occurring prob- lems not identified (IOM 2006).

Although the evidence does not point to a single optimal level of integration, accrediting bodies, purchasers, and Federal and State agencies can greatly facilitate integration of services by implementing certain overarching strategies, identified by the IOM Committee (see the table). The IOM (2006) report endorses a conceptual model that was developed by Friedmann and colleagues (2000a) (see the figure) to illustrate the spectrum of care inte- gration. In this model, according to Friedmann and colleagues (2000a, p. 445), mechanisms for coordinating services range from “the ad hoc, market- based purchase of services from local providers to the complete control and coordination of a fully integrated, centralized service delivery system.” It seems entirely plausible that more extensive and formalized integrative mechanisms would improve the quality of care for patients with CODs and would offer the best chance of improv- ing their outcomes. It is worth noting however, that this model emerged from an examination of how service coordination affected service utiliza- tion of drug treatment patients; it did not specifically address services for CODs, and did not examine patient outcomes beyond utilization. Thus, much more research needs to be con- ducted comparing the organization of care for CODs.

The flow of confidential information poses a complex barrier to implement- ing integrated care for patients with CODs. Patient health information is carefully (and rightly) protected, and

Impact of Integrated Care on Outcomes of Patients With Co-Occurring Disorders

The findings of several Drug and Alcohol Research Team (DART) studies support prior research and clinical consensus that integrated care can improve outcomes for patients with co-occurring disorders (CODs):

• Alcohol and other drug (AOD) treatment patients with AOD abuse–related medical or psychiatric conditions who received integrated medical care and AOD treatment were more likely to be abstinent at 6 months than those who received usual independent medical care (69 percent vs. 55 percent; P < 0.006). The odds of total abstinence for the COD patients receiving integrated services was larger for the integrated than the independent treatment groups (odds ratio 1.90; P < 0.005) (Weisner et al. 2001). Receiving this integrated care during treatment continued to be related to remission for those with co-occurring conditions 5 years later (Mertens et al. 2008).

• Patients with co-occurring AOD and mental health conditions who received more hours of psychiatric services contemporaneously with their AOD treatment were more likely to report abstinence at 1 year (χ2 = 4.79, 1 df, P < 0.05). For those who had less than 2 months of concurrent COD and psychiatric services, the odds of being abstinent at 1 year were less than one-fourth of those with 2 and more months of services (χ2 = 7.94, 2 df, P < 0.05) (Chi et al. 2006a).

• Adolescent AOD treatment patients with co-occurring mental health disorders who received psychiatric services were more likely to be abstinent at 6 months than those who did not. Those who attended treatment in AOD programs that were colocated with mental health clinics had higher odds of abstinence from both alcohol and drugs (odds ratio 1.57 [95% confidence interval: 1.03–2.39]), drugs (1.84 [1.87–2.85]), and of returning after intake to initiate COD treatment than others (2.28 [1.44–3.61]; P < 0.001) (Sterling and Weisner 2005).

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information about the treatment of AOD problems is particularly well- guarded by Federal and State regula- tions and organizational policies, such as 42 CFR, part 2 (Electronic Code of Federal Regulations (e-CFR) 2009). Although preventing sensitive and potentially damaging patient information from falling into the wrong hands is essential, these regula- tions, originally designed to protect drug-treatment patients from legal prosecution, have had the unintended consequence of inhibiting the coordi- nation of health care across agencies and departments. The stringent requirements for obtaining consent to release information (especially challenging for some patients with CODs) may inhibit coordination of care, enhanced referral, consultation, and follow-up. For example, integra- tion of care may be compromised if a provider in one program cannot determine if a patient has followed through with a referral, or if a patient has a health condition that is related to, could be exacerbated by, or requires medication which is contraindicated with AOD use. Moreover, these regu- lations and practices can serve to reinforce the stigma associated with AOD and mental health problems.

The IOM recommends that sharing of information between providers treating the same patient become more routine. Clinicians should discuss with each patient the importance of sharing diagnoses, medications, and other therapies between providers treating CODs to enable collabora- tive care between clinicians. The report acknowledges that information on mental health and AOD condi- tions is sensitive and that sharing this information often is governed by Federal and State laws and individual organization practices. The report therefore calls on State and Federal entities and organizations implementing additional information policies to re-examine their policies and practices on information sharing to ensure that they are not inappropriately interfering with coordinating care (IOM 2006). The rapid development of health information technology (IT) and the

Table Institute of Medicine (IOM) Recommendations for Implementing Quality Integrated Care for Individuals With Co-Occurring Disorders (CODs).

• Coordination of care and integrated treatment by leadership and all key stakeholders. Development of a shared vision among systems of care (Minkoff 1991, 1997, 2001; Mueser et al. 2003).

• A “no wrong door” policy. Wherever individuals enter a service system, they will find access to care, including “anticipation of comorbidity and formal determination of intent to treat or refer.”

• Clear and agreed-upon definitions of coordination of care, formally documented between providers and in purchaser agreements. This will help ensure coordination and accountability for outcomes.

• Assertive outreach and patient engagement and retention activities, key to improving outcomes for COD patients.

• Development and adoption of standardized performance indicators across organizations and systems.

• Comprehensive assessment practices across systems of care (e.g., alcohol and other drug treatment programs, mental health departments, primary care, chronic-disease programs, and emergency departments). The IOM specifically recommends (1) screening for alcohol misuse by all adults, including pregnant women (U.S. Preventive Services Task Force); (2) screening for a co-occurring mental or substance-use problem at initial presentation with either condition; and (3) screening of entrants into child welfare and juvenile justice systems, because of the high prevalence of CODs among children (IOM 2006). Assessments on-site when possible, by referral when necessary.

• Interdisciplinary training of staff, to enhance clinical capacity and fluency with diagnostic and treatment placement criteria, and therapeutic techniques, regardless of type of program.

• Comprehensive services across programs and across disorders (e.g., individual and group therapy, family therapy, vocational counseling, assistance with housing and income programs, case managements, etc.).

• All types of disorders treated as “primary.” No program, patient, type of disorder, or approach to treatment is considered more important than others.

• Motivational enhancement activities, which studies show are among the most effective components of care (Cleary et al. 2008).

• Availability of long-term services and continuity of care across programs and time. Patients may benefit from a disease management/chronic care rather than an episodic treatment approach.

• “Reduction of negative consequences” or harm-reduction philosophy (Mueser et al. 2003). Improvement in mental health symptoms and functioning should be emphasized as important interim goals.

• Compatible administrative infrastructures, including information technology systems and instruments, electronic medical records, and assessment tools.

• Sharing of patient information, including patient records when possible, and encouragement of patients to consent to releasing information. Programs should require clear guidelines and safeguards around the use, disclosure, and protection of confidential health information.

• Flexible funding across systems to reduce barriers posed by distinct financing mechanisms.

• Colocation of services and clinicians whenever possible (Friedmann et al. 2000a; Hellerstein et al. 1995; Sterling and Weisner 2005).

• Clinical integration of services whenever possible (i.e., dual services provided by the same clinicians, or clinicians in the same programs).

• Program and organizational linkages with other systems involved with the patient (e.g., criminal justice and welfare systems, schools, and employee assistance programs).

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Joint Program

Onsite program/outstanding across agencies

Case management/transportation

Referral agreement

Ad hoc arrangements between individual providers in different systems

Figure Continuum of care coordination for patients with alcohol and other drug use disorders and co-occurring disorders ranging from mild severity (bottom) to high severity (top).

SOURCE: Friedmann et al. 2000a.

growing adoption of electronic medi- cal records further complicate these issues. Integrated health IT systems could potentially contribute significantly to the integration of care for patients with CODs and improve the quality of care, and the field must carefully weigh these potential benefits against privacy concerns. Several leading pol- icy groups are considering this issue, which was included as one of the key strategic areas at the “National Summit on Defining a Strategy for Behavioral Health Information Management and Its Role Within the Nationwide Health Information Infrastructure,” convened in 2005 by the Substance Abuse and Mental Health Services Administration (SAMHSA). The summit concluded that “Legal issues should be clarified and in some cases changed to facilitate appropriate information sharing across service systems for care coordination and service improvement” (Substance Abuse and Mental Health Services Administration and Software and Technology Vendors’ Association 2005, p. 2).

Discussion

Many factors have converged to focus attention on the nature and quality of health care for people with CODs, not

least of which is the realization that, whatever the causes, these patients have not been served well by the traditional treatment system(s). As a result, there seems to be a greater openness to considering new models of care for these patients. For example, in 2009 NIAAA, NIDA, and the National Institute on Mental Health (NIMH) came together at a conference entitled “Integrating Services, Integrating Research for Co-Occurring Conditions: A Need for New Views and Action” to begin to focus on a new agenda for collaborative research on CODs. Other developments, such as the adoption of HEDIS performance measures dis- cussed above and the enactment of national mental health and addiction treatment parity legislation, surely will have an impact on the integration of services for CODs. Furthermore, the rapid evolution of health IT systems will undoubtedly shape the way patient information is shared between programs and providers and has the potential to increase collaboration significantly if concerns about patient privacy are adequately addressed. All of these environmental developments merit close observation and study as they evolve.

Clearly, changes in the health care system and in models of service delivery also will affect the way care is orga-

nized for all patients, not only those with CODs. Advocates of a model called patient-centered medical home (PCMH)2 have called for including behavioral health services in a fully integrated model for delivering primary care, AOD, and mental health services (Arvantes 2008; Croghan and Brown 2010), consistent with the current health care reform discussions that stress less fragmentation in service delivery (Rittenhouse and Shortell 2009). A broad coalition of health care stake- holders, including 17 specialty soci- eties (e.g., the American College of Physicians, the American Academy of Pediatrics, and the American Academy of Family Physicians), have endorsed the model, and it currently is being tested through demonstration pilot projects in some major public and private health plans (Berenson et al. 2008; Rittenhouse and Shortell 2009). A full understanding of this model and its strengths and limitations is still evolving (Berenson et al. 2008; Sidorov 2008), but it likely would increase coordination and quality of care for patients with CODs.

As previously noted, integrated treatment for CODs has not been studied extensively, and the field needs to compare different interventions and combinations of interventions, preferably in carefully controlled trials. Because of the sparse research, it is especially important to study models of care integrating medical and AOD treatment (such as the PCMH men- tioned above), whether in medical settings or in AOD programs. Because most research and program develop- ment have focused on patients with co-occurring severe AOD disorders and severe mental illness, it also is necessary to examine the effects of integrated treatment interventions and models on patients with lower- severity CODs, including those who may not meet diagnostic criteria for specific disorders (e.g., DSM diagnoses for depression, anxiety, AOD abuse

2 The PCMH is a model of a primary care organization that delivers the core functions of primary health care in a manner that is patient-centered, comprehensive, coordinated, allows better access, and emphasizes quality and safety improvement) (Agency for Healthcare Research and Quality 2010).

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or dependence) but whose co-occurring problems impede their chances for positive outcomes. These patients comprise a much larger group than those with severe CODs but may be underserved in programs where patients with more severe conditions receive more clinical or program attention. Thus, policymakers and program planners seeking to improve health care systems for COD patients must take care to not “integrate” programs to an extent that non-COD patients, especially those with AOD problems, effectively are excluded from treatment because they do not meet diagnostic criteria. Models of services delivery such as the “quadrant model” of care, which has been endorsed by the National Association of State Alcohol and Drug Abuse Directors, should be considered and incorporated. This model, which emphasizes a continuum of chemical dependency and mental health services based on the combined severity of co-occurring AOD and mental health problems, explicitly includes lower-severity patients whose treatment might take place in any of the three treatment contexts (i.e., AOD, mental health, or medical settings) (IOM 2006).

Beyond studying specific interven- tions, however, it is necessary to eval- uate programs’ and systems’ overall COD competency. Researchers and policymakers have argued that broader best practices need to be developed that “apply to the entire system of care and that require integrated system planning involving both MH and SA treatment agencies,” and that “… a focus on best practices at the program level is being replaced by a focus on the system level.”(Minkoff 2001, p. 597) This systems-level research should include studies of the develop- ment, refinement, and dissemination of measures of organizational COD capacity (McGovern et al. 2007).

Advocates for change have influ- enced providers and policymakers who serve patients with CODs. It now is generally acknowledged that these patients have had to navigate fragmented systems and that they have received treatment that is less

accessible and less effective than the health care system has the potential to deliver. After years of underestimating the presence of CODs, providers and policymakers now recognize that these conditions are highly prevalent and that, in fact, the majority of patients with AOD problems most likely have a COD. Research on the effectiveness of interventions and models of care for treating CODs has substantially grown in recent years and now is a major focus of the leading research institutes. This is an exciting time for the field. Although the challenges of providing (and studying) integrated services for patients with CODs remain, health care stake holders are accumu- lating the research and building the organizational models to support substantial advances in providing more easily accessible treatment with the potential to greatly improve out- comes for patients with CODs. �

Acknowledgments

This research is supported by NIAAA grants R37AA10359 and RO1AA10359, NIDA grant R01DA15803, and the Robert Wood Johnson Foundation (grant 048784).

Financial Disclosure

The authors declare that they have no competing financial interests.

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