cod-workshop

Integrating Dual Diagnosis Treatment: Achieving Positive Public Safety and Public Health Outcomes for Offenders with CoOccurring Disorders

Fred Osher, M.D. Director, Health Systems and Services Policy

Introduction to Discussion }

High prevalence of Co-occurring Disorders (COD) in criminal justice system } } } } }

High rates of co-occurring dx in MI and SA populations Poor outcomes associated with COD Increased criminal activity associated with addiction and poverty (i.e. crimes of survival amongst homeless persons) Increased arrests associated with COD Poor services upon re-entry

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History of non-integrated responses to COD

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Increased interest in “integrated treatment” as an EBP

Case Example: Steve } } } } }

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28 years old Bipolar Disorder Crack Abuse/Heroin Dependence Felony charge/ on parole Hepatitis C with elevated liver function tests Unemployed Living in shelter

PARALLELS: Mental Illnesses and Addictions ALCOHOLISM/ADDICTION

(Minkoff)

MAJOR MENTAL ILLNESS

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A biological illness.

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A biological illness.

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Hereditary (in part).

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Hereditary (in part).

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Chronicity

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Chronicity

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Incurability

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Incurability

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Leads to lack of control of behavior and emotions

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Leads to lack of control of behavior and emotions

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Affects the whole family

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Affects the whole family

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Symptoms can be controlled with proper treatment

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Symptoms can be controlled with proper treatment

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Progression of the disease without treatment

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Progression of the disease without treatment

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Disease of denial

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Disease of denial

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Facing the disease can to lead to depression and despair.

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Facing the disease can to lead to depression and despair.

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Disease is often seen as a “moral issue,” due to personal weakness rather than biological causes

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Disease is often seen as a “moral issue,” due to personal weakness rather than biological causes

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Feelings of guilt and failure

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Feelings of guilt and failure

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Feelings of shame and stigma

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Feelings of shame and stigma

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Physical, mental, and spiritual disease

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Physical, mental, and spiritual disease

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Definition: Co-occurring Disorders }

The term refers to co-occurring substance use (abuse or dependence) and mental disorders.

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Clients said to have co-occurring disorders when at least one disorder of each type can be established independently of the other and is not simply a cluster of symptoms resulting from a single disorder.

COCE, 2007 Council of State Governments Justice Center

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Consequences of Co-occurring Disorders Increased vulnerability to relapse and rehospitalization } Housing instability and homelessness } Noncompliance with medications and treatment } Inability to manage finances } Increased vulnerability physical illnesses - HIV infection and hepatitis } Higher service utilization and costs } Increased vulnerability to incarceration }

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% of respondents

Prevalence of Co-Occurring Disorders ECA Study 100 90 80 70 60 50 40 30 20 10 0

Schizophrenia General Population

Alcohol Use Disorder

Drug Use Disorder Alcohol or Drug Use Disorder Regier et al., JAMA, 1990 Council of State Governments Justice Center

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Co-occurring Mental and Addictive Disorders Nonaddictive Psychiatric Disorders

B

A C

Substance Use Disorders

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Heterogeneity of the Population with Co-occurring Disorders High severity Alcohol and other drug abuse

III

Low severity

IV

Substance abuse system

State hospitals, Jails/prisons, Emergency Rooms, etc.

I

II

Primary health Care settings

Mental health system High severity

Mental Illness Council of State Governments Justice Center

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Hypothesis for Justice Involved Persons with COD

Interventions (at the program or provider level) that reduce substance use (licit and illicit) and improve levels of functioning in persons with COD will reduce both their frequency of involvement with the justice system and their time spent in justice settings or under correctional supervision.

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Principles …..

Integrated treatment 2. Individualized treatment planning 3. Assertiveness 4. Close monitoring 5. Longitudinal perspective/Stages of Change 6. Harm Reduction Strategies 7. Employ Evidence Based Practices 8. Stable living situation 9. Cultural competency and consumer centeredness 10. Optimism 1.

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1. Integrated treatment Traditional models of treatment for homeless persons with dual disorders results in poor outcomes } Integrated treatment associated with better outcomes } Supported by integrated systems of care } Need to bring in housing, health, and other service arenas } Integrated Dual Disorders Treatment to be discussed as an evidence based practice }

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Integrated treatment (cont.) }

Traditional models of treatment for dual disorders results in poor outcomes } } } }

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no treatment -- high utilization of E.R., jails, hospitals sequential treatment parallel treatment -- burden of integration on individual Fragmentation

Integrated treatment associated with better outcomes in SMI and non-SMI

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Integration at three levels

(COCE, 2005)

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System Integration - The process by which individual systems or collaborating systems organize themselves to implement services integration to clients with COD and their families.

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Services integration The participation of providers trained in both substance abuse and mental health services to develop a single treatment plan addressing both sets of conditions and the continuing formal interaction and cooperation of these providers in the ongoing reassessment and treatment of the client.

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Integrated interventions are specific treatment strategies or techniques in which interventions for all COD diagnoses or symptoms are combined in a single contact or series of contacts over time.

Research Limitations }

Lack of specificity of the intervention

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Lack of generalizability } }

From severity and types of disorders and types of offenses studied From non justice-involved-COD samples } }

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Justice involved singly dx samples Non-justice involved COD sample

Lack of research ------- period.

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Research on Integrated Programs: EBPs for Justice Involved Persons with COD }

Modified Therapeutic Communities

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Integrated Dual Disorders Treatment

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Assertive Community Treatment } } }

ACT FACT FICM

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Fidelity to Dual Diagnosis Principles (McHugo et al, 1999) Percent of Participants in Stable Remission for High-fidelity ACT Programs (E:n=61) vs. Low-fidelity ACT Programs (G: n=26)

50 40 30 20 10

Assessment Point

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36

m

o.

30

m

o.

24

m

o. m 18

12

m

o.

6

m

e in el as

o.

0

B

Percent in Remission

60

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Past Year Mental Health Care and Treatment for Adults Aged 18 or Older with Both Serious Mental Illness and a Substance Use Disorder (NSDUH, 2008)

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2. Individualized treatment planning Treatment planning is derived from a comprehensive assessment } Accurate assessment is difficult to do: }

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poor clinician assessment skills lack of standardized instruments inaccuracy of self-report

Use of several approaches concurrently Assess for SA, MH, and Criminogenic Risk Longitudinal nature of assessments

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3. Assertiveness Responsibility of systems to support outreach and engagement services } Successful interventions: }

} }

“go wherever the client is” work with family, landlords and employers

Assertive Community Treatment (ACT) to be discussed as an evidence based practice } Inherent in integrated supervision and treatment models }

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4. Close monitoring }

Intensive supervision needed until stable

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Sometimes coercive, always persuasive } } }

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representative payeeship mandatory substance abuse treatment urine testing

Often used as an extension of court sanctions and conditions of release Council of State Governments Justice Center

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5. Longitudinal perspective }

Mental health, substance use disorders, and disease are chronic, relapsing conditions

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Treatment occurs continuously over years

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Period of supervision is a discrete period within the recovery process

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Handoffs between providers over time is critical to ensure continuity Council of State Governments Justice Center

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5. Stages of change }

Engagement - connecting people to treatment

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Persuasion - convincing engaged clients to accept treatment

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Active treatment - range of behavioral, psychoeducational and medical interventions

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Relapse prevention - prevention and management of relapses Council of State Governments Justice Center

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Course of Attaining Stable Remission Graphics are QuickTim needed decom e™to ansee dpressor a this picture.

10 0 90 80 Recovered 70 Relap se Prevention

Percent

60

La te Active Treatment

50

Early Active Treatme nt

40

La te Persuasion

30

Early Persuasion

20

Eng agement

10

Pre-enga gement

0 0 mo.

6 mo. 12 mo. 18 mo. 24 mo. 30 mo. 36 mo.

Assessment Po int

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6. Harm reduction strategies Continuum from abstinenceproblematic use abuse/dependence } Reducing quantity/frequency of use decreases likelihood of negative consequences } Provide alternatives to traditional abstinence only philosophies } More likely to engage those who don’t yet have treatment and/or abstinence as goals } Controversial in treatment and criminal justice communities }

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7. Employ Evidence-Based Practices Evidence-Based Practices are: “the integration of the best research evidence with clinical expertise and patient values.�

Institute of Medicine, 2000

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Pyramid of Research Evidence (COCE, 2005) 8 7 6 5 4 3

Expert Panel Review of Res earc h Evidence Meta-Anal ytic Studies

ns Clinic al Trial Replic atio ns io at ul With Different Pop Literature Reviews Analyz ing S tudies

linical Trial Single S tudy /Controlled C ental S tudies Multiple Quasi-­‐ Experim ing le Group Des ign Larg e S cale, Multi-­‐S ite, S

Quas i-­‐Experimental

2 1

Sing le Group Pre/Pos t Pilot S tudies

Case S tudies

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The Bottom Line on EBPs EBP Integrated Tx ACT Supported Emp. Illness Mgmt.

Trauma Int./ Inf Cognitive Tx Medications

Data for J I ++++ +++ +

Impact ++++ +++ +++

+ ++

++ +++

+++++ +++++

++++ +++++

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8. Stable living situation }

Not having a home makes assessment difficult and protracted

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Range of safe, affordable housing options are necessary } }

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safe havens or low demand residences for engagement and persuasion alcohol and drug free housing during active treatment and relapse prevention

Separate assessment and treatment from housing Council of State Governments Justice Center

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9. Cultural competency and consumer centeredness }

Seek to understand - don’t assume a shared set of values or impose one’s own

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Respect cultural differences

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Value the consumer’s point of view

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10. Optimism }

Critical ingredient for recovery

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Hope as an antidote to despair

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Peer supervision and training needed to bolster staff optimism

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Discussion What is the availability of integrated treatment within your jurisdiction? } What funds are used to access these services? } How are people prioritized for these services? }

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Are different strategies used for members of different quadrants? Different risk levels?

How is information shared between behavioral health and } } }

Law enforcement?

Courts?

Corrections?

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Thank you

Fred Osher, M.D. Director Health Systems and Service Policy Council of State Governments Justice Center fosher@csg.org

www.consensusproject.org

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