WHAT CAN I EXPECT?: DUAL SUBSTANCE USE AND MENTAL HEALTH TREATMENT FOR MILITARY POPULATIONS

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1 WHAT CAN I EXPECT?: DUAL SUBSTANCE USE AND MENTAL HEALTH TREATMENT FOR MILITARY POPULATIONS René Lento, PhD Lauren Brenner, PhD September 25, 2018

2 DISCLOSURES None

3 HOME BASE PROGRAM 3

4 LEARNING OBJECTIVES 1. To identify the underlying factors that contribute to substance use disorders in a military population 2. To understand the array of treatment options available/recommended for dual-diagnosis patients 3. To be familiar with local and online resources for Service Members/Veterans and their families

5 PREVALENCE In a 2015 national survey, 21 million people or 8% US population met criteria for a substance use disorder (SUD) 1 National trends indicate similar or lower prevalence of SUD in Veterans compared to civilians across all age ranges 2,3 However Higher rates for male Veterans ages compared to civilian peers 2,3 > 40% of US Veterans have a life-time history of alcohol use disorder 4 Elevated risk among Veterans with non-routine discharge(e.g., misconduct) 5 Increased prescribing of opioids and sedative-hypnotics and abuse of prescription opioids among Veterans with PTSD 6 1 CBHSQ, 2016; 2 Hoggatt et al., 2017; 3 Pemberton et al., 2016; 4 Fuehrlein et al., 2016; 5 Brignone et al., 2017; 6 Teeters et al., 2017

6 SUBSTANCE USE DISORDERS (SUD) Not all use constitutes a substance use disorder DSM-5 requires 2 or more of the following: Physical Dependence Tolerance Withdrawal Use-Related Behavior Use larger amounts or longer than intended Repeated attempts to quit or reduce use Much time spent using or recovering from use Use in hazardous situations Cravings Impaired Functioning Neglect major roles in order to use Social, interpersonal problems related to use Give up important activities in order to use Use despite knowing that it causes/worsens physical or psychological conditions

7 IS USE A DISEASE OR A CHOICE? Sources: NIDA brochure: Drugs, brain, and behavior, the science of addiction (2014); PNAS 101: (2

8 THE RECOVERY PROCESS Sources: NIDA brochure: Drugs, brain, and behavior, the science of addiction (2014); J Neurosci 21: (

9 WHY USE? COMMON FUNCTIONS Automatic pilot (people, places, things, emotions) Withdrawal symptoms Boredom or Loneliness Fun/Celebrate Socialize Anxiety/Hypervigilance (in crowds, social events, etc.) Intrusive memories Nightmares Sleep or Numbness Emotional & physical pain

10 DUAL-DIAGNOSIS PTSD/ SUD Anxiety/ Depression

11 DUAL-DIAGNOSIS TREATMENT 1. Treat mental health conditions that can contribute to substance use 2. Prevent substance use from interfering with successful treatment of other diagnoses Image Source: Therapist Aid LLC

12 IMPLICATIONS FOR DUAL TREATMENT Address environmental & behavioral reinforcers i.e. get needs met and make life more rewarding without substances Treat underlying mental health conditions Consider neuro-biological aspects

13 MATCHING PATIENT TO LEVEL-OF-CARE Higher LOC Inpatient Detox + Hospitalization Intensity of Level of Clinical Care Intensive Outpatient Program (IOP); Partial Hospitalization Case Management Residential Program Individual, Group, Medication Outpatient Care Lower LOC Community & Recreational Groups, Self-help Lower Risk Patient s Stratified Risk/SUD Severity Higher Risk

14 COMMUNITY & REC GROUPS; SELF-HELP Increase self-understanding (e.g., reasons for use, patterns of use) Meet needs for socializing, connection, validation, fun/pleasure, accountability Practice safe coping skills AA, NA, MA, CA SMART Recovery Fitness, Exercise Groups Volunteering VetChange.org

15 CASE MANAGEMENT Address the barriers that are keeping substance use viable or are posing barriers to recovery Finances, Employment Issues Legal Issues Unsafe Housing, Homelessness Custody Issues Lack of Transportation Lack of Insurance

16 OUTPATIENT CARE: PTSD-SUD OPTIONS Motivational Interviewing (MI) Mindfulness Based Relapse Prevention (MBRP) Cognitive Behavioral Therapy (CBT) for SUD Prolonged Exposure for PTSD (PE) Cognitive Processing Therapy for PTSD (CPT) CBT for Insomnia (CBT-I) CBT for SUD + PE for PTSD (COPE) Seeking Safety

17 OUTPATIENT CARE: TRANS-DIAGNOSTIC Dialectical Behavior Therapy Skills (DBT) Acceptance & Commitment Therapy (ACT)

18 OUTPATIENT CARE - MEDICATION Opioid Use Disorder Methadone Alcohol Use Disorder Disulfiram (Antabuse) Buprenophine (Suboxone, Subutex, Zubsolv) Naltrexone PO = taken orally, daily IM = 28-day muscular injection (Vivitrol) Narcan to reverse opioid OD Acamprosate Naltrexone

19 HIGHER LEVEL-OF-CARE (HLOC) Intensive Outpatient Program (IOP) Minimum 9hrs treatment/week, usually delivered in 3hr sessions (~3-6 weeks) Partial Hospitalization & Residential Programs (~30-90 days) Detox & Hospitalization Alcohol, Benzodiazepines Opioids Hallucinogens (spice, PCP) more likely for intoxication vs. withdrawal

20 FAMILY INVOLVEMENT Support & Information Coaching into Care Repairing the System Psychoeducation Al-Anon, Alateen, Support Groups Community Reinforcement Approach and Family Treatment (CRAFT) Couples therapy

21 GENERAL FACTORS TO ASSESS Readiness to engage in care Motivational Interviewing at any stage Precontemplation Contemplations Preparation Action Maintenance Safety Children in the home Access to firearms Violence towards self Violence against others

22 APPROACH TO TREATMENT GOALS Abstinence-based No use whatsoever Treatment first Often the goal after initial harm reduction approach and Motivational Enhancement Some programs moving to allow use of medications for addiction such as suboxone Harm Reduction Decrease problems associated with use, reduce risk and negative consequences in using Medication options encouraged Needle exchange programs Alternate substances or forms of using NOT about condoning risky behavior

23 RESOURCES

24 HOME BASE: HOW TO CONTACT For more information about our clinic: To make an appointment: Call our Front Desk at For questions about clinical cases or referrals Lauren Brenner, René Lento,

25 Their Mission Is Complete. Ours Has Just Begun.