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1 Page: 1 of 6 Policy It is the policy of Bay-Arenac Behavioral Health Authority (BABHA) to publish prescriber practice guidelines for the treatment of persons with co-occurring mental health and substance abuse disorders. Purpose This policy and procedure was developed to educate psychiatric providers including psychiatrists, physician assistants, nurse practitioners and nurses about agency endorsed prescriber practice guidelines concerning the treatment of persons with co-occurring mental health and substance use disorders. Education Applies to All BABHA Staff Selected BABHA Staff, as follows: Psychiatrists and Agency Nurses - Clinical All Contracted Providers: Policy Only Policy and Procedure Selected Contracted Providers, as follows: Psychiatrists, Physician Assistants, Nurse Practitioners, and Clinical Nurses Policy Only Policy and Procedure Other:

2 Page: 2 of 6 Definitions Co-morbid Conditions: Refers to the existence of two or more diseases or conditions in the same individual at the same time. It may be the case that one of the conditions or disorders may have started before the other. Contingent Learning: The circumstances which operate to maintain a behavior, whether desirable or undesirable. Dual Diagnosis Capable: Programs that address co-occurring mental and substance-related disorders in their policies and procedures, assessment, treatment planning, program content and discharge planning. Co-occurring Disorders: One or more disorders are present related to the use of alcohol and/or other drugs of abuse as well as one or more mental disorders. Dual Diagnosis Enhanced: Programs that provide unified substance abuse and mental health treatment to persons who are, compared to those treatable in Dual Diagnosed Capable programs, more symptomatic and/or functionally impaired as a result of their co-occurring disorder. Dual Diagnosis: An individual has two separate but very interrelated diagnoses: 1) a psychiatric diagnosis and 2) a substance abuse diagnosis which may include both drugs and alcohol. Harm Reduction: A set of practical strategies, such as motivational interviewing, that reduce negative consequences of alcohol and/or drug use, incorporating a spectrum of strategies from safer use, to managed use to abstinence. Physician to Physician Consultation: Peers, such as psychiatrists, share supportive and critical feedback on persons with challenging issues.

3 Page: 3 of 6 Procedures 1. Background: BABHA has adopted the principles and practices of the Comprehensive Continuous Integrated System of Care (CCISC) (Minkoff & Cline, 2004) as a set of guidelines for our prescribers to practice when treating persons with a co-occurring disorder. CCISC is a model for system design which permits any system to address the problem of Cooccurring Disorders in an organized manner within the context of existing resources. The basic premise of this model is that all programs become dual diagnosis programs meeting minimal standards of Dual Diagnosis Capability, and all clinicians (including psychopharmacology prescribers) become dual diagnosis clinicians meeting minimal standards of dual diagnosis competency. The most recent version of the comprehensive CCISC practice guidelines were developed by Kenneth Minkoff, MD in 2001, based on work of a consensus panel that led to a SAMHSA report in 1998 entitled: Individuals with Co-occurring Disorders in Managed Care Systems: Standards of Care, Practice Guidelines, Workforce Competencies, and Training Curricula (Minkoff, 1998). The 2001 updated version of the practice guideline section of the report is being utilized by the Behavioral Health Recovery Management Project in the State of Illinois, and is available on line at The attached document is an update of the psychopharmacology section of that document with revisions specific to BABHA. The need for this document is based on the recognition that although there are psychopharmacology guidelines that have been developed for the treatment of individuals with a variety of mental illnesses OR substance disorders, most practitioners have neither training, or experience, in an organized approach to the individuals who have various combinations of mental health AND substance conditions who commonly present in clinical practice, particularly in public sector settings. Defined steps or methods, prescribed by management, for the proper and consistent use of forms, sequences, and channels to be followed by individuals and by units of the organization are to facilitate the implementation of agency policies.

4 Page: 4 of 6 2. Practitioner Responsibilities: All BABHA psychiatrists and nurses including contract psychiatrists, physician assistants, nurse practitioners, and nurses are strongly encouraged to acquaint themselves with the general principles and clinical practice guidelines of the CCISC as outlined in the Prescriber Practice Guidelines for Co-Occurring Mental Health and Substance Use Disorders issued by BABHA Integrated Services Implementation Team in August The aforementioned document addresses psychopharmacologic treatment strategies specific to the treatment of individuals with psychiatric and/or substance use disorders. General strategies for managing interactive effects of substance use on psychiatric symptoms and interventions, mechanisms for physician to physician coordination of care, and treatment of individuals with chronic pain are also covered. 3. Annual Review of Prescriber Practice Guidelines: In keeping with improvements in best practices related to psychopharmacologic prescribing practices and interventions for individuals with psychiatric and/or substance use disorders, all network psychiatrists will review all prescriber practice guidelines at least annually. Any changes to said guidelines will be subject to review and approval by the BABHA Medical Director. Attachments Prescriber Practice Guidelines for Co-Occurring Mental Health and, Integrated Services Implementation Team, August, 2010.

5 Page: 5 of 6 Related Forms N/A Related Materials N/A References/Legal Authority: Minkoff, K. Chair. CMHS Managed Care Initiative Panel on Co-occurring Disorders. Cooccurring psychiatric and substance disorders in managed care systems: standards of care, practice guidelines, workforce competencies, and training curricula. Center for Mental Health Policy and Services Research. Philadelphia. January, Retrieved from Minkoff, K. Behavioral Health Recovery Management Service Planning Guidelines: Co-occurring Psychiatric and Substance Disorders. Illinois Department of Human Services' Office of Alcoholism and Substance Abuse. April, Minkoff, K. Comprehensive Continuous Integrated System of Care: Psychopharmacology Guidelines for Individuals with Co-Occurring Psychiatric and Substance Abuse Disorders. Private Practice, Harvard University. January, 2005.

6 Page: 6 of 6 Submission Form Approving Body/Committee/Supervisor: Clinical Leadership Team M. Swank Author/Reviewer: Michael Swank Kim Withrow Approval/Review Date: /1/13 Result: Deletion New No Changes Replacement Revision List reason for deletion/replacement/revision here. If replacement, list policy to be replaced. New Triennial review: Updated with Person First Language and deleted obsolete information