Concurrent Disorders Dr. Christy Sutherland MD CCFP dipabam Medical Director, PHS Community Services Methadone/Buprenorphine 101 Workshop April 1, 2017
Overview Introduction Epidemiology Treatment Principles and Issues Community Resources Summary
What are concurrent disorders? Any combination of mental disorder and substance use disorder
Why so common? Disorder Fostering Disorder can substances unmask psychiatric disorders? Overlapping neurobiological pathways Underlying genetic factors (common vulnerabilities) Diagnostic confounding Trauma, chronic stress, and loss Complex and bi-directional
Substance Use Disorder and Mental Health High burden of morbidity and mortality Under-diagnosed Undertreated Chronic conditions Lacks a solid research base as they are often excluded from trials
Mental Illness and Substance Use Disorder Higher rates of: Relapse, hospitalization, violence, incarceration, homelessness, victimization, medical complications (HIV, Hep C) Worse clinical course, treatment outcome and prognosis Other common factors: Poverty and deprivation Neurocognitive impairment Conduct disorder Personality disorders (especially Antisocial)
Drug-related symptoms mimicking depression or mania Bipolar symptoms symptoms Euphoria Energy Appetite Grandiosity Depression symptoms Anhedonia Apathy Depressed mood suicidality paranoia
Diagnoses to consider Acute intoxication Acute withdrawal Sub-acute or prolonged withdrawal Substance induced mood disorder Pre-existing mood disorder Combination
Substance-induced Mental Disorder People often meet criteria for depression, or anxiety, but these symptoms resolved quickly in recovery 26 32% of patients in recovery will have ongoing MDD or GAD, and will need treatment
Substance Use Disorder and Depression Major Depression is the most common co-occurring psychiatric disorder among patients presents for treatment for SUD Lifetime prevalence rates 15 20% Despite abstinence, some depression symptoms will persist this is the population we need to find and treat
Substance Use Disorder and Depression Who has SUD and who has true underlying Major Depression? Timeline Intoxication/withdrawal Persistence of depressive symptoms Look for most of the day every day symptoms Ask what has worked in the past?
Substance Use Disorder and Depression Opioids Intoxication: apathy, dysphoria Withdrawal: dysphoria, irritability, anxiety, insomnia, fatigue Patients with MDD and SUD have a worse prognosis than those without SUD
Substance Use Disorder and Depression Methadone makes patients feel better About 50 % of patients will have resolution of depression syndrome in the first 2 weeks of methadone Treat depression with CBT, contingency management or SSRI Improvements in mood often lead to less substance use However, in general Treating only the depression will not be enough to also resolve the addiction addiction needs it s own treatment
Substance Use Disorder and Depression And pain!! Pain is dysphoric Chronic opioid use blunts happiness Chronic opioid use deregulates sleep and coping skills
Substance Use Disorder and Anxiety 17.7 % of people with anxiety disorder also meet criteria for substance use disorder 36.3% of opioid users will meet criteria for anxiety disorder at some time in their lives Lots of overlap between anxiety and benzodiazepine and opioid withdrawal CBT has a lot of evidence to support it s use
Substance Use Disorder and Anxiety Anxiety and nicotine Nicotine is a CYP inducer so monitor coffee intake and anxiety in early recovery
Substance Use Disorder and Anxiety Benzodiazepines are contraindicated Increased mortality Risk of cognitive impairment Worsen PTSD Risk of diversion and addiction
Substance Use and Suicide Rate of suicide attempts in this population is high One study has shown that AA reduced suicide risk
Substance Use and Bipolar Manic episodes are usually longer than intoxication episodes Pharmacologic treatment is the mainstay of treating bipolar Mood stabilizers Be conscious of safety may need hospitalization
Substance Use and Psychosis Methamphetamine users have 11 times the risk of psychosis than the general population This psychosis may continue for up to two years of abstinence 53% of cocaine users admitted to treatment have a history of cocaine induced psychosis
Substance Use and Psychosis Challenging to treat due to lack of research Generally, not considered a primary psychotic disorder until there are ongoing symptoms after one month of abstinence 1 5% of individuals with substance induced psychosis will have ongoing symptoms after one month of abstinence
Substance Use and Psychosis 47% of people with schizophrenia have lifetime experience of substance use disorder 70 90% have nicotine use disorder Most research occurs in emergency room setting Opioid withdrawal can worsen psychosis
Medication in Recovery People in recovery often have complex and conflicting feelings about being on medication 12-step and other supports can discourage medication use Sometimes is framed as an underlying failure or defect Help the patient reframe this idea and support them in continuing on helpful medication
www.heretohelp.bc.ca
Burnaby Centre for Mental Health and Addiction Integrated psychiatry and addiction care In-patient extended stay Groups (12-step, CBT, exercise, healthy living) Physiotherapy Smoking cessation Trauma and pain groups
Summary Screen patients for mental health comorbidity Be mindful of the timeline connection between substances and psychiatric symptoms Treat the addiction Treat the mental illness Recognize the complex, interdependent, and overlapping clinical picture for patients with cooccurring substance use disorder and mental illness
The idea that some lives matter less is the root of all that is wrong with the world. Paul Farmer