Addicted, Crazy or Addicted, Crazy or Both?Both?

Now What?Now What?Dual Diagnosis in the CD PatientDual Diagnosis in the CD Patient

Mark Menestrina, MD, Mark Menestrina, MD, FASAMFASAM

Brighton Hospital / Brighton Hospital / SEMCASEMCA

mmenestrina@brightonhospitmmenestrina@brightonhospital.orgal.org

Michigan Judges’ MI Michigan Judges’ MI 8/20118/2011

Part 1 (the “teaser”)Part 1 (the “teaser”)

Addiction ReviewAddiction Review Classification of Mental Classification of Mental

DisordersDisorders Review of Common DisordersReview of Common Disorders Association of Mental Health Association of Mental Health

Disorders with SUDsDisorders with SUDs

Part 2Part 2

Review of Selected Classes of Review of Selected Classes of Psychiatric MedicationsPsychiatric Medications

Pharmacology for Recovery Pharmacology for Recovery Safe Prescribing for Individuals Safe Prescribing for Individuals

with SUDswith SUDs

Addiction ReviewAddiction Review

WE LIVE IN A MAGICAL WE LIVE IN A MAGICAL THINKING MEDICATION THINKING MEDICATION

SEEKING SOCIETYSEEKING SOCIETY

USA is 4.7% of the World PopulationUSA is 4.7% of the World Population

But we consume almost 50% of the But we consume almost 50% of the World’s Drugs and most of the World’s World’s Drugs and most of the World’s Pain MedicationPain Medication

Media / TV / Radio flood us with Media / TV / Radio flood us with messages…messages…

We are taught not to tolerate any We are taught not to tolerate any discomfort without taking something discomfort without taking something to feel betterto feel better

ADDICTION IS A BRAIN ADDICTION IS A BRAIN CHEMISTRY DISEASECHEMISTRY DISEASE

Involves the Meso-Limbic System (Primitive)Involves the Meso-Limbic System (Primitive) Neurotransmitter Mediated (Not Conscious)Neurotransmitter Mediated (Not Conscious) Denial is a Hallmark FeatureDenial is a Hallmark Feature Emotional, Physical, PsychologicalEmotional, Physical, Psychological Chronic, Progressive, potentially FatalChronic, Progressive, potentially Fatal Affects Family, Community, Society and Affects Family, Community, Society and

SchoolsSchools ~10% are susceptible to Addiction…Treatable ~10% are susceptible to Addiction…Treatable

DiseaseDisease Different than Abuse, anyone can Abuse Different than Abuse, anyone can Abuse

Drugs or Alcohol.…Preventable BehaviorDrugs or Alcohol.…Preventable Behavior

IT’S NOT REALLY A IT’S NOT REALLY A DISEASE…IS IT?DISEASE…IS IT?

1956 AMA designates Alcoholism as a 1956 AMA designates Alcoholism as a disease, Drug Addiction as a disease disease, Drug Addiction as a disease followedfollowed

““But you have a choice”But you have a choice” Like depression 30 years ago, or Like depression 30 years ago, or

oncology 40 years agooncology 40 years ago Compare to other Chronic DiseasesCompare to other Chronic Diseases When we do treat Addiction, we do so When we do treat Addiction, we do so

Acutely, and wonder why we have poor Acutely, and wonder why we have poor resultsresults

12

Can you find the (alleged) Can you find the (alleged) future alcoholic?future alcoholic?

LACK OF LACK OF WILLPOWER?WILLPOWER?13

IF ADDICTION / IF ADDICTION / CHEMICAL CHEMICAL

DEPENDENCE IS DEPENDENCE IS TRULY A TRULY A

DISEASE….WHY DON’T DISEASE….WHY DON’T WE TREAT IT AS WE TREAT IT AS

SUCH?SUCH?

Leading Causes of Leading Causes of DeathDeath

Data for the U.S. 2007Data for the U.S. 2007

Age 25-44Age 25-44

InjuryInjuryCancerCancer

Heart DiseaseHeart DiseaseSuicideSuicide

HomicideHomicideHIVHIV

Liver DiseaseLiver DiseaseStrokeStroke

DiabetesDiabetes

Age 15-24Age 15-24

InjuryInjuryHomicideHomicideSuicideSuicideCancerCancer

Heart DiseaseHeart DiseaseCongenital Congenital

StrokeStrokeDiabetesDiabetes

Google: Alcoholism + Humor

ADDICTION vs. ABUSEADDICTION vs. ABUSE

ALCOHOLISM, ALCOHOLISM, DRUG DRUG ADDICTION, ADDICTION, CHEMICAL CHEMICAL DEPENDENCEDEPENDENCE

A TREATABLE A TREATABLE DISEASEDISEASE

DRUG ABUSE, DRUG ABUSE, ALCOHOL ALCOHOL ABUSEABUSE

A PREVENTABLE A PREVENTABLE BEHAVIORBEHAVIOR

THE NEW GATEWAY FOR THE NEW GATEWAY FOR MANY YOUNG PEOPLE…MANY YOUNG PEOPLE…

ADDICTION TREATMENT ADDICTION TREATMENT MADE EASY…. “A” to “B”MADE EASY…. “A” to “B”

NEGATIVENEGATIVE

Consequences: Consequences: The job, liver, The job, liver, judge, wife, judge, wife, boss, friend get boss, friend get the individual’s the individual’s attention!attention!

POSITIVE POSITIVE Reinforcement: Reinforcement: The individual The individual actually begins actually begins to like and to like and enjoy “recovery”enjoy “recovery”

While this process is achievable, it is not likely to all make sense to the patient. It may involve 12 step, counseling, treatment of co-morbid conditions, Medication Assisted Treatments and other modalities.

HOW TO SPOT A HUNTER WITH A DUI CONVICTION….

Co-Occurring DisordersCo-Occurring Disorders

Psychiatric Illness & Psychiatric Illness & AddictionAddiction

GeneralizationsGeneralizationsBoth are common problemsBoth are common problems

Having one increases the risk for having the Having one increases the risk for having the otherother

Having one complicates the treatment of the Having one complicates the treatment of the otherother

when both are presentwhen both are present

““Dual Diagnosis” cases are over represented Dual Diagnosis” cases are over represented

among homeless and incarcerated among homeless and incarcerated

““Dual Diagnosis” have increased risk of HIV Dual Diagnosis” have increased risk of HIV andand

other serious medical conditionsother serious medical conditions

Classification of Mental Classification of Mental Disorders…DSM-IV-TR Disorders…DSM-IV-TR

The official classification system of The official classification system of psychiatric conditions in use in the USApsychiatric conditions in use in the USA

Criteria in DSM are used to facilitate Criteria in DSM are used to facilitate communication among professionals, for communication among professionals, for research standards, and for 3research standards, and for 3rdrd party party payor communicationpayor communication

DSM- A mental disorder is a disorder DSM- A mental disorder is a disorder with significant behavioral or with significant behavioral or psychological symptoms associated with psychological symptoms associated with present distress, disability or increased present distress, disability or increased risk of suffering death, pain, disability or risk of suffering death, pain, disability or loss of freedomloss of freedom

THE 5 AXES OF DSMTHE 5 AXES OF DSM

I. CLINICAL DISORDERSI. CLINICAL DISORDERS II. PERSONALITY DISORDERS and II. PERSONALITY DISORDERS and

MENTAL RETARDATIONMENTAL RETARDATION III. GENERAL MEDICAL CONDITIONSIII. GENERAL MEDICAL CONDITIONS IV. PSYCHOSOCIAL AND IV. PSYCHOSOCIAL AND

ENVIORNMENTAL PROBLEMSENVIORNMENTAL PROBLEMS V. GAF (Global Assessment of V. GAF (Global Assessment of

Functioning)Functioning)

ASAM DIMENSIONSASAM DIMENSIONS

I. ACUTE INTOXICATION OR I. ACUTE INTOXICATION OR

WITHDRAWAL POTENTIALWITHDRAWAL POTENTIAL

II. BIOMEDICAL CONDITIONSII. BIOMEDICAL CONDITIONS

III. EMOTIONAL, BEHAVIORAL OR III. EMOTIONAL, BEHAVIORAL OR

COGNITIVE CONDITIONSCOGNITIVE CONDITIONS

IV. READINESS TO CHANGEIV. READINESS TO CHANGE

V. RELAPSE POTENTIALV. RELAPSE POTENTIAL

VI. RECOVERY/LIVING VI. RECOVERY/LIVING ENVIORNMENTENVIORNMENT

DSM at Work…(or not!)DSM at Work…(or not!)Major Depressive EpisodeMajor Depressive Episode

A.A. Five (or more) of the following Five (or more) of the following symptoms have been present during symptoms have been present during the same 2-week period and represent the same 2-week period and represent a change from previous functioning; a change from previous functioning; at least one of the symptoms is either at least one of the symptoms is either (1) depressed mood or (2) loss of (1) depressed mood or (2) loss of interest or pleasure.interest or pleasure.

Note: Do not include symptoms that Note: Do not include symptoms that are clearly due to a general medical are clearly due to a general medical condition, or mood-incongruent condition, or mood-incongruent delusions or hallucinationsdelusions or hallucinations

MD…continuedMD…continued

(1) Depressed mood most of the day, (1) Depressed mood most of the day, nearly every day, as indicated by either nearly every day, as indicated by either subjective report (e.g., feels sad or subjective report (e.g., feels sad or empty) or observation made by others empty) or observation made by others (e.g., appears tearful) Note: In children (e.g., appears tearful) Note: In children and adolescents, can be irritable mood.and adolescents, can be irritable mood.

(2) Markedly diminished interest or (2) Markedly diminished interest or pleasure in all, or almost all, activities pleasure in all, or almost all, activities most of the day, nearly every day (as most of the day, nearly every day (as indicated by either subjective account or indicated by either subjective account or observation made by others)observation made by others)

MD…continuedMD…continued

(3) Significant weight loss when not (3) Significant weight loss when not dieting or weight gain (e.g., a change of dieting or weight gain (e.g., a change of more than 5% of body weight in a month), more than 5% of body weight in a month), or decrease or increase in appetite nearly or decrease or increase in appetite nearly every day. Note: In children, consider every day. Note: In children, consider failure to make expected weight gains.failure to make expected weight gains.

(4) Insomnia or hypersomnia nearly (4) Insomnia or hypersomnia nearly every dayevery day

(5) Psychomotor agitation or (5) Psychomotor agitation or retardation nearly every day (observable retardation nearly every day (observable by others, not merely subjective feelings by others, not merely subjective feelings of restlessness or being slowed down)of restlessness or being slowed down)

MD…continuedMD…continued

(6) Fatigue or loss of energy nearly (6) Fatigue or loss of energy nearly every dayevery day

(7) Feelings of worthlessness or (7) Feelings of worthlessness or excessive or inappropriate guilt (which excessive or inappropriate guilt (which may be delusional) nearly every day (not may be delusional) nearly every day (not merely self-reproach or guilt about being merely self-reproach or guilt about being sick)sick)

(8) Diminished ability to think or (8) Diminished ability to think or concentrate, or indecisiveness, nearly concentrate, or indecisiveness, nearly every day (either by subjective account every day (either by subjective account or as observed by othersor as observed by others

MD…continuedMD…continued

(9) Recurrent thoughts of death (not (9) Recurrent thoughts of death (not just fear of dying), recurrent suicidal just fear of dying), recurrent suicidal ideation without a specific plan, or a ideation without a specific plan, or a suicide attempt or a specific plan for suicide attempt or a specific plan for committing suicide.committing suicide.

B.B. The symptoms do not meet criteria for The symptoms do not meet criteria for a Mixed Episode (see p. 171)a Mixed Episode (see p. 171)

C.C. The symptoms cause clinically The symptoms cause clinically significant distress or impairment in significant distress or impairment in social, occupational, or other important social, occupational, or other important areas of functioning.areas of functioning.

MD…continuedMD…continued

D.D. The symptoms are not due to the direct The symptoms are not due to the direct physiological effects of a substance (e.g., a physiological effects of a substance (e.g., a drug of abuse, a medication) or a general drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism)medical condition (e.g., hypothyroidism)

E.E. The symptoms are not better accounted The symptoms are not better accounted for by Bereavement, i.e., after the loss of a for by Bereavement, i.e., after the loss of a loved one, the symptoms persist for longer loved one, the symptoms persist for longer than 2 months or are characterized by than 2 months or are characterized by marked functional impairment, morbid marked functional impairment, morbid preoccupation with worthlessness, suicidal preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or ideation, psychotic symptoms, or psychomotor retardation.psychomotor retardation.

MD…diagnosis in the MD…diagnosis in the real worldreal world

Depressed mood plus….Depressed mood plus….

S sleep disturbanceS sleep disturbanceI loss of interest or pleasure I loss of interest or pleasure

(anhedonia)(anhedonia)G feelings of guilt or worthlessnessG feelings of guilt or worthlessnessE low energyE low energyC poor concentration or memoryC poor concentration or memoryA appetite disturbanceA appetite disturbanceP psychomotor agitation or retardationP psychomotor agitation or retardationS suicidal ideationS suicidal ideation

REMEMBER THAT DSM REMEMBER THAT DSM CRITERIA ARE HELPFUL CRITERIA ARE HELPFUL GUIDELINES…..BUT WE GUIDELINES…..BUT WE ALL HAVE A LITTLE (OR ALL HAVE A LITTLE (OR

A LOT) IN EACH OF A LOT) IN EACH OF US!!!US!!!

REVIEW OF COMMON REVIEW OF COMMON DISORDERSDISORDERS

SCHIZOPHRENIASCHIZOPHRENIA AFFECTIVE DISORDERSAFFECTIVE DISORDERS ANXIETY DISORDERS (including ANXIETY DISORDERS (including

PTSD)PTSD) PERSONALITY DISORDERSPERSONALITY DISORDERS ATTENTION DEFICIT ATTENTION DEFICIT

HYPERACTIVITYHYPERACTIVITY EATING DISORDERSEATING DISORDERS SUBSTANCE RELATED DISORDERSSUBSTANCE RELATED DISORDERS

SCHIZOPHRENIASCHIZOPHRENIA

Complex illness, characterized by Complex illness, characterized by hallucinations, delusions, behavioral hallucinations, delusions, behavioral disturbances, disrupted social disturbances, disrupted social functioning, disorganized speech and functioning, disorganized speech and ‘negative symptoms’‘negative symptoms’

0.5-1% Prevalence0.5-1% Prevalence Violent acts no more frequent than Violent acts no more frequent than

the general populationthe general population Reduced life expectancy, 40% attempt Reduced life expectancy, 40% attempt

suicide, 10-20% succeed suicide, 10-20% succeed Treatment antipsychotic medicationsTreatment antipsychotic medications

AFFECTIVE DISORDERS~ AFFECTIVE DISORDERS~ MOOD DISORDERSMOOD DISORDERS

DEPRESSION: common, often DEPRESSION: common, often missed, not hard to diagnose when missed, not hard to diagnose when you look for it, often severe, often you look for it, often severe, often recurrent, costly and highly treatablerecurrent, costly and highly treatable

BIPOLAR DISORDERS ~ Depression BIPOLAR DISORDERS ~ Depression with episodes of elevated moodwith episodes of elevated mood

BIPOLAR I= with at least one manic BIPOLAR I= with at least one manic episodeepisode

BIPOLAR II= with hypomanic BIPOLAR II= with hypomanic episodesepisodes

Affective DisordersAffective Disorders

DIAGNOSISDIAGNOSIS CRITERIACRITERIA

MDDMDD Severe Sx, >5 Sx, > Severe Sx, >5 Sx, > 2 Wks2 Wks

DYSTHYMIADYSTHYMIA Less severe, more Less severe, more persistentpersistent

BIPOLAR IBIPOLAR I Mania and Mania and DepressionDepression

BIPOLAR IIBIPOLAR II Hypomania, Hypomania, Depression?Depression?

CYCLOTHYMIACYCLOTHYMIA Less severe, more Less severe, more persistentpersistent

SUBSTANCE-SUBSTANCE-INDUCEDINDUCED

Consequence of Consequence of Use or w/dUse or w/d

ANXIETY DISORDERSANXIETY DISORDERS

GENERALIZED ANXIETY GENERALIZED ANXIETY DISORDERDISORDER

SOCIAL PHOBIASOCIAL PHOBIA SIMPLE PHOBIASSIMPLE PHOBIAS PANIC DISORDERPANIC DISORDER AGORAPHOBIAAGORAPHOBIA PTSDPTSD

PERSONALITY PERSONALITY DISORDERSDISORDERS

CLUSTECLUSTERR

DESCRIPTIODESCRIPTIONN

DISORDERSDISORDERS

AA Odd/EccentricOdd/Eccentric Paranoid/Paranoid/Schizoid/Schizoid/

SchizotypalSchizotypal

BB Dramatic/Dramatic/ErraticErratic

Antisocial/Antisocial/Borderline/Borderline/Histrionic/Histrionic/NarcissisticNarcissistic

CC Anxious/Anxious/FearfulFearful

Avoidant/Avoidant/Dependent/Dependent/

Obsessive-Obsessive-CompulsiveCompulsive

ADHDADHD

Inattention, hyperactivity, Inattention, hyperactivity, impulsivityimpulsivity

ADHD does associate with higher ADHD does associate with higher risk for SUDs, but this may be risk for SUDs, but this may be limited to those with coexisting limited to those with coexisting conduct or bipolar disorderconduct or bipolar disorder

Treating ADHD with stimulants Treating ADHD with stimulants actually appears to be associated actually appears to be associated with a decreased risk of developing a with a decreased risk of developing a subsequent SUDsubsequent SUD

EATING DISORDERSEATING DISORDERS

ANOREXIA: often severely restrict caloric ANOREXIA: often severely restrict caloric intake or excessively exercise, are intake or excessively exercise, are underweightunderweight

BULEMIA: often alternate eating with BULEMIA: often alternate eating with starvation or purging, are usually normal starvation or purging, are usually normal weightweight

Both groups may abuse appetite Both groups may abuse appetite suppressants, diuretics or laxativessuppressants, diuretics or laxatives

BULEMICS appear to be at risk for SUDsBULEMICS appear to be at risk for SUDs One study found ANOREXICS to be at One study found ANOREXICS to be at

lower risk for SUDslower risk for SUDs

SUBSTANCE INDUCED SUBSTANCE INDUCED DISORDERSDISORDERS

These disorders mimic other These disorders mimic other psychiatric disorders, but they are in psychiatric disorders, but they are in fact caused, directly or indirectly, by fact caused, directly or indirectly, by use of substancesuse of substances

This is a tremendous source of This is a tremendous source of misdiagnosis, and results in misdiagnosis, and results in ineffective treatment of the ineffective treatment of the substance disordersubstance disorder

We live in a society where it is more We live in a society where it is more socially acceptable to be mentally ill socially acceptable to be mentally ill than chemically dependentthan chemically dependent

Diagnoses Associated with Diagnoses Associated with Class of Class of

Substances…..DSM-IV-TRSubstances…..DSM-IV-TR

DepenDependd

AbuseAbuse IntoxIntox W/DW/D

AlcoholAlcohol ++ ++ ++ ++

AmphetamiAmphetaminesnes

++ ++ ++ ++

CannabisCannabis ++ ++ ++

CocaineCocaine ++ ++ ++ ++

OpioidsOpioids ++ ++ ++ ++

SedativesSedatives ++ ++ ++ ++

Substance Induced Mental Substance Induced Mental DisordersDisorders

Organic Brain SyndromesOrganic Brain Syndromes

SI Delirium SI Delirium

SI Persisting SI Persisting DementiaDementia

SI Amnestic DisorderSI Amnestic Disorder

Mimic Axis I DisordersMimic Axis I Disorders

SI Psychotic DisorderSI Psychotic Disorder

SI Mood DisorderSI Mood Disorder

SI Anxiety DisorderSI Anxiety Disorder

Hallucinogen Hallucinogen Persisting Persisting Perceptual Perceptual DisorderDisorder

SI Sexual SI Sexual DysfunctionDysfunction

SI Sleep DisorderSI Sleep Disorder

ASSOCIATION OF MENTAL ASSOCIATION OF MENTAL DISORDERS WITH SUDsDISORDERS WITH SUDs

SUDs includeSUDs includeADDICTION: a treatable ADDICTION: a treatable

diseasediseaseABUSE: a preventable ABUSE: a preventable

behaviorbehavior

2003 National Survey of 2003 National Survey of Drug Use and Health Drug Use and Health

(NSDUH)(NSDUH)

21.3% of Adults with Serious 21.3% of Adults with Serious Mental Illness (SMI) had a Mental Illness (SMI) had a Substance Use Disorder (SUD)Substance Use Disorder (SUD)

7.9% of Adults without SMI had a 7.9% of Adults without SMI had a SUDSUD

Nicotine and Mental IllnessNicotine and Mental IllnessGrant, B.F. et al, 2004Grant, B.F. et al, 2004

12 MONTH 12 MONTH PREVALENCPREVALENCEE

ODDS ODDS RATIORATIO

MOOD MOOD DISORDERDISORDER

21%21% 3.33.3

ANXIETY ANXIETY DISORDERDISORDER

22%22% 2.72.7

PERSONALIPERSONALITY TY DISORDERDISORDER

32%32% 3.33.3

Serious Mental Illness Serious Mental Illness and Its Co-Occurrence and Its Co-Occurrence

with Substance Use with Substance Use Disorders, 2002Disorders, 2002

Epstein, Barker, Vorburger and Epstein, Barker, Vorburger and Murtha, 2004Murtha, 2004

SAMHSA.GOVSAMHSA.GOV

17.5 million Adults with 17.5 million Adults with SMI (Serious Mental SMI (Serious Mental

Illness) 8.3% of populationIllness) 8.3% of population

18-25yo 13.2%18-25yo 13.2% 26-49yo 9.5%26-49yo 9.5% >50yo 4.9%>50yo 4.9%

Female 10.5%Female 10.5% Male 6.0%Male 6.0%

>1 race 13.6%>1 race 13.6% Nat Am 12.5%Nat Am 12.5%

28.9% used illicit 28.9% used illicit drug/yrdrug/yr

Illicit drug/yr 17.1%Illicit drug/yr 17.1% No drug/yr 6.9%No drug/yr 6.9%

SMI did not vary by SMI did not vary by past year alcohol usepast year alcohol use

‘‘Heavy” alcohol/mo Heavy” alcohol/mo 11.1%11.1%

vs. 8.1% vs. 8.1%

Co-Occurrence of SMI & Co-Occurrence of SMI & SUDSUD

33.2 million SMI or SUD33.2 million SMI or SUD

13.4 million (40.4%) SMI13.4 million (40.4%) SMI 15.5 million (47.4%) SUD15.5 million (47.4%) SUD 4.0 million (12.2%) SMI + SUD4.0 million (12.2%) SMI + SUD

Both Disorders: 23.2% of Both Disorders: 23.2% of SMISMI

20.4% of 20.4% of SUDSUD

Rates of SMI…….Rates of SMI…….

Without any SUDWithout any SUD 7.0%7.0%

Alcohol Dependence or Alcohol Dependence or AbuseAbuse

19.0%19.0%

Illicit Drug Dependence or Illicit Drug Dependence or AbuseAbuse

29.1%29.1%

Alcohol and Drug Use Alcohol and Drug Use DisorderDisorder

30.1%30.1%

Lifetime SUD Among Lifetime SUD Among Persons with Mental Persons with Mental

Disorders….Regier et al, Disorders….Regier et al, 19901990

MENTAL MENTAL DISORDERDISORDER

LIFETIMLIFETIMEE

PREVPREV

LIFETIMELIFETIME

PREV PREV SUDSUD

ODDS ODDS RATIORATIO

schizophreniaschizophrenia 1.5%1.5% 47.0%47.0% 4.64.6

antisocial antisocial p.d.p.d.

2.6%2.6% 83.6%83.6% 29.629.6

anxiety anxiety disordersdisorders

14.6%14.6% 23.7%23.7% 1.71.7

OCDOCD 2.5%2.5% 32.8%32.8% 2.52.5

affective affective disordersdisorders

8.3%8.3% 32.0%32.0% 2.62.6

any disorderany disorder 16.2%16.2% 28.9%28.9% 2.72.7

Why the Association??Why the Association??

Common Risk Factors & Etiologies, Common Risk Factors & Etiologies, genetic or environmentalgenetic or environmental

Addiction might lead to Mental IllnessAddiction might lead to Mental Illness Psychiatric Illness might lead to Psychiatric Illness might lead to

Addiction…the “Self-Treating Addiction…the “Self-Treating Hypothesis”Hypothesis”

Self-Limiting Acute Effects of a Self-Limiting Acute Effects of a Substance (or withdrawal from it) may Substance (or withdrawal from it) may be mistaken for a psychiatric illnessbe mistaken for a psychiatric illness

Affective Disorders…Affective Disorders…Association with SUD Association with SUD

Regier et.al. 1990Regier et.al. 1990SMISMI SUDSUD ODDS ODDS

RATIORATIO

Any Any Affective Affective

AlcoholAlcohol 1.91.9

Any Any Affective Affective

CocaineCocaine 5.95.9

Any Any Affective Affective

OpiatesOpiates 5.05.0

Any Any Affective Affective

BarbituratesBarbiturates 6.66.6

Any Any Affective Affective

HallucinogeHallucinogensns

5.95.9

Bipolar Bipolar DisorderDisorder

Any SUDAny SUD 6.66.6

Unipolar d/oUnipolar d/o Any SUDAny SUD 1.91.9

Summary PointsSummary Points Co-Occurring Disorders are CommonCo-Occurring Disorders are Common May be difficult to differentiate from May be difficult to differentiate from

Substance Induced DisordersSubstance Induced Disorders Consider “Watchful Waiting” in less Consider “Watchful Waiting” in less

definite cases when degree of definite cases when degree of impairment is not as severeimpairment is not as severe

Treatment is often ChallengingTreatment is often Challenging Both Disorders need to be addressed Both Disorders need to be addressed

when both are truly presentwhen both are truly present May be “Road Blocked” by May be “Road Blocked” by

Insurance/Funding SourcesInsurance/Funding Sources

““NEVER DOUBT THAT A NEVER DOUBT THAT A SMALL GROUP OF SMALL GROUP OF

DEDICATED CITIZENS DEDICATED CITIZENS CAN CHANGE THE CAN CHANGE THE

WORLD…INDEED IT IS WORLD…INDEED IT IS THE ONLY THING THAT THE ONLY THING THAT

EVER HAS”EVER HAS”

Margaret MeadeMargaret Meade