Comprehensive Continuous Integrated System of Care (CCISC)
Psychopharmacology
Practice
Guidelines for Individuals with
Co-occurring Psychiatric and Substance Use Disorders (COD)
January,
2005
Developed by
Kenneth
Minkoff, MD
Clinical
Assistant Professor of Psychiatry,
Senior
Systems Consultant, ZiaLogic
With invaluable
assistance from
Terry Schwartz, MD,
Jeff Rowe, MD, and other members of the
Psychopharmacology Committee of the
Based on the
psychopharmacology guidelines in
Minkoff (2001),
Service Planning Guidelines for Co-occurring Psychiatric and Substance
Disorders
Kenneth Minkoff, MD
Background
Individuals with co-occurring
psychiatric and substance disorders (COD) represent a challenging population
associated with poorer outcomes and higher costs in multiple domains. In addition, the prevalence of comorbidity is
sufficiently high that we can say that comorbidity is an expectation, not an
exception throughout the system of care.
Consequently, individuals with cod cannot be adequately served with only
a few specialized programs; rather, the expectation of comorbidity must be
addressed throughout the system of care.
The Comprehensive Continuous Integrated System of Care (CCISC) (Minkoff
& Cline, 2004) is a model for system design which permits any system to
address this problem 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 clinician (including
psychopharmacology prescribers) become dual diagnosis clinicians meeting
minimal standards of dual diagnosis competency, but each program and each
clinician has a different job. The job
of each program is based first on what it is already designed to be doing, and
the people with cod who are already being seen, but the goal is to organize the
infrastructure of the program to routinely provide matched services to those
individuals within the context of the program design, which in turn defines
specific clinical practices for clinicians working within that setting, that
define their competency requirements.
The service matching in this model is based on a set of evidence-based
principles in the context of an integrated philosophic model that makes sense
from the perspective of mental health and addiction treatment. These principles in turn have been utilized
to develop practice guidelines that define the process of assessment and
treatment matching at the clinical level, and outline the “job” of each program
in the system as well.
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
The
seven general principles of CCISC are designed to provide a welcoming,
accessible, integrated, continuous, and comprehensive system of care to
patients with CODs. These principles,
and their application to psychopharmacology, are listed below:
All
psychiatrists need to develop comfort with the likelihood that any patient
requiring psychopharmacologic evaluation may also have a substance use disorder,
and be able to incorporate this expectation into every clinical contact,
beginning with assessment, and continuing throughout the treatment
process. Consequently, it is necessary
to have an organized evidence based approach to assessment and treatment of
individuals who present with co-occurring conditions of any type. In addition, given the expected complexity of
many patients with co-occurring disorders, it is helpful to routinely organize
access to peer consultation (defined
below) as a valuable way for prescribers to obtain help and guidance when
treating patients with unusual or complicated clinical situations.
Successful
psychopharmacology is not an absolute science governed by the application of
rigid rules. Rather, it is best
performed in the context of an empathic, hopeful relationship, which integrates
ongoing attention to both psychiatric and substance use issues. Emphasis needs to be placed on an initial
integrated (both mental health and substance use) evaluation and continuous
re-evaluation of diagnoses and treatment response.
Practitioners
of psychopharmacology in mental health settings should not underestimate the
importance of ongoing inquiry regarding co-occurring substance use, continued
encouragement of healthy decision making regarding substance use, and support
to other caregivers who are engaged with the patient and his or her family in
addressing these issues.
|
Both High Severity |
MI Low Severity SUD High Severity |
|
MI High Severity SUD Low Severity |
Both Low Severity |
This
model divides individuals throughout a service system into four quadrants based
on high and low severity of each disorder. Psychopharmacologic strategies may
need to be adjusted based on type and level of severity of each illness in COD. In particular, individuals with high severity
mental illness are more likely to be considered high priority mental health
clients with Serious and Persistent Mental Illness (SPMI) and associated
disability, who are a high priority for continuing engagement in
psychopharmacologic treatment in the mental health system. Individuals with high severity substance use
disorders generally are those with active substance dependence (addiction), as
opposed to those with lower severity disorders, such as substance abuse. Pharmacologic strategies for either mental
illness or substance use disorder may vary, depending on the severity of the
mental illness and the diagnosis of dependence versus abuse (see below).
As
most individuals cannot legally prescribe their own medication, the ability to
receive medication for the treatment of CODs is a vital aspect of the
integrated treatment relationship. Given
that treatment involves learning, the psychopharmacologic treatment
relationship needs to balance ongoing necessary continuity of care (see below) with opportunities for contingent learning (negotiation of
type, quantity, and duration of treatment with any medication) without threat
of loss of the treatment relationship.
This contingent learning may
require a “trial and error” process and several attempts before
successful. Contingency plans are most
effective in the context of a good therapeutic alliance.
Thus,
in general, psychopharmacologic interventions are designed to maximize outcome
of two primary disorders, as follows:
a. For diagnosed psychiatric illness, the
individual receives the most clinically effective psychopharmacologic strategy
available, regardless of the status of the comorbid substance disorder. (N.B. Special
considerations apply for utilization of addictive or potentially addictive
medications that may have psychiatric indications, such as benzodiazepines and
stimulants. See below.)
b. For diagnosed substance disorder, appropriate
psychopharmacologic strategies (e.g., disulfiram, naltrexone, opiate maintenance)
are used as ancillary treatments to support a comprehensive program of
recovery, regardless of the status of the comorbid psychiatric disorder
(although taking into account the individual's cognitive capacity and
disability).
Within
the application of the above rules, there is some evidence for improvement in
certain addictive disorders reported with several medications that also have
common psychiatric indications (e.g.,
SSRIs, buproprion, topiramate) (See below). Although there is little evidence
to support selecting one medication for any combination as a “magic bullet”,
the prescriber may want to consider the possible impact on a co-occurring
substance use disorder when choosing medication for a psychiatric disorder.
Psychopharmacologic
practice may vary depending on whether the individual is requiring acute
stabilization (e.g., detoxification) versus relapse prevention or
rehabilitation. In addition, within the
psychopharmacologic relationship, individuals may be engaged in active
treatment or prolonged stabilization of one disorder (usually mental illness),
which may provide an opportunity for the prescriber to participate in provision
of motivational strategies regarding other comorbid conditions.
This principle provides the framework for practice guidelines and
treatment matching generally, including the application of the practice
guidelines to psychopharmacologic practice.
Clinical Practice Guidelines
Utilizing the principles as a foundation, the following
clinical practice guidelines can be developed.
These guidelines include both specific recommended or suggested
practices, as well as providing a suggested sequence for prioritization of
clinical activities.
1. Welcoming: All
psychopharmacologic practitioners should strive to welcome individuals with
co-occurring disorders into treatment as a high risk, high priority population,
and to engage them in empathic, hopeful, integrated and continuing treatment
relationships in which outcomes of psychopharmacologic intervention can be
optimally successful.
2. Access: Because
of the importance of engaging individuals in treatment as quickly as possible,
and because (as will be noted below) initial diagnostic evaluation is based
significantly upon historical data, there
should be no arbitrary length of sobriety requirement for access to comorbid
psychiatric evaluation. Initial evaluations should only require
that the client be able to carry on a reasonable conversation, and not require
that alcohol or drug levels be below any arbitrary figure. Referral for psychopharmacologic evaluation
should occur as quickly as possible (based on triage of acuity and dangerous
risk factors). Maintaining
existing non-addictive psychotropic medication
during detoxification and early recovery is strongly recommended as substance
abuse increases the risk of destabilization of the mental illness.
3. Safety: The
first priority in the evaluation process is to maintain safety, both for the
patient and the treatment staff.
Psychopharmacologic intervention can be vital in this effort. In situations involving acutely dangerous
behavior, it may be necessary to utilize antipsychotics and other sedatives
(including benzodiazepines) to establish behavioral control. In acute withdrawal situations requiring
medical detoxification, use of detoxification medications for addicted
psychiatric patients is no different than for patients with addiction
only.
4. Integrated Assessment
(ILSA): Assessment and diagnosis of individuals with
CODs is based on a process of integrated
longitudinal strength based assessment
(ILSA) (See Center for Substance
Abuse Treatment, Treatment Improvement Protocol #42, 2005), which begins as
soon as the patient is welcomed into care, immediate safety established, and
the capacity to obtain a history (from client or collaterals) is present. This process incorporates a careful chronological description of both
disorders; including emphasis on onset, interactions,
effects of treatment, and contributions to stability and relapse of either disorder. As
with all psychiatric disorders, obtaining information from family members and
collateral caregivers can be extremely
helpful. Particular attention to assessing previous
periods of sobriety or limited use for presence of psychiatric symptoms, and
history of medication responses with or without sobriety can be useful.
Diagnosis
of persistent psychiatric disorders in patients with COD can be difficult given
the overlap of symptoms with substance use disorders. Information about the presence of symptoms
and need for continued psychiatric treatment either prior to onset of substance
use disorder, or during periods of abstinence or low substance use of 30 days
or longer can be vital in making a meaningful psychiatric diagnosis. These periods of time can occur at ANY TIME
in the patient’s history after the onset
of illness, and do not have to be current.
Diagnostic
and treatment decisions regarding psychiatric illness are ideally made when the
comorbid substance disorder is stabilized, ideally for 30 days or longer. Nonetheless, thorough assessment (as
described above) can provide reliable indications for diagnosis and immediate initiation or continuation of
psychopharmacologic treatment, even
for individuals who are actively using.
This is particularly true for individuals with more
serious and persistent mental illness and more severe symptomatology,
regardless of diagnosis.
Diagnostic
and treatment decisions regarding substance disorder are best made when the
comorbid psychiatric disorder is at baseline. Nonetheless, thorough assessment
can provide
reliable information about the course and severity of substance disorder, even
for an individual whose mental illness is destabilized, and can provide
reliable indications for diagnosis and immediate
initiation or continuation of psychopharmacologic treatment (e.g., opiate
maintenance).
Finally,
integrated assessment during periods of stabilization may also provide evidence
that justify rescinding a previously made diagnosis, and carefully
discontinuing medication that may seem to have no further indication, either
because the condition for which treatment was initiated has completely resolved
(e.g., substance induced psychosis), or because further evaluation indicates
that justification for the diagnosis no longer
exists.
5. Continuity: Provision
of necessary non-addictive medication for treatment of psychotic illness and
other known serious mental illness must be initiated or
maintained regardless of continuing
substance use. Individuals whose substance use appears to be
significantly risky warrant closer monitoring or supervision, NOT treatment
discontinuation.
Peer consultation is indicated for cases in which the treating
psychiatrist is considering medication discontinuation due to ongoing substance
use for an individual with known or probable serious and persistent mental
illness, including persistent substance induced disorders.
In patients with
active substance dependence or substance dependent patients in early recovery, non-addictive medication for any
psychiatric disorders may be initiated or maintained,
provided reasonable historical evidence for the value/need for the medication is present.
Over time, within
the context of a continuing psychopharmacologic relationship, continuing
re-evaluation of diagnosis and psychopharmacologic regimes is recommended, both
to insure appropriate continuity of stabilizing medication for established
disorders, as well as to insure discontinuation of medication for disorders
that have resolved, discontinuation of medication that is not effective, and
cautious discontinuation of treatment for disorders whose diagnosis appears to
be no longer supported (while maintaining awareness that there is always a risk
of recurrence in discontinuing medication, even for asymptomatic individuals)..
6. Consultation for
Prescribers: It is highly recommended that every system establish a mechanism
for expert and/or peer consultation to assist both psychopharmacology
prescribers and other members of the treatment team in making decisions
regarding challenging patients. Consultation provides a framework for obtaining
clinical support, as well as for reviewing clinical decision making from a risk
management standpoint. Furthermore, work with people who have CODs can be both
frustrating and very rewarding, and the peer consultation process can be a
vehicle for both recognizing special effort by clinicians, as well as to
support the clinical team when dealing with particularly challenging cases. Examples of appropriate cases for expert or
peer consultation include (but are not limited to):
1.
Continuation of treatment with
benzodiazepines (beyond detoxification) in patients with known substance
dependence.
2.
Discontinuation of psychiatric
medications for a substance using patient with a serious, persistent
psychiatric illness.
3.
Unilateral termination of clinical care
for any patient with CODs
7. Psychopharmacological
Treatment Strategies
A. General principles: In patients with psychotic presentations, with or without
active substance dependence, initiation of treatment for psychosis is generally
urgent. In patients with known active substance
dependence and non-psychotic presentations, it is recommended to utilize the
integrated longitudinal assessment process
to determine the probability of a
treatable mental health diagnosis before medication is initiated. It can be very difficult to make an accurate diagnosis and effectively monitor
treatment without this first step. It is
understood that all diagnoses are “presumptive” and subject to change as new
information becomes available. If there is uncertainty about diagnosis after
reasonable history taking, evidence for initial efforts to discontinue
substance use may need to occur prior to initiation of psychopharmacology, in
order to establish a framework for further diagnostic evaluation. However, for high risk patients, with or
without psychosis, developing a treatment relationship is a priority, and there
should not be an arbitrary length of time required before treatment initiation takes place, nor should absolute diagnostic certainty be
required. Individuals with reasonable
probability of a treatable disorder can be treated
Psychotropic
medications, particularly for anxiety and mood disorders, should be clearly
directed to the treatment of known or probable
psychiatric disorders, not to medicate feelings. It is important to communicate to patients
with addiction that successful treatment of a comorbid anxiety or mood disorder
with medication is not intended to remove normal painful feelings (such as
normal anxiety or depressed feelings).
The medication is meant to help the patient feel his or her painful
feelings accurately, and to facilitate the process of developing healthy
capacities to cope with those feelings without using substances. If psychotropic medications are used for
mental illness in individuals with addiction, or if medication is used in the
treatment of the addiction itself, the following precepts may be helpful to
communicate to the patient:
“The use of
medication for either type of disorder does not imply that it is no longer
necessary for the patient to focus on the
importance of his/her own work in recovery from addiction. Consequently,
utilizing medication to help treat addiction should always
be considered as an ancillary tool to a full addiction recovery program.”
Addicts
in early recovery have great difficulty regulating medication; fixed dose regimes, not PRN's, are recommended in the
treatment of mood and anxiety disorders.
Just
as in individuals with single disorders, and perhaps more so, it is important
to engage patients with co-occurring disorders as much as possible in
understanding the nature of the illness or illnesses for which they are being
treated, and to participating in partnership with prescribers in determining
the best course of treatment. For this
reason, most established medication algorithms (e.g. TMAP) and practice
guidelines recommend that medication
education and peer support regarding understanding the risks and benefits
of medication use are incorporated into standard treatment practice. This is certainly true for individuals with
co-occurring disorders, for whom information provided by peers may be
particularly helpful in making good choices and decisions regarding both taking
medication and reduction or elimination of substance use.
1. Psychotic
Disorders: Use the best psychotropic agent available for
the condition. Improving psychotic or negative symptoms may promote substance recovery. This
includes treatment of substance-induced psychoses, as well as psychosis
associated with conventional psychiatric disorders.
a. Atypical neuroleptics: Consider
olanzapine, risperidone, quetiapine, aripiprazole, ziprasidone or clozapine. In addition, it is well documented that
clozapine has a direct effect on reducing substance use in this population,
beyond any improvement in psychotic symptoms, and therefore may be specifically
indicated for selected patients.
b. Typical neuroleptics: Consider use in
adjunct to the atypicals, especially in situations of acute agitation,
unresolved psychosis, and acute decompensation
c. Many
individuals with cod will benefit from depot antipsychotic medications. Both
typical and atypical neuroleptics (e.g., risperidone) are available in depot
form. There have not been specific
studies about the utilization of depot risperidone in individuals with
co-occurring substance use disorder, but there is no apparent contraindication
to its use.
2. Major Depression:
The relative safety profile of SSRI’s (and to a somewhat lesser extend SNRI’s
such as venlafaxine), other newer generation antidepressants and possibly
buproprion (though higher seizure risk must be considered) make their use
reasonable (risk-benefit assessment) in the treatment of individuals with
CODs. SSRI’s have been demonstrated to
be associated with lower alcohol use in a subset of alcohol dependent patients,
with or without depression. The use of
tricyclic antidepressants (TCAs) and MAO inhibitors (MAOIs) can be more
difficult and possibly more dangerous in the COD population if there is a risk
of active substance use..
3. Bipolar Disorder:
Use the best mood stabilizer or combination of mood stabilizers that match the
needs of the patient. Be aware that
rapid cycling and mixed states may be more common, hence consider valproate,
oxycarbamazepine, carbamazepine or olanzapine (and other atypicals), in
patients who may have these variants.
4. ADHD: Initial treatment recommendations, in
early sobriety, have included buproprion. Recently, atomoxetine has been
available, and may be a reasonable first choice, though there have not been
specific studies in co-occurring populations.
In both adolescents and adults, there is clear evidence that if
stimulant medications are necessary to stabilize ADHD, then these medications
can be used safely, once addiction is adequately stabilized and/or the patient
is properly monitored, and will be associated with better outcomes for both
ADHD and substance use disorder.
5. Anxiety disorders:
Consider SSRIs, venlafaxine, buspirone, clonidine and possibly mood stabilizers
such as valproate, carbamazepine, oxycarbamazepine, gabapentin, and topiramate,
as well as atypical neuroleptics. There is evidence of effectiveness of
topiramate for nightmares and flashbacks associated with PTSD.
For patients with known substance
dependence (active or remitted), the continuation of prescriptions for of
benzodiazepines, addictive pain medications, or non- specific
sedative/hypnotics is not recommended, with or without comorbid psychiatric
disorder. On the other hand, medications with addiction potential should not be
withheld for carefully selected patients with well-established abstinence who demonstrates specific beneficial responses to
them without signs of misuse, merely because
of a history of addiction. However, consideration of continuing prescription of potentially addictive medications
for consumers with diagnosed substance
dependence, is an indication for both (a) careful discussion of risks and benefits with the patient (and, where indicated,
the family) and (b) documentation of expert
consultation or peer review.
Sleep
disturbances are common in mental illness as well as
substance use disorders in early recovery. Use of non-addictive sedating
medications (e.g., trazodone) may be used with a careful risk benefit
assessment.
C. Psychopharmacologic Strategies in
the Treatment of Substance Use Disorders
There is an increasing repertoire of medications
available to treat substance use disorders, including medications that appear
to directly interrupt the core brain processes associated with lack of control
of use. All of these medications have
demonstrated effectiveness in populations who may also have psychiatric
disorders, including severe mental illnesses.
1. Disulfiram
A. Disulfiram interferes with the
metabolism of alcohol via alcohol dehydrogenase, so that individuals who use
alcohol will get ill to varying degrees when taking this medication. This can be a valuable tool in assisting
individuals to resist impulsive drinking, but generally must be combined with
additional recovery programming and/or positive contingencies. Disulfiram should NOT be used to coerce
sobriety in any patient.
B. As a dopamine beta-hydroxylase inhibitor,
disulfiram occasionally will exacerbate psychosis, necessitating adjustment of
antipsychotic medication
C. As a dopamine beta-hydroxylase inhibitor,
disulfiram has also been found to reduce
cocaine craving and cocaine usage in some studies.
2. Opiate
maintenance treatment
A. Methadone
and LAAM are well established treatments for opiate dependence, and have
been found to be successful in individuals with a wide range of psychiatric
comorbidity, in the context of methadone treatment programs.. Methadone dosing is now informed by the
capacity to measure trough levels. The
prescriber must be aware that there are enzymatic interactions that affect the
interaction of methadone with various psychotropics, the details of which are
beyond the scope of these guidelines, but which should be reviewed when such
combinations are being initiated.
B. Buprenorphine has been more
recently introduced for opiate maintenance, does not require participation in a
formal “program”, like methadone, and can be provided in office based settings
by physicians who have addiction specialization and/or who have had eight hours
of training. Oral buprenorphine is
provided combined with naloxone to prevent diversion for parenteral use. It is
a mixed m-opiate receptor agonist () and a k-receptor antagonist, that appears
to be easier to utilize, with fewer side effects, and less severe abuse or
withdrawal risk, than methadone.
Although not well studied in the co-occurring disordered population, all
indications in the literature indicate that it is effective. Again, there are a range of interactions that
may occur with enzymes that metabolize psychotropic medication, that need to be
reviewed when initiating treatment.
3. Naltrexone
A. Opiate dependence: Naltrexone is a
relatively long acting opiate blocker that can be effective given three times
weekly for opiate dependence, particularly when combined with significant
contingencies to support adherence.
B. Alcohol dependence: Naltrexone has been
demonstrated to be effective in reducing alcohol use through reducing craving
and loss of control, presumably by affecting endogenous opiate pathways that
are involved in the development of the brain disorder of alcohol
dependence. Naltrexone has been
demonstrated to be effective in individuals with schizophrenia and other mental
illnesses in preliminary studies.
4. Acamprosate Available in
5.
Bupropion for nicotine dependence appears to have an effect on reward pathways associated with nicotine use. . Nicotine replacement for nicotine dependence, including
nicotine patch, gum, and more recently, nasal
spray, which most closely mimics the
effects of smoking in nicotine delivery.
Bupropion and nicotine replacement combined tend to result in better outcomes than either alone
6. Topiramate
for alcohol dependence (one study) has some potential value through
its effect on GABA receptors
7. Desipramine
for cocaine craving has yielded very inconsistent findings.
8. Dopaminergic
agents for cocaine craving have also yielded inconsistent findings,
with risk of exacerbation of psychosis.
9.
Serotoninergic agents (e.g., SSRIs) have been found in some studies
to have
a beneficial effect in reducing alcohol use in non-depressed alcoholics, particularly in certain
subtypes of alcohol dependence.
D. General Strategies for Managing
Interactive Effects of Substance Use on Psychiatric Symptoms and Interventions
The effects of
various substances on psychiatric presentations and on psychiatric treatment
are quite variable. Discussion of the
effects of each type of substance on psychiatric symptoms and medications are
described in most textbooks, and are beyond the scope of these guidelines. The
prescriber should always keep in mind that the best way to evaluate the effect
of a particular pattern of substance use on a particular client is to get a
good history from that client and collaterals.
Further, although there are unquestionably unpredictable risks that may
be attached to continuing substance use in individuals receiving psychiatric
care, the risks of poor outcome associated with NOT TREATING a known mental
illness appear to significantly outweigh the risks of continuing treatment in
an individual who is continuing to use substances. Individuals who engage in particularly risky
behavior should be monitored more closely, not discontinued from necessary
psychiatric or medical treatment.
E. Special Stage Specific Strategies
1.
Motivational
Interventions: In clinical situations where the
psychiatric diagnosis and/or severity of substance disorder
are unclear, psychotropic medications may be initiated if there is a reasonable
indication, and used as part of a strategy to facilitate
engagement in treatment and the creation of contingency contracts to promote abstinence.
2.
Contingency
Management Interventions:
Within the context of a psychopharmacologic relationship where necessary
medication is provided, interventions that may be considered optional or
discretionary can be linked to incremental progress in addressing substance use
disorders. In addition, in individuals
receiving benzodiazepines, emergence of substance use can be addressed by
creating contingency plans that allow the individual to maintain benzodiazepine
dosage only if abstinence is maintained. Slow reduction of dosage can offer
multiple opportunities for the patient to regain the original dosage by
re-establishing abstinence. Evidence of
severe overuse or overdosage with benzodiazepines, however, is usually an
indication for discontinuation, often in a hospital setting.
8. Continuing Evaluation and Re-evaluation
It is important not to expect that diagnostic
certainty can be obtained at the beginning of treatment. Individuals may begin on medication for a
presumed diagnosis during periods of substance use, and once they have stopped
using the presumed diagnosis may appear to clear up, necessitating the
discontinuation of medication.
Conversely, once individuals stop using, psychiatric disorders may
emerge or worsen, requiring the initiation of medication. It is important to maintain an open minded
stance, and to consider all possibilities.
Each patient must be considered as an individual, and continuity of care
provides an opportunity to become increasingly more accurate about diagnosis
and treatment over time.