User login
Caring for patients with co-occurring mental health & substance use disorders
THE CASE
Janice J* visits her family physician with complaints of chest pain, shortness of breath, and heart palpitations that are usually worse at night. Her medical history is significant for deep vein thrombosis secondary to an underlying hypercoagulability condition (rheumatoid arthritis) diagnosed 2 months earlier. She also has a history of opioid use disorder and has been on buprenorphine/naloxone therapy for 3 years. Her family medical history is unremarkable. She works full-time and lives with her 8-year-old son. On physical exam, she appears anxious; her cardiac and pulmonary exams are normal. A completed workup rules out cardiac or pulmonary problems.
- What is your diagnosis?
- How would you treat this patient?
* The patient’s name has been changed to protect her identity.
CO-OCCURRING DISORDERS: SCOPE OF THE PROBLEM
Co-occurring disorders, previously called “dual diagnosis,” refers to the coexistence of a mental health disorder and a substance use disorder. The obsolete term, dual diagnosis, specified the presence of 2 co-occurring Axis I diagnoses or the presence of an Axis I diagnosis and an Axis II diagnosis (such as mental disability). The change in nomenclature more precisely describes the co-existing mental health and substance use disorders.
Currently the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, (DSM-5) includes no diagnostic criteria for this dual condition.1 The criteria for mental health disorders and for substance use disorders comprise separate lists. Criteria for substance use disorder fall broadly into categories of “impaired [self] control, social impairment, risky behaviors, increased tolerance, and withdrawal symptoms.”1 It is estimated that 8.5 million US adults have co-occurring disorders, per the 2017 National Survey on Drug Use and Health conducted by the Substance Abuse and Mental Health Services Administration.2 Distinguishing which of the 2 conditions occurred first can be challenging. It has been suggested that the lifetime prevalence of a mental health disorder with a coexisting substance use disorder is greater than 40%3,4 (TABLE 11,4-8). For patients with schizophrenia and bipolar disorder, these numbers may be higher.
The consequences of undiagnosed and untreated co-occurring disorders include poor medication adherence, physical comorbidities (and decreased overall health), diminished self-care, increased suicide risk or aggression, increased risky sexual behavior, and possible incarceration.9
WHEN SHOULD YOU SUSPECT CO-OCCURRING DISORDERS?
Diagnosing a second condition can also be difficult when a patient’s symptoms are actually adverse effects of substances or prescribed medications. For example, a patient with worsening anxiety may also exhibit increasing blood pressure resistant to treatment. The cause of the patient’s fluctuating blood pressures may actually be the result of his or her use of alcohol to self-treat the anxiety. In addition to self-medication, other underlying factors may be at play, including genetic vulnerability, environment, and lifestyle.14 In the case we present, the patient’s conditions arose independently.
Anxiety disorders, with a lifetime risk of 28.8% in the US population,4 may be the primary mental health issue in many patients with co-occurring disorders, but this cannot be assumed in lieu of a complete workup.2,8,9,15 Substance use disorders in the general population have a past-year and lifetime prevalence of 14.6%.1,4,16,17 Because the causal and temporal association between anxiety and substance abuse is not always clear, it’s important to separate the diagnoses of the mental health and substance use disorders.
Continue to: MAKING THE DIAGNOSIS
MAKING THE DIAGNOSIS
To make an accurate diagnosis of co-occurring disorder, it is essential to take a complete history focusing on the timeline of symptoms, previous diagnoses and treatments, if any, and substance-free periods. Details gathered from these inquiries will help to separate symptoms of a primary mental health disorder from adverse effects of medication, withdrawal symptoms, or symptoms related to an underlying chronic medical condition.
Optimally, the diagnosis of a mental health disorder should be considered following a substance-free period. If this is not possible, a chart review may reveal a time when the patient did not have a substance use disorder.18
A diagnosis of substance use disorder requires that the patient manifest at least 2 of 11 behaviors listed in the DSM-5 over a 12-month period.1 The criteria focus on the amount of substance used, the time spent securing the substance, risky behaviors associated with the substance, and tolerance to the substance.
DON'T DEFER MENTAL HEALTH Tx
It is necessary to treat co-occurring disorders simultaneously. The old idea of deferring treatment of a mental health issue until the substance use disorder is resolved no longer applies.19,20 Treating substance use problems without addressing comorbid mental health issues can negatively impact treatment progress and increase risk for relapse. In a similar way, leaving substance use problems untreated is associated with nonadherence in mental health treatment, poor engagement, and dropout.21,22
Integrated services. Due to this condition’s level of clinical complexity, the optimal treatment approach is an interdisciplinary one in which integrated services are offered at a single location by a team of medical, mental health, and substance use providers (see “The case for behavioral health integration into primary care” in the June issue). An evidence-based example of such an approach is the Integrated Dual Disorder Treatment (IDDT) model—a comprehensive, integrated method of treating severe mental health disorders, including substance use disorders.21,22 IDDT combines coordinated services such as pharmacologic, psychological, educational, and social interventions to address the needs of patients and their family members. The IDDT model conceptualizes and treats co-occurring disorders within a biopsychosocial framework. Specific services may include medical detoxification, pharmacotherapy, patient and family education, behavioral and cognitive therapies, contingency management, self-help support groups, supported employment, residential/housing assistance, and case management services.23,24
Continue to: Medications for the mental health component
Medications for the mental health component. For patients who prefer medication treatment to cognitive behavioral therapy (CBT), or for whom CBT is unavailable, treat the mental health disorder per customary practice for the diagnosis (TABLE 225-30). For psychotic disorders, use an antipsychotic, adding a selective serotonin reuptake inhibitor (SSRI) or serotonin-norepinephrine reuptake inhibitor (SNRI) as needed depending on the presence of negative symptoms.25,31 For bipolar spectrum disorder, start a mood stabilizer32; for depressive disorders initiate an SSRI or SNRI.27 Anxiety disorders respond optimally when treated with SSRIs or SNRIs. Buspirone may be prescribed alone or as an adjunct for anxiety, and it does not cause mood-altering or withdrawal effects. Benzodiazepines in a controlled and monitored setting are an option in some antianxiety treatment plans. Consultation with a psychiatrist will help to determine the best treatment in these situations.
In all cases, treat the substance use disorder concurrently. Treatment options vary depending on the substance of choice. Although often overlooked, there can be simultaneous nicotine abuse. Oral or inhaled medications for nicotine abuse treatment are limited. The range of pharmacologic options for alcohol use disorder includes naltrexone, acamprosate, and disulfiram.29,33 Pharmacologic treatment options for opioid use disorder include naltrexone, methadone, and a combination of naloxone and buprenorphine.34
Physicians who wish to prescribe buprenorphine must qualify for and complete a certified 8 hour waiver-training course, which is then approved by the Drug Enforcement Agency (under the DATA 2000 – Drug and Alcohol Act 2000). The physician obtains the designation of a data-waived physician and is assigned a special identification number to prescribe these medications.35,36 Methadone may be provided only in a licensed methadone maintenance program. Regular and random drug urine screen requirements apply to all treatment programs.
Psychosocial and behavioral interventions are essential to the successful treatment of co-occurring disorders. Evidence-based behavioral and cognitive therapies are recommended for promoting adaptive coping skills and healthy lifestyle behaviors in co-occurring disorder populations.23,24,37-40 Motivational interviewing enhances motivation and adherence when patients demonstrate resistance or ambivalence.41,42 Mindfulness-based interventions have been shown to be effective and may be particularly beneficial for treating cravings/urges and promoting relapse prevention.37,39,40,43-46
Psychotropic medications, as with other treatment components, are most effective when used in combination with services that simultaneously address the patient’s biological, psychological, and social needs.
Continue to: The grassroots organization...
The grassroots organization National Alliance on Mental Illness (www.nami.org) recommends self-help and support groups, which include 12-step, faith-based and non-faith–based programs.20
For any treatment method to be successful, there needs to be a level of customization and individualization. Some patients may respond to medication or nonmedication treatments only, and others may need a combination of treatments.
CASE
The physician recalls a past diagnosis of anxiety and asks Ms. J if there are any new stressors or changes causing concern. The patient expresses concern about an opioid use relapse secondary to her recent diagnosis of rheumatoid arthritis, which may be life altering or limiting.
Even though she has been doing well and has been adherent to her daily buprenorphine treatment, she worries for the well-being of her family and what would happen if she cannot work, becomes incapacitated, or dies at a young age. She has never considered herself an anxious person and is surprised that anxiety could cause such pronounced physical symptoms.
The physician discusses different modalities of treatment, including counseling with an onsite psychologist, a trial of an anti-anxiety medication such as sertraline, or return office visits with the physician. They decide first to schedule an appointment with the psychologist, and Ms. J promises to find more time for self-wellness activities, such as exercise.
After 3 months of therapy, the patient decides to space out treatment to every 2 to 3 months and does not report any more episodes of chest pain or shortness of breath.
CORRESPONDENCE
Kristen Rundell, MD, Northwood-High Building, 2231 N. High Street, Suite 211, Columbus, OH 43201; kristen.rundell@osumc.edu.
1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: APA; 2013.
2. SAMHSA. Key substance use and mental health indicators in the United States: results from the 2017 National Survey on Drug Use and Health. 2017. https://www.samhsa.gov/data/sites/default/files/cbhsq-reports/NSDUHFFR2017/NSDUHFFR2017.htm#cooccur2. Accessed August 16, 2019.
3. Conway KP, Compton W, Stinson FS, et al. Lifetime comorbidity of DSM-IV mood and anxiety disorders and specific drug use disorders: results from the National Epidemiologic Survey on Alcohol and Related Conditions. J Clin Psychiatry. 2006;67:247-257.
4. Kessler RC, Berglund P, Demler O, et al. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62:593-602.
5. Grant BF, Stinson FS, Dawson DA, et al. Prevalence and co-occurrence of substance use disorders and independent mood and anxiety disorders: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry. 2004;61:807-816.
6. Dixon L. Dual diagnosis of substance abuse in schizophrenia: prevalence and impact on outcomes. Schizophr Res. 1999;35(suppl):S93-S100.
7. Merikangas KR, Jin R, He JP, et al. Prevalence and correlates of bipolar spectrum disorder in the World Mental Health Survey Initiative. Arch Gen Psychiatry. 2011;68:241-251.
8. Cottler LB, Compton WM 3rd, Mager D, et al. Posttraumatic stress disorder among substance users from the general population. Am J Psychiatry. 1992;149:664-670.
9. Kessler RC, Angermeyer M, Anthony JC, et al. Lifetime prevalence and age-of-onset distributions of mental disorders in the World Health Organization’s World Mental Health Survey Initiative. World Psychiatry. 2007;6:168-176.
10. Burns L, Teesson M, O’Neill K. The impact of comorbid anxiety and depression on alcohol treatment outcomes. Addiction. 2005;100:787-796.
11. Magidson JF, Liu SM, Lejuez CW, et al. Comparison of the course of substance use disorders among individuals with and without generalized anxiety disorder in a nationally representative sample. J Psychiatr Res. 2012;46:659666.
12. Boschloo L, Vogelzangs N, van den Brink W, et al. Alcohol use disorders and the course of depressive and anxiety disorders. Br J Psychiatry. 2012;200:476-484.
13. Schuckit MA. Comorbidity between substance use disorders and psychiatric conditions. Addiction. 2006;101(suppl 1):76-88.
14. Buckley PF. Prevalence and consequences of the dual diagnosis of substance abuse and severe mental illness. J Clin Psychiatry. 2006;67(suppl 7):5-9.
15. Salo R, Flower K, Kielstein A, et al. Psychiatric comorbidity in methamphetamine dependence. Psychiatry Res. 2011;186:356-361.
16. Torrens M, Gilchrist G, Domingo-Salvany A. Psychiatric comorbidity in illicit drug users: substance-induced versus independent disorders. Drug Alcohol Depend. 2011;113:147-156.
17. Buckner JD, Timpano KR, Zvolensky MJ, et al. Implications of comorbid alcohol dependence among individuals with social anxiety disorder. Depress Anxiety. 2008;25:1028-1037.
18. Kushner MG, Abrams K, Borchardt C. The relationship between anxiety disorders and alcohol use disorders: a review of major perspectives and findings. Clin Psychol Rev. 2000;20:149-171.
19. McHugh RK. Treatment of co-occurring anxiety disorders and substance use disorders. Harv Rev Psychiatry. 2015;23:99-111.
20. National Alliance on Mental Illness. Dual diagnosis. NAMI Web site. www.nami.org/Learn-More/Mental-Health-Conditions/related-conditions/dual-diagnosis. Reviewed August 2017. Accessed July 23, 2019.
21. SAMSHA. Substance Abuse Treatment for Persons with Co-Occurring Disorders. Treatment Improvement Protocol (TIP) series No. 42. HHS Publication No. (SMA) 13-3992. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2013.
22. SAMHSA. Treatment of co-occurring disorders. In: Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2005.
23. Drake RE, Mueser KT, Brunette MF, et al. A review of treatments for people with severe mental illnesses and co-occurring substance use disorders. Psychiatr Rehabil J. 2004;27:360-374.
24. Kola LA, Kruszynski R. Adapting the integrated dual-disorder treatment model for addiction services. Alcohol Treat Q. 2010;28:437-450.
25. American Psychiatric Association. Practice guideline for the treatment of patients with schizophrenia, 2nd ed. https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/schizophrenia.pdf. Published 2010. Accessed August 2, 2019.
26. American Psychiatric Association. Practice guideline for the treatment of patients with bipolar disorder, 2nd ed. https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/bipolar.pdf. Published 2010. Accessed August 2, 2019.
27. American Psychiatric Association. Practice Guideline for the Treatment of Patients with Major Depressive Disorder. https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/mdd.pdf. Published October 2010. Accessed July 23, 2019.
28. American Psychiatric Association. Practice guideline for the treatment of patients with panic disorder, 2nd ed. https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/panicdisorder.pdf. Published January 2009. Accessed August 2, 2019.
29. American Psychiatric Association. Practice guideline for the pharmacological treatment of patients with alcohol use disorder. https://psychiatryonline.org/doi/pdf/10.1176/appi.books.9781615371969. Accessed August 2, 2019.
30. American Psychiatric Association. Practice guideline for the treatment of patients with substance use disorders, 2nd ed. https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/substanceuse.pdf. Published 2010. Accessed August 2, 2019.
31. Petrakis IL, Nich C, Ralevski E. Psychotic spectrum disorders and alcohol abuse: a review of pharmacotherapeutic strategies and a report on the effectiveness of naltrexone and disulfiram. Schizophr Bull. 2006;32:644-654.
32. McIntyre RS, Yoon J. Efficacy of antimanic treatments in mixed states. Bipolar Disord. 2012;14(suppl 2):22-36.
33. Volpicelli JR, Alterman AI, Hayashida M, et al. Naltrexone in the treatment of alcohol dependence. Arch Gen Psychiatry. 1992;49:876-880.
34. Lee JD, Nunes EV Jr, Novo P, et al. Comparative effectiveness of extended-release naltrexone versus buprenorphine-naloxone for opioid relapse prevention (X:BOT): a multicentre, open-label, randomized controlled trial. Lancet. 2018;391:309-318.
35. US Department of Justice. DEA requirements for DATA waived physicians (DWPs). Drug Enforcement Administration, Diversion Control Division Web site. www.deadiversion.usdoj.gov/pubs/docs/dwp_buprenorphine.htm. Accessed August 2, 2019.
36. SAMHSA. Buprenorphine waiver management. https://www.samhsa.gov/medication-assisted-treatment/buprenorphine-waiver-management. SAMHSA Web site. Updated May 7, 2019. Accessed August 2, 2019.
37. Bowen S, Chawla N, Witkiewitz K. Mindfulness-based relapse prevention for addictive behaviors. In: Baer RA, ed. Mindfulness-Based Treatment Approaches: A Clinician’s Guide to Evidence Base and Applications. London, UK: Elsevier; 2014.
38. Dixon L, McFarlane W, Lefley H, et al. Evidence-based practices for services to families of people with psychiatric disabilities. Psychiatr Serv. 2001;52:903-910.
39. Hayes SC, Levin M, Plumb-Vilardaga J, et al. Acceptance and commitment therapy and contextual behavioral science: examining the progress of a distinctive model of behavioral and cognitive therapy. Behav Ther. 2013;44:180-198.
40. Osilla KC, Hepner KA, Muñoz RF, et al. Developing an integrated treatment for substance use and depression using cognitive behavioral therapy. J Subst Abuse Treat. 2009;37:412-420.
41. Martino S, Carroll K, Kostas D, et al. Dual diagnosis motivational interviewing: a modification of motivational interviewing for substance-abusing patients with psychotic disorders. J Subst Abuse Treat. 2002;23:297-308.
42. Rollnick S, Miller WR. What is motivational interviewing? Behav Cogn Psychother. 1995;23:325-334.
43. Garland EL. Disrupting the downward spiral of chronic pain and opioid addiction with mindfulness-oriented recovery enhancement: a review of clinical outcomes and neurocognitive targets. J Pain Palliat Care Pharmacother. 2014;28:122-129.
44. Garland EL, Manusov EG, Froeliger B, et al. Mindfulness-oriented recovery enhancement for chronic pain and prescription opioid misuse: results from an early-stage randomized controlled trial. J Consult Clin Psychol. 2014;82:448-459.
45. Marlatt GA, Donovan DM. Relapse Prevention: Maintenance Strategies in the Treatment of Addictive Behaviors, 2nd ed. New York, NY: Guilford Press; 2007.
46. Zgierska A, Rabago D, Chawla N, et al. Mindfulness meditation for substance use disorders: a systematic review. Subst Abus. 2009;30:266-294.
THE CASE
Janice J* visits her family physician with complaints of chest pain, shortness of breath, and heart palpitations that are usually worse at night. Her medical history is significant for deep vein thrombosis secondary to an underlying hypercoagulability condition (rheumatoid arthritis) diagnosed 2 months earlier. She also has a history of opioid use disorder and has been on buprenorphine/naloxone therapy for 3 years. Her family medical history is unremarkable. She works full-time and lives with her 8-year-old son. On physical exam, she appears anxious; her cardiac and pulmonary exams are normal. A completed workup rules out cardiac or pulmonary problems.
- What is your diagnosis?
- How would you treat this patient?
* The patient’s name has been changed to protect her identity.
CO-OCCURRING DISORDERS: SCOPE OF THE PROBLEM
Co-occurring disorders, previously called “dual diagnosis,” refers to the coexistence of a mental health disorder and a substance use disorder. The obsolete term, dual diagnosis, specified the presence of 2 co-occurring Axis I diagnoses or the presence of an Axis I diagnosis and an Axis II diagnosis (such as mental disability). The change in nomenclature more precisely describes the co-existing mental health and substance use disorders.
Currently the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, (DSM-5) includes no diagnostic criteria for this dual condition.1 The criteria for mental health disorders and for substance use disorders comprise separate lists. Criteria for substance use disorder fall broadly into categories of “impaired [self] control, social impairment, risky behaviors, increased tolerance, and withdrawal symptoms.”1 It is estimated that 8.5 million US adults have co-occurring disorders, per the 2017 National Survey on Drug Use and Health conducted by the Substance Abuse and Mental Health Services Administration.2 Distinguishing which of the 2 conditions occurred first can be challenging. It has been suggested that the lifetime prevalence of a mental health disorder with a coexisting substance use disorder is greater than 40%3,4 (TABLE 11,4-8). For patients with schizophrenia and bipolar disorder, these numbers may be higher.
The consequences of undiagnosed and untreated co-occurring disorders include poor medication adherence, physical comorbidities (and decreased overall health), diminished self-care, increased suicide risk or aggression, increased risky sexual behavior, and possible incarceration.9
WHEN SHOULD YOU SUSPECT CO-OCCURRING DISORDERS?
Diagnosing a second condition can also be difficult when a patient’s symptoms are actually adverse effects of substances or prescribed medications. For example, a patient with worsening anxiety may also exhibit increasing blood pressure resistant to treatment. The cause of the patient’s fluctuating blood pressures may actually be the result of his or her use of alcohol to self-treat the anxiety. In addition to self-medication, other underlying factors may be at play, including genetic vulnerability, environment, and lifestyle.14 In the case we present, the patient’s conditions arose independently.
Anxiety disorders, with a lifetime risk of 28.8% in the US population,4 may be the primary mental health issue in many patients with co-occurring disorders, but this cannot be assumed in lieu of a complete workup.2,8,9,15 Substance use disorders in the general population have a past-year and lifetime prevalence of 14.6%.1,4,16,17 Because the causal and temporal association between anxiety and substance abuse is not always clear, it’s important to separate the diagnoses of the mental health and substance use disorders.
Continue to: MAKING THE DIAGNOSIS
MAKING THE DIAGNOSIS
To make an accurate diagnosis of co-occurring disorder, it is essential to take a complete history focusing on the timeline of symptoms, previous diagnoses and treatments, if any, and substance-free periods. Details gathered from these inquiries will help to separate symptoms of a primary mental health disorder from adverse effects of medication, withdrawal symptoms, or symptoms related to an underlying chronic medical condition.
Optimally, the diagnosis of a mental health disorder should be considered following a substance-free period. If this is not possible, a chart review may reveal a time when the patient did not have a substance use disorder.18
A diagnosis of substance use disorder requires that the patient manifest at least 2 of 11 behaviors listed in the DSM-5 over a 12-month period.1 The criteria focus on the amount of substance used, the time spent securing the substance, risky behaviors associated with the substance, and tolerance to the substance.
DON'T DEFER MENTAL HEALTH Tx
It is necessary to treat co-occurring disorders simultaneously. The old idea of deferring treatment of a mental health issue until the substance use disorder is resolved no longer applies.19,20 Treating substance use problems without addressing comorbid mental health issues can negatively impact treatment progress and increase risk for relapse. In a similar way, leaving substance use problems untreated is associated with nonadherence in mental health treatment, poor engagement, and dropout.21,22
Integrated services. Due to this condition’s level of clinical complexity, the optimal treatment approach is an interdisciplinary one in which integrated services are offered at a single location by a team of medical, mental health, and substance use providers (see “The case for behavioral health integration into primary care” in the June issue). An evidence-based example of such an approach is the Integrated Dual Disorder Treatment (IDDT) model—a comprehensive, integrated method of treating severe mental health disorders, including substance use disorders.21,22 IDDT combines coordinated services such as pharmacologic, psychological, educational, and social interventions to address the needs of patients and their family members. The IDDT model conceptualizes and treats co-occurring disorders within a biopsychosocial framework. Specific services may include medical detoxification, pharmacotherapy, patient and family education, behavioral and cognitive therapies, contingency management, self-help support groups, supported employment, residential/housing assistance, and case management services.23,24
Continue to: Medications for the mental health component
Medications for the mental health component. For patients who prefer medication treatment to cognitive behavioral therapy (CBT), or for whom CBT is unavailable, treat the mental health disorder per customary practice for the diagnosis (TABLE 225-30). For psychotic disorders, use an antipsychotic, adding a selective serotonin reuptake inhibitor (SSRI) or serotonin-norepinephrine reuptake inhibitor (SNRI) as needed depending on the presence of negative symptoms.25,31 For bipolar spectrum disorder, start a mood stabilizer32; for depressive disorders initiate an SSRI or SNRI.27 Anxiety disorders respond optimally when treated with SSRIs or SNRIs. Buspirone may be prescribed alone or as an adjunct for anxiety, and it does not cause mood-altering or withdrawal effects. Benzodiazepines in a controlled and monitored setting are an option in some antianxiety treatment plans. Consultation with a psychiatrist will help to determine the best treatment in these situations.
In all cases, treat the substance use disorder concurrently. Treatment options vary depending on the substance of choice. Although often overlooked, there can be simultaneous nicotine abuse. Oral or inhaled medications for nicotine abuse treatment are limited. The range of pharmacologic options for alcohol use disorder includes naltrexone, acamprosate, and disulfiram.29,33 Pharmacologic treatment options for opioid use disorder include naltrexone, methadone, and a combination of naloxone and buprenorphine.34
Physicians who wish to prescribe buprenorphine must qualify for and complete a certified 8 hour waiver-training course, which is then approved by the Drug Enforcement Agency (under the DATA 2000 – Drug and Alcohol Act 2000). The physician obtains the designation of a data-waived physician and is assigned a special identification number to prescribe these medications.35,36 Methadone may be provided only in a licensed methadone maintenance program. Regular and random drug urine screen requirements apply to all treatment programs.
Psychosocial and behavioral interventions are essential to the successful treatment of co-occurring disorders. Evidence-based behavioral and cognitive therapies are recommended for promoting adaptive coping skills and healthy lifestyle behaviors in co-occurring disorder populations.23,24,37-40 Motivational interviewing enhances motivation and adherence when patients demonstrate resistance or ambivalence.41,42 Mindfulness-based interventions have been shown to be effective and may be particularly beneficial for treating cravings/urges and promoting relapse prevention.37,39,40,43-46
Psychotropic medications, as with other treatment components, are most effective when used in combination with services that simultaneously address the patient’s biological, psychological, and social needs.
Continue to: The grassroots organization...
The grassroots organization National Alliance on Mental Illness (www.nami.org) recommends self-help and support groups, which include 12-step, faith-based and non-faith–based programs.20
For any treatment method to be successful, there needs to be a level of customization and individualization. Some patients may respond to medication or nonmedication treatments only, and others may need a combination of treatments.
CASE
The physician recalls a past diagnosis of anxiety and asks Ms. J if there are any new stressors or changes causing concern. The patient expresses concern about an opioid use relapse secondary to her recent diagnosis of rheumatoid arthritis, which may be life altering or limiting.
Even though she has been doing well and has been adherent to her daily buprenorphine treatment, she worries for the well-being of her family and what would happen if she cannot work, becomes incapacitated, or dies at a young age. She has never considered herself an anxious person and is surprised that anxiety could cause such pronounced physical symptoms.
The physician discusses different modalities of treatment, including counseling with an onsite psychologist, a trial of an anti-anxiety medication such as sertraline, or return office visits with the physician. They decide first to schedule an appointment with the psychologist, and Ms. J promises to find more time for self-wellness activities, such as exercise.
After 3 months of therapy, the patient decides to space out treatment to every 2 to 3 months and does not report any more episodes of chest pain or shortness of breath.
CORRESPONDENCE
Kristen Rundell, MD, Northwood-High Building, 2231 N. High Street, Suite 211, Columbus, OH 43201; kristen.rundell@osumc.edu.
THE CASE
Janice J* visits her family physician with complaints of chest pain, shortness of breath, and heart palpitations that are usually worse at night. Her medical history is significant for deep vein thrombosis secondary to an underlying hypercoagulability condition (rheumatoid arthritis) diagnosed 2 months earlier. She also has a history of opioid use disorder and has been on buprenorphine/naloxone therapy for 3 years. Her family medical history is unremarkable. She works full-time and lives with her 8-year-old son. On physical exam, she appears anxious; her cardiac and pulmonary exams are normal. A completed workup rules out cardiac or pulmonary problems.
- What is your diagnosis?
- How would you treat this patient?
* The patient’s name has been changed to protect her identity.
CO-OCCURRING DISORDERS: SCOPE OF THE PROBLEM
Co-occurring disorders, previously called “dual diagnosis,” refers to the coexistence of a mental health disorder and a substance use disorder. The obsolete term, dual diagnosis, specified the presence of 2 co-occurring Axis I diagnoses or the presence of an Axis I diagnosis and an Axis II diagnosis (such as mental disability). The change in nomenclature more precisely describes the co-existing mental health and substance use disorders.
Currently the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, (DSM-5) includes no diagnostic criteria for this dual condition.1 The criteria for mental health disorders and for substance use disorders comprise separate lists. Criteria for substance use disorder fall broadly into categories of “impaired [self] control, social impairment, risky behaviors, increased tolerance, and withdrawal symptoms.”1 It is estimated that 8.5 million US adults have co-occurring disorders, per the 2017 National Survey on Drug Use and Health conducted by the Substance Abuse and Mental Health Services Administration.2 Distinguishing which of the 2 conditions occurred first can be challenging. It has been suggested that the lifetime prevalence of a mental health disorder with a coexisting substance use disorder is greater than 40%3,4 (TABLE 11,4-8). For patients with schizophrenia and bipolar disorder, these numbers may be higher.
The consequences of undiagnosed and untreated co-occurring disorders include poor medication adherence, physical comorbidities (and decreased overall health), diminished self-care, increased suicide risk or aggression, increased risky sexual behavior, and possible incarceration.9
WHEN SHOULD YOU SUSPECT CO-OCCURRING DISORDERS?
Diagnosing a second condition can also be difficult when a patient’s symptoms are actually adverse effects of substances or prescribed medications. For example, a patient with worsening anxiety may also exhibit increasing blood pressure resistant to treatment. The cause of the patient’s fluctuating blood pressures may actually be the result of his or her use of alcohol to self-treat the anxiety. In addition to self-medication, other underlying factors may be at play, including genetic vulnerability, environment, and lifestyle.14 In the case we present, the patient’s conditions arose independently.
Anxiety disorders, with a lifetime risk of 28.8% in the US population,4 may be the primary mental health issue in many patients with co-occurring disorders, but this cannot be assumed in lieu of a complete workup.2,8,9,15 Substance use disorders in the general population have a past-year and lifetime prevalence of 14.6%.1,4,16,17 Because the causal and temporal association between anxiety and substance abuse is not always clear, it’s important to separate the diagnoses of the mental health and substance use disorders.
Continue to: MAKING THE DIAGNOSIS
MAKING THE DIAGNOSIS
To make an accurate diagnosis of co-occurring disorder, it is essential to take a complete history focusing on the timeline of symptoms, previous diagnoses and treatments, if any, and substance-free periods. Details gathered from these inquiries will help to separate symptoms of a primary mental health disorder from adverse effects of medication, withdrawal symptoms, or symptoms related to an underlying chronic medical condition.
Optimally, the diagnosis of a mental health disorder should be considered following a substance-free period. If this is not possible, a chart review may reveal a time when the patient did not have a substance use disorder.18
A diagnosis of substance use disorder requires that the patient manifest at least 2 of 11 behaviors listed in the DSM-5 over a 12-month period.1 The criteria focus on the amount of substance used, the time spent securing the substance, risky behaviors associated with the substance, and tolerance to the substance.
DON'T DEFER MENTAL HEALTH Tx
It is necessary to treat co-occurring disorders simultaneously. The old idea of deferring treatment of a mental health issue until the substance use disorder is resolved no longer applies.19,20 Treating substance use problems without addressing comorbid mental health issues can negatively impact treatment progress and increase risk for relapse. In a similar way, leaving substance use problems untreated is associated with nonadherence in mental health treatment, poor engagement, and dropout.21,22
Integrated services. Due to this condition’s level of clinical complexity, the optimal treatment approach is an interdisciplinary one in which integrated services are offered at a single location by a team of medical, mental health, and substance use providers (see “The case for behavioral health integration into primary care” in the June issue). An evidence-based example of such an approach is the Integrated Dual Disorder Treatment (IDDT) model—a comprehensive, integrated method of treating severe mental health disorders, including substance use disorders.21,22 IDDT combines coordinated services such as pharmacologic, psychological, educational, and social interventions to address the needs of patients and their family members. The IDDT model conceptualizes and treats co-occurring disorders within a biopsychosocial framework. Specific services may include medical detoxification, pharmacotherapy, patient and family education, behavioral and cognitive therapies, contingency management, self-help support groups, supported employment, residential/housing assistance, and case management services.23,24
Continue to: Medications for the mental health component
Medications for the mental health component. For patients who prefer medication treatment to cognitive behavioral therapy (CBT), or for whom CBT is unavailable, treat the mental health disorder per customary practice for the diagnosis (TABLE 225-30). For psychotic disorders, use an antipsychotic, adding a selective serotonin reuptake inhibitor (SSRI) or serotonin-norepinephrine reuptake inhibitor (SNRI) as needed depending on the presence of negative symptoms.25,31 For bipolar spectrum disorder, start a mood stabilizer32; for depressive disorders initiate an SSRI or SNRI.27 Anxiety disorders respond optimally when treated with SSRIs or SNRIs. Buspirone may be prescribed alone or as an adjunct for anxiety, and it does not cause mood-altering or withdrawal effects. Benzodiazepines in a controlled and monitored setting are an option in some antianxiety treatment plans. Consultation with a psychiatrist will help to determine the best treatment in these situations.
In all cases, treat the substance use disorder concurrently. Treatment options vary depending on the substance of choice. Although often overlooked, there can be simultaneous nicotine abuse. Oral or inhaled medications for nicotine abuse treatment are limited. The range of pharmacologic options for alcohol use disorder includes naltrexone, acamprosate, and disulfiram.29,33 Pharmacologic treatment options for opioid use disorder include naltrexone, methadone, and a combination of naloxone and buprenorphine.34
Physicians who wish to prescribe buprenorphine must qualify for and complete a certified 8 hour waiver-training course, which is then approved by the Drug Enforcement Agency (under the DATA 2000 – Drug and Alcohol Act 2000). The physician obtains the designation of a data-waived physician and is assigned a special identification number to prescribe these medications.35,36 Methadone may be provided only in a licensed methadone maintenance program. Regular and random drug urine screen requirements apply to all treatment programs.
Psychosocial and behavioral interventions are essential to the successful treatment of co-occurring disorders. Evidence-based behavioral and cognitive therapies are recommended for promoting adaptive coping skills and healthy lifestyle behaviors in co-occurring disorder populations.23,24,37-40 Motivational interviewing enhances motivation and adherence when patients demonstrate resistance or ambivalence.41,42 Mindfulness-based interventions have been shown to be effective and may be particularly beneficial for treating cravings/urges and promoting relapse prevention.37,39,40,43-46
Psychotropic medications, as with other treatment components, are most effective when used in combination with services that simultaneously address the patient’s biological, psychological, and social needs.
Continue to: The grassroots organization...
The grassroots organization National Alliance on Mental Illness (www.nami.org) recommends self-help and support groups, which include 12-step, faith-based and non-faith–based programs.20
For any treatment method to be successful, there needs to be a level of customization and individualization. Some patients may respond to medication or nonmedication treatments only, and others may need a combination of treatments.
CASE
The physician recalls a past diagnosis of anxiety and asks Ms. J if there are any new stressors or changes causing concern. The patient expresses concern about an opioid use relapse secondary to her recent diagnosis of rheumatoid arthritis, which may be life altering or limiting.
Even though she has been doing well and has been adherent to her daily buprenorphine treatment, she worries for the well-being of her family and what would happen if she cannot work, becomes incapacitated, or dies at a young age. She has never considered herself an anxious person and is surprised that anxiety could cause such pronounced physical symptoms.
The physician discusses different modalities of treatment, including counseling with an onsite psychologist, a trial of an anti-anxiety medication such as sertraline, or return office visits with the physician. They decide first to schedule an appointment with the psychologist, and Ms. J promises to find more time for self-wellness activities, such as exercise.
After 3 months of therapy, the patient decides to space out treatment to every 2 to 3 months and does not report any more episodes of chest pain or shortness of breath.
CORRESPONDENCE
Kristen Rundell, MD, Northwood-High Building, 2231 N. High Street, Suite 211, Columbus, OH 43201; kristen.rundell@osumc.edu.
1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: APA; 2013.
2. SAMHSA. Key substance use and mental health indicators in the United States: results from the 2017 National Survey on Drug Use and Health. 2017. https://www.samhsa.gov/data/sites/default/files/cbhsq-reports/NSDUHFFR2017/NSDUHFFR2017.htm#cooccur2. Accessed August 16, 2019.
3. Conway KP, Compton W, Stinson FS, et al. Lifetime comorbidity of DSM-IV mood and anxiety disorders and specific drug use disorders: results from the National Epidemiologic Survey on Alcohol and Related Conditions. J Clin Psychiatry. 2006;67:247-257.
4. Kessler RC, Berglund P, Demler O, et al. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62:593-602.
5. Grant BF, Stinson FS, Dawson DA, et al. Prevalence and co-occurrence of substance use disorders and independent mood and anxiety disorders: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry. 2004;61:807-816.
6. Dixon L. Dual diagnosis of substance abuse in schizophrenia: prevalence and impact on outcomes. Schizophr Res. 1999;35(suppl):S93-S100.
7. Merikangas KR, Jin R, He JP, et al. Prevalence and correlates of bipolar spectrum disorder in the World Mental Health Survey Initiative. Arch Gen Psychiatry. 2011;68:241-251.
8. Cottler LB, Compton WM 3rd, Mager D, et al. Posttraumatic stress disorder among substance users from the general population. Am J Psychiatry. 1992;149:664-670.
9. Kessler RC, Angermeyer M, Anthony JC, et al. Lifetime prevalence and age-of-onset distributions of mental disorders in the World Health Organization’s World Mental Health Survey Initiative. World Psychiatry. 2007;6:168-176.
10. Burns L, Teesson M, O’Neill K. The impact of comorbid anxiety and depression on alcohol treatment outcomes. Addiction. 2005;100:787-796.
11. Magidson JF, Liu SM, Lejuez CW, et al. Comparison of the course of substance use disorders among individuals with and without generalized anxiety disorder in a nationally representative sample. J Psychiatr Res. 2012;46:659666.
12. Boschloo L, Vogelzangs N, van den Brink W, et al. Alcohol use disorders and the course of depressive and anxiety disorders. Br J Psychiatry. 2012;200:476-484.
13. Schuckit MA. Comorbidity between substance use disorders and psychiatric conditions. Addiction. 2006;101(suppl 1):76-88.
14. Buckley PF. Prevalence and consequences of the dual diagnosis of substance abuse and severe mental illness. J Clin Psychiatry. 2006;67(suppl 7):5-9.
15. Salo R, Flower K, Kielstein A, et al. Psychiatric comorbidity in methamphetamine dependence. Psychiatry Res. 2011;186:356-361.
16. Torrens M, Gilchrist G, Domingo-Salvany A. Psychiatric comorbidity in illicit drug users: substance-induced versus independent disorders. Drug Alcohol Depend. 2011;113:147-156.
17. Buckner JD, Timpano KR, Zvolensky MJ, et al. Implications of comorbid alcohol dependence among individuals with social anxiety disorder. Depress Anxiety. 2008;25:1028-1037.
18. Kushner MG, Abrams K, Borchardt C. The relationship between anxiety disorders and alcohol use disorders: a review of major perspectives and findings. Clin Psychol Rev. 2000;20:149-171.
19. McHugh RK. Treatment of co-occurring anxiety disorders and substance use disorders. Harv Rev Psychiatry. 2015;23:99-111.
20. National Alliance on Mental Illness. Dual diagnosis. NAMI Web site. www.nami.org/Learn-More/Mental-Health-Conditions/related-conditions/dual-diagnosis. Reviewed August 2017. Accessed July 23, 2019.
21. SAMSHA. Substance Abuse Treatment for Persons with Co-Occurring Disorders. Treatment Improvement Protocol (TIP) series No. 42. HHS Publication No. (SMA) 13-3992. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2013.
22. SAMHSA. Treatment of co-occurring disorders. In: Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2005.
23. Drake RE, Mueser KT, Brunette MF, et al. A review of treatments for people with severe mental illnesses and co-occurring substance use disorders. Psychiatr Rehabil J. 2004;27:360-374.
24. Kola LA, Kruszynski R. Adapting the integrated dual-disorder treatment model for addiction services. Alcohol Treat Q. 2010;28:437-450.
25. American Psychiatric Association. Practice guideline for the treatment of patients with schizophrenia, 2nd ed. https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/schizophrenia.pdf. Published 2010. Accessed August 2, 2019.
26. American Psychiatric Association. Practice guideline for the treatment of patients with bipolar disorder, 2nd ed. https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/bipolar.pdf. Published 2010. Accessed August 2, 2019.
27. American Psychiatric Association. Practice Guideline for the Treatment of Patients with Major Depressive Disorder. https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/mdd.pdf. Published October 2010. Accessed July 23, 2019.
28. American Psychiatric Association. Practice guideline for the treatment of patients with panic disorder, 2nd ed. https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/panicdisorder.pdf. Published January 2009. Accessed August 2, 2019.
29. American Psychiatric Association. Practice guideline for the pharmacological treatment of patients with alcohol use disorder. https://psychiatryonline.org/doi/pdf/10.1176/appi.books.9781615371969. Accessed August 2, 2019.
30. American Psychiatric Association. Practice guideline for the treatment of patients with substance use disorders, 2nd ed. https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/substanceuse.pdf. Published 2010. Accessed August 2, 2019.
31. Petrakis IL, Nich C, Ralevski E. Psychotic spectrum disorders and alcohol abuse: a review of pharmacotherapeutic strategies and a report on the effectiveness of naltrexone and disulfiram. Schizophr Bull. 2006;32:644-654.
32. McIntyre RS, Yoon J. Efficacy of antimanic treatments in mixed states. Bipolar Disord. 2012;14(suppl 2):22-36.
33. Volpicelli JR, Alterman AI, Hayashida M, et al. Naltrexone in the treatment of alcohol dependence. Arch Gen Psychiatry. 1992;49:876-880.
34. Lee JD, Nunes EV Jr, Novo P, et al. Comparative effectiveness of extended-release naltrexone versus buprenorphine-naloxone for opioid relapse prevention (X:BOT): a multicentre, open-label, randomized controlled trial. Lancet. 2018;391:309-318.
35. US Department of Justice. DEA requirements for DATA waived physicians (DWPs). Drug Enforcement Administration, Diversion Control Division Web site. www.deadiversion.usdoj.gov/pubs/docs/dwp_buprenorphine.htm. Accessed August 2, 2019.
36. SAMHSA. Buprenorphine waiver management. https://www.samhsa.gov/medication-assisted-treatment/buprenorphine-waiver-management. SAMHSA Web site. Updated May 7, 2019. Accessed August 2, 2019.
37. Bowen S, Chawla N, Witkiewitz K. Mindfulness-based relapse prevention for addictive behaviors. In: Baer RA, ed. Mindfulness-Based Treatment Approaches: A Clinician’s Guide to Evidence Base and Applications. London, UK: Elsevier; 2014.
38. Dixon L, McFarlane W, Lefley H, et al. Evidence-based practices for services to families of people with psychiatric disabilities. Psychiatr Serv. 2001;52:903-910.
39. Hayes SC, Levin M, Plumb-Vilardaga J, et al. Acceptance and commitment therapy and contextual behavioral science: examining the progress of a distinctive model of behavioral and cognitive therapy. Behav Ther. 2013;44:180-198.
40. Osilla KC, Hepner KA, Muñoz RF, et al. Developing an integrated treatment for substance use and depression using cognitive behavioral therapy. J Subst Abuse Treat. 2009;37:412-420.
41. Martino S, Carroll K, Kostas D, et al. Dual diagnosis motivational interviewing: a modification of motivational interviewing for substance-abusing patients with psychotic disorders. J Subst Abuse Treat. 2002;23:297-308.
42. Rollnick S, Miller WR. What is motivational interviewing? Behav Cogn Psychother. 1995;23:325-334.
43. Garland EL. Disrupting the downward spiral of chronic pain and opioid addiction with mindfulness-oriented recovery enhancement: a review of clinical outcomes and neurocognitive targets. J Pain Palliat Care Pharmacother. 2014;28:122-129.
44. Garland EL, Manusov EG, Froeliger B, et al. Mindfulness-oriented recovery enhancement for chronic pain and prescription opioid misuse: results from an early-stage randomized controlled trial. J Consult Clin Psychol. 2014;82:448-459.
45. Marlatt GA, Donovan DM. Relapse Prevention: Maintenance Strategies in the Treatment of Addictive Behaviors, 2nd ed. New York, NY: Guilford Press; 2007.
46. Zgierska A, Rabago D, Chawla N, et al. Mindfulness meditation for substance use disorders: a systematic review. Subst Abus. 2009;30:266-294.
1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: APA; 2013.
2. SAMHSA. Key substance use and mental health indicators in the United States: results from the 2017 National Survey on Drug Use and Health. 2017. https://www.samhsa.gov/data/sites/default/files/cbhsq-reports/NSDUHFFR2017/NSDUHFFR2017.htm#cooccur2. Accessed August 16, 2019.
3. Conway KP, Compton W, Stinson FS, et al. Lifetime comorbidity of DSM-IV mood and anxiety disorders and specific drug use disorders: results from the National Epidemiologic Survey on Alcohol and Related Conditions. J Clin Psychiatry. 2006;67:247-257.
4. Kessler RC, Berglund P, Demler O, et al. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62:593-602.
5. Grant BF, Stinson FS, Dawson DA, et al. Prevalence and co-occurrence of substance use disorders and independent mood and anxiety disorders: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry. 2004;61:807-816.
6. Dixon L. Dual diagnosis of substance abuse in schizophrenia: prevalence and impact on outcomes. Schizophr Res. 1999;35(suppl):S93-S100.
7. Merikangas KR, Jin R, He JP, et al. Prevalence and correlates of bipolar spectrum disorder in the World Mental Health Survey Initiative. Arch Gen Psychiatry. 2011;68:241-251.
8. Cottler LB, Compton WM 3rd, Mager D, et al. Posttraumatic stress disorder among substance users from the general population. Am J Psychiatry. 1992;149:664-670.
9. Kessler RC, Angermeyer M, Anthony JC, et al. Lifetime prevalence and age-of-onset distributions of mental disorders in the World Health Organization’s World Mental Health Survey Initiative. World Psychiatry. 2007;6:168-176.
10. Burns L, Teesson M, O’Neill K. The impact of comorbid anxiety and depression on alcohol treatment outcomes. Addiction. 2005;100:787-796.
11. Magidson JF, Liu SM, Lejuez CW, et al. Comparison of the course of substance use disorders among individuals with and without generalized anxiety disorder in a nationally representative sample. J Psychiatr Res. 2012;46:659666.
12. Boschloo L, Vogelzangs N, van den Brink W, et al. Alcohol use disorders and the course of depressive and anxiety disorders. Br J Psychiatry. 2012;200:476-484.
13. Schuckit MA. Comorbidity between substance use disorders and psychiatric conditions. Addiction. 2006;101(suppl 1):76-88.
14. Buckley PF. Prevalence and consequences of the dual diagnosis of substance abuse and severe mental illness. J Clin Psychiatry. 2006;67(suppl 7):5-9.
15. Salo R, Flower K, Kielstein A, et al. Psychiatric comorbidity in methamphetamine dependence. Psychiatry Res. 2011;186:356-361.
16. Torrens M, Gilchrist G, Domingo-Salvany A. Psychiatric comorbidity in illicit drug users: substance-induced versus independent disorders. Drug Alcohol Depend. 2011;113:147-156.
17. Buckner JD, Timpano KR, Zvolensky MJ, et al. Implications of comorbid alcohol dependence among individuals with social anxiety disorder. Depress Anxiety. 2008;25:1028-1037.
18. Kushner MG, Abrams K, Borchardt C. The relationship between anxiety disorders and alcohol use disorders: a review of major perspectives and findings. Clin Psychol Rev. 2000;20:149-171.
19. McHugh RK. Treatment of co-occurring anxiety disorders and substance use disorders. Harv Rev Psychiatry. 2015;23:99-111.
20. National Alliance on Mental Illness. Dual diagnosis. NAMI Web site. www.nami.org/Learn-More/Mental-Health-Conditions/related-conditions/dual-diagnosis. Reviewed August 2017. Accessed July 23, 2019.
21. SAMSHA. Substance Abuse Treatment for Persons with Co-Occurring Disorders. Treatment Improvement Protocol (TIP) series No. 42. HHS Publication No. (SMA) 13-3992. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2013.
22. SAMHSA. Treatment of co-occurring disorders. In: Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2005.
23. Drake RE, Mueser KT, Brunette MF, et al. A review of treatments for people with severe mental illnesses and co-occurring substance use disorders. Psychiatr Rehabil J. 2004;27:360-374.
24. Kola LA, Kruszynski R. Adapting the integrated dual-disorder treatment model for addiction services. Alcohol Treat Q. 2010;28:437-450.
25. American Psychiatric Association. Practice guideline for the treatment of patients with schizophrenia, 2nd ed. https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/schizophrenia.pdf. Published 2010. Accessed August 2, 2019.
26. American Psychiatric Association. Practice guideline for the treatment of patients with bipolar disorder, 2nd ed. https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/bipolar.pdf. Published 2010. Accessed August 2, 2019.
27. American Psychiatric Association. Practice Guideline for the Treatment of Patients with Major Depressive Disorder. https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/mdd.pdf. Published October 2010. Accessed July 23, 2019.
28. American Psychiatric Association. Practice guideline for the treatment of patients with panic disorder, 2nd ed. https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/panicdisorder.pdf. Published January 2009. Accessed August 2, 2019.
29. American Psychiatric Association. Practice guideline for the pharmacological treatment of patients with alcohol use disorder. https://psychiatryonline.org/doi/pdf/10.1176/appi.books.9781615371969. Accessed August 2, 2019.
30. American Psychiatric Association. Practice guideline for the treatment of patients with substance use disorders, 2nd ed. https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/substanceuse.pdf. Published 2010. Accessed August 2, 2019.
31. Petrakis IL, Nich C, Ralevski E. Psychotic spectrum disorders and alcohol abuse: a review of pharmacotherapeutic strategies and a report on the effectiveness of naltrexone and disulfiram. Schizophr Bull. 2006;32:644-654.
32. McIntyre RS, Yoon J. Efficacy of antimanic treatments in mixed states. Bipolar Disord. 2012;14(suppl 2):22-36.
33. Volpicelli JR, Alterman AI, Hayashida M, et al. Naltrexone in the treatment of alcohol dependence. Arch Gen Psychiatry. 1992;49:876-880.
34. Lee JD, Nunes EV Jr, Novo P, et al. Comparative effectiveness of extended-release naltrexone versus buprenorphine-naloxone for opioid relapse prevention (X:BOT): a multicentre, open-label, randomized controlled trial. Lancet. 2018;391:309-318.
35. US Department of Justice. DEA requirements for DATA waived physicians (DWPs). Drug Enforcement Administration, Diversion Control Division Web site. www.deadiversion.usdoj.gov/pubs/docs/dwp_buprenorphine.htm. Accessed August 2, 2019.
36. SAMHSA. Buprenorphine waiver management. https://www.samhsa.gov/medication-assisted-treatment/buprenorphine-waiver-management. SAMHSA Web site. Updated May 7, 2019. Accessed August 2, 2019.
37. Bowen S, Chawla N, Witkiewitz K. Mindfulness-based relapse prevention for addictive behaviors. In: Baer RA, ed. Mindfulness-Based Treatment Approaches: A Clinician’s Guide to Evidence Base and Applications. London, UK: Elsevier; 2014.
38. Dixon L, McFarlane W, Lefley H, et al. Evidence-based practices for services to families of people with psychiatric disabilities. Psychiatr Serv. 2001;52:903-910.
39. Hayes SC, Levin M, Plumb-Vilardaga J, et al. Acceptance and commitment therapy and contextual behavioral science: examining the progress of a distinctive model of behavioral and cognitive therapy. Behav Ther. 2013;44:180-198.
40. Osilla KC, Hepner KA, Muñoz RF, et al. Developing an integrated treatment for substance use and depression using cognitive behavioral therapy. J Subst Abuse Treat. 2009;37:412-420.
41. Martino S, Carroll K, Kostas D, et al. Dual diagnosis motivational interviewing: a modification of motivational interviewing for substance-abusing patients with psychotic disorders. J Subst Abuse Treat. 2002;23:297-308.
42. Rollnick S, Miller WR. What is motivational interviewing? Behav Cogn Psychother. 1995;23:325-334.
43. Garland EL. Disrupting the downward spiral of chronic pain and opioid addiction with mindfulness-oriented recovery enhancement: a review of clinical outcomes and neurocognitive targets. J Pain Palliat Care Pharmacother. 2014;28:122-129.
44. Garland EL, Manusov EG, Froeliger B, et al. Mindfulness-oriented recovery enhancement for chronic pain and prescription opioid misuse: results from an early-stage randomized controlled trial. J Consult Clin Psychol. 2014;82:448-459.
45. Marlatt GA, Donovan DM. Relapse Prevention: Maintenance Strategies in the Treatment of Addictive Behaviors, 2nd ed. New York, NY: Guilford Press; 2007.
46. Zgierska A, Rabago D, Chawla N, et al. Mindfulness meditation for substance use disorders: a systematic review. Subst Abus. 2009;30:266-294.
