Integrating Treatment... Making Connections With Drug Courts

4/24/2013
Tennessee Co-Occurring Disorders Collaborative

STRENGTHENING INDIVIDUALS, FAMILIES, AND COMMUNITIES THROUGH EDUCATION AND AWARENESS

Integrating Treatment
MAKING CONNECTIONS FOR RECOVERY
11/14/2012
Individuals who have at least one mental
SAMHSAs 2002 report to Congress defines co-occurring disorders as:
disorder as well as an alcohol or drug use disorder. While these disorders may interact differently in any one person (e.g., an episode of
depression may trigger a relapse into alcohol abuse, or cocaine use may exacerbate schizophrenic symptoms),
at least one
disorder of each type can be diagnosed independently of the other.
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Are Co-Occurring Disorders Common?
Simply put,
The term co-occurring disorders typically refers to having one or more diagnosed mental illness coupled with one or more addictive disorder.
As a matter of fact,
41% to 65.5% with Substance Use Disorder (SUD) have at least one Mental Health (MH) disorder; 51% with a MH disorder also have at least one SUD (Kessler et al).
YES

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10 million U.S. residents each year.

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Are Co-Occurring Disorders Common?

10% account for 71% of our nations healthcare costs. Two-thirds of that 10% are diagnosed with co-occurring MH/SUD (Buck, 2001, CMHS Office of Managed Care). It is estimated that 196,000 Tennesseans suffer from cooccurring disorders. (National Household Survey, 2008 noted that 393,000 Tennesseans reported dependence or abuse of illicit drugs or alcohol. This estimate is based on NHS and national COD prevalence data.)
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Parallels (Minkoff)
1. 2. 3. 4. 5.
Biological (no fault) illness Hereditary (in part) Chronicity Incurability Leads to lack of control of behavior and emotions + and symptoms Affects the whole family Disease progresses without treatment Symptoms can be controlled with proper treatment Disease of denial, (both disease & its chronicity)
13. 14. 15. 11.
As a matter of fact,
Facing the disease can lead to depression & despair Disease is often seen as a moral issue & personal weakness rather than biological Feelings of guilt & failure Feelings of shame & stigma Physical, mental and spiritual disease
12.
YES
6. 7. 8. 9.
10.
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Which came first . . .

Mental Illness Addiction
Drug abuse may bring about symptoms of another mental illness. Increased risk of psychosis in vulnerable marijuana users suggests this possibility. Mental disorders can lead to drug abuse, possibly as a means of self-medication. Patients suffering from anxiety or depression may rely on alcohol, tobacco, and other drugs to temporarily alleviate their symptoms.
There are several hypotheses regarding the onset and direction of co-occurring disorders. Science has not settled on one specific explanation and there may be multiple causal factors. The prevalence of co-occurring mental illness and addiction does not necessarily prove causation.
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These disorders could also be caused by shared risk factors, such as

Overlapping genetic vulnerabilities. Predisposing genetic factors may make a person susceptible to both addiction and other mental disorders or to having a greater risk of a second disorder once the first appears. Overlapping environmental triggers. Stress, trauma (such as physical or sexual abuse), and early exposure to drugs are common environmental factors that can lead to addiction and other mental illnesses.
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National Institute of Health, 2010
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Involvement of similar brain regions. Brain systems that respond to reward and stress, for example, are affected by drugs of abuse and may show abnormalities in patients with certain mental disorders. Drug use disorders and other mental illnesses are developmental disorders. That means they often begin in the teen years or even youngerperiods when the brain experiences dramatic developmental changes. Early exposure to drugs of abuse may change the brain in ways that increase the risk for mental disorders. Also, early symptoms of a mental disorder may indicate an increased risk for later drug use. However, there are several factors at play: genetic vulnerability, psychosocial experiences, and/or general environmental influences. A 2005 study highlights this complexity, with the finding that frequent marijuana use during adolescence can increase the risk of psychosis in adulthood, but only in individuals who carry a particular gene variant. Early Occurrence Increases Later Risk. Strong evidence has emerged showing early drug use to be a risk factor for later substance abuse problems; additional findings suggest that it may also be a risk factor for the later occurrence of other mental illnesses.
National Institute on Drug Abuse, 2010

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It is also true that having a mental disorder in childhood or adolescence can increase the risk of later drug abuse problems, as frequently occurs with conduct disorder and untreated attention-deficit hyperactivity disorder (ADHD). This presents a challenge when treating children with ADHD, since effective treatment often involves prescribing stimulant medications with abuse potential. This issue has generated strong interest from the research community, and although the results are not yet conclusive, most studies suggest that ADHD medications do not increase the risk of drug abuse among children with ADHD. Regardless of how comorbidity develops, it is common in youth as well as adults. Given the high prevalence of comorbid mental disorders and their likely adverse impact on substance abuse treatment outcomes, drug abuse programs for adolescents should include screening and, as needed, treatment for comorbid mental disorders.
Poorer functioning and outcomes
Higher risk for HIV and higher rates of HIV infection
Higher rates of relapse
Slower treatment progress
Significantly higher physical healthcare costs and more severe and chronic medial conditions
More likely to be refused admission or to be prematurely discharged from A&D and MH treatment
The Impacts of Co-Occurring Disorders
At least 50% of individuals who are homeless have COD (SAMHSA, 2011)
59% more inpatient psychiatric admissions
Increased emergency service use

Increased criminal justice involvement and arrests
Primary predictor of readmission Major predictors of excessive inpatient utilization
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We actually know a lot about the impact of co-occurring disorders on individuals, families, and our communities.
11/14/2012
Impact on our health care system

People who suffer with this usually have more episodes of relapse and more emergency room visits. They have to go to inpatient hospitals to address symptoms of mental illness and addiction more often than people who are dealing with one disease. We also know that people with co-occurring disorders have higher rates of chronic diseases such as HIV, diabetes, hepatitis and high blood pressure.
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Impact on our communities

Homelessness At least 50% of people who are homeless have co-occurring disorders. Left untreated, they have little chance at obtaining jobs and permanent housing. Workforce Mental illness and substance abuse drains over $100 billion from American businesses. More workers are absent due to stress and anxiety than physical illness or accident.
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Impact on the criminal justice system

In the local jail systems, 76% of inmates with mental health issues reported substance use. Untreated mental illness (or mental illness and a co-occurring substance abuse disorder) is a strong predictor of recidivism.
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Impact on our families

It is estimated that 40% to 80% of families of children involved in the child welfare system have substance abuse problems. In 2010, Tennessee had approx. 8,000 children and adolescents in state custody. Of the families involved in the states foster care system, prevalence data tells us that approx. 2,000 to 4,000 families are impacted by substance abuse issues or co-occurring disorders.
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Changing Philosophy Moves Us Together

Historically, mental health service providers and addictions service providers had differing philosophical approaches to treatment and recovery of co-occurring disorders. Providers addressed screening, diagnosis, treatment and recovery from (sometimes) opposing standpoints.
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Bringing the Pieces Together

The idea that mental illness and addiction are separate and unconnected has led to treatment programs that are separate and unconnected. However, we know that an integrated treatment approach works best.
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A No Wrong Door Approach

Motivating Empathic Integrated Comprehensive & Individualized Continuous Hope in Recovery
(& Pre-motivating Assertive Outreach)
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Continuous Focus on Hope in Recovery

Three Step Process (Minkoff)
1. Empathize with reality of despair. 2. Establish legitimacy of need to ASK for extensive help. 3. Emphasize a hopeful vision of pride and dignity to counter self-stigmatization.
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REFERENCES
DiClemente, C. (2004). Addiction and Change: Understanding and Intervening in the Process, UMBC Psychology, www.umbc.edu/psych/habi Kessler, R., Nelson, C., McGonagle, K., Edlund, M., Frank, R., & Leaf, P. (1996). The Epidemiology of Co-occurring Addictive and Mental Disorders: Implications for Prevention and Service Utilization. American Journal of Orthopsychiatry, 66 (1), 17-31. National Institute on Drug Abuse. (2007). Topics in Brief: Comorbid Drug Abuse and Mental Illness. http://www.drugabuse.gov/publications/topics-in-brief/comorbiddrug-abuse-mental-illness National Institute on Drug Abuse. (2010). Comobidity: Addiction and Other Mental Illnesses. Pub. No. 10-5771. http://www.drugabuse.gov/publications/researchreports/comorbidity-addiction-other-mental-illnesses U.S. Department of Health and Human Services, Substance Abuse Mental Health Services Administration, Center for Substance Abuse Services. (2007). Substance Abuse Treatment for Persons with Co-Occurring Disorders (DHHS Publication No. (SMA) 05-3992). U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration. (2002). Report to Congress on the Prevention and Treatment of Co-Occurring Substance Abuse Disorders and Mental Disorders. Rockville, MD: Substance Abuse and Mental Health Services Administration. Genetic Science Learning Center. (2012, August 6). Drugs Alter the Brain's Reward Pathway. Learn.Genetics. Retrieved November 12, 2012, from http://learn.genetics.utah.edu/content/addiction/drugs/index.html
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42 Rutledge Street, Nashville, TN 37210-2043 (615) 244-2220 | (800) 568-2642 toll free in TN | Fax: (615) 254-8331
How many people are affected?
What do we mean by co-occurring disorders?

In the Substance Abuse Mental Health Services Administration 2002 Report to Congress, co-occurring disorders were defined as . . . . . . individuals who have at
least one mental disorder as well as an alcohol or drug use disorder. While these disorders may interact differently in any one person (e.g., an episode of depression may trigger a relapse into alcohol abuse, or cocaine use may exacerbate schizophrenic symptoms), at least one disorder of each type can be diagnosed independently of the other. Simplyput, acooccurringdisordertypically referstoanindividualhavingone, ormore,diagnosedmentalillness coupledwithone,ormore, diagnosedaddictivedisorder.
It is estimated that over 10 million people across the United States are struggling with co-occurring disorders. Many of these people do not access treatment services, and when they do, the treatment is often not integrated or delivered in a way that best meets their needs. Based on national prevalence data it is estimated that in Tennessee approximately 196,000 individuals suffer from co-occurring disorders.
What is the impact of co-occurring disorders?

We actually know a lot about the impact of co-occurring disorders on individuals, families and our community. Impact on our healthcare system . . . People who suffer with this usually have more episodes of relapse and more emergency room visits. They have to go to inpatient hospitals to address symptoms of mental illness and addiction more often than people who are dealing with one disease. We also know that people with cooccurring disorders have higher rates of chronic diseases such as HIV, diabetes, hepatitis and high blood pressure. Impact on the Criminal Justice System . . . In the local jail systems, 76% of inmates with mental health issues reported substance use. Untreated mental illness, or mental illness and a co-occurring substance abuse disorder, is a strong predictor of recidivism. Impact on our families . . . It is estimated that approximately 60% of families of children involved in the child welfare system have substance use problems with at least one-half of those being diagnosed with a co-occurring mental illness. In 2010, Tennessee had approximately 8,000 children and adolescents in state custody. Of the families involved in the states foster care system, prevalence data tells us that approximately 2,000 to 4,000 families are impacted by substance use and a cooccurring mental illness which have a negative impact on health, relationships, safety, employment and education and poses greater challenges in maintaining recovery or resiliency than those with a single diagnosis. Impact on our communities . . . Homelessness - At least 50% of people who are homeless have co-occurring disorders. Left untreated, they have little chance at obtaining jobs and permanent housing. Workforce - Mental illness and substance abuse drains over $100 billion from American businesses. More workers are absent due to stress and anxiety than physical illness or accident.
CO-OCCURRING DISORDERS: Moving Tennessee Toward Integration

What can we do to influence change?
Create and support a no wrong door community-based integrated treatment approach, so that mental health centers and addictions treatment providers are equipped to help, no matter who comes through their door for assistance. The presence of co-occurring disorders is the expectation rather than the exception. Increase treatment opportunities. Last year in Tennessee, approximately 12,000 people received treatment for addictive disorders. Due to limited resources, less than 3% of those with co-occurring disorders received treatment through our addictions treatment system. Advocate for a continuum of treatment options, including inpatient and outpatient care, supportive housing, and peer-to-peer support provides the best possible opportunity for recovery. Provide Tennesseans with the resources to manage these diseases and the support to maintain life-long recovery. Treatment works and recovery is possible. Provide co-occurring disorder training. Workforce development is critical. Tennessee has a wealth of experienced, dedicated clinicians who want to help. Providing them with the most up-to-date information and training on evidence-based practices will ensure our place as leaders in the field of co-occurring disorders treatment.
Randy Jessee, Ph.D. Senior Vice President Specialty Services Frontier Health 1167 Spratlin Park Drive Gray, Tennessee 37615 423-467-3720 rjessee@frontierhealth.org
Vickie Harden, MSSW

Senior Vice President for Clinical Services Volunteer Behavioral Health Care System 118 North Church Street P.O. Box 1559 Murfreesboro, Tennessee 37133-1559 615-278-6255 vharden@vbhcs.org
Hilde Phipps, MA, LADAC

Director of Adult Addiction Services Helen Ross McNabb Center Centerpointe 5310 Ball Camp Pike Knoxville, Tennessee 37921 865-523-4704 ext. 3417 hilde.phipps@mcnabb.org
Jim Jones
Clinical Manager/Crisis Manager Pathways Behavioral Health Services 238 Summar Drive Jackson, Tennessee 38301 731-541-8200 jim.jones@wth.org
11/14/2012
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Joint Resolution . . .
MISSION STATEMENT
The mission of the CoOccurring Disorders Collaborative is to create a common understanding of the impact and treatment of cooccurring disorders in our communities and to share knowledge about the conditions and available resources, reduce stigma, and accurately direct people to timely and effective prevention, treatment, and support.
STEERINGCOMMITTEE CHAIRMAN
RandyJessee,Ph.D.,SeniorVicePresidentSpecialtyServices, FrontierHealth,Gray
NAMITENNESSEE
COFOUNDINGORGANIZATIONOFTHETENNESSEECOOCCURRING DISORDERSCOLLABORATIVE JeffFlahey,ExecutiveDirector,NAMITennessee,Nashville DickBaxter,Ph.D.,President,NAMITennessee RobinNobling,ExecutiveDirector,NAMIDavidsonCounty,Nashville
Whereas, it is recognized that consumers with co-occurring disorders have unique and complex needs. Whereas, there is an identified need for increased education and awareness among treatment providers, consumers, families and our communities regarding co-occurring disorders and its impact. Whereas, we recognize that a collaborative effort involving consumers, families and treatment providers insures the most effective treatment and recovery outcomes. Whereas, NAMI Tennessee, the Tennessee Association of Mental Health Organizations (TAMHO), and the Tennessee Association of Alcohol, Drug and Other Addiction Services (TAADAS) commit to the provision of ongoing education and increasing awareness to eliminate barriers to access for persons with co-occurring disorders. Whereas, these organizations commit to develop the strongest treatment delivery system, recovery/support services, and advocacy activities for persons with co-occurring disorders in communities across our state. Whereas, such efforts will reduce barriers between treatment professionals, reduce stigma experienced by consumers and their families and increase our communities ability to respond to the needs of consumers with co-occurring disorders. Whereas, each organization has a unique perspective and expertise in the area of co-occurring disorders treatment, recovery and advocacy. Now Therefore Be It Resolved, NAMI Tennessee, TAMHO, and TAADAS will hereby collaborate with one another to increase awareness of the impact of co-occurring mental illness and addictive disorders on 11/14/2012 consumers, their families and our communities.
GRANTADMINISTRATOR Tennessee Association ofMental Health Organizations
TENNESSEEASSOCIATION OFALCOHOL,DRUG& OTHERADDICTIONSERVICES(TAADAS)

MaryLindenSalter,ExecutiveDirector,TAADAS DebbieHillin,President,TAADAS,Nashville CharlotteHoppers,ExecutiveDirectorGraceHouse, Memphis
CHARGE
The CoOccurring Disorders Collaborative Steering Committee serves as the primary statewide structure to oversee and coordinate the planning, development, and implementation of all phases of the CoOccurring Disorders Collaborative activities and initiatives to include ensuring consistency, accountability, and sustainability of cooccurring disorder strategies and provide strategic and operational recommendations through the committee and subcommittee structure.
TENNESSEEASSOCIATION OFMENTALHEALTH ORGANIZATIONS (TAMHO)

COFOUNDINGORGANIZATIONOFTHETENNESSEECOOCCURRING DISORDERSCOLLABORATIVE RandyJessee,Ph.D.,SeniorVicePresidentSpecialtyServices,Frontier Health,Gray JimJones,ClinicalManager/CrisisManager,Pathways,Jackson VickieHarden,SeniorVicePresidentforClinicalServices,Volunteer BehavioralHealthCareSystem,Murfreesboro VickieGriffey,CoordinatorA&DCareyCounselingCenter,Paris TeresaFuqua,DirectorofMemberServices,TAMHO,Nashville EllynWilbur,ExecutiveDirector,TAMHO,Nashville
TENNESSEEVOICESFORCHILDREN(TVC)
CharlotteBryson,ExecutiveDirector,Nashville
TENNESSEECOALITION FORMENTALHEALTHAND SUBSTANCEABUSESERVICES

RobertJ.Benning,Chairman(CEO,Ridgeview,OakRidge)
TENNESSEEASSOCIATION OFALCOHOLANDDRUG ABUSECOUNSELORS(TAADAC)

TobyAbrahms,President,Nashville CharlieHiatt,RiverCityCounseling,Chattanooga
TENNESSEEDEPARTMENTOFMENTALHEALTHAND SUBSTANCEABUSESERVICES(TDMHSAS)
RodBragg,AssistantCommissioner,DivisionofSubstanceAbuse Services,Nashville Sejal West,AssistantCommissioner,DivisionofMentalHealth Services,Nashville KenHorvath,CoOccurringDisordersSpecialist,DivisionofSubstance AbuseServices,Nashville AngelaMcKinneyJones,DirectorofPreventionServices,Divisionof SubstanceAbuseServices,Nashville
MENTALHEALTHAMERICAOFMIDDLETENNESSEE
(FormerlyMentalHealthAssociationofMiddleTN) TomStarling,Ed.D.,President/CEO,Nashville
TENNESSEEMENTALHEALTHCONSUMERS ASSOCIATION(TMHCA)
AnthonyFox,ExecutiveDirector,Nashville CarolinaGeorge,Nashville
11/14/2012
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4/24/2013

Tennessee Co-Occurring Disorders Collaborative

Tennessee Co-Occurring Disorders Collaborative

Individuals who have at least one mental

SAMHSAs 2002 report to Congress defines co-occurring disorders as:

disorder of each type can be diagnosed independently of the other.

Tennessee Co-Occurring Disorders Collaborative

Tennessee Co-Occurring Disorders Collaborative

Are Co-Occurring Disorders Common?

10 million U.S. residents each year.

Tennessee Co-Occurring Disorders Collaborative

Tennessee Co-Occurring Disorders Collaborative

Are Co-Occurring Disorders Common?

Tennessee Co-Occurring Disorders Collaborative

Tennessee Co-Occurring Disorders Collaborative

Which came first . . .

These disorders could also be caused by shared risk factors, such as

National Institute of Health, 2010

Tennessee Co-Occurring Disorders Collaborative

Tennessee Co-Occurring Disorders Collaborative

National Institute on Drug Abuse, 2010

National Institute on Drug Abuse, 2007

Tennessee Co-Occurring Disorders Collaborative

Tennessee Co-Occurring Disorders Collaborative

Poorer functioning and outcomes

Higher risk for HIV and higher rates of HIV infection

Higher rates of relapse

Slower treatment progress

The Impacts of Co-Occurring Disorders

59% more inpatient psychiatric admissions

Increased emergency service use

Primary predictor of readmission Major predictors of excessive inpatient utilization

National Institute on Drug Abuse, 2007

Tennessee Co-Occurring Disorders Collaborative

Tennessee Co-Occurring Disorders Collaborative

Impact on our health care system

Tennessee Co-Occurring Disorders Collaborative

Tennessee Co-Occurring Disorders Collaborative

Impact on our communities

Impact on the criminal justice system

Tennessee Co-Occurring Disorders Collaborative

Tennessee Co-Occurring Disorders Collaborative

Impact on our families

Changing Philosophy Moves Us Together

Tennessee Co-Occurring Disorders Collaborative

Tennessee Co-Occurring Disorders Collaborative

Bringing the Pieces Together

A No Wrong Door Approach

Tennessee Co-Occurring Disorders Collaborative

Tennessee Co-Occurring Disorders Collaborative

Continuous Focus on Hope in Recovery

Tennessee Co-Occurring Disorders Collaborative

Tennessee Co-Occurring Disorders Collaborative

How many people are affected?

What do we mean by co-occurring disorders?

What is the impact of co-occurring disorders?

CO-OCCURRING DISORDERS: Moving Tennessee Toward Integration

Vickie Harden, MSSW

Hilde Phipps, MA, LADAC

Tennessee Co-Occurring Disorders Collaborative

Tennessee Co-Occurring Disorders Collaborative

GRANTADMINISTRATOR Tennessee Association ofMental Health Organizations

TENNESSEEASSOCIATION OFALCOHOL,DRUG& OTHERADDICTIONSERVICES(TAADAS)