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Co-occurring Disorders: The “Z-axis” Complexities of Co-Occurring Conditions Conference June 2004 Washington, DC. Richard Saitz MD, MPH, FACP, FASAM Clinical Addiction Research and Education Unit Section of General Internal Medicine Center to Prevent Alcohol Problems Among Young People

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Co-occurring Disorders:The “Z-axis”Complexities of Co-Occurring Conditions ConferenceJune 2004Washington, DC

Richard Saitz MD, MPH, FACP, FASAM

Clinical Addiction Research and Education Unit

Section of General Internal Medicine

Center to Prevent Alcohol Problems Among Young People

Boston University and Boston Medical Center


Outline
Outline

  • What we mean by comorbidity

  • Conceptual framework

  • Risk for co-occurring disorders

  • Services not currently coordinated

  • MH/SA impact care for chronic medical conditions

  • Models of care for patients with co-occurring disorders

  • Research directions



Case 1
Case #1

  • A 40 year old man is transferred from a group home to the general medical hospital with diabetic ketoacidosis; he stopped taking his antipsychotic. He refuses insulin because he believes it will harm him. After initial treatment he stabilizes but cannot return to his home because he won’t take insulin. He is too medically complex for the psychiatric hospital and is declined by addictions treatment programs. He remains in the medical hospital where consultation for MH conditions is available.


Case 2
Case #2

  • A 54 year old man with Type 2 diabetes has alcohol dependence. He has poor glycemic control and severe hypertriglyceridemia. His alcohol use limits medication choices; he is on maximal doses of oral agents. He takes his lipid lowering medication once instead of twice a day to avoid drinking and taking medication. He declines alcoholism treatment.


Outline

  • What we mean by comorbidity

  • Conceptual framework

  • Risk for co-occurring disorders

  • Services not currently coordinated

  • MH/SA impact care for chronic medical conditions

  • Models of care for patients with co-occurring disorders

  • Research directions


Service Coordination by Severity

Integration

Alcohol, Tobacco & Other Drug Severity

Collaboration

Consultation

Mental Illness Severity

Adapted from SAMHSA 2002 Report to Congress on the Prevention and

Treatment of Co-occurring Substance Abuse and Mental Disorders


Service Coordination by Severity

Integration

Hospital, ED

Alcohol, Tobacco

& Other

Drug Severity

Collaboration

Primary Health

Consultation

Mental Illness Severity

The

“Z-axis”

Medical Severity

Medical Specialty


Outline

  • What we mean by comorbidity

  • Conceptual framework

  • Risk for co-occurring disorders

  • Services not currently coordinated

  • MH/SA impact care for chronic medical conditions

  • Models of care for patients with co-occurring disorders

  • Research directions


Alcohol related emergency and hospital utilization us
Alcohol-related Emergency and Hospital Utilization, US

  • Emergency

    • 29 visits/1000 persons each year

    • 8% of all ED visits

  • Hospital

    • 7.4% of acute admissions to short-stay, non-Federal general hospitals

    • 1.8 million hospitalizations per year

McDonald AJ et al. Arch Intern Med 2004; 164: 531 - 537.

Smothers BA et al. Arch Intern Med 2003; 163: 713 - 719.


Alcohol related diagnoses aafs 1
Alcohol-related Diagnoses, AAFs<1

Pulmonary and other respiratory tuberculosis 0.25

Malignant neoplasm of lip, oral cavity, and pharynx 0.50 Malignant neoplasm of esophagus 0.75

Malignant neoplasm of stomach 0.20

Malignant neoplasm of liver and intrahepatic bile ducts0.15

Malignant neoplasm of larynx 0.50

Diabetes mellitus 0.05

Essential hypertension 0.076

Cerebrovascular disease 0.065

Pneumonia and influenza 0.05

Diseases of esophagus, stomach, and duodenum 0.10

Cirrhosis of liver without mention of alcohol 0.50

Biliary cirrhosis 0.50

Acute pancreatitis 0.42

Chronic pancreatitis 0.60


Medical disorders more common in patients with substance use disorder psychotic disorder and both
Medical Disorders More Common in Patients with Substance Use Disorder, Psychotic Disorder, and Both

  • Diabetes

  • Hypertension

  • Heart Disease*

  • Asthma*

  • Gastrointestinal Disorders*

  • Skin Infections*

  • Malignant Neoplasms

  • Acute Respiratory Disorders*

*highest risk in those with both

Dickey B et al. Psych Services 2002;53(7):861-7.


Comorbidity in a detoxification sample
Comorbidity in a Detoxification Sample Disorder, Psychotic Disorder, and Both

  • 470 adults with no primary medical care in a short-term residential detoxification unit, mean age 36

    • 47% had chronic medical illness

    • 90% had CES-D score >16

    • 70% reported moderate to severe pain at least intermittently during 2 years of follow-up

      • Intermittent pain associated with relapse (OR 2.0)

      • Persistent pain associated with relapse (OR 5.2)

DeAlba I et al. Am J Addictions 2004;13:33-45.

Larson MJ et al. CPDD Abstract 2004.

Saitz R et al. HSR 2004;39(3):587-606.


Mertens JR et al. Arch Intern Med 2003; 163: 2511 - 2517. Disorder, Psychotic Disorder, and Both


Outline Disorder, Psychotic Disorder, and Both

  • What we mean by comorbidity

  • Conceptual framework

  • Risk for co-occurring disorders

  • Services not currently coordinated

  • MH/SA impact care for chronic medical conditions

  • Models of care for patients with co-occurring disorders

  • Research directions


Patients in addiction treatment not receiving medical care and vice versa
Patients in Addiction Treatment not Receiving Medical Care, and Vice Versa

  • Of 5,824 adults entering addiction treatment in Massachusetts, 41% had no physician

    • Prior substance abuse treatment or mental health treatment were not associated with having a physician

  • Of those with a primary care physician, 45% reported the physician unaware of their addiction

Saitz R et al. Substance Abuse 1997;18:187-195.

Saitz R et al. Am J Drug Alcohol Abuse 1997;23:343-354.


Patients with severe mental illness where are they medical care
Patients with Severe Mental Illness and Vice VersaWhere are they? Medical Care

Bosworth HB et al. Psych Services 2004 June;55:708-10.


Outline and Vice Versa

  • What we mean by comorbidity

  • Conceptual framework

  • Risk for co-occurring disorders

  • Services not currently coordinated

  • MH/SA impact care for chronic medical conditions

  • Models of care for patients with co-occurring disorders

  • Research directions


Quality of diabetes care
Quality of Diabetes Care and Vice Versa

Desai MM et al. Am J Psychiatry 2002;159(9): 1584-90.


Alcohol use and incident diabetic retinopathy
Alcohol Use and Incident Diabetic Retinopathy and Vice Versa

Howard AA et al. Ann Intern Med. 2004;140(3):211–219.


Catheterization and Revascularization after Myocardial Infarction

Druss BG et al. JAMA 2000; 283: 506 - 511.


Influence of mental health and addictions on hepatitis c therapy
Influence of Mental Health and Addictions on Hepatitis C Therapy

  • 154 patients with HIV, alcohol abuse, hepatitis C

  • 81 (53%) had contraindications to interferon

    • 52 heavy drinking

    • 15 had CD4<100

    • 14 IDU with needle sharing

    • 14 decompensated liver disease

    • 13 recent suicidal ideation

  • 54 (35%) had lesser contraindications to interferon

    • 47 had significant depressive symptoms

    • 8 Had CD4 100-200

    • 7 were drinking alcohol (“moderate amounts”)

    • 7 IDU

Nunes et al. Abstract at CPDD 2004


Substance use depressive symptoms and hiv outcomes
Substance use, Depressive symptoms, and HIV Outcomes Therapy

  • Prospective cohort study of 350 adults with HIV and alcohol problems

  • Depressive symptoms and substance use were associated with worse adherence

  • Substance use was associated with less HIV viral load suppression

  • Substance abuse treatment

    • reduced the odds of ED utilization (AOR 0.5)

    • increased the odds of HAART for HIV (AOR 1.70)

    • not associated with 30-day HAART adherence or HIV viral load suppression

Palepu A et al. J Subst Abuse Treat 2003;25:37-42 and Palepu et al. Addiction 2004;99:361-8


Major depression in patients with myocardial infarction
Major Depression in Patients with Myocardial Infarction Therapy

Frasure-Smith N et al. JAMA 1993;270(15):1819-1825


Treating major depression in patients with myocardial infarction
Treating Major Depression in Patients with Myocardial Infarction

  • Randomized, clinical trial

  • 2,481 men and women hospitalized with MI and depression (75%) or lower perceived social support (25%)

  • CBT and group therapy for 6 months

  • Results:

    • Improvements in depressive symptoms and perceived social support

    • No difference in 24% death or recurrent MI


Outline Infarction

  • What we mean by comorbidity

  • Conceptual framework

  • Risk for co-occurring disorders

  • Services not currently coordinated

  • MH/SA impact care for chronic medical conditions

  • Models of care for patients with co-occurring disorders

  • Research directions


The teachable moment
The “teachable moment” Infarction

  • Definition: naturally occurring health events thought to motivate individuals to spontaneously adopt risk-reducing health behaviors

  • Smoking cessation

    • Pregnancy, hospitalization and disease diagnosis, high (10-78%)

    • Clinic visits (2-10%) consistently lower

McBride CM et al. Health Educ Res 2003;18(2):156-70


Integrated Primary Care and Addiction Treatment Infarction

  • Overall sample: trend towards higher costs and no difference in abstinence

  • Subgroup with substance abuse-related medical or psychiatric conditions

    • --More likely to be abstinent in integrated care

    • group (69% vs. 55%, p=0.006)

Weisner C et al. JAMA 2001;286:1715-23.


Integrated medical and alcoholism care
Integrated Medical and Alcoholism Care Infarction

  • Randomized trial of a thorough multidisciplinary evaluation, and care plan (N=101)

  • Monthly primary care visits to review drinking and medical problems

  • Mental health, social services and more intensive alcohol treatment on site

  • 2-year results:

    • 30-day abstinence increased from 47% to 74%

    • Mortality decreased from 30% to 19%

Willenbring ML & Olson DH. Arch Intern Med 1999;159:1946-52

Willenbring ML et al. J Stud Alcohol. 1995;56:337-343


Potential impact of buprenorphine treatment in primary care
Potential Impact of Buprenorphine Treatment in Primary Care Infarction

  • Initial experience with 37 patients (30 max. at any one time). Median age 31.

    • 68% had no previous primary medical care

    • 59% had medical comorbidity

    • 43% had Hepatitis C (a quarter of these diagnosed at entry)

    • 54% had psychiatric comorbidity (80% with no psychiatric care)

    • 86% retained in care 4 months

Alford DP et al. SGIM Abstract 2004.


What is Primary Care? Infarction

  • Integrated and accessible health services provided by primary care clinicians (generally MD, NP, PA)

  • Addresses the majority of health care needs

  • Sustained personal relationship between patient and clinician

  • Does not consider mental health separately from physical health

  • Intrinsic to PC are opportunities to promote health and prevent disease

Institute of Medicine. Primary Care: America’s Health in a New Era. National Academy Press, Washington, DC. 1996.


Receipt of Primary Care Improves Addiction Severity Infarction

Saitz et al. Submitted.


Care for people with drug abuse or dependence
Care for People with Drug Abuse or Dependence Infarction

Laine C et al. JAMA, May 2001; 285: 2355 - 2362.


Chronic disease management
Chronic Disease Management Infarction

  • 1,801 older adults with depression or dysthymia in 18 primary care clinics

    • Mean 3 chronic conditions

  • 20 minute educational video, booklet, visit with nurse or psychologist case manager in primary care, with medical and psychiatric consultation as needed

  • Results: Significant reduction in depressive symptoms, functional impairment, and arthritis pain and functional outcomes (for the 1001 with arthritis)

Lin EHB et al. JAMA 2003; 290: 2428 - 2429

Unützer J et al. JAMA 2002; 288: 2836 - 2845


Outline Infarction

  • What we mean by comorbidity

  • Conceptual framework

  • Risk for co-occurring disorders

  • Services not currently coordinated

  • MH/SA impact care for chronic medical conditions

  • Models of care for patients with co-occurring disorders

  • Research directions


Research agenda
Research Agenda Infarction

  • Prevalence of co-occurring MH/SA disorders and medical disorders

  • Impact of one medical/MH/SA disorder on the incidence, severity, quality of care and health outcomes of others

  • Development and testing of new models of care that

    • bring needed care to the patient with “triple diagnosis”

    • can address comorbidity in the face of varied levels of severity of comorbidities

  • Identify and overcome barriers to implementation



Extra slides

Extra Slides Infarction


Alcohol related diagnoses aafs 11
Alcohol-related diagnoses InfarctionAAFs=1

Alcoholic psychoses

Alcohol dependence syndrome

Nondependent abuse of alcohol

Alcoholic polyneuropathy

Alcoholic cardiomyopathy

Alcoholic gastritis

Alcoholic fatty liver

Acute alcoholic hepatitis

Alcoholic cirrhosis of liver

Alcoholic liver damage, unspecified

Excessive blood level of alcohol

Accidental poisoning by ethyl alcohol, not elsewhere specified


Cardiac catheterization after myocardial infarction
Cardiac Catheterization after Myocardial Infarction Infarction

Druss BG et al. JAMA 2000; 283: 506 - 511.



Preventive care mammography
Preventive Care: Mammography Infarction

  • Older women with schizophrenia

    • 62% in past 2 years

  • Age-matched controls

    • 86% in past 2 years

Dickerson FB et al. Psych Services 2002;53:882-4.


Alcohol use and diabetes
Alcohol Use and Diabetes Infarction

  • Incident diabetes

    • 18 prospective cohort studies: U-shaped relationship

  • Glycemic control

    • 6 experimental studies of up to 6 drinks given to 5-20 subjects with diabetes

      • 3 found decreases in serum glucose

      • 3 found no difference each

  • Diabetes medications

    • In 2 studies, immediate glycemic response to 3-drink challenge did not differ

      • 23 subjects taking troglitazone or placebo

      • 50 subjects before and after sulfonylurea

Howard AA et al. Ann Intern Med. 2004;140(3):211–219.


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