Co-Occurring Treatment: Latest TrendsThe Circle Program at CMHIP:Fully Integrated Dual-Diagnosis Inpatient Treatment

Elizabeth ‘Libby’ Stuyt, MDMedical Director, Circle ProgramColorado Mental Health Institute at Pueblo2012 Colorado Behavioral Healthcare CouncilAnnual Training ConferenceSeptember 28, 2012

Circle ProgramMission Statement

To help persons with co-occurring mental illness and substance dependence learn how to maintain sobriety, psychiatric stability, medication compliance, social responsibility and personal integrity outside the hospital setting.

Circle Program

•20 bed, 90-day inpatient treatment program•Men and women, 18 - 65•Dual diagnosis – substance abuse and mental

illness•Abstinence based (no addictive medications)•Totally tobacco free since 2000•Funded by the State of Colorado•Treating people who have failed everything

else•40 hours of group per week•Lots of written work

Treatment TeamThe treatment team consists of a board

certified addiction psychiatrist, a psychologist, a social worker, a team leader, a recreational therapist, 6 registered nurses, 2 licensed psychiatric technicians, and 4 mental health workers, all of whom are at some level of Certified Addiction Counselors.

Treatment team is also supported by chaplain services, registered dietitians, physical therapists, vocational therapists, occupational therapists, teachers for GED services and medical, surgical, and dental services to meet individual treatment needs.

Addiction is a disease of the learning and memory part of the brain•Treatment involves stopping the substances,

allowing the brain to heal, and re-wiring the brain – enabling new learning ▫Cognitive/Behavioral Treatment

Dialectical Behavioral Therapy (DBT) Strategies for Self-Improvement and Change

(SSIC)▫Relapse Prevention▫Cue Exposure▫Creating a society with societal rules that need

to be followed (Behavioral Awareness)

People often start using and continue using substances as a way to cope with stress•Treatment also needs to teach people how to manage stress without using addictive substances

•Stress Management Techniques▫NADA acudetox – 5 point ear acupuncture ▫Other meridian therapies – TAT, EFT, TFT▫Mindful Meditation, Yoga, Tai Chi, exercise▫Biofeedback – Heartmath ® - based on heart

rate variability - Cardiac Coherence

Patient Population•Patients come from all over the state of

Colorado – 60% from the Denver-metro area•Patients are referred by mental health

centers, DSS, ADAD, probation/parole officers, public defenders, judges

•The program is voluntary and doors are not locked

•75% have legal problems and treatment is a condition of probation, parole or diversion

Application Process•Application and patient agreement must be

complete and signed by the patient, we also need:

•Current psychiatric assessment documenting mental illness diagnosis and current treatment

•Documentation of previous substance abuse treatment, either inpatient or outpatient (DUI classes or detox don’t count)

•Standardized Offender Assessment and/or resolution of pending charges if legal problems are present

What is the Circle Program?•Very intense, cognitive/behavioral

program•40 hours of group per week, 18 different

groups, some meet once a week, some occur several times a week

•Homework assignments from every group•Many rules – patients are expected to

report themselves and peers for rule violations

•Level system – based on Stages of Change

Groups – Based on Four Treatment Cornerstones•Relapse Prevention•Behavioral Change•Education•Origin of Issues

Relapse Preventionlearning to manage cravings and stress that lead to relapse • Resolutions (cue exposure response

prevention)• Re-entry (recovery plan)• Recreational Therapy (voluntary exercise)• Support Groups (AA, DTR, voluntary 12-step

group)• 5-point NADA ear acupuncture (voluntary)• Biofeedback training - Heartmath®• Thought Field Therapy (voluntary)• Yoga, Tai Chi, pool therapy, physical

therapy (pain management)

Restorative Yoga

Not so restorative Yoga

Behavioral Change•HOPE group (Behavioral Awareness)

▫Gift system▫Teaching tools▫Peer coordinators

•Strategies for Self-Improvement and Change (SSC 1)▫Thinking reports▫Addressing criminal thoughts and

behaviors•Dialectical Behavioral Therapy (DBT)

Educational Groups•Recovery Education – how drugs and

alcohol affect the body, how medications work, how different therapies work

•Symptoms Management – signs and symptoms of mental illness

•Discovery Group•Talk with the Doc

Origin of Issues Groups•Parenting•Men’s and Women’s Trauma/Process

Group•Men’s and Women’s Anger Group

Individual Work•On admission – Plan of Care Formulation

– given goals to work on for first month▫Substance abuse ▫Mental health – diagnostic exploration

worksheets▫Physical problems – chronic pain management

•Plan of Care Review – treatment team reviews work from previous month and assigns new work for the next month

•Brain Synchronization Therapy

Successful Completion•Remaining the full recommended time in

treatment•Completing all program components ex:

parenting, SSC 1, re-entry, resolutions•Completing all written assignments from

groups and on plan of care, including recovery plan

•Not engaging in major rule violations•No continuous pattern of minor rule

violations•Moving up in the level system

Level System•Developed to reflect “stages of change”

model•All patients start out at level

▫Precontemplation •Staff determine levels on a weekly basis

based on progress made on POC and homework, group attendance, documented major and minor rule violations

Levels•Precontemplation

▫Minimal compliance, not ready to make changes

•Contemplation▫Increasing but inconsistent

compliance, thinking about change•Action

▫Decision to change, actively changing behavior

•Ownership▫Consistently demonstrating change

and appropriate behavior

Effects of Creating Tobacco Free Treatment • Comparison of all patients treated in the six

months before going tobacco free on January 1, 2000 and the years after going tobacco free.

• In the six months before – patients allowed to go outside to smoke.

• After going tobacco free patients are expected to completely refrain from tobacco use during the three months of treatment.

• All patients are given a great deal of education regarding tobacco use and encouraged to quit. Tobacco is full integrated into every aspect of treatment.

Patient’s decision regarding tobacco use before and after program is tobacco free

Decision regarding tobacco use after treatment

Six months before

tobacco free - 1999

N=111

First year after going

tobacco free - 2000

N=157

Three year

period 2006 – 2008

N=285

Three Year period

2009-2011

N=231

Plans to continue tobacco 75% 61% 40% 33%

Quit using tobacco with

plans to remain

abstinent

12% 24% 51% 55%

No tobacco use on admit

13% 15% 9% 12%

So What Happens after Treatment?

• Current Outcome study – following patients for one year after completing 3 months inpatient treatment in a tobacco free environment

• Self-report, probation officer, family member• 231 consecutive admissions and discharges

from January 1, 2009 – December 31, 2011 • 80% successfully completed program (n=185)• Of those eligible (179), 86% enrolled to

participate in outcome study (n=154)• By December 31, 2011, 68% completed the

one year follow-up (n=105)

Demographics of 231 patients admitted and discharged 2009-2011

• 55% male• 78% Caucasian, 15% Hispanic, 6% African

American, 1% Asian• Age = 35 ± 11 years (18 – 65)• Primary Drug Dependence

▫ 33% Alcohol▫ 31% Polysubstance▫ 15% Methamphetamine▫ 10% Cocaine▫ 7% Opiates▫ 4% Cannabis

• Nicotine Dependence – 88%

Psychiatric Diagnoses• Primary Psychiatric Diagnoses

▫29% PTSD▫22% Depression ▫17% Bipolar▫12% Anxiety ▫10% Schizophrenia/Schizoaffective ▫6% Substance Induced psych symptoms ▫4% Other

• 79% have an Axis II diagnosis▫ 34% Borderline Personality disorder▫ 16% Antisocial Personality disorder

What determines program completion?• No difference by gender (p=.4104)• No difference by race (p=.3402)• No difference by age (p=.1258)• No difference by primary psychiatric diagnosis

(p=.4834)• No difference by primary drug dependence

(p=.4898)• No difference by number of previous treatment

programs attended (p=.8792)• No difference by tobacco use on admission

(p=.08)• Mean LOS for completers = 87 ± 7 days• Mean LOS for non-completers = 40 ± 22 days

Presence of Axis II diagnosis affects program completion•98% of those with no personality disorder

diagnosis completed the program•87% of those with Borderline Personality

completed the program•59% of those with Antisocial Personality)

completed the program• p<.0001

Attitude regarding tobacco predicts program completion•67% of those who used tobacco while in

treatment versus 83% of those who did not use tobacco completed the program (p=0.02)

•48% of those planning to use tobacco ASAP after discharge, completed the program versus 93% who were planning to attempt to stay quit or expressed ambivalence regarding tobacco use (p<.0001)

Other factors aiding in program completion

•Having a probation officer and accountability▫85% on probation completed▫71% of the voluntary patients completed▫53% of civil commitments completed▫p=.0013

•NADA acudetox appears to help with program completion▫Those completing had 12 ± 9 acudetox

sessions▫Those not completing had 5 ± 5 sessions▫ p<.0001

Patients using tobacco were more likely to use NADA acudetox and were more likely to remain in treatment longer the more sessions they had.

-20

0

20

40

60

80

100

120

140

160

LOS

-5 0 5 10 15 20 25 30 35acudetox sessions

Y = 69.048 + .811 * X; R^2 = .089

Regression PlotSplit By: tobaccoCell: yes

30

40

50

60

70

80

90

100

110

LO

S

-5 0 5 10 15 20 25 30 35 40acudetox sessions

Y = 79.175 + .287 * X; R^2 = .048

Regression PlotSplit By: tobaccoCell: no

p<.0001p=.2616

0

20

40

60

80

100

120

LOS

-5 0 5 10 15 20 25 30 35acudetox sessions

Y = 48.441 + 1.592 * X; R^2 = .155

Regression PlotSplit By: tobacco p txCell: plans to smoke

0

20

40

60

80

100

120

140

160

LOS

-5 0 5 10 15 20 25 30 35acudetox sessions

Y = 84.307 + .137 * X; R^2 = .01

Regression PlotSplit By: tobacco p txCell: wants to quit

30

40

50

60

70

80

90

100

110

LOS

-5 0 5 10 15 20 25 30 35 40acudetox sessions

Y = 79.077 + .276 * X; R^2 = .045

Regression PlotSplit By: tobacco p txCell: n/a

70

75

80

85

90

95

100

105

LOS

0 2.5 5 7.5 10 12.5 15 17.5 20 22.5 25acudetox sessions

Y = 88.694 - .336 * X; R^2 = .055

Regression PlotSplit By: tobacco p txCell: ambivalent

p=.2879 p=.4896

p=.001 p=.2714

Plan for Tobacco Use after Discharge

2001 – 2003

N=440

2006 – 2009

N=340

Plans to smoke 41% complete 57% complete

Plans to stay quit 80% complete 92% completep<0.0001

Plans to smoke ≥ 8 sessions NADA

<8 sessions NADA

57% complete

24% complete

83% complete

44% complete

Attitude about Tobacco Use as a predictor of outcome

86% of the 58 patients with Borderline PD completed treatment and they remained significantly longer in treatment the more acudetox sessions they had (averaging 13 ± 9 sessions)

40

50

60

70

80

90

100

110

LOS

-5 0 5 10 15 20 25 30 35 40acudetox sessions

Y = 78.134 + .367 * X; R^2 = .07

Regression PlotSplit By: axis IICell: borderline pdInclusion criteria: Criteria 2 from 2009 to 2010 178 patients.csv (imported).svd

p=.0454

98% of the 44 patients with no Axis II diagnosis completed treatment and averaged 13 ± 9 acudetox sessions

70

80

90

100

110

120

130

140

150

160

LOS

-5 0 5 10 15 20 25 30 35acudetox sessions

Y = 90.51 - .227 * X; R^2 = .039

Regression PlotSplit By: axis IICell: no dxInclusion criteria: Criteria 2 from 2009 to 2010 178 patients.csv (imported).svd

p=.2007

Preliminary Data – as of January 2012

• 105 patients have completed one year follow-up after discharge from the program. Information obtained on 101 for full year, 4 were lost to follow-up

• 54% sober and doing well at end of year▫ 30% continuously abstinent▫ 16% relapsed but got back on track▫ 7% one or more slips but back on track

• 22% continuing to relapse• 19% re-offended and incarcerated• 4% deceased• 2% relapsed and back in treatment

There was no difference between status at the end of the year and:

•Gender (p=.6837)•Race (p=.4738)•Primary drug dependence (p=.7149)•Primary psych diagnosis (p=.8409)•Tobacco use prior to admission (p=.7068)•Legal status (p=.2617)•Presence of Axis II diagnosis (p=.0518)

Tobacco use was significantly correlated with relapse

•Non-tobacco use increased from 12% to 25% at the end of the year.

•Those using tobacco were much more likely to relapse. (p=.012)

•Those continuously abstinent were more likely to not be using tobacco. (p=.0326)

•For those who relapsed to drugs or alcohol▫9 ± 4 months to first relapse for non-tobacco

user▫6 ± 5 months to first relapse for tobacco user

(p=.0117)

Cost Benefits of Program•First 40 patients in outcome study who were

referred to Circle as a condition of probation▫ 21 (52%) sober and doing well at the end of the

year. 9 (23%) relapsed but still on probation successfully, 8 (20%) re-offended and incarcerated, 2 (5%) deceased. (January 2011)

• All 40 were looking at a 2-6 year term in DOC if not successful in Circle

• Average of 3 previous inpatient treatment programs prior to Circle without benefit

• Most had already spent considerable time in and out of jail/prison proving just incarceration doesn’t work

How Circle Saves the State of Colorado Money•Cost of three months at Circle - $36,000•Cost one year general population DOC

$36,000•Cost of one year DOC-TC - $73,000•40 X 72,000 (2yrs DOC-GP) = $2,880,000•40 X 36,000 (1 yr DOC-GP) + 40 X 73,000 (1

yr DOC-TC) = $4,360,000•40 X 36,000 (Circle 3 mos) = $1,440,000•40 X 36,000 (Circle 3 mos) + 8 X 72,000 (20%

recidivism – 2 yrs DOC-GP) = $2,016,000•2,880,000 – 2,016,000 = $ 864,000•4,360,000 – 2,016,000 = $ 2, 3440,000