Integrating Treatment...Making Connections with Drug Courts

4/24/2013

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Tennessee Co-Occurring Disorders CollaborativeSTRENGTHENING INDIVIDUALS, FAMILIES, AND COMMUNITIES THROUGH EDUCATION AND AWARENESS

MAKING CONNECTIONSFOR RECOVERY

Integrating Treatment

11/14/20121


SAMHSA’s 2002 report to Congress defines co-occurring disorders 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.

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The term “co-occurring disorders” typically refers to having one or more diagnosed mental illness coupled with

one or more addictive disorder.

Simply put,


Are Co-Occurring Disorders Common?

As a matter of

fact, YES

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).

10 million U.S. residents each year.

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As a matter of

fact, YES

Are Co-Occurring Disorders Common?

10% account for 71% of our nation’s 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 co-

occurring 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.)11/14/20125


Parallels (Minkoff)1. Biological (no fault) illness2. Hereditary (in part)3. Chronicity4. Incurability5. Leads to lack of control of behavior and

emotions6. + and – symptoms7. Affects the whole family8. Disease progresses without treatment9. Symptoms can be controlled with proper

treatment10. Disease of denial, (both disease & its

chronicity)

11. Facing the disease can lead to depression & despair

12. Disease is often seen as a “moral issue” & personal weakness rather than biological

13. Feelings of guilt & failure14. Feelings of shame & stigma15. Physical, mental and spiritual disease

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Mental Illness Addiction

Which came first . . .

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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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.

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.

National Institute of Health, 2010 11/14/20128

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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 younger—periods 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.

National Institute on Drug Abuse, 201011/14/20129


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.

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.

National Institute on Drug Abuse, 200711/14/201210


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.

National Institute on Drug Abuse, 2007 11/14/201211


Poorer functioning and outcomes

Higher rates of relapse

Significantly higher physical healthcare costs and more severe

and chronic medial conditions

At least 50% of individuals who are homeless have COD

(SAMHSA, 2011)

Increased emergency service use

Increased criminal justice involvement and arrests

The Impacts of Co-Occurring

Disorders

Higher risk for HIV and higher rates of HIV infection

Slower treatment progress

More likely to be refused admission or to be prematurely discharged from A&D and MH

treatment

59% more inpatient psychiatric admissions

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.

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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. 11/14/201214


Impact on our communities

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. 11/14/201215

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.


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 state’s 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. 11/14/201217


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 TogetherThe 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.11/14/201219


A “No Wrong Door” Approach

Motivating (& Pre-motivating – Assertive Outreach)

Empathic

Integrated

Comprehensive & Individualized

Continuous Hope in Recovery

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Continuous Focus onHope 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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R E F E R E N C E SDiClemente, 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/comorbid-

drug-abuse-mental-illness

National Institute on Drug Abuse. (2010). Comobidity:

Addiction and Other Mental Illnesses. Pub. No. 10-5771.

http://www.drugabuse.gov/publications/research-

reports/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


42 Rutledge Street, Nashville, TN 37210-2043(615) 244-2220 | (800) 568-2642 toll free in TN | Fax: (615) 254-8331

11/14/201223

Randy Jessee, Ph.D.Senior Vice President Specialty ServicesFrontier Health1167 Spratlin Park Drive Gray, Tennessee [email protected]

Vickie Harden, MSSWSenior Vice President for Clinical ServicesVolunteer Behavioral Health Care System118 North Church StreetP.O. Box 1559Murfreesboro, Tennessee [email protected]

Hilde Phipps, MA, LADACDirector of Adult Addiction ServicesHelen Ross McNabb CenterCenterpointe5310 Ball Camp PikeKnoxville, Tennessee 37921865-523-4704 ext. [email protected]

Jim JonesClinical Manager/Crisis ManagerPathways Behavioral Health Services238 Summar DriveJackson, Tennessee [email protected]


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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 aswell 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.“

Simply put, a co‐occurring disorder typically refers to an individual having one, or more, diagnosed mental illness coupled with one, or more, diagnosed addictive disorder.

How many people are affected?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 co-occurring 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 state’s foster care system, prevalence data tells us that approximately 2,000 to 4,000 families are impacted by substance use and a co-occurring 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-OCCURRINGDISORDERS:

Moving TennesseeToward 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.

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42 Rutledge Street, Nashville, TN 37210-2043(615) 244-2220 | (800) 568-2642 toll free in TN | Fax: (615) 254-8331Joint

Resolution . . . 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 consumers, their families and our communities. 11/14/2012

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MISSION STATEMENTThe mission of the Co‐Occurring

Disorders Collaborative is to create a common understanding of the

impact and treatment of co‐occurring 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.


42 Rutledge Street, Nashville, TN 37210-2043(615) 244-2220 | (800) 568-2642 toll free in TN | Fax: (615) 254-8331

11/14/201226

CHARGEThe Co‐Occurring Disorders

Collaborative Steering Committee serves as the

primary statewide structure to oversee and coordinate the planning, development, and

implementation of all phases of the Co‐Occurring Disorders Collaborative activities and

initiatives to include ensuring consistency, accountability, and

sustainability of co‐occurring disorder strategies and provide

strategic and operational recommendations through the committee and subcommittee

structure.

STEERING COMMITTEE CHAIRMANRandy Jessee, Ph.D., Senior Vice President Specialty Services, Frontier Health, Gray

GRANT ADMINISTRATORTennessee Association of Mental Health Organizations

TENNESSEE ASSOCIATION OF ALCOHOL, DRUG & OTHER ADDICTION SERVICES (TAADAS)Mary Linden Salter, Executive Director, TAADASDebbie Hillin, President, TAADAS, NashvilleCharlotte Hoppers, Executive Director Grace House, Memphis

TENNESSEE VOICES FOR CHILDREN (TVC)Charlotte Bryson, Executive Director, Nashville

TENNESSEE COALITION FOR MENTAL HEALTH AND SUBSTANCE ABUSE SERVICESRobert J. Benning, Chairman (CEO, Ridgeview, Oak Ridge)

TENNESSEE ASSOCIATION OF ALCOHOL AND DRUG ABUSE COUNSELORS (TAADAC)Toby Abrahms, President, NashvilleCharlie Hiatt, River City Counseling, Chattanooga

MENTAL HEALTH AMERICA OF MIDDLE TENNESSEE(Formerly Mental Health Association of Middle TN)Tom Starling, Ed.D., President/CEO, Nashville

TENNESSEE MENTAL HEALTH CONSUMERS’ ASSOCIATION (TMHCA)Anthony Fox, Executive Director, NashvilleCarolina George, Nashville

NAMI TENNESSEECO‐FOUNDING ORGANIZATION OF THE TENNESSEE CO‐OCCURRING DISORDERS COLLABORATIVEJeff Flahey, Executive Director, NAMI Tennessee, NashvilleDick Baxter, Ph.D., President, NAMI TennesseeRobin Nobling, Executive Director, NAMI Davidson County, Nashville

TENNESSEE ASSOCIATION OF MENTAL HEALTH ORGANIZATIONS (TAMHO)CO‐FOUNDING ORGANIZATION OF THE TENNESSEE CO‐OCCURRING DISORDERS COLLABORATIVERandy Jessee, Ph.D., Senior Vice President Specialty Services, Frontier Health, GrayJim Jones, Clinical Manager/Crisis Manager, Pathways, JacksonVickie Harden, Senior Vice President for Clinical Services, Volunteer Behavioral Health Care System, MurfreesboroVickie Griffey, Coordinator A&D Carey Counseling Center, ParisTeresa Fuqua, Director of Member Services, TAMHO, NashvilleEllyn Wilbur, Executive Director, TAMHO, Nashville

TENNESSEE DEPARTMENT OF MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES (TDMHSAS)Rod Bragg, Assistant Commissioner, Division of Substance Abuse Services, NashvilleSejalWest, Assistant Commissioner, Division of Mental Health Services, NashvilleKen Horvath, Co‐Occurring Disorders Specialist, Division of Substance Abuse Services, NashvilleAngela McKinney Jones, Director of Prevention Services, Division of Substance Abuse Services, Nashville

Integrating Treatment...Making Connections with Drug Courts

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