Co-Occurring Disorders Expected rather than the Exception

1
Co-Occurring DisordersExpected rather than the
Exception

• Tribal Justice Safety One OJP
• Tribal Training and Technical Assistance
  Session III
• Shelton, WA
• June 5, 2007
• Elizabeth I. Lopez, Ph.D.
• US Department of Health and Humans Services
• Substance Abuse and Mental Health Services
  Administration

2
Presentation Overview

• Definition of Co-Occurring Disorders
• Epidemiology of Co-Occurring Disorders
• Overview of SAMHSA Co-Occurring Activities
• SAMHSA Targeted Co-Occurring Programs
• COSIG
• COCE
• National Policy Academy on Co-Occurring Disorders
• Upcoming AI/AN Policy Academy
• Discussion

3
Definition Co-occurring Disorders

• The term refers to co-occurring substance use
  (abuse or dependence) and mental disorders.
• Clients said to have co-occurring disorders have
  one or more mental disorders as well as one or
  more disorders relating to the use of alcohol
  and/or other drugs.
• A diagnosis of a co-occurring disorder (COD)
  occurs when at least one disorder of each type
  can be established independently of the other and
  is not simply a cluster of symptoms resulting
  from a single disorder.

4
Co-Occurring Disorders

• Epidemiology
• What do we know about
• Co-Occurring Disorders?

5
Co-Occurring Disorders

• We know that co-occurring disorders are
  increasing becoming the expectation rather than
  the exception.

6
Co-Occurrence of SMI and Substance Use Disorders
among Adults Aged 18 or Older 2003
NSDUH 2003
7
Co-Occurrence of SPD and Substance Use Disorder
in the Past Year among Adults Aged 18 or Older
2005
Up by 1 million in 2 years
14.9 Million
19.4 Million
5.2 Million
Substance Use Disorder (SUD) Only
Serious Psychological Distress (SPD) Only
Co-Occurring SUD and SPD
8
Substance Use among Adults Aged 18 or Older, by
Major Depressive Episode in the Past Year 2005
9
Substance Use among Youths Aged 12 to 17, by
Major Depressive Episode in the Past Year 2005
Percent Using Substance
Past Year Illicit Drug Use
Daily Cigarette Use in Past Month
Past Month Heavy Alcohol Use
Past Year Marijuana Use
Past Year Psycho-therapeutics Use
10
Co-Occurring Psychiatric Problems
Source CSAT AT Outcome Data Set (n9,276
adolescents)
11
Co-Occurring Disorders Expected rather than the
Exception

• We know that individuals with a
• co-occurring disorder are less likely to receive
  treatment for BOTH disorders.

12
Past Year Treatment among Adults Aged 18 or
Older with Both Serious Psychological Distress
and a Substance Use Disorder 2005
Treatment for Both Mental Health and Substance
Use Problems
Treatment Only for Mental Health Problems
34.3
8.5
Substance Use Treatment Only
4.1
No Treatment
53.0
5.2 Million Adults with Co-Occurring SPD and
Substance Use Disorder
Note Due to rounding, these percentages do not
add to 100 percent.
13
Mean Age for Past Year Initiates, by Illicit
Drug 2004
NSDUH, 2004
14
Past Month Illicit Drug Use among Persons Aged 12
or Older, by Age 2004
15
Co-Occurring DisordersExpected rather than the
Exception

• American Indian/Alaskan Native Communities face
• unique challenges with co-occurring substance
• abuse and psychological conditions
• Historical trauma
• Stigma / Discrimination
• Preserving cultural healing traditions
• Multiple funding streams / delivery systems for
  behavioral health services

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Substance Use and AI/AN

• Rates of past year use disorders were higher
  among American Indians and Alaska Natives than
  members of other racial groups for alcohol,
  illicit drug use, marijuana, cocaine, and
  hallucinogen use disorders. 
•  
• Although in the past year American Indians and
  Alaska Natives were less likely than persons of
  other racial backgrounds to have used alcohol
  (60.8 vs. 65.8), they were more likely to have
  an alcohol use disorder (10.7 vs. 7.6).
• For illicit drug use in the past year, American
  Indians and Alaska Natives were more likely than
  persons of other racial backgrounds both to have
  used an illicit drug (18.4 vs. 14.6) and to
  have an illicit drug use disorder (5.0 vs.
  2.9).
• NSDUH 2005

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Substance Abuse/Dependence MDE or SPD by AI/AN
and Non-AI/AN
with Co-Occurring Conditions
Source NSDUH 2004 2005
AI/ANAmerican Indian/Alaska Native MDEMajor
Depressive Episode SPD Serious Psychological
Distress ID Illicit Drugs AlcAlcohol
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Current Use of Illicit Drugs among Persons Aged
12 or Older, by Race 2002 -2004
Percent Using in Past Month
NSDUH 2002-2004
19
Current Use of Illicit Drugs among Youth Aged 12
to 17, by Race 2002-2004
Percent Using in Past Month
NDSUH 2002-2004
20
Current Use of Illicit Drugs among Persons Aged
26 or Older, by Race 2002-2004
Percent Using in Past Month
National Survey on Drug Use and Health 2004
21
Current Use of Alcohol among Persons Aged 12 or
Older, by Race 2002- 2004
Percent Using in Past Month
National Survey on Drug Use and Health 2004
22
Heavy Use of Alcohol among Persons Aged 12 or
Older, by Race 2002-2004
Percent Using in Past Month
National Survey on Drug Use and Health 2004
23
Received Substance Use Treatment in the Past
Year among Persons Aged 12 or Older, by Race 2004
Percentage
24
Substance Dependence or Abuse in the Past Year
among Persons Aged 12 or Older, by Race 2004
Percentage
25
Substance Abuse

• Individuals with alcohol and drug problems
• Prevalence rates for current alcohol abuse and/or
  dependence among Northern Plains and Southwestern
  Vietnam veterans have been estimated to be as
  high as 70 compared to 11 - 32 of their white,
  black, and Japanese American counterparts.
• The estimated rate of alcohol-related deaths for
  AI/AN is much higher than for the general
  population.

26
Mental health

• Exposure to trauma
• The rate of violent victimization of AI/AN is
  more than twice the national average
• Higher rate of traumatic exposure - 22 rate of
  PTSD for AI/AN, compared to 8 in the general
  U.S. population

27
Mental health

• Availability of Mental Health Services
• Approximately 101 AI/AN mental health
  professionals are available per 100,000 AI/AN,
  compared to 173 per 100,000 for whites.
• In 1996, only about 29 psychiatrists in the U.S.
  were of AI/AN heritage.

28
Mental health

• Access to Mental Health Services
• The Indian Health Service (IHS) is the Federal
  agency responsible for providing health care to
  Native populations
• 20 of AI/AN report access to IHS clinics, which
  are located mainly on reservations

29
Mental health

• Medicaid is the primary insurer for 25 of AI/AN
• Approximately 50 of AI/AN have employer-based
  insurance coverage, compared to 72 of whites
• 24 of AI/AN have no health insurance, compared
  to 16 of the U.S. population

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Risk and Protective Factors for Substance Use
among American Indian or Alaska Native Youths

• American Indian or Alaska Native youths were more
  likely to perceive moderate to no risk of
  substance use
• A larger percentage of American Indian or Alaska
  Native youths did not perceive strong parental
  disapproval of youth substance use than youths in
  other racial/ethnic groups
• American Indian or Alaska Native youths were more
  likely to believe that all or most of the
  students in their school get drunk at least once
  a week

NSDUH 2002 - 2003
31
SAMHSA Response to addressthe Co-occurring
Disorders
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SAMHSA Co-Occurring Initiatives

• Report To Congress (2002)
• Federal Leadership
• Cross Agency Matrix Action Plan
• Co-occurring State Incentive Grants
• Co-occurring Center for Excellence
• Key publications TIP 42/COD Toolkits
• Co-occurring Policy Academies

33
Congress called on SAMHSA to prepare a report
outlining the scope of the problem of
co-occurring disorders, current treatment
approaches, best practice models, and prevention
efforts. This report was mandated to include
a summary of the manner in which individuals with
co-occurring disorders are receiving treatment,
a summary of practices for preventing
substance abuse disorders among individuals who
have a mental illness and are at risk of having
or acquiring a substance abuse disorder a
summary of evidence-based practices for treating
individuals with co-occurring disorders and
recommendations for implementing such practices
and a summary of improvements necessary to
ensure that individuals with co-occurring
disorders receive the services they need.
34
Report to Congress on the Preventionand
Treatment of Co-OccurringSubstance Abuse
Disorders and Mental Disorders

• Released November 2002
• Raised the awareness of Co-occurring Disorders
• Included a Five-Year Blueprint for Action
• SAMHSA adopted road map to address Co-occurring
  Disorders

35
(No Transcript)
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Co-Occurring Matrix WorkgroupChair and Membership

• A. Kathryn Power. M.Ed.
• Director
• Center for Mental Health Service (CMHS)
• H. Westley Clark, M.D., J.D. M.P.H
• Director
• Center for Substance Abuse Treatment (CSAT)
• SAMHSA Workgroup representation
• Center for Mental Health Services Office of the
  Administrator
• Center for Substance Abuse Treatment Office of
  Applied Studies
• Center for Substance Abuse Prevention Office of
  Communications
• Office of Policy, Planning Budget

37
No Wrong Door Policy

• Each provider should be aware that he/she has the
  responsibility to address the range of client
  needs
• wherever a client presents for care
• whenever a client presents for care
• properly refer clients for appropriate care as
  needed
• follow-up on referrals to ensure clients received
  proper care

38
SAMHSA Co-occurring Matrix Action PlanFY
2006/2007 Purpose

• To expand and improve prevention, appropriate
  treatment and other supportive services to
  individuals with and/or at risk for co-occurring
  disorders.
• Approximately 5.2 million individuals in the
  United States are estimated to be affected by
  co-occurring mental and substance abuse
  disorders. However, only a small percentage of
  these individuals receive treatment that
  addresses both disorders.

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SAMHSA Co-Occurring Matrix Action PlanLong Term
Measures

• Increase the percentage of persons with
  co-occurring disorders who receive appropriate
  treatment services that address both disorders.
• Increase the percentage of adolescents aged 12
  17 who receive appropriate prevention services
  that address substance abuse and mental health.
• Increase the percentage of persons who experience
  reduced impairment from their co-occurring
  disorders following appropriate treatment.

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SAMHSA Co-Occurring Matrix Action PlanOutcome /
Annual Measures

• Increased percent of prevention and treatment
  settings that
• screen for co-occurring disorders
• assess for co-occurring disorders
• provide treatment to clients through
  collaborative, consultative and integrated models
  of care

41
SAMHSA Co-Occurring Matrix Action Plan Outcome
/ Annual Measures

• Increase the number of grantees (States, Tribes,
  communities, and providers) measuring and
  reporting on co-occurring programs, practices,
  and models of treatment (accountability)
• Increase the number of States and Tribes with
  State or Tribal-Level actions plans for improving
  access to mainstream and specialty services for
  individuals with co-occurring disorders(capacity)
  
• Increase the number of people trained to
  implement appropriate co-occurring prevention and
  integrated treatments among States, communities,
  providers and consumers (effectiveness)

42
SAMHSA Co-Occurring Action PlanFY 2006-2007 Key
Activities

• Ensure that co-occurring disorders are a
  significant focus in the following major grant
  programs, as appropriate Mental Health Systems
  Transformation SIG, Access to Recovery, and the
  Strategic Prevention Framework SIG
• Monitor the extent to which the Co-Occurring
  State Incentive Grant (COSIG) addresses those
  populations prioritized on the SAMHSA Matrix that
  are appropriate and relevant to the programs
  within the matrix area
• Create and disseminate a nationally accepted
  framework for developing, implementing, and
  sustaining co-occurring disorders prevention and
  treatment service systems.

43
SAMHSA Co-Occurring Matrix Action PlanFY
2006-2007 Key Activities-continued

• Increase the number of candidate programs
  addressing co-occurring disorders that apply for
  review to the National Registry of Evidence-based
  Programs and Practices (NREPP) addressing
  co-occurring disorders
• Hold a policy academy for Tribal organizations,
  tribal communities, and tribal governments to
  assist in developing and sustaining service
  systems for the unique needs of AI/AN with and at
  risk for co-occurring disorders and for
  interested States who have not participate in a
  policy academy to date.

44
SAMHSA Strategic Plan for Co-Occurring Disorders
Mission To expand and improve prevention, appropriate treatment and other supportive services to individuals with and/or at risk for co-occurring disorders Key Drivers Report to Congress Presidents New Freedom Initiative SAMHSA Co-Occurring Action Plan SAMHSA Matrix IOM Report Target Population Adult and Youth with Co-Occurring Disorders Adult and Youth at risk for Co-Occurring Disorders States, Tribes, Local Communities Mechanisms COSIG Specialized TA (COCE/Policy Academy) Training Curriculum/Publication (TIP 42/Tool Kits) Outcomes Individual Increase access to appropriate prevention treatment services Provider Increase number of people trained to implement appropriate COD treatment Community/System Increase number of States, Tribes, Communities with comprehensive action plans
45
National Outcome Measures (NOMS)Domains

• Abstinence from Drug / Alcohol Use / Reduced
  Morbidity
• Employment / Education
• Crime and Criminal Justice
• Family and Living Conditions
• Access / Capacity
• Retention
• Social Connectedness
• Perception of Care
• Cost Effectiveness
• Use of Evidence-Based Practices

46
Co-Occurring DisordersExpected rather than the
Exception

• Linking Co-Occurring Disorders with key SAMHSA
  Matrix Areas
• Mental Health System Transformation
• Substance Abuse Treatment Capacity
• Strategic Prevention Framework

47
Treatment Implications of Comorbidity Between
Alcohol and/or Drug Use Disorders and Other
Psychiatric Disorders

• Adolescents and adults with co-occurring
  disorders are not treated
• Increased severity, disability and impairment in
  social/occupational functioning
• Resistance to pharmacologic treatment
• Lower probability of recovery
• Increased suicidality
• Increased economic burden of each comorbid
  condition

48
Co-Occurring Disorders Expected rather than the
Exception

• Areas of Focus for the Treatment of COD
• Innovative Models of Integrated Treatment
• Sharing Lessons Learned across programs
• Workforce Development
• Working with Tribal, Rural Communities
• Child, Adolescent, Family and Older Adults
• Cultural Competency Training for Local Providers

49
Co-Occurring Disorders Expected rather than the
Exception

• Co-Occurring Programs
• Co-Occurring State Incentive Grant
• (COSIG)

50
Co-occurring State Incentive Grants (COSIG)

• Supports grantees in overcoming service delivery
  barriers
• Supports grantees in systems change and
  infrastructure development
• Enhancing service coordination, networks and
  linkages to support quality care
• Improving financial incentives for integrated
  care
• Information sharing among stakeholders
• 17 grantees

51
Co-occurring State Incentive Grants (COSIG)

• Key Program Accomplishments
• Implemented first COD program within CJ System
• Redesigned and implemented a website to transfer
  information between local practitioners and
  States
• Implemented a voucher system to acquire ancillary
  services needed by COD clients
• Established Statewide common data warehouse about
  persons within the MH and SA systems

52
History of COSIG Funding
Grants Awarded (annually in September)
Year Number Awarded States Receiving Award Funding Agency
2003 7 AR, PA, HI, MO, TX, AK, LA Jointly by CSAT and CMHS
2004 4 OK, VA, AZ, NM CMHS
2005 4 CT, DC, ME, VT CMHS
2006 2 MN, SC CSAT
53
Co-occurring State Incentive Grants (COSIG)

• Lessons Learned
• Involve Senior State/Tribal Leadership
• Family/Consumer Participation
• Engage provider community in COSIG planning
• Program accountability
• Measures of success Linking outcomes
• Evaluation Update

54
Co-Occurring Disorders Expected rather than the
Exception

• SAMHSA Co-Occurring Center for Excellence (COCE)
• http//coce.samhsa.gov

55
COCE

• Funded through SAMHSA, is a leading national
  resource for the field of co-occurring mental and
  substance use disorders
• Consists of national and regional experts who
  join service recipients in shaping COCEs
  mission, guiding principles, and approaches
• Accomplishes its mission through technical
  assistance and training, delivered through
  multiple vehicles

56
COCE Mission

• To receive and transmit advances in treatment for
  all levels of COD severity
• To guide enhancements in the infrastructure and
  clinical capacities of service systems
• To foster the infusion and adoption of evidence-
  and consensus-based COD treatment and program
  innovations into clinical practice.

57
COCE Targeted Populations

• States / Tribes receiving COSIG funding
• States / Tribes not yet receiving COSIG funding,
  including Co-Occurring Policy Academy States and
  all other States / Tribes
• AI/AN tribes and organizations, clinical
  providers, other providers, agencies and systems
  through which clients might enter the COD
  treatment system

58
Key Focus of COCE Program

• COSIG TA
• Policy Academy TA
• Community TA
• COCE Web site
• COCE Training / Material Development

59
Co-Occurring DisordersExpected rather than the
Exception

• Prevention Co-Occurring Disorders
• Operationalizing the Role of Prevention

60
Prevention Strategies for Co-Occurring Disorders

• Develop evidence based strategies, programs, and
  practices that target risk/protective factors of
  at risk kids
• Develop individual and family-based case
  management systems that target families of
  addicted and/or those presenting w/ mental health
  disorders to clinics, hospitals etc.
• Develop programs across the life span

61
Tip 42 Substance Abuse Treatment for Persons
with Co-Occurring Disorders

• This TIP revises TIP 9,
• Assessment and Treatment
• of Patients With Coexisting
• Mental Illness and Alcohol
• and Other Drug Abuse.
• 1st printing of Tip 42
• 27,000
• 2nd printing of Tip 42
• 50,000

62
Co-Occurring Disorders Expected rather than the
Exception

• National Policy Academy on Co-Occurring
  Disorders

63
National Policy Academy on Co-Occurring Disorders

• The purpose of the National Policy Academy on
  Co-Occurring Mental and Substance Abuse Disorders
  is to enhance the provision of co-occurring
  services in States, Tribes and communities.
• The Policy Academy brings together Teams
  comprised of individuals with policy-making
  influence in conjunction with nationally
  recognized faculty and facilitators who assist
  the Teams to develop a comprehensive Action Plan
  to enhance the provision of, and expand access
  to, effective prevention, treatment, and related
  services for co-occurring disorders within their
  jurisdiction.

64
National Policy Academy on Co-Occurring Disorders

• The overarching goal of SAMHSAs National
  Policy on Co-Occurring Substance Use and Mental
  Disorders is to enhance the provision of
  co-occurring services in States, Tribes and
  communities.
• This goal is supported by four objectives of
  the Policy Academy.

65
National Policy Academy on Co-Occurring
DisordersObjectives

• To assist States, Tribes and local policymakers
  in the development of an Action Plan intended to
  improve access to appropriate services for people
  with co-occurring substance use and mental
  disorders
• To create and/or reinforce relationships among
  the Governors office, Legislators, Government
  and local program administrators, and
  stakeholders from the public and private sectors
• To provide an environment conducive to the
  process of strategic decision-making within the
  context of co-occurring disorders and
• To assist State, Tribal and local policymakers in
  identifying issues or areas of concern that may
  result in a formal request for technical
  assistance.

66
National Policy Academy on Co-Occurring
Disorders

• The Policy Academy model sequential process
• Pre-meeting work, a technical assistance site
  visit, and SWOT (Strengths, Weaknesses,
  Opportunities, Threats) analysis
• Formal Academy meeting (on-site live technical
  assistance)
• Post-meeting technical assistance and follow-up
• Ongoing implementation (on-site technical
  assistance)

67
National Policy Academy on Co-Occurring Disorders

• Strategic / specialized technical
  assistance approach
• Not a grant program - no new funding for
  services
• Focus on improving services for people with
  co-occurring disorders
• Innovation in health care reimbursement
• Focus on prevention / recovery
• Evidence of partnership with substance
  abuse and mental health treatment systems

68
National Policy Academy on Co-Occurring Disorders

• Desired Outcomes
• Operationalize No Wrong Door for all people
  with co-occurring disorders
• Culturally relevant and appropriate service
  systems
• Building partnership across mental health and
• and substance abuse prevention services
  treatment systems
• Identify institutionalized barriers and develop
  strategies to overcome

69
National Policy Academy on Co-Occurring Disorders

• Cohort I (April 2004)Alabama Arizona
  Connecticut Hawaii Louisiana Maine Michigan
  Missouri North Carolina South Dakota
• Cohort II (Jan 2005)California Georgia
  Illinois Iowa New Mexico Oklahoma Texas
  Virginia Washington
• Cohort III (Sept. 2005)Delaware Indiana
  Kansas Maryland Montana New York Ohio Rhode
  Island
• Tribal Policy Academy (Sept. 2007)

70
National Policy Academy on Co-Occurring Disorders

• Key Program Accomplishments
• Much of the success of the Policy Academy is
  that it transcends a typical strategic planning
  retreat or a conference, in that it seeds a
  process of cross-agency collaboration and systems
  change.
• The design facilitates leaders, policy makers
  and advocates from each Team to build on its
  strengths, develop policy strategies and
  implement action plans for transforming practice
  before, during, and after the Academy meeting.

71
National Policy Academy on Co-Occurring Disorders

• Key Program Accomplishments (cont.)
• Locally defined shared vision
• Innovative financing strategies and leverage
  existing resources
• Culturally relevant approach
• Cross sector policy makers / providers /
  stakeholders working together

72
National Policy Academy on Co-Occurring
Disorders AI/AN

• Planning Underway for tentatively scheduled
  academy - September 2007
• Invitation released May 2007 applications due
  June 15, 2007.

73
National Policy Academy on Co-Occurring
Disorders
Key review factors that will shape eligibility
criteria Capacity/Readiness Outline
Need Current Health/ Behavioral Health Delivery
Approach Multi-level commitment Current Health
/ Behavioral Health Financing Structures Willingn
ess to collaborate / partner with other entities
delivering behavioral health delivery
services Interest and willingness to share
lessons learned from the policy academy with
other communities
74
The National Policy Academy on Co-Occurring
Substance Use and Mental Disorders A Schematic
Overview
The Policy Academy Model A Multi-Stage Process
Post-Academy Technical Assistance
Selection Process
Academy Orientation
Formal Academy Meeting

• Conference calls, SAMHSA
• communications introduce Tribes
• to Academy process
• Pre-Academy site visits
• provide Academy orientation
• enhance understanding of
• Academy model
• develop common vision, priorities, strategies,
  and draft S.W.O.T. analysis
• initiate identification of technical
  assistance needs
• formalizes team leadership and
  decision- making process

• Facilitates delivery of technical
• assistance and action plan
• development across multiple
• formats (i.e., plenaries,
• presentations, Team working
• sessions)
• Teams present vision
• statements and Tribal-related key
• issues and efforts
• Formal presentations on systems change,
  evidence- based practices, prevention, funding,
  resources, and other co-occurring curriculum
  areas
• Policy Teams
• continue developing action plans and
  identifying technical assistance needs
• receive feedback and technical assistance from
  faculty and peers

• Policy teams
• finalize strategies (short-and long- range) and
  specific action steps
• submit revised action plan for SAMHSA
  review/feedback
• prioritize and coordinate technical
  assistance with COCE and other TA
• implement action plans
• submit semi-annual progress reports to
  SAMHSA

• Applicants responded to a
• Letter of Invitation specifying
• formal eligibility criteria
• clearly defined problem
• high-level commitment
• breadth, depth, and
• authority of proposed
• Tribal team
• Peer review selection process of participating
  teams/delegations

Enhances the Provision of Co-Occurring Services
in Communities
75
Next Steps for SAMHSACo-occurring Portfolio

• Institutionalizing No Wrong Door
• Unique needs of special populations
• (Children, rural, AI/AN)
• Core Co-Occurring Competencies
• Supporting Integrated System Sustainability
• Evidence-based COD programs
• Disparate Funding Streams/Reimbursement
• Licensing/Certification
• Cultural Competent/Relevant Service System

76
Co-Occurring Disorders Expected rather than the
Exception

• For more information
• www.samhsa.gov
• www.samhsa.gov/Matrix/matrix_cooc.aspx
• 1-800-729-6686
• 1-800-487-4889 (TDD)
• Publication Ordering and Funding Information

77
Co-Occurring DisordersExpected rather than the
Exception

• Thank you!
• Elizabeth I. Lopez, Ph.D.
• US Department of Health Human Services
• Substance Abuse and Mental Health Services
  Administration
• Office of Policy, Planning Budget
• 240-276-2242 (voice)
• 240-276-2252 (fax)
• Elizabeth.lopez_at_samhsa.hhs.gov

78
Co-Occurring DisordersExpected rather than the
Exception

• Discussion
• Recommendations
• Questions
• Thoughts