Dual Addictions Kathleen M Carroll PhD Yale University School of Medicine

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Dual AddictionsKathleen M Carroll PhDYale
University School of Medicine
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Overview

• Definitions and terms
• Epidemiology Rates and risks
• Onset Gateways and destinations
• Treatments Everything we dont know

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Terms

• Comorbidity Co-occurrence of two conditions or
  disorders
• Dual diagnosis Co-occurrence of alcohol/drug
  use disorder and another psychiatric disorder
  (heterotypic comorbidity)
• Homotypic comorbidity Co-occurrence of
  disorders within a diagnostic grouping (e.g.,
  substance use disorders)

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Major US epidemiologic surveys
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National Epidemiologic Survey on Alcohol and
Related Conditions (NESARC)

• Previous surveys in US, Canada, Australia confirm
  probabilities of alcohol use disorder rise with
  drug use disorder visa versa
• Only NESARC diagnosis specific (multiple types of
  drugs rather than lumping)
• Includes data on help seeking
• Focus on 12-month (current), rather than lifetime
  disorders
• Oversampling of African Americans and Hispanics

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DSM-IV Substance Dependence

• Maladaptive use leading to clinically significant
  impairment or distress, shown by 3 of the
  following in the same 12-month period
• Use of the substance more or longer than intended
• Persistent desire or unsuccessful efforts to cut
  down or stop
• A great deal of time spent on use of the
  substance or getting over its effects
• Important activities given up or reduced because
  of use
• Continued use despite knowledge of a serious
  physical or psychological problem
• Tolerance
• Withdrawal, or use to avoid withdrawal

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DSM-IV Substance Abuse

• Not dependent, and maladaptive use leading to
  clinically significant impairment or distress,
  shown by 1 of the following
• Continued use despite social/interpersonal
  problems
• Hazardous use (e.g., driving when impaired by
  alcohol)
• Frequent use leading to failure to function in
  major roles
• Legal problems

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NESARC 12-month prevalence rates
Stinson et al, (2005) DAD
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12-month prevalence Drug use disorders
Stinson et al, (2005) DAD
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Demographics

• Users of alcohol drugs more likely to be
• Male (74)
• Younger (18-29) (65)
• Never married (63)
• Similar to drug-only with respect to education,
  ethnicity, income

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Rates of alcohol use disorders among those with
specific drug use disorders NESARC
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Alcohol use among those with specific drug use
disorders and visa-versa
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Comorbidity NESARC
Stinson et al, (2005) DAD
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12-month prevalence treatment seeking by
disorder NESARC
Stinson et al, (2005) DAD
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12-month prevalence treatment seeking by
disorder NESARC
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Factors associated with multiple substance use

• Retention of use through gateway progression
• Pharmacologic effects of combinations, including
  modulation, treatment of withdrawal and
  uncomfortable effects
• Genetic evidence of common mechanisms,
  vulnerability in some families
• Availability, market trends

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Gateway pattern of drug initiation Kandel et al
Cigarettes
Alcohol
Cannabis
NCS-R Only 5.2 Violate this pattern
Other illicit
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Risk of developing disorder, given use
Anthony et al. 1994, Comparative epidemiology, NCS
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NESARC Hazard rates for alcohol and drug use
disorders
Hasin et al., 2007 Arch Gen Psychiatry
Compton et al. 2007 Arch Gen Psychiatry
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Drug-alcohol comorbidity associated with

• Earlier onset
• Higher severity
• Higher psychiatric comorbidity
• Higher rates of treatment seeking
• Higher rates of dropout once in treatment
• Less socioeconomic support
• Poorer treatment outcome

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Limited research on treatment of homotypic
comorbidity

• Users of multiple substances usually excluded
  from treatment research
• Difficulty in meeting needs of heterogeneous
  populations in single trial
• Complexity of assessment (time frame,
  availability of biologic indicators, time)
• Complexity of targeting multiple substances
  simultaneously (licit, illicit)Safety and
  compliance concerns, especially in pharmacologic
  trials
• Pharmacologic specificity

Rounsaville et al, 2003
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Available pharmacotherapies for substance use
disorders
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Emerging pharmacologic strategies for homotypic
comorbidity
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Original rationale for disulfiram as treatment
for cocaine users

• Clinical observation of high levels of concurrent
  alcohol-cocaine use (60-70 of patients)
• Rationale Reducing alcohol use may reduce
  concurrent cocaine use
• Better ability to utilize coping skills (Marlatt
  et al)
• Alcohol powerful conditioned cue (Higgins et al)
• Cocaethylene (Jatlow, McCance)

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Open outpatient study, cocaine-alcohol users
attaining 3 weeks abstinence
Carroll et al., 1998
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Double blind trial of disulfiram for cocaine
dependence in methadone maintenance N67
Petrakis et al 2000
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Randomized outpatient clinical trial
Disulfiram, CBT, and IPT, N121
Carroll et al., 2004
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Cocaine outcomes for those who did NOT meet
criteria for alcohol abuse or dependence (n58)
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Behavioral therapy studies of alcohol-drug users
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Behavioral therapies tend to be effective across
types of substance use
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Clinical Trials Network17 Current Nodes, gt200
CTPs
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Clinical Trials Network MET Trials Participant
Characteristics

• Mean age 35
• 29 female (ltMI)
• 42 Caucasian (ltMI)
• 12 years of education
• 28 mandated or legal referral
• Primary substance use problem
• Alcohol 29 (ltMI)
• Marijuana 16
• Cocaine 23 (gtMI)
• Methamphetamine 4 (ltMI)
• Opioids 9
• Benzodiazepenes 1

Ball et al., 2007
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CTN MET/MI studies Design
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CTN MET longitudinal outcomes
Ball et al.., 2007
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CTN MET/MI studies Outcomes for alcohol subgroups
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CBT 4 CBTComputer Based Therapy/CBT

• 6 modules, 1 hour each, high flexibility
• Highly user friendly, no text to read, linear
  navigation
• Video examples of characters struggling real life
  situations
• Multimedia presentation of skills
• Repeat movie with character using skills
• to change ending
• Interactive exercises, quizzes
• Multiple examples of
• homework

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Computer-based training in CBT CBT4CBT

• All comers few restriction on participation,
  only require some drug use in past 30 days
• 43 female
• 45 African American, 12 Hispanic
• 23 employed
• 37 on probation/parole
• 59 primary cocaine problem, 18 alcohol, 16
  opioids, 7 marijuana
• 79 users of more than one drug or alcohol

Carroll et al., in press, Am J Psychiatry
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Primary outcomes, 8 weeksCBTTAU versus TAU
Carroll et al., in press, Am J Psychiatry
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Treatment of Dual AddictionsGeneral strategies

• Target, treat most severe disorder and any
  requiring detoxification first
• Utilize pharmacotherapies when available
• Attend to psychiatric and medical comorbidity
• Frequent monitoring, chronic care model
• Sequential targeting may be important for some
  treatments (eg. contingency management)

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I wonder why were not getting any new converts.