Substance Abuse and Mental Disorders

The Co-Occurring Center for Excellence. Addressing mental disorders and alcoholism, addiction co-occurring.

The Co-Occurring Center for Excellence (COCE) was created by SAMHSA in 2003 to provide information and a range of services to mental health and substance abuse administrators and policymakers at state and local levels, their counterparts in tribal and Native populations, clinical providers, other providers, and all other agencies and systems through which clients may enter the treatment system.

COCE provides state-of-the-art and sustainable technical assistance, training, information and resources, and links to other resources that serve persons with co-occurring disorders.

http://www.coce.samhsa.gov/

See also;

The Dual Diagnosis Recovery Sourcebook :
A Physical, Mental, and Spiritual Approach to Addiction with an Emotional Disorder
by Dennis Ortman

Methadone Patients Drink Heavily

Correlates of alcohol use among methadone-maintained adults

This prospective study (n = 190) examined correlates of alcohol use from baseline data of a longitudinal trial conducted among moderate and heavy alcohol users receiving methadone maintenance therapy (MMT).

The sample included MMT clients who were 18â€“55 years of age, and were receiving MMT from five large methadone maintenance clinics in the Los Angeles area.

Half of the sample was heavy drinkers and nearly half (46%) reported heroin use. Using a structured questionnaire, correlates of heavy alcohol use included White and Hispanic ethnicity, and fair or poor physical health combined with older age (?50 years). We also found that MMT clients who were younger than 50 years, regardless of health status, were more likely to be heavy drinkers.

Compared with moderate alcohol consumers, a greater number of heavy alcohol users also experienced recent victimization.

To optimize MMT, alcohol screening should be part of routine assessment and alcohol treatment should be made available within MMT programs.

Moreover, special consideration should be provided to the most vulnerable clients, such as the younger user, those with a long-term and current history of heavy drug use, and those victimized and reporting fair or poor health. In addition, promoting attention to general physical and mental health problems within MMT programs may be beneficial in enhancing health outcomes of this population.

Research report; Adeline Nyamathi, Allan Cohen, Mary Marfisee, Steven Shoptaw, Barbara Greengold, Viviane de Castro, Daniel George and Barbara Leake. Drug and Alcohol Dependence. Volume 101, Issues 1-2, 1 April 2009, Pages 124-127. Correlates of alcohol use among methadone-maintained adults

Se also;

Clinical Guide to Alcohol Treatment: The Community Reinforcement Approach

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Dual Disorders, Dual Diagnosis

Dual Disorders – Third Edition

Depression. Schizophrenia. Post-traumatic stress disorder. Bipolar disorder.

Millions of individuals diagnosed with psychiatric or emotional disorders must battle an equally menacing and powerful disease–chemical dependency–alcoholism, drug addiction, medication addiction.

First published in 1993, Dual Disorders is the leading text on the biological and psychological relationship between mental illness and addiction.

The third edition of this Hazelden best-seller has been updated to include the latest research, information about new medications, and an explanation of new diagnostic criteria.

Key features and benefits

outlines the relationship between chemical dependency and psychiatric disorders

contains important resources for chemically dependent individuals and their families

presents practical relapse prevention strategies

pharmacotherapy

Dual Disorders – Buy 3rd Ed today!

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Alcohol and Hepatitis

Due to their high prevalence in the general population, alcohol use and abuse can be associated with hepatitis B and C virus infections and it has been demonstrated that alcohol plays a role as a co-morbid factor in the development of liver disease.

There is evidence that alcohol abuse accelerates the progression of liver fibrosis and affects the survival of patients with chronic hepatitis C. The mechanism by which alcohol worsens hepatitis C virus-related liver disease has not been fully clarified, but enhanced viral replication, increased oxidative stress, cytotoxicity and impairment of immune response could play a relevant role.

Alcohol abuse also seems to reduce both sensitivity to interferon and adherence to treatment.

It sounds reasonable to presume that the mechanisms enhancing liver damage in patients affected by hepatitis B are similar to those involved in hepatitis C virus infection.

However, more studies are warranted to improve our knowledge about the interaction between alcohol intake and hepatitis B virus infection.

In conclusion alcohol abuse is associated with an accelerated progression of liver injury, leading to an earlier development of cirrhosis, higher incidence of hepatocellular carcinoma, and higher mortality.

Abstinence from alcohol could reverse some of these deleterious effects.

Research report; Gitto S, Micco L, Conti F, Andreone P, Bernardi M. Alcohol and viral hepatitis: a mini-review. Dig Liver Dis. 2009 Jan;41(1):67-70. Epub 2008 Jul 3.

See also;

The Alcoholic

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Natrexone for Alcoholics

A synopsis of the pharmacological rationale, properties and therapeutic effects of depot preparations of naltrexone for treating alcohol dependence.

Although oral naltrexone has been shown to diminish alcohol reinforcement, its limitations as a medication include its small treatment effect size, plasma level fluctuation and adverse events.

The pharmacokinetic profile of naltrexone could be optimised by intramuscular administration, sustaining its release over several weeks.

As a result, plasma levels would remain relatively constant; high enough to reduce drinking, low enough to minimise side effects.

Two injectable naltrexone depot preparations, Vivitrex and Naltrel, have been tested as pharmacotherapy for alcohol dependence.

Their adverse-event profiles seem to be mild compared with oral naltrexone.

Vivitrex has shown efficacy at reducing heavy drinking significantly among alcohol-dependent men.

Naltrel helped reduce relapse and promote abstinence in two samples of alcohol-dependent individuals. Additional efficacy studies are warranted.

Johnson BA. Expert Opin Pharmacother. 2006 Jun;7(8):1065-73. A synopsis of the pharmacological rationale, properties and therapeutic effects of depot preparations of naltrexone for treating alcohol dependence.

Pharmacotherapy Principles & Practice
by Marie A. Chisholm-Burns, Barbara G. Wells, Terry L. Schwinghammer, Patrick M. Malone, Jill M. Kolesar, John C. Rotschafer, Joseph T. DiPiro

Antidepressant Induced Mania

Antidepressant Induced Mania (ADM) Among People with Co-Occurring Disorders (COD). Sometimes, informally called Bipolar III disorder.

A recent study of medical charts at a bipolar specialty clinic gives new support to the idea that antidepressants can induce mania in some bipolar patients.

For some time, clinicians have been concerned about the problem of antidepressant-induced mania (ADM), but most research has not supported the connection between antidepressants and manic or hypomanic episodes.

This study looked at ADM and examined differences between patients with bipolar disorder and a substance use disorder (SUD) and patients without SUD.

The article presents solid evidence for a significantly increased risk of ADM in patients with co-occurring bipolar disorder and SUD. The article also comments about why the increased risk to these clients may not have been identified in prior research.

Manwani and colleagues investigated medical charts from 98 patients who were treated at a bipolar clinic between 2000 and 2004. These patients accounted for 335 antidepressant trials during that period. Of the sample, 55 patients (accounting for 184 of the trials) had a lifetime history of a SUD.

For this study, an episode of ADM was defined as hypomanic or manic symptoms within 12 weeks of beginning a new antidepressant medication.

There were some substantial differences between patients who did and did not have a SUD historyâ€”e.g., clients with SUD were almost twice as likely as those without SUD to be prescribed lithium (48.3% vs. 28.5%), and clients without SUD were twice as likely to receive divalproex as those with SUD (43% vs. 20.1%) and almost three times as likely to be prescribed an antipsychotic (31.8% vs. 11.4%).

The univariate analysis of differences in the number of antidepressant trials leading to ADM between patients with and without a SUD history showed little difference in the percentage of ADM episodes they experienced (20.7% of trials for those with SUD and 21.4% of trials for those without).

However, using a multivariate regression model of analysis, the authors found that:

Patients with a lifetime SUD were five times as likely to experience ADM,
The incidence of an antidepressant trial leading to an ADM was greater for clients with Type II or with bipolar disorder not otherwise specified than for Type I,
Females were more likely than males to have an episode of ADM in response to an antidepressant trial, and
Bupropion was the antidepressant least likely to cause an ADM.

The authors surmise that older research studies excluding people with a SUD might have led to subject pools that underrepresented individuals considerably more likely to experience an ADM than the subjects studied. Additionally, they describe how other confounding factors might have served to hide the effects of having a history of SUD on the likelihood of suffering an ADM.

A discussion of the limitations of their study (e.g., it was non-randomized, non-blind; concomitant therapy may have obscured treatment effect; no measures of adherence to medication regimens) is also given.

Research; Manwani, S. G., Pardo, T. B., Albanese, M. J., Zablotsky, B., Goodwin, F. K., & Ghaemi, S. N. (2006). Substance use disorder and other predictors of antidepressant-induced mania: a retrospective chart review. Journal of Clinical Psychiatry, 67(9), 1341â€“1345.

Co-Occurring Disorders Research and Resources Monthly Review. The Co-Occurring Center for Excellence (COCE), of the Substance Abuse and Mental Health Services Administration (SAMHSA), Vol. 1, No. 5, December 2006. Readers interested in finding out more about COCE should visit the Web site: http://coce.samhsa.gov/

See also;

Dual Diagnosis,
Counseling the Mentally Ill Substance Abuser
by Katie Evans, J. Michael Sullivan

Anti Craving Medication Works

Extended-Release Naltrexone Works Particularly Well for Abstinent Patients with Dependence

Many patients with alcohol dependence do not receive the full benefits of treatment because they do not adhere to it. In part to address issues with adherence, extended-release (ER) naltrexone, which is released over a month after one injection, was developed. Pharmacotherapy researchers assessed ER-naltrexone efficacy in a subgroup of 82 subjects in a larger clinical trial who had ?4 days of abstinence.

In that subgroup, 380 mg of ER-naltrexone in 28 subjects versus placebo in 28 subjects

increased the time to first drink (median days, 41 versus 12);
increased continuous abstinence over 6 months (32% versus 11%);
increased time to first heavy drinking (>180 versus 20 days);
decreased days with any drinking (median days per month, 0.7 versus 7.2);
decreased days with heavy drinking (median days per month, 0.2 versus 2.9).

Smaller benefits, which were not always statistically significant, were found among 28 subjects treated with 190 mg of ER-naltrexone.

Comments by Michael Levy, PhD:
In this industry-sponsored secondary analysis of a small subgroup of subjects who had achieved just 4 or more days of abstinence before entering treatment, those who received ER-naltrexone in conjunction with psychosocial treatment had better treatment outcomes than those who received placebo. Medications with proven benefit for the treatment of alcohol dependence tend to be underutilized in general. This study suggests that ER-naltrexone is another treatment option for clients with alcohol dependence who have achieved even a short duration of abstinence.

Research Reference: Oâ€™Malley SS, Garbutt JC, Gastfriend DR, et al. Efficacy of extended-release naltrexone in alcohol-dependent patients who are abstinent before treatment. J Clin Psychopharm. 2007;27(5):507â€“512.

From; Join Together Online

Brief-TSF is designed to as adjunctive therapy for anti-craving medication.

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Prescription Drug Overdose Becomes Big Killer

Washington residents are dying from unintended drug poisoning in numbers beginning to approach deaths in car crashes, and overdose deaths blamed on legal drugs now exceed fatal overdoses caused by illicit drugs, the Spokane Spokesman-Review reported Feb. 4th 2008.

Prescription-drug overdoses have increased 800 percent in Washington between 1995, when 45 overdose deaths were reported, to 2004, when 411 state residents died from overdoses on drugs like hydrocodone and methadone. “Prescription drug overdose deaths have been climbing through the roof,” said Jennifer Sabel, an epidemiologist at the Washington Department of Health. “Even doctors don’t really realize the magnitude of the deaths.”

In nearby Idaho, drug poisonings rose from 32 in 2000 to 62 in 2004. Some victims died because they misused patches containing powerful painkillers like Fentanyl, while others suffered from a toxic mix of prescription painkillers and alcohol or over-the-counter medications like Benadryl. “Users may be lulled into thinking prescription medications are safe as opposed to ’street drugs,’ ” said Spokane County Medical Examiner Sally Aiken.

Overall opiate-related deaths in Washington rose from 260 in 1995 to 555 in 2004; auto crashes kill about 650 residents in the state each year. Mentions of prescription opiates on death certificates has risen even as involvement of illicit drugs like heroin have fallen by a third during the same period.

The trend is echoed by research conducted by the federal Centers for Disease Control and Prevention (CDC), which found that mentions of narcotic painkillers on death certificates rose 91 percent between 1999 and 2002. “This is a national problem,” said Dr. Gary Franklin, medical director for Washington’s Department of Labor and Industries.

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