Individuals who have a serious mental illness (SMI) with serious functional impairment are some of the most challenging patients, and they often find drugs and alcohol to be their preferred 'medication' over prescribed medications. High percentages of patients with SMI have serious co-occurring substance use disorders (SUDs). Health care professionals have a huge challenge to help our co-occurring population achieve recovery. We must be experts at integrated treatment including managing anxiety, psychosis, mood, and attention deficit hyperactivity disorder (ADHD) and SUDs if we are to help patients achieve stability and recovery. Furthermore, our patients must be integral members of the treatment team, fully engaged in their treatment program, and connected with their providers to help prevent relapse and achieve mutually agreed upon treatment goals.
Patients with bipolar disorder who are in good recovery from drugs and alcohol, for example, may do very well on their mood stabilizers until their mood destabilizes into mania or depression. At that juncture, they are at high risk for relapse. Mania is a mood episode that can be euphoric or irritable in nature, insight is limited, and judgment may be poor contributing to relapse. The severely consequential outcomes of a manic episode can be devastating. Depressive episodes also present risk factors for relapse or increased use of substances. The hopelessness and feelings of worthlessness promote seeking 'relief' from substances or an 'I don't care anymore' attitude. Persons with major depressive episodes, either bipolar or unipolar, do not see anything beyond immediate relief from emotional pain. When we ask patients how they got started in using alcohol and drugs, they will often say they started after a traumatic event to 'numb out' their feeling as they search for a moment of calm and relief. They may say it was the only way to be able to sleep, or they may admit they use to stay high, such as using cocaine or methamphetamine in mania. It is multifactorial as is relapse. Their stored brain memory is that substances provide something to take them away from their circumstances, to alter their awareness, and to provide a measure of comfort even for a very short time. Their stored brain memory of the consequences of using drugs and alcohol is competing with the overwhelming 'call' or craving to use again. Because their brain circuits have been hijacked by substance use in the past, the brain is ready to go right back into the addicted circuit that starts again once substance use begins, perhaps even when craving starts in anticipation of drug use (Stahl, 2013). When we understand the neurobiology of craving and SUDs as well as the neurobiology of the mental disorders, we can comprehend how complex and challenging the recovery process is for these individuals.
The patient who relapses, and starts using drugs and alcohol again, may miss outpatient appointments, run out of medications and not call, end up in the emergency department or jail, get sent to treatment, and lose or have lost the support of family and friends. We as health care professionals get frustrated, and maybe even angry, with this patient who did 'not comply' with treatment. Perhaps, we should rethink this perception of failure and recognize that these multiple brain disorders are highly unpredictable. We do not know what environmental stressors may trigger mania, depression, hallucinations, paranoia, flashbacks, or panic attacks. We rely on the patient's subjective experience to develop a list of the earliest signs of mania, depression, and psychosis. Physical health issues, change in living status, legal issues, relationship issues, job and financial problems, weather changes, and triggers of past trauma are only some examples of the many factors that may destabilize patients.
What are some solutions to this commonly occurring complex dilemma? One is to make sure patients have regular and frequent appointments with a competent and compassionate provider. One of the most important protective factors for preventing relapse is the relationship with the provider. If patients are engaged with their providers, they may be more likely when they recognize early signs of relapse or new episodes to call for help and reduce the risk of relapse. Second, the SUDs and the mental disorders must be addressed at each appointment. If patients are in 12-step recovery groups, then assessing their attendance and participation should be a part of each encounter. Exploring reasons for not going to meetings, or not contacting a sponsor, should be addressed, not in a punitive manner, but by allowing the patient to express reasons for not attending and then encouraging patient to set reasonable goals. We should never assume a patient is not using substances. We should ask in a matter-of-fact manner so that patients will be more likely to be honest and assess craving by asking 'are you craving?' Drug screens are another tool that we have, as long as they are presented to the patient as a way to measure progress.
One of the most important strategies we have to promote recovery in our patients with SMI and SUDs is to provide a comprehensive diagnostic evaluation. If a patient has four different anxiety disorders, bipolar I disorder, posttraumatic stress disorder, cannabis use disorder, and alcohol use disorder, all diagnoses should be documented and addressed in the treatment plan. Screening for these disorders using reliable and valid tools provides initial data that can be used in the full psychiatric evaluation process. Every disorder may impact quality of life and functionality. This is a challenge only in our agencies and private practices where the push is for productivity and meeting benchmarks and in agencies where only certain diagnoses are covered by managed care. Patients benefit when they are informed of what we have found on our evaluations. We should help patients link their own issues with their family history to help patients see how these issues are often inherited. If they have experienced trauma, we should help them understand how their symptoms relate to trauma so that they can see that this is essentially a normal reaction to something abnormal that happened to them. Our patients need to know that all disorders are brain disorders, including SUDs, and that these disorders can be treated. They are reassured to know that we will address all of their disorders in their treatment plan.
Certainly, it is a dilemma when working with patients who have both psychosis and SUDS. Should we treat psychosis such as that occurring in schizoaffective disorder and schizophrenia if the patient is using alcohol, marijuana, or other drugs? If we truly practice in an integrated model and believe that recovery is possible, then we move to developing a treatment plan that addresses psychosis, including adequate doses of antipsychotics and other needed medications. If the SUD is in the mild-to-moderate severity level (APA, 2013), then we should discuss, using motivational interviewing and screening, brief intervention, and referral to treatment (SBIRT) principles, how to reduce amounts and ask for a trial of abstinence. If the patient is not open to abstinence, then working with the patient to lower intake to an agreed upon amount is the next step. Even if a patient can only agree to not drink one night of the week, sticking to this commitment is a huge step that is to be commended for the willingness and courage to change drinking patterns. Small incremental goals often can be achieved on an outpatient basis leading to larger goals such as abstinence.
Patients may benefit from incentives, such as assuring a patient that ADHD stimulants may be safe to prescribe once the patient is not abusing drugs and/or alcohol. Individuals who are in college want to be successful, but chronic cannabis use coupled with untreated ADHD and bipolar disorder may find themselves unable to meet their educational goals. Patients can be encouraged through motivational interviewing to diminish and stop the cannabis use so that the ADHD can be safely addressed with stimulants. Until then, nonstimulants and mood stabilizers can provide significant benefit to enhance the willingness and support the plan to stop cannabis altogether.
Patients may also benefit from long-acting injectable (LAI) antipsychotics for schizophrenia. Can using an LAI reduce relapse to psychosis? By all means, yes. Can LAI help with drug and alcohol abuse? It makes sense that full coverage of an antipsychotic for 2-4 weeks means nomissed doses and no missed doses means the potential of providing stability so that the patient will be able to focus on getting off drugs and in a solid recovery program.
Many times, patients relapse merely by walking home in their neighborhood. They are triggered by familiar places and people, such as crack houses, bars, and dealers. We have treatment programs with housing alternatives for those with wealth; they are not easy to find for those on social security disability. A multidisciplinary team meeting needs to address the complex patient who frequently relapses. States that have exceptional recovery models need to share what they have learned. In many instances, patients can only get into substance use treatment by first come first serve basis. If they are not in line by a certain time of the morning, they are turned away. It is very frustrating to not be able to find affordable treatment programs and easy access for our patients.
All substance use treatment programs need to focus on diagnosing and treating mental illness, promoting safety, and preventing suicide while using evidence-based treatment approaches that are individualized and family focused. A relapse prevention plan needs to include symptoms of mental illness as potential triggers for relapse. A provider certified in both psychiatry and addictions (e.g., PMHNP and CARN-AP) along with a multidisciplinary treatment team is a good model for supporting recovery. Medication-assisted treatment for SUDs should be provided whenever appropriate along with careful titration of medications for the other psychiatric disorders. Many patients require multiple medications, often at high doses, to achieve stability. Patients need ease of access to their providers and encouragement to 'check in' often especially if they are at high risk. Increasing the frequency of visits and using protected email or Skype in between visits provide a patient with the connection they need to be accountable.
There are many patients with SMI and SUDs (co-occurring disorders) who, unfortunately, fear any kind of treatment. Their families need tremendous support to encourage their loved one to seek and accept help. They need education to understand what problems their loved ones have, and they need encouragement to not lose hope and to seek help for themselves such as AL Anon, NAMI, or DBSA meetings as well as family and individual therapy.
Some of the greatest rewards we have as providers are sharing with a patient the joy and satisfaction of giving up cannabis, reaching milestones of abstinence from alcohol and prescription opiates, being able to go to work without voices saying how worthless one is, sleeping well every night, not spending excessively, completing and passing courses, developing meaningful relationships, and quitting smoking. These are amazing accomplishments. The journey may take many different turns before it reaches its goal, but to be there sharing in someone's journey truly is a gift.
We can support efforts to improve access; participate in community boards that improve services; support local, state, and federal initiatives; and bring addiction specialists together with mental health specialists working collaboratively to assure evidence-based quality treatment. Ideally, one provider should provide the integrated treatment (SAMHSA, 2006). We should promote knowledge of co-occurring disorders and treatment to all providers working in this field. Treatment of mental illness such as bipolar disorder, major depressive disorder, schizophrenia, ADHD, and anxiety and treatment of SUDs must be addressed from the start and continue through all aspects of treatment. We should operate in integrated systems where mental health and addictions professionals work together to promote continuity and quality of care (SAMHSA, 2006). We must collaborate with professionals in primary care, human services, education, housing, and criminal justice to meet the complex needs of individuals with co-occurring disorders (SAMHSA, 2006). The brain is always under construction so we are caregivers of our patients' brain development when we choose to work in this field. We must believe that our patients have the capacity for recovery (SAMHSA, 2006). We must be compassionate respectful providers who listen and validate, who promote goal setting for improved outcomes, and who celebrate successes with our patients.
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