Co-Occurring Treatment:
Latest Trends
The Circle Program at CMHIP:
Fully Integrated Dual-Diagnosis Inpatient Treatment
Elizabeth ‘Libby’ Stuyt, MD
Medical Director, Circle Program
Colorado Mental Health Institute at Pueblo
2012 Colorado Behavioral Healthcare Council
Annual Training Conference
September 28, 2012
Circle Program
Mission Statement
To help persons with co-occurring
mental illness and substance
dependence learn how to maintain
sobriety, psychiatric stability,
medication compliance, social
responsibility and personal integrity
outside the hospital setting.
Circle Program
• 20 bed, 90-day inpatient treatment program
• Men and women, 18 - 65
• Dual diagnosis – substance abuse and mental
illness
• Abstinence based (no addictive medications)
• Totally tobacco free since 2000
• Funded by the State of Colorado
• Treating people who have failed everything else
• 40 hours of group per week
• Lots of written work
Treatment Team
The treatment team consists of a board
certified addiction psychiatrist, a
psychologist, a social worker, a team leader, a
recreational therapist, 6 registered nurses, 2
licensed psychiatric technicians, and 4 mental
health workers, all of whom are at some level
of Certified Addiction Counselors.
Treatment team is also supported by chaplain
services, registered dietitians, physical
therapists, vocational therapists, occupational
therapists, teachers for GED services and
medical, surgical, and dental services to meet
individual treatment needs.
Addiction is a disease of the learning
and memory part of the brain
• Treatment involves stopping the substances,
allowing the brain to heal, and re-wiring the
brain – enabling new learning
▫ Cognitive/Behavioral Treatment
 Dialectical Behavioral Therapy (DBT)
 Strategies for Self-Improvement and Change (SSIC)
▫ Relapse Prevention
▫ Cue Exposure
▫ Creating a society with societal rules that need to
be followed (Behavioral Awareness)
People often start using and continue using
substances as a way to cope with stress
• Treatment also needs to teach people how
to manage stress without using addictive
substances
• Stress Management Techniques
▫ NADA acudetox – 5 point ear acupuncture
▫ Other meridian therapies – TAT, EFT, TFT
▫ Mindful Meditation, Yoga, Tai Chi, exercise
▫ Biofeedback – Heartmath ® - based on heart
rate variability - Cardiac Coherence
Patient Population
• Patients come from all over the state of Colorado
– 60% from the Denver-metro area
• Patients are referred by mental health centers,
DSS, ADAD, probation/parole officers, public
defenders, judges
• The program is voluntary and doors are not
locked
• 75% have legal problems and treatment is a
condition of probation, parole or diversion
Application Process
• Application and patient agreement must be
complete and signed by the patient, we also
need:
• Current psychiatric assessment documenting
mental illness diagnosis and current treatment
• Documentation of previous substance abuse
treatment, either inpatient or outpatient (DUI
classes or detox don’t count)
• Standardized Offender Assessment and/or
resolution of pending charges if legal problems
are present
What is the Circle Program?
• Very intense, cognitive/behavioral program
• 40 hours of group per week, 18 different groups,
some meet once a week, some occur several
times a week
• Homework assignments from every group
• Many rules – patients are expected to report
themselves and peers for rule violations
• Level system – based on Stages of Change
Groups – Based on Four Treatment
Cornerstones
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•
•
•
Relapse Prevention
Behavioral Change
Education
Origin of Issues
Relapse Prevention
learning to manage cravings and
stress that lead to relapse
•
•
•
•
•
•
•
•
Resolutions (cue exposure response prevention)
Re-entry (recovery plan)
Recreational Therapy (voluntary exercise)
Support Groups (AA, DTR, voluntary 12-step
group)
5-point NADA ear acupuncture (voluntary)
Biofeedback training - Heartmath®
Thought Field Therapy (voluntary)
Yoga, Tai Chi, pool therapy, physical therapy
(pain management)
Restorative Yoga
Not so restorative Yoga
Behavioral Change
• HOPE group (Behavioral Awareness)
▫ Gift system
▫ Teaching tools
▫ Peer coordinators
• Strategies for Self-Improvement and Change
(SSC 1)
▫ Thinking reports
▫ Addressing criminal thoughts and behaviors
• Dialectical Behavioral Therapy (DBT)
Educational Groups
• Recovery Education – how drugs and alcohol
affect the body, how medications work, how
different therapies work
• Symptoms Management – signs and symptoms
of mental illness
• Discovery Group
• Talk with the Doc
Origin of Issues Groups
• Parenting
• Men’s and Women’s Trauma/Process Group
• Men’s and Women’s Anger Group
Individual Work
• On admission – Plan of Care Formulation –
given goals to work on for first month
▫ Substance abuse
▫ Mental health – diagnostic exploration worksheets
▫ Physical problems – chronic pain management
• Plan of Care Review – treatment team
reviews work from previous month and
assigns new work for the next month
• Brain Synchronization Therapy
Successful Completion
• Remaining the full recommended time in
treatment
• Completing all program components ex:
parenting, SSC 1, re-entry, resolutions
• Completing all written assignments from groups
and on plan of care, including recovery plan
• Not engaging in major rule violations
• No continuous pattern of minor rule violations
• Moving up in the level system
Level System
• Developed to reflect “stages of change” model
• All patients start out at level
▫ Precontemplation
• Staff determine levels on a weekly basis based on
progress made on POC and homework, group
attendance, documented major and minor rule
violations
Levels
• Precontemplation
▫ Minimal compliance, not ready to make
changes
• Contemplation
▫ Increasing but inconsistent compliance,
thinking about change
• Action
▫ Decision to change, actively changing
behavior
• Ownership
▫ Consistently demonstrating change and
appropriate behavior
Effects of Creating Tobacco Free Treatment
• Comparison of all patients treated in the six months
before going tobacco free on January 1, 2000 and
the years after going tobacco free.
• In the six months before – patients allowed to go
outside to smoke.
• After going tobacco free patients are expected to
completely refrain from tobacco use during the three
months of treatment.
• All patients are given a great deal of education
regarding tobacco use and encouraged to quit.
Tobacco is full integrated into every aspect of
treatment.
Patient’s decision regarding tobacco use
before and after program is tobacco free
Decision
regarding
tobacco
use after
treatment
Six months
before
tobacco
free - 1999
N=111
First year
after going
tobacco
free - 2000
N=157
Three year
period
2006 –
2008
Plans to
continue
tobacco
75%
61%
40%
33%
12%
24%
51%
55%
13%
15%
9%
12%
Quit using
tobacco with
plans to
remain
abstinent
No tobacco
use on admit
N=285
Three Year
period
2009-2011
N=231
So What Happens after Treatment?
• Current Outcome study – following patients for one
year after completing 3 months inpatient treatment
in a tobacco free environment
• Self-report, probation officer, family member
• 231 consecutive admissions and discharges from
January 1, 2009 – December 31, 2011
• 80% successfully completed program (n=185)
• Of those eligible (179), 86% enrolled to participate
in outcome study (n=154)
• By December 31, 2011, 68% completed the one year
follow-up (n=105)
Demographics of 231 patients
admitted and discharged 2009-2011
• 55% male
• 78% Caucasian, 15% Hispanic, 6% African
American, 1% Asian
• Age = 35 ± 11 years (18 – 65)
• Primary Drug Dependence
▫
▫
▫
▫
▫
▫
33% Alcohol
31% Polysubstance
15% Methamphetamine
10% Cocaine
7% Opiates
4% Cannabis
• Nicotine Dependence – 88%
Psychiatric Diagnoses
• Primary Psychiatric Diagnoses
▫ 29% PTSD
▫ 22% Depression
▫ 17% Bipolar
▫ 12% Anxiety
▫ 10% Schizophrenia/Schizoaffective
▫ 6% Substance Induced psych symptoms
▫ 4% Other
• 79% have an Axis II diagnosis
▫ 34% Borderline Personality disorder
▫ 16% Antisocial Personality disorder
What determines program completion?
•
•
•
•
•
•
•
•
•
No difference by gender (p=.4104)
No difference by race (p=.3402)
No difference by age (p=.1258)
No difference by primary psychiatric diagnosis
(p=.4834)
No difference by primary drug dependence
(p=.4898)
No difference by number of previous treatment
programs attended (p=.8792)
No difference by tobacco use on admission (p=.08)
Mean LOS for completers = 87 ± 7 days
Mean LOS for non-completers = 40 ± 22 days
Presence of Axis II diagnosis affects
program completion
• 98% of those with no personality disorder
diagnosis completed the program
• 87% of those with Borderline Personality
completed the program
• 59% of those with Antisocial Personality)
completed the program
• p<.0001
Attitude regarding tobacco predicts
program completion
• 67% of those who used tobacco while in
treatment versus 83% of those who did not use
tobacco completed the program (p=0.02)
• 48% of those planning to use tobacco ASAP after
discharge, completed the program versus 93%
who were planning to attempt to stay quit or
expressed ambivalence regarding tobacco use
(p<.0001)
Other factors aiding in program
completion
• Having a probation officer and accountability
▫
▫
▫
▫
85% on probation completed
71% of the voluntary patients completed
53% of civil commitments completed
p=.0013
• NADA acudetox appears to help with program
completion
▫ Those completing had 12 ± 9 acudetox sessions
▫ Those not completing had 5 ± 5 sessions
▫ p<.0001
Patients using tobacco were more likely to use
NADA acudetox and were more likely to remain in
treatment longer the more sessions they had.
Regression Plot
Split By: tobacco
Cell: yes
110
160
100
140
90
120
80
100
70
80
LOS
LOS
Regression Plot
Split By: tobacco
Cell: no
60
60
40
50
20
40
0
30
-5
0
5
10
15
20
25
acudetox sessions
Y = 79.175 + .287 * X; R^2 = .048
30
35
p=.2616
40
-20
-5
0
5
10
15
20
acudetox sessions
Y = 69.048 + .811 * X; R^2 = .089
25
30
35
p<.0001
Regression Plot
Split By: tobacco p tx
Cell: w ants to quit
Regression Plot
Split By: tobacco p tx
Cell: plans to sm oke
160
120
140
100
120
100
LOS
LOS
80
60
80
60
40
40
20
20
0
0
-5
0
5
10
15
20
acudetox sessions
Y = 48.441 + 1.592 * X; R^2 = .155
Regression Plot
Split By: tobacco p tx
Cell: n/a
25
30
-5
10
15
20
acudetox sessions
Y = 84.307 + .137 * X; R^2 = .01
35
p=.001
5
Regression Plot
Split By: tobacco p tx
Cell: am bivalent
110
105
100
100
90
25
30
35
p=.2714
95
LOS
80
LOS
0
70
90
85
60
80
50
75
40
70
30
-5
0
5
10
15
20
25
acudetox sessions
Y = 79.077 + .276 * X; R^2 = .045
30
35
40
p=.2879
0
2.5
5
7.5
10 12.5 15 17.5 20
acudetox sessions
Y = 88.694 - .336 * X; R^2 = .055
22.5
25
p=.4896
Attitude about Tobacco Use as a
predictor of outcome
Plan for Tobacco
Use after
Discharge
2001 – 2003
N=440
2006 – 2009
N=340
Plans to smoke
41% complete
57% complete
Plans to stay quit
80% complete
92% complete
p<0.0001
Plans to smoke
≥ 8 sessions NADA
<8 sessions NADA
57% complete
24% complete
83% complete
44% complete
86% of the 58 patients with Borderline PD completed
treatment and they remained significantly longer in
treatment the more acudetox sessions they had
(averaging 13 ± 9 sessions)
Regression Plot
Split By: axis II
Cell: borderline pd
Inclusion criteria: Criteria 2 from 2009 to 2010 178 patients.csv (im ported).svd
110
100
LOS
90
80
70
60
50
40
-5
0
5
10
15
20
25
acudetox sessions
Y = 78.134 + .367 * X; R^2 = .07
30
35
40
p=.0454
98% of the 44 patients with no Axis II diagnosis
completed treatment and averaged 13 ± 9
acudetox sessions
Regression Plot
Split By: axis II
Cell: no dx
Inclusion criteria: Criteria 2 from 2009 to 2010 178 patients.csv (im ported).svd
160
150
140
LOS
130
120
110
100
90
80
70
-5
0
5
10
15
20
acudetox sessions
Y = 90.51 - .227 * X; R^2 = .039
25
30
35
p=.2007
Preliminary Data – as of January 2012
• 105 patients have completed one year follow-up
after discharge from the program. Information
obtained on 101 for full year, 4 were lost to follow-up
• 54% sober and doing well at end of year
▫ 30% continuously abstinent
▫ 16% relapsed but got back on track
▫ 7% one or more slips but back on track
•
•
•
•
22% continuing to relapse
19% re-offended and incarcerated
4% deceased
2% relapsed and back in treatment
There was no difference between
status at the end of the year and:
•
•
•
•
•
•
•
Gender (p=.6837)
Race (p=.4738)
Primary drug dependence (p=.7149)
Primary psych diagnosis (p=.8409)
Tobacco use prior to admission (p=.7068)
Legal status (p=.2617)
Presence of Axis II diagnosis (p=.0518)
Tobacco use was significantly
correlated with relapse
• Non-tobacco use increased from 12% to 25% at
the end of the year.
• Those using tobacco were much more likely to
relapse. (p=.012)
• Those continuously abstinent were more likely
to not be using tobacco. (p=.0326)
• For those who relapsed to drugs or alcohol
▫ 9 ± 4 months to first relapse for non-tobacco user
▫ 6 ± 5 months to first relapse for tobacco user (p=.0117)
Cost Benefits of Program
• First 40 patients in outcome study who were
referred to Circle as a condition of probation
▫ 21 (52%) sober and doing well at the end of the
year. 9 (23%) relapsed but still on probation
successfully, 8 (20%) re-offended and
incarcerated, 2 (5%) deceased. (January 2011)
• All 40 were looking at a 2-6 year term in DOC if not
successful in Circle
• Average of 3 previous inpatient treatment programs
prior to Circle without benefit
• Most had already spent considerable time in and out of
jail/prison proving just incarceration doesn’t work
How Circle Saves the
State of Colorado Money
•
•
•
•
•
•
•
•
•
Cost of three months at Circle - $36,000
Cost one year general population DOC $36,000
Cost of one year DOC-TC - $73,000
40 X 72,000 (2yrs DOC-GP) = $2,880,000
40 X 36,000 (1 yr DOC-GP) + 40 X 73,000 (1 yr
DOC-TC) = $4,360,000
40 X 36,000 (Circle 3 mos) = $1,440,000
40 X 36,000 (Circle 3 mos) + 8 X 72,000 (20%
recidivism – 2 yrs DOC-GP) = $2,016,000
2,880,000 – 2,016,000 = $ 864,000
4,360,000 – 2,016,000 = $ 2, 3440,000