Treatment for Substance Use Disorders
and Co-Occurring MH Disorders:
New Initiatives in the VA
James R. McKay, Ph.D.
Professor of Psychology in Psychiatry
University of Pennsylvania
Center of Excellence in Substance Abuse Treatment and
Education
Philadelphia VA CESATE
Outline of the Presentation
• Treatment for substance use disorders (SUD) in the VA
– Practice guidelines
– Evidence-based behavioral and pharmacological treatments
• Treatment for co-occurring SUD and PTSD
– Numbers
– Practice guidelines
– Most recent research
• Treatment for co-occurring SUD and depression
• New initiatives to reorganize MH treatment in VA
• Examples of major rollouts of EBT for SUD in VA
Treatment
Uniform Services Handbook
and
Practice Guidelines
Purpose of the Handbook
• Describe levels of care within VA system
• Specify SUD treatments that VA programs
must be able to offer veterans
• Define the required features of programs at
different levels in the continuum, including
staffing, duration of care, and case loads
• Define standards for access
Practice Guidelines
• Provide step-by-step directions, presented in
clinical algorithms, for every type of SUD
treatment
–
–
–
–
–
Detoxifiation
Assessment and treatment planning
Residential treatment
Outpatient treatment
pharmacotherapy
MH screening in the VA
• All patients are screened once per year for alcohol
problems, PTSD, and depression
• Vets who come up positive are supposed to be
referred to either a brief intervention or to
SUD/MH specialty care
• In practice, less than 50% of vets with a positive
alcohol screen are referred
• Referral rates are higher for those with positive
PTSD or depression screen
Evidence-Based Treatments for SUD:
Large-Scale Training Initiatives
in the VA
Cognitive-Behavioral Therapy
(CBT)
• CBT focuses on changing cognitions and behaviors
thought to increase vulnerability to relapse
– Cognitions:
• All or nothing thinking
• Catastrophic thinking
• Attributional biases
– Behaviors:
•
•
•
•
Spending time with other substance users
Going to “high risk” locations
Interpersonal conflict
Unstructured time
Contingency Management
• Provides rewards for drug negative urine
samples or attendance at sessions
• Requires patient to provide urine samples 23x/week, and rapid analysis of samples
• Amount of reward can escalate with serial
success and reset to lower amounts if
substance use occurs
• Probably our most effective treatment for
stimulant dependence
Motivational Enhancement Therapy
• Many individuals with SUD are not ready for
abstinence oriented treatment
• MET is designed to help people with SUD who are
relatively unmotivated
• Techniques
–
–
–
–
–
Compare patient’s substance use to normative data
Roll with resistance (non-confrontational)
Open ended questions combined with reflective listening
Express Empathy
Develop Discrepancies between behavior and goals
• Usually done in 3-4 sessions
Medications for the
Treatment of SUD
Medications Approved in the US
to Treat Alcohol Dependence
•
•
•
•
Disulfiram (Antabuse): 1949
Naltrexone (ReVia): 1994
Acamprosate (Campral): 2004
Long-acting Naltrexone (Vivitrol): 2006
Opiate Addiction
• Two agonist medications are effective for opiate
dependence:
– Methadone (dispensed daily in programs)
– Buprenorphine (can be dispensed by private physician
in office)
• The antagonist medication naltrexone is highly
effective, but very underused
• All must be used as long-term, maintenance
medications in order to be effective
Are these meds used in the VA?
• Medications to reduce alcohol use:
– Less than 10% of patients who might benefit
from these meds receive them
– Reasons for low rate are being explored in a
number of research studies
• Medications to treat opiate use disorders
– VA provides both methadone and
buprenorphine
Treatment of Co-Occurring
PTSD and SUD
Epidemiology
Fiscal Year (FY) 2008 Prevalence of
Co-Occurring Conditions in Veterans Seeking
Treatment in Veterans Health Administration (VHA)
Major Depressive
Disorder
PTSD
N=351,708
MDD & SUD
PTSD & SUD
23%
23%
N=80,588
SUD
N=387,807
Sch & SUD
BP & SUD
26%
33%
Schizophrenia
VETERANS HEALTH ADMINISTRATION
Bipolar
Fiscal Year (FY) 2013 Prevalence of
Co-Occurring Conditions in Veterans Seeking
Treatment in Veterans Health Administration (VHA)
Major Depressive
Disorder (MDD)
PTSD
N=535,506 (up 52%)
PTSD & SUD
26.5%
N=142,163
(up 76%)
SUD
N=516,095 (up 33%)
Schizophrenia
VETERANS HEALTH ADMINISTRATION
Bipolar(BP)
Mental Disorders1 among Veterans2
Returning from Deployment
Cumulative from 1st Quarter FY 2002 through 1st Quarter FY 2014
Disease Category (ICD 9 code)
Total O/O/O
Veterans3
Change
Q1FY11-FY12
Change since
Q1FY12-FY13
Change since
Q1FY13-FY14
PTSD (309.81)
311,688
22.5%
20.7%
19.0%
Depressive Disorders (311)
248,891
26.4%
24.5%
21.3%
Neurotic Disorders (300)
229,361
29.5%
27.4%
26.1%
Tobacco Use Disorder (305.1)
183,054
21.5%
19.7%
17.0%
Affective Psychoses (296)
152,587
27.7%
23.9%
23.2%
Alcohol Abuse (305.0)
73,029
26.6%
23.0%
19.2%
Alcohol Dependence (303)
72,055
29.8%
26.4%
22.0%
Drug Abuse (305.2-9)
53,839
33.7%
29.4%
26.4%
Drug Dependence (304)
40,630
34.7%
31.0%
26.3%
1 Includes
provisional and confirmed diagnoses. http://www.publichealth.va.gov/epidemiology/reports/oefoifond/health-care-utilization/
These are cumulative administrative data since FY 2002.
3 A total of 572,569 unique patients received one or more diagnoses of a possible mental disorder.
2
VETERANS HEALTH ADMINISTRATION
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VHA Trends in Diagnoses by Drug for
Veterans with PTSD and SUD
35,000
30,000
25,000
20,000
15,000
10,000
5,000
0
FY02
FY03
FY04
FY05
Cocaine
VETERANS HEALTH ADMINISTRATION
FY06
Opioids
FY07
FY08
FY09
Cannibis
FY10
FY11
FY12
Amphetamines
FY13
PTSD-SUD Treatment in the VA
Summary of VA/DoD PTSD Guideline
Recommendations for Co-occurring SUD
1. All patients diagnosed with PTSD should receive comprehensive
assessment for SUD, including nicotine dependence
2. Recommend and offer cessation treatment to patients with
nicotine dependence
3. Patients with SUD and PTSD should be educated about the
relationships between PTSD and substance abuse. The patient’s
prior treatment experience and preference should be considered
since no single intervention approach for the co-morbidity has yet
emerged as the treatment of choice.
VETERANS HEALTH ADMINISTRATION
Summary of VA/DoD PTSD Guideline
Recommendations for Co-occurring SUD
4. Treat other concurrent substance use disorders consistent with
VA/DoD clinical practice guidelines for SUD including concurrent
pharmacotherapy:
a. Addiction-focused pharmacotherapy should be discussed,
considered, available and offered, if indicated, for all patients with
alcohol dependence and/or opioid dependence
b. Once initiated, addiction-focused pharmacotherapy should
be monitored for adherence and treatment response.
Ravelski, Olivera-Figueroa & Petrakis (2014). PTSD and comorbid AUD: a review of pharmacological and alternative treatment
options. Substance Abuse and Rehabilitation, 5, 25-36 http://dx.doi.org/10.2147/SAR.S37399
VETERANS HEALTH ADMINISTRATION
Summary of VA/DoD PTSD Guideline
Recommendations for Co-occurring SUD
5. Provide multiple services in the most accessible setting to
promote engagement and coordination of care for both
conditions.
6. Reassess response to treatment for SUD periodically and
systematically, using standardized and valid self report
instrument(s) and laboratory tests. Indicators of SUD treatment
response include ongoing substance use, craving, side effects of
medication, emerging symptoms, etc.
7. There is insufficient evidence to recommend for or against any
specific psychosocial approach to addressing PTSD that is comorbid with SUD.
VETERANS HEALTH ADMINISTRATION
Recent Research Findings
Cochrane Report on PTSD/SUD Treatment
- Roberts, Roberts, Jones, Bisson
Roberts NP, Roberts PA, Jones N, Bisson JI. Psychological interventions for
post-traumatic stress disorder and comorbid substance use disorder.
Cochrane Database of Systematic Reviews 2014, Issue 2. Art. No.:
CD010204. DOI: 10.1002/14651858.CD010204.pub2. Submitted for
publication
• Searched up to Jan 10, 2014
• RCT’s of individual or group psychotherapy with
PTSD/SUD participants, compared with waiting
list, usual care, or other psychotherapy
• 14 studies included
• Meta-analysis with over 1400 participants total
VETERANS HEALTH ADMINISTRATION
Cochrane Review Results
• Main comparison was CBT with trauma processing v.
CBT without trauma focus (coping skills)
• Overall quality of evidence was low to very low
– i.e., future research very likely to change estimate of effect
VETERANS HEALTH ADMINISTRATION
Results:
Individual Trauma Focused Interventions
w/Concurrent or Integrated SUD Treatment
• PTSD symptoms
– More effective than TAU or minimal intervention in
reduction in symptoms at post-treatment and followup
• Substance use
– No effects at post-treatment, but more effective than
comparison conditions at 5-7 month follow-up
• Higher drop out rate than TAU
VETERANS HEALTH ADMINISTRATION
Results:
Non-Trauma Focused Interventions
• Most studies looked at group-based interventions
• No positive effect on PTSD symptoms or SUD
compared to TAU
• Full course Seeking Safety more effective at end of
treatment than TAU, but not at follow-up
• Drop out rate comparable to TAU
VETERANS HEALTH ADMINISTRATION
Other Findings
• High drop out rate across all studies
• Review based on small number of studies, some
small or poorly designed
• Need for further study given low to very low quality
of research
• Need to interpret results with caution
VETERANS HEALTH ADMINISTRATION
Results
• Naltrexone produced better alcohol use outcomes than
placebo (mean difference = -7.93 % days drinking)
• No significant effect for either naltrexone or prolonged
exposure on PTSD outcomes
• Authors note that PE did not worsen drinking outcomes
• Low PTSD severity <10 on PSS (exploratory analysis)
–
–
–
–
70% PE + nalrexone
55% PE + placebo
44% supportive + naltrexone
37% supportive + placebo
VETERANS HEALTH ADMINISTRATION
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Considerations
• Excluded substance dependence except for nicotine
and cannabis
• Excluded for opiate use in past month prior to study
entry
• Required abstinence prior to study participation
VETERANS HEALTH ADMINISTRATION
Design and Results
• Design
– COPE (PE + CBT/RP) compared to TAU
– 103 participants with PTSD and SUD dx
– Followed for 9 months
• Results
– COPE produced greater reductions in PTSD symptom
severity than TAU (mean difference -16.1)
– No differences in substance use outcomes
VETERANS HEALTH ADMINISTRATION
Considerations
• Most participants polysubstance users
– Median = 4 substances in past month
• The most common main drugs of concern were
heroin (21%), cannabis (19%), amphetamines (17%),
benzodiazepines (15%), alcohol (11%), cocaine (6%)
• Only 54% of COPE-assigned participants attended
sessions with exposure
– Most who did only attended one or two sessions
• Treatment took close to a year for some participants
VETERANS HEALTH ADMINISTRATION
Kaysen et al., 2014
• Method
– Chart review of 536 Veterans receiving at least one
session of Cognitive Processing Therapy (CPT)
– 90% male
• Looked at outcomes in three groups:
– Current AUD (11% of sample)
– Lifetime but not current AUD (39% of sample)
– No AUD (50% of sample)
VETERANS HEALTH ADMINISTRATION
Results
• Comparable drop out rates in all 3 groups
(m = 9 CPT sessions attended)
• Comparable symptom improvement in all 3 groups
• Decrease in PTSD symptoms by all groups
• Decrease in MDD symptoms by all groups
VETERANS HEALTH ADMINISTRATION
Considerations
•
•
•
•
Chart review
No randomization
No alcohol use outcomes
No follow up
• But…
– First study showing CPT works as well in those with AUD as
in those without AUD
VETERANS HEALTH ADMINISTRATION
Where Are We Now?
• Nothing to contradict PTSD Clinical Practice
Guideline recommendations
• Treatment for alcohol use disorder or other SUD
together with PTSD treatment
• Trauma focused (evidence based) PTSD
treatments are tolerable and perform as well or
better than other treatments
VETERANS HEALTH ADMINISTRATION
What do Vets Want?
• Pilot study by Back et al. (2014) looked at the treatment
preferences of 35 veterans with SUD and PTSD
• Perceptions of SUD and PTSD
– 94% perceived a relationship between SUD and PTSD symptoms
– 85% perceived that increased PTSD symptoms led to increased SUD
– 62% believed that improvement led to decrease in substance use
• Preferred sequence of treatments:
– Integrated SUD/PTSD treatment: 66%
– Treat SUD first: 20%
– Treat PTSD first: 9%
VETERANS HEALTH ADMINISTRATION
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Treatment of Co-Occurring
SUD and Depression
New CBT-Based Interventions
• Building Recovery by Improving Goals,
Habits, and Thoughts (BRIGHT)
– Group based CBT for SUD patients with
depression
– Delivered by SUD counselors, with little or no
formal training in mental health care
– Well-suited to the VA, given reliance on group
counseling
Initial Research
• Watkins et al. (2012)
– Quasi-experimental study compared residential TX to
same plus BRIGHT groups
– Participants had SUD + major depression
– Results:
• 3 months: Positive effect for BRIGHT over TAU on BDI (p<
.01) and SF-12 (p< .05)
• 6 months: Positive effect for BRIGHT over TAU on BDI (p=
.08) and SF-12 (p< .05)
• Also, fewer days of substance use problems in BRIGHT, but
no effect on alcohol use
Training Counselors to Provide BRIGHT
• VA Study (G. Curran, PI)
• Developed a web-based, interactive training
program plus weekly telephone supervision
• If successful, could replace more costly and time
consuming in-person training protocols
• Pilot study produced very encouraging results
• Three training products are now available on
TMS, and are being used by providers
Reorganization of VA SUD
Services
Where services are provided
• Specialty SUD programs
– Drug free
– Opiate maintenance
• Behavioral Health Integrated Programs
(BHIP)– panel model
• Primary care-based integrated teams
Where all this is going
• Greater management of SUD patients in
BHIP or primary care programs
• Referral to SUD specialty care for more
severe patients and those who keep
relapsing
• Idea is to stabilize patient in SUD specialty
care, and refer back to BHIP or primary
care team.
Levels of Care for Mental Health
Level 1
Level 2
Level 3
Level 4
Level 5
Interdisciplinary
PACT Mental
Health Providers
(PC-MHI)
General
Mental Health
Team-based
Care:
Behavioral
Health
Interdisciplinary
Program (BHIP)
Specialty
Outpatient
Programs
Residential
Rehabilitation
& Treatment
Programs
(RRTPs)
Inpatient
Services
VETERANS HEALTH ADMINISTRATION
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The Behavioral Interdisciplinary Health Program
(BHIP) Team
• What is a GMH team (BHIP team)?
– Interdisciplinary team of mental health providers
– Manages a specific panel of Veterans
– Administrative support
– Tracking patient visits and measures over time
• Each facility to develop one BHIP team
according to OMHO staffing model
VETERANS HEALTH ADMINISTRATION
Outpatient General Mental Health Staffing Model:
Behavioral Health Interdisciplinary Program
(BHIP) Team Pilots
• This preliminary model is being piloted in VISNs 1, 4, 17, and 22. Teams
with the staffing model clinical ratios have been launched, and it is
expected that team size and panel composition may change over time
with feedback from the pilots.
• The overarching goal for this staffing model is to build interdisciplinary
teams who will provide the majority of mental health care necessary for a
panel of assigned Veterans and thus open access to mental health care for
all eligible Veterans.
• Teams leverage the expertise of individual members to provide recoveryoriented, evidence-based treatments for all mental health issues presented
by Veterans.
• Adjustments will be made to the model and team formation on an
ongoing basis as new data is obtained.
VETERANS HEALTH ADMINISTRATION
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Mental Health Services Before and After BHIP
Team Rollout
Before
After
Some providers may be practicing
individually in discipline-specific or
specialty-specific silos
Interdisciplinary, team-based care
Some providers may not be practicing
at the top of their license/scope of
practice
Practicing closer to top of license/
scope
Clerical support varies widely across
the system
More consistent clerical support for
teams
Often there is limited or no dedicated
time for indirect patient care activities
Dedicated time for indirect patient
care activities
VETERANS HEALTH ADMINISTRATION
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Initiatives in the VA to
Disseminate Evidence-Based
Interventions:
Measurement-Based Care
Contingency Management

A 17-item measure of addiction problem severity that is designed to support
measurement-based care (MBC) in SUD specialty care settings.

Retrospectively examines the patient's behavior in the past 30-days.

Item selection based on research on predictors of relapse and outcome

Initial psychometric evaluation indicates the BAM items are reliable and sensitive
to change (Cacciola et al., 2013).
Cacciola, J. S., Alterman, A. I., DePhilippis, D., Drapkin,M., Valades, C., Fala, N., et al. (2013). Development and initial
evaluation of the Brief Addiction Monitor (BAM). Journal of Substance Abuse Treatment, 44, 256–263,
http://dx.doi.org/10.1016/j.jsat.2012.07.013.
Substance Use
Risk Factors
Protective
Factors
Any alcohol use
Craving
Self-efficacy
Heavy alcohol use
Sleep problems
Self-help
Drug use
Mood
Religion/spirituality
Risky situations
Work, school
Family/social
problems
Income
Physical health
Social supports for
recovery
The MBC perspective:
 The baseline data and feedback inform initial treatment planning.
 The follow-up data and feedback inform treatment changes.
 Follow-up BAMs also may be used in the context of outreach to
out-of-treatment veterans.
The POLICY perspective (MH Handbook):
 (k) Patients with substance use illness need to be offered long-
term management for substance use illness and any other
coexisting psychiatric and general medical conditions. The
patient's condition needs to be monitored in an ongoing
manner, and care needs to be modified, as appropriate, in
response to changes in their clinical status.
Four regional CM trainings were conducted in 2011
To support fidelity and competency in the delivery of CM, the
Philadelphia CESATE has been convening coaching teleconferences
with CM providers.
 Prior to enrolling patients in CM, providers participated in 2 CM
Planning calls to review their CM implementation plan.
 Once CM commences at their facility, providers participate in 4
Implementation calls in the first 6 months of implementation and
ongoing calls every 6 months thereafter.
 Providers submit Implementation Review forms which help identify
departures from the proper protocol.


Since the final regional training in July 2011, 90 VA
programs have begun delivering CM
 82/90 (91%) are targeting abstinence
 8/90 (9%) are targeting treatment attendance
 …>80% Participation Rate on CM Coaching Calls
 …>1200 veterans have received CM targeting abstinence.
 …>90% of the nearly 15,000 urine specimens collected
across all VHA CM programs have tested negative for the
target drug.

Conclusions
Comorbidity is Common
• Over 140,000 vets with SUD and PTSD in
FY13– up 76% from FY2008!!
• Between 23 and 35% of vets with major
depression, schizophrenia, and bipolar
disorder also have SUD
Pressing Questions
• More information about individual treatments for
SUD and PTSD than about combined SUD/PTSD TX
– Best combinations of psychotherapy and/or
pharmacotherapy?
– Concurrent v. integrated?
• How to improve retention?
– Shared decision making
– Treatment matching?
When to Offer PE or CPT?
• No metric yet
• Case by case decision with pts using collaborative
approach
• Abstinent or willing to cut down?
– Willing not to use in a way that would disrupt treatment
• Motivated for treatment
• What supports are in place?
Strong emphasis on quality care
• Requirements for the kind of care vets can
expect to receive are outlined in:
– Uniform Services Handbook
– Practice Guidelines
• Increased emphasis on evidence-based SUD
treatments and measurement-based care
• Large-scale training initiatives within VA to
disseminate evidence-based practices
Reorganization of MH services
• Introduction of BHIP and PACT models
• Attempt to manage patients more
effectively across the continuum of care
• Concern about how to staff BHIP and still
maintain adequate staffing for SUD
specialty care
Thanks to Collaborators
• Penn and Phila VA
–
–
–
–
–
–
–
–
Donna Coviello
Dom DePhilippis
Michelle Drapkin
Jessica Goodman
Megan Ivey
Kevin Lynch
Dave Oslin
Debbie Van Horn
• Other Institutions
– Jon Morgenstern
(Columbia)
– Dan Kivlahan (U Wash)
– Susan Murphy (U Mich)
– Don Shepard (Brandeis)
– Mike French (U Miami)
Funding and Disclosures
• Funding from NIAAA
– R01 AA10341 and R01 AA014850
– P01-AA016821
• Funding from NIDA
– R01 DA020623
– K24-DA029062
• Funding from VHA
• Caron Treatment Centers covers a portion of my
U Penn salary
• No pharmaceutical company consultation
Contact Information
James R. McKay, Ph.D.
Center on the Continuum of Care in the Addictions
3440 Market St., Suite 370
Philadelphia, PA 19104
(215) 746-7704
jimrache@mail.med.upenn.edu