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What is managing aggression and potentially violent situations?
Managing aggressive behaviour and potentially violent situations is not about stopping young people or others from experiencing and/or expressing anger. It is natural for all people to feel anger, an emotion that arouses people psychologically & physically in threatening situations.

Some young people find it difficult to express anger and frustration in a constructive way and at times aggressive behaviour and violence is the result. Youth AOD services and practitioners are required at times to manage aggressive behaviour and potentially violent situations. To do so organisations operating youth AOD services need to create a culture of non-violence and put in place measures that minimise the risk of aggression and violence occurring. Where incidents involving aggressive and potentially violent behaviour do occur, practitioners need to be enabled to respond effectively and both provide and access follow up care and support. Further, processes should be adopted that promote organisational learning and modification of systems and practices to prevent recurrence of incidents involving aggressive and potentially violent behaviour

Organisations that manage aggressive behaviour and potentially violent situations effectively can enact their duty of care for both clients and staff. In Victoria, WorkSafe (2003) and the State Government of Victoria (2007) have developed guidelines that help organisations and practitioners respond to workplace aggression. The aim is to minimise and eliminate wherever practicable the risks of work place violence related to occupational assault and implement strategies, controls and supports where total elimination of risk is not possible.

WorkSafe Victoria also defines the term occupational violence and aggression as any incident where an employee is abused, threatened or assaulted in circumstances arising out of or in the course of their employment. This includes:

Verbal, physical or psychological abuse

Threats or other intimidating behaviours

Intentional physical attack such as hitting, pinching or scratching

Aggravated assault

Threats with weapons or objects

Sexual harassment and sexual assault

Why is managing aggression and potentially violent situations effectively important in youth AOD work?
Like all young people, those who become clients of youth AOD services are learning how to understand and regulate their emotions. Anger is a powerful human emotion that some clients struggle to express and manage in a constructive way. At times this means that when clients feel angry, they lose control become aggressive. In turn this can escalate into violence. Alternatively, youth AOD clients might also have learned to use aggression and violence to manipulate or control a situation through intimidation and threats.

Helping young people find viable ways of living in the world without resorting to aggression and violence will often be integral to the process of addressing substance use problems. Even so, practitioners and other staff working in youth AOD services should not 'accept' that being subject to aggression and violence 'goes with the territory'. Incidents involving aggression and violence can have harmful physical, emotional, psychological and social consequences for staff and clients, including the perpetrator.

There are measures that can be taken to prevent incidents of aggression and violence occurring. Where incidents do occur, there are also effective strategies that can be employed by managers and practitioners that minimise risks to staff and clients and prevent escalation of aggression and violent behaviour.

The State Government of Victoria (2007) require healthcare providers, such as organisations operating youth AOD services, to prioritise actions and coordinate mechanisms for preventing workplace injury and the health consequences arising from exposure to violence.

High quality services constantly work towards creating a culture of non-violence where violence of any form perpetrated against any person is not tolerated and staff are not blamed incidents of violence.

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Managing aggression & potentially violent situations

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What is managing aggression and potentially violent situations?Managing aggressive behaviour and potentially violent situations is not about stopping young people or others from experiencing and/or expressing anger. It is natural for all people to feel anger, an emotion that arouses people psychologically & physically in threatening situations.

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This strategic guidance is aimed at adult social care employers and commissioners working specifically with adults with a range of support and care needs such as older people with conditions across the dementia spectrum, people with mental health and personality conditions and those with learning disabilities who have particularly complex needs and/or are labelled as challenging services. The guide aims to help employers with developing competency and expertise in providing support to people who challenge, across different groups.

It will address two specific challenges that employers need to consider - no matter what 'client group' they are working with. These are:

1. Organisational actions: how to design, recruit and retain a workforce that is equipped to support people who challenge.

2. Workforce skills and knowledge: what competencies and qualities organisations need to recruit and train for when building a workforce with people.

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england; social care; adult social care; social work; social workforce skills

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Supporting staff working with people who challenge services guidance for employers

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This strategic guidance is aimed at adult social care employers and commissioners working specifically with adults with a range of support and care needs such as older people with conditions across the dementia spectrum, people with mental health and personality conditions and those with learning disabilities who have particularly complex needs and/or are labelled as challenging services.

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In this session we will learn: that aggression and frustration are linked; to understand some causes of frustration; to recognise our own feelings and respond to them appropriately
1 hour
Create a safe and positive learning environment by agreeing ground rules for the session.

Other resources

Digital resources

Activity

1. Pass a ball around the classroom. When a student holds it, they can say something that someone might find frustrating. It can be something big or small. Note the different things that people find frustrating.
Note Frustration - Aggression theory
When people think that they are being prevented from achieving a goal, their frustration can turn to aggression. The closer you get to a goal, the greater your excitement and expectation of the pleasure of getting there becomes. The closer you are, the more frustrated you get by being held back. When the frustration is unexpected, this also increases the likelihood of aggression.

In 1941, a researcher called Barker conducted an experiment. He put some toys behind a wire screen where children could see them, but not play with them. After a while, he let them go and play with them, but the children became quite destructive, because they had been frustrated about not being able to get to them sooner. Another example is when football crowds become aggressive when their team is losing.

1. Talk in small groups about something they had heard in magazines or media about someone being aggressive, road rage or public arguments. Share some of these.

2. Ask students to consider the things that might have been going on (we have to make some assumptions or talk more generally about what can create feelings of anger) How do people react to feelings of anger or frustration?

3. Read through Kayleigh's day either as a role play in groups or together as a class

4. Discuss in pairs: What 'things' affected Kayleigh's feelings through the day?

5. Discuss the following in groups: What could Kayleigh have done before hand to prevent pressure from building up? What else could have been going for Kayleigh (we don't know everything)? Decide two top tips for Kayleigh to prevent a repetition of this day.

6. Using the handout, now consider a few things that they find can instigate angry feelings or aggression e.g. people riding bikes on the path, someone pushing in front of me. For each one of these, what they could do to help ease those feelings and help work towards a more positive outcome. Discuss what the person was thinking and therefore feeling. What needs to change to help manage the situation without developing angry feelings and the possibility of aggression.

7. Feed back as a class and share ideas. Which ones did they think were the most realistic or best ideas? Go through the fact sheet and share good ideas with the class. If there is time, practice some of these.

8. Ask students to think of something individually and privately which makes them feel angry or aggressive. Consider how they can think about it differently and what they could do to address those feelings. Write what could be done differently to improve the situation. Share these.

Key message

We all find things frustrating in our day sometimes and we can get cross with ourselves and others. But we can learn to think differently about what has happened - and to think of practical things we can do to help ourselves.

Reflection

What can I do to try to relieve feelings of frustration and anger?

Links

This session links to: Let it out | Managing stress | Coping with changes | My support network | Positive thinking | Listening skills
Make sure young people know what support is available and how to access this support.

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We all find things frustrating in our day sometimes and we can get cross with ourselves and others. But we can learn to think differently about what has happened - and to think of practical things we can do to help ourselves.

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Module 1 Co-occurring needs training 24th Feb ppt

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Module 2 cooccurring mental health and substance use

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Session 3 dual diagnosis training 10.03.21

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Sponsored by the Mayor of London's Rough Sleeping Innovation Fund

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Dialectical Behavior Therapy: DBT Skills, Worksheets, Videos

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Want to learn DBT? Take control of your thoughts, emotions, and relationships. Watch the free exercises, complete the worksheets, and see the change.

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Helping those in Need of Mental Health Support - Mental Health Response Winter 2020

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McLean Hospital Borderline Personality Disorder Family and Consumer Education Initiative

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The Comorbidity of Borderline Personality Disorder and Substance Abuse

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Side by Side | A community platform by Mind

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Recommendations

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.

Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

This guideline should be read in conjunction with NICE's guideline on coexisting severe mental illness (psychosis) and substance misuse: assessment and management in healthcare settings. This covers the assessment of, and support for, adults and young people (aged 14 and older) who have a suspected or known clinical diagnosis of psychosis with coexisting substance misuse.

The following should ensure service specifications take into account the recommendations in this guideline:

Commissioners of mental health, substance misuse and primary care

Local authorities when commissioning support services, including housing and other services provided by the public, community and voluntary sectors.

1.1 First contact with services

These recommendations are for all staff who may be the first point of contact with young people and adults with coexisting severe mental illness and substance misuse working in:

health (including urgent care and liaison services)

social care

public health

voluntary and community sector organisations

housing (for example, homeless shelters or temporary accommodation)

criminal justice system.

1.1.1 Identify and provide support to people with coexisting severe mental illness and substance misuse. Aim to meet their immediate needs, wherever they present. This includes:

looking out for multiple needs (including physical health problems, homelessness or unstable housing)

remembering they may find it difficult to access services because they face stigma.

1.1.2 Be aware that the person may have a range of chronic physical health conditions including:

1.1.3 Be aware that people's unmet needs may lead them to have a relapse or may affect their physical health. This could include: social isolation, homelessness, poor or lack of stable housing, or problems obtaining benefits.

1.1.4 Provide direct help, or get help from other services, for any urgent physical health, social care, housing or other needs.

1.1.5 Ensure the safeguarding needs of all people with coexisting severe mental illness and substance misuse, and their carers and wider family, are met. (See also the section on safeguarding issues in the NICE guideline on coexisting severe mental illness (psychosis) and substance misuse: assessment and management in healthcare settings.)

1.1.6 Ensure the person is referred to and followed up within secondary care, and that mental health services take the lead for assessment and care planning (see sections 1.2 and 1.3).

1.2 Referral to secondary care mental health services

1.2.1 Ensure secondary care mental health services:

On acceptance to secondary care mental health services

1.2.2 Provide a care coordinator working in mental health services in the community to:

1.2.3 Ensure the care coordinator works with other services to address the person's social care, housing, physical and mental health needs, as well as their substance misuse problems, and provide any other support they may need.

Involving people with coexisting severe mental illness and substance misuse in care planning

1.2.4 Involve the person (and their family or carers if the person wants them involved) in developing and reviewing the care plan (as needed) to ensure it is tailored to meet their needs. This includes offering the person information about the services available so they can decide which ones would best meet their jointly identified needs and goals. Also involve practitioners from:

1.2.5 Ensure the care plan:

1.2.6 Share a copy of the care plan with the person's family or carers (if the person agrees). In line with local information sharing agreements, share copies with other services as needed (see section 1.4 for recommendations on information sharing).

Carers

1.2.7 Ensure carers (including young carers) who are providing support are aware they are entitled to, and are offered, an assessment of their own needs (see NICE's guideline on supporting adult carers). If the carer wishes, make a referral to their local authority for a carer's assessment (in line with the Care Act 2014). When undertaking an assessment, consider:

1.2.8 Based on the carer's assessment:

1.3 The care plan: multi-agency approach to address physical health, social care, housing and other support needs

1.3.1 The person's care coordinator should adopt a collaborative approach with other organisations (involving shared responsibilities and regular communication) when developing or reviewing the person's care plan. This includes substance misuse services, primary and secondary care health, social care, local authorities and organisations such as housing and employment services.

1.3.2 Ensure the care plan includes an assessment of the person's physical health, social care and other support needs, and make provision to meet those needs. This could include:

personal care and hygiene

family and personal relationships

learning new skills for future employment or while in employment (including those administering social security benefits)

pregnancy and childcare responsibilities.

1.3.3 Consider covering behaviours in the care plan that may affect the person's physical or mental health, in addition to their substance misuse (see NICE's Pathways on drug misuse and alcohol-use disorders). Pay particular attention to:

1.3.4 Explore any barriers to self-care to help the person look after their own physical health. Address these barriers in the care plan.

1.3.5 Consider incorporating activities in the care plan that can help to improve wellbeing and create a sense of belonging or purpose. For example, encourage sport or recreation activities, or attendance at community groups that support their physical health or social needs. Ensure activities take account of a range of different abilities. Consider, for example:

1.3.6 Consider the following approaches to keep people involved in their care plan:

Practical one-to-one support, for example in relation to housing, education, training or employment.

Support to develop self-care skills, for example, to help them develop their budgeting skills so they know how to allocate enough money to buy food. Or support to help them develop their cooking skills.

Practical help with tasks that are important to the person, for example, housework or occupational support.

Support at appointments, for example:

arranging or travelling with them to hospital outpatient appointments or attendance at support groups

arranging for an advocate to accompany them at their appointments and provide independent advocacy (see section 1.6 for recommendations on maintaining contact between services and people with coexisting severe mental illness and substance misuse who use them).

1.3.7 Consider the suitability of the type of housing (for example, high to low support or independent tenancies), employment, detox, rehabilitation services or other support identified for the person, in collaboration with relevant providers. Take the person's preferences into account.

1.3.8 Ensure agencies and staff communicate with each other so the person is not automatically discharged from the care plan because they missed an appointment. All practitioners involved in the person's care should discuss a non-attendance.

Review

1.3.9 Hold multi-agency and multidisciplinary case review meetings annually, as set out in the Care Programme Approach or more frequently, based on the person's circumstances. (A care coordinator in the secondary care mental health team should usually arrange this.) Use this to check the person's physical health needs (including any adverse effects from medications), social care, housing or other support needs. Involve practitioners from a range of disciplines, including:

1.3.10 Ensure the care plan is updated in response to changing needs or circumstances.

Discharge or transition

1.3.11 Before discharging the person from their care plan (the Care Programme Approach) or before they move between services, settings or agencies (for example, from inpatient care to the community, or from child and adolescent mental health services to adult mental health services) ensure:

1.3.12 Reassess the person's needs to ensure there is continuity of care when they are at a transition point in their life. Particular groups who may need additional support include:

1.4 Partnership working between specialist services, health, social care and other support services and commissioners

1.4.1 Work together to encourage people with coexisting severe mental illness and substance misuse to use services. Consider:

using an agreed set of local policies and procedures that is regularly reviewed by key strategic partners

working across traditional institutional boundaries

being responsive to requests for advice and joint-working arrangements

sharing the response to risk management.

1.4.2 Ensure joint strategic working arrangements are in place so that:

services can offer continuity of care and service provision (for example, when commissioning contracts are due to expire)

services are based on a local needs or a joint strategic needs assessment

service quality is monitored and data sharing protocols are in place (see also recommendations 1.4.6 and 1.4.7).

1.4.3 Consider including the needs of people with coexisting severe mental illness and substance misuse in other local needs assessment strategies, for example, on housing, employment projects, alcohol, drug services or crime prevention.

1.4.4 Agree joint care pathways to:

Meet the health, social care or other support needs and preferences of people with coexisting severe mental illness and substance misuse, wherever they may present.

Give people access to a range of primary healthcare and social care providers including GP practices, pharmacies, podiatrists, dentists, social workers, housing, housing support or benefit advisers.

Ensure people have prompt access to local services (including direct referrals if possible).

Ensure staff follow people up to make sure their needs are being met.

Ensure continuity of care to support people at different transition points in their lives.

1.4.5 Ensure referral processes and care pathways within and across agencies are consistent and that governance arrangements are in place. This includes local care pathways to meet the physical health, social care, housing and support needs of people with coexisting severe mental illness and substance misuse.

Information sharing

1.4.6 Agree a protocol for information sharing between secondary care mental health services and substance misuse, health, social care, education, housing, voluntary and community services (see the Caldicott Guardian Manual).

1.4.7 Adopt a consistent approach to getting people with coexisting severe mental illness and substance misuse help from the most relevant service by:

1.5 Improving service delivery

Making health, social care and other support services more inclusive

1.5.1 Ensure existing health and social care services (including substance misuse services) are adapted to engage with and meet the needs of people with coexisting severe mental illness and substance misuse.

1.5.2 Involve people with coexisting severe mental illness and substance misuse, their family or carers in improving the design and delivery of existing services (see section 1.2). This may include them providing training, developing interventions to help people or taking part in steering committees.

1.5.3 Provide local services in places that are easily accessible, safe and discreet. Bear in mind any perceived stigma involved in being seen to use the service. Consider flexible opening times, drop-in sessions, or meeting people in their preferred locations.

1.5.4 Ensure people with coexisting severe mental illness and substance misuse, their family or carers are given accurate information about relevant local services (including, for example, community or family support groups). Also ensure they are given help to make initial contact with services. This could include information on how to access services, ways to contact the service, opening hours and how long the waiting list may be.

1.5.5 Raise staff awareness of the needs of people with coexisting severe mental illness and substance misuse, including the fact that they may be traumatised. Ensure staff can meet their needs.

Adapting existing secondary care mental health services

1.5.6 Adapt existing specialist services to meet both a person's coexisting severe mental illness and substance misuse needs and their wider health and social care needs. Do not create a specialist 'dual diagnosis' service.

1.5.7 Offer interventions that aim to improve engagement with all services, support harm reduction, change behaviour and prevent relapse. Take advice from substance misuse services (if applicable) about these interventions. (See NICE's Pathways on coexisting severe mental illness and substance misuse: assessment and management in healthcare settings; psychosis and schizophrenia in young people and adults; bipolar disorder; self-harm; alcohol-use disorders and drug misuse.)

1.5.8 Offer individual, face-to-face or phone appointment sessions to encourage people with coexisting severe mental illness and substance misuse to use services. Offer phone sessions to their family or carers. Sessions could cover:

1.5.9 Consider the following:

Support for staff

1.5.10 Ensure the care coordinator in secondary care mental health services is supervised and receives professional development to provide or coordinate flexible, personalised care.

1.5.11 Recognise that different attitudes towards, or knowledge of, mental health and drug- or alcohol-related problems may exist between agencies and that this may present a barrier to delivering services. To overcome this:

1.5.12 Ensure practitioners have the resilience and tolerance to help people with coexisting severe mental illness and substance misuse through a relapse or crisis, so they are not discharged before they are fully equipped to cope or excluded from services (see section 1.6).

1.6 Maintaining contact between services and people with coexisting severe mental illness and substance misuse who use them

1.6.1 Recognise that even though building a relationship with the person and seeing even small improvements may take a long time, it is worth persevering. It involves:

showing empathy and using a non-judgemental approach to listen, identify and be responsive to the person's needs and goals

providing consistent services, for example, if possible keeping the same staff member as their point of contact and the same lead for organising care

staying in contact by using the person's chosen method of communication (for example, by letter, phone, text, emails or outreach work, if possible).

1.6.2 Explore with the person why they may stop using services that can help them. This may include:

fragmented care or services

inflexible services (for example, not taking into account that the side effects the person may experience from medication may affect their attendance at appointments)

inability to attend because, for example, services are not local, transport links are poor, or services do not provide childcare

not being allowed to attend, for example because they have started misusing substances again

fear of stigma, prejudice or being labelled as having both mental health and substance misuse problems

feeling coerced into using treatments or services that do not reflect their preferences or their readiness to change

previous poor relationships with practitioners

other personal, cultural, social, environmental or economic reasons.

1.6.3 Help those who may find it difficult to engage with services to get into and stay connected with services. Start and maintain contact using proactive, flexible approaches (see recommendation 1.3.6).

1.6.4 Recognise that people with coexisting severe mental illness and substance misuse are at higher risk of not using, or losing contact with, services. There are specific populations who are more at risk. These include men, young people, older people and women who are pregnant or have recently given birth. It also includes:

people who are homeless

people who have experienced or witnessed abuse or violence

people with language difficulties

people who are parents or carers who may fear the consequences of contact with statutory services.

1.6.5 Ensure any loss of contact or non-attendance at any appointment or activity is viewed by all practitioners involved in the person's care as a matter of concern. Follow-up actions could include:

contacting the person to rearrange an appointment

visiting the person at home

contacting any other practitioners involved in their care, or family or carers identified in the person's care plan (see recommendation 1.2.4)

contacting the person's care coordinator within mental health services in the community immediately if there is a risk of self-harm or suicide, or at least within 24 hours if there are existing concerns.

Terms used in this guideline

This section defines terms that have been used in a specific way for this guideline. For general definitions, please see the glossary.

Relapse

A recurrence or exacerbation of a person's mental health problems, a return to substance misuse, or both.

Severe mental illness

Severe mental illness includes a clinical diagnosis of: schizophrenia, schizotypal and delusional disorders, or bipolar affective disorder, or severe depressive episodes with or without psychotic episodes.

Specialist services

Specialist services refers to secondary care mental health services and dual diagnosis services.

Substance misuse

Substance misuse refers to the use of legal or illicit drugs, including alcohol and medicine, in a way that causes mental or physical damage. This may include low levels of substance use that would not usually be considered harmful or problematic, but may have a significant effect on the mental health of people with a mental illness such as psychosis.

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Coexisting severe mental illness and substance misuse: community health and social care services

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People have the right to be involved in discussions and make informed decisions about their care, as described in your care. Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

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Abstract

The British Association for Psychopharmacology guidelines for the treatment of substance abuse, harmful use, addiction and comorbidity with psychiatric disorders primarily focus on their pharmacological management. They are based explicitly on the available evidence and presented as recommendations to aid clinical decision making for practitioners alongside a detailed review of the evidence. A consensus meeting, involving experts in the treatment of these disorders, reviewed key areas and considered the strength of the evidence and clinical implications. The guidelines were drawn up after feedback from participants. The guidelines primarily cover the pharmacological management of withdrawal, short- and long-term substitution, maintenance of abstinence and prevention of complications, where appropriate, for substance abuse or harmful use or addiction as well management in pregnancy, comorbidity with psychiatric disorders and in younger and older people.

Introduction

The first British Association for Psychopharmacology evidence-based guidelines for 'the pharmacological management of substance misuse, addiction and comorbidity' were published in 2004 ( Lingford-Hughes et al., 2004). This is a substantial revision of that original document but using the same criteria ( Table 1) and taking into account a number of recent documents from the National Institute for Health and Clinical Excellence (NICE) and other organisations which significantly enhanced the knowledge base. As before, the guidelines are not intended to provide an equivalent comprehensive review of psychosocial interventions since this is a major topic in its own right. In addition, the word 'patient' is used throughout the document for consistency, although it is acknowledged that in many treatment centres, 'client' or 'user' is the preferred term.

Categories of evidence and strength of recommendations

Scope of these guidelines

Our aim is to provide helpful and pragmatic guidelines for clinicians such as psychiatrists and GPs involved in prescribing to people with substance abuse or harmful use or addiction alone and with psychiatric comorbidity. However, the update should also be of interest to other practitioners in the substance misuse field, non-specialists, patients and their families. This revision was undertaken to update the guidelines in the light of new evidence focussing on areas not covered by guidelines published since the original BAP guidelines (e.g. from NICE). We have searched for new evidence concerning pharmacological management of alcohol, nicotine, opioids, benzodiazepines, stimulants and associated comorbidity with mental health problems and substance use or abuse in pregnancy. In addition we have covered pharmacotherapy for younger and older people, for those with personality disorder, as well as for 'club drugs' and cannabis and polydrug users. We review pharmacotherapies in common clinical use as well as those with limited but promising evidence and highlight important areas of 'key uncertainty'. We have reviewed the evidence in as brief a format as possible and refer readers to the other guidelines such as NICE, where more detail is provided. Whilst some avenues have developed, it is notable that many key uncertainties remained unchanged since 2004.

Classification of substance abuse, harmful use and dependence

We have not covered in depth how to safely prescribe the pharmacotherapies described here, since guidance is constantly updated. The reader is recommended to consult current resources such as British National Formulary (BNF), Summaries of Product Characteristics (SPC) ( http://www.medicines.org.uk/emc/). We also suggest seeking appropriate support and supervision from peers and clinical governance if required, since many of the medications described do not hold a licence for the indication under discussion in UK, though may in other countries.

Methodology

A consensus meeting was held on 8 December 2009 involving experts in the field of addiction and comorbidity. These included reviewers who gave brief presentations of their key area, with an emphasis on systematic reviews (e.g. Cochrane Database) and randomised controlled trials (RCTs) where possible, although inevitably much of the information presented did not come from these sources. This was followed by a discussion of the important issues to identify consensus and areas of uncertainty regarding the quality of evidence and strength of recommendations. A draft of this review of the literature, which was updated during writing with any subsequently published literature, was then circulated to all participants and other interested parties. Feedback was incorporated, wherever possible, into this final version.

Identification of relevant evidence

The range of disorders covered in these guidelines did not allow for a systematic review or meta-analysis of all possible data from primary sources. Existing systematic reviews and RCTs were identified from MEDLINE and EMBASE searches, from the Cochrane Database as well as from guidelines and identification by experts in the field.

Evidence categories and strength of recommendations

Categories of evidence for causal relationships (including treatment) and strength of recommendations are given in Table 1 and are taken from Shekelle et al. (1999). The strength of recommendation reflects not only the evidence but also the importance of the study. For instance, it is possible to have methodologically sound (category I) evidence about an area of practice that is clinically irrelevant or has such a small effect that it is of little practical importance, and therefore attracts a lower strength of recommendation. More commonly, however, it has been necessary to extrapolate from the available evidence leading to weaker levels of recommendation (B, C or D) based upon category I evidence statements. For some of the treatments, the strength of the recommendation may refer to not using this treatment approach. Where recommendations are not strictly based on systematic evidence at all, but represent an important consensus (practical or ethical), we have indicated 'S' (standard of care). The recommendations are there to give clinicians options in using pharmacotherapeutic approaches. However, not all options may be appropriate for every individual or clinical situation, and consequently they should not be seen as prescriptive.

Treatment aims

There are several possible aims when planning treatment for substance use disorders, ranging from those pertinent to the individual, for example reduced risk of infection from stopping injecting, through to those concerning society, for example reduction in crime. We emphasise that a shared understanding of treatment aims between patient and prescriber are key, alongside the fact that adequate demonstrable planning with the patient concerning their goals is required by many commissioners and services. Clarity is important since the same pharmacotherapy may be used for substitution as well as withdrawal/detoxification, for example methadone or buprenorphine in opiate addiction.

withdrawal syndromes

relapse prevention and maintenance of abstinence

reduction of harms associated with illicit drug use by prescribing a substitute drug or drugs (e.g. methadone maintenance treatment in which aims may include cessation of injecting, reduction or cessation of illicit heroin use, and reduction or cessation of other high-risk behaviours)

prevention of complications of substance use (e.g. use of thiamine to prevent Wernicke's encephalopathy and Korsakoff's syndrome)

In this guideline, we have tried to indicate clearly the aims of each treatment. Goals should be set and agreed between the patient and prescriber. We have not included the pharmacological treatments used in management of severe acute intoxication or overdose. Such management usually takes place in Accident and Emergency departments.

Alcohol

Management of withdrawal and detoxification

Acute alcohol withdrawal, its associated risks and management including settings and pharmacological management or 'medically assisted withdrawal', has been systematically reviewed for NICE guidelines, by groups led by Royal College of Physicians ( NICE, CG100, 2010c) (Ia) and by Royal College of Psychiatrists ( NICE, CG115, 2011a) (Ia) as well as by Cochrane ( Amato et al., 2010; Minozzi et al., 2010) (Ia). The recommendations in both NICE guidelines are broadly in agreement with our previous recommendations supporting the use of benzodiazepines. One difference, however, was that the CG100 guidelines, whose remit was management within a general medical inpatient setting, recommended a 'symptom-triggered' regimen (see Hecksel et al. (2008) regarding issues of managing in general medical setting) (III). However, the CG115 guidelines emphasised that this approach was only for inpatients or residential settings if the appropriate level of monitoring was available. These NICE guidelines recommended a fixed-dose regimen for community-based withdrawal. A recent study not available for inclusion in either NICE guidelines reported that outpatient alcohol withdrawal could be managed effectively and safely using chlordiazepoxide either with a symptom triggered or a fixed-schedule regimen ( Elholm et al., 2011). The median of total doses of chlordiazepoxide over 10 days were 725mg in symptom triggered (range: 50 - 2800) and 875mg in fixed-schedule (range: 100 - 1900). In addition, the CG100 guidelines recommended clomethiazole as an alternative for inpatients, although to be used cautiously. The CG115 guidelines did not recommend using clomethiazole in the community.

The use of anticonvulsants continues to receive attention, since reducing glutamate overactivity is now thought to be key in reducing risk of brain toxicity during withdrawal. Undergoing more than two detoxifications has been associated with poorer performance on some cognitive tasks although a causal link has not been proven ( Duka et al., 2004; Loeber et al., 2010). Krupitsky et al. (2007) (Ib) reported that a range of antiglutamatergic approaches such as memantine (NMDA antagonist), topiramate (AMPA/kainate inhibitor) or lamotrigine (glutamate release inhibitor) were efficacious in treating alcohol withdrawal similarly to diazepam. A Cochrane review ( Minozzi et al., 2010) (Ia) was cautious about anticonvulsants, stating that there was 'insufficient evidence in favour of anticonvulsants for treatment of alcohol withdrawal' although they seemed to have 'limited side effects' and 'might be effective for some symptoms', for example seizures. NICE, CG100, (2010c) (Ia) recommended using carbamazepine or benzodiazepines, although in the UK there is less clinical experience in using anticonvulsants. NICE, CG115, (2011a) (Ia) guidelines did not comment on use of carbamazepine.

Due to concerns about carbamazepine's safety and tolerability, alternative anticonvulsants, for example oxcarbazepine, levetiracetam, pregabalin, have been investigated. Studies may show benefits compared with placebo but no one anticonvulsant has emerged as preferential (e.g. Anton et al., 2009 (Ib); Barrons and Roberts, 2010 (Ia); Bonnet et al., 2010 (III); Di Nicola et al., 2010 (IIb); Martinotti et al., 2010 (Ib); Richter et al., 2010 (Ib)). The role for anticonvulsants in alcohol withdrawal therefore still remains unclear. However, the finding that using carbamazepine during withdrawal was followed by longer time to eventual return to drinking than with using the benzodiazepine, lorazepam ( Malcolm et al., 2002) (Ib), raises the question of whether benzodiazepine withdrawal leaves the brain vulnerable to relapse. Consequently, determining how to measure impact on markers of neurotoxicity is critical to answer this important question.

Acamprosate has been shown to reduce the hyperglutamatergic state during alcohol withdrawal in animal models and may have neuroprotective potential ( Mann et al., 2008) (IV). A clinical study showed acamprosate reduced glutamate levels in the brain 25 days after initiation of benzodiazepine-treated alcohol withdrawal ( Umhau et al., 2010) (Ib). Starting acamprosate 8 days prior to detoxification and continuing for 15 days without other medication for withdrawal resulted in reduced arousal level measured with magnetoencephalography and improved decreased wake time after sleep onset and increased stage 3 and REM sleep latency ( Boeijinga et al., 2004 (Ib); Staner et al., 2006 (Ib)). Gual and Lehert (2001) (Ib) and anecdotally, clinicians who routinely use acamprosate during detoxification in addition to usual medication for alcohol withdrawal report no unwanted events and suggest acamprosate improves symptoms. However, a full randomised placebo-controlled trial has yet to be completed. Another small ( n = 16 vs. 18) trial designed to see if giving acamprosate in addition to medication for alcohol withdrawal rather than starting it at the end of the detoxification improved drinking outcomes, found no benefit in drinking outcomes, indeed this approach might worsen some ( Kampman et al., 2009) (Ib).

Although many alcohol-withdrawal episodes take place without any pharmacological support, particularly in those patients with a mild level of alcohol dependence, in the presence of symptoms medication should be given. Detoxification should be planned as part of a treatment programme to increase the likelihood of patients successfully altering their subsequent drinking behaviour. Early identification and treatment of alcohol dependence can reduce the level of complications.

regimens

Alcohol-related brain disorder

Wernicke-Korsakoff syndrome (WKS) is now considered to be a unitary disorder comprising acute Wernicke's encephalopathy (WE) which proceeds in a proportion of cases to Korsakoff's syndrome. Adequate assessment and diagnosis still remain a challenge despite WKS being well recognised as a complication of harmful alcohol use. Thiamine replacement is still the critical intervention for WKS, and increased vulnerability is associated with genetic susceptibility in association with poor diet ( Sechi and Serra, 2007) (IV).

It has been suggested that a presumptive diagnosis of WE should be made for any patient with a history of alcohol dependence who shows one or more of the following: evidence of ophthalmoplegia, ataxia, acute confusion, memory disturbance, unexplained hypotension, hypothermia, coma, or unconsciousness ( Sechi and Serra, 2007) (IV). Alcohol or benzodiazepine or carbamazepine intoxication may complicate the presentation. Operational criteria for the diagnosis of WE have been proposed with only two of the classic triad (ophthalmoplegia, ataxia, confusion) and dietary deficiencies ( Caine et al., 1997) (IV). Although they help in distinguishing the problem from other potentially coexisting conditions such as alcohol withdrawal or hepatic encephalopathy, they are not yet widely used. Patients commonly deemed 'at risk' of developing WE during a hospital admission or a planned detoxification are those whose drinking has exceeded 15 units per day for a month or more and where there is evidence of recent weight loss or vomiting or diarrhoea or malnutrition or peripheral neuropathy or chronic ill-health. This is based only on 'expert opinion', but derives also from the established causal relationship of WE to severe malnutrition and hyperemesis of pregnancy.

A high index of suspicion must be maintained at all times regarding WE since it rarely presents with all signs and symptoms. The following recommendations are based on uncontrolled trials and from empirical clinical practice.

Preventing lapse and relapse, promoting and maintaining abstinence

When taking evidence from trials to UK practice, it is important to consider a trial's inclusion/exclusion criteria and where they were conducted. In particular, recent trials of pharmacotherapy in US settings do not necessarily come to the same conclusion as those conducted in European studies ( Garbutt, 2009). In US trials patients may be recruited via advertisement, may be less dependent, able to stop drinking without medication, less anxious, and not want abstinence, which contrasts with European trials where patients are generally recruited from specialist alcohol services and tend to be highly dependent, require medically assisted alcohol withdrawal and a majority are aiming for abstinence. However, such differences can be used to inform clinicians what types of patients are more likely to benefit from that medication.

Reviewing the place of medication in relapse prevention, NICE (2011a) has recently recommended that ' after a successful withdrawal for people with moderate and severe alcohol dependence, consider offering acamprosate or oral naltrexone in combination with an individual psychological intervention (cognitive behavioural therapies, behavioural therapies or social network and environment-based therapies) focused specifically on alcohol misuse'. In addition, 'for harmful drinkers and people with mild alcohol dependence who have not responded to psychological interventions alone, or who have specifically requested a pharmacological intervention, consider offering acamprosate or oral naltrexone in combination with an individual psychological intervention (cognitive behavioural therapies, behavioural therapies or social network and environment-based therapies) or behavioural couples therapy'. We endorse the recommendation that pharmacotherapy should be the default position, such that the decision not to prescribe is made actively for those patients presenting with harmful alcohol use or abuse that have not benefited from psychosocial interventions and for everyone with dependence, rather than only thinking of medication for more complex patients. The range of medications are described below. We have considered a broader range of pharmacological approaches than NICE (2011a).

There are a number of good-quality systematic reviews and meta-analyses of trials of acamprosate including those by Cochrane ( Rösner et al., 2010a) (Ia), NICE (2011a) (Ia), Health Technology Board of Scotland ( Slattery et al., 2003) (Ia), Swedish Board ( Berglund et al., 2003) (Ia), and the Spanish Agency for Health Technology Assessment ( Bouza et al., 2004) (Ia) in addition to those by Mann et al. (2004), Kranzler and van Kirk (2001), Mason and Ownby (2000), Rösner et al. (2008) and Mason and Heyser (2010) (Ia). These reviews broadly come to the same conclusion that compared with placebo, acamprosate is moderately effective in increasing the amount of abstinence after detoxification; for example Rösner et al. (2010a) (Ia) report RR 0.86 (95% CI 0.81-0.91), and NICE CG115 (2011a) (Ia) report RR = 0.83 (95% CI = 0.77-0.88). The 'number needed to treat' (NNT) was calculated as 9-11 (e.g. Rösner et al., 2010a; Slattery et al., 2003) (Ia). Notably, later systematic reviews and meta-analyses report smaller effect sizes due to three reasonably sized recent negative studies conducted in the USA and Australia (COMBINE, Anton et al., 2006 (see below); Mason et al., 2006; Morley et al., 2006) (Ib). However, some of these studies included low-severity patients with few withdrawal symptoms, that is, patients who may be less likely to respond to acamprosate.

Naltrexone as an oral tablet is licensed in the USA, some European countries and recently in the UK (one formulation) to improve drinking behaviour. NICE (2011a) recommended that oral naltrexone, or acamprosate, be offered to those who are moderately to severely dependent, and to those less dependent or drinking harmfully if failing to improve. Early trials used dose of 50 mg/day, although more recent US studies have used 100 mg/day. In the UK, 50 mg/day is more typically used, and it is unclear whether or how much extra benefit is accrued from higher doses.

There are four published trials comparing acamprosate with naltrexone, of which two also studied them combined. The earlier European trials reported that naltrexone (50 mg/day) was superior to acamprosate (1998 mg/day) or placebo, and the combination conferred no additional benefit to naltrexone but improved outcomes compared with acamprosate ( Kiefer et al., 2003; Rubio et al., 2001) (Ib).

In summary, taking into account the potential difference between European patient samples and the sample included in the COMBINE study, it appears there is no overall superiority of naltrexone over acamprosate that would apply to the UK patient population. From their review, Rösner et al. (2008) (Ia) concluded that 'acamprosate was found to be more effective in preventing a lapse, whereas naltrexone was better in preventing a lapse from becoming a relapse'.

Disulfiram has been used for many years to help people remain abstinent. Disulfiram blocks aldehyde dehydrogenase, causing accumulation of acetaldehyde if alcohol is consumed, resulting in nausea, flushing, and palpitations. This deters people from drinking ( Fuller and Roth, 1979) (Ib). Disulfiram also blocks dopamine-b-hydroxylase in the brain, so increasing dopamine and reducing noradrenaline, and this may contribute to its clinical effects in alcoholism or cocaine addiction (see later; Schroeder et al., 2010).

Many of the trials of disulfiram were conducted some decades ago and were therefore not as rigorously undertaken as those for newer medications. In addition, due to the alcohol-disulfiram reaction, patients entering trials of disulfiram have to be aware they could be taking disulfiram. Systematic reviews of older trials report that disulfiram is no better than placebo in preventing lapse to drinking ( NICE 2011a; Slattery et al., 2003) (Ia). More recent trials of disulfiram have compared it with newer medications such as naltrexone, acamprosate or topiramate ( de Sousa and de Sousa, 2004, 2005; de Sousa et al., 2008; Laaksonen et al., 2008) (Ib). When taking medication for 12 weeks, disulfiram has been shown to be superior to naltrexone or acamprosate in prolonging time to first drink and number of 'heavy drinking days' ( Laaksonen et al., 2008) (Ib). All medication was 'supervised' by someone. However, in a subsequent 12-week phase of targeted medication taken in 'a craving situation', there were no differences between disulfiram, naltrexone and acamprosate ( Laaksonen et al., 2008) (Ib). Two open but randomised pragmatic trials of disulfiram in a private clinic in Mumbai reported that disulfiram (250 mg/day) was superior to either naltrexone (50 mg/day) or topiramate (150 mg/day) in lengthening time to relapse and maintaining abstinence ( de Sousa and de Sousa, 2004, 2005; de Sousa et al., 2008) (IIa).

NICE (2011a) (Ia) recommended that disulfiram should be tried after acamprosate or naltrexone, or where the patient indicates a preference for it. There is no evidence to guide how long to prescribe disulfiram, but clearly it can only be started once alcohol free for at least 24 hr. Patients must also be warned about potential for a reaction with alcohol for up to 7 days after stopping disulfiram. An open prospective study lasting 9 years reported that 2 years of treatment with disulfiram or calcium carbimide resulted in overall abstinence rates of 50%; however, not all patients could take disulfiram or calcium carbimide so received 'sham' treatment, and the authors emphasised the importance of its psychological ingredient ( Krampe et al., 2006) (IIb)

While in the UK the usual daily disulfiram dose is 200 mg once a day, it can be given in higher doses. For instance, in trials with comorbid alcohol and cocaine dependence, 500 mg/day was used (Carroll et al., 1998) (Ib). In addition, disulfiram can be given in larger doses less frequently than daily, which might be advantageous if asking patients to attend a service and have their medication supervised or witnessed. However, Ulrichsen et al. (2010) (IIb) reported that 800 mg of supervised disulfiram given twice a week over 26 weeks was no better than just attending twice a week without taking disulfiram. Notably, over half of recruits failed to be randomised since some definitely wanted disulfiram and others failed to show up.

Baclofen is a GABA-B agonist that is licensed for controlling muscle spasms; it does not hold a licence for use in alcohol dependence, although it is being used by some clinicians. Preclinical evidence demonstrated that GABA-B receptors are key modulators of dopaminergic neuronal firing and baclofen can reduce ethanol self-administration. An Italian RCT of baclofen in cirrhotic alcohol-dependent patients wanting to be abstinent showed baclofen significantly increased the number maintaining abstinence compared with placebo (71% vs. 29%; Addolorato et al., 2007) (Ib). By comparison, another RCT in the USA reported no superiority of baclofen over placebo in reducing 'heavy drinking' or increasing abstinence ( Garbutt et al., 2010) (Ib). This difference in effectiveness may relate to the fact that the cirrhotic patients tended to be more severely dependent, anxious, required medication for detoxification, and wanted sobriety, which contrasted with those in the US study. Baclofen reduced anxiety in both populations. It has therefore been suggested that those with greater anxiety and withdrawal symptoms are more likely to benefit from baclofen. In addition, the more comprehensive psychosocial treatment in the US study for both groups may have confounded differences in outcome, whereas there was less available in the Italian study.

Both of these studies used baclofen 10 mg tds (total 30 mg/d). However, secondary analysis of a trial suggests that 20 mg tds may be superior to 10 mg tds ( Addolorato et al., 2011) (Ib). This would be consistent with other studies of baclofen in methamphetamine, cocaine and nicotine dependence, where higher doses of 60 mg/day and 80 mg/day have been studied. Of note, a high-profile case report detailed a patient taking up to 270 mg/day to control his alcohol consumption and craving before reducing to a lower 'maintenance' level ( Ameisen, 2005).

There are a number of trials of other pharmacotherapies in alcoholism, although these are often small, open, single studies or not placebo-controlled. For example, antagonising dopaminergic activity with newer generation antipsychotics such as aripiprazole has shown some limited efficacy ( Anton et al., 2008; Martinotti et al., 2009). GHB, a GABA-B agonist which also acts on GHB receptors in the brain and is used to treat narcolepsy, has also shown efficacy in treating alcohol withdrawal and relapse prevention (see review by Addolorato et al., 2009). It has a licence in some European countries, but concerns about its abuse potential currently limits its use in the UK ( Leone et al., 2010) (Ia); however, the advent of a new solid formulation (Alcover) may make this less of an issue (see Chick and Nutt, 2012). Finally, the 5HT3 antagonist, ondansetron, has shown promise, particularly in early onset alcoholism ( Johnson, 2010). The mechanistic concepts behind these and other approaches to addiction treatments are discussed in Nutt et al., 2012.

Opioid dependence

Opioid maintenance treatments

Management of withdrawal from opioid drugs

The goals of treatment are to alleviate withdrawal symptoms and to complete withdrawal without adverse effects. In evaluating the outcome of the withdrawal process, it is important to distinguish the outcome of withdrawal itself from longer-term measures such as continued abstinence from heroin. Heroin dependence is often a chronic relapsing disorder.

In the Cochrane review by Gowing et al. (2009a) (Ia), buprenorphine appeared equivalent to methadone at tapered doses in reducing the severity of withdrawal symptoms. The withdrawal symptoms may resolve more quickly with buprenorphine. There was a trend for better completion rates with buprenorphine (four studies, RR 1.18, 95% CI 0.93-1.49). Buprenorphine was better than α2 agonists at ameliorating withdrawal symptoms. Buprenorphine was associated with lower mean peak withdrawal scores (four studies, SMD -0.45, 95% CI -0.64 to -0.25, p < 0.001) and lower mean overall withdrawal scores (two studies, SMD -0.59, 95% CI -0.79 to -0.39). Completion of detoxification was more likely with buprenorphine than α2 agonists (10 studies, RR 1.64, 95% CI 1.31-2.06).

Opiate dependence: relapse prevention and maintaining abstinence

There has been very little investigation of the role of pharmacotherapy in relapse prevention or maintaining abstinence compared with alcohol or stimulants. Naltrexone is the only pharmacotherapy that has received much attention, but one trial of baclofen (60 mg/day) in abstinent opioid addicts showed promise in promoting abstinence, reducing withdrawal and depressive symptoms ( Assadi et al., 2003).

A good-quality systematic review by Cochrane ( Minozzi et al., 2011 (Ia)) and a NICE technology appraisal ( NICE, 2007d) (Ia) have been recently published of naltrexone maintenance treatment to support maintenance of abstinence from opioid drugs in formerly dependent patients following detoxification. Naltrexone is prescribed for oral use as a 50 mg tablet. The studies on which these guidelines are based have been of patients prescribed the oral preparation. However, since the mid-1990s, naltrexone subcutaneous implants and intramuscular depots have been developed, although they are not yet licensed in the UK as pharmacological products.

The Cochrane reviewers ( Minozzi et al., 2011) (Ia) concluded that there was no significant difference in treatment retention for people treated with naltrexone with or without adjunctive psychosocial therapy compared with placebo with or without psychosocial therapy (six studies, RR 1.43, 95%CI 0.72-2.82). There was a significant reduction in illicit heroin use as assessed by urinalysis (six studies RR 0.72; 95% CI 0.58-0.90) but the difference was not statistically significant when comparing the studies of naltrexone versus placebo only. Naltrexone with psychosocial treatment showed reduced re-incarceration rates compared with psychosocial treatment alone (two studies RR 0.47, 95%CI 0.26-0.84) but the sample size was small.

The NICE technology appraisal ( NICE, 2007d) (Ia) considered the Cochrane review together with 13 RCTs and three non-randomised comparative studies. None of the studies were conducted in the UK, the studies were of poor to moderate quality, and randomisation was not adequately reported in the RCTs. The degree of supervision of medication in the studies was variable. Nine of the RCTs studied the effectiveness of strategies to improve retention on naltrexone, such as incentive vouchers, psychosocial therapies and pharmaceutical agents. The main outcomes reported were retention in treatment, relapse rates and re-incarceration rates. Given that outcomes for retention and abstinence were likely to be higher in clinical practice than reported in the RCTs, as in practice treatment is targeted at highly motivated people seeking abstinence, NICE concluded that naltrexone is an appropriate treatment option in detoxified formerly opioid-dependent people who have high motivation and with adequate supervision.

An RCT of 56 patients given a 6-month naltrexone implant versus usual aftercare found naltrexone was associated with significantly fewer days of heroin use in the 6-month follow-up period ( Kunøe et al., 2009) (Ib). In an RCT of 60 patients, Comer et al. (2006) (Ib) found improved retention in treatment for injectable sustained-release naltrexone compared with placebo, and that retention was higher for those given higher dose naltrexone. Superior effects on abstinence from illicit drugs were not demonstrated. An RCT of 70 patients reported that a naltrexone implant significantly reduced relapse to heroin use and resulted in higher blood naltrexone levels compared with oral ( Hulse et al., 2009) (Ib). In a comparison of two separate trials (one of oral naltrexone and one of injectable sustained-release naltrexone), Brooks et al. (2010) (IIb) concluded that patients with severe baseline heroin use showed better outcomes when treated with oral naltrexone and intensive psychosocial therapy (behavioural naltrexone therapy), while those with less severe baseline heroin use showed better outcomes with injectable naltrexone. However, these conclusions are uncertain as they are drawn from a comparison of the interventions in two separate, though concurrent, trials ( Brooks et al., 2010) (IIb). Others have reported that many patients did not accept a second injection ( Kunøe et al., 2010), and plasma levels of naltrexone implants have been shown not to remain at the targeted levels for the intended time ( Hulse et al., 2009).

Benzodiazepine dependence

Background

These guidelines address two differing patient populations: the 'therapeutic dose' users, which includes patients who have been prescribed benzodiazepines usually on a long-term basis for a disorder such as anxiety or insomnia but who do not abuse their prescription, and the other patients who misuse their prescription and/or use illicit benzodiazepines, often in high doses. This may include benzodiazepines purchased via the internet ( Levine, 2007). Individuals in either category may be dependent. Abuse of benzodiazepines is often associated with other substance abuse (e.g. to 'come down' from stimulants or to enhance the effect of opioids). It is important to establish the presence or absence of dependence to help determine whether pharmacological treatment is appropriate. Problems consistent with ICD-10 or DSM-IV dependence criteria in addition to physiological withdrawal symptoms should be elicited. Use patterns in high-dose abusers include once-daily dosing to maximise effect, seeking euphoric or sedative effects, escalating dosages, 'binge' use and very high self-reported doses. The withdrawal syndrome can be severe.

The literature and evidence base on the management of 'therapeutic dose' dependence is far more extensive and systematic than for the management of benzodiazepine dependence in illicit, high-dose users. Transferring the management principles from the 'therapeutic dose' literature to illicit drug users is affected not only by the differing clinical picture, but also by the need to avoid abuse and diversion of any prescribed medication ( Fenton et al., 2010; Seivewright, 2000).

Management of benzodiazepine dependence in 'therapeutic dose' users

Management often takes place in primary care and can include minimal interventions, gradual dose reduction and gradual dose reduction with additional psychological or pharmacological treatments. A stepped approach can be considered, moving through minimal interventions to gradual dose reduction and then additional therapies aimed at specific symptoms. Minimal or brief interventions include GPs sending a letter advising patients of the need to reduce their benzodiazepine prescription, and provision of booklets on self-help strategies. In primary care populations, minimal interventions were more effective than routine care in achieving cessation of benzodiazepine use (three studies, OR = 4.37, CI 2.28-8.40) increasing the success rates from 5% to 22% ( Parr et al., 2008)(1a))

Dose-reduction schedules frequently last several weeks, although there is wide variation from abrupt discontinuation to discontinuation over a year or more ( Oude Voshaar et al., 2006a) (Ia). Gradual dose reduction is preferable to abrupt discontinuation of benzodiazepine ( Denis et al., 2006) (Ia). Switching from a short half-life benzodiazepine to a long half-life benzodiazepine before gradual taper does not receive much support ( Denis et al., 2006 (Ia); Murphy and Tyrer, 1991 (Ib)), but may be useful if reduction of short half-life benzodiazepine causes problematic withdrawal symptoms. In primary care patients who had failed to cease benzodiazepine use with minimal intervention, gradual dose reduction was more effective than routine care in achieving cessation of use (51% vs. 15%) ( Oude Voshaar et al., 2003) (1b). At 15-month follow-up 36% of those who received gradual dose reduction were abstinent based on benzodiazepine prescription data, compared with 15% of those who received routine care ( Oude Voshaar et al., 2006b) (Ib). The British National Formulary contains advice on gradual benzodiazepine reducing regimes (see BNF).

Gradual dose reduction and additional psychological therapies

Additional psychological therapies increase cessation rates compared with both routine care (three studies, OR = 3.38, CI 1.86-6.12) and gradual dose reduction alone (seven studies, OR = 1.82, CI 1.25-2.67) ( Parr et al., 2008) (Ia). The psychological interventions employed in these studies generally included some form of group CBT. Compared with gradual dose reduction alone, additional psychological intervention seemed particularly beneficial in patients using benzodiazepines for insomnia and panic disorder (1b). In a primary care study Baillargeon et al. (2003) (Ib) reported that 77% of patients with chronic insomnia withdrew from benzodiazepines with gradual dose reduction and group CBT compared with 38% with gradual dose reduction alone (OR = 5.3, CI 1.8-16.2). The effect persisted at 12-month follow-up. Morin et al. (2004) (Ib) found similar results in their study of older adults with chronic insomnia. Patients who received gradual dose reduction plus CBT were more likely to be benzodiazepine-free after the initial intervention (85%), compared with those who received gradual dose reduction alone (48%) or CBT alone (54%). For panic disorder patients attempting to stop benzodiazepines, successful discontinuation was significantly greater in the gradual dose reduction plus CBT group, than the gradual dose reduction alone group (76% vs. 25%, p < 0.005) ( Otto et al., 1993) (Ib). A pilot study of CBT delivered via the internet for cessation of benzodiazepine use found good acceptability amongst participants but limited take-up ( Parr et al., 2011) (IIb).

Gradual dose reduction plus additional pharmacotherapy has shown no benefit compared with gradual dose reduction alone in a meta-analysis (14 studies, OR = 1.30, CI 0.97-1.73) ( Parr et al., 2008) (Ia). The 14 studies involved 11 different pharmacotherapies. Four of the pharmacotherapies showed significant effects on benzodiazepine discontinuation rates in single studies (1b). Garfinkel et al. (1999) (IIb) reported discontinuation rates of 77% with the addition of melatonin compared with 25% with gradual dose reduction alone. Rickels et al. (1999) (Ib) added sodium valproate, trazodone or placebo to a benzodiazepine taper. At 5 weeks post-taper, 79% of sodium valproate and 67% of trazodone, but only 31% of placebo patients were benzodiazepine free. These differences were not maintained at 12 weeks post-taper. Adjunctive paroxetine in patients without major depression increased discontinuation rates compared with gradual dose reduction alone (46% vs. 17%) ( Nakao et al., 2006) (Ib). However, in patients in primary care with depression, adding paroxetine to gradual dose reduction did not increase benzodiazepine discontinuation rates above gradual dose reduction and placebo, with two-thirds in each group ceasing benzodiazepine use. In both groups depressive ratings improved with no significant effect of paroxetine, but paroxetine did have a beneficial effect on anxiety symptoms ( Zitman and Couvée, 2001) (Ib). Within the meta-analysis the odds ratio for these two paroxetine studies was significant (OR = 1.73, CI 1.01-2.96) ( Parr et al., 2008) (Ib).

Two studies of imipramine with conflicting results were not reported in the meta-analysis. In patients with generalised anxiety disorder and long-term benzodiazepine use, imipramine increased discontinuation rates compared with placebo (83% vs. 37%, p < 0.01). Buspirone also increased discontinuation rates but non-significantly compared with placebo (68% vs. 37%, p < 0.06) ( Rickels et al., 2000)(1b). However, in patients with panic disorder and long-term benzodiazepine use, imipramine or buspirone did not significantly increase discontinuation rates ( Rynn et al., 2003) (Ib).

Flumazenil (a benzodiazepine antagonist) reduced withdrawal symptoms and craving compared with an oxazepam taper over 8 days in benzodiazepine-dependent patients. Flumazenil-treated patients also had greater abstinence rates post detoxification ( Gerra et al., 2002) (Ib). A flumazenil infusion has also been shown to be a safe and effective treatment for benzodiazepine withdrawal ( Hood et al., 2009) (III).

Management of benzodiazepine dependence in high-dose and/or illicit drug users

There is little evidence to guide practitioners in the management of this often difficult-to-treat population. Patients should be assessed to determine why they are using benzodiazepines, and alternative treatment strategies employed for problems such as anxiety and insomnia. The presence of alcohol or other illicit drug abuse or dependence should be determined.

Benzodiazepine abuse is frequent amongst heroin users and those in opioid substitution treatment ( Gelkopf et al., 1999; Gossop et al., 1998; Jaffe et al., 2004). Ongoing current benzodiazepine use is associated with concurrent poorer clinical outcomes in this population ( Darke et al., 2010) (III). Prescribing of benzodiazepines during opioid substitution treatment is common, despite a lack of research to support this ( Reed et al., 2011) (III). Such prescribing can often slip into de facto maintenance despite the lack of evidence for this. Use of benzodiazepines in combination with opioids is associated with increased opioid toxicity and performance deficits ( Lintzeris et al., 2006; Nielsen et al., 2007) (III). A history of prescription of benzodiazepines was associated with mortality in Scottish patients receiving methadone in primary care ( McCowan et al., 2009) (III).

Vorma et al. (2002) (Ib) evaluated gradual dose reduction with CBT versus an unspecified standard withdrawal regime in high-dose benzodiazepine users. There was no significant difference in discontinuation rates (13% experimental group vs. 27% control group, OR 0.4 (0.1-1.5), p = 0.20). Over half the users in each group were able to reduce their dose by > 50% (54% vs. 59%). Reductions to therapeutic dose levels were maintained ( Vorma et al., 2003) (Ib)). McGregor et al. (2003) (Ib) conducted an RCT of fixed gradual dose reduction (5-10 mg reduction per day) versus symptom-triggered diazepam taper methods during inpatient benzodiazepine withdrawal treatment in 44 high-dose benzodiazepine users. There were no significant differences in abstinence rates (27% gradual dose reduction vs. 18% symptom triggered). Both groups showed a reduction in benzodiazepine dosage of 86% to around 14 mg which was maintained at 1 month post-discharge. Liebrenz et al. (2010) have proposed the need to evaluate agonist substitution treatment in high-dose benzodiazepine dependence, where individuals have not been able to undergo withdrawal. However, they recognise this needs to be balanced against the risks, particularly in regard to negative effects on cognition and memory.

In an open study in methadone-maintained benzodiazepine-dependent patients, clonazepam was substituted for their benzodiazepine of choice. Patients were then either detoxified from or maintained on clonazepam, and outcome measured was self-reported illicit benzodiazepine use. Illicit benzodiazepine use was reduced in the maintenance group compared with the detoxification group ( Weizman et al., 2003) (III). Wickes et al. (2000) (III) described five case studies of clobazam maintenance in methadone-maintained patients with mixed results. Clobazam was reported by the patients as being less sedating than diazepam.

Other small studies in benzodiazepine-dependent methadone-maintained patients have examined community reduction and contingency management. McDuff et al. (1993) (III) reported that 12 out of 22 patients misusing primarily alprazolam completed an outpatient reduction procedure which averaged 7.8 weeks. Contingency management with rewards for benzodiazepine-free urines showed some success. However, results were not maintained at the end of the contingency phase ( Stitzer et al., 1982) (III).

Z-drugs - zaleplon, zolpidem and zopiclone

Recommendations: benzodiazepine dependence

Establishing the presence or absence of physiological withdrawal symptoms and the dependence syndrome is important in determining whether pharmacological treatment is appropriate.

Stimulant drugs: cocaine (including crack), methamphetamine and amphetamine

Research on pharmacotherapy for stimulant drugs has focused mainly on the treatment of dependent users of the various forms of cocaine and amphetamine. Treatment goals are usually the management of withdrawal and the maintenance of abstinence, although the value of substitution treatment with harm reduction goals is also considered. Overall, the evidence supporting pharmacological treatment is weak.

Management of withdrawal from stimulant drugs

Cocaine dependence: preventing relapse, maintaining abstinence

A range of antidepressant drugs has been investigated for treating cocaine dependence or problematic use, including desipramine (17 trials, 75-300 mg); fluoxetine (five trials, 20-60mg); nefazodone (<400 mg) and ritanserin (10 mg) (two trials each); bupropion (three trials, 300 mg) and one trial each with imipramine (150-300 mg), buspirone (30 mg), gepirone 16 mg), paroxetine (20 mg), citalopram (20 mg), venlafaxine (<150 mg), selegiline (20 cm ² patch containing 1.0 mg/cm ²), tryptophan (8 g/day), sertraline (110 mg) and imipramine (150-300 mg). Some 37 randomised studies with (3551 participants) have been meta-analysed ( Pani et al., 2011) (Ia). Studies of patients with concurrent opioid dependence were studied separately, but yielded similar results. Desipramine performed no better than placebo in terms of retention in treatment, although there was a non-significant trend in favour of desipramine in terms of cocaine-free urines. One trial favoured imipramine over placebo in terms of clinical self-report, and one trial suggested that fluoxetine maintained people in treatment. However, there was no significant effect when selecting studies using operationally defined diagnostic criteria. Pani et al. (2011) concluded that the evidence did not support the efficacy of antidepressants. There has since been a small open trial of reboxetine which showed some improvement but also adverse effects ( Szerman et al., 2005) (III). In summary, there is no evidence to support the use of antidepressants for cocaine dependence (1a).

Amphetamine dependence: preventing relapse, maintaining abstinence

Shearer et al. (2009) (Ib) studied 80 methamphetamine-dependent subjects allocated randomly to modafinil (200 mg/day) ( n = 38) or placebo ( n = 42) under double-blind conditions. There were no differences in methamphetamine abstinence, craving or severity of dependence, although medication-compliant subjects tended to provide more 'clean' urine samples over the 10-week treatment period ( p = 0.07). There were significant reductions in systolic blood pressure ( p = 0.03) and in weight gain ( p = 0.05) in modafinil-compliant subjects compared with placebo.

Recommendations: stimulant drugs

There is no convincing evidence supporting the use of pharmacological treatment for amphetamine and cocaine abuse and dependence. Psychosocial interventions such as CBT and contingency management remain the mainstay of treatment (S).

We do not recommend the use of dopamine agonists, antidepressants or anticonvulsants (A).

Disulfiram is not yet an established treatment for cocaine use, but clinicians should be alert to further studies as the current small evidence base is of interest (C).

There is no clear evidence to support substitute prescribing of dexamphetamine for treatment of cocaine or amphetamine dependence, but definitive studies are warranted and clinicians should be alert to further studies (D).

'Club' drugs

Ecstasy (MDMA)

Ecstasy dependence is rare, and there are no specific trials examining it. Depressive symptoms in MDMA users may lead to an antidepressant being prescribed, but it is likely to be ineffective in many (see comorbid section).

A MixMag 2009 Survey revealed that 19% (227/1197) MDMA users had ever been prescribed antidepressants, 9.5% (113/1180) had ever taken MDMA while on antidepressants and 8.8% in the last 12 months. This is of concern due to risks of interaction, 5HT syndrome, as well as poor efficacy. As for other comorbid disorders, the advice is to delay diagnosis of depressive disorder until 2-4 weeks abstinent.

Gamma-hydroxybutyric acid (GHB) and its precursors

The majority of case reports are with benzodiazepines but high initial doses (40-120 mg diazepam in first 24 h, sometimes more) are usually needed ( Bell and Collins, 2011; McDonough et al., 2004). There are case reports of the use of other sedative agents, mainly pentobarbital, in patients resistant to treatment with benzodiazepines ( McDonough et al., 2004; Schneir et al., 2001; Sivilotti et al., 2001) (III). A recent study reported a titration and tapering procedure in 23 moderate to severe GHB-dependent inpatients whereby pharmaceutical GHB replaced illicit GHB, which was then tapered over 1 week ( de Jong et al., 2012) (III). Patients experienced low withdrawal symptoms and none developed psychosis or delirium. Given that GHB/GBL have GABA-B agonist activity, baclofen may be used in withdrawal in much the same way that benzodiazepines are used in alcohol withdrawal, particularly as it is much safer than barbiturates (see case report LeTourneau et al., 2008) (III). Bell and Collins (2011) have reported a case series of 19 patients treated for withdrawal from GBL, most of whom were outpatients. They used high-dose diazepam (mean dose in the first 24 h 75 mg) together with baclofen (10 mg tds). Sixteen patients completed withdrawal, although several had lapses to GBL use during treatment. One patient developed delirium that required admission to an inpatient detoxification unit. Insomnia, anxiety and depression were common persisting symptoms for some weeks after withdrawal.

Cannabis

Dependence on cannabis is third behind that to tobacco and alcohol in terms of population prevalence, with up to 1% of the European population meeting criteria ( Wittchen et al., 2011). Research related to pharmacological treatment of cannabis abuse and dependence focuses mainly on alleviation of withdrawal symptoms to aid quit attempts ( Budney et al., 2004; Cui et al., 2001; Hart, 2005). The symptoms are primarily emotional and behavioural, although appetite change, weight loss, and physical discomfort are also reported. An assessment scale for cannabis withdrawal has recently been developed by Allsop and colleagues (2011). Pharmacological approaches and studies have recently been reviewed ( van den Brink, 2012).

Treating cannabis withdrawal

There are two small randomised, double-blind placebo-controlled trials of oral tetrahydrocannabinol (THC) ( Budney et al., 2007; Haney et al., 2004) (Ib) which reduced withdrawal symptoms, including reduction in sleep problems and anxiety. Doses ranged from 30-90 mg daily. Reductions in craving and depressed mood were greater with higher doses.

Haney et al. (2008) compared oral THC (60 mg) with placebo, with lofexidine (2.4 mg) and with a combination of THC and lofexidine treatment under laboratory conditions with mixed results. The combination of lofexidine and oral THC produced the most robust improvements in sleep and decreased withdrawal symptoms, craving, and relapse. In a more recent, larger study ( Levin et al., 2011) (Ib) 156 cannabis-dependent adults were enrolled in a randomised, double-blind, placebo-controlled, 12-week trial of dronabinol 20 mg twice a day or placebo started after 1 week of abstinence. There was no significant difference between treatment groups in the proportion of participants who achieved 2 weeks of abstinence. Dronabinol was well tolerated, improved treatment retention and provided better relief from withdrawal symptoms than placebo.

To date there appears to be no substantial evidence for antidepressant prescribing to aid cannabis withdrawal. Depressed mood is more common in cannabis users and therefore clinicians are likely to consider antidepressant use. It is possible however that prescribing some antidepressants such as SSRIs and bupropion may exacerbate anxiety and insomnia in the early stages of withdrawal.

A study of rimonabant was discontinued because of significant medication side effects (Montebello M, personal communication). It is unknown whether other antagonists would have a similar effect.

Polydrug use

In clinical practice, it is common for patients to abuse or even to have developed dependence on more than one drug. One approach is to apply evidence-based treatments for each drug simultaneously or sequentially. However, it would be helpful to have a clear evidence base for a treatment strategy for polydrug users, so we have examined treatment studies including patients who were using more than one drug in the month prior to starting treatment.

Opioids and cocaine

There is a published 24-week phase RCT of a cocaine vaccine in methadone maintenance patients ( Martell et al., 2009) (Ib). Five vaccinations were given over 12 weeks; 38% of patients achieved high IgG levels with significant reduction in cocaine use, although this treatment would be expected to remain effective for 2 months only.

Studies mainly examine detoxification from both substances in inpatient settings but there are no RCTs. de Wet and colleagues (2004) (III) reported that opioid patients using benzodiazepines experienced more severe withdrawal symptoms, including opioid-specific withdrawal symptoms, than users of opioids alone during inpatient detoxification. A pilot study of 27 patients comparing buprenorphine plus carbamazepine with oxazepam plus carbamazepine ( Schneider et al., 2000) (III) showed similar completion rates for both groups but superior symptom relief in the buprenorphine/carbamazepine group.

Reed and colleagues (2007) (IIb), in a preliminary study of patients undergoing inpatient detoxification, found superior completion rates and less severe withdrawal symptoms in opioid and benzodiazepine-dependent patients where buprenorphine was used for management of withdrawal rather than methadone. Kristensen and colleagues (2006) (IIb) compared a buprenorphine and valproate regime with a clonidine and carbamazepine regime in an open-label study of inpatient detoxification from both opioids and benzodiazepines. Earlier symptom relief was achieved with the buprenorphine/valproate combination.

Studies in community settings are limited. A study of benzodiazepine detoxification for those regularly using benzodiazepines, mostly alprazolam, reported 12 out of 22 methadone patients were successful ( McDuff et al., 1993) (IIb). Weizman and colleagues (2003) (III) compared detoxification from benzodiazepines using clonazepam with clonazepam maintenance treatment in patients engaged in a methadone maintenance programme. Low-dose maintenance appeared more successful than detoxification in preventing illicit benzodiazepine use (66 patients followed for 1 year).

Alcohol and cocaine

This is a common comorbidity and challenging to treat.

Naltrexone appears ineffective in reducing either alcohol or cocaine use in alcohol and cocaine users when used at daily doses of 50 mg ( Hersh et al., 1998; Schmitz et al., 2004) (Ib) or 100 mg ( Schmitz et al., 2009) (Ib). Higher doses of naltrexone, such as 100 mg/day and 150 mg/day, may have beneficial effects in combined dependence, particularly in men ( McCaul, 1996; Oslin et al., 1999; Pettinati et al., 2008b) (Ib). Those with higher severity of cocaine but not alcohol dependence were less likely to achieve abstinence from cocaine ( Ahmadi et al., 2009). Early benefit at 2 months was lost at 6 months ( McCaul, 1996) (Ib). Schmitz et al. (2009) found no differences between naltrexone (100 mg/day) and placebo added to contingency management. Poor compliance and engagement in treatment is consistently found.

Nicotine dependence

Nicotine dependence is recognised in ICD-10 and DSM-IV as a psychiatric disorder. The defining features include failed attempts to abstain, powerful urges to use nicotine, and withdrawal symptoms on cessation. An estimated 80% of cigarette smokers are classifiable as dependent by DSM-IV criteria, and the treatment of nicotine dependence has been investigated in a large number of well-conducted RCTs. There are high-quality systematic reviews ( Moore et al., 2009; Stead et al., 2008) (Ia) and treatment guidelines ( USDHHS, 2008; West et al., 2000).

The main harmful effects of nicotine dependence arise from long-term health effects of tobacco constituents other than nicotine, and this is particularly true for smoking cigarettes. The benefits and sustainability of reductions in cigarette consumption are uncertain; therefore the primary goal of treatment is permanent cessation of smoking. An abstinent period of 6 months or longer is widely regarded as an acceptable marker for successful cessation, in that it permits a quite accurate prediction of permanent cessation: relapse after this time is estimated at around 50% over a lifetime ( West et al., 2005). However, there has been more recent interest in the use of nicotine replacement products for patients attempting to reduce their cigarette consumption (Nicotine Assisted Reduction in Smoking) prior to planning a specific quit attempt, as well as for those who are ready to quit. In this strategy, the long-term goal remains permanent cessation, but a short-term goal may be to reduce smoking by at least 50%, with a review of the quitting goal after 3 months.

Nicotine replacement therapy

Nicotine replacement therapy (NRT) consists of products that allow smokers to obtain therapeutic doses of nicotine without other toxins, to provide a partial substitute for smoking and to aid smoking cessation. Nicotine from the product binds to nicotinic acetylcholinergic receptors in the central nervous system in a dose-dependent manner. This reduces urges to smoke and nicotine withdrawal symptoms, and partially blocks the rewarding effect of a cigarette if a lapse occurs.

A variety of nicotine replacement products are available. These include nicotine-containing gum (2 mg and 4 mg), transdermal patches (varying doses), inhalator/inhaler, nasal spray (0.5 mg per dose, usually administered two doses at a time), sublingual tablet, mouth-spray, lozenge and now electronic cigarettes (though these are not typically seen as anti-smoking devices). These products have differing rates of delivery of nicotine. Transdermal patches provide the slowest delivery. The nasal spray and electronic cigarette provides the fastest delivery (tmax is around 10 min), although the gum, inhalator, lozenge, mouth-spray and sublingual tablet typically achieve peak levels within 30 min of use. In many countries, including the UK, products may be used singly or in combination (usually of the transdermal patch plus a faster-acting product). In some countries, such as the USA, combination use is not permitted, according to the label.

When used with a quit attempt, NRT should be started on, or up to 2 weeks prior to, the target quit date. It should be used for a minimum of 8 weeks, and then as long as is necessary. As described above, NRT can be used with the goal of smoking reduction, where there is a long-term goal of smoking cessation: the aim is to reduce cigarette consumption by at least 50%, and the quitting goal should be reviewed after 3 months.

All the above forms of NRT can help people who make a quit attempt to increase their chances of successfully stopping smoking. From the findings of a Cochrane review ( Stead et al., 2008) (Ia) based on 111 trials with over 40,000 participants, NRTs have been estimated to increase the rate of quitting by 50-70%. There is evidence (from six trials) that combining a nicotine patch with a rapid-delivery form of NRT (nicotine combination therapy) is more effective than a single type of NRT (nicotine monotherapy). Pooled evidence from four trials indicates that starting a nicotine patch for a brief period before the target quit date significantly increases the rate of cessation compared with initiating the patch on the quit day. Indirect comparisons of a large number of trials showed no difference in success rates between regimes involving abrupt cessation of nicotine patch use and those in which tapered doses of nicotine patch were used.

Antidepressants

There are several reasons to believe antidepressants might help in smoking cessation. Nicotine withdrawal may produce depressive symptoms or precipitate a depressive episode; nicotine may have antidepressant effects that maintain smoking, and antidepressants may substitute for this effect; and some antidepressants may have a specific effect on neural pathways (e.g. inhibiting monoamine oxidase) or receptors, (e.g. blockade of nicotinic-cholinergic receptors) underlying nicotine addiction ( Hughes et al., 2007) (Ia).

The atypical antidepressant bupropion has been well studied and is licensed as an aid to smoking cessation. It has dopaminergic and adrenergic actions, and also appears to act as an antagonist at the nicotinic acetylcholinergic receptor ( Fryer and Lukas, 1999). Bupropion is produced as a sustained release tablet formulation. Results of a meta-analysis of 49 trials ( Hughes et al., 2007) (Ia) show bupropion to be more effective than placebo in promoting continuous abstinence from smoking. This effect appears to be independent of its antidepressant action, and the effect is also independent of the patient's history of depression.

In their meta-analysis and Cochrane review, Hughes and colleagues (2007) (Ia) considered the following antidepressant drugs in addition to bupropion: nortriptyline; SSRIs including fluoxetine, paroxetine and sertraline; monoamine oxidase inhibitors; venlafaxine; and St John's Wort. There was clear evidence for effectiveness of nortriptyline and bupropion, and both are well tolerated. No significant effects were found for fluoxetine, paroxetine, sertraline, the monoamine oxidase inhibitor moclobemide, or for venlafaxine. There were no long-term trials of St John's Wort.

Anxiolytic drugs

Anxiolytic drugs have also been of interest to aid smoking cessation. The rationale for this is that anxiety symptoms are present in nicotine withdrawal, and that smoking is a behaviour that is sometimes used to relieve anxiety. In a meta-analysis and Cochrane review, Hughes and colleagues found one trial each for diazepam, meprobamate, metoprolol and oxprenolol, and two trials for buspirone ( Hughes et al., 2000) (Ia). No trial showed a significant effect in helping smokers to quit, but confidence intervals were wide. The authors conclude that the role for anxiolytic drugs cannot be ruled out on current evidence.

Nicotine receptor partial agonists

Nicotine receptor partial agonists may help people to stop smoking by a combination of counteracting withdrawal symptoms (acting as an agonist) and reducing smoking satisfaction (acting as an antagonist, see Nutt et al., 2012). In the review and meta-analysis by Cahill et al. (2011) (Ia), 11 trials of varenicline were identified. Varenicline at standard dose increased the chances of successful long-term smoking cessation between two- and threefold compared with placebo or bupropion. Varenicline has been found in direct and indirect comparisons in RCTs to be more effective than bupropion or nicotine patches ( Cahill et al., 2011; NICE, 2007e) (Ia). It has also been associated with higher success rates in routine clinical practice ( Brose et al., 2011) (III). It is unclear whether varenicline is more effective than optimised NRT (for example patches plus a faster-delivery form of NRT). Lower-dose regimens of varenicline also increased success rates, while reducing the incidence of adverse events (the most common being nausea). Limited evidence suggests that varenicline may have a role to play in relapse prevention. There have been reports of possible serious adverse events, including depressed mood, agitation and suicidal thoughts, but their relationship to varenicline has not been substantiated ( Gunnell et al., 2009; Tonstad et al., 2010) (III). Varenicline has not been established as safe in pregnancy, breast-feeding or adolescence. There is evidence that a very low-cost partial agonist which is available in some parts of Europe, cytisine, is effective in aiding cessation ( West et al., 2011).

Nicotine vaccines

Nicotine vaccines are currently in development. These induce antibodies which bind to the nicotine molecule to prevent it entering the brain, and are intended as relapse prevention adjunctive treatment, rather than a cessation treatment. Data to date are suggestive of efficacy, but there is currently insufficient evidence for them to be recommended for use.

Recommendations: nicotine

NRT, varenicline, bupropion, nortriptyline and cytisine are all effective in aiding smoking cessation. Prescriptions for one of these should be offered to all smokers (A).

Optimal results can be expected with either varenicline or combination of NRT patch plus a faster-acting form of NRT (A).

All smokers should also be encouraged to use behavioural support where this is available (for example in the UK National Health Service all smokers should have access to a trained stop-smoking practitioner), but unwillingness to use behavioural support should not preclude prescribing pharmacotherapy (A).

All pharmacotherapies can safely be used in patients with stable cardiac disease (A).

NRT should be considered to aid smoking reduction as a prelude to quitting in smokers not ready to make a quit attempt but willing to reduce (A).

Although effectiveness is not established in these patient groups, NRT can be considered on an individual basis for pregnant women and for young people under 18 (D).

Nortriptyline and cytisine are very low-cost, effective medications that may be of particular value in low to middle income countries (D).

Key uncertainties

It is not clear whether varenicline is more effective than combination of NRT patch and a faster acting product.

The benefits of combining multiple treatments need to be evaluated.

There is uncertainty about whether NRT bought over the counter is currently proving effective in some populations.

It is not clear whether cytisine is more or less effective than varenicline under a similar dosing schedule.

Pregnancy

In pregnancy, the general principles of best practice need to apply to the foetus as well as to the woman. There are a number of sources of evidence and good practice to guide practitioners despite the difficulties, ethical and otherwise, of conducting RCTs in this population. We focus here on pharmacotherapy, and the reader is directed elsewhere for broader management issues, for example NICE clinical guideline on pregnancy and complex social factors which included women who misuse alcohol and/or drugs ( NICE, 2010b) (Ia), the Confidential Enquiries into Maternal Deaths reports ( Centre for Maternal and Child Enquiries (CMACE), 2011), NICE guidance on antenatal and postnatal mental health ( NICE, 2007a) (Ia) and smoking ( NICE, 2010a) (Ia), and the Cochrane review on improving pregnancy outcomes by pre-pregnancy health promotion ( Whitworth and Dowswell, 2009) (Ia). There are also Cochrane reviews of psychosocial interventions and opioid agonist maintenance treatment for pregnant women ( Minozzi et al., 2008; Terplan and Lui, 2007) (Ia).

Problems with the evidence base include the facts that much comes from the USA and no RCTs were conducted in the UK, polysubstance misuse is the norm in the UK, numbers in RCTs are small, and the high prevalence of nicotine use as a potential confounder.

Assessment and antenatal care

Enabling pregnant substance users to access antenatal care is vital. In 2006-2008, 11% of all maternal deaths were in substance misusers ( CMACE, 2011) and 44% of substance-misusing women received no/little antenatal care. Some 31% of maternal deaths from suicides were in substance misusers. Assessment tools such as T-ACE, TWEAK or AUDIT C have been shown to have the highest sensitivity for identifying prenatal risk of drinking ( Burns et al., 2010).

Early information-sharing between the GP, maternity and addiction services is essential. All women who are substance users should have integrated specialist care that includes professionals in addiction, child safeguarding, specialist midwifery and obstetrics ( CMACE, 2011; NICE, 2010b).

Women who are substance users and who attend drug treatment programmes are likely to have better antenatal care and better general health than those who do not engage with treatment services. Addiction services should fast-track pregnant women into treatment and engage substance-misusing partners ( Department of Health, 2007).

Opioids

Opioid dependence is associated with increased maternal and neonatal complications. Maintenance treatment with an opioid substitute can prevent the adverse effects on the foetus of repeated withdrawals and periods of intoxication. The UK guidelines on clinical management of harmful drug use or abuse or dependence cover general management strategies for pregnant opioid-dependent women ( Department of Health, 2007).

MMT in pregnancy is associated with improved compliance with antenatal care, reduced maternal morbidity and improved neonatal outcomes ( Burns et al., 2007; Fajemirokun-Odudeyi et al., 2006; Kandall et al., 1999) (IV). The most appropriate methadone dose in pregnancy is still debated. Some practitioners favour higher doses to limit illicit drug use and counteract the increased methadone clearance in pregnancy, which may necessitate a dose increase in the third trimester ( Drozdick et al., 2002; Wolff et al., 2005). Others favour lower doses to try to reduce the incidence of neonatal abstinence syndrome (NAS) ( Dashe et al., 2004) or using the lowest doses compatible with stability ( Dryden et al., 2009). Splitting the daily dose in the third trimester can be a helpful strategy (III). A recent systematic review and meta-analysis did not find an association between high or low-dose maternal MMT and severity of NAS ( Cleary et al., 2010) (III). A prospective study of pregnant women prescribed up to 110 mg/day of methadone did not find an association between methadone dose and measures of NAS ( Gray et al., 2010 (III)). However, a recent retrospective cohort study found a dose-response relationship between maternal methadone dose at delivery and NAS ( Cleary et al., 2011).

There is increasing experience with buprenorphine during pregnancy. Improvements in perinatal outcomes were similar for methadone and buprenorphine in a prospective observational study ( Lejeune et al., 2006 (III)). Of note, buprenorphine combined with naloxone is contraindicated in pregnancy (BNF, SPC), so all studies have used buprenorphine. In a Cochrane review of maintenance opioid agonist treatments in pregnancy ( Minozzi et al., 2008 (Ia)) two studies compared methadone (at doses between 40-100 mg/day) with buprenorphine (at doses between 8-24 mg/day) ( Fischer et al., 2006; Jones et al., 2005) (Ib). Comparing methadone with buprenorphine there was no difference in maternal treatment drop-out rates (two studies), NAS (two studies), use of heroin (one study) or APGAR scores (one study). Kakko et al. (2008) (III) found that buprenorphine was associated with lower levels of NAS and increased birth weight. A recent multicentre international RCT of buprenorphine and methadone in 175 pregnant opioid-dependent women (the MOTHER study) found that babies of mothers treated with buprenorphine had less severe neonatal abstinence symptoms requiring less medication and shorter stays in hospital ( Jones et al., 2010) (1b).

Stimulants

A Cochrane review of psychosocial interventions for pregnant women examined nine trials of contingency management or motivational interviewing ( Terplan and Lui, 2007) (Ia). The majority of women used opiates and cocaine. Contingency management may increase treatment retention but there is no clear effect on drug abstinence. There was no evidence to support motivational interviewing. RCTs focussing on obstetric and neonatal outcomes are needed. The Department of Health guidelines recommend offering psychological approaches including family intervention to pregnant women misusing stimulants ( Department of Health, 2007). Substitute prescribing is not recommended.

Alcohol

There is much controversy regarding how much alcohol is 'safe' to drink in pregnancy ( Carson et al., 2010; NICE, 2008; O'Leary et al., 2007); however, there is no evidence of a threshold level of alcohol consumption during pregnancy above which alcohol is harmful to the baby. NICE (2008) states "in the absence of clear evidence of a threshold it would appear that drinking no more than 1.5 units/day is not associated with harm to the baby but there remains a possibility that there is an increased miscarriage rate in association with alcohol consumption although the evidence is limited and of poor quality". There is limited evidence that binge drinking, as defined by drinking five or more standard drinks in a single episode, may be associated with neuro-developmental harm to the baby ( NICE, 2008). UK government advice is currently not to drink during pregnancy or when trying to conceive ( Department of Health, 2008). If a woman chooses to drink, they should drink no more than '1-2 units once or twice a week' and that binge drinking (> 7.5 units) on a single occasion may be harmful ( Department of Health, 2008; NICE, 2008). In addition, a man is also recommended not to drink excessively to improve fertility.

No relapse prevention medication has been evaluated in pregnancy suitable for a systematic Cochrane review ( Smith et al., 2009) (Ia), and existing studies of pharmacological interventions in alcohol treatment exclude pregnant women. The BNF advises to avoid acamprosate in pregnancy and to avoid disulfiram in the first trimester. Naltrexone is licensed in UK to prevent relapse in opioid dependence and the BNF says it can be used if 'benefit outweighs risk'. In the USA, advice is to avoid any of these medications unless 'potential benefit outweighs risks' ( TIP, 2009) (IV). In addition, appropriate birth control is recommended while on these medications.

There is therefore little research evidence for the efficacy or the safety of pharmacological treatments in pregnancy or breast feeding, and these are best avoided.

Comorbidity

Symptoms of psychiatric disorders such as depression, anxiety and psychosis are the rule rather than the exception in patients misusing drugs and/or alcohol. In addition, these psychiatric disorders increase the risk of harmful substance use, abuse or dependence, and patients may be physically unwell. Such patients are often the most challenging to engage and treat, and their prognosis is frequently poor. The number of placebo-controlled trials is small, and although increasing steadily there remains little evidence to guide treatment, particularly in the adolescent or old age populations. There are now national guidelines to guide treatment of comorbidity in UK ( NICE, 2011a, 2011b) (Ia), in Australia ( Mills et al., 2009) (IV) as well as management within relevant BAP guidelines (see for example those for ADHD (not covered in these guidelines), schizophrenia, bipolar disorder at www.bap.org.uk) (IV). We therefore concentrate on the psychopharmacology of treating such comorbid disorders. As previously discussed, all studies include a psychosocial intervention.

While it is common to refer to a patient's psychiatric disorder or substance use disorder as primary or secondary, this may have limited use clinically. It is important to establish whether substance use may be contributing to their psychiatric problems. Such an assessment may be appropriate at every meeting, particularly if there are changes in their psychiatric presentation. While removing or minimising the contribution of harmful substance use is an important aim, it is often not achieved. In addition, misplaced attribution of the psychiatric disorder purely to substance use can occur, and may result in the patient achieving abstinence but not being reassessed, or never having their psychiatric problems adequately addressed because they never achieve abstinence. Pragmatically, both disorders may have to be treated concurrently, although improvement in one does not necessarily result in improvement in the other.

The literature contains a wide variety of types of studies and outcomes, but few RCTs or even trials, with many being case series. Most do not use 'intention to treat' analysis and have small samples (e.g. n = 16-100) and short duration (days to weeks). In some studies, the primary outcome measure is the psychiatric disorder, with secondary outcomes being substance related, and neither the goal regarding substance use, for example reduction or abstinence, nor the extent and nature of psychosocial interventions is discussed. Reductions in psychiatric symptoms, for example depression, can be reported although patients did not necessarily have a diagnosis of depression.

In the following sections we primarily focus on studies where the impact of the medication on substance use outcomes is reported from the perspective of pharmacotherapy for the psychiatric disorder as well as for substance use disorder. Some pharmacotherapy has not been studied in patients with a comorbid psychiatric disorder. However, such absence of evidence due, in part, to difficulties in studying this population and lack of 'pharma' interest in conducting such large-scale trials should not deter prescribing, given its potential effectiveness.

Assessment

It is important to distinguish between substance-induced and substance-related psychiatric disorders. While it is advisable to allow at least 2 weeks of abstinence before making diagnosis of a psychiatric disorder, this is often impractical. A complete substance history should be obtained, including nicotine and so-called 'legal highs' as well as drugs bought off the internet, with urinalysis and blood tests. To establish how a patient's substance use and other psychiatric disorder are linked, the order of onset of their psychiatric disorder and substance use, family history and effect of previous treatments of comorbid psychiatric disorder should be determined.

Bipolar disorder

The limited evidence is presented in several systematic reviews and guidelines available, including BAP bipolar guidelines ( Goodwin et al., 2009 (IV); NICE, 2011b (Ia), TIP, 2006 (IV); Spanish ( Casas et al., 2008) (IV) and Australian guidelines ( Mills et al., 2009) (IV); and comprehensive reviews by Vornik and Brown (2006) and Tiet and Mausbach (2007)).

After nicotine, the most commonly abused substance is alcohol. The majority of bipolar disorder patients report using substances, including alcohol, to reduce anxiety (e.g. Bizzarri et al., 2007). Given the overlap between and increased risk of mania and harmful alcohol use, abuse or dependence, detoxification from alcohol may be needed early in treatment of mania alongside mood stabilisation. Trials are generally conducted in a depressive or mixed phase, or maintenance phase.

Existing standard pharmacological approaches appear effective in comorbid bipolar disorder and there is no robust evidence for better efficacy of any one particular pharmacological approach. Compliance may be affected by warnings about not drinking alcohol when taking a mood stabiliser. There is evidence for the use of carbamazepine, valproate and antipsychotics for improving alcohol-related outcomes.

The combination of lithium and valproate has been compared with lithium alone in two trials. Patients with BPD I and alcohol dependence completed a few days of stabilisation on lithium, after which valproate or placebo was added for 24 weeks ( Salloum et al., 2005) (Ib) The lithium plus valproate group had a significantly lower proportion of heavy drinking days ( p = 0.02) and a trend toward fewer drinks per heavy drinking day ( p = 0.055) than the lithium plus placebo group, although manic and depressive symptoms improved equally in both groups. In the other trial, patients with BPD I or II and alcohol, cannabis or cocaine abuse or dependence entered a 6-month stabilisation 'open' phase with lithium and valproate, followed by a blinded 6-month 'maintenance' phase comparing this combination with lithium alone ( Kemp et al., 2009) (Ib). Only 31 of the 145 patients were randomised in the maintenance phase, and the combination was not superior in improving any of their chosen outcome measures including 'time to treatment' for a mood episode or time to discontinuation with medication. However, in those that entered the maintenance phase, substance use was reduced so that more than half were no longer abusing alcohol or cannabis or cocaine. The combination of lithium and valproate resulted in greater improvements in drinking outcomes. Therefore both trials suggest a combination of lithium and valproate may be better than lithium alone for substance abuse; however, the combination is not superior in improving mood.

In two open-label studies, Brown and colleagues reported that the addition of lamotrigine improved mood - depression and mania - and reduced cocaine craving and use ( Brown et al., 2003, 2006) (Ib).

An RCT of add-on quetiapine (600 mg/day) found no improvement in alcohol use or craving in those with bipolar disorder and alcohol abuse or dependence ( Brown et al., 2008) (Ib). An open trial that included patients with alcohol dependence and bipolar disorder ( n = 10), or schizoaffective disorder ( n = 2) and/or borderline personality disorder ( n = 10) found that quetiapine alone improved psychiatric symptoms, and decreased alcohol consumption and craving ( Martinotti et al., 2008) (IIb). A double-blind placebo-controlled trial reported no benefit of quetiapine (400 mg/day, up to 800 mg/day) as an adjunct to lithium or divalproex in reducing number of heavy drinking days, nor improvement in bipolar disorder ( Stedman et al., 2010) (Ib).

In an open-label study of 20 patients with bipolar disorder or schizoaffective disorder, a switch to aripiprazole resulted in improved depression, mania and BPRS scores as well as reduction in cocaine and alcohol craving, and amount spent on alcohol, but not cocaine use ( Brown et al., 2005) (IIb).

A secondary analysis of the trial ( Petrakis et al., 2005) (Ib) comparing disulfiram and naltrexone alone and in combination with placebo, in patients with a psychiatric comorbidity, compared those with psychosis spectrum, of which the majority (73%) had bipolar disorder, with the remaining non-psychotic participants ( Petrakis et al., 2006b) (Ib). There was no significant difference between the psychotic and non-psychotic groups in retention or compliance; however, the 'psychotic group' complained about more side effects, drank more heavily and had less abstinence, but responded more to either naltrexone or disulfiram. In the 'psychotic group', placebo resulted in little change in their frequency of heavy drinking days (12/84); however, there was a significant reduction in drinking with naltrexone (3/84), disulfiram (4/84) and the combination (6/84). There was no difference between the medications. Despite improvement in drinking, there was no significant change in psychiatric symptoms rated with PANSS.

There is evidence that naltrexone can reduce number of drinking days from a pilot RCT where it was added to a CBT programme aimed at bipolar disorder and alcohol dependence, delivered over 16 weeks alongside usual medication ( Brown et al., 2009) (Ib).

An RCT in those with bipolar disorder and alcohol dependence compared acamprosate with placebo in addition to their mood-stabilising medication ( Tolliver et al., 2012) (Ib). While acamprosate showed no benefit in drinking related outcomes, the study was small ( n = 30), of short duration (8 weeks), and levels of alcohol drinking were low with more abstinent than drinking days at baseline. However, acamprosate was well tolerated and had no adverse effects on mood. An anxiety disorder was present in about 75% of the group and associations with increased depressive symptoms and greater alcohol consumption were reported ( Prisciandaro et al., 2011, 2012). Anticonvulsants and antipsychotics were associated with greater alcohol use and lithium with lower alcohol consumption.

Schizophrenia

Managing substance use in patients with schizophrenia is a significant challenge, and there are still limited empirical data to guide clinicians. The debate continues about the influence of substances, particularly cannabis, on causing schizophrenia de novo, increasing vulnerability and increasing relapse rates. There is some evidence to suggest that vulnerability to psychosis and substance use may be shared, rather than substances being taken to ameliorate psychotic symptoms or overcome side-effects of medication ( Chambers et al., 2001). Nicotine is the most commonly abused substance, with up to 85% of patients with schizophrenia smoking cigarettes. Alcohol is the next most commonly abused substance, followed by cannabis. With the introduction of restrictions on smoking, more patients are being offered nicotine substitution and cessation programmes. Recent comprehensive and systematic reviews have described some of the challenges and management ( Lubman et al., 2010; San et al., 2007; Wobrock and Soyka, 2009), and see other guidelines ( Barnes et al., 2011; Mills et al., 2009; NICE, 2011b). A recent Cochrane review concluded that there was no good evidence for effectiveness of any one particular psychosocial treatment in psychotic spectrum disorders comorbid with substance abuse ( Cleary et al., 2008) (Ia). Of note, a recent trial in the UK showed that integrated motivational interviewing and CBT in addition to standard care was no better than standard care alone in improving psychiatric or substance use outcomes ( Barrowclough et al., 2010) (Ib). Another trial in the Netherlands found that training parents in 'motivational interviewing and interaction skills' focused on reducing cannabis use resulted in reduced cannabis use in their young adult offspring with schizophrenia compared with routine family support ( Smeerdijk et al., 2011). However, there were no differences in the patients' general level of functioning and in reducing parents' stress and sense of burden. Throughout these guidelines we have used the terminology to describe antipsychotics as in the original paper, that is, typical or atypical or first or second-generation antipsychotic (FGA, SGA).

The majority of studies covering schizophrenia comorbid with harmful substance use, abuse or dependence are still not prospective RCTs but rather retrospective surveys, open trials or case series. We will focus on reports published since the last guidelines in 2004.

With regard to treating schizophrenia itself, recent evidence from CUtLASS1 and CATIE trials indicates that FGA are not inferior to SGA ( Barnes et al., 2011) (IV). This has had a large impact on recommendations suggesting FGA were appropriate as 'first line' rather than favouring SGA over FGA, as happened after the introduction of many SGA ( Barnes et al., 2011) (IV). The lack of extrapyramidal side effects of many SGAs may be now outweighed by their effects on physical health and associated impact on morbidity and mortality. Substance abuse also impacts adversely on physical health, and therefore reducing its impact, such as stopping smoking, is likely to have significant health benefits.

There have been a number of trials of alcohol relapse-prevention medication in patients with schizophrenia, but there are none for illicit substances of abuse. Smoking cessation is discussed below.

There is one study comparing the effects acamprosate with placebo on cognitive functioning in 30 patients with schizophrenia ( Ralevski et al., 2011) (Ib). There were no adverse effects, including on cognitive functioning, and drinking improved in both groups.

There are only case reports of baclofen (25 mg tds; Agabio et al., 2007) (III) and acamprosate (666mg tds; tek et al., 2008) (III) reducing alcohol consumption in single patients with schizophrenia.

Patients have high rates of smoking, which contributes to their higher rates of physical morbidity and mortality. However, recently there have been changes with restrictions on smoking in public places and hospitals, and the general health of patients with schizophrenia is receiving more attention. Whilst many patients with schizophrenia do quit smoking with pharmacological support from NRT or bupropion, quit rates are less than half of those seen in the general population.

An early RCT found that nicotine transdermal patches resulted in limited numbers stopping smoking, but those on atypical antipsychotics fared better than those on typical antipsychotics ( George et al., 2000) (Ib). Tidey et al. (2002) (IIb) found that a nicotine patch (21 mg) did not further improve quit rates achieved with contingency management.

As an adjunctive to psychological support, bupropion has been shown to aid smoking cessation, to be safe and well tolerated, and there is some evidence to suggest that those on atypical antipsychotics are more likely to be able to quit ( George et al., 2002; Weiner et al., 2001) (Ib).

A Cochrane review of smoking cessation in schizophrenia concluded that bupropion increased smoking abstinence rates. However, it did not find any evidence for benefit from NRT ( Tsoi et al., 2010) (Ia). Of the psychosocial interventions, only contingency management could be supported.

Depression

Depressive symptoms are very common in opioids addicts, with about half meeting criteria for major depression: this may motivate them to present for treatment for opioid dependence. Often other substances such as alcohol and cocaine contribute to their depressed mood. Despite this comorbidity there is evidence that such patients do well in opioid treatment and certainly no worse than non-depressed patients ( Ngo et al., 2011; Nunes et al., 2004) (III). Higher doses may be needed for methadone-maintained patients with depression, and enrolment and stabilisation in such programmes alone is likely to have a beneficial effect on their psychiatric symptoms ( Tenore, 2008) (IV). This may be a direct effect of opioid agonism on the reward pathway as well as secondary consequences on their chaotic lifestyle. Buprenorphine may have advantages over methadone in treating depressed opioid addicts due to its kappa antagonism, although this has not been shown consistently ( Dean et al., 2004 (IIb); Gerra et al., 2006 (III)). Nevertheless, in about 10-20%, depression will persist ( Nunes et al., 2004) (IV).

Overall, antidepressant treatment within methadone maintenance programmes can improve depressive symptoms but robust effects on mood are not usual, nor are improvements in opioid or other drug use.

Lastly, although it is theoretically possible for naltrexone to worsen mood, this has not been seen clinically. Recent studies in newly abstinent heroin addicts have not found naltrexone induction and/or maintenance to worsen mood, but instead to improve it ( Dean et al., 2006 (Ib); Mysels et al., 2011 (IIb)).

Those antidepressants with mixed pharmacology such as tricyclics (e.g. imipramine or desipramine) appear to be better than SSRIs (e.g. fluoxetine, sertraline) ( Nunes and Levin, 2004) (Ia). A meta-analysis of four studies with SSRIs showed an OR = 1.85 (95% CI 0.73-4.68), and the three studies with other antidepressants showed an OR = 4.15 (95% CI 1.35-12.75) ( Torrens et al., 2005) (Ia).

The effect on alcohol outcomes was mixed: Nunes and Levin (2004) (Ia) found that in those studies with depression effect sizes over 0.5, the effect size on substance outcome was 0.56 (95% CI 0.33-0.79), whereas almost no impact on substance use was seen in those studies with a lower depression effect size. Once again, antidepressants with mixed pharmacology performed better, resulting in significantly greater reductions in drinking (OR = 1.99, 95% CI 0.78-5.08), whilst SSRIs did not (OR = 0.93, 95% CI 0.45-1.91) ( Torrens et al., 2005) (Ia).

Patients comorbid for substance abuse and depression should be treated for their depression, but improving mood and/or antidepressants may not necessarily reduce their substance abuse; therefore specific, appropriate substance-focussed treatment should also be delivered. While the meta-analyses suggest that antidepressants with mixed pharmacology tend to do better than SSRIs, there is little information on the newer drugs. An open study reported that mirtazapine (15-45 mg/day) was well tolerated in depressed alcoholics and resulted in reductions in depression, anxiety and alcohol craving over 8 weeks ( Yoon et al., 2006) (IIb). One small double-blind RCT reported that both amitriptyline (titrated up to 125-150 mg/day) and mirtazapine (titrated up to 45-60 mg/day) resulted in similar improvements in depression, anxiety and alcohol craving, although drinking outcomes were not reported ( Altintoprak et al., 2008) (Ib). Mirtazapine was better tolerated.

One 26-week trial has reported that escitalopram (20 mg/day) or memantine (20 mg/day) resulted in similar improvements in depression and anxiety in patients with major depressive disorder ( Muhonen et al., 2008) (Ib). No differences were seen in cognition during the trial or between groups and impact on drinking was not reported.

As described in the nicotine section, there are strong links between smoking and depressive symptoms. Most trials examining the impact of depressive disorder have studied those with a past rather than current history, and those with symptoms rather than a disorder. One meta-analysis concluded that a lifetime history of major depression did not appear to be an independent risk factor for cessation failure in smoking cessation treatment ( Hitsman et al., 2003) (Ia). Another systematic review and meta-analysis reported identifying only three RCTs that included those with current depression, and only one involved pharmacotherapy ( Gierisch et al., 2012) (Ia).

Another RCT included both those with a current history or those with a past unipolar depressive disorder and compared bupropion with placebo in smokers being treated with standard group CBT and nicotine patch and not antidepressant medication ( Evins et al., 2007) (Ib). The primary analysis did not show an advantage of bupropion over placebo; however, the drop-out rate was high (50%) and the effectiveness of other treatments may have led to a ceiling effect.

Taking into account the other studies that included those with depressive symptoms, Gierisch et al. (2012) concluded that patients with depression should be encourage to seek help from smoking cessation services that include both NRT and behavioural mood management.

Anxiety

Anxiety is a common symptom in people with harmful alcohol use, abuse, dependence and withdrawal, and alcohol is used as self-medication by many with anxiety disorders, especially social anxiety ( Regier et al., 1990). Anxiety reduces during alcohol withdrawal and in the following few weeks ( Brown et al., 1991, Liappas et al., 2002), but if it persists, relapse rates increase up to twofold ( Brown et al., 1991; Kushner et al., 2005). Some studies show improvement in substance use by treating comorbid anxiety (e.g. Fals-Stewart and Schafer, 1992; Tollefson et al., 1992) (Ib), although others found no effect on substance use (e.g. Bowen et al., 2000; Schade et al., 2005; Thomas et al., 2008) (Ib).

In the context of anxiety disorders, it may be that many people do not get adequate treatment due to concerns about using benzodiazepines. It has been reported that abstinent alcohol-dependent patients may be at greater risk of benzodiazepine abuse and dependence, and patients who are severely dependent with antisocial personality disorder or with polysubstance abuse are most at risk of abusing benzodiazepines ( Ciraulo and Nace, 2000) (IV). Therefore there should be a clear favourable risk:benefit ratio, but benzodiazepines do have a role in treating anxiety and alcohol use disorders.

A recent study of Iraq and Afghanistan veterans compared paroxetine (titrated to 40mg/d) with desipramine (titrated to 200mg/d) (i.e. serotonergic vs noradrenergic uptake inhibitor) with or without adjunctive naltrexone ( Petrakis et al., 2012). Desipramine had comparable efficacy to paroxetine in treating PTSD but had superior efficacy in reducing alcohol consumption. Notably naltrexone did not show efficacy in this population for drinking outcomes compared to the previous secondary analysis ( Petrakis et al., 2006c). This could have been due to the study design including that patients were specifically recruited for the recent study and were started or changed their antidepressant rather than on long-standing pharmacotherapies.

In patients with comorbid PTSD and alcohol dependence, sertraline (150 mg/day) was not superior to placebo in reducing alcohol consumption over 12 weeks, with both groups showing improvement in their drinking but not their PTSD ( Brady et al., 2005) (Ib). Further analysis revealed that sertraline in those whose PTSD predated their alcohol dependence improved alcohol outcomes; however, in those that were more severely dependent, sertraline resulted in more drinking than placebo. This is similar to what is seen in early versus late-onset alcoholism (see alcohol section), and emphasises that SSRI medication should be used with caution in those with harmful alcohol use, abuse or dependence.

While prospective RCTs are not available for other alcohol relapse medication in those with comorbid anxiety disorders, both acamprosate and baclofen have shown some benefit in reducing anxiety in post-hoc analyses of trials in alcohol dependence (see alcohol section).

Personality disorder and treatment for substance use disorders

Studies of pharmacological treatment for substance use disorders typically do not exclude people with personality disorders, hence it is likely they were included in most studies. 'Mainstream' studies of drug treatments for substance use disorders are therefore of relevance to patients with personality disorder.

There is a commonly held view that personality disorder predicts poor response to treatment for substance use disorders. However, there are a number of studies showing that although people with personality disorder may have greater pre- and post-treatment problem severity, they can improve as much as those without personality disorders ( Verheul, 2001) (IV). This suggests that drug and alcohol users with personality disorders probably benefit from standard treatments for substance use disorders. These studies range across MMT for opioid dependence ( Alterman et al., 1998; Cacciola et al., 1996; Darke et al., 1996) (III), treatments for alcohol dependence ( Powell et al., 1992; Verheul et al., 1999) (III), as well as some based on mixed populations of substance use disorders ( Cacciola et al., 1995; Cecero et al., 1999) (III). In one study of disulfiram and naltrexone for treatment of alcohol dependence ( Ralevski et al., 2007) (Ib), patients with comorbid Axis I psychiatric disorders and either antisocial personality disorder or borderline personality disorder responded as well to treatment with either medication as patients without personality disorder. Moreover, Rohsenow et al. (2007) (Ib) found patients with antisocial traits had better alcohol outcomes in response to treatment with naltrexone than patients without antisocial traits.

Sleep

Insomnia is commonly seen in people who misuse substances and can occur during intoxication, withdrawal or become more evident during abstinence. Sleep problems are often cited by patients as a reason they began to drink heavily or relapse, and poor sleep has been shown to be associated with poorer outcomes (see Brower and Perron, 2010). As for other comorbidities, a comprehensive assessment is key to determine the relationship between sleep problems and substance use and to inform a management plan. Rather than use additional pharmacotherapy, review of their existing pharmacotherapy with advice about 'sleep hygiene' ( Wilson et al., 2010) is likely to be the best approach.

Younger people: children and adolescence

The definition of young people may range from the age of 10-25 years. For this document, we are focussing on children and young people under the age of 18. Young people are still physically and mentally growing, and their brain, particularly their frontal lobes, continues developing into the early 20s. Thus the neurobiological impact and consequences of substances on this developing plastic brain is likely to be different to those on an adult, fully developed brain. The 'reward and motivation' system, such as the ventral striatum, develops at an earlier stage before the 'top-down' control from the prefrontal cortex is established ( Somerville and Casey, 2010). In addition, it may be that the exposure of a developing plastic brain to substances may result in increased risk of acquiring a chronic addictive disorder ( O'Brien 2007; Spear, 2007). There is also a potential increased risk of mental illness, for example cannabis and psychosis ( Moore et al., 2007). Research indicates that the experience of craving for, and withdrawal symptoms from, addictive substances are similar in adult and younger populations ( Thomas et al., 2005).

Substance use is common in young people, with high levels of prevalence in the UK compared with elsewhere in Europe and USA ( Frischer et al., 2003). Alcohol is the most common substance used ( British Medical Association, 2003). About 1% of 14-16-year-olds in the United Kingdom drink alcohol nearly every day, and are therefore at high risk of alcohol use disorder. Recently, the WHO estimated that the main risk factor for disability-adjusted life years in 10-24-year-olds was alcohol, with illicit drug use also significantly contributing ( Gore et al., 2011).

Young people generally present with problems with alcohol and/or cannabis to specialist drug and alcohol services. For recent guidance about assessment and prescribing in young people as well as underlying principles of care, responsibilities and consent see Gilvarry and Britton, (2009) (IV).

While emphasis is put on psychosocial, harm reduction and family interventions as appropriate approaches in young people, pharmacotherapy is an important component for some. As for adults, medication can be used for stabilisation, detoxification, relapse prevention and preventing complications. However, in younger people pharmacotherapy for relapse prevention is less commonly used and is not recommended for routine use ( Gilvarry and Britton, 2009). This emphasises the need for a specialist multidisciplinary team, including specialists in addiction to initiate treatment and those to care for mental and physical health and social needs in young people.

A complicating factor is that pharmacotherapy is not generally licensed for use in 'younger' people, with age limits varying. For example, in the UK, acamprosate is licensed for over 18-year-olds, methadone is not licensed for children under age of 13, and buprenorphine is licensed for those aged 16 and over. Doses of medication may need to be adjusted from those for adults, given the difference in pharmacokinetics and pharmacodynamics between adults and younger people. Generally, guidance is that pharmacotherapy should only be used after careful assessment of risks and benefits, and in the context of a comprehensive treatment plan embracing various psychosocial approaches ( Gilvarry and Britton, 2009; Upadhyaya and Deas, 2008) (IV). With only a few studies and the majority conducted in the USA with generally small numbers, mostly male participants, and short treatment or follow-up periods, there is little evidence on which to base guidance. Nevertheless, pharmacotherapy should be considered in young people with a diagnosis of dependence.

Alcohol

A placebo-controlled RCT of acamprosate (1332 mg/day two tablets, one tablet, one tablet) in 26 16-19-year-olds with chronic or episodic alcohol dependence reported improved drinking outcomes in the acamprosate group during the 90-day study ( Niederhofer and Staffen, 2003a) (Ib). They reported that the proportion of patients who remained abstinent was higher in the acamprosate group (seven vs. two) and that the mean cumulative abstinence duration was significantly greater in the acamprosate group (79.8 (SD 37.5) vs. 32.8 (SD 19.0)). Acamprosate was well tolerated with no difference in reported side effects to placebo.

Disulfiram (250 mg/day) use in a 16 and in a 17-year-old resulted in prolonged abstinence for one young man but not the other, in whom compliance was poor ( Myers et al., 1994) (III). A double-blind placebo-controlled study of disulfiram 200 mg daily (two 50 mg tablets mane, one 50 mg tablet at midday and one 50 mg tablet in the evening) in 26 16-19-year-olds reported disulfiram resulted in significantly greater abstinence ( Niederhofer and Staffen, 2003b) (Ib). No significant difference was seen between the groups.

A prospective open-label trial of ondansetron (4 μg/kg) alongside weekly CBT in 12 treatment-seeking 14-20-year-olds found improvement in drinking outcomes over 8 weeks ( Dawes et al., 2005) (IIb). However, there was no placebo group.

Opioids

The use of opioids, including 'street' and prescription opioids, appears to be on the rise in young people and has recently been reviewed ( Subramaniam et al., 2009). Gilvarry and Britton (2009) (IV) provide guidance about prescribing opioid substitutes to young people. While in adults, stabilisation with an opioid substitute followed by long-term maintenance is common, this is a more controversial approach in young people with a limited history of opioid use and minimal adverse consequences. In such cases, substitution followed soon after by detoxification may be a more appropriate approach.

Optimal pharmacotherapy for detoxification has limited evidence, so advice for adults can be followed ( Gilvarry and Britton, 2009, (IV); NICE, 2007 (Ia)). Buprenorphine, particularly with naloxone, is favoured by some due to its better tolerability, adverse event profile, and easier dose reduction to abstinence. An RCT compared buprenorphine with clonidine in detoxification of 36 opioid-dependent adolescents (13-18 years old; Marsch et al., 2005) (Ib). Buprenorphine improved retention in treatment for 1 month compared with clonidine (72% vs. 39%), provided more opiate-free urines (64% vs. 32%), and more started naltrexone afterwards (61% vs. 5%).

Another randomised trial compared two different regimens of buprenorphine-naloxone over 12 weeks in 150 15-21-year-olds ( Woody et al., 2008) (Ib). It compared buprenorphine-naloxone, 24 mg per day for 9 weeks, then tapered to week 12 with buprenorphine-naloxone prescribed up to 14 mg per day and then tapered to day 14 (called 'detox' group). Compared with the buprenorphine-naloxone group, the 'detox' group had more opioid-positive urines at weeks 4 (61% vs. 26%) and 8 (54% vs. 23%) but not 12 (51% vs. 43%) when both groups were not receiving any substitute prescription. Retention in treatment was better in the buprenorphine-naloxone group (70% vs. 20%). The majority in both groups resumed opioid use in the following 12 months. This study suggests that short-term treatment with buprenorphine-naloxone results in better outcomes than detoxification; however, once treatment stops, this gain is lost.

For relapse prevention, the extended-release formulation of naltrexone (XR-naltrexone) requires monthly injections which can overcome compliance issues. In a case series of 16 individuals, average age 18 (range 16-20 years), XR-naltrexone was well tolerated, with 10 being retained for the 4-month treatment period ( Fishman et al., 2010) (III). The majority of patients (11) were abstinent or had substantial reductions in opioid use, and nine met criteria for a 'good' outcome at 4 months. Importantly, there were no reports of overdoses despite many testing the blockade.

Other substances of abuse

There is no evidence to inform practice. For benzodiazepine dependence, maintenance prescribing is not recommended and detoxification with diazepam is recommended ( Gilvarry and Britton, 2009) (IV). For all other substances of abuse, including stimulants, cannabis and Ecstasy, psychosocial approaches are considered the best approach and medication, if required for reducing problems such as insomnia, should only be used cautiously on a limited basis.

Comorbidity

A pilot placebo-controlled trial of sertraline alongside CBT in 10 depressed alcohol-dependent adolescents reported that mood and drinking improved similarly in both groups ( Deas et al., 2000) (Ib). Sertraline (25 mg/day increased to 100 mg by week 4) was well tolerated over the 12-week trial. An open-label 12-week trial of fluoxetine in depressed alcohol-dependent and alcohol-abusing adolescents reported significantly improved depression and drinking outcomes ( Cornelius et al., 2001) (IIb). Fluoxetine was well tolerated. However, there was no placebo group, which limits drawing conclusions from this study.

A double-blind placebo-controlled trial over 6 weeks in 25 adolescents, mean age of 16 years, with bipolar disorder and secondary substance dependence reported that lithium was an efficacious treatment of both ( Geller et al., 1998) (Ib). Alcohol and cannabis were the most common dependencies, although nicotine is not mentioned.

There is limited evidence on treatment of substance use disorders in younger people on which to base recommendations to guide specific pharmacological approaches. However, it is important that pharmacotherapy be considered, particularly in alcohol, opioid or nicotine dependence, and ideally by a specialist multidisciplinary service.

Older adults

In 2001, people over 65 made up 16% of England's population and this is forecast to rise to 21% by 2026 ( Falaschetti et al., 2002), increasing demands on the substance misuse treatment system over the next two decades ( Gfroerer et al., 2003). A recent report is recommended reading ( Crome, 2011). Some key points in this report are that psychiatric comorbidities of substance misuse are common in older people; older people are at increased risk of adverse physical effects of substance misuse, even at relatively modest levels of intake; older men are at greater risk of developing alcohol and illicit drug misuse problems than older women; and older women are at greater risk of developing problems associated with prescribed or over-the counter medication than men. In addition, the relationship between cognitive function and substance (particularly alcohol) use is complex, as is that between functional mental health problems (e.g. anxiety and depression) and substance use, with the direction of causality often unclear. Lower safe levels of alcohol consumption (1.5 units/day; 11/week) are proposed. Older people can and do benefit from treatment, and in some cases have better outcomes than younger people ( Moy et al., 2011).

There is a lack of evidence to guide practitioners on managing substance misuse in older adults. Elderly people are typically excluded from clinical trials of pharmacotherapy, despite the increasing need for an evidence base as the UK population ages. According to recent figures for England and Wales, 1.5% of the 55-59 year age group among the general population reported use of any illicit drug in the previous year, with 0.1% reporting use of a class A drug. This compares with 18.1% and 7.8%, respectively, for 20-24 year olds ( Hoare and Moon, 2010).

There are difficulties in the detection and management of substance misuse problems in older adults. Reasons include inadequate drug and alcohol history-taking in the elderly, low referral rates to specialist drug and alcohol services, and greater use of prescription drugs with potential for misuse ( Gottlieb, 2004; McInnes and Powell, 1994; Simoni-Wastila and Yang, 2006). Treatment should be within multidisciplinary settings with input from addiction specialists and specialists in older people's physical and mental health.

The normal physiological changes of ageing result in important pharmacokinetic and pharmacodynamic changes. Pharmacokinetic changes result from changes in body composition and hepatic and renal function. This results in an increased volume of distribution of lipid-soluble drugs and reduced hepatic and renal clearance. These changes lead to prolongation of plasma elimination half-life. From a pharmacodynamic perspective, age-dependent changes tend to increase sensitivity to drugs. Reduced homeostatic mechanisms may lengthen the time older adults require to regain steady-state levels following changes in drug therapy ( Mangoni and Jackson, 2004). Pharmacological treatment should be started at a low dose and titrated slowly.

Drug misusers have higher mortality rates than the age-matched general population, and older drug users have additionally to deal with the increasing physical health problems of ageing. Older opioid users are at greater risk of death due to traumatic and somatic causes ( Clausen et al., 2009). Clausen et al. (2009) also found that older opioid users were at higher risk of fatal overdose after leaving opioid maintenance treatment. Cardiovascular diseases and tumours (often hepatic) were the most common causes of death among drug users aged 55 or over in one long-term follow-up study ( Stenbacka et al., 2010).

Opioids

Firoz and Carlson (2004) (III) compared outcomes for methadone treatment in 54 older adults (>55 years) with 705 adults under 55 years of age. The mean age for the older adults was 62 years (range 55-82). The older adults had improved outcomes on drug use measures at 9 months compared with the younger adults. The groups did not differ in medical or psychiatric problems.

Among entrants to a New York methadone programme, older adults were more likely to have had longer periods of treatment, less likely to report current heroin use and overall drug use, but were more likely to have a history of comorbid alcohol misuse ( Rajaratnam et al., 2009) (III). Fareed et al. (2009) (III) conducted a retrospective chart review of older patients enrolled in a methadone maintenance programme. Patients who remained in treatment showed statistically significant improvements in drug use, psychiatric, medical and legal problems.

There is no direct evidence about methadone dosing regimens for maintenance treatment in older adults. Guidance from the pain management literature recommends opioid doses should be reduced, there should be a longer time interval between doses, and creatinine clearance should be monitored ( Pergolizzi et al., 2008) (IV). As maintenance treatment utilises daily dosing of methadone, slower dose titration is advisable.

In the absence of a specific evidence base for buprenorphine and naltrexone in this population, treatment decisions should be based on extrapolations from the general opioid evidence base. Clinicians should be mindful of the changes of ageing and accompanying increases in comorbidity which may necessitate dose adjustments. Evidence from the alcohol literature can be used to inform about the safety of naltrexone. Buprenorphine may be the optimal choice for those with renal dysfunction requiring maintenance treatment ( Pergolizzi et al., 2008) (IV).

Alcohol

Benzodiazepines remain the treatment of choice, but the doses may need to be reduced in older people ( NICE, 2011a). Shorter acting benzodiazepines (e.g. oxazepam) may be preferred, especially where there is concern about accumulation leading to over-sedation ( Mayo-Smith et al., 2004) (III).

There is an absence of high-quality evidence on pharmacological interventions for maintaining abstinence in older people, and extrapolations should be made from the adult evidence base ( NICE, 2011a). In trials of naltrexone treatment only 2.6% of subjects were over 65 years of age, and in placebo-controlled clinical trials of acamprosate 1% were 65 years or older (Teter, personal communication).

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BAP updated guidelines: evidence-based guidelines for the pharmacological management of substance abuse, harmful use, addiction and comorbidity: recommendations from BAP - AR Lingford-Hughes, S Welch, L Peters, DJ Nutt, , 2012

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Abstract The British Association for Psychopharmacology guidelines for the treatment of substance abuse, harmful use, addiction and comorbidity with psychiatric disorders primarily focus on their pharmacological management. They are based explicitly on the available evidence and presented as recommendations to aid clinical decision making for practitioners alongside a detailed review of the evidence.

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Schizophrenia is a severe and disabling illness of the brain that affects the way the mind works often causing disturbed behaviour and disrupting normal living. It will affect about 1 in 100 of the population and starts mainly in late teens and early twenties, at the very time that most people are starting out on their adult life and beginning to realise their plans and ambitions. Today in the UK almost a quarter of a million people are being treated for schizophrenia: it affects men and women alike and cuts across all social classes and ethnic backgrounds.

Schizophrenia is one of the major public health challenges facing us today and yet its true impact is very poorly understood by the general public. The cruelly high death toll from suicide and the higher vulnerability to physical ailments mean that people living with schizophrenia will die 10 to 20 years earlier than average
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Today in the UK , improved medications coupled with better access to talking therapies have led to better clinical outcomes but social outcomes still lag far behind. At the moment very few people who are diagnosed with schizophrenia will manage to get into work, drive or own their own home despite recovering a large part of their mental functioning. Recovery, true recovery, therefore remains an aspiration that we are yet to achieve

On this website we publish the views and experiences of people who have known schizophrenia from the inside and who do not believe that a diagnosis of schizophrenia need be a life sentence. We believe that the aim should be not simply to survive but to thrive.

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LWS Speaking Out

Read what Living with Schizophrenia has to say about topical issues in mental health

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Living With Schizophrenia | Information & Support

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Schizophrenia is a severe and disabling illness of the brain that affects the way the mind works often causing disturbed behaviour and disrupting normal living. It will affect about 1 in 100 of the population and starts mainly in late teens and early twenties, at the very time that most people are starting out on their adult life and beginning to realise their plans and ambitions.

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Progress - National Consortium of Consultant Nurses in Dual Diagnosis & Substance Abuse: Out of your head Guides

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Progress - National Consortia of Nurse Consultants in Dual Diagnosis: UK Treatment for people suffering from sustance addictions and mental illness

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5 Strategies for Working With Clients With Co-Occurring Disorders

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Maintaining a therapeutic alliance with clients who have co-occurring disorders (COD) is important-and difficult. The first section of this chapter reviews guidelines for addressing these challenges. It stresses the importance of the counselor's ability to manage feelings and biases that could arise when working with clients with COD (sometimes called countertransference).

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, Owner at Organizational Wellness & Learning Systems, Inc.

Published on

Most approaches to mindfulness are geared toward the individual level and not the social or community level to which traditional mindfulness methods were targeted. It is not only about our own personal growth but the enlightenment of the community as a whole. We are never separate. And this insight is fundamental for any effective wellbeing effort (workplace or otherwise). This experiential webinar will feature a cursory overview of mindfulness (definition, measurement, practices) and participants will be invited to complete introspective surveys about their own mindfulness to help ground the social conversation for the webinar. We will then contemplate seven different ways in which wellness champions can show up in a mindful way within the social context (community or sangha) of their work setting. These are listed below. Participants will be invited to self-assess their capacity for each and given tools to continue developing each.

· The Values Clarifier (Your Cause, Calling, or Legacy)
· The Intentional Centerer (Breathe...Breathe...Breathe)
· The Heedful Relater (Loving Kindness)
· The Compassionate Nudger (Mindfully Encourage)
· The Knower of Impact (Integrity, Foresight, and Social Contagion)
· The Thriver (All Stress is Grist for the Mill)
· The Garnerer of Trust (We are One)

Learning Objectives
1) Define mindfulness and identify at least one measure and practice of mindfulness
2) Distinguish intra-personal mindfulness from inter-personal mindfulness
3) Identify seven different ways that wellness champion may embody mindfulness in their interactions with others

About The Presenters
Dr. Joel Bennett President
Organizational Wellness & Learning Systems
Website: www.organizationalwellness.com

Joel Bennett, PhD, is President of Organizational Wellness & Learning Systems (OWLS), a consulting firm that specializes in evidence-based wellness and e-learning technologies to promote organizational health and employee well-being. Dr. Bennett first delivered stress management programming in 1985 and OWLS programs have since reached over 30,000 workers across the United States.

Lindsay Simone, Manager of Wellness Programs
ACEC Life & Health Trust

Lindsay currently serves as Manager of Wellness Programs for the Designed Wellness program that is offered to all firms that are members of and have medical insurance coverage through ACEC Life & Health Trust. She graduated from University of Illinois at Urbana-Champaign and received a Masters in Wellness Management and Business from Ball State University.

1. 1. Mindful Champion Mindful Workplace Joel B. Bennett, PhD Organizational Wellness & Learning Systems Lindsay Simone (commentator) Designed Wellness, American Council of Engineering Companies

2. 2. Learning Objectives * Define mindfulness and identify at least one measure and practice of mindfulness * Distinguish intra-personal mindfulness from inter- personal mindfulness * Identify seven different ways that wellness champions may embody mindfulness in their interactions with others

3. 3.  Most approaches to mindfulness are geared toward the individual level and not the social or community level to which traditional mindfulness methods were targeted.  It is not only about our own personal growth but the enlightenment of the community as a whole.  We are never separate.  And this insight is fundamental for any effective wellbeing effort (workplace or otherwise).

4. 4.  This experiential webinar will feature a cursory overview of mindfulness (definition, measurement, practices)  You are invited to complete surveys about your own mindfulness to help ground our conversation.  We will contemplate seven different ways in which wellness champions can show up in a mindful way within the social context (community or sangha) of their work setting.

5. 5.  The Valu es Clar ifier * Your Cause, Calling, or Legacy  The Intentional Center er * Breathe...Breathe...Breathe  The Heedfu l R elater * Loving Kindness  The Com passionate Nu dger * Mindfully Encourage  The K now er of Im pact * Integrity, Foresight, Social Contagion  The Gar ner er of Tr u st * We are One  The Thr iv er * All Stress is Grist for the Mill

6. 6. Mindfulness Definition (recent) * Inherent human capacity * Both process and outcome * A way of being * Awareness that emerges when we pay attention to our experience in a particular way; intentionally, in the present moment, with curiosity, acceptance, and kindness, and non-judgmentally * An embodied practice that recognizes the interconnection of the mind- body system with an anchored awareness that returns to the breath and present moment Burke, C. (2013). An Exploration of the Effects of Mindfulness Training and Practice in Association with Enhanced Wellbeing for Children and Adolescents. In Wellbeing : A Complete Reference Guide, Volume 6. F. A. Huppert & C.l. Cooper (Eds)

7. 7. * Mindfulness meditation establishes the distinction between the observer and the observed. * Through the realization of the transiency of all mind content, it brings about a subsidence of desire for sensory and emotional phenomena and, * Finally, an almost disappearance of mind content (primary purpose) - strengthening the Observer * The other benefits of mindfulness - calm, physical health, stress reduction - are relatively trivial and can lessen its effectiveness for its primary purpose. Mindfulness Definition (older)

8. 8. "The term "mindfulness" is used to refer to an extraordinarily wide range of phenomena ranging from mindfulness as a state, to mindfulness as a trait and finally mindfulness as an independent variable, that is, something that is manipulated in an experiment" Dav idson, R . J . (2010). Em pir ical ex plor ations of m indfu lness: conceptu al and m et hodological conu ndr u m s. Em otion. https://www.youtube.com/watch?v=7tRdDqXgsJ0

9. 9. http://thedianerehmshow.org/shows/2014-12-01/ellen_langer_mindfulness_and_the_power_of_thought

10. 10. What is your interest in this webinar? (check all that apply) 1) I have a mindfulness practice 2) I am a wellness champion 3) Personal interest in being mindful at work 4) Professional interest in bringing mindfulness to work 5) I seek enlightenment (nourish the 'observing self')

11. 11. Dispositional Mindfulness* *Items adapted from Baer, R. A., Smith, G. T., Hopkins, J., Krietemeyer, J., & Toney, L. (2006). Using self-report assessment methods to explore facets of mindfulness. Assessment, 13(1), 27-45. - Instrument seen multiple adaptations and cited in close to 2000 publications - correlates with wellbeing a quick exploratory non-scientific survey (do not use to self-diagnose)

12. 12. I perceive my feelings and emotions without having to react to them. Usually when I have distressing thoughts or images, I am able just to notice them without reacting. Factor 1: Nonreactivity to Inner Experience " Yes" to bot h?

13. 13. I pay attention to sensations, such as the wind in my hair or sun on my face. I notice changes in my body, such as whether my breathing slows down or speeds up. Factor 2: Observing & Noticing " Yes" to bot h?

14. 14. I rush through activities without being really attentive to them. I find it difficult to stay focused on what's happening in the present. Factor 3: Acting with awareness vs. Automatic Pilot " No" to bot h?

15. 15. I'm good at finding the words to describe my feelings. Even when I'm feeling terribly upset, I can find a way to put it into words. Factor 4: Describing/Labeling with words " Yes" to bot h?

16. 16. I think some of my emotions are bad or inappropriate and I shouldn't feel them. I make judgments about whether my thoughts are good or bad. Factor 5: Non-judging of experience " No" to bot h?

17. 17. Overall, how mindful are you?

18. 18. Overall, how mindful are you? (Check all that apply based on previous slides - e.g., Yes to both). Check All That Apply  I am nonreactive to Inner Experience (e.g., just notice)  I Notice and Observe (e.g., sensations)  I act with Awareness, not automatic pilot  I Describe/Label experience with words  I am Non-judging of experience

19. 19. I am nonreactive to Inner Experience I Notice and Observe (e.g., sensations) I act with Awareness, not automatic pilot I Describe/Label experience with words I am Non-judging of experience INTRA-PERSONAL I don't let others upset me; other's stress and negativity are their issue I pay attention to nonverbal and emotion cues of others & work with such cues to meet others I listen well (not thinking what I will say next); not a "knee jerk" talker, blurter (distracted) I label the feelings and opinions I have of others and can let them go I remain open-minded & non judging of others INTER-PERSONAL

20. 20. Interpersonal Mindfulness has 7 Champion Embodiments

21. 21. Anyone* who has a role† to play: fostering cultural conditions that lead to improved health and well-being amongst staff and the worksite as a whole in facilitating the implementation of a wellness or prevention program; engaging participants in that program; Champion *internal or external; formal or informal; selected or volunteered; Professionally trained or line-level † Sparkplug, ambassadors, advocates, coordinators

22. 22. Rev iew Each 1. Core of Observer 2. Traits 3. References 4. Self-Reflections

23. 23. Rev iew Each 1. Core of Observer 2. Traits 3. References 4. Self-Reflections As a champion, there is a four step-process for embodying interpersonal mindfulness 1) Practice in daily mind body routines 2) Intend to show-up mindfully in relations 3) Fit those intentions with your work role 4) Monitor micro-climates you interact with* *assumes you are a champion and are EMBEDDED to some degree in the social climate

24. 24.  Values Clarifier A Sense of Your Cause, Calling, or Legacy * Sense of right action (do the right thing) * Values guided behavioral skills * Appealing to principles and virtues * Work is inspired by higher values & purpose * Self-reflection, balance, humility in the service of a higher good

25. 25.  Values Clarifier I reflect on my life values. I am fulfilling my values through my work. I share values of wellbeing with my coworkers.A Sense of Your Cause, Calling, or Legacy

26. 26. Intentional Centerer Breathe Breathe Breathe * Commitment to regular practice * Returning to mindful state throughout daily activities * Able to main an "observer" mind-set in business transactions * Access to "inner" tools to remain centered * Mindful of breath, sensations, surroundings

27. 27. I practice mindfulness (centering) regularly. I can stay calm and centered at work. I am centered in my interactions with coworkers. Intentional Centerer Breathe Breathe Breathe

28. 28. Heedful Relater Loving Kindness * A sense we are contributing to life, happiness, others wellbeing * Access to states of compassion, sympathetic joy, for others * Applying this sense and these states in our daily interactions * Making skillful communication a priority (not hurtful) * Working at both the gut-level and the heart-level

29. 29. I experience feelings of kindness/compassion. I can empathize with difficulties of coworkers. My team communicates well with each other. Heedful Relater Loving Kindness

30. 30. Compassionate Nudger Mindfully Encourage * Aware of specific steps to take when approaching others * Knows difference between confrontational & supportive * Seeks first to listen and gradually engage at level of readiness * Practices "interpersonal" mindfulness qualities in interaction * Maintains a realistic and sincere tone of encouragement

31. 31. I know resources for mental health needs (EAP). I am comfortable expressing my concerns to those experiencing stress. I encourage others at work to get help if needed. Compassionate Nudger Mindfully Encourage

32. 32. Knower of Impact Integrity, Foresight, Social Contagion * Mindful of local social networks, friendships, peers of peers * Aware of own perceptual biases that can mislead * Thoughtful of how words and actions have ripple effects * Seeks to enhance positive ripple effect via role modeling * Understand your contribution, be open to feedback, adjust

33. 33. I measure my words before I speak. I am aware of the impact my acts have on others. Members of my team have a positive impact on each other. Knower of Impact Integrity, Foresight, Social Contagion

34. 34. Garnerer of Trust We are one * Works to avoid & dismantle silos, terrain, or turf in work culture * Focus is on "one team, one vision, one success" (see Lencioni) * Trust x Purpose = Joy (see Zak) * Seeks every opportunity for face-to-face converse to build trust * Make building trust explicit (you can count on me) (see Covey)

35. 35. Garnerer of Trust We are one I think about what is best for the team. I do my best to gain others trust. People on my team feel a sense of belonging.

36. 36. Which THREE mindful champion types do you most identify with? (Select up to three)  Values Clarifier  The Intentional Centerer  The Heedful Relater or Compassionate Nudger  The Knower of Impact  The Garnerer of Trust

37. 37. The Thriver All Stress is Grist for the Mill * Practices resilience in the face of stress (confidence, centering) * Sees the hidden opportunities in adversity and crisis * Patient with negative states & attitudes/balanced with joyfulness * Ability to relax ego and go with the flow * Embraces some aspect of spirituality in one's work

38. 38. The Thriver All Stress is Grist for the Mill I experience joy and fulfillment. I am inspired and vitalized by the work I do. My workplace is an exciting place to be.

39. 39. Reflecting on the three items for the Thriver, how much are you a Thriver in your work? * Rarely * Sometimes * Often * Very Often * Every day Up your thrive quotient!

40. 40. Review Definitions Intrapersonal Interpersonal Champion

41. 41. Action Steps * Explore mindfulness or enhance current practice * Cultivate interpersonal mindfulness * Focus on one of the 7 embodiments to cultivate, read, and practice in that area * Check out any of the books or resources and consider a book club at work

42. 42. What is your intention in applying ideas and insights reviewed in this webinar? (check all that apply)  I learned nothing new to apply  I will begin/enhance my personal mindfulness practice  I will be a mindful champion via one of the 7 types  I will up my thrive quotient  Apply? Apply? I am already enlightened!

43. 43. UPCOMING OPPORTUNITIES

44. 44. Competency-Based Wellness Champion Certification Training Webinar-Based, Six Sessions, Starts February 11, earn up to 22 CEU Joel Bennett, PhD President, Organizational Wellness & Learning Systems Michaela Conley, MA, MCHES, CSMS President, HpLive.org & HPCareer.Net Lindsay Simone, MA, CHES Manager of Wellness Programs ACEC Life/Health Trust Michael Arloski, PhD, PCC, CWP CEO & Founder at Real Balance Global Wellness Services Laura Putnam, MA CEO and founder of Motion Infusion, Inc., Sharon Soldano BBA Manager, WorkLife, Wellness & Recognition at MD Anderson Cancer Center FOUNDATIONS DESIGN & STAFF ENGAGEMENT Well-Being, Culture & Intrinsic Motives COACHING: DAILY, INFORMAL, ONGOING Coaching the culture with champions COMMUNICATION & CULTURE Touch points, Peer support, Climate 2 3 4 5Your Hosts 1 6 INTRODUCTION: YOUR PERSONAL LEADERSHIP ACCOMPLISHMENTS & CELEBRATION Start here Finish here Tabatha Elsberry, CHES, CWS Health Fitness Program Manager Northwestern Energy

45. 45. J oel Bennett, P hD * President, OWLS * learn@organizationalwellness.com * 817.921.4260 * @orgwellness L indsay Sim one, MA CHES * Manager of Wellness Programs * ACEC Life/Health Trust * lindsay@aceclifehealthtrust.com * 708-257-8332

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Owner at Organizational Wellness & Learning Systems, Inc. Published on Most approaches to mindfulness are geared toward the individual level and not the social or community level to which traditional mindfulness methods were targeted. It is not only about our own personal growth but the enlightenment of the community as a whole.

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This entry is our analysis of a document considered particularly relevant to improving outcomes from drug or alcohol interventions in the UK. The original document was not published by Findings; click Title to order a copy. The summary conveys the findings and views expressed in the document. Below is a commentary from Drug and Alcohol Findings.

Links to other documents. Hover over for notes. Click to highlight passage referred to. Unfold extra text
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Better care for people with co-occurring mental health and alcohol/drug use conditions: a guide for commissioners and service providers.

Unable to obtain a copy by clicking title? Try this Public Health England.
Public Health England, 2017
alternative source.

People with co-occurring mental health and substance use problems are often unable to access the care they need. This 2017 guide from Public Health England describes what better care would look like, underpinned by the principles that there is 'no wrong door' for accessing support, and it is 'everyone's job' the other side of the door to help.
Summary With the support of NHS England, which leads the National Health Service in England, Public Health England developed a guide to improve care for people with co-occurring mental health and drug/alcohol problems. It was intended to be used byThe guide was intended for commissioners, providers and people who use mental health and alcohol/drug services, including: clinical commissioning groups; local authorities - particularly directors of public health, children's services and adult social services and alcohol and drug commissioners; health and wellbeing boards; NHS England specialised commissioning teams; NHS England regional teams; NHS health and justice commissioners; users of mental health and substance use services, their families and carers (including young carers); mental health, substance use and other service providers in community and secure settings; prison governors and other agencies working in the criminal justice system; and police and crime commissioners. commissioners and providers of mental health and alcohol and drug treatment services, as well as people who use these services, and aimed to: support local areas to commission timely and effective responses for people with co-occurring conditions; encourage commissioners and service providers to work together to improve access to services that reduce harm, improve health, and enhance recovery; and enable services to respond effectively and flexibly to people's needs and prevent exclusion.

There are two principles informing the goal of "better care":

1. Everyone's job. Co-occurring conditions are the norm rather than the exception, and commissioners and providers of mental health and alcohol and drug use services have a joint responsibility to work collaboratively to meet the needs of people with co-occurring conditions. The UK's National Institute for Health and Care Excellence (NICE) does not recommend the use of specialist dual diagnosis teams. While dual diagnosis practitioners can be an important part of a multi-disciplinary team, particularly in clinical lead roles, the prevalence of co-occurring conditions in mental health and alcohol/drug settings is sufficiently high to make it vital for all services to be competent to respond to these needs.

2. No wrong door. Providers should have an open door policy for people with co-occurring conditions, supported by commissioners that enable services to respond collaboratively, effectively and flexibly to presenting needs, offering compassionate and non-judgemental care centred around the person's needs, accessible from every access point.

Delivering effective care

Available evidence and feedback from experts by experience indicate that the following principles should form the basis of the delivery of care for people with co-occurring conditions:

Therapeutic alliance. When a stronger supportive relationship is established, people are more likely to complete treatment, actively explore problems, experience less distress and more pleasant mood, abstain from alcohol and drugs during treatment, and achieve better long-term substance use outcomes. This will include:
* showing empathy and using a non-judgemental approach to listening;
* identifying and being responsive to the person's needs and goals;
* working flexibly and persistently across sector boundaries to respond to a range of needs, not just one presenting need;
* ensuring staff have the resilience and tolerance to help people through relapse or crisis so that patients are not discharged before they are fully equipped to cope, or excluded from services.

'How do you see your alcohol/drug/tobacco use helping or hindering your mental health?'

Collaborative delivery of care. Care may be provided by the same person or by relevant practitioners/services working in close collaboration. This requires accountability and clarity of role, information-sharing agreements, and shared care planning, with the individual at the centre of the process. There should be a named person who can coordinate care packages and act as a central point of contact for the client, their carers, and other service providers. When assessing co-occurring conditions, practitioners should think about the interrelationship and mutual influence of both conditions, rather than assessing each part separately. The key question should be 'How do you see your alcohol/drug/tobacco use helping or hindering your mental health and vice versa?'

Care that clearly reflects the views, motivations and needs of the person. This should include:
* engagement in a meaningful therapeutic relationship;
* creation of a safe and positive environment where people can feel able to engage in an honest dialogue about their situation and goals for treatment;
* providing help with practical aspects of care of importance to the person as a way of facilitating engagement;
* being prepared to be flexible about the focus of care rather than imposing rigid treatment goals;
* recognising the person's level of motivation to address mental health and alcohol/drug use problems and adapting the approach accordingly;
* recognising that change can be slow especially when there are multiple needs at play, and taking a long-term view of progress;
* use of behavioural change strategies to facilitate dialogue about goals and aspirations.

Care that supports and involves carers and family members. Carers (including young carers) have needs in their own right. As part of delivering timely, compassionate and effective care to people with co-occurring problems, practitioners should identify carers and family members who may have unmet needs, making appropriate referrals for carers' assessments and/or to family support services. This may include: considering the impact of caring on their mental and physical health; that carers may not be aware of or included in any plans or decisions made by the person; the extent to which the carer can/will meet the person's support needs; and the need to create support networks.

Therapeutic optimism. Practitioners should demonstrate a genuine belief in the possibility of recovery, and all interaction and engagement with people using services should be undertaken in a spirit of optimism, with a clear commitment to helping them achieve recovery. In practical terms, services should adopt a 'whole person' approach, supporting people to enjoy the rights and responsibilities of active participation in their community. This may involve ensuring that their housing, education, training and employment needs are understood and met; it may require family or parenting support. Local mutual aid organisations and recovery communities can often play a key role in supporting a person's recovery journey.

Episodes of intoxication are safely managed. People can be at risk of harm to self and/or others when experiencing a mental health crisis, and the risks are heightened if they are intoxicated. Services need to ensure that they are equipped to respond, which means having staff able to identify the signs of intoxication, and responding appropriately to the associated risks such as not being able to maintain one's own safety, physical risks (toxicity, overdose) and disinhibition (possibly enhancing feelings of distress or anger). Once the crisis has been managed and urgent mental and physical health needs have been met it is important to use the opportunity to engage the person in subsequent treatment.

Advice and support about stopping smoking is a routine part of care. All practitioners should be delivering very brief advice to people with co-occurring conditions who smoke. Opportunities for harm reduction for people unwilling or unable to stop smoking should be available, including access to nicotine replacement therapies and behavioural support. Opportunities to revisit the delivery of very brief advice should be taken as part of a care review, rather than continued acceptance of the status quo of being unwilling or unable to stop smoking.

Workforce development. People working in mental health and substance use services will require different levels of skills and knowledge depending on their roles and seniority. There will also need to be sufficient people with expertise in co-occurring conditions to be able to provide supervision and clinical leadership.

No wrong door

'No wrong door' doesn't mean that people have to receive care at the first service they attend, but all services should:
* be proactive, flexible, compassionate and anti-discriminatory in their response;
* offer rapid assessment and referral if appropriate;
* offer a rapid response to urgent physical, mental health, and social care needs, while also making plans for longer term care and support;
* have a named lead who can coordinate care and wrap-around support from multiple providers effectively, underpinned by clear communication reflected in case notes;
* explore with clients why they may have stopped using services in the past and agree a plan to help them stay engaged.

A key part of the 'no wrong door' principle is that providers should make every contact count - taking every opportunity to reduce health harms by offering advice and support to stop smoking, eat healthily, maintain a healthy weight, drink alcohol within the lower risk guidelines, undertake the recommended amount of physical activity, and improve their mental health and wellbeing.

Actions for commissioners and providers

1. Develop a shared local understanding of co-occurring conditions, including prevalence and likely demand as well as a shared vision, aspiration and desired outcomes.

2. Agree a lead or joint lead commissioner with authority to commission across NHS mental health services and local authority public health services.

3. Agree an appropriate senior strategic board to oversee commissioning activity and monitor outcomes, supported by shared or aligned quality governance structures.

4. Undertake joint commissioning across mental health and alcohol/drugs/tobacco with a named lead. The lead commissioner(s) should work closely with National Offender Management Service and NHS England commissioners to ensure continuity of care between community and prison settings for all those with co-occurring conditions moving between community and criminal justice care settings.

5. Ensure that co-occurring substance use and mental health problems are addressed as an integral part of all relevant care pathways locally, which should be adequately resourced, co-produced with experts by experience and carers, signed up to by all relevant providers (not just mental health and alcohol/drug treatment providers), able to respond to the full range of mental health and alcohol/drug needs, and able to maximise opportunities for engagement and eventual recovery.

6. Commission an effective and compassionate 24/7 urgent and emergency mental health care response for all ages, which includes the provision of adequate health-based places of safety for people who police believe to have a mental health problem or to be intoxicated, and at risk of causing harm to themselves or another. The service should offer screening and further interventions as necessary to keep people safe and connect them with other services for longer term care.

7. Monitor providers closely on the effectiveness of their response to intoxicated people in mental health crisis, people who are frequently excluded from services because their condition is not judged severe enough, and people with particular risk and vulnerability such as children and young people, people living with children, people homeless or at risk of becoming homeless, and people experiencing domestic abuse. Consider incentivising contracts to support engagement and positive outcomes for people with additional risk/vulnerability factors.

8. Make sure that commissioning involves experts by experience and carers in decisions about services and care. Capacity building and investment in client/carer involvement may be needed to ensure that involvement is effective and meaningful.

9. Make sure commissioned providers have staff that are supported and competent to effectively meet all presenting needs with respect, compassion and belief in the possibility of recovery, and following the evidence base/ NICE guidelines. There should be an appropriate level of clinical expertise to oversee and ensure quality of service provision for this group in both sets of services.

10. Ensure that the increased risk of suicide for people with co-occurring conditions is well understood locally, that local suicide prevention plans include a strong focus on alcohol and drug use and that the local suicide multi-agency partnership group is given sight of commissioning decisions and service developments.

11. Collaborate across services and with input from experts by experience and carers to develop an integrated 'offer' of care which addresses physical health, social care, housing and other needs as well as mental health and alcohol/drug/tobacco use. This offer should recognise that increased levels of need, risk and vulnerability will require increased support, and should take account of specific needs. For people with severe mental illness this would be led by and managed within the care programme approach process by a mental health team. [ Unfold supplementary text to read definitions of collaborative care, integrated care, and the care programme approach.]

12. Review service access criteria with experts by experience. Make sure they are not used to exclude people based on levels of alcohol and/or drug dependency, or on diagnoses (or lack of diagnoses) of mental illness, but are used to actively support people to get the help they need.

13. Make sure local arrangements enable reporting and investigation of serious untoward incidents and management of risks. Quality governance and local safeguarding should be shared across mental health and alcohol/drugs services.

14. Consider what changes might be needed to enable practitioners to work assertively and flexibly to engage (and re-engage) people - particularly supporting people with chaotic lifestyles and complex needs to manage their appointments. This may require extended opening hours, offering a drop-in service, co-locating with or operating satellite services alongside other key services such as homelessness or domestic violence services, and using text reminders and/or daily 'check ins'.

15. Ensure comprehensive assessment and interventions compliant with NICE guidelines are available and delivered by competent, adequately trained and supervised practitioners.

16. Ensure mental health practitioners have the skills and knowledge to respond to people presenting with drug and alcohol problems, and drug and alcohol practitioners are able to respond to people presenting with mental health problems.

17. Ensure that drug and alcohol services and stop smoking services are assertively promoted across all mental health services for those with co-occurring drug and alcohol problems.

commentary The featured guidance published in 2017 sought to resolve perennial questions about whose responsibility it is to support people with co-existing mental health and substance use problems:

Should substance use services take the lead in coordinating their clients' care, or should this be taken on by mental health services?

Is either willing and able to take on both issues, or would a better option be to create new integrated services?

The principles underpinning the guidance were clear and unambiguous: it is everyone's job to support people with co-occurring mental health and substance use problems; and, there is no wrong door for accessing effective, flexible, compassionate and non-judgemental services.

Complementing this is a set of NICE quality statements published in August 2019 for improving the quality of care that people with co-existing severe mental illness and substance use problems receive:

Statement one: "People aged 14 and over with suspected or confirmed severe mental illness are asked about their use of alcohol and drugs."

Statement two: "People aged 14 and over are not excluded from mental health services because of coexisting substance misuse or from substance misuse services because of coexisting severe mental illness."

Statement three: "People aged 14 and over with coexisting severe mental illness and substance misuse have a care coordinator working in mental health services when they are identified as needing treatment from secondary care mental health services."

Statement four: "People aged 14 and over with coexisting severe mental illness and substance misuse are followed up if they miss any appointment."

Australian guidelines updated in 2016 recommend universal mental health screening for people accessing substance use services, and say that mental health issues do not pose an "insurmountable barrier" to effective substance use treatment. In the past the tendency has been to establish the order of onset of the mental health and substance use issues, in an effort to identify which is the 'primary disorder'. Although establishing the order of onset can be useful for understanding the relationship between conditions, the guidelines emphasise that once the comorbid conditions are present it is most likely that the relationship between them is one of "mutual influence" rather than there being a "clear causal pathway".

An Effectiveness Bank hot topic discusses the barriers that have traditionally stifled access to appropriate support for people with co-existing mental health and substance use problems, and identifies opportunities and occasions to improve the lives of those affected.

Last revised 12 September 2019. First uploaded 29 August 2019

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This entry is our analysis of a document considered particularly relevant to improving outcomes from drug or alcohol interventions in the UK. The original document was not published by Findings; click Title to order a copy. The summary conveys the findings and views expressed in the document.

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Welcome to the Sussex Recovery College's Brighton and Hove campus, offering educational courses as a route to recovery from mental health challenges. The Brighton and Hove campus of the Sussex Recovery College is jointly run by Southdown and Sussex Partnership NHS Foundation Trust.

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Welcome to the English Hearing Voices Network website. We are one of many similar networks around the world. If you're looking for support in your own country check out Intervoice's National Network list. The USA network can be found here: HVN USA

If you hear voices, see visions or have similar sensory experiences - you're not alone. The statistics vary, but somewhere between 3 and 10% of the population have experiences like these (increasing to about 75% if you include one off experiences like hearing someone call your name out loud).

Despite being relatively common, many people who hear voices, see visions or have similar experiences feel alone. Fear of prejudice, discrimination, and being dismissed as 'crazy' can keep people silent. At a time when we are told that it is 'time to talk', it is important that anyone courageous enough to speak out is met with respect and empathy.

People of all ages and backgrounds can hear voices at some point in their life, for many different reasons. Whilst some are distressed by their experiences, people can - and do - find ways of living with them.
We focus on helping to create respectful and empowering spaces, whilst challenging the inequalities & oppressive practices that hold people back.
Our aims are to:

Raise awareness of the diversity of voices, visions and similar experiences

Challenge negative stereotypes, stigma and discrimination

Help create more spaces for people of all ages and backgrounds to talk freely about voice-hearing, visions and similar sensory experiences

Raise awareness of a range of different ways to manage distressing, confusing or difficult voices

Encourage a more positive response to voice-hearing and related experiences in healthcare settings and wider society

Some of the things we do:

Sharing information and free resources through our website, social media, e-bulletin, newsletter and email information service

Engaging with the media to present realistic and hopeful perspectives on hearing voices and related experiences

Offering workshops, training and events - subject to resources

Supporting members who want to set up a Hearing Voices Group

Some of the things we don't do

Run groups directly (we provide guidance and networking opportunities for those who do run groups)

Provide crisis or long-term support (we connect people with available resources where possible). See Getting Help & Support for more info

Contact Us

If you would like to find out more about our work, become a member or get your self-help group listed on our website, please contact us at:

National Hearing Voices Network (HVN)
86-90 Paul Street
London
EC2A 4NE
Email: info@hearing-voices.org

Whilst we do our best to reply promptly, our email is managed by a small team of trained volunteers and we get more enquiries than we can often manage. If you need help in a crisis, please call 111. For less urgent help, see our getting help and support page.

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Welcome to the English Hearing Voices Network website. We are one of many similar networks around the world. If you're looking for support in your own country check out Intervoice's National Network list. The USA network can be found here: HVN USA If you hear voices, see visions or have similar sensory experiences - you're not alone.

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We improve the lives of people severely affected by mental illness through our network of local groups and services, expert information and successful campaigning. Our goal is to make sure everyone severely affected by mental illness has a good quality of life.

Get advice and information

About mental illness

1 in 4 people will experience a mental illness in their lifetime. People can, and often do, recover with the right treatment and support. Our advice and information pages can help you learn more about conditions, symptoms and diagnoses, so you or a loved one can get the help you need.

Living with mental illness

Living with a mental illness should not be a barrier to a good quality of life. Our advice and information pages contain all you need to know about getting the proper treatment and support for you or a loved one and what you can do if you feel the help you are getting is not right.

Rights and restrictions

If you experience mental illness or care for someone who does, it is essential to know your rights. Our information pages has advice on mental health laws, rights and restrictions, social care, welfare, and resources about the police, courts & prison service.

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No matter how bad things are, we can help.

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1 in 4 people will be affected by a mental health problem in their lifetime - we are here to support them when they do.

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National charity helping people with Anxiety - Anxiety UK

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Service update: We are currently experiencing extended waiting times for assessment in some parts of our adult service. Our team will review your referral as promptly as possible and where we have longer waits, someone will soon be in touch with you to discuss your needs.

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Overview | Coexisting severe mental illness (psychosis) and substance misuse: assessment and management in healthcare settings | Guidance | NICE

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Evidence-based recommendations on assessing and managing people aged 14 years and over with coexisting severe mental illness (psychosis) and substance misuse

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IRETA | Institute for Research, Education & Training in Addictions

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Description

Patients with mental health disorders are at increased risk for substance use disorders, and vice versa. Many approaches to treatment address one or the other, despite their interconnection. In this webinar, learn to better address co-occurring disorders' biological, psychological, and social components.

Presenter

Antoine Douaihy, MD is currently on the faculty of the University of Pittsburgh's School of Medicine in the Department of Psychiatry. He serves as co-director of UPMC Tobacco Treatment Service and the Senior Academic Director of Pitt's Addiction Medicine Services. His clinical and research interests lie in addiction and its psychosocial treatments, and HIV and AIDS. Dr. Douaihy is an investigator in numerous NIDA, NIAAA, and NIMH clinical research trials and collaborates as a co-investigator with Pennsylvania Mid-Atlantic AIDS Education and Training Center (AETC).

Additional Resources

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Treating a Patient with a Co-Occurring Disorder - IRETA | Institute for Research, Education & Training in Addictions

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Patients with mental health disorders are at increased risk for substance use disorders, and vice versa. Many approaches to treatment address one or the other, despite their interconnection. In this webinar, learn to better address co-occurring disorders' biological, psychological, and social components.

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Featured

Sophie Cox

Senior Comms and Marketing Officer, Mental Health at Work

As you probably know, the Mental Health at Work Commitment is a simple framework to support employers in making a positive change around mental health. It builds on what we already know actually works: based on the  Thriving at Work  standards, pulling from the pledges and standards that are already out there, and using up-to-date research from UK employers and mental health experts.

Launched in 2019, we've seen almost 3,000 employers sign up - which means that over 5 million people at work are actively being supported with their mental health.

Read article

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Paying attention to mental health in the workplace has never been more important. Mental Health at Work is here to help you find what you need.

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5 Strategies for Working With Clients With Co-Occurring Disorders

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Maintaining a therapeutic alliance with clients who have co-occurring disorders (COD) is important-and difficult. The first section of this chapter reviews guidelines for addressing these challenges. It stresses the importance of the counselor's ability to manage feelings and biases that could arise when working with clients with COD (sometimes called countertransference).

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Are the drugs enough? Counselling and therapy in substitute prescribing programmes

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Drug and Alcohol Findings Effectiveness Bank analysis titled: Are the drugs enough? Counselling and therapy in substitute prescribing programmes

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The complexity and challenge of 'dual diagnosis'

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Drug and Alcohol Findings Effectiveness Bank analysis titled: The complexity and challenge of 'dual diagnosis'

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In 2010, The National Dual Diagnosis Programme (National Mental Health Development Unit, Department of Health) led by Ann Gorry and Tom Dodd, commissioned a group of consultant nurses (PROGRESS) and Coventry University to develop an innovative online awareness raising resource relating to people who have both mental health and drug/alcohol use issues (also known as " dual diagnosis "). This programme is free to access and aimed at clinical staff, people who use services and their carers, and other interested parties.

Aim of project
The overall aim of the project has been to develop and evaluate an e-learning training resource for practitioners, service users, carers and the public for dual diagnosis awareness. This means an awareness of the basic issues, and is not intended to create dual diagnosis "specialists" or replace skills-based training, although it would serve as a good introduction prior to commencing a more formal training course. It is based on level 1 capabilities set out in the Capabilities Framework for dual diagnosis.

This resource is also highlighted as a useful resource by NICE in relation to implementation of the NICE Clinical Guidance for Psychosis and Co-Existing Substance Misuse CLICK HERE to see

Who is involved?
Dr Liz Hughes (Huddersfield University) has developed the e-learning content while working at Coventry University with colleagues from PROGRESS (Consortium of Consultant Nurses in dual diagnosis) and will continue to liaise with members of PROGRESS regarding the formatting and development of the e-learning. Dr Lynn Clouder and colleagues in the Centre for Interprofessional E-Learning at Coventry University have turned the content into an online resource. Service user and carer involvement has been essential to this project. They have been consulted regarding the content, and a group have agreed to be filmed, and these clips form part of the learning resource.

E-learning content
The e-learning consists of 4 sections/modules:

1. Introduction to dual diagnosis including definitions, impact and attitudes
2. Mental health awareness and how it impacts on drug/alcohol use
3. Substance use awareness and how it impacts on mental health
4. Skills and interventions focusing on the process of change and what helps.

The e-learning resource is suitable for practitioners both qualified and unqualified, as well as service users and carers, and members of the public. The language of the materials is simple and jargon free. We also provide information about where to find out more on a range of subjects. There is a workbook template to print off and we advise people to use this to make notes while they work through the resource. We also suggest that you print off and keep some of the key documents that are of interest to you. This is not intended to be an exhaustive resource on dual diagnosis, and we also advise you to follow some of the weblinks and explore further resources that may be of interest to you. We will add relevant documents to supplement this resource on the PROGRESS website.

For further information, please contact Dr Liz Hughes: :E.C.Hughes@hud.ac.uk

Your Say:

If you would like to comment on this article. Please use the form below.

Other People Said:

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2012-06-12 17:03:11 Home Page Progress - National Consortium of Consultant Nurses in Dual Diagnosis & Substance Use: E-Learning Key Documents Info for health workers

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In 2010, The National Dual Diagnosis Programme (National Mental Health Development Unit, Department of Health) led by Ann Gorry and Tom Dodd, commissioned a group of consultant nurses (PROGRESS) and Coventry University to develop an innovative online awareness raising resource relating to people who have both mental health and drug/alcohol use issues (also known as " dual diagnosis ").

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A quick guide for registered managers of mental health services for young people

Quotations from young people who have experienced feelings of anger and aggression:

Everything goes red and I can't think. I need to have time to calm down without people talking to me.

I lash out and become a person I don't recognise.

It bubbles up and won't go away unless it's released.

Violent and aggressive behaviours have a huge impact, affecting the health and safety of the young person as well as carers, staff and others using the service.

As far as possible, focus on preventing, anticipating and reducing the risk of violent and aggressive behaviour occurring.

Involve the young person in decisions about their care wherever possible, and collaborate with whoever has parental responsibility. When supporting the young person to manage and minimise any violent or aggressive behaviours, consider their physical, intellectual, emotional and psychological maturity, including any variation in their development.

"Difficult behaviour is usually the symptom of a problem and not the problem itself." - East Riding of Yorkshire Council

Preventing violent and aggressive behaviours

Understanding the likely causes of violent and aggressive behaviours helps to prevent them happening. Together with the young person, when they are in a calm and safe space:

Triggers can be:

De-escalation

De-escalation means using techniques, both verbal and non-verbal, to reduce agitation and avoid violent and aggressive behaviour. It may include the use of 'when needed' medication in combination with other techniques.

De-escalation requires advance planning and it is more likely to be successful when staff:

Have a close working relationship with the young person and are able to sensitively monitor changes in their mood or composure.

Show respect and empathy at all times.

Use verbal and non-verbal skills to help the young person avoid or manage situations that are known to be difficult.

Encourage the young person to recognise their own triggers and early warning signs.

Consider whether the young person might benefit from help to develop greater self-control and techniques for self-soothing.

If the young person becomes agitated:

start any actions agreed in their care plan and advance plan straightaway

use one member of staff as the main communicator

control your own verbal and non-verbal expressions of anxiety or frustration

use calming techniques and distraction

offer them the opportunity to move away to a quiet room or area

keep in mind the aim to build emotional bridges and maintain a relationship.

Only use restrictive interventions if all attempts to defuse the situation have failed and there is a risk of harm to the young person or other people. Continue to attempt de-escalation during the restrictive intervention.

Training

To help reduce the risk of violent and aggressive behaviours, and avoid the use of restrictive interventions wherever possible, staff should have training specific to working with young people. Training should include a focus on de-escalation and cover:

the early signs of agitation, irritation, anger and aggression

the likely causes of aggressive or violent behaviour

de-escalation techniques and ways to encourage relaxation

the importance of personal space

how to respond to agitation in a reasonable and professional way that avoids provocation.

Anyone who might use restrictive interventions should be trained in how to do so safely with young people.

Staff should be aware of relevant legislation, organisational policies and procedures, and how to respond effectively and appropriately.

Share information within the organisation about the triggers and early warning signs identified by the young people using the service to help inform learning and practice.
This content has been co-produced by NICE and SCIE and is based on NICE's guideline and quality standard on violence and aggression.

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Reducing the risk of violent and aggressive behaviours

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A quick guide for registered managers of mental health services for young people Quotations from young people who have experienced feelings of anger and aggression: Everything goes red and I can't think. I need to have time to calm down without people talking to me. I lash out and become a person I don't recognise.

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Abstract

Motivational Interviewing (MI) is a brief treatment approach for helping patients develop intrinsic motivation to change addictive behaviors. While initially developed to target primary substance using populations, professionals are increasingly recognizing the promise this approach has for addressing the motivational dilemmas faced by patients who have co-occurring psychiatric and psychoactive substance use disorders. Unfortunately, this recognition has not lead to a clear explication of how MI might be adopted for specific diagnostic populations of dually diagnosed patients. In this article we describe how we have applied the principles and practices of MI to patients who have psychotic disorders and co-occurring drug or alcohol use problems. Specifically, we provide two supplemental guidelines to augment basic MI principles (adopting an integrated dual diagnosis approach, accommodating cognitive impairments and disordered thinking). We present recommended modifications to primary MI skill sets (simplifying open-ended questions, refining reflective listening skills, heightening emphasis on affirmations, integrating psychiatric issues into personalized feedback and decisional balance matrices). Finally, we highlight other clinical considerations (handling psychotic exacerbation and crisis events, recommended professional qualifications) when using MI with psychotic disordered dually diagnosed patients.

Keywords: Motivational interviewing, Dually diagnosed, Substance abuse, Psychotic disorder, Treatment engagement

1. Introduction

Motivational Interviewing (MI) is a brief psychotherapeutic intervention for helping patients change addictive behaviors. Over the past two decades William Miller and his colleagues have detailed the principles, practices, and research supporting this treatment approach. Motivational Interviewing: Preparing People for Change Addictive Behavior by Miller and Rollnick (2002) provides the most comprehensive singular and updated presentation of MI techniques and strategies. In addition, there are several comprehensive research reviews of the efficacy of MI ( Dunn, Deroo, & Rivara, 2001; Miller, 1983; 1985; 1996; 1998).

Conceptually, MI is a blend of principles drawn from motivational psychology, Rogerian therapy, and the stages of change model of recovery. MI aims to facilitate and enhance the patient's intrinsic motivation to change substance use or other problem behaviors by engaging the patient in an empathetically supportive but strategically directed conversation about the patient's use of substances and related life events. Typically, the MI therapist uses a variety of techniques to help increase intrinsic motivation for change. These techniques can be divided into two categories: microskills and strategies ( Rollnick, Heather, & Bell, 1992).

Microskills function to initiate and facilitate an open discussion with the patient about problem areas. These skills include the use of open-ended questioning, reflective listening, using affirmations, and summarizing the patient's comments in a balanced manner. The therapist uses these skills to accurately understand the patient's perceptions about a problem, heighten the patient's problem recognition, and resolve ambivalence about changing it. The therapist's consistent and competent use of microskills is essential for the creation of MI's highly empathic and collaborative style.

Motivational Interviewing strategies involve increasingly directive techniques for building intrinsic motivation for change, particularly when the microskills alone have not achieved this aim. These techniques involve asking direct open-ended questions to increase problem awareness, concern, or intention and optimism to change. Therapists may construct decisional balance matrices to elicit the patient's perceptions of the costs and benefits of remaining the same or trying to change. Additionally, therapists may attempt to create discrepancies between the patient's current behavior and his or her goals, values, or self-perceptions. Therapists also commonly use supportive feedback of selected objective assessment results within the body of an overall MI style to promote problem recognition and desire to change. Through the skillful use of these skill sets, the therapist attempts to move the patient from a position of establishing the patient's motivation for change to strengthening the patient's commitment to attempt the change. If the patient's resistance to change arises during any phase of the interview, the therapist avoids argumentation and encourages the patient to conversationally explore his or her resistance using one or more of the microskills or MI strategies.

Support for the efficacy of MI has come from many sources. It has been effective in reducing alcohol consumption in nontreatment community samples of drinkers ( Miller, Benefield, & Tonigan, 1993; Miller, Sovereign, & Krege, 1988), in patients participating in an inpatient alcohol treatment facility ( Brown & Miller, 1993), and among outpatients seeking traditional substance abuse treatment services ( Bien, Miller, & Boroughs, 1993) or receiving MI as the sole intervention ( Project MATCH Research Group, 1997). Across these studies positive treatment outcomes persisted during follow-up periods ranging from 3 to 15 months.

As a consequence of Miller's compelling rationale for MI, its potential for wider application, and research supporting its clinical utility and efficacy for alcoholism treatment, investigators have begun to systematically apply MI to additional problem areas. Some of these areas have included heroin dependence ( Saunders et al., 1995), cocaine dependence ( Stotts, Schmitz, Rhoades, & Grabowski, 2001), nicotine dependence ( Butler et al., 1999) and adolescent smoking ( Lawendowski, 1998), HIV risk behavior ( Carey et al., 1997), obesity ( Smith, Heckemeyer, Kratt, & Mason, 1997), diabetes care ( Stott, Rollnick, Pill, & Rees, 1995), and bulimia nervosa ( Treasure et al., 1999). Recently, the use of motivational techniques with patients who have cooccurring substance abuse and psychiatric problems or dual disorders has begun to be explored ( Carey, 1996; Daley & Zuckoff, 1998; Van Horn and Bux, 2001; Ziedonis & Fischer, 1996; Ziedonis & Trudeau, 1997).

1.1. Rationale for MI with dually diagnosed patients

As a therapeutic approach MI seems very well suited for dually diagnosed patients. The severe and disabling symptoms, frequent failed treatment episodes, and poor functional adjustments often contribute to the patient's demoralization and lack of intrinsic motivation for alcohol and drug abstinence or sustained efforts to productively manage their dual disorders ( Brady et al., 1996; Carey, 1996; Ziedonis & Fischer, 1996). References to these patients' low motivation for change occur throughout the literature ( Drake & Wallach, 1989; Minkoff, 1989) and have led many who specialize in dual diagnosis treatment to emphasize the primary importance of engagement and motivational enhancement strategies ( Carey, 1996; Kofoed & Keyes, 1988; Ziedonis & Fischer; 1996; Ziedonis & Trudeau, 1997). Given these observations and recommendations, MI's emphasis on building motivation for change and strategies for handling resistance to the change process have made MI a very appealing approach in the dual diagnosis field.

Very few studies, however, have been conducted to examine MI's efficacy with dually diagnosed patients. In one pilot study ( Swanson, Pantalon, & Cohen, 1999), the effect of MI on outpatient treatment adherence among psychiatric and dually diagnosed inpatients was investigated. The results suggested that the proportion of dually diagnosed patients who attended their first outpatient appointment was significantly higher for patients who had received the MI (42%) than for those in standard treatment alone (16%). Substance use treatment outcomes were not evaluated in this study.

In a pilot study conducted by our group ( Martino, Carroll, O'Malley, & Rounsaville, 2000), we randomly assigned patients with co-occurring psychotic or mood disorders and alcohol or drug abuse or dependence to either a one-session 45-60 minutes MI or equivalently long standard preadmission session. The session occurred immediately before the patients started a dual diagnosis partial hospital program. We found that MI, in comparison to the standard preadmission interview, yielded better patient program attendance patterns (less program tardiness and early departures and greater number of days attended). While we did not find significant differences in substance use between the conditions, the MI group had lower substance use indices than the standard interviewing condition using a small pilot study sample size ( n = 23).

Despite these encouraging initial pilot study results and the consensus about the probable utility of MI for patients who have dual disorders, few professionals have written about how to modify MI for this population. Published reports of motivation-based interventions for patients with dual disorders typically imply a direct application of MI. Namely, these reports state that many patients who have dual disorders have little motivation to change their substance abuse problems or have recurrent wavering commitments to alcohol or drug abstinence. Additionally, the reports uphold the nonconfrontational MI approach as preferable to the traditionally confrontational substance abuse treatment strategies when working with dually diagnosed patients ( Beeder & Millman, 1992; Bellack & DiClemente, 1999; Carey, 1996). Beyond summarizing the now familiar MI strategies, the reports do not describe modifications needed to effectively use MI as an interviewing strategy within this population or detail how to use MI with specific psychiatric diagnostic groups of substance abusing patients within the larger rubric of dually diagnosed patients. Moreover, the numerous clinical challenges posed by dually diagnosed patients, such as active psychotic symptoms, treatment and medication noncompliance, cognitive impairments and disordered thinking, and social stigma suggest that a direct application of MI may be ill advised and ineffective. To address this shortcoming, this article describes our experience in using MI with patients who have psychotic disorders (Schizophrenia, Schizoaffective Disorder, Schizophreniform Disorder, and Psychotic Disorder NOS) and co-occurring drug or alcohol use problems (henceforth referred to as dually diagnosed patients). We call our approach Dual Diagnosis Motivational Interviewing or DDMI.

2. Methods

2.1. Subjects

Two groups of dually diagnosed patients participated in the development of DDMI. The first group consisted of 12 patients with psychotic disorders who had been subjects in our initial pilot study ( Martino et al., 2000). Clinical experience with these patients provided the basis for the first draft of a two-session manualized DDMI. The second group included 7 patients who received this initial version of DDMI. In both groups the patients had been referred to a dual diagnosis ambulatory program (see Martino, McCance-Katz, Workman, & Boozang, 1995, for program description) by clinicians from inpatient and outpatient facilities. Prior to entering the program, we approached patients who met eligibility criteria to request their participation in the respective phases of DDMI's development. Eligible subjects had to have co-occurring DSM-IV psychotic and substance use disorders based upon the clinical consensus of the referring treatment team. In addition, they had to report abuse of at least one substance in the past two months, take at least one psychotropic medication for their psychiatric condition, not have active symptoms necessitating inpatient psychiatric or detoxification treatment, and have basic reading and comprehension skills. All subjects provided written informed consent.

describes the demographic and diagnostic characteristics of both participant groups. Across the groups, the subjects typically were in the 25-45 age range, single, unemployed, experiencing severe psychiatric symptoms, and abusing alcohol, cocaine, or cannabis. Most subjects abused more than one substance. The number of male and female participants was similar. The first group, however, had a higher percentage of ethnic minorities, a somewhat lower level of educational attainment, and a more even distribution of types of psychotic disorders than the second group.

Table 1

2.2. Procedures for developing DDMI

We developed DDMI using a Stage I Model of Behavior Therapy research ( Rounsaville, Carroll, & Onken, 2001). Initially, we used standard MI techniques within a onesession, 45-60 minute ambulatory program preadmission interview for the first group of subjects who had participated in our pilot study. Within the overall MI therapeutic style, common techniques used in the session included querying patients to elicit self-motivational statements, providing feedback from preadmission questionnaires, and completing a decisional balance activity.

Based on this experience, we isolated MI principles and practices that we believed required modification to better accommodate the clinical challenges posed by dually diagnosed patients. We organized these modifications into a two-session manualized working version of DDMI following the procedures outlined by Carroll and Nuro (1997). The second group of subjects received this initial version of DDMI. We videotaped all sessions. Using informal subject feedback, review of videotaped sessions, and our clinical judgment, we further refined the DDMI approach and made final modifications to recommended guidelines and techniques. The Human Investigation Committee of the institution where we conducted this project approved all the procedures.

3. Dual Diagnosis Motivational Interviewing

While the DDMI approach adheres to the basic tenets of MI and relies upon many of its fundamental strategies, we have found that specific emphases and technical modifications of MI make it more clinically amenable for substance abusing patients who have psychotic disorders. We have organized our discussion of applying MI to dually diagnosed patients into four areas: (a) supplemental guidelines to MI basic principles; (b) MI microskill modifications; (c) modifications to MI strategies and (d) other clinical considerations. provides an overview of how we have modified the standard practices of MI to address the clinical challenges posed by dually diagnosed patients. We detail each area of modification below.

Table 2

MI Standard Practices

Dual Diagnosis Clinical Challenge

DDMI Modifications

Provides personalized feedback from objective substance-related assessment results

Psychiatric problems that interact with substance use should be part of the personalized feedback.

Uses comparisons of interviewer- and patient- rated severity items across Addiction Severity Index problem areas, with emphasis on substance use and psychiatric condition; uses Positive and Negative Syndrome Scale for feedback about psychotic symptoms.

Constructing a 2 × 2 decisional balance matrix can be confusing to patients.

Focuses only on the positive and negative aspects of changing behavior.

3.1. Supplemental guidelines to MI basic principles

The foundation of DDMI lies in its adoption of the four MI basic principles that guide all therapists' interactions with patients, namely: (a) expressing empathy; (b) developing discrepancy; (c) rolling with resistance and avoiding argumentation; and (d) supporting self-efficacy. The therapist upholds these principles throughout the interview to create and sustain an environment that promotes the patient's comfortable exploration of problem areas, resolution of ambivalence toward change, and planning and initiation of change efforts. In this regard DDMI is no different than MI. However, we have found two supplemental guidelines to MI's basic principles helpful to increase the chance that DDMI achieves similar aims as MI when working with dually diagnosed patients who have psychotic disorders. The two supplements are: (a) adopting an integrated dual diagnosis interview approach that targets more than substance use; and (b) accommodating cognitive impairments and disordered thinking.

3.1.1. Adopting an integrated dual diagnosis approach that targets more than substance use

Adopting an integrated approach to substance abuse and psychiatric treatment is the sine qua non of the dual diagnosis field ( Drake, Bartels, Teague, Noordsy, & Clark, 1993; Drake, Mercer-McFadden, Mueser, McHugo, & Bond, 1998; Drake et al., 2001; Minkoff, 2001; Minkoff & Drake, 1991; Rosenthal, Hellerstein, & Miner, 1992). In this regard, dual diagnosis interventions attempt to address both problem areas equally and with an understanding of how the dual disorders and related life events interact with one another. For example, dually diagnosed patients may use substances to lessen negative psychotic symptoms such as blunted affect, depersonalization, or social inhibition or to reduce discomfort caused by positive psychotic symptoms such as auditory hallucinations or paranoid delusions. In other instances, patients might not acknowledge psychotic difficulties and prefer to see their psychiatric symptoms as substance-induced. As applied to DDMI, therapists remain mindful of these types of potential interactions, so they can strategically explore with the patient both the problem areas and their effects on one another using the microskills and MI strategies. For example, the therapist may query the patient with general open-ended questions such as, "How does your drug use affect your psychiatric symptoms?" or use more evocative questions that pull for specific selfmotivational statements, such as, "How does your use of drugs cause problems for you psychiatrically?" Failure to discern how both areas inform the patient's motivational base may reduce the therapist's effectiveness in building and strengthening the patient's motivation and capacity to prepare for change.

As a corollary to this integrated approach, DDMI targets a wider array of behavior than is typical in MI. Though several investigators have begun to apply MI to behavioral domains other than addiction problems ( Dunn, DeRoo, & Rivara, 2001), MI's traditional primary target for change has been on substance use. This focus is insufficient to meet the complex change challenges confronted by substance abusing patients with psychotic disorders. Thus, DDMI includes two other domains as additional targets for change, treatment and medication compliance.

Enhancing motivation for treatment compliance is crucial for several reasons. First, dually diagnosed patients are notorious for treatment program noncompliance ( Drake & Wallach, 1989; Richardson, Craig, & Haugland, 1985) if they participate in treatment at all ( Drake, McLaughlin, Pepper, & Minkoff, 1991). Second, noncompliance with treatment can lead to numerous adverse consequences such as poorer clinical outcomes ( Eisenthal, Emery, Lazare, & Udin, 1978), violent behavior ( Zitrin, Hardesty, Burdock, & Drossman, 1976), and increased rates of rehospitalization ( Drake, Osher, & Wallach, 1989; Lyons & McGovern, 1989) and utilization of emergency services and jails ( Bartels et al., 1993). DDMI attempts to enhance the patient's motivation for treatment compliance by building and strengthening the patient's commitment to participate in dual diagnosis specialty ambulatory programs and other related outpatient services.

Regarding medication compliance, adherence to appropriate pharmacotherapy is essential to the successful treatment of dually diagnosed psychotic disordered patients ( Drake et al., 1989; Osher & Kofoed, 1989; Owen, Fischer, Booth, & Cuffel, 1996; Zweben & Smith, 1989). DDMI tries to promote the patient's motivation for medication compliance by exploring the patient's view about taking prescribed medications and to attend to obstacles that may have diminished the patient's adherence to medication regimens in the past.

3.1.2. Accommodating cognitive impairments and disordered thinking

The second supplemental guideline to MI's basic principles is the need to accommodate cognitive impairments and disordered thinking resulting from the patient's psychotic disorder, prolonged substance abuse, preoccupation with present crisis or combinations of these factors ( Bellack & DiClemente, 1999). Cognitive impairments among dually diagnosed patients may include problems with attention and concentration, short-term and working memory, organizing and abstracting information, and mental flexibility ( Bell, Lysaker, Milstein, & Beam-Goulet, 1994; Green, 1996; Lysaker, Bell, Zito, & Bioty, 1995; Seidman et al., 1993). To address these information processing impediments, DDMI incorporates strategies of repetition, use of simple and concrete verbal and visual materials, and breaks within sessions. Disordered thinking may include circumstantiality, tangentiality, thought blocking, or other pervasive psychotic symptoms such as paranoia or grandiosity that may impede the motivational enhancement process. In particular, interviews that have insufficient structure or that excessively delve into emotionally laden material or psychotic belief systems may heighten the patient's psychotic symptoms and reduce the effectiveness of the therapist to motivate the patient for change. Likewise, trying to follow the patient's conversational lead when the patient continues to veer from a logical pathway may be very difficult for the therapist and patient and result in the therapist becoming confused and uncertainty about what part of the patient's discourse to reflect. To navigate these occurrences, the DDMI therapist places more emphasis on the strategic nature of guiding the conversation with the patient in a manner that promotes the patient's logical organization and reality testing without sacrificing the collaborative and respectful tenor of MI. This article's subsections that describe recommended modifications to MI microskills and strategies provide specific examples of how DDMI accommodates cognitive impairments and disordered thinking processes common to dually diagnosed patients.

3.2. MI microskill modifications

The core MI microskills are asking open-ended questions, listening reflectively (including summarizing), and affirming the patient. These microskills also are fundamental to the DDMI approach. We have found, however, that each microskill requires slight modification or unique emphasis to be most effective when used with dually diagnosed patients. We also have found that the general supportive and collaborative MI style of interaction established by the therapist's use of microskills often is unfamiliar to patients with dual disorders who may have become accustomed to a more directive and authoritarian style of traditional psychiatric interviewing. In traditional interviewing, the therapist most often controls the immediate direction of the interview by using numerous closed-ended questions to determine diagnoses, obtain biopsychosocial information, and prescribe treatments. Because many dually diagnosed patients expect a traditional interviewing framework, the DDMI therapist first provides the patient with a brief and simple introduction to DDMI before asking openended questions and beginning the reflective listening process. For example:

"Before we begin, I would like to explain what we will do in this meeting. I recognize that you may have talked with many professionals in the past about your use of substances and psychiatric issues. We also will talk about these areas today and any other areas that are important to you but perhaps in a slightly different way. My main interest is in understanding how you view your problems and get to know you better. I would like to talk with you about how alcohol or drug use and psychiatric issues have affected your life from your point of view. I may ask you a few questions along the way, but mostly I want to listen to what you have to say and make sure I have correctly understood what you have told me."

3.2.1. Simplifying open-ended questions

After the opening remarks, the therapist typically begins with an open-ended question (e.g., What brings you here today?). Asking open-ended questions is a primary MI strategy, particularly at the early stages of the interview when a therapist encourages the patient to talk about his or her perception of specific problem areas. Open-ended questions (e.g., What type of psychiatric issues have you been grappling with in your life?) are questions that result in more than a "yes/no" response and that encourage the patient to elaborate on a topic rather than to provide a terse answer or very specific information. These types of questions generally provide the patient with ample opportunities to express his or her viewpoint uninterrupted by the therapist. While fairly straightforward, we have found that open-ended questions are most effective with dually diagnosed patients when the therapist asks them in very clear and concise terms and avoids compound questions that may be difficult for psychotic patients to track. For example, the question, "What types of psychiatric symptoms do you experience and how does your use of cocaine affect your symptoms in the short term and long term?" is complex and may overwhelm the patient's organizational capacity to respond to it. DDMI therapists try to avoid these types of open-ended questions and strive to simplify them at all times.

3.2.2. Refining reflective listening skills

Listening reflectively to patients is a vital MI microskill that infuses the entire interviewing process. Reflective listening means that the therapist takes time to carefully understand what the patient has said and confirms this understanding with the patient by repeating it back to him or her in similar (simple reflection) or somewhat transformed ways (restatement, paraphrasing, double-sided reflection). By using this microskill, the therapist unveils the structure of the patient's motivational base and uses this structure as a foundation from which to establish and resolve ambivalence toward change. In MI, competent reflective listening is a difficult task that requires keen therapist attention and capacity to organize and rephrase what the patient has said.

Yet in DDMI, by comparison, reflective listening is an even more challenging microskill for a therapist to implement effectively. Patients with psychotic disorders may exhibit some degree of disordered thinking and poor reality testing that might unravel further in the absence of a sufficiently structured interview or in the face of a therapist's repeated reflection of fundamentally psychotic material. Beyond requiring therapists to heighten their active attention to meaningful and logically organized elements of the patient's discourse, we have found several other recommendations useful for how to most effectively listen reflectively with psychotic disordered substance abusing patients. These recommendations are: (a) using simple and concise language; (b) reflecting often; (c) using metaphors; (d) avoiding excessive focus on despairing patients' statements and negative life events; (e) logically organizing patients' statements with summaries; and ( f ) giving patients enough time to respond to reflections. We summarize these recommendations with examples in .

3.2.3. Heightening emphasis on affirmations

The last MI microskill is affirming the patient. The therapist affirms the patient by acknowledging the patient's personal qualities and efforts that promote change. The execution of this microskill is the same in DDMI as it is in MI. The caveat to its use in DDMI is in the heightened emphasis placed upon affirming patients during the interview process. Dually diagnosed patients often have had the personally invalidating experience of combined social stigma associated with their substance use and psychotic disorders ( Evans & Sullivan, 1989) and feeling misfit to treatment systems that do not have integrated dual diagnosis care ( Ridgely, Goldman, & Willenbring, 1990). In DDMI, the therapist strives to affirm patients who may not be accustomed to receiving such support. For example, a therapist might express appreciation for a patient's candor and ability to talk about what the patient sees as problematic after the patient has criticized several prior treatment experiences. Likewise, a therapist might express appreciation to a patient who has had a history of treatment noncompliance for attending a session or taking medications as prescribed. We have found that dually diagnosed patients experience a therapist's frequent complimenting of their personal qualities and initial change efforts inspiring and very helpful in establishing a supportive and collaborative interviewing tone.

3.3. Modifications to MI strategies

DDMI incorporates many of the commonly used MI strategies. These strategies include the use of evocative open-ended questions to elicit self-motivational statements (e.g., What concerns you about how your drug use affects your psychiatric condition?). They also include a variety of MI techniques for handling resistance skillfully. Mastery of this skill set is very important for DDMI therapists because dually diagnosed patients often express resistance in reaction to perceived coercive forces (therapists or case managers, psychiatrists, residential or vocational counselors, probation officers, child protective services personnel) compelling them to make changes. Dually diagnosed patients also may have paranoid proclivities that heighten their baseline levels of resistance irrespective of external contingencies on them. An area of significant modification to standard MI practice is in the DDMI therapist's efforts to develop discrepancy in the patient's perceptions of his or her problems. Specifically, in DDMI we have revised the methods of providing personalized feedback and constructing decisional balance matrices as a means to alter the patient's view that substance use or psychiatric issues are not problematic. We describe these modifications to MI strategies below.

3.3.1. Providing personalized and engaging feedback that addresses dual diagnosis concerns

In MI, feedback typically involves a therapist providing a structured review of objective assessment results in an empathetic and collaborative style. The therapist explores with patients their reaction to the feedback and the possible relationships between the patients' use of substances, their problems or concerns, and their intention to change their behavior. In DDMI, feedback also must include information about psychiatric symptoms and contain mechanisms for exploring the interaction of these symptoms with the patients' use of substances and the impact on their functioning overall. In addition, the feedback needs to be simple in presentation, flexible to accommodate different areas relevant to dual diagnosis recovery, and capable of compelling patients to look at their long-standing problem areas in a renewed light.

To accommodate these requirements, we prepared a pamphlet for patients to organize the presentation of feedback into areas relevant for dual diagnosis recovery. These areas include feedback about the patient's substance use from the Addiction Severity Index or ASI ( McLellan, Luborsky, Woody, & O'Brien, 1980; McLellan et al., 1985), the patient's psychotic symptoms from the Positive and Negative Syndrome Scale or PANSS ( Kay, Fizbein, & Opler, 1987), how substance use and psychotic-related problems interact, and a model of dual diagnosis recovery. Both the ASI and PANSS are structured clinical interviews administered to patients, scored and compiled into feedback forms prior to the DDMI sessions. The ASI is designed to provide problem severity ratings (lifetime and past 30 days) in areas commonly affected in people who abuse alcohol and drugs (alcohol and drug use, medical condition, employment, legal status, family relations, and psychiatric condition). For each problem area, patients also provide subjective ratings of their recent (past 30 days) problem severity by indicating the importance they attach to seeking treatment for it. Using a color-coded bar chart comparing the recent ASI and patient-rated severity items per problem area, the DDMI therapist compares and contrasts the ratings, notes rating discrepancies, and promotes the patients' exploration of their substance use in relationship to other areas, particularly in interaction with the psychiatric condition.

The PANSS is designed to evaluate positive, negative, and other symptom dimensions of schizophrenia phenomenon. The PANSS provides a score for how much a patient experiences symptoms that are in excess of what most people experience (positive symptoms), such as delusions or hallucinations. It also provides a score for how much a patient experiences symptoms that involve the absence of thoughts and feelings that most people experience (negative symptoms), such as feeling emotionally flat or having slowed thinking. As in the ASI feedback, we present these two dimensions in a color-coded bar chart format. Based on patient input, we renamed the positive symptoms "hot" symptoms (i.e., symptoms that make patients feel like they are boiling inside) and color-coded the bar in red. Similarly, we renamed the negative symptoms "cold" symptoms (i.e., symptoms that make patients feel like they are frozen inside) and color-coded the bar in blue. We found this metaphor helped the patients understand and relate to the scores better and made the feedback activity more engaging. As with the ASI, the DDMI therapist reviews and explores the patient-specific information with the patient to promote psychiatric problem recognition and related motivation for change.

The pamphlet ends with a discussion of the interaction of substance use and psychotic disorders and presents a metaphor of a three-legged stool model of dual diagnosis recovery (see ). In brief, the therapist describes how many dually diagnosed patients have found that their ability to make productive change in their lives has rested upon three principles: staying clean and sober, taking medications as prescribed, and participating in a dual diagnosis treatment program. Using a demonstration model, the therapist notes how these principles represent three legs of the stool supporting the seat of dual diagnosis recovery. Beginning with an open-ended question, the therapist asks the patient what happens when an individual does not use or strengthen one or more legs of the stool. Next, the therapist unscrews one of the stool's legs and demonstrates how the stool falls in the absence of a critical area of support. While this feedback strategy contains elements that are not unique to MI (e.g., Socratic questioning), we have found that this simple and interactive model is very engaging for patients and helpful in garnering and organizing their motivation for productively addressing their dual disorders.

3.3.2. Constructing decisional balance matrices appropriate for dually diagnosed patients

Another frequently used technique in MI is the construction of a decisional balance matrix. In this technique, the therapist tries to normalize ambivalence by having the patient discuss the positive and negative aspects of continuing a behavior (e.g., drinking alcohol) and trying to change it (e.g., not drinking alcohol). The therapist typically records what the patient enumerates into a 2 × 2 matrix and then explores with the patient the array of underlying attitudes that make up the competing dimensions of the patient's motivation for change. Beyond applying this technique to the patient's substance use, DDMI also uses the decisional balance technique to explore the patient's ambivalence about getting treatment for his or her dual disorders. Here, we defined treatment as participation in a dual diagnosis specialty program and taking prescribed medications. The consolidation of two treatment areas into one decisional balance activity reduces the task demands placed on the patients without neglecting the primary targets of DDMI. We also determined that many dually diagnosed patients found completion of a 2 × 2 matrix confusing and redundant. For example, the negative expectancies for not using a substance ("I won't feel good") often are inversely related to the positive expectancies for continuing to use a substance ("I will feel good."). To simplify the task, DDMI focuses only on the patient's anticipation of positive and negative aspects of changing a behavior and the relative balance of these two areas in promoting or hindering a patient's motivation for change. Examples of items that comprise the decisional balance activities used in DDMI (Positives and Negatives of Staying Clean and Sober and Getting Treatment for My Dual Disorders) are presented in .

3.4. Other clinical considerations

We believe that the modifications described above help therapists use MI more effectively with dually diagnosed patients. Nevertheless, we qualify our recommendation of MI for use with this population by emphasizing how patients must have sufficient psychiatric stability to benefit from MI's ample use of verbal persuasion and logical reasoning, albeit in the overall MI style. When patients are too psychotically disorganized to logically attend to the content of the interview or consistently remain based in reality, they are not appropriate for DDMI and may require other types of interventions (e.g., crisis intervention, pharmacotherapy) first. If patients' psychotic symptoms are so severe that patients cannot make informed decisions or properly take care of their basic needs, DDMI therapists must be prepared to arrange for the patients' hospitalization.

In addition to psychotic exacerbation, dually diagnosed patients have higher rates of suicidality and homicidality ( Craig, Linm, El-Defrawi, & Goldman, 1985; Drake et al.,1989; Lyons & McGovern, 1989; Turner & Tsuang, 1990) than substance abusing patients without co-occurring psychiatric conditions. Therefore, DDMI requires that therapists are capable of performing risk assessments of patients' dangerousness to self and others and are knowledgeable about the policies and procedures for handling patients who the therapists deem are at imminent risk for self- and otherdestructive behavior. As with grave disability caused by psychosis, when patients pose clear threats to themselves and others, therapists must alter their style of intervention away from DDMI where collaboration and patients' freedom of choice operate, to crisis intervention where therapists' decision making and direction, even if coercive, matter most. Under these circumstances, safeguarding the patient and the public through immediate protective measures supersedes the basic principles underlying DDMI. To anticipate these events and to be clear about the related clinical dilemmas posed by them, we routinely review with patients in the interview the circumstances that necessitate involuntary protective measures.

These issues and the general clinical complexity of most dually diagnosed patients dictate that DDMI therapists have special professional qualifications. We have found that beyond supporting the highly empathic and collaborative MI style, therapists should have at least one year of supervised work experience with dually diagnosed patients to demonstrate familiarity with psychotic phenomenon and to adequately appreciate the possible interactions of substance use and psychotic functioning. In addition, therapists must have familiarity with psychotropic medications and potential side effects, given that most of these patients receive prescribed antipsychotic and mood stabilizing medications for their psychiatric conditions. Finally, DDMI requires consistently scheduled and ad hoc therapist supervision to continuously refine the therapist's skills in applying MI to dually diagnosed patients and to aptly handle crisis situations.

4. Conclusions

Motivational Interviewing is a promising treatment approach to use with dually diagnosed patients. Within this promise, we have found that MI requires modifications to accommodate the special needs of substance abusing patients who have psychotic disorders. DDMI is our initial attempt to systematically develop and describe how MI might be altered for this patient population and be most effective in promoting the patients' productive efforts to change previously problematic behaviors. We recognize that the complex and severe problems experienced by dually diagnosed patients may limit the ultimate capacity of a brief two-session intervention like DDMI to render beneficial impact. Nonetheless, studies of brief motivational interventions have shown their effectiveness in reducing substance use outcomes with high-average effect sizes comparable to more extensive treatments ( Bien, Miller, & Tonigan, 1993), particularly when they are used to enhance engagement in intensive treatment-as-usual ( Dunn et al., 2001). If our initial pilot study ( Martino et al., 2000) showing some benefit of a one-session motivational interview for dually diagnosed patients is any indication, a two-session and carefully developed DDMI may have the potential for greater merit as a brief intervention. Our current effort to examine the feasibility and effectiveness of DDMI in a randomized controlled trial will address this issue directly and will be the subject of future reports. Finally, while we have presented DDMI as an independent clinical intervention, we recognize that DDMI might best function as a complement to the many recommended health service system approaches described by Drake and others ( Drake et al., 1993, 1998, 2001; Minkoff, 2001) to improve treatment outcomes for dually diagnosed patients. In this regard, DDMI may be viewed as a guideline for how service providers might best interact with dually diagnosed patients on an individual level while they work with these patients in the context of the broader service system.

Acknowledgments

Grant P50DA09241 from the National Institute on Drug Abuse (NIDA) supported this project. We also acknowledge the support provided by the staff members of the Yale New Haven Psychiatric Hospital's Dual Diagnosis Service who permitted us to conduct this study in their clinical setting.

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Dual Diagnosis Motivational Interviewing: a modification of Motivational Interviewing for substance-abusing patients with psychotic disorders

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Motivational Interviewing (MI) is a brief treatment approach for helping patients develop intrinsic motivation to change addictive behaviors. While initially developed to target primary substance using populations, professionals are increasingly recognizing the promise this approach has for addressing the motivational dilemmas faced by patients who have co-occurring psychiatric and psychoactive substance use disorders.

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Abstract

There is compelling evidence that comorbid borderline personality disorder (BPD) negatively impact the clinical courses and outcomes of substance use disorders (SUD). Conversely, there is little evidence that concurrent SUD exacerbates the clinical characteristics of BPD. Thus, this study sought to examine whether the presence of current substance dependence among BPD patients would be associated with stronger BPD-relevant personality traits and behavioral characteristics. Female BPD patients without (BOR; n = 37) or with current substance dependence (BSUD; n = 19), and female non-BPD/SUD controls (CON; n = 48) were compared with respect to impulsivity, affective lability, affective intensity, externalizing behaviors, and self-harming/suicidal tendencies, taking into consideration their comorbid mood disorders, anxiety disorders, and antisocial personality disorder. Results indicated that both BOR and BSUD groups scored higher than CON in most of the measures, but BOR and BSUD failed to reveal significant group differences especially when the influence of comorbid psychopathology was removed. The overall pattern of findings remained identical even when comparing BPD patients with vs. without the diagnosis of lifetime substance dependence. Our results do not support the notion that BPD individuals with SUD display more severe BPD features than individuals with BPD alone.

Keywords: Borderline personality disorder, Substance abuse, Impulsiveness, Affective lability, Axis II

Borderline personality disorder (BPD) is a severe psychological condition characterized by marked impulsivity, affective dysregulation, identity disturbance, anger dyscontrol, and life-threatening/self-damaging behaviors ( American Psychiatric Association, 2000). BPD often occurs with other psychiatric conditions, including mood disorders, anxiety disorders, and other Axis-II personality disorders ( Widiger & Trull, 1993). Substance use disorders (SUDs) have been highlighted as a common comorbid condition of BPD ( Trull, Sher, Minks-Brown, Durbin, & Burr, 2000). In stark contrast with the relatively low prevalence of BPD in the general population (approximately 2%), the prevalence of BPD among substance users is estimated as 5 to 32% ( Bornovalova & Daughters, 2007). Likewise, almost up to 60% of individuals with BPD present with a comorbid SUD ( Trull et al., 2000).

This comorbidity is attributable at least in part to the partial overlap in the diagnostic criteria for these two disorders; substance abuse is a type of self-damaging impulsivity when diagnosing BPD according to DSM-IV criteria. It is doubtful, however, that the striking co-occurrence of BPD and SUD can be fully explained by criteria overlap. Several authors have suggested that some important personality traits (e.g., affective instability and impulsivity) underlie the development of both conditions and thus explain the large portion of their comorbidity ( Bornovalova, Lejuez, Daughters, Rosenthal, & Lynch, 2005; Trull et al., 2000). Furthermore, both BPD and SUD are often associated with early adverse life experiences (e.g., childhood physical/sexual abuse and a dysfunctional family), which may also contribute to the development of disinhibitory psychopathology ( Brown & Anderson, 1991; Trull et al., 2000).

The literature has extensively documented the deleterious impact of comorbid BPD among substance users on various clinical outcomes, including more severe drug use, higher rates of needle sharing, a higher likelihood of suicide attempt, poorer global psychological health, and poorer treatment outcomes for SUD (e.g., Kruedelbach, McCormick, Schulz, & Grueneich, 1993; Nace, Saxon, & Shore, 1986). Furthermore, the presence of BPD is associated with an earlier onset age of SUD, which has been shown to be linked to more severe physical, emotional, and social consequences (e.g., Linehan et al., 1999; Links, Heslegrave, Mitton, van Reekum, & Patrick 1995). Taken together, the literature provides compelling evidence that comorbid BPD renders the psychopathology and clinical outcomes of SUD more serious.

Although not as robust, there are a few studies suggesting that comorbid SUD may render the psychopathology and clinical outcomes of BPD more serious. Links et al (1995) found that individuals with both BPD and SUD exhibited more severe BPD psychopathology, including self-destructive and suicidal tendencies at 7-year follow-up, relative to those whose initial diagnosis was BPD or SUD only. Relatedly, Zanarini et al. (2004) also reported that compared to mood disorders or anxiety disorders, SUDs were more strongly associated with the failure to attain symptomatic remission among BPD patients at 6-year follow-up. Another study reported that young BPD patients (age 30 years or younger) with comorbid alcohol use disorder (AUD) were more impulsive than BPD patients without any history of SUD ( Wilson, Fertuck, Kwitel, Stanley, & Stanley, 2006). Moreover, the current literature suggests that some of the core personality traits of BPD such as affective dysregulation and impulsivity also underlie the psychopathology of SUD (e.g., Cooper, Frone, Russell, & Mudar, 1995; Kruedelbach et al., 1993). Thus, it is conceivable that SUD added to BPD may exacerbate BPD-relevant personality features and behavioral characteristics. However, overall, there is a paucity of evidence as to whether comorbid SUD exacerbates BPD features.

Thus, the principal aim of the current study was to compare BPD patients with current substance dependence, BPD patients without current substance dependence, and controls without these diagnoses, with respect to BPD-relevant personality traits and behavioral characteristics, including (a) impulsivity, (b) affective lability, (c) affective intensity, (d) self-harming/suicidal tendencies, and (e) externalizing behaviors. This study focused on the more severe form of SUD, substance dependence as opposed to substance abuse, in order to enhance the likelihood of detecting the negative impact of comorbid SUD among BPD patients. We tested the following specific hypotheses that, on these BPD-relevant personality traits and related behavioral characteristics, (a) BPD patients would score higher than non-BPD/SUD comparison controls, and (b) BPD patients with current substance dependence would score higher than BPD patients without current substance dependence due to the potential additive/interactive effect of comorbidity.

Method

Participants

Study participants included 104 females: (a) BPD patients without current substance dependence (BOR; n = 37), (b) BPD patients with current substance dependence (BSUD; n = 19), and (c) a comparison control group that did not meet lifetime diagnostic criteria for BPD or SUD (CON; n = 48). Participants ranged in age from 18 to 60 years ( M = 35.85, SD = 11.37). Demographic details are presented in . Of 19 BSUD patients, 58% reported current dependence on one drug and 42% reported current dependence on two drugs. Drugs used by these patients included cocaine/crack (42.1%), alcohol (36.8%), sedatives (21.1%), opiates (21.1%), marijuana (5.3%), amphetamine (5.3%), and PCP (5.3%).

Measures

Recruitment

A broad range of recruitment approaches were employed in this study. Prospective participants with BPD were generally recruited from inpatient units at The University of Mississippi Medical Center (although study participation did not begin until the participant was discharged from the inpatient unit) or from local community mental health centers. In addition, some BPD participants (BOR and BSUD) and all CON participants were recruited through advertisements placed in local newspapers and fliers posted in the community. Individuals responding to recruitment materials were scheduled for a diagnostic and psychosocial assessment at which time they provided informed consent and were administered the C-DIS and self-report measures by experienced Bachelor or Masters-level research assistants. The SIDP-IV and M.I.N.I. were administered by Masters- or Doctoral-level research staff. Individuals meeting diagnostic criteria for a psychotic disorder or experiencing an active manic episode were excluded from the study. Participants meeting criteria for a lifetime substance abuse or dependence diagnosis (other than nicotine or caffeine dependence), but not meeting criteria for BPD, were excluded from the study. Nicotine and/or caffeine use disorders did not constitute exclusion criteria for any of the three study groups. All participants were compensated for their involvement in this study.

Data Analyses

Group differences were examined utilizing univariate/multivariate analyses of variance (ANOVAs) or non-parametric tests such as Pearson's Chi-square test, Fisher's exact test or Mann-Whitney U test depending on the parametric/non-parametric properties of the data in question. When multiple comparisons were needed, family-wise Type I error was controlled by conducting multivariate analyses of variance (MANOVAs) or using a Bonferroni correction.

Results

Demographic Characteristics

No group differences emerged for age, ethnicity, or race. Chi-square analyses revealed significant group differences in marital status ( X ² = 17.24, p < .01) and current employment status ( X ² = 48.85, p < .01). Significant chi-square results were further analyzed by inspecting standardized residuals (see Hinkle, Wiersma, & Jurs, 1994; absolute values of 2.0 or greater are considered major contributors to significant chi-square statistics). The BSUD group had fewer married/cohabiting individuals (5.3%) and more divorced individuals (42.1%) than would have been expected by chance. The CON group had more individuals employed full-time (47.9%) and less unemployed individuals (2.1%), whereas there were more unemployed individuals in both the BOR (45.9%) and BSUD (84.2%) groups beyond chance level. Education was not equally distributed across groups ( X ² = 28.27, p < .01). In the CON group, 31.9% attained a 4-year college or higher level degree, whereas, only 8.1% and 5.3% reached the same educational level in the BOR and BSUD groups, respectively. The CON participants also reported higher gross income in the past year than BOR or BSUD participants, F(2, 101) = 5.72, p < .01.

Group Differences on Covariate Variables (Diagnostic Status of Axis-I and ASPD Features)

In the preliminary analyses, we compared the three groups on diagnostic status of various Axis-I conditions and ASPD that constituted the covariates in the main analyses. First, significant group differences were shown for several mood and anxiety disorders: major depressive disorder (MDD), dysthymia, panic disorder, social phobia, generalized anxiety disorder (GAD), obsessive-compulsive disorder (OCD), and post-traumatic stress disorder (PTSD). For MDD, panic disorder, GAD, OCD, and PTSD, the BOR group satisfied diagnostic criteria to a greater degree compared to the CON group. For dysthymia, the BSUD group met diagnostic criteria to a greater degree compared to the CON group. For social phobia, both BOR and BSUD groups met diagnostic criteria to a greater degree compared to the CON group. Follow-up Fisher's exact test comparing the BOR and BSUD groups on Axis-I comorbidity revealed no significant group difference. Second, we examined ASPD features using both continuous scores and binary diagnostic outcomes. An ANOVA using continuous ASPD scores obtained from the SIDP-IV showed a significant main effect for group, F(2,101) = 79.28, p < .001, η p ² = .61. Follow-up post-hoc tests showed that both the BOR and BSUD groups scored higher than the CON group. The BSUD group also scored higher than BOR group [means and SDs: BSUD = 11.84 (5.18), BOR = 6.78 (4.16), CON = .58 (1.66)]. With respect to the diagnostic status of ASPD, a significant group difference was observed, X ² (2, n = 104) = 26.22, p < .001 (BSUD = 47.4%, BOR = 13.5%, and CON = 0%). The ASPD diagnostic rate was more than three times higher among the BSUD group relative to the BOR group, X ²(1, n = 56) = 7.67, p < .01.

Overall Borderline Personality Features

With respect to overall borderline personality features (as indexed by the PAI-BOR), an ANOVA revealed a significant group difference, F(2,89) = 126.87, p < .001, η p ²= .74). As expected, Bonferroni post-hoc tests showed that both the BOR and BSUD groups scored higher than the CON group on the PAI-BOR [Mean (SD): BOR - 51.82 (10.80), BSUD - 55.68 (9.36), CON - 18.28 (10.67)], but the two BPD groups did not differ from one another. After statistically removing the influence of the three covariate variables (i.e., diagnostic status of mood disorders, anxiety disorders, and ASPD), the overall group difference was still significant, F(2,86) = 31.63, p < .001, η p ²= .42. Additional analyses on the PAI-BOR subscales revealed the same pattern of group differences: the two BPD groups scored higher than the CON group on all PAI-BOR subscales, but the BOR and BSUD groups did not differ.

Impulsivity

A MANOVA with three subscales of the BIS-11 revealed a significant main effect for group [Wilks' Lambda = .35, F(6, 192) = 21.82, p < .001, η p ² = .41]. Follow-up univariate and Bonferroni post-hoc tests revealed that on the BIS-Attentional Impulsiveness [ F(2, 98) = 68.84, p < .001, η p ² = .58] and BIS-Motor Impulsiveness [ F(2, 98) = 48.93, p < .001, η p ² = .50] subscales, both BPD groups scored higher than CON, and BSUD also scored higher than BOR (see for group means and standard deviations). On the BIS-Nonplanning Impulsiveness [ F(2, 98) = 43.83, p < .001, η p ² = .47], both BPD groups scored higher than CON, but BOR did not differ from BSUD.

When the Axis-I and ASPD diagnostic status covariates were included in the model, the overall group difference still remained significant, Wilks' Lambda = .71, F(6, 186) = 5.92, p < .001, η p ² = .16. However, the BOR-BSUD group differences on BIS-Attentional Impulsiveness and BIS-Motor Impulsiveness were rendered non-significant following the inclusion of these covariates. Only the CON group remained significantly different from the two BPD groups in all BIS-11 subscales. Follow-up analyses, in which each covariate was entered separately, revealed that it was the inclusion of ASPD diagnostic status (not mood disorders or anxiety disorders diagnostic status) that attenuated the BOR-BSUD group differences.

Affective Lability

A MANOVA using the six subscales of the ALS as dependent variables revealed a significant main effect for group, Wilks' Lambda = .21, F(12,192) = 19.21, p < .001, η p ² = .55. Follow-up analyses showed that both BPD groups scored higher than the CON group, and the BSUD group also scored significantly higher than the BOR group on ALS-DEP [ F(2,101) = 85.16, p < .001, η p ² = .63] and ALS-ANX [ F(2,101) = 103.32, p < .001, η p ² = .67]. On the other four subscales of the ALS, both BPD groups scored higher than the CON group, but the BOR and BSUD groups did not differ.

When the influence of diagnostic status of mood and anxiety disorders and ASPD were removed as covariates, the multivariate effect of group remained still significant, Wilks' Lambda = .54, F(12,184) = 5.89, p < .001, η p ² = .26. However, the BOR-BSUD group differences on ALS-DEP and ALS-ANX were rendered non-significant following the inclusion of these covariates. Follow-up analyses, in which each covariate was entered separately, revealed that it was the inclusion of ASPD diagnostic status (not mood disorders or anxiety disorders diagnostic status) that attenuated the BOR-BSUD group differences.

Affective Intensity and Reaction

There was a main effect for group in a MANOVA using the three subscales of the AIM as dependent measures, Wilks' Lambda = .55, F(6,240) = 13.75, p < .001, η p ² = .26. Follow-up univariate and post-hoc tests revealed that both BOR and BSUD groups scored higher than the CON group on AIM-Negative, F(2,122) = 22.52, p < .001, η p ² = .27, and AIM-Neutral, F(2,122) = 44.49, p < .001, η p ² = .42. However, these group differences were not significant after removing the influence of the three covariate variables, Wilks' Lambda = .92, F(6,190) = 1.40, p = .22, η p ² = .04.

Self-Harming and Suicidal Tendencies

To control for the risk of family-wise type 1 error, a Bonferroni correction was applied to the following analyses (alpha = .01). Twelve-month prevalence of self-harm and suicidal tendencies was examined only for the BOR and BSUD groups because the CON participants reported no occurrence of self-harming/suicidal behaviors. Due to the highly skewed nonparametric nature of the frequency data, Mann-Whitney U tests were conducted. Results showed that the BOR and BSUD groups did not differ on any of these items: (a) self-harming while upset, mean (median) frequencies ⁴: BOR = 4.03 (.50) vs. BSUD =1.00 (0), p = .14, (b) self-harming while not upset: BOR = .61 (0) vs. BSUD = .58 (0), p = .51, (c) suicide attempt: BOR = .84 (0) vs. BSUD = .89 (0), p = .64, and (d) suicidal ideation: BOR = 4.42 (4.00) vs. BSUD = 4.12 (4.00), p = .55 (both means and medians were inspected as central tendency indices because most of the median values were zero due to highly skewed frequencies of self-harming and suicidal behavior). Additionally, we compared the BOR and BSUD groups on the binary status of these self-harming/suicidal variables (i.e., presence vs. absence during the past 12 months). However, Fisher's Exact tests indicated no group difference on these comparisons.

Externalizing Behaviors

To control for the risk of family-wise type 1 error, a Bonferroni correction was applied to the following analyses (alpha = .01). Kruskal-Wallis tests indicated significant group differences ( p < .001 for all comparisons) on all four externalizing behavior indices (i.e., physical fight, planned crime, unplanned crime, and risky sexual behavior). Further analyses were performed using Mann-Whitney tests to compare only the BOR and BSUD groups because 96% of CON participants reported no occurrence of these behaviors during the past 12 month. Results showed that the BSUD group reported higher frequencies of unplanned crime [mean (median) frequencies: BOR = 1.46 (0) vs. BSUD = 3.32 (2.00), p = .013] and risky sexual behavior [BOR = .70 (0) vs. BSUD = 3.11 (1.0), p = .039] than the BOR group, but these differences were not significant after applying a Bonferroni correction.

BPD without a History of Substance Dependence vs. BPD with Lifetime Substance Dependence

Finally, we considered the possibility that the current grouping schemes (BPD with or without current substance dependence) might have obscured potential group differences on several key variables (i.e., impulsivity, affective lability, affective intensity and reaction, self-harming and suicidal features, as well as overall BPD symptoms). Thus, we repeated the same analytic procedures using the same covariates after regrouping our BPD patients into those without a history of substance dependence ( n = 18) vs. those with a lifetime substance dependence diagnosis ( n = 38). Results indicated the same pattern of findings: the two BPD patient groups classified based on the presence/absence of a lifetime substance dependence diagnosis did not significantly differ in any of the studied domains, including impulsivity, affective lability, affective intensity, self-harming and suicidal features, externalizing behaviors, and overall BPD symptoms.

Discussion

The current literature indicates escalated impulsivity, affective dysregulation, externalizing, and self-harming/suicidal behaviors in both BPD and SUD (e.g., Coffey, Gudleski, Saladin, & Brady, 2003; Cooper et al., 1995; Kruedelbach et al., 1993). This study hypothesized that these personality traits and behavioral characteristics would be reported to a greater degree in BPD individuals if a current substance dependence diagnosis was present. Overall, the current data provided only partial support for our study hypotheses. As expected, relative to non-BPD/SUD controls, both BPD groups with and without substance dependence scored higher on impulsivity, affective lability, externalizing behaviors, self-harming/suicidality, and overall BPD symptoms. However, contrary to prediction, BPD patients did not differ on most of these variables as a function of the presence/absence of current or lifetime comorbid substance dependence. Although impulsivity and affective dysregulation have been considered as core pathogenic processes underlying both BPD and SUD ( Bornovalova et al., 2005; Trull et al., 2000), the presence of current/lifetime substance dependence was not associated with a further escalation in these personality traits in our sample of BPD individuals. Nor did self-harming/suicidal attempt and ideation or externalizing behaviors during the past 12 months significantly differ among BPD participants as a function of comorbid substance dependence status. Moreover, the overall severity of borderline personality symptoms did not differ between the two BPD groups. Taken together, our findings are at odds with the common notion that individuals with both BPD and SUD present much worse clinical cases compared to individuals with BPD only. It may be that the serious consequences of the comorbidity between BPD and SUD are primarily driven by the presence of BPD as opposed to SUD such that the negative impact of comorbidity is much greater when BPD is added upon SUD compared to the reverse.

The two BPD groups showed differences in some domains of impulsivity (i.e., attentional and motor impulsiveness) and affective lability (i.e., shift from normal to depressed or anxious moods), but these differences disappeared once the ASPD diagnostic status was taken into consideration. In the current study, the only significant difference observed between the BOR and BSUD groups was ASPD features and diagnostic status. The comorbidity rate of ASPD was more than twice as high in BSUD participants as in BOR participants (47.4% vs. 13.5% for classification based on the current substance dependence, 31.6% vs. 11.1% for classification based on the lifetime substance dependence). These findings add to the literature showing a close linkage between ASPD and SUD ( Mueser et al., 1999; Regier et al., 1990). Moreover, these data suggest the possibility that if increased impulsivity and affective lability are observed with the additional diagnosis of SUD among BPD patients, it may be better accounted for by comorbid ASPD features rather than by the presence of comorbid SUD.

Some limitations of the present study should be noted. First, the exclusion of males limits the generalizability of the current findings. According to DSM-IV-TR ( APA, 2000), BPD is characterized by a preponderance of females. However, considering the gender differences observed in BPD (e.g., Zlotnick, Rothschild, & Zimmerman, 2002), it is yet to be shown whether current findings would be replicated among BPD males. Second, this study relied on cross-sectional data obtained via self-report measures and structured diagnostic interviews. Our data may not reflect how comorbid SUD would affect emotional regulation and related behavioral characteristics among BPD patients in their natural environment over time. Third, this study did not assess self-harming and externalizing behaviors thoroughly, but instead relied on 8 self-report items, thus leaving some important aspects of these variables uncovered (e.g., emotional states and intention). Fourth, this study is underpowered to examine the potential impact of various recruitment sources on the current findings. A possibility is that inpatient units may present overall more severe psychiatric cases than local community sources. However, it seems unlikely that the two BPD groups were unequally affected by specific recruitment strategies for a few reasons: (a) on additional study questions, the two BPD groups showed no differences in frequencies of previous hospitalization and the utilization of outpatient clinics for psychiatric problems, and (b) all BPD patients in this study were assessed in our laboratory after being discharged from hospital or stabilized. Finally, this study did not include a patient group presenting with SUD only because the principal aim of our study was to understand the impact of substance dependence on BPD. However, given the absence of differences between the BOR and BSUD groups, the SUD only group would have enhanced the interpretation of the current findings.

In summary, despite these limitations, the current study suggests that BPD-relevant personality traits and behavioral characteristics may not vary among BPD patients as a direct function of comorbid substance dependence. Rather, it appears that the negative consequences of comorbidity on personality traits and behavioral characteristics primarily may be driven by BPD and, perhaps, features frequently associated with SUD, such as ASPD.

Acknowledgments

This research was supported, in part, by National Institute of Mental Health grant MH069627 (PI: Coffey).

Footnotes

Publisher's Disclaimer: The following manuscript is the final accepted manuscript. It has not been subjected to the final copyediting, fact-checking, and proofreading required for formal publication. It is not the definitive, publisher-authenticated version. The American Psychological Association and its Council of Editors disclaim any responsibility or liabilities for errors or omissions of this manuscript version, any version derived from this manuscript by NIH, or other third parties. The published version is available at www.apa.org/journals/per.

Han-Joo Lee is now at the Department of Psychology, University of Wisconsin, Milwaukee.

¹Our original project assessed both males and females with BPD. The present study examines only females because the small number of males in the larger project does not allow us to properly analyze the influence of gender. Considering some meaningful gender differences in BPD documented in the current literature (e.g., Zlotnick, Rothschild, & Zimmerman, 2002), we decided to confine the current data analyses to females to reduce interpretative ambiguity.

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Pfohl B, Blum N, Zimmerman M. Structured Interview for DSM-IV Personality: SIDP-IV. University of Iowa; Iowa City. IA: 1995. [Google Scholar]

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# data[].attributes.attachment_link.title
Does Comorbid Substance Use Disorder Exacerbate Borderline Personality Features?: A Comparison of Borderline Personality Disorder Individuals with vs. without Current Substance Dependence

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There is compelling evidence that comorbid borderline personality disorder (BPD) negatively impact the clinical courses and outcomes of substance use disorders (SUD). Conversely, there is little evidence that concurrent SUD exacerbates the clinical characteristics of BPD. Thus, this study sought to examine whether the presence of current substance dependence among BPD patients would be associated with stronger BPD-relevant personality traits and behavioral characteristics.

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