Hello and welcome. I'm Amy Cohen, a member of the Clinical Expert Team with SMI Advisor and an Associate Research Professor in UCLA's Department of Psychiatry and Biobehavioral Science. I'm really pleased that you're joining us for today's SMI Advisor webinar, Understanding Incomorbid Substance Use Disorders and Serious Mental Illness. SMI Advisor, also known as the Clinical Support System for Serious Mental Illness, is an APA and SAMHSA initiative devoted to helping clinicians implement evidence-based care for those living with serious mental illness. Working with experts from across the SMI clinician community, our interdisciplinary effort has been designed to help you get the answers you need to care for your patients. Now I'd like to introduce you to the faculty for today's webinar, Amanda Simonton and Dr. Donna Rowland. Amanda Simonton is a board-certified psychiatric mental health nurse practitioner licensed and trained to treat behavioral health concerns across the lifespan. Amanda's clinical and research focus is to improve recovery for individuals with substance use disorders, particularly those with opioid use disorder. And Dr. Donna Rowland is a Clinical Associate Professor and the Director of Psychiatric Mental Health Nurse Practitioner Program at the University of Texas. Dr. Rowland serves on the National Board of Directors of the American Psychiatric Nurses Association and is a core member of SMI Advisor's clinical expert team. Amanda and Donna, thank you both for leading today's webinar. This is Donna and I have no disclosures to report. This is Amanda and I have no disclosures. Hello. Today we will look at knowing the prevalence of co-occurring severe mental illness and substance use disorders, as well as learning about heavy drinking, identify substance use disorders and high-risk alcohol consumption, and evaluate treatment options for effectively managing these dual diagnoses. We'll begin by turning to relevant definitions and examining prevalence rates. According to the American Society of Addiction Medicine, addiction is a chronic disease and results in dysfunction in the neurological circuits. This results in dysfunctional behaviors and negative health outcomes. Similar to other chronic diseases, it has cycles of relapse and remission and without treatment can result in disability and premature death. The APA's DSM-5 also defines substance use disorders. The substance-related disorders encompass nine separate classes of drugs, which are not fully distinct. Instead of achieving a reward system activation through adaptive behaviors, drugs of abuse directly activate the reward pathways. In addition to the substance-related disorders, the DSM-5 also includes gambling disorder, reflecting evidence that gambling behaviors activate systems similarly to those of drugs, producing behavioral symptoms that appear comparable to those produced by the substance use disorders. Almost 20 million Americans have a substance use disorder, approximately 10% of the U.S. population. This includes 2.1 million with an opioid use disorder and 14.5 million with an alcohol use disorder. Drug overdoses became the leading cause of accidental death in 2016, including almost 64,000 drug overdoses. Of those, 42,000 overdoses were related to prescription opioids and heroin. Only one in 10 persons with substance use disorders received treatment in the previous year. There have been sharp increases in deaths involving synthetic opioids other than methadone, such as illicitly manufactured fentanyl. Largest increase in opioid overdose death rates was in males between the ages of 25 to 44. While opioid use disorder accounts for about 10% of substance use disorders, opioids account for 66% of overdose deaths. There are high rates of comorbid substance use disorders and serious mental illness. It can be difficult to establish a chronological order of these disorders, especially if the patient is not a great historian. About half of the individuals with a mental illness will experience a substance use disorder during their lifetime and vice versa. About half of persons with substance use disorders have a mental illness. These comorbidities occur together for three proposed reasons. First, there are common risk factors, environmental issues, stress and trauma, inherited genes, and epigenetics. Second, mental illnesses can contribute to substance use, whereby patients might be self-medicating their psychiatric symptoms. Thirdly, substance use can contribute to developing mental illnesses. Substance use and symptoms precede the psychiatric symptoms sometimes and may produce changes that can underline predispositions or even create disorders due to their effect on the circuitry of the brain. Tobacco use and schizophrenia have very high comorbidities. 30% of those with mental illness report smoking, which is about 66% higher than the general population. Yet 70% to 80% of persons with schizophrenia report tobacco use. This graph illustrates the prevalence of comorbid substance use disorders and serious mental illness. The red bar at the top looks at the percentage of adults with any mental illness and substance use disorder, which is 33.4% or 8.5 million adults. The bottom bar on the graph that's blue looks at those with serious mental illness and substance use disorder, 1.3% of adults or 3.1 million. 2.28% of individuals with serious mental illness have a substance use disorder. We'll shift now to look at the DSM-5 diagnostic criteria for substance use disorders in a little bit more detail. The DSM-5 moves toward a diagnosis for each substance based on a continuum from mild to severe. Each substance a person uses will receive its own diagnosis in relation to its spectrum level. The fourth edition of the DSM, the DSM-4, described two distinct disorders, alcohol abuse and alcohol dependence, with specific criteria for each. In 2013, when the DSM-5 came out, this integrated the two DSM-4 disorders, alcohol abuse and alcohol dependence, into a single disorder called alcohol use disorder with mild, moderate, and severe subclassifications. And I use alcohol use disorder as a prototype for all nine drug classes for substance use disorders right now. The essential feature of a substance use disorder is a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues using a substance despite significant substance related problems. An important characteristic of substance use disorders is an underlying change in brain circuits that may persist beyond detoxification. Substance use disorders in the DSM-5 include the nine classes of drugs I mentioned. Also includes substance induced disorders. For example, alcohol induced major neurocognitive disorder or dementia. Also included are things like intoxication or withdrawal symptoms. The DSM-5 introduced a non-substance related addictive disorder or gambling disorder. These are the nine classes of drugs included in the DSM-5 substance use disorders. Alcohol, cannabis, hallucinogens, inhalants, opioids, sedative, hypnotic, and anxiolytics, stimulants, which should be specified as amphetamine type or cocaine or other, tobacco, and then a category of other substance use disorders. This category includes things like cathinones, K2 spice, and research drugs. Cathinone is a drug that's similar to ephedrine and other amphetamines. More commonly we're seeing substance use disorders with K2 or spice, which are synthetic cannabinoids, which are psychoactive. Criteria across substances are parallel and we apply all these criteria to all substance use disorders. For a diagnosis, there must be a problematic pattern of substance use leading to clinically significant impairment or distress manifest by at least two or more of the following 11 criteria within a 12-month period. We'll go through those criteria in detail in the next few slides. Severity is established based on the symptom quantity. So mild severity would mean that the patient met diagnostic criteria for two or three criteria. The most common criteria would be four to five criteria and six or more criteria would yield a severe severity of the substance use disorder. Specifiers for remission are also available. Early remission from three to 12 months and sustained remission for 12 months and beyond. Opioid use disorder has another specifier for on-maintenance therapy, which Amanda will address when she talks about MAT. So if a patient has multiple substance use disorders, they may have different severities. For example, they may have a severe alcohol use disorder and a comorbid mild cocaine use disorder. Gone are the days of the DSM-IV diagnosis of polysubstance abuse or dependence. We can no longer use these diagnoses. DSM-V requires a diagnosis per substance with severity rating for each. The criteria are split into four sets. The first set is about impaired control. The individual may take the substance in larger amounts. There's a persistent desire to cut down. There's a great deal of time spent obtaining the substance, for example, being completely focused on drug-seeking behaviors, and criterion four in the set of cravings, which is cravings, which is a new criterion in the DSM-V, an intense desire or urge for that drug. Set number two, social impairment, including a failure to fulfill major role obligations, for example, losing a job or losing repetitive jobs, continuing to use despite having persistent or recurrent social or interpersonal problems, for example, having a relationship instability, and criterion seven, activities being given up or reduced. And set three is risky use, criterion eight, using in situations in which it is physically hazardous, for example, IV drug use or drinking and driving would fall into this category. And criterion nine, continuing substance use despite knowledge of having a persistent physical or psychological problem. And the last criterion set are pharmacological, including tolerance and withdrawal. Tolerance is signaled by requiring a markedly increased dose of the substance to achieve the desired effect. Withdrawal syndrome, symptoms occur when the substance is stopped or decreased. After developing withdrawal symptoms, the individual is likely to consume the substance to relieve the symptoms. Withdrawal symptoms vary greatly across the process of substances. These criteria are not necessarily considered for individuals taking stimulant medications, opioids, sedatives, hypnotics, or anxiolytics solely under appropriate medical supervision. In contrary to popular belief, a person who has tolerance only does not make them someone who is addicted or has a substance use disorder. If you only have one symptom, you don't meet criteria for a diagnosis. Similarly, a patient having just withdrawal from alcoholism, for example, does not make one an alcoholic or having an alcohol use disorder. More criteria are required to meet diagnosis, as well as the clinically significant impairment or distress. Let's look now at risky drinking. The National Institute on Alcohol Abuse and Alcoholism, or NIAAA, and SAMHSA, Substance Abuse and Mental Health Services Administration, have definitions of binge drinking, and both say that this pattern of drinking increases alcohol concentration levels and typically occurs after four drinks for women and five drinks for men. NIAAA says this happens in a couple of hours, two hours, and SAMHSA says on the same occasion. SAMHSA also has a definition of heavy drinking, which is binge drinking five or more days in the past month. Those four drinks for women and five drinks for men are measured on a standard drink size chart, which in no way guides alcohol service or consumption in real life. Let's look at this closely in order to quantify drinks accurately. One standard beer is 12 ounces of regular beer, and in a bar, most beers are served in pint glasses, which are 16 ounces. Pints of cans are taller than this and can be anywhere from 16 to 24 ounces. Standard bottle beers from 12 to 13 ounces, and a lot of craft beers, are sold in 22-ounce bottles. Malt liquor, eight to nine ounces of malt liquor is a standard drink. And let's look at wine. Five ounces of wine is a standard drink. In most restaurants, you'll see a six-ounce pour being the standard, and in a lot of places lately, I'm being asked if I would like a six or a nine-ounce pour. Standards are not matching these charts in real life. As far as liquor goes, a 1.5-ounce fluid shot is the standard, and pours are sometimes six ounce and sometimes, excuse me, 1.5 or two or more for liquor. Percentages of heavy binge drinking can be rather high. About 27% of persons 18 years or older reported engaging in binge drinking in the previous month. 7% of adults 18 years or older reported engaging in heavy drinking in the previous month. Again, heavy drinking is defined as binge drinking five-plus days in the past month. Alcohol-related deaths are the third leading cause of preventable deaths behind tobacco and poor diet and physical inactivity. In looking for prevention options, talking to your patients with serious mental illness about their substance use patterns is important. Using gentle, accepting language with motivational interviewing can be particularly useful in this population to decrease stigma, increase feelings of acceptance, and increase the likelihood that they will open up to you. Co-occurrences of alcohol use disorder and mental illness are reported here in ranges. These statistics are reported differently and often lumped in with all substance use disorders. So, when looking at anxiety and alcohol use disorders, the comorbid rates are from 20 to 40%. For major depressive disorder, 35 to 40%. For bipolar disorders, 5 to 61%. Alcohol use disorder and bipolar have a lifetime occurrence of 5%. In general, patients with bipolar disorder more frequently show comorbid substance use and anxiety disorders than do patients with unipolar major depression. Comorbid substance use disorders and anxiety disorders worsen the prognosis of illness and markedly increase the risk of suicide among patients with both unipolar major depressive and bipolar disorders. Who should we talk to about this binge and heavy drinking? This graph illustrates who binge drinks by age category. Individuals with comorbid psychiatric disorders are engaging in binge drinking across all age groups. Either 1 in 10 to 1 in 4 are binge drinking, depending on the age group classification. Serious mental illnesses are the chronic illnesses of youth, and those first two bars on the graph are very high. Working with transitional age youth with serious mental illness gives us the opportunity to screen early for alcohol and substance use disorders. Now we'll look at some of the screening tools available for risky substance use. Serious mental illness and substance use disorder screening and assessment are typically done separately. For substance use disorders, we'll talk about the tools above in just a moment. For serious mental illness, consider using things like the PHQ-9 for depression, GAD-7 for anxiety, the MDQ or the BSDS for bipolar disorder, which are all open source and available online. For adults, for alcohol and substance use disorder screening, we would start with the CAGE AID questionnaire. It is short and straightforward, and if alcohol is the primary substance, we could move on to using the audit, which we'll talk about in a moment. For adolescents, we would start with the CRAFT screening tool, and if it is positive, we would utilize the DAST or the BAST for more information. As far as urine drug screens go, consider shared decision-making and rapport-building with the patient, as well as the policies of the facility in which you're working. The CAGE tool uses an acronym of its questions, Cut Down, Annoyed, Guilty, and Eye Opener. It has a sensitivity of 70 to 79, specificity of 77 to 85 percent. A score of two or more is a positive screen on the CAGE. The audit, the Alcohol Use Disorders Identification Test, you'll see that here on the left, it has 10 questions specific to drinking with reported frequencies, sensitivity 83 and specificity of 90 percent. If you look at the audit question number three, it says, how often do you have five or more drinks on one occasion, indicating binge drinking? For adolescents and transitional-age youth, here's the CRAFT. It has three to nine questions, depending on the scoring of Part A. If the scoring is negative on Part A, then you do not need to move forward to Part B. Part B stands for the keywords of the six items in CRAFT, par, relax, alone, forget, friends, and trouble. A CRAFT score of two or higher is optimal for identifying any problem, with a sensitivity of 76, specificity of 94 percent. The DAST, or the Drug Abuse Screening Test, adolescent version, is here on the right. Use this with a positive CRAFT score. The 20 questions are more detailed and may be helpful in guiding treatment. It has a sensitivity of 85 and a specificity of 73 percent. The questions on the DAST include items addressing clinical impairment. Screening for alcohol and substance use in patients with serious mental illness is essential. Health-related outcomes of alcohol and substance use disorders include things like injuries, violence, STDs, diseases, cancer, and progression into serious substance use disorders. And now we'll shift to my co-presenter, Amanda, who will talk about looking at philosophy behind treatment approaches of motivational interviewing. So looking at some unifying principles of this, I want y'all to just keep this in the forefront of your mind as we're thinking about treating individuals with substance use disorders. Staying cognizant of these while talking to patients who may have issues with substance use will improve your rapport with your patients and increase the likelihood of moving them toward change or recovery. So we want to think of addiction and substance use disorders as medical diseases of the brain. They're similar and resemble other chronic diseases such as diabetes, heart disease, and asthma in regards to the genetic transmission, the relapse, and remitting course they may take. And people relapse because relapse or recurrence of symptoms is one of the core features of this and all chronic diseases and not a moral failing. Looking a little bit closer at comparative relapse rates of those with type 1 diabetes, asthma, and hypertension, you can see that, especially looking at that third bullet, 30 to 50% of individuals with type 1 diabetes and 50 to 70% of individuals with hypertension or asthma are at some point in a year are going to experience a recurrence of symptoms that's going to require them to seek medical intervention. And when you look at the same rates are true for those who have substance use disorders. This research came out of McClellan 2000 and it's one of the seminal articles that emphasize and further demonstrated that substance use disorders are similar to other chronic illnesses. And ultimately, when we recognize this, we can see that we set the bar incredibly high for individuals with substance use disorders, especially when we're thinking it's going to take one, three, five attempts to get into recovery and just stay there for the rest of their life. So we just want to be a little more realistic about the remitting and relapsing course of these substance use disorders. As providers, we, especially those who have prescriptive authority, can look into options for becoming wavered for buprenorphine medication-assisted treatment. And we want to make sure that we have an appropriate knowledge of the discontinuation or withdrawal presentation. And we want to make sure that we have an appropriate knowledge of the discontinuation or withdrawal presentation and the appropriate interventions for symptom management of individuals who are trying to come off of whatever their drug of choice might be. For example, I had a patient with alcohol use disorder who was seeking to go through withdrawal at home. She had presented to her primary care provider requesting as-needed medications such as something for sleep, maybe Vistaril for anxiety. And because the PCP didn't seem fully aware of the withdrawal symptoms, she ended up being diagnosed with bipolar disorder, which she does not have, and only prescribed Seroquel. So luckily, she was at a lower end of her substance use, so she did not end up having a seizure at risk. But if that had been another individual with higher alcohol use, that could have been a really catastrophic situation. Additionally, we wanna make sure that we have a strong referral network of individual and group therapy resources and knowledge of inpatient or outpatient substance use centers so that we can provide those to our patients if they need higher support and structure for their early recovery attempt. And of course, as I've mentioned before, we wanna understand the nature that relapses in all chronic diseases and work to normalize that experience in chronic disease management for our patients. So words are powerful, and language matters. So we wanna emphasize the medical necessity of the treatment and intervention choices that we're making for our patients. I mean, withdrawal can be fatal and is in fact a medical condition. So I might emphasize to a patient that they should probably go through a medically-assisted withdrawal rather than stating that they need detox. Additionally, I always use that my client has a substance use disorder, of course, emphasizing whatever their drug of choice might be versus calling them an addict. Now, I have plenty of patients that still refer to themselves as alcoholics or I'm an opioid addict or I'm a heroin addict, and that's fine, but I always remain in the disposition that they have a substance use disorder. When we use that language, it's more likely that they are gonna see it, that it's a disorder, a disease that can be treated rather than something that is like a issue with the individual. So how can we further emphasize getting these individuals towards change or improving some of their health behaviors? We can utilize motivational interviewing, which is a person-centered counseling style for addressing the common problem of ambivalence towards change. It has a relational component that focuses on empathy and joining with our patients, as well as a technical component, which helps us to actually evoke and reinforce change talk. So if we think about change on a continuum from thought, word, action, we're ultimately going for that second step at word. Ultimately, people initially think about the change they wanna make, then they start talking about it, whether it's to their family, friends, their providers, and eventually they make the change. Motivational interviewing allows us to evoke that change talk so that hopefully they'll get to the step of action quicker. Anyone who is interacting with an individual with a substance use disorder or mental illness can utilize motivational interviewing. MI can be implemented without formal training. However, I will suggest getting a training class to become more competent in the implementation of this clinical style, as well as getting comfortable with understanding where the flagposts may be and what we wanna hold onto so that we can kind of emphasize change talk further and not let it pass us by. So the core skills of motivational interviewing include ORS, open-ended questions, affirmations, reflections, and summaries. Open-ended questions are the who, what, when, where, how? We generally, as a rule of thumb, want to avoid why because generally most people don't know why. So I'm not gonna ask, why are you continuing to drink versus what would be helpful to help you get into an early recovery episode? Or how might we go about decreasing your alcohol use? And it helps further strengthen our collaboration. Affirmations are used to recognize, support, and encourage a person's strengths and efforts. I must note affirmations are not praise. So I'm gonna use I versus you statements. Rather than saying, you're doing great, which is somewhat superficial, I might say something like, I can see you're making a lot of changes in your life to decrease your alcohol use. So I'm actually taking a real example from what they're doing and recognizing it so that they can feel like I'm really seeing the efforts that they're taking in their early recovery. Reflections keep the individual talking, exploring, and considering. They can be simple or complex. Even as a person, I use motivational interviewing on a daily basis with my patients, and I still frequently go to those simple repeating or rephrasing what my patients say. And more often than not, they'll correct me if I'm incorrect in my repeating or if I've rephrased something incorrectly. Summaries ultimately pull together multiple points of information to help emphasize certain elements of their narrative. So I mentioned those flag posts that we would look for while talking to patients about change. So that's DARN, desire, ability, reasons, and needs. Within the course of talking to your clients, they might naturally start saying something along these lines. You know, I really wanna stop smoking. I've quit smoking or quit drinking before. I can probably try again. And those are what I'm gonna try to hold on to and have them emphasize. However, many of us probably know that there's plenty of cases where patients don't demonstrate any of this type of language. So that's where clinicians might use questions that actually further evoke that type of language, such as how would you want things to be different? How confident are you if you made up your mind? What might be the good things about quitting drinking? And again, you can kind of see in those questions, I'm still using that who, what, when, where, how, and there's no why in there. Sometimes, because we don't have enough time for it here, you will see DARNCAT. The other acronym is C-A-T, which is commitment, action, and taking steps. While I don't have time to cover it here, I do emphasize or encourage that you look for opportunities to get further training because they can go into more details on other signposts that you might see in patient language to evoke change talk. So how are we gonna respond once we see one of these flag posts? Fortunately, although we have another acronym, it's very similar to our first one. So we're gonna get them to elaborate. We're gonna affirm those desires, the ability, the reasons, and the needs that they're stating. We'll reflect on what they've said, and also we are gonna summarize so that we make sure that we got the major points in context of the conversation we've just had. So within that elaboration, again, we're gonna use the who, what, when, where, how, and it's gonna provide additional detail or clarification, or may even ask them to give an example of what they're talking about so that we make sure we're on the same page with our patients. I've already discussed the affirmations, reflections, and summaries, and they're actually not different here when we're responding to change talk. So just keep in mind, you can keep it simple for those reflections. Affirmations are not praise, and summaries are gonna pull together multiple points of content to really emphasize the most important points within your conversation with your patient. So while we're using motivational interviewing and considering our treatment options for our patients, we really wanna understand what their goal is. While in a perfect world, all of my patients would go into abstinence, I understand that there's times where that's just not what their goal is, and I can't, I'm not gonna be paternalistic and push that on them. And also the APA emphasizes that the initial goals of treatment of individuals with substance use disorders should be agreed upon by the patient and the clinician and documented in their medical record. So some patients might be ready to fully take on abstinence, others wanna reduce how many days they have abuse, and even harm reduction has to be considered a win. So if I have a patient who is using IV heroin, if I can get them to a point where either they're not using IV or they're not sharing needles or they're keeping a Narcan rescue kit with them, I still consider that a win and I'm moving them more on the spectrum of change and getting into recovery than purely saying, if it's not abstinence, then we're not doing it. Questions you might wanna consider to really understand context and help guide what treatment decisions you'd make would be, when was your last recovery attempt? What's your longest recovery episode? What worked, what didn't work? Did you take medications to assist you? Was that helpful or what didn't work in the past? And what supports do you have in place currently to help you in your new recovery episode? So the Comprehensive Addiction and Recovery Act, I just wanted to provide you all this information so that you understand that within the last 10 years, we've had a big push legislatively that have infused the system with more money to support those with substance use disorders, specifically coming out of the CARE Act was providing the buprenorphine waiver to nurse practitioners and physician assistants. And then more recently, the Support for Patients and Communities Act has extended the ability of that waiver indefinitely, which is huge. So moving forward, we really wanna consider medication-assisted treatment for our patients with substance use disorders. MAT is the use of FDA-approved medications for the treatment of substance use disorders. And it's best if it's combined with counseling and behavioral therapies for a whole patient approach. We should really start to consider these options as first-line treatments. They are. Rather than having my patient with an alcohol use disorder go through one, two, five, 20 relapse episodes before I'm gonna suggest them being on a medication, I'm gonna do that from day one when they're requesting how they might more effectively get into a sustained recovery episode. Additionally, these treatments are appropriate for individuals with SMI. So here I have listed, we're gonna specifically talk about opioid use disorder and alcohol use disorder, and the medications that are FDA-indicated for those. As you can see on this list, naltrexone is indicated for both alcohol use disorder and opioid use disorder, so I'm gonna save it till the end to discuss. Starting with alcohol use disorder, we're gonna cover acamprosate, desulfiram, and naltrexone. Acamprosate, or Camprol, its mechanism of action theoretically reduces excitatory glutamate and increases inhibitory GABA. Withdrawal from alcohol following chronic use can lead to excessive glutamate activity and deficient GABA, so that's why this medication would be particularly effective as an individual is coming off of alcohol use. Some of the side effects include diarrhea, nausea, anxiety, and depression. I wanna highlight, since we're discussing SUDs and SMI, that one of the major warnings is that it may cause suicidal ideation or behavior. So if you have an individual who either has a mental health illness that, like, major depressive disorder and is predisposed to that, or has a history of having suicidal ideation or behavior, you'd wanna avoid this medication. Contraindication is severe renal impairment or allergies, but one of the pearls is that it is not hepatically metabolized, so it's particularly advantageous in those chronic daily alcohol users who may have done some liver damage, and you might wanna consider it if their liver enzymes are out of range. Desulfiram, or Antabuse. Mechanism of action is that it irreversibly inhibits aldehyde dehydrogenase, which is the enzyme involved in the second-stage metabolism of alcohol. I'm sure quite a few of you have already heard of this medication because it's been around for a really long time. So the individual takes this medication daily, and if at any point they end up consuming alcohol, they have some pretty negative effects, and they experience flushing, headaches, nausea, and vomiting, with the ultimate goal to create this negative conditioning. We don't want the positive effect of drinking alcohol to be a factor any longer. One of the warnings is that it can lead to a myocardial infarction, or congestive heart failure, or respiratory disease, so you wanna keep these in mind, and you definitely wanna check liver function before starting. Also, it cannot be started in an individual. They have to be at least 12 hours after their last drink. Another big highlight, since we're discussing co-occurring serious mental illness and the substance use disorders, is that if your patient has a history of psychosis, or is on Zoloft, you should not prescribe this medication because those are contraindications. So moving on to opioid use disorder. We have methadone, buprenorphine, and naltrexone. Some of the settings that you're gonna see these medications prescribed include inpatient treatment, such as detox, residential, PHP, outpatient settings, and opioid treatment programs. I have an asterisk there because specifically for methadone, that one cannot be prescribed in an outpatient setting purely for opioid use disorder. It can only be prescribed and administered through an opioid treatment program, which we commonly know as methadone clinics. Also, depending on the state you're in and what role you might be playing as either a clinician or a prescriber, there's certain laws around practice that might dictate what you can and cannot prescribe. So for roles, we have nurse practitioners, PAs, and MDs, which are our prescribers. Our RNs are gonna be administering the medications and on the ground doing our assessment and our social worker and case managers are helping us with referral, treatment planning, and therapy. So methadone is a full mu agonist, which produces similar effects as morphine, but with a longer onset and doesn't have any euphoric producing properties. It is most appropriate in conjunction with appropriate social and medical services, and that's why it's only allowed to be prescribed and administered through those OTP programs. Common side effects are similar to other opioids. Major warnings are that it's a Schedule II medication and it can cause prolonged QT intervals, so you wanna keep that in mind with the other medications you might be prescribing, and you really wanna be mindful if your patient is also prescribed a CNS depressant, particularly benzodiazepines. Buprenorphine, we've been kind of talking about throughout, so this is the one that as a physician, nurse practitioner, or physician's assistant, you would need a waiver to be able to prescribe. When it's purely buprenorphine, it's subutex. When it's in combination with naloxone, it is suboxone. It is a partial agonist that binds to the mu opioid receptors and prevents the exogenous opioid from binding, which prevents pleasurable effects of opioid consumption. I commonly, if I'm prescribing this in an outpatient setting, I'm gonna prescribe the suboxone because it decreases any abuse potential. Subutex or buprenorphine on its own does have the chance of being abused. Side effects are very similarly in line with other opioids, so headache and constipation are gonna be most common. The biggest warning is that it requires abstinence from the full agonist before your first dose, and ultimately, there's very specific criteria on how you initiate this medication and why I would encourage getting the waiver so that you can, even if you don't think you're gonna prescribe it, that you understand how it's supposed to be initiated and how it should be taken by any patients that you might have coming in on it. So naltrexone, this is the one that is covered for both opioid and alcohol use disorder. It is an opioid receptor antagonist and ultimately sits on those receptors and prevents the pleasurable effects of any exogenous opioid consumption while also modulating that system, which helps to decrease the reinforcing effects of alcohol and opioids and also helps decrease cravings. As my practice goes, I'm generally encouraging individuals with the opioid use disorder or alcohol use disorder to start here, particularly if they have insurance and they can get the Vivitrol because they're gonna be covered for a month. One of the common issues I have with the other medications is that since they're oral, they are discontinued. So having a once-monthly injection makes it a little easier and less likely they'll discontinue as well as, I mean, who wants to take a medication every day? One of the major warnings is that patients may attempt to overcome the blockade and start taking larger amounts of their opioids. So you'd wanna know that in their history if they've ever done that in the past because if they have, this would not be an appropriate medication to start again. And contraindications are also any hepatic issues. So you wanna make sure to check their liver enzymes. As a general rule, they have to be at least three times outside the normal to not start. So you still have quite a bit of range, even if they're a little outside of their liver function test to start this medication. Wanted to briefly touch on naloxone. We don't have much time here, but this is ultimately our rescue medication. It is not used as medication-assisted treatment, so they're not gonna take it daily. But any individual that has an opioid use disorder or is using opioids or heroin, I encourage to have on their person at all times as well as encouraging their family members to keep this on them. In Texas, we have a standing order that allows any individual, doesn't have to be the person who has an opioid use disorder, to go into a pharmacy and request this medication. Also, our standing order allows that the person who prescribes, dispenses, or administers the naloxone are protected from liability. One of the major notes should be if someone goes through an overdose, needs the rescue Narcan, that emergency services should be engaged immediately because even if the Narcan gets them out of the initial overdose episode, over time, the Narcan will wear off. And if they've taken a large amount of opioid, then that can still come back in later and put them back into an overdose situation. So you wanna make sure they're getting medical treatment. So some treatment considerations. Do we treat the SMI or SUD first? General rule of thumb, we're gonna try to treat the substance use disorder first because if an individual is actively using any substance, it's gonna be very difficult to get them on a regimented treatment for their serious mental illness. Ultimately, that's gonna be dictated though on other factors. So if someone is actively suicidal, then of course we're gonna wanna address that first. And it may in fact come in combination of treatment of their substance use disorder and their mental illness in an inpatient setting at the same time. Additionally, we wanna think about where patients are in the recovery status. Even if you're an individual who is not actively treating those with substance use disorders, always asking about their substance use history and if they're in recovery so that you're not putting some of your treatment, your treatment doesn't put them at risk for a relapse episode. And always make sure to check your prescription monitoring program. Substance use disorders are complex and frequently comorbid with other mental illnesses. So if an individual screens positive for substance use related issue, we wanna make sure that we're referring them to mental health services and getting them a full psyche valve, which may reveal co-occurring conditions that might influence the selection of which pharmacotherapy we're choosing. And finally, as we've said, substance use disorders are a prevalent problem in the United States and very few individuals receive treatment. Motivational interviewing is particularly effective at helping improve change talk and health behaviors in those with SMI and substance use disorders. MAT is an appropriate first line option for some individuals and should be considered. And ultimately, nurses also have contact with individuals at every point of the recovery process. So we really wanna think about our ground people and who are eyes and ears for our patients and making sure we're taking a full interdisciplinary approach to treating these individuals who have these co-occurring issues. Thank you.

Amy Cohen

SMI Advisor

Amanda Simonton

Dr. Donna Rowland

substance use disorders

serious mental illness

DSM-5

medication-assisted treatment