Good afternoon. And thank you for joining. My name is Andrew sachs and and the and on behalf of the American psychiatric association welcome to today's webinar. The connection between mental health and opioid use disorder. Today's activity is presented on behalf of the samsa funded providers clinical support system. A program that is operated collaboratively by nineteen medical. Specialty organizations including the APA. Please note that following today's presentation. You will receive a follow up email within one hour of the webinar. This email will contain the instructions to claim your one credit hour for attending. This activity offers c e credit for physicians nurses nurse practitioners pharmacists physician assistants and social workers. Next slide. Please feel free to submit your questions throughout the presentation by typing them into the question area labeled a few and a at the bottom of your screen in the attendee control panel. Will do our best to reserve ten to fifteen minutes at the end of the presente nation for two and a. Next. Now i would like to introduce you to the faculty for two days webinar dr Mark Duncan. Dr Duncan is an assistant professor at the university of Washington. The department of psychiatry and behavioral sciences. Doctor Duncan's career has been largely focused. On the intersection of mental health and primary care having been trained in both family medicine and addiction psychiatry. He currently practices in very this integrated care settings as a consulting psychiatrist and in the outpatient adult psychiatry clinic and i will say on a personal note and. Dr Duncan. Is a graduate of the addiction psychiatry fellowship that i was the director of at that time and a close colleague of mine in the department where we are elaborating on research so i'm really thrilled to. Have a dr Duncan here today to him. A present on this important topic so odd dr Duncan please proceed. So again thank you for the a generous and warm welcome Dutch sections great to be here. So i and. So I'll be talking about the connection between mental health disorders and opioid use disorders. And i think hopefully by the end of this of. Activity in a warm feeling good idea of the prevalence between these two. I will talk about why these commonly called her and tugboat and have a good idea about the impact they can have in a. And then a few a next steps as far as a how to. Do i think about addressing them. Alright so to start off. Just kind of a quick little poll hear how common. Do you all think is the co-occurrence of opioid use disorders and mental health disorders. And the kind of take that into the little the the. The this the quiz l kind of pop up to twenty five twenty six for thirty seven. Fifty one to seventy five seventy six to one hundred. Alright. Okay so good so there's a. There's definitely a clear recognition that. This is commonly seen and it doesn't take long if you're practicing in this. Clinical area to see as overlap. On a common basis for a pizza from any of your Patience. When you look at the actual numbers and this is a survey data. From the national survey on drug use and health by Samsung from. Twenty fifteen twenty seventeen of adults as they had. They surveyed one hundred and seventy thousand and they've. Let their and those who had. Opioid use disorder were about fifteen hundred of those they looted from of those how he had mental health issues. So you see a bit of arrange if he have serious mental health. Illnesses in the past year you're close to. Twenty seven percent of any mental health symptoms though is over sixty four percent. And when talking about what is a serious mental illness they're basically. Of this is a perfidious and for basically. Just described a serious functional impairment that would interfere or limit with one or more major life activities. So. This does not necessarily mean that this would be just people with schizophrenia or maybe bipolar one. Or some of the other. Or just severe like psychotic depression as you might think of as being like the most severe this is. This could be just anything that awesome cruise PTSD your depression but the bottom line is is that they're very common and you're going to see them arguably the plant where you work in the majority of your patient population so it's good to have a clear understanding of the relationship why are we seeing this. And do and what are the impacts is going habitats the on treatment. For you look at some of the specific. Mental health disorders in oh you do you want to draw your attention to the red lines those are people with all you deed. And you can see the ones that really kind of trend over to the right there and that includes are the ones such as depression anxiety. PTSD kind of in the middle that eighty one. Point one percent and then. Eighty hd and then there's a separate category in there which includes antisocial personality disorder and borderline personality disorder. So you know if he sometimes is going to be hard to know like what is what should i be looking for. A at the very least i would argue you're going to be why looking for depression anxiety and. But also not far beyond behind that is your grandma look for eighty hd and. PTSD cause again they're going to have the most significant they're going to some impacts on overall treatment outcomes. For both sets of symptoms. Now per personality disorders and. Without the treatments for those we. Can be very effective they are offered little bit harder to. Access for people especially around the expertise of the therapists. That is often do he did. And they more challenging to diagnose. So while i when i would not. Suggest as you want to ignore anything. In those categories and it's just there to treatment is this little bit harder to achieve and but it's good to keep in mind that he had even though you may have. A pretty wrote a pretty good a treatment plan around depression or anxiety there may be some other things going on like and a social borderline. That those treatments are not going to be addressing and so just kind of keep have some awareness around ad and a think through what are some potential options if you have any in your community around address he knows. All right now in addition to mental health symptoms and in particular i want to highlight suicide. So what we know is that. Suicide. Obviously. Is a very severe. A. Thing that is coming out as you commonly see a mental health is whereas across. Many mental health disorders it's not just depression we see people at higher risk for suicide with PTSD higher risk for suicide and in anxiety disorders. Obviously also as schizophrenia bipolar and so forth. I so a suicide and mental health disorders are. Something you that should be always on your radar now what about within the context him an opioid use disorder. Is what is the the level of suicidality there are certainly at this was from a national vital statistics. A system that looked at death certificates from two thousand and two thousand and seventeen and what they found was at and now these are desperate difficult so you know there's always going to be potentially some miss classification and occurs here but the they saw the following trans one of which that unintentional does increase which we all are aware of and actually been highlighted in the opioid. And and drug overdose deaths numbers that we've seen even more recently was continue to grow. But we also saw that there was an increase in and in the number of suicides although the percentage of that up from the overall. Overdose deaths was little bit lower but look at the rate of suicide per one hundred thousand. That went up. And then i kind of in addition to that we saw that there is an increase we see that within the oh you the context and this is a and data from twenty fifteen and twenty twenty national survey on drug use and health. Which is a nationally representative cr cross-sectional survey of people over twelve. We saw that people with odi and this isn't a colored category have increases. Levels of suicidal ideation. Increase levels of planning around suicide an increased levels of attempts that are all statistically significant. So in addition to seen an increase la levels of mental health symptoms in disorders we also see higher levels of suicidal ideations and attempts. Something that we definitely do not want overlook and I'll talk about that a towards the end about you know how do you look for that and were some things to consider. But it is something you want to keep in mind from the get-go. Because has. Your when someone's substance use in a particular and also o u d of course. Is not being treated. Yo asking about this that instability is still there you know until. Hopefully you know you kind of get their substance use more stable and you're helping them how to enter into kind of a maintenance phase where we're thinking about ojo de treatment. But. It's something that some should be a definitely part of your a review system is when you're. Tight with people that are entering your program. Alright so let's shift gears little bit and talked about the impact of mental health disorders and o u d treatment so again a is going to pop up. What do you all think is is kind of limited really treat Delia d s mean problem we're kind of thinking that this is a and and. You know this is just substance induced what about treated or maybe it's it it's sick inefficient you need to treat them at all disorder as as kind of a. Self medication hypothesis and maybe we just need a kite use higher doses of buprenorphine there is no evidence there around you know it's potential for depression. PTSD symptoms. Or maybe we really need to think of this from a more integrated care approach. Alright integrated care of her it's alright good we are definitely in sync here. You know when you think about someone's and. You know how people are presenting to you what is going on with their lives the mental health symptoms oh you the symptoms these are integrated within their person in i'm as. Not going to get into why that is occurring. But we really need to kind of think of them as from an integrated care approach and not necessarily a step wise. Another are a couple of steps with a highlight but in general we want to keep this integrated. Care approach at the forefront because that is really. Going to i'd be most beneficial for people. Alright. So what are some of the impacts of mental health disorders and or you d treatment as so this is. A secondary analysis in the large study called the start to. Study. Start a treatment with agonist replacement therapies this was at nine federally licensed on period treatment programs. They had seven hundred and forty people on buprenorphine a started five hundred and twenty nine methadone is from oh six to one nine so. You know that if you know a few years ago still but i think it's very relevant. And a looked at people over five years and they saw the advertisement trajectories in for groups those who had no mental health disorders. Those who had anxiety disorder which they also included PTSD and because at the time or PTSD was kind of come together with anxiety disorders in the dsm. Major depressive disorders and bipolar disorder so what did they find answer the outcome so what about more once in treatment. Always found that to be saying that people interestingly with depression seemed to be intrigued me and for longer than people with no mental health disorders although that is a little bit of an inconsistent finding when you look at some of the other studies but there is something there. That they are these people are kind of speculate that maybe. You know. Be a with depression have some. More motivation to change their opioid use if they're seeking treatment and so forth. And. The also what about more opioid use or so they saw some trends across. These different categories but it was really only significant for bipolar so you can see some. Where do you think about mental health disorders some. Increase the in opioid use potentially when their entry treatment. But across the board. For all of these categories you saw a greater symptomatology around addition symptoms. Psychiatric and physical health symptoms and jump in general poorer quality of life. So while they are some interesting the of maybe people with mental health disorders maybe there is reasons why they're engaging a little bit longer and. You know how unstable as or opioid use going to be once and treatment may not be. And as. As a sure thing but in general they're they're going to struggle and treatment due to just persistent symptoms. That. You're just kind of treating their o u d is not going to necessarily address completely. Now what about eighty hd and know pat you on the other side i imagine that eighty hd is. Fairly is jan one of the common disorders you're gonna want to look at and there's a few reasons and it into a few reasons why you want to pay attention and in here they are one of which is we see earlier answered a substance use yet longer duration of active as you do you use more frequent have you ever use patterns you know there's a lot of executive dysfunction is occurring within a within eighty hd. And a lower difficult and more difficulty achieving remission. Lower retention rates. It's just harder for people with eighty hd especially in an untreated eighty hd to engage and stick with treatment. As you might expect and they have of you know people of Haiti hd have problems sticking with school sticking with their jobs sticking in relationships. This is comes out in su di treatment as well and makes it and makes a strong case for really looking at this to see what you know how we can help these people. What about treatment of eighty hd and mega talked a lot about treatment in general but i do want to mention this as because oftentimes when you think about when we thought about treating eighty hd and. In as you d we we always relate it. I always thought of and often light well. Let's get their substance use disorder. A you know kind of stabilized and you know avoid stimulants in i lesser a thing and i have kind of progress little bits where. I have found stimulus potentially it'd be very helpful and this is kind of backed up by some. Data here that i'm highlighting one of which are that it the treatment including stimulants lead to greater long term retention. And that interestingly idiots the med treatments were better predictors for retention even them buprenorphine in this particular study. Individuals receiving no eighty h demands. Were almost five times fold increase in attrition at ninety days. Which again we were seen earlier that it's just harder for people to kind of stick into treatment. If they're hd is not addressed. Alright what about can have already impacting mental health disorder treatment. So you know if your idea is not been. Appropriately addressed you're going to have missed foul of poor psychiatric met inherent therapy. Could there could be a lot of therapy interfering behaviors and you could have the effects of the substances and the psychiatric symptoms general the intoxication withdraw cycle that people go through and so forth so a takeaway from this at and again this a. What am i i will. This is kind of that step wise treatment that i was at addressing a. Addressing to you are just a minute ago. When you're thinking about. Addressing a working with someone who has lady and mental health disorders. You know you're going to want you. Get their oil d treated first with medications. Or you're gonna want to monitor for their suicidality and but soon after starting a treatment you know and i'm think this is a post induction you know what i mean my own clinic i'm thinking this is certainly i'm asking about suicidality and safety issues but by week to when i'm seeing someone back to see how things went your i'm going to be looking in do it equipped a closer assessment on their mental health disorder symptoms as well and i'm going to I'll highlight a little bit later about the use of screeners in this particular contexts. I would argue that you don't wanna wait for some lenses enter kind of a maintenance phase around there ojo d treatment you want to be thinking about this very soon because those untreated symptoms you'll be proofing is great but it's not a treatment for anxiety disorders that treatment for PTSD. You know is that of there's that robust evidence for us effectiveness around depression in. Some of you know and so you need to think about what are we doing and looking for how severe the these symptoms and what can we do to help the person. Address the symptoms so that they stay engaged. In they. Are increasing their functional and getting to their goals as around treatment. Alright so in recap so he saw that msg in oil the freeway coworker. We saw that. See of odi put people at higher risk for suicide he can complicate the treatment course. It can lead to worse worse symptoms and quality life. So why do we see this overlap. Here's another kind of pole as see what people think. As a genetic vulnerabilities is a common brain areas life stress substance induced. Disorders a b c maybe six none of the above. Alright so lots of five options one two and three and i would argue that that is correct and when it was kind of walk through a few of those are right now. Ah. Alright so what are some has shared risk factors for mental health disorders in oh you do. There are six these were highlighted in a very nice night a report of on a team that i'm going to kind of expand on a little bit but i thought he did nice job kind of companies. Ah so they include things like genetics epigenetics environmental factors b main region stress and isas there is some overlap between all of these of course. But i do we are going to do kind of want to highlight each of these as well. Alright so what about genetics. So. It's pretty clear that there is a significant level of heritability of as Judy's now for context i put depressive disorders here as well and for eighty hd and. A and opioids in particular about fifty percent. Why is that why do we. Overlap because there's a significant amount of. Overlap in the James that are involved in the systems that those genes are involved with so if you look at now i have not listed all of the systems that these are involved with when it comes to behaviors and mental health disorders and substance use disorders. They are very complex behaviors there's lots of genes there's lots of of. Brain says items. That are involved with the ultimate manifestation and so forth but here is just a kind of a general recap so you have opioid receptors or that are involved. And. You know the you article power people responding to or your receptor is how are people responding to. Reward systems dopamine receptors and. Neurotrophic factors neurotrophic factors are involved for. Growth survival differentiation of the neurons and in substance dependence they can be. There thought to be a result of and impacting. Synaptic plasticity and and as to some of the learning behaviors and a come round and and more so we see a significant amount degree of genetic systems that are overlapping here. Now what about genetic factors. Are so. I epigenetic factors so. In general epigenetic factors refers to the study of changes in the regulation of gene activity and expression. That are not dependent on your gene sequence so yeah there's going to be some sort of environmental pressure. They're going to impact a host of systems that are involved in the expression or. The regulation of jeans and that can change how those genes are expressed are regulated which ultimately will lead you behavioral changes. Some of these. It gets very complicated i and i am not a geneticist. But just to highlight some of the systems are involved the include things like histone modification hydride snowflake one and so forth you know what are what are what is histone modification histones of the know to kind of go back into you are. Biochem. Lectures. From school. Those are involved with condensing the your DNA material. They're kind of like spools at DNA gets wrapped around and depending on whether the how these are modified they can loosen up. Your diet you know kind of that spoiling of DNA or they can tighten it. Which is going to have the impact. On do you know. How things are replicated you know gene expression of proteins and so forth which ultimately the to behavioral change. Now if you look at for example the depression and o u d. You can see that epigenetic factors are can affect similar regions the brain so your frontal cortex your nucleus accumbens. Your hippocampus and your reward center and you don't you think of the the frontal cortex you know that's couldn't you ultimately have issues around. Motor tasks judgment abstract thinking creative creativity. You think of the nucleus incumbents. That's info stated in a lot of you know around motivation emotional processing and and olympic motor interfaces around certain like psychoactive drugs. Are so all of these areas are can be affected. By. Epigenetic mechanisms. In effect kind of brain plasticity. From environmental forces. Now what are some environmental forces that can put pressure on those epigenetic factors. They include things like economic stability there could be things like employment was insecurity housing instability poverty education access. You know early childhood access to. Preschool in. Environment enrollment in highschool highschool graduation so forth healthcare access to your neighborhood. So you know what level of crime violence quality of housing. Access to healthy food. Social issues with it as a civic participation discrimination incarceration social cohesion. These are all on their own. Risk factors for the development of mental health disorders and or u d and so again rest and then these are going to be have an impact on a be genetic factors and which are all kind of in the context of these underlying genetic factors with puts people at risk. One thing i will highlight about cities environmental factors. Is you know it's going to be important to think about how do you address these. Be. With any with any given person in order to help both their mental health symptoms. And their. Ojo d and the speaker case where substance use disorders. At large. What about neurobiology and so again we've kind of I've got a little bit over this with just how the epigenetics can impact. Some of these areas of the brain but if you look at just depression neurobiology you have regions that are involved that the frontal longer thalamus try it on pair of private law hippocampus you have difference circuits that are involved your prefrontal sub cortical circuits prefrontal hippocampus all hypothalamic circuits neurotransmitters dopamine serotonin go. Could make and so forth. These are also a plane a role in or and it can be affected. By substance use. And. You know you again do you think about. Some of the neurotransmitters in particular the reward systems and the endogenous opioid systems of the of these are these neurotransmitters are involved in these circuits. That are impacted by exogenous opioid use. So let's look a little bit closer at that and protect color. So you know anything about endogenous these are opioid since your body makes itself. That are used in. Regulating. Physical pain. Pain a social rejection. Reward system and so forth. But if you look at in particular depression is social rejection and endogenous opioids are you know. Are playing a role in that if you experienced and you're going to have potentially reduced opioid release and slower emotional recovery of these. Of these symptoms now in the case of exciting opioid use in the context of and o u d and that's going to help replenish some of that reduced opioid released that is happening in the occurrence of these mental health symptoms and disorders and that's where you know people are going to that's where this kind of self medication hypothesis comes from. That's when people will tell you that you know i need my opioid these opioids to address the depressive symptoms. That i'm dealing with or whether that although hall kind of take your pick. But all of this is kind of. Is. Is connected in what we see as a mood disorders. Increase the risk of transitioning from short term up your treatment to launch a mulberry this is from from some of the the chronic from some of the paint literature current mood disorders initiate people current mood disorders initiate of who is it more commonly slightly more commonly. In that increased dose and duration of over your treatment has been associated with developing depression so receive. Again this back and forth. That mental health symptoms are putting people at higher risk for developing a period use disorders and that operate treatment on his own. Can impact the development of depressive disorder hers and symptoms. Now what about stress and so. Stressed by definition is a processes and involved perception appraisal responsible harmful threatening or challenging events or stimuli. These can be emotional. Physiologically challenging are accurate activate a stress response and then you're going to have adaptive processes to help regains in at home sit homeostasis so. As we saw just in his previous slide how do. You know social rejection and some depressive symptoms can lead to lower levels of endogenous opioids. To have regained some that homeostasis those exogenous where the whole appearance of people are using. And from outside the body are going to help. Potentially at least temporarily achieve some that homeostasis. Stress in. Many areas of the brain. Such that involved in things like learning. Motivation and a patient. Impulsivity stress is played a role it alters dopamine pathways. So again this is kind of highly lighting you know. A potentially the the role of that epigenetics that i was mentioning and then the risk factor for developing mental disorders goes up when people are under stress. And then childhood and and or since a trauma and adverse childhood experiences or aces and we know that trauma general can increase the risk for substitutes disorders and mental health disorders. Five veterans with PTSD has a co-occurring substance use disorders. If you look at childhood it. Evers childhood experiences in general this is from a retrospective cohort study of eighty six hundred adults. Who had experienced five or more adverse childhood experiences in those experiences include things like emotional and physical or sexual abuse domestic violence household dysfunction. Among other things and they are are at higher increase their increased risk for development of substance use. Increase risk for development of mental health disorders. Up to eighty percent of people with o u d have and. Sniff sniff hit level of aces. And forty six percent of only the patients have three plus aces fireplace aces seven to ten percent increased likelihood of stds. So we're seeing this yeah again another kind of overlap aware. Going through these adverse childhood experiences is putting the people at risk for both of these. And again you know there's. There's probably a lot going on there from some of those environmental factors. Stressors that people are dealing with the epigenetics and the underlying genetics and became she has prevention. You know you think about. Your. Unforeseen people obviously if you as you're and adults they've already gone through these and but you know if you are it in a clinic system where you are working with kids and or adolescence and who may be experiencing at the moment or or may not in the one. Trying to assess. People's risk for this and potentially helping the president. Pence potentially change the trajectory. Could really impact. Some very severe consequences. Of that aces lead to. Alright so again to summarize we see that they're frequently called Corinne. Higher risk for suicide. It can complicate or the treatment course it can lead to inc worsening of symptoms were both mental health and psychiatric. In the reason is because there is a significant overlap in devel but mental causes in risk factors and so honest honestly of surprise when i come across someone who does not have some sort of co-occurring mental health disorder. And. Just due to the fact. That their risk for developing symptoms is and if is is so higher. Unfortunately there is a huge treatment gap. And seventy to seventy five percent will not receive both mental health and as you need treatment. There are some risk factors for who has even lower eyes of receiving treatment and why is that and human resources so just kind of workforce issue use. The infrastructure of your of your program of your team do you have conditions that can and. Evaluate and address somebody had been a hall symptoms does your does your team assessing for mental health symptoms in addition to their substance use. Collision participation their knowledge base. There and. You know. Appreciate you all joining the us to try to kind of. You know. Develop a deeper knowledge based on this and i encourage you all to takes some in his back looking your own programs and and try to work with your colleagues in order to help. Bring this up. A. Implement more of these sorts of things in your program if you're not already. Access to specialty services such a psychiatric care is always very challenging and and. Structural racism a treatment systems. The list could go on with there's many reasons. That this is going on. Honestly though i don't get too discouraged because of. It's not like all it's not like he had to focus all your attention just and one there maybe a multiple different things and starting where and sometimes at the lowest hanging fruit and you know to try to. Wherever they happens to be able to program you know is is going to be better. Than. Nothing. Alright so. Here is a case as. Is a question valve after this to twenty six year old male with will you deep is now Teresa in the treatment in the patient continues to admit to using federal one day a week despite reports taking twenty four six. Of buprenorphine last one. Fortunately he has been shown up to appointments on time but when you kind of dear assessment is mood poor he looks tired. Mildly disheveled. Are you expect things that kind of be starting to turn around and little bit better mood. Maybe but that are self care i need just endorses just feel like he's barely making it in life. Alright so what would you do next you know you could screen him for a mental health disorder alarmed you further stabilizes is only two weeks you know maybe maybe wait for six weeks or for. Refer empty mental health clinic. You're concerned about that and screen him for additional substance use ask him why he is using federal and still. Still an address at and. And or referred again fewer mental health clinic you obviously don't don't care six there. But where would you start and yeah there's there's plenty a few right answers here. Alright. Yeah so in general most people felt the screen 'em for mental disorder good or again where i feel like we're in sync here this is exactly the direction i was hoping to. Add that i will be taking you all. Some people thought about further stabilization and i you I'll say that certainly. That definitely happens you know if they're still awesome ongoing federal use you maybe you know is he taking all of the buprenorphine your prescribing. You know maybe he's kind of getting into that steady-state still. So i don't think that whatever. Stabilizing effects buprenorphine has that those are completely finalized at this point. So that may continue to improve refer him to a mental health clinic. You may think that it's always good to to think about that you know i i would. Kind of just suggest starting off just to see if there is a mental health disorder going on here first. Screen for additional substance use. Definitely want to do that. You know your you see. You know at least out here in Washington we see alive ongoing Matthews you don't make you know is has the Matthews tapered off or the instrument meth withdraw you know or you know who knows. Some other substances that are going on. Ask about. The ongoing federal use you'll definitely want to do you mean you'll you'll do all of these. Sorts of issues and. And but i want to highlight in particular the screening. I think that that's something you definitely. That made people may not always think about although you all did which is great. But something you don't want to overlook so as profile follow from this case and have endorsed no other substance use number of the medical issues stable housing good source of support and but he did screen. It did screen him for depression in his scores and ninety nine twenty seven. His number nine at which is the question around self harm or feeling better off or wanting to be better are feeling like you'd be better off dead it was a to out of threes as. I definitely concerning and and you know so then you'll think about you know is a pansy using man's therapy suicide safety plan you know how would you are some people get i'm not going to get into this extensively. But in general i would. Tend to. Build a more aggressive. In my depression treatment and. Just because you don't you want to kind of get start treatment started. Sooner than later you know there's you can kind of look to see you can kind of figure out in one of the ways you can kind of figure out our people's to pray as of symptoms more extreme than what you typically see you know either symptoms pretty severe. Than what you would typically see for someone who's. A kind of two weeks in and maybe they're taking their buprenorphine every day and you know otherwise things are pretty stable the of these would point to me to say okay let's let's get moving on as sooner than later. Alright so what are some practical tips freezing screeners. For depression i liked Peters few nine. This is generally available and most clinical settings you may already be using this and. You not you can use number nine to assess suicidality and take i wouldn't necessarily chalk up a high ph d nine at that first visit. As suggestive of a depressive disorder i i will repeat though that screen after a couple of weeks. And you know a you kind of look. The pizza the the. S nine has been used in in the context of. An addiction treatment clinic and has been found to be a. No accurate way of screening for depression within us su di population and fairly early on is even in close to his earliest two weeks you look at anxiety i would suggest using the g eighty seven again is commonly used already i think it's a fair. And screener to use and this has not been. Widely studied within a. As you sort of context but does have i believe one and have found that it was helpful. Anxiety symptoms are very tricky they cant allowed to withdraw and then come up with ongoing substance use and so you know it's one thing that i will definitely kind of be repeating a more frequently than not for bipolar i would recommend using the CIA d i city three. Vs something like the m que. The em dia que. Era to me is. As it wishes the mood disorder questionnaire and that is a very kind of. Too sensitive doesn't really Tommy people are positive it doesn't tell me that they have bipolar i found it more helpful for willing bipolar out the md huh so i prefer the city three if i'm going to be trying to screen for bipolar PTSD. The PC PTSD five as great. Five items screeners a brief and you can use this earlier and then. Due to the unique features of the diagnosis of says trauma exposure and of or in some of the the other like hyper vigilant some of the other things that are just not typically replicated from a substance and and eighty hd so the adults and rating scale. Is commonly years at this has been and. Used in substance use disorder populations. If this is a screener so you know it's going to catch a lot of people. Is not very. Specific necessarily but. I think it's it's quick it's is available and and if someone is. That is a negative and srs then to me and that really as rule out a d h d if they are positive. I'm going to need into a further evaluation and and net me inclusive and longer screeners me be like the counters or. Something like that and so forth but. It's nice it's nice to kind of look at that a pretty. Early again cause loud eighteen. Especially outside the context of math are are pretty record you can pick those are pretty quickly. With mass things get more complicated which again i can get into right now. But what i really look for is at childhood history of eighty hd. Before they started using meth. Alright the other thing I'll highlight as around suicidality one is the Colombia's suicide severity rating scale. You if i had to pick one scale to used to assess suicide risk this would be it it's a six question tool. It's been. It's available over a hundred and forty languages has been widely study invalidated. It is the only tool and this this is the reason bringing this up to assess for intensity frequency and changes in suicidal ideation over time. Now you may ask what about number nine on the thq. Is that appropriate you know you know asking someone to add one more. Six items questions year. Clinic workflow may not be doable. Is the s canine adequate so a couple of caveats i think you can use it but you also want to recognize that it may. Generate a lot of false positives. Because it's not in is not going to be addressing that intensity and frequency. That the Columbia does. It and it doesn't. Assess can current plans and you you know and so you could use this as a preliminary assessment and then use something like the Columbia as a follow up. I think in general the appears tonight is better than nothing but also just recognize that there are some weaknesses as there are within his career. And if we really kind of wanted to go with one at and. Or would say is. Probably a little bit more of a better screener the Columbia suicide security rescale would be a. The other thing I'll highlight is. There is the new nine eight suicide and crisis lifeline so in case. This is up and running. Since began the year. A direct connection to compassionate and accessible care. If you provider support you can also providers can do. Or a loved ones. Can. Dial this number. If you if you have some questions around crisis so family members in particular is over two hundred crisis centers and where these numbers have been right at you and then. That studies show that colors feel less suicidal less depressed less overwhelmed. The a lot of times i used to tell people to ultimately call nine one one. This is the number that i am referring people to use when they are having those sorts of thoughts the people that are picking up this line or can be much much better position from a training standpoint. To. Talk with people who are having. Some suicidal. Thoughts. Alright so the last. Kind of. Finally kind of getting wrapping things up your. I want to highlight. Yeah we talked about how these are integrated you're both mental health disorders and you. And are within one person as they are coming up know as are being manifested in that person are often manifested in in a granted way and i would argue that. You within our systems we need you further integrate this. Both from a streaming standpoint that means brain mental health screeners into your su di treatment. Programs or clinics or wherever you're at and and then the next step from a treatment standpoint. You want it really try to continue to go down that integrated role now this is obviously not going to be available necessarily but i the my main takeaway is that i would avoid sequential treatment so the idea of let's get there's a o u d stable first and then we'll address their mental health disorder symptoms and you know what happens is is again as a highlighted if you're not addressing their mental health symptoms. That is going to be potentially very disruptive to your own to your all your the treatment efforts and the the Patience evers. Themselves at the actually really trying to work on. If you can you know so ideally so ideally you can do this in is integrated fashioned with and kind of the same. Clinic where you can kind of coordinate. With pace with your providers that or maybe more oriented to mental health. Symptoms and in try to develop you know kind of treatment plans that are going to be reinforcing to each other and so forth. A lot of places don't have that if you have like a more of a parallel. Sort of system where you have an addition treatments center. Of their people may go to you. And then you have a mental health symptoms of system that they could be that they also could access at the same time. That's going can be better i would again not wait for one to kind of get better before doing the other you want to really address both at the same time. And you know if it's in a parallel sort of fast can you know that's fine you know it's i would personally. I think that's a better approach. Than trying to wait for one or the other. Alright so. In summary we talked about how these frequently caulker. There's the higher risk for suicide it can complicate your treatment course when. Mental around mental health symptoms is gonna lead to more symptomatology both physically mentally psychologically. And that there is and the reason for this as there is a significant overlap in developmental causes from a genetic standpoint. The environment impacting our genetics those Abby genetic factors stresses childhood history of adverse childhood events. Environmental factors these are all kind of coming together. That on that ultimate they can be too ultimate manifestation of both substance use and mental health disorders. In the same person and it really. Do. Points to the need to scream screen and ultimately treat mental health disorders. In all patients with lady avoiding as sequences trying to do as much of an integrated or simultaneous sort of treatment approach. As you can cause that's ultimately going to be. Where you're going to find the most benefit. Do. Alright. So with that i think we are done i appreciate and ones and attention and. Forward to answer some questions so thanks. Oh. Let's see we need to get to and. I think the net maybe the next slide i'm not sure. And oh i guess we're in were accurate go back up. Please we are we're it right site thank you dr Duncan for this great i very informative. A stimulating presentation we do have a few minutes. Ah for questions. On in a number of questions on hat have been injured some i answered that were simpler i answered in writing already but. We can proceed to ah but i. Present you with some of the things that came up. And. So on. Michael Miller i asked both the question and puts in a comment so. The and i i think you partially address this that it would be good to elaborate i think if someone is actively using opioids how'd you know a symptoms of depression or true. A major depressive disorder. Given the dysphoria from. A in quotes dopamine withdraw and quote. Associated with obesity with raw if a person is physically dependent and on a roller coaster of being and quotes high and in quotes dope sick how can you say that the symptoms are from a separate and co-morbid disorder. Yeah i know this is a great question it is a very can be very challenging. So that's why i would recommend that you know you get people started on their buprenorphine and you know you can assess the symptoms. Early on you know at that time of the initial assessment if you want you. But you're going to want a kind of track those symptoms again so use your check your p s few nine again in a week or two and and hopefully they have stabilized. You know they are in their the stabilization point where they're getting out of that this. Your that intoxication. Withdraw cycle that has a lot of dysphoria to it and you can see what's left you can start to see what's left over. If you're noticing a trend that some one symptoms are remain persistently high when you have seen in many other people those symptoms start to what to wane. Within those first couple of weeks that's going to be a clue that they have that this could be and underline major depressive disorder and not just solely due to their opioids of course you can you try to get some his three around. You know. Past depressive symptoms especially during periods of abstinence you know when did these depressive symptoms start with your periods before their opioid use the lights of history. Things that you can get you that also provide some clues but the first clue is really the persistence of a high level of depressive symptoms. Despite those that early stabilization period that i would look for. Okay and then i just will say or. Dr Miller added the comment about his own practice if i can't find major depressive disorder bipolar spectrum clearly present. During a greater than six months drug free span for clearly present. Free su di onset i don't diagnose the mood disorder so that. You don't have to respond to that but. I i wanted to get that out there said that next we have kind of implementation and systems question. Of that. Can be challenging. On this was from an anonymous attendee. Our facility requires mental health stabilization before induction. How would you suggest that we make this shift i. Presume they mean the shift to. I. Immediately treating the o u d rather than mental health stabilization first. Yeah. Well i mean i i think that. Do. You know it's. You can look at the evidence and see this that is going to be very difficult for. People to. Well being a place where you know they're gonna be able to access to mental health. Disorder treatment. Until there is substance use disorder is. You know. It's just can be hard for people to access. That treatment a know until they you know because. It you know he is is not entirely clear. And. What's. You know. For for okay so bet that so and let me just make sure i have this question right is it the question is is add. And this system is waiting to treat their lady until their mental health symptoms are stable that that's the way i understand that okay okay. Well i mean i guess to me it comes back to. You know what are some of the rest yeah. There's really. I think there's a. Very clear. Compelling case we made that we can't wait around a treat someone's o u d. There's too much risk for overdose. Especially with mental out there and and it's going to be very difficult to treat their mental health disorder. With the uncontrolled whoa of. D and but again at overdose risk is very pressing and. I i don't think that there's a good reason to wait on that. We need to get started on that as soon as possible. Okay so he has had that's that's. What we want to do and changing a system can be challenging so we recognize that. Aren't so. That and i I'll tell everyone right now and the itself there's a lot of great questions of people put in just rights the last minute you're not going to get to all of them. We'll we'll see if we can Navy. Address some of them in writing after the. Webinar so are passionate ask the questions. On. It it it if opioids increased incidence of depression is that NY reason to treat the o u d first so that's kind of the foot flip side of the coin that you just addressed. Well while right so again i i would i would suggest that we start them on you know if his buprenorphine or mouth on whatever it is. And monitor their. Depressive symptoms but don't wait too long you know again i would. Suggest your after the the first week after i'm starting their way if are already treatment or week to i'm checking in about their depressive symptoms because there is going to be a significant reduction in those symptoms. Once the as or oh you stabilizes. But again i yeah you're. If you see a high level of persistent symptoms as can be a clue that there's more to it than just the opioids i i get i get pretty cautious around waiting for their symptoms to resolve. As earlier d stabilizes because one me know that the co-occurrences high for depression and Rudy and and to you know if their depression goes untreated it's going to impact your ability to really he successfully addressed or lady. So we got a couple questions on benzodiazepines that. I'm just gonna paraphrase i think it's that it's important area to talk about so what what if any is. The role of benzodiazepines in treating. People who have o u d and another. A co-occurring mental health disorder. Okay. So i do not see a significant role for benzodiazepines. In the treme and i personally try to avoid using them i mean i think in the certain. Certain patients i have. We have ultimately kind of gone in that direction but i try to keep that to a minimum. There is problems with them. For from a. Substance misuse standpoint. Do you know potentially applications around a diversion and you know and they can be very problematic for patients over time so my use of them i might use them very briefly when a in a very complicated withdraw sort of. Scenario but for ongoing treatment of of. Anxiety symptoms i'm looking at other options. Okay art the last question here on this is from Timothy shoe. Are there are those individuals at increased. Risk of psychosis from their mood disorder who exacerbate that risk. With psychosis caused by. An abuse of math or other stimulants would you treat with and anti psychotic medications. So. Yes i would. There is a. If someone is having a psychotic symptoms due to math and your especially within kind of of mercy department context. At. You can use those and even in that context or his motives for using benzodiazepines. As well. Do we also know there's some interesting kind of preliminary evidence around using and psychotics to help people stay off of math. From a treatment standpoint this is not something that i would recommend kind of to routinely do but. There there is put some potential benefit their which reassure is my. Thinking about using. Math or use being anti psychotics a treat their. Psychosis or related to math so. It's a there's a lot going on there in that question but i. Would would be thinking about using them if they are psychotic symptoms in that context. It thank you offer the great questions and i apologize that can't answer all of them but we will she what we can do about up some post hoc answers and so on next slide please. On and on if before i have a close i do want to mention. Our information about our next webinar which is going to occur on February fourteenth then it's. Hot. Dovetails nicely with ah what a dr Duncan present day the topic will be substance use a screening in primary chair and you'll receive our and. It and marketing email about that and. Very soon. So on. Thank you again off for participating. Please visit www dot e css now dot org and see the variety of helpful resources on that are offered including the free theseus as mentor program which offers general information to clinicians about evidence base clinical crack Mrs. Of and in prescribing. Medications for opioid use disorder. Or next slide. Also there there's a p css discussion forum on and i. That can be very helpful for all of you that put those great questions in the q and a day we didn't have. Time for if he joined this forum. Or you can ask a question on any time on and get to get some a knowledgeable of responses so on. The. The the mentors have a lot of expertise. On in a treatment many clinical education. So i encourage you to i use that a resource and next slide. I dislike Alice i'm all of the organizations that are involved in the css. I today's activity was presented on behalf of the samsa funded funded providers i clinical support system. A program operated collaboratively by all these organizations including the a p a. And next. So. Again thank you for joining today and we hope to see you soon a particularly at our next webinar on February fourteenth and that. Concludes our presentation for today.

mental health

opioid use disorder

webinar

Dr. Mark Duncan

American Psychiatric Association

SAMHSA-funded Providers Clinical Support System

co-occurring disorders

integrated care approach

screening for mental health disorders