For people with dual disorders, the attempt
to obtain professional help can be bewildering and confusing. They may have
problems arising within themselves as a result of their psychiatric and AOD use
disorders as well as problems of external origin that derive from the conflicts,
limitations, and clashing philosophies of the mental health and addiction treatment
systems. For example, internal problems such as frustration, denial, or depression
may hinder their ability to recognize the need for help and diminish their
ability to ask for help. A typical external problem might be the confusion experienced
when individuals need services but lack knowledge about the different goals
and processes of various types of available services. Other problems of external
origin may be very fundamental, such as the inability to pay for child care services
or the lack of transportation to the only available outpatient program.
Historically, when patients in AOD treatment exhibited vivid and acute psychiatric symptoms,
the symptoms were either: 1) unrecognized, 2) observed but misdescribed as
toxicity or "acting-out behavior," or 3) accurately identified, prompting the patients
to be discharged or referred to a mental health program. Virtually the same
process occurred for patients in mental health treatment who exhibited vivid and
acute symptoms of AOD use disorders.
Mislabeling, rejecting, failing
to recognize, or automatically transferring patients with dual disorders can
result in inadequate treatment, with patients falling between the cracks of treatment
systems. The symptoms of psychiatric and AOD use disorders often fluctuate in intensity
and frequency. Current symptom presentation may reflect a short-term change
in the course of long-term dual disorders. Thus, even when patients receive
traditional professional help, treatment may address only selected aspects of their
overall problem unless treatment is coordinated among services including AOD, mental
health, social, and medical programs.
As a result, the treatment system itself
may be a stumbling block for some people attempting to receive ongoing, appropriate,
and comprehensive treatment for combined psychiatric and AOD use disorders.
Thus, treatment services for patients with dual disorders must be sensitive
to both the individual's and the treatment system's impediments to the initiation
and continuation of treatment.
People with dual disorders who want
to engage in the treatment process (or who need to do so) frequently encounter
not one but several treatment systems, each having its own strengths and weaknesses.
These treatment systems have different clinical approaches.
Actually, there is no single mental health
system, although most States have a set of public mental health centers. Rather,
mental health services are provided by a variety of mental health professionals
including psychiatrists; psychologists; clinical social workers; clinical nurse specialists;
other therapists and counselors including marriage, family, and child counselors
(MFCCs); and paraprofessionals.
These mental health personnel work in a
variety of settings, using a variety of theories about the treatment of specific
psychiatric disorders. Different types of mental health professionals (for example,
social workers and MFCCs) have differing perspectives; moreover, practitioners
within a given group often use different approaches.
A major strength of
the mental health system is the comprehensive array of services offered, including counseling,
case management, partial hospitalization, inpatient treatment, vocational rehabilitation,
and a variety of residential programs. The mental health system has a relatively
large variety of treatment settings. These settings are designed to provide
treatment services for patients with acute, subacute, and long-term symptoms. Acute
services are provided by personnel in emergency rooms and hospital units of several
types and by crisis-line personnel, outreach teams, and mental health law commitment
specialists. Subacute services are provided by hospitals, day treatment programs,
mental health center programs, and several types of individual practitioners.
Long-term settings include mental health centers, residential units, and
practitioners' offices. Clinicians vary with regard to academic degrees, styles, expertise,
and training. Another strength of the mental health system is the growing
recognition at all system levels of the role of case management as a means to individualize
and coordinate services and secure entitlements.
Medication is more often
used in psychiatric treatment than in addiction treatment, especially for severe
disorders. Medications used to treat psychiatric symptoms include psychoactive and
nonpsychoactive medications. Psychoactive medications cause an acute change in mood, thinking,
or behavior, such as sedation, stimulation, or euphoria.
Psychoactive
medications (such as benzodiazepines) prescribed to the average patient with psychiatric
problems are generally taken in an appropriate fashion and pose little or no risk
of abuse or addiction. In contrast, the use of psychoactive medications by
patients with a personal or family history of an AOD use disorder is associated
with a high risk of abuse or addiction.
Some medications used in psychiatry
that have mild psychoactive effects (such as some tricyclic antidepressants
with mild sedative effects) appear to be misused more by patients with an AOD
disorder than by others. Thus, a potential pitfall is prescribing psychoactive
medications to a patient with psychiatric problems without first determining whether
the individual also has an AOD use disorder.
While most clinicians
in the mental health system generally have expertise in a biopsychosocial
approach to the identification, diagnosis, and treatment of psychiatric disorders,
some lack similar skills and knowledge about the specific drugs of abuse, the
biopsychosocial processes of abuse and addiction, and AOD treatment, recovery, and relapse.
Similarly, AOD treatment professionals may have a thorough understanding
of AOD abuse treatment but not psychiatric treatment.
As with mental health treatment, no
single addiction treatment system exists. Rather, there is a collection of different
types of services such as social and medical model detoxification programs, short-
and long-term treatment programs, methadone detoxification and maintenance
programs, long-term therapeutic communities, and self-help adjuncts such as the 12-step
programs. These programs can vary greatly with respect to treatment goals and philosophies.
For example, abstinence is a prerequisite for entry into some programs,
while it is a long-term goal in other programs. Some AOD treatment programs
are not abstinence oriented. For example, some methadone maintenance programs
have the overt goal of eventual abstinence for all patients, while others promote
continued methadone use to encourage psychosocial stabilization.
As with mental
health treatment, addiction treatment is provided by a diverse group of practitioners,
including physicians, psychiatrists, psychologists, certified addiction counselors,
MFCCs, and other therapists, counselors, and recovering paraprofessionals. There
can be a wide difference in experience, expertise, and knowledge among these
diverse providers. As with mental health treatment, most States have public and
private AOD treatment systems.
The strengths of addiction treatment services
include the multidisciplinary team approach with a biopsychosocial emphasis, and
an understanding of the addictive process combined with knowledge of the drugs
of abuse and the 12-step programs. In typical addiction treatment, medications
are used to treat the complications of addiction, such as overdose and withdrawal.
However, few medications that directly treat or interrupt the addictive
process, such as disulfiram and naltrexone, have been identified or regularly used.
Maintenance medications such as methadone are crucial for certain patients.
However, most addiction treatment professionals attempt to eliminate patients'
use of all drugs.
Similarities of Mental Health and Addiction Treatment Systems
Variety of treatment settings and program types
Public and private settings
Multiple levels of care
Biopsychosocial
models
Increasing use of case and care management
Value of self-help adjuncts.
Many who work in the addiction treatment field have only a limited understanding
of medications used for psychiatric disorders. Historically, some people
have mistakenly assumed that all or most psychiatric medications are psychoactive
or potentially addictive. Many addiction treatment staff tend to avoid the
use of any medication with their patients, probably in reaction to those whose
addiction included prescription medications such as diazepam (Valium). Many staff
have a lack of training and experience in the use of such medications. In the
treatment of dual disorders, a balance must be made between behavioral interventions
and the appropriate use of nonaddicting psychiatric medications for those who
need them to participate in the recovery process. Withholding medications from
such individuals increases their chances of AOD relapse.
An important
adjunct to addiction treatment services is the massive system of consumer-developed
groups, such as the 12-step program of Alcoholics Anonymous (AA). Participants
in AA and other self-help groups (Narcotics Anonymous [NA], Cocaine Anonymous
[CA], etc.) can provide needed support and encouragement for patients in treatment.
Importantly, these services are widespread nationally and internationally.
While self-help programs are not considered treatment per se, they are
integral adjuncts to professional treatment services.
However, patients in
self-help groups may give others inappropriate advice regarding medication compliance,
based on personal experience, fears of medication, or incomplete knowledge about
the role of medication in dual disorders. In many urban areas, there are specialized
12-step groups for people with dual disorders. In these so-called "Double Trouble"
meetings, medication compliance is a part of "working the program."
Primary health care providers (physicians and nurses)
have historically been the largest single point of contact for patients seeking
help with psychiatric and AOD use disorders. Physicians and nurses are uniquely
qualified to manage life-threatening crises and to treat medical problems related
and unrelated to psychiatric and substance use disorders. And because they
are in contact with such large numbers of patients, they have an exceptional
opportunity to screen and identify patients with psychiatric and AOD disorders.
However, physicians -- especially primary care physicians -- are able to devote very little
time to each
patient. Pressured for time, these physicians may prescribe such psychiatric medications
as antidepressants or anxiolytics or medication such as disulfiram or naltrexone
as a primary approach, rather than as an adjunctive approach. Indeed, primary
care physicians are the largest single prescriber of antianxiety medications.
Some of these medications, such as the benzodiazepines, are psychoactive
and can be abused.
Also, physicians and nurses have historically been
trained to focus on the medical consequences of addiction, such as withdrawal,
overdose, or hepatitis, without assessing, treating, or actively referring the individual
for treatment of the addiction itself. The role of physicians with regard
to addiction is changing through the leadership of national organizations
such as the American Society of Addiction Medicine, the American Academy of
Psychiatrists on Alcohol and Addiction, and the Association of Medical Education and
Research on Substance Abuse. Similar groups exist for nurses and allied health
care professionals. Such groups can provide medical professionals with important
information and education about the biopsychosocial nature of addiction and treatment,
especially regarding patients with dual disorders.
Traditionally, patients
in mental health settings have had the responsibility of getting themselves
to treatment services and appointments as a sign of treatment motivation.
More recently, and in recognition that many severely mentally ill patients
are unwilling or unable to use traditional community-based services, the mental
health field has emphasized the role of case management. Case management (also
called care management) can help to engage, link, and support patients in needed
community services. Case management can help to reduce the negative consequences
to the individual from lack of followup and participation in treatment. Without
case management, many severely ill patients would decompensate, need to be hospitalized,
or become homeless.
The case management model identifies individual
limitations, deficits, and strengths and aggressively attempts to provide patients with
what they need. When a patient rejects professional assistance, the case manager
assumes the responsibility for finding a different way to get the individual to
accept assistance. The case manager may minimize the negative consequences to
the individual in order to engage or maintain the patient in treatment. This
activity might be seen as "enabling" by traditional addiction treatment personnel.
In contrast, the addiction treatment system focuses on individual responsibility,
including the responsibility of accepting help. Motivation for recovery is enhanced
through confrontation of the adverse consequences of addiction. Further, addiction
intervention and treatment involve diminishing the individual's denial about the presence
and severity of the addiction through direct but therapeutic confrontation
of examples of addiction-related behaviors. Thus, traditionally, patients
in the addiction treatment system who did not want help or could not tolerate
confrontation might not get help. Mental health personnel might regard this situation
as an abandonment of the most needy. More recently, the addiction treatment
system has been developing case management models to better address treatment-resistant
patients.
Treatment of patients with dual disorders must blend both mental health and AOD treatment
models, with each applied at appropriate times and in appropriate situations according
to patients' needs. There should be a balance between clinician and patient
acceptance of responsibility for treatment and recovery from dual disorders.
For example, in AOD treatment, clinical staff and fellow patients often aggressively
confront patients who deny that they have an AOD problem or who minimize the severity
of their problem. However, treatment of individuals with dual disorders first
requires innovative approaches to engage them in treatment as a prerequisite to
confrontation. The role of confrontation may need to be substantially modified, particularly
in the treatment of disorganized or psychotic patients, who may tolerate confrontation
only in later stages of treatment (when their symptoms are stable and they are
engaged in the treatment process).
In addiction treatment, the focus is
often on the "here and now," while in mental health treatment, the focus is often
on past developmental issues. Mental health practitioners may identify AOD
abuse as a symptom of a prior trauma rather than an illness in its own right.
The focus of treatment may be on the developmental issues, with the assumption
that the AOD use disorder will improve automatically once these issues are treated.
Inadvertently, the mental health therapist can enable AOD use to continue.
Within parts of the addiction
treatment system, abstinence from psychoactive drugs is a precondition to participate
in treatment. For the more severely ill
patients with dual disorders (such as patients with schizophrenia), abstinence from
AODs is often considered a goal, possibly a long-term goal, similar to the approach
at some methadone maintenance programs. On the other hand, treatment of less
severe dual psychiatric conditions, such as depression or panic disorder, should
require AOD abstinence, since AOD use compromises both diagnosis and treatment
(see individual chapters).
For some patients with dual disorders, requiring
abstinence as a condition of entering treatment may hinder or discourage engagement
in the treatment process. For these patients, abstinence may be redefined
as a goal, with encouragement provided for incremental steps in the reduction
of amount and frequency of drug use. For example, patients who experience
homelessness and housing instability likely do not live in drug-free environments.
For such patients, it may be unrealistic to mandate abstinence as a requirement
for treatment. Exhibit 3-1 describes some of the
treatment strategy differences for managing patients in mental health, addiction,
and dual disorder treatment approaches.
As the mental health
and AOD abuse treatment fields have become increasingly aware of the existence
of patients with dual disorders, various attempts have been made to adapt
treatment to the special needs of these patients (Baker, 1991; Lehman et al., 1989;Minkoff,
1989; Minkoff and Drake, 1991; Ries,
1993a). These attempts have reflected philosophical differences about the
nature of dual disorders, as well as differing opinions regarding the best way
to treat them. These attempts also reflect the limitations of available resources,
as well as differences in treatment responses for different types and severities
of dual disorders. Three approaches have been taken to treatment.
The first and historically most
common model of dual disorder treatment is sequential treatment. In this model
of treatment, the patient is treated by one system (addiction or mental health)
and then by the other. Indeed, some clinicians believe that addiction treatment
must always be initiated first, and that the individual must be in a stage of
abstinent recovery from addiction before treatment for the psychiatric disorder can
begin. On the other hand, other clinicians believe that treatment for the psychiatric disorder
should begin prior to the initiation of abstinence and addiction treatment. Still
other clinicians believe that symptom severity at the time of entry to treatment
should dictate whether the individual is treated in a mental health setting or
an addiction treatment setting or that the disorder that emerged first should
be treated first.
The term sequential treatment describes
the serial or nonsimultaneous participation in both mental health
and addiction treatment settings. For example, a person with dual disorders
may receive treatment at a community mental health center program during occasional
periods of depression and attend a local AOD treatment program following infrequent
alcoholic binges. Systems that have developed serial treatment approaches generally
incorporate one of the above orientations toward the treatment of patients with dual
disorders.
A related approach involves parallel treatment:
the simultaneous involvement of the patient in both mental health and addiction
treatment settings. For example, an individual may participate in AOD education
and drug refusal classes at an addiction treatment program, participate in
a 12-step group such as AA, and attend group therapy and medication education
classes at a mental health center. Both parallel and sequential treatment involve
the utilization of existing treatment programs and settings. Thus, mental
health treatment is provided by mental health clinicians, and addiction treatment
is provided by addiction treatment clinicians. Coordination between settings
is quite variable.
A third model, called integrated treatment, is an approach that
combines elements of both mental health and addiction treatment into a unified and
comprehensive treatment program for patients with dual disorders. Ideally, integrated
treatment involves clinicians cross-trained in both mental health and addiction,
as well as a unified case management approach, making it possible to monitor
and treat patients through various psychiatric and AOD crises.
There
are advantages and disadvantages in sequential, parallel, and integrated treatment
approaches. Differences in dual disorder combinations, symptom severity, and degree
of impairment greatly affect the appropriateness of a treatment model for
a specific individual. For example, sequential and parallel treatment may
be most appropriate for patients who have a very severe problem with one disorder,
but a mild problem with the other. However, patients with dual disorders who
obtain treatment from two separate systems frequently receive conflicting therapeutic
messages; in addition, financial coverage and even confidentiality laws vary between
the two systems.
Treatment Models
Sequential: The
patient participates in one system, then the other.
Parallel: The patient
participates in two systems simultaneously.
Integrated: The patient participates
in a single unified and comprehensive treatment program for dual disorders.
In contrast, integrated treatment places the burden of treatment continuity
on a case manager who is expert in both psychiatric and AOD use disorders.
Further, integrated treatment involves simultaneous treatment of both
disorders in a setting designed to accommodate both problems.
Mental
health and addiction treatment programs that are being designed to accommodate
patients with dual disorders should be modified to address the specific needs of
these patients. Although there are different dual disorder treatment models,
all such programs must address several key issues that are critical for successful
treatment. These issues include: 1) treatment engagement, 2) treatment continuity
and comprehensiveness, 3) treatment phases, and 4) continual reassessment and
rediagnosis.
In general, treatment
engagement refers to the process of initiating and sustaining the patient's participation
in the ongoing treatment process. Engagement can involve such enticements
as providing help with the procurement of social services, such as food, shelter,
and medical services. Engagement can also involve removing barriers to treatment
and making treatment more accessible and acceptable, for example, by providing
day and evening treatment services. Engagement can be enhanced by providing
adjunctive services that may appear to be indirectly related to the disorders, such
as child care services, job skills counseling, and recreational activities.
It may also be coercive, such as through involuntary commitment or a designated
payee.
Engagement begins with efforts that are designed to enlist people into treatment,
but it is a long-term process with the goals of keeping patients in treatment
and helping them manage ongoing problems and crises. Essential to the engagement
process is: 1) a personalized relationship with the individual, 2) over an extended
period of time, with 3) a focus on the stated needs of the individual.
For patients with dual disorders, engagement in the treatment process is essential,
although the techniques used will depend upon the nature, severity, and disability
caused by an individual's dual disorders. An employed person with panic disorder
and episodic alcohol abuse will require a different type of engagement than
a homeless person with schizophrenia and polysubstance dependence. With
respect to severe conditions such as psychosis and violent behaviors, therapeutic
coercive engagement techniques may include involuntary detoxification, involuntary
psychiatric treatment, or court-mandated acute treatment.
To treat patients with dual disorders, it is critical
to develop continuity between treatment programs and treatment components,
as well as treatment continuity over time. In practice, many patients participate
in treatment at different sites. Even in integrated treatment programs, many
patients require different treatment services during different phases of treatment.
For this reason, treatment should include an integrated dual disorder
case management program, which can be located within a mental health setting,
an addiction treatment setting, or a collaborative program.
An overall system for
treating dual disorders includes mental health and addiction treatment programs,
as well as collaborative integrated programs. Programs should be designed
to: 1) engage clients, 2) accommodate various levels of severity and disability,
3) accommodate various levels of motivation and compliance, and 4) accommodate
patients in different phases of treatment. There should be access to abstinence-mandated
programs and abstinence-oriented programs, as well as to drug maintenance programs.
Different levels of care, ranging from more to less intense treatment,
should be available.
In general, the medical term acute describes phenomena that begin
quickly and require rapid response. Acute problems are contrasted with chronic
problems. Most commonly, acute stabilization of patients with dual disorders refers
to the management of physical, psychiatric, or drug toxicity crises. These
include injury, illness, AOD-induced toxic or withdrawal states, and behavior that
is suicidal, violent, impulsive, or psychotic.
The acute stabilization
of AOD use disorders typically begins with detoxification, such as inpatient
detoxification for patients with significant withdrawal or outpatient detoxification for
mild to moderate withdrawal, as well as nonmedical withdrawal, such as occurs
in social-model detoxification programs. Also, initiation of methadone maintenance
can provide outpatient acute stabilization for patients addicted to opioids.
Acute stabilization of psychiatric symptoms more frequently occurs within a mental
health or emergency medical setting, but involves a range of treatment intensity.
Patients with severe symptoms, especially psychotic, violent, or impulsive
behaviors, usually require acute psychiatric inpatient treatment and psychiatric medications,
while patients with less severe symptoms can be treated in outpatient or day
treatment settings.
Dual disorder programs that provide stabilization to
patients with acute needs should have the capability to:
Identify medical,
psychiatric, and AOD use disorders
Treat a range of illness severity
Provide drug detoxification, psychiatric medications, and other biopsychosocial
levels of treatment
Provide a range of intensities of service.
These programs should be capable of promoting the patient's engagement with the
treatment system. They should be able to aggressively provide linkages to other programs
that will provide ongoing treatment and engagement.
The medical term subacute describes the
status of a medical disorder at points between the acute condition and either
resolution or chronic state. The subacute phase of a medical problem occurs as the
acute course of the problem begins to diminish, or when symptoms emerge or reemerge
but are not yet severe enough to be described as acute.
For example,
patients recently detoxified from AODs frequently experience subacute symptoms such
as insomnia and anxiety that may linger for a few days or weeks. On the other
hand, recently detoxified patients with dual disorders may experience subacute
symptoms of insomnia and anxiety either as subacute withdrawal symptoms or as a
prelude to relapse with depression. Although the subacute phase is not generally
regarded as a period of crisis, ignoring these symptoms and failing to assess and
treat them may lead to symptom escalation, decompensation, and relapse.
As AOD-induced toxic or withdrawal symptoms resolve, constant reassessment
and rediagnosis is required. During this phase, a psychoeducational and behavioral
approach should be used to educate patients about their disorders and symptomatology.
During this phase, treatment providers should provide assessment and planning
for dealing with long-term issues such as housing, long-term treatment, and
financial stability.
Biopsychosocial Assessment Issues From the AOD and Psychiatric Perspectives
AOD
Psychiatric
Biological:
Alcohol on breath
Positive drug tests
Abnormal laboratory tests
Injuries and trauma
Toxicity and withdrawal
Impaired cognition
Abnormal laboratory tests
Neurological exams
Using psychiatric medications
Other medications, conditions
Psychological:
Intoxicated behavior
Withdrawal symptoms
Denial and manipulation
Responses to AOD assessments
AOD use history
Mental status exam: Affect mood, psychosis, etc.
Stress, situational factors
Self-image, defenses, etc.
Social:
Collateral information from others
Social interactions and lifestyle
Involvement with other AOD groups
Family history of AOD use disorders
Family history
Housing and employment histories
Support systems: Family, friends, others
Current psychiatric therapy
Hospitalization
ABC Model for Psychiatric Screening
Appearance, alertness, affect, and anxiety:
Appearance:
General appearance, hygiene, and dress.
Alertness:
What is the level of consciousness?
Affect:
Elation or depression: gestures, facial expression, and speech.
Anxiety:
Is the individual nervous, phobic, or panicky?
Behavior:
Movements:
Rate (Hyperactive, hypoactive, abrupt, or constant?).
The treatment settings for long-term
treatment, rehabilitation, and recovery from dual disorders include outpatient, day
treatment, and residential settings. Ideally, treatment intensity is dictated by
disorder severity and motivation for treatment, as well as by personal and local
treatment resources. In more severe conditions, ongoing dual disorder case management
is essential. The management of long-term severe conditions is described
in more detail in the chapter on psychotic disorders (Chapter
8).
With regard to the initiation and maintenance of sobriety in patients with dual
disorders, another way of looking at acute, subacute, and long-term phases involves
a four-step approach that leads to abstinence. This approach is particularly
important for patients with severe psychiatric problems and an AOD use disorder
(Minkoff and Drake, 1991; Ries, 1993a).
Individual case management.
Individual case management provides an initial
introduction to treatment goals and concepts and may provide assistance with regard
to crises, housing, and entitlements. An individual treatment plan is developed.
Persuasion groups.
Patients who display
strong denial about their AOD use disorder and lack motivation can attend persuasion
groups, which provide basic AOD education and treatment engagement. Premature,
potent, and direct confrontation and an insistence on abstinence should be avoided
since these approaches may prompt more fragile patients to leave treatment.
Active treatment groups.
Active treatment groups consist of patients
who have accepted the goal of abstinence and are relatively mentally stable.
These groups use supervised peer confrontation and a psychoeducational-behavioral
approach to AOD abuse.
Abstinence support groups.
Finally, abstinence support groups consist of patients who are essentially committed
to abstinence and are relatively stable mentally, who require ongoing education
and support for sobriety and the development of relapse prevention skills.
Psychiatric and AOD abuse treatment issues are woven into the groups in such a way
that concrete
issues (such as medication compliance) are addressed in persuasion groups, while
abstract concepts (such as self-image) are addressed in active treatment or abstinence
support groups. Some patients -- such as severely psychotic patients -- may not be able
to advance beyond persuasion groups or active treatment groups.
Each of the following chapters
will address assessment and evaluation issues relative to specific psychiatric
disorders. Specific assessment tools may be recommended for certain interventions
and certain settings. Irrespective of the treatment or intervention setting,
and notwithstanding the crisis that may have initiated the treatment contact,
all treatment contacts with patients who may have dual disorders should include
a basic screening for psychiatric and AOD use disorders. These issues are
addressed in detail in the chapters on mood, personality, and psychotic disorders.
With respect to both psychiatric and AOD use disorders, the assessment
process should be sensitive to biological, psychological, and social issues.
Full assessments of patients with dual disorders should be performed by clinicians
who have certified training in the areas that they assess. However, clinicians
who are not certified can learn to perform screening tests. Assessments of
patients who may have dual disorders should include at least a brief mental status
exam to assess for the presence and severity of psychiatric problems, as well
as a screening for AOD use disorders.
The "ABC" model described on
the previous page is a simple screening technique for the presence of psychiatric
disorders. The CAGE questionnaire and the CAGE questionnaire modified for other drugs
(CAGEAID) are rapid and accurate screening tools for AOD use disorders
(Exhibit 3-2).
The substances used most often by patients with dual disorders are the
same as those used by society in general: alcohol, marijuana, cocaine, and
more rarely, opioids. It is recommended that all front-line AOD and mental
health staff receive detailed training in the use of a mental status exam and
AOD screening tests.
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