Con Amy Dennis e Tamara Pryor ho presentato il tema "la comorbilità fra Disturbo Alimentare e Disturbo da Uso di Sostanze" alla Conferenza internazionale ICED della Academy, AEd a Chicago 2018
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2009 – A small pilot study of 22 American, nationally known, well established eating disorder programs was conducted to explore the availability of Substance abuse treatment for comorbid patients
2010 – Eating Disorder/Substance Abuse SIG was chartered – Dr. Amy Baker Dennis and her colleague Dr. Bethany Helfman gathered enough signatures to petition the AED Board to charter the ED/ Substance abuse SIG.
2011 – First SIG organizational meeting was held at AED
2012 – First SIG sponsored panel was held
2014 – First medical textbook exploring the “state of the art” in the treatment of ED patients with comorbid SUD and addictions. This book brought together researchers and clinicians from both the ED and SUD communities to explore the concept of integrated evidence based interventions for the dual diagnosed patient
2017 – Began the replication study to see if the range and availability of services for ED patients with SUD has improved in the past decade
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26 residential programs
48 PHP and
45 IOP for a total of 119 programs participated
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All programs accepted female patients, 87% accepted male patients and 84% say they accept non-binary patients
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Almost all programs accept private pay and insurance
Medicaid/ medicare through single case agreements and many of the residential programs do not accept medicaid or medicare.
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100% of programs stated that they screen before intake for the presence of past and present SUD.
83% of the 119 programs stated that they accepted and treat patients with active SUD - 17% stated that they do not accept SUD patients
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Of the residential programs, 73% stated that they accept and treat
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PHP 83% accept and treat
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And 81% of IOP programs (40 programs) state that they accept and treat.
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So 19 (out of 26) residential programs said that they accepted patients with active SUDs – so 27% do not accept comorbid patients.
Now when we drilled down to see what kind of SUD patients these programs actually treat, we found that 4 of the 19 residential programs (21%) only accepted patients with laxative, diuretic of OTC diet pills but no other types of substance.
So, out of 26 residential programs, only 15 actually treat significant SUD.
Over half of the residential programs accepted patients with Cannabis, Alcohol, Sedative hypnotic, or stimulant use disorders. But less than half of the programs accepted patients with benzodiazapine, opiate addiction or poly substance abuse.
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6 out of 48 PHP programs stated that they do not accept active substance abusers into their PHP program.
All of the PHP programs accepted laxative, diuretic and OTC diet pills into their programs
Again, Alcohol and Cannabis abuse were accepted by 3 quarters of the programs
And Stimulants and Benzos were treated in 65% of the programs with Opiate addiction treated in 56%
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19% (8 out of the 45 programs surveyed) do not accept active substance abusers
All of the programs that do, accept laxative, diuretic and OTC diet pill abusers
70% accept cannabis and alcohol abusers, but again, sedative hypnotics, opiate abusers and poly substance abusers are seen by just about half of the programs.
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5% of the programs provide Sequential treatment – onsite (one disorder treated first and then the other in the same facility) – Some larger hospitals have an SUD program that provides medically assisted detox and rehab. Once the patient is stable and sober, they transfer the patient to the ED unit.
9% of programs provide Sequential treatment – off site (one disorder treated first then the other utlizing offsite providers) – Some programs will send their patients to an offsite program for detox and rehab and then accept them into their ED program once they are stable and sober
16% od programs provide Parallel or concurrent – onsite (both disorders treated simultaneously but by different providers onsite) Some programs have both an SUD and ED program and patients are treated in the same facility for both disorders but the treatment providers are different in each program
23% of programs provide Parallel or concurrent – off site (both disorders treated simultaneously by providers both on and offsite) These programs will accept dual diagnosed patients if they are working with substance use providers in a program off-site. This also includes programs that
47% of programs surveyed said they provide Integrated treatment (screening, assessment and treatment of both disorders are provided by the same treatment providers at the same location)
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Improve treatment delivery – reduces spliting
Improve continuity of care – all levels of care understand and treat both conditions
Reduces time in treatment and costs because they don’t need multiple admissions to different locations
Hopefully, because both disorders are addressed and the patient is fully aware of the relationship between (Good integrated treatment focuses on uncovering the adaptive function of the substance use) them it will improve outcome
And reduces consumer confusion.
Creates a climate of “no wrong door” in the ED system of treatment. Meaning my fantasy is that we can construct a delivery system in the ED field at inpatient, residential, partial or Outpatient and we have integrated services for these patients at every level of care.
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When we look at this chart we see that 90% of programs provide DBT, 88% of the programs provide CBT – CBTE which are evidence based intervention for both ED and SUD. Likewise we see that programs are providing IPT and Integrated Cognitive Affective treatment and Interpersonal Psychotherapy which are evidence based interventions for ED and Motivational interviewing, contingency management, 12 step facilitation and behavioral couple/family treatment that are all evidence based interventions for SUD
21% said “other” and identified that they used ACT – Acceptance and Commitment therapy, Relational –Cultural Therapy, or provided support groups for patients,
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One of the interesting findings is that less than ½ of the programs require SUD patients to attend meetings. Only 33% of programs actually can detox an SUD patient and ongoing urine or breathalyzer tests are not universally employed.
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The biggest barrier that was identified was finding professionals that have training to treat both ED and SUD patients
Secondly, there are high relapse rates and poor treatment outcomes with this population. Some of this is the nature of these two disorders, but some it may be due to the fact that we do not have any controlled treatment trials that can guide our treatment interventions
Some programs identified programmatic barriers. Cost associated with cross training ED staff to treat SUD, increasing nursing staff to do urine testing, negative transference to patients from the clinical staff and milieu disruptions from integrating SUD patients. Others site the fact that many comorbid patients lack the motivation for sobriety.
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Research participants: Unfortunately I am not able to accurately tell you how many people we reached out to fill out this survey. We contacted everyone, in every program that we are familiar with, either by email or phone. In many cases, it took multiple contacts and promises of lunches and dinners the next time we were together in the same city at the same time! We also made a comprehensive list of programs and sent email requests to their program directors asking them to fill out a brief 10 minute survey with little response. We also posted this survey on both the AED main discussion board and on the ED/SUD SIG discussion board and had only one program that responded. We have come to understand that doing survey research is much like treating eating disorders – It is a marathon – not a sprint!!
Generalizability : Our goal was to get at least 1 program from every state in the US and every province in Canada to respond. As you can see, we were only able to get 26 states and 3 provinces to participate. We had multiple responses from States that have large metropolitan areas but very few from places that very limited treatment resources for ED patients and often provide ED treatment through telemedicine or send patients out of state for treatment.
Definition of integrated treatment: Although we defined the concept of integrated treatment (comprehensive ED/SUD services provided in one location, by the same treatment team) in the survey, we are very aware that programs that say they have “integrated treatment” are quite different. We built into this survey a follow-up phase where we will be speaking with programs either face-to-face, a Skype interview or by phone. Our goal is to better understand “How” programs are delivering integrated treatment. We know that some programs mix all patients together and give general SUD information to all patients, where other programs have created a “dual diagnosis track” where all patients that are struggling with SUD travel through the program together.
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Preliminary data. We will continue to try to get representation for every state in the US and as many programs as we can identify in Canada
We intend to “drill down” to find out what each program is doing when they say that they provide integrated treatment
For the last 18 years, I have been providing consultation and training to SUD programs and presenting at SUD conferences on the treatment of ED. Tamara has also spent a considerable amount of time consulting with SUD programs and helping them create good screening tool and helping them create protocols for treatment. If these programs do not want to provide integrated treatment services, they need to be connected to ED programs that they can refer to that will provide both the ED/SUD services.
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Parallel – Red Rocks dietician, Orlando
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Read parts of interview on Integrative treatment from Mountainside Treatment.
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Read parts of interview on Integrative treatment from Mountainside Treatment.
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