Co-Morbid Mental Health Problems and Substance Use Problems (Dual Diagnosis)

Comorbid mental health problems frequently are identified in conjunction with substance use disorders. This is often called "Dual Diagnosis." Inpatient settings are likely to manage dual diagnosis at the same time as the substance abuse treatment.

However, for patients with substance use problems that will be managed in primary care, such as a tobacco user or a person with mild to moderate alcohol abuse, referral for dual diagnosis is indicated. For example, an individual attempting to quit smoking or mild alcohol use disorder and who also suffers from anxiety or depression may benefit from counseling in addition to medical management of their substance problem.

Choosing which type of mental health professional for the referral depends upon multiple factors, such as:

  • Need for medical management (psychiatry)
  • Ability to pay/insurance coverage (a walk-in clinic is likely to cost less than a private therapist, for example).
  • Areas of specialty (does the provider specialize in substance abuse issues?)

View ReferencesHide References
Kessler RC. The epidemiology of dual diagnosis. Biological Psychiatry. 2004; 56(10): 730–737. Available at: Accessed on: 2013-10-24.
What is Medication-Assisted Treatment?

Individuals who are physically dependent may benefit from medication-assisted treatment in support of abstienence, and in some cases, detoxification. Medication assisted treatment needs to be combined with psychosocial treatment in order to be effective. Medication-assisted treatment may be used at multiple treatment level. The FDA has approved five medications for use in medication-assisted treatment (MAT) for alcohol and opioid use disorders:

  • buprenorphine, with or without naloxone (opioid use disorder)
  • methadone (opioid use disorder)
  • naltrexone (alcohol and opioid use disorder)
  • acamporosate (alcohol use disorder)
  • disulfiram (alcohol use disorder)

Buprenorphine and Methadone. The first two medications, buprenorphine and methadone, can be used for the initial process of quitting opioids (first stage of treatment - detoxification) and help reduce the need for in-patient care at this stage (ASAM, 2015; SAMHSA, 2015; SAMHSA, 2016). Buprenorphine and methadone also help in managing the worst of the period of withdrawal from opioids by relieving withdrawal symptoms and psychological cravings. Buprenorphine and methadone work via the opioid receptors; the same ones responsible for problematic dependence on opioids (ONDCP, 2012). They have weaker effects and/or have slower onset, so the individual does not feel "high" from taking them.

Naltrexone has a different mechanism, as it acts by blocking the receptors where opioids were having their effects (antagonist). By blocking the opioid receptors, the pleasant effects of opioids and alcohol are blocked (USDHHS, 2016). Naltrexone is used to block alcohol cravings, but may not be effective at reducing opioid cravings.

Naltrexone is supplied as tablets to be taken daily or as an extended release injection (USDHHS, 2016). The injection is more effective and can be given by an individual licensed and authorized to prescribe it by the state.

Acamprosate is used for alcohol maintenance (USDHHS, 2016). It acts by normalizing the brain neurochemistry, reducing cravings.

Acamprosate is given as a delayed-release tablet, provided by prescription and is not a scheduled substance. It can be given by an individual licensed and authorized to prescribe it by the state

Disulfiram is used for alcohol maintenance (USDHHS, 2016). It acts by creating metabolic products that cause a negative reaction and nausea, thus motivating the individual not to drink to avoid having this experience.

Disulfiram is given as a tablet and is not a scheduled substance.

These medications can be used to support long-term maintenance of being free from dependence on opioids (other than those being used in treatment) as they can be taken safely for years. Additionally, MAT has a higher rate of success than medication-free treatment. Whether or not medication-assisted treatment is chosen, however, psychosocial treatment is an important component of treatment and should be integrated into the overall treatment plan for your patients.

How Is the Treatment Chosen?

The provider and patient work together to select the best treatment considering:

  • Whether the patient is open to taking a medication to assist with treatment, including an understanding of the physical dependence they will have on methadone or buprenorphine
  • Efficacy, requirements/costs, side effects, and risks of each medication
  • Patient preference among the choices
  • Past experience with treatment
View ReferencesHide References
American Society of Addiction Medicine (ASAM). The ASAM National Practice Guideline For the Use of Medications in the Treatment of Addiction Involving Opioid Use. . June 1, 2015. Available at: Accessed on: 2015-10-06.
Office of National Drug Control Policy. Medication Assisted Treatment for Opioid Addiction. Healthcare Brief ONDCP. 2012. Available at: Accessed on: 2016-11-30.
SAMHSA. Medication and Counseling Treatment. Medication Assisted Treatment. 2015; 9/28/15: . Available at: Accessed on: 2016-11-30.
Substance Abuse and Mental Health Services Administration. Sublingual and Transmucosal Buprenorphine for Opioid Use Disorder: Review and Update. Advisory. Winter 2016; 15 (1): . Available at: Accessed on: 2016-03-05.
Family Therapies

Family Therapies engage family members and friends to help support the patient's recovery and long-term abstinence. Different kinds of family therapies meet a variety of patient needs. Family Behavior Therapy (FBT) and Behavioral Couples Therapy (BCT) are most often used by adult patients (NIDA, 2012; USDHHS, 2016).

  • Family Behavior Therapy (FBT) looks at not only the substance use but also surrounding family issues that may contribute, such as conflicts in the home or mental disorders in the family (NIDA, 2012; USDHHS, 2016). FBT helps the patient set goals, develop skills, eliminate or change factors that might prevent treatment success, and prepare both the patient and their social support system for treatment. Therapy can last up to 20 sessions (NIDA, 2012; USDHHS, 2016).
  • Behavioral Couples Therapy (BCT) involves both patient and their spouse. It includes the patient making a "daily sobriety contract" and the spouse supporting this commitment, giving the patient some accountability (NIDA, 2012; USDHHS, 2016). The couple also learns effective communication and how to become involved in positive social activities that are substance-free (NIDA, 2012; USDHHS, 2016).
Twelve-Step Facilitation Therapy

Twelve-Step Facilitation Therapy (TSF) uses individual therapy sessions to support becoming involved in a 12-step program (NIDA, 2012; USDHHS, 2016). It includes milestones of acceptance, surrender, and active involvement, similar to 12 step programs.

The Matrix Model

The Matrix Model combines multiple evidence-based practices (family and group therapy, relapse prevention, self-help, reduction of other risky behaviors, and drug education) in a coordinated, sequential approach (NIDA, 2012; USDHHS, 2016). The treatment centers around group therapy (3 times a week for 16 weeks) which promotes social support, individual counseling, cognitive behavior therapy, family education, and urine drug testing in order to achieve the patient's overall goal of abstinence (NIDA, 2012; USDHHS, 2016).

View ReferencesHide References
National Institute on Drug Abuse. Principles of Drug Addiction Treatment: A Research-Based Guide. Rockville, Md: National Institute on Drug Abuse. 2012; December: . Available at: Accessed on: 2016-11-30.
USDHHS. Facing Addiction in America. The Surgeon General's Report on Alcohol, Drugs, and Health. Surgeon General Reports. 2016. Available at: Accessed on: 2016-11-17.

Counseling is typically a part of any treatment program. A number of evidence-based treatment types have been shown to be effective for substance use disorders and may be a part of the treatment program to which you refer a patient. Alternatively, you may refer a patient who does not need that level of care directly for such counseling:

Cognitive-Behavioral Therapy

Cognitive-Behavioral Therapy (CBT) is grounded in the theory that certain patterns of behavior and thoughts can contribute to the development and maintenance of substance use disorders (NIDA, 2012; USDHHS, 2016). Weekly individual sessions (usually lasting 12-24 weeks) teach patients to identify thought and behavior patterns through self-monitoring and to cope with them as they arise in order to decrease substance use (NIDA, 2012; USDHHS, 2016). CBT has been shown to increase the rate of long-term treatment success and improve mental health outcomes for those with co-occurring mental health disorders (NIDA, 2012; USDHHS 2016).

Contingency Management and Community Reinforcement Approach

Contingency Management centers around tangible positive reinforcement for positive behavior change (NIDA, 2012; USDHHS, 2016). Positive behavior, such as participation in therapy sessions or having a negative urine drug test, is rewarded with vouchers that can be exchanged for desired objects, goods, or activities. Having a goal to work towards along with a tangible reward has been shown to be more effective than traditional treatment approaches in terms of longer abstinence and active engagement in treatment.

Community Reinforcement Approach (CRA) Plus Vouchers is an outpatient program that furthers the positive reinforcement approach by combining the voucher system with group therapy (NIDA, 2012; USDHHS, 2016). Group counseling sessions focus on how to reduce substance use and build support systems for long-term abstinence (NIDA, 2012; USDHHS, 2016).

Motivational Enhancement Therapy

Motivational Enhancement Therapy (MET) utilizes motivational interviewing techniques to support patients having uncertainty about ceasing substance use (NIDA, 2012; USDHHS, 2016). Patients develop awareness of how their actions and goals are misaligned, which often increases motivation to change their behaviors to meet their goals. MET uses empathy and support rather than confrontational tactics in order to promote change, which leads to self-efficacy in the patient and better long-term outcomes.

View ReferencesHide References
National Institute on Drug Abuse. Principles of Drug Addiction Treatment: A Research-Based Guide. Rockville, Md: National Institute on Drug Abuse. 2012; December: . Available at: Accessed on: 2016-11-30.
USDHHS. Facing Addiction in America. The Surgeon General's Report on Alcohol, Drugs, and Health. Surgeon General Reports. 2016. Available at: Accessed on: 2016-11-17.

The following is a table reviewing details of the ASAM placement criteria that were described earlier in this module under each level of care, as well as a few additional details. Providers who are responsible for triaging patients to the appropriate level of care, use these criteria. Familiarity with the basics of these criteria, even if you are not responsible for such triage, can be helpful in making an appropriate referral and with talking to patients.

Brief Interventions Outpatient Treatment Intensive Outpatient Treatment Residential Treatment Inpatient Hospitalization
Dimension Level 0.5 Level I Level II Level III Level III-IV
Potential for Withdrawal or Intoxication No risk of withdrawal Minimal risk of severe withdrawal Minimal risk of severe withdrawal Up to a moderate risk of withdrawal Moderate to severe risk of withdrawal
Medical None or stable None or stable None or stable No need to a possible need for medical monitoring Needs monitoring and 24 hour medical care
Behavioral/Psychiatric None or stable None or stable Mild to moderate in severity; needs monitoring No comorbidities to moderately severe comorbidities and/or inability to control impulses Moderately severe to severe comorbidities requiring 24 hour psychiatric care
Readiness to Change Has insight into how substance affects their goals Cooperative but needs motivation and structured therapy to make positive changes Moderate to significant degree of resistance; needs structure to make positive changes Significant resistance; little to no insight; requires structure and motivating strategies No insight, high degree of resistance and/or poor impulse control
Relapse, Continued Use, or Continued Problem Potential Requires skills to change current patterns Can remain abstinent Moderate to significant degree of automaticity; needs monitoring and support May understand relapse but higher automaticity; requires structure and 24 hour monitoring Cannot control use with dangerous consequences
Environment/Support Has social support and a supportive recovery environment Has a supportive recovery environment Has less of a supportive structure than what is needed to cope; needs additional structure Dangerous environment; higher structure needed to allow for recovery and patient coping Dangerous recovery environment; needs structure to succeed in recovery

(Adapted from Mee-Lee et al., 2013)

Medical Treatment of Withdrawal and Comorbidities

Doctor with checklistThe medical treatment components address the physical dependence and any other health effects from the substance use problem.

Inpatient/Outpatient Detoxification Treatment. Medications are typically used during early abstinence from the substance to ease withdrawal symptoms. The medications used are selected in part based on the addictive substance. Some examples the most commonly used medications are the following:

  • Tobacco - varenicline (brand name Chantix), bupropion (brand name Zyban), nicotine replacement (patch, lozenge, gum)
  • Alcohol - acamprosate (brand name Campral), disulfiram (brand name Antabuse), and naltrexone (brand names oral Depade and ReVia, injectable Vivitrol)
  • Opioid addiction - methadone or buprenorphine. Also, naltrexone after detoxification.
Psychosocial Treatment

Substance abuse counseling component can take a number of approaches. The two most widely used are:

  1. Cognitive-Behavioral Approaches. Cognitive-behavioral therapy is based on relating thoughts and behavior. The therapy helps the client to recognize and modify maladaptive thoughts that are contributing to the addictive behavior (Waldron & Turner, 2008). Stress management techniques may also be taught, such as meditation, exercise, and relaxation techniques.

  2. Group-Based Approaches. Group therapy is frequently used in both inpatient and outpatient treatment (SAMHSA & CSAT, 2005). Benefits unique to group-based treatments include witnessing others recover and reducing isolation. Multiple therapeutic approaches, including cognitive behavioral approaches, confrontation, and supportive therapies can be used with groups.

Other psychosocial factors that may be important to consider include whether or not there is a need for case management and whether family or friends should be involved.

View ReferencesHide References
Substance Abuse and Mental Health Administration (SAHMSA). Tip 34: Brief interventions and brief therapies for substance abuse. DHHS Publication No. (SMA) 99-3353. 1999. Available at: Accessed on: 2010-08-31.
Waldron HB, Turner CW. Evidence-based psychosocial treatments for adolescent substance abuse. Journal of Clinical Child & Adolescent Psychology. 2008; 37: 238-261. Available at: Accessed on: 2015-06-17.

More detailed criteria for placement are provided in the ASAM Criteria, which are used by trained providers to place patients. Even if you are referring patients to a substance use counselor or addiction specialist, for this detailed assessment, a familiarity with the criteria will help you explain your referral.

According to their Patient Placement Criteria, the following 6 patient dimensions should be considered when formulating a treatment plan (Mee-Lee et al., 2013):

Dimension Things to Consider
Acute Intoxication and/or Withdrawal Potential Assess whether the patient is currently intoxicated, is at risk of precipitated withdrawal, or is currently in withdrawal.
Biomedical Conditions and Complications Consider the patient's existing medical conditions and/or illnesses and how they might affect treatment.
Emotional, Behavioral, or Cognitive Conditions and Complications Note the patient's psychiatric illnesses and psychological, behavioral, emotional, or cognitive problems, and determine if they are related to or are independent of the substance use disorder.
Readiness to Change Assess the patient's readiness to change, and determine how willing he/she is to begin treatment.
Relapse, Continued Use, or Continued Problem Potential Try to ascertain what the outcome will be if treatment is not successful, and consider if the patient can combat cravings and cues that might lead to relapse.
Recovery/Living Environment Determine if the patient's home and work environments contribute to or detract from treatment efforts and what family and social support is available.
View ReferencesHide References
Mee-Lee D (ed). The ASAM Criteria . . 2013; 3rd edition: . Available at: Accessed on: 2014-09-12.

The best option for Mrs. Capello is probably outpatient treatment that provides intensive treatments, in which the patient lives at home and participates in the program several days per week. A program that provides counseling and medical support would be ideal.

Outpatient treatment where she only meets with a counselor once per week is not likely to be enough support at first, but is a good option for later in her treatment.

Residential treatment might be more than she needs. It is indicated for a patient who lacks motivation or social support or one who needs monitored detoxification, but does not need other medical or psychiatric management. Mrs. Capello does have both social support and motivation.


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