By Stacey C. Conroy, LCSW, MPH

Stacey C. Conroy LCSW, MPH is the Supervisory Social Worker for Mental Health & Substance Abuse at the Richmond VA Medical and a Clinical Instructor in Psychiatry for Virginia Commonwealth University.

This article was initially published in the Spring 2016 edition of the OCD Newsletter. 

Editor’s Note: This article is the second in a two-part series about co-occurring substance use disorder (SUD) and OCD. A town hall panel on OCD and substance use disorder (OCD–SUD) at the 22nd Annual OCD Conference in Boston provided a clear indication of the critical and unique needs of those affected by OCD–SUD. A theme that came up repeatedly during this panel discussion concerned the need for stronger advocacy regarding effective treatment strategies for these potentially devastating co-occurring disorders. This two-part series is intended to provide a foundational framework for the recommended, concurrent treatment of OCD-SUD utilizing evidence-based practices that have been developed independently for each disorder. Part one of this series can be located by clicking here.

Mark’s* OCD symptoms revolved around his fears of becoming severely ill and he worried constantly about coming into contact with germs. As a teenager, he began routinely disinfecting surfaces around the house and keeping his bedroom in a particular order to facilitate regular cleaning. Mark often worried he’d forgotten one surface, and would clean the entire area again. During his late teens, Mark began drinking alcohol socially with friends, and over time, discovered that drinking while taking benzodiazepines provided a sense of relief and control over his anxiety and fears of illness.

Unfortunately, Mark’s use of these two substances increased to the point that he was using them both daily, and the sense of relief and control the substances had initially provided him was harder to achieve now. In addition, the negative consequences of substance use began to cause more stress, and Mark’s anxiety and fears of illness began to intensify again.

At this point, Mark decided to enter treatment. Since he was experiencing the most distress due to his substance use, Mark decided to enter a residential substance use treatment program. While initially helpful, the program staff ended up discharging Mark for “non-compliance” because he was consistently late for treatment groups. The truth, however, was that Mark was late to groups due to his time-consuming cleaning rituals. But because he was too embarrassed to disclose his OCD symptoms, Mark chose to leave treatment.

At a later date, Mark returned to this same SUD treatment program, and this time the staff noticed the excessive cleaning rituals. Again, it was observed that these behaviors were getting in the way of him attending treatment groups. In fact, some of the staff even thought Mark had OCD, but unfortunately, because they felt unequipped to help him with his OCD symptoms, they chose again to discharge him for non-compliance.

After this second discharge, Mark now decided to try to get treatment for his OCD symptoms, which had continued to get worse. Mark first tried to find a residential program specializing in OCD, but he was told that because he had an active problem with addiction, he was disqualified for admission. This happened again and again.

Mark then thought he might have better luck looking for outpatient treatment for his OCD and his SUD. Again, he was met with clinician after clinician who told him they would only treat his OCD if he had been sober for at least 3 months. Therapists who would treat his SUD did not understand the anxiety and the impairment caused by his OC; so again, Mark found himself at a loss about how to access effective treatment options.

*The client’s name has been changed to protect their privacy.

Unfortunately, Mark’s experience is not unique. Many OCD programs often refer individuals with SUD to substance abuse treatment as a prerequisite of admission. SUD programs often do not screen specifically for OCD, and even if they did, most clinicians at SUD programs are not adequately trained to treat OCD. Over time, as OCD symptoms interfere with an individual’s ability to meet the expectations of the SUD program, the individual often fails and is discharged for non-compliance. Similarly, if a patient is in an OCD program and relapses with substance use, they are discharged for non-compliance.

The intention of this article is to make the case for a new treatment model. Evidence-based treatments exist for OCD and SUD on their own, but this new treatment model seeks to combine these methods into a concurrent treatment program addressing both OCD and SUD simultaneously.

ASSESSMENT 

Studies on OCD report the lifetime prevalence for co-occurring OCD and SUD are consistently in the range of 25 percent1,2 (with some variation in this estimate having to do with which substance was being studied and, in some cases, differed based on gender). For those individuals who meet criteria for both disorders, it is critical to develop a comprehensive assessment in order to deliver effective treatment. It is also important to keep in mind that it is common for individuals with both OCD and SUD to hide symptoms due in part to embarrassment, shame, and/or denial of symptom severity. As a result, assessment is often a process of information gathering over the course of several sessions; it is not just a one-session event.

SUD assessment in OCD treatment

Studies on anxiety disorders3 and OCD2 with comorbid SUD consistently indicate that SUD developed secondary to the patient’s anxiety disorder in more than 60 percent of participants. Based on these findings, it is strongly recommended that if you are primarily an anxiety and/or OCD therapist, you should consider adding the following questions to your assessment to determine the possibility of a co-occurring SUD:

1) How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons?4
2) In the last year, have you ever drunk or used drugs more than you meant to?
3) Have you felt you wanted or needed to cut down on your drinking or drug use in the last year?5

“Yes” answers to any of the above question would warrant further assessment for SUD, which would include information on the substance(s) being used, the frequency of use (e.g., daily, weekly, or monthly), and how recently the individual used a substance. Depending on the severity of the SUD, the impact on treatment outcomes may be significantly different. Please refer to the DSM V,6 which provides criteria on the distinction between mild, moderate, and severe symptoms for SUD.

One other thing to keep in mind during the assessment phase is that withdrawal from alcohol and/or benzodiazepines has the potential to be life-threatening, and a medically supervised detoxification may be needed prior to moving forward with any treatment for either OCD or SUD.

OCD assessment in SUD treatment

For the remaining 40 percent of individuals with anxiety or OCD and co-occurring SUD, the SUD developed first and thus their treatment likely began through SUD specialty services. As such, there is an important need to screen for OCD in SUD clients. If you are primarily an SUD provider, here are some basic screening questions you could consider to rule in (or out) the likelihood of OCD:
1) Do you have thoughts that make you anxious that you cannot get rid of, no matter how hard you try?
2) Do you keep things extremely clean or wash your hands frequently?
3) Do you check things to excess?7

“Yes” answers to any of these questions would warrant further assessment for OCD. If it appears that OCD may be present, further assessment includes finding out more specific details of the patient’s obsessions and compulsions, including the level of distress associated with each and the degree to which symptoms are getting in the way of functioning.

Family Involvement

Once you are able to identify co-morbid OCD–SUD, another important factor to consider in your assessment is how the OCD and/or SUD symptoms have affected the family dynamic. It is common with both OCD8,9 and SUD10 for families to accommodate/enable patients, often with the intention of being supportive. It is not uncommon for there to be a parallel recovery process for family members, impacting their ability and/or willingness to participate in the treatment process. Involving a family member or significant person (such as a friend, sponsor, or religious leader) who is willing to assist in the treatment and recovery maintenance process can be beneficial to treatment.

Treatment History

Finally, review the patient’s past treatment history in detail. Questions about what types of treatments were tried, what those treatment interventions looked like, and what level of buy-in or engagement the patient had, can go a long way in properly orienting the patient to the current proposed treatment plan and, in some cases, can correct any misinformation they had about their mental health struggles and treatment.

For example, those patients who have been (finally) accurately diagnosed with OCD may have had multiple treatment episodes, received ineffective treatment, and/or have had no experience with exposure and response prevention (ERP) therapy (please see more below about this type of treatment). Those previously diagnosed with SUD may have attended 12-step meetings in the past, but may have never understood the different types of meetings, how to obtain a sponsor, or written out any “step work.” And a 12-step approach might have been the only “treatment” model they have been exposed to thus far.

Once you feel confident in your assessment, the next step is to talk in some detail with the patient about their diagnosis of OCD–SUD and provide them with an initial framework for treatment. This will likely include what their treatment options are and what the potential benefits of involving family or a significant person of the patient’s choosing in their treatment.

TREATMENT

As described in Mark’s experience detailed above, the status quo for treating OCD and a co-occurring SUD is that an individual enters treatment for one disorder (typically whichever is most severe), but then symptoms of the other disorder interfere, resulting in discontinuation of treatment. This bouncing back and forth between unsuccessful attempts to treat each disorder separately becomes a significant obstacle for long-term recovery from either one.

One option, therefore, is to consider treating symptoms of both disorders at the same time. The concurrent treatment model described below borrows the best of treatment from both worlds and considers ways to combine them. First, I will review the treatments for OCD and SUD separately. Then, I will use an example to illustrate how these treatments have been combined together.

Exposure Response Prevention (ERP) for OCD

ERP is categorized as a “behavior therapy” because the focus is primarily on modifying the patient’s behavior. In ERP, patients with OCD are asked to confront or “expose” themselves to the thoughts, images, objects, and/or situations that lead to anxiety and/or trigger their obsessions. Response prevention in ERP refers to making a choice to not engage in a compulsive behavior once the anxiety or obsessions have been triggered.7, 11

Twelve Step Facilitation (TSF)

TSF for SUD patients integrates professional treatment with the experiences of attending a mutual self-help group thereby enhancing the benefits and utilization of 12-step meetings, such as Alcoholics Anonymous (AA). This is a brief, structured, manual-driven approach to facilitating early recovery from alcohol abuse, alcoholism, and other drug abuse and addiction problems.12 Clinicians may choose to utilize the manual or adapt treatment based on the principles of TSF. An example of a TSF intervention could include actively reviewing the benefits of meetings the patient has been attending. The goal would be to underscore the value of decreased isolation and increased recovery-focused social interactions. Specific self-directed activities could also be included between sessions, such as asking the patient to read and review literature like chapters from the AA Big Book.13

Cognitive Behavioral Therapy (CBT)

CBT is a broader treatment approach that has been used effectively with both OCD and SUD patients. The focus of CBT is to teach individuals to increase awareness of their thought processes and to respond differently to negative patterns of thinking and behavior. For instance, cognitive-behavioral therapy might help a person be aware of the stressors, situations, and feelings that lead to substance use so the person can then avoid them or make different choices when they occur.14 Similarly, CBT treatment for OCD can address the patient’s reactive response to the experience of obsessions. A CBT therapist in this case might teach the patient how to increase awareness of when they experience obsessions and begin to coach different responses the patient can engage in as opposed to compulsive behavior.

Medication Assisted Treatment (MAT)

MAT is the combination of medication and behavioral treatments. MAT is supported in several studies on both SUD15, 16 and OCD.7 These studies have looked at OCD and SUD separately, though results consistently indicate that the addition of medication in combination with behavioral treatment is an effective option that often improves outcomes.

A CASE EXAMPLE OF CONCURRENT TREATMENT FOR OCD-SUD

One of the few treatment facilities in the United States that uses a concurrent treatment model for OCD-SUD is the program at AMITA Health/Alexian Brothers in Hoffman Estates, IL. Their goal is to attempt to meet treatment needs for individuals with co-occurring OCD-SUD “under one roof.” At this program, an inpatient detox serves as the starting place for those who need it. Once a patient completes detox, they can then “step down” into the Center for Addiction Medicine (CAM) Partial Hospital Program (this program also serves as the “starting place” for those not needing detox).

Clinicians at CAM actively screen for OCD, and patients identified as having both OCD and SUD are then “cross-tracked” into both CAM and the Center for Anxiety and OCD. For the first two weeks while a patient is working on their recovery at CAM, he or she can cross-track into groups in the OCD program (one hour a day, three days a week) to start to become familiar with what anxiety/OCD is and the roles it plays in one’s life, in addition to how poor use of coping strategies can inadvertently increase anxiety and OCD symptoms. This basic education is very essential, as the person with OCD has often spent years either denying the OCD or masking it with substance use. At CAM, therapy involves groups around mindfulness skills training, problem solving, shame and guilt, relapse prevention, and the stages of change. After two weeks of recovery, the patient can then switch to primary OCD treatment at the Center for Anxiety & OCD and continue to cross-track with CAM.

Treatment at the Center for Anxiety and OCD consists of two to three hours a day of CBT and ERP, along with education groups about anxiety management, problem solving, and mindfulness. While in the OCD program, weekly drug tests are conducted to assure that recovery is being maintained, and patients can still continue on their medications (even drugs like Suboxone and Methadone).

In the CAM cross-track, the patient will spend several hours a week (one to two hours a day, two to three days a week) still working in groups with that cohort of patients they got to know while first addressing their recovery at CAM. This positive peer support is essential. They will also have access to learning further coping skills of how to handle cravings and learn skills involved in purposely living a sober life. All cross-tracked patients are fully involved in each program — they are not separated out from the other patients — so that they have full access to peers with OCD and peers with substance use disorders.

Both programs have components of medication education, nutrition, and expressive therapy. There are also 12-step meetings held at the hospital that patients can attend, as well as anxiety-focused support groups. Patients in the partial hospital program meet weekly with a psychiatrist to review medications, and family sessions are encouraged to get everyone on board about what is best for treatment.

The two programs work in conjunction, with clinicians recognizing there are stressors that may lead to relapse. In this program, relapses are assessed as possible warning signs. That is, the therapist considers that maybe the OCD work is going along too fast and might need to slow down a bit. Case managers from both programs have access to the patient chart and are able to meet together in weekly staffing conferences to review progress and setbacks. Family sessions can also be conducted to see how external stressors are affecting progress in the program so the patient and their family are approaching their recovery and OCD in ways that will be helpful and not a hindrance.

AREAS NEEDING SPECIAL CARE IN A CONCURRENT OCD–SUD TREATMENT PROGRAM

Relapse Prevention

ERP is, by design, intended to expose patients to situations that raise their anxiety levels as part of the treatment process. As noted above, for some patients this may increase SUD cravings. As such, individual providers and treatment programs should plan for potential lapses during treatment, along with how these may be addressed. The current strategy at most treatment facilities is to discharge a patient for relapsing; however, outcomes following administrative discharge are poor for both disorders.17, 18 Instead of discharging OCD–SUD patients who relapse, an alternative would be to treat each instance based on its own merits (as noted above by the clinicians at Amita/Alexian Brothers). Those in charge of treatment planning could consider the following factors before discharge:
• A review of the patient’s overall engagement in treatment prior to the relapse
• A consideration as to whether this was a one-time return to substance use or a full blown relapse to repetitive substance use
• Consideration on the part of the therapist as to the pace of the patient’s ERP. Were the expectations of the therapist too overwhelming for the patient, and should there be a change in treatment expectations instead?
• Was the patient receiving enough support and given access to all resources that might have circumvented the relapse?
• Would the addition of medications for either OCD or SUD provide additional support during the treatment process?

Instead of considering relapses as markers to discontinue treatment, a relapse could be used as a point in time to allow for a reassessment of the recovery process. What might have been missing? What needs to be shored up? Or, is this in fact an indication of the patient’s non-engagement in the treatment process? Rather than jump to the latter as the most likely conclusion, it is recommended that this be assessed further.

Withdrawal & Medications

Several medications have been found effective in treating SUD involving opioids, alcohol, and nicotine in adults.16 Currently no FDA-approved medications exist to treat SUD involving cannabis, cocaine, or methamphetamine.

A note about cannabis, cocaine, or methamphetamine addiction: It is a misconception that there are no withdrawals from these substances. There are indeed, and symptoms may include fatigue, low frustration tolerance, and in more severe cases, a period of significant depression. Though these symptoms usually resolve without the need for medically supervised withdrawal, this is a leading reason insurance often will not cover inpatient detoxification for these substances. Patients may have difficulty with motivation or attention in sessions if experiencing withdrawals from cocaine, cannabis, or methamphetamine during early weeks of treatment. It is important to recognize these as signs of withdrawal and not a lack of engagement in the treatment process.

Also, medication management of SUD symptoms typically only address issues associated with one substance being used. For example, a common issue in utilizing medication in the absence of behavioral treatment for SUD involves patient changing to a new primary substance. If you begin a medication to assist with opioid dependence, a patient who does not change established behaviors and cognitions might begin to use alcohol. For those who struggle with multiple substance use problems, CBT and other behavioral interventions can often improve outcomes.

Additional Notes on Treatment Strategies
For those therapists and program directors interested in developing a treatment model similar to the one at Amita/Alexian Brothers, here are some points to consider:

• Treating SUD concurrently with OCD will require changes in contracting and treatment planning. At the outpatient level of care, this may involve increasing the number of sessions per week. For example, one session could be dedicated to ERP, while the second session is dedicated to SUD. At more intensive levels of care, treatment programs could mix ERP coaching sessions into the patient’s day along with an emphasis on therapist-led TSF-based interventions.

• CBT-based approaches have been shown to be helpful for both individuals with OCD and those with SUD. In a combined model, the therapist can also help the patient to explore the cognitions and behaviors that may increase and/or maintain symptoms of the other disorder. For substance use, this may include exploring the pros and cons of continued use, self-monitoring to identify triggers for cravings, identifying situations that might put one at risk for use, and developing specific coping skills to deal with cravings and high-risk situations.14 If the substance use provides relief from OCD symptoms, a patient may believe this is a reason for continued use. Or, a desire to maintain friendships may have a patient going to the local sports bar to watch a game with friends which, in early recovery, would constitute a high-risk situation.

• As many OCD specialists know, medications for OCD typically start with using serotonin reuptake inhibitors, or SRIs. However, for those not specializing in the treatment of OCD, it is important to note the dosing and duration, since effective treatment of OCD with SRIs does not follow standard prescribing protocols for treating depression. Treatment for OCD often requires higher doses and can take up to 12 weeks before assessing how effective it might be for the individual.

• OCD programs would greatly benefit from having at least one SUD specialist on staff who could develop treatment plans and provide professional consultation to treatment teams.

SUMMARY

Common traits of both OCD and SUD are isolation, shame, and fear. In addition to facing these personal obstacles, patients must also navigate a treatment system that has room for significant improvement. In particular, the existing state of affairs in which dual-diagnosed patients are passed back and forth between SUD and OCD programs, with each one unwilling to treat both issues and discharging patients due to “unacceptable” behavior.

This pair of articles on co-occurring OCD–SUD were intended to spark further conversation about the state of affairs for those affected by both disorders. The hope is that those affected by OCD–SUD begin to step forward and share their experiences, struggles, and hope for recovery, and that mental health providers in both the OCD and SUD worlds begin to ask themselves whether their current practice is optimal.

Avenues for research on OCD–SUD are abundant, as the current research base is extremely limited. Additional research, treatment protocols, and provider education are desperately needed to meet the needs of this population. Knowledge is power, but until programs (both residential and outpatient) are willing to equip themselves to effectively treat OCD–SUD, the treatment outcomes for this co-occurrence will remain poor.

References:

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