saskatoon day 2

Treatments for Methamphetamine-Related Disorders : 

Treatments for Methamphetamine-Related Disorders Richard. A. Rawson, Ph.D. UCLA Integrated Substance Abuse Programs Los Angeles California rrawson@mednet.ucla.edu www.uclaisap.org Saskatoon, Saskatchewan February 2005 Supported by National Institute on Drug Abuse and the Pacific Southwest Technology Transfer Center

MA Treatment Issues: 

MA Treatment Issues Acute MA Overdose Acute MA Psychosis MA “Withdrawal” Initiating MA Abstinence MA Relapse Prevention Protracted Cognitive Impairment and Symptoms of Paranoia

Acute MA Psychosis: 

Acute MA Psychosis Extreme Paranoid Ideation Well Formed Delusions Hypersensitivity to Environmental Stimuli Stereotyped Behavior “Tweaking” Panic, Extreme Fearfulness High Potential for Violence

Treatment of MA Psychosis: 

Treatment of MA Psychosis Typical ER Protocol for MA Psychosis: Haloperidol - 5mg Atypical antipsychotic (eg. respiridone) Clonazepam - 1 mg Cogentin - 1 mg Quiet, Dimly Lit Room Restraints

MA “Withdrawal”: 

MA “Withdrawal” - Depression - Paranoia - Fatigue - Cognitive Impairment - Anxiety - Agitation - Anergia - Confusion Duration: 2 Days - 2 Weeks

Treatment of MA “Withdrawal”: 

Treatment of MA “Withdrawal” Hospitalization/Residential Supervision if: Danger to Self or Others, or, so Cognitively Impaired as to be Incapable of Safely Traveling to and from Clinic Otherwise Intensive Outpatient Treatment

Treatment of MA “Withdrawal”: 

Treatment of MA “Withdrawal” Intensive Outpatient Treatment: No Pharmacotherapy Available Positive, Reassuring Context Directive, Behavioral Intervention Educate Regarding Time Course of Symptom Remission Recommend Sleep and Nutrition Low Stimulation Acknowledge Paranoia, Depression

Initiating MA Abstinence: 

Initiating MA Abstinence Key Clinical Issues: Depression Cognitive Impairment Continuing Paranoia Anhedonia Behavioral/Functional Impairment Hypersexuality Conditioned Cues Irritability/Violence

Treatment of MA Disorders: 

Treatment of MA Disorders Traditional Treatments: Therapeutic Community Minnesota Model Outpatient Counseling Psychotherapy

Treatment of MA Disorders: 

Treatment of MA Disorders State of Empirical Evidence: No Information on TC or “Minnesota Model” Approaches No Pharmacotherapy with Demonstrated Efficacy Results of Cocaine Treatment Research Extrapolated to MA Treatment

Treatments for Stimulant-Use Disorders with Empirical Support: 

Treatments for Stimulant-Use Disorders with Empirical Support Motivational Interviewing Cognitive-Behavioral Therapy (CBT) Community Reinforcement Approach Contingency Management Matrix Model

The CSAT Methamphetamine Treatment Project: 

Richard Rawson Ph.D. U.C.L.A. Integrated Substance Abuse Programs (I.S.A.P.) The MTP Site Investigators Funded by the Center for Substance Abuse Treatment The CSAT Methamphetamine Treatment Project A Multi-site Trial of a Manualized Psychosocial Protocol for the Treatment of Methamphetamine Dependence

CSAT MTP Project Goals:: 

CSAT MTP Project Goals: To study the clinical effectiveness of the Matrix Model To compare the effectiveness of the Matrix model to other locally available outpatient treatments To establish the cost and cost effectiveness of the Matrix model compared to other outpatient treatments To explore the replicability of the Matrix model and challenges involved in technology transfer

Matrix ModelAn Integrated, Empirically-based, Manualized Treatment Program: 

Matrix Model An Integrated, Empirically-based, Manualized Treatment Program

Manuals in Psychosocial Treatment: 

Manuals in Psychosocial Treatment Reduce therapist differences Ensure uniform set of services Can more easily be evaluated Enhance training capabilities Facilitate research to practice

Matrix Model ofOutpatient Treatment: 

Matrix Model of Outpatient Treatment Organizing Principles of Matrix Treatment Program components based upon scientific literature on promotion of behavior change. Program elements and schedule selected based on empirical support in literature and application. Program focus is on current behavior change in the present and not underlying “causes” or presumed “psychopathology”. Matrix “treatment” is a process of “coaching”, educating, supporting and reinforcing positive behavior change.

Matrix Model ofOutpatient Treatment: 

Matrix Model of Outpatient Treatment Organizing Principles of Matrix Treatment Non-judgmental, non-confrontational relationship between therapist and patient creates positive bond which promotes program participation. Therapist as a “coach” Positive reinforcement used extensively to promote treatment engagement and retention. Verbal praise, group support and encouragement other incentives and reinforcers.

Matrix Model ofOutpatient Treatment: 

Matrix Model of Outpatient Treatment Organizing Principles of Matrix Treatment Accurate, understandable, scientific information used to educate patient and family members Effects of drugs and alcohol Addiction as a “brain disease” Critical issues in “recovering” from addiction

Matrix Model ofOutpatient Treatment: 

Matrix Model of Outpatient Treatment Organizing Principles of Matrix Treatment Behavioral strategies used to promote cessation of drug use and behavior change Scheduling time to create “structure” Educating and reinforcing abstinence from all drugs and alcohol Promoting and reinforcing participation in non- drug-related activities

Matrix Model ofOutpatient Treatment: 

Matrix Model of Outpatient Treatment Organizing Principles of Matrix Treatment Cognitive-Behavioral strategies used to promote cessation of drug use and prevention of relapse. Teaching the avoidance of “high risk” situations Educating about “triggers” and “craving” Training in “thought stopping” technique Teaching about the “abstinence violation effect” Reinforcing application of principles with verbal praise by therapist and peers

Matrix Model ofOutpatient Treatment: 

Matrix Model of Outpatient Treatment Organizing Principles of Matrix Treatment Involvement of family members to support recovery. Encourage participation in self-help meetings Urine testing to monitor drug use and reinforce abstinence Social support activities to maintain abstinence

Elements of the Matrix Model: 

Elements of the Matrix Model Engagement/Retention Structure Information Relapse Prevention Family Involvement Self Help Involvement Urinalysis/Breath Testing

The Matrix Model: 

The Matrix Model Urine or breath alcohol tests once per week, weeks 1-16

Slide24: 

  Table 1. Sites participating in the MTP (from Herrell et al, 2000)

Slide25: 

Table 4. MTP Participant Characteristics (taken from baseline ASI)

Slide26: 

Table 7. Comparison of retention between groups within sites, with Matrix truncated to the length of TAU at each site

Sample Description: 

Sample Description

Baseline Demographics: 

Baseline Demographics

Gender Distribution of Participants: 

Gender Distribution of Participants

Ethnic Identification of Participants: 

Ethnic Identification of Participants

Marital Status of Participants: 

Marital Status of Participants

Employment Status of Participants: 

Employment Status of Participants

Route of Methamphetamine Administration: 

Route of Methamphetamine Administration

Slide34: 

Route of Administration by MTP Site (N=978) Site Oral Nasal Smoke IV Billings 0% 2% 42% 56% Concord 0% 10% 59% 30% Costa Mesa 0% 8% 65% 27% Hayward 1% 35% 57% 5% Honolulu 0% 1% 96% 3% San Diego 1% 11% 61% 28% San Mateo, ODASA 0% 6% 94% 0% San Mateo, Pyramid 0% 23% 64% 13% OVERALL PERCENT : 0% 11% 65% 24%

Changes from Baseline to Treatment-end: 

Changes from Baseline to Treatment-end

Days Paid for Work in Past 30: 

Days Paid for Work in Past 30 Possible is 0-30; tpaired=6.01; p-value<0.000 (highly sig.)

Total Income (Past 30 days) of Participants: 

Total Income (Past 30 days) of Participants tpaired=2.34; p-value=0.02 (sig.)

ASI Composite Scores: 

ASI Composite Scores Possible is 0-1; Higher : worse problem tpaired: *p-value<0.03 (sig.), **p-value<0.000 (highly sig.)

Days of Methamphetamine Use in Past 30 (ASI): 

Days of Methamphetamine Use in Past 30 (ASI) Possible is 0-30; tpaired=20.90; p-value<0.000 (highly sig.)

Days of Marijuana Use in Past 30 (ASI): 

Days of Marijuana Use in Past 30 (ASI) Possible is 0-30; tpaired=8.02; p-value<0.000 (highly sig.)

Days of Alcohol Use in Past 30 (ASI): 

Days of Alcohol Use in Past 30 (ASI) Possible is 0-30; tpaired=6.47; p-value<0.000 (highly sig.)

BSI Scores (mean): 

BSI Scores (mean) 1Possible, all scores, is 0-4; *all p-values<0.000 (highly sig.)

Positive Symptom Total (PST) from Brief Symptom Inventory (BSI): 

Positive Symptom Total (PST) from Brief Symptom Inventory (BSI) Possible is 0-53; tpaired=14.33; p-value<0.000 (highly sig.)

Slide44: 

Figure 1. Overall participant follow-up by treatment condition and time point

Slide45: 

Figure 3. Participant retention throughout treatment, by site and treatment group

Slide46: 

Figure 2. Mean number of weekly data visits attended, by treatment length and treatment group (Matrix group data truncated to the length of TAU)

Slide47: 

Figure 4. Percent completing treatment, by group

Slide48: 

Figure 5. Mean number of MA-free urine samples, by treatment length and treatment group (Matrix group data truncated to the length of TAU)

Slide49: 

Figure 6. Participant self-report of MA use (number of days during the past 30) at enrollment, discharge, and 6-month follow-up, by treatment condition

Route of Administration and Risk Behavior in Two Treatment Samples of Methamphetamine Users : 

Route of Administration and Risk Behavior in Two Treatment Samples of Methamphetamine Users CSAT MTP Study (978) NIDA MCTG Study (257)

CSAT MTP Project Injection Risk Behavior (N=978): 

CSAT MTP Project Injection Risk Behavior (N=978)

CSAT MTP Project Sexual Risk Behavior (N=978): 

CSAT MTP Project Sexual Risk Behavior (N=978)

Route of Administration by MCTG site (N=253): 

Route of Administration by MCTG site (N=253)

NIDA MCTG Project Injection Risk Behavior (N=257): 

NIDA MCTG Project Injection Risk Behavior (N=257)

NIDA MCTG Project Sexual Risk Behavior (N=257): 

NIDA MCTG Project Sexual Risk Behavior (N=257)  

METHAMPHETAMINE ADDICTION TREATMENT THINK TANK (MATTT)JANUARY 12, 2000: 

METHAMPHETAMINE ADDICTION TREATMENT THINK TANK (MATTT) JANUARY 12, 2000 Targets for Clinical Trials Dependence Intoxication / Overdose Cognitive impairment Develop infrastructure for clinical studies Phase I, clin/pharm inpatient studies Cue craving Phase II & III outpatient studies

METHAMPHETAMINE ADDICTION TREATMENT THINK TANK (MATTT)JANUARY 12, 2000: 

METHAMPHETAMINE ADDICTION TREATMENT THINK TANK (MATTT) JANUARY 12, 2000 Cont… III. Pre-clinical Animal Models (locomotion, drug discrimination/substitution, reinforcement) IV. Medications list (Bupropion, Selegiline, Lobeline, Dopamine Agonists, SSRIs, GABA agonists) Medications with positive signal from cocaine trials (Reserpine, Cabergoline, Disulfiram)

DA SPONSORED METHAMPHETAMINEMEDICATIONS TRIALS: 

DA SPONSORED METHAMPHETAMINE MEDICATIONS TRIALS

NIDA SPONSORED METHAMPHETAMINEMEDICATIONS TRIALS: 

NIDA SPONSORED METHAMPHETAMINE MEDICATIONS TRIALS

NIDA SPONSORED METHAMPHETAMINEMEDICATIONS TRIALS: 

NIDA SPONSORED METHAMPHETAMINE MEDICATIONS TRIALS

MCTG: The Problem: 

MCTG: The Problem NIDA has a desire to speed up the development of medications for the treatment of methamphetamine use disorders. Too few research groups available in areas of the US with extensive methamphetamine use.

Addiction Medication Trials1990-2000: 

Addiction Medication Trials 1990-2000 Potential Cocaine Pharmacotherapies Evaluated: 62 Number of Cocaine Pharmacotherapies Clinical Trials: 102 Potential Methamphetamine Pharmacotherapies Evaluated: 7 Number of Methamphetamine Clinical Trials: 5 As complexity of medication testing and regulatory system becomes more complex it is difficult for new investigators to initiate research

MCTG: A Response: 

MCTG: A Response Establish a training/coordinating center to train, organize and monitor sites. Establish a set of medication testing sites in regions with extensive methamphetamine use and an MD and team that can conduct trials. Decide on a medication(s) and protocol for study Initiate studies

Slide67: 

Division of Treatment Research & Development 19 September 2000 Methamphetamine Clinical Trials Group (MCTG) Los Angeles, CA UCLA Coordinating Center Richard Rawson, , PI

BUPROPION STUDY FOR METHAMPHETAMINE DEPENDENCE: 

BUPROPION STUDY FOR METHAMPHETAMINE DEPENDENCE 300 Subjects; 5 Sites; Outpatient Study Placebo Controlled; DB; Bupropion SR 150 mg BID + Psychotherapy 3 x / Week 2 – 4 weeks screening; 12 weeks treatment; 30 days F/U Outcome Measures Methamphetamine Use (urine, self-report) Cognitive functions ASI (Behavioral, vocational, social functioning) HRBS (HIV Risk) Timeline: November 2000 – November 2001

Slide69: 

MCTG Road Map FY2003 FY2004 FY2005 Selegiline oral I Lobeline I Reserpine I Tiagabine I Cabergoline I Disulfiram I Selegiline II Bupropion I Bupropion II FY2006 Ondansetron IIa Ondansetron IIb US/Thai Behavioral Study Lobeline II Aripiperazole II Tiagabine II Cabergoline II Disulfiram II GBR 12909 GBR 12909 II confidential Modafinil IIa US/Thai Aripiperazole I Reserpine II

Slide70: 

“TOP DOWN” APPROACH “BOTTOMS UP” APPROACH Medications to Treat Stimulant Addiction

Methamphetamine Clinical Trials Group: 

Methamphetamine Clinical Trials Group UCLA is the coordinating center for clinical studies 5 Sites participate on a contractual basis Primary focus-reduction of methamphetamine use All trials use a behavioral platform for all treated subjects

MCTG Studies: 

MCTG Studies Behavioral Platform Study (completed Oct, 2002). Ondansetron Study (to be completed May 1, 2003. Bupropion Study (to begin June 1, 2003)

MCTG Behavioral “Platform” Study: 

MCTG Behavioral “Platform” Study All participants were scheduled to attend and take part in a 90-minute cognitive behavioral therapy (CBT) group thrice weekly during the 12 weeks of treatment. The CBT procedure consisted of 36 group sessions (3 per week for 12 weeks). The 90-minute groups had 4-8 participants and each session was guided by a worksheet from a manual (Rawson, et al., 1989). Each worksheet presented a concept or a brief exercise that explained or illustrated an aspect of CBT.

MA Use in Past 30 Days: 

MA Use in Past 30 Days

MA Use Life Time: 

MA Use Life Time

MA Route of Administration : 

MA Route of Administration

Percentage of study candidates who achieved enrollment, evaluable and completer requirements: 

Percentage of study candidates who achieved enrollment, evaluable and completer requirements

Tx Retention by Site: 

Tx Retention by Site

Average weeks of retention across sites: 

Average weeks of retention across sites

Self-report of MA free days by site during protocol participation: 

Self-report of MA free days by site during protocol participation

MA-free UA during protocol involvement: Comparison by routes of administration of MA: 

MA-free UA during protocol involvement: Comparison by routes of administration of MA

Urinalysis results: Baseline vs. week 13 for participants providing both baseline and study termination samples: 

Urinalysis results: Baseline vs. week 13 for participants providing both baseline and study termination samples

Initiating MA Abstinence: 

Initiating MA Abstinence Key Clinical Issues Depression Cognitive Impairment Continuing Paranoia Anhedonia Behavioral/Functional Impairment Hypersexuality Conditioned Cues Irritability/Violence

Slide84: 

www.drugabuse.gov

Outpatient Treatment Recommendations: Empirically-Supported: 

Outpatient Treatment Recommendations: Empirically-Supported Multiple Weekly Sessions for at least 90-120 days 3 visits per week minimum, recommended. Family involvement important 12-step facilitation and participation valuable Urinalysis and breath alcohol testing needed Medications of value with some patients

Manuals in Psychosocial Treatment: 

Manuals in Psychosocial Treatment Reduces therapist differences Ensures uniform set of services Can more easily be evaluated Enhances training capabilities Facilitates research to practice

Research-based Behavioral Treatments: 

Research-based Behavioral Treatments Relapse Prevention Marlatt, Gordon and Carroll Supportive-Expressive Psychotherapy Luborsky, Woody, McLellan, O’Brien Individualized Drug Counseling Cocaine Collaborative Study

Research-based Behavioral Treatments: 

Research-based Behavioral Treatments Community Reinforcement plus Vouchers Higgens Matrix Model of Intensive Outpatient Treatment Rawson, Obert, McCann

The Matrix Model:It is many treatments in one: 

The Matrix Model: It is many treatments in one Out-patient, office-based Easy to understand Structure, structure, structure Continuing attendance is important

Organizing Principles of Matrix Treatment: 

Organizing Principles of Matrix Treatment Program components based on scientific literature promoting behavior change Program elements and schedule selected based on empirical support in literature and application

Organizing Principles of Matrix Treatment: 

Organizing Principles of Matrix Treatment Program focus is on behavior change in the present, not on assumed underlying psychopathology Matrix treatment is a process of “coaching”, supporting, reinforcing and supporting positive behavior change

Organizing Principles of Matrix Treatment: 

Organizing Principles of Matrix Treatment Non-confrontational, non-judgmental relationship between therapist and patient creates positive bond which promotes program participation. Positive reinforcement, incentives and contingencies used extensively to promote treatment engagement and retention.

Organizing Principles of Matrix Treatment: 

Organizing Principles of Matrix Treatment Accurate, understandable scientific information used to educate patient and family members Cognitive behavioral strategies used to promote drug cessation and relapse prevention

Organizing Principles of Matrix Treatment: 

Organizing Principles of Matrix Treatment Family therapy interventions used to engage families in recovery process Self help resources introduced and participation encouraged

Organizing Principles of Matrix Treatment: 

Organizing Principles of Matrix Treatment Urine and breath/alcohol testing used to monitor drug/alcohol use and support abstinence. Social support activities provided to help maintain abstinence

Slide96: 

How it looks in Practice Matrix Model of Outpatient Treatment

Matrix ModelPutting It All Together: 

Matrix Model Putting It All Together

Matrix Model Groups: 

Matrix Model Groups Early Recovery (Engaging) Relapse Prevention (Learning) Social Support (Maintaining) MATRIX

Matrix Treatment GroupsDifferent from General Therapy: 

Matrix Treatment Groups Different from General Therapy Focus on behavior vs. feeling Visit frequency results in strong transference Transference is encouraged Transference is utilized Goal is stability (vs. emotional catharsis)

Matrix Treatment GroupsDifferent from General Therapy: 

Matrix Treatment Groups Different from General Therapy Focus is on abstinence Bottom line is always continued abstinence Therapist frequently pursues less motivated clients The behavior is more important than the reason behind it

Matrix Treatment GroupsDifferent from Residential Treatment: 

Matrix Treatment Groups Different from Residential Treatment Less confrontational Progresses more slowly Focus is on present “Core Issues” not immediately addressed Allegiance is to the therapist; vs. group

Matrix Treatment GroupsDifferent from Residential Treatment: 

Matrix Treatment Groups Different from Residential Treatment Non-judgmental attitude is basis of client-therapist bond Change recommendations based on scientific data Changes incorporated immediately into therapeutic style

Slide103: 

Matrix Early Recovery Groups

Early Recovery Groups: 

Early Recovery Groups Scheduling and Calendars Triggers Questionnaires and Chart 12 Step Introduction Alcohol Issues Thoughts Emotions and Behaviors KISS (and other 12-step slogans)

Early Recovery Issues  Engaging and Retaining: 

Early Recovery Issues Engaging and Retaining TRIGGERS

Triggers and Cravings: 

Triggers and Cravings

Triggers and Cravings: 

Triggers and Cravings Pavlov’s Dog: UCR

Triggers and Cravings: 

Triggers and Cravings Pavlov’s Dog: CR

Early Recovery Issues  Engaging and Retaining: 

Early Recovery Issues Engaging and Retaining

Slide110: 

Early Recovery Issues Engaging and Retaining

MATRIX MODEL TREATMENT Triggers - Places: 

MATRIX MODEL TREATMENT Triggers - Places Drug dealer’s home Bars and clubs Drug use neighborhoods Freeway offramps Worksite Street corners

MATRIX MODEL TREATMENT Triggers - Things: 

MATRIX MODEL TREATMENT Triggers - Things Paraphernalia Sexually explicit magazines/movies Money/bank machines Music Movies/TV shows about alcohol and other drugs Secondary alcohol or other drug use

MATRIX MODEL TREATMENT Triggers - Times: 

MATRIX MODEL TREATMENT Triggers - Times Periods of idle time Periods of extended stress After work Payday/AFDC payment day Holidays Friday/Saturday night Birthdays/Anniversaries

MATRIX MODEL TREATMENT Triggers - Emotional States: 

MATRIX MODEL TREATMENT Triggers - Emotional States  Anxiety  Fatigue  Anger  Boredom  Frustration  Adrenalized states  Sexual arousal  Sexual deprivation  Gradually building emotional states with no expected relief

THOUGHT STOPPING: 

THOUGHT STOPPING Prevents the thought from developing into an overpowering craving Requires practice

MOTIVATIONAL INTERVIEWING: 

MOTIVATIONAL INTERVIEWING Increase Motivation Decrease Resistance Increase retention Better outcomes

MATRIX MODEL TREATMENT: 

MATRIX MODEL TREATMENT STRUCTURE

MATRIX MODEL TREATMENT: 

MATRIX MODEL TREATMENT INFORMATION

MATRIX MODEL TREATMENT Information - What: 

MATRIX MODEL TREATMENT Information - What - Substance abuse - Sex and recovery and the brain - Relapse prevention issues - Triggers and cravings - Emotional readjustment - Stages of recovery - Medical effects - Relationships and recovery - Alcohol/marijuana

MATRIX MODEL TREATMENT Information - Why: 

MATRIX MODEL TREATMENT Information - Why Reduces confusion and guilt Explains addict behavior Gives a roadmap for recovery Clarifies alcohol/marijuana issue Aids acceptance of addiction Gives hope/realistic perspective for family

Triggers and CravingsHuman Brain: 

Triggers and Cravings Human Brain

Cognitive Process During Addiction: 

Cognitive Process During Addiction Relief From Depression Anxiety Loneliness Insomnia Euphoria Increased Status Increased Energy Increased Sexual/Social Confidence Increased Work Output Increased Thinking Ability AOD Introductory Phase May Be Illegal May Be Expensive Hangover/Feeling Ill May Miss Work

Conditioning Process During Addiction: 

Conditioning Process During Addiction Introductory Phase Triggers Parties Special Occasions Responses Pleasant Thoughts about AOD No Physiological Response Infrequent Use Strength of Conditioned Connection Mild

Development of Obsessive ThinkingIntroductory Phase: 

Development of Obsessive Thinking Introductory Phase

Development of Craving Response: 

Development of Craving Response Introductory Phase Entering Using Site Use of AODs  Heart/Pulse Rate  Respiration  Adrenaline  Energy  Taste AOD Effects

Slide127: 

Cognitive Process During Addiction Maintenance Phase Depression Relief Confidence Boost Boredom Relief Sexual Enhancement Social Lubricant Vocational Disruption Relationship Concerns Financial Problems Beginnings of Physiological Dependence

Slide128: 

Conditioning Process During Addiction Maintenance Phase Strength of Conditioned Connection Triggers Parties Friday Nights Friends Concerts Alcohol “Good Times” Sexual Situations Responses Thoughts of AOD Eager Anticipation of AOD Use Mild Physiological Arousal Cravings Occur as Use Approaches Occasional Use Moderate

Slide130: 

Development of Craving Response Maintenance Phase Entering Using Site Physiological Response Use of AODs AOD Effects  Heart  Breathing  Adrenaline Effects  Energy Taste  Heart  Blood Pressure  Energy

Slide131: 

Cognitive Process During Addiction Disenchantment Phase Social Currency Occasional Euphoria Relief From Lethargy Relief From Stress Nose Bleeds Infections Relationship Disruption Family Distress Impending Job Loss

Slide132: 

Conditioning Process During Addiction Disenchantment Phase Strength of Conditioned Connection Triggers Weekends All Friends Stress Boredom Anxiety After Work Loneliness Responses Continual Thoughts of AOD Strong Physiological Arousal Psychological Dependency Strong Cravings Frequent Use STRONG

Slide133: 

AOD

Slide134: 

Thinking of Using Mild Physiological Response Entering Using Site  Heart Rate  Breathing Rate  Energy  Adrenaline Effects Powerful Physiological Response Use of AODs AOD Effects  Heart Rate  Breathing Rate  Energy  Adrenaline Effects  Heart  Blood Pressure  Energy

Slide135: 

Cognitive Process During Addiction Disaster Phase Relief From Fatigue Relief From Stress Relief From Depression Weight Loss Paranoia Loss of Family Seizures Severe Depression Unemployment Bankruptcy

Slide136: 

Strength of Conditioned Connection Triggers Any Emotion Day Night Work Non-Work Responses Obsessive Thoughts About AOD Powerful Autonomic Response Powerful Physiological Dependence Automatic Use OVERPOWERING

Slide137: 

Development of Obsessive Thinking Disaster Phase

Slide138: 

Development of Craving Response Disaster Phase Thoughts of AOD Using Place Powerful Physiological Response  Heart Rate  Breathing Rate  Energy  Adrenaline Effects

Outpatient Treatment Strategies: 

Outpatient Treatment Strategies Scheduling

Slide140: 

Matrix Relapse Prevention Groups

Matrix Relapse Prevention Group Topics (Sample): 

Matrix Relapse Prevention Group Topics (Sample) Alcohol -The Legal Drug Boredom Avoiding Relapse Drift/Mooring Lines Guilt and Shame Motivation for Recovery Truthfulness Work and Recovery Staying Busy Relapse Prevention Dealing with Feelings

Roadmap for Recovery: 

Roadmap for Recovery Withdrawal Early Abstinence/Honeymoon Protracted Abstinence or The Wall Adjustment/Resolution

Roadmap for RecoveryThe Wall: 

Roadmap for Recovery The Wall Return to Old Behaviors Anhedonia Anger Depression Emotional Swings Unclear Thinking Isolation Family Problems Cravings Return Irritability Abstinence Violation Protracted Abstinence

Slide144: 

Other Components of the Matrix Model

Components Of The Matrix Model: 

Components Of The Matrix Model Family Education Lectures Conjoint Sessions Urine Testing Relapse Analysis Self help Initiation MATRIX

The CSAT Methamphetamine Treatment Project: 

The CSAT Methamphetamine Treatment Project A Multi-site Trial of a Manualized Psychosocial Protocol for the Treatment of Methamphetamine Dependence Richard A. Rawson, Principal Investigator

JLObert@matrixinstitute.org www.matrixinstitute.org www. uclaisap.org www.nida.nih.gov: 

JLObert@matrixinstitute.org www.matrixinstitute.org www. uclaisap.org www.nida.nih.gov

Research Conducted by Steven Shoptaw, Ph.D. and Colleagues: 

Research Conducted by Steven Shoptaw, Ph.D. and Colleagues Friends Research Institute, Inc./UCLA Integrated Substance Abuse Programs

Behavioral Therapies for Gay Male Stimulant Abusers: Study Objective: 

Behavioral Therapies for Gay Male Stimulant Abusers: Study Objective To evaluate the comparative efficacy of behavioral drug abuse treatments in gay and bisexual, methamphetamine-dependent men in Los Angeles : Methamphetamine use High-risk sexual behaviors Depression ratings SOURCE: S. Shoptaw, et al.

Slide150: 

Adaptation of a Gay-Specific Intervention Standard CBT CBT+ gay-specific HIV-Risk Reduction External Triggers: Sporting Events Gay Pride Festival Concerts Bathhouse Movies Halloween Relapse Justification: “I just got injured. “My friend just died I might as well use.” [AIDS] and using will make me forget for awhile.” One Day at a Time: “Tomorrow something “I seroconverted even will happen to ruin though I knew about this.” safer sex.” Specific Topics: * Coming Out All Over Again: Reconstructing Your Gay Identity * Being Gay and Doing Gay * Preventing Relapse to High-risk Sex * Living in an HIV World * Several session that involve “Aunt Tina” SOURCE: S. Shoptaw, et al.

Discussion: 

Discussion Demonstrates value in applying culturally specific treatments for urban gay substance abusers Concept of targeting both drug use and sexual risk behaviors appears valid Supported by fully 3/5 of sample HIV infected at baseline SOURCE: S. Shoptaw, et al.

Multi-Epidemics and the Implications for Prevention and Treatment/Service Provision: 

Multi-Epidemics and the Implications for Prevention and Treatment/Service Provision Methamphetamine, HIV/AIDS, and Hepatitis C

Treatment Implications for MSM who use Methamphetamine: 

Treatment Implications for MSM who use Methamphetamine HIV+ meth-using MSM may benefit from a variety of treatment approaches that address underlying motivations for meth use, and the link between meth use and sexual risk behavior. There is a need to recognize the role of gay sexuality and HIV+ identity in the recovery process. SOURCE: S. Semple, et al. (2002) Journal of Substance Abuse Treatment, 22: 149-156

Treatment Implications for MSM who use Methamphetamine: 

Treatment Implications for MSM who use Methamphetamine Safer sex can occur in the context of meth use. Factors other than drug use are important determinants of condom use. Physicians who provide treatment to HIV+ meth users should probe for drug use and provide warnings as to the potential for added physical, mental health, and social problems to those who engage in drug use. SOURCE: Patterson and Semple (2003) Journal of Urban Health, 80: iii77-iii87.

What is the Best Approach to the Patient with HCV?: 

What is the Best Approach to the Patient with HCV? Screen for substance use. Provide treatment for substance use! Coordinate medical care and substance abuse treatment. Assess, monitor, and support medication adherence and mental health. SOURCE: Brian Edlin, M.D., Institute for Health Policy Studies, University of California, San Francisco.

What About Caring for Injection Drug Users who are HCV positive?: 

What About Caring for Injection Drug Users who are HCV positive? Educate, counsel, and provide support to avoid sharing syringes and other injection equipment (cookers, cottons) and to avoid any blood contact (giving and receiving injections). Provide access to sterile syringes through referral to syringe exchange programs or syringe prescription. (www.cdc.gov/idu/facts/physician.htm) SOURCE: Brian Edlin, M.D., Institute for Health Policy Studies, University of California, San Francisco.

Prevention and Treatment of Infectious Diseases with Substance-Using Patients: 

Prevention and Treatment of Infectious Diseases with Substance-Using Patients Assess patient’s interest and readiness to adopt various risk reduction strategies. Instruct patients in safer sex and safer injection. Assess and address patient’s mental health status and needs. Assess and address patient’s housing and subsistence needs. Offer confidential testing and counseling for HIV, HBV, HCV, STDs, and TB. SOURCE: Brian Edlin, M.D., Institute for Health Policy Studies, University of California, San Francisco.

Prevention and Treatment of Infectious Diseases with Substance-Using Patients: 

Prevention and Treatment of Infectious Diseases with Substance-Using Patients Provide vaccination for hepatitis A and B to patients without serologic evidence of prior infection. For patients with HIV, HBC, HCV, or TB, discuss treatment options, including risks, benefits, adverse effects, the need for adherence, and the risk of reinfection. For patients considering treatment, assess the likelihood of difficulty with adherence and offer adherence support. SOURCE: Brian Edlin, M.D., Institute for Health Policy Studies, University of California, San Francisco.

HIV and the Border: 

HIV and the Border To what extent are patterns in urban areas replicated in rural areas? What are the HIV risk factors for day laborers/migrant workers working along the US/Mexico border? What about individuals who are infected in U.S. and then return to their families in Mexico Do Mexican residents move to or visit the U.S. to access HIV services?

Policy Implications: 

Policy Implications Maturing AIDS epidemic in US and shrinking public resources underscore importance of working at the “core” of the epidemic Behavioral changes associated with drug abuse treatment prevent HIV transmission and increase general health of individual and community Questions of the cost-benefits to this method remain, but effect sizes provide strong justification for further work with this population

Practical Application of Contingency Management (It’s Rewarding): 

Practical Application of Contingency Management (It’s Rewarding) Michael J. McCann, MA Matrix Institute on Addictions

Contingency Management (CM): 

Contingency Management (CM) CM: application of reinforcement contingencies to urine results or behaviors (attendance in treatment; completion of agreed upon activities).

Engagement and Retention: 

Engagement and Retention Strategies for engaging and retaining Warmth and empathy Flexibility A safe environment Motivational interviewing approach Contingency management

Some Reactions to CM: 

Some Reactions to CM Why do it? Sobriety is its own reward. Good idea, but who can afford it? How do you do it without research staff to manage it?

Contingency Management: Overview: 

Contingency Management: Overview Research findings Application of CM in the Matrix Institute clinics Ideas for practical application of CM

Research Findings: 

Research Findings Highlight efficacy Raise questions about real-world applicability due to cost and complexity

Contingency Management: Steve Higgins, Ph.D.: 

Contingency Management: Steve Higgins, Ph.D. Community Reinforcement Approach (CRA) Marital Therapy Vocational Assistance Skills Training New social and recreational activities Antabuse Vouchers ($977)

Contingency Management: Higgins et al., 1993: 

Contingency Management: Higgins et al., 1993 24-week treatment 3 times per week urines Conditions Standard treatment CRA plus vouchers

Contingency Management: Higgins et al., 1993: 

Contingency Management: Higgins et al., 1993

Contingency Management: Higgins et al., 1994: 

Contingency Management: Higgins et al., 1994 How much of CRA effect is CM? 24-week treatment 3 times per week urines Conditions CRA only CRA plus vouchers

Contingency Management: Higgins et al., 1994: 

Contingency Management: Higgins et al., 1994

Contingency Management: Rawson et al., 2002: 

Contingency Management: Rawson et al., 2002 Cognitive-Behavioral Treatment vs CM only (no counseling) Cocaine users in methadone treatment 16 weeks 3 visits per week

Contingency Management: Rawson et al., 2002: 

Contingency Management: Rawson et al., 2002 Cognitive-behavioral Treatment (CBT) 90 minute groups Cognitive/behavioral Drug cessation Lifestyle change Relapse prevention

Contingency Management: Rawson et al., 2002: 

Contingency Management: Rawson et al., 2002 Contingency Management Vouchers for stimulant-free urines Escalating schedule Bonuses for 3 consecutive clean ($10) Reset with 5 clean Total earnings possible: $1277

Contingency Management: Rawson et al., 2002: 

Contingency Management: Rawson et al., 2002 Cocaine-using methadone patients Four conditions: CM CBT CBT & CM Methadone only

Cocaine-free Urine Samples During StudyRawson et al., 2002: 

Cocaine-free Urine Samples During Study Rawson et al., 2002 P<.001 CM>MM CBT & CM>MM

Percent Subjects Achieving 3 Consecutive Weeks Cocaine-freeRawson et al., 2002: 

Percent Subjects Achieving 3 Consecutive Weeks Cocaine-free Rawson et al., 2002 P<.02 CM>MM CBT & CM >MM

Days used cocaine in past month Rawson et al., 2002: 

Days used cocaine in past month Rawson et al., 2002 Week 26: CM<MM; CBT<MM Week 52: CBT<MM

CM in Practice: Lower CostPetry et al, 2000: 

CM in Practice: Lower Cost Petry et al, 2000 42 alcohol dependent patients Standard treatment (12-Step, life skills, coping skills, RP, AIDS education, social-recreational); 4-week intensive Standard treatment plus CM Target behaviors: breath alcohol test; 3 treatment goal activities 8-week study period

CM in Practice: Lower CostPetry et al, 2000: 

CM in Practice: Lower Cost Petry et al, 2000

Contingency Management: Research Findings : 

Contingency Management: Research Findings Many more studies support CM Effective with wide variety of abused substances Nicotine Alcohol Heroin Benzodiazepines Cocaine and Methamphetamine

CM in Practice: Challenges: 

CM in Practice: Challenges Must be simple Easy to track target behaviors Simple schedules—escalating schedules, resets, etc. Little burden on the counselor or administrative staff (can’t reward patients and punish staff) No research assistant

CM in Practice: More Challenges: 

CM in Practice: More Challenges Addressing staff resistance Patients should not have to be “paid”; recovery is the reward Motivation needs to come from within Reframe CM as an engagement technique along with traditional interventions and approaches

CM in practice: Readiness for Patients: 

CM in practice: Readiness for Patients The old attitude: “patients need to be ready for treatment.” New attitude: “treatments need to be ready for patients.”