Meth SummitMeth SummitMonday, October 16, 2006Monday, October 16, 2006

Sponsored by the County CommissionersSponsored by the County Commissioners

Of Of

Larimer and Weld CountiesLarimer and Weld Counties

What about Meth treatment?What about Meth treatment?

What does the research What does the research indicate about treatment?indicate about treatment?

Investigational MedicationInvestigational Medicationfor High Blood Pressurefor High Blood Pressure

Blo

od P

ress

ure

Before Tx Tx Tx Removed

Treatment Works!!!

New Behavioral Treatment New Behavioral Treatment for Methamphetamine Usefor Methamphetamine Use

Leve

l of U

se

Before Tx Tx Tx Removed

Treatment Failed!!!

Relapse Rates Are Similar for Drug Dependence andOther Chronic Illnesses

Relapse Rates Are Similar for Drug Dependence andOther Chronic Illnesses

00

1010

2020

3030

4040

5050

6060

7070

8080

9090

100100

Drug Dependence

Drug Dependence

Type I DiabetesType I

DiabetesHypertensionHypertension AsthmaAsthma

40 t

o 60

%40

to

60%

30 t

o 50

%30

to

50% 50

to

70%

50 t

o 70

%

50 t

o 70

%50

to

70%

Source: McLellan, A.T. et al., JAMA, Vol 284(13), October 4, 2000.Source: McLellan, A.T. et al., JAMA, Vol 284(13), October 4, 2000.

Per

cen

t of

Pat

ien

ts W

ho

Rel

apse

Per

cen

t of

Pat

ien

ts W

ho

Rel

apse

Predictors of Retention in Predictors of Retention in Treatment for more than 90 Treatment for more than 90 daysdays1.1.Higher rates of retention for menHigher rates of retention for men

2.2.Legal supervision increases treatment retentionLegal supervision increases treatment retention

3.3.Injection users were retained more poorlyInjection users were retained more poorly

4.4.Those with chronic mental illness were retained Those with chronic mental illness were retained more poorlymore poorly

5.5.Daily users are retained more poorly than those Daily users are retained more poorly than those who use less often than dailywho use less often than daily

6.6.Those who began use at an older age were Those who began use at an older age were retained better than those who started when retained better than those who started when youngeryounger

7.7.Those who are older at admission were retained Those who are older at admission were retained betterbetter

Optimal candidates for outpatient Optimal candidates for outpatient treatment include:treatment include:

• Those who do not inject MA.Those who do not inject MA.

• Those without chronic mental illness and those without Those without chronic mental illness and those without significant psychiatric symptoms at admission.significant psychiatric symptoms at admission.

• Those who are using MA less than daily at admission.Those who are using MA less than daily at admission.

• Those under legal supervision (especially drug court).Those under legal supervision (especially drug court).

• Older individuals (over 21)Those who are not disabled.Older individuals (over 21)Those who are not disabled.

• Those who have a stable living situation (without active Those who have a stable living situation (without active drug users).drug users).

Successful Outpatient Treatment Successful Outpatient Treatment PredictorsPredictors

•Durations Durations over 90 daysover 90 days ( (with with continuing carecontinuing care for another 9 for another 9 months).months).

•Techniques and clinic practices Techniques and clinic practices that improve that improve treatment retentiontreatment retention are critical.are critical.

•Treatment should include Treatment should include 3-5 clinic 3-5 clinic visits per weekvisits per week for at least 90 days. for at least 90 days.

Successful Outpatient Treatment Successful Outpatient Treatment PredictorsPredictors

•Employ Employ evidence-based practicesevidence-based practices [i.e., CBT, CM, Community [i.e., CBT, CM, Community Reinforcement Approach, Motivational Reinforcement Approach, Motivational Interviewing, Matrix Model].Interviewing, Matrix Model].

•FamilyFamily involvement and involvement and 12-step12-step programs appear to improve programs appear to improve outcome.outcome.

•Urine testingUrine testing (at least weekly is (at least weekly is recommended)recommended)

Special treatment consideration Special treatment consideration should be made for the following should be made for the following groups of individuals:groups of individuals:

• FemaleFemale MA users (higher rates of MA users (higher rates of depression; very high rates of previous and depression; very high rates of previous and present sexual and physical abuse; present sexual and physical abuse; responsibilities for children).responsibilities for children).

• InjectionInjection MA users (very high rates of MA users (very high rates of psychiatric symptoms; severe withdrawal psychiatric symptoms; severe withdrawal syndromes; high rates of hepatitis).syndromes; high rates of hepatitis).

• MA users who take MAMA users who take MA daily daily or in very or in very high high dosesdoses..

Special treatment consideration Special treatment consideration should be made for the following should be made for the following groups of individuals:groups of individuals:

• HomelessHomeless, chronically mentally ill and/or , chronically mentally ill and/or individuals with high levels of psychiatric individuals with high levels of psychiatric symptoms at admission.symptoms at admission.

• Individuals Individuals under the age of 21under the age of 21..

• Gay menGay men (at very high risk for HIV and (at very high risk for HIV and hepatitis).hepatitis).

Treatments for Methamphetamine

• Cognitive Behavioral Therapies

• Motivational Interviewing

• Contingency Management

• MATRIX Model

• New Medications (treatment and overdose) are being developed

Brief cognitive behavioral interventions for Brief cognitive behavioral interventions for regular amphetamine users: a step in the regular amphetamine users: a step in the right directionright direction• Design: RTCDesign: RTC• Intervention: 2 session vs 4 session CBTIntervention: 2 session vs 4 session CBT• Findings  There was Findings  There was a significant increase in the a significant increase in the

likelihood of abstinencelikelihood of abstinence from amphetamines among from amphetamines among those receiving two or more treatment sessions. those receiving two or more treatment sessions. – The number of treatment sessions attended had a The number of treatment sessions attended had a

significant short-term significant short-term beneficial effect on level of beneficial effect on level of depressiondepression. .

– There was a marked There was a marked reduction in amphetamine usereduction in amphetamine use among this sample over time for both groups.among this sample over time for both groups.

– Reduction in amphetamine use was accompanied by Reduction in amphetamine use was accompanied by significant improvementssignificant improvements in stage of change, in stage of change, benzodiazepine use, tobacco smoking, polydrug use, benzodiazepine use, tobacco smoking, polydrug use, injecting risk-taking behavior, criminal activity level, injecting risk-taking behavior, criminal activity level, and psychiatric distress and depression level.and psychiatric distress and depression level.

Baker, et al; Addiction: Vol 100, March 2005Baker, et al; Addiction: Vol 100, March 2005

Cognitive Behavioral Therapy & Cognitive Behavioral Therapy & Contingency Management for Contingency Management for Stimulant DependenceStimulant Dependence

• Design Randomized clinical trial. Design Randomized clinical trial. • Participants Stimulant-dependent individuals Participants Stimulant-dependent individuals

((nn=171).=171).• Intervention CM, CBT, or combined CM and CBT, Intervention CM, CBT, or combined CM and CBT,

16-week treatment conditions. CM condition 16-week treatment conditions. CM condition participants received vouchers for stimulant-free participants received vouchers for stimulant-free urine samples. CBT condition participants urine samples. CBT condition participants attended three 90-minute group sessions each attended three 90-minute group sessions each week. week.

• Results Results CMCM procedures produced procedures produced better retentionbetter retention and and lower rates of stimulantlower rates of stimulant use during the study use during the study period. period. – Self-reported stimulant use was reduced from baseline Self-reported stimulant use was reduced from baseline

levels at all follow-up points for all groups and urinalysis levels at all follow-up points for all groups and urinalysis data did not differ between groups at follow-up. data did not differ between groups at follow-up.

– While CM produced robust evidence of efficacy during While CM produced robust evidence of efficacy during treatment application, treatment application, CBT produced comparable longer-CBT produced comparable longer-term outcomesterm outcomes. There was no evidence of an additive . There was no evidence of an additive effect when the two treatments were combined. The effect when the two treatments were combined. The response of response of cocaine and methamphetamine users cocaine and methamphetamine users appeared comparable. appeared comparable.

Rawson, RA et al. Addiction, Jan 2006Rawson, RA et al. Addiction, Jan 2006

Cognitive Behavioral Therapy & Cognitive Behavioral Therapy & Contingency Management for Contingency Management for Stimulant DependenceStimulant Dependence(cont’d)(cont’d)

• Conclusions: Conclusions: – CMCM is an efficacious treatment for is an efficacious treatment for reducing reducing

stimulant usestimulant use– CM is CM is superior during treatmentsuperior during treatment to a CBT to a CBT

approach. approach. – CM is usefulCM is useful in engaging substance in engaging substance

abusers, retaining them in treatment, and abusers, retaining them in treatment, and helping them achieve abstinence from helping them achieve abstinence from stimulant use. stimulant use.

– CBT also reduces drug useCBT also reduces drug use from baseline from baseline levels and produces comparable outcomes levels and produces comparable outcomes on all measures at follow-up.on all measures at follow-up.

Rawson, RA et al. Addiction, Jan 2006Rawson, RA et al. Addiction, Jan 2006

Motivation Motivation Interviewing GoalsInterviewing Goals• Increase Increase

MotivationMotivation• Decrease Decrease

ResistanceResistance• Increase Increase

retentionretention• Better Better

outcomesoutcomes

Four Principles ofFour Principles ofMotivational Motivational InterviewingInterviewing

1. Express empathy

2. Develop discrepancy

3. Avoid argumentation

4. Support self-efficacy

BUILDING MOTIVATIONBUILDING MOTIVATIONOARSOARS

•Open-ended questioning

•Affirming

•Reflective listening

•Summarizing

Contingency ManagementContingency Management

• A technique employing the systematic A technique employing the systematic delivery of positive reinforcement for delivery of positive reinforcement for desired behaviors. In the treatment of desired behaviors. In the treatment of methamphetamine dependence, vouchers methamphetamine dependence, vouchers or prizes can be “earned” for submission or prizes can be “earned” for submission of methamphetamine-free urine samplesof methamphetamine-free urine samples..

Contingency Management for Contingency Management for treatment of methamphetamine treatment of methamphetamine dependencedependence

• Design: RTCDesign: RTC• Method: 113 patients diagnosed with Method: 113 patients diagnosed with

methamphetamine abuse or dependence were methamphetamine abuse or dependence were randomly assigned to receive either treatment as randomly assigned to receive either treatment as usual (TAU) or TAU plus contingency management. usual (TAU) or TAU plus contingency management.

• Results indicate that Results indicate that both groups were retainedboth groups were retained in in treatment for equivalent times treatment for equivalent times – those in the those in the combined group accrued more combined group accrued more

abstinenceabstinence and were and were abstinent for a longerabstinent for a longer period of time. period of time.

– These results suggest that contingency These results suggest that contingency management has promise as a component in management has promise as a component in methamphetamine use disorder treatment methamphetamine use disorder treatment strategies.strategies.

Roll, JM et al, Archives of General Psychiatry, (In Press)Roll, JM et al, Archives of General Psychiatry, (In Press)

Mean number of abstinences

0

5

10

15

20

25

CM Control

Mean weeks of consecutive abstinence

0

1

2

3

4

5

6

CM Control

The Matrix Model: The Matrix Model: Organizing PrinciplesOrganizing Principles

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.

Extensive Use of Positive Reinforcement Techniques

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.

The Matrix Model: The Matrix Model: Organizing PrinciplesOrganizing Principles

Accurate, understandable, scientific information used to educate patient and family member

Effects of drugs and alcohol

Addiction as a “brain disease”

Critical issues in “recovering” from addiction

Meth and sex

Conditioned cues and craving

The Matrix Model: The Matrix Model: Organizing PrinciplesOrganizing Principles

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

The Matrix Model: The Matrix Model: Organizing PrinciplesOrganizing Principles

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

The Matrix Model: The Matrix Model: Organizing PrinciplesOrganizing Principles

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

The Matrix Model: The Matrix Model: Organizing PrinciplesOrganizing Principles

Matrix Model TreatmentMatrix Model TreatmentKey Concept: StructureKey Concept: Structure

•Self-designed structure (scheduling)

•Eliminate avoidable triggers

•Makes concrete the concept of “One day at a time”

•Reduces anxiety

•Counters the addict lifestyle

•Provides basic foundation for ongoing recovery

MATRIX MODEL TREATMENTMATRIX MODEL TREATMENT

STRUCTURE Treatment Program Activities

Recreational/LeisureActivities

12-Step Meetings School

Sports Being with Drug-free Friends

Time Scheduling Exercise

Work Family-related Events

Church/Synagogue Island Building

MATRIX MODEL TREATMENT MATRIX MODEL TREATMENT Information - WhatInformation - 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 MATRIX MODEL TREATMENT Information - WhyInformation - 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

MedicationsMedications

• Currently, there are no medications that Currently, there are no medications that can quickly and safely reverse life can quickly and safely reverse life threatening MA overdose.threatening MA overdose.

• There are no medications that can reliably There are no medications that can reliably reduce paranoia and psychotic reduce paranoia and psychotic symptoms, that contribute to episodes of symptoms, that contribute to episodes of dangerous and violent behavior dangerous and violent behavior associated with MA use.associated with MA use.

Status of Medication Research for Status of Medication Research for Methamphetamine DependenceMethamphetamine Dependence

Negative ResultsNegative Results Under ConsiderationUnder Consideration• ImipramineImipramine Gabapentin Gabapentin• DesipramineDesipramine Modafinil Modafinil• TyrosineTyrosine Topirimate Topirimate• OndansetronOndansetron Disulfiram Disulfiram• FluoxetineFluoxetine Lobeline Lobeline

AripiprazoleAripiprazole

Promising EvidencePromising Evidence: Bupropion; : Bupropion; Methylphenidate SRMethylphenidate SR

Promising Promising Pharmacotherapies? Pharmacotherapies? • BupropionBupropion reduces craving and reinforcing reduces craving and reinforcing

effectseffects of methamphetamine in a laboratory of methamphetamine in a laboratory self-administration study. Newton, T. et al self-administration study. Newton, T. et al (Biological Psychiatry, Dec, 2005) (Biological Psychiatry, Dec, 2005)

• BupropionBupropion reduces meth usereduces meth use in an outpatient in an outpatient trial, with particularly strong effect trial, with particularly strong effect with lesswith less severe userssevere users. Elkashef, A. et al (recently . Elkashef, A. et al (recently completed; reported at the ACNP completed; reported at the ACNP methamphetamine satelite meeting in Kona, methamphetamine satelite meeting in Kona, Hawaii) Hawaii)

• Methylphenidate SRMethylphenidate SR (sustained release) has (sustained release) has shown promise in a recent Finnish study with shown promise in a recent Finnish study with very heavy amphetamine injectorsvery heavy amphetamine injectors. Tiihonen, . Tiihonen, J. et al (recently completed; reported at the J. et al (recently completed; reported at the ACNP methamphetamine satelite meeting in ACNP methamphetamine satelite meeting in Kona, Hawaii) Kona, Hawaii)

For more information, contact:For more information, contact:(Most information in this presentation was taken from Thomas Freese)(Most information in this presentation was taken from Thomas Freese)

Thomas E. Freese, Ph.D.Thomas E. Freese, Ph.D.310-445-0874 x304310-445-0874 x304

tefreese@ix.netcom.comtefreese@ix.netcom.comwww.psattc.orgwww.psattc.org

www.uclaisap.orgwww.uclaisap.org OrOr

Kendall P. Alexander, LCSWKendall P. Alexander, LCSWIsland Grove Regional Treatment CenterIsland Grove Regional Treatment Center

970-313-1186970-313-1186

kalexander@islandgrovecenter.orgkalexander@islandgrovecenter.org