Evidence Based Practices: An Overview

1. Evidence Based Practices:An Overview Desiree MacPhail-Crevecoeur, Ph.D. Integrated Substance Abuse Programs University of California, Los Angeles

2. Overview • Part One: Addiction as a Chronic Disease • The Addicted Brain • A chronic, relapsing disease • Part Two: What are Evidence Based Practices? • Part Three: Cognitive Behavioral Therapy • Part Four: Motivational Interviewing • Part Five: Medically Assisted Treatments

3. Part One: Addiction as a Chronic Brain Disease

4. Addiction = Brain Disease Addiction is a brain disease that is chronic and relapsing in nature. 4

5. 5

6. How a neuron works 6

7. The Reward System Natural rewards Food Water Sex Nurturing 8

8. How the Reward System Works 9

9. 10

10. Activating the System with Drugs 11

11. The Brain After Drug Use (1) Control Methamphetamine 12 (Source: McCann et al. (1998). Journal of Neuroscience, 18, 8417-8422.)

12. Partial Recovery of Brain Dopamine Transporters in Methamphetamine Abuser After Protracted Abstinence 3 0 ml/gm METH Abuser (1 month detox) Normal Control METH Abuser (24 months detox)

13. The Brain After Drug Use (2) 14 DA = Days Abstinent

14. Drugs Change the Brain After repeated drug use, “deciding” to use drugs is no longer voluntary because DRUGS CHANGE THE BRAIN! 15

15. IOM Quality Chasm Recommendations “Substance use disorder treatment should move toward building its standards of care, performance measurement and quality, information and cost measures upon a chronic illness model rather than the current, acute illness-based, fragmented and deficient system of health care.”

16. Acute Care Treatment Model Substance Abusing Patient Treatment Non- Substance Abusing Patient

17. Traditional Service Approach Severe Symptoms Acute symptoms, Discontinuous treatment Crisis management Remission Time 18 Resource: Tom Kirk, Ph.D.

18. NQF Recommendations “Patients treated for Substance Use Disorders (SUD) should be engaged in long-term, ongoing managementof their care. Primary medical care providers should support and monitor ongoing recovery in collaboration with the specialty provider who is managing their SUD.”

19. A Recovery-Oriented Approach Severe Symptoms Continuous Treatment Response Remission Time 20 Resource: Tom Kirk, Ph.D

20. A Continuing Care Model Substance Abusing Patient Detox Duration Determined by Performance Criteria Rehabilitation Duration Determined by Performance Criteria Continuing Care Recovering Patient

21. Lessons from Chronic Illness • Medications relieve symptoms but…. behavioral change is necessary for sustained benefit • Treatment effects usually don’t last very long after treatment stops.

22. Lessons from Chronic Illness • Patients who are not insome form of treatment or monitoringare at elevated risk for relapse. In addiction this could include monitoring or AA

23. Summary • Drugs affect the brain in ways that are long term but reversible. • These brain changes profoundly influence cognition, emotions and behavior. • There are multiple forms of treatment that can be effective in treating addicted individuals. • Addiction and many psychiatric illnesses are chronic illnesses, and, like other chronic disorders, require continuous ongoing (not episodic) treatment and support.

24. Part Two: Evidence Based Practices

25. What are Evidence Based Practices? Interventions that show consistent scientific evidence of being related to preferred client outcomes. 26

26. Evidence Based Practices Standards of Care are Changing It is abundantly clear that not all treatment works, some types show evidence of being more effective than others >1000 clinical trials published in Addiction Cities, states and other funding sources are increasingly demanding the use of EBPs Closer integration of behavior health with healthcare will apply same standards 27 What Defines “Evidence Based Practices” and What Does it Mean to Implement EBT? NIDA Blending Meeting,? November 2006

27. Principles of Effective Treatment 1. No single treatment is appropriate for all 2. Treatment needs to be readily available 3. Effective treatment attends to the multiple needs of the individual 4. Treatment plans must be assessed and modified continually to meet changing needs 5. Remaining in treatment for an adequate period of time is critical for treatment effectiveness 28 - NIDA (1999) Principles of Drug Addiction Treatment

28. Principles of Effective Treatment 6. Counseling and other behavioral therapies are critical components of effective treatment 7. Medications are an important element of treatment for many patients 8. Co-existing disorders should be treated in an integrated way 9. Medical detox is only the first stage of treatment 10. Treatment does not need to be voluntary to be effective 29 - NIDA (1999) Principles of Drug Addiction Treatment

29. Principles of Effective Treatment 11. Possible drug use during treatment must be monitored continuously 12. Treatment programs should assess for HIV/AIDS, Hepatitis B & C, Tuberculosis and other infectious diseases and help clients modify at-risk behaviors 13. Recovery can be a long-term process and frequently requires multiple episodes of treatment 30 - NIDA (1999) Principles of Drug Addiction Treatment

30. Examples of Evidence Based Practices Contingency management Medically Assisted Treatment Brief intervention Cognitive–behavioral interventions Community reinforcement Behavioral contracting Motivational enhancement therapy 12-step facilitation 31

31. Part 3: Cognitive Behavioral Therapy (CBT) & Relapse Prevention StrategiesOne Example of an Evidence Based Practice 32

32. What is CBT and how is it used in addiction treatment? CBT is a form of “talk therapy” that is used to teach, encourage, and support individuals to reduce / stop their harmful drug use. CBT provides skills that are valuable in assisting people in gaining initial abstinence from drugs (or in reducing their drug use). CBT also provides skills to help people sustain abstinence (relapse prevention) 33

33. What is relapse prevention (RP)? RP is a cognitive-behavioral treatment (CBT) with a focus on the maintenance stage of addictive behaviour change that has two main goals: To prevent the occurrence of initial lapses after a commitment to change has been made and To prevent any lapse that does occur fromescalating into a full-blow relapse Because of the common elements of RP and CBT, we will refer to all of the material in this training module as CBT 34

34. Foundation of CBT: Social Learning Theory Cognitive behavioral therapy (CBT) Provides critical concepts of addiction and how to not use drugs Emphasizes the development of new skills Involves the mastery of skills through practice 35

35. Why is CBT useful? (1) CBT is a counseling-teaching approach well-suited to the resource capabilities of most clinical programs CBT has been extensively evaluated in rigorous clinical trials and has solid empirical support CBT is structured, goal-oriented, and focused on the immediate problems faced by substance abusers entering treatment who are struggling to control their use 36

36. Why is CBT useful? (2) CBT is a flexible, individualized approach that can be adapted to a wide range of clients as well as a variety of settings (inpatient, outpatient) and formats (group, individual) CBT is compatible with a range of other treatments the client may receive, such as pharmacotherapy 37

37. Important concepts in CBT (1) In the early stages of CBT treatment, strategies stress behavioral change. Strategies include: planning time to engage in non-drug related behaviour avoiding or leaving a drug-use situation. 38

38. Important concepts in CBT (2) CBT attempts to help clients: Follow a planned schedule of low-risk activities Recognize drug use (high-risk) situations and avoid these situations Cope more effectively with a range of problems and problematic behaviors associated with using 39

39. Important concepts in CBT (3) As CBT treatment continues into later phases of recovery, more emphasis is given to the “cognitive” part of CBT. This includes: Teaching clients knowledge about addiction Teaching clients about conditioning, triggers, and craving Teaching clients cognitive skills (“thought stopping” and “urge surfing”) Focusing on relapse prevention 40

40. Foundations of CBT The learning and conditioning principles involved in CBT are: Classical conditioning Operant conditioning Modelling 41

41. Classical conditioning: Addiction Repeated pairings of particular events, emotional states, or cues with substance use can produce craving for that substance Over time, drug or alcohol use is paired with cues such as money, paraphernalia, particular places, people, time of day, emotions Eventually, exposure to cues alone produces drug or alcohol cravings or urges that are often followed by substance abuse 42

42. Classical conditioning: Application to CBT techniques Understand and identify “triggers” (conditioned cues) Understand how and why “drug craving” occurs Learn strategies to avoid exposure to triggers Cope with craving to reduce / eliminate conditioned craving over time 43

43. Operant conditioning: Addiction Drug use is a behavior that is reinforced by the positive reinforcement that occurs from the pharmacologic properties of the drug. Once a person is addicted, drug use is reinforced by the negative reinforcement of removing or avoiding painful withdrawal symptoms. 44

44. Operant conditions (1) Positive reinforcement strengthens a particular behaviour (e.g., pleasurable effects from the pharmacology of the drug; peer acceptance) Punishmentis a negative condition that decreases the occurrence of a particular behavior (e.g., If you sell drugs, you will go to jail. If you take too large a dose of drugs, you can overdose.) 45

45. Operant conditions (2) Negative reinforcementoccurs when a particular behavior becomes stronger by avoiding or stopping a negative condition (e.g., If you are having unpleasant withdrawal symptoms, you can reduce them by taking drugs.). 46

46. Operant conditioning: Application to CBT techniques Functional Analysis – identify high-risk situations and determine reinforcers Examine long- and short-term consequences of drug use to reinforce resolve to be abstinent Schedule time and receive praise Develop meaningful alternative reinforcers to drug use 47

47. Modeling: Definition Modeling: To imitate someone or to follow the example of someone. In behavioral psychology terms, modeling is a process in which one person observes the behavior of another person and subsequently copies the behavior. 48

48. Basis of substance use disorders: Modeling When applied to drug addiction, modeling is a major factor in the initiation of drug use. For example, young children experiment with cigarettes almost entirely because they are modeling adult behavior. During adolescence, modeling is often the major element in how peer drug use can promote initiation into drug experimentation. 49

49. Modeling: Application to CBT techniques Client learns new behaviors through role-plays Drug refusal skills Watching clinician model new strategies Practicing those strategies Observe how I say “NO!” NO thanks, I do not smoke 50

50. CBT Techniques for Addiction Treatment: Functional Analysis / The 5 Ws 51