Treatments for Methamphetamine-Related Disorders

1. Treatments for Methamphetamine-Related Disorders Richard A. Rawson, Ph.D. UCLA Integrated Substance Abuse Program, Sacramento, CA Dec 2, 2004 rrawson@mednet.ucla.edu www.uclaisap.org

2. Speed • It is methamphetamine powder ranging in color from white, yellow, orange, pink, or brown. • Color variations are due to differences in chemicals used to produce it and the expertise of the cooker. • Other names: shabu, crystal, crystal meth, crank, tina, yaba

3. Ice High purity methamphetamine crystals or coarse powder ranging from translucent to white, sometimes with a green, blue, or pink tinge.

4. The Language of America’s Meth Users • Crank, meth, crystal, ice: methamphetamine • Cooking: making meth • Slamming: injecting • Rig: hypothermic needle • Run: multiple days of using meth without sleeping • Crash: long period of sleep following a run • Tweaking: going on a long run • Tweaker: chronic meth users • Shadow people: image commonly cited by meth uses in periods of paranoia

5. The Language of California Meth Cops • User lab: ounce-quality lab for a tweaker’s personal use • Smurfing: buying small quantities of pseudoephedrine at many stores, a tweaker practice • Real nice lab: 10-pound (or larger) superlab operated by Mexican cartels in California • Step on it: dilute meth with an inactive ingredient • Mope: migrant worker hired to operate a superlab • Low crawl: police technique to approach a superlab unseen • Leg bail: what mopes do when surprised by low-crawling cops, to flee

7. Methamphetamine: A Growing Menace in Rural America • In 1998, rural areas nationwide reported 949 methamphetamine labs. • Last year, 9,385 were reported. • This year, 4,589 rural labs had been reported as of July 26. • Source: El Paso Intelligence Center (EPIC), U.S. DEA

8. Groups with High Rates of Meth Use • Women • Residents in Western/Midwestern Rural Areas and Small/Medium Cities • Predominantly Caucasian, Increasing Numbers of Hispanics • Gay Men • Adolescents

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

10. Treatment of MA Psychosis • Typical ER Protocol for MA Psychosis: • Haloperidol - 5mg • Or Atypical Anti-psychotic • Clonazepam - 1 mg • Cogentin - 1 mg • Quiet, Dimly Lit Room • Restraints??

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

12. 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

13. 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

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

15. Initiating MA Abstinence • Key Elements of Treatment: • Structure • Information in Understandable Form • Family Support • Positive Reinforcement • 12-Step Participation • No Pharmacologic Agent Currently Available

16. Treatment of MA Disorders • State of Empirical Evidence: • No Information on TC or “Minnesota Model” Approaches • No Pharmacotherapy with Demonstrated Efficacy • Bupropion, Selegline, Topirimate under Investigation • Ondansetron, Prozac, Zoloft, Flupentixol, Despiramine found not to be useful • Results of Cocaine Treatment Research Extrapolated to MA Treatment • Results with CM, CBT, and Matrix Equivalent with Cocaine and Meth Users

17. Treatments for Stimulant-Use Disorders with Empirical Support • Motivational Interviewing • Cognitive-Behavioral Therapy (CBT) • Contingency Management • 12-Step Facilitation • Matrix Model

18. Early Recovery Issues Engaging and Retaining Motivational Interviewing Elicit behavior change Respect autonomy Tolerate patient ambivalence Explore consequences

19. Precontemplation Contemplation Maintenance Preparation Action Stages of ChangeProchaska & DiClemente

20. Affirmations • Patient-focused • Intended to: • Support patient’s involvement • Encourage continued attendance • Assist patient in seeing positives • Support patient’s strengths

21. Social Learning Theory (Relapse Prevention Marlatt & Gordon, 1995) Operant Conditioning (Positive Reinforcement) Modeling Classical Conditioning (Paired Stimuli) Cognitive Behavioral Therapy

22. Cognitive Behavioral Therapy(CBT) Goals To use learning processes to help individuals reduce drug use To help patients: • Recognize Situations • Avoid Situations • Cope with Problems and Behaviors

23. Cognitive Behavioral Therapy • Basic Assumptions: • Drug/Alcohol use is learned behavior. • No assumption of underlying psychopathology • Classical and operant conditioning factors involved • “Treatment” is a process of teaching, coaching and reinforcing. • New, alternative behaviors must be established. • Therapist is teacher, coach, and source of positive reinforcement. • Can be delivered in group or individual setting

24. Vouchers Inexpensive Gifts Take-home Access to Housing Methadone Doses Access to Work Therapy Gold Stars Contingency Management with Vouchers

25. Contingency Management • Basic Assumptions: • Drug and alcohol use behavior can be controlled using operant reinforcement procedures. • Vouchers can be used as proxy’s for money or goods. • Vouchers should be redeemed for items incompatible with drug use. • Escalating the value of the voucher for consecutive weeks of abstinence promotes better performance. • Counseling/therapy may or may not be required in conjunction with CM procedure.

26. Contingency Management • Key concepts: • Behavior to be modified must be objectively measured. • Behavior to be modified (e.g., urine test results) must be monitored frequently. • Reinforcement must be immediate. • Penalties for unsuccessful behavior (e.g., positive Ua) can reduce voucher amount. • Vouchers may be applied to a wide range of prosocial alternative behaviors .

27. A Multi-Site Comparison of Psychosocial Approaches for the Treatment of Methamphetamine DependenceThe Methamphetamine Treatment Project Corporate Authors*Addiction (June, 2004)

28. Matrix Model ofOutpatient 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.

29. Matrix Model ofOutpatient 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.

30. Matrix Model ofOutpatient 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

31. Matrix Model ofOutpatient 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

32. Matrix Model ofOutpatient 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

33. Matrix Model ofOutpatient 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

34. Primary Measures to Build the Model • Retention, Retention, Retention • Drug-free UA’s

35. Matrix ModelAn Integrated, Empirically-based, Manualized Treatment Program

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

37. The CSAT Methamphetamine Treatment Project

38. 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

39. Matrix Vs Treatment as Usual: Study Design • 8 sites • Participants randomly assigned to Matrix Model treatment or Treatment as Usual in each site. • Dependent Measures: Retention in treatment; urinalysis results; self report of meth use; ASI scores (in Rx, at D/C and FU

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

41. Baseline Demographics

42. Gender Distribution of Participants

43. Ethnic Identification of Participants

44. Marital Status of Participants

45. Employment Status of Participants

46. Route of Methamphetamine Administration

47. Changes from Baseline to Treatment-end

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

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

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