Treatments for Methamphetamine-Related Disorders

1. 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 Supported by National Institute on Drug Abuse and the ATTC: Pacific Southwest Technology Transfer Center

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

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

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

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

6. 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

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

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

9. Is Treatment for Methamphetamine Effective? A major demand that competes for scarce community resources are for the treatment needs of those who have become addicted to methamphetamine (MA).

10. Meth Treatment Effectiveness? A pervasive rumor has surfaced in many geographic areas with elevated MA problems: • MA users are virtually untreatable with negligible recovery rates. • Rates from 5% to less than 1% have been quoted in newspaper articles and reported in conferences. **The resulting conclusion is that spending money on treating MA users is futile and wasteful, BUT no data exists that supports these statistics**

11. Meth Treatment Statistics During the 2002-2003 fiscal year: • 35,947 individuals were admitted to treatment in California under the Substance Abuse and Crime Prevention Act funding. • Of this group, 53% reported MA as their primary drug problem

12. Statistics Analysis of: • Drop out rates • Retention in treatment rates • Re-incarceration rates • Other measures of outcome All these measures indicate that MA users respond in an equivalent manner as individuals admitted for other drug abuse problems.

13. Data Parameters • LACPRS admission and discharge data for 16 months • July 2003 – October 2004 • Only Outpatient Counseling • Cocaine (N = 5,046) • Methamphetamine (N = 5,278)

14. Cocaine Demographics 68.6% Male 31.4% Female Age: M = 39.4, SD = 9.6 (range 18-78 yrs) Proposition 36: 42.8% Mental Illness: 13% Homeless: 10.9% Methamphetamine Demographics 64.6% Male 35.4% Female Age: M = 32.3, SD = 8.9 (range 18-65 yrs) Proposition 36: 53% Mental Illness: 7.8% Homeless: 5.7% Population Demographics

15. Racial Demographics by Primary Drug

16. Route of Administration

17. Secondary Drug Use by Primary Drug

18. Cocaine Mean LOS = 137.5 days Range = 0 – 835 Median = 84 Mode = 0 Less than 14 Days = 12% Less than 30 days = 9.8% Methamphetamine Mean LOS = 132.7 days Range = 0 – 870 Median = 79 Mode = 0 Less than 14 Days = 10.1% Less than 30 days = 13.6% Length of Stay (LOS)

19. Additional Information on Population

20. Mean Days of Primary Drug Use in Last 30 Days

21. Why the “MA treatment doesn’t work” perceptions? • Many of the geographic regions impacted by MA do not have extensive treatment systems for severe drug dependence. • Medical and psychiatric aspects of MA dependence exceeds program capabilities. • High rate of use by women, their treatment needs and the needs of their children can be daunting. • Although some traditional elements may be appropriate, many staff report feeling unprepared to address many of the clinical challenges presented by these patients

22. Clinical Challenges of MA Users • Poor treatment engagement rates • High drop out rates • Severe paranoia • High relapse rates • Ongoing episodes of psychosis • Severe craving • Protracted dysphoria • Anhedonia

23. Steps to Address Treatment Needs of MA Users • Psychiatric/Professional Mental Health Staffing • Add Treatment Programming for Women Exposed to Violence and Their Kids • Training, Training, Training

24. Medications • Currently, there are no medications that can quickly and safely reverse life threatening MA overdose. • There are no medications that can reliably reduce paranoia and psychotic symptoms, that contribute to episodes of dangerous and violent behavior associated with MA use.

25. Medications considered for Meth Negative ResultsUnder Consideration • Imipramine Bupropion • Desipramine Modafinil • Tyrosine Topirimate • Ondansetron Disulfiram • Fluoxetine Lobeline Gabapentin Aripiprazole

26. Bupropion: An efficacious pharmacotherapy? • Newton et al 2005 Bupropion reduces craving and reinforcing effects of meth • Elkashef (recently completed) Bupropion reduces meth use in an outpatient trial, with particularly strong effect with less severe users.

27. Special treatment consideration should be made for the following groups of individuals: • Female MA users (higher rates of depression; very high rates of previous and present sexual and physical abuse; responsibilities for children). • Injection MA users (very high rates of psychiatric symptoms; severe withdrawal syndromes; high rates of hepatitis). • MA users who take MA daily or in very high doses. • Homeless, chronically mentally ill and/or individuals with high levels of psychiatric symptoms at admission. • Individuals under the age of 21. • Gay men (at very high risk for HIV and hepatitis).

28. Treatment Options

29. CSAT Tip #33 • A useful resource that presents a review of the existing knowledge about treatment effectiveness with stimulant users. • The following issues should be addressed by the clinical staff: • Meth and sexual behavior • Meth and weight gain • Meth and ongoing paranoia

30. An Unfortunate, But Common Treatment Process Detox- Only Admissions Tele Monitoring Detox Residential Rehab IOP Rehab Outpatient Cont Care AA -Tele Monitoring

31. A Continuing Care Model Detox Duration Determined by Performance Criteria Rehab Duration Determined by Performance Criteria Continuing Care Recovering Patient

32. An Ideal Model – No Discharge Substance Abusing Patient Tele Monitoring Hospital Detox Residential Rehab IOP Rehab Outpatient Cont Care AA -Tele Monitoring Regular Performance Measurement

33. Behavioral/Cognitive Behavioral Treatments • Cognitive/Behavioral Therapy-CBT • Motivational Interviewing-MI • Contingency Management-CM • 12 Step Facilitation Therapy • Community Reinforcement Approach-CRA • Matrix Model of Outpatient Treatment

34. Cognitive Behavioral Therapy • Based upon Social Learning Theory (Bandura and others) • Also referred to as Relapse Prevention Therapy • Applied to treatment of alcoholism, cocaine dependence, nicotine dependence and marijuana abuse.

35. Cognitive Behavioral Therapy • Key Concepts • Encouraging and reinforcing behavior change • Recognizing and avoiding high risk settings • Behavioral planning (scheduling) • Coping skills • Conditioned “triggers” • Understanding and dealing with craving • Abstinence violation effect • Understanding basic psychopharmacology principles • Self-efficacy

36. Motivational Interviewing • Based upon Prochaska and DiClemente Stages of Change Theoretical Model • Also referred to as Motivational Enhancement Therapy • Applied with many substances, data primarily with alcoholics • Major Publications/Studies: Miller and Rollnick, 1991; Project MATCH

37. Motivational Interviewing • Basic Assumptions • People change their thinking and behavior according to a series of stages • Individuals may enter treatment at different “stages of change” • It is possible to influence the natural change process with MI techniques • MI can be used to engage individuals in longer term treatment and to promote specific behavior changes • Confrontation of “denial” can be counterproductive and or harmful to some individuals

38. Motivational Interviewing • Key Concepts • Empathy and therapeutic alliance • Give feedback and reframe • Create dissonance • Focus of discrepancy of expected and actual • Reinforce change • Roll with resistance

39. Community Reinforcement Approach • Basic assumptions • Drug and alcohol use are positively reinforced behaviors. They can be reduced/eliminated by proper application of behavioral techniques. • To successfully build an effective intervention, some techniques should focus on reducing drug and alcohol use and others should focus on acquisition of new incompatible behaviors

40. Community Reinforcement Approach • Key concepts • Behavioral analysis and teach conditioning information. • Positive reinforcement with vouchers for drug free urine samples • Behavioral marriage counseling • Shape and reinforce new behavioral repetiore. • Coping skill/Drug refusal skill training • Vocational Counseling • Frequent urine testing

41. 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

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

43. 12 Step Facilitation Therapy • The therapist acts as a resource and advocate of the 12-Step approach to recovery: • Explains the AA view of alcoholism, analyzes slips and resistance to AA in terms of disease of alcoholism and denial. • Introduces AA-Steps and concepts by applying these to patient history • Advocates Reliance on fellowship of AA and its role in ongoing recovery • 12 sessions 1:1 • 12 step Facilitation Manual can be downloaded from the NIAAA web site • Book: 12 Step Facilitation Handbook …..by Nowitzki and Baker

44. Matrix Model ofOutpatient Treatment Organizing Principles of Matrix Treatment • Structured intensive outpatient approach delivered over a 16 week period, with ongoing aftercare. Matrix “treatment” is a process of “coaching”, educating, supporting and reinforcing positive behavior change. • Positive reinforcement used extensively to promote treatment engagement and retention. • Verbal praise, group support and encouragement other incentives and reinforcers.

45. 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.

46. Matrix Model ofOutpatient Treatment Organizing Principles of Matrix Treatment Accurate, understandable, scientific information used to educate patient and family members Behavioral strategies used to promote cessation of drug and alcohol use Promote and reinforce participation in non-drug related activities Cognitive-Behavioral strategies used to promote cessation of drug use and prevention of relapse

47. 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

48. Treatments for Meth Users with Empirical Support

49. Why CM? • It has proven effective for treating every type of substance abuse disorder to which it has been applied (e.g., Higgins & Silverman, 1999) • It is one of the most effective treatments for cocaine abuse (e.g., Rawson, R.A. McCann, M.J, Huber, A. Shoptaw, S., Farabee, D. Reiber, C. and Ling, W., 2002) • A laboratory model of CM suggests that methamphetamine abusers will forgo opportunities to self-administer methamphetamine in exchange for small monetary reinforcers (e.g., Roll & Newton, In press)

50. Total # of negative samples provided CM+TAU TAU Roll, et al., American Journal of Psychiatry, In Press