Meth Summit

1. Meth Summit Monday, October 16, 2006 Sponsored by the County Commissioners Of Larimer and Weld Counties What about Meth treatment?

2. What does the research indicate about treatment?

3. Investigational Medicationfor High Blood Pressure Treatment Works!!!

4. New Behavioral Treatment for Methamphetamine Use Treatment Failed!!!

5. 50 to 70% 50 to 70% 40 to 60% 30 to 50% Relapse Rates Are Similar for Drug Dependence and Other Chronic Illnesses 100 90 80 70 60 Percent of Patients Who Relapse 50 40 30 20 10 0 Drug Dependence Type I Diabetes Hypertension Asthma Source: McLellan, A.T. et al., JAMA, Vol 284(13), October 4, 2000.

6. Predictors of Retention in Treatment for more than 90 days • Higher rates of retention for men • Legal supervision increases treatment retention • Injection users were retained more poorly • Those with chronic mental illness were retained more poorly • Daily users are retained more poorly than those who use less often than daily • Those who began use at an older age were retained better than those who started when younger • Those who are older at admission were retained better

7. Optimal candidates for outpatient treatment include: • Those who do not inject MA. • Those without chronic mental illness and those without significant psychiatric symptoms at admission. • Those who are using MA less than daily at admission. • Those under legal supervision (especially drug court). • Older individuals (over 21)Those who are not disabled. • Those who have a stable living situation (without active drug users).

8. Successful Outpatient Treatment Predictors • Durations over 90 days (with continuing care for another 9 months). • Techniques and clinic practices that improve treatment retention are critical. • Treatment should include 3-5 clinic visits per week for at least 90 days.

9. Successful Outpatient Treatment Predictors • Employ evidence-based practices[i.e., CBT, CM, Community Reinforcement Approach, Motivational Interviewing, Matrix Model]. • Family involvement and 12-step programs appear to improve outcome. • Urine testing (at least weekly is recommended)

10. 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.

11. Special treatment consideration should be made for the following groups of individuals: • 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).

12. Treatments for Methamphetamine • Cognitive Behavioral Therapies • Motivational Interviewing • Contingency Management • MATRIX Model • New Medications • (treatment and overdose) • are being developed

13. Brief cognitive behavioral interventions for regular amphetamine users: a step in the right direction • Design: RTC • Intervention: 2 session vs 4 session CBT • Findings  There was a significant increase in the likelihood of abstinence from amphetamines among those receiving two or more treatment sessions. • The number of treatment sessions attended had a significant short-term beneficial effect on level of depression. • There was a marked reduction in amphetamine use among this sample over time for both groups. • Reduction in amphetamine use was accompanied by significant improvements in stage of change, benzodiazepine use, tobacco smoking, polydrug use, injecting risk-taking behavior, criminal activity level, and psychiatric distress and depression level. Baker, et al; Addiction: Vol 100, March 2005

14. Cognitive Behavioral Therapy & Contingency Management for Stimulant Dependence • Design Randomized clinical trial. • Participants Stimulant-dependent individuals (n=171). • Intervention CM, CBT, or combined CM and CBT, 16-week treatment conditions. CM condition participants received vouchers for stimulant-free urine samples. CBT condition participants attended three 90-minute group sessions each week. • Results CM procedures produced better retention and lower rates of stimulant use during the study period. • Self-reported stimulant use was reduced from baseline levels at all follow-up points for all groups and urinalysis data did not differ between groups at follow-up. • While CM produced robust evidence of efficacy during treatment application, CBT produced comparable longer-term outcomes. There was no evidence of an additive effect when the two treatments were combined. The response of cocaine and methamphetamine users appeared comparable. Rawson, RA et al. Addiction, Jan 2006

15. Cognitive Behavioral Therapy & Contingency Management for Stimulant Dependence(cont’d) • Conclusions: • CM is an efficacious treatment for reducing stimulant use • CM is superior during treatment to a CBT approach. • CM is useful in engaging substance abusers, retaining them in treatment, and helping them achieve abstinence from stimulant use. • CBT also reduces drug use from baseline levels and produces comparable outcomes on all measures at follow-up. Rawson, RA et al. Addiction, Jan 2006

16. Motivation Interviewing Goals • Increase Motivation • Decrease Resistance • Increase retention • Better outcomes

17. Four Principles ofMotivational Interviewing 1. Express empathy 2. Develop discrepancy 3. Avoid argumentation 4. Support self-efficacy

18. BUILDING MOTIVATIONOARS • Open-ended questioning • Affirming • Reflective listening • Summarizing

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

20. Contingency Management for treatment of methamphetamine dependence • Design: RTC • Method: 113 patients diagnosed with methamphetamine abuse or dependence were randomly assigned to receive either treatment as usual (TAU) or TAU plus contingency management. • Results indicate that both groups were retained in treatment for equivalent times • those in the combined group accrued more abstinence and were abstinent for a longer period of time. • These results suggest that contingency management has promise as a component in methamphetamine use disorder treatment strategies. Roll, JM et al, Archives of General Psychiatry, (In Press)

23. The Matrix Model: Organizing 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.

24. The Matrix Model: Organizing Principles 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.

25. The Matrix Model: Organizing 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

26. The Matrix Model: Organizing 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

27. The Matrix Model: Organizing 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

28. The Matrix Model: Organizing 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

29. Matrix Model TreatmentKey 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

30. Recreational/Leisure Activities Treatment Program Activities 12-Step Meetings School Sports Being with Drug-free Friends Time Scheduling Exercise Work Family-related Events Church/Synagogue Island Building MATRIX MODEL TREATMENT STRUCTURE

31. 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

32. 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

33. 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.

34. Status of Medication Research for Methamphetamine Dependence Negative ResultsUnder Consideration • Imipramine Gabapentin • Desipramine Modafinil • Tyrosine Topirimate • Ondansetron Disulfiram • Fluoxetine Lobeline Aripiprazole Promising Evidence: Bupropion; Methylphenidate SR

35. Promising Pharmacotherapies? • Bupropionreduces craving and reinforcing effects of methamphetamine in a laboratory self-administration study. Newton, T. et al (Biological Psychiatry, Dec, 2005) • Bupropionreduces meth use in an outpatient trial, with particularly strong effect with lesssevere users. Elkashef, A. et al (recently completed; reported at the ACNP methamphetamine satelite meeting in Kona, Hawaii) • Methylphenidate SR (sustained release) has shown promise in a recent Finnish study with very heavy amphetamine injectors. Tiihonen, J. et al (recently completed; reported at the ACNP methamphetamine satelite meeting in Kona, Hawaii)

36. For more information, contact: (Most information in this presentation was taken from Thomas Freese) Thomas E. Freese, Ph.D. 310-445-0874 x304 tefreese@ix.netcom.com www.psattc.org www.uclaisap.org Or Kendall P. Alexander, LCSW Island Grove Regional Treatment Center 970-313-1186 kalexander@islandgrovecenter.org