The Voice of Recovery: Effectively Treating Methamphetamine Users and their Families

1. The Voice of Recovery: Effectively Treating Methamphetamine Users and their Families Michael S. Shafer, Ph.D.

2. Motivation for Treatment • Why is it harder for a stimulant abuser to enter the treatment system?

3. Motivation for Treatment • Why is it harder for a stimulant abuser to enter the treatment system? • What does it mean to say someone is motivated to do treatment?

4. Motivation for Treatment • Why is it harder for a stimulant abuser to enter the treatment system? • What does it mean to say someone is motivated to do treatment? • How can we compete with the pull of drugs like methamphetamine?

5. How Stimulants Affect the Willingness to Enter Treatment Methamphetamine does NOT make you sick; therefore, the drug use is not the problem. Methamphetamine allows long periods of no drug use; certainly the drug is not the problem.

6. Drugs Sedatives Stimulants Opioids Alcohol Medical Treatment Yes No Yes Yes Medical & Psychosocial Treatment Approaches for Various Commonly Abused Substances Psychosocial Treatment Yes Yes Yes Yes

7. www.drugabuse.gov

8. 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

9. 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

10. 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 - NIDA (1999) Principles of Drug Addiction Treatment

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

12. Acute MA Overdose • Slowing of Cardiac Conduction • Ventricular Irritability • Hypertensive Episode • Hyperpyrexic Episode • CNS Seizures and Anoxia

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

14. Treatment of MA Psychosis • Typical ER Protocol for MA Psychosis • Haloperidol - 5mg • Clonazepam - 1 mg • Cogentin - 1 mg • Quiet, Dimly Lit Room • Restraints

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

16. 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

17. 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

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

19. Initiating MA Abstinence Key Elements of Treatment • Structure • Information in Understandable Form • Family Support • Positive Reinforcement • 12-Step Participation

20. Treatment of MA Disorders State of Empirical Evidence • No Information on TC or “Minnesota Model” Approaches • No Pharmacotherapy with Demonstrated Efficacy • Results of Cocaine Treatment Research Extrapolated to MA Treatment

21. NIDA Therapy Manuals for Drug Addictionbehavioral and cognitive treatment approaches proven effective through research A Cognitive-Behavioral Approach: Treating Cocaine Addiction A Community Reinforcement Plus Vouchers Approach: Treating Cocaine Addiction Manual 1 Manual 2

22. A Cognitive-Behavioral Approach: Treating Cocaine Addiction Manual 1 Kathleen M. Carroll, Ph.D. April 1998

23. Cognitive Behavioral TherapyThe Essential Tasks Functional analyses of substance use Individualized training • Coping with Craving • Managing Using Thoughts • Problemsolving • Recognizing Seemingly Irrelevant Decisions • Refusal Skills

24. Cognitive Behavioral TherapyThe Essential Tasks (con’t.) Examining substance use cognitions Identifying and debriefing past and future high-risk situations Encouraging and reviewing extra- session implementation of skills Practicing skills during sessions

25. Cognitive Behavioral Therapy2 Critical Components Skills Training (Act) Functional Analysis (Analyze)

26. Cognitive Behavioral TherapyFunctional Analysis Thoughts Feelings Circumstances Before and After Use

27. Cognitive Behavioral TherapySkills Training Avoiding High-Risk Situations Stopping Drug Thoughts Social Skills Employment Issues For Present and for Future

28. Cognitive Behavioral TherapySkills Training

29. Community Reinforcement Plus Vouchers Approach: Treating Cocaine Addiction Manual2 Budney & Higgins April 1998

30. An operant model where approximations of the desired behaviors are encouraged and rewarded to facilitate progress toward specified goals. • Underlying emphasis of this approach is to reward abstinence behaviors so that individuals make healthy lifestyle choices.

31. Relapse prevention strategies and motivational interviewing are fundamental parts of this approach. • The two major goals of CRA include elimination of positive reinforcement for drug use and enhancement of positive reinforcement for sobriety.

32. Core Program Components of CRA • Behavioral Orientation • Skills Instruction • Sobriety Sampling • Treatment Planning

33. Behavioral Orientation • Use of Functional Analysis to Identify Antecedents and Consequences of Addictive Behavior • Non-Confrontational Counseling Styles, using tenets of Motivational Interviewing, prompt rule, and reinforcing successive approximations of sobriety • Use of Role Playing to Practice Skills • Use of Modeling to Demonstrate Desirable Skills

34. Skills Instruction • Social/recreational skills • Communication skills, including behavioral marital counseling • Problem solving skills • Employability skills • Drink refusal skills, including duration training

35. Sobriety Sampling • Behavioral Contracts Negotiated with Clients for Progressively Longer Periods of Sobriety • Agnostic Medications (Disulfurim/Antabuse) Prescribed and Used with Monitors

36. Treatment Planning • Formalized Process for Treatment Planning • Treatment Plan Focused on Responding to Client Identified Sources and Barriers to Personal Happiness – Use of the Happiness Scale

37. Demonstrated Clinical Efficacy • Alcoholics • Opiate and cocaine abusers • Homeless populations 3 meta-analysis of the substance abuse treatment research have identified CRA as one of the top five treatments in producing positive outcomes for low costs.

38. Incentives in Treatmentof Cocaine DependenceReview of the Literature(Higgins 1996) 11 Studies Positive Treatment Effects 2 Studies No Significant Difference 13 Studies

39. MATRIX MODEL TREATMENT Components of Stimulant Addiction Syndrome Behavioral Disruption Cognitive Disruption Emotional Disruption Family/Relationship Disruption

40. Early Recovery Groups Relapse Prevention Groups Individual Sessions Family Education Group 12-Step Meetings Social Support Groups Relapse Analysis Urine Testing Treatment Components of the Matrix Model

41. DAY 180 DAY 0 DAY 15 DAY 45 DAY 120 Adjustment Honeymoon The Wall Withdrawal Resolution STAGES OF RECOVERY

42. WITHDRAWAL STAGE • Medical Problems • Alcohol Withdrawal • Depression • Difficulty Concentrating • Severe Cravings • Contact with Stimuli • Excessive Sleep Day 0 to Day 15

43. Primary Manifestation of Withdrawal Stage Behavioral Cognitive Confusion, Inability to Concentrate Behavioral Inconsistency Emotional Relationship Depression/Anxiety, Self-Doubt Mutual Hostility, Fear

44. Key Concept: Structure • Self-designed structure (scheduling) • Makes concrete the idea of “one day at a time” • Eliminate avoidable triggers • Reduces anxiety • Counters the addict lifestyle • Provides basic foundation for ongoing recovery

45. Ways to Create Structure • Time scheduling • Going to treatment • Attending 12-step meetings • Exercising • Performing athletic activities • Attending school • Going to work • Attending church

46. Pitfalls of Structure • Scheduling unrealistically • Neglecting recreation • Being perfectionistic • Therapist imposing schedule • Spouse/parent imposing schedule

47. Paranoia Depression Disordered sleep patterns Withdrawal Stage: Relapse Factors • Unstructured time • Proximity of triggers • Alcohol/marijuana use • Powerful cravings

48. HONEYMOON STAGE • Overconfidence • Over-involvement with work • Inability to prioritize • Inability to initiate change • Alcohol use • Episodic cravings • Treatment termination Day 15 to Day 45

49. Primary Manifestation of Honeymoon Stage Behavioral Cognitive High energy, Unfocused behavior Inability to prioritize Emotional Relationship Overconfidence, Feeling cured Denial of addiction disorder

50. Substance abuse & the brain Sex and recovery Relapse prevention issues Triggers and cravings Emotional readjustment Stages of recovery Medical effects Relationships and recovery Alcohol/marijuana Information - What