Understanding Substance Abuse & Addiction: What Research, Psychology & Medicine Have to Teach Us

1. Understanding Substance Abuse & Addiction:What Research, Psychology & Medicine Have to Teach Us TRUST Clinic Speaker Series Oakland, Ca. June 20, 2014 Joan Zweben, Ph.D. Executive Director, East Bay Community Recovery Project www.EBCRP.org Clinical Professor of Psychiatry, UCSF

2. Disclosures • Dr. Zweben has no conflict of interest to disclose. • Dr. Zweben’s bias is that evidence-supported, safe treatment for SUDS should be equally available throughout our system of care, including medication treatment. • Dr. Zweben’s bias is that evidence-based interventions are only one component of individualized treatment planning, not a substitute for comprehensive care.

3. Evolution of Substance Abuse Treatment in the U.S. How Did We Get Here?

4. National Institute on Alcoholism & Alcohol Abuse (NIAAA) • Founded 1970 as a center within NIH • Research on the biology of alcoholism, psychosocial issues, treatment (1990’s) • Produced educational materials for prevention, but initially not a leader in the treatment field. • Pressure from community groups led to more treatment research

5. National Institute on Drug Abuse (NIDA) • Founded 1972 to promote creation of tx system + research on clinical issues • Goal: what programs were contributing to reducing social costs of addiction • Tx system developed for the indigent (uninsured), funded by federal, state and local entities • Research emphasis on tx modalities

6. Chronology • AA – 1935. Bill Wilson, Dr. Bob Smith in Akron, Ohio • Minnesota Model – 1950’s (Hazelden) • Therapeutic Communities – 1958, Synanon; proliferated rapidly • Methadone maintenance – 1965, Dole & Nyswander • Drug Courts 1989, Miami-Dade County, Florida

7. Treatment Modalities:Therapeutic Communities • long term (6-18 months) residential tx • the community is the agent of change • peer relationships, open communication and feedback are basic tools • “must function” model • activities to maintain daily operations a primary element in therapeutic interactions

8. TC’s, Continued • change self-image and behavior • self-examination and confession • extended family concept • possibility of ascendancy within the system • re-entry • outcome data supports its efficacy

9. Methadone Maintenance • most misunderstood, stigmatized modality • most highly regulated modality • rationale for maintenance therapy: Dole, receptor system dysfunction • strong empirical support for efficacy and safety (50 years of data) • valuable tool in reducing the spread of AIDS • not a cure-all, but makes the patient accessible to intervention for other problems

10. Opioid Maintenance Therapy: Hot Button Issues • Dosing: politics, blood levels, etc. • Diversion • Opioid addicted pregnant women • Medical maintenance • Tapering off methadone • Methadone “vs” buprenorphine “vs” naltrexone (Vivitrol)

11. Minnesota Model • Hazelden, Wilmar (1950’s) • AA principles replace mental health model; alcoholism as a primary disorder • multidisciplinary team approach • respect for the alcoholic; respite from environment • need and value of aftercare

12. Minnesota ModelContinued • origin of 28-day length of stay • CATOR: document outcomes • controlled studies do not support efficacy, with some exceptions • managed care

13. Social/Community Model • Influence on treatment &prevention • Emphasis on the micro & macro community • AA principles • Experiential knowledge essential; everyone both gives and receives help • Positive sober environment is crucial • One ancestor of ROSC

14. Drug Courts (1) Goal: integrate substance abuse treatment with legal case processing (pretrial) K EY PRINCIPLES: • Identification/referral as soon as possible after arrest • Early professional dx of treatment needs • Matching needs to appropriate tx

15. Drug Courts (2) • Making treatment a court-monitored requirement; provide judicial review and supervision of progress in treatment • Holding defendants accountable through a series of graduated sanctions and rewards • Providing appropriate follow-up and support services following treatment (Sherin & Mahoney, 1996; TIP #23)

16. Drug Courts (3) • NIJ (2003) study of 17,000 graduates found only 16.4% had been rearrested and charged with a felony one year later (Roman et al, 2003). • Reduced cost to victim and criminal justice system • Increase retention in treatment • Others: juveniles, DWI, family, mental health (Huddleston et al, 2004)

17. Treatment Philosophies

18. Treatment Philosophies: Abstinence • abstain from drug of choice • abstain from other intoxicants drug substitution role in precipitating relapse • dependable control not possible; hence detach • widest margin of safety

19. What is Abstinence? • A person is abstinent if he/she is not drinking or using illicit drugs, and using legal ones as prescribed. Thus, medications are compatible with recovery. • Physical dependence ≠ addiction • Note: medications are tools, not solutions

20. Treatment Philosophies:Harm Reduction • “Harm reduction is a set of strategies that encourage substance users and service providers to reduce the harm done to drug users, their loved ones and communities by their licit and illicit drug use.” • The Harm Reduction Working Group & Coalition, 1995

21. Arenas for Harm Reduction • HIV/ STD outreach and education • needle exchange • homeless populations: wet, damp housing • SMI clients - Harborview model • methadone maintenance (damage control component) • drop in centers • users’ support groups • money management/payee • community HR education

22. Pitfalls of Abstinence-Oriented Treatment • Failure to assess motivation level before pushing abstinence commitment • Failure to understand factors promoting continued use • Unrealistic timetables • Power struggle vs clinical approach • Failure to recognize fluctuating motivation • Inappropriate termination of treatment

23. Pitfalls of Harm Reduction Approach • Inappropriately low expectations for what client can achieve • Difficulty setting clear goals • Reluctance to ask client to abstain completely • Underestimate risks/lethality • Clinician alcohol and/or illicit drug use

24. The Substance Abuse Treatment System: Finding Good Care

25. Paradigm Shift • Chronic Care Model:When treated as a chronic illness, relapse rates are as good or better than other chronic illnesses (McLellan et al. 2005) • Recovery Oriented System of Care (ROSC): Support person centered and self-directed approaches to care that build on the strengths and resilience of individuals, families and communities to take responsibility for their sustained health, wellness and recovery from alcohol and drug problems (CSAT) (Rawson & Freese. 2010) 25

26. Recovery Oriented System of Care (ROSC) • ROSCs are founded on a chronic care model of substance use treatment and recovery services that use recovery management approaches to engage and treat, and provide recovery support services that help individuals/families sustain their recovery. (Rawson & Freese. 2010) 26

28. Broadening Our Target Population The Changing Health Care Landscape

29. Different policies for different levels of Severity In Treatment ~2,300,000 LOTS Addiction ~ 25,000,000 (Focus on Treatment) Diabetes ~24,000,000 “Harmful Use” – 68,000,000 (Focus on Early Intervention)) Little or No Use (Focus on Prevention)) LITTLE

30. Distribution of AOD Problems • 2M people (.08%) receiving treatment • 21M people (7%) have problems but are not receiving treatment • 1.1% made effort to get tx • 3.7% felt they needed tx but made no effort to get it • 95.2% did not feel they needed tx • 60-80 M (20-25%) using at risky levels (UCLA/ATTC 2013)

31. Using at Risky Levels (60-80 million) • Do not meet diagnostic criteria • Level of use indicates risk of developing problems • Examples: • Drinks 3-4 glasses of wine several times per week • Pregnant woman occasionally uses vodka to relieve stress • Adolescent to smokes mj with friends on weekends • Occasionally takes 1-2 extra vicodin to help with pain (UCLA/ATTC 2013)

32. Implications As long as the specialty care programs (AOD treatment programs) are the only places which address SUD: • most people with severe problems will not receive treatment. • virtually all with risky use will not receive professional attention. (UCLA-ATTC 2013)

33. Value of Behavioral Health Source: Wyatt Matas, 2013

34. Value of Behavioral Health 49% of Medicaid Beneficiaries with disabilities have a psychiatric illness. Top 3 behavioral dyads: • Psychiatric/Cardiovascular • Psychiatric/Central Nervous System • Psychiatric/ Pulmonary

35. Healthcare Settings for Locating Individuals with SUD • Primary care settings • Emergency rooms/Trauma centers • Prenatal clinics/OB/Gyn offices • Medical specialty settings for diabetes, liver and kidney disease, transplant programs • Pediatrician offices • College health centers • Mental health settings (UCLA-ATTC 2013)

36. Workforce Implications • MH/AOD clinicians will be working in many different settings where teamwork is key • Holistic, integrative perspective and approach; Sick care + wellness care • Screening & brief intervention integral • MI principles and skills essential • Availability for drop in or scheduled meetings; “hallway consults”

37. Evidence-Based Practices and Treatment Interventions Rationale, Challenges & Perils

38. Why Use Evidence-Based Principles and Practices? • To go beyond our preferences and biases • To improve the effectiveness of what we do: what works best, for whom • Because funders will increasingly insist on optimum utilization of inadequate resources

39. Evidence Based Principles & Practices vs Evidence Based Treatment Interventions • Principles and practices are derived from different types of research. • Rigor often trumps relevance in determining what type of research is valued. • Policy makers must be educated on these issues.

40. Important Distinctions • Evidence-based principles and practices guide system development • Example: care that is appropriately comprehensive and continuous over time will produce better outcomes • Evidence-based treatment interventions are important elements in the overall picture. They are not a substitute for overall adequate care.

41. Types of Studies • Quasi-experimental studies – some control over confounding factors; less rigorous than RCT’s • Correlational studies – systematic observation across cases or programs • Longitudinal studies • Naturalistic studies

42. Evidence-Based Principles • Retention improves outcomes; we need to engage people, not discharge them prematurely. • Addicts/alcoholics are a heterogeneous population, not a particular personality type. • Addiction behaves like other chronic disorders • Problem-service matching strategies improve outcomes. (Other matching strategies disappointing.) • Harm reduction approaches yield benefits in terms of public health and safety. • Pts in methadone maintenance show a higher reduction in morbidity and mortality and improvement in psychosocial indicators than heroin users outside treatment or not on MAT.

43. Policies and Practices Not Supported by Research • Requiring abstinence as a condition of access to substance abuse or mental health treatment • Denying access to AOD treatment programs for people on prescribed medications • Arbitrary prohibitions against the use of certain prescribed medications • Discharging clients for alcohol/drug use

44. Evidence-Based Practices:Key Issues in the Debate

45. Efficacy Studies Specific psychosocial interventions are usually investigated in random assignment studies using manualized treatments in carefully controlled trials. Samples and settings are homogeneous and treatment is standardized. Specific procedures assure fidelity to the model.

46. Random Assignment Controlled Trials (RCT’s) Gold standard for pharmacological and many psychosocial interventions Examples with strong efficacy: • Cognitive behavioral therapy • Motivational enhancement therapy • Behavioral marital therapy • Community reinforcement approach • Relapse prevention • Social skills training (see Miller et al, 2005)

47. Adaptive Designs:An Emerging Paradigm • Individualize treatment using decision rules that recommend when and for whom tx should change • Utilize a sequence of treatments, randomizing S’s based on clinical response • Starts with consensus-based clinical guidelines and fine tunes the sequence • Example: The STAR-D study

48. Are RCT’s Over-rated?

49. QUERI RCT Mark Willenbring MD (ASAM 2006)

50. Issues with RCT’s • Is the research question an appropriate question? • Example: CBT A compared with CBT B, vs CBT A compared with TAU • Are the treatment effects modest or robust? • What is the cost to achieve and maintain the intervention? Are the results worth it?