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Treatments for Methamphetamine-Related Disorders. Richard A. Rawson, Ph.D. UCLA Integrated Substance Abuse Program, Sacramento, CA Dec 2, 2004 [email protected] www.uclaisap.org. Speed. It is methamphetamine powder ranging in color from white, yellow, orange, pink, or brown.

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Treatments for methamphetamine related disorders l.jpg

Treatments for Methamphetamine-Related Disorders

Richard A. Rawson, Ph.D.

UCLA Integrated Substance Abuse Program,

Sacramento, CA

Dec 2, 2004

[email protected]

www.uclaisap.org


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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


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Ice

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


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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


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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


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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


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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


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Acute MA Psychosis

  • Extreme Paranoid Ideation

  • Well Formed Delusions

  • Hypersensitivity to Environmental Stimuli

  • Stereotyped Behavior “Tweaking”

  • Panic, Extreme Fearfulness

  • High Potential for Violence


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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??


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MA “Withdrawal”

- Depression - Paranoia

- Fatigue - Cognitive Impairment

- Anxiety - Agitation

- Anergia - Confusion

  • Duration: 2 Days - 2 Weeks


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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


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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


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Initiating MA Abstinence

  • Key Clinical Issues:

    • Depression

    • Cognitive Impairment

    • Continuing Paranoia

    • Anhedonia

    • Behavioral/Functional Impairment

    • Hypersexuality

    • Conditioned Cues

    • Irritability/Violence


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Initiating MA Abstinence

  • Key Elements of Treatment:

    • Structure

    • Information in Understandable Form

    • Family Support

    • Positive Reinforcement

    • 12-Step Participation

  • No Pharmacologic Agent Currently Available


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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


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Treatments for Stimulant-Use Disorders with Empirical Support

  • Motivational Interviewing

  • Cognitive-Behavioral Therapy (CBT)

  • Contingency Management

  • 12-Step Facilitation

  • Matrix Model


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Early Recovery Issues Support Engaging and Retaining

Motivational Interviewing

Elicit behavior change

Respect autonomy

Tolerate patient ambivalence

Explore consequences


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Precontemplation Support

Contemplation

Maintenance

Preparation

Action

Stages of ChangeProchaska & DiClemente


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Affirmations Support

  • Patient-focused

  • Intended to:

    • Support patient’s involvement

    • Encourage continued attendance

    • Assist patient in seeing positives

    • Support patient’s strengths


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Social Learning Theory Support

(Relapse Prevention

Marlatt & Gordon, 1995)

Operant Conditioning

(Positive

Reinforcement)

Modeling

Classical

Conditioning

(Paired Stimuli)

Cognitive Behavioral Therapy


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Cognitive Behavioral Therapy Support(CBT) Goals

To use learning processes to help individuals reduce drug use

To help patients:

  • Recognize Situations

  • Avoid Situations

  • Cope with Problems and Behaviors


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Cognitive Behavioral Therapy Support

  • 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


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Vouchers Support

Inexpensive Gifts

Take-home

Access to Housing

Methadone

Doses

Access to

Work Therapy

Gold Stars

Contingency Management with Vouchers


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Contingency Management Support

  • 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.


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Contingency Management Support

  • 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 .


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


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Matrix Model of Treatment of Methamphetamine DependenceOutpatient 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.


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Matrix Model of Treatment of Methamphetamine DependenceOutpatient 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.


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Matrix Model of Treatment of Methamphetamine DependenceOutpatient 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


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Matrix Model of Treatment of Methamphetamine DependenceOutpatient 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


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Matrix Model of Treatment of Methamphetamine DependenceOutpatient 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


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Matrix Model of Treatment of Methamphetamine DependenceOutpatient 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


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Primary Measures to Build the Model Treatment of Methamphetamine Dependence

  • Retention, Retention, Retention

  • Drug-free UA’s


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Matrix Model Treatment of Methamphetamine DependenceAn Integrated, Empirically-based, Manualized Treatment Program


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Elements of the Matrix Model Treatment of Methamphetamine Dependence

  • Engagement/Retention

  • Structure

  • Information

  • Relapse Prevention

  • Family Involvement

  • Self Help Involvement

  • Urinalysis/Breath Testing


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The CSAT Methamphetamine Treatment of Methamphetamine Dependence

Treatment Project


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Project Goals: Treatment of Methamphetamine Dependence

  • 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


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Matrix Vs Treatment as Usual: Study Design Treatment of Methamphetamine Dependence

  • 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


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The Matrix Model Treatment of Methamphetamine Dependence

  • Urine or breath alcohol tests once per week, weeks 1-16


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Baseline Demographics Treatment of Methamphetamine Dependence


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Gender Distribution of Participants Treatment of Methamphetamine Dependence


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Ethnic Identification of Participants Treatment of Methamphetamine Dependence


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Marital Status of Participants Treatment of Methamphetamine Dependence


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Employment Status of Participants Treatment of Methamphetamine Dependence


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Route of Methamphetamine Administration Treatment of Methamphetamine Dependence


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Changes from Baseline to Treatment-end Treatment of Methamphetamine Dependence


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Days Paid for Work in Past 30 Treatment of Methamphetamine Dependence

Possible is 0-30; tpaired=6.01; p-value<0.000 (highly sig.)


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Total Income (Past 30 days) of Participants Treatment of Methamphetamine Dependence

tpaired=2.34; p-value=0.02 (sig.)


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ASI Composite Scores Treatment of Methamphetamine Dependence

Possible is 0-1;

Higher : worse problem

tpaired: *p-value<0.03 (sig.),

**p-value<0.000 (highly sig.)


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Days of Methamphetamine Use in Past 30 (ASI) Treatment of Methamphetamine Dependence

Possible is 0-30; tpaired=20.90; p-value<0.000 (highly sig.)


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Days of Marijuana Use in Past 30 (ASI) Treatment of Methamphetamine Dependence

Possible is 0-30; tpaired=8.02; p-value<0.000 (highly sig.)


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Days of Alcohol Use in Past 30 (ASI) Treatment of Methamphetamine Dependence

Possible is 0-30; tpaired=6.47; p-value<0.000 (highly sig.)


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Beck Depression Inventory (BDI) Total Scores Treatment of Methamphetamine Dependence

Possible is 0-63; tpaired=16.87; p-value<0.000 (highly sig.)


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BSI Scores (mean) Treatment of Methamphetamine Dependence

1Possible, all scores, is 0-4; *all p-values<0.000 (highly sig.)


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Positive Symptom Total (PST) from Brief Symptom Inventory (BSI)

Possible is 0-53; tpaired=14.33; p-value<0.000 (highly sig.)





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Figure 6. Participant self-report of MA use (number of days during the past 30) at enrollment,

discharge, and 6-month follow-up, by treatment condition


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Matrix vs TAU: Results Summary during the past 30) at enrollment,

  • Matrix Model demonstrated superior retention and more meth negative urine samples and longer periods of continuous abstinence during treatment period.

  • Both conditions showed very significant improvement at discharge and follow up points as measured by UA, self-report and ASI scores. No difference between groups.


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Outcomes of Treatment for Methamphetamine Use: during the past 30) at enrollment, LA County (“Treatment-as-Usual”)

M.-L. Brecht

UCLA Integrated Substance Abuse Programs


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Purpose during the past 30) at enrollment,

  • Describe time to relapse to MA use

  • Identify predictors of longer time to relapse

  • Describe other outcome measures (% months with MA use, crime, employment)


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Design during the past 30) at enrollment,

  • Random sample of MA admissions (mostly from 1996)

  • From Los Angeles county-funded outpatient and residential programs

  • 76% of sampled clients were located; 75% of those participated in study (n=365)

  • Interviewed in 1999-2000, follow-up in 2001-2003

  • Analysis sample n=350

  • Data from detailed natural history interview


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Sample during the past 30) at enrollment, (n=350)

  • Gender: 56% male, 44% female

  • Ethnicity: 47% non-Hispanic White

    30% Hispanic

    17% African-American

    6% other

  • Education: 32% less than high school

    21% high school grad/GED

    47% some college/tech/trade school


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13yr. during the past 30) at enrollment,

15

17

19

21

23

Alcohol

Downers

Tranquilizers

Marijuana

Hallucinogens

Ecstasy

Tobacco

Heroin

PCP

Crack

Cocaine

Inhalants

Methamphetamine

Average Age First Use of Substance

97-100% have used

Over 50% have used

Less than 50% have used


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Sampled Treatment Episode during the past 30) at enrollment,

• Age at admission 29.4 yr.

• Residential 62%

Outpatient 38%

• Legal pressure 51%

• 1st time in treatment 58%

• Time in treatment 3.7 mo.

• Completed tx 46%


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Results—Predictors of Time to Relapse during the past 30) at enrollment, (multivariate Cox model, predictors p<.05)


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  • Better outcomes for those during the past 30) at enrollment,

    • With longer time in treatment (e.g. those with 4 or more mo. of treatment have almost double the rate of 24 and 48 mo. abstinence)

    • With more sessions per month of individual counseling

  • Worse outcomes for those

    • Who have sold MA


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Pattern of Relapse: during the past 30) at enrollment, Graph Shows Difference Between Less vs. More Vulnerable

More vulnerable=with MA sales (n=129)

Less vulnerable=all others


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Pattern of Relapse: during the past 30) at enrollment,

More Vulnerable Split into 2 Groups (More Treatment vs. Less Treatment)

More treatment (n=65) = 4 or more months of tx and/or

4 or more individual counseling sessions


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Other Outcomes: during the past 30) at enrollment,

% of Months with MA Use, Crime, Employment

Before, During, and After Treatment


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Other Clinical Issues during the past 30) at enrollment,

  • Meth injectors have poorer outcomes than those who use via IN or smoke

  • Major relapse factors

    • Marijuana use

    • Alcohol use

    • High availability of meth

    • Staying around other meth users


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