Treatments for Methamphetamine-Related Disorders I (General)

1. Treatments for Methamphetamine-Related Disorders I (General) Richard A. Rawson, Ph.D. UCLA Integrated Substance Abuse Programs CATES Conference, August 20, 2004 Sacramento, California

2. Methamphetamine (MA):Psychiatric Consequences • Paranoid reactions • Permanent memory loss • Depressive reactions • Hallucinations • Psychotic reactions • Panic disorders • Rapid addiction

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

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

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

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

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

8. 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

9. 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

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

11. Initiating MA Abstinence • Key Elements of Treatment: • Structure • Information in Understandable Form • Family Support • Positive Reinforcement • 12-Step Participation • No Pharmacologic Agent Currently Available

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

13. 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

14. Treatments for Stimulant-Use Disorders with Empirical Support • Motivational Interviewing • Cognitive-Behavioral Therapy (CBT) • Community Reinforcement Approach • Contingency Management • Matrix Model

15. Motivational Interviewing, 2nd Edition, Miller and Rollnick We can’t help wondering, why don’t people change? You would think: • that having had a heart attack would be enough to persuade a man to quit smoking, change his diet, exercise more, and take his medication. • Addictive behaviors persist despite overwhelming evidence of their destructiveness.

16. Early Recovery Issues Engaging and Retaining Motivational Interviewing Elicit behavior change Respect autonomy Tolerate patient ambivalence Explore consequences

17. Precontemplation Contemplation Maintenance Preparation Action Stages of ChangeProchaska & DiClemente

18. Affirmations • Patient-focused • Intended to: • Support patient’s involvement • Encourage continued attendance • Assist patient in seeing positives • Support patient’s strengths

19. Reflective Listening • Listen to what patient says and to what patient means • Check out assumptions • Create an environment of empathy (nonjudgmental) • Patient and counselor do not have to agree • Be aware of intonation (statement, not question)

20. Summarizing Summaries capture both sides of the ambivalence: (You say that ___________ but you also mentioned that ________________). Summaries also prompt clarification and further elaboration from the patient.

21. Change Talk • Recognizing the problem • Expressing concern • Stating intention to change • Being optimistic about change

22. Providing Feedback • Elicit (ask for permission) • Give feedback or advice • Elicit again (the patient’s view of how the advice will work for him/her)

23. Social Learning Theory (Relapse Prevention Marlatt & Gordon, 1995) Operant Conditioning (Positive Reinforcement) Modeling Classical Conditioning (Paired Stimuli) Cognitive Behavioral Therapy

24. Cognitive Behavioral Therapy(CBT) Goals To use learning processes to help individuals reduce drug use To help patients: • Recognize Situations • Avoid Situations • Cope with Problems and Behaviors

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

26. Cognitive Behavioral Therapy • 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

27. 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.

28. 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

29. Vouchers Inexpensive Gifts Take-home Access to Housing Methadone Doses Access to Work Therapy Gold Stars Contingency Management with Vouchers

30. 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.

31. Contingency Management • 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.

32. A Multi-Site Comparison of Psychosocial Approaches for the Treatment of Methamphetamine DependenceRichard A. Rawson, Ph.D.and The Methamphetamine Treatment Project Corporate Authors*Addiction (June, 2004)