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TGM --Therapeutic Goals Management for Drug Addiction. 药物成瘾的治疗目标管理. Joseph Schumacher, Ph.D., Professor 约瑟夫 舒马赫,哲学博士,教授 University of Alabama at Birmingham USA, 美国亚拉巴马大学伯明翰分校 May 2009 2009 年 5 月. Treatment for drug addiction 药物成瘾的治疗. Self-help Groups 自救小组 Twelve Step Model 12 步模式
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TGM --Therapeutic Goals Management for Drug Addiction 药物成瘾的治疗目标管理 Joseph Schumacher, Ph.D.,Professor 约瑟夫 舒马赫,哲学博士,教授 University of Alabama at Birmingham USA, 美国亚拉巴马大学伯明翰分校 May 2009 2009年5月
Treatment for drug addiction药物成瘾的治疗 • Self-help Groups • 自救小组 • Twelve Step Model • 12步模式 • Psychosocial (Relapse Prevention) • 心理社会层面(预防复吸) • Harm Reduction • 危害减低 • Pharmacotherapies • 药物治疗 • Behavioral (Contingency Management) • 行为层面(意外事件管理)
Contingency Management意外事件管理 • Based on operant conditioning • 基于操作条件反射 • Can augment existing usual care • 可以加强现有的常规护理 • Studied with cocaine and heroin addiction • 研究了可卡因和海洛因成瘾 • Systematic reinforcement of target response • 系统性强化目标反应 • Target typically drug abstinence • 锁定经典的戒毒 • Target response objectively measured • 锁定客观评价的应对 • Reinforcement usually positive (reset) • 强化措施通常会收到积极效果(重新调整) • Reinforcement valued and schedule escalating • 评估强化措施 • Vouchers and prizes (as in Fishbowl Lottery) • 代金券和奖品(参见鱼缸彩票干预方法)
Evidence for CM意外事件管理的证据 • “Few behavioral or psychosocial treatment approaches to health problems are as extensively grounded in such diverse and rigorous empirical support as contingency management interventions.” • 对于健康问题,很少有行为学或心理学治疗措施能够像意外事件管理这样有着内容宽泛,经验成熟的支持。 • Joseph Brady, Ph.D., Johns Hopkins Univ. • 约瑟夫 布拉迪,哲学博士,约翰霍普金斯大学
Higgins, Heil and Lussier (2004)希金斯,黑尔和卢思尔(2004) • Reviewed 55 controlled treatment outcome studies • 回顾了55个有对照的治疗结果研究 • Voucher-based CM and community reinforcement therapy • 基于票据的意外事件管理和社区强化治疗 • Across wide range of substances and populations • 涉及多种毒品和多个人群 • From first study in 1991 to March of 2003 • 从1991年第一个研究到2003年3月 • 85% noted significant changes in at least one target behaviors • 85%的调查对象至少有一种目标行为产生了明显的改变 • Including – cocaine, opiates, tobacco, alcohol, marijuana, treatment attendance, medication compliance, and productivity. • 包括-可卡因、阿片类、烟草、酒精、大麻、参加治疗、药物依从性和成果
基线 阶段 苯甲酰芽子碱 序列尿样
NIDA Clinical Trials Network (CTN)国家药物滥用研究所临床试验网络(CTN) • Largest controlled investigation of the effectiveness of evidence-based treatments in community-based settings • 关于社区循证治疗效果最大的病例对照研究 • MIEDAR (Motivational Incentives for Enhanced Drug Abuse recovery) evaluation • 评估强化药物滥用恢复的动机激励策略(MIEDAR) • Showed the incentive program improved treatment retention and drug abstinence • 显示:激励项目提高了治疗的维持率和戒断比例 • Among 8 outpatient psychosocial treatment programs • 在8个心理社会门诊治疗项目中得以运用 • And stimulant abstinence in 6 methadone maintenance programs -- where half were women and half were minorities • 6个美沙酮维持治疗项目均显示有促进戒断的作用—这些项目中女性占半数,少数族群也站半数
Birmingham Homeless Cocaine Studies (1991-2008)伯明翰流浪者可卡因研究(1991-2008) • Develop and test innovative treatment for cocaine addiction among homeless • 在流浪者中制定并评估全新的可卡因成瘾治疗 • First to use work therapy and housing/shelter as reinforcement for cocaine abstinence • 首先用安排工作和解决住所作为戒断的激励 • Also developed TGM to reinforce goals in major life areas related to addiction as adjunct to Behavioral Day Treatment Program • 此外还制订了TGM策略,用以强化流浪者成瘾相关的主要生活领域的目标,作为每日行为治疗项目的一个补充 • Sponsored by National Institutes of Health NIDA • 受美国国立卫生研究院国家药物滥用研究所的资助 • 4 RCTs in Birmingham, 1 Transport Treatment in Houston, and 1 Ukraine Transport. • 伯明翰有4个随机对照试验,休斯顿有1个干预现场转换研究,在乌克兰还有1个干预现场转换研究
Proportion Abstinent at 6 Months 6个月戒断比例 Proportion CM Only DT Only CM + DT Neither 只有CM 只有DT 都有 都没有 Homeless 3 Homeless1 Homeless 4 Homeless 2
Terminology词语释义 • BDT (Behavioral Day Treatment) 每日行为治疗 • TGM (Therapeutic Goals Management) 治疗目标管理 • IGD (Initial Goal Development) 初始目标发展 • GRG (Goal Review Group) 目标评审小组 • GDG (Goal Development Group) 目标发展小组 • GR (Goal Reward) 目标奖赏 • TGM Plan (Therapeutic Goals Management Plan) 治疗目标管理方案 • Inpatient TGM Plan (1 month long-term goals) 病人治疗目标管理方案(1个月远期目标) • Outpatient Aftercare TGM Plan(4 month long-term goals) 门诊病人预后关怀治疗目标管理方案(4个月远期目标) • Final TGM Plan (indefinite long-term goals) • LTG (long-term goal) 远期目标 • STG (short-term goal) 近期目标 • One-time, On-going, Individualized 一次性,持续性,个性化 • AEB (as evidenced by) 由谁证明 • Participant 调查对象 • Psychologist 心理医生 • Peers 同伴 • Seven life areas: drug use, housing, work, HIV risk, recreation, health, social support, plus other. • 七个生活领域:药物使用、家务、工作、HIV危险、娱乐、健康、社会支持和其他。 • IDU (injection drug use, user) • 静脉吸毒者(IDU)
Manual: Orientation to philosophy手册:靠近哲学 • Reduce negative consequences (not just use) and improve functioning in life areas • 减少负面后果(不仅仅是药物滥用),增强生活能力 • TGM elicits and negotiates, not advises • TGM策略只引导和沟通,不规劝 • Individualized, not standardized • 个性化的,不是统一的 • TGM is positive, not negative, in its approach and focus • TGM无论其策略还是侧重,都是积极的,而不是消极的, • Finally, TGM is a behavioral intervention that reinforces goal attainment • 最后,TGM是用来促进目标实现的行为干预
Manual: Orientation to TGM手册:定位TGM • Initial Goal Development 初始目标发展 • Major Life Areas 重要生活领域 • TGM Plan TGM 方案 • Goal Review Group 目标评审组 • Goal Development Group 目标发展组 • Goal Reward 目标奖赏
Manual: Initial Goal Development手册:初始目标发展 • Participant will obtain individualized feedback from baseline assessment results. • 通过基线调查的评估结果,调查对象将获得个性化的反馈 • Participant will identify any dissatisfaction in 7 life areas. • 调查对象将指出7个生活领域中的任何不快 • Participant will identify perceived ideals and define long-term goals in 7 life areas. • 调查对象将确定希望达到的目标,给出7个生活领域里的远期目标 • Participant will identify needs and resources in 7 life areas. • 调查对象将确定7个生活领域里的各种需求和资源 • Participant will define specific, objective, and measurable short-term goals for each life area. • 调查对象将确定7个生活领域里的各种特殊、客观、而且是可测量的近期目标 • Participant will complete initial TGM Plan. • 调查对象将完成最初的TGM方案
Opiate IDU “Check-up”阿片类静脉吸毒者“检查” • 1) Opiate Consumption (urine drug test, Form D90 interview [77]); • 使用阿片类毒品(尿药试验,D90表格访谈[77]) • 2) Opiate IDU Related Problems (Inventory of Drug Consequences [76], Addiction Severity Index [78]); • 阿片类静脉吸毒者相关问题(药物使用后果量表[76],成瘾严重程度指标[78]) • 3) Opiate Dependence (DSM IV Substance Related Disorder diagnosis using the SCID [79], Short Opiate Withdrawal Scale [80]); • 阿片依赖(DSM IV药物相关不良反应诊断,使用SCID[79],简明阿片戒断量表[80]) • 4) Physical Health (HIV/AIDS test using OraQuick Rapid HIV-1 Antibody Test including pre- and post-test counseling (OraSure Technologies, Inc.), SF-36-v2 Health Survey [81], physical exam, TB test); • 身体健康(使用OraQuick 快速HIV-1抗体检测HIV/AIDS,包括检测前和检测后咨询,SF-36-v2健康调查[81],体检,结核检测) • 5) Psychological Health (Beck Depression Inventory II [82], Brief Symptom Inventory [83]); • 心理健康(Beck抑郁量表II[82],简明症状量表[83] ) • 6) Risk Factors (family history of drug/alcohol problems, HIV Risk Assessment Battery [84], HIV Knowledge Questionnaire [85]); and • 危险因素(药物/酒精滥用家族史,Batter HIV危险评估[84],HIV只是问卷) • 7) Readiness to Change (U. of Rhode Island Change Assessment Scale-URICA [86]). • 准备改变(罗德岛大学改变评估量表-URICA [86])
初始目标发展工作表 生活领域 调查对象 编号 心理医生 日期 第一步:个性化的IDU检查反馈(结果的总结) 第二步:确定远期目标 a. 请告诉我关于您的(生活领域)? b.您的IDU检查显示了您生活领域的以下情况。反馈结果来自上面 c. 您对您的药物和/或酒精使用的方式和后果满意么? d. 您想改变(这个生活领域的)目前模式的那些方面? e. 在这个生活领域,您期望通过治疗达到怎样的理想或远期目标? f. 这对您来说是有意义并且合理的远期目标么? 远期目标
第三步:列出优势和需求 b. 为了实现(远期目标),您需要哪3件东西? c. 目前您有哪3个优势或资源有助于您实现远期目标)? 第四步:确立近期目标
Manual: Goal Review Group手册:目标评估小组 • Participant will review all long-term and short-term goals by life area • 调查对象将对各个生活领域的所有远期和近期目标进行自我评估 • Participant will present evidence of short-term goal progress • 调查对象将为近期目标的进展提供证据 • Participant will rate progress on all short-term goals • 调查对象将对所有近期目标的进展评分 • Participant will receive progress rating from peers on all goals • 调查对象将获得同伴对其所有目标的进展评分 • Participant will identify barriers to short-term goal progress • 调查对象将指出影响近期目标进展的障碍 • Participant will rate progress toward each long-term goal by life area • 调查对象将对各个生活领域的每一个远期目标进展评分 • Participant will receive social and tangible reward • 调查对象将得到社会性的和可及的奖赏
Manual: Goal Development Group手册:目标发展小组 • Participant will review each short-term goal by life area • 调查对象将评估各个生活领域的所有近期目标 • Participant will update needs by life area • 调查对象将根据生活目标调整需求 • Participant will update short-term goals as needed by life area • 必要时,调查对象将根据生活目标调整近期目标 • Participant will update long-term goals if needed by life area • 必要时,调查对象将根据生活目标调整调整长期目标
Manual: Reward for opiate abstinence手册:阿片戒断的奖赏 • Urine toxicology testing • 尿毒理学检测 • Database managed • 数据库管理 • Voucher characteristics • 代金券特点 • Escalating pay scale for sustained abstinence • 额度随维持的戒断时间增加而增加 • Bonus for 3 consecutive opiate free tests • 对连续3次参加阿片免费检测的,基于额外奖励 • Voucher reset for positive or missed test • 调整尿检阳性和不参加尿检者的代金券额度 • Paper voucher used for feedback • 用于反馈的纸质代金券 • Redeeming vouchers • 赎回代金券
Manual: Reward for goal achievement手册:完成目标的奖赏 • To reinforce goal attainment in life areas • 为促成各个生活领域目标的实现 • Petry Fishbowl Lottery • Petry鱼缸彩票干预方法 • 250 slips: sorry, small, large, JUMBO • 250个纸条:对不起,小(奖赏),大(奖赏), 非常大的(奖赏) • 2 draws for 80%, 5 draws for 100% • 抽中2个得80%,抽中5个的100% • 1 cumulative bonus draw for each consecutive 100% week, reset back to 1 draw if < 100% • 每连续100%周有累及额外抽中1个,如果<100%则调整回1个抽中
Manual: Materials手册:材料 • Sample TGM Plan for Ruslan 为Ruslan制定的TGM方案 • IDU Check-Up IDU检查 • Initial Goal Development Worksheets 初始目标发展工作表 • TGM Plan (forms by life area) TGM方案(分生活领域) • TGM Sample Goals TGM样本目标 • Wall Calendar 悬挂式年历 • AEB Journal AEB杂志 • Goal Progress Documentation (each participant) 目标进展记录(每个调查对象) • Treatment Attendance Logs 参与治疗日志 • Drug Test Result Charts (each participant) 药物监测结果图表(每个调查对象) • Goal Progress Percentage Charts (each participant) 目标进展比例图表(每个调查对象) • Goal Rating Chart 目标评分图表