Evidence-Based Research Findings on Substance Use Disorders

1. Evidence-Based Research Findings on Substance Use Disorders Homeless Families – February 8, 2007 Joan E. Zweben, Ph.D. Executive Director The 14th Street Clinic & EBCRP Health Sciences Clinical Professor of Psychiatry, University of California, San Francisco

2. Goals • Alert you to issues in the EBP debate that may affect you soon • Give basic overview of evidence-based principles and practices • Introduce two widely used models for engagement and treatment of substance use problems • Describe family program for methamphetamine users at EBCRP

3. Substance Abuse Treatment:Finding Good Care

4. What do we need to know to improve care?

5. Clinician Questions I • Should we admit people who are still drinking and using? • Should they see a psychiatrist while they are still drinking/using? • Should we discharge them if they don’t comply with our exacting program requirements? • Should we discharge them if they drink/use?

6. Clinician Questions II • Should we require them to attend 12-step programs? • Do recovering counselors do better/worse than others? • Do harm reduction goals produce greater public health and safety benefits than abstinence goals?

7. 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.

8. 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.

9. 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 • Harm reduction approaches yield benefits for public health and safety. • Problem-service matching strategies improve outcomes. (Other matching strategies disappointing.)

10. 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

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

12. 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.

13. 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)

14. Are RCT’s Over-rated?

15. QUERI RCT Mark Willenbring MD (ASAM 2006)

16. 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?

17. Important to Extend the Evidence Hierarchy • RCT designs have limitations and are not always best for investigating key aspects of behavior change process: • What influences people to seek and engage in treatment? • How do these self-selection processes and contextual influences contribute to the change process? (Tucker & Roth, Addiction, 2006)

18. IMPLEMENTATION ISSUES

19. Barrier: Resource Allocation 99% = Investment in Intervention Research to develop solutions ($95 billion/yr) 1% = Investment in Implementation Research to make effective use of those solutions (Up from ¼% in 1977) ($1.8 Trillion/yr on service) Dean Fixsen, 2006

20. Can we assume that interventions with documented efficacy will be effective in the community if we only implement them correctly?

21. Important Questions to Ask What are the characteristics of interventions that can: • Reach large numbers of people, especially those who can most benefit • Be broadly adopted by different settings • Be consistently implemented by different staff with moderate training and expertise • Produce replicable and long lasting effects (with minimal negative impact) at reasonable costs. (Glasgow et al, AJPH, 2003)

22. Ineffective Implementation Strategies “…experimental studies indicate that dissemination of information does not result in positive implementation outcomes (changes in practitioner behavior) or intervention outcomes (benefits to consumers)” (Fixsen et al, 2005)

23. Key Ingredients • Presenting information; instructions • Demonstrations (live or taped) • Practice key skills; behavior rehearsal • Feedback on Practice • Other reinforcing strategies; peer and organizational support (Fixsen et al, 2005)

24. Specific Treatment Issues & Approaches

25. Abstinence-Oriented Treatment & Harm Reduction • Polarization unnecessary and misleading • Those who succeed quickly do not remain in specialty treatment. We are working with people who have trouble establishing and maintaining abstinence. • Go beyond the rhetoric and look at what people/programs actually do.

26. 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

27. 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

28. Motivational Enhancement Strategies • Widely adopted • Principles widely applicable outside substance abuse treatment • TIP 33: Enhancing Motivation for Change in Substance Abuse Treatment - order from: www.ncadi.samhsa.org

29. Goals and Benefits • Inspiring motivation to change • Preparing clients to enter treatment • Engaging and retaining clients in treatment • Increasing participation and involvement • Improving treatment outcomes • Encouraging a rapid return to treatment if symptoms recur

30. Stages of Change • Precontemplation • Contemplation • Preparation • Action • Maintenance Prochaska , DiClementi, and Norcross (1992)

31. The Matrix ModelRichard Rawson, Ph.D., Jeanne Obert, MFT & Colleagues (Los Angeles) It is many treatments in one: • Components based on scientific literature promoting behavior change. • Emphasis on collaborative relationship with client. • Teaches early recovery and relapse prevention skills • Facilitates participation in 12-step meetings

32. Organizing Principals I • Non-confrontational, non-judgmental relationship between therapist and client creates positive bond that promotes participation. • Positive reinforcement, incentives and contingencies used extensively to promote treatment engagement and retention.

33. Organizing Principles II • Accurate, understandable scientific information used to educate the client and family members • Cognitive behavioral strategies used to promote drug cessation and relapse prevention • Family therapy interventions used to engage families in the recovery process • Social support activities provided to help maintain abstinence

34. Evidence-Based Family Treatment in Substance Abuse • Behavioral strategic family therapy (BSFT) • Behavioral marital therapy • Multidimensional family therapy for adolescents • Multisystemic therapy (MST) • Family consultation approach (FAMCON)

35. Family Treatments (Adolescents) • Well defined, family-focused engagement strategies outperform other, more standard engagement strategies. • Retention is better. • We don’t know much about how or for whom they work. • Definitions and outcomes vary widely. • Much more research is needed. (Rorbach and Shoham, 2006)

36. Limitations • Small pool of family therapists • Smaller pool with substance abuse expertise • Training for some approaches is very expensive • No studies of homeless families (exclusively)

37. EBCRP Family Oriented Treatment for Methamphetamine Users I SPECIFIC FAMILY ELEMENTS • Couples and family counseling to address relationship issues • Supportive family therapy – for parents and young children; facilitate bonding and address other issues • Family education groups – 16 wk group to address the basics of addiction and recovery, using “family in recovery” model (Matrix)

38. EBCRP Family Oriented Treatment for Methamphetamine Users II • Parenting support groups – to increase parenting skills as well as provide support and feedback for parents in recovery • Multi-family groups – to explore changes in family structure that occur when a family is in recovery

39. Some Final Points….. • Learn about research so you can educate your funders • Most substance abuse treatment is a blend of evidence-based practices and activities that have not been well studied • Find community partners who will work to meet the needs of your clients.

40. Acknowledgements • Center for Substance Abuse Treatment, for treatment funding (since 1990) that encouraged innovation and supported our ability to do comprehensive, evidence-based care. • Clinical Trials Network, National Institute on Drug Abuse for providing arena (since 2002) for collaboration that greatly fostered mutual understanding to bridge the gap between treatment and research.

41. RESOURCES • Download slides from: www.ebcrp.org (go to Presentations) • Order TIPS and Matrix Manuals from: www.ncadi.samhsa.org