INTIMATE PARTNER VIOLENCE AND METHAMPHETAMINE USE AN OVERVIEW OF TREATMENT EXPERIENCE.
The Matrix Model Treatment Approach for Methamphetamine ... · Treatment Approach for...
Transcript of The Matrix Model Treatment Approach for Methamphetamine ... · Treatment Approach for...
1
The Matrix Model The Matrix Model Treatment Approach for Treatment Approach for
Methamphetamine DependenceMethamphetamine DependenceMethamphetamine DependenceMethamphetamine Dependence
Michael J. McCann, MAMichael J. McCann, MAMatrix Institute on AddictionsMatrix Institute on AddictionsArlington, VAArlington, VAMay 9, 2006May 9, 2006
OverviewOverview
Methamphetamine effects on the brainMethamphetamine effects on the brainpp
Treatment approaches in light of brain effectsTreatment approaches in light of brain effects
The Matrix Model treatment approachThe Matrix Model treatment approach
Does methamphetamine treatment work? Does methamphetamine treatment work?
2
A Major Reason PeopleA Major Reason People
Meth Treatment is ChallengingMeth Treatment is Challenging
A Major Reason People Take a Drug is they Like
What It Does to Their Brains
A Major Reason People Take a Drug is they Like
What It Does to Their Brains
200200
ut
ut NAc shellNAc shell
FOODFOOD200200
seli
ne)
seli
ne) SEXSEX
Natural Rewards Elevate Dopamine Natural Rewards Elevate Dopamine LevelsLevels
Natural Rewards Elevate Dopamine Natural Rewards Elevate Dopamine LevelsLevels
00
5050
100100
150150
00 6060 120120 180180
% o
f B
asal
DA
Ou
tpu
% o
f B
asal
DA
Ou
tpu NAc shellNAc shell
EmptyEmptyBoxBoxFeedingFeeding
100100
150150
DA
Co
nce
ntr
atio
n (
% B
as
DA
Co
nce
ntr
atio
n (
% B
as
1515
00
55
1010
Co
pu
lation
Freq
uen
cC
op
ulatio
n F
requ
enc
00 6060 120120 180180Time (min)Time (min)
Source: Di Chiara et al.Source: Di Chiara et al.
MountsMountsIntromissionsIntromissionsEjaculationsEjaculations
cy
cy
SampleNumberSampleNumber
11 22 33 44 55 66 77 88 99 10101111121213131414151516161717
ScrScrScrScrBasBasFemale 1 PresentFemale 1 Present
ScrScrFemale 2 PresentFemale 2 Present
ScrScr
Source: Fiorino and PhillipsSource: Fiorino and Phillips
3
200200
300300
400400
Ba
sa
l Re
lea
se
Ba
sa
l Re
lea
se
DADADOPACDOPACHVAHVA
AccumbensAccumbens COCAINECOCAINE
150150
200200
250250B
as
al R
ele
as
eB
as
al R
ele
as
e AccumbensAccumbens
0.50.51.01.02.52.51010
Dose (mg/kg)Dose (mg/kg)MORPHINEMORPHINE
Effects of Drugs on Dopamine LevelsEffects of Drugs on Dopamine LevelsEffects of Drugs on Dopamine LevelsEffects of Drugs on Dopamine Levels
800800900900
1000100011001100
al R
ele
as
ea
l Re
lea
se
DADA
AccumbensAccumbens AMPHETAMINEAMPHETAMINE
00
100100
200200
00 11 22 33 44 5 hr5 hrTime After CocaineTime After Cocaine
% o
f B
% o
f B
00
100100
00 11 22 33 44 5hr5hrTime After MorphineTime After Morphine
% o
f %
of
200200
250250
l Re
lea
se
l Re
lea
se
AccumbensAccumbensCaudateCaudate
NICOTINENICOTINE
00100100200200300300400400500500600600700700
00 11 22 33 44 5 hr5 hrTime After AmphetamineTime After Amphetamine
% o
f B
as
a%
of
Ba
sa DADA
DOPACDOPACHVAHVA
00
100100
150150
00 11 22 3 hr3 hrTime After NicotineTime After Nicotine
% o
f B
as
a%
of
Ba
sa CaudateCaudate
Source: Di Chiara and ImperatoSource: Di Chiara and Imperato
Prolonged Drug Use ChangesProlonged Drug Use Changes
Meth Treatment is ChallengingMeth Treatment is Challenging
Prolonged Drug Use ChangesProlonged Drug Use Changesthe Brain In Fundamentalthe Brain In Fundamentaland Longand Long--Lasting WaysLasting Ways
4
Decreased dopamine transporter binding in Decreased dopamine transporter binding in METH users resembles that inMETH users resembles that in
ParkinsonParkinson’’s Disease patientss Disease patients
Source: McCann U.D.. et al.,Journal of Neuroscience, 18, pp. 8417-8422, October 15, 1998.
Control Meth PDAvg. 3 yrs. abstinent
5
“This is your Brain on Meth”“This is your Brain on Meth”
Dr. Paul Thompson of UCLA; brain mapping Dr. Paul Thompson of UCLA; brain mapping study. study.
Meth users in their 30s with 10 years of use.Meth users in their 30s with 10 years of use.
11% loss in brain pleasure/reward center tissue.11% loss in brain pleasure/reward center tissue.
He described “a forest fire” of brain damage.He described “a forest fire” of brain damage.
Navigating through daily life and applying what Navigating through daily life and applying what is learned in treatment may be difficult is learned in treatment may be difficult (reminders, simplicity, redundancy)(reminders, simplicity, redundancy)
Meth in the BrainMeth in the BrainMeth in the BrainMeth in the Brain
6
7
8
Methamphetamine: Methamphetamine: Neurochemical MechanismsNeurochemical Mechanisms
Enters dopamine vesiclesEnters dopamine vesicles
Vesicles deplete themselves of dopamineVesicles deplete themselves of dopamine
METH
METH
9
METH
METH
Meth Treatment is ChallengingMeth Treatment is Challenging
Prolonged meth use changes the brainProlonged meth use changes the braing gg g
Prolonged effects require appropriate treatment Prolonged effects require appropriate treatment approaches approaches
10
Effective Treatments for Effective Treatments for MethamphetamineMethamphetamine DependenceDependenceMethamphetamine Methamphetamine DependenceDependence
The Matrix InstituteThe Matrix Institute
Established 1984Established 1984s b s ds b s d 5 clinics in Southern California5 clinics in Southern California San Bernardino County 1985; >50% meth usersSan Bernardino County 1985; >50% meth users
11
Some Core Elements of Some Core Elements of the Matrix Modelthe Matrix Model
Elements of Effective TreatmentElements of Effective Treatmentwith Methamphetamine Users with Methamphetamine Users
Focus on the present; behavior vs feelingsFocus on the present; behavior vs feelings Focus on the present; behavior vs feelingsFocus on the present; behavior vs feelings
Structure: 3 X week meetings; 16 weeksStructure: 3 X week meetings; 16 weeks
Information on addiction and recoveryInformation on addiction and recovery
Teach relapse preventionTeach relapse prevention
Uri t tiUri t ti Urine testingUrine testing
Introduce and encourage selfIntroduce and encourage self--helphelp
12
Matrix Program Schedule (Sample)Matrix Program Schedule (Sample)
Monday Wednesday Friday
Weeks 1-4
Early Recovery Skills
Weeks 1-12Family/Education
Weeks 1-4
Early Recovery Skills
Weeks 1-16 Relapse Prevention Weeks 13-16
Weeks 1-16Relapse PreventionRelapse Prevention Weeks 13-16
Social SupportRelapse Prevention
Urine and breath alcohol tests once per week, weeks 1-16Ten Individual/Conjoint sessions during 1st 16 weeks
Simple, redundant, & relevant informationSimple, redundant, & relevant information
Cl i l di i i d iCl i l di i i d iClassical conditioning and cravingClassical conditioning and craving
The brain and addictionThe brain and addiction
13
Information: ConditioningInformation: Conditioning
Pavlov’s Dog
Information: ConditioningInformation: Conditioning
Pavlov’s Dog
14
Conditioning Process During Conditioning Process During AddictionAddiction
Social Phase
Triggers•Parties
Responses•Pleasant Thoughts
Strength of Conditioned Connection
Mild
•Special OccasionsPleasant Thoughts about AOD
•No Physiological Response
•Infrequent Use
Development of Craving ResponseDevelopment of Craving Response
Addiction Phase
Thinking of Using
Mild Physiological Response
Entering Using Site
Heart Rate
Breathing Rate
Energy
Adrenaline Effects
Powerful Physiological R
Use of AODs AOD EffectsResponse
Heart Rate
Breathing Rate
Energy
Adrenaline Effects
Heart
Blood Pressure
Energy
15
Cognitive Process During AddictionCognitive Process During Addiction
Disenchantment Phase
Social Currency
Occasional Euphoria
Relief From Lethargy
Relief From Stress
Nose Bleeds
Infections
Relationship Disruption
Family Distress
Impending Job Loss
Conditioning and the Brain: Conditioning and the Brain: Message to PatientsMessage to Patients
Will power, good intentions are not enoughWill power, good intentions are not enoughp , g gp , g g
Behavior needs to changeBehavior needs to change
Insight will not affect cravingsInsight will not affect cravings
D l ith i id t iD l ith i id t i Deal with cravings: avoid triggersDeal with cravings: avoid triggers
Deal with cravings: thoughtDeal with cravings: thought--stoppingstopping
SchedulingScheduling
16
Treatment: Information & PersuasionTreatment: Information & Persuasion
DRUG
Early Recovery Skills GroupEarly Recovery Skills Group
Drug cessationDrug cessationgg
Identify triggersIdentify triggers
Get rid of paraphernaliaGet rid of paraphernalia
Avoid triggersAvoid triggers--schedule timeschedule time
ThoughtThought--stopping for cravingsstopping for cravingsThoughtThought stopping for cravingsstopping for cravings
1212--step introductionstep introduction
17
Matrix Model Key ComponentMatrix Model Key Component
Information
The Roadmap to Recovery
Information: Roadmap for RecoveryInformation: Roadmap for Recovery
•Withdrawal
•Early Abstinence, Honeymoon
•Protracted Abstinence, the Wall
•Adjustment/Resolution
18
Information: the WallInformation: the Wall
Protracted Abstinence: “The Wall”Protracted Abstinence: “The Wall”
4545--120 days after last use120 days after last use
19
Partial Recovery of Brain from Methamphetamine After Abstinence
3
Normal Control METH Abuser(1 month abstinent)
METH Abuser(14 months abstinent)
0
ml/gm
Source: Volkow, ND et al., Journal of Neuroscience 21, 9414-9418, 2001.
Dopamine improvements after 1 year, but not cognitive and motor functioning
Roadmap for RecoveryRoadmap for Recovery
Return to Old Behaviors
Emotional Swings
AnhedoniaAnger
Depression
Unclear Thinking
Isolation
Family Problems
Cravings Return
Protracted Abstinence
Abstinence Violation
20
The WallThe Wall
Treatment implicationsTreatment implicationsSi lSi l SimpleSimple
RedundantRedundant Frequent visits for an extended periodFrequent visits for an extended period
Message to patientsMessage to patientsIt t k hil f b i t h lIt t k hil f b i t h l It takes a while for your brain to healIt takes a while for your brain to heal
Don’t make mistakes explaining your feelingsDon’t make mistakes explaining your feelings Be patient; Don’t give upBe patient; Don’t give up
Relapse Prevention GroupsRelapse Prevention Groups
Relapse PreventionRelapse Preventionpp Patients need to develop new behaviorsPatients need to develop new behaviors
Learn to monitor signs of vulnerability to Learn to monitor signs of vulnerability to relapserelapse
Recovery is more than not using D.O.C.Recovery is more than not using D.O.C.
R i th t i d dR i th t i d d Recovery is more than not using drugs and Recovery is more than not using drugs and alcoholalcohol
21
Relapse Prevention TopicsRelapse Prevention Topics
Relapse PreventionRelapse PreventionO i f th t thi d ’t “j t h ”O i f th t thi d ’t “j t h ” Overview of the concept; things don’t “just happen”Overview of the concept; things don’t “just happen”
Using BehaviorUsing Behavior Old behaviors need to changeOld behaviors need to change
ReRe--emergence signals relapse risk (it’s a duck)emergence signals relapse risk (it’s a duck)
Relapse JustificationRelapse JustificationS k h k ”S k h k ” “Stinking thinking”“Stinking thinking”
Recognize and stopRecognize and stop
Relapse Prevention TopicsRelapse Prevention Topics
Dangerous EmotionsDangerous EmotionsL li d i tiL li d i ti Loneliness, anger, deprivationLoneliness, anger, deprivation
Be Smart, not StrongBe Smart, not Strong Avoid the dangerous people and placesAvoid the dangerous people and places Don’t rely on will powerDon’t rely on will power
Avoiding Relapse DriftAvoiding Relapse Drift Identify “mooring lines”Identify “mooring lines”dentify mooring linesdentify mooring lines Monitor driftMonitor drift
22
Relapse Prevention TopicsRelapse Prevention Topics
Total AbstinenceTotal Abstinence Other drug/alcohol use impedes recovery growthOther drug/alcohol use impedes recovery growthg/ p y gg/ p y g Development of new dependencies is possibleDevelopment of new dependencies is possible
Taking Care of BusinessTaking Care of Business Addiction is fullAddiction is full--timetime Normal responsibilities often neglectedNormal responsibilities often neglected
Taking Care of YourselfTaking Care of Yourself Health, groomingHealth, grooming New selfNew self--imageimage
Relapse AnalysisRelapse Analysis
Session to be done when relapse occurs after a Session to be done when relapse occurs after a period of sobrietyperiod of sobrietyperiod of sobrietyperiod of sobriety
Functional analysisFunctional analysis
Continued drug use is better addressed with Continued drug use is better addressed with Early Recovery topicsEarly Recovery topicsEarly Recovery topicsEarly Recovery topics
Relapse should be framed as learning experience Relapse should be framed as learning experience for clientfor client
23
Relapse and SexRelapse and Sex
My sexual My sexual drivedrive is increased by the use of …is increased by the use of …
85 390100
ng
18.1 20.5
43.9
70.655.3
11 1
85.3
55.6
2030405060708090
erce
nt R
espo
ndin
"Yes
"
malefemale
11.1
01020
Pe
opiates alcohol cocaine meth
Primary Drug of Abuse
(Rawson et al., 2002)
24
My sexual My sexual pleasurepleasure is enhanced by the use of …is enhanced by the use of …
90100
g
16.0 18.224.4
38.244.7
11 1
73.5 66.7
2030405060708090
rcen
t R
espo
nd
ing
"Y
es"
malefemale
11.1
01020
Per
opiates alcohol cocaine meth
Primary Drug of Abuse
(Rawson et al., 2002)
My sexual My sexual performanceperformance is improved by the use of …is improved by the use of …
100
19.115.9
24.432.4
18.4
58.8 61.1
2030405060708090
cent
Res
pond
ing
"Y
es"
malefemale
11.1
01020
Per
c
opiates alcohol cocaine meth
Primary Drug of Abuse(Rawson et al., 2002)
25
Other Components of the Other Components of the Matrix ModelMatrix Model
Family Education LectureFamily Education Lecture
Conjoint SessionsConjoint Sessions
Urine TestingUrine Testing
S lf H lp Initi ti nS lf H lp Initi ti n Self Help InitiationSelf Help Initiation
Matrix ModelMatrix ModelUrinalysis And Breath TestingUrinalysis And Breath Testing
M th d f M it i T t t PMethod for Monitoring Treatment Progress
Treatment Accountability
Assistance for Patient
Reduces Arguments
Provides Data for Family or Employer
26
The “5%” MythThe “5%” Myth
Myth: Only 5% of meth users are successful in Myth: Only 5% of meth users are successful in treatmenttreatmenttreatmenttreatment
Does treatment work? Does treatment work? Fact: Some treatments workFact: Some treatments work EvidenceEvidence--based treatments based treatments
Motivational InterviewingMotivational Interviewinggg Contingency ManagementContingency Management Cognitive/Behavioral Treatment (Matrix Model)Cognitive/Behavioral Treatment (Matrix Model)
The “5%” MythThe “5%” Myth
Wide dissemination may be selfWide dissemination may be self--fulfillingfulfilling Communities won’t support treatment Communities won’t support treatment
Funders won’t fund treatmentFunders won’t fund treatment
Meth users won’t enter treatmentMeth users won’t enter treatment
Practitioners won’t expect treatment to workPractitioners won’t expect treatment to work
27
Comparison of Meth and Cocaine UsersComparison of Meth and Cocaine UsersRawson et al., 2000, Journal of Psychoactive DrugsRawson et al., 2000, Journal of Psychoactive Drugs
500 methamphetamine users500 methamphetamine users
224 cocaine users224 cocaine users
Matrix San Bernardino CountyMatrix San Bernardino County
Identical program and staffIdentical program and staff
Comparison of Meth and Cocaine UsersComparison of Meth and Cocaine UsersRawson et al., 2000, Journal of Psychoactive DrugsRawson et al., 2000, Journal of Psychoactive Drugs
Identical treatment outcomesIdentical treatment outcomes
Mean Weeks in Treatment
17.1 18
12
16
20
24
eeks
Meth
% Clean Urines
81% 87%
60%
80%
100%
Meth
0
4
8
Weeks in Treatment
We
Cocaine
0%
20%
40%
% Clean Urines
Cocaine
28
Matrix Model vs TAUMatrix Model vs TAURawson et al., 2004, AddictionRawson et al., 2004, Addiction
978 Methamphetamine users seeking treatment978 Methamphetamine users seeking treatment 978 Methamphetamine users seeking treatment 978 Methamphetamine users seeking treatment CSAT multiCSAT multi--site study; 1998site study; 1998--20022002
Costa Mesa; San Diego; Hayward; Concord; Costa Mesa; San Diego; Hayward; Concord; San Mateo; Billings; HonoluluSan Mateo; Billings; Honolulu
Matrix Model vs Treatment as UsualMatrix Model vs Treatment as Usual Random assignmentRandom assignment
Baseline DemographicsBaseline Demographics
AgeAge 32.8 years32.8 years
MaleMale
EducationEducation
Meth useMeth use
Marijuana useMarijuana use
55%55%
12.2 years12.2 years
7.5 years7.5 years
7 2 years7 2 years Marijuana useMarijuana use
Alcohol useAlcohol use
7.2 years7.2 years
7.6 years7.6 years
29
Route of Methamphetamine UseRoute of Methamphetamine Use
64%70%
24%
11%20%
30%
40%
50%
60%
ent
Usi
ng b
y R
oute
nasalsmokeiv
11%
0%
10%
20%
Route of Administration
Per
c
Weeks in TreatmentWeeks in Treatment
8.28
9
5
3
4
5
6
7
8
Wee
ks
**0
1
2
Matrix TAU
**
30
Weeks Continuous AbstinenceWeeks Continuous Abstinence
67
3
6
2
3
4
5
6
Wee
ks
0
1
2
Matrix TAU
**
Mean Number of UA’s that wereMean Number of UA’s that wereMAMA--free during treatmentfree during treatment
10 Matrix
0
2
4
6
8
BilCo Co Ha Ho Sa Sa Sa
TAU
Billings
Concord
CostaMesa
Hayward
Honolulu
SanDiego
SanMateoO
DAS
SanMateoPyra
31
Mean Number of Weeks in Treatment
1012
f vi
sits
MatrixTAU
02468
10
Bi C C H H S S S
mea
n nu
mbe
r of TAU
Billings
Concord
CostaMesa
Hayward
Honolulu
SanDiego
SanMateoODAS
SanMateoPyra
SITE
11.312
Self-report of MA use during the past 30 daysat baseline, discharge, and 6-month follow-up.
4.3 4.44
6
8
10
Day
s
Baseline
Discharge
6-month FU
0
2
Matrix
32
Urine Results: % MethUrine Results: % Meth--freefree
66%69%
70%
75%
66%
59%
35%
40%
45%
50%
55%
60%
65%
70%
% m
eth
-fre
e
Discharge
6 months
12 months
25%
30%
35%
Matrix