The Voice of Recovery: Effectively Treating Methamphetamine Users and their Families Michael S....
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Transcript of The Voice of Recovery: Effectively Treating Methamphetamine Users and their Families Michael S....
The Voice of Recovery: Effectively Treating Methamphetamine
Users and their Families
Michael S. Shafer, Ph.D.
Motivation for Treatment• Why is it harder for a
stimulant abuser to enter the treatment system?
Motivation for Treatment• Why is it harder for a
stimulant abuser to enter the treatment system?
• What does it mean to say someone is motivated to do treatment?
Motivation for Treatment• Why is it harder for a
stimulant abuser to enter the treatment system?
• What does it mean to say someone is motivated to do treatment?
• How can we compete with the pull of drugs like methamphetamine?
How Stimulants Affect the Willingness to Enter
Treatment
Methamphetamine does NOT make you sick; therefore, the drug use is not the problem.
Methamphetamine allows long periods of no drug use; certainly the drug is not the problem.
Medical & Psychosocial Treatment Approaches for Various Commonly Abused
Substances
Drugs
SedativesStimulants
OpioidsAlcohol
Medical Treatment
Yes
NoNoYesYes
Psychosocial Treatment
YesYesYesYes
www.drugabuse.gov
Principles of Effective Treatment
1. No single treatment is appropriate for all2. Treatment needs to be readily available3. Effective treatment attends to the multiple
needs of the individual4. Treatment plans must be assessed and
modified continually to meet changing needs5. Remaining in treatment for an adequate
period of time is critical for treatment effectiveness
Principles of Effective Treatment
6. Counseling and other behavioral therapies are critical components of effective treatment
7. Medications are an important element of treatment for many patients
8. Co-existing disorders should be treated in an integrated way
9. Medical detox is only the first stage of treatment
10. Treatment does not need to be voluntary to be effective
11. Possible drug use during treatment must be monitored continuously
12. Treatment programs should assess for HIV/AIDS, Hepatitis B & C, Tuberculosis and other infectious diseases and help clients modify at-risk behaviors
13. Recovery can be a long-term process and frequently requires multiple episodes of treatment
- NIDA (1999) Principles of Drug Addiction Treatment
Principles of Effective Treatment
MA Treatment Issues
Acute MA Overdose Acute MA Psychosis MA “Withdrawal” Initiating MA Abstinence MA Relapse Prevention Protracted Cognitive Impairment and Symptoms of Paranoia
Acute MA Overdose
Slowing of Cardiac Conduction Ventricular Irritability Hypertensive Episode Hyperpyrexic Episode CNS Seizures and Anoxia
Acute MA Psychosis
Extreme Paranoid Ideation Well Formed Delusions Hypersensitivity to Environmental
Stimuli Stereotyped Behavior “Tweaking” Panic, Extreme Fearfulness High Potential for Violence
Treatment of MA Psychosis
• Typical ER Protocol for MA Psychosis– Haloperidol - 5mg– Clonazepam - 1 mg– Cogentin - 1 mg– Quiet, Dimly Lit Room– Restraints
MA “Withdrawal”
- Depression - Paranoia- Fatigue - Cognitive
Impairment - Anxiety - Agitation- Anergia - Confusion
• Duration: 2 Days - 2 Weeks
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
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
Initiating MA AbstinenceKey Clinical Issues
– Depression– Cognitive Impairment– Continuing Paranoia– Anhedonia– Behavioral/Functional Impairment– Hypersexuality– Conditioned Cues– Irritability/Violence
Initiating MA Abstinence
Key Elements of Treatment– Structure– Information in
Understandable Form– Family Support– Positive Reinforcement– 12-Step Participation
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
NIDA Therapy Manuals for Drug Addiction
behavioral and cognitive treatment approaches
proven effective through research
A Cognitive-Behavioral Approach: Treating Cocaine Addiction
A Community Reinforcement Plus Vouchers Approach: Treating Cocaine Addiction
Manual 2
Manual 1
A Cognitive-Behavioral Approach: Treating Cocaine
Addiction
Kathleen M. Carroll, Ph.D.April 1998
Manual 1
Cognitive Behavioral TherapyThe Essential Tasks
Functional analyses of substance useIndividualized training
• Coping with Craving• Managing Using Thoughts• Problemsolving• Recognizing Seemingly Irrelevant
Decisions• Refusal Skills
Cognitive Behavioral TherapyThe Essential Tasks (con’t.)
Examining substance use cognitionsIdentifying and debriefing past and future high-risk situationsEncouraging and reviewing extra-session implementation of skillsPracticing skills during sessions
Cognitive Behavioral Therapy2 Critical Components
FunctionalAnalysis(Analyze)
Skills Training(Act)
Cognitive Behavioral TherapyFunctional Analysis
Thoughts
Circumstances
Feelings
Before and After Use
Cognitive Behavioral TherapySkills Training
Stopping DrugThoughts
SocialSkills
AvoidingHigh-RiskSituations
EmploymentIssues
For Present and for Future
Cognitive Behavioral Therapy
Skills Training
Cessation Strategies
Use Repetition Anticipate Obstacles
Generalizable Skills
Practice Mastering
Skills
Monitor Closely
Basic Skills First
Give a Clear Rational
Use the Data
Match Material to Patient
Needs
Get a Commitment
Explore Resistance
Community Reinforcement Plus Vouchers Approach:
Treating Cocaine Addiction
Budney & HigginsApril 1998
Manual 2
• An operant model where approximations of the desired behaviors are encouraged and rewarded to facilitate progress toward specified goals.
• Underlying emphasis of this approach is to reward abstinence behaviors so that individuals make healthy lifestyle choices.
• Relapse prevention strategies and motivational interviewing are fundamental parts of this approach.
• The two major goals of CRA include elimination of positive reinforcement for drug use and enhancement of positive reinforcement for sobriety.
Core Program Components of CRA
• Behavioral Orientation
• Skills Instruction
• Sobriety Sampling
• Treatment Planning
Behavioral Orientation
• Use of Functional Analysis to Identify Antecedents and Consequences of Addictive Behavior
• Non-Confrontational Counseling Styles, using tenets of Motivational Interviewing, prompt rule, and reinforcing successive approximations of sobriety
• Use of Role Playing to Practice Skills• Use of Modeling to Demonstrate
Desirable Skills
Skills Instruction
• Social/recreational skills• Communication skills, including
behavioral marital counseling• Problem solving skills• Employability skills• Drink refusal skills, including
duration training
Sobriety Sampling
• Behavioral Contracts Negotiated with Clients for Progressively Longer Periods of Sobriety
• Agnostic Medications (Disulfurim/Antabuse) Prescribed and Used with Monitors
Treatment Planning
• Formalized Process for Treatment Planning
• Treatment Plan Focused on Responding to Client Identified Sources and Barriers to Personal Happiness – Use of the Happiness Scale
Demonstrated Clinical Efficacy
• Alcoholics • Opiate and cocaine abusers • Homeless populations
3 meta-analysis of the substance abuse treatment research have identified CRA
as one of the top five treatments in producing positive outcomes for low
costs.
Incentives in Treatmentof Cocaine Dependence
Review of the Literature(Higgins 1996)
13 Studies
11 StudiesPositive Treatment Effects
2 StudiesNo Significant Difference
MATRIX MODEL TREATMENT
Behavioral Disruption Cognitive Disruption
Emotional DisruptionFamily/Relationship
Disruption
Components of Stimulant
Addiction Syndrome
Treatment Components of the Matrix Model
• Early Recovery Groups
• Relapse Prevention Groups
• Individual Sessions
• Family Education Group
• 12-Step Meetings
• Social Support Groups
• Relapse Analysis
• Urine Testing
STAGES OF RECOVERY
Withdrawal
DAY
0
DAY
15
Honeymoon
DAY
45
The Wall
DAY
120
Resolution
Adjustment
DAY
180
• Medical Problems• Alcohol Withdrawal• Depression• Difficulty
Concentrating• Severe Cravings• Contact with Stimuli• Excessive Sleep
Day 0 to Day 15
WITHDRAWAL STAGE
Primary Manifestation of Withdrawal Stage
Behavioral Cognitive
RelationshipEmotional
BehavioralBehavioralInconsistencyInconsistency
Confusion, Inability to Concentrate
Depression/Anxiety,Self-Doubt
Mutual Hostility,Fear
Self-designed structure (scheduling)
Makes concrete the idea of “one day at a time”
Eliminate avoidable triggers
Reduces anxiety
Counters the addict lifestyle
Provides basic foundation for ongoing recovery
Key Concept: Structure
Ways to Create Structure
Time scheduling
Going to treatment
Attending 12-step meetings
Exercising
Performing athletic activities
Attending school
Going to work
Attending church
Pitfalls of Structure
Scheduling unrealistically
Neglecting recreation
Being perfectionistic
Therapist imposing schedule
Spouse/parent imposing schedule
Unstructured time
Proximity of triggers
Alcohol/marijuana use
Powerful cravings
Withdrawal Stage: Relapse Factors
• Paranoia
• Depression
• Disordered sleep patterns
• Overconfidence• Over-involvement with
work• Inability to prioritize• Inability to initiate change• Alcohol use• Episodic cravings• Treatment termination
HONEYMOON STAGE
Day 15 to Day 45
Primary Manifestation of Honeymoon Stage
Behavioral Cognitive
RelationshipEmotional
High energy,High energy,
Unfocused behaviorUnfocused behavior Inability to prioritize
Overconfidence,Feeling cured
Denial of addiction disorder
Information - What
• Substance abuse & the brain
• Sex and recovery
• Relapse prevention issues
• Triggers and cravings
• Emotional readjustment
• Stages of recovery
• Medical effects
• Relationships and recovery
• Alcohol/marijuana
Information - Why
Reduces confusion and guilt
Explains addict behavior
Gives a roadmap for recovery
Clarifies alcohol/marijuana issue
Aids acceptance of addiction
Gives hope/realistic perspective for family
Relapse Factors: Honeymoon Stage
Overconfidence
Secondary alcohol or other drug use
Discontinuation of structure
Resistance to behavior change
Return to addict lifestyle
Inability to prioritize
Periodic paranoia
Return to Old Behaviors
Anhedonia
Anger
Depression
Emotional Swings
Unclear Thinking
Isolation
Family ProblemsCravings Return
Irritability
Abstinence Violation
Primary Manifestation of the
Wall Stage
Behavioral Cognitive
RelationshipEmotional
Sluggish,Sluggish,Low Energy/InertiaLow Energy/Inertia
Relapse Justification
Depression,Anhedonia
Irritability, Mutual Blaming, Impatience
Relapse Factors: Sexual Behavior
Sexual arousal producing craving
Concern about sexual dysfunction
Concern over sexual abstinence
Concern over sexual disinterest
Loss of intensity of sexual enjoyment
Relapse Factors: Sexual Behavior
Shame/Guilt about sexual behavior
Sexual behavior and intimacy
Sobriety and monogamy
Relapse Factors: Alcohol/Marijuana
Stimulant craving induction
Pharmacologic coping method
12-Step philosophy conflict
Abstinence violation effect
Marijuana amotivational syndrome
Interferes with new behaviors
Key Concept: Relapse Justification
Definition:
The rational part of the brain attempts to provide a logical explanation for justifying behavior which moves the client closer to his drug of choice
Relapse thoughts gain power when not openly recognized and discussed
The Wall: Relapse Factors
• Increased emotions• Interpersonal conflict• Relapse justification• Anhedonia/loss of
motivation
• Insomnia/low energy/fatigue
• Paranoia
• Dissolution of structure
• Behavioral drift
• Secondary alcohol or drug use
• Resistance to exercise
Primary Manifestation of Adjustment Stage
Behavioral Cognitive
RelationshipEmotional
SloppinessSloppinessRegarding LimitsRegarding Limits
Drifting From Commitment to Recovery
Experiencing Normal Emotions
Surfacing of Long-Term Issues
Relapse Factors: Adjustment Stage
Relaxation of structure
Struggle over acceptance of addiction
Maintenance of recovery momentum/ commitment
Six-month syndrome
Re-emergence of underlying pathology
Evaluation of the Matrix Model
Key findings from a recently completed CSAT-funded 8-site evaluation of the Matrix model
Study participants treated with the Matrix Model were retained in treatment longer and gave more drug-free urine samples than participants treated in the community “Treatment as Usual” condition.
Outcomes for both Matrix and Treatment as Usual indicated that participants reduced their use of MA from an average of 11 days in the previous 30 at admission to approximately 4 days at discharge and both follow up points.
At discharge and follow-up points between 57% and 68% of participants in both groups reported no MA use for the previous 30 days and approximately the same number gave drug free urine samples (samples were collected on over 80% of participants, under observation)
Participants in both treatment groups showed significant improvement in employment status, family relations, legal problems and psychiatric symptoms.
In one site, all participants were currently enrolled in a drug court program.
Participants in this site had better outcomes than in all other sites, suggesting that drug court involvement was very effective.
On numerous measures, individuals who injected MA had poorer outcomes than individuals who snorted or smoked MA. Smokers also, exhibited considerable difficulty, but not as severe as injectors.
The following recommendations are based upon a reading and synthesis of the treatment research on MA to date (2005).
Outpatient treatment can be quite effective for treating individuals who abuse or are dependent upon methamphetamine.
Characteristics of successful treatment are:
Recommendations for Methamphetamine Treatment Policy and Program Development
Treatment should include 3-5 clinic visits per week for at least 90 days (with continuing care for another 9 months).
Techniques and clinic practices that improve treatment retention are critical.
Contingency managementFamily involvementCall backs for missed appointmentsFood
Treatment content and approaches currently demonstrated effective with cocaine users are applicable to methamphetamine users – Cognitive Behavioral Therapy– Contingency Management– Community Reinforcement Approach– Motivational Interviewing– Matrix Model
Family Involvement and 12 Step Program involvement appear to improve outcomes.
Urine Testing (at least weekly is mandatory)
A Word About
Urine….
Some Considerations on the Use of Urinalysis
Used as a means of providing irrefutable evidence of sobriety
Negative test results (reflecting non-use) provide opportunities for celebration, therapeutic milestones, and contingency pay-outs
Positive test results provide opportunities for therapeutic intervention and relapse analysis
Thresholds and Time Lapses for Urine Detection of Various
Substances
Drug Abbrev. Threshold
Min Time
Max Time
Methamphetamine mAMP 1000 ng/ml
1-3 hr. 2-4 d
Cannabis THC 50 ng/ml 6-18 hr 10-30 d
Cocaine COC 300 ng/ml 1-4 hr 2-4 d
Ecstasy MDMA 500 ng/ml 1 hr 2-3 day
PCP PCP 25 ng/ml 5-7 hr 6-28 d
Comparison Shopping for Urine Testing
Large sample of online vendors from which to select
Decisions to make on the frequency of testing, number of substances to test for, whether using panel tests or integrated cups, and whether adulteration is to be tested
Comparison Shopping for Urine Testing
Costs of panel tests range from $1.76 (single panel) to $22.90 (10 panel)
Costs of integrated cups range from $7.33 (3 substances) to $24.50 (10 substances)
Costs of panel tests at local retailers range from $11.99 (single panel) to $29.99 (6 panel)…no single panel tests for meth available in retail
Some Best Practice Indicators for the Therapeutic Use of UrinalysisSampling schedule should be specified based
upon target substanceSample frequently, at least 2-3 times per weekEnsure collection of valid samples (dedicated
collection room, no personal belongings accompanying clients, consider use of staff monitors)
Sample assaying should be done onsite with results communicated to the client immediately
Used sample equipment and supplies are disposed of properly
Optimal candidates for outpatient treatment include:
• Non injection methamphetamineusers
• Those without chronic mental illness and those without significant psychiatric symptoms at admission
• Those who are using methamphetamine less than daily at admission
• Those under legal supervision (especially drug court)
• Older individuals (over 21)
• Those who are not disabled
• Those who have a stable living situation (without active drug users)
Special Population Considerations
Female methamphetamine users (higher rates of depression; very high rates of previous and present sexual and physical abuse; responsibilities for children)
Injection methamphetamine users (very high rates of psychiatric symptoms; severe withdrawal syndromes; high rates of hepatitis)
Methamphetamine users who take methamphetamine daily or in very high doses
Homeless, chronically mentally ill and/or individuals with high levels of psychiatric symptoms at admission
Individuals under the age of 21
Gay men (at very high risk for HIV and hepatitis)
Some Good Web Resources….
http://www.crystalmeth.org/ (CMA groups)http://www.nida.nih.gov/Infofacts/methamphetamine.html
(NIDA Fact Sheet on Meth)http://www.methamphetamine.org/ (Portal to the
CSAT Meth Treatment Project)http://www.nida.nih.gov/ResearchReports/Methamph/Methamph.html
(NIDA Research Report)http://www.matrixinstitute.org/ (Matrix Institute)http://www.uclaisap.org/ (UCLA – Integrated
Substance Abuse Programs)
Some Good Technical Resources…
• Contingency Management: Using Motivational Incentives to Improve Drug Abuse Treatment (available
Yale University Psychotherapy Development Center) • A Community Reinforcement Approach: Treating
Cocaine Addiction (available through NIDA)
• Matrix Model of Individualized Intensive Outpatient Stimulant Treatment: A 16 week Individualized Program for the Treatment of Stimulant Abuse and Dependence Disorders (available through Hazelden Press)
• TIP 33: Treatment for Stimulant Use Disorders (available through SAMHSA)