1. The Voice of Recovery: Effectively Treating Methamphetamine Users and their Families Michael S. Shafer, Ph.D.

2. Motivation for Treatment Why is it harder for a stimulant abuser to enter the treatment system?

3. 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?

4. 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?

5. 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.

6. Medical & Psychosocial Treatment Approaches for Various Commonly Abused Substances Drugs Sedatives Stimulants Opioids Alcohol Medical Treatment YesNo Psychosocial Treatment Yes

7. www.drugabuse.gov

8. Principles of Effective Treatment 1. No single treatment is appropriate for all 2. Treatment needs to be readily available 3. Effective treatment attends to the multiple needs of the individual 4. Treatment plans must be assessed and modified continually to meet changing needs 5. Remaining in treatment for an adequate period of time is critical for treatment effectiveness

9. 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

10. 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

11. MA Treatment Issues Acute MA Overdose Acute MA Psychosis MA Withdrawal Initiating MA Abstinence MA Relapse Prevention Protracted Cognitive Impairment and Symptoms of Paranoia

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

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

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

15. MA Withdrawal - Depression- Paranoia - Fatigue- Cognitive Impairment - Anxiety- Agitation - Anergia- Confusion Duration: 2 Days - 2 Weeks

16. 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

17. 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

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

19. Initiating MA Abstinence Key Elements of Treatment –Structure –Information in Understandable Form –Family Support –Positive Reinforcement –12-Step Participation

20. 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

21. 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

22. A Cognitive-Behavioral Approach: Treating Cocaine Addiction Kathleen M. Carroll, Ph.D. April 1998 Manual 1

23. Cognitive Behavioral Therapy The Essential Tasks Functional analyses of substance use Individualized training Coping with Craving Managing Using Thoughts Problemsolving Recognizing Seemingly Irrelevant Decisions Refusal Skills

24. Cognitive Behavioral Therapy The Essential Tasks (cont.) Examining substance use cognitions Identifying and debriefing past and future high-risk situations Encouraging and reviewing extra- session implementation of skills Practicing skills during sessions

25. Cognitive Behavioral Therapy 2 Critical Components Functional Analysis (Analyze) Skills Training (Act)

26. Cognitive Behavioral Therapy Functional Analysis Thoughts Circumstances Feelings Before and After Use

27. Cognitive Behavioral Therapy Skills Training Stopping Drug Thoughts Social Skills Avoiding High-Risk Situations Employment Issues For Present and for Future

28. Cognitive Behavioral Therapy Skills Training

29. Community Reinforcement Plus Vouchers Approach: Treating Cocaine Addiction Budney & Higgins April 1998 Manual 2

30. 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.

31. 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.

32. Core Program Components of CRA Behavioral Orientation Skills Instruction Sobriety Sampling Treatment Planning

33. 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

34. Skills Instruction Social/recreational skills Communication skills, including behavioral marital counseling Problem solving skills Employability skills Drink refusal skills, including duration training

35. Sobriety Sampling Behavioral Contracts Negotiated with Clients for Progressively Longer Periods of Sobriety Agnostic Medications (Disulfurim/Antabuse) Prescribed and Used with Monitors

36. 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

37. 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.

38. Incentives in Treatment of Cocaine Dependence Review of the Literature (Higgins 1996) 13 Studies 11 Studies Positive Treatment Effects 2 Studies No Significant Difference

39. MATRIX MODEL TREATMENT Behavioral DisruptionCognitive Disruption Emotional Disruption Family/Relationship Disruption Components of Stimulant Addiction Syndrome

40. 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

41. STAGES OF RECOVERY Withdrawal DAY 0 DAY 15 Honeymoon DAY 45 The Wall DAY 120 Resolution Adjustment DAY 180

42. Medical Problems Alcohol Withdrawal Depression Difficulty Concentrating Severe Cravings Contact with Stimuli Excessive Sleep Day 0 to Day 15 WITHDRAWAL STAGE

43. Primary Manifestation of Withdrawal Stage Behavioral Cognitive RelationshipEmotional BehavioralInconsistency Confusion, Inability to Concentrate Depression/Anxiety, Self-Doubt Mutual Hostility, Fear

44. 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

45. Ways to Create Structure Time scheduling Going to treatment Attending 12-step meetings Exercising Performing athletic activities Attending school Going to work Attending church

46. Pitfalls of Structure Scheduling unrealistically Neglecting recreation Being perfectionistic Therapist imposing schedule Spouse/parent imposing schedule

47. Unstructured time Proximity of triggers Alcohol/marijuana use Powerful cravings Withdrawal Stage: Relapse Factors Paranoia Depression Disordered sleep patterns

48. 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

49. Primary Manifestation of Honeymoon Stage Behavioral Cognitive RelationshipEmotional High energy, Unfocused behavior Inability to prioritize Overconfidence, Feeling cured Denial of addiction disorder

50. 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

51. 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

52. 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

53. Return to Old Behaviors Anhedonia Anger Depression Emotional Swings Unclear Thinking Isolation Family Problems Cravings Return Irritability Abstinence Violation

54. Primary Manifestation of the Wall Stage Behavioral Cognitive RelationshipEmotional Sluggish, Low Energy/Inertia Relapse Justification Depression, Anhedonia Irritability, Mutual Blaming, Impatience

55. 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

56. Relapse Factors: Sexual Behavior Shame/Guilt about sexual behavior Sexual behavior and intimacy Sobriety and monogamy

57. Relapse Factors: Alcohol/Marijuana Stimulant craving induction Pharmacologic coping method 12-Step philosophy conflict Abstinence violation effect Marijuana amotivational syndrome Interferes with new behaviors

58. 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

59. 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

60. Primary Manifestation of Adjustment Stage Behavioral Cognitive RelationshipEmotional Sloppiness Regarding Limits Drifting From Commitment to Recovery Experiencing Normal Emotions Surfacing of Long-Term Issues

61. 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

62. Evaluation of the Matrix Model Key findings from a recently completed CSAT-funded 8-site evaluation of the Matrix model

63. 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.

64. 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.

65. 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)

66. Participants in both treatment groups showed significant improvement in employment status, family relations, legal problems and psychiatric symptoms.

67. 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.

68. 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.

69. 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

70. Treatment should include 3-5 clinic visits per week for at least 90 days (with continuing care for another 9 months).

71. Techniques and clinic practices that improve treatment retention are critical. Contingency management Family involvement Call backs for missed appointments Food

72. 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

73. Family Involvement and 12 Step Program involvement appear to improve outcomes.

74. Urine Testing (at least weekly is mandatory)

75. A Word About Urine….

76. 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

77. Thresholds and Time Lapses for Urine Detection of Various Substances DrugAbbrev.Threshol d Min Time Max Time MethamphetaminemAMP1000 ng/ml 1-3 hr.2-4 d CannabisTHC50 ng/ml6-18 hr10-30 d CocaineCOC300 ng/ml1-4 hr2-4 d EcstasyMDMA500 ng/ml1 hr2-3 day PCP 25 ng/ml5-7 hr6-28 d

78. 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

79. 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

80. Some Best Practice Indicators for the Therapeutic Use of Urinalysis Sampling schedule should be specified based upon target substance Sample frequently, at least 2-3 times per week Ensure 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

81. Optimal candidates for outpatient treatment include: Non injection methamphetamine users 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)

82. 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)

83. Some Good Web Resources…. http://www.crystalmeth.org/http://www.crystalmeth.org/ (CMA groups) http://www.nida.nih.gov/Infofacts/methamphetamine.htmlhttp://www.nida.nih.gov/Infofacts/methamphetamine.html (NIDA Fact Sheet on Meth) http://www.methamphetamine.org/http://www.methamphetamine.org/ (Portal to the CSAT Meth Treatment Project) http://www.nida.nih.gov/ResearchReports/Methamp h/Methamph.htmlhttp://www.nida.nih.gov/ResearchReports/Methamp h/Methamph.html (NIDA Research Report) http://www.matrixinstitute.org/http://www.matrixinstitute.org/ (Matrix Institute) http://www.uclaisap.org/http://www.uclaisap.org/ (UCLA – Integrated Substance Abuse Programs)

84. 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)