Presentation on theme: "6th Annual Co-Occurring Disorders Conference"— Presentation transcript:
16th Annual Co-Occurring Disorders Conference Party and Play: The Drug-Sex Fusion and Methamphetamine Abuse Treatment ImplicationsThomas Freese, Ph.D.Sherry Larkins, Ph.D.Peter Theodore, Ph.D.6th Annual Co-Occurring Disorders ConferenceLong Beach, CA.
2Goals of PresentationProvide overview of disease and biopsychosocial models of addiction.Discuss methamphetamine abuse treatment options including harm reduction, individual therapy, support groups, intensive outpatient programming, and residential treatment.Provide HOPE and ENCOURAGEMENT!!!
3Addiction: Disease Model Substance use disorders are chronic, progressive, relapsing conditions that require comprehensive treatment.Disease label helps to reduce shame, guilt, and stigma associated with diagnosis.
4Biopsychosocial Model: Biology of Addiction Brain Chemistry (Neurotransmitters)Dopamine, Serotonin, NorepinephrineBrain StructuresAmygdala/hippocamus (memory)Limbic System (pleasure)Prefrontal Cortex (reasoning and judgement)
5Relative Impact on Dopamine Release Time After Methamphetamine% Basal ReleaseMETHAMPHETAMINE123hr15001000500Accumbens100200300400Time After Cocaine% of Basal ReleaseDADOPACHVAAccumbensCOCAINE100150200250123 hrTime After Nicotine% of Basal ReleaseAccumbensCaudateNICOTINE1001502002501234hrTime After Ethanol% of Basal Release0.250.52.5AccumbensDose (g/kg ip)ETHANOLSource: Shoblock and Sullivan; Di Chiara and Imperato
6Dopamine Surge: Pleasant Effects Profound euphoriaEnhanced moodExtreme pleasureIncreased energy and productivityFocus on pleasurable activities like SEX!!!!Uninhibited sexual fantasiesIncreased confidenceSense of Invulnerability
7Dopamine Depletion: Withdrawal What Goes Up Must Come Down:DepressionLack of interestLack of motivationIsolationIncreased Risk for Suicidality
9Pharmacological Treatments None clinically proven!!!Theoretical mechanism of actionIncrease function of the pre-frontal cortexre-establish inhibitory control, increase logic, analytical reasoning, reflective thinkingDecrease function of limbic regionsreduce cravings and impulsivity; extinction of conditioned cuesCurrent Clinical Trials are investigating:PrometaBuproprion (Wellbutrin)Modafinil (Provigil)Baclofen (Lioresal)
10Prometa for Methamphetamine Not Clinically ProvenClinical trials underwayPrescription Cocktail:Flumazenil (GABAA agonist)Gabapentin (restore 1 and 4 receptors)Both decrease depression, anxiety, compulsivity, siezures, and withdrawal sxsHydroxyzyne (Atarex; sedative)Promotes sleep in the eveningAncecdotal Evidence:Fast acting to eliminate cravingsHelps improve cognitive functioningMedically supervised/administeredAdjunct to Psychosocial/Behavioral CounselingTreatment Protocol: 1) Initial administration of prescription cocktail combined with nutritional supplements lasts 2 to 3 days in a medically supervised setting; 2) 3 weeks later, second administration of prescription cocktail on two consecutive days; 3) Professional individual and/or group counseling across treatment (approximately 1 month).
11Buproprion Antidepressant Inhibits reuptake of serotonin, norepinephrine, and dopamineRecent clinical trial (Elkashef, Rawson, Anderson, et al., 2006)151 Meth Dependent patients treated with Buproprion and Behavioral Group Tx.Placebo-controlledSaw reductions in MA use with Buproprion among those with low/moderate dependenceAssociated with fewer cravings for MA (Newton, Roach, De la Garza, et al., 2006)Elkashef, Rawson, Anderson et al. (2006): 6 community based clinics in 4 states (California, Hawaii, Iowa, Missouri). Trend level (p=0.09) reductions in MA use among those treated with buproprion, 150 mg twice daily; low/moderate use defined as <18 days in past 30 days.
12Modafinil Nonamphetamine-type stimulant May counter effects from MA withdrawalDepression and fatigueHas been shown to improve cognitive functioning and executive functioningImproves impulse control
13Baclofen GABA-like medication Indirectly acts as a dopamine agonistDouble-blind trial testing effects of baclofen, gabapentin, and placebo for MA abuse (Heinzerling, Shoptaw, Peck, et al., 2006)Those receiving Baclofen and who demonstrated strong adherence showed greater improvementGABA itself did not yield a treatment effect.
14Psychosocial Treatments Four areas to address:Behavioral DisruptionCognitive DisruptionEmotional DisruptionFamily/RelationshipDisruption
15Treatment Modalities: Increasing Structure and Intensity Harm ReductionNon-treatment seeking meth usersIndividual Therapy/CounselingWeekly Support GroupsIntensive Outpatient Programming (IOP)Often CBT basedResidential SettingsOften social model of recovery12-Step Model may supplement all of the above
16Harm Reduction Programs Safety FirstProvide information to increase awareness of dangers associated with meth use and risky sexual practicesSkills BuildingTeach techniques that minimize risk of health-related consequences from meth use and sexual riskGroup Format is CommonVan Ness Prevention Division (1419 N. La Brea)GUYS Group (MSM)Transaction (Transgender)AIDS Project Los AngelesAIDS Pacific AIDS Intervention TeamHomeless Healthcare (needle exchange)Gay and Lesbian Center (drop in group; starting in June)
19Medical/Clinical Settings: Brief Intervention – 5 A’s AskImplement an office wide system for every MSM at every visit, meth-use status is queried and documentedAdviseIn a clear, strong, and personalized manner, urge every meth user to quitAssessAsk every meth user if he is willing to make a quit attempt now (next 30 days)AssistHelp the patient plan, provide practical counseling, recommend meds, be supportiveArrangeProvide for follow-up support, phone callsAdapted from Fiore et al., 2000, Treating Tobacco Use and Dependence
20Individual Counseling: Relapse Factors during Withdrawal Unstructured timeProximity of triggersAlcohol/marijuana usePowerful cravingsParanoiaDepressionDisordered sleep patterns
21Individual Counseling: Relapse Factors in Early Recovery Sexual BehaviorDysfunction, abstinence, and loss of interestLack of intensity, pleasure, satisfactionShame/Guilt about sexFears about intimacy and monogamySex triggers cravingsAlcohol/Marijuana/Other DrugsImpaired JudgementIncreased Craving → RelapseDrug SubstitutionDecreased motivation for recoveryInterferes with new behaviors
23General Counseling: Additional Clinical Tips Provide Informatione.g., stages of recovery, impact on the brain, medical effects, triggers and cravings, sex and relationship in recovery, relapse prevention issuesHow information helps:Reduces confusion and guiltExplains addict behaviorGives a roadmap for recoveryClarifies alcohol/marijuana issueAids acceptance of addictionGives hope/realistic perspective for family
24Hitting The Wall: Working with Relapse Intense emotionsInterpersonal conflictAnhedonia/loss of motivationInsomnia/fatigueBehavioral drift (use of alcohol/other drugs)ParanoiaDissolution of structureRelapse JustificationsThe rational part of the brain attempts to provide a logical explanation for why it is okay to use one’s drug of choiceJustifications gain power if not recognized and discussed
25Hitting The Wall: Relapse Justifications Common examples:My friend gave it to me.I needed it for a specific purpose.weight, energy, productivity, boredom, sex, depression, anxiety, loneliness, isolationI wanted to test myself.I already screwed up. Might as well continue.It wasn’t my fault. It’s all around me.I found some by mistake. Forgot I had it.
26Moving Beyond the Wall: Clinical Tips Increase awareness of relapse justificationsEducate about Relapse AnalysisEducate about Drug SubstitutionDecisional BalanceList pros and cons of drug usePlay the tape through (think of consequences)Strengthen/rehearse coping skillse.g., thought stopping, stress managementExpand social supportIncrease meetings and support groupsdevelop new friendships
27Later in Recovery: Clinical Tips 6 Month SyndromeReview progressRevise goalsSurfacing of Deeper IssuesEncourage additional mental health services in community as neededExpanding of social support networkRe-defining Identity in a Sober WorldRelapse PreventionEmphasize Balance in RecoveryWork, sleep, recreation, spirituality, relationships, 12-step and/or recovery- based groups
28Weekly Support Groups Low intensity and unstructured in topic Recovery-based focusActive users seeking treatment mixed with those in early recoveryOpen enrollmentCommunity-based settingsGay and Lesbian Center(Mondays and Wednesdays, 7:00)-meth specificBeing Alive (Mondays, 6:30)-meth specificGLC (Thursdays, 7:00)-all substancesAIDS Project Los AngelesHollywood Mental Health
29Intensive Outpatient Programs (IOPs) Built around a specific treatment modelGreater intensity than support groupsMeet multiple times per weekHighly structured and focusedEmpirical basis and/or incorporate empirically derived techniquesCognitive behavioral basisManualized content with handouts and visualsSome follow 12-step philosophySome programs offer day treatment services.
30Intensive Outpatient Programs: Level of Intensity Varies Tarzana Treatment CenterBehavioral Health ServicesThe Matrix InstituteGlendale Memorial HospitalHomeless HealthcareAlternatives (Gay and Bisexual Men)Friends La Brea (Gay and Bisexual Men)Adapted from Matrix Model
31The Matrix Model (IOP)An integrated, empirically-based, manualized treatment programModel integrates treatment components from various modalities:cognitive-behavioral (CBT); motivational interviewing; relapse prevention and analysis; psychoeducation; family systems; 12-step
32Matrix IOP Structure 16 Weeks of Structured Programming Early Recovery Groups (Skill building)ENGAGING + LEARNINGRelapse Prevention Groups (Skill building)Family Education and CounselingLEARNING36 Weeks of Continuing CareSocial Support Groups (Skill Rehearsal + Modeling)MAINTAINING
33Matrix Treatment Components Individual / Conjoint Family Sessions (3)Weeks 1, 5 or 6, and 16; 50 minEarly Recovery Skills Groups (8)Weeks 1-4; twice weekly; 50 minRelapse Prevention Groups (32)Weeks 1-16; twice weekly; 90 minFamily Education Groups (12)Weeks 1-12; once weekly; 90 minContinuing Care / Social Support Groups (36)Weeks 13-48; once weekly; 90 min12-Step/Community Support (twice weekly)Urine Testing (weekly)
35Matrix Structural Details IOP groups are open-endedClients may begin at any timeOrder of groups not important as topics are frequently repeated across groupsIOP groups occur mainly on M/W/F12-step groups and community-based support groups required on T/Th and Sat/Sun
36Manualized Treatment Enhance training capabilities Facilitate research to practiceReduce therapist differencesEnsure uniform treatment deliveryWorksheets, Pictures and Visual CuesDecrease burden related to cognitive impairment (short-term memory loss)Repetition of material across sessions and in various formats/structuresHandouts increase comprehension of material
37Individual/Family Sessions Structure1st half of session with individual client2nd half of session includes familyGoals of including primary support system when appropriate and possible:Address dysfunctional relationship/family dynamics to foster change in the clientIncrease awareness of how changes in the client impacts his/her family systemComplements family education groups.
38Early Recovery Skills Groups: Structure and Format Small groups: Maximum of 10 clientsLed by counselor and advanced clientAdvanced = at least 8 weeks abstinenceStructured + Educational (NOT therapy)Structure and routine reduces “loss of control”Models need to builds structure in daily lifeTeaching set of skills enables and empowers clients to achieve abstinence
39Early Recovery Groups: Sample Topics Scheduling and CalendarsExternal and Internal TriggersCommon Challenges in Early RecoveryBody Chemistry in Early Recovery12 Step IntroductionAlcohol IssuesThoughts Emotions and Behaviors
40Relapse Prevention Groups: Structure and Format Mondays and FridaysAddress weekends as periods of high relapse potentialCo-FacilitatorsPrimary counselor: groups comprised of set of clients assigned to same individual counselorAdvanced ClientClients learn from one another in a series of supportive, guided sessionsRecognize signs of impending relapseStrengthen skills to redirect and avoid relapse triggers
41Relapse Prevention Groups: Four Fundamental Messages Relapse is not a random eventRelapse is a process that follows predictable patternsThe ability to identify “signs” of a relapse is crucial to relapse preventionIf relapse occurs, conduct a “relapse analysis”Examine the precipitating thoughts, feelings, and behaviors
42Relapse Prevention Groups: Sample Topics Alcohol -The Legal DrugBoredomGuilt and Shame (Emotional Triggers)TrustTruthfulnessWork and RecoverySex and RecoveryStaying Busy (Scheduling Time)Coping with Feelings and DepressionMaking New Friends
43Relapse Prevention Groups: More Sample Topics Anticipating and Preventing RelapseRelapse JustificationTotal AbstinenceTaking Care of YourselfBe Smart; Not StrongDefining SpiritualityReducing StressManaging AngerCompulsive BehaviorsRepairing Relationships
44Social Support Groups: “Continuing Care” Learn social skills in the absence of drugs and alcoholAdvanced clients strengthen recovery skills by serving as role models for clients earlier in recoveryDiscuss and explore issues that complicate recovery:patience, intimacy, isolation, rejection, work
46Methamphetamine and Sexual Risk Strong connection between MA use, sexual risk behaviors, and prevalence of HIV in MSM (Shoptaw et al., 2005; Reback, 1997).MSM in Pacific Northwest who reported recent UAI were 4 times more likely to have used MA before or during sex than those reporting no UAI (Hirshfield et al., 2004)56% of MSM surveyed in 4 U.S. cities who reported MA use in past 6 months also reported UAI (CDC, 2001).
47Conditioned ResponseFrequent pairing of drug use and sexual risk behaviors creates strong conditioned associations between the two behaviorsdrugs become a trigger for sexsex becomes a trigger for drug useDrug use becomes a means of sexual expression for many MSM
48Policy Model for Methamphetamine Use, HIV Prevalence and Interventions Cost/IntensityShoptaw S, Reback CJ. Associations between methamphetamine use and HIV among men who have sex with men: A model for guiding public policy. Journal of Urban Health. 2006; 83(6):Among GBM there is a time to infection association between extent of meth use (both in length of time and number of episodes); In occasional users in Hollywood contacted via street outreach (1st bar – Reback’s work), Dr. Cathy Reback finds a stable association of about 25% HIV prevalence for those who mention meth use in the previous 30 days; In chronic users (2nd bar – Reback’s 1997 ethnography), men who use on average about once per month but are not yet having devastation from their use and are not seeking treatment report about 40% HIV prevalence; In outpatient treatment settings (3rd bar – Shoptaw and Reback) it’s 61% and in residential treatment settings for GLBT methamphetamine abusers, HIV positive rate is 86% in Interventions that target broad portions of the gay/bi community, including the meth users are cheap, hit large numbers of people, but are designed for helping prevent new users or helping to prevent one-time users from becoming regular users.. Interventions on the right (treatment) are expensive, target a small group, and demand substantial behavior change. Both aspects are needed.TreatmentPreventionShoptaw & Reback (2006). Journal of Urban Health, 83 (6),
49Empirically Validated Treatments Contingency Management (CM):Provide increasingly valuable reinforcers for consecutive urine samples clean of methamphetamineCognitive Behavioral Therapy (CBT):Cognitive/Behavioral strategies for instilling abstinence and preventing relapseGay-Specific Cognitive Behavioral Therapy (GCBT) :CBT that is culturally tailored to address gay-specific issues; emphasize HIV risk reductionFriends La Brea:Combines CM and GCBT to provide optimal treatment experience.
52A Gay-specific Cognitive Behavioral Treatment In addition to cognitive behavioral therapy, the gay-specific treatment intervention (GCBT) focuses on:Gay cultureGay identityGay sexHIVRecreating a gay life independent from methamphetamine use
53Cognitive Behavioral Treatment A Gay-specificCognitive Behavioral TreatmentStandard CBT GCBTExternal Triggers: Sporting Events Gay Pride Festival Concerts Bathhouse Movies HalloweenRelapse Justification: “I just got injured. “My friend just died [of I might as well use.” AIDS] and using will make me forget.”One Day at a Time: “Tomorrow something “I seroconverted even will happen to ruin though I knew about this.” safer sex.”Specific Topics:] Coming Out All Over Again: Reconstructing Your Identity] Drugs, Sex, and Euphoric Recall] Preventing Relapse to High-risk Sex] Living in an HIV World] Several session that involve “Aunt Tina”
54Treatment Issues: Focus on Sexuality Many gay and bisexual men need assistance in redefining/rediscovering their sexuality.Issues to explore include:sexual identity, internalized homophobia, self-esteem, shame, guilt, and social isolationHIV status
58Outcomes by Condition ** p<.01 *** p<.001 CM (n=42) CBT (n=40) CM+CBT (n=40)GCBT (n=40)% Completers**59%40%74%62%Consecutive Negative Urines in weeks**5.2 weeks2.1 weeks7.2 weeks3.5 weeksUnprotect rec anal intercourse at termination (times in 30 days)***1.1 (3.1)2.0 (5.5)2.2 (4.0)0.5 (1.9)Shoptaw S, et al. Drug Alcohol Depend. 2005;78:
59Sexual Risk Reduced: UARI Past 30 Days Shoptaw S, et al. Drug Alcohol Depend. 2005;78:
60Residential Treatment Programs Highly structured inpatient programsDaily individual and group counselingFood, housing, and mental health careOften follow a social model of recoverySeveral options:Tarzana Treatment CenterClare FoundationRedgate Memorial HospitalCri-HelpNew Directions (Veterans)Substance Abuse Foundation (HIV+ clients)Alternatives (GLBT)Van Ness Recovery House (GLBT)
61Final Thoughts Across Models Keep it simple; One day at a timeShort-term, realistic goalsAvoid Depth Psychotherapy in Early RecoveryGaining insight vs. deeper emotional processingStrengthen coping skills prior to deeper processingAssess for competing, co-morbid diagnoses:Depression, anxiety disorders, psychosis, ADHDRelapse = Opportunity for growth; gaining dataCognitively reframe beliefs of “failure”Remain aware of multicultural and diversity issuesrace, ethnicity, religion, SES, education, acculturation, gender and sexual identity