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6th Annual Co-Occurring Disorders Conference

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1 6th Annual Co-Occurring Disorders Conference
Party and Play: The Drug-Sex Fusion and Methamphetamine Abuse Treatment Implications Thomas Freese, Ph.D. Sherry Larkins, Ph.D. Peter Theodore, Ph.D. 6th Annual Co-Occurring Disorders Conference Long Beach, CA.

2 Goals of Presentation Provide 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!!!

3 Addiction: 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.

4 Biopsychosocial Model: Biology of Addiction
Brain Chemistry (Neurotransmitters) Dopamine, Serotonin, Norepinephrine Brain Structures Amygdala/hippocamus (memory) Limbic System (pleasure) Prefrontal Cortex (reasoning and judgement)

5 Relative Impact on Dopamine Release
Time After Methamphetamine % Basal Release METHAMPHETAMINE 1 2 3hr 1500 1000 500 Accumbens 100 200 300 400 Time After Cocaine % of Basal Release DA DOPAC HVA Accumbens COCAINE 100 150 200 250 1 2 3 hr Time After Nicotine % of Basal Release Accumbens Caudate NICOTINE 100 150 200 250 1 2 3 4hr Time After Ethanol % of Basal Release 0.25 0.5 2.5 Accumbens Dose (g/kg ip) ETHANOL Source: Shoblock and Sullivan; Di Chiara and Imperato

6 Dopamine Surge: Pleasant Effects
Profound euphoria Enhanced mood Extreme pleasure Increased energy and productivity Focus on pleasurable activities like SEX!!!! Uninhibited sexual fantasies Increased confidence Sense of Invulnerability

7 Dopamine Depletion: Withdrawal
What Goes Up Must Come Down: Depression Lack of interest Lack of motivation Isolation Increased Risk for Suicidality

8 Amygdala/hippocampus
Prefrontal Cortex Limbic System Amygdala/hippocampus

9 Pharmacological Treatments
None clinically proven!!! Theoretical mechanism of action Increase function of the pre-frontal cortex re-establish inhibitory control, increase logic, analytical reasoning, reflective thinking Decrease function of limbic regions reduce cravings and impulsivity; extinction of conditioned cues Current Clinical Trials are investigating: Prometa Buproprion (Wellbutrin) Modafinil (Provigil) Baclofen (Lioresal)

10 Prometa for Methamphetamine
Not Clinically Proven Clinical trials underway Prescription Cocktail: Flumazenil (GABAA agonist) Gabapentin (restore 1 and 4 receptors) Both decrease depression, anxiety, compulsivity, siezures, and withdrawal sxs Hydroxyzyne (Atarex; sedative) Promotes sleep in the evening Ancecdotal Evidence: Fast acting to eliminate cravings Helps improve cognitive functioning Medically supervised/administered Adjunct to Psychosocial/Behavioral Counseling Treatment 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).

11 Buproprion Antidepressant
Inhibits reuptake of serotonin, norepinephrine, and dopamine Recent clinical trial (Elkashef, Rawson, Anderson, et al., 2006) 151 Meth Dependent patients treated with Buproprion and Behavioral Group Tx. Placebo-controlled Saw reductions in MA use with Buproprion among those with low/moderate dependence Associated 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.

12 Modafinil Nonamphetamine-type stimulant
May counter effects from MA withdrawal Depression and fatigue Has been shown to improve cognitive functioning and executive functioning Improves impulse control

13 Baclofen GABA-like medication
Indirectly acts as a dopamine agonist Double-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 improvement GABA itself did not yield a treatment effect.

14 Psychosocial Treatments
Four areas to address: Behavioral Disruption Cognitive Disruption Emotional Disruption Family/Relationship Disruption

15 Treatment Modalities: Increasing Structure and Intensity
Harm Reduction Non-treatment seeking meth users Individual Therapy/Counseling Weekly Support Groups Intensive Outpatient Programming (IOP) Often CBT based Residential Settings Often social model of recovery 12-Step Model may supplement all of the above

16 Harm Reduction Programs
Safety First Provide information to increase awareness of dangers associated with meth use and risky sexual practices Skills Building Teach techniques that minimize risk of health-related consequences from meth use and sexual risk Group Format is Common Van Ness Prevention Division (1419 N. La Brea) GUYS Group (MSM) Transaction (Transgender) AIDS Project Los Angeles AIDS Pacific AIDS Intervention Team Homeless Healthcare (needle exchange) Gay and Lesbian Center (drop in group; starting in June)

17 Harm Reduction

18 Harm Reduction: Informational Websites

19 Medical/Clinical Settings: Brief Intervention – 5 A’s
Ask Implement an office wide system for every MSM at every visit, meth-use status is queried and documented Advise In a clear, strong, and personalized manner, urge every meth user to quit Assess Ask every meth user if he is willing to make a quit attempt now (next 30 days) Assist Help the patient plan, provide practical counseling, recommend meds, be supportive Arrange Provide for follow-up support, phone calls Adapted from Fiore et al., 2000, Treating Tobacco Use and Dependence

20 Individual Counseling: Relapse Factors during Withdrawal
Unstructured time Proximity of triggers Alcohol/marijuana use Powerful cravings Paranoia Depression Disordered sleep patterns

21 Individual Counseling: Relapse Factors in Early Recovery
Sexual Behavior Dysfunction, abstinence, and loss of interest Lack of intensity, pleasure, satisfaction Shame/Guilt about sex Fears about intimacy and monogamy Sex triggers cravings Alcohol/Marijuana/Other Drugs Impaired Judgement Increased Craving → Relapse Drug Substitution Decreased motivation for recovery Interferes with new behaviors

22 General Counseling: Clinical Tips
Help Build Structure (Schedule Time) Meetings, treatment, school, work, volunteer, gym/exercise, athletics, religion/spirituality Common Mistakes Scheduling unrealistically Neglecting recreation Perfectionism Therapist or partner imposing schedule

23 General Counseling: Additional Clinical Tips
Provide Information e.g., stages of recovery, impact on the brain, medical effects, triggers and cravings, sex and relationship in recovery, relapse prevention issues How information helps: 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

24 Hitting The Wall: Working with Relapse
Intense emotions Interpersonal conflict Anhedonia/loss of motivation Insomnia/fatigue Behavioral drift (use of alcohol/other drugs) Paranoia Dissolution of structure Relapse Justifications The rational part of the brain attempts to provide a logical explanation for why it is okay to use one’s drug of choice Justifications gain power if not recognized and discussed

25 Hitting 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, isolation I 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.

26 Moving Beyond the Wall: Clinical Tips
Increase awareness of relapse justifications Educate about Relapse Analysis Educate about Drug Substitution Decisional Balance List pros and cons of drug use Play the tape through (think of consequences) Strengthen/rehearse coping skills e.g., thought stopping, stress management Expand social support Increase meetings and support groups develop new friendships

27 Later in Recovery: Clinical Tips
6 Month Syndrome Review progress Revise goals Surfacing of Deeper Issues Encourage additional mental health services in community as needed Expanding of social support network Re-defining Identity in a Sober World Relapse Prevention Emphasize Balance in Recovery Work, sleep, recreation, spirituality, relationships, 12-step and/or recovery- based groups

28 Weekly Support Groups Low intensity and unstructured in topic
Recovery-based focus Active users seeking treatment mixed with those in early recovery Open enrollment Community-based settings Gay and Lesbian Center (Mondays and Wednesdays, 7:00)-meth specific Being Alive (Mondays, 6:30)-meth specific GLC (Thursdays, 7:00)-all substances AIDS Project Los Angeles Hollywood Mental Health

29 Intensive Outpatient Programs (IOPs)
Built around a specific treatment model Greater intensity than support groups Meet multiple times per week Highly structured and focused Empirical basis and/or incorporate empirically derived techniques Cognitive behavioral basis Manualized content with handouts and visuals Some follow 12-step philosophy Some programs offer day treatment services.

30 Intensive Outpatient Programs: Level of Intensity Varies
Tarzana Treatment Center Behavioral Health Services The Matrix Institute Glendale Memorial Hospital Homeless Healthcare Alternatives (Gay and Bisexual Men) Friends La Brea (Gay and Bisexual Men) Adapted from Matrix Model

31 The Matrix Model (IOP) An integrated, empirically-based, manualized treatment program Model integrates treatment components from various modalities: cognitive-behavioral (CBT); motivational interviewing; relapse prevention and analysis; psychoeducation; family systems; 12-step

32 Matrix IOP Structure 16 Weeks of Structured Programming
Early Recovery Groups (Skill building) ENGAGING + LEARNING Relapse Prevention Groups (Skill building) Family Education and Counseling LEARNING 36 Weeks of Continuing Care Social Support Groups (Skill Rehearsal + Modeling) MAINTAINING

33 Matrix Treatment Components
Individual / Conjoint Family Sessions (3) Weeks 1, 5 or 6, and 16; 50 min Early Recovery Skills Groups (8) Weeks 1-4; twice weekly; 50 min Relapse Prevention Groups (32) Weeks 1-16; twice weekly; 90 min Family Education Groups (12) Weeks 1-12; once weekly; 90 min Continuing Care / Social Support Groups (36) Weeks 13-48; once weekly; 90 min 12-Step/Community Support (twice weekly) Urine Testing (weekly)

34 Matrix Weekly Structure

35 Matrix Structural Details
IOP groups are open-ended Clients may begin at any time Order of groups not important as topics are frequently repeated across groups IOP groups occur mainly on M/W/F 12-step groups and community-based support groups required on T/Th and Sat/Sun

36 Manualized Treatment Enhance training capabilities
Facilitate research to practice Reduce therapist differences Ensure uniform treatment delivery Worksheets, Pictures and Visual Cues Decrease burden related to cognitive impairment (short-term memory loss) Repetition of material across sessions and in various formats/structures Handouts increase comprehension of material

37 Individual/Family Sessions
Structure 1st half of session with individual client 2nd half of session includes family Goals of including primary support system when appropriate and possible: Address dysfunctional relationship/family dynamics to foster change in the client Increase awareness of how changes in the client impacts his/her family system Complements family education groups.

38 Early Recovery Skills Groups: Structure and Format
Small groups: Maximum of 10 clients Led by counselor and advanced client Advanced = at least 8 weeks abstinence Structured + Educational (NOT therapy) Structure and routine reduces “loss of control” Models need to builds structure in daily life Teaching set of skills enables and empowers clients to achieve abstinence

39 Early Recovery Groups: Sample Topics
Scheduling and Calendars External and Internal Triggers Common Challenges in Early Recovery Body Chemistry in Early Recovery 12 Step Introduction Alcohol Issues Thoughts Emotions and Behaviors

40 Relapse Prevention Groups: Structure and Format
Mondays and Fridays Address weekends as periods of high relapse potential Co-Facilitators Primary counselor: groups comprised of set of clients assigned to same individual counselor Advanced Client Clients learn from one another in a series of supportive, guided sessions Recognize signs of impending relapse Strengthen skills to redirect and avoid relapse triggers

41 Relapse Prevention Groups: Four Fundamental Messages
Relapse is not a random event Relapse is a process that follows predictable patterns The ability to identify “signs” of a relapse is crucial to relapse prevention If relapse occurs, conduct a “relapse analysis” Examine the precipitating thoughts, feelings, and behaviors

42 Relapse Prevention Groups: Sample Topics
Alcohol -The Legal Drug Boredom Guilt and Shame (Emotional Triggers) Trust Truthfulness Work and Recovery Sex and Recovery Staying Busy (Scheduling Time) Coping with Feelings and Depression Making New Friends

43 Relapse Prevention Groups: More Sample Topics
Anticipating and Preventing Relapse Relapse Justification Total Abstinence Taking Care of Yourself Be Smart; Not Strong Defining Spirituality Reducing Stress Managing Anger Compulsive Behaviors Repairing Relationships

44 Social Support Groups: “Continuing Care”
Learn social skills in the absence of drugs and alcohol Advanced clients strengthen recovery skills by serving as role models for clients earlier in recovery Discuss and explore issues that complicate recovery: patience, intimacy, isolation, rejection, work

45 Treatment Must Address the Meth/Sex Fusion

46 Methamphetamine 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).

47 Conditioned Response Frequent pairing of drug use and sexual risk behaviors creates strong conditioned associations between the two behaviors drugs become a trigger for sex sex becomes a trigger for drug use Drug use becomes a means of sexual expression for many MSM

48 Policy Model for Methamphetamine Use, HIV Prevalence and Interventions
Cost/Intensity Shoptaw 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. Treatment Prevention Shoptaw & Reback (2006). Journal of Urban Health, 83 (6),

49 Empirically Validated Treatments
Contingency Management (CM): Provide increasingly valuable reinforcers for consecutive urine samples clean of methamphetamine Cognitive Behavioral Therapy (CBT): Cognitive/Behavioral strategies for instilling abstinence and preventing relapse Gay-Specific Cognitive Behavioral Therapy (GCBT) : CBT that is culturally tailored to address gay-specific issues; emphasize HIV risk reduction Friends La Brea: Combines CM and GCBT to provide optimal treatment experience.



52 A Gay-specific Cognitive Behavioral Treatment
In addition to cognitive behavioral therapy, the gay-specific treatment intervention (GCBT) focuses on: Gay culture Gay identity Gay sex HIV Recreating a gay life independent from methamphetamine use

53 Cognitive Behavioral Treatment
A Gay-specific Cognitive Behavioral Treatment Standard CBT GCBT External Triggers: Sporting Events Gay Pride Festival Concerts Bathhouse Movies Halloween Relapse 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”

54 Treatment 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 isolation HIV status




58 Outcomes 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 weeks 2.1 weeks 7.2 weeks 3.5 weeks Unprotect 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:

59 Sexual Risk Reduced: UARI Past 30 Days
Shoptaw S, et al. Drug Alcohol Depend. 2005;78:

60 Residential Treatment Programs
Highly structured inpatient programs Daily individual and group counseling Food, housing, and mental health care Often follow a social model of recovery Several options: Tarzana Treatment Center Clare Foundation Redgate Memorial Hospital Cri-Help New Directions (Veterans) Substance Abuse Foundation (HIV+ clients) Alternatives (GLBT) Van Ness Recovery House (GLBT)

61 Final Thoughts Across Models
Keep it simple; One day at a time Short-term, realistic goals Avoid Depth Psychotherapy in Early Recovery Gaining insight vs. deeper emotional processing Strengthen coping skills prior to deeper processing Assess for competing, co-morbid diagnoses: Depression, anxiety disorders, psychosis, ADHD Relapse = Opportunity for growth; gaining data Cognitively reframe beliefs of “failure” Remain aware of multicultural and diversity issues race, ethnicity, religion, SES, education, acculturation, gender and sexual identity

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