Presentation on theme: "What is the evidence for time limiting addiction treatment?"— Presentation transcript:
What is the evidence for time limiting addiction treatment?
Survey of treatment literature on time limited treatment Few true randomized trials.. Different conclusions based on patient group (severity, comorbidy problems, type of substance) Implications for rebuilding a treatment system
1271 index admissions to publicly funded clinics (cocaine 64%, alcohol 44%, opioids 41%, marijuana 14%; 59% female, 87% AA) 3 year follow up (98% of those living, 35 died ) 47% attain 12 months of abstinence Mean time from first use to first treatment= 9 years Median time from first to last use = 27 years. Longer treatment career for males, those with earlier first use (esp <15), multiple treatment episodes, and mental distress.
None Moderate Severe Mild Intensity of behavior Level of problems Dependence Abuse Problems Likely intensity/ Duration of treatment Duration of treatment Should be proportional to severity, chronicity Of use and related problems
Response generally happens early More of a bad thing is rarely better. More of a good thing is probably better Its probably better to think about time to the targeted outcome (abstinence)
If the good thing is an effective empirically validated therapy. Brief therapies effective first line for lower severity individuals—Good evidence for alcohol Few well-done trials where a well-defined cohort is randomized to different lengths of an empirically validated therapy
653 treatment seeking individuals dependent on prescription opioids Adaptive treatment model: Phase 1: 2 week buprenorphine/naloxone stabilization + 2 week taper, 8 week follow up Successful patients (no opioid use at end of tratment) complete Unsuccessful patients enter Phase II. ▪ 12 weeks bup/nal, 4 week taper, 8 week follow-up
653 randomized 5% successful phase 1 50 % successful Phase 2 9% successful at final week follow-up
Buprenorphine, naltrexone, methadone etc. tend to be effective only while the individual is taking it Medications are opportunities to provide treatment and services to support sustained change Stepwise discontinuation with frequent monitoring.
CM very effective while contingencies in place Dropoff after contingencies stop But…..those who attain longer periods of abstinence better outcomes in follow-up Petry proposal-After care model, VI schedule of reinforcement up to 6 months. If missing or positive, frequency increases Likely to be less expensive and more acceptable to patients than standard aftercare
7 modules, ~1 hour each, high flexibility Highly user friendly, no text to read, linear navigation Based on NIDA CBT manual Multiple strategies for presenting skills Video examples of characters struggling real life situations Repeat movie with character using skills to change ‘ending’ Interactive exercises, quizzes Multiple examples of ‘homework’
Highly engaging-capture attention of substance users, retain them in treatment Deliver potent dose of evidence based cognitive and behavioral strategies- Focus on key generalizable skills Durability of effects-skills practice Modeling-demonstration of skills in realistic situations under stress Breadth of users-all drugs, balance of gender and ethnicity Security- NO identifying information or PHI
8 week randomized clinical trial Outpatient community treatment program Standard treatment (weekly individual + group therapy) (TAU) vs. CBT4CBT + TAU CBT4CBT offered in up to 2 weekly sessions 6 month follow-up Carroll et al., Am J Psychiatry, 2008
“All comers”: few restriction on participation, only require some drug use in past 30 days 43% female 45% African American, 12% Hispanic 23% employed 37% on probation/parole 59% primary cocaine problem, 18% alcohol, 16% opioids, 7% marijuana 79% users of more than one drug or alcohol
Figure 2: STROOP task: Comparison of Post- to Pretreatment, CBT4CBT versus TAU Stroop activity decreases from pre- to post- CBT4CBT but not TAU X-=21pFWE=.05 CBT Stroop Post > Pre TAU Stroop Post > Pre
Self help for less severe cases/treatment entry -Use until abstinent or treatment indicated Medication platforms (office based buprenorphine) Use until stabilized Outpatient care Endpoint-abstinence, demonstration of skills
SBIRT: Referral for treatment without following through Office based buprenorphine without assertive care Multiple admissions for the same ineffective treatment (detoxification only) Persisting in a treatment to which the patient has not responded. Discharging patients for being symptomatic
Assess -Severity -Comorbid problems -Resources Treat to criterion Objective, clinically meaningful outcome Increase intensity Add medication Add CM Add support Decrease intensity Taper Support monitor Re-assess Predetermined time Clear feedback on criterion Evaluation of mechanism