Treatment of Methamphetamine Dependence: Does Treatment Work? Mary Lynn Brecht, Ph.D. Richard A. Rawson, Ph.D Semel Institute for Neuroscience and Human Behavior David Geffen School of Medicine University of California at Los Angeles Supported by: National Institute on Drug Abuse (NIDA) National Institute on Drug Abuse (NIDA) Pacific Southwest Technology Transfer Center (SAMHSA) Pacific Southwest Technology Transfer Center (SAMHSA) International Network of Treatment and Rehabilitation Resource Centres (UNODC)

U.S. Treatment Admissions for Primary Methamphetamine Abuse

Are Treatment Outcomes for Individuals with Methamphetamine Dependence Different than for Other Drug Dependencies?

Meth Treatment Effectiveness? A pervasive rumor has surfaced in many geographic areas with elevated MA problems:  MA users are virtually untreatable with negligible recovery rates.  Rates from 5% to less than 1% have been quoted in newspaper articles and reported in conferences.  Representatives for some commercial treatment concerns have suggested there are no effective treatments for methamphetamine dependence.

CA Treatment System Outcomes % Using in Past 30 Days by Type of Drug Based on 81,382 episodes of treatment Source: ISAP Evaluation of CalOMS, Rawson et al., 2008

% Completing Treatment-- CA SACPA Meth Users Source: Anglin et al., Criminal Justice Treatment Admissions, J. of Psychoactive Drugs, 2007

Do Methamphetamine Users Respond Differently to Treatment than Cocaine Users?

Comparability of Treatment Outcome: Cocaine vs Methamphetamine Alice Huber, Walter Ling and Richard Rawson * Cohorts of methamphetamine dependent patients (N=500) and cocaine dependent patients (N=224) treated with a standardized, outpatient treatment protocol (Matrix Model) at the same clinic site, by the same staff over the same time period, demonstrated very similar treatment response on virtually all treatment participation and outcome measures * Jnl of Addictive Diseases, 18, 1997, P

Differences between methamphetamine users and cocaine users in treatment Amy L. Copeland and James L. Sorensen* The two populations did not differ in treatment adherence, as measured by clinic attendance, drug-free urines, and successful completion of treatment. The two populations did not differ in treatment adherence, as measured by clinic attendance, drug-free urines, and successful completion of treatment. * Drug and Alcohol Dependence, Volume 62, March 2001, Pages 91-95

Treatment response by primary drug of abuse: Does methamphetamine make a difference? Bill Luchansky, Antoinette Krupski, and Kenneth Stark*  For both adults and youth, the results showed that across outcomes, there were few differences between MA users and users of other hard drugs, whereas there were consistent differences between MA users and users of alcohol and marijuana. Alcohol and marijuana users tended to have more positive outcomes than the other groups. * Journal of Substance Abuse Treatment Vol 32, 2007, Pages Journal of Substance Abuse Treatment Journal of Substance Abuse Treatment

Summary  Treatment outcome data indicate that psychosocial treatments used in community treatment programs produce comparable outcomes for methamphetamine dependent individuals and those with other forms of drug dependency

Treatments for Stimulant-use Disorders with Empirical Support  Cognitive-Behavioral Therapy (CBT)  Community Reinforcement Approach  Contingency Management  12 Step Facilitation All have empirical support for the treatment of cocaine dependence

Methamphetamine Treatment: Controlled Clinical Trials Cognitive Behavioral Therapy Contingency Management Matrix Model

CBT: Basic Assumptions  Emphasizes cognitive aspects of drug/alcohol use as learned behavior Role of cognitions in abstinence Role of cognitions in abstinence  “Treatment” is a teaching process, coaching and reinforcing; “therapist” is a teacher/coach  No assumption of underlying psychopathology  New, alternative behaviors must be established  Can be delivered in group or individual settings

Contingency Management  A technique employing the systematic delivery of positive reinforcement for desired behaviors. In the treatment of methamphetamine dependence, vouchers or prizes can be “earned” for submission of methamphetamine-free urine samples.

Cognitive Behavioral Therapy and Contingency Management for Stimulant Dependence  Participants Stimulant-dependent individuals (n = 171).  Intervention CM, CBT, or combined CM and CBT, 16-week treatment conditions. CM condition participants received vouchers for stimulant-free urine samples. CBT condition participants attended three 90-minute group sessions each week..  Results CM procedures produced better retention and lower rates of stimulant use during the study period Self-reported stimulant use was reduced from baseline levels at all follow-up points for all groups and urinalysis data did not differ between groups at follow-up. While CM produced robust evidence of efficacy during treatment application, CBT produced comparable longer-term outcomes. There was no evidence of an additive effect when the two treatments were combined. The response of cocaine and methamphetamine users appeared comparable.  Conclusions: This study suggests that CM is an efficacious treatment for reducing stimulant use and is superior during treatment to a CBT approach. CBT also reduces drug use from baseline levels and produces comparable outcomes on all measures at follow-up.  Rawson, RA et al. Addiction, Jan 2006

FIGURE 1. Program Retention by Group

FIGURE 2. Stimulant–free Urine Samples by Group

FIGURE 3. Self-Reported Stimulant Use

Contingency Management: An Evidence-Based Component of Methamphetamine Use Disorder Treatments* *Roll, J. Contingency management: an evidence based component of methamphetamine use disorder treatments. Addiction. 2007;102 (Suppl. 1):

Contingency Management for Treatment of Methamphetamine Dependence  Design: RTC  Method: 113 patients diagnosed with methamphetamine abuse or dependence were randomly assigned to receive either treatment as usual (TAU) or TAU plus contingency management.  Results indicate that both groups were retained in treatment for equivalent times but those in the combined group accrued more abstinence and were abstinent for a longer period of time. These results suggest that contingency management has promise as a component in methamphetamine use disorder treatment strategies. * Roll JM, Petry NM, Stitzer ML, et al: Contingency management for the treatment of methamphetamine use disorders. Am J Psychiatry 163(11): , 2006

Matrix Model  Is a manualized, 16-week, non-residential, psychosocial approach used for the treatment of drug dependence.  Manuals Can be downloaded at SAMHSA.gov  Designed to integrate several interventions into a comprehensive approach. Elements include: Individual counseling Individual counseling Cognitive behavioral therapy Cognitive behavioral therapy Motivational interviewing Motivational interviewing Positive reinforcement for behavior change Positive reinforcement for behavior change Family education groups Family education groups Urine testing Urine testing Participation in 12-step programs Participation in 12-step programs

Treatment Components of the Matrix Model Individual Sessions Early Recovery Groups Relapse Prevention Groups Family Education Group 12-Step Meetings Social Support Groups Relapse Analysis Urine Testing MATRIX

Rawson, R.A., Marinelli-Casey, P., Anglin, M.D., Dickow, A., Frazier, Y., Gallagher, C., Galloway, G.P., Herrell, J., Huber, A., McCann, M.J., Obert, J., Pennell, S., Reiber, C., Vandersloot, D., Zweben, J., and the Methamphetamine Treatment Project Corporate Authors. (2004). A multi-site comparison of psychosocial approaches for the treatment of methamphetamine dependence. Addiction, 99, The CSAT Methamphetamine Treatment Project A Multi-site Trial of a Manualized Psychosocial Protocol for the Treatment of Methamphetamine Dependence

Mean Number of Weeks in Treatment

Mean Number of UA’s that were MA-free during treatment

Urinalysis Results  Results of Ua Tests at Discharge, 6 months and 12 Months post admission ** Matrix GroupTAU GroupMatrix GroupTAU Group D/C: 66% MA-free 65% MA-free 6 Ms: 69% MA-free 67% MA-free 12 Ms: 59% MA-free 55% MA-free **Over 80% follow up rate in both groups at all points

Predictors of In-treatment Performance and Post-Treatment Outcomes in a Methamphetamine- Dependent Adults

Predictors of Long-Term Abstinence Predictors of no MA use at treatment discharge, and at the 6- and 12-mos follow-ups includes:  MA use of < 15 days at baseline,  Lifetime MA use of < 2 years  No previous drug abuse treatment  Providing 3 consecutive MA-free UAs during treatment

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