The Matrix Model Treatment Approach for Methamphetamine Dependence Michael J. McCann, MA Matrix Institute on Addictions Arlington, VA May 9, 2006

Overview Methamphetamine effects on the brain Treatment approaches in light of brain effects The Matrix Model treatment approach Does methamphetamine treatment work?

Meth Treatment is Challenging A Major Reason People Take a Drug is they Like What It Does to Their Brains

Natural Rewards Elevate Dopamine Levels 50 100 150 200 60 120 180 Time (min) % of Basal DA Output NAc shell Empty Box Feeding Source: Di Chiara et al. FOOD 100 150 200 DA Concentration (% Baseline) Mounts Intromissions Ejaculations 15 5 10 Copulation Frequency Sample Number 1 2 3 4 6 7 8 9 11 12 13 14 16 17 Scr Bas Female 1 Present Female 2 Present Source: Fiorino and Phillips SEX

Effects of Drugs on Dopamine Levels Source: Di Chiara and Imperato Effects of Drugs on Dopamine Levels 100 150 200 250 1 2 3 4 5hr Time After Morphine % of Basal Release Accumbens 0.5 1.0 2.5 10 Dose (mg/kg) MORPHINE 100 200 300 400 1 2 3 4 5 hr Time After Cocaine % of Basal Release DA DOPAC HVA Accumbens COCAINE 100 200 300 400 500 600 700 800 900 1000 1100 1 2 3 4 5 hr Time After Amphetamine % of Basal Release DA DOPAC HVA Accumbens AMPHETAMINE 100 150 200 250 1 2 3 hr Time After Nicotine % of Basal Release Accumbens Caudate NICOTINE

Meth Treatment is Challenging Prolonged Drug Use Changes the Brain In Fundamental and Long-Lasting Ways

Decreased dopamine transporter binding in METH users resembles that in Parkinson’s Disease patients If DAT is decreased in young METH users (almost to that observed in Parkinson’s Disease), and DAT decreases with age, may we see an increase in the number of Parkinsonian patients over time? Control Meth PD Avg. 3 yrs. abstinent Source: McCann U.D.. et al.,Journal of Neuroscience, 18, pp. 8417-8422, October 15, 1998.

“This is your Brain on Meth” Dr. Paul Thompson of UCLA; brain mapping study. Meth users in their 30s with 10 years of use. 11% loss in brain pleasure/reward center tissue. He described “a forest fire” of brain damage. Navigating through daily life and applying what is learned in treatment may be difficult (reminders, simplicity, redundancy)

Meth in the Brain

Methamphetamine: Neurochemical Mechanisms Enters dopamine vesicles Vesicles deplete themselves of dopamine

METH METH

METH METH

Meth Treatment is Challenging Prolonged meth use changes the brain Prolonged effects require appropriate treatment approaches

Effective Treatments for Methamphetamine Dependence

The Matrix Institute Established 1984 5 clinics in Southern California San Bernardino County 1985; >50% meth users

Some Core Elements of the Matrix Model

Elements of Effective Treatment with Methamphetamine Users Focus on the present; behavior vs feelings Structure: 3 X week meetings; 16 weeks Information on addiction and recovery Teach relapse prevention Urine testing Introduce and encourage self-help

Matrix Program Schedule (Sample) Monday Wednesday Friday Weeks 1-4 Early Recovery Skills Weeks 1-12 Family/Education Weeks 1-16 Relapse Prevention Weeks 13-16 Social Support Urine and breath alcohol tests once per week, weeks 1-16 Ten Individual/Conjoint sessions during 1st 16 weeks

Simple, redundant, & relevant information Classical conditioning and craving The brain and addiction

Information: Conditioning Slide 9 Pavlov would feed dogs and ring a bell at the same time. The dogs would see and smell the food which would then stimulate, or trigger, their lower brains ( the autonomic nervous systems) causing the dogs to produce saliva and secrete gastric fluids in anticipation of digestion. In a relatively short amount of time, Pavlov and his colleagues would ring the bell without the presence of food, and the dogs would still produce saliva and gastric fluid as if food were present. The dogs connected the sound of the bell, the trigger, with anticipation of eating, and responded involuntarily physically to the powerful trigger, or stimulus, of the bell. Once a dog has been conditioned in this way, no matter how smart or well-trained the dog is, a dog will continue to produce fluids at the sound of the bell. He has no choice. The human brain responds in exactly the same way to the conditioned drugs and alcohol triggers that produce cravings. Drugs and alcohol produce changes in the brain, which result in feelings of pleasure. When triggers cause a person to experience cravings, the brain responds as if the actual chemicals are taken into the system. In other words, the brain is “drooling” in reaction to these triggers. This reaction occurs whether or not the person intends to use. The only way that Pavlov’s dog can avoid drooling is by avoiding the bell. The chemically dependent person can also avoid his or her brain’s reaction by avoiding triggers. Pavlov’s Dog

Information: Conditioning Slide 9 Pavlov would feed dogs and ring a bell at the same time. The dogs would see and smell the food which would then stimulate, or trigger, their lower brains ( the autonomic nervous systems) causing the dogs to produce saliva and secrete gastric fluids in anticipation of digestion. In a relatively short amount of time, Pavlov and his colleagues would ring the bell without the presence of food, and the dogs would still produce saliva and gastric fluid as if food were present. The dogs connected the sound of the bell, the trigger, with anticipation of eating, and responded involuntarily physically to the powerful trigger, or stimulus, of the bell. Once a dog has been conditioned in this way, no matter how smart or well-trained the dog is, a dog will continue to produce fluids at the sound of the bell. He has no choice. The human brain responds in exactly the same way to the conditioned drugs and alcohol triggers that produce cravings. Drugs and alcohol produce changes in the brain, which result in feelings of pleasure. When triggers cause a person to experience cravings, the brain responds as if the actual chemicals are taken into the system. In other words, the brain is “drooling” in reaction to these triggers. This reaction occurs whether or not the person intends to use. The only way that Pavlov’s dog can avoid drooling is by avoiding the bell. The chemically dependent person can also avoid his or her brain’s reaction by avoiding triggers. Pavlov’s Dog

Conditioning Process During Addiction Social Phase Strength of Conditioned Connection Mild Triggers Parties Special Occasions Responses Pleasant Thoughts about AOD No Physiological Response Infrequent Use Slide 13 Unknowingly, the AOD user is conditioning his brain every time a dose of his/her drug of choice is ingested. There is no automatic limbic response associating people, places or times with AOD use.

Development of Craving Response Addiction Phase Thinking of Using Mild Physiological Response Entering Using Site  Heart Rate  Breathing Rate  Energy  Adrenaline Effects Powerful Physiological Response Use of AODs Slide 23 In this phase, the craving response is a powerful event. The person feels an overpowering physical reaction in situations further and further removed from the drugs themselves. The craving response is almost as powerful as the actual AOD’s physical reaction. AOD Effects  Heart Rate  Breathing Rate  Energy  Adrenaline Effects Heart Blood Pressure Energy

Cognitive Process During Addiction Disenchantment Phase Social Currency Occasional Euphoria Relief From Lethargy Relief From Stress Nose Bleeds Infections Relationship Disruption Family Distress Impending Job Loss Slide 20 During the Disenchantment Phase of the cognitive process of a developing addiction, the scales tip from the positive to the negative. The consequences of AOD use are severe and the user’s life begins to become unmanageable. At this point the cortical rational decision is to stop using, but the cortex is not in control any longer. Thinking, evaluating, and decision making appear to be happening, but behavior is contradictory. The user may sincerely resolve to quit using, and yet, may find himself out of control at the first thought of AODs, the first encounter with a fellow user, or at the availability of cash or other potent triggers.

Conditioning and the Brain: Message to Patients Will power, good intentions are not enough Behavior needs to change Insight will not affect cravings Deal with cravings: avoid triggers Deal with cravings: thought-stopping Scheduling

Treatment: Information & Persuasion DRUG ,,Slide 10 The part of the brain affected by mood-altering substances is the same part of the brain that makes us seek food when we are hungry, water when we are thirsty, and is responsible for sexual pleasure. It promotes our survival modes. When a person hasn’t eaten for a long period of time, the focus on getting food or water overpowers all other concerns. When long-term drugs or alcohol use occurs, the brain can become “short-circuited” and adapt to these chemicals as if survival depends on them. There is a demonstration, discussed in a lecture by the late Dr. Sidney Cohen that reflects the power of drugs on the brain and behavior. If you release a caged rodent and it has the option to run into a well-lit area or a dark area, it will always run into the dark. Mice and other small rodents have been conditioned to automatically seek out the dark, which will protect them from predators. This is a ingrained survival mechanism evolving over millions of years to this species. If the rodent is given doses of cocaine in the light,in a relatively short time, the next time the rodent is released, it will automatically go into the lit field. Thus reversing the conditioning that took place over millions of years. This demonstrates that the power of drugs has the ability to grossly distort normal mammalian brain chemistry.

Early Recovery Skills Group Drug cessation Identify triggers Get rid of paraphernalia Avoid triggers-schedule time Thought-stopping for cravings 12-step introduction

Matrix Model Key Component Information The Roadmap to Recovery

Information: Roadmap for Recovery Withdrawal Early Abstinence, Honeymoon Protracted Abstinence, the Wall Adjustment/Resolution Slide 2 Stages to be discussed: Withdrawal Early Abstinence/Honeymoon Protracted Abstinence/The Wall Adjustment/Resolution

Information: the Wall Protracted Abstinence: “The Wall” 45-120 days after last use

Partial Recovery of Brain from Methamphetamine After Abstinence 3 ml/gm Normal Control METH Abuser (1 month abstinent) METH Abuser (14 months abstinent) Source: Volkow, ND et al., Journal of Neuroscience 21, 9414-9418, 2001. Dopamine improvements after 1 year, but not cognitive and motor functioning

Return to Old Behaviors Protracted Abstinence Roadmap for Recovery THE WALL Return to Old Behaviors Anhedonia Anger Depression Emotional Swings Unclear Thinking Isolation Family Problems Slide 22 Protracted abstinence, or the Wall, is the “main event” of the recovery process. A. During the Wall, there is a shift back from the high of the Honeymoon phase to a point, not as low as Withdrawal, but still not “normal.” B. After abstaining for some time, it may not be obvious that there may be some feelings still related to the after-effects of drug and alcohol use. The person in recovery needs to be reminded that the Wall is temporary and that it is a sign of the brain “getting well.” C. A person in the Wall typically experiences a lack of energy and an emotional state ranging from apathy to depression. 1. It is important to continue the behavioral changes that have developed to this point. 2. A sequence of inertia, boredom, loss of recovery, focus, relapse justification, and finally relapse can be prevented. D. The addicted brain may begin to influence behavior, and using drugs and alcohol can seem to start making sense again. E. Things can be kept in check if treatment contact is continued. 1. Treatment termination is a threat during the Wall. 2. Preparation for these feelings during the Honeymoon period and constant encouragement during the Wall are critical to ensure treatment continuation. Cravings Return Abstinence Violation Protracted Abstinence

The Wall Treatment implications Message to patients Simple Redundant Frequent visits for an extended period Message to patients It takes a while for your brain to heal Don’t make mistakes explaining your feelings Be patient; Don’t give up

Relapse Prevention Groups Patients need to develop new behaviors Learn to monitor signs of vulnerability to relapse Recovery is more than not using D.O.C. Recovery is more than not using drugs and alcohol

Relapse Prevention Topics Overview of the concept; things don’t “just happen” Using Behavior Old behaviors need to change Re-emergence signals relapse risk (it’s a duck) Relapse Justification “Stinking thinking” Recognize and stop

Relapse Prevention Topics Dangerous Emotions Loneliness, anger, deprivation Be Smart, not Strong Avoid the dangerous people and places Don’t rely on will power Avoiding Relapse Drift Identify “mooring lines” Monitor drift

Relapse Prevention Topics Total Abstinence Other drug/alcohol use impedes recovery growth Development of new dependencies is possible Taking Care of Business Addiction is full-time Normal responsibilities often neglected Taking Care of Yourself Health, grooming New self-image

Relapse Analysis Session to be done when relapse occurs after a period of sobriety Functional analysis Continued drug use is better addressed with Early Recovery topics Relapse should be framed as learning experience for client

Relapse and Sex

My sexual drive is increased by the use of … (Rawson et al., 2002)

My sexual pleasure is enhanced by the use of … (Rawson et al., 2002)

My sexual performance is improved by the use of … (Rawson et al., 2002)

Other Components of the Matrix Model Family Education Lecture Conjoint Sessions Urine Testing Self Help Initiation

Matrix Model Urinalysis And Breath Testing Method for Monitoring Treatment Progress Treatment Accountability Assistance for Patient Reduces Arguments Provides Data for Family or Employer

The “5%” Myth Myth: Only 5% of meth users are successful in treatment Does treatment work? Fact: Some treatments work Evidence-based treatments Motivational Interviewing Contingency Management Cognitive/Behavioral Treatment (Matrix Model)

The “5%” Myth Wide dissemination may be self-fulfilling Communities won’t support treatment Funders won’t fund treatment Meth users won’t enter treatment Practitioners won’t expect treatment to work

Comparison of Meth and Cocaine Users Rawson et al Comparison of Meth and Cocaine Users Rawson et al., 2000, Journal of Psychoactive Drugs 500 methamphetamine users 224 cocaine users Matrix San Bernardino County Identical program and staff

Comparison of Meth and Cocaine Users Rawson et al Comparison of Meth and Cocaine Users Rawson et al., 2000, Journal of Psychoactive Drugs Identical treatment outcomes

Matrix Model vs TAU Rawson et al., 2004, Addiction 978 Methamphetamine users seeking treatment CSAT multi-site study; 1998-2002 Costa Mesa; San Diego; Hayward; Concord; San Mateo; Billings; Honolulu Matrix Model vs Treatment as Usual Random assignment

Baseline Demographics Age Male Education Meth use Marijuana use Alcohol use 32.8 years 55% 12.2 years 7.5 years 7.2 years 7.6 years

Route of Methamphetamine Use

Weeks in Treatment **

Weeks Continuous Abstinence **

Mean Number of UA’s that were MA-free during treatment Billings: Matrix produces a higher number of MA-free UA’s. t= -3.87 p=0.000 significant parametric Concord: Matrix produces a higher number of MA-free UA’s. t= -2.48, p=0.014 significant parametric CostaMesa: Matrix produces a higher number of MA-free UA’s. t=-2.81, p=0.005 significant parametric Honolulu: Matrix produces a higher number of MA-free UA’s. t= -4.14, p=0.000 significant parametric SanMateo, Pyramid: Matrix produces a higher number of MA-free UA’s. t= -2.21, p=0.029 significant parametric

Mean Number of Weeks in Treatment

Self-report of MA use during the past 30 days at baseline, discharge, and 6-month follow-up.

Urine Results: % Meth-free