Methamphetamine South Dakota Day 2

Methamphetamine Treatment Contingency Management Matrix Model

Urines were collected under direct observation. Combined data from several pilot studies (Roll, Huber, et al., in press; Roll & Shoptaw, in press All studies provided vouchers with specified monetary values for the provision of urine samples which indicated no recent methamphetamine use. Urines were collected under direct observation. Vouchers could be exchanged for goods or services that were congruent with developing a drug free lifestyle

CTN 006 methamphetamine data (Roll, et al.,in prep.) Used the variable magnitude of reinforcement procedure developed by Petry. 113 methamphetamine abusing individuals were part of the larger trial. Received the chance to win prizes for the provision of stimulant negative urine samples.

Methamphetamine Outcomes from CTN 006

The CSAT Methamphetamine Treatment Project

The Matrix Model: It is many treatments in one Out-patient, office-based Easy to understand Structure, structure, structure Continuing attendance is important

Organizing Principles of Matrix Treatment Program components based on scientific literature promoting behavior change Program elements and schedule selected based on empirical support in literature and application

Organizing Principles of Matrix Treatment Program focus is on behavior change in the present, not on assumed underlying psychopathology Matrix treatment is a process of “coaching”, supporting, reinforcing and supporting positive behavior change

Organizing Principles of Matrix Treatment Non-confrontational, non-judgmental relationship between therapist and patient creates positive bond which promotes program participation. Positive reinforcement, incentives and contingencies used extensively to promote treatment engagement and retention.

Organizing Principles of Matrix Treatment Accurate, understandable scientific information used to educate patient and family members Cognitive behavioral strategies used to promote drug cessation and relapse prevention

Organizing Principles of Matrix Treatment Family therapy interventions used to engage families in recovery process Self help resources introduced and participation encouraged

Organizing Principles of Matrix Treatment Urine and breath/alcohol testing used to monitor drug/alcohol use and support abstinence. Social support activities provided to help maintain abstinence

How it looks in Practice Matrix Model of Outpatient Treatment How it looks in Practice

Matrix Model Putting It All Together

Project Structure: Study Sites Billings, MT Honolulu, HI San Mateo, CA (2) San Diego, CA Concord, CA Costa Mesa, CA Hayward, CA Coordinating Center UCLA Integrated Substance Abuse Programs Steering Committee Scientific Advisory Board Community Advisory Board

Baseline Demographics Participants Served (n) 1016 Age (mean) 32.8 years Education (mean) 12.2 years Methamphetamine Use (mean) 7.5 years Marijuana Use (mean) 7.2 years Alcohol Use (mean) 7.6 years

Gender Distribution of Participants

Ethnic Identification of Participants

Route of Methamphetamine Administration

Changes from Baseline to Treatment-end

Days of Methamphetamine Use in Past 30 (ASI) Possible is 0-30; tpaired=20.90; p-value<0.000 (highly sig.)

Beck Depression Inventory (BDI) Total Scores Possible is 0-63; tpaired=16.87; p-value<0.000 (highly sig.)

Positive Symptom Total (PST) from Brief Symptom Inventory (BSI) Possible is 0-53; tpaired=14.33; p-value<0.000 (highly sig.)

Mean Number of Weeks in Treatment

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

Figure 4. Percent completing treatment, by group

discharge, and 6-month follow-up, by treatment condition Figure 6. Participant self-report of MA use (number of days during the past 30) at enrollment, discharge, and 6-month follow-up, by treatment condition

Treatments for Stimulant-Use Disorders with Empirical Support Motivational Interviewing Cognitive-Behavioral Therapy (CBT) Community Reinforcement Approach Contingency Management Matrix Model

Motivational Interviewing Based upon Prochaska and DiClemente Stages of Change Theoretical Model Also referred to as Motivational Enhancement Therapy Applied with many substances, data primarily with alcoholics Major Publications/Studies: Miller and Rollnick, 1991; Project MATCH

Motivational Interviewing Basic Assumptions People change their thinking and behavior according to a series of stages Individuals may enter treatment at different “stages of change” It is possible to influence the natural change process with MI techniques MI can be used to engage individuals in longer term treatment and to promote specific behavior changes Confrontation of “denial” can be counterproductive and or harmful to some individuals

Motivational Interviewing Key Concepts Empathy and therapeutic alliance Give feedback and reframe Create dissonance Focus of discrepancy of expected and actual Reinforce change Roll with resistance

Motivational Interviewing Resources Miller and Rollnick 1991 NIAAA Project MATCH manual CSAT TIP on Motivational Techniques NIDA Tool Box

Substance Abuse Treatment 2004 The Increasing Role of Science Motivation Carrots and Sticks

One Way of Thinking Change is motivated by discomfort. The Stick Change is motivated by discomfort. If you can make people feel bad enough, they will change. People have to “hit bottom” to be ready Corollary: People don’t change because they haven’t suffered enough

Another Way of Thinking The Carrot People are ambivalent about change Constructive behavior change comes from connecting with something valued, cherished and important Intrinsic motivation for change comes out of an accepting, empowering, safe atmosphere where the painful present can be challenged People get stuck because of their ambivalence

Motivational Interviewing, 2nd Edition. Miller and Rollnick We can’t help wondering, why don’t people change? You would think: that having had a heart attack would be enough to persuade a man to quit smoking, change his diet, exercise more, and take his medication A needs assessment is a useful process to help a buprenorphine patient identify problem areas beyond the immediate drug addiction. Social issues: amount of drug and alcohol use in the social environment; unemployment; dependence on illegal sources of income; eligibility for public assistance; need for housing; legal problems.

Matrix Early Recovery Groups

Early Recovery Groups Scheduling and Calendars Triggers Questionnaires and Chart 12 Step Introduction Alcohol Issues Thoughts Emotions and Behaviors KISS (and other 12-step slogans)

Early Recovery Issues Engaging and Retaining TRIGGERS

Triggers and Cravings I.P. Pavlov (1849-1936) Slide 8 In 1904, I.P. Pavlov, a Russian scientist, received the Nobel Prize for a series of experiments he conducted on the physiology of digestion. These experiments were continued by some of his students and later came to be known as the principles of classical conditioning.

Triggers and Cravings Pavlov’s Dog: UCR 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: UCR

Triggers and Cravings Pavlov’s Dog: CR 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: CR

Early Recovery Issues Engaging and Retaining Trigger Thought Craving Use Slide 10 Environmental stimuli (external triggers) or emotional conditions (internal triggers) will often cause the recovering addict to think of using drugs and/or alcohol. For example, the patient runs into his old source of drugs at the market. Or, the patient gets into a fight with her husband, and immediately thinks of having a drink. Historically, she has always had a drink after fighting with her spouse. A single thought of drinking or using will typically pass through one’s mind in 30 to 90 seconds, allowing one to continue thinking about AODs. AOD use is often the beginning of the relapse process. This inflames the neurochemistry of the addiction and moves the brain into the craving stage. At this craving stage, it is very difficult, if not impossible, to stop the slide into drug or alcohol use. To the actively using addict/alcoholic or the substance abuser in early recover, the Trigger - Thought - Craving - Use sequence feels as if it happens simultaneously. You feel triggered, and you immediately want to use. Knowing this process can be very helpful to the recovering addict/alcoholic. The successful key in dealing with the process is to avoid it getting started. It is extremely important to stop the thought when it first begins and to prevent it from building into an overpowering craving. It is vitally important to do this as soon as you recognize the thoughts occurring. This can be accomplished by using a number of Thought Stopping techniques.

Early Recovery Issues Engaging and Retaining Trigger Thought Craving Use Slide 11 Another way to envision this process is to see the Trigger - Thought - Craving - Use sequence as moving along a steep downhill slide. The time to use Thought Stopping is right after one recognizes the first thought of using. The biological process, as shown by the small circle moving towards the man, is still relatively small. It is possible to stop this process when it is in the craving stage, but much more difficult. When in craving mode, the small circle is now enormous -- a huge mountain. The addict/alcoholic may truly not want to use and attempt to deflect the cravings, but more often than not, the cravings are so powerful that they roll over the addict/alcoholic propelling him/her to relapse.

MATRIX MODEL TREATMENT Triggers - Places Drug dealer’s home Bars and clubs Drug use neighborhoods Freeway offramps Worksite Street corners Slide 14 Places that are triggers.

MATRIX MODEL TREATMENT Triggers - Things Paraphernalia Sexually explicit magazines/movies Money/bank machines Music Movies/TV shows about alcohol and other drugs Secondary alcohol or other drug use Slide 15 Objects or things that are triggers.

MATRIX MODEL TREATMENT Triggers - Times Periods of idle time Periods of extended stress After work Payday/AFDC payment day Holidays Friday/Saturday night Birthdays/Anniversaries Slide 16 Periods of time that are triggers.

MATRIX MODEL TREATMENT Triggers - Emotional States  Anxiety  Fatigue  Anger  Boredom  Frustration  Adrenalized states  Sexual arousal  Sexual deprivation  Gradually building emotional states with no expected relief Slide 17 The reality for most addicts/alcoholics is that any emotional state, positive or negative, can be a trigger if it has been historically associated with drug or alcohol use.

THOUGHT STOPPING Trigger Thought Thought Stopping Continued Thoughts Use Cravings Slide 18 For the addict/alcoholic, the choice remains to continue thinking about drug and/or alcohol use, which can lead to cravings, and most probably, using again or to practice thought stopping, which prevents the thoughts from developing into an overpowering craving. Prevents the thought from developing into an overpowering craving Requires practice

Accepting Non-Judgmental Empowering Supportive Understanding Patient Elicited Collaborative Ambivalence Normal Facilitative Show video, elicit from audience what they see, discuss list of qualities from best mentor

MOTIVATIONAL INTERVIEWING Increase Motivation Decrease Resistance Increase retention Better outcomes

MATRIX MODEL TREATMENT STRUCTURE Treatment Program Activities Recreational/Leisure Activities 12-Step Meetings School Sports Being with Drug-free Friends Time Scheduling Exercise Work Family-related Events Church/Synagogue Island Building

MATRIX MODEL TREATMENT INFORMATION

MATRIX MODEL TREATMENT Information - What - Substance abuse - Sex and recovery and the brain - Relapse prevention issues - Triggers and cravings - Emotional readjustment - Stages of recovery - Medical effects - Relationships and recovery - Alcohol/marijuana

MATRIX MODEL TREATMENT Information - Why 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

Triggers and Cravings Human Brain Slide 11 In order to understand the reality of addiction and recovery, we must look at two important areas of the brain. In a healthy brain, the cerebral cortex, or outside portion of the brain, is responsible for rational thinking. It is the decision-maker, the on-board computer of the human being. Underneath the cortex there is a much older, more primitive part of the brain’s anatomy, the limbic system. It has also been called the reptilian brain or the mammalian brain. To a greater or lesser degree this lower part of the brain mediates all forms of addiction. It is where the pleasure regard system is located and where most, if not all, pro species and pro individual life mechanisms originate. Unlike the cortex it is not under conscious, or voluntary, control. The powerful effects of drugs and alcohol, on this and other parts of the brain, can lead to addictive use, therefore losing the normal, rational restraints on behavior. Accepting addiction as a neurobehavioral disorder is a step towards recovery.

Cognitive Process During Addiction Introductory Phase Relief From Depression Anxiety Loneliness Insomnia Euphoria Increased Status Increased Energy Increased Sexual/Social Confidence Increased Work Output Increased Thinking Ability May Be Illegal May Be Expensive Hangover/Feeling Ill May Miss Work AOD Slide 12 Alcohol and other drug (AOD) use is relatively infrequent during the Introductory Phase of the cognitive process of addiction. It may be limited to a few times a year, by chance or on special occasions. The positives of AOD use seem to outweigh the negatives.

Conditioning Process During Addiction Introductory 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 Obsessive Thinking Introductory Phase Sports Food School TV Girlfriend Hobbies Job AOD Family Exercise Parties Slide 14 During this Introductory Phase, AOD use is one small component of a person’s overall thought process.

Development of Craving Response Introductory Phase AOD Effects Entering Using Site Use of AODs  Heart/Pulse Rate  Respiration  Adrenaline  Energy  Taste Slide 15 Craving response is the combined experiences of AOD triggers activating the limbic system and the continuing AOD thoughts associated with these triggers. During this Introductory Phase, the limbic system is activated directly AODs, and depending upon whether the substance is a stimulant or a depressant, results in the increase or decrease of physiological arousal.

Cognitive Process During Addiction Maintenance Phase Vocational Disruption Relationship Concerns Financial Problems Beginnings of Physiological Dependence Depression Relief Confidence Boost Boredom Relief Sexual Enhancement Social Lubricant Slide 16 During the Maintenance Phase of the cognitive process during addiction, the frequency of AOD use increases, to perhaps, monthly or weekly. In terms of effects and negative consequences, the scales are beginning to lean more in the negative direction.

Maintenance Phase Conditioning Process During Addiction Strength of Conditioned Connection Triggers Parties Friday Nights Friends Concerts Alcohol “Good Times” Sexual Situations Responses Thoughts of AOD Eager Anticipation of AOD Use Mild Physiological Arousal Cravings Occur as Use Approaches Occasional Use Moderate Slide 17 Conditioning has begun. The people, places and things associated with AOD use have become triggers. Exposure to these triggers causes thoughts about AOD use. These thoughts originating in the brain are mild physiological reactions producing drives to find and use AODs.

Development of Obsessive Thinking Maintenance Phase AOD Food School TV Girlfriend Hobbies Job Family Exercise Parties Slide 18 Thoughts of AOD use begin to occur more frequently.

Development of Craving Response Physiological Response Maintenance Phase Entering Using Site Physiological Response Use of AODs AOD Effects  Heart  Breathing  Adrenaline Effects  Energy Taste  Heart  Blood Pressure  Energy Slide 19 A mild physiological arousal occurs in situations closely associated with AOD use. As the person encounters AOD triggers, the limbic system is activated and AOD cravings occur. When drugs and/or alcohol are finally ingested, a concurrent physiological state (arousal or quiescence in relation to the properties of the drug ingested) will usually occur.

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.

Disenchantment Phase Conditioning Process During Addiction Strength of Conditioned Connection Triggers Weekends All Friends Stress Boredom Anxiety After Work Loneliness Responses Continual Thoughts of AOD Strong Physiological Arousal Psychological Dependency Strong Cravings Frequent Use STRONG Slide 21 It is usually at this point that a person crosses the line into addiction. Despite the negative consequences of continued AOD use the addiction is evidenced by the loss of rational control. Triggers in this phase produce a powerful physiological response that drives the user to acquire and use AODs. The higher rational brain is observing that it makes to use anymore.

Development of Obsessive Thinking Disenchantment Phase AOD Food TV Girlfriend Job Family Parties Slide 22 During the Disenchantment Phase, the frequency of AOD thinking increases, which begins to crowd out thoughts of other aspects in life. AOD

Development of Craving Response Disenchantment Phase Thinking of Using Mild Physiological Response Entering Using Site  Heart Rate  Breathing Rate  Energy  Adrenaline Effects Powerful Physiological Response Use of AODs AOD Effects 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.  Heart Rate  Breathing Rate  Energy  Adrenaline Effects  Heart  Blood Pressure  Energy

Cognitive Process During Addiction Disaster Phase Relief From Fatigue Relief From Stress Relief From Depression Weight Loss Paranoia Loss of Family Seizures Severe Depression Unemployment Bankruptcy Slide 24 In the Disaster Phase, the AOD use is often robotic and automatic. There is no rational restraint upon the drug use; it makes no sense at all. The user’s behavior in the phase is much like the behavior of addicted laboratory animals that use drugs until they die.

Conditioning Process During Addiction Disaster Phase Strength of Conditioned Connection OVERPOWERING Triggers Any Emotion Day Night Work Non-Work Responses Obsessive Thoughts About AOD Powerful Autonomic Response Powerful Physiological Dependence Automatic Use Slide 25 Here the person is either using daily or in binges, which most likely will be interrupted by physical collapse, hospitalization, or arrest. The constant powerful craving from the limbic system and/or severe physiological dependency overwhelms the cortex.

Development of Obsessive Thinking Disaster Phase AOD Slide 26 Thoughts of AODs dominate the user’s consciousness.

Development of Craving Response Disaster Phase Thoughts of AOD Using Place Powerful Physiological Response  Heart Rate  Breathing Rate  Energy  Adrenaline Effects Slide 27 In the Disaster Phase, the craving can often be compared to actual AOD effects, and in some cases, these powerful effects may be the result of merely thinking about certain drugs.

Matrix Relapse Prevention Groups

Matrix Relapse Prevention Group Topics (Sample) Alcohol -The Legal Drug Boredom Avoiding Relapse Drift/Mooring Lines Guilt and Shame Motivation for Recovery Truthfulness Work and Recovery Staying Busy Relapse Prevention Dealing with Feelings

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

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 Irritability Abstinence Violation Protracted Abstinence

Other Components of the Matrix Model

Components Of The Matrix Model Family Education Lectures Conjoint Sessions Urine Testing Relapse Analysis Self help Initiation MATRIX