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

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

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

4. Natural Rewards Elevate Dopamine Levels50
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

5. 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

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

7. 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 , October 15, 1998.

9. “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)

10. Meth in the Brain

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

16. METH
METH

17. METH
METH

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

19. Effective Treatments for Methamphetamine Dependence

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

21. Some Core Elements of the Matrix Model

22. 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

23. 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

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

25. 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

26. 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

27. 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.

28. 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

29. 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.

30. 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

31. 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.

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

33. Matrix Model Key Component
Information
The Roadmap to Recovery

34. 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

35. Information: the Wall Protracted Abstinence: “The Wall”
days after last use

37. Partial Recovery of Brain from Methamphetamine After Abstinence3
ml/gm
Normal Control
METH Abuser
(1 month abstinent)
METH Abuser
(14 months abstinent)
Source: Volkow, ND et al., Journal of Neuroscience 21, , 2001.
Dopamine improvements after 1 year, but not cognitive and motor functioning

38. 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

39. 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

40. 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

41. 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

42. 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

43. 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

44. 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

45. Relapse and Sex

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

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

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

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

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

51. 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)

52. 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

53. 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

54. 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

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

56. 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

57. Route of Methamphetamine Use

58. Weeks in Treatment **

59. Weeks Continuous Abstinence**

60. Mean Number of UA’s that were MA-free during treatment
Billings: Matrix produces a higher number of MA-free UA’s.
t= 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

61. Mean Number of Weeks in Treatment

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

63. Urine Results: % Meth-free