1. Treatments for Methamphetamine- Related Disorders Richard A. Rawson, Ph.D, Professor Integrated Substance Abuse Programs Semel Institute for Neuroscience and Human Behavior David Geffen School of Medicine University of California at Los Angeles www.uclaisap.org rrawson@mednet.ucla.edu 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) United Nations Office of Drugs and Crime United Nations Office of Drugs and Crime

2. 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. 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. Rates from 5% to less than 1% have been quoted in newspaper articles and reported in conferences. **The resulting conclusion is that spending money on treating MA users is futile and wasteful, BUT no data exists that supports these statistics**

3. Meth Treatment Statistics During the 2002-2003 fiscal year: 35,947 individuals were admitted to treatment in California under the Substance Abuse and Crime Prevention Act funding. Of this group, 53% reported MA as their primary drug problem

4. Statistics A comparison of treatment outcomes between individuals diagnosed with methamphetamine dependence and all other diagnostic groups indicated no between group significant differences in any treatment outcome measures including: Retention in treatment rates Urinalysis data during treatment Rates of treatment program completion. All these measures indicate that MA users respond in an equivalent manner as individuals admitted for other drug abuse problems.

5. Comparability of Treatment Outcome: Cocaine vs Methamphetamine Huber, Ling and Rawson (Jnl of Addictive Diseases, 1997). 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

6. MA Users (n = 500) Cocaine Users (n = 224) Early Recovery Group + 3.4(4.4)3.7(3.3) Relapse Prevention Group + 23.7(29.0)21.0(26.8) Family Education Group + 11.6(14.0)12.2(12.8) Social Support Group + 4.4(14.9)4.3(18.2) Total of Treatment Hours Received + 52.9(51.4) 54.5(49.3) Weeks in Treatment + 17.1(22.3)18.0(21.3) Urine Sample Collected + 8.3(8.0)8.1(7.6) Percentage of Samples Positive for Primary Drug ++ 19.3% 13.3% Table 3. Treatment Experience to Methamphetamine and Cocaine Users { Treatment Received in Number of Hours } + Numbers presented are means and (standard deviations) ++ Numbers presented are percentages

8. Why the “MA treatment doesn’t work” perceptions? Many of the geographic regions impacted by MA do not have extensive treatment systems for severe drug dependence. Medical and psychiatric aspects of MA dependence exceeds program capabilities. High rate of use by women, their treatment needs and the needs of their children can be daunting. Although some traditional elements may be appropriate, many staff report feeling unprepared to address many of the clinical challenges presented by these patients

9. CSAT Tip #33 A useful resource that presents a review of the existing knowledge about treatment effectiveness with stimulant users. A useful resource that presents a review of the existing knowledge about treatment effectiveness with stimulant users.

10. Medications Currently, there are no medications that can quickly and safely reverse life threatening MA overdose. There are no medications that can reliably reduce paranoia and psychotic symptoms, that contribute to episodes of dangerous and violent behavior associated with MA use.

11. Medications considered for Meth Negative ResultsUnder Consideration ImipramineBupropion DesipramineModafinil TyrosineTopirimate OndansetronDisulfiram FluoxetineLobeline GabapentinAripiprazole

12. Bupropion: An efficacious pharmacotherapy? Newton et al 2005 Bupropion reduces craving and reinforcing effects of meth Elkashef (recently completed) Bupropion reduces meth use in an outpatient trial, with particularly strong effect with less severe users.

13. Treatments for Stimulant-use Disorders with Empirical Support Cognitive-Behavioral Therapy (CBT) Motivational Interviewing Community Reinforcement Approach Contingency Management 12 Step Facilitation All have demonstrated efficacy for the treatment of cocaine dependence

14. Cognitive Behavioral Therapy Key Concepts –Encouraging and reinforcing behavior change –Recognizing and avoiding high risk settings –Behavioral planning (scheduling) –Coping skills –Conditioned “triggers” –Understanding and dealing with craving –Abstinence violation effect –Understanding basic psychopharmacology principles –Self-efficacy

15. 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

17. Methamphetamine Treatment: Controlled Clinical Trials Brief Cognitive Behavioral Therapy Extended Cognitive Behavioral Therapy Contingency Management Matrix Model

18. Cognitive Behavioral Therapy and Contingency Management for Stimulant Dependence Design Randomized clinical trial. 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. CM procedures produced better retention and lower rates of stimulant use during the study period. Results 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. CM is useful in engaging substance abusers, retaining them in treatment, and helping them achieve abstinence from stimulant use. 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

19. FIGURE 2. Stimulant–free Urine Samples by Group

20. FIGURE 3. Self-Reported Stimulant Use

21. 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. Contingency Management for the Treatment of Methamphetamine Use Disorders. Roll, JM et al, Archives of General Psychiatry, (In Press)

22. 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.

23. Methamphetamine Outcomes from CTN 006

24. Roll, et al., American Journal of Psychiatry, In Press CM + TAU TAU

25. Conclusions CM appears to increase the abstinence rates when combined with psychosocial treatments Suggests CM should be an integral part of methamphetamine use disorder treatment modalities

26. Contingency Management: A Meta-analysis A recent meta-analysis reports that CM results in a successful treatment episode 61% of the time while other treatments with which it has been compared result in a successful treatment episode 39% of the time (Prendergast, Podus, Finney, Greenwell & Roll, submitted)

27. Matrix Model Most extensively evaluated approach for the treatment of MA dependence. Incorporates a set of treatment elements which have empirical support, including behavioral strategies, cognitive behavioral strategies, motivational interviewing, positive reinforcement, psycho-education, 12 Step participation, family involvement

28. Matrix Model of Outpatient Treatment Organizing Principles of Matrix Treatment  Program components based upon scientific literature on promotion of behavior change.  Program elements and schedule selected based on empirical support in literature and application.  Program focus is on current behavior change in the present and not underlying “causes” or presumed “psychopathology”.  Matrix “treatment” is a process of “coaching”, educating, supporting and reinforcing positive behavior change.

29. Matrix Model of Outpatient Treatment Organizing Principles of Matrix Treatment  Non-judgmental, non-confrontational relationship between therapist and patient creates positive bond which promotes program participation.  Therapist as a “coach”  Positive reinforcement used extensively to promote treatment engagement and retention.  Verbal praise, group support and encouragement other incentives and reinforcers.

30. Matrix Model of Outpatient Treatment Organizing Principles of Matrix Treatment  Accurate, understandable, scientific information used to educate patient and family members  Effects of drugs and alcohol  Addiction as a “brain disease”  Critical issues in “recovering” from addiction

31. Matrix Model of Outpatient Treatment Organizing Principles of Matrix Treatment  Behavioral strategies used to promote cessation of drug use and behavior change  Scheduling time to create “structure”  Educating and reinforcing abstinence from all drugs and alcohol  Promoting and reinforcing participation in non- drug-related activities

32. Matrix Model of Outpatient Treatment Organizing Principles of Matrix Treatment  Cognitive-Behavioral strategies used to promote cessation of drug use and prevention of relapse.  Teaching the avoidance of “high risk” situations  Educating about “triggers” and “craving”  Training in “thought stopping” technique  Teaching about the “abstinence violation effect”  Reinforcing application of principles with verbal praise by therapist and peers

33. Matrix Model of Outpatient Treatment Organizing Principles of Matrix Treatment  Involvement of family members to support recovery.  Encourage participation in self-help meetings  Urine testing to monitor drug use and reinforce abstinence  Social support activities to maintain abstinence

34. The Matrix Model MondayWednesdayFriday Early Recovery Skills Weeks1-4Family/education Weeks 1-12 Early Recovery Skills Weeks1-4 Relapse Prevention Weeks 1-16 Social Support Weeks 13-16 Relapse Prevention Weeks 1-16  Urine or breath alcohol tests once per week, weeks 1-16

35. Richard Rawson Ph.D. U.C.L.A. Integrated Substance Abuse Programs (I.S.A.P.) The MTP Site Investigators Funded by the Center for Substance Abuse Treatment The CSAT Methamphetamine Treatment Project A Multi-site Trial of a Manualized Psychosocial Protocol for the Treatment of Methamphetamine Dependence

36. CSAT MTP Project Goals: To study the clinical effectiveness of the Matrix Model To compare the effectiveness of the Matrix model to other locally available outpatient treatments To establish the cost and cost effectiveness of the Matrix model compared to other outpatient treatments To explore the replicability of the Matrix model and challenges involved in technology transfer

37. Baseline Demographics Participants Served (n) 978 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

38. Gender Distribution of Participants

39. Ethnic Identification of Participants

40. Route of Methamphetamine Administration

41. Route of Administration by MTP Site (N=978) SiteOralNasal Smoke IV Billings0%2%42%56% Concord0%10%59%30% Costa Mesa0%8%65%27% Hayward1%35%57%5% Honolulu0%1%96%3% San Diego1%11%61%28% San Mateo, ODASA0%6%94%0% San Mateo, Pyramid0%23%64% 13% OVERALL PERCENT :0%11%65%24%

42. Changes from Baseline to Treatment-end

43. ASI Composite Scores Possible is 0-1; Higher : worse problem t paired : *p-value<0.03 (sig.), **p-value<0.000 (highly sig.)

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

45. Days of Marijuana Use in Past 30 (ASI) Possible is 0-30; t paired =8.02; p-value<0.000 (highly sig.)

46. Days of Alcohol Use in Past 30 (ASI) Possible is 0-30; t paired =6.47; p-value<0.000 (highly sig.)

47. Mean Number of Weeks in Treatment

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

49. Figure 4. Percent completing treatment, by group

50. 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

51. Urinalysis Results Results of Ua Tests at Discharge, 6 months and 12 Months post admission ** Matrix 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

52. Clinical Challenges in Treating MA-Dependent Patients

53. Special treatment consideration should be made for the following groups of individuals: Female MA users (higher rates of depression; very high rates of previous and present sexual and physical abuse; responsibilities for children). Injection MA users (very high rates of psychiatric symptoms; severe withdrawal syndromes; high rates of hepatitis). MA users who take MA daily or in very high doses. Homeless, chronically mentally ill and/or individuals with high levels of psychiatric symptoms at admission. Individuals under the age of 21. Gay men (at very high risk for HIV and hepatitis).

54. Acute MA Psychosis Extreme Paranoid Ideation Well Formed Delusions Hypersensitivity to Environmental Stimuli Stereotyped Behavior “Tweaking” Panic, Extreme Fearfulness High Potential for Violence

55. Treatment of MA Psychosis Typical ER Protocol for MA Psychosis: – Haloperidol - 5mg – Or, atypical antipsychotic (eg. respiridone) – Clonazepam - 1 mg – Cogentin - 1 mg – Quiet, Dimly Lit Room – Restraints

56. MA “Withdrawal” - Depression- Paranoia - Fatigue- Cognitive Impairment - Anxiety- Agitation - Anergia- Confusion Duration: 2 Days - 2 Weeks

57. Treatment of MA “Withdrawal” Hospitalization/Residential Supervision if: –MA Injectors –Danger to Self or Others, or, so Cognitively Impaired as to be Incapable of Safely Traveling to and from Clinic –Otherwise Intensive Outpatient Treatment

58. Initiating MA Abstinence Key Clinical Issues: – Depression – Cognitive Impairment – Continuing Paranoia – Anhedonia – Behavioral/Functional Impairment – Hypersexuality – Conditioned Cues – Irritability/Violence

59. Clinical Tools

60. Clinical Challenges of MA Users Clinical Challenges of MA Users Poor treatment engagement rates Severe paranoia Ongoing episodes of psychosis Severe craving Protracted dysphoria and mood disturbance Anhedonia Sleep disorders Concentration and memory problems Sexual Issues Weight Gain PTSD symptoms, secondary to trauma

61. Strategies for addressing engagement problems NIATX strategies Motivational Interviewing skills Contingency management

62. Strategies for addressing psychosis and paranoia Psychosis resulting from acute MA intoxication will typically resolve within 12-24 hours. Persistent psychosis may require anti-psychotic medication Paranoia is very common throughout treatment. Typically lessens over the first 2 weeks, but can have recurances. Avoid confrontation and emotional intense or cognitively complex therapeutic techniques. Reassure that recovery will occur with time. “Normalize” symptoms as part of recovery

63. Strategies for addressing dysphoria mood disturbance, sleep disturbance and anhedonia Education about timetable of MA recovery - The “Wall” Encouragement and support of group members Reports of improvement from patients and staff in later recovery Moderate caffeine intake late in the day Exercise Psychiatric evaluation for persisting significant symptoms of depression

64. Strategies for addressing cognitive and memory problems Keep it simple Use visual images Handouts Reminder cards Reminder notes

65. Strategies for addressing sexual issues Education Individual sessions to allow for acknowledgement of sexual involvements during MA use Creating realistic expectations of sexual response and experience in recovery Relationship of sexual arousal and craving

66. Strategies for addressing weight gain Education about MA recovery and necessity of proper diet Exercise, exercise, exercise Body image discussion with other recovering women

67. Strategies for addressing trauma issues Insure current safe living situation “Seeking safety” Other trauma and substance abuse models Women’s groups Individual sessions Acknowledgement of poor child care practices and consequent feeling of guilt and remose

68. Treatment Tools from Matrix Model Matrix Manual free from SAMHSA Manuals and videos also available from Hazelden Publishing

70. MATRIX MODEL TREATMENT INFORMATION

71. 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

72. 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

73. Triggers and Cravings Human Brain

74. Cognitive Process During Addiction Relief From Depression Anxiety Loneliness Insomnia Euphoria Increased Status Increased Energy Increased Sexual/Social Confidence Increased Work Output Increased Thinking Ability AOD Introductory Phase May Be Illegal May Be Expensive Hangover/Feeling Ill May Miss Work

75. Conditioning Process During Addiction Introductory Phase Triggers Parties Special Occasions Responses Pleasant Thoughts about AOD No Physiological Response Infrequent Use Strength of Conditioned Connection Mild

76. Development of Obsessive Thinking Introductory Phase Sports Food School TV Girlfriend Hobbies Job AOD Family Exercise Parties

77. Development of Craving Response Introductory Phase Entering Using Site Use of AODs AOD Effects  Heart/Pulse Rate  Respiration  Adrenaline  Energy  Taste

78. Cognitive Process During Addiction Maintenance Phase Depression Relief Confidence Boost Boredom Relief Sexual Enhancement Social Lubricant Vocational Disruption Relationship Concerns Financial Problems Beginnings of Physiological Dependence

79. Conditioning Process During Addiction Maintenance Phase 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

80. Development of Obsessive Thinking Maintenance Phase AOD Food School TV Girlfriend Hobbies Job AOD Family Exercise Parties

81. Development of Craving Response Maintenance Phase Entering Using Site Physiological Response Use of AODs AOD Effects  Heart  Blood Pressure  Energy  Heart  Breathing  Adrenaline Effects  Energy Taste

82. 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

83. Conditioning Process During Addiction Disenchantment Phase 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

84. Development of Obsessive Thinking Disenchantment Phase AOD Food AOD TV Girlfriend AOD Job AOD Family AOD Parties AOD

85. 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 AODsAOD Effects  Heart Rate  Breathing Rate  Energy  Adrenaline Effects  Heart  Blood Pressure  Energy

86. 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

87. Conditioning Process During Addiction Disaster Phase Strength of Conditioned Connection Triggers Any Emotion Day Night Work Non-Work Responses Obsessive Thoughts About AOD Powerful Autonomic Response Powerful Physiological Dependence Automatic Use OVERPOWERING

88. Development of Obsessive Thinking Disaster Phase AOD

89. Development of Craving Response Disaster Phase Thoughts of AOD Using Place Powerful Physiological Response  Heart Rate  Breathing Rate  Energy  Adrenaline Effects

90. Outpatient Recovery Issues TRIGGERS

91. Trigger Definition A trigger is a stimulus which has been repeatedly associated with the preparation for, anticipation of or the use of drugs and/or alcohol. These stimuli include people, things, places, times of day, and emotional states.

92. Triggers and Cravings (1849-1936)

93. Triggers and Cravings Pavlov’s Dog

94. MATRIX MODEL TREATMENT Triggers - People Drug-using friends/dealer Voices of drug friends/dealer Absence of significant other Sexual partners in illicit sex Groups discussing drug use

95. MATRIX MODEL TREATMENT Triggers - Places Drug dealer’s home Bars and clubs Drug use neighborhoods Freeway offramps Worksite Street corners

96. 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

97. 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

98. 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

99. Triggers & Cravings TriggerThoughtCravingUse

100. Trigger Thought Craving Use Triggers & Cravings

101. Triggers and Cravings Thought Stopping Visual Imagery Snapping Relaxation Call Someone Pray Urge-Surfing

102. MATRIX MODEL TREATMENT Key Concept: Thought Stopping Prevents the thought from developing into an overpowering craving Requires practice TriggerThought Thought Stopping Continued ThoughtsUseCravings

103. STAGES OF RECOVERY - STIMULANTS OVERVIEW Withdrawal Honeymoon The Wall Adjustment Resolution DAY 0 DAY 15 DAY 45 DAY 120 DAY 180

104. Stages of Recovery - Stimulants WITHDRAWAL STAGE DAY 0 DAY 15 Medical Problems Alcohol Withdrawal Depression Difficulty Concentrating Severe Cravings Contact with Stimuli Excessive Sleep PROBLEMS ENCOUNTERED

105. MATRIX MODEL TREATMENT Relapse Factors - Withdrawal Stage Unstructured time Proximity of triggers Alcohol/marijuana use Powerful cravings Paranoia Depression Disordered sleep patterns

106. Stages of Recovery - Stimulants HONEYMOON STAGE DAY 15 DAY 45 Overconfidence Inability to Prioritize Memory Problems Difficulty Concentrating Intense feelings Other Substance Abuse Treatment Termination PROBLEMS ENCOUNTERED

107. MATRIX MODEL TREATMENT Structure - Ways to Create Time scheduling Attending 12-step meetings Going to treatment Exercising Attending school Going to work Performing athletic activities Attending church

108. MATRIX MODEL TREATMENT Structure - Pitfalls Scheduling unrealistically Neglecting recreation Being perfectionistic Therapist imposing schedule Spouse/parent imposing schedule

109. MATRIX MODEL TREATMENT Relapse Factors - Honeymoon Stage Secondary alcohol or other drug use Discontinuation of structure Resistance to behavior change Return to addict lifestyle Periodic paranoia

110. Stages of Recovery - Stimulants THE WALL DAY 45 DAY 120 Inertia Depression Return to Cocaine Stimuli Relapse Justification Cognitive Rehearsal Treatment Termination Alcohol Use Relapse PROBLEMS ENCOUNTERED

111. “The Wall” One Patient’s Account Physical Symptoms: “Lack of energy was almost constant even if I slept for hours. Lack of memory, inability to concentrate and a grey film over my vision clouded my world. My sleep became mixed-up. I would be dead tired during the day and experience insomnia at night.”

112. “The Wall” One Patient’s Account Apathy: “Throughout The Wall I didn’t care about anything or anybody. Including myself. Nothing seemed important, nothing felt good. Boredom and hopelessness were constant companions. I felt the whole thing would never end.”

113. “The Wall” One Patient’s Account Loneliness and Isolation: “More than anything I felt alone. I felt like I was the only person in the world who knew how I felt. Even my therapist and my C.A group didn’t understand. I went to meetings and often still felt alone.”

114. MATRIX MODEL TREATMENT Relapse Factors - The Wall Stage - Increased emotions- Dissolution of structure - Interpersonal conflict- Behavioral drift - Relapse justification- Secondary alcohol or - Anhedonia/loss of other drug use motivation- Resistance to exercise - Insomnia/low energy/fatigue- Paranoia

115. Stages of Recovery - Stimulants ADJUSTMENT STAGE DAY 120 DAY 180 Vocational Dissatisfaction Relationship Problems Overconfidence Lack of Goals PROBLEMS ENCOUNTERED

116. Outpatient Recovery Issues RELAPSE FACTORS

117. Outpatient Recovery Issues Relapse Factors - Sexual Behavior Concern about sexual dysfunction Concern over sexual abstinence Concern over sexual disinterest Loss of intensity of sexual enjoyment Shame/guilt about sexual behavior Sexual arousal producing craving Sexual behavior and intimacy Sobriety and monogamy

118. Outpatient Recovery Issues Relapse Factors - Alcohol/Marijuana Cortical disinhibition Stimulant craving induction Pharmacologic coping method 12-Step philosophy conflict Abstinence violation effect Marijuana amotivational syndrome Interferes with new behaviors

119. Outpatient Recovery Issues Relapse Factors - Time Periods Unstructured time Transition periods Protracted abstinence Holidays Chronic stress, fatigue, or boredom Anniversary dates Periods of emotional turmoil

120. Outpatient Recovery Issues Relapse Factors - Addict Behavior Lying/stealing Having extramarital/illicit sex Using secondary substances Returning to bars/drug friends Being unreliable/irresponsible Behaving compulsively/impulsively Isolating

121. Outpatient Recovery Issues Relapse Factors - Addict Thinking Paranoia Relapse justifications: “I’m not an addict anymore” “I’m testing myself” “I need to work” “Other drugs/alcohol are OK” “Catastrophic events” “Negative emotional states”

122. Outpatient Recovery Issues Relapse Factors - Relationships Addict must deal with family’s: Extreme anger and blaming Unwillingness to change/trust Hypervigilance - excessive monitoring Sexual anxieties Adjustment to non-victim status Conflict with recovery activities

123. Roadmap for Recovery When To Use Thought Stopping River of Relapse (Relapse Drift)

124. Stages of Recovery - Stimulants RESOLUTION STAGE DAY 180 Anger Guilt Isolation Boredom PROBLEMS ENCOUNTERED Interpersonal Communication Issues

125. Matrix Relapse Prevention Groups

126. 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

127. Other Components of the Matrix Model

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

129. Thank you rrawson@mednet.ucla.edu www.uclaisap.org