1. Treatments for Methamphetamine-Related Disorders I (General)
Richard A. Rawson, Ph.D.
UCLA Integrated Substance Abuse Programs
CATES Conference, August 20, 2004
Sacramento, California

2. Methamphetamine (MA): Psychiatric Consequences
Paranoid reactions
Permanent memory loss
Depressive reactions
Hallucinations
Psychotic reactions
Panic disorders
Rapid addiction

3. MA Treatment Issues Acute MA Overdose Acute MA Psychosis
MA “Withdrawal”
Initiating MA Abstinence
MA Relapse Prevention
Protracted Cognitive Impairment and Symptoms of Paranoia

4. Acute MA Overdose Slowing of Cardiac Conduction
Ventricular Irritability
Hypertensive Episode
Hyperpyrexic Episode
CNS Seizures and Anoxia

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

6. Treatment of MA Psychosis
Typical ER Protocol for MA Psychosis:
Haloperidol - 5mg
Clonazepam - 1 mg
Cogentin - 1 mg
Quiet, Dimly Lit Room
Restraints

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

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

9. Treatment of MA “Withdrawal”
Intensive Outpatient Treatment:
No Pharmacotherapy Available
Positive, Reassuring Context
Directive, Behavioral Intervention
Educate Regarding Time Course of Symptom Remission
Recommend Sleep and Nutrition
Low Stimulation
Acknowledge Paranoia, Depression

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

11. Initiating MA Abstinence
Key Elements of Treatment:
Structure
Information in Understandable Form
Family Support
Positive Reinforcement
12-Step Participation
No Pharmacologic Agent Currently Available

12. Treatment of MA Disorders
Traditional Treatments:
Therapeutic Community
Minnesota Model
Outpatient Counseling
Psychotherapy

13. Treatment of MA Disorders
State of Empirical Evidence:
No Information on TC or “Minnesota Model” Approaches
No Pharmacotherapy with Demonstrated Efficacy
Results of Cocaine Treatment Research Extrapolated to MA Treatment

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

15. 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.
Addictive behaviors persist despite overwhelming evidence of their destructiveness.
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.

16. Early Recovery Issues Engaging and Retaining
Motivational Interviewing
Elicit behavior change
Respect autonomy
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.
Tolerate patient ambivalence
Explore consequences

17. Stages of Change Prochaska & DiClemente
Precontemplation
Contemplation
Preparation
Action
Maintenance

18. Affirmations Patient-focused Intended to:
Support patient’s involvement
Encourage continued attendance
Assist patient in seeing positives
Support patient’s strengths
Audience give examples of affirmations

19. Reflective Listening
Listen to what patient says and to what patient means
Check out assumptions
Create an environment of empathy (nonjudgmental)
Patient and counselor do not have to agree
Be aware of intonation (statement, not question)
Demonstrate difference between question and reflection, give some to the audience to train

20. Summarizing Summaries capture both sides of the ambivalence:
(You say that ___________ but you also mentioned that ________________).
Summaries also prompt clarification and further elaboration from the patient.

21. Change Talk Recognizing the problem Expressing concern
Stating intention to change
Being optimistic about change

22. Providing Feedback Elicit (ask for permission) Give feedback or advice
Elicit again (the patient’s view of how the advice will work for him/her)

23. Cognitive Behavioral Therapy
Operant Conditioning
(Positive
Reinforcement)
Social Learning Theory
(Relapse Prevention
Marlatt & Gordon, 1995)
Modeling
Classical
Conditioning
(Paired Stimuli)

24. Cognitive Behavioral Therapy (CBT) Goals
To use learning processes to help individuals reduce drug use
To help patients:
Recognize Situations
Avoid Situations
Cope with Problems and Behaviors

25. Cognitive Behavioral Therapy Functional Analysis
Feelings
Before and After Use
Thoughts
Circumstances

26. Cognitive Behavioral Therapy
Basic Assumptions:
Drug/Alcohol use is learned behavior.
No assumption of underlying psychopathology
Classical and operant conditioning factors involved
“Treatment” is a process of teaching, coaching and reinforcing.
New, alternative behaviors must be established.
Therapist is teacher, coach, and source of positive reinforcement.
Can be delivered in group or individual setting

27. Community Reinforcement Approach
Basic assumptions:
Drug and alcohol use are positively reinforced behaviors. They can be reduced/eliminated by proper application of behavioral techniques.
To successfully build an effective intervention, some techniques should focus on reducing drug and alcohol use and others should focus on acquisition of new incompatible behaviors.

28. Community Reinforcement Approach
Key concepts:
Behavioral analysis and teach conditioning information
Positive reinforcement with vouchers for drug free urine samples
Behavioral marriage counseling
Shape and reinforce new behavioral repetiore.
Coping skill/Drug refusal skill training
Vocational Counseling
Frequent urine testing

29. Contingency Management with Vouchers
Inexpensive Gifts
Take-home
Methadone
Doses
Access to Housing
Gold Stars
Access to
Work Therapy

30. Contingency Management
Basic Assumptions:
Drug and alcohol use behavior can be controlled using operant reinforcement procedures.
Vouchers can be used as proxy’s for money or goods.
Vouchers should be redeemed for items incompatible with drug use.
Escalating the value of the voucher for consecutive weeks of abstinence promotes better performance.
Counseling/therapy may or may not be required in conjunction with CM procedure.

31. Contingency Management
Key concepts:
Behavior to be modified must be objectively measured.
Behavior to be modified (e.g., urine test results) must be monitored frequently.
Reinforcement must be immediate.
Penalties for unsuccessful behavior (e.g., positive UA) can reduce voucher amount.
Vouchers may be applied to a wide range of prosocial alternative behaviors.

32. A Multi-Site Comparison of Psychosocial Approaches for the Treatment of Methamphetamine Dependence     Richard A. Rawson, Ph.D. and The Methamphetamine Treatment Project Corporate Authors* Addiction (June, 2004)