1. Treatments for Methamphetamine-Related Disorders Richard A. Rawson, Ph.D. UCLA Integrated Substance Abuse Program, Vancouver, Canada Nov, 16, 2004 www.uclaisap.org

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

3. Treatment of MA Psychosis Typical ER Protocol for MA Psychosis: Typical ER Protocol for MA Psychosis:  Haloperidol - 5mg  Or Atypical Anti-psychotic  Clonazepam - 1 mg  Cogentin - 1 mg  Quiet, Dimly Lit Room  Restraints??

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

5. Treatment of MA “Withdrawal” Hospitalization/Residential Supervision if: 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

6. Treatment of MA “Withdrawal” Intensive Outpatient Treatment: 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

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

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

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

10. Treatment of MA Disorders State of Empirical Evidence: State of Empirical Evidence:  No Information on TC or “Minnesota Model” Approaches  No Pharmacotherapy with Demonstrated Efficacy  Bupropion, Selegline, Topirimate under Investigation  Ondansetron, Prozac, Zoloft, Flupentixol, Despiramine found not to be useful  Results of Cocaine Treatment Research Extrapolated to MA Treatment  Results with CM, CBT, and Matrix Equivalent with Cocaine and Meth Users

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

12. Early Recovery Issues Engaging and Retaining

13. Stages of Change Prochaska & DiClemente

14. Affirmations Patient-focused Patient-focused Intended to: Intended to:  Support patient’s involvement  Encourage continued attendance  Assist patient in seeing positives  Support patient’s strengths

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

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

17. Cognitive Behavioral Therapy Basic Assumptions: 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

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

19. Contingency Management Basic Assumptions: 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.

20. Contingency Management Key concepts: 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.

21. 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)

22. 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.

23. 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.

24. 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

25. 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

26. 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

27. 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

28. Matrix Model An Integrated, Empirically-based, Manualized Treatment Program

29. Elements of the Matrix Model Engagement/Retention Structure Information Relapse Prevention Family Involvement Self Help Involvement Urinalysis/Breath Testing

30. 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

31. Matrix vs. Treatment as Usual: Study Design 8 sites 8 sites Participants randomly assigned to Matrix Model treatment or Treatment as Usual in each site. Participants randomly assigned to Matrix Model treatment or Treatment as Usual in each site. Dependent Measures: Retention in treatment; urinalysis results; self report of meth use; ASI scores (in Rx, at D/C and FU) Dependent Measures: Retention in treatment; urinalysis results; self report of meth use; ASI scores (in Rx, at D/C and FU)

32. Matrix vs. TAU: Results Summary Matrix Model demonstrated superior retention and more meth negative urine samples and longer periods of continuous abstinence during treatment period. Matrix Model demonstrated superior retention and more meth negative urine samples and longer periods of continuous abstinence during treatment period. Both conditions showed very significant improvement at discharge and follow up points as measured by UA, self-report and ASI scores. No difference between groups Both conditions showed very significant improvement at discharge and follow up points as measured by UA, self-report and ASI scores. No difference between groups