Treatment of Methamphetamine Dependence: A Current Update

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Treatment of Methamphetamine Dependence A
Current Update

• Richard A. Rawson, Ph.D, Professor
• Semel Institute for Neuroscience and Human
  Behavior
• David Geffen School of Medicine
• University of California at Los Angeles
• www.uclaisap.org
• rrawson_at_mednet.ucla.edu
• Supported by
• National Institute on Drug Abuse (NIDA)
• Pacific Southwest Technology Transfer Center
  (SAMHSA)
• International Network of Treatment and
  Rehabilitation Resource Centres (UNODC)

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Can Methamphetamine Users be Successfully Treated?

• Successful treatment of methamphetamine (MA)
  users employs many elements in common with
  treatment strategies for other groups of drug
  users.
• There is no evidence that MA users have poorer
  outcomes than other groups of drug users.
• However, with attention to some specific clinical
  issues and application of some specific clinical
  strategies, treatment outcomes can be
  substantially improved.

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Clinical Challenges with Methamphetamine
Dependent Individuals

• Limited Understanding of Addiction
• Cognitive Impairment
• Anhedonia
• Sexual Reactivity and Meth Craving
• Elevated Potential for Violence
• Persisting Flashbacksof Meth Paranoia
• Sleep Disorders
• Poor Retention in Outpatient Treatment
• Elevated Rates of Psychiatric Co-morbidity

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Behavioral/Cognitive Behavioral Treatments

• Cognitive/Behavioral Therapy-CBT
• Motivational Interviewing-MI
• Contingency Management-CM
• 12 Step Facilitation Therapy
• Community Reinforcement Approach-CRA
• Matrix Model of Outpatient Treatment

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Clinical Strategies to Enhance Treatment Outcomes
with Methamphetamine Users

• Educate clients about the reality of MA addiction
  including
• biology impacted by MA
• conditioning factors that create craving
• common relapse scenarios (eg. drug using friends,
  alcohol, extended periods of unstructured time)
• how MA impacts families
• potential benefits of mental health care
• relationship between participation in
  aftercare/community care and relapse/recidivism.

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Clinical Strategies to Enhance Treatment Outcomes
with Methamphetamine Users

• Employ varied adult learning formats to increase
  comprehension and retention of knowledge in view
  of cognitive deficiencies (especially verbal
  memory problems).
• Incorporate presentations by recovering MA users
  to reinforce treatment messages.
• Provide workbooks and learning aids on relapse
  prevention for clients to take with them into
  continuing care.

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Clinical Strategies to Enhance Treatment Outcomes
with Methamphetamine Users

• Strategies to reduce anhedonia and negative mood
  states, episodic paranoia, sleep problems
  (aerobic exercise, Yoga, Tai Chi, meditation)
• Anger management strategies (to cope with
  possible serotonergic dysregulation-induced
  irritability).
• Groups to address extensive maladaptive sexual
  behaviors and expectations.
• Whenever possible, educate family members about
  ways they can promote recovery.

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Clinical Strategies to Enhance Treatment Outcomes
with Methamphetamine Users

• During pre-release period (30 days?) emphasize
  relapse prevention tools, including time
  planning, identifying triggers and high risk
  situations, practice craving prevention/reduction
  strategies and behavioral strategies for saying
  no.
• To the extent possible make residential treatment
  and community aftercare as congruent and
  complimentary as possible. Coordinate treatment
  content, language, philosophy and recovery
  message between residential care and community
  aftercare.

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Clinical Strategies to Enhance Treatment Outcomes
with Methamphetamine Users

• The single most important factor for positive
  treatment outcome will be the degree to which
  clients are retained in post-residential
  treatment.
• Use community care organizations with a continuum
  of care that can decrease and increase intensity
  of care when clinically indicated.
• Create treatment plans that maximize compliance
• Employ positive reinforcement (vouchers-contingenc
  y management) methods to promote retention and
  prosocial alternative behaviors.
• Coordinate parole monitoring and treatment
  participation in community care.
• Make mental health care available.
• Involve family in community care services.

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The Matrix ModelIt is many treatments in one

• Out-patient, office-based
• Easy to understand
• Structure, structure, structure
• Continuing attendance is important

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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

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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

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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.

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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

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Organizing Principles of Matrix Treatment

• Family therapy interventions used to engage
  families in recovery process
• Self help resources introduced and participation
  encouraged

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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

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Matrix Model of Outpatient Treatment
How it looks in Practice
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Matrix ModelPutting It All Together
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Matrix Model Groups

• Early Recovery (Engaging)
• Relapse Prevention (Learning)
• Social Support (Maintaining)

MATRIX
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Matrix Treatment GroupsDifferent from General
Therapy

• Focus on behavior vs. feeling
• Visit frequency results in strong transference
• Transference is encouraged
• Transference is utilized
• Goal is stability (vs. emotional catharsis)

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Matrix Treatment GroupsDifferent from General
Therapy

• Focus is on abstinence
• Bottom line is always continued abstinence
• Therapist frequently pursues less motivated
  clients
• The behavior is more important than the reason
  behind it

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Matrix Treatment GroupsDifferent from
Residential Treatment

• Less confrontational
• Progresses more slowly
• Focus is on present
• Core Issues not immediately addressed
• Allegiance is to the therapist vs. group

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Matrix Treatment GroupsDifferent from
Residential Treatment

• Non-judgmental attitude is basis of
  client-therapist bond
• Change recommendations based on scientific data
• Changes incorporated immediately into therapeutic
  style

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Matrix Early Recovery Groups
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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)

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Early Recovery Issues Engaging and Retaining
TRIGGERS
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Triggers and Cravings
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Triggers and Cravings
Pavlovs Dog UCR
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Triggers and Cravings
Pavlovs Dog CR
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Early Recovery Issues Engaging and Retaining
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Early Recovery Issues Engaging and Retaining
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MATRIX MODEL TREATMENT Triggers - Places

• Drug dealers home
• Bars and clubs
• Drug use neighborhoods
• Freeway offramps
• Worksite
• Street corners

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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

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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

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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
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THOUGHT STOPPING

• Prevents the thought from developing into an
  overpowering craving
• Requires practice

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Accepting Non-Judgmental Empowering Supportive Und
erstanding
Patient Elicited Collaborative Ambivalence
Normal Facilitative
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MOTIVATIONAL INTERVIEWING

• Increase Motivation
• Decrease Resistance
• Increase retention
• Better outcomes

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MATRIX MODEL TREATMENT
STRUCTURE
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MATRIX MODEL TREATMENT
INFORMATION
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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
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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

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

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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

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Development of Obsessive ThinkingIntroductory
Phase
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Development of Craving Response
Introductory Phase
Entering Using Site
Use of AODs
AOD Effects ? Heart/Pulse Rate ? Respiration ?
Adrenaline ? Energy ? Taste
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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
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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
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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
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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
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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
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AOD
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Thinking of Using
Mild Physiological Response
Entering Using Site
? Heart Rate ? Breathing Rate ? Energy ?
Adrenaline Effects
Powerful Physiological Response
Use of AODs
AOD Effects
? Heart Rate ? Breathing Rate ? Energy ?
Adrenaline Effects
? Heart ? Blood Pressure ? Energy
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Cognitive Process During Addiction
Disaster Phase
Relief From Fatigue Relief From Stress Relief
From Depression
Weight Loss Paranoia Loss of Family Seizures Sever
e Depression Unemployment Bankruptcy
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Strength of Conditioned Connection
OVERPOWERING

• Responses
• Obsessive Thoughts About AOD
• Powerful Autonomic Response
• Powerful Physiological Dependence
• Automatic Use

• Triggers
• Any Emotion
• Day
• Night
• Work
• Non-Work

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Development of Obsessive ThinkingDisaster Phase
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Development of Craving Response
Disaster Phase
Thoughts of AOD Using Place
Powerful Physiological Response
? Heart Rate ? Breathing Rate ? Energy ?
Adrenaline Effects
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Outpatient Treatment Strategies

• Scheduling

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Matrix Relapse Prevention Groups
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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

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Roadmap for Recovery
Withdrawal Early Abstinence/Honeymoon Protracted
Abstinence or The Wall Adjustment/Resolution
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Roadmap for RecoveryThe Wall
THE WALL
Return to Old Behaviors Anhedonia Anger Depression
Emotional Swings Unclear Thinking Isolation Family
Problems
Cravings Return Irritability Abstinence Violation
Protracted Abstinence
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Other Components of the Matrix Model
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Components Of The Matrix Model

• Family Education Lectures
• Conjoint Sessions
• Urine Testing
• Relapse Analysis
• Self help Initiation

MATRIX
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The CSAT Methamphetamine Treatment Project

• A Multi-site Trial of a Manualized
  Psychosocial Protocol for the Treatment of
  Methamphetamine Dependence
• Richard A. Rawson, Principal Investigator