EvidenceBased Practice: Psychosocial Interventions

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Evidence-Based Practice Psychosocial
Interventions
Maxine Stitzer, Ph.D. Johns Hopkins Univ
SOM NIDA Blending Conference June 3, 2008
Cincinnati, Ohio
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Talk Outline

• What is an evidence-based practice?
• What practices are evidence-based?
• Why should these be used?
• How to decide which one(s) to use?

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What Is An Evidence-Based Practice?

• Developed by researchers
• Subjected to controlled evaluation
• Shown efficacious in 2 or more trials

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Compared to Usual Care Practices

• Therapy specified in a detailed manual
• Therapists trained to proficiency
• Therapists monitored for adherence
• presence of specified and absence of
  non-specified elements
• Clients meet inclusion and exclusion criteria
• may be less complicated cases
• Detailed data collected on outcomes

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Efficacy research shows that practices can work
under ideal conditions
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Do Evidence-Based Practices Work in Real World
Settings?

• Research conducted by NIDA CTN has verified
  effectiveness of some evidence-based practices
• Motivational Interviewing
• Contingency Management
• Others are yet to be tested
• 12-step Facilitation
• Cognitive-Behavioral Therapy

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What Psychosocial Therapies are Evidence-based?

• Motivational Interviewing (MI/MET)
• Contingency Management (CM)
• Cognitive-behavioral therapy (CBT)

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MI/MET What Is It

• Style of therapist-client interaction
• Utilizes basic counseling skills for rapport
• Reflective listening, open-ended questions, avoid
  arguments and lectures
• Provide feedback and develop discrepancies to
  motivate change talk and hopefully, behavior
  change

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MI/MET Techniques

• O open ended questions
• A affirmation
• R reflective listening
• S summary statements

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MI/MET Evidence For Efficacy

• Improved compliance in medical patients
• Reduced drinking in alcoholics
• Drug users contacted in a medical setting

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MI in Drug Treatment Settings

• Evidence mixed
• Some studies find benefits
• Others find no benefits

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CTN MI Study Methods

• 418 patients randomized at 5 sites
• 375 were exposed to protocol
• Counselors trained in MI conducted intake session
  as a MI sandwich
• Client-centered discussion with reflection,
  open-ended questions, etc before after intake
  questionnaires

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Patients assigned to MI completed more sessions
than those in standard treatment
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More MI patients were retained at 1-month
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No differences in retention at the 84-day
follow-up
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No differences in drug use during first 28 days
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Alcohol users (n172)were the ones who benefited
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If a little MI is good (improved attendance and
retention) would more be better?Second CTN MI
study delivered 3 sessions of MI-style therapy
vs3 sessions of individual TAU
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MET Study Outcomes
MET
TAU Significance Days Enrolled
72 69 ns Retained 4 mos ()
41 46 ns Positive UA 21
28 ns ( in 28 days)

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MET Effectiveness in Alcoholics
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MI Overview

• Excellent foundation for counseling skills
• Builds client internal motivation for change
• Evidence-based practice with good data supporting
  use with alcoholics
• Jury still out on effectiveness with drug users
  especially in treatment settings

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CBT What Is It

• Structured skills training lessons
• Manage cravings
• Avoid triggers
• Drug refusal
• Coping/problem solving
• Lectures, practice, homework
• Manualized
• NIDA Therapy Manual for Drug Addiction 1

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CBT Efficacy Evaluation

• Many studies have demonstrated efficacy
• Some show during treatment effects
• Some show benefits only after treatment ends
  (sleeper effects)

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IOP Treatment CBT vs 12-Step
Maude Griffin et al., 1998
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CBT vs Clinical Management 1x per week
Carroll et al., 1994
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CBT Overview

• Provides structured content for DA therapy
• Potential for building highly useful skills
• Coping, problem solving, drug avoidance, etc
• Potential limitations
• Do clients learn what is taught?
• Do clients put learning into practice?

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Contingency ManagementMotivational Incentives
What Is It

• Provides tangible positive reinforcement for
  specified behavior
• Behavior can be attendance, drug abstinence, goal
  achievement
• Reinforcers can be cash-value vouchers or prizes

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Voucher Point System

• Increasing magnitude, bonus, up to 1000
• 2.50 10.00
• 3.75 11.25
• 5.00 10 12.50 10
• 6.25 13.75
• 7.50 15.00
• 8.75 10 16.25 10
• Advantages demonstrated efficacy, accommodate
  personal preferences, less likely to exchange for
  drugs
• Disadvantages cost, staffing for management,
  delay to receipt of some items, worth less than
  cash?

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Voucher Incentives in Outpatient Drug-free
Treatment
Higgins et al. Am. J. Psychiatry, 1993
Cocaine negative urines
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Intermittent schedule/prize system

• Draws from a fishbowl
• Advantages can be less expensive than vouchers
  cost can be controlled by varying size and cost
  of prizes and percentage of winning chips

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Retention Alcoholics in Outpatient Psychosocial
Treatment
Petry et al., 2000
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Time to first heavy drinking episode
plt.05
Petry et al., 2000
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CTN MIEDAR Study

• Stimulant abusers randomly assigned to usual care
  with or without abstinence incentives
• 415 psychosocial counseling
• 388 methadone maintained
• Drug-free urines earn draws from an abstinence
  bowl during a 3-month study
• Negative for cocaine, methamphet and alcohol ---gt
  escalating draws
• Also negative for opiates, THC ---gt bonus draws

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Total Earnings

• 400 in prizes could be earned on average
• If participant tested negative for all targeted
  drugs over 12 consecutive weeks

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Incentives Improve Retention in Counseling
Treatment
100
80
60
50
Percentage Retained
40
35
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RH 1.6 CI1.2,2.0
0
2
4
6
8
10
12
Study Week
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Percent of Submitted Samples Testing Stimulant
and Alcohol Negative
100
80
60
Percentage negative samples
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Abstinence Incentive
Usual Care
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0
1
3
5
7
9
11
13
15
17
19
21
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Study Visit
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Abstinence Incentives in Psychosocial Counseling
Tx

• Incentives lengthened duration of drug-free
  treatment participation
• Presumably improving long-term outcomes
• May be useful for all clients as relapse
  prevention
• Suggests clinic-wide implementation
• Attendance incentive may achieve same goal
• If clients remain abstinent during treatment

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Combination of treatments may be best for
long-term recovery
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Why Should Evidence-Based Practices Be Used?

• Enhance counseling skills and proficiency
• Engage in culture of CQI
• Improve treatment outcomes
• Satisfy accreditation boards federal and
  insurance payers

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Which Evidence-Based Practices Should Be Used?

• Selected by needs of the clinic?
• Selected by needs of the clients?
• Selected by research effect sizes?
• All used in some logical adoption sequence?

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Sequential Adoption Plan

• Motivational Interviewing
• Contingency Management
• Cognitive-Behavior Therapy

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Needs of Clinic and Clients

• Improve early engagement (MI/MET)
• Improve retention (CM)
• Stop on-going drug use (CM)
• Prevent relapse (CM/CBT)
• Build alternative non-drug reinforcers (CBT)

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Evidence-Based Practices Summary

• Shown efficacious in clinical trials and
  effective in real world settings
• Adoption improves care quality and outcomes
• Three recommended are MI, CM and CBT
• Sequential adoption and combined use may be
  optimal strategy

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Benefits of EBP Adoption

• Counselors will like it
• New counseling skills (MI), structured content
  (CBT) and behavior change tools (CM)
• Clients will like it
• Therapy may be more engaging and useful
• Funders will like it
• Pathway to better outcomes