Understanding Substance Abuse & Addiction: What Research, Psychology & Medicine Have to Teach Us TRUST Clinic Speaker Series Oakland, Ca. June 20, 2014 Joan Zweben, Ph.D. Executive Director, East Bay Community Recovery Project Clinical Professor of Psychiatry, UCSF

Disclosures Dr. Zweben has no conflict of interest to disclose. Dr. Zweben’s bias is that evidence-supported, safe treatment for SUDS should be equally available throughout our system of care, including medication treatment. Dr. Zweben’s bias is that evidence-based interventions are only one component of individualized treatment planning, not a substitute for comprehensive care.

Evolution of Substance Abuse Treatment in the U.S. How Did We Get Here?

National Institute on Alcoholism & Alcohol Abuse (NIAAA) Founded 1970 as a center within NIH Research on the biology of alcoholism, psychosocial issues, treatment (1990’s) Produced educational materials for prevention, but initially not a leader in the treatment field. Pressure from community groups led to more treatment research

National Institute on Drug Abuse (NIDA) Founded 1972 to promote creation of tx system + research on clinical issues Goal: what programs were contributing to reducing social costs of addiction Tx system developed for the indigent (uninsured), funded by federal, state and local entities Research emphasis on tx modalities

Chronology AA – Bill Wilson, Dr. Bob Smith in Akron, Ohio Minnesota Model – 1950’s (Hazelden) Therapeutic Communities – 1958, Synanon; proliferated rapidly Methadone maintenance – 1965, Dole & Nyswander Drug Courts 1989, Miami-Dade County, Florida

Treatment Modalities: Therapeutic Communities long term (6-18 months) residential tx the community is the agent of change peer relationships, open communication and feedback are basic tools “must function” model activities to maintain daily operations a primary element in therapeutic interactions

TC’s, Continued change self-image and behavior self-examination and confession extended family concept possibility of ascendancy within the system re-entry outcome data supports its efficacy

Methadone Maintenance most misunderstood, stigmatized modality most highly regulated modality rationale for maintenance therapy: Dole, receptor system dysfunction strong empirical support for efficacy and safety (50 years of data) valuable tool in reducing the spread of AIDS not a cure-all, but makes the patient accessible to intervention for other problems

Opioid Maintenance Therapy: Hot Button Issues Dosing: politics, blood levels, etc. Diversion Opioid addicted pregnant women Medical maintenance Tapering off methadone Methadone “vs” buprenorphine “vs” naltrexone (Vivitrol)

Minnesota Model Hazelden, Wilmar (1950’s) AA principles replace mental health model; alcoholism as a primary disorder multidisciplinary team approach respect for the alcoholic; respite from environment need and value of aftercare

Minnesota Model Continued origin of 28-day length of stay CATOR: document outcomes controlled studies do not support efficacy, with some exceptions managed care

Social/Community Model Influence on treatment & prevention Emphasis on the micro & macro community AA principles Experiential knowledge essential; everyone both gives and receives help Positive sober environment is crucial One ancestor of ROSC

Drug Courts (1) Goal: integrate substance abuse treatment with legal case processing (pretrial) KEY PRINCIPLES: Identification/referral as soon as possible after arrest Early professional dx of treatment needs Matching needs to appropriate tx

Drug Courts (2) Making treatment a court-monitored requirement; provide judicial review and supervision of progress in treatment Holding defendants accountable through a series of graduated sanctions and rewards Providing appropriate follow-up and support services following treatment (Sherin & Mahoney, 1996; TIP #23)

Drug Courts (3) NIJ (2003) study of 17,000 graduates found only 16.4% had been rearrested and charged with a felony one year later (Roman et al, 2003). Reduced cost to victim and criminal justice system Increase retention in treatment Others: juveniles, DWI, family, mental health (Huddleston et al, 2004)

Treatment Philosophies

Treatment Philosophies: Abstinence abstain from drug of choice abstain from other intoxicants drug substitution role in precipitating relapse dependable control not possible; hence detach widest margin of safety

What is Abstinence? A person is abstinent if he/she is not drinking or using illicit drugs, and using legal ones as prescribed. Thus, medications are compatible with recovery. Physical dependence ≠ addiction Note: medications are tools, not solutions

Treatment Philosophies: Harm Reduction “Harm reduction is a set of strategies that encourage substance users and service providers to reduce the harm done to drug users, their loved ones and communities by their licit and illicit drug use.” The Harm Reduction Working Group & Coalition, 1995

Arenas for Harm Reduction HIV/ STD outreach and education needle exchange homeless populations: wet, damp housing SMI clients - Harborview model methadone maintenance (damage control component) drop in centers users’ support groups money management/payee community HR education

Pitfalls of Abstinence-Oriented Treatment Failure to assess motivation level before pushing abstinence commitment Failure to understand factors promoting continued use Unrealistic timetables Power struggle vs clinical approach Failure to recognize fluctuating motivation Inappropriate termination of treatment

Pitfalls of Harm Reduction Approach Inappropriately low expectations for what client can achieve Difficulty setting clear goals Reluctance to ask client to abstain completely Underestimate risks/lethality Clinician alcohol and/or illicit drug use

The Substance Abuse Treatment System: Finding Good Care

Paradigm Shift Chronic Care Model: When treated as a chronic illness, relapse rates are as good or better than other chronic illnesses (McLellan et al. 2005) Recovery Oriented System of Care (ROSC): Support person centered and self-directed approaches to care that build on the strengths and resilience of individuals, families and communities to take responsibility for their sustained health, wellness and recovery from alcohol and drug problems (CSAT) (Rawson & Freese. 2010) 25

Recovery Oriented System of Care (ROSC) ROSCs are founded on a chronic care model of substance use treatment and recovery services that use recovery management approaches to engage and treat, and provide recovery support services that help individuals/families sustain their recovery. (Rawson & Freese. 2010) 26

Broadening Our Target Population The Changing Health Care Landscape

Different policies for different levels of Severity Addiction ~ 25,000,000 (Focus on Treatment) “Harmful Use” – 68,000,000 (Focus on Early Intervention)) Little or No Use (Focus on Prevention)) Diabetes ~24,000,000 LITTLE LOTS In Treatment ~ 2,300,000

Distribution of AOD Problems 2M people (.08%) receiving treatment 21M people (7%) have problems but are not receiving treatment 1.1% made effort to get tx 3.7% felt they needed tx but made no effort to get it 95.2% did not feel they needed tx M (20-25%) using at risky levels (UCLA/ATTC 2013)

Using at Risky Levels (60-80 million) Do not meet diagnostic criteria Level of use indicates risk of developing problems Examples: Drinks 3-4 glasses of wine several times per week Pregnant woman occasionally uses vodka to relieve stress Adolescent to smokes mj with friends on weekends Occasionally takes 1-2 extra vicodin to help with pain (UCLA/ATTC 2013)

Implications As long as the specialty care programs (AOD treatment programs) are the only places which address SUD: most people with severe problems will not receive treatment. virtually all with risky use will not receive professional attention. (UCLA-ATTC 2013)

Value of Behavioral Health Source: Wyatt Matas, 2013

Value of Behavioral Health 49% of Medicaid Beneficiaries with disabilities have a psychiatric illness. Top 3 behavioral dyads: 1. Psychiatric/Cardiovascular 2. Psychiatric/Central Nervous System 3. Psychiatric/ Pulmonary

Healthcare Settings for Locating Individuals with SUD Primary care settings Emergency rooms/ Trauma centers Prenatal clinics/OB/Gyn offices Medical specialty settings for diabetes, liver and kidney disease, transplant programs Pediatrician offices College health centers Mental health settings (UCLA-ATTC 2013)

Workforce Implications MH/AOD clinicians will be working in many different settings where teamwork is key Holistic, integrative perspective and approach; Sick care + wellness care Screening & brief intervention integral MI principles and skills essential Availability for drop in or scheduled meetings; “hallway consults”

Evidence-Based Practices and Treatment Interventions Rationale, Challenges & Perils

Why Use Evidence-Based Principles and Practices? To go beyond our preferences and biases To improve the effectiveness of what we do: what works best, for whom Because funders will increasingly insist on optimum utilization of inadequate resources

Evidence Based Principles & Practices vs Evidence Based Treatment Interventions Principles and practices are derived from different types of research. Rigor often trumps relevance in determining what type of research is valued. Policy makers must be educated on these issues.

Important Distinctions Evidence-based principles and practices guide system development Example: care that is appropriately comprehensive and continuous over time will produce better outcomes Evidence-based treatment interventions are important elements in the overall picture. They are not a substitute for overall adequate care.

Types of Studies Quasi-experimental studies – some control over confounding factors; less rigorous than RCT’s Correlational studies – systematic observation across cases or programs Longitudinal studies Naturalistic studies

Evidence-Based Principles Retention improves outcomes; we need to engage people, not discharge them prematurely. Addicts/alcoholics are a heterogeneous population, not a particular personality type. Addiction behaves like other chronic disorders Problem-service matching strategies improve outcomes. (Other matching strategies disappointing.) Harm reduction approaches yield benefits in terms of public health and safety. Pts in methadone maintenance show a higher reduction in morbidity and mortality and improvement in psychosocial indicators than heroin users outside treatment or not on MAT.

Policies and Practices Not Supported by Research Requiring abstinence as a condition of access to substance abuse or mental health treatment Denying access to AOD treatment programs for people on prescribed medications Arbitrary prohibitions against the use of certain prescribed medications Discharging clients for alcohol/drug use

Evidence-Based Practices: Key Issues in the Debate

Efficacy Studies Specific psychosocial interventions are usually investigated in random assignment studies using manualized treatments in carefully controlled trials. Samples and settings are homogeneous and treatment is standardized. Specific procedures assure fidelity to the model.

Random Assignment Controlled Trials (RCT’s) Gold standard for pharmacological and many psychosocial interventions Examples with strong efficacy: Cognitive behavioral therapy Motivational enhancement therapy Behavioral marital therapy Community reinforcement approach Relapse prevention Social skills training (see Miller et al, 2005)

Adaptive Designs: An Emerging Paradigm Individualize treatment using decision rules that recommend when and for whom tx should change Utilize a sequence of treatments, randomizing S’s based on clinical response Starts with consensus-based clinical guidelines and fine tunes the sequence Example: The STAR-D study

Are RCT’s Over-rated?

Mark Willenbring MD (ASAM 2006)

Issues with RCT’s Is the research question an appropriate question? Example: CBT A compared with CBT B, vs CBT A compared with TAU Are the treatment effects modest or robust? What is the cost to achieve and maintain the intervention? Are the results worth it?

What About the Therapeutic Alliance? Studies outside substance abuse show this accounts for a greater % of the variance than specific techniques Different “specific” therapies yield similar outcomes, but there is wide variability across sites and therapists More therapist education/experience does not improve efficacy (Adapted from W.R. Miller, Oct 06)

Practice-Based Evidence Studies and meta-analyses report moderate to large effects of indiv therapists Gather client outcome data from routine practice Give real-time feedback & suggestions to improve performance Flag pts at risk for treatment failure or dropout (Glassner-Edwards & Rawson, 2010)

IMPLEMENTATION ISSUES

Levers for Change Financing Infrastructure development Legislation Regulation Accreditation (education programs, service delivery organizations) Certification and licensure Performance based contracting

Degrees of Implementation: Process Putting new operating procedures in place: Conducting workshops Providing supervision Change information reporting forms New innovation-related language is adopted Is this functionally related to new practices or merely lip service? (Dean Fixsen, 2005)

Can we assume that interventions with documented efficacy will be effective in the community if we only implement them correctly?

Rethinking the Efficacy-to- Effectiveness Transition Assumption that effectiveness research naturally flows from efficacy research is faulty. The tight controls of efficacy studies limit their generalizability. Focus more on intervention reach, adoption, implementation, and maintenance. Published studies should include more info on external validity. (Glasgow et al, AJPH, 2003)

Important Questions to Ask What are the characteristics of interventions that can: 1. Reach large numbers of people, especially those who can most benefit 2. Be broadly adopted by different settings 3. Be consistently implemented by different staff with moderate training and expertise 4. Produce replicable and long lasting effects (with minimal negative impact) at reasonable costs. (Glasgow et al, AJPH, 2003)

Considerations What is to be gained? Does the organizational culture support adoption? Is training available? Is clinical supervision available?

Ineffective Implementation Strategies “…experimental studies indicate that dissemination of information does not result in positive implementation outcomes (changes in practitioner behavior) or intervention outcomes (benefits to consumers)” (Fixsen et al, 2005)

Opinion Leaders: A Key to Knowledge Adoption Identified by peers as respected for their knowledge in a particular area Trained in the use of an evidence-based curriculum They then train their peers and supervise the application of the curriculum Changes in counselor behaviors and attitudes are measured to determine the effectiveness of the implementation process ( Rugs D, Hills HA, Peters R, 2004 at

Key Ingredients Presenting information; instructions Demonstrations (live or taped) Practice key skills; behavior rehearsal Feedback on Practice Other reinforcing strategies; peer and organizational support (Fixsen et al, 2005)

Coaching Training and coaching are a continuous set of operations designed to produce changes Newly-learned behavior is crude compared to performance by a master practitioner Such behavior is fragile and needs to be supported in the face of reactions of others Such behavior is incomplete and will need to be shaped to be most functional in the service setting. (Fixsen et al, 2005)

Dissemination Mechanisms NIDA’s Clinical Trials Network (CTN) CSAT’s Addition Technology Transfer Centers (ATTC) -centers/?rc=pacificsouthwest

Challenges & Perils

Policy and Funding Policy makers misinterpreting research findings; drawing inappropriate conclusions Example: buprenorphine (“transfer methadone pts to BPN and taper them off”) Using EBT’s takes precedence over individualizing care Funders adopting a “pick from this list” approach Achieving fidelity takes labor intensive supervision, and many states don’t fund supervision.

Marketing Impostors Distinguishing evidence from marketing “We have some of the highest success rates in the country” “You should only have to do this once.” Presenting multiple anecdotes with no comparison or control groups as “proof”

Research to Practice Issues Inadequate effectiveness studies Huge gaps in the research literature (s.g., group interventions, therapist variables)? High training fees for “proven” practices Fidelity vs cultural competence: What is the tradeoff between fidelity and the need to adapt interventions for specific populations? How can we make cultural adaptations and maintain the treatment effects?

Infrastructure Development The existing infrastructure cannot handle the expectation for data collection Funders want data but do not want to pay the costs Data collected by funders is often not used to improve services Workforce crisis is a huge problem and an opportunity. Must supply resources for training.

Stay Focused on Basic Principles Maintain commitment to the principle of individualizing treatment When an evidence-based treatment doesn't work for an individual, some staff members conclude that the problem is that the treatment isn't being implemented correctly, rather than examining the possibility that it does not fit the needs of the client. Example from Dual Dx listserve: dualdx.treatment.org

Is There Another Way? Fund programs to develop the infrastructure to examine how they are doing with whom Draw on EBT’s to improve in areas where there are problems Clarify realistic performance standards

APA Definition Evidence-based psychotherapy is resources-based: best practices are built on a foundation of empirical research, comprehensible and reasoned theories, clinical observation and expertise, and patients' values, contributions and responses.

Evidence-Based Skills Training Establish clear goals Identify feasible objectives, adaptable to different settings Take into account the limitations of the current health care system Train in core evidence-based skills, rather than emphasizing manualized EBPs (Glassner-Edwards & Rawson, 2010)

Treatment Issues

Co-Occurring Psychiatric & Substance Use Disorders COD are the norm, not the exception “No wrong door;” guided referrals, “warm handoffs” Assessment: distinguish between substance induced conditions and independent disorders Treatment should be integrated, focusing on safety, stabilization, maintenance of gains Trauma-informed care

Cognitive Behavioral Therapies Based on social learning theories Identify the antecedents and consequences of drug use Skills training – identify high risk situations, use behavioral and cognitive strategies to avoid situations or cope effectively Includes relapse prevention strategies (Carroll & Onken, AJP, 2005)

Motivational Enhancement Strategies Widely adopted Principles widely applicable outside substance abuse treatment TIP 33: Enhancing Motivation for Change in Substance Abuse Treatment - order from:

Goals and Benefits Inspiring motivation to change Preparing clients to enter treatment Engaging and retaining clients in treatment Increasing participation and involvement Improving treatment outcomes Encouraging a rapid return to treatment if symptoms recur

Community Reinforcement Approaches Environmental influences play a powerful role in encouraging or discouraging substance use Social, recreational, familial and vocational forces can be use to promote behavior change Goal: make sober lifestyle more rewarding than the use of substances Counselor must find and use the client’s intrinsic reinforcers

CRA: Examples CRAFT – work with spouse/parent to change social environment; remove inadvertent reinforcement for drinking and using; reinforce abstinence Job seeking and keeping; improving satisfaction with job Identify new sources of recreation Behavioral skills: communication, problem solving, drink/drug refusal

Contingency Management Systematic delivery of positive reinforcement for desired behaviors (e.g., negative toxicology screens) Vouchers Prizes Other privileges, rewards, etc.

Essential Ingredients in the Recovery Process A community that supports the recovery process A path for personal development that has no financial barriers Can use alternative groups but the 12- Step system is the most comprehensive

Download Slides: