Treatments for Methamphetamine-Related Disorders Richard A. Rawson, Ph.D. UCLA Integrated Substance Abuse Program, Sacramento, CA Dec 2, 2004

Speed It is methamphetamine powder ranging in color from white, yellow, orange, pink, or brown. It is methamphetamine powder ranging in color from white, yellow, orange, pink, or brown. Color variations are due to differences in chemicals used to produce it and the expertise of the cooker. Color variations are due to differences in chemicals used to produce it and the expertise of the cooker. Other names: shabu, crystal, crystal meth, crank, tina, yaba Other names: shabu, crystal, crystal meth, crank, tina, yaba

Ice High purity methamphetamine crystals or coarse powder ranging from translucent to white, sometimes with a green, blue, or pink tinge.

The Language of America’s Meth Users Crank, meth, crystal, ice: methamphetamine Crank, meth, crystal, ice: methamphetamine Cooking: making meth Cooking: making meth Slamming: injecting Slamming: injecting Rig: hypothermic needle Rig: hypothermic needle Run: multiple days of using meth without sleeping Run: multiple days of using meth without sleeping Crash: long period of sleep following a run Crash: long period of sleep following a run Tweaking: going on a long run Tweaking: going on a long run Tweaker: chronic meth users Tweaker: chronic meth users Shadow people: image commonly cited by meth uses in periods of paranoia Shadow people: image commonly cited by meth uses in periods of paranoia

The Language of California Meth Cops User lab: ounce-quality lab for a tweaker’s personal use User lab: ounce-quality lab for a tweaker’s personal use Smurfing: buying small quantities of pseudoephedrine at many stores, a tweaker practice Smurfing: buying small quantities of pseudoephedrine at many stores, a tweaker practice Real nice lab: 10-pound (or larger) superlab operated by Mexican cartels in California Real nice lab: 10-pound (or larger) superlab operated by Mexican cartels in California Step on it: dilute meth with an inactive ingredient Step on it: dilute meth with an inactive ingredient Mope: migrant worker hired to operate a superlab Mope: migrant worker hired to operate a superlab Low crawl: police technique to approach a superlab unseen Low crawl: police technique to approach a superlab unseen Leg bail: what mopes do when surprised by low- crawling cops, to flee Leg bail: what mopes do when surprised by low- crawling cops, to flee

Methamphetamine: A Growing Menace in Rural America In 1998, rural areas nationwide reported 949 methamphetamine labs. In 1998, rural areas nationwide reported 949 methamphetamine labs. Last year, 9,385 were reported. Last year, 9,385 were reported. This year, 4,589 rural labs had been reported as of July 26. This year, 4,589 rural labs had been reported as of July 26. Source: El Paso Intelligence Center (EPIC), U.S. DEA Source: El Paso Intelligence Center (EPIC), U.S. DEA

Groups with High Rates of Meth Use Women Women Residents in Western/Midwestern Rural Areas and Small/Medium Cities Residents in Western/Midwestern Rural Areas and Small/Medium Cities Predominantly Caucasian, Increasing Numbers of Hispanics Predominantly Caucasian, Increasing Numbers of Hispanics Gay Men Gay Men Adolescents Adolescents

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

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??

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

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

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

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

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

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

Treatments for Stimulant-Use Disorders with Empirical Support Motivational Interviewing Motivational Interviewing Cognitive-Behavioral Therapy (CBT) Cognitive-Behavioral Therapy (CBT) Contingency Management Contingency Management 12-Step Facilitation 12-Step Facilitation Matrix Model Matrix Model

Early Recovery Issues Engaging and Retaining

Stages of Change Prochaska & DiClemente

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

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

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

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

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

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.

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.

A Multi-Site Comparison of Psychosocial Approaches for the Treatment of Methamphetamine Dependence The Methamphetamine Treatment Project Corporate Authors* Addiction (June, 2004)

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.

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.

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

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

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

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

Primary Measures to Build the Model Retention, Retention, Retention Retention, Retention, Retention Drug-free UA’s Drug-free UA’s

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

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

Project Goals: To study the clinical effectiveness of the Matrix Model To compare the effectiveness of the Matrix model to other locally available outpatient treatments To establish the cost and cost effectiveness of the Matrix model compared to other outpatient treatments To explore the replicability of the Matrix model and challenges involved in technology transfer

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

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 Relapse Prevention Weeks 1-16  Urine or breath alcohol tests once per week, weeks 1-16

Baseline Demographics Participants Served (n) 1016 Age (mean) 32.8 years Education (mean) 12.2 years Methamphetamine Use (mean) 7.5 years Marijuana Use (mean) 7.2 years Alcohol Use (mean) 7.6 years

Gender Distribution of Participants

Ethnic Identification of Participants

Marital Status of Participants

Employment Status of Participants

Route of Methamphetamine Administration

Changes from Baseline to Treatment-end

Days Paid for Work in Past 30 Possible is 0-30; t paired =6.01; p-value<0.000 (highly sig.)

Total Income (Past 30 days) of Participants t paired =2.34; p-value=0.02 (sig.)

ASI Composite Scores Possible is 0-1; Higher : worse problem t paired : *p-value<0.03 (sig.), **p-value<0.000 (highly sig.)

Days of Methamphetamine Use in Past 30 (ASI) Possible is 0-30; t paired =20.90; p-value<0.000 (highly sig.)

Days of Marijuana Use in Past 30 (ASI) Possible is 0-30; t paired =8.02; p-value<0.000 (highly sig.)

Days of Alcohol Use in Past 30 (ASI) Possible is 0-30; t paired =6.47; p-value<0.000 (highly sig.)

Beck Depression Inventory (BDI) Total Scores Possible is 0-63; t paired =16.87; p-value<0.000 (highly sig.)

BSI Scores (mean) BL 1 Tx-end Paired t * Somatization Obsessive-Compulsive Interpersonal Sensitivity Depression Anxiety Hostility Phobic Anxiety Paranoid Ideation Psychoticism Possible, all scores, is 0-4; * all p-values<0.000 (highly sig.)

Positive Symptom Total (PST) from Brief Symptom Inventory (BSI) Possible is 0-53; t paired =14.33; p-value<0.000 (highly sig.)

Mean Number of Weeks in Treatment

Figure 3. Participant retention throughout treatment, by site and treatment group

Mean Number of UA’s that were MA-free during treatment

Figure 6. Participant self-report of MA use (number of days during the past 30) at enrollment, discharge, and 6-month follow-up, by treatment condition

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.

Outcomes of Treatment for Methamphetamine Use: LA County (“Treatment-as-Usual”) M.-L. Brecht UCLA Integrated Substance Abuse Programs

Purpose Describe time to relapse to MA use Describe time to relapse to MA use Identify predictors of longer time to relapse Identify predictors of longer time to relapse Describe other outcome measures (% months with MA use, crime, employment) Describe other outcome measures (% months with MA use, crime, employment)

Design Random sample of MA admissions (mostly from 1996) Random sample of MA admissions (mostly from 1996) From Los Angeles county-funded outpatient and residential programs From Los Angeles county-funded outpatient and residential programs 76% of sampled clients were located; 75% of those participated in study (n=365) 76% of sampled clients were located; 75% of those participated in study (n=365) Interviewed in , follow-up in Interviewed in , follow-up in Analysis sample n=350 Analysis sample n=350 Data from detailed natural history interview Data from detailed natural history interview

Sample (n=350) Gender:56% male, 44% female Gender:56% male, 44% female Ethnicity:47% non-Hispanic White Ethnicity:47% non-Hispanic White 30% Hispanic 17% African-American 6% other 6% other Education:32% less than high school Education:32% less than high school 21% high school grad/GED 47% some college/tech/trade school

Average Age First Use of Substance 13yr Alcohol Marijuana Tobacco Heroin Tranquilizers Ecstasy Crack Inhalants Downers Hallucinogens PCP Cocaine Methamphetamine % have used Over 50% have used Less than 50% have used

Sampled Treatment Episode Age at admission29.4 yr. Age at admission29.4 yr. Residential62% Residential62% Outpatient 38% Outpatient 38% Legal pressure51% Legal pressure51% 1st time in treatment 58% 1st time in treatment 58% Time in treatment3.7 mo. Time in treatment3.7 mo. Completed tx 46% Completed tx 46%

Results—Predictors of Time to Relapse (multivariate Cox model, predictors p<.05) Predictor Risk ratio (95% CI) Parental divorce 1.36* ( ) MA sales 1.36* ( ) No. months in tx.93** ( ) No. individual counseling sessions.98* ( ) *p<.05, **p<.01, model chi-square=30.6, df=4, p<.001

Better outcomes for those Better outcomes for those  With longer time in treatment (e.g. those with 4 or more mo. of treatment have almost double the rate of 24 and 48 mo. abstinence)  With more sessions per month of individual counseling Worse outcomes for those Worse outcomes for those  Who have sold MA

Pattern of Relapse: Graph Shows Difference Between Less vs. More Vulnerable More vulnerable=with MA sales (n=129) Less vulnerable=all others

Pattern of Relapse: More Vulnerable Split into 2 Groups (More Treatment vs. Less Treatment) More treatment (n=65) = 4 or more months of tx and/or 4 or more individual counseling sessions

Other Outcomes: % of Months with MA Use, Crime, Employment Before, During, and After Treatment

Other Clinical Issues Meth injectors have poorer outcomes than those who use via IN or smoke Meth injectors have poorer outcomes than those who use via IN or smoke Major relapse factors Major relapse factors  Marijuana use  Alcohol use  High availability of meth  Staying around other meth users