EMPIRICALLY-SUPPORTED TREATMENTS FOR STIMULANT DEPENDENCE RICHARD A. RAWSON, Ph.D. UCLA INTEGRATED SUBSTANCE ABUSE PROGRAMS (ISAP) October 9, 2004

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

Cognitive Behavioral Therapy Based upon Social Learning Theory (Bandura and others) Based upon Social Learning Theory (Bandura and others) Also referred to as Relapse Prevention Therapy Also referred to as Relapse Prevention Therapy Applied to treatment of alcoholism, cocaine dependence, nicotine dependence and marijuana abuse. Applied to treatment of alcoholism, cocaine dependence, nicotine dependence and marijuana abuse.

Cognitive Behavioral Therapy Key Concepts Key Concepts  Encouraging and reinforcing behavior change  Recognizing and avoiding high risk settings  Behavioral planning (scheduling)  Coping skills  Conditioned “triggers”  Understanding and dealing with craving  Abstinence violation effect  Understanding basic psychopharmacology principles  Self-efficacy

Cognitive Behavioral Therapy Resources Resources  Marlatt and Gordon 1985  NIDA CB Manual  NIAAA Project Match CB Manual  Gorski Publications  Washton Publications

Motivational Interviewing Based upon Prochaska and DiClemente Stages of Change Theoretical Model Based upon Prochaska and DiClemente Stages of Change Theoretical Model Also referred to as Motivational Enhancement Therapy Also referred to as Motivational Enhancement Therapy Applied with many substances, data primarily with alcoholics Applied with many substances, data primarily with alcoholics Major Publications/Studies: Miller and Rollnick, 1991; Project MATCH Major Publications/Studies: Miller and Rollnick, 1991; Project MATCH

Motivational Interviewing Basic Assumptions Basic Assumptions  People change their thinking and behavior according to a series of stages  Individuals may enter treatment at different “stages of change”  It is possible to influence the natural change process with MI techniques  MI can be used to engage individuals in longer term treatment and to promote specific behavior changes  Confrontation of “denial” can be counterproductive and or harmful to some individuals

Motivational Interviewing Key Concepts Key Concepts  Empathy and therapeutic alliance  Give feedback and reframe  Create dissonance  Focus of discrepancy of expected and actual  Reinforce change  Roll with resistance

Motivational Interviewing Resources Resources  Miller and Rollnick 1991  NIAAA Project MATCH manual  CSAT TIP on Motivational Techniques  NIDA Tool Box

Community Reinforcement Approach Basic assumptions Basic assumptions  Drug and alcohol use are positively reinforced behaviors. They can be reduced/eliminated by proper application of behavioral techniques.  To successfully build an effective intervention, some techniques should focus on reducing drug and alcohol use and others should focus on acquisition of new incompatible behaviors.

Community Reinforcement Approach Key concepts Key concepts  Behavioral analysis and teach conditioning information  Positive reinforcement with vouchers for drug free urine samples  Behavioral marriage counseling  Shape and reinforce new behavioral repertoire  Coping skill/Drug refusal skill training  Vocational Counseling  Frequent urine testing

Community Reinforcement Approach Resources Resources  Meyers and Smith 1995  NIDA CRA Manual  Higgins and Silverman 2000

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 pro-social alternative behaviors

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

Matrix Model of Outpatient Treatment Organizing Principles of Matrix Treatment Create explicit structure and expectations Establish positive, collaborative relationship with patient Teach information and cognitive-behavioral concepts Positively reinforce positive behavior change

Matrix Model of Outpatient Treatment Organizing Principles of Matrix Treatment (cont.) Provide corrective feedback when necessary Educate family regarding stimulant abuse recovery Introduce and encourage self-help participation Use urinalysis to monitor drug use

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

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

Matrix Model: Resources Matrix Treatment Manual (Matrix Institute, Matrix Treatment Manual (Matrix Institute, CSAT TIP 33 CSAT TIP 33 CSAT TAP Matrix Manual CSAT TAP Matrix Manual