Treatments for Methamphetamine-Related Disorders I (General) Richard A. Rawson, Ph.D. UCLA Integrated Substance Abuse Programs CATES Conference, August 20, 2004 Sacramento, California

Methamphetamine (MA): Psychiatric Consequences Paranoid reactions Permanent memory loss Depressive reactions Hallucinations Psychotic reactions Panic disorders Rapid addiction

MA Treatment Issues Acute MA Overdose Acute MA Psychosis MA “Withdrawal” Initiating MA Abstinence MA Relapse Prevention Protracted Cognitive Impairment and Symptoms of Paranoia

Acute MA Overdose Slowing of Cardiac Conduction Ventricular Irritability Hypertensive Episode Hyperpyrexic Episode CNS Seizures and Anoxia

Acute MA Psychosis Extreme Paranoid Ideation Well Formed Delusions Hypersensitivity to Environmental Stimuli Stereotyped Behavior “Tweaking” Panic, Extreme Fearfulness High Potential for Violence

Treatment of MA Psychosis Typical ER Protocol for MA Psychosis: Haloperidol - 5mg 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

Treatment of MA “Withdrawal” 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: 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: Depression Cognitive Impairment Continuing Paranoia Anhedonia Behavioral/Functional Impairment Hypersexuality Conditioned Cues Irritability/Violence

Initiating MA Abstinence Key Elements of Treatment: Structure Information in Understandable Form Family Support Positive Reinforcement 12-Step Participation No Pharmacologic Agent Currently Available

Treatment of MA Disorders Traditional Treatments: Therapeutic Community Minnesota Model Outpatient Counseling Psychotherapy

Treatment of MA Disorders State of Empirical Evidence: No Information on TC or “Minnesota Model” Approaches No Pharmacotherapy with Demonstrated Efficacy Results of Cocaine Treatment Research Extrapolated to MA Treatment

Treatments for Stimulant-Use Disorders with Empirical Support Motivational Interviewing Cognitive-Behavioral Therapy (CBT) Community Reinforcement Approach Contingency Management Matrix Model

Motivational Interviewing, 2nd Edition, Miller and Rollnick We can’t help wondering, why don’t people change? You would think: that having had a heart attack would be enough to persuade a man to quit smoking, change his diet, exercise more, and take his medication. Addictive behaviors persist despite overwhelming evidence of their destructiveness. A needs assessment is a useful process to help a buprenorphine patient identify problem areas beyond the immediate drug addiction. Social issues: amount of drug and alcohol use in the social environment; unemployment; dependence on illegal sources of income; eligibility for public assistance; need for housing; legal problems.

Early Recovery Issues Engaging and Retaining Motivational Interviewing Elicit behavior change Respect autonomy Slide 11 Another way to envision this process is to see the Trigger - Thought - Craving - Use sequence as moving along a steep downhill slide. The time to use Thought Stopping is right after one recognizes the first thought of using. The biological process, as shown by the small circle moving towards the man, is still relatively small. It is possible to stop this process when it is in the craving stage, but much more difficult. When in craving mode, the small circle is now enormous -- a huge mountain. The addict/alcoholic may truly not want to use and attempt to deflect the cravings, but more often than not, the cravings are so powerful that they roll over the addict/alcoholic propelling him/her to relapse. Tolerate patient ambivalence Explore consequences

Stages of Change Prochaska & DiClemente Precontemplation Contemplation Preparation Action Maintenance

Affirmations Patient-focused Intended to: Support patient’s involvement Encourage continued attendance Assist patient in seeing positives Support patient’s strengths Audience give examples of affirmations

Reflective Listening Listen to what patient says and to what patient means Check out assumptions Create an environment of empathy (nonjudgmental) Patient and counselor do not have to agree Be aware of intonation (statement, not question) Demonstrate difference between question and reflection, give some to the audience to train

Summarizing Summaries capture both sides of the ambivalence: (You say that ___________ but you also mentioned that ________________). Summaries also prompt clarification and further elaboration from the patient.

Change Talk Recognizing the problem Expressing concern Stating intention to change Being optimistic about change

Providing Feedback Elicit (ask for permission) Give feedback or advice Elicit again (the patient’s view of how the advice will work for him/her)

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 help patients: Recognize Situations Avoid Situations Cope with Problems and Behaviors

Cognitive Behavioral Therapy Functional Analysis Feelings Before and After Use Thoughts Circumstances

Cognitive Behavioral Therapy 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

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

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

Contingency Management 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: 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     Richard A. Rawson, Ph.D. and The Methamphetamine Treatment Project Corporate Authors* Addiction (June, 2004)