1. Meth Summit Monday, October 16, 2006 Sponsored by the County Commissioners Of Larimer and Weld Counties What about Meth treatment?

2. What does the research indicate about treatment?

3. Investigational Medication for High Blood Pressure Treatment Works!!!

4. New Behavioral Treatment for Methamphetamine Use Treatment Failed!!!

5. Relapse Rates Are Similar for Drug Dependence and Other Chronic Illnesses Relapse Rates Are Similar for Drug Dependence and Other Chronic Illnesses 0 0 10 20 30 40 50 60 70 80 90 100 Drug Dependence Drug Dependence Type I Diabetes Type I Diabetes Hypertension Asthma 40 to 60% 30 to 50% 50 to 70% Source: McLellan, A.T. et al., JAMA, Vol 284(13), October 4, 2000. Percent of Patients Who Relapse

6. Limitations on Current Treatments Training and development of knowledgeable clinical personnel are essential elements to successfully address the challenges of treating MA users. Training and development of knowledgeable clinical personnel are essential elements to successfully address the challenges of treating MA users. Training alone is insufficient if the funding necessary to deliver these treatment recommendations is not available. Training alone is insufficient if the funding necessary to deliver these treatment recommendations is not available. Treatment funding policies that promote short duration or non-intensive outpatient services are inappropriate for providing adequate funding for MA users. Treatment funding policies that promote short duration or non-intensive outpatient services are inappropriate for providing adequate funding for MA users.

7. Predictors of Retention in Treatment for more than 90 days 1. Higher rates of retention for men 2. Legal supervision increases treatment retention 3. Injection users were retained more poorly 4. Those with chronic mental illness were retained more poorly 5. Daily users are retained more poorly than those who use less often than daily 6. Those who began use at an older age were retained better than those who started when younger 7. Those who are older at admission were retained better

8. Optimal candidates for outpatient treatment include: Those who do not inject MA. Those who do not inject MA. Those without chronic mental illness and those without significant psychiatric symptoms at admission. Those without chronic mental illness and those without significant psychiatric symptoms at admission. Those who are using MA less than daily at admission. Those who are using MA less than daily at admission. Those under legal supervision (especially drug court). Those under legal supervision (especially drug court). Older individuals (over 21)Those who are not disabled. Older individuals (over 21)Those who are not disabled. Those who have a stable living situation (without active drug users). Those who have a stable living situation (without active drug users).

9. Successful Outpatient Treatment Predictors Durations over 90 days (with continuing care for another 9 months). Durations over 90 days (with continuing care for another 9 months). Techniques and clinic practices that improve treatment retention are critical. Techniques and clinic practices that improve treatment retention are critical. Treatment should include 3-5 clinic visits per week for at least 90 days. Treatment should include 3-5 clinic visits per week for at least 90 days.

10. Successful Outpatient Treatment Predictors Employ evidence-based practices [i.e., CBT, CM, Community Reinforcement Approach, Motivational Interviewing, Matrix Model]. Employ evidence-based practices [i.e., CBT, CM, Community Reinforcement Approach, Motivational Interviewing, Matrix Model]. Family involvement and 12-step programs appear to improve outcome. Family involvement and 12-step programs appear to improve outcome. Urine testing (at least weekly is recommended) Urine testing (at least weekly is recommended)

11. Special treatment consideration should be made for the following groups of individuals: Female MA users (higher rates of depression; very high rates of previous and present sexual and physical abuse; responsibilities for children). Female MA users (higher rates of depression; very high rates of previous and present sexual and physical abuse; responsibilities for children). Injection MA users (very high rates of psychiatric symptoms; severe withdrawal syndromes; high rates of hepatitis). Injection MA users (very high rates of psychiatric symptoms; severe withdrawal syndromes; high rates of hepatitis). MA users who take MA daily or in very high doses. MA users who take MA daily or in very high doses.

12. Special treatment consideration should be made for the following groups of individuals: Homeless, chronically mentally ill and/or individuals with high levels of psychiatric symptoms at admission. Homeless, chronically mentally ill and/or individuals with high levels of psychiatric symptoms at admission. Individuals under the age of 21. Individuals under the age of 21. Gay men (at very high risk for HIV and hepatitis). Gay men (at very high risk for HIV and hepatitis).

13. Assumptions in Working with Mandated Clients Someone who continues to use is in denial. in denial. The best way to break through the denial is direct confrontation.

14. Assumptions in Working with Mandated Clients People change only when they have to. People change only when they have to. The first and most important step in recovery is to admit and accept the fact that you have the disease of addiction. The first and most important step in recovery is to admit and accept the fact that you have the disease of addiction.

15. What Research Tells Us about Addiction People with drug and alcohol dependencies do not have unique personalities

16. What Research Tells Us about Denial People with dependencies show no higher level of denial than the normal population Measures of denial are not clearly related to treatment or outcome

17. What Research Tells Us about Treatment Patient drug use, compliance, and outcome are powerfully influenced by therapist characteristics and environment Direct confrontation yields poorer compliance and outcomes

18. Motivation for Treatment Why is it harder for a stimulant abuser to enter the treatment system? Why is it harder for a stimulant abuser to enter the treatment system? What does it mean to say someone is motivated to do treatment? What does it mean to say someone is motivated to do treatment? How can we compete with the pull of drugs like methamphetamine? How can we compete with the pull of drugs like methamphetamine?

19. Methamphetamine Withdrawal Depression Depression Difficulty Concentrating Difficulty Concentrating Severe Cravings Severe Cravings Paranoia Paranoia Exhaustion Exhaustion Confused Confused

20. 1. Express Empathy Acceptance facilitates change Skillful reflective listening is fundamental Ambivalence is normal

21. 2. Develop Discrepancy Awareness of consequences is important Discrepancy between behaviors and goals motivates change Have the client present reasons for change

22. 3. Avoid Argumentation Resistance is signal to change strategies Labeling is unnecessary Shift perceptions Clients attitudes shaped by their words, not yours

23. 4. Support Self-Efficacy Belief that change is possible isimportant motivator Client is responsible for choosing and carrying out actions to change There is hope in the range of alternative approaches available

24. How Stimulants Effect the Willingness to Enter Treatment Methamphetamine does NOT make you sick; therefore, the drug use is not the problem. Methamphetamine allows long periods of no drug use; certainly the drug is not the problem.

25. Treatments for Methamphetamine Cognitive Behavioral Therapies Motivational Interviewing Contingency Management MATRIX Model New Medications (treatment and overdose) are being developed

26. Brief cognitive behavioral interventions for regular amphetamine users: a step in the right direction Design: RTC Design: RTC Intervention: 2 session vs 4 session CBT Intervention: 2 session vs 4 session CBT Findings There was a significant increase in the likelihood of abstinence from amphetamines among those receiving two or more treatment sessions. Findings There was a significant increase in the likelihood of abstinence from amphetamines among those receiving two or more treatment sessions. –The number of treatment sessions attended had a significant short-term beneficial effect on level of depression. –There was a marked reduction in amphetamine use among this sample over time for both groups. –Reduction in amphetamine use was accompanied by significant improvements in stage of change, benzodiazepine use, tobacco smoking, polydrug use, injecting risk-taking behavior, criminal activity level, and psychiatric distress and depression level. Baker, et al; Addiction: Vol 100, March 2005

27. Cognitive Behavioral Therapy & Contingency Management for Stimulant Dependence Design Randomized clinical trial. Design Randomized clinical trial. Participants Stimulant-dependent individuals (n=171). Participants Stimulant-dependent individuals (n=171). Intervention CM, CBT, or combined CM and CBT, 16-week treatment conditions. CM condition participants received vouchers for stimulant-free urine samples. CBT condition participants attended three 90-minute group sessions each week. Intervention CM, CBT, or combined CM and CBT, 16-week treatment conditions. CM condition participants received vouchers for stimulant-free urine samples. CBT condition participants attended three 90-minute group sessions each week. Results CM procedures produced better retention and lower rates of stimulant use during the study period. Results CM procedures produced better retention and lower rates of stimulant use during the study period. –Self-reported stimulant use was reduced from baseline levels at all follow-up points for all groups and urinalysis data did not differ between groups at follow-up. –While CM produced robust evidence of efficacy during treatment application, CBT produced comparable longer- term outcomes. There was no evidence of an additive effect when the two treatments were combined. The response of cocaine and methamphetamine users appeared comparable. Rawson, RA et al. Addiction, Jan 2006

28. Cognitive Behavioral Therapy & Contingency Management for Stimulant Dependence (contd) Conclusions: Conclusions: –CM is an efficacious treatment for reducing stimulant use –CM is superior during treatment to a CBT approach. –CM is useful in engaging substance abusers, retaining them in treatment, and helping them achieve abstinence from stimulant use. –CBT also reduces drug use from baseline levels and produces comparable outcomes on all measures at follow-up. Rawson, RA et al. Addiction, Jan 2006

29. Motivation Interviewing Goals Increase Motivation Increase Motivation Decrease Resistance Decrease Resistance Increase retention Increase retention Better outcomes Better outcomes

30. Four Principles of Motivational Interviewing 1.Express empathy 2.Develop discrepancy 3.Avoid argumentation 4.Support self- efficacy

31. BUILDING MOTIVATION OARS Open-ended questioning Affirming Reflective listening Summarizing

32. Contingency Management A technique employing the systematic delivery of positive reinforcement for desired behaviors. In the treatment of methamphetamine dependence, vouchers or prizes can be earned for submission of methamphetamine-free urine samples. A technique employing the systematic delivery of positive reinforcement for desired behaviors. In the treatment of methamphetamine dependence, vouchers or prizes can be earned for submission of methamphetamine-free urine samples.

33. Contingency Management for treatment of methamphetamine dependence Design: RTC Design: RTC Method: 113 patients diagnosed with methamphetamine abuse or dependence were randomly assigned to receive either treatment as usual (TAU) or TAU plus contingency management. Method: 113 patients diagnosed with methamphetamine abuse or dependence were randomly assigned to receive either treatment as usual (TAU) or TAU plus contingency management. Results indicate that both groups were retained in treatment for equivalent times Results indicate that both groups were retained in treatment for equivalent times –those in the combined group accrued more abstinence and were abstinent for a longer period of time. –These results suggest that contingency management has promise as a component in methamphetamine use disorder treatment strategies. Roll, JM et al, Archives of General Psychiatry, (In Press)

34. MSM-specific cognitive behavioral therapy, and contingency management for the treatment of methamphetamine dependent MSMs Design: Randomized clinical trial Design: Randomized clinical trial Methods: 162 MSM randomly assigned to one of 4 conditions; CM, CBT, CBT plus CM, MSM-specific CBT. Methods: 162 MSM randomly assigned to one of 4 conditions; CM, CBT, CBT plus CM, MSM-specific CBT. Results: All conditions showed significant reductions in meth use by self-report and urinalysis, Results: All conditions showed significant reductions in meth use by self-report and urinalysis, –CM and CM plus CBT showing significantly better reductions. –Gay specific intervention also showed promise. Shoptaw et al Drug and Alcohol Dependence, 79, 2005

37. Matrix Model Is a manualized, 16-week, non-residential, psychosocial approach used for the treatment of drug dependence. Is a manualized, 16-week, non-residential, psychosocial approach used for the treatment of drug dependence. Designed to integrate several interventions into a comprehensive approach. Elements include : Designed to integrate several interventions into a comprehensive approach. Elements include : –Individual counseling –Cognitive behavioral therapy –Motivational interviewing –Family education groups –Urine testing –Participation in 12-step programs

38. Matrix Model in Treatment of Methamphetamine Dependence Design: Randomized clinical trial. Design: Randomized clinical trial. Method: 978 treatment-seeking, MA-dependent persons were randomly assigned to receive either TAU at each site, or a manualized 16-week treatment (Matrix Model) for their MA dependence. Method: 978 treatment-seeking, MA-dependent persons were randomly assigned to receive either TAU at each site, or a manualized 16-week treatment (Matrix Model) for their MA dependence. Results: Those who were assigned to Matrix treatment: Results: Those who were assigned to Matrix treatment: –attended more clinical sessions, –stayed in treatment longer, –provided more MA-free urine samples during the treatment period, and –had longer periods of MA abstinence than those assigned to receive TAU. Rawson, R et al Addiction vol 99, 2004

39. Matrix Model in Treatment of Methamphetamine Dependence (contd) Measures of drug use and functioning collected at treatment discharge and 6 months post- admission indicate significant improvement by participants in all sites and conditions when compared to baseline levels, but the superiority of the Matrix approach did not persist at these two time points. Measures of drug use and functioning collected at treatment discharge and 6 months post- admission indicate significant improvement by participants in all sites and conditions when compared to baseline levels, but the superiority of the Matrix approach did not persist at these two time points. Conclusions: Study results demonstrate a significant initial step in documenting the efficacy of the Matrix approach. Although the superiority of the Matrix approach over TAU was not maintained at the posttreatment time points, the in-treatment benefit is an important demonstration of empirical support for this psychosocial treatment approach. Conclusions: Study results demonstrate a significant initial step in documenting the efficacy of the Matrix approach. Although the superiority of the Matrix approach over TAU was not maintained at the posttreatment time points, the in-treatment benefit is an important demonstration of empirical support for this psychosocial treatment approach. Rawson, R et al Addiction vol 99, 2004

40. The Matrix Model: Organizing Principles 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.

41. Extensive Use of Positive Reinforcement Techniques 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. The Matrix Model: Organizing Principles

42. Accurate, understandable, scientific information used to educate patient and family member Effects of drugs and alcohol Addiction as a brain disease Critical issues in recovering from addiction Meth and sex Conditioned cues and craving The Matrix Model: Organizing Principles

43. 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 The Matrix Model: Organizing Principles

44. 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 The Matrix Model: Organizing Principles

45. 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 The Matrix Model: Organizing Principles

46. Matrix Model Treatment Key Concept: Structure Self-designed structure (scheduling) Eliminate avoidable triggers Makes concrete the concept of One day at a time Reduces anxiety Counters the addict lifestyle Provides basic foundation for ongoing recovery

47. MATRIX MODEL TREATMENT STRUCTURE Treatment Program Activities Recreational/Leisure Activities 12-Step Meetings School SportsBeing with Drug-free Friends Time SchedulingExercise WorkFamily-related Events Church/SynagogueIsland Building

48. MATRIX MODEL TREATMENT Information - What - Substance abuse- Sex and recovery and the brain- Relapse prevention issues - Triggers and cravings- Emotional readjustment - Stages of recovery- Medical effects - Relationships and recovery - Alcohol/marijuana

49. MATRIX MODEL TREATMENT Information - Why Reduces confusion and guilt Explains addict behavior Gives a roadmap for recovery Clarifies alcohol/marijuana issue Aids acceptance of addiction Gives hope/realistic perspective for family

50. Medications Currently, there are no medications that can quickly and safely reverse life threatening MA overdose. Currently, there are no medications that can quickly and safely reverse life threatening MA overdose. There are no medications that can reliably reduce paranoia and psychotic symptoms, that contribute to episodes of dangerous and violent behavior associated with MA use. There are no medications that can reliably reduce paranoia and psychotic symptoms, that contribute to episodes of dangerous and violent behavior associated with MA use.

51. Status of Medication Research for Methamphetamine Dependence Negative Results Under Consideration Imipramine Gabapentin Imipramine Gabapentin Desipramine Modafinil Desipramine Modafinil Tyrosine Topirimate Tyrosine Topirimate Ondansetron Disulfiram Ondansetron Disulfiram Fluoxetine Lobeline Fluoxetine Lobeline Aripiprazole Aripiprazole Promising Evidence: Bupropion; Methylphenidate SR

52. Promising Pharmacotherapies? Bupropion reduces craving and reinforcing effects of methamphetamine in a laboratory self- administration study. Newton, T. et al (Biological Psychiatry, Dec, 2005) Bupropion reduces craving and reinforcing effects of methamphetamine in a laboratory self- administration study. Newton, T. et al (Biological Psychiatry, Dec, 2005) Bupropion reduces meth use in an outpatient trial, with particularly strong effect with less severe users. Elkashef, A. et al (recently completed; reported at the ACNP methamphetamine satelite meeting in Kona, Hawaii) Bupropion reduces meth use in an outpatient trial, with particularly strong effect with less severe users. Elkashef, A. et al (recently completed; reported at the ACNP methamphetamine satelite meeting in Kona, Hawaii) Methylphenidate SR (sustained release) has shown promise in a recent Finnish study with very heavy amphetamine injectors. Tiihonen, J. et al (recently completed; reported at the ACNP methamphetamine satelite meeting in Kona, Hawaii) Methylphenidate SR (sustained release) has shown promise in a recent Finnish study with very heavy amphetamine injectors. Tiihonen, J. et al (recently completed; reported at the ACNP methamphetamine satelite meeting in Kona, Hawaii)

53. For more information, contact: (Most information in this presentation was taken from Thomas Freese) Thomas E. Freese, Ph.D. 310-445-0874 x304 tefreese@ix.netcom.com www.psattc.org www.uclaisap.org Or Kendall P. Alexander, LCSW Island Grove Regional Treatment Center 970-313-1186 kalexander@islandgrovecenter.org