1. What is the evidence for time limiting addiction treatment?

2.  Survey of treatment literature on time limited treatment  Few true randomized trials..  Different conclusions based on patient group (severity, comorbidy problems, type of substance)  Implications for rebuilding a treatment system

3.  1271 index admissions to publicly funded clinics (cocaine 64%, alcohol 44%, opioids 41%, marijuana 14%; 59% female, 87% AA)  3 year follow up (98% of those living, 35 died )  47% attain 12 months of abstinence  Mean time from first use to first treatment= 9 years  Median time from first to last use = 27 years.  Longer treatment career for males, those with earlier first use (esp <15), multiple treatment episodes, and mental distress.

5. None Moderate Severe Mild Intensity of behavior Level of problems Dependence Abuse Problems Likely intensity/ Duration of treatment Duration of treatment Should be proportional to severity, chronicity Of use and related problems

6.  Response generally happens early  More of a bad thing is rarely better.  More of a good thing is probably better  Its probably better to think about time to the targeted outcome (abstinence)

7.  If the good thing is an effective empirically validated therapy.  Brief therapies effective first line for lower severity individuals—Good evidence for alcohol  Few well-done trials where a well-defined cohort is randomized to different lengths of an empirically validated therapy

9. 118 methamphetamine users, 4 month treatment

10.  653 treatment seeking individuals dependent on prescription opioids  Adaptive treatment model:  Phase 1: 2 week buprenorphine/naloxone stabilization + 2 week taper, 8 week follow up  Successful patients (no opioid use at end of tratment) complete  Unsuccessful patients enter Phase II. ▪ 12 weeks bup/nal, 4 week taper, 8 week follow-up

11. 653 randomized 5% successful phase 1 50 % successful Phase 2 9% successful at final week follow-up

12.  Buprenorphine, naltrexone, methadone etc. tend to be effective only while the individual is taking it  Medications are opportunities to provide treatment and services to support sustained change  Stepwise discontinuation with frequent monitoring.

13.  CM very effective while contingencies in place  Dropoff after contingencies stop  But…..those who attain longer periods of abstinence better outcomes in follow-up  Petry proposal-After care model, VI schedule of reinforcement up to 6 months. If missing or positive, frequency increases  Likely to be less expensive and more acceptable to patients than standard aftercare

14.  7 modules, ~1 hour each, high flexibility  Highly user friendly, no text to read, linear navigation  Based on NIDA CBT manual  Multiple strategies for presenting skills  Video examples of characters struggling real life situations  Repeat movie with character using skills to change ‘ending’  Interactive exercises, quizzes  Multiple examples of ‘homework’

15.  Highly engaging-capture attention of substance users, retain them in treatment  Deliver potent dose of evidence based cognitive and behavioral strategies-  Focus on key generalizable skills  Durability of effects-skills practice  Modeling-demonstration of skills in realistic situations under stress  Breadth of users-all drugs, balance of gender and ethnicity  Security- NO identifying information or PHI

17.  8 week randomized clinical trial  Outpatient community treatment program  Standard treatment (weekly individual + group therapy) (TAU) vs. CBT4CBT + TAU  CBT4CBT offered in up to 2 weekly sessions  6 month follow-up Carroll et al., Am J Psychiatry, 2008

18. “All comers”: few restriction on participation, only require some drug use in past 30 days  43% female  45% African American, 12% Hispanic  23% employed  37% on probation/parole  59% primary cocaine problem, 18% alcohol, 16% opioids, 7% marijuana  79% users of more than one drug or alcohol

19. Carroll et al., 2008, Am J Psychiatry

21. Kiluk et al, Addiction, 2010

22. CBT v TAU % positive urine Coping Skills (1) b=5.2* (4) b=3.3 (2) b=.3* (3) b=8.3** Kiluk et al, Addiction, 2010

23. Carroll et al., 2009, DAD

24.  101 DSM-IV cocaine-dependent methadone maintained opioid users population  Standard treatment (weekly group therapy) (TAU) vs. CBT4CBT + TAU  CBT4CBT offered in up to 2 weekly sessions,  6 month follow-up  Sample: 60% female, 40% minority, 89% unemployed, higher levels psychiatric comorbidity (29% depressive disorder, 30% anxiety disorder), multiple other substance use Carroll et al., under review

27. Figure 2: STROOP task: Comparison of Post- to Pretreatment, CBT4CBT versus TAU Stroop activity decreases from pre- to post- CBT4CBT but not TAU X-=21pFWE=.05 CBT Stroop Post > Pre TAU Stroop Post > Pre

28.  Self help for less severe cases/treatment entry -Use until abstinent or treatment indicated  Medication platforms (office based buprenorphine)  Use until stabilized  Outpatient care Endpoint-abstinence, demonstration of skills

29.  SBIRT: Referral for treatment without following through  Office based buprenorphine without assertive care  Multiple admissions for the same ineffective treatment (detoxification only)  Persisting in a treatment to which the patient has not responded.  Discharging patients for being symptomatic

30. Assess -Severity -Comorbid problems -Resources Treat to criterion Objective, clinically meaningful outcome Increase intensity Add medication Add CM Add support Decrease intensity Taper Support monitor Re-assess Predetermined time Clear feedback on criterion Evaluation of mechanism