methamphetamine south dakota day 2 methamphetamine treatment contingency management matrix model

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  • Methamphetamine

    South Dakota Day 2

  • Methamphetamine Treatment

    Contingency ManagementMatrix Model

  • Combined data from several pilot studies (Roll, Huber, et al., in press; Roll & Shoptaw, in pressAll studies provided vouchers with specified monetary values for the provision of urine samples which indicated no recent methamphetamine use.Urines were collected under direct observation.Vouchers could be exchanged for goods or services that were congruent with developing a drug free lifestyle

  • Cm Amph

    9.55.81.30.9

    14101.20.98

    CM (n=55)

    Standard care (n=69)

    Number of samples

    mean meth neg

    Slow Esc. + Bonus86

    Slow Esc.63

    De-Esc + Bonus86

    Standard25

    Means

    % relapsing following 4-wks of abstinence

    mean abs

    192.4

    92

    Mean number of abstinences

    Mean number of abstinences

    Sheet1

    MeansSEMs

    Mean number of abstinences

    CM192.4

    Control92

    MeansSEM

    Slow Esc. + Bonus86

    Slow Esc.63

    De-Esc + Bonus86

    Standard25

    Sheet2

    Sheet3

  • Cm Amph

    9.55.81.30.9

    14101.20.98

    CM (n=55)

    Standard care (n=69)

    Number of samples

    mean meth neg

    Slow Esc. + Bonus86

    Slow Esc.63

    De-Esc + Bonus86

    Standard25

    Means

    % relapsing following 4-wks of abstinence

    mean abs

    41

    1.11.1

    Mean number of abstinences

    Mean weeks of consecutive abstinence

    Sheet1

    MeansSEMs

    Mean number of abstinences

    CM41

    Control1.11.1

    MeansSEM

    Slow Esc. + Bonus86

    Slow Esc.63

    De-Esc + Bonus86

    Standard25

    Sheet2

    Sheet3

  • CTN 006 methamphetamine data(Roll, et al.,in prep.)Used the variable magnitude of reinforcement procedure developed by Petry. 113 methamphetamine abusing individuals were part of the larger trial.Received the chance to win prizes for the provision of stimulant negative urine samples.

  • Methamphetamine Outcomes from CTN 006

    Cm Amph

    9.55.81.30.9

    14101.20.98

    CM (n=55)

    Standard care (n=69)

    Number of samples

    Sheet1

    MeansSEMs

    LDA# Negative UrineLDA# Negative UrineUrines

    CM (n=55)9.5141.31.2

    Standard care (n=69)5.8100.90.98

    Sheet2

    Sheet3

  • The Matrix Model:It is many treatments in one

    Out-patient, office-basedEasy to understandStructure, structure, structureContinuing attendance is important

  • Organizing Principles of Matrix Treatment

    Program components based on scientific literature promoting behavior change

    Program elements and schedule selected based on empirical support in literature and application

  • Organizing Principles of Matrix Treatment

    Program focus is on behavior change in the present, not on assumed underlying psychopathology

    Matrix treatment is a process of coaching, supporting, reinforcing and supporting positive behavior change

  • Organizing Principles of Matrix Treatment

    Non-confrontational, non-judgmental relationship between therapist and patient creates positive bond which promotes program participation.

    Positive reinforcement, incentives and contingencies used extensively to promote treatment engagement and retention.

  • Organizing Principles of Matrix Treatment

    Accurate, understandable scientific information used to educate patient and family members

    Cognitive behavioral strategies used to promote drug cessation and relapse prevention

  • Organizing Principles of Matrix Treatment

    Family therapy interventions used to engage families in recovery process

    Self help resources introduced and participation encouraged

  • Organizing Principles of Matrix Treatment

    Urine and breath/alcohol testing used to monitor drug/alcohol use and support abstinence.

    Social support activities provided to help maintain abstinence

  • How it looks in PracticeMatrix Model of Outpatient Treatment

  • Matrix ModelPutting It All Together

    Week

    Monday

    Tuesday

    Wednesday

    Thursday

    Friday

    Saturday

    & Sunday

    Weeks

    1

    Through

    4

    6-7 pm

    Early

    Recovery

    Skills

    7-8:30 pm

    Relapse

    Prevention

    |

    |

    |

    |

    |

    |

    |

    7-8:30 pm

    Family

    Education

    Group

    |

    |

    |

    |

    |

    |

    |

    6-7 pm

    Early

    Recovery

    Skills

    7-8:30 pm

    Relapse

    Prevention

    12-Step

    Meetings

    and Other

    Recovery

    Activities

    Weeks

    5

    Through

    16

    7-8:30 pm

    Relapse

    Prevention

    Group

    |

    |

    12-Step

    Meeting

    |

    7-8:30 pm

    Family

    Education Group

    Or

    Transition

    Group

    |

    |

    12-Step

    Meeting

    |

    7-8:30 pm

    Relapse Prevention

    Group

    Weeks

    17

    Through

    52

    |

    |

    |

    |

    7-8:30 pm

    Social

    Support

    |

    |

    |

    |

    Urine testing and breath-alcohol testing conducted weekly

    One individual session is included in each of the program phases

  • Project Structure:Study SitesBillings, MTHonolulu, HISan Mateo, CA (2)San Diego, CAConcord, CACosta Mesa, CAHayward, CA Coordinating CenterUCLA Integrated Substance Abuse ProgramsSteering CommitteeScientific Advisory BoardCommunity Advisory Board

  • Baseline Demographics

  • Gender Distribution of Participants

  • Ethnic Identification of Participants

  • Route of Methamphetamine Administration

  • Changes from Baseline to Treatment-end

  • Days of Methamphetamine Use in Past 30 (ASI)Possible is 0-30; tpaired=20.90; p-value
  • Beck Depression Inventory (BDI) Total ScoresPossible is 0-63; tpaired=16.87; p-value
  • Positive Symptom Total (PST) from Brief Symptom Inventory (BSI)Possible is 0-53; tpaired=14.33; p-value
  • Mean Number of Weeks in Treatment

  • Mean Number of UAs that were MA-free during treatment

  • Figure 4. Percent completing treatment, by group

  • x2=4.68, p=0.031

    This completer measure is computed by comparing the last visit ever seen to the length of the treatment assigned.If the last visit seen is equal to the treatment length, the participant is a completer. If the last visit ever seen is less than the treatment length, the participant is not a completer.

  • 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

  • Overall Repeated measures analyses:The effect of TIME is wildly significant; F=124.43, p

  • Treatments for Stimulant-Use Disorders with Empirical SupportMotivational InterviewingCognitive-Behavioral Therapy (CBT)Community Reinforcement Approach Contingency ManagementMatrix Model

  • Motivational InterviewingBased upon Prochaska and DiClemente Stages of Change Theoretical ModelAlso referred to as Motivational Enhancement TherapyApplied with many substances, data primarily with alcoholicsMajor Publications/Studies: Miller and Rollnick, 1991; Project MATCH

  • Motivational InterviewingBasic AssumptionsPeople change their thinking and behavior according to a series of stagesIndividuals may enter treatment at different stages of changeIt is possible to influence the natural change process with MI techniquesMI can be used to engage individuals in longer term treatment and to promote specific behavior changesConfrontation of denial can be counterproductive and or harmful to some individuals

  • Motivational InterviewingKey ConceptsEmpathy and therapeutic allianceGive feedback and reframe Create dissonanceFocus of discrepancy of expected and actualReinforce changeRoll with resistance

  • Motivational InterviewingResourcesMiller and Rollnick 1991NIAAA Project MATCH manualCSAT TIP on Motivational TechniquesNIDA Tool Box

  • Substance Abuse Treatment 2004 The Increasing Role of ScienceMotivation Carrots and Sticks

  • One Way of ThinkingChange is motivated by discomfort.If you can make people feel bad enough, they will change.People have to hit bottom to be ready

    Corollary: People dont change because they havent suffered enoughThe Stick

  • Another Way of ThinkingPeople are ambivalent about changeConstructive behavior change comes from connecting with something valued, cherished and importantIntrinsic motivation for change comes out of an accepting, empowering, safe atmosphere where the painful present can be challengedPeople get stuck because of their ambivalence

    The Carrot

  • Motivational Interviewing, 2nd Edition. Miller and Rollnick We cant help wondering, why dont 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

  • Matrix Early Recovery Groups

  • Early Recovery Groups

    Scheduling and CalendarsTriggersQuestionnaires and Chart12 Step IntroductionAlcohol IssuesThoughts Emotions and BehaviorsKISS (and other 12-step slogans)

  • Early Recovery Issues Engaging and RetainingTRIGGERS

  • Triggers and Cravings

  • Triggers and CravingsPavlovs Dog: UCR

  • Triggers and CravingsPavlovs Dog: CR

  • Early Recovery Issues Engaging and Retaining

  • Early Recovery Issues Engaging and Retaining

  • MATRIX MODEL TREATMENT Triggers - PlacesDrug dealers homeBars and clubsDrug use neighborhoodsFreeway offrampsWorksiteStreet corners

  • MATRIX MODEL TREATMENT Triggers - ThingsParaphernaliaSexually explicit magazines/moviesMoney/bank machinesMusicMovies/TV shows about alcohol and other drugsSecondary alcohol or other drug use

  • MATRIX MODEL TREATMENT Triggers - TimesPeriods of idle timePeriods of extended stressAfter workPayday/AFDC payment dayHolidaysFriday/Saturday nightBirthdays/Anniversaries

  • MATRIX MODEL TREATMENT Triggers - Emotional States Anxiety Fatigue Anger Boredom Frustration Adrenalized states Sexual arousal Sexual deprivation Gradually building emotional states with no expected relief

  • THOUGHT STOPPINGPrevents the thought from developing into an overpowering cravingRequires practice

  • MOTIVATIONAL INTERVIEWINGIncrease MotivationDecrease ResistanceIncrease retentionBetter outcomes

  • MATRIX MODEL TREATMENTSTRUCTURE

  • MATRIX MODEL TREATMENTINFORMATION

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

  • MATRIX MODEL TREATMENT Information - WhyReduces confusion and guiltExplains addict behaviorGives a roadmap for recoveryClarifies alcohol/marijuana issueAids acceptance of addictionGives hope/realistic perspective for family

  • Triggers and CravingsHuman Brain

  • Cognitive Process During Addiction

    Relief FromDepressionAnxietyLonelinessInsomniaEuphoriaIncreased StatusIncreased EnergyIncreased Sexual/Social ConfidenceIncreased Work OutputIncreased Thinking AbilityAODIntroductory PhaseMay Be IllegalMay Be ExpensiveHangover/Feeling IllMay Miss Work

  • Conditioning Process During AddictionIntroductory PhaseTriggersPartiesSpecial OccasionsResponsesPleasant Thoughts about AODNo Physiological ResponseInfrequent UseStrength of Conditioned ConnectionMild

  • Development of Obsessive ThinkingIntroductory Phase

  • Development of Craving ResponseIntroductory PhaseEntering Using SiteUse of AODs Heart/Pulse Rate Respiration Adrenaline Energy TasteAOD Effects

  • Cognitive Process During AddictionMaintenance PhaseDepression ReliefConfidence BoostBoredom ReliefSexual EnhancementSocial LubricantVocational DisruptionRelationship ConcernsFinancial ProblemsBeginnings of Physiological Dependence

  • Conditioning Process During AddictionMaintenance PhaseStrength of Conditioned ConnectionTriggersPartiesFriday NightsFriendsConcertsAlcoholGood TimesSexual SituationsResponsesThoughts of AODEager Anticipation of AOD UseMild Physiological ArousalCravings Occur as Use ApproachesOccasional UseModerate

  • Development of Craving ResponseMaintenance PhaseEntering Using SitePhysiological ResponseUse of AODsAOD Effects Heart

    Breathing

    AdrenalineEffects

    EnergyTaste Heart

    Blood Pressure

    Energy

  • Cognitive Process During AddictionDisenchantment PhaseSocial CurrencyOccasional EuphoriaRelief From LethargyRelief From StressNose BleedsInfectionsRelationship DisruptionFamily DistressImpending Job Loss

  • Conditioning Process During AddictionDisenchantment PhaseStrength of Conditioned ConnectionTriggersWeekendsAll FriendsStressBoredomAnxietyAfter WorkLonelinessResponsesContinual Thoughts of AODStrong Physiological ArousalPsychological DependencyStrong CravingsFrequent UseSTRONG

  • AOD

  • Thinking of UsingMild Physiological ResponseEntering Using Site Heart Rate Breathing Rate Energy Adrenaline EffectsPowerful Physiological ResponseUse of AODsAOD Effects Heart Rate Breathing Rate Energy Adrenaline Effects Heart Blood Pressure Energy

  • Cognitive Process During AddictionDisaster PhaseRelief From FatigueRelief From StressRelief From DepressionWeight LossParanoiaLoss of FamilySeizuresSevere DepressionUnemploymentBankruptcy

  • Strength of Conditioned ConnectionTriggersAny EmotionDayNightWorkNon-WorkResponsesObsessive Thoughts About AODPowerful Autonomic ResponsePowerful Physiological DependenceAutomatic UseOVERPOWERING

  • Development of Obsessive ThinkingDisaster Phase

  • Development of Craving ResponseDisaster PhaseThoughts of AOD Using PlacePowerful Physiological Response Heart Rate

    Breathing Rate

    Energy

    Adrenaline Effects

  • Matrix Relapse Prevention Groups

  • Matrix Relapse Prevention Group Topics (Sample)

    Alcohol -The Legal DrugBoredomAvoiding Relapse Drift/Mooring LinesGuilt and ShameMotivation for RecoveryTruthfulnessWork and RecoveryStaying BusyRelapse PreventionDealing with Feelings

  • Roadmap for RecoveryWithdrawalEarly Abstinence/Honeymoon Protracted Abstinence orThe WallAdjustment/Resolution

  • Roadmap for RecoveryThe WallReturn to Old BehaviorsAnhedoniaAngerDepressionEmotional SwingsUnclear ThinkingIsolationFamily ProblemsCravings ReturnIrritabilityAbstinence ViolationProtracted Abstinence

  • Other Components of the Matrix Model

  • Components Of The Matrix Model

    Family Education LecturesConjoint SessionsUrine TestingRelapse AnalysisSelf help Initiation MATRIX

    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.Slide 8

    In 1904, I.P. Pavlov, a Russian scientist, received the Nobel Prize for a series of experiments he conducted on the physiology of digestion. These experiments were continued by some of his students and later came to be known as the principles of classical conditioning.Slide 9

    Pavlov would feed dogs and ring a bell at the same time. The dogs would see and smell the food which would then stimulate, or trigger, their lower brains ( the autonomic nervous systems) causing the dogs to produce saliva and secrete gastric fluids in anticipation of digestion. In a relatively short amount of time, Pavlov and his colleagues would ring the bell without the presence of food, and the dogs would still produce saliva and gastric fluid as if food were present. The dogs connected the sound of the bell, the trigger, with anticipation of eating, and responded involuntarily physically to the powerful trigger, or stimulus, of the bell. Once a dog has been conditioned in this way, no matter how smart or well-trained the dog is, a dog will continue to produce fluids at the sound of the bell. He has no choice. The human brain responds in exactly the same way to the conditioned drugs and alcohol triggers that produce cravings. Drugs and alcohol produce changes in the brain, which result in feelings of pleasure. When triggers cause a person to experience cravings, the brain responds as if the actual chemicals are taken into the system. In other words, the brain is drooling in reaction to these triggers. This reaction occurs whether or not the person intends to use. The only way that Pavlovs dog can avoid drooling is by avoiding the bell. The chemically dependent person can also avoid his or her brains reaction by avoiding triggers.Slide 9

    Pavlov would feed dogs and ring a bell at the same time. The dogs would see and smell the food which would then stimulate, or trigger, their lower brains ( the autonomic nervous systems) causing the dogs to produce saliva and secrete gastric fluids in anticipation of digestion. In a relatively short amount of time, Pavlov and his colleagues would ring the bell without the presence of food, and the dogs would still produce saliva and gastric fluid as if food were present. The dogs connected the sound of the bell, the trigger, with anticipation of eating, and responded involuntarily physically to the powerful trigger, or stimulus, of the bell. Once a dog has been conditioned in this way, no matter how smart or well-trained the dog is, a dog will continue to produce fluids at the sound of the bell. He has no choice. The human brain responds in exactly the same way to the conditioned drugs and alcohol triggers that produce cravings. Drugs and alcohol produce changes in the brain, which result in feelings of pleasure. When triggers cause a person to experience cravings, the brain responds as if the actual chemicals are taken into the system. In other words, the brain is drooling in reaction to these triggers. This reaction occurs whether or not the person intends to use. The only way that Pavlovs dog can avoid drooling is by avoiding the bell. The chemically dependent person can also avoid his or her brains reaction by avoiding triggers.Slide 10

    Environmental stimuli (external triggers) or emotional conditions (internal triggers) will often cause the recovering addict to think of using drugs and/or alcohol. For example, the patient runs into his old source of drugs at the market. Or, the patient gets into a fight with her husband, and immediately thinks of having a drink. Historically, she has always had a drink after fighting with her spouse. A single thought of drinking or using will typically pass through ones mind in 30 to 90 seconds, allowing one to continue thinking about AODs. AOD use is often the beginning of the relapse process. This inflames the neurochemistry of the addiction and moves the brain into the craving stage. At this craving stage, it is very difficult, if not impossible, to stop the slide into drug or alcohol use. To the actively using addict/alcoholic or the substance abuser in early recover, the Trigger - Thought - Craving - Use sequence feels as if it happens simultaneously. You feel triggered, and you immediately want to use. Knowing this process can be very helpful to the recovering addict/alcoholic. The successful key in dealing with the process is to avoid it getting started. It is extremely important to stop the thought when it first begins and to prevent it from building into an overpowering craving. It is vitally important to do this as soon as you recognize the thoughts occurring. This can be accomplished by using a number of Thought Stopping techniques.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.Slide 14

    Places that are triggers.Slide 15

    Objects or things that are triggers.

    Slide 16

    Periods of time that are triggers.Slide 17

    The reality for most addicts/alcoholics is that any emotional state, positive or negative, can be a trigger if it has been historically associated with drug or alcohol use.

    Slide 18For the addict/alcoholic, the choice remains to continue thinking about drug and/or alcohol use, which can lead to cravings, and most probably, using again or to practice thought stopping, which prevents the thoughts from developing into an overpowering craving.Show video, elicit from audience what they see, discuss list of qualities from best mentorSlide 11

    In order to understand the reality of addiction and recovery, we must look at two important areas of the brain. In a healthy brain, the cerebral cortex, or outside portion of the brain, is responsible for rational thinking. It is the decision-maker, the on-board computer of the human being. Underneath the cortex there is a much older, more primitive part of the brains anatomy, the limbic system. It has also been called the reptilian brain or the mammalian brain. To a greater or lesser degree this lower part of the brain mediates all forms of addiction. It is where the pleasure regard system is located and where most, if not all, pro species and pro individual life mechanisms originate. Unlike the cortex it is not under conscious, or voluntary, control. The powerful effects of drugs and alcohol, on this and other parts of the brain, can lead to addictive use, therefore losing the normal, rational restraints on behavior. Accepting addiction as a neurobehavioral disorder is a step towards recovery.Slide 12

    Alcohol and other drug (AOD) use is relatively infrequent during the Introductory Phase of the cognitive process of addiction. It may be limited to a few times a year, by chance or on special occasions. The positives of AOD use seem to outweigh the negatives.Slide 13

    Unknowingly, the AOD user is conditioning his brain every time a dose of his/her drug of choice is ingested. There is no automatic limbic response associating people, places or times with AOD use.Slide 14

    During this Introductory Phase, AOD use is one small component of a persons overall thought process.Slide 15

    Craving response is the combined experiences of AOD triggers activating the limbic system and the continuing AOD thoughts associated with these triggers.

    During this Introductory Phase, the limbic system is activated directly AODs, and depending upon whether the substance is a stimulant or a depressant, results in the increase or decrease of physiological arousal.Slide 16

    During the Maintenance Phase of the cognitive process during addiction, the frequency of AOD use increases, to perhaps, monthly or weekly. In terms of effects and negative consequences, the scales are beginning to lean more in the negative direction.Slide 17

    Conditioning has begun. The people, places and things associated with AOD use have become triggers. Exposure to these triggers causes thoughts about AOD use. These thoughts originating in the brain are mild physiological reactions producing drives to find and use AODs.Slide 18

    Thoughts of AOD use begin to occur more frequently.Slide 19

    A mild physiological arousal occurs in situations closely associated with AOD use. As the person encounters AOD triggers, the limbic system is activated and AOD cravings occur. When drugs and/or alcohol are finally ingested, a concurrent physiological state (arousal or quiescence in relation to the properties of the drug ingested) will usually occur.Slide 20

    During the Disenchantment Phase of the cognitive process of a developing addiction, the scales tip from the positive to the negative. The consequences of AOD use are severe and the users life begins to become unmanageable. At this point the cortical rational decision is to stop using, but the cortex is not in control any longer. Thinking, evaluating, and decision making appear to be happening, but behavior is contradictory. The user may sincerely resolve to quit using, and yet, may find himself out of control at the first thought of AODs, the first encounter with a fellow user, or at the availability of cash or other potent triggers.Slide 21

    It is usually at this point that a person crosses the line into addiction. Despite the negative consequences of continued AOD use the addiction is evidenced by the loss of rational control. Triggers in this phase produce a powerful physiological response that drives the user to acquire and use AODs. The higher rational brain is observing that it makes to use anymore.Slide 22

    During the Disenchantment Phase, the frequency of AOD thinking increases, which begins to crowd out thoughts of other aspects in life.Slide 23

    In this phase, the craving response is a powerful event. The person feels an overpowering physical reaction in situations further and further removed from the drugs themselves. The craving response is almost as powerful as the actual AODs physical reaction.Slide 24

    In the Disaster Phase, the AOD use is often robotic and automatic. There is no rational restraint upon the drug use; it makes no sense at all. The users behavior in the phase is much like the behavior of addicted laboratory animals that use drugs until they die.Slide 25

    Here the person is either using daily or in binges, which most likely will be interrupted by physical collapse, hospitalization, or arrest. The constant powerful craving from the limbic system and/or severe physiological dependency overwhelms the cortex.Slide 26

    Thoughts of AODs dominate the users consciousness.

    Slide 27

    In the Disaster Phase, the craving can often be compared to actual AOD effects, and in some cases, these powerful effects may be the result of merely thinking about certain drugs.Slide 2

    Stages to be discussed:

    WithdrawalEarly Abstinence/HoneymoonProtracted Abstinence/The WallAdjustment/ResolutionSlide 22Protracted abstinence, or the Wall, is the main event of the recovery process.A. During the Wall, there is a shift back from the high of the Honeymoon phase to a point, not as low as Withdrawal, but still not normal.B. After abstaining for some time, it may not be obvious that there may be some feelings still related to the after-effects of drug and alcohol use. The person in recovery needs to be reminded that the Wall is temporary and that it is a sign of the brain getting well.C. A person in the Wall typically experiences a lack of energy and an emotional state ranging from apathy to depression.1. It is important to continue the behavioral changes that have developed to this point.2. A sequence of inertia, boredom, loss of recovery, focus, relapse justification, and finally relapse can be prevented.D. The addicted brain may begin to influence behavior, and using drugs and alcohol can seem to start making sense again.E. Things can be kept in check if treatment contact is continued.1. Treatment termination is a threat during the Wall.2. Preparation for these feelings during the Honeymoon period and constant encouragement during the Wall are critical to ensure treatment continuation.