Treatments for Methamphetamine-Related Disorders I

(General)

Richard A. Rawson, Ph.D.Richard A. Rawson, Ph.D.

UCLA Integrated Substance Abuse UCLA Integrated Substance Abuse ProgramsPrograms

CATES Conference, August 20, 2004CATES Conference, August 20, 2004

Sacramento, CaliforniaSacramento, California

Methamphetamine (MA):Psychiatric Consequences

Paranoid reactionsParanoid reactions Permanent memory lossPermanent memory loss Depressive reactionsDepressive reactions HallucinationsHallucinations Psychotic reactionsPsychotic reactions Panic disordersPanic disorders Rapid addictionRapid addiction

MA Treatment Issues

Acute MA OverdoseAcute MA Overdose Acute MA PsychosisAcute MA Psychosis MA “Withdrawal”MA “Withdrawal” Initiating MA AbstinenceInitiating MA Abstinence MA Relapse PreventionMA Relapse Prevention Protracted Cognitive Impairment Protracted Cognitive Impairment

and Symptoms of Paranoiaand Symptoms of Paranoia

Acute MA Overdose

Slowing of Cardiac ConductionSlowing of Cardiac Conduction Ventricular IrritabilityVentricular Irritability Hypertensive EpisodeHypertensive Episode Hyperpyrexic EpisodeHyperpyrexic Episode CNS Seizures and AnoxiaCNS Seizures and Anoxia

Acute MA Psychosis

Extreme Paranoid IdeationExtreme Paranoid Ideation Well Formed DelusionsWell Formed Delusions Hypersensitivity to Environmental Hypersensitivity to Environmental

StimuliStimuli Stereotyped Behavior “Tweaking”Stereotyped Behavior “Tweaking” Panic, Extreme FearfulnessPanic, Extreme Fearfulness High Potential for ViolenceHigh Potential for Violence

Treatment of MA Psychosis

Typical ER Protocol for MA Typical ER Protocol for MA Psychosis:Psychosis: Haloperidol - 5mgHaloperidol - 5mg Clonazepam - 1 mgClonazepam - 1 mg Cogentin - 1 mgCogentin - 1 mg Quiet, Dimly Lit RoomQuiet, Dimly Lit Room RestraintsRestraints

MA “Withdrawal”

- Depression- Depression - Paranoia- Paranoia

- Fatigue- Fatigue - Cognitive - Cognitive ImpairmentImpairment

- Anxiety- Anxiety - Agitation- Agitation

- Anergia- Anergia - Confusion- Confusion

DurationDuration: 2 Days - 2 Weeks: 2 Days - 2 Weeks

Treatment of MA “Withdrawal” Hospitalization/Residential Hospitalization/Residential

Supervision if:Supervision if: Danger to Self or Others, or, so Danger to Self or Others, or, so

Cognitively Impaired as to be Cognitively Impaired as to be Incapable of Safely Traveling to Incapable of Safely Traveling to and from Clinicand from Clinic

Otherwise Intensive Outpatient Otherwise Intensive Outpatient TreatmentTreatment

Treatment of MA “Withdrawal” Intensive Outpatient Treatment:Intensive Outpatient Treatment:

No Pharmacotherapy AvailableNo Pharmacotherapy Available Positive, Reassuring ContextPositive, Reassuring Context Directive, Behavioral InterventionDirective, Behavioral Intervention Educate Regarding Time Course of Educate Regarding Time Course of

Symptom RemissionSymptom Remission Recommend Sleep and NutritionRecommend Sleep and Nutrition Low StimulationLow Stimulation Acknowledge Paranoia, DepressionAcknowledge Paranoia, Depression

Initiating MA Abstinence

Key Clinical Issues:Key Clinical Issues: DepressionDepression Cognitive ImpairmentCognitive Impairment Continuing ParanoiaContinuing Paranoia AnhedoniaAnhedonia Behavioral/Functional ImpairmentBehavioral/Functional Impairment HypersexualityHypersexuality Conditioned CuesConditioned Cues Irritability/ViolenceIrritability/Violence

Initiating MA Abstinence Key Elements of Treatment:Key Elements of Treatment:

StructureStructure Information in Understandable Information in Understandable

FormForm Family SupportFamily Support Positive ReinforcementPositive Reinforcement 12-Step Participation12-Step Participation

No Pharmacologic Agent Currently No Pharmacologic Agent Currently AvailableAvailable

Treatment of MA Disorders

Traditional Treatments:Traditional Treatments: Therapeutic CommunityTherapeutic Community Minnesota ModelMinnesota Model Outpatient CounselingOutpatient Counseling PsychotherapyPsychotherapy

Treatment of MA Disorders

State of Empirical Evidence:State of Empirical Evidence: No Information on TC or No Information on TC or

“Minnesota Model” “Minnesota Model” ApproachesApproaches

No Pharmacotherapy with No Pharmacotherapy with Demonstrated EfficacyDemonstrated Efficacy

Results of Cocaine Treatment Results of Cocaine Treatment Research Extrapolated to MA Research Extrapolated to MA TreatmentTreatment

Treatments for Stimulant-Use Disorders with Empirical Support

Motivational InterviewingMotivational Interviewing Cognitive-Behavioral Therapy Cognitive-Behavioral Therapy

(CBT)(CBT) Community Reinforcement Community Reinforcement

Approach Approach Contingency ManagementContingency Management Matrix ModelMatrix Model

Motivational Interviewing, 2nd Edition,

Miller and Rollnick

We can’t help wondering, why We can’t help wondering, why don’tdon’t

people change? people change?

You would think:You would think: that having had a heart attack would be enough that having had a heart attack would be enough

to persuade a man to quit smoking, change his to persuade a man to quit smoking, change his diet, exercise more, and take his medication.diet, exercise more, and take his medication.

Addictive behaviors persist despite Addictive behaviors persist despite overwhelming evidence of their destructiveness.overwhelming evidence of their destructiveness.

Early Recovery Issues Engaging and Retaining

Stages of ChangeProchaska & DiClemente

Affirmations

Patient-focused Patient-focused Intended to:Intended to:

Support patient’s involvementSupport patient’s involvement Encourage continued attendanceEncourage continued attendance Assist patient in seeing positivesAssist patient in seeing positives Support patient’s strengthsSupport patient’s strengths

Reflective Listening

Listen to what patient says and to what Listen to what patient says and to what patient patient meansmeans

Check out assumptionsCheck out assumptions Create an environment of empathy Create an environment of empathy

(nonjudgmental)(nonjudgmental) Patient and counselor do not have to agreePatient and counselor do not have to agree Be aware of intonation (statement, not Be aware of intonation (statement, not

question)question)

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)Elicit (ask for permission)

Give feedback or adviceGive feedback or advice

Elicit again (the patient’s view of how Elicit again (the patient’s view of how the advice will work for him/her)the advice will work for him/her)

Cognitive Behavioral Therapy

Operant Conditioning(Positive

Reinforcement)

Social Learning Theory(Relapse PreventionMarlatt & Gordon, 1995)

ModelingClassical

Conditioning(Paired Stimuli)

Cognitive Behavioral Therapy(CBT) Goals

To use learning processes to help To use learning processes to help individuals reduce drug useindividuals reduce drug use

To help patients:To help patients:•Recognize SituationsRecognize Situations•Avoid SituationsAvoid Situations•Cope with Problems and Cope with Problems and BehaviorsBehaviors

Cognitive Behavioral TherapyFunctional Analysis

Thoughts

Circumstances

Feelings

Before and After Use

Cognitive Behavioral Therapy Basic Assumptions:Basic Assumptions:

Drug/Alcohol use is learned behavior.Drug/Alcohol use is learned behavior. No assumption of underlying psychopathologyNo assumption of underlying psychopathology Classical and operant conditioning factors Classical and operant conditioning factors

involvedinvolved ““Treatment” is a process of teaching, coaching Treatment” is a process of teaching, coaching

and reinforcing.and reinforcing. New, alternative behaviors must be New, alternative behaviors must be

established. established. Therapist is teacher, coach, and source of Therapist is teacher, coach, and source of

positive reinforcement.positive reinforcement. Can be delivered in group or individual settingCan be delivered in group or individual setting

Community Reinforcement Approach Basic assumptions:Basic assumptions:

Drug and alcohol use are positively Drug and alcohol use are positively reinforced behaviors. They can be reinforced behaviors. They can be reduced/eliminated by proper application reduced/eliminated by proper application of behavioral techniques.of behavioral techniques.

To successfully build an effective To successfully build an effective intervention, some techniques should intervention, some techniques should focus on reducing drug and alcohol use focus on reducing drug and alcohol use and others should focus on acquisition of and others should focus on acquisition of new incompatible behaviors.new incompatible behaviors.

Community Reinforcement Approach

Key concepts:Key concepts: Behavioral analysis and teach conditioning Behavioral analysis and teach conditioning

informationinformation Positive reinforcement with vouchers for drug Positive reinforcement with vouchers for drug

free urine samplesfree urine samples Behavioral marriage counselingBehavioral marriage counseling Shape and reinforce new behavioral repetiore.Shape and reinforce new behavioral repetiore. Coping skill/Drug refusal skill trainingCoping skill/Drug refusal skill training Vocational CounselingVocational Counseling Frequent urine testingFrequent urine testing

Contingency Management with Vouchers

Vouchers Inexpensive Gifts

Take-homeMethadone

Doses

Access to Housing

Gold StarsAccess to

Work Therapy

Contingency Management Basic Assumptions:Basic Assumptions:

Drug and alcohol use behavior can be Drug and alcohol use behavior can be controlled using operant reinforcement controlled using operant reinforcement procedures.procedures.

Vouchers can be used as proxy’s for Vouchers can be used as proxy’s for money or goods.money or goods.

Vouchers should be redeemed for items Vouchers should be redeemed for items incompatible with drug use.incompatible with drug use.

Escalating the value of the voucher for Escalating the value of the voucher for consecutive weeks of abstinence consecutive weeks of abstinence promotes better performance.promotes better performance.

Counseling/therapy may or may not be Counseling/therapy may or may not be required in conjunction with CM required in conjunction with CM procedure.procedure.

Contingency Management

Key concepts:Key concepts: Behavior to be modified must be Behavior to be modified must be

objectively measured.objectively measured. Behavior to be modified (e.g., urine test Behavior to be modified (e.g., urine test

results) must be monitored frequently.results) must be monitored frequently. Reinforcement must be immediate.Reinforcement must be immediate. Penalties for unsuccessful behavior (e.g., Penalties for unsuccessful behavior (e.g.,

positive UA) can reduce voucher amount.positive UA) can reduce voucher amount. Vouchers may be applied to a wide range Vouchers may be applied to a wide range

of prosocial alternative behaviors.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)