Treatments for Methamphetamine-Related DisordersRichard A. Rawson, Ph.D.UCLA Integrated Substance Abuse Program,Sacramento, CA Dec 2, 2004rrawson@mednet.ucla.eduwww.uclaisap.org

Speed It is methamphetamine powder ranging in color from white, yellow, orange, pink, or brown. Color variations are due to differences in chemicals used to produce it and the expertise of the cooker. Other names: shabu, crystal, crystal meth, crank, tina, yaba

IceHigh purity methamphetamine crystals or coarse powder ranging from translucent to white, sometimes with a green, blue, or pink tinge.

The Language of Americas Meth UsersCrank, meth, crystal, ice: methamphetamineCooking: making methSlamming: injectingRig: hypothermic needleRun: multiple days of using meth without sleepingCrash: long period of sleep following a runTweaking: going on a long runTweaker: chronic meth usersShadow people: image commonly cited by meth uses in periods of paranoia

The Language of California Meth CopsUser lab: ounce-quality lab for a tweakers personal useSmurfing: buying small quantities of pseudoephedrine at many stores, a tweaker practiceReal nice lab: 10-pound (or larger) superlab operated by Mexican cartels in CaliforniaStep on it: dilute meth with an inactive ingredientMope: migrant worker hired to operate a superlabLow crawl: police technique to approach a superlab unseenLeg bail: what mopes do when surprised by low-crawling cops, to flee

Methamphetamine: A Growing Menace in Rural AmericaIn 1998, rural areas nationwide reported 949 methamphetamine labs.

Last year, 9,385 were reported.

This year, 4,589 rural labs had been reported as of July 26.

Source: El Paso Intelligence Center (EPIC), U.S. DEA

Groups with High Rates of Meth UseWomenResidents in Western/Midwestern Rural Areas and Small/Medium CitiesPredominantly Caucasian, Increasing Numbers of HispanicsGay MenAdolescents

Acute MA PsychosisExtreme Paranoid IdeationWell Formed DelusionsHypersensitivity to Environmental StimuliStereotyped Behavior TweakingPanic, Extreme FearfulnessHigh Potential for Violence

Treatment of MA PsychosisTypical ER Protocol for MA Psychosis:Haloperidol - 5mgOr Atypical Anti-psychoticClonazepam - 1 mgCogentin - 1 mgQuiet, Dimly Lit RoomRestraints??

MA Withdrawal- Depression- Paranoia- Fatigue- Cognitive Impairment- Anxiety- Agitation- Anergia- Confusion

Duration: 2 Days - 2 Weeks

Treatment of MA WithdrawalHospitalization/Residential Supervision if:Danger to Self or Others, or, so Cognitively Impaired as to be Incapable of Safely Traveling to and from ClinicOtherwise Intensive Outpatient Treatment

Treatment of MA WithdrawalIntensive Outpatient Treatment:No Pharmacotherapy AvailablePositive, Reassuring ContextDirective, Behavioral InterventionEducate Regarding Time Course of Symptom RemissionRecommend Sleep and NutritionLow StimulationAcknowledge Paranoia, Depression

Initiating MA AbstinenceKey Clinical Issues:DepressionCognitive ImpairmentContinuing ParanoiaAnhedoniaBehavioral/Functional ImpairmentHypersexualityConditioned CuesIrritability/Violence

Initiating MA AbstinenceKey Elements of Treatment:StructureInformation in Understandable FormFamily SupportPositive Reinforcement12-Step ParticipationNo Pharmacologic Agent Currently Available

Treatment of MA DisordersState of Empirical Evidence:No Information on TC or Minnesota Model ApproachesNo Pharmacotherapy with Demonstrated EfficacyBupropion, Selegline, Topirimate under InvestigationOndansetron, Prozac, Zoloft, Flupentixol, Despiramine found not to be usefulResults of Cocaine Treatment Research Extrapolated to MA TreatmentResults with CM, CBT, and Matrix Equivalent with Cocaine and Meth Users

Treatments for Stimulant-Use Disorders with Empirical SupportMotivational InterviewingCognitive-Behavioral Therapy (CBT)Contingency Management12-Step FacilitationMatrix Model

Early Recovery Issues Engaging and Retaining

Stages of ChangeProchaska & DiClemente

AffirmationsPatient-focused Intended to:Support patients involvementEncourage continued attendanceAssist patient in seeing positivesSupport patients strengths

Cognitive Behavioral Therapy

Cognitive Behavioral Therapy(CBT) Goals

To use learning processes to help individuals reduce drug use

To help patients:Recognize SituationsAvoid SituationsCope with Problems and Behaviors

Cognitive Behavioral TherapyBasic Assumptions:Drug/Alcohol use is learned behavior.No assumption of underlying psychopathologyClassical and operant conditioning factors involvedTreatment 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

Contingency Management with Vouchers

Contingency ManagementBasic Assumptions:Drug and alcohol use behavior can be controlled using operant reinforcement procedures.Vouchers can be used as proxys 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 ManagementKey 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

The Methamphetamine Treatment Project Corporate Authors*

Addiction (June, 2004)

Matrix Model ofOutpatient TreatmentOrganizing Principles of Matrix Treatment 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.

Matrix Model ofOutpatient TreatmentOrganizing Principles of Matrix Treatment 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.

Matrix Model ofOutpatient TreatmentOrganizing Principles of Matrix Treatment Accurate, understandable, scientific information used to educate patient and family membersEffects of drugs and alcoholAddiction as a brain diseaseCritical issues in recovering from addiction

Matrix Model ofOutpatient TreatmentOrganizing Principles of Matrix Treatment

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

Matrix Model ofOutpatient TreatmentOrganizing Principles of Matrix Treatment

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

Matrix Model ofOutpatient TreatmentOrganizing Principles of Matrix Treatment

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

Primary Measures to Build the ModelRetention, Retention, RetentionDrug-free UAs

Matrix ModelAn Integrated, Empirically-based, Manualized Treatment Program

Relapse Prevention

Family and Group Therapy

Motivational

Interviewing

12- Step Involvement

Psychoeducation

Social Support

Elements of the Matrix ModelEngagement/RetentionStructureInformationRelapse PreventionFamily InvolvementSelf Help InvolvementUrinalysis/Breath Testing

Project Goals:

To study the clinical effectiveness of the Matrix Model

To compare the effectiveness of the Matrix model to other locally available outpatient treatments

To establish the cost and cost effectiveness of the Matrix model compared to other outpatient treatments

To explore the replicability of the Matrix model and challenges involved in technology transfer

Matrix Vs Treatment as Usual: Study Design8 sitesParticipants randomly assigned to Matrix Model treatment or Treatment as Usual in each site.Dependent Measures: Retention in treatment; urinalysis results; self report of meth use; ASI scores (in Rx, at D/C and FU

The Matrix Model Urine or breath alcohol tests once per week, weeks 1-16

Baseline Demographics

Gender Distribution of Participants

Ethnic Identification of Participants

Marital Status of Participants

Employment Status of Participants

Route of Methamphetamine Administration

Changes from Baseline to Treatment-end

Days Paid for Work in Past 30Possible is 0-30; tpaired=6.01; p-value

Total Income (Past 30 days) of Participantstpaired=2.34; p-value=0.02 (sig.)

ASI Composite ScoresPossible is 0-1;Higher : worse problemtpaired: *p-value

Days of Methamphetamine Use in Past 30 (ASI)Possible is 0-30; tpaired=20.90; p-value

Days of Marijuana Use in Past 30 (ASI)Possible is 0-30; tpaired=8.02; p-value

Days of Alcohol Use in Past 30 (ASI)Possible is 0-30; tpaired=6.47; p-value

Beck Depression Inventory (BDI) Total ScoresPossible is 0-63; tpaired=16.87; p-value

BSI Scores (mean)1Possible, all scores, is 0-4; *all p-values

Positive Symptom Total (PST) from Brief Symptom Inventory (BSI)Possible is 0-53; tpaired=14.33; p-value

Mean Number of Weeks in Treatment

Figure 3. Participant retention throughout treatment, by site and treatment group

Mean Number of UAs that were MA-free during treatment

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

Matrix vs TAU: Results SummaryMatrix Model demonstrated superior retention and more meth negative urine samples and longer periods of continuous abstinence during treatment period.Both conditions showed very significant improvement at discharge and follow up points as measured by UA, self-report and ASI scores. No difference between groups.

Outcomes of Treatment for Methamphetamine Use:LA County (Treatment-as-Usual)M.-L. BrechtUCLA Integrated Substance Abuse Programs

PurposeDescribe time to relapse to MA useIdentify predictors of longer time to relapseDescribe other outcome measures (% months with MA use, crime, employment)

DesignRandom sample of MA admissions (mostly from 1996)From Los Angeles county-funded outpatient and residential programs76% of sampled clients were located; 75% of those participated in study (n=365)Interviewed in 1999-2000, follow-up in 2001-2003Analysis sample n=350 Data from detailed natural history interview

Sample (n=350)Gender:56% male, 44% female

Ethnicity:47% non-Hispanic White30% Hispanic 17% African-American 6% other

Education:32% less than high school21% high school grad/GED47% some college/tech/trade school

Average Age First Use of Substance97-100% have usedOver 50% have usedLess than 50% have used

Sampled Treatment Episode

Age at admission29.4 yr.

Residential62% Outpatient 38%

Legal pressure51%

1st time in treatment 58%

Time in treatment3.7 mo.

Completed tx 46%

ResultsPredictors of Time to Relapse(multivariate Cox model, predictors p

Better outcomes for thoseWith longer time in treatment (e.g. those with 4 or more mo. of treatment have almost double the rate of 24 and 48 mo. abstinence)With more sessions per month of individual counselingWorse outcomes for thoseWho have sold MA

Pattern of Relapse: Graph Shows Difference Between Less vs. More VulnerableMore vulnerable=with MA sales (n=129)Less vulnerable=all others

Pattern of Relapse:More Vulnerable Split into 2 Groups (More Treatment vs. Less Treatment)More treatment (n=65) = 4 or more months of tx and/or4 or more individual counseling sessions

Other Outcomes:% of Months with MA Use, Crime, EmploymentBefore, During, and After Treatment

Chart2

67.039442.093729.9308

16.472812.412112.9427

33.664818.993138.6888

MA Use

Crime

Work

Avg. % of Months with Activity

Sheet1

Sheet1

67.039442.093729.9308

16.472812.412112.9427

33.664818.993138.6888

MA Use

Crime

Work

Avg. % of Months with Activity

Sheet2

Sheet3

Other Clinical IssuesMeth injectors have poorer outcomes than those who use via IN or smokeMajor relapse factorsMarijuana useAlcohol useHigh availability of methStaying around other meth users

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.Audience give examples of affirmationsEllsworth Kelly. Sculpture for a Large Wall. 1957. 104 anodized aluminum panels, overall 11' 5" x 65' 5" x 2' 4". Gift of Jo Carole and Ronald S. Lauder24 programs that serve a majority of MA usersAdmissions divided by gender/ethnicity/residential-outpatient

NHI is self-report (also do urine test-90% consistency)DiverseRepresentative of sampled admissions and MA treatment populationRed: most have usedGreen: more than half have usedLight blue: fewer have used

Order: what wed expect (alcohol/mj/tobacco first)MA much later in sequence & age (avg. 19yr)Diverse tx (tx-as-usual)/variety of programsAlso wide range of services:

Additional univariate relationships:tx completion% pre-tx months (in 24) with MA useIf we predict 48mo abstinence, we have similar predictors, except thatspecific tx services are not significant, but pre-tx MA use remains significant in multiv. Logistic model (pseudo rsq=.09Weve also tried to identify characteristics associated withmore positive treatment outcomes

Considered background & personal char. (socio-demographic, family,vulnerabilities),drug use historycrimetreatmentAlso considered other outcome measures, so that we could summarizespecific before, during, after tx periods, e.g.% of months with MA usecrimeemploymentConsiderable drop during txsome increase in MA use/crime for 24mo after txbut still with levels less than 24mo before txemployment also goes down during tx but then increasesa lot after tx (higher than before tx)Multivariate predictors of %post-tx MA use (but rsq=.07):primarily tx variablesAdditional univariate predictors: whites, more educated (but NS in multiv)