Treatments for Methamphetamine-Related Disorders Richard A. Rawson, Ph.D, ProfessorIntegrated Substance Abuse ProgramsSemel Institute for Neuroscience and Human BehaviorDavid Geffen School of MedicineUniversity of California at Los Angeleswww.uclaisap.orgrrawson@mednet.ucla.edu

Supported by: National Institute on Drug Abuse (NIDA) Pacific Southwest Technology Transfer Center (SAMHSA) United Nations Office of Drugs and Crime

Meth Treatment Effectiveness?A pervasive rumor has surfaced in many geographic areas with elevated MA problems:

MA users are virtually untreatable with negligible recovery rates.Rates from 5% to less than 1% have been quoted in newspaper articles and reported in conferences.

**The resulting conclusion is that spending money on treating MA users is futile and wasteful, BUT no data exists that supports these statistics**

Meth Treatment StatisticsDuring the 2002-2003 fiscal year:

35,947 individuals were admitted to treatment in California under the Substance Abuse and Crime Prevention Act funding.

Of this group, 53% reported MA as their primary drug problem

StatisticsA comparison of treatment outcomes between individuals diagnosed with methamphetamine dependence and all other diagnostic groups indicated no between group significant differences in any treatment outcome measures including:Retention in treatment ratesUrinalysis data during treatmentRates of treatment program completion.

All these measures indicate that MA users respond in an equivalent manner as individuals admitted for other drug abuse problems.

Comparability of Treatment Outcome: Cocaine vs MethamphetamineHuber, Ling and Rawson (Jnl of Addictive Diseases, 1997).Cohorts of methamphetamine dependent patients (N=500) and cocaine dependent patients (N=224) treated with a standardized, outpatient treatment protocol (Matrix Model) at the same clinic site, by the same staff over the same time period, demonstrated very similar treatment response on virtually all treatment participation and outcome measures

Table 3. Treatment Experience to Methamphetamine and Cocaine Users

{Treatment Received in Number of Hours} + Numbers presented are means and (standard deviations)++ Numbers presented are percentages

Why the MA treatment doesnt work perceptions?Many of the geographic regions impacted by MA do not have extensive treatment systems for severe drug dependence.Medical and psychiatric aspects of MA dependence exceeds program capabilities.High rate of use by women, their treatment needs and the needs of their children can be daunting.Although some traditional elements may be appropriate, many staff report feeling unprepared to address many of the clinical challenges presented by these patients

CSAT Tip #33

A useful resource that presents a review of the existing knowledge about treatment effectiveness with stimulant users.

MedicationsCurrently, 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.

Medications considered for MethNegative ResultsUnder ConsiderationImipramineBupropionDesipramineModafinilTyrosineTopirimateOndansetronDisulfiramFluoxetineLobelineGabapentinAripiprazole

Bupropion: An efficacious pharmacotherapy? Newton et al 2005 Bupropion reduces craving and reinforcing effects of methElkashef (recently completed) Bupropion reduces meth use in an outpatient trial, with particularly strong effect with less severe users.

Treatments for Stimulant-use Disorders with Empirical Support

Cognitive-Behavioral Therapy (CBT)Motivational InterviewingCommunity Reinforcement Approach Contingency Management12 Step Facilitation

All have demonstrated efficacy for the treatment of cocaine dependence

Cognitive Behavioral TherapyKey ConceptsEncouraging and reinforcing behavior change Recognizing and avoiding high risk settingsBehavioral planning (scheduling)Coping skillsConditioned triggersUnderstanding and dealing with cravingAbstinence violation effectUnderstanding basic psychopharmacology principlesSelf-efficacy

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

Methamphetamine Treatment: Controlled Clinical Trials

Brief Cognitive Behavioral Therapy Extended Cognitive Behavioral TherapyContingency ManagementMatrix Model

Cognitive Behavioral Therapy and Contingency Management for Stimulant DependenceDesign Randomized clinical trial. 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. CM procedures produced better retention and lower rates of stimulant use during the study period. Results 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. Conclusions: This study suggests that CM is an efficacious treatment for reducing stimulant use and 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

FIGURE 2. Stimulantfree Urine Samples by Group

FIGURE 3. Self-Reported Stimulant Use

Contingency Management for treatment of methamphetamine dependence

Design: RTCMethod: 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 but 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.

Contingency Management for the Treatment of Methamphetamine Use Disorders. Roll, JM et al, Archives of General Psychiatry, (In Press)

Contingency ManagementA 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.

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

Roll, et al., American Journal of Psychiatry, In PressCM + TAU TAU

ConclusionsCM appears to increase the abstinence rates when combined with psychosocial treatmentsSuggests CM should be an integral part of methamphetamine use disorder treatment modalities

Contingency Management: A Meta-analysisA recent meta-analysis reports that CM results in a successful treatment episode 61% of the time while other treatments with which it has been compared result in a successful treatment episode 39% of the time (Prendergast, Podus, Finney, Greenwell & Roll, submitted)

Matrix ModelMost extensively evaluated approach for the treatment of MA dependence.Incorporates a set of treatment elements which have empirical support, including behavioral strategies, cognitive behavioral strategies, motivational interviewing, positive reinforcement, psycho-education, 12 Step participation, family involvement

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

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

The CSAT Methamphetamine Treatment Project

Richard Rawson Ph.D.U.C.L.A. Integrated Substance Abuse Programs (I.S.A.P.)The MTP Site InvestigatorsFunded by the Center for Substance Abuse Treatment

A Multi-site Trial of a Manualized Psychosocial Protocol for the Treatment of Methamphetamine Dependence

CSAT MTP 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

Baseline Demographics

Gender Distribution of Participants

Ethnic Identification of Participants

Route of Methamphetamine Administration

Route of Administration by MTP Site (N=978)SiteOralNasal Smoke IVBillings0%2%42%56%Concord0%10%59%30%Costa Mesa0%8%65%27%Hayward1%35%57%5%Honolulu0%1%96%3%San Diego1%11%61%28%San Mateo, ODASA0%6%94%0%San Mateo, Pyramid0%23%64%13%OVERALL PERCENT :0%11%65%24%

Changes from Baseline to Treatment-end

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

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

Urinalysis Results Results of Ua Tests at Discharge, 6 months and 12 Months post admission **Matrix GroupTAU GroupD/C: 66% MA-free 65% MA-free6 Ms: 69% MA-free 67% MA-free12 Ms: 59% MA-free 55% MA-free

**Over 80% follow up rate in both groups at all points

Clinical Challenges in Treating MA-Dependent Patients

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).

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.

Homeless, chronically mentally ill and/or individuals with high levels of psychiatric symptoms at admission.

Individuals under the age of 21.

Gay men (at very high risk for HIV and hepatitis).

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 antipsychotic (eg. respiridone)Clonazepam - 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:MA InjectorsDanger to Self or Others, or, so Cognitively Impaired as to be Incapable of Safely Traveling to and from ClinicOtherwise Intensive Outpatient Treatment

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

Clinical Tools

Clinical Challenges of MA UsersPoor treatment engagement ratesSevere paranoiaOngoing episodes of psychosisSevere cravingProtracted dysphoria and mood disturbanceAnhedonia Sleep disordersConcentration and memory problemsSexual IssuesWeight GainPTSD symptoms, secondary to trauma

Strategies for addressing engagement problems

NIATX strategiesMotivational Interviewing skillsContingency management

Strategies for addressing psychosis and paranoia Psychosis resulting from acute MA intoxication will typically resolve within 12-24 hours.Persistent psychosis may require anti-psychotic medicationParanoia is very common throughout treatment. Typically lessens over the first 2 weeks, but can have recurances.Avoid confrontation and emotional intense or cognitively complex therapeutic techniques.Reassure that recovery will occur with time.Normalize symptoms as part of recovery

Strategies for addressing dysphoria mood disturbance, sleep disturbance and anhedoniaEducation about timetable of MA recovery- The WallEncouragement and support of group membersReports of improvement from patients and staff in later recoveryModerate caffeine intake late in the dayExercisePsychiatric evaluation for persisting significant symptoms of depression

Strategies for addressing cognitive and memory problemsKeep it simpleUse visual imagesHandoutsReminder cardsReminder notes

Strategies for addressing sexual issuesEducationIndividual sessions to allow for acknowledgement of sexual involvements during MA useCreating realistic expectations of sexual response and experience in recoveryRelationship of sexual arousal and craving

Strategies for addressing weight gain Education about MA recovery and necessity of proper dietExercise, exercise, exerciseBody image discussion with other recovering women

Strategies for addressing trauma issuesInsure current safe living situationSeeking safetyOther trauma and substance abuse modelsWomens groupsIndividual sessionsAcknowledgement of poor child care practices and consequent feeling of guilt and remose

Treatment Tools from Matrix ModelMatrix Manual free from SAMHSAManuals and videos also available from Hazelden Publishing

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 AODsAOD Effects Heart/Pulse Rate Respiration Adrenaline Energy Taste

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

Blood Pressure

Energy Heart Breathing Adrenaline Effects EnergyTaste

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

Outpatient Recovery IssuesTRIGGERS

TriggerDefinitionA trigger is a stimulus which has been repeatedly associated with the preparation for, anticipation of or the use of drugs and/or alcohol. These stimuli include people, things, places, times of day, and emotional states.

Triggers and Cravings

Triggers and CravingsPavlovs Dog

MATRIX MODEL TREATMENT Triggers - PeopleDrug-using friends/dealerVoices of drug friends/dealerAbsence of significant otherSexual partners in illicit sexGroups discussing drug use

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

Triggers & Cravings

Triggers & Cravings

Triggers and Cravings

Thought StoppingVisual ImagerySnappingRelaxationCall SomeonePrayUrge-Surfing

MATRIX MODEL TREATMENT Key Concept: Thought StoppingPrevents the thought from developing into an overpowering cravingRequires practice

STAGES OF RECOVERY - STIMULANTSOVERVIEWWithdrawalHoneymoonThe WallAdjustmentResolutionDAY0DAY15DAY45DAY120DAY180

Stages of Recovery - StimulantsWITHDRAWAL STAGEDAY0DAY15Medical ProblemsAlcohol WithdrawalDepressionDifficulty ConcentratingSevere CravingsContact with StimuliExcessive SleepPROBLEMSENCOUNTERED

MATRIX MODEL TREATMENT Relapse Factors - Withdrawal StageUnstructured timeProximity of triggersAlcohol/marijuana usePowerful cravingsParanoiaDepressionDisordered sleep patterns

Stages of Recovery - StimulantsHONEYMOON STAGEDAY15DAY45OverconfidenceInability to PrioritizeMemory ProblemsDifficulty Concentrating

Intense feelingsOther Substance AbuseTreatment TerminationPROBLEMSENCOUNTERED

MATRIX MODEL TREATMENT Structure - Ways to CreateTime schedulingAttending 12-step meetingsGoing to treatmentExercisingAttending schoolGoing to workPerforming athletic activitiesAttending church

MATRIX MODEL TREATMENT Structure - PitfallsScheduling unrealisticallyNeglecting recreationBeing perfectionisticTherapist imposing scheduleSpouse/parent imposing schedule

MATRIX MODEL TREATMENT Relapse Factors - Honeymoon Stage

Secondary alcohol or other drug useDiscontinuation of structureResistance to behavior changeReturn to addict lifestylePeriodic paranoia

Stages of Recovery - StimulantsTHE WALLDAY45DAY120InertiaDepressionReturn to Cocaine StimuliRelapse JustificationCognitive RehearsalTreatment Termination

Alcohol Use RelapsePROBLEMSENCOUNTERED

The Wall One Patients AccountPhysical Symptoms:

Lack of energy was almost constant even if I slept for hours. Lack of memory, inability to concentrate and a grey film over my vision clouded my world. My sleep became mixed-up. I would be dead tired during the day and experience insomnia at night.

The Wall One Patients AccountApathy:

Throughout The Wall I didnt care about anything or anybody. Including myself. Nothing seemed important, nothing felt good. Boredom and hopelessness were constant companions. I felt the whole thing would never end.

The Wall One Patients AccountLoneliness and Isolation:

More than anything I felt alone. I felt like I was the only person in the world who knew how I felt. Even my therapist and my C.A group didnt understand. I went to meetings and often still felt alone.

MATRIX MODEL TREATMENT Relapse Factors - The Wall Stage- Increased emotions- Dissolution of structure- Interpersonal conflict- Behavioral drift- Relapse justification- Secondary alcohol or - Anhedonia/loss of other drug use motivation- Resistance to exercise- Insomnia/low energy/fatigue- Paranoia

Stages of Recovery - StimulantsADJUSTMENT STAGEDAY120DAY180Vocational DissatisfactionRelationship ProblemsOverconfidenceLack of Goals

PROBLEMSENCOUNTERED

Outpatient Recovery IssuesRELAPSE FACTORS

Outpatient Recovery IssuesRelapse Factors - Sexual BehaviorConcern about sexual dysfunctionConcern over sexual abstinenceConcern over sexual disinterestLoss of intensity of sexual enjoymentShame/guilt about sexual behaviorSexual arousal producing cravingSexual behavior and intimacySobriety and monogamy

Outpatient Recovery IssuesRelapse Factors - Alcohol/MarijuanaCortical disinhibitionStimulant craving inductionPharmacologic coping method12-Step philosophy conflictAbstinence violation effectMarijuana amotivational syndromeInterferes with new behaviors

Outpatient Recovery IssuesRelapse Factors - Time PeriodsUnstructured timeTransition periodsProtracted abstinenceHolidaysChronic stress, fatigue, or boredomAnniversary datesPeriods of emotional turmoil

Outpatient Recovery IssuesRelapse Factors - Addict BehaviorLying/stealingHaving extramarital/illicit sexUsing secondary substancesReturning to bars/drug friendsBeing unreliable/irresponsibleBehaving compulsively/impulsivelyIsolating

Outpatient Recovery IssuesRelapse Factors - Addict ThinkingParanoiaRelapse justifications:Im not an addict anymoreIm testing myselfI need to workOther drugs/alcohol are OKCatastrophic eventsNegative emotional states

Outpatient Recovery IssuesRelapse Factors - RelationshipsAddict must deal with familys:Extreme anger and blamingUnwillingness to change/trustHypervigilance - excessive monitoringSexual anxietiesAdjustment to non-victim statusConflict with recovery activities

Roadmap for RecoveryWhen To Use Thought StoppingRiver of Relapse(Relapse Drift)

Stages of Recovery - Stimulants

RESOLUTION STAGEDAY180AngerGuiltIsolationBoredom

PROBLEMSENCOUNTEREDInterpersonal Communication Issues

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

Other Components of the Matrix Model

Components Of The Matrix Model

Family Education LecturesConjoint SessionsUrine TestingRelapse AnalysisSelf help Initiation MATRIX

Thank you

rrawson@mednet.ucla.eduwww.uclaisap.org

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

Definition of a trigger.

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 13

People who are triggers.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 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 37Simply put, thought stopping interrupts the usual process that culminates in using/drinking. The usual reaction to thoughts is to argue with the developing thought/craving. The argument usually results in the addiction winning. Arguing proceeds negotiation, compromise, justification, and, possibly, relapse. Thought stopping ends this process before relapse can begin. Saying, STOP either in your head, or aloud, in response to the first hint of a thought usually stops cravings in their tracks.Here some thought stopping techniques.Visualization or other sensory imagery - Picture a switch, or lever, in your mind. Imagine yourself actually moving it from ON to OFF stopping the drug or alcohol thoughts. Have another picture ready to think about in place of the drug or alcohol thoughts. It should be an image, or thought, that is pleasurable or meaningful to you and, historically, did not involve drug or alcohol use. If the thought stopping works, but the thoughts frequently keep coming back, you may have to change your environment or engage yourself in a task that requires your full concentration.Snapping - Tie a rubber band loosely around your wrist. Pull the band and snap pit lightly against your wrist as you say, NO, to the drug/or alcohol thoughts. As above, have another thought ready to take the place of the drug and alcohol thoughts.Prayer - Praying can be an effective thought stopping technique.Relaxation - Feelings or hollowness, heaviness, and cramping in the stomach are cravings. These can often be relieved by breathing in deeply (filling the lungs with air) and slowly breathing out. Do this three times. You should be able to feel the tightness leave your body. Repeat this whenever the feeling returns.Call someone - Talking to another person provides an outlet for your feelings and allows you to hear your own thinking process. Have phone numbers of supportive people with you always, so you can use the numbers when you need them.

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.Slide 8

Relapse factors during the withdrawal stage - During withdrawal, patients are disoriented, depressed, fatigued, and feel very much out of control. They do not understand what is happening to them, and require very explicit direction during this period. During this stage, drug and alcohol triggers, thoughts, and cravings may be prevalent. A depleted neurochemistry translates into irritability, depression and disordered sleep.Slide 21Relapse factors during the Honeymoon Stage - During this stage, the patients mood typically improves, energy increases, cravings diminish, confidence and optimism increase; and, it may feel as if the problem with chemical substances is over. This stage is also popularly known as the pink cloud stage. Many patients become over-involved with work to the point of workaholism. An inability to prioritize may be a problem during this period. One of the most important treatment activities during this stage involves channeling, in some order of importance, the honeymoon energy toward specific recovery tasks. It is critical that patients recognize that this period is temporary. They need to use the energy available during this period to put together a solid structure of activities and build momentum that will carry through subsequent recovery stages.Slide 33Relapse factors during the Wall stage - This period is viewed as the major hurdle during the recovery period. As low energy, anhedonia, difficulty concentrating, loss of sex drive, and insomnia return, relapse vulnerability increases for the patient. Patients often perceive that these symptoms will persist indefinitely.

Some of the factors relating to relapse in the Wall include these: low energy, irritability, or anhedonia that may result in interpersonal conflict, dissolution of structure, behavioral drifts, and resistance to exercise. This, in turn, can open the way to relapse justification, alcohol use, and drug use.

It is critical that patients anticipate the Wall, accurately perceiving it as a temporary phase and dealing with it by continuing the recovery activities that were established during the initial weeks of treatment. Exercise and regular program contact, as well as support from self-help groups are particularly beneficial during this time.Slide 35Yet another metaphorical depiction of the relapse process is shown in this slide. One can imagine the relapse drift as being caught in a river with a strong and swift current. If the addict/alcoholic swims hard enough he/she may be able to get out of the current and to safety on the riverbank. However, the closer one gets to the waterfalls, the stronger and faster the current becomes. Once you go over the falls, you cannot swim against gravity and back up the waterfalls.