Methamphetamine: What do we do? Thomas E. Freese, Ph.D. [email protected] Pacific Southwest Addiction Technology Transfer Center UCLA Integrated Substance

Methamphetamine: What do we do?

Thomas E. Freese, [email protected]

Pacific Southwest Addiction Technology Transfer CenterUCLA Integrated Substance Abuse Programs

www.psattc.orgwww.uclaisap.org

Motivational Interviewing

Stages of Change:Primary Tasks

1. PrecontemplationDefinition: Not yet considering change or is unwilling or unable to change.

Primary Task:Raising Awareness 2. Contemplation

Definition: Sees the possibility of change but is ambivalent and uncertain.

Primary Task:Resolving ambivalence/Helping to choose change

3. DeterminationDefinition: Committed to changing.Still considering what to do.

Primary Task:Help identify appropriate change strategies

4. ActionDefinition: Taking steps toward change but hasn’t stabilized in the process.

Primary Task:Help implement change strategiesand learn to eliminate potential relapses

5. MaintenanceDefinition: Has achieved the goals and is working to maintain change.

Primary Task:Develop new skills for maintaining recovery

6. RecurrenceDefinition: Experienced a recurrence of the symptoms.

Primary Task:Cope with consequences and determine what to do next

•O

•A

•R

•S

BUILDING MOTIVATION OARS

•Open-ended questioning

•Affirming

•Reflective listening

•Summarizing

An Important MI Skill:Forming Reflections

Adapted from Exercise By

Bill Miller

Forming Reflections

To help participants learn how to form effective

reflective-listening statements

• Repeating – Repeating what was just said.

• Rephrasing – Substituting a few words that may slightly change the emphasis.

• Paraphrasing – Major restatement of what person said. Listener infers meaning of what was said. Can be thought of as continuing the thought.

• Reflecting Feeling - Listener reflects not just the words, but the feeling or emotion underneath what the person is saying.

NIDA-SAMHSA Blending Initiative 8

1. Simple Reflection (repeat)

2. Amplified Reflection (rephrasing andparaphrasing)

3. Double-Sided Reflection (rephrasing,paraphrasing and reflecting feeling)

Forming Reflections Instructions• Listener is making a guess at what the

speaker means and offers it for a response.

• Reflection has to be in the form of a statement rather than a question. (Voice turns down, not up at the end of the reflection)

• Discuss why statements work better than questions as reflections.

Forming Reflections Divide into groups of three• Participants in each triad take turns

being the speaker. The other two people listen and offer reflections. Some helpful stems to making reflections

are: So you feel . . . . . . It sounds like you . . . . You’re wondering if . . . . .

• The speaker responds to each statement with elaboration.

Forming Reflections: Debriefing

• How did the speakers feel in this exercise?

• How easy was it to generate reflections?

• What problems did you have?(Reminder: No MI interview will ever consist of only reflections. A good ratio to aim for is at least one reflection for every 3 questions.)

What’s the Best Way to Facilitate This Change?

• Constructive behavior change comes from connecting with something valued, cherished and important

• Intrinsic motivation for change comes out of an accepting, empowering, safe atmosphere where the painful present can be challenged

The Carrot

Use the Microskills of MI to:

Express Empathy

• Acceptance facilitates change• Skillful reflective listening is

fundamental• Ambivalence is normal


Develop Discrepancy• Discrepancy between present

behaviors and important goals or values motivates change

• Awareness of consequences is important

• Goal is to have the PERSON present reasons for change

Decisional Balance


Avoid Argumentation• Resistance is signal to change

strategies• Labeling is unnecessary• Shift perceptions • Peoples’ attitudes are shaped

by their words, not yours

Support Self-Efficacy• Belief that change is possible is an

important motivator• Person is responsible for choosing

and carrying out actions to change• There is hope in the range of

alternative approaches available


Providing Feedback

• Elicit (ask for permission)

• Give feedback or advice

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

Change Talk is Happening When a Client Makes Statements that Indicate:

Recognition of a problem

A concern about the problem

Statements indicating an intention to change

Expressions of optimism about change

• Increased willingness to explore change

• Fewer questions about the problems

• More questions about change

• Self-motivational statements

• Resolve

• Looking ahead

• Experimenting with change

Signs of Readiness to Change

How Do I Finish?• Develop a Change Plan with the

consumer by: Offering a menu of change options Developing a behavior contract Lowering barriers to action Enlisting social support Educating the consumer about

treatment

You Are Using MI If You:• Talk less than your client does

• Offer one refection for every three questions

• Reflect with complex reflections more than half the time

• Ask mostly open-ended questions

• Avoid getting ahead of your client’s stage of readiness (warning, confronting, giving unwelcome advice, taking “good” side of the argument)

Sample MI Interview Questions

The Matrix Model Treatment

An Evidence-Based Practice

Baseline Demographics

Participants Served (n) 1,016

Age (mean) 32.8 years

Education (mean) 12.2 years

Methamphetamine Use (mean) 7.5 years

Marijuana Use (mean) 7.2 years

Alcohol Use (mean) 7.6 years

Changes from Baseline to Treatment-end

Days of Methamphetamine Use

in Past 30 (ASI)

4.4

11.5

0

2

4

6

8

10

12

BL Tx end

Mea

n D

ays U

se

Possible is 0-30; tpaired=20.90; p-value<0.000 (highly sig.)

Beck Depression Inventory (BDI) Total Scores

15.4

9.9

0

5

10

15

20

BL Tx end

Mea

n T

otal

Sco

re

Possible is 0-63; tpaired=16.87; p-value<0.000 (highly sig.)

Mean Number of Weeks in Treatment

02468

1012

mea

n nu

mbe

r of v

isits

MatrixTAU

Mean Number of UA’s that were MA-free during treatment

0

2

4

6

8

10 MatrixTAU

Route of Administration by Site

0%10%20%30%40%50%60%70%80%90%

100%

Perc

en

t oral

nasal

smoke

IV

P<.05

Drop Rates by Route

0

10

20

30

40

50

60%

Dro

p a

t b

aseli

ne 3

0 d

ays

IN

SM

IDU

P<.05

Treatment Length by Route

0

1

2

3

4

5

6

7

8

9

10L

en

gth

in

Tre

atm

en

t (w

ks)

IN

SM

IDU

P<.05

Treatment Completion by Route

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7P

rop

ort

ion

of

Co

mp

leti

on

IN

SM

IDU

P<.05

MA-Free Samples by Route

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7P

rop

ort

ion

of

MA

-fre

e U

A (

3 w

ks)

IN

SM

IDU

P<.05

Hepatitis C by Route

0

10

20

30

40

50

60

70

80

% P

rev

ela

nc

e

IN (n=

SM (n=

IDU (n=)

P<.05

Overall participant follow-up by treatment condition and time

point492

401 421 425

486

397 420 425

0

100

200

300

400

500

Matrix TAU

Baseline Discharge 6 mo 12 mo

Abstinence Rates: % Reporting No Meth Use (past 30

days)

59 6368

57 61 63

0102030405060708090

100

Matrix TAU

Discharge 6 mo 12 mo

6966 70 66 68 73

0102030405060708090

100

Matrix TAU

Discharge 6 mo 12 mo

Urinalysis Results: % Meth Negative

Methamphetamine Abuse Among Men Who Have Sex With Men (MSM) in Los Angeles, California

This work supported by NIDA grantsR01 DA 11031 & R21 DA 018075

Study questions• What are the drug use and sexual risk behavior

changes for gay and bisexual men with methamphetamine dependence that result from treatment using the following interventions? Contingency Management (CM) Cognitive-Behavioral therapy (CBT) Combined (CBT+CM) Gay-specific Cognitive-Behavioral Therapy (GCBT)

DESIGN

2 Week Baseline

16-Week Data collection

6 Months 1st Follow-up

12 Months 2nd Follow-up

CM (n=42)

CBT (n=40)

CM + CBT (n=40)

GCBT (n=40)

Screen

Baseline and Randomization

End of treatment Follow-up Follow-up

Treatment Outcomes

Retention in Treatment

0

2

4

6

8

10

12

14

Wee

ks

CBT (n=40) CM (n=42) CBT+CM (n=40) GCBT (n=40)

F(3,158)=3.78, p<.01; CBT < CM and CBT+CM, p<.05

Consecutive Clean UA’s

0

5

10

15

20

25

CBT (n=40) CM (n=42) CBT+CM (n=40) GCBT (n=40)

F(3,158)=11.08, p<.001; CBT < CM and CBT+CM, p<.001

Mean Unprotected Receptive Anal Intercourse

0

0.5

1

1.5

2

2.5

3

3.5

4

Baseline Wk 4 Wk 8 Wk 12 Wk 16

CM

CBT

CM+CBT

GCBT

Depression Ratings

0

2

4

6

8

10

12

14

16

Baseline Week 1 Week 4 Week 16 Week 52

Study Visit

Avg

BD

I S

core

Baseline to Week 52 reductions p<.01; Peck et al., 2005

Women

Overwhelming Prevalence of Exposure to Childhood Adverse Events (CAEs)Previous research focused on drug-dependent women:

77% - 90% report histories of childhood trauma

29% - 70% report childhood emotional and physical abuse

19% to 59% report childhood sexual abuse 60% report witnessing frequent domestic violence

59% - 90% report continued physical/sexual abuse in adolescent and adult relationships

Childhood Trauma is Linked with Poor Mental Health Among Women

Histories of childhood trauma often linked to: Post-Traumatic Stress Disorder Depression Personality Disorders Panic Disorders Eating Disorders And, co-occurring Substance Abuse Disorders

Messina, 2008

Women Reported Greater Exposure to CAE’s vs. Men

55

3742

27

42

11

63

50

40

26

55

39

1720

0

10

20

30

40

50

60

70

80

90

100Women Men

*Bivariate Comparisons Significant at p<.01.

Increased Mental Health Problems with Greater Exposure to CAEs (N=587)


0102030405060708090

100

ZERO ONE TWO THREE FOUR >FIVEAdverse Childhood Experiences

%

Depression Antisocial Personality Dis. Suicidality BSI GSI >63

Increased Physical Health Problems with Greater Exposure to CAEs (N=587)


0%

10%20%

30%40%50%

60%70%

80%90%

100%

*Dental Problems

Hypertension

*Headaches/Migraines

*Back/Neck Injury

*Tumor/Cyst/A

bscess

ZERO ONE TWO

THREE FOUR >FIVE

Increased Physical Health Problems with Greater Exposure to CAEs (N=587)


0%10%20%30%40%50%60%70%80%90%

100%

*Bladder/Bowel D

isease

*Asthma

*Arthriti

s/Rheumatism

*STDs

*Hepatitis

ZERO ONE TWO

THREE FOUR >FIVE

Justice-Involved Populations

Participation in Drug/Alcohol Abuse Treatment During Incarceration

Urban Institute, 2003

None 80%

Drug / Alcohol

Treatment

2%

AA or NA Participation

8% Both

10%

% Arrest-Free Since Release at 18-Month Follow-up

* Significantly different from comparison group at p<.05

Comparison: N=242

Drop-outs: N=184

Completed Treatment:

N=172Completed

Treatment & Aftercare:

N=207

47%

62%65%

74%

0%

20%

40%

60%

80%

100%

**

*

DELAWARE CORRECTIONS-BASEDTHERAPEUTIC COMMUNITY TREATMENT CONTINUUM

% Drug-Free Since Release by Self-Report and Urine Test at 18-Month Follow-up


Comparison: N=242

Drop-outs: N=184


N=172Completed


N=20715%

29% 30%

43%

0%

20%

40%

60%

80%

100%

**

*


% Arrest-Free Since Releaseat 5-Year Follow-up


Comparison: N=217

Drop-outs: N=108


N=91Completed


N=12423% 28%

42%48%

0%

20%

40%

60%

80%

100%

* *

*


% Drug-Free Since Release by Self-Report and Urine Test at 5-Year Follow-up


Comparison: N=217

Drop-outs: N=108


N=91Completed


N=124

4%17%

21% 26%

0%

20%

40%

60%

80%

100%

* *


The same is True of Women in the Criminal Justice System?

Treatment group women had substantially more severe psychological problems

Equal numbers RTC at 6 & 12-months

Parolees who went to aftercare were significantly less likely to have RTC than women who were in prison treatment only

Specific Interventions

What is Relapse Prevention?

• Relapse prevention is a set of cognitive behavioral techniques and information that teach, coach and support abstinence from AOD and the acquisition of new behaviors. It is essentially the teaching and supporting of skills that are needed for sobriety.

What are the Goals of Relapse Prevention Training?

• Provide AOD users in treatment with skills to avoid any use of AOD.

• Prevent a slip from becoming a relapse

• Prevent a relapse from becoming re-addiction.

Cognitive Behavioral Therapy

• Basic Assumptions: Drug/Alcohol use is learned behavior No assumption of underlying psychopathology Classical and operant conditioning factors

involved “Treatment” 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

Cognitive Behavioral Therapy

• Key Concepts Encouraging and reinforcing behavior change Recognizing and avoiding high risk settings Behavioral planning (scheduling) Coping skills Conditioned “triggers” Understanding and dealing with craving Abstinence violation effect Understanding basic psychopharmacology

principles Self-efficacy

LEAD IN SESSIONSGoals

1. To provide structured place for new patients to learn about recovery skills and self-help programs.

2. Introduce patients to basic tools of recovery.

3. To introduce outside involvement and create an expectation of participation as part of treatment.

Goals

4. Help patients adjust to participating in groups.

5. Provide a model for gaining initial abstinence.

LEAD IN SESSIONS

TopicsScheduling

Methamphetamine and the BrainTriggers and Thought Stopping

Getting Rid of ParaphernaliaHIV and Hepatitis Risk12 Step Introduction

LEAD IN SESSIONS

RELAPSE PREVENTION GROUP

Goals

1. To allow clients to interact with other people in recovery.

2. To present specific relapse prevention material.

3. To allow co-leader to share long term sobriety experience.

Goals (continued)

4. To produce some groups cohesion among clients

5. To allow group leader to witness interpersonal interaction of clients.

6. To allow clients to benefit from participating in a long-term group experience.


Reminders

1. Beginning and ending on time will demonstrate how important the therapist views being on time.

2. Paying attention to time allotted to each client and to keeping the group safe will make clients feel the therapist is in control and be less anxious.


Reminders

4. Groups are organized around topics (unlike therapy groups).

5. Therapist has to control energy level of group; raise level of flat group, calm excessively high energy group.

6. Therapist should be aware of space and seating influences


Reminders

7. Focus of the group needs to always be relapse prevention.

8. Unstable or new members may be asked to listen only.

9. Plan should exist for handling unexpected intoxicated client who shows up for group.


Sample Topics• Alcohol -The Legal Drug• Boredom• Avoiding Relapse

Drift/Mooring Lines• Guilt and Shame• Motivation for Recovery• Truthfulness• Work and Recovery• Staying Busy• Relapse Prevention• Dealing with Feelings

• Total Abstinence• Sex and Recovery• Trust• Be Smart; Not Strong• Defining Spirituality• Relapse Justification• Reducing Stress• Managing Anger• Compulsive Behaviors• Repairing

Relationships


Some Specific Examples of Interventions That Are

Particularly Effective with Meth Users

CalendarFunctional Analysis

Results from the CADDs Data System (2001)

*The statewide data collection system, CADDs has information on the relative usefulness of treatment for MA users, by comparing them to cocaine users.

Sample Size and Early Drop Out

• Outpatient Treatment: MA users = 27,026 COC users = 11,160

• Early Dropout: Outpatient COC admissions were slightly

more likely to drop out of treatment before 30 days (25.5%) as compared to MA admissions (24.1%). P = .003

Predictors (cont’)

• Early dropout for both MA and COC users was associated with:

1. Being disabled2. Chronic mental illness3. Daily use of primary drug4. Injection use

• Early dropout is less likely for those under legal supervision, older age of first use of primary substance, and older age at admission.

Predictors of Retention in Treatment for more than 90

days1. Higher rates of retention for men

2. Legal supervision increases treatment retention

3. Those who began use at an older age were retained better than those who started when younger

4. Those who are older at admission were retained better

5. Injection users were retained more poorly

6. Those with chronic mental illness were retained more poorly

7. Daily users are retained more poorly than those who use less often than daily

Limitations on Current Treatments

• Training and development of knowledgeable clinical personnel are essential elements to successfully address the challenges of treating MA users.

• Training alone is insufficient if the funding necessary to deliver these treatment recommendations is not available.

• Treatment funding policies that promote short duration or non-intensive outpatient services are inappropriate for providing adequate funding for MA users.

Successful Outpatient Treatment Predictors

• Durations over 90 days (with continuing care for another 9 months).

• Techniques and clinic practices that improve treatment retention are critical.

• Treatment should include 3-5 clinic visits per week for at least 90 days.

• Employ evidence based practice (e.g., CBT, CM, Community Reinforcement Approach, Motivational Interviewing, Matrix Model).

• Family involvement and 12-step program appear to improve outcome.

• Urine testing (at least weekly is mandatory)

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).


Individuals:

• Injection MA users (very high rates of psychiatric symptoms; severe withdrawal syndromes; high rates of hepatitis).


Individuals:

• 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).

Contact your Local ATTC

www.attcnetwork.org

Thomas E. Freese, [email protected]

www.uclaisap.orgwww.psattc.org (Pacific Southwest)

www.pattc.org (Prairielands)

Documents

Methamphetamine: What do we do? Thomas E. Freese, Ph.D. [email protected] Pacific Southwest Addiction Technology Transfer Center UCLA Integrated Substance