The Voice of Recovery: Effectively Treating Methamphetamine Users and their Families Michael S. Shafer, Ph.D

The Voice of Recovery: Effectively Treating Methamphetamine

Users and their Families

Michael S. Shafer, Ph.D.

Motivation for Treatment• Why is it harder for a

stimulant abuser to enter the treatment system?



• What does it mean to say someone is motivated to do treatment?



• What does it mean to say someone is motivated to do treatment?

• How can we compete with the pull of drugs like methamphetamine?

How Stimulants Affect the Willingness to Enter

Treatment

Methamphetamine does NOT make you sick; therefore, the drug use is not the problem.

Methamphetamine allows long periods of no drug use; certainly the drug is not the problem.

Medical & Psychosocial Treatment Approaches for Various Commonly Abused

Substances

Drugs

SedativesStimulants

OpioidsAlcohol

Medical Treatment

Yes

NoNoYesYes

Psychosocial Treatment

YesYesYesYes

www.drugabuse.gov

Principles of Effective Treatment

1. No single treatment is appropriate for all2. Treatment needs to be readily available3. Effective treatment attends to the multiple

needs of the individual4. Treatment plans must be assessed and

modified continually to meet changing needs5. Remaining in treatment for an adequate

period of time is critical for treatment effectiveness


6. Counseling and other behavioral therapies are critical components of effective treatment

7. Medications are an important element of treatment for many patients

8. Co-existing disorders should be treated in an integrated way

9. Medical detox is only the first stage of treatment

10. Treatment does not need to be voluntary to be effective

11. Possible drug use during treatment must be monitored continuously

12. Treatment programs should assess for HIV/AIDS, Hepatitis B & C, Tuberculosis and other infectious diseases and help clients modify at-risk behaviors

13. Recovery can be a long-term process and frequently requires multiple episodes of treatment

- NIDA (1999) Principles of Drug Addiction Treatment


MA Treatment Issues

Acute MA Overdose Acute MA Psychosis MA “Withdrawal” Initiating MA Abstinence MA Relapse Prevention Protracted Cognitive Impairment and Symptoms of Paranoia

Acute MA Overdose

Slowing of Cardiac Conduction Ventricular Irritability Hypertensive Episode Hyperpyrexic Episode CNS Seizures and Anoxia

Acute MA Psychosis

Extreme Paranoid Ideation Well Formed Delusions Hypersensitivity to Environmental

Stimuli Stereotyped Behavior “Tweaking” Panic, Extreme Fearfulness High Potential for Violence

Treatment of MA Psychosis

• Typical ER Protocol for MA Psychosis– Haloperidol - 5mg– Clonazepam - 1 mg– Cogentin - 1 mg– Quiet, Dimly Lit Room– Restraints

MA “Withdrawal”

- Depression - Paranoia- Fatigue - Cognitive

Impairment - Anxiety - Agitation- Anergia - Confusion

• Duration: 2 Days - 2 Weeks

Treatment of MA “Withdrawal”

Hospitalization/Residential Supervision if:– Danger to Self or Others, or, so

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

– Otherwise Intensive Outpatient Treatment

Treatment of MA “Withdrawal”

Intensive Outpatient Treatment– No Pharmacotherapy Available– Positive, Reassuring Context– Directive, Behavioral Intervention– Educate Regarding Time Course of

Symptom Remission– Recommend Sleep and Nutrition– Low Stimulation– Acknowledge Paranoia, Depression

Initiating MA AbstinenceKey Clinical Issues

– Depression– Cognitive Impairment– Continuing Paranoia– Anhedonia– Behavioral/Functional Impairment– Hypersexuality– Conditioned Cues– Irritability/Violence

Initiating MA Abstinence

Key Elements of Treatment– Structure– Information in

Understandable Form– Family Support– Positive Reinforcement– 12-Step Participation

Treatment of MA Disorders

State of Empirical Evidence– No Information on TC or

“Minnesota Model” Approaches– No Pharmacotherapy with

Demonstrated Efficacy– Results of Cocaine Treatment

Research Extrapolated to MA Treatment

NIDA Therapy Manuals for Drug Addiction

behavioral and cognitive treatment approaches

proven effective through research

A Cognitive-Behavioral Approach: Treating Cocaine Addiction

A Community Reinforcement Plus Vouchers Approach: Treating Cocaine Addiction

Manual 2

Manual 1

A Cognitive-Behavioral Approach: Treating Cocaine

Addiction

Kathleen M. Carroll, Ph.D.April 1998

Manual 1

Cognitive Behavioral TherapyThe Essential Tasks

Functional analyses of substance useIndividualized training

• Coping with Craving• Managing Using Thoughts• Problemsolving• Recognizing Seemingly Irrelevant

Decisions• Refusal Skills

Cognitive Behavioral TherapyThe Essential Tasks (con’t.)

Examining substance use cognitionsIdentifying and debriefing past and future high-risk situationsEncouraging and reviewing extra-session implementation of skillsPracticing skills during sessions

Cognitive Behavioral Therapy2 Critical Components

FunctionalAnalysis(Analyze)

Skills Training(Act)

Cognitive Behavioral TherapyFunctional Analysis

Thoughts

Circumstances

Feelings

Before and After Use

Cognitive Behavioral TherapySkills Training

Stopping DrugThoughts

SocialSkills

AvoidingHigh-RiskSituations

EmploymentIssues

For Present and for Future

Cognitive Behavioral Therapy

Skills Training

Cessation Strategies

Use Repetition Anticipate Obstacles

Generalizable Skills

Practice Mastering

Skills

Monitor Closely

Basic Skills First

Give a Clear Rational

Use the Data

Match Material to Patient

Needs

Get a Commitment

Explore Resistance

Community Reinforcement Plus Vouchers Approach:

Treating Cocaine Addiction

Budney & HigginsApril 1998

Manual 2

• An operant model where approximations of the desired behaviors are encouraged and rewarded to facilitate progress toward specified goals.

• Underlying emphasis of this approach is to reward abstinence behaviors so that individuals make healthy lifestyle choices.

• Relapse prevention strategies and motivational interviewing are fundamental parts of this approach.

• The two major goals of CRA include elimination of positive reinforcement for drug use and enhancement of positive reinforcement for sobriety.

Core Program Components of CRA

• Behavioral Orientation

• Skills Instruction

• Sobriety Sampling

• Treatment Planning

Behavioral Orientation

• Use of Functional Analysis to Identify Antecedents and Consequences of Addictive Behavior

• Non-Confrontational Counseling Styles, using tenets of Motivational Interviewing, prompt rule, and reinforcing successive approximations of sobriety

• Use of Role Playing to Practice Skills• Use of Modeling to Demonstrate

Desirable Skills

Skills Instruction

• Social/recreational skills• Communication skills, including

behavioral marital counseling• Problem solving skills• Employability skills• Drink refusal skills, including

duration training

Sobriety Sampling

• Behavioral Contracts Negotiated with Clients for Progressively Longer Periods of Sobriety

• Agnostic Medications (Disulfurim/Antabuse) Prescribed and Used with Monitors

Treatment Planning

• Formalized Process for Treatment Planning

• Treatment Plan Focused on Responding to Client Identified Sources and Barriers to Personal Happiness – Use of the Happiness Scale

Demonstrated Clinical Efficacy

• Alcoholics • Opiate and cocaine abusers • Homeless populations

3 meta-analysis of the substance abuse treatment research have identified CRA

as one of the top five treatments in producing positive outcomes for low

costs.

Incentives in Treatmentof Cocaine Dependence

Review of the Literature(Higgins 1996)

13 Studies

11 StudiesPositive Treatment Effects

2 StudiesNo Significant Difference

MATRIX MODEL TREATMENT

Behavioral Disruption Cognitive Disruption

Emotional DisruptionFamily/Relationship

Disruption

Components of Stimulant

Addiction Syndrome

Treatment Components of the Matrix Model

• Early Recovery Groups

• Relapse Prevention Groups

• Individual Sessions

• Family Education Group

• 12-Step Meetings

• Social Support Groups

• Relapse Analysis

• Urine Testing

STAGES OF RECOVERY

Withdrawal

DAY

0

DAY

15

Honeymoon

DAY

45

The Wall

DAY

120

Resolution

Adjustment

DAY

180

• Medical Problems• Alcohol Withdrawal• Depression• Difficulty

Concentrating• Severe Cravings• Contact with Stimuli• Excessive Sleep

Day 0 to Day 15

WITHDRAWAL STAGE

Primary Manifestation of Withdrawal Stage

Behavioral Cognitive

RelationshipEmotional

BehavioralBehavioralInconsistencyInconsistency

Confusion, Inability to Concentrate

Depression/Anxiety,Self-Doubt

Mutual Hostility,Fear

Self-designed structure (scheduling)

Makes concrete the idea of “one day at a time”

Eliminate avoidable triggers

Reduces anxiety

Counters the addict lifestyle

Provides basic foundation for ongoing recovery

Key Concept: Structure

Ways to Create Structure

Time scheduling

Going to treatment

Attending 12-step meetings

Exercising

Performing athletic activities

Attending school

Going to work

Attending church

Pitfalls of Structure

Scheduling unrealistically

Neglecting recreation

Being perfectionistic

Therapist imposing schedule

Spouse/parent imposing schedule

Unstructured time

Proximity of triggers

Alcohol/marijuana use

Powerful cravings

Withdrawal Stage: Relapse Factors

• Paranoia

• Depression

• Disordered sleep patterns

• Overconfidence• Over-involvement with

work• Inability to prioritize• Inability to initiate change• Alcohol use• Episodic cravings• Treatment termination

HONEYMOON STAGE

Day 15 to Day 45

Primary Manifestation of Honeymoon Stage



High energy,High energy,

Unfocused behaviorUnfocused behavior Inability to prioritize

Overconfidence,Feeling cured

Denial of addiction disorder

Information - What

• Substance abuse & the brain

• Sex and recovery

• Relapse prevention issues

• Triggers and cravings

• Emotional readjustment

• Stages of recovery

• Medical effects

• Relationships and recovery

• Alcohol/marijuana

Information - Why

Reduces confusion and guilt

Explains addict behavior

Gives a roadmap for recovery

Clarifies alcohol/marijuana issue

Aids acceptance of addiction

Gives hope/realistic perspective for family

Relapse Factors: Honeymoon Stage

Overconfidence

Secondary alcohol or other drug use

Discontinuation of structure

Resistance to behavior change

Return to addict lifestyle

Inability to prioritize

Periodic paranoia

Return to Old Behaviors

Anhedonia

Anger

Depression

Emotional Swings

Unclear Thinking

Isolation

Family ProblemsCravings Return

Irritability

Abstinence Violation

Primary Manifestation of the

Wall Stage



Sluggish,Sluggish,Low Energy/InertiaLow Energy/Inertia

Relapse Justification

Depression,Anhedonia

Irritability, Mutual Blaming, Impatience

Relapse Factors: Sexual Behavior

Sexual arousal producing craving

Concern about sexual dysfunction

Concern over sexual abstinence

Concern over sexual disinterest

Loss of intensity of sexual enjoyment

Relapse Factors: Sexual Behavior

Shame/Guilt about sexual behavior

Sexual behavior and intimacy

Sobriety and monogamy

Relapse Factors: Alcohol/Marijuana

Stimulant craving induction

Pharmacologic coping method

12-Step philosophy conflict

Abstinence violation effect

Marijuana amotivational syndrome

Interferes with new behaviors

Key Concept: Relapse Justification

Definition:

The rational part of the brain attempts to provide a logical explanation for justifying behavior which moves the client closer to his drug of choice

Relapse thoughts gain power when not openly recognized and discussed

The Wall: Relapse Factors

• Increased emotions• Interpersonal conflict• Relapse justification• Anhedonia/loss of

motivation

• Insomnia/low energy/fatigue

• Paranoia

• Dissolution of structure

• Behavioral drift

• Secondary alcohol or drug use

• Resistance to exercise

Primary Manifestation of Adjustment Stage



SloppinessSloppinessRegarding LimitsRegarding Limits

Drifting From Commitment to Recovery

Experiencing Normal Emotions

Surfacing of Long-Term Issues

Relapse Factors: Adjustment Stage

Relaxation of structure

Struggle over acceptance of addiction

Maintenance of recovery momentum/ commitment

Six-month syndrome

Re-emergence of underlying pathology

Evaluation of the Matrix Model

Key findings from a recently completed CSAT-funded 8-site evaluation of the Matrix model

Study participants treated with the Matrix Model were retained in treatment longer and gave more drug-free urine samples than participants treated in the community “Treatment as Usual” condition.

Outcomes for both Matrix and Treatment as Usual indicated that participants reduced their use of MA from an average of 11 days in the previous 30 at admission to approximately 4 days at discharge and both follow up points.

At discharge and follow-up points between 57% and 68% of participants in both groups reported no MA use for the previous 30 days and approximately the same number gave drug free urine samples (samples were collected on over 80% of participants, under observation)

Participants in both treatment groups showed significant improvement in employment status, family relations, legal problems and psychiatric symptoms.

In one site, all participants were currently enrolled in a drug court program.

Participants in this site had better outcomes than in all other sites, suggesting that drug court involvement was very effective.

On numerous measures, individuals who injected MA had poorer outcomes than individuals who snorted or smoked MA. Smokers also, exhibited considerable difficulty, but not as severe as injectors.

The following recommendations are based upon a reading and synthesis of the treatment research on MA to date (2005).

Outpatient treatment can be quite effective for treating individuals who abuse or are dependent upon methamphetamine.

Characteristics of successful treatment are:

Recommendations for Methamphetamine Treatment Policy and Program Development

Treatment should include 3-5 clinic visits per week for at least 90 days (with continuing care for another 9 months).

Techniques and clinic practices that improve treatment retention are critical.

Contingency managementFamily involvementCall backs for missed appointmentsFood

Treatment content and approaches currently demonstrated effective with cocaine users are applicable to methamphetamine users – Cognitive Behavioral Therapy– Contingency Management– Community Reinforcement Approach– Motivational Interviewing– Matrix Model

Family Involvement and 12 Step Program involvement appear to improve outcomes.

Urine Testing (at least weekly is mandatory)

A Word About

Urine….

Some Considerations on the Use of Urinalysis

Used as a means of providing irrefutable evidence of sobriety

Negative test results (reflecting non-use) provide opportunities for celebration, therapeutic milestones, and contingency pay-outs

Positive test results provide opportunities for therapeutic intervention and relapse analysis

Thresholds and Time Lapses for Urine Detection of Various

Substances

Drug Abbrev. Threshold

Min Time

Max Time

Methamphetamine mAMP 1000 ng/ml

1-3 hr. 2-4 d

Cannabis THC 50 ng/ml 6-18 hr 10-30 d

Cocaine COC 300 ng/ml 1-4 hr 2-4 d

Ecstasy MDMA 500 ng/ml 1 hr 2-3 day

PCP PCP 25 ng/ml 5-7 hr 6-28 d

Comparison Shopping for Urine Testing

Large sample of online vendors from which to select

Decisions to make on the frequency of testing, number of substances to test for, whether using panel tests or integrated cups, and whether adulteration is to be tested

Comparison Shopping for Urine Testing

Costs of panel tests range from $1.76 (single panel) to $22.90 (10 panel)

Costs of integrated cups range from $7.33 (3 substances) to $24.50 (10 substances)

Costs of panel tests at local retailers range from $11.99 (single panel) to $29.99 (6 panel)…no single panel tests for meth available in retail

Some Best Practice Indicators for the Therapeutic Use of UrinalysisSampling schedule should be specified based

upon target substanceSample frequently, at least 2-3 times per weekEnsure collection of valid samples (dedicated

collection room, no personal belongings accompanying clients, consider use of staff monitors)

Sample assaying should be done onsite with results communicated to the client immediately

Used sample equipment and supplies are disposed of properly

Optimal candidates for outpatient treatment include:

• Non injection methamphetamineusers

• Those without chronic mental illness and those without significant psychiatric symptoms at admission

• Those who are using methamphetamine less than daily at admission

• Those under legal supervision (especially drug court)

• Older individuals (over 21)

• Those who are not disabled

• Those who have a stable living situation (without active drug users)

Special Population Considerations

Female methamphetamine users (higher rates of depression; very high rates of previous and present sexual and physical abuse; responsibilities for children)

Injection methamphetamine users (very high rates of psychiatric symptoms; severe withdrawal syndromes; high rates of hepatitis)

Methamphetamine users who take methamphetamine 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)

Some Good Web Resources….

http://www.crystalmeth.org/ (CMA groups)http://www.nida.nih.gov/Infofacts/methamphetamine.html

(NIDA Fact Sheet on Meth)http://www.methamphetamine.org/ (Portal to the

CSAT Meth Treatment Project)http://www.nida.nih.gov/ResearchReports/Methamph/Methamph.html

(NIDA Research Report)http://www.matrixinstitute.org/ (Matrix Institute)http://www.uclaisap.org/ (UCLA – Integrated

Substance Abuse Programs)

Some Good Technical Resources…

• Contingency Management: Using Motivational Incentives to Improve Drug Abuse Treatment (available

Yale University Psychotherapy Development Center) • A Community Reinforcement Approach: Treating

Cocaine Addiction (available through NIDA)

• Matrix Model of Individualized Intensive Outpatient Stimulant Treatment: A 16 week Individualized Program for the Treatment of Stimulant Abuse and Dependence Disorders (available through Hazelden Press)

• TIP 33: Treatment for Stimulant Use Disorders (available through SAMHSA)

Documents

The Voice of Recovery: Effectively Treating Methamphetamine Users and their Families Michael S. Shafer, Ph.D