Methamphetamine: What do we do?

1. Methamphetamine: What do we do? Thomas E. Freese, Ph.D. tefreese@ix.netcom.com Pacific Southwest Addiction Technology Transfer Center UCLA Integrated Substance Abuse Programs www.psattc.org www.uclaisap.org

2. Motivational Interviewing

3. 1. Precontemplation Definition: Not yet considering change or is unwilling or unable to change. Primary Task: Raising Awareness 6. Recurrence Definition: Experienced a recurrence of the symptoms. Primary Task: Cope with consequences and determine what to do next 2. Contemplation Definition: Sees the possibility of change but is ambivalent and uncertain. Primary Task: Resolving ambivalence/ Helping to choose change Stages of Change:Primary Tasks 5. Maintenance Definition: Has achieved the goals and is working to maintain change. Primary Task: Develop new skills for maintaining recovery 3. Determination Definition: Committed to changing. Still considering what to do. Primary Task: Help identify appropriate change strategies 4. Action Definition: Taking steps toward change but hasn’t stabilized in the process. Primary Task: Help implement change strategies and learn to eliminate potential relapses

4. BUILDING MOTIVATION OARS • O • A • R • S • Open-ended questioning • Affirming • Reflective listening • Summarizing

5. An Important MI Skill:Forming Reflections Adapted from Exercise By Bill Miller

6. Forming Reflections To help participants learn how to form effective reflective-listening statements

7. Levels of Reflection 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.

8. Types of Reflective Statements • 1. Simple Reflection (repeat) • Amplified Reflection (rephrasing and • paraphrasing) • Double-Sided Reflection (rephrasing, • paraphrasing and reflecting feeling) NIDA-SAMHSA Blending Initiative 8

9. 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.

10. 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.

11. 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.)

12. 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

13. Use the Microskills of MI to: Express Empathy Acceptance facilitates change Skillful reflective listening is fundamental Ambivalence is normal

14. Use the Microskills of MI to: 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

15. Decisional Balance

16. Use the Microskills of MI to: Avoid Argumentation Resistance is signal to change strategies Labeling is unnecessary Shift perceptions Peoples’ attitudes are shaped by their words, not yours

17. 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 Use the Microskills of MI to:

18. 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)

19. 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

20. Signs of Readiness to Change • Increased willingness to explore change • Fewer questions about the problems • More questions about change • Self-motivational statements • Resolve • Looking ahead • Experimenting with change

21. 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

22. You Are Using MI If You: • Talk less than your client does • Offer one refection for every three questions • Reflect with complexreflections 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)

23. Sample MI Interview Questions

24. The Matrix Model Treatment An Evidence-Based Practice

25. The CSAT Methamphetamine Treatment Project

26. Baseline Demographics

27. Changes from Baseline to Treatment-end

28. Days of Methamphetamine Use in Past 30 (ASI) Possible is 0-30; tpaired=20.90; p-value<0.000 (highly sig.)

29. Beck Depression Inventory (BDI) Total Scores Possible is 0-63; tpaired=16.87; p-value<0.000 (highly sig.)

30. Mean Number of Weeks in Treatment

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

32. Route of Administration by Site P<.05

33. Drop Rates by Route P<.05

34. Treatment Length by Route P<.05

35. Treatment Completion by Route P<.05

36. MA-Free Samples by Route P<.05

37. Hepatitis C by Route P<.05

38. Overall participant follow-up by treatment condition and time point

39. Abstinence Rates: % Reporting No Meth Use (past 30 days)

40. Urinalysis Results: % Meth Negative

41. Methamphetamine Abuse Among Men Who Have Sex With Men (MSM) in Los Angeles, California This work supported by NIDA grants R01 DA 11031 & R21 DA 018075

42. 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)

43. DESIGN

44. Treatment Outcomes

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

46. Consecutive Clean UA’s F(3,158)=11.08, p<.001; CBT < CM and CBT+CM, p<.001

47. Mean Unprotected Receptive Anal Intercourse

48. Depression Ratings Avg BDI Score Baseline to Week 52 reductions p<.01; Peck et al., 2005

49. Women

50. 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