What is the evidence for time limiting addiction treatment?

1. What is the evidence for time limiting addiction treatment? Kathleen M CarrollProfessor of PsychiatryYale University School of Medicinekathleen.carroll@yale.edu

2. Overview • Survey of treatment literature on time limited treatment • Few true randomized trials. . • Different conclusions based on patient group (severity, comorbidy problems, type of substance) • Implications for rebuilding a treatment system

3. Addicts careers (Dennis et al., 2005, JSAT) • 1271 index admissions to publicly funded clinics (cocaine 64%, alcohol 44%, opioids 41%, marijuana 14%; 59% female, 87% AA) • 3 year follow up (98% of those living, 35 died ) • 47% attain 12 months of abstinence • Mean time from first use to first treatment= 9 years • Median time from first to last use = 27 years. • Longer treatment career for males, those with earlier first use (esp <15), multiple treatment episodes, and mental distress.

4. Dennis et al: Addict careers

5. Addiction is a chronic relapsing disease, but we’re not always treating addiction Severe Dependence Likely intensity/ Duration of treatment Duration of treatment Should be proportional to severity, chronicity Of use and related problems Moderate Abuse Mild Problems Intensity of behavior None Level of problems

6. Can we assume…. • Response generally happens early • More of a bad thing is rarely better. • More of a good thing is probably better • Its probably better to think about time to the targeted outcome (abstinence)

7. More of a good thing is usually good-- • If the good thing is an effective empirically validated therapy. • Brief therapies effective first line for lower severity individuals—Good evidence for alcohol • Few well-done trials where a well-defined cohort is randomized to different lengths of an empirically validated therapy

8. Marijuana example: Marijuana Treatment Project (N=450) Marijuana use through 15 months

9. Methamphetamine example:Randomization to CM-3 different durations (Roll, J.M. et al. 2013) 118 methamphetamine users, 4 month treatment

10. Prescription opioid dependent patients, Weiss et al., 2012 Arch General Psychiatry • 653 treatment seeking individuals dependent on prescription opioids • Adaptive treatment model: • Phase 1: 2 week buprenorphine/naloxone stabilization + 2 week taper, 8 week follow up • Successful patients (no opioid use at end of tratment) complete • Unsuccessful patients enter Phase II. • 12 weeks bup/nal, 4 week taper, 8 week follow-up

11. Prescription opioid dependent patients, Weiss et al., 2012 Arch General Psychiatry 9% successful at final week follow-up

12. Duration of medications • Buprenorphine, naltrexone, methadone etc. tend to be effective only while the individual is taking it • Medications are opportunities to provide treatment and services to support sustained change • Stepwise discontinuation with frequent monitoring.

13. Making CM more durable • CM very effective while contingencies in place • Dropoff after contingencies stop • But…..those who attain longer periods of abstinence better outcomes in follow-up • Petry proposal-After care model, VI schedule of reinforcement up to 6 months. If missing or positive, frequency increases • Likely to be less expensive and more acceptable to patients than standard aftercare

14. ‘CBT 4 CBT’Computer Based training for CBT • 7 modules, ~1 hour each, high flexibility • Highly user friendly, no text to read, linear navigation • Based on NIDA CBT manual • Multiple strategies for presenting skills • Video examples of characters struggling real life situations • Repeat movie with character using skills to change ‘ending’ • Interactive exercises, quizzes • Multiple examples of ‘homework’

15. Core principles: CBT4CBT development • Highly engaging-capture attention of substance users, retain them in treatment • Deliver potent dose of evidence based cognitive and behavioral strategies- • Focus on key generalizable skills • Durability of effects-skills practice • Modeling-demonstration of skills in realistic situations under stress • Breadth of users-all drugs, balance of gender and ethnicity • Security- NO identifying information or PHI

17. Overview: Initial randomized clinical trial • 8 week randomized clinical trial • Outpatient community treatment program • Standard treatment (weekly individual + group therapy) (TAU) vs. CBT4CBT + TAU • CBT4CBT offered in up to 2 weekly sessions • 6 month follow-up Carroll et al., Am J Psychiatry, 2008

18. Participants, first trial “All comers”: few restriction on participation, only require some drug use in past 30 days • 43% female • 45% African American, 12% Hispanic • 23% employed • 37% on probation/parole • 59% primary cocaine problem, 18% alcohol, 16% opioids, 7% marijuana • 79% users of more than one drug or alcohol

19. Primary outcome (% drug-positive urine toxicology screens), 8 weeks, CBT+TAU versus TAU Carroll et al., 2008, Am J Psychiatry

20. Primary outcome: Longest consecutive abstinence, in days, at 8 weeks by condition Carroll et al., 2008, Am J Psychiatry

21. Skill level though 6 month follow-up: Quality of best response by condition Kiluk et al, Addiction, 2010

22. Quality of coping skills as mediator of outcome in CBT4CBT Coping Skills (3) b=8.3** (2) b=.3* % positive urine CBT v TAU • b=5.2* (4) b=3.3 Kiluk et al, Addiction, 2010

23. Durability of Effects: 6 month follow-up Carroll et al., 2009, DAD

24. Overview: Second randomized trial • 101 DSM-IV cocaine-dependent methadone maintained opioid users population • Standard treatment (weekly group therapy) (TAU) vs. CBT4CBT + TAU • CBT4CBT offered in up to 2 weekly sessions, • 6 month follow-up • Sample: 60% female, 40% minority, 89% unemployed, higher levels psychiatric comorbidity (29% depressive disorder, 30% anxiety disorder), multiple other substance use Carroll et al., under review

25. Primary post treatment outcomes: Cocaine-MMP sample Carroll et al., under review

26. Follow-up: Frequency of cocaine use by month; cocaine-methadone sample

27. Figure 2: STROOP task: Comparison of Post- to Pretreatment, CBT4CBT versus TAU Stroop activity decreases from pre- to post- CBT4CBT but not TAU CBT Stroop Post > Pre TAU Stroop Post > Pre pFWE=.05 X-=21

28. CBT4CBT-Duration • Self help for less severe cases/treatment entry -Use until abstinent or treatment indicated • Medication platforms (office based buprenorphine) • Use until stabilized • Outpatient care Endpoint-abstinence, demonstration of skills

29. Irrational practices/Perverse incentives in US system • SBIRT: Referral for treatment without following through • Office based buprenorphine without assertive care • Multiple admissions for the same ineffective treatment (detoxification only) • Persisting in a treatment to which the patient has not responded. • Discharging patients for being symptomatic

30. Adapting treatment to patient response • Assess • -Severity • Comorbid problems • Resources Treat to criterion Objective, clinically meaningful outcome Re-assess Predetermined time Clear feedback on criterion Evaluation of mechanism Decrease intensity Taper Support monitor Increase intensity Add medication Add CM Add support