Evidence-Based Practice: Psychosocial Interventions

1. Evidence-Based Practice: Psychosocial Interventions Maxine Stitzer, Ph.D. Johns Hopkins Univ SOM NIDA Blending Conference June 3, 2008 Cincinnati, Ohio

2. Talk Outline • What is an evidence-based practice? • What practices are evidence-based? • Why should these be used? • How to decide which one(s) to use?

3. What Is An Evidence-Based Practice? • Developed by researchers • Subjected to controlled evaluation • Shown efficacious in 2 or more trials

4. Compared to Usual Care Practices • Therapy specified in a detailed manual • Therapists trained to proficiency • Therapists monitored for adherence • presence of specified and absence of non-specified elements • Clients meet inclusion and exclusion criteria • may be less complicated cases • Detailed data collected on outcomes

5. Efficacy research shows that practices can work under ideal conditions

6. Do Evidence-Based Practices Work in Real World Settings? • Research conducted by NIDA CTN has verified effectiveness of some evidence-based practices • Motivational Interviewing • Contingency Management • Others are yet to be tested • 12-step Facilitation • Cognitive-Behavioral Therapy

7. What Psychosocial Therapies are Evidence-based? • Motivational Interviewing (MI/MET) • Contingency Management (CM) • Cognitive-behavioral therapy (CBT)

8. MI/MET: What Is It • Style of therapist-client interaction • Utilizes basic counseling skills for rapport • Reflective listening, open-ended questions, avoid arguments and lectures • Provide feedback and develop discrepancies to motivate “change talk” and hopefully, behavior change

9. MI/MET Techniques • O open ended questions • A affirmation • R reflective listening • S summary statements

10. MI/MET: Evidence For Efficacy • Improved compliance in medical patients • Reduced drinking in alcoholics • Drug users contacted in a medical setting

12. MI in Drug Treatment Settings • Evidence mixed • Some studies find benefits • Others find no benefits

13. CTN MI Study Methods • 418 patients randomized at 5 sites • 375 were exposed to protocol • Counselors trained in MI conducted intake session as a MI “sandwich” • Client-centered discussion with reflection, open-ended questions, etc before & after intake questionnaires

14. Patients assigned to MI completed more sessions than those in standard treatment

15. More MI patients were retained at 1-month

16. No differences in retention at the 84-day follow-up

17. No differences in drug use during first 28 days

18. Alcohol users (n=172)were the ones who benefited

19. If a little MI is good (improved attendance and retention) would more be better?Second CTN MI study delivered 3 sessions of MI-style therapy vs3 sessions of individual TAU

20. MET Study Outcomes METTAUSignificance Days Enrolled 72 69 ns Retained 4 mos (%) 41 46 ns Positive UA 21 28 ns (% in 28 days)

21. MET: Effectiveness in Alcoholics

22. MI Overview • Excellent foundation for counseling skills • Builds client internal motivation for change • Evidence-based practice with good data supporting use with alcoholics • Jury still out on effectiveness with drug users especially in treatment settings

23. CBT: What Is It • Structured skills training lessons • Manage cravings • Avoid triggers • Drug refusal • Coping/problem solving • Lectures, practice, homework • Manualized • NIDA Therapy Manual for Drug Addiction #1

24. CBT Efficacy Evaluation • Many studies have demonstrated efficacy • Some show during treatment effects • Some show benefits only after treatment ends (“sleeper” effects)

25. IOP Treatment: CBT vs 12-Step Maude Griffin et al., 1998

26. CBT vs Clinical Management: 1x per week Carroll et al., 1994

27. CBT Overview • Provides structured content for DA therapy • Potential for building highly useful skills • Coping, problem solving, drug avoidance, etc • Potential limitations • Do clients learn what is taught? • Do clients put learning into practice?

28. Contingency ManagementMotivational Incentives: What Is It • Provides tangible positive reinforcement for specified behavior • Behavior can be attendance, drug abstinence, goal achievement • Reinforcers can be cash-value vouchers or prizes

29. $10 Voucher Point System Increasing magnitude, bonus, up to $1000 $2.50 $10.00 $3.75 $11.25 $5.00 +$10 $12.50 + $10 $6.25 $13.75 $7.50 $15.00 $8.75 + $10 $16.25 + $10 Advantages: demonstrated efficacy, accommodate personal preferences, less likely to exchange for drugs Disadvantages: cost, staffing for management, delay to receipt of some items, worth less than cash?

30. Voucher Incentives in Outpatient Drug-free Treatment Higgins et al. Am. J. Psychiatry, 1993 Cocaine negative urines

31. Intermittent schedule/prize system • Draws from a fishbowl • Advantages: can be less expensive than vouchers; cost can be controlled by varying size and cost of prizes and percentage of winning chips

32. Retention: Alcoholics in Outpatient Psychosocial Treatment Petry et al., 2000

33. Time to first heavy drinking episode p<.05 Petry et al., 2000

34. CTN MIEDAR Study • Stimulant abusers randomly assigned to usual care with or without abstinence incentives • 415 psychosocial counseling • 388 methadone maintained • Drug-free urines earn draws from an abstinence bowl during a 3-month study • Negative for cocaine, methamphet and alcohol ---> escalating draws • Also negative for opiates, THC ---> bonus draws

35. Total Earnings • $400 in prizes could be earned on average • If participant tested negative for all targeted drugs over 12 consecutive weeks

36. Control Incentive Incentives Improve Retention in Counseling Treatment 100 80 60 50% Percentage Retained 40 35% 20 RH = 1.6 CI=1.2,2.0 0 2 4 6 8 10 12 Study Week

37. Percent of Submitted Samples Testing Stimulant and Alcohol Negative 100 80 60 Percentage negative samples 40 Abstinence Incentive Usual Care 20 0 1 3 5 7 9 11 13 15 17 19 21 23 Study Visit

38. Abstinence Incentives in Psychosocial Counseling Tx • Incentives lengthened duration of drug-free treatment participation • Presumably improving long-term outcomes • May be useful for all clients as relapse prevention • Suggests clinic-wide implementation • Attendance incentive may achieve same goal • If clients remain abstinent during treatment

39. Combination of treatments may be best for long-term recovery

41. Why Should Evidence-Based Practices Be Used? • Enhance counseling skills and proficiency • Engage in culture of CQI • Improve treatment outcomes • Satisfy accreditation boards; federal and insurance payers

42. Which Evidence-Based Practices Should Be Used? • Selected by needs of the clinic? • Selected by needs of the clients? • Selected by research effect sizes? • All used in some logical adoption sequence?

43. Sequential Adoption Plan • Motivational Interviewing • Contingency Management • Cognitive-Behavior Therapy

44. Needs of Clinic and Clients • Improve early engagement (MI/MET) • Improve retention (CM) • Stop on-going drug use (CM) • Prevent relapse (CM/CBT) • Build alternative non-drug reinforcers (CBT)

45. Evidence-Based Practices Summary • Shown efficacious in clinical trials and effective in real world settings • Adoption improves care quality and outcomes • Three recommended are MI, CM and CBT • Sequential adoption and combined use may be optimal strategy

46. Benefits of EBP Adoption • Counselors will like it • New counseling skills (MI), structured content (CBT) and behavior change tools (CM) • Clients will like it • Therapy may be more engaging and useful • Funders will like it • Pathway to better outcomes