Treatments for Methamphetamine-Related Disorders

1. Treatments for Methamphetamine-Related Disorders Richard A. Rawson, Ph.D, Professor Integrated Substance Abuse Programs Semel Institute for Neuroscience and Human Behavior David Geffen School of Medicine University of California at Los Angeles www.uclaisap.org rrawson@mednet.ucla.edu Supported by: National Institute on Drug Abuse (NIDA) Pacific Southwest Technology Transfer Center (SAMHSA) United Nations Office of Drugs and Crime

2. Meth Treatment Effectiveness? A pervasive rumor has surfaced in many geographic areas with elevated MA problems: • MA users are virtually untreatable with negligible recovery rates. • Rates from 5% to less than 1% have been quoted in newspaper articles and reported in conferences. **The resulting conclusion is that spending money on treating MA users is futile and wasteful, BUT no data exists that supports these statistics**

3. Meth Treatment Statistics During the 2002-2003 fiscal year: • 35,947 individuals were admitted to treatment in California under the Substance Abuse and Crime Prevention Act funding. • Of this group, 53% reported MA as their primary drug problem

4. Statistics A comparison of treatment outcomes between individuals diagnosed with methamphetamine dependence and all other diagnostic groups indicated no between group significant differences in any treatment outcome measures including: • Retention in treatment rates • Urinalysis data during treatment • Rates of treatment program completion. All these measures indicate that MA users respond in an equivalent manner as individuals admitted for other drug abuse problems.

5. Comparability of Treatment Outcome: Cocaine vs Methamphetamine • Huber, Ling and Rawson (Jnl of Addictive Diseases, 1997). • Cohorts of methamphetamine dependent patients (N=500) and cocaine dependent patients (N=224) treated with a standardized, outpatient treatment protocol (Matrix Model) at the same clinic site, by the same staff over the same time period, demonstrated very similar treatment response on virtually all treatment participation and outcome measures

6. Table 3. Treatment Experience to Methamphetamine and Cocaine Users MA Users (n = 500) Cocaine Users (n = 224) Early Recovery Group+ 3.4(4.4) 3.7(3.3) Relapse Prevention Group+ 23.7(29.0) 21.0(26.8) Family Education Group+ 11.6(14.0) 12.2(12.8) Social Support Group+ 4.4(14.9) 4.3(18.2) Total of Treatment Hours Received+ 52.9(51.4) 54.5(49.3) Weeks in Treatment+ 17.1(22.3) 18.0(21.3) Urine Sample Collected+ 8.3(8.0) 8.1(7.6) Percentage of Samples Positive for Primary Drug++ 19.3% 13.3% {Treatment Received in Number of Hours} + Numbers presented are means and (standard deviations) ++ Numbers presented are percentages

8. Why the “MA treatment doesn’t work” perceptions? • Many of the geographic regions impacted by MA do not have extensive treatment systems for severe drug dependence. • Medical and psychiatric aspects of MA dependence exceeds program capabilities. • High rate of use by women, their treatment needs and the needs of their children can be daunting. • Although some traditional elements may be appropriate, many staff report feeling unprepared to address many of the clinical challenges presented by these patients

9. CSAT Tip #33 A useful resource that presents a review of the existing knowledge about treatment effectiveness with stimulant users.

10. Medications • Currently, there are no medications that can quickly and safely reverse life threatening MA overdose. • There are no medications that can reliably reduce paranoia and psychotic symptoms, that contribute to episodes of dangerous and violent behavior associated with MA use.

11. Medications considered for Meth Negative ResultsUnder Consideration • Imipramine Bupropion • Desipramine Modafinil • Tyrosine Topirimate • Ondansetron Disulfiram • Fluoxetine Lobeline Gabapentin Aripiprazole

12. Bupropion: An efficacious pharmacotherapy? • Newton et al 2005 Bupropion reduces craving and reinforcing effects of meth • Elkashef (recently completed) Bupropion reduces meth use in an outpatient trial, with particularly strong effect with less severe users.

13. Treatments for Stimulant-use Disorders with Empirical Support • Cognitive-Behavioral Therapy (CBT) • Motivational Interviewing • Community Reinforcement Approach • Contingency Management • 12 Step Facilitation All have demonstrated efficacy for the treatment of cocaine dependence

14. 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

15. Motivational Interviewing • Key Concepts • Empathy and therapeutic alliance • Give feedback and reframe • Create dissonance • Focus of discrepancy of expected and actual • Reinforce change • Roll with resistance

17. Methamphetamine Treatment: Controlled Clinical Trials Brief Cognitive Behavioral Therapy Extended Cognitive Behavioral Therapy Contingency Management Matrix Model

18. Cognitive Behavioral Therapy and Contingency Management for Stimulant Dependence • Design Randomized clinical trial. • Participants Stimulant-dependent individuals (n = 171). • Intervention CM, CBT, or combined CM and CBT, 16-week treatment conditions. CM condition participants received vouchers for stimulant-free urine samples. CBT condition participants attended three 90-minute group sessions each week. CM procedures produced better retention and lower rates of stimulant use during the study period. • Results Self-reported stimulant use was reduced from baseline levels at all follow-up points for all groups and urinalysis data did not differ between groups at follow-up. While CM produced robust evidence of efficacy during treatment application, CBT produced comparable longer-term outcomes. There was no evidence of an additive effect when the two treatments were combined. The response of cocaine and methamphetamine users appeared comparable. • Conclusions: This study suggests that CM is an efficacious treatment for reducing stimulant use and is superior during treatment to a CBT approach. CM is useful in engaging substance abusers, retaining them in treatment, and helping them achieve abstinence from stimulant use. CBT also reduces drug use from baseline levels and produces comparable outcomes on all measures at follow-up. • Rawson, RA et al. Addiction, Jan 2006

19. FIGURE 2. Stimulant–free Urine Samples by Group

20. FIGURE 3. Self-Reported Stimulant Use

21. Contingency Management for treatment of methamphetamine dependence • Design: RTC • Method: 113 patients diagnosed with methamphetamine abuse or dependence were randomly assigned to receive either treatment as usual (TAU) or TAU plus contingency management. • Results indicate that both groups were retained in treatment for equivalent times but those in the combined group accrued more abstinence and were abstinent for a longer period of time. These results suggest that contingency management has promise as a component in methamphetamine use disorder treatment strategies. • Contingency Management for the Treatment of Methamphetamine Use Disorders. Roll, JM et al, Archives of General Psychiatry, (In Press)

22. Contingency Management • A technique employing the systematic delivery of positive reinforcement for desired behaviors. In the treatment of methamphetamine dependence, vouchers or prizes can be “earned” for submission of methamphetamine-free urine samples.

23. Methamphetamine Outcomes from CTN 006

24. CM + TAUTAU Roll, et al., American Journal of Psychiatry, In Press

25. Conclusions • CM appears to increase the abstinence rates when combined with psychosocial treatments • Suggests CM should be an integral part of methamphetamine use disorder treatment modalities

26. Contingency Management: A Meta-analysis • A recent meta-analysis reports that CM results in a successful treatment episode 61% of the time while other treatments with which it has been compared result in a successful treatment episode 39% of the time (Prendergast, Podus, Finney, Greenwell & Roll, submitted)

27. Matrix Model • Most extensively evaluated approach for the treatment of MA dependence. • Incorporates a set of treatment elements which have empirical support, including behavioral strategies, cognitive behavioral strategies, motivational interviewing, positive reinforcement, psycho-education, 12 Step participation, family involvement

28. Matrix Model ofOutpatient Treatment Organizing Principles of Matrix Treatment • Program components based upon scientific literature on promotion of behavior change. • Program elements and schedule selected based on empirical support in literature and application. • Program focus is on current behavior change in the present and not underlying “causes” or presumed “psychopathology”. • Matrix “treatment” is a process of “coaching”, educating, supporting and reinforcing positive behavior change.

29. Matrix Model ofOutpatient Treatment Organizing Principles of Matrix Treatment • Non-judgmental, non-confrontational relationship between therapist and patient creates positive bond which promotes program participation. • Therapist as a “coach” • Positive reinforcement used extensively to promote treatment engagement and retention. • Verbal praise, group support and encouragement other incentives and reinforcers.

30. Matrix Model ofOutpatient Treatment Organizing Principles of Matrix Treatment • Accurate, understandable, scientific information used to educate patient and family members • Effects of drugs and alcohol • Addiction as a “brain disease” • Critical issues in “recovering” from addiction

31. Matrix Model ofOutpatient Treatment Organizing Principles of Matrix Treatment • Behavioral strategies used to promote cessation of drug use and behavior change • Scheduling time to create “structure” • Educating and reinforcing abstinence from all drugs and alcohol • Promoting and reinforcing participation in non- drug-related activities

32. Matrix Model ofOutpatient Treatment Organizing Principles of Matrix Treatment • Cognitive-Behavioral strategies used to promote cessation of drug use and prevention of relapse. • Teaching the avoidance of “high risk” situations • Educating about “triggers” and “craving” • Training in “thought stopping” technique • Teaching about the “abstinence violation effect” • Reinforcing application of principles with verbal praise by therapist and peers

33. Matrix Model ofOutpatient Treatment Organizing Principles of Matrix Treatment • Involvement of family members to support recovery. • Encourage participation in self-help meetings • Urine testing to monitor drug use and reinforce abstinence • Social support activities to maintain abstinence

34. The Matrix Model • Urine or breath alcohol tests once per week, weeks 1-16

35. The CSAT Methamphetamine Treatment Project A Multi-site Trial of a Manualized Psychosocial Protocol for the Treatment of Methamphetamine Dependence Richard Rawson Ph.D. U.C.L.A. Integrated Substance Abuse Programs (I.S.A.P.) The MTP Site Investigators Funded by the Center for Substance Abuse Treatment

36. CSAT MTP Project Goals: • To study the clinical effectiveness of the MatrixModel • To compare the effectiveness of the Matrix model to other locally available outpatient treatments • To establish the cost and cost effectiveness of the Matrix model compared to other outpatient treatments • To explore the replicability of the Matrix model and challenges involved in technology transfer

37. Baseline Demographics

38. GenderDistribution of Participants

39. Ethnic Identification of Participants

40. Route of Methamphetamine Administration

41. Route of Administration by MTP Site (N=978) Site Oral Nasal Smoke IV Billings 0% 2% 42% 56% Concord 0% 10% 59% 30% Costa Mesa 0% 8% 65% 27% Hayward 1% 35% 57% 5% Honolulu 0% 1% 96% 3% San Diego 1% 11% 61% 28% San Mateo, ODASA 0% 6% 94% 0% San Mateo, Pyramid 0% 23% 64% 13% OVERALL PERCENT : 0% 11% 65% 24%

42. Changes from Baseline to Treatment-end

43. ASI Composite Scores Possible is 0-1; Higher : worse problem tpaired: *p-value<0.03 (sig.), **p-value<0.000 (highly sig.)

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

45. Days of Marijuana Use in Past 30 (ASI) Possible is 0-30; tpaired=8.02; p-value<0.000 (highly sig.)

46. Days of Alcohol Use in Past 30 (ASI) Possible is 0-30; tpaired=6.47; p-value<0.000 (highly sig.)

47. Mean Number of Weeks in Treatment

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

49. Figure 4. Percent completing treatment, by group

50. Figure 6. Participant self-report of MA use (number of days during the past 30) at enrollment, discharge, and 6-month follow-up, by treatment condition