Treatment of Methamphetamine Treatment of Methamphetamine Dependence: Dependence:

Does Treatment Work?Does Treatment Work?

Mary Lynn Brecht, Ph.D. Mary Lynn Brecht, Ph.D. Richard A. Rawson, Ph.DRichard A. Rawson, Ph.D

Semel Institute for Neuroscience and Human BehaviorSemel Institute for Neuroscience and Human BehaviorDavid Geffen School of MedicineDavid Geffen School of Medicine

University of California at Los AngelesUniversity of California at Los Angeleswww.uclaisap.orgwww.uclaisap.org

rrawson@mednet.ucla.edurrawson@mednet.ucla.edu

Supported by:Supported by: National Institute on Drug Abuse (NIDA)National Institute on Drug Abuse (NIDA)

Pacific Southwest Technology Transfer Center (SAMHSA)Pacific Southwest Technology Transfer Center (SAMHSA)International Network of Treatment and Rehabilitation Resource International Network of Treatment and Rehabilitation Resource

Centres (UNODC)Centres (UNODC)

U.S. Treatment Admissions for Primary U.S. Treatment Admissions for Primary Methamphetamine AbuseMethamphetamine Abuse

0

20,000

40,000

60,000

80,000

100,000

120,000

140,000

160,000

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Are Treatment Outcomes for Are Treatment Outcomes for Individuals with Methamphetamine Individuals with Methamphetamine Dependence Different than for Other Dependence Different than for Other

Drug Dependencies?Drug Dependencies?

Meth Treatment Effectiveness?Meth Treatment Effectiveness?

A pervasive rumor has surfaced in many A pervasive rumor has surfaced in many geographic areas with elevated MA problems:geographic areas with elevated MA problems:

MA users are virtually untreatable with negligible recovery MA users are virtually untreatable with negligible recovery rates.rates.

Rates from 5% to less than 1% have been quoted in Rates from 5% to less than 1% have been quoted in newspaper articles and reported in conferences.newspaper articles and reported in conferences.

Representatives for some commercial treatment concerns Representatives for some commercial treatment concerns have suggested there are no effective treatments for have suggested there are no effective treatments for methamphetamine dependence.methamphetamine dependence.

CA Treatment System OutcomesCA Treatment System Outcomes% Using in Past 30 Days by Type of Drug% Using in Past 30 Days by Type of Drug

7482

63 6156 56

44

56

36

26 28 28

0

50

100

Alcohol Heroin/op Coc/crack Marijuana Meth/amph Other

Pe

rce

nt

admission discharge

Based on 81,382 episodes of treatmentSource: ISAP Evaluation of CalOMS, Rawson et al., 2008

% Completing Treatment--% Completing Treatment--CA SACPA Meth UsersCA SACPA Meth Users

36

26 29 30 33

0

50

100

Alcohol Heroin/op Coc/crack Marijuana Meth/amph

Pe

rce

nt

Source: Anglin et al., Criminal Justice Treatment Admissions, J. of Psychoactive Drugs, 2007

Do Methamphetamine Users Respond Do Methamphetamine Users Respond Differently to Treatment than Cocaine Differently to Treatment than Cocaine

Users?Users?

Comparability of Treatment Outcome: Cocaine vs Comparability of Treatment Outcome: Cocaine vs MethamphetamineMethamphetamine

Alice Huber, Walter Ling and Richard Rawson * Alice Huber, Walter Ling and Richard Rawson *

Cohorts of methamphetamine dependent patients (N=500) Cohorts of methamphetamine dependent patients (N=500) and cocaine dependent patients (N=224) treated with a and cocaine dependent patients (N=224) treated with a standardized, outpatient treatment protocol (Matrix standardized, outpatient treatment protocol (Matrix Model) at the same clinic site, by the same staff over the Model) at the same clinic site, by the same staff over the same time period, demonstrated very similar treatment same time period, demonstrated very similar treatment response on virtually all treatment participation and response on virtually all treatment participation and outcome measures outcome measures

* Jnl of Addictive Diseases, 18, 1997, P 41-50.* Jnl of Addictive Diseases, 18, 1997, P 41-50.

Differences between methamphetamine users and Differences between methamphetamine users and cocaine users in treatmentcocaine users in treatment

Amy L. Copeland and James L. Sorensen*Amy L. Copeland and James L. Sorensen*

The two populations did not differ in treatment The two populations did not differ in treatment adherence, as measured by clinic attendance, adherence, as measured by clinic attendance, drug-free urines, and successful completion of drug-free urines, and successful completion of treatment. treatment.

* Drug and Alcohol Dependence* Drug and Alcohol Dependence, , Volume 62, Volume 62, March 2001, Pages 91-95March 2001, Pages 91-95

Treatment response by primary drug of abuse: Does Treatment response by primary drug of abuse: Does methamphetamine make a difference? methamphetamine make a difference?

Bill Luchansky, Antoinette Krupski, and Kenneth Stark*Bill Luchansky, Antoinette Krupski, and Kenneth Stark*

For both adults and youth, the results showed For both adults and youth, the results showed that across outcomes, there were few that across outcomes, there were few differences between MA users and users of differences between MA users and users of other hard drugs, whereas there were consistent other hard drugs, whereas there were consistent differences between MA users and users of differences between MA users and users of alcohol and marijuana. Alcohol and marijuana alcohol and marijuana. Alcohol and marijuana users tended to have more positive outcomes users tended to have more positive outcomes than the other groups. than the other groups.

**Journal of Substance Abuse TreatmentJournal of Substance Abuse Treatment Vol 32, 2007, Pages 89-96 Vol 32, 2007, Pages 89-96

SummarySummary

Treatment outcome data indicate that Treatment outcome data indicate that psychosocial treatments used in community psychosocial treatments used in community treatment programs produce comparable treatment programs produce comparable outcomes for methamphetamine dependent outcomes for methamphetamine dependent individuals and those with other forms of drug individuals and those with other forms of drug dependencydependency

Treatments for Stimulant-use Disorders with Treatments for Stimulant-use Disorders with Empirical SupportEmpirical Support

Cognitive-Behavioral Therapy (CBT)Cognitive-Behavioral Therapy (CBT) Community Reinforcement Approach Community Reinforcement Approach Contingency ManagementContingency Management 12 Step Facilitation12 Step Facilitation

All have empirical support for the treatment All have empirical support for the treatment of cocaine dependenceof cocaine dependence

Methamphetamine Treatment: Controlled Methamphetamine Treatment: Controlled Clinical TrialsClinical Trials

Cognitive Behavioral TherapyCognitive Behavioral Therapy

Contingency ManagementContingency Management

Matrix ModelMatrix Model

CBT: Basic AssumptionsCBT: Basic Assumptions

Emphasizes cognitive aspects of drug/alcohol use Emphasizes cognitive aspects of drug/alcohol use as learned behavioras learned behavior Role of cognitions in abstinenceRole of cognitions in abstinence

““Treatment” is a teaching process, coaching and Treatment” is a teaching process, coaching and reinforcing; “therapist” is a teacher/coachreinforcing; “therapist” is a teacher/coach

No assumption of underlying psychopathologyNo assumption of underlying psychopathology New, alternative behaviors must be established New, alternative behaviors must be established Can be delivered in group or individual settingsCan be delivered in group or individual settings

Contingency ManagementContingency Management

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

Cognitive Behavioral Therapy and Contingency Cognitive Behavioral Therapy and Contingency Management for Stimulant DependenceManagement for Stimulant Dependence

Participants Stimulant-dependent individuals (Participants Stimulant-dependent individuals (nn = 171). = 171).

Intervention CM, CBT, or combined CM and CBT, 16-week treatment conditions. CM 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 received vouchers for stimulant-free urine samples. CBT condition participants attended three 90-minute group sessions each week.. condition participants attended three 90-minute group sessions each week..

Results CM procedures produced better retention and lower rates of stimulant use Results CM procedures produced better retention and lower rates of stimulant use during the study period Self-reported stimulant use was reduced from baseline levels during the study period 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 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 at follow-up. While CM produced robust evidence of efficacy during treatment application, CBT produced comparable longer-term outcomes. There was no application, CBT produced comparable longer-term outcomes. There was no evidence of an additive effect when the two treatments were combined. The response evidence of an additive effect when the two treatments were combined. The response of cocaine and methamphetamine users appeared comparable. of cocaine and methamphetamine users appeared comparable.

Conclusions: This study suggests that CM is an efficacious treatment for reducing Conclusions: This study suggests that CM is an efficacious treatment for reducing stimulant use and is superior during treatment to a CBT approach. CBT also reduces stimulant use and is superior during treatment to a CBT approach. CBT also reduces drug use from baseline levels and produces comparable outcomes on all measures at drug use from baseline levels and produces comparable outcomes on all measures at follow-up.follow-up.

Rawson, RA et al. Addiction, Jan 2006Rawson, RA et al. Addiction, Jan 2006

FIGURE 1. Program Retention by GroupFIGURE 1. Program Retention by Group

15.5

27.6 28.6

0

8

16

24

32

Cognitive-Behavioral Therapy

(CBT)

ContingencyManagement (CM)

CBT+CM

Group (F = 10.2, df = 2, P < 0.0001)

Mea

n N

umbe

r FIGURE 2. Stimulant–free Urine Samples by GroupFIGURE 2. Stimulant–free Urine Samples by Group

0

2

4

6

8

10

12

Cognitive-Behavioral Therapy

(CBT)

ContingencyManagement (CM)

CBT+CM

Mea

n D

ays

of S

tim

ulan

t U

se

Baseline 17 Weeks 26 Weeks 52 Week

FIGURE 3. Self-Reported Stimulant UseFIGURE 3. Self-Reported Stimulant Use

Contingency Management: An Evidence-Based Contingency Management: An Evidence-Based Component of Methamphetamine Use Disorder Component of Methamphetamine Use Disorder

Treatments*Treatments*

*Roll, J. Contingency management: an evidence based component of methamphetamine use disorder treatments. Addiction. 2007;102

(Suppl. 1):114-120.

Contingency Management for Treatment of Contingency Management for Treatment of Methamphetamine DependenceMethamphetamine Dependence

Design: RTCDesign: RTC Method: 113 patients diagnosed with methamphetamine abuse or Method: 113 patients diagnosed with methamphetamine abuse or

dependence were randomly assigned to receive either treatment as dependence were randomly assigned to receive either treatment as usual (TAU) or TAU plus contingency management. usual (TAU) or TAU plus contingency management.

Results indicate that both groups were retained in treatment for Results indicate that both groups were retained in treatment for equivalent times but those in the combined group accrued more equivalent times but those in the combined group accrued more abstinence and were abstinent for a longer period of time. These abstinence and were abstinent for a longer period of time. These results suggest that contingency management has promise as a results suggest that contingency management has promise as a component in methamphetamine use disorder treatment strategies.component in methamphetamine use disorder treatment strategies.

* Roll JM, Petry NM, Stitzer ML, et al: Contingency management for * Roll JM, Petry NM, Stitzer ML, et al: Contingency management for the treatment of methamphetamine use disorders. Am J Psychiatry the treatment of methamphetamine use disorders. Am J Psychiatry 163(11):1993-1999, 2006163(11):1993-1999, 2006

Mean number of abstinences

0

5

10

15

20

25

CM Control

Mean weeks of consecutive abstinence

0

1

2

3

4

5

6

CM Control

Matrix ModelMatrix Model Is a manualized, 16-week, non-residential, psychosocial Is a manualized, 16-week, non-residential, psychosocial

approach used for the treatment of drug dependence.approach used for the treatment of drug dependence.

Manuals Can be downloaded at SAMHSA.govManuals Can be downloaded at SAMHSA.gov

Designed to integrate several interventions into a Designed to integrate several interventions into a comprehensive approach. Elements include:comprehensive approach. Elements include: Individual counselingIndividual counseling Cognitive behavioral therapyCognitive behavioral therapy Motivational interviewingMotivational interviewing Positive reinforcement for behavior changePositive reinforcement for behavior change Family education groupsFamily education groups Urine testingUrine testing Participation in 12-step programsParticipation in 12-step programs

Treatment Components of Treatment Components of the Matrix Modelthe Matrix Model

Individual SessionsIndividual Sessions

Early Recovery GroupsEarly Recovery Groups

Relapse Prevention Relapse Prevention GroupsGroups

Family Education GroupFamily Education Group

12-Step Meetings12-Step Meetings

Social Support GroupsSocial Support Groups

Relapse AnalysisRelapse Analysis

Urine TestingUrine TestingM

ATR

IX

Rawson, R.A., Marinelli-Casey, P., Anglin, M.D., Dickow, A., Frazier, Y., Gallagher, C., Galloway, G.P., Rawson, R.A., Marinelli-Casey, P., Anglin, M.D., Dickow, A., Frazier, Y., Gallagher, C., Galloway, G.P.,

Herrell, J., Huber, A., McCann, M.J., Obert, J., Pennell, S., Reiber, C., Vandersloot, D., Zweben, J., and Herrell, J., Huber, A., McCann, M.J., Obert, J., Pennell, S., Reiber, C., Vandersloot, D., Zweben, J., and

the Methamphetamine Treatment Project Corporate Authors. (2004). A multi-site comparison of the Methamphetamine Treatment Project Corporate Authors. (2004). A multi-site comparison of

psychosocial approaches for the treatment of methamphetamine dependence. psychosocial approaches for the treatment of methamphetamine dependence. AddictionAddiction, 99, 708-, 99, 708-

717.717.

The CSAT The CSAT Methamphetamine Methamphetamine Treatment ProjectTreatment Project

A Multi-site Trial of a Manualized Psychosocial Protocol for the Treatment of Methamphetamine

Dependence

Mean Number of Weeks in Treatment

02468

1012

SITE

mea

n nu

mbe

r of

vis

its MatrixTAU

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

0

2

4

6

8

10

SITE

mea

n nu

mbe

r of

MA

-fre

e U

A's Matrix

TAU

Urinalysis Results Urinalysis Results

Results of Ua Tests at Discharge, 6 Results of Ua Tests at Discharge, 6 months and 12 Months post admission **months and 12 Months post admission **

• Matrix GroupMatrix Group TAU GroupTAU Group

D/C: 66% MA-freeD/C: 66% MA-free 65% MA-free 65% MA-free

6 Ms: 69% MA-free6 Ms: 69% MA-free 67% MA-free 67% MA-free

12 Ms: 59% MA-free12 Ms: 59% MA-free 55% MA-free 55% MA-free

**Over 80% follow up rate in both groups at all points**Over 80% follow up rate in both groups at all points

Predictors of In-treatment Predictors of In-treatment Performance and Post-Treatment Performance and Post-Treatment Outcomes in a Methamphetamine-Outcomes in a Methamphetamine-

Dependent AdultsDependent Adults

Predictors of Long-Term AbstinencePredictors of Long-Term Abstinence

Predictors of no MA use at treatment Predictors of no MA use at treatment discharge, and at the 6- and 12-mos discharge, and at the 6- and 12-mos follow-ups includes:follow-ups includes:

MA use of MA use of << 15 days at baseline, 15 days at baseline, Lifetime MA use of < 2 yearsLifetime MA use of < 2 years No previous drug abuse treatmentNo previous drug abuse treatment Providing 3 consecutive MA-free UAs Providing 3 consecutive MA-free UAs

during treatmentduring treatment

Thank youThank you

rrawson@mednet.ucla.edurrawson@mednet.ucla.eduwww.uclaisap.orgwww.uclaisap.org

www.methamphetamine.orgwww.methamphetamine.org