The Treatment of Illicit Drug Taking

Transcription

1 The Treatment of Illicit Drug Taking David A. Deitch, Ph.D. University of California San Diego Clinical Professor of Psychiatry and Director, Addiction Training Center 1 Alcohol Vs. Illicit Drugs and the istory of Response Models developed to heroin Other general models Criteria Outcome data to major models Crime and drugs Using prisons Data on prison therapeutic community treatment Characteristics of therapeutic communities Pathways into addiction Personality disorders considerations 2 Development of the Criminal Justice Model A Policy Time Line The War On Drugs Development of Treatment from a Social Perspective & 1988 Anti-Drug Abuse Act arrison Narcotic Act ( March 1, 1915) Founding of AA, end of WWI Lexington& Fortworth Civil Addict Program NARA Act Establishment of NIAA, NIDA and TASC s -30 s 1

2 Treatment of eroin Addiction: Modalities/Philosophies SELF-REGULATING COMMUNITY PSYCOTERAPEUTIC OPIOD MAINTENANCE NARCOTIC ANTAGONIST MEDICAL DISTRIBUTION SUPERVISORY-DETERRENT FAIT AND DEDICATION RELAPSE PREVENTION ( CARACTER RESTRUCTURING) ( SELF-MEDICATION; EGO DEFECT) ( SPECIFIC DEFECT CORRECTION) ( CONDITIONING; LEARNING) ( ARM REDUCTION) ( EUPORIA-TEMPTATION) ( SPIRITUAL VOID) ( LEARNING, CRAVINGS, COPING) MULTIMODALITY J. Jaffe ( ETIOLOGICAL ETEROGENEITY) 4 Detoxification Pharmacological Chemical Dependency Programs Therapeutic Communities Outpatient Model Social Model 12 Step 5 Social Criteria for Treatment Success Diminish crime in community Diminish tax consumptive behavior Diminish illicit substance abuse Increase tax productive behavior Increase personal well being 6 2

3 Sociodemographic Characteristics of Clients Entering Treatment by Modality DARP 7 Outpatient Methadone Treatment (OMT) Changes From Before to After Treatment 8 IBR S Quarterly Newsletter, Vol..7, Number 4, Winter 1997\98 Outpatient Drug Free (ODF) Treatment Changes From Before to After Treatment 9 IBR S Quarterly Newsletter, Vol..7, Number 4, Winter 1997\98 3

4 Long-Term Residential (LTR) Treatment Changes From Before to After Treatment 10 IBR S Quarterly Newsletter, Vol..7, Number 4, Winter 1997\98 Short-Term Changes From Before to After Treatment 11 IBR S Quarterly Newsletter, Vol..7, Number 4, Winter 1997\98 eroin 12 Psychology of Addictive Behaviors, Vol. 11:4, December

5 Crack Cocaine 13 Psychology of Addictive Behaviors, Vol. 11:4, December 1997 Injecting 14 Psychology of Addictive Behaviors, Vol. 11:4, December 1997 Sharing 15 Psychology of Addictive Behaviors, Vol. 11:4, December

6 Effects of Long-Term Residential Treatment Percent 16 Psychology of Addictive Behaviors, Vol. 11:4, December 1997 Effects of Out Patient Drug Free Treatment Percent 17 Psychology of Addictive Behaviors, Vol. 11:4, December 1997 Drug Abuse Treatment Outcome Study (91-93) Characteristics of Drug Abuse Treatment Outcome Study Follow-up Frame and Weighted Sample of Respondents Long Term Residential Therapeutic Community Client Characteristics Frame Respondents other behavior (N=2,293; %) (N=676; %) More than 30 yrs of age Male African American or ispanic igh School or general equivalency diploma Married or living as married Criminal justice referral Previous drug treatment Private health insurance Treatment duration more than 3 months

7 Drug Use Preadmission year Follow-up year other behavior (N=2,293; %) (N=676; %) eroin a Cocaine a Marijuana a Alcohol b Suicidal thoughtsattempts Predatory illegal activity Sexual behavior risk Less than full-time work ealth limitations Note. Preadmission year data are reported for the follow-up frame (N), and the follow-up year data are reported for the weighted sample of respondents(n). a Weekly or more frequent use of drug during the 1-year period. b Weekly or more frequent use with five or more drinks at a sitting. 1) Prevention or reduction of withdrawal symptoms 2) Prevention or reduction of drug craving 3) Prevention of relapse to use of addictive drug 4) Restoration to or toward normalcy of any physiological function disrupted by drug use 20 Methadone L-AAM (L-alpha acetylmethadol) Buprenophine Center for Substance Abuse Treatment (CSAT) 21 7

8 Prevention of onset of withdrawal syndrome for 24 hours or more Reduction or elimination of drug hunger or craving Blockade of euphoric effects of illicit narcotics 22 *Intake 2 Days ASI SADS-L Risk of IV behavior Urine/breath tests *Pre-Treatment 2 Weeks Random Assignment of Patients: N = mg IV education and test *Post-Treatment At 6 & 12 ASI Month Points Risk of IV behavior Urine/breath tests 23 Experimental Group (methadone) Control Group (no methadone) P P No drug abuse Expelled from treatment 1 Sepsis & endocarditis 2 Leg amputation 3 Sepsis P In prison 24 8

9 Experimental Group (methadone) Control Group (no methadone) P P 25 ADEQUATE DOSE...BASED ON CLINICAL & LABORATORY DATA 26 Drug Effect Overdose Intoxication Euphoria No Drug Effect ( Normal ) Time in hours 27 9

10 Early dose adjustments to approximate established Tolerance Threshold REMEMBER STEADY-STATE PARMACOLOGY Today s dose repeated tomorrow will have a greater effect and the next day, and the next until steady-state is achieved Provide full relief and prevention of withdrawal signs and symptoms and ensure reduction in drug hunger/craving 28 Daily Dose in MGS. 29 Methadone Dose Range Less than 60 mg mg 80+ mg Relative Risk of Leaving Treatment 100 (baseline) Capelhorn & Bell,

11 Svikis et al. Johns opkins 146 Cocaine Abusing, Pregnant Women Seeking Pre-Natal Care - Not Treatment 100 Received - 1-Week Residential Tx. Instill Abstinence Orientation 46 Received - Standard Pre-Natal Care Costs and Complications of Delivery Control Women 63% 100 Treated Women *37% Control Women 2534 gms 34 wks 100 Treated Women *2939 gms *39 wks 33 11

12 46 Control Women 39 days $46, Treated Women *7 days *$14, Therapeutic Community Enduring Principles Concern for the state of our soul and our physical survival Search for meaning: transcending truths Challenge and admonish with love Be invasive - accountable to the community Public disclosure of acts, fears, hopes, guilts Public expiation for wrongs done Banishment is possible - - done with concern for survival Leadership by elders - - by models 35 It a is place that believes: You can change - Unfold The group can facilitate this change The individual must take responsibility There are structures to accommodate this Act as if - Go through the motions University of California, David San Deitch, Diego PhD, Addictions UCSD, Technology ATTC Transfer Center,

13 Requisite/Pervasive T.C. is a Social Learning Model - Learn through Challenge and Action - Learn through Universality of our Condition - Learn through Disclosure and Exposure - Fantasies, Angers, Fears, opes University of California, San Diego Addictions Technology Transfer Center, Structured Activities and Expectations - Ranges from groups of all types - Through conduct in all areas of community life (the way I make my bed, keep my closet, dress, communicate, show concern for others, etc.) Environmental - Atmosphere of caring and respect for the person as well as challenge - Unwritten philosophy - signs - visual aids - Symbols/Rituals (the way things are done) University of California, San Diego Addictions Technology Transfer Center, Seminars and Discussions/Reading and Learning Every Day Learn to Play Every Day 39 13

14 Staffing TC Trained leadership TC Trained recovered people TC and academic trained people - MSW, PhD, RN, MD Mix should be trained in transdisciplinary with cross skill abilities Must share - belief system value system Model - walk the walk not just talk the talk 40 IX XII GOALS To learn: Compassion Achievement Responsibility VI III 41 Doctors Administrator Counselors Specialists T.C. Teacher COMMUNITY Psychologist Maintenance Cook Social Worker Family Therapist Nurse University of California, David San Deitch, Diego PhD, Addictions UCSD, ATTC Technology Transfer Center,