Treatment of Methamphetamine Dependence: Does Treatment Work? Mary Lynn Brecht, Ph.D. Richard A. Rawson, Ph.D 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) International Network of Treatment and Rehabilitation Resource Centres (UNODC)
160,000 140,000 120,000 100,000 80,000 60,000 40,000 20,000 U.S. Treatment Admissions for Primary Methamphetamine Abuse 0 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006
Are Treatment Outcomes for Individuals with Methamphetamine Dependence Different than for Other Drug Dependencies?
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. Representatives for some commercial treatment concerns have suggested there are no effective treatments for methamphetamine dependence.
CA Treatment System Outcomes % Using in Past 30 Days by Type of Drug 100 74 82 admission discharge Percent 50 44 56 63 61 36 56 56 26 28 28 0 Alcohol Heroin/op Coc/crack Marijuana Meth/amph Other Based on 81,382 episodes of treatment Source: ISAP Evaluation of CalOMS, Rawson et al., 2008
% Completing Treatment-- CA SACPA Meth Users 100 Percent 50 36 26 29 30 33 0 Alcohol Heroin/op Coc/crack Marijuana Meth/amph Source: Anglin et al., Criminal Justice Treatment Admissions, J. of Psychoactive Drugs, 2007
Do Methamphetamine Users Respond Differently to Treatment than Cocaine Users?
Comparability of Treatment Outcome: Cocaine vs Methamphetamine Alice Huber, Walter Ling and Richard Rawson * 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 * Jnl of Addictive Diseases, 18, 1997, P 41-50.
Differences between methamphetamine users and cocaine users in treatment Amy L. Copeland and James L. Sorensen* The two populations did not differ in treatment adherence, as measured by clinic attendance, drug-free urines, and successful completion of treatment. * Drug and Alcohol Dependence, Volume 62, March 2001, Pages 91-95
Treatment response by primary drug of abuse: Does methamphetamine make a difference? Bill Luchansky, Antoinette Krupski, and Kenneth Stark* For both adults and youth, the results showed that across outcomes, there were few differences between MA users and users of other hard drugs, whereas there were consistent differences between MA users and users of alcohol and marijuana. Alcohol and marijuana users tended to have more positive outcomes than the other groups. *Journal of Substance Abuse Treatment Vol 32, 2007, Pages 89-96
Summary Treatment outcome data indicate that psychosocial treatments used in community treatment programs produce comparable outcomes for methamphetamine dependent individuals and those with other forms of drug dependency
Treatments for Stimulant-use Disorders with Empirical Support Cognitive-Behavioral Therapy (CBT) Community Reinforcement Approach Contingency Management 12 Step Facilitation All have empirical support for the treatment of cocaine dependence
Methamphetamine Treatment: Controlled Clinical Trials Cognitive Behavioral Therapy Contingency Management Matrix Model
CBT: Basic Assumptions Emphasizes cognitive aspects of drug/alcohol use as learned behavior Role of cognitions in abstinence Treatment is a teaching process, coaching and reinforcing; therapist is a teacher/coach No assumption of underlying psychopathology New, alternative behaviors must be established Can be delivered in group or individual settings
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.
Cognitive Behavioral Therapy and Contingency Management for Stimulant Dependence 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.. 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 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. 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
FIGURE 1. Program Retention by Group
FIGURE 2. Stimulant free Urine Samples by Group 32 27.6 28.6 Mean Number 24 16 8 15.5 0 Cognitive- Behavioral Therapy (CBT) Contingency Management (CM) CBT+CM Group (F = 10.2, df = 2, P < 0.0001)
FIGURE 3. Self-Reported Stimulant Use Mean Days of Stimulant Use 12 10 8 6 4 2 0 Cognitive- Behavioral Therapy (CBT) Contingency Management (CM) CBT+CM Baseline 17 Weeks 26 Weeks 52 Week
Contingency Management: An Evidence-Based Component of Methamphetamine Use Disorder 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 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. * Roll JM, Petry NM, Stitzer ML, et al: Contingency management for the treatment of methamphetamine use disorders. Am J Psychiatry 163(11):1993-1999, 2006
Mean weeks of consecutive abstinence 6 5 4 3 2 1 0 CM Control
Matrix Model Is a manualized, 16-week, non-residential, psychosocial approach used for the treatment of drug dependence. Manuals Can be downloaded at SAMHSA.gov Designed to integrate several interventions into a comprehensive approach. Elements include: Individual counseling Cognitive behavioral therapy Motivational interviewing Positive reinforcement for behavior change Family education groups Urine testing Participation in 12-step programs
Treatment Components of the Matrix Model Individual Sessions Early Recovery Groups Relapse Prevention Groups Family Education Group 12-Step Meetings Social Support Groups Relapse Analysis Urine Testing
The CSAT Methamphetamine Treatment Project A Multi-site Trial of a Manualized Psychosocial Protocol for the Treatment of Methamphetamine Dependence 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 the Methamphetamine Treatment Project Corporate Authors. (2004). A multi-site comparison of psychosocial approaches for the treatment of methamphetamine dependence. Addiction, 99, 708-717.
Mean Number of Weeks in Treatment mean number of visits 12 10 8 6 4 2 0 Billings Concord CostaMesa Hayward Honolulu SanDiego SanMateoODAS Matrix TAU SanMateoPyra SITE
Mean Number of UA s that were MA-free during treatment mean number of MA-free UA's 10 8 6 4 2 0 Billings Concord CostaMesa Hayward Honolulu SanDiego SanMateoODAS Matrix TAU SanMateoPyra SITE
Urinalysis Results Results of Ua Tests at Discharge, 6 months and 12 Months post admission ** Matrix Group TAU Group D/C: 66% MA-free 65% MA-free 6 Ms: 69% MA-free 67% MA-free 12 Ms: 59% MA-free 55% MA-free **Over 80% follow up rate in both groups at all points
Predictors of In-treatment Performance and Post-Treatment Outcomes in a Methamphetamine- Dependent Adults
Predictors of Long-Term Abstinence Predictors of no MA use at treatment discharge, and at the 6- and 12-mos follow-ups includes: MA use of < 15 days at baseline, Lifetime MA use of < 2 years No previous drug abuse treatment Providing 3 consecutive MA-free UAs during treatment
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