Evidence-Based Practice: Psychosocial Interventions

Maxine Stitzer, Ph.D.

Johns Hopkins Univ SOM

NIDA Blending Conference

June 3, 2008

Cincinnati, Ohio

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?

What Is An Evidence-Based Practice?

• Developed by researchers

• Subjected to controlled evaluation

• Shown efficacious in 2 or more trials

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

Efficacy research shows that practices can work under ideal

conditions

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

What Psychosocial Therapies are Evidence-based?

• Motivational Interviewing (MI/MET)• Contingency Management (CM)• Cognitive-behavioral therapy (CBT)

–

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

MI/MET Techniques

• O open ended questions

• A affirmation

• R reflective listening

• S summary statements

MI/MET: Evidence For Efficacy

• Improved compliance in medical patients

• Reduced drinking in alcoholics

• Drug users contacted in a medical setting

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MI in Drug Treatment Settings

• Evidence mixed– Some studies find benefits– Others find no benefits

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

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

5.02

4.03

0

1

2

3

4

5

6Number of

sessions/ 28 days

Treatment condition

MIStandard treatment

More MI patients were retained at 1-month

84

74

0.00

100.00

Treatment condition

MI

Standard

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

0

100

Percent retained at

CTP

Treatment

MIStandard

0

1

2

3

4

5

6

7Days of

primary drug use/28 days

Treatment condition

MIStandard

No differences in drug use during first 28 days

0

1

2

3

4

5

6Averge number of sessions/

first 28 days

Treatment condition

MIStandard

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

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 vs

3 sessions of individual TAU

MET Study Outcomes

MET TAU Significance

Days Enrolled 72 69 ns

Retained 4 mos (%) 41 46 ns

Positive UA 21 28 ns (% in 28 days)

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MET: Effectiveness in Alcoholics

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

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

CBT Efficacy Evaluation

• Many studies have demonstrated efficacy

• Some show during treatment effects

• Some show benefits only after treatment ends (“sleeper” effects)

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IOP Treatment: CBT vs 12-Step

Maude Griffin et al., 1998

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Carroll et al., 1994

CBT vs Clinical Management: 1x per week

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?

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

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?

$10

Voucher Incentives in Outpatient Drug-free Treatment

0

20

40

60

80

100

2 4 6 8 10 12 14 16 18 20 22 24

BehavioralStandard

Weeks of Treatment

Perc

ent

of S

ubje

cts

Higgins et al. Am. J. Psychiatry, 1993

Cocaine negative urines

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

Retention: Alcoholics in Outpatient Psychosocial Treatment

0

20

40

60

80

100

120

2 4 6 8

weeks

% R

etai

ned

STDCM

Petry et al., 2000

0

20

40

60

80

100

2 4 6 8

Weeks

% N

ot R

elap

sed

STDCM

Time to first heavy drinking episodeTime to first heavy drinking episode

p<.05

Petry et al., 2000

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

Total Earnings

• $400 in prizes could be earned on average– If participant tested negative for all targeted

drugs over 12 consecutive weeks

Study Week

Per

cen

tage

Ret

ain

ed

0

20

40

60

80

100

2 4 6 8 10 12

RH = 1.6 CI=1.2,2.0

Incentives Improve Retention in Counseling Treatment

Control

Incentive

50%

35%

Percent of Submitted Samples Testing Stimulant and Alcohol Negative

0

20

40

60

80

100

1 3 5 7 9 11 13 15 17 19 21 23

Study Visit

Per

cen

tag

e n

egat

ive

sam

ple

s

Abstinence Incentive

Usual Care

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

Combination of treatments may be best for long-term recovery

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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

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?

Sequential Adoption Plan

• Motivational Interviewing

• Contingency Management

• Cognitive-Behavior Therapy

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)

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

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