Treatment: What Y’all Should Treatment: What Y’all Should KnowKnow

Honorable Peggy Hora (ret.)Honorable Peggy Hora (ret.)

Steve HansonSteve HansonNYS Office of Alcoholism and NYS Office of Alcoholism and

Substance Abuse ServicesSubstance Abuse Services

How Treatment Doesn’t Work…How Treatment Doesn’t Work…You are all

Cured!

““It’s easy to give up It’s easy to give up smoking. smoking.

I have done it a I have done it a thousand times.”thousand times.”

Mark TwainMark Twain

People ask: People ask: Does Treatment Work?Does Treatment Work?

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Treatment Research Institute

Outcome In HypertensionOutcome In Hypertension

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Outcome In AddictionOutcome In Addiction

Addiction is like…Addiction is like…

The dog does not want The dog does not want to let go of the bone to let go of the bone (addiction/ denial).(addiction/ denial).It gets excited when it It gets excited when it thinks its going to get its thinks its going to get its bone (craving)bone (craving)It always wants more It always wants more bones (loss of control)bones (loss of control)The dog lives in/for the The dog lives in/for the moment.moment.

A dog with a bone

Treatment is like…Treatment is like…

You teach the dog’s You teach the dog’s owner to control the owner to control the dog.dog.

You develop a variety You develop a variety of tools (relapse of tools (relapse prevention) to help prevention) to help the dog be obedient.the dog be obedient.

Some dogs are Some dogs are harder to train.harder to train.

Obedience School for the Dog

Some Dogs/Addictions are Worse Some Dogs/Addictions are Worse than othersthan others

What Boomer is ThinkingWhat Boomer is Thinking

What can I getaway with?They won’t test me

for another week.

Try the second-hand smoke

excuse.We can talk our way out of this.

I want to get highI want to get highI WANT TO GET HIGH!!!

Early Recovery IssuesEarly Recovery Issues

Loss of lifestyleLoss of lifestyle

Loss of Coping StrategyLoss of Coping Strategy

WithdrawalWithdrawal

Cognitive deficits related to early Cognitive deficits related to early abstinenceabstinence

Cognitive DeficitsCognitive Deficits

Memory problems- short term lossMemory problems- short term loss

Difficulty with abstractionsDifficulty with abstractions

Difficulty with impulse controlDifficulty with impulse control

Similar performance to those with Similar performance to those with brain damage - improves.brain damage - improves.

Treatment Seeks to EnhanceTreatment Seeks to Enhance

Motivation – Why change?Motivation – Why change?

Insight – What to change?Insight – What to change?

Skills – How to change?Skills – How to change?

MotivationMotivation

MotivationMotivation

Motivation is key to making and sustaining a Motivation is key to making and sustaining a long term change.long term change.

Realistically, motivation waxes and wanesRealistically, motivation waxes and wanes

Increasing motivation helps prevent relapseIncreasing motivation helps prevent relapse

Drug Courts provide external (incentives & Drug Courts provide external (incentives & sanctions) motivatorssanctions) motivators

Participants will hopefully become internally Participants will hopefully become internally motivated (it’s the right thing to do, I feel good motivated (it’s the right thing to do, I feel good when I’m clean, etc.)when I’m clean, etc.)

MotivationMotivation

How we wish it workedHow we wish it worked How it really worksHow it really works

Changing People Places & ThingsChanging People Places & Things

I can hang outWith my old friendsAnd not chase the

fox

HEY GUYS!!THERE GOES THE FOX!!LET’S GET’EM!

InsightInsight

You only know what you only know.You only know what you only know.

Participants do not automatically know Participants do not automatically know what to do to stay sober and why.what to do to stay sober and why.

Helping them understand behavioral Helping them understand behavioral patterns.patterns.

Getting them to think outside of their “box”Getting them to think outside of their “box”

Your SurgeonYour Surgeon

I’ve never done one of these before. ButI did talk about it ingroup… and I stayedat a Holiday Inn Express!

Skill BuildingSkill Building

Wanting to be able to do something Wanting to be able to do something doesn’t mean you can do it.doesn’t mean you can do it.

Knowing what to do doesn’t mean you’ll do Knowing what to do doesn’t mean you’ll do it (right) when it counts.it (right) when it counts.

Keys to skill building:Keys to skill building:– Practice, practice, practicePractice, practice, practice– Reward the behavior you are trying to Reward the behavior you are trying to

encourage - conditioningencourage - conditioning

What Kind of Treatment?What Kind of Treatment?Hmmnn..Outpatient?Inpatient? Residential?Detox?Leeches?

ASAM PLACEMENT CRITERIAASAM PLACEMENT CRITERIA

LEVELS OF I. OUTPT II. INTENSIVE III. MED IV. MED OF CARE OUTPT MON INPT MGD INPT CRITERIA

Withdrawal no risk minimal some risk severe risk

Medical Complications no risk manageable

medical monitoring

required

24-hr acute med. care required

Psych/Behav Complications no risk mild severity moderate

24-hr psych. & addiction Tx required

Readiness For Change cooperative

cooperative but requires

structure

high resist., needs 24-hr motivating

Relapse Potential

maintains abstinence

more symptoms, needs close monitoring

unable to control use in

outpt care

Recovery Environment supportive

less support, w/ structure

can cope

danger to recovery, logistical

incapacity for outpt

Treatment Must AddressTreatment Must Address

BehaviorBehavior

Medical / BiologicalMedical / Biological

Affect / EmotionalAffect / Emotional

Social / FamilySocial / Family

CognitiveCognitive

SpiritualSpiritual

““Treatment should be tailored to the needs Treatment should be tailored to the needs of the individual and guided by an of the individual and guided by an

individualized treatment plan that is individualized treatment plan that is developed in consultation with the patient”developed in consultation with the patient”

American Society of Addiction Medicine’s Patient Placement Criteria - Second Edition Revised (ASAM PPC-2R)American Society of Addiction Medicine’s Patient Placement Criteria - Second Edition Revised (ASAM PPC-2R)

What Works?What Works?

Treatment outcome research reveals a Treatment outcome research reveals a number of effective treatment approaches number of effective treatment approaches

or types to consider when developing a or types to consider when developing a treatment continuum for Drug Courtstreatment continuum for Drug Courts

Motivational ApproachesMotivational Approaches Motivational approaches focus on engaging substance Motivational approaches focus on engaging substance

users in considering, initiating and continuing substance users in considering, initiating and continuing substance abuse treatment while stopping their use of alcohol and abuse treatment while stopping their use of alcohol and other drugs. other drugs.

““Being where the client is” – what they are motivated by.Being where the client is” – what they are motivated by.

Motivational approaches involve combining “motivational Motivational approaches involve combining “motivational interviewing” with a stages-of-change model.interviewing” with a stages-of-change model.

Stages of change include; pre-contemplation regarding Stages of change include; pre-contemplation regarding change, contemplation, preparation, action, and change, contemplation, preparation, action, and maintenancemaintenance

New WindowsNew Windows

Just one more question. I’m having a hard time understanding why you don’t think your drug use is a problem. You said earlier that you wanted to stop using because your life would be better, and you could keep a job. What exactly is it that you want?

Motivation:Motivation:Sober Me vs. Using MeSober Me vs. Using Me

Sober MeSober Me

Wants to be soberWants to be soberDoesn’t want to Doesn’t want to relapserelapseLikes not having Likes not having hangovershangoversWants to stay out of Wants to stay out of jailjailLikes keeping a jobLikes keeping a jobLikes having people Likes having people trust them.trust them.

Using MeUsing Me

Likes being highLikes being high

Likes hanging out in Likes hanging out in fun placesfun places

Says “One won’t hurt!”Says “One won’t hurt!”

Doesn’t mind lying to Doesn’t mind lying to peoplepeople

Doesn’t really care Doesn’t really care about job (except for about job (except for the $$)the $$)

Doesn’t think they can Doesn’t think they can get caughtget caught

Cognitive Behavioral Therapy Cognitive Behavioral Therapy (CBT) Approaches(CBT) Approaches

A research review of meta-analyses found that cognitive A research review of meta-analyses found that cognitive behavioral approaches consistently appear to be among behavioral approaches consistently appear to be among the most effective treatment therapy for substance the most effective treatment therapy for substance abusers (Taxman, 1999).abusers (Taxman, 1999).

CBT approaches suggest that unless offenders’ faulty CBT approaches suggest that unless offenders’ faulty thinking is addressed, there is a reduced likelihood of thinking is addressed, there is a reduced likelihood of long-term change.long-term change.

The three main cognitive models now utilized by criminal The three main cognitive models now utilized by criminal justice agencies are Reasoning and Rehabilitation justice agencies are Reasoning and Rehabilitation (R&R), Thinking for a Change and Moral Reconation (R&R), Thinking for a Change and Moral Reconation Therapy (MRT®). Therapy (MRT®).

Thinking ErrorsThinking ErrorsHanson! I want to see you in my office first

thing tomorrow!

YOU’RE FIRED!!

Community Reinforcement Community Reinforcement Approach plus VouchersApproach plus Vouchers

Uses the community to reward non-using behavior Uses the community to reward non-using behavior so that the client makes healthy lifestyle changesso that the client makes healthy lifestyle changes

High levels of satisfaction in drug and alcohol free High levels of satisfaction in drug and alcohol free lifestyles are needed to compete with the lifestyles are needed to compete with the reinforcement derived from substance use and the reinforcement derived from substance use and the substance-using lifestylesubstance-using lifestyle

The CRA approach is analogous to helping a child The CRA approach is analogous to helping a child conclude—through experience, not talking—that it’s conclude—through experience, not talking—that it’s more satisfying to be good than to be naughty.more satisfying to be good than to be naughty.

Rewarding the BehaviorRewarding the Behavior

Dealing with RelapseDealing with Relapse

Circuits Involved In Drug Abuse and Addiction

All of these must be considered in developing strategies to effectively treat addiction

STOP

GO

GoGo & & StopStop

Craving elicits Craving elicits Go!!Go!!

Powerful Powerful Activity in limbic system not frontal cortex Activity in limbic system not frontal cortex Feeling/reacting vs. thinking/planningFeeling/reacting vs. thinking/planning

Thinking initiates Thinking initiates Stop!!Stop!!Addicts have “bad brakes” – Addicts have “bad brakes” – Stop!Stop! Hard to stop this fast moving car. Hard to stop this fast moving car.

Fred Flintstone Brakes

Pharmacological ApproachesPharmacological Approaches

Goals – Provide:Goals – Provide:– relief from withdrawal symptoms, relief from withdrawal symptoms, – prevent drugs from working, prevent drugs from working, – reduce craving, reduce craving, – aversive reactionsaversive reactions

These actions are helpful in These actions are helpful in

reducing relapse and increasing reducing relapse and increasing

retention in programsretention in programs

Pharmacological ApproachesPharmacological Approaches

MethadoneMethadone – Opiate addiction – reduces – Opiate addiction – reduces craving, mediates withdrawal symptoms, helps craving, mediates withdrawal symptoms, helps restore normal functioningrestore normal functioning

BuprenorphineBuprenorphine – similar to methadone, may be – similar to methadone, may be prescribed by an MD with special training)prescribed by an MD with special training)

AcamprosateAcamprosate – reduction of alcohol cravings – reduction of alcohol cravings

AntabuseAntabuse – produces adverse reaction with – produces adverse reaction with alcohol usealcohol use

Pharmacological ApproachesPharmacological Approaches

Naltrexone/NalmefeneNaltrexone/Nalmefene – stops opiates from – stops opiates from working, changes alcohol action for some working, changes alcohol action for some – reduction in relapse– reduction in relapse

NeurontinNeurontin – helps with insomnia in early – helps with insomnia in early recoveryrecovery

Clonidine Clonidine – reduction of withdrawal – reduction of withdrawal symptoms – possible reduction in cravingssymptoms – possible reduction in cravings

BaclofenBaclofen – possible reduction in cocaine – possible reduction in cocaine cravingscravings

AMYGDALAR CONNECTIVITY during brief .5 sec Cocaine Cues

Drug 2 amyg conx (n=7)

Placebo

Baclofen

Source: Childress, et al, unpublishedSource: Childress, et al, unpublished

Baclofen blunts AMYGDALAR CONNECTIVITY

““All you students who skipped All you students who skipped school today are suspended!”school today are suspended!”

Responses to RelapseResponses to Relapse

Sanction – If you use this will happen – Sanction – If you use this will happen – Directly connects consequences to useDirectly connects consequences to use

Sanction if not honest about relapse – Sanction if not honest about relapse – Focus on changing the dishonesty about Focus on changing the dishonesty about usingusing

Increase treatment intensity – more Increase treatment intensity – more frequent – residential – etc.frequent – residential – etc.

Hold Accountable, but:Hold Accountable, but:

Keep them in treatmentKeep them in treatment

More intensive treatment if repeat relapseMore intensive treatment if repeat relapse

Keep engaged in supports and other Keep engaged in supports and other activities (ed/voc, self help, etc.,)activities (ed/voc, self help, etc.,)

When is Enough, Enough?When is Enough, Enough?

How many strikes??How many strikes??

Is there demonstration of effort?Is there demonstration of effort?

Is this the typical pattern for the individual?Is this the typical pattern for the individual?

Is the team frustrated and want to move Is the team frustrated and want to move on?on?

Is the behavior harming anyone?Is the behavior harming anyone?

What are the other participants learning?What are the other participants learning?