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
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
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
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)
QuickTime™ and aTIFF (Uncompressed) decompressor
are needed to see this picture.
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)
QuickTime™ and aTIFF (Uncompressed) decompressor
are needed to see this picture.
IOP Treatment: CBT vs 12-Step
Maude Griffin et al., 1998
QuickTime™ and aTIFF (Uncompressed) decompressor
are needed to see this picture.
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
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
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