Understanding Substance Abuse & Addiction:What Research, Psychology & Medicine Have to Teach Us

TRUST Clinic Speaker SeriesOakland, Ca. June 20, 2014

Joan Zweben, Ph.D. Executive Director, East Bay Community Recovery

Projectwww.EBCRP.org

Clinical Professor of Psychiatry, UCSF

Disclosures Dr. Zweben has no conflict of interest to

disclose. Dr. Zweben’s bias is that evidence-

supported, safe treatment for SUDS should be equally available throughout our system of care, including medication treatment.

Dr. Zweben’s bias is that evidence-based interventions are only one component of individualized treatment planning, not a substitute for comprehensive care.

Evolution of Substance Abuse Treatment in the U.S.

How Did We Get Here?

National Institute on Alcoholism & Alcohol Abuse (NIAAA)

Founded 1970 as a center within NIH

Research on the biology of alcoholism, psychosocial issues, treatment (1990’s)

Produced educational materials for prevention, but initially not a leader in the treatment field.

Pressure from community groups led to more treatment research

National Institute on Drug Abuse (NIDA)

Founded 1972 to promote creation of tx system + research on clinical issues

Goal: what programs were contributing to reducing social costs of addiction

Tx system developed for the indigent (uninsured), funded by federal, state and local entities

Research emphasis on tx modalities

Chronology AA – 1935. Bill Wilson, Dr. Bob Smith in

Akron, Ohio Minnesota Model – 1950’s (Hazelden) Therapeutic Communities – 1958,

Synanon; proliferated rapidly Methadone maintenance – 1965, Dole &

Nyswander Drug Courts 1989, Miami-Dade County,

Florida

Treatment Modalities:Therapeutic CommunitiesTreatment Modalities:Therapeutic Communities long term (6-18 months)

residential tx the community is the agent of

change peer relationships, open

communication and feedback are basic tools

“must function” model activities to maintain daily

operations a primary element in therapeutic interactions

TC’s, ContinuedTC’s, Continued

change self-image and behavior self-examination and confession extended family concept possibility of ascendancy within

the system re-entry outcome data supports its efficacy

Methadone MaintenanceMethadone Maintenance

most misunderstood, stigmatized modality

most highly regulated modality rationale for maintenance therapy: Dole,

receptor system dysfunction strong empirical support for efficacy and

safety (50 years of data) valuable tool in reducing the spread of

AIDS not a cure-all, but makes the patient

accessible to intervention for other problems

Opioid Maintenance Therapy: Hot Button IssuesOpioid Maintenance Therapy: Hot Button Issues

Dosing: politics, blood levels, etc. Diversion Opioid addicted pregnant women Medical maintenance Tapering off methadone Methadone “vs” buprenorphine

“vs” naltrexone (Vivitrol)

Minnesota ModelMinnesota Model

Hazelden, Wilmar (1950’s) AA principles replace mental

health model; alcoholism as a primary disorder

multidisciplinary team approach respect for the alcoholic; respite

from environment need and value of aftercare

Minnesota ModelContinuedMinnesota ModelContinued

origin of 28-day length of stay CATOR: document outcomes controlled studies do not support

efficacy, with some exceptions managed care

Social/Community ModelSocial/Community Model

Influence on treatment & prevention

Emphasis on the micro & macro community

AA principles Experiential knowledge essential;

everyone both gives and receives help

Positive sober environment is crucial

One ancestor of ROSC

Drug Courts (1)Drug Courts (1)Goal: integrate substance abuse

treatment with legal case processing (pretrial)

K EY PRINCIPLES: Identification/referral as soon as

possible after arrest Early professional dx of treatment needs Matching needs to appropriate tx

Drug Courts (2)Drug Courts (2) Making treatment a court-monitored

requirement; provide judicial review and supervision of progress in treatment

Holding defendants accountable through a series of graduated sanctions and rewards

Providing appropriate follow-up and support services following treatment

(Sherin & Mahoney, 1996; TIP #23)

Drug Courts (3)Drug Courts (3) NIJ (2003) study of 17,000 graduates

found only 16.4% had been rearrested and charged with a felony one year later (Roman et al, 2003).

Reduced cost to victim and criminal justice system

Increase retention in treatment Others: juveniles, DWI, family, mental

health (Huddleston et al, 2004)

Treatment PhilosophiesTreatment Philosophies

Treatment Philosophies: AbstinenceTreatment Philosophies: Abstinence

abstain from drug of choice abstain from other intoxicants

drug substitutionrole in precipitating relapse

dependable control not possible; hence detach

widest margin of safety

What is Abstinence? A person is abstinent if he/she is

not drinking or using illicit drugs, and using legal ones as prescribed. Thus, medications are compatible with recovery.

Physical dependence ≠ addiction Note: medications are tools, not

solutions

Treatment Philosophies:Harm ReductionTreatment Philosophies:Harm Reduction

“Harm reduction is a set of strategies that encourage substance users and service providers to reduce the harm done to drug users, their loved ones and communities by their licit and illicit drug use.”

The Harm Reduction Working Group & Coalition, 1995

Arenas for Harm ReductionArenas for Harm Reduction

HIV/ STD outreach and education needle exchange homeless populations: wet, damp housing SMI clients - Harborview model methadone maintenance (damage control

component) drop in centers users’ support groups money management/payee community HR education

Pitfalls of Abstinence-Oriented TreatmentPitfalls of Abstinence-Oriented Treatment Failure to assess motivation level before

pushing abstinence commitment Failure to understand factors promoting

continued use Unrealistic timetables Power struggle vs clinical approach Failure to recognize fluctuating

motivation Inappropriate termination of treatment

Pitfalls of Harm Reduction ApproachPitfalls of Harm Reduction Approach

Inappropriately low expectations for what client can achieve

Difficulty setting clear goals Reluctance to ask client to abstain

completely Underestimate risks/lethality Clinician alcohol and/or illicit drug

use

The Substance Abuse Treatment System: Finding Good Care

The Substance Abuse Treatment System: Finding Good Care

Paradigm Shift

Chronic Care Model: When treated as a chronic illness, relapse rates are as good or better than other chronic illnesses (McLellan et al. 2005)

Recovery Oriented System of Care (ROSC): Support person centered and self-directed approaches to care that build on the strengths and resilience of individuals, families and communities to take responsibility for their sustained health, wellness and recovery from alcohol and drug problems (CSAT)

(Rawson & Freese. 2010)25

Recovery Oriented System of Care (ROSC)

ROSCs are founded on a chronic care model of substance use treatment and recovery services that use recovery management approaches to engage and treat, and provide recovery support services that help individuals/families sustain their recovery.

(Rawson & Freese. 2010)

26

Broadening Our Target Population

The Changing Health Care Landscape

Different policies for different levels of

Severity

Addiction ~ 25,000,000(Focus on Treatment)

“Harmful Use” – 68,000,000(Focus on Early Intervention))

Little or No Use(Focus on Prevention))

Diabetes ~24,000,000

LITTLE

LOTS In Treatment ~ 2,300,000

Distribution of AOD Problems

2M people (.08%) receiving treatment

21M people (7%) have problems but are not receiving treatment 1.1% made effort to get tx 3.7% felt they needed tx but made no

effort to get it 95.2% did not feel they needed tx

60-80 M (20-25%) using at risky levels

(UCLA/ATTC

2013)

Using at Risky Levels (60-80 million)

Do not meet diagnostic criteria Level of use indicates risk of

developing problems Examples:

Drinks 3-4 glasses of wine several times per week Pregnant woman occasionally uses vodka to relieve

stress Adolescent to smokes mj with friends on weekends Occasionally takes 1-2 extra vicodin to help with pain

(UCLA/ATTC 2013)

ImplicationsAs long as the specialty care programs (AOD treatment programs) are the only places which address SUD: most people with severe problems will

not receive treatment. virtually all with risky use will not

receive professional attention.(UCLA-ATTC 2013)

Value of Behavioral Health

Source: Wyatt Matas, 2013

Value of Behavioral Health

49% of Medicaid Beneficiaries with disabilities have a psychiatric illness. Top 3 behavioral dyads: 1. Psychiatric/Cardiovascular 2. Psychiatric/Central Nervous System 3. Psychiatric/ Pulmonary

Healthcare Settings for Locating Individuals with SUD Primary care settings Emergency rooms/

Trauma centers Prenatal clinics/OB/Gyn offices Medical specialty settings for

diabetes, liver and kidney disease, transplant programs

Pediatrician offices College health centers Mental health settings

(UCLA-ATTC 2013)

Workforce Implications MH/AOD clinicians will be working in

many different settings where teamwork is key

Holistic, integrative perspective and approach; Sick care + wellness care

Screening & brief intervention integral

MI principles and skills essential Availability for drop in or scheduled

meetings; “hallway consults”

Evidence-Based Practices and Treatment Interventions

Evidence-Based Practices and Treatment Interventions

Rationale, Challenges & Perils

Why Use Evidence-Based Principles and Practices?Why Use Evidence-Based Principles and Practices?

To go beyond our preferences and biases

To improve the effectiveness of what we do: what works best, for whom

Because funders will increasingly insist on optimum utilization of inadequate resources

Evidence Based Principles & Practices vs Evidence Based Treatment Interventions

Evidence Based Principles & Practices vs Evidence Based Treatment Interventions

Principles and practices are derived from different types of research.

Rigor often trumps relevance in determining what type of research is valued.

Policy makers must be educated on these issues.

Important DistinctionsImportant Distinctions Evidence-based principles and

practices guide system development Example: care that is appropriately

comprehensive and continuous over time will produce better outcomes

Evidence-based treatment interventions are important elements in the overall picture. They are not a substitute for overall adequate care.

Types of StudiesTypes of Studies

Quasi-experimental studies – some control over confounding factors; less rigorous than RCT’s

Correlational studies – systematic observation across cases or programs

Longitudinal studies Naturalistic studies

Evidence-Based PrinciplesEvidence-Based Principles Retention improves outcomes; we need to

engage people, not discharge them prematurely.

Addicts/alcoholics are a heterogeneous population, not a particular personality type.

Addiction behaves like other chronic disorders Problem-service matching strategies improve

outcomes. (Other matching strategies disappointing.)

Harm reduction approaches yield benefits in terms of public health and safety.

Pts in methadone maintenance show a higher reduction in morbidity and mortality and improvement in psychosocial indicators than heroin users outside treatment or not on MAT.

Policies and Practices Not Supported by ResearchPolicies and Practices Not Supported by Research Requiring abstinence as a condition of

access to substance abuse or mental health treatment

Denying access to AOD treatment programs for people on prescribed medications

Arbitrary prohibitions against the use of certain prescribed medications

Discharging clients for alcohol/drug use

Evidence-Based Practices:Key Issues in the Debate

Efficacy StudiesEfficacy StudiesSpecific psychosocial interventions

are usually investigated in random assignment studies using manualized treatments in carefully controlled trials. Samples and settings are homogeneous and treatment is standardized. Specific procedures assure fidelity to the model.

Random Assignment Controlled Trials (RCT’s)Random Assignment Controlled Trials (RCT’s)

Gold standard for pharmacological and many psychosocial interventions

Examples with strong efficacy: Cognitive behavioral therapy Motivational enhancement therapy Behavioral marital therapy Community reinforcement approach Relapse prevention Social skills training

(see Miller et al, 2005)

Adaptive Designs:An Emerging ParadigmAdaptive Designs:An Emerging Paradigm Individualize treatment using decision

rules that recommend when and for whom tx should change

Utilize a sequence of treatments, randomizing S’s based on clinical response

Starts with consensus-based clinical guidelines and fine tunes the sequence

Example: The STAR-D study

Are RCT’s Over-rated?

Are RCT’s Over-rated?

QUERI

Mark Willenbring MD (ASAM 2006)

Issues with RCT’s Is the research question an

appropriate question? Example: CBT A compared with CBT

B, vs CBT A compared with TAU Are the treatment effects modest

or robust? What is the cost to achieve and

maintain the intervention? Are the results worth it?

What About the Therapeutic Alliance?What About the Therapeutic Alliance? Studies outside substance abuse

show this accounts for a greater % of the variance than specific techniques

Different “specific” therapies yield similar outcomes, but there is wide variability across sites and therapists

More therapist education/experience does not improve efficacy

(Adapted from W.R. Miller, Oct 06)

Practice-Based EvidencePractice-Based Evidence Studies and meta-analyses report

moderate to large effects of indiv therapists

Gather client outcome data from routine practice

Give real-time feedback & suggestions to improve performance

Flag pts at risk for treatment failure or dropout

(Glassner-Edwards & Rawson, 2010)

IMPLEMENTATION ISSUESIMPLEMENTATION ISSUES

Levers for ChangeLevers for Change Financing Infrastructure development Legislation Regulation Accreditation (education programs,

service delivery organizations) Certification and licensure Performance based contracting

Degrees of Implementation:Process

Degrees of Implementation:Process

Putting new operating procedures in place:

Conducting workshops Providing supervision Change information reporting forms New innovation-related language is

adopted Is this functionally related to new

practices or merely lip service? (Dean Fixsen, 2005)

Can we assume that interventions with documented efficacy will be effective in the community if we only implement them correctly?

Rethinking the Efficacy-to-Effectiveness TransitionRethinking the Efficacy-to-Effectiveness Transition Assumption that effectiveness research

naturally flows from efficacy research is faulty.

The tight controls of efficacy studies limit their generalizability.

Focus more on intervention reach, adoption, implementation, and maintenance.

Published studies should include more info on external validity.

(Glasgow et al, AJPH, 2003)

Important Questions to AskImportant Questions to Ask

What are the characteristics of interventions that can:

1. Reach large numbers of people, especially those who can most benefit

2. Be broadly adopted by different settings

3. Be consistently implemented by different staff with moderate training and expertise

4. Produce replicable and long lasting effects (with minimal negative impact) at reasonable costs.

(Glasgow et al, AJPH, 2003)

ConsiderationsConsiderations What is to be gained? Does the organizational culture

support adoption? Is training available? Is clinical supervision available?

Ineffective Implementation StrategiesIneffective Implementation Strategies

“…experimental studies indicate that dissemination of information does not result in positive implementation outcomes (changes in practitioner behavior) or intervention outcomes (benefits to consumers)”

(Fixsen et al, 2005)

Opinion Leaders:A Key to Knowledge Adoption

Opinion Leaders:A Key to Knowledge Adoption Identified by peers as respected for

their knowledge in a particular area Trained in the use of an evidence-based

curriculum They then train their peers and

supervise the application of the curriculum

Changes in counselor behaviors and attitudes are measured to determine the effectiveness of the implementation process

(Rugs D, Hills HA, Peters R, 2004 at www.seekingsafety.org)

Key IngredientsKey Ingredients Presenting information;

instructions Demonstrations (live or taped) Practice key skills; behavior

rehearsal Feedback on Practice Other reinforcing strategies; peer

and organizational support (Fixsen et al,

2005)

CoachingCoachingTraining and coaching are a continuous

set of operations designed to produce changes

Newly-learned behavior is crude compared to performance by a master practitioner

Such behavior is fragile and needs to be supported in the face of reactions of others

Such behavior is incomplete and will need to be shaped to be most functional in the service setting.

(Fixsen et al, 2005)

Dissemination Mechanisms

NIDA’s Clinical Trials Network (CTN)http://www.drugabuse.gov/

CSAT’s Addition Technology Transfer Centers (ATTC)

http://www.attcnetwork.org/regional-centers/?rc=pacificsouthwest

Challenges & Perils

Policy and FundingPolicy and Funding Policy makers misinterpreting research

findings; drawing inappropriate conclusions Example: buprenorphine (“transfer

methadone pts to BPN and taper them off”) Using EBT’s takes precedence over

individualizing care Funders adopting a “pick from this list”

approach Achieving fidelity takes labor intensive

supervision, and many states don’t fund supervision.

Marketing Impostors

Distinguishing evidence from marketing“We have some of the highest success rates in the country”“You should only have to do this once.”

Presenting multiple anecdotes with no comparison or control groups as “proof”

Research to Practice IssuesResearch to Practice Issues

Inadequate effectiveness studies Huge gaps in the research literature

(s.g., group interventions, therapist variables)?

High training fees for “proven” practices Fidelity vs cultural competence: What is

the tradeoff between fidelity and the need to adapt interventions for specific populations? How can we make cultural adaptations and maintain the treatment effects?

Infrastructure DevelopmentInfrastructure Development

The existing infrastructure cannot handle the expectation for data collection

Funders want data but do not want to pay the costs

Data collected by funders is often not used to improve services

Workforce crisis is a huge problem and an opportunity. Must supply resources for training.

Stay Focused on Basic PrinciplesStay Focused on Basic Principles

Maintain commitment to the principle of individualizing treatment

When an evidence-based treatment doesn't work for an individual, some staff members conclude that the problem is that the treatment isn't being implemented correctly, rather than examining the possibility that it does not fit the needs of the client.

Example from Dual Dx listserve: dualdx.treatment.org

Is There Another Way?Is There Another Way?

Fund programs to develop the infrastructure to examine how they are doing with whom

Draw on EBT’s to improve in areas where there are problems

Clarify realistic performance standards

APA DefinitionAPA DefinitionEvidence-based psychotherapy is

resources-based: best practices are built on a foundation of empirical research, comprehensible and reasoned theories, clinical observation and expertise, and patients' values, contributions and responses.

Evidence-Based Skills TrainingEvidence-Based Skills Training Establish clear goals Identify feasible objectives,

adaptable to different settings Take into account the limitations of

the current health care system Train in core evidence-based skills,

rather than emphasizing manualized EBPs

(Glassner-Edwards & Rawson, 2010)

Treatment IssuesTreatment Issues

Co-Occurring Psychiatric & Substance Use Disorders COD are the norm, not the exception “No wrong door;” guided referrals,

“warm handoffs” Assessment: distinguish between

substance induced conditions and independent disorders

Treatment should be integrated, focusing on safety, stabilization, maintenance of gains

Trauma-informed care

Cognitive Behavioral TherapiesCognitive Behavioral Therapies Based on social learning theories Identify the antecedents and

consequences of drug use Skills training – identify high risk

situations, use behavioral and cognitive strategies to avoid situations or cope effectively

Includes relapse prevention strategies

(Carroll & Onken, AJP, 2005)

Motivational Enhancement Strategies

Widely adopted Principles widely applicable outside

substance abuse treatment TIP 33: Enhancing Motivation for

Change in Substance Abuse Treatment - order from: www.ncadi.samhsa.org

Goals and BenefitsGoals and Benefits Inspiring motivation to change Preparing clients to enter treatment Engaging and retaining clients in

treatment Increasing participation and

involvement Improving treatment outcomes Encouraging a rapid return to treatment

if symptoms recur

Community Reinforcement ApproachesCommunity Reinforcement Approaches Environmental influences play a

powerful role in encouraging or discouraging substance use

Social, recreational, familial and vocational forces can be use to promote behavior change

Goal: make sober lifestyle more rewarding than the use of substances

Counselor must find and use the client’s intrinsic reinforcers

CRA: ExamplesCRA: Examples CRAFT – work with spouse/parent to

change social environment; remove inadvertent reinforcement for drinking and using; reinforce abstinence

Job seeking and keeping; improving satisfaction with job

Identify new sources of recreation Behavioral skills: communication,

problem solving, drink/drug refusal

Contingency ManagementContingency Management

Systematic delivery of positive reinforcement for desired behaviors (e.g., negative toxicology screens)

Vouchers Prizes Other privileges, rewards, etc.

Essential Ingredients in the Recovery ProcessEssential Ingredients in the Recovery Process

A community that supports the recovery process

A path for personal development that has no financial barriers

Can use alternative groups but the 12-Step system is the most comprehensive

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