Meth dependence is a difficult disorder to treat. The following
characterization of the clinical challenges of treating meth users is
condensed from CSAT TIP #33. Withdrawal from meth dependence is characterized
by a protracted anhedonia and dysphoria that is accompanied by severe
craving for the drug. Craving frequently occurs in response to
exposure to conditioned cues (stimuli present during past episodes
of meth use and euphoria). Such cues evoke powerful craving for
meth via classical conditioning principles. The likelihood of continued
meth smoking or injecting appears to be, in part, related to the strength
of the craving experienced from these craving-generating cues. The
withdrawal dysphoria present in the context of ubiquitous meth availability
and ubiquitous conditioned cues can produce a very pernicious dependence;
indeed, inpatient hospitalization may be indicated to treat long-term
meth dependence, at least in initial stages of detoxification. Medically
managed inpatient care is expensive, however, and widespread meth abuse
has appeared in impoverished populations with very limited access to
such inpatient resources.
Psychosocial/Behavioral Treatments. Presently, there are
two approaches that have evidence to support their efficacy for the treatment
of meth dependence, but there is a much larger literature on treatments
that work with the other major illicit stimulant problem in the U.S.,
cocaine dependence. Although there are a number of differences
in the pharmacology and physiological effects produced by meth and cocaine,
these drugs have many common properties and similar effects. Research
examining the treatment responses of meth and cocaine users suggests
that cocaine and meth users have very similar outcomes when exposed to
the same treatments. In addition, large scale treatment system
evaluations have reported comparable outcomes for cocaine and meth users.
Matrix Model. During the 1980s, the Matrix Institute
on Addictions group in Southern California created a multi-element treatment
manual with funding support from NIDA, designed for application with
stimulant users on an outpatient basis. The Matrix approach evolved
over time, incorporating treatment elements with support from scientific
evidence, including cognitive behavioral therapies (i.e., relapse prevention
techniques), a positively reinforcing treatment context, many components
of motivational interviewing, family involvement, accurate psychoeducational
information,12-step facilitation efforts, and regular urine testing. The
approach is delivered using a combination of group and individual sessions
delivered approximately three times per week over a 16 week period followed
by a 36 week continuing care support group and 12 step program participation. Over
15,000 cocaine and meth users have been treated with this approach during
the past 20 years. The manual and related materials have been published
by Hazelden and SAMHSA. (for more details see www.Hazelden.org, www.SAMHSA.gov,
and Matrix Institute)
In 1999, CSAT funded a large scale evaluation of the Matrix Model for
the treatment of meth users coordinated by UCLA. Roughly 1,000
meth dependent individuals were admitted into eight different treatment
study sites. In each of the eight sites, 50% of the participants
were randomly assigned to either Matrix treatment or to a “treatment
as usual” (TAU) condition, which was comprised of a variety of
counseling techniques idiosyncratic to each site. The study results
showed that individuals assigned to treatment in the Matrix approach
received substantially more treatment services, were retained in treatment
longer, gave more meth-negative urine samples during treatment and completed
treatment at a higher rate than those in the TAU condition. These
in-treatment data suggested a superior response to the Matrix approach. When
data at discharge and follow up were examined, it appeared that both
treatment conditions produced comparable post-treatment outcomes. Participants
in both conditions showed very significant reductions in meth use, significant
improvements in psychosocial functioning, and substantial reductions
in psychological symptoms, including depression. Follow up data
indicated that over 60 percent of both treatment groups reported no meth
use and gave urine samples that tested negative for meth (and cocaine)
use. Use of other drugs, such as alcohol and marijuana were also
significantly reduced.
A particularly interesting finding was that across the eight treatment
sites, the ‘drug court site’, e.g., the one that enrolled
individuals who were participating under a drug court program, produced
superior results compared to the other seven sites, suggesting a substantial
beneficial influence of drug court involvement. Overall, this evaluation
is the largest controlled study of meth treatments that has ever been
conducted.
Contingency Management (CM). Positive reinforcement is
a powerful tool in increasing desired behaviors. School teachers
who give ‘special prizes’ for superior performance, companies
who give employee incentive bonuses for meeting production goals, AA
meetings that give ‘chips’ and cakes to acknowledge successful
progress in achieving sobriety are all examples of the effective use
of positive reinforcement. Many existing treatment programs informally
use positive reinforcement as part of their treatment milieu. Frequently,
the reinforcement takes the form of verbal praise, or earning program
privileges, or ‘graduating’ to a higher level of status in
the program or some other practice to acknowledge and reward progress
in treatment. CM is simply the systematic application of these
same reinforcement principles. In many of the studies investigating
CM approaches, treatment participants can earn ‘vouchers’ that
are exchangeable for non-monetary desired items (e.g., free movie tickets,
restaurant dinners, grocery vouchers, gasoline coupons, etc.). Typically
the individual can earn larger valued rewards for longer periods of continuous
abstinence from drugs and alcohol.
Over the past 30 years, a number of researchers and research groups
at Johns Hopkins (Stitzer, Silverman), Vermont (Higgins and colleagues),
Connecticut (Petry and colleagues), and UCLA (Roll and colleagues) have
demonstrated the powerful effect of CM techniques to reduce heroin, benzodiazepine,
cocaine and nicotine use. Recently CM techniques have been implemented
with meth users in Southern California by the group at UCLA and by researchers
in the NIDA Clinical Trials Network. The results of these investigations
have provided powerful support to the efficacy of this behavioral strategy
as treatment for meth abuse. Individuals who have been assigned
to CM conditions have shown better retention in treatment, lower rates
of meth use and longer periods of sustained abstinence over the course
of their treatment experience. Without question, CM is a powerful
technique that can play an extremely valuable role in improving the treatment
response of meth-dependent individuals.
Medications. Research efforts to develop medications to
aid in the treatment of meth-related disorders are at a relatively early
stage of development. Currently there are no medications that can
quickly and safely reverse life threatening meth overdoses. Similarly,
there are no medications that can reliably reduce the paranoia and psychotic
symptoms that frequently contribute to episodes of dangerous and violent
behavior associated with meth use. As clinicians will attest, it
would be tremendously helpful to have medications that could help meth
users recover more quickly from the effects of chronic use. Medication(s)
that could reduce symptoms in the early days and weeks of recovery could
be extremely valuable in promoting engagement and retention in behavioral
and psychosocial treatments.
The problem of relapse to meth use is a complex process. However,
one important set of contributing factors is the unpleasant emotional
and cognitive impairments that accompany the protracted abstinence syndrome
for months after meth use is discontinued. Medications that could
lessen the severity of these symptoms could be of tremendous value in
providing more successful treatments. At present, there have been
fewer than 10 placebo-controlled double-blind efficacy trials of potential
meth pharmacotherapies. One of the limiting factors in rapidly evaluating
medications for meth-related disorders is that there are relatively few
experienced pharmacotherapy research groups in the midwestern and western
geographical areas impacted by meth. The need to develop new research
groups capable of conducting addiction pharmacotherpy groups west of
the Mississippi is a critical need to increase the pace of medication
development.
In response to this need, the National Institute on Drug Abuse (NIDA)
has recently established the Methamphetamine Clinical Trials Group (MCTG),
a network designed to provide new clinical research teams and sites in
geographic areas where meth use is a major public health problem. This
network funded by NIDA, consists of sites in San Diego and Costa Mesa,
California, Honolulu, Hawaii, Des Moines, Iowa and Kansas City, Missouri
and a coordinating center at UCLA. Studies of promising pharmacotherapies
will be moved into these sites for assessment in double-blind, placebo-controlled
trials.