Overview of Various Psychosocial Treatments for Opioid Use Disorder Adam C. Brooks, Ph.D. Treatment Research Institute Philadelphia, PA

Psychosocial Treatment Context • Focusing on the use of treatment to support MAT • Abstinence / drug-free models do exist – Poorer track records – Greater risk for relapse – Involved psychosocial models (TC, Rehab, etc.)

• Treatments discussed here can apply to those settings as well

Goals of Psychosocial Treatment • Modify the underlying processes that maintain or reinforce use behavior. • Encourage engagement with pharmacotherapy (e.g. medication compliance). • Treat any concomitant psychiatric disorders that either complicate a substance use disorder or act as a trigger for relapse.

ASAM Minimum Components • Assessment of psychosocial needs; • Supportive individual and/or group counseling;

• Linkages to existing family support systems; and • Referrals to community-based services.

ASAM Additional Components • Increased Structure and Intensity • Specific Social Needs Assistance (employment, family, housing) • Case Management Services

What Type? How Much? • We really don’t know YET • Many fewer studies with patients with OUD where psychosocial treatment made a difference • Many “mixed” findings • Many of them in the context of methadone • Less robust evidence regarding what SPECIFICALLY works with bup, naltrexone • RESULTS MAY VARY!

Mixed Findings? • Patients receiving evidence-based counseling: – Improving on one outcome but not another – Improving in one study but results are not replicated – Improvements are short-lived

• Drug use might not be any better, but patients are retained longer • Gains are only maintained during treatment, but lost in follow-up

Right Tool at the Right Time • • • • •

Engage the Patient in Treatment Support Medication Initiation / Compliance Engage Support for Abstinence Build Coping Skills Build Lasting Lifestyle Changes

Engaging the Patient \ SBIRT and MI

What is Motivational Interviewing? • Brief intervention approach designed to mobilize clients’ internal resources for change by enhancing intrinsic motivation • Goals: – reduce ambivalence about stopping substance use – increasing commitment to change – increasing self-efficacy to make needed changes

• Intended as a prelude to treatment • Found to work as a stand alone intervention

Empirical Support for MI AS OF 2013 • 107 random assignment clinical trials • 63 with alcohol and/or drug users •MI vs. no treatment •MI vs. brief intervention •MI+ intensive treatment

•Robust and enduring effects when MI is added at the beginning of treatment •MI increases treatment retention •MI increases treatment adherence •MI increases staff-perceived motivation MI

•Best evidence for effectiveness was when MI was added to intensive treatment •The effects of motivational interviewing emerge relatively quickly *[A Meta-Analysis of Research on Motivational Interviewing Treatment Effectiveness (MARMITE) Annual Review of Clinical Psychology Vol 1, 2005]

Empirical Support for MI, cont’d • Average short term effect size dc = 0.77 • Average 12-month effect size dc = 0.30 • Highest effect sizes for health behaviors/HIV (short term dc = 0.71 long term dc = 0.30) • Moderate effects for alcohol (short term dc = 0.41 long term dc = 0.26) *[A Meta-Analysis of Research on Motivational Interviewing Treatment Effectiveness (MARMITE) Annual Review of Clinical Psychology Vol 1, 2005]

Not OUD Specific • Not really tested directly with OUDs to any great extent – mostly with alcohol • However, provides excellent context of the spirit with which to identify and approach OUD

SBIRT • Screen (everyone for problematic opioid use) • Brief Intervention (for those with only risky use) • Referral to Treatment (for those with OUD) • SBIRT – Track record established for moderate drinking – Not effective at getting people to treatment

SBIRT + FU • SBIRT (as tested with single episode interventions) does not seem to be effective with OUD • In practice, when delivered with regular check-ins and follow-ups, it should be the foundation of care • Don’t forget the FU! The most important part!

Resources for Training in MI • Miller and Rollnick (2002). Motivational Interviewing.

• www.motivationalinterview.org • www.drinkerscheckup.com • 2-day workshop, audiotape certification

Initiating Medication Compliance

Compliance Enhancement • Physician managed CE protocols have a great track record! • Don’t skimp on them because the patient is also getting treatment elsewhere. • Tested types: – Medication Management – Compliance Enhancement

Compliance Enhancement Elements • 20 minutes, Bi-weekly, then Monthly • Reviewing Patient Medication Habits • Problem Solving Compliance Problems • Answering Questions about Side Effects

Engaging Support 12 Step Facilitation

12-Step Facilitation: Principles • Geared towards fostering 12-Step involvement • Locus of change is: – Not therapist – Not patient – Within the 12-Step Fellowship

• Not doing therapy, but facilitating the client’s engagement with the fellowship

12-Step Facilitation: Principles • Collaborative Approach – “Don’t have to believe anything. All of its 12-Steps are but suggestions” (AA, 1952, p. 26) – Clinician consistently confronts client behavior / noncompliance – Does not threaten termination of treatment

• Focus – Begin recovery process

12SF Objectives • Active Involvement – – Sampling, then committing to meetings (90 in 90) – Increasing out of meeting contact (getting / using phone numbers) – Engagement with sponsor

• Identification and Bonding – Facilitator helps clients identify with fellowship – Encourages keeping of a journal

12 Step Facilitation • Nowinski and Baker (1992) • Making Alcoholics Anonymous Easier (MAAEZ: Kaskutas et al 2009) – designed for group

• Numerous adaptations for group treatment

Core Program: Early Recovery

• Introduction and assessment • Acceptance • People, places, and routines • Surrender • Getting Active

Evidence for 12SF • Equal performance in Project MATCH • Fairly equivalent performance in two trials against CBT for cocaine dependence • Less conclusive evidence for this approach (no control tests) • Particularly fraught with OUD / MAT approach

Resources for Training in 12SF • Nowinski and Baker (1992). Twelve Step Facilitation Handbook.

• http://www.nida.nih.gov/ADAC/ADAC10.html

MAAEZ (Kaskutas et al., 2009)

Build Social Skills / Lifestyle Changes Cognitive-Behavioral Treatment / Community Reinforcement Approach

Addiction as Learned Behavior • Social Learning – viewing family, role models • Operant Learning – chemical high is reinforcing

• Classical Conditioning – neutral stimuli paired with reinforcing high • Biophysical “learning” (habituation) -- tolerance

Coping Skills Deficits • Addictive learning crowds out functional learning • Deficits in coping skills result

• Skills deficits prevent clients from: – Planning ahead for abstinence – Problem solving – Coping with stress of craving and high risk situations

• Treatment teaches corrective coping skills – To a lesser extent, engineers reinforcing abstinence situations

CBT Type Treatments • Relapse Prevention (Marlatt & Gordon, 1985) • Social Skills Training

• Community Reinforcement Approach (Hunt & Azrin 1973) • Behavioral Self-Control Therapy • Cognitive Therapy (to a lesser extent)

Better to call it . . .

BcT

“BcT” Type Treatments • Typically rely heavily on behavior change • Little emphasis on cognitive refutation • Behavior change and some abstinence is a necessary precursor to any cognitive work

Evidence for CBT Type Treatments • Highly rated on MESA GRANDE (Miller & Wilbourne, 2002) • Meta-analysis shows low moderate effect sizes – d = 0.028, 0.032 (Dutra et al., 2008)

• CRA shows stronger effects • Results generally strong against placebos, attention controls • Often no differences between CBT and other credible treatments

CBT + • CBT performs more strongly combined with contingency management (CM) • CBT / CRA + Meds – Naltrexone – Methadone – Buprenorphine

CBT as Brief Treatment • Typically provided in 12 sessions • Beginning to see briefer CBT presentations

• Some adolescent approaches 6 sessions • 6, 12, or 24 sessions over 12 weeks? – Covi et al. 2002 showed no differences in cocaine tx

• Most essential modules in a BcT approach can be covered in 4-6 sessions

Elements of CBT • Building positive expectancies in treatment • Functional analysis of using behavior

• Skills for coping with craving and urges • Substance refusal skills • Managing positive and negative emotions • Seemingly irrelevant decisions • Communication skills, problem solving

Community Reinforcement Approach • Behavioral Approach akin to CBT • More intensive, focused on changing the patient’s environmental reinforcers • Family, social, vocational, educational goals • Increased number of sessions • When possible, involves regular conjoint sessions with a significant other / family member

For Whom is BT a Fit? • Strongest evidence base for CBT/CRA approach • Resistant to 12-Step??? • No-to-little cognitive-impairment • There are excellent packages for adolescents

Resources for Training in CBT • Carroll, K.M. (1998) Cognitive-behavioral treatment for cocaine dependence. • Monti et al. (2002). Treating alcohol dependence: A coping skills training guide. • The Matrix Model • 3-day workshop, audiotape certification

• http://www.nidatoolbox.org/

Contingency Management // Motivational Incentives A few weeks of paid abstinence- $$ The beginning of a full recovery -- priceless

Contingency Management • Use of payments, gift certificates, or prizes to reinforce patients for engagement in early treatment • Small payments that escalate in value with each successive targeted behavior • Most effective behavioral treatment that is barely ever used

Why Focus on Motivation? • Clients don’t always come to treatment regularly • Even when they come to treatment, they don’t always engage fully in the treatment process • Those clients that do attend and engage in treatment often relapse after treatment

• How successful can treatment be if clients don’t show up, aren’t engaged, or can’t sustain treatment gains?

How does it work? • Select observable, agreed upon, verifiable behaviors – Attendance – Abstinence from Opioids

• Provide Reinforcement Every Time to initiate Behavior • Gradually increase Intermittency to Maintain Behavior

Higgins et al. • Randomly assigned 40 clients to receive standard treatment with motivational incentives or standard treatment alone • Used Vouchers to initiate abstinence and the Community Reinforcement Approach (CRA) to sustain it after treatment • Rewarded clients with vouchers when they provided a clean urine • Amount of voucher increased the longer the client was abstinent

• Recruited family and friends and taught

them how to provide social rewards and how to avoid enabling

Abstinence Results 100 90 80 70 Voucher + CRA 60 50 Standard 40 30 20 10 0

12 10 8

6 4 2 0

Mean Duration In Weeks

5+ wks

10+ wks

20+ wks

Percent of Clients Achieving Duration of Abstinence

• Voucher + CRA clients remained abstinent longer

Advances in CM • CM approaches have been shown to greatly enhance the effects of other behavioral treatments – CBT alone (d = 0.28, d = 0.32) – CM alone (d = 0.58) – CBT + CM (d = 1.02)

• “Fishbowl” CM approaches are low-cost and achieve comparable approaches—tested in realworld clinics

For Whom is CM a Fit? • Anyone for whom an external reinforcer is useable • Particularly criminal justice, adolescents, MR

Resources for Training in CM • NIDA’s Blending Products http://www.nida.nih.gov/blending/PAMI.html

• Promoting Awareness of Motivational Incentives

Computerized CBT / CRA !!! • Three studies showing strong effects from computer-assisted CBT

• Both as a supplement and an integrated treatment – Clinician extender – Integrates video modeling, learning checks

• Enhances coping skills, leads to better drug outcomes

Thanks for your attention! [email protected]

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