Embed Size (px)
Citation preview
The Matrix Model The Matrix Model Treatment Approach for Treatment Approach for
Methamphetamine Methamphetamine DependenceDependence
Michael J. McCann, MAMichael J. McCann, MAMatrix Institute on AddictionsMatrix Institute on AddictionsArlington, VAArlington, VAMay 9, 2006May 9, 2006
OverviewOverview
Methamphetamine effects on the brainMethamphetamine effects on the brain Treatment approaches in light of brain Treatment approaches in light of brain
effectseffects The Matrix Model treatment approachThe Matrix Model treatment approach Does methamphetamine treatment Does methamphetamine treatment
work? work?
A Major Reason People Take a Drug is they Like
What It Does to Their Brains
A Major Reason People Take a Drug is they Like
What It Does to Their Brains
Meth Treatment is Meth Treatment is ChallengingChallenging
00
5050
100100
150150
200200
00 6060 120120 180180Time (min)Time (min)
% o
f B
asal
DA
Ou
tpu
t%
of
Bas
al D
A O
utp
ut
NAc shellNAc shell
EmptyEmpty
BoxBoxFeedingFeeding
Source: Di Chiara et al.Source: Di Chiara et al.
FOODFOOD
100100
150150
200200
DA
Co
nce
ntr
ati
on
(%
Bas
elin
e)D
A C
on
cen
tra
tio
n (
% B
asel
ine)
MountsMountsIntromissionsIntromissionsEjaculationsEjaculations
1515
00
55
1010
Co
pu
latio
n F
req
ue
nc
yC
op
ula
tion
Fre
qu
en
cy
SampleNumberSampleNumber
11 22 33 44 55 66 77 88 99 10101111121213131414151516161717
ScrScrScrScrBasBasFemale 1 PresentFemale 1 Present
ScrScrFemale 2 PresentFemale 2 Present
ScrScr
Source: Fiorino and PhillipsSource: Fiorino and Phillips
SEXSEX
Natural Rewards Elevate Dopamine Natural Rewards Elevate Dopamine LevelsLevels
Natural Rewards Elevate Dopamine Natural Rewards Elevate Dopamine LevelsLevels
00100100200200300300400400500500600600700700800800900900
1000100011001100
00 11 22 33 44 5 hr5 hrTime After AmphetamineTime After Amphetamine
% o
f B
as
al
Re
lea
se
% o
f B
as
al
Re
lea
se
DADADOPACDOPACHVAHVA
AccumbensAccumbens AMPHETAMINEAMPHETAMINE
00
100100
200200
300300
400400
00 11 22 33 44 5 hr5 hrTime After CocaineTime After Cocaine
% o
f B
as
al
Re
lea
se
% o
f B
as
al
Re
lea
se
DADADOPACDOPACHVAHVA
AccumbensAccumbens COCAINECOCAINE
00
100100
150150
200200
250250
00 11 22 33 44 5hr5hrTime After MorphineTime After Morphine
% o
f B
as
al
Re
lea
se
% o
f B
as
al
Re
lea
se AccumbensAccumbens
0.50.51.01.02.52.51010
Dose (mg/kg)Dose (mg/kg)MORPHINEMORPHINE
00
100100
150150
200200
250250
00 11 22 3 hr3 hrTime After NicotineTime After Nicotine
% o
f B
as
al
Re
lea
se
% o
f B
as
al
Re
lea
se
AccumbensAccumbensCaudateCaudate
NICOTINENICOTINE
Source: Di Chiara and ImperatoSource: Di Chiara and Imperato
Effects of Drugs on Dopamine LevelsEffects of Drugs on Dopamine LevelsEffects of Drugs on Dopamine LevelsEffects of Drugs on Dopamine Levels
Prolonged Drug Use ChangesProlonged Drug Use Changesthe Brain In Fundamentalthe Brain In Fundamentaland Long-Lasting Waysand Long-Lasting Ways
Meth Treatment is Meth Treatment is ChallengingChallenging
Source: McCann U.D.. et al.,Journal of Neuroscience, 18, pp. 8417-8422, October 15, 1998.
Decreased dopamine transporter Decreased dopamine transporter binding in METH users binding in METH users
resembles that inresembles that in Parkinson’s Disease patients Parkinson’s Disease patients
Control Meth PDAvg. 3 yrs. abstinent
““This is your Brain on This is your Brain on Meth”Meth”
Dr. Paul Thompson of UCLA; brain mapping Dr. Paul Thompson of UCLA; brain mapping study. study.
Meth users in their 30s with 10 years of use.Meth users in their 30s with 10 years of use. 11% loss in brain pleasure/reward center 11% loss in brain pleasure/reward center
tissue.tissue. He described “a forest fire” of brain damage.He described “a forest fire” of brain damage. Navigating through daily life and applying Navigating through daily life and applying
what is learned in treatment may be difficult what is learned in treatment may be difficult (reminders, simplicity, redundancy)(reminders, simplicity, redundancy)
Meth in the BrainMeth in the Brain
Methamphetamine: Methamphetamine: Neurochemical Neurochemical
MechanismsMechanisms
Enters dopamine vesiclesEnters dopamine vesicles Vesicles deplete themselves of Vesicles deplete themselves of
dopaminedopamine
METH
METH
METH
METH
Meth Treatment is Meth Treatment is ChallengingChallenging
Prolonged meth use changes the Prolonged meth use changes the brainbrain
Prolonged effects require Prolonged effects require appropriate treatment approaches appropriate treatment approaches
Effective Treatments for Effective Treatments for Methamphetamine Methamphetamine
DependenceDependence
The Matrix InstituteThe Matrix Institute
Established 1984Established 1984 5 clinics in Southern California5 clinics in Southern California San Bernardino County 1985; >50% San Bernardino County 1985; >50%
meth usersmeth users
Some Core Some Core Elements of the Elements of the Matrix ModelMatrix Model
Elements of Effective Elements of Effective TreatmentTreatment
with Methamphetamine with Methamphetamine Users Users
Focus on the present; behavior vs Focus on the present; behavior vs feelingsfeelings
Structure: 3 X week meetings; 16 Structure: 3 X week meetings; 16 weeksweeks
Information on addiction and recoveryInformation on addiction and recovery Teach relapse preventionTeach relapse prevention Urine testingUrine testing Introduce and encourage self-helpIntroduce and encourage self-help
Matrix Program Schedule Matrix Program Schedule (Sample)(Sample)
Monday Wednesday
Friday
Weeks 1-4
Early Recovery Skills Weeks 1-12Family/Education
Weeks 1-4
Early Recovery Skills
Weeks 1-16 Relapse Prevention Weeks 13-16
Social Support
Weeks 1-16 Relapse Prevention
Urine and breath alcohol tests once per week, weeks 1-16Ten Individual/Conjoint sessions during 1st 16 weeks
Simple, redundant, & relevant Simple, redundant, & relevant informationinformation
Classical conditioning and Classical conditioning and cravingcraving
The brain and addictionThe brain and addiction
Information: ConditioningInformation: Conditioning
Pavlov’s Dog
Information: ConditioningInformation: Conditioning
Pavlov’s Dog
Conditioning Process During Conditioning Process During AddictionAddiction
Social Phase
Triggers•Parties•Special Occasions
Responses•Pleasant Thoughts about AOD•No Physiological Response•Infrequent Use
Strength of Conditioned Connection
Mild
Development of Craving Development of Craving ResponseResponseAddiction Phase
Thinking of Using
Mild Physiological Response
Entering Using Site
Heart Rate
Breathing Rate
Energy
Adrenaline Effects
Powerful Physiological Response
Use of AODs AOD Effects
Heart Rate
Breathing Rate
Energy
Adrenaline Effects
Heart
Blood Pressure
Energy
Cognitive Process During Cognitive Process During AddictionAddiction
Disenchantment Phase
Social Currency
Occasional Euphoria
Relief From Lethargy
Relief From Stress
Nose Bleeds
Infections
Relationship Disruption
Family Distress
Impending Job Loss
Conditioning and the Brain: Conditioning and the Brain: Message to PatientsMessage to Patients
Will power, good intentions are not Will power, good intentions are not enoughenough
Behavior needs to changeBehavior needs to change Insight will not affect cravingsInsight will not affect cravings
Deal with cravings: avoid triggersDeal with cravings: avoid triggers Deal with cravings: thought-stoppingDeal with cravings: thought-stopping SchedulingScheduling
Treatment: Information & Treatment: Information & PersuasionPersuasion
DRUG
Early Recovery Skills GroupEarly Recovery Skills Group
Drug cessationDrug cessation Identify triggersIdentify triggers Get rid of paraphernaliaGet rid of paraphernalia Avoid triggers-schedule timeAvoid triggers-schedule time Thought-stopping for cravingsThought-stopping for cravings 12-step introduction12-step introduction
Matrix Model Key Matrix Model Key ComponentComponent
Information
The Roadmap to Recovery
Information: Roadmap for Information: Roadmap for RecoveryRecovery
•Withdrawal
•Early Abstinence, Honeymoon
•Protracted Abstinence, the Wall
•Adjustment/Resolution
Information: the WallInformation: the Wall
Protracted Abstinence: “The Wall”Protracted Abstinence: “The Wall”
45-120 days after last use45-120 days after last use
Partial Recovery of Brain from Methamphetamine After Abstinence
Normal Control METH Abuser(1 month abstinent)
METH Abuser(14 months abstinent)
0
3
ml/gm
Source: Volkow, ND et al., Journal of Neuroscience 21, 9414-9418, 2001.
Dopamine improvements after 1 year, but not cognitive and motor functioning
Roadmap for RecoveryRoadmap for Recovery
Return to Old BehaviorsAnhedonia
AngerDepression
Emotional Swings
Unclear Thinking
Isolation
Family Problems
Cravings Return
Protracted Abstinence
Abstinence Violation
The WallThe Wall
Treatment implicationsTreatment implications SimpleSimple RedundantRedundant Frequent visits for an extended periodFrequent visits for an extended period
Message to patientsMessage to patients It takes a while for your brain to healIt takes a while for your brain to heal Don’t make mistakes explaining your Don’t make mistakes explaining your
feelingsfeelings Be patient; Don’t give upBe patient; Don’t give up
Relapse Prevention Relapse Prevention GroupsGroups
Relapse PreventionRelapse Prevention Patients need to develop new Patients need to develop new
behaviorsbehaviors Learn to monitor signs of Learn to monitor signs of
vulnerability to relapsevulnerability to relapse Recovery is more than not using Recovery is more than not using
D.O.C.D.O.C. Recovery is more than not using Recovery is more than not using
drugs and alcoholdrugs and alcohol
Relapse Prevention Relapse Prevention TopicsTopics
Relapse PreventionRelapse Prevention Overview of the concept; things don’t “just Overview of the concept; things don’t “just
happen”happen” Using BehaviorUsing Behavior
Old behaviors need to changeOld behaviors need to change Re-emergence signals relapse risk (it’s a duck)Re-emergence signals relapse risk (it’s a duck)
Relapse JustificationRelapse Justification ““Stinking thinking”Stinking thinking” Recognize and stopRecognize and stop
Relapse Prevention Relapse Prevention TopicsTopics
Dangerous EmotionsDangerous Emotions Loneliness, anger, deprivationLoneliness, anger, deprivation
Be Smart, not StrongBe Smart, not Strong Avoid the dangerous people and placesAvoid the dangerous people and places Don’t rely on will powerDon’t rely on will power
Avoiding Relapse DriftAvoiding Relapse Drift Identify “mooring lines”Identify “mooring lines” Monitor driftMonitor drift
Relapse Prevention Relapse Prevention TopicsTopics
Total AbstinenceTotal Abstinence Other drug/alcohol use impedes recovery Other drug/alcohol use impedes recovery
growthgrowth Development of new dependencies is possibleDevelopment of new dependencies is possible
Taking Care of BusinessTaking Care of Business Addiction is full-timeAddiction is full-time Normal responsibilities often neglectedNormal responsibilities often neglected
Taking Care of YourselfTaking Care of Yourself Health, groomingHealth, grooming New self-imageNew self-image
Relapse AnalysisRelapse Analysis
Session to be done when relapse Session to be done when relapse occurs after a period of sobrietyoccurs after a period of sobriety
Functional analysisFunctional analysis
Continued drug use is better Continued drug use is better addressed with Early Recovery topicsaddressed with Early Recovery topics
Relapse should be framed as learning Relapse should be framed as learning experience for clientexperience for client
Relapse and SexRelapse and Sex
My sexual My sexual drivedrive is increased by the is increased by the use of …use of …
18.1 20.5
43.9
70.655.3
11.1
85.3
55.6
0102030405060708090
100
Per
cent
Res
pond
ing
"Yes
"
opiates alcohol cocaine meth
Primary Drug of Abuse
malefemale
(Rawson et al., 2002)
My sexual My sexual pleasurepleasure is enhanced by is enhanced by the use of …the use of …
16.0 18.224.4
38.244.7
11.1
73.5 66.7
0102030405060708090
100
Per
cent
Res
pond
ing
"Yes
"
opiates alcohol cocaine meth
Primary Drug of Abuse
malefemale
(Rawson et al., 2002)
My sexual My sexual performanceperformance is improved by is improved by the use of …the use of …
19.115.9
24.432.4
18.411.1
58.8 61.1
0102030405060708090
100
Per
cent
Res
pond
ing
"Yes
"
opiates alcohol cocaine meth
Primary Drug of Abuse
malefemale
(Rawson et al., 2002)
Other Components of Other Components of the the
Matrix ModelMatrix Model Family Education LectureFamily Education Lecture Conjoint SessionsConjoint Sessions Urine TestingUrine Testing Self Help InitiationSelf Help Initiation
Matrix ModelMatrix ModelUrinalysis And Breath Urinalysis And Breath
TestingTesting
Method for Monitoring Treatment ProgressTreatment Accountability
Assistance for Patient
Reduces Arguments
Provides Data for Family or Employer
The “5%” MythThe “5%” Myth
Myth: Only 5% of meth users are Myth: Only 5% of meth users are successful in treatmentsuccessful in treatment
Does treatment work? Does treatment work? Fact: Some treatments workFact: Some treatments work Evidence-based treatments Evidence-based treatments
Motivational InterviewingMotivational Interviewing Contingency ManagementContingency Management Cognitive/Behavioral Treatment (Matrix Cognitive/Behavioral Treatment (Matrix
Model)Model)
The “5%” MythThe “5%” Myth
Wide dissemination may be self-Wide dissemination may be self-fulfillingfulfilling Communities won’t support treatment Communities won’t support treatment Funders won’t fund treatmentFunders won’t fund treatment Meth users won’t enter treatmentMeth users won’t enter treatment Practitioners won’t expect treatment to Practitioners won’t expect treatment to
workwork
Comparison of Meth and Comparison of Meth and Cocaine UsersCocaine Users
Rawson et al., 2000, Journal of Rawson et al., 2000, Journal of Psychoactive DrugsPsychoactive Drugs
500 methamphetamine users500 methamphetamine users 224 cocaine users224 cocaine users Matrix San Bernardino Matrix San Bernardino
CountyCounty Identical program and staffIdentical program and staff
Comparison of Meth and Comparison of Meth and Cocaine UsersCocaine Users
Rawson et al., 2000, Journal of Rawson et al., 2000, Journal of Psychoactive DrugsPsychoactive Drugs Identical treatment outcomesIdentical treatment outcomes
Mean Weeks in Treatment
17.1 18
0
4
8
12
16
20
24
Weeks in Treatment
Wee
ks MethCocaine
% Clean Urines
81% 87%
0%
20%
40%
60%
80%
100%
% Clean Urines
MethCocaine
Matrix Model vs TAUMatrix Model vs TAURawson et al., 2004, AddictionRawson et al., 2004, Addiction
978 Methamphetamine users seeking 978 Methamphetamine users seeking treatment treatment
CSAT multi-site study; 1998-2002CSAT multi-site study; 1998-2002 Costa Mesa; San Diego; Hayward; Concord; Costa Mesa; San Diego; Hayward; Concord; San Mateo; Billings; HonoluluSan Mateo; Billings; Honolulu
Matrix Model vs Treatment as UsualMatrix Model vs Treatment as Usual Random assignmentRandom assignment
Baseline DemographicsBaseline Demographics
AgeAge MaleMale EducationEducation Meth useMeth use Marijuana useMarijuana use Alcohol useAlcohol use
32.8 years32.8 years
55%55%
12.2 years12.2 years
7.5 years7.5 years
7.2 years7.2 years
7.6 years7.6 years
Route of Methamphetamine UseRoute of Methamphetamine Use
24%
11%
64%
0%
10%
20%
30%
40%
50%
60%
70%
Route of Administration
Per
cent
Usi
ng b
y R
oute
nasalsmokeiv
Weeks in TreatmentWeeks in Treatment
5
8.2
0
1
2
3
4
5
6
7
8
9
Matrix TAU
Wee
ks
**
Weeks Continuous AbstinenceWeeks Continuous Abstinence
3
6
0
1
2
3
4
5
6
7
Matrix TAU
Wee
ks
**
Mean Number of UA’s that Mean Number of UA’s that werewere
MA-free during treatmentMA-free during treatment
0
2
4
6
8
10 MatrixTAU
Mean Number of Weeks in Treatment
02468
1012
SITE
mea
n nu
mbe
r of
vis
its MatrixTAU
11.3
4.3 4.4
0
2
4
6
8
10
12
Matrix
Day
s
Baseline
Discharge
6-month FU
Self-report of MA use during the past 30 daysat baseline, discharge, and 6-month follow-up.
Urine Results: % Meth-Urine Results: % Meth-freefree
66%69%
59%
25%30%35%40%45%50%
55%60%65%70%75%
Matrix
% m
eth-
free
Discharge6 months12 months
