1

The Matrix Model The Matrix Model Treatment Approach for Treatment Approach for

Methamphetamine DependenceMethamphetamine DependenceMethamphetamine DependenceMethamphetamine Dependence

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 brainpp

Treatment approaches in light of brain effectsTreatment approaches in light of brain effects

The Matrix Model treatment approachThe Matrix Model treatment approach

Does methamphetamine treatment work? Does methamphetamine treatment work?

2

A Major Reason PeopleA Major Reason People

Meth Treatment is ChallengingMeth Treatment is Challenging

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

200200

ut

ut NAc shellNAc shell

FOODFOOD200200

seli

ne)

seli

ne) SEXSEX

Natural Rewards Elevate Dopamine Natural Rewards Elevate Dopamine LevelsLevels

Natural Rewards Elevate Dopamine Natural Rewards Elevate Dopamine LevelsLevels

00

5050

100100

150150

00 6060 120120 180180

% o

f B

asal

DA

Ou

tpu

% o

f B

asal

DA

Ou

tpu NAc shellNAc shell

EmptyEmptyBoxBoxFeedingFeeding

100100

150150

DA

Co

nce

ntr

atio

n (

% B

as

DA

Co

nce

ntr

atio

n (

% B

as

1515

00

55

1010

Co

pu

lation

Freq

uen

cC

op

ulatio

n F

requ

enc

00 6060 120120 180180Time (min)Time (min)

Source: Di Chiara et al.Source: Di Chiara et al.

MountsMountsIntromissionsIntromissionsEjaculationsEjaculations

cy

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

3

200200

300300

400400

Ba

sa

l Re

lea

se

Ba

sa

l Re

lea

se

DADADOPACDOPACHVAHVA

AccumbensAccumbens COCAINECOCAINE

150150

200200

250250B

as

al R

ele

as

eB

as

al R

ele

as

e AccumbensAccumbens

0.50.51.01.02.52.51010

Dose (mg/kg)Dose (mg/kg)MORPHINEMORPHINE

Effects of Drugs on Dopamine LevelsEffects of Drugs on Dopamine LevelsEffects of Drugs on Dopamine LevelsEffects of Drugs on Dopamine Levels

800800900900

1000100011001100

al R

ele

as

ea

l Re

lea

se

DADA

AccumbensAccumbens AMPHETAMINEAMPHETAMINE

00

100100

200200

00 11 22 33 44 5 hr5 hrTime After CocaineTime After Cocaine

% o

f B

% o

f B

00

100100

00 11 22 33 44 5hr5hrTime After MorphineTime After Morphine

% o

f %

of

200200

250250

l Re

lea

se

l Re

lea

se

AccumbensAccumbensCaudateCaudate

NICOTINENICOTINE

00100100200200300300400400500500600600700700

00 11 22 33 44 5 hr5 hrTime After AmphetamineTime After Amphetamine

% o

f B

as

a%

of

Ba

sa DADA

DOPACDOPACHVAHVA

00

100100

150150

00 11 22 3 hr3 hrTime After NicotineTime After Nicotine

% o

f B

as

a%

of

Ba

sa CaudateCaudate

Source: Di Chiara and ImperatoSource: Di Chiara and Imperato

Prolonged Drug Use ChangesProlonged Drug Use Changes

Meth Treatment is ChallengingMeth Treatment is Challenging

Prolonged Drug Use ChangesProlonged Drug Use Changesthe Brain In Fundamentalthe Brain In Fundamentaland Longand Long--Lasting WaysLasting Ways

4

Decreased dopamine transporter binding in Decreased dopamine transporter binding in METH users resembles that inMETH users resembles that in

ParkinsonParkinson’’s Disease patientss Disease patients

Source: McCann U.D.. et al.,Journal of Neuroscience, 18, pp. 8417-8422, October 15, 1998.

Control Meth PDAvg. 3 yrs. abstinent

5

“This is your Brain on Meth”“This is your Brain on 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 tissue.11% loss in brain pleasure/reward center tissue.

He described “a forest fire” of brain damage.He described “a forest fire” of brain damage.

Navigating through daily life and applying what Navigating through daily life and applying what is learned in treatment may be difficult is learned in treatment may be difficult (reminders, simplicity, redundancy)(reminders, simplicity, redundancy)

Meth in the BrainMeth in the BrainMeth in the BrainMeth in the Brain

6

7

8

Methamphetamine: Methamphetamine: Neurochemical MechanismsNeurochemical Mechanisms

Enters dopamine vesiclesEnters dopamine vesicles

Vesicles deplete themselves of dopamineVesicles deplete themselves of dopamine

METH

METH

9

METH

METH

Meth Treatment is ChallengingMeth Treatment is Challenging

Prolonged meth use changes the brainProlonged meth use changes the braing gg g

Prolonged effects require appropriate treatment Prolonged effects require appropriate treatment approaches approaches

10

Effective Treatments for Effective Treatments for MethamphetamineMethamphetamine DependenceDependenceMethamphetamine Methamphetamine DependenceDependence

The Matrix InstituteThe Matrix Institute

Established 1984Established 1984s b s ds b s d 5 clinics in Southern California5 clinics in Southern California San Bernardino County 1985; >50% meth usersSan Bernardino County 1985; >50% meth users

11

Some Core Elements of Some Core Elements of the Matrix Modelthe Matrix Model

Elements of Effective TreatmentElements of Effective Treatmentwith Methamphetamine Users with Methamphetamine Users

Focus on the present; behavior vs feelingsFocus on the present; behavior vs feelings Focus on the present; behavior vs feelingsFocus on the present; behavior vs feelings

Structure: 3 X week meetings; 16 weeksStructure: 3 X week meetings; 16 weeks

Information on addiction and recoveryInformation on addiction and recovery

Teach relapse preventionTeach relapse prevention

Uri t tiUri t ti Urine testingUrine testing

Introduce and encourage selfIntroduce and encourage self--helphelp

12

Matrix Program Schedule (Sample)Matrix Program Schedule (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

Weeks 1-16Relapse PreventionRelapse Prevention Weeks 13-16

Social SupportRelapse Prevention

Urine and breath alcohol tests once per week, weeks 1-16Ten Individual/Conjoint sessions during 1st 16 weeks

Simple, redundant, & relevant informationSimple, redundant, & relevant information

Cl i l di i i d iCl i l di i i d iClassical conditioning and cravingClassical conditioning and craving

The brain and addictionThe brain and addiction

13

Information: ConditioningInformation: Conditioning

Pavlov’s Dog

Information: ConditioningInformation: Conditioning

Pavlov’s Dog

14

Conditioning Process During Conditioning Process During AddictionAddiction

Social Phase

Triggers•Parties

Responses•Pleasant Thoughts

Strength of Conditioned Connection

Mild

•Special OccasionsPleasant Thoughts about AOD

•No Physiological Response

•Infrequent Use

Development of Craving ResponseDevelopment of Craving Response

Addiction Phase

Thinking of Using

Mild Physiological Response

Entering Using Site

Heart Rate

Breathing Rate

Energy

Adrenaline Effects

Powerful Physiological R

Use of AODs AOD EffectsResponse

Heart Rate

Breathing Rate

Energy

Adrenaline Effects

Heart

Blood Pressure

Energy

15

Cognitive Process During AddictionCognitive Process During Addiction

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 enoughWill power, good intentions are not enoughp , g gp , g g

Behavior needs to changeBehavior needs to change

Insight will not affect cravingsInsight will not affect cravings

D l ith i id t iD l ith i id t i Deal with cravings: avoid triggersDeal with cravings: avoid triggers

Deal with cravings: thoughtDeal with cravings: thought--stoppingstopping

SchedulingScheduling

16

Treatment: Information & PersuasionTreatment: Information & Persuasion

DRUG

Early Recovery Skills GroupEarly Recovery Skills Group

Drug cessationDrug cessationgg

Identify triggersIdentify triggers

Get rid of paraphernaliaGet rid of paraphernalia

Avoid triggersAvoid triggers--schedule timeschedule time

ThoughtThought--stopping for cravingsstopping for cravingsThoughtThought stopping for cravingsstopping for cravings

1212--step introductionstep introduction

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Matrix Model Key ComponentMatrix Model Key Component

Information

The Roadmap to Recovery

Information: Roadmap for RecoveryInformation: Roadmap for Recovery

•Withdrawal

•Early Abstinence, Honeymoon

•Protracted Abstinence, the Wall

•Adjustment/Resolution

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Information: the WallInformation: the Wall

Protracted Abstinence: “The Wall”Protracted Abstinence: “The Wall”

4545--120 days after last use120 days after last use

19

Partial Recovery of Brain from Methamphetamine After Abstinence

3

Normal Control METH Abuser(1 month abstinent)

METH Abuser(14 months abstinent)

0

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 Behaviors

Emotional Swings

AnhedoniaAnger

Depression

Unclear Thinking

Isolation

Family Problems

Cravings Return

Protracted Abstinence

Abstinence Violation

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The WallThe Wall

Treatment implicationsTreatment implicationsSi lSi l SimpleSimple

RedundantRedundant Frequent visits for an extended periodFrequent visits for an extended period

Message to patientsMessage to patientsIt t k hil f b i t h lIt t k hil f b i t h l It takes a while for your brain to healIt takes a while for your brain to heal

Don’t make mistakes explaining your feelingsDon’t make mistakes explaining your feelings Be patient; Don’t give upBe patient; Don’t give up

Relapse Prevention GroupsRelapse Prevention Groups

Relapse PreventionRelapse Preventionpp Patients need to develop new behaviorsPatients need to develop new behaviors

Learn to monitor signs of vulnerability to Learn to monitor signs of vulnerability to relapserelapse

Recovery is more than not using D.O.C.Recovery is more than not using D.O.C.

R i th t i d dR i th t i d d Recovery is more than not using drugs and Recovery is more than not using drugs and alcoholalcohol

21

Relapse Prevention TopicsRelapse Prevention Topics

Relapse PreventionRelapse PreventionO i f th t thi d ’t “j t h ”O i f th t thi d ’t “j t h ” Overview of the concept; things don’t “just happen”Overview of the concept; things don’t “just happen”

Using BehaviorUsing Behavior Old behaviors need to changeOld behaviors need to change

ReRe--emergence signals relapse risk (it’s a duck)emergence signals relapse risk (it’s a duck)

Relapse JustificationRelapse JustificationS k h k ”S k h k ” “Stinking thinking”“Stinking thinking”

Recognize and stopRecognize and stop

Relapse Prevention TopicsRelapse Prevention Topics

Dangerous EmotionsDangerous EmotionsL li d i tiL li d i ti 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”dentify mooring linesdentify mooring lines Monitor driftMonitor drift

22

Relapse Prevention TopicsRelapse Prevention Topics

Total AbstinenceTotal Abstinence Other drug/alcohol use impedes recovery growthOther drug/alcohol use impedes recovery growthg/ p y gg/ p y g Development of new dependencies is possibleDevelopment of new dependencies is possible

Taking Care of BusinessTaking Care of Business Addiction is fullAddiction is full--timetime Normal responsibilities often neglectedNormal responsibilities often neglected

Taking Care of YourselfTaking Care of Yourself Health, groomingHealth, grooming New selfNew self--imageimage

Relapse AnalysisRelapse Analysis

Session to be done when relapse occurs after a Session to be done when relapse occurs after a period of sobrietyperiod of sobrietyperiod of sobrietyperiod of sobriety

Functional analysisFunctional analysis

Continued drug use is better addressed with Continued drug use is better addressed with Early Recovery topicsEarly Recovery topicsEarly Recovery topicsEarly Recovery topics

Relapse should be framed as learning experience Relapse should be framed as learning experience for clientfor client

23

Relapse and SexRelapse and Sex

My sexual My sexual drivedrive is increased by the use of …is increased by the use of …

85 390100

ng

18.1 20.5

43.9

70.655.3

11 1

85.3

55.6

2030405060708090

erce

nt R

espo

ndin

"Yes

"

malefemale

11.1

01020

Pe

opiates alcohol cocaine meth

Primary Drug of Abuse

(Rawson et al., 2002)

24

My sexual My sexual pleasurepleasure is enhanced by the use of …is enhanced by the use of …

90100

g

16.0 18.224.4

38.244.7

11 1

73.5 66.7

2030405060708090

rcen

t R

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nd

ing

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malefemale

11.1

01020

Per

opiates alcohol cocaine meth

Primary Drug of Abuse

(Rawson et al., 2002)

My sexual My sexual performanceperformance is improved by the use of …is improved by the use of …

100

19.115.9

24.432.4

18.4

58.8 61.1

2030405060708090

cent

Res

pond

ing

"Y

es"

malefemale

11.1

01020

Per

c

opiates alcohol cocaine meth

Primary Drug of Abuse(Rawson et al., 2002)

25

Other Components of the Other Components of the Matrix ModelMatrix Model

Family Education LectureFamily Education Lecture

Conjoint SessionsConjoint Sessions

Urine TestingUrine Testing

S lf H lp Initi ti nS lf H lp Initi ti n Self Help InitiationSelf Help Initiation

Matrix ModelMatrix ModelUrinalysis And Breath TestingUrinalysis And Breath Testing

M th d f M it i T t t PMethod for Monitoring Treatment Progress

Treatment Accountability

Assistance for Patient

Reduces Arguments

Provides Data for Family or Employer

26

The “5%” MythThe “5%” Myth

Myth: Only 5% of meth users are successful in Myth: Only 5% of meth users are successful in treatmenttreatmenttreatmenttreatment

Does treatment work? Does treatment work? Fact: Some treatments workFact: Some treatments work EvidenceEvidence--based treatments based treatments

Motivational InterviewingMotivational Interviewinggg Contingency ManagementContingency Management Cognitive/Behavioral Treatment (Matrix Model)Cognitive/Behavioral Treatment (Matrix Model)

The “5%” MythThe “5%” Myth

Wide dissemination may be selfWide 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 workPractitioners won’t expect treatment to work

27

Comparison of Meth and Cocaine UsersComparison of Meth and Cocaine UsersRawson et al., 2000, Journal of Psychoactive DrugsRawson et al., 2000, Journal of Psychoactive Drugs

500 methamphetamine users500 methamphetamine users

224 cocaine users224 cocaine users

Matrix San Bernardino CountyMatrix San Bernardino County

Identical program and staffIdentical program and staff

Comparison of Meth and Cocaine UsersComparison of Meth and Cocaine UsersRawson et al., 2000, Journal of Psychoactive DrugsRawson et al., 2000, Journal of Psychoactive Drugs

Identical treatment outcomesIdentical treatment outcomes

Mean Weeks in Treatment

17.1 18

12

16

20

24

eeks

Meth

% Clean Urines

81% 87%

60%

80%

100%

Meth

0

4

8

Weeks in Treatment

We

Cocaine

0%

20%

40%

% Clean Urines

Cocaine

28

Matrix Model vs TAUMatrix Model vs TAURawson et al., 2004, AddictionRawson et al., 2004, Addiction

978 Methamphetamine users seeking treatment978 Methamphetamine users seeking treatment 978 Methamphetamine users seeking treatment 978 Methamphetamine users seeking treatment CSAT multiCSAT multi--site study; 1998site study; 1998--20022002

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 32.8 years32.8 years

MaleMale

EducationEducation

Meth useMeth use

Marijuana useMarijuana use

55%55%

12.2 years12.2 years

7.5 years7.5 years

7 2 years7 2 years Marijuana useMarijuana use

Alcohol useAlcohol use

7.2 years7.2 years

7.6 years7.6 years

29

Route of Methamphetamine UseRoute of Methamphetamine Use

64%70%

24%

11%20%

30%

40%

50%

60%

ent

Usi

ng b

y R

oute

nasalsmokeiv

11%

0%

10%

20%

Route of Administration

Per

c

Weeks in TreatmentWeeks in Treatment

8.28

9

5

3

4

5

6

7

8

Wee

ks

**0

1

2

Matrix TAU

**

30

Weeks Continuous AbstinenceWeeks Continuous Abstinence

67

3

6

2

3

4

5

6

Wee

ks

0

1

2

Matrix TAU

**

Mean Number of UA’s that wereMean Number of UA’s that wereMAMA--free during treatmentfree during treatment

10 Matrix

0

2

4

6

8

BilCo Co Ha Ho Sa Sa Sa

TAU

Billings

Concord

CostaMesa

Hayward

Honolulu

SanDiego

SanMateoO

DAS

SanMateoPyra

31

Mean Number of Weeks in Treatment

1012

f vi

sits

MatrixTAU

02468

10

Bi C C H H S S S

mea

n nu

mbe

r of TAU

Billings

Concord

CostaMesa

Hayward

Honolulu

SanDiego

SanMateoODAS

SanMateoPyra

SITE

11.312

Self-report of MA use during the past 30 daysat baseline, discharge, and 6-month follow-up.

4.3 4.44

6

8

10

Day

s

Baseline

Discharge

6-month FU

0

2

Matrix

32

Urine Results: % MethUrine Results: % Meth--freefree

66%69%

70%

75%

66%

59%

35%

40%

45%

50%

55%

60%

65%

70%

% m

eth

-fre

e

Discharge

6 months

12 months

25%

30%

35%

Matrix