the csat methamphetamine treatment project

Richard Rawson Ph.D.

U.C.L.A. Integrated Substance Abuse Programs (I.S.A.P.)The MTP Site InvestigatorsFunded by the Center for Substance Abuse Treatment

The CSAT Methamphetamine Treatment Project

A Multi-site Trial of a Manualized Psychosocial Protocol for the Treatment of Methamphetamine

Dependence

• Powerfully addictive stimulant that dramatically affects the central nervous system

• Made easily in clandestine labs with OTC ingredients

What Is Methamphetamine?

Methamphetamine comes in many forms and can be:

• Smoked• Snorted• Orally Ingested• Injected

How Is Methamphetamine Taken?

Scope of the Methamphetamine Problem Worldwide

According to surveys and estimates by WHO and UNDCP, methamphetamine is the most widely used illicit drug in the world except for cannabis.

World wide it is estimated there are over 35 million regular users of methamphetamine, as compared to approximately 15 million heroin users and 10 million cocaine users

Scope of Methamphetamine Use in the United States

Methamphetamine abuse, long reported as the dominant drug problem in Honolulu, Hawaii and San Diego, CA, has become a substantial drug problem in other sections of the West, Midwest & Southwest, as well.

Indications that it is spreading to rural and urban sections of the South and East coast.

Once traditionally associated with white, male, blue-collar workers.

Now is being used by more diverse population groups that change over time and differ by geographic area.

Groups with High Rates of Meth Use

Women Residents in Western/Midwestern Rural

Areas and Small/Medium Cities Predominantly Caucasian, Increasing

Numbers of Hispanics Gay Men

CSAT MTP Project Goals:

To study the clinical effectiveness of the Matrix Model

To compare the effectiveness of the Matrix model to other locally available outpatient treatments

To establish the cost and cost effectiveness of the Matrix model compared to other outpatient treatments

To explore the replicability of the Matrix model and challenges involved in technology transfer

Manuals in Psychosocial Treatment

Reduce therapist differences

Ensure uniform set of services

Can more easily be evaluated

Enhance training capabilities

Facilitate research to practice

Matrix Model ofOutpatient Treatment

Organizing Principles of Matrix Treatment Program components based upon scientific

literature on promotion of behavior change.

Program elements and schedule selected based on empirical support in literature and application.

Program focus is on current behavior change in the present and not underlying “causes” or presumed “psychopathology”.

Matrix “treatment” is a process of “coaching”, educating, supporting and reinforcing positive behavior change.


Organizing Principles of Matrix Treatment Non-judgemental, non-confrontational

relationship between therapist and patient creates positive bond which promotes program participation.

Therapist as a “coach”

Positive reinforcement used extensively to promote treatment engagement and retention.

Verbal praise, group support and encouragement other incentives and reinforcers.


Organizing Principles of Matrix Treatment

Accurate, understandable, scientific information used to educate patient and family members

Effects of drugs and alcohol

Addiction as a “brain disease”

Critical issues in “recovering” from addiction


Organizing Principles of Matrix Treatment Behavioral strategies used to promote

cessation of drug use and behavior change

Scheduling time to create “structure”

Educating and reinforcing abstinence from all drugs and alcohol

Promoting and reinforcing participation in non- drug-related activities


Organizing Principles of Matrix Treatment Cognitive-Behavioral strategies used to

promote cessation of drug use and prevention of relapse.

Teaching the avoidance of “high risk” situations

Educating about “triggers” and “craving”

Training in “thought stopping” technique

Teaching about the “abstinence violation effect”

Reinforcing application of principles with verbal praise by therapist and peers


Organizing Principles of Matrix Treatment Involvement of family members to support

recovery.

Encourage participation in self-help meetings

Urine testing to monitor drug use and reinforce abstinence

Social support activities to maintain abstinence

Matrix ModelAn Integrated, Empirically-based, Manualized Treatment Program

Relapse Prevention Family and Group Therapy

Motivational Interviewing

12- Step Involvement

Psychoeducation Social Support

Elements of the Matrix Model

Engagement/Retention Structure Information Relapse Prevention Family Involvement Self Help Involvement Urinalysis/Breath Testing

The Matrix ModelMonday Wednesday Friday

Early Recovery Skills

Weeks1-4

Family/education

Weeks 1-12

Early Recovery Skills

Weeks1-4

Relapse Prevention

Weeks 1-16

Social Support

Weeks 13-16

Relapse Prevention

Weeks 1-16

Urine or breath alcohol tests once per week, weeks 1-16

Table 1. Sites participating in the MTP (from Herrell et al, 2000)

Coordinating Center Principal Investigators

Directors

University of California at Los Angeles (UCLA) Integrated Substance Abuse Programs (ISAP)

M. Douglas Anglin, Ph.D. Richard A. Rawson, Ph.D.

Patricia Marinelli-Casey, Ph.D. , Project Director Jeanne Obert, MFT, Clinical Alice Huber, Ph.D. Research Chris Reiber, Ph.D. Statistics

Grantee / Site* Principal Investigator Lead Evaluator

County of San Mateo, Belmont, CA:Two sites: ODASA and Pyramid

Yvonne Frazier, Ph.D. County of San Mateo, Alcohol and Drug Services; Belmont, CA

Joseph Guydish, Ph.D. University of California at San Francisco; San Francisco, CA

East Bay Community Recovery Project, Hayward, CA

Joan Zweben, Ph.D. East Bay Community Recovery Project; Hayward, CA

Judith Cohen, Ph.D., M.P.H. East Bay Community Recovery Project; Hayward, CA

Matrix Institute, Costa Mesa, CA

Michael McCann, M.A. Matrix Institute; Costa Mesa, CA

Vikas Gulati, B.S. Matrix Institute; Costa Mesa, CA

New Leaf Treatment Center, Lafayette, CA

Gantt Galloway, Pharm.D. New Leaf Treatment Center; Lafayette, CA

Janice Stalcup, Ph.D. New Leaf Treatment Center; Lafayette, CA

San Diego Association of Governments, San Diego, CA

Susan Pennell, M.A. San Diego Association of Governments; San Diego, CA

Cynthia Burke, Ph.D. San Diego Association of Governments; San Diego, CA

South Central Regional Mental Health Center, Billings, MT

Denna Vandersloot, B.S. South Central Regional Mental Health Center; Billings, MT

Russell H. Lord, Ph.D. Montana State University; Billings, MT

St. Francis Medical Center, Honolulu, HI

A lice Dickow, B.A. St. Francis Women’s Addiction Treatment Center, Hawaii; Honolulu, HI

Ewa Stamper, Ph.D. St. Francis Women’s Addiction Treatment Center, Hawaii; Honolulu, HI

Site Duration of Treatment Intensive

Phase

Individual Sessions

Group Sessions12-Step Program

Involvement

Site 1

8 wks 1x/wk x 4-8 wks, 30-50 min each

4x/wk x 4-8 wks, 3hr each, families

attend 1x/wk

required; 1x/wk x 4-8 wks

Site 2

12 wks 1x/wk x 12 wks, 1 hr each

5x/wk x 2wk,3x/wk x 2wks, 2x/wk x 8 wks

recommended

Site 3


none recommended

Site 4

16 wks 1x/wk x 16 wks, 10-15 min each

3x/wk x 16 wks, 1 hr each

required; 3x/wk x 16 wks

Site 5

12 wks 1x/wk x 12 wks, 30-60 min each

3x/wk x 12 wks, 90 min each and

2x/wk x 12 wks, 60-90 min each

required; 1x/wk x 12 wks

Site 6

12 wks 1x/wk – 2x/mo x 12 wks, 1 hr each

2x/wk x 12 wks, 90 min each,

families attend 1x/2 wks

recommended

Site 7


2x/wk x 16 wks, 2 hrs each

recommended

Site 8

12 wks 2x/wk x 12 wks,1 hr each

1x/wk x 12 wks, 2 hrs each

required; 6 meetings

Table 2. Treatment-As-Usual: Elements of Treatment

Site

TAU (n)

Matrix 16-week (n)

Total

Site 1

69

73

142

Site 2 78 77 155

Site 3 77 76 153

Site 4 50 57 107

Site 5 61 63 124

Site 6 73 70 143

Site 7 24 22 46

Site 8 54 54 108

Overall TOTAL

486 492 978

Table 3. Enrollment in the MTP by Site and Treatment Condition

Characteristic Summary

% Male 45

Age (Yrs.), mean (sd) 32.8 (8.0)

Ethnicity (%)

Caucasian 60

African-American 2

American Indian 3

Asian/Pacific Islander 17

Hispanic 18

Educational Attainment Level (yrs.), mean (sd) 12.2 (1.7)

% Employed 69

% Married (and not separated) 16

Overall Substance Use Patterns-Lifetime (yrs.), mean (sd)

Methamphetamine 7.54 (6)

Alcohol 7.6 (8.5)

Cocaine 1.75 (3.5)

Cannabis 7.15 (8)

Overall Substance Use Patterns—Days in Past 30, mean (sd)

Methamphetamine 11.53 (9.6)

Alcohol 4.72 (7.3)

Cocaine 0.21 (1)

Cannabis 4.38 (8.3)

Preferred Route of Administration of MA (%)

Oral 0

Nasal 11

Smoked 65

IV- injection 24

Table 4. MTP Participant Characteristics (taken from baseline ASI)

Sample Description

Baseline Demographics

Participants Served (n) 1016

Age (mean) 32.8 years

Education (mean) 12.2 years

Methamphetamine Use (mean)

7.5 years

Marijuana Use (mean) 7.2 years

Alcohol Use (mean) 7.6 years

Gender Distribution of Participants

45

55

0

10

20

30

40

50

60

female male

Gender

Per

cen

t

Ethnic Identification of Participants60

2 3

17 18

0

10

20

30

40

50

60

Ethnic Identification

Per

cent

caucasian

african amer

native amer

asian/pac isl

hispanic

Marital Status of Participants

16

33

50

0

10

20

30

40

50

Marital Status

Per

cent

married/remar.

separated/div.

single/widowed

Employment Status of Participants69

2

23

6

0

10

20

30

40

50

60

70

80

Employment Status

Pe

rce

nt

FT/PT

Retired/Disable

Unemployed

Student/Control Env.

Route of Methamphetamine Administration

24

11

64

0

10

20

30

40

50

60

70

Route of Administration

Per

cen

t U

sin

g b

y R

ou

te

nasal

smoke

iv

Changes from Baseline to Treatment-end

Days Paid for Work in Past 30

10.4

8.2

0

2

4

6

8

10

12

BL Tx end

Mea

n D

ays

Pai

d

Possible is 0-30; tpaired=6.01; p-value<0.000 (highly sig.)

Total Income (Past 30 days)of Participants

1211

1096

1000

1200

1400

BL Tx end

Mea

n To

tal I

ncom

e ($

)

tpaired=2.34; p-value=0.02 (sig.)

0.53

0.230.260.24

0.21

0.11

0.21 0.220.19

0.10

0.15

0.08

0.49

0.21

0.0

0.1

0.2

0.3

0.4

0.5

0.6

Me

an

Co

mp

os

ite

Sc

ore

BL

Tx end

ASI Composite Scores

Possible is 0-1;

Higher : worse problemtpaired: *p-value<0.03 (sig.),

**p-value<0.000 (highly sig.)

Days of Methamphetamine Use in Past 30 (ASI)

4.4

11.5

0

2

4

6

8

10

12

BL Tx end

Mea

n D

ays

Use


Days of Marijuana Use in Past 30 (ASI)

2.4

4.5

0

2

4

6

8

10

12

BL Tx end

Mea

n D

ays

Use


Days of Alcohol Use in Past 30 (ASI)

3.3

4.8

0

2

4

6

8

10

12

BL Tx end

Mea

n D

ays

Use


Beck Depression Inventory (BDI) Total Scores

9.9

15.4

0

5

10

15

20

BL Tx end

Mea

n To

tal S

core


BSI Scores (mean)

BL1 Tx-endPaired t

*

Somatization 0.7 0.5 7.67

Obsessive-Compulsive 1.2 0.9 11.40

Interpersonal Sensitivity 1.0 0.7 11.40

Depression 1.2 0.8 11.98

Anxiety 0.9 0.6 11.24

Hostility 0.8 0.6 9.39

Phobic Anxiety 0.6 0.4 8.47

Paranoid Ideation 1.1 0.7 11.49

Psychoticism 0.9 0.6 10.70

1Possible, all scores, is 0-4; *all p-values<0.000 (highly sig.)

Positive Symptom Total (PST) from Brief Symptom Inventory (BSI)

18

26

0

10

20

30

BL Tx end

Mea

n #

sym

ptom

s


Site (TAU length,

wks.)

TAUMean SD

Matrix 16-weekMean SD

Site 1 (8) 17.2 25.2

Site 2 (12)

21.7 26.1

Site 3 (12)

6.3 28.4

Site 4 (16)

22.8 31.5

Site 5 (12)

15.4 25.7

Site 6 (12)

2.1 25.2

Site 7 (16)

13.8 35.4

Site 8 (12)

3.9 22.2

Overall summary 12.7 26.8

Table 5. Summary of the number of clinical contacts made by participants, by treatment group and site

Figure 3. Participant retention throughout treatment, by site and treatment group

Site

TAU length (wks.)

Log-rank

Chi-square

p

Site 1

8

-20.07

33.17

<0.0001

Site 2 12 -9.49 4.98 0.026

Site 3 12 -8.39 3.68 0.055

Site 4 16 1.64 0.26 0.610

Site 5 12 -22.30 28.74 <0.0001

Site 6 12 -17.46 17.87 <0.0001

Site 7 16 -5.01 3.34 0.067

Site 8 12 -10.59 7.99 0.005

Table 7. Comparison of retention between groups within sites, with Matrix truncated to the length of TAU at each site

65.8459.15Not Completer

34.1640.85Completer

TAUMatrix 16

x2=4.68, p=0.031

Figure 4. Percent completing treatment, by group

3.75 4.29

8.04

3.38 3.29

7.28

0

2

4

6

8

10

8-wk 12-wk 16-wk

Tx-Length Group

mea

n nu

mbe

r of M

A-fre

e ur

ines

Matrix16

TAU

Figure 5. Mean number of MA-free urine samples, by treatment length and treatment group (Matrix group data truncated to the length of TAU)

Site (TAU length, wks.)

Raw Data Truncated Data

Matrix16 TAU Matrix16 TAU

t pmean SD mean SD mean SD mean SD

Site 1 (8)

6.23 3.383.75 3.38

-0.76 0.45

Site 2 (12)

6.25 4.194.86 4.19

-0.94 0.35

Site 3 (12)

5.75 3.624.61 3.62

-1.52 0.13

Site 4 (16)

8.44 8.68.44 8.6

0.13 0.89

Site 5 (12)

5.19 1.724.30 1.72

-3.70 0.0003

Site 6 (12)

4.24 3.273.3 3.27

-0.04 0.97

Site 7 (16)

7.0 4.547.0 4.54

-1.50 0.14

Site 8 (12)

5.39 3.304.28 3.30

-1.23 0.22

Table 8. Summary of the number of MA-free urine samples provided by participants, by treatment group and site

Site (TAU length, wks.)

Raw Data Truncated Data

Matrix16 TAU Matrix16 TAU

t pmean SD mean SD mean SD mean SD

Site 1 (8)3.575 2.754 2.877 2.754

-0.982 0.328

Site 2 (12)3.753 2.474 3.377 2.474 -1.47 0.144

Site 3 (12)3.197 1.805 3.013 1.805 -2.16 0.033

Site 4 (16)6.140 5.560 6.140 5.560

-0.546 0.586

Site 5 (12)3.889 1.279 3.429 1.279

-3.393 0.001

Site 6 (12)2.429 2.342 2.314 2.342 0.2 0.841

Site 7 (16) 4.682 2.542 4.682 2.542

-1.586 0.121

Site 8 (12) 2.833 2.130 2.519 2.130

-0.551 0.583

Table 9. Longest MA abstinent period by treatment group and site

5.116.41

10.62

4.045.15

9.7

0

2

4

6

8

10

12

8-wk 12-wk 16-wk

Tx-Length Group

mea

n nu

mbe

r of v

isits

Matrix16

TAU

Figure 2. Mean number of weekly data visits attended, by treatment length and treatment group (Matrix group data truncated to the length of TAU)

Discharge UA Resultby Attendance During Treatmentand Group

0%

20%

40%

60%

80%

100%

Percent of Data Visits Attended During Treatment

0%

20%

40%

60%

80%

100%


Matrix 16 TAU

clean missing dirty

4 9 2 4 8 6

4 0 1 3 9 74 2 1 4 2 0

M a tr ix 1 6 -w k . T A U

nu

mb

er

of

pa

rtic

ipa

nts

B a s e l in eD is c h a rg e6 -m o n th F U

Figure 1. Overall participant follow-up by treatment condition and time point

6-mos. F.U. UA Resultby Attendance During Treatment and Group

0%

20%

40%

60%

80%

100%


0%

20%

40%

60%

80%

100%


Matrix 16 TAU

MA- missing MA+

68%66%6 Month Follow-up

66%69%Discharge

TAUMatrix 16

x2=4.68, p=0.031

Figure 5. Urinalysis Results: %Meth Negative

11.3 11.8

4 .3 4 .44 .4 4 .0

0

2

4

6

8

10

12

M atrix 16-w k. TAUmea

n n

um

ber

of

day

s o

f M

A u

se

Baseline

Discharge

6-m onth FU

Figure 6. Participant self-report of MA use (number of days during the past 30) at enrollment, discharge, and 6-month follow-up, by treatment condition

MTP Study Conclusions

A multisite evaluation of a research-based intervention can be conducted in community sites during a 3 year period.

Six research-naïve sites and 2 experienced sites successfully were trained and conducted all necessary research activities for a complex clinical trial.

A complex psychosocial treatment protocol was successfully replicated at 8 sites over a 3 year period.

Over 1000 MA-Users received free treatment.


Treatment for MA dependence associated with improvements in many domains including drug use, mj use, mood, Income

Matrix treatment results in longer retention, more sessions attended, more treatment completers, more MA-negative Uas, longer periods of MA abstinence

* Except for drug court site


Outcomes at discharge and follow-up demonstrated comparable results between Matrix and TAU

Program compliance associated with superior urinalysis results at discharge and follow-up


The design of multi-site studies has to carefully consider priorities among the following issues:– Priority of testing the null hypothesis of the primary

study outcomes– Flexibility to accommodate all investigators

individual site priorities and site program variability

the csat methamphetamine treatment project

Documents

matrix modelto

treatment engagement

positive behavior change

promotion of behavior

program participation

cost effectiveness

program elements

program focus