Treatment

Chippewa Cree seek traditional approaches to break methamphetamine, alcohol addiction
ROCKY BOY’S RESERVATION - From sweats to sweet grass, native culture has many traditional healing techniques.
The Chippewa Cree Tribe Monday launched a new approach to addressing health problems - chief among them methamphetamine and alcohol
addiction. The Ojibwa Ne-i-yah-w Initiative aims to infuse western treatment and court systems with tribal culture. A team of people from social
services, the tribal college, the court system and health services will join a council of elders in guiding addicts through treatment
and recovery.
“We want to reimmerse our culture into a system that has failed us,” said tribal council member and leader of the new initiative, Jonathon
Windy Boy. “We’re at the forefront, the pioneers, of reaching out of existing services to catch those at risk, to re-emerge the family and
empower the community as a whole.” Traditional court and treatment systems don’t consider the effect an
arrest or an addict can have on the whole family. Because Indians often have close-knit extended families, the number of people
affected is more extensive. Their end goal is to construct a new cultural and learning lodge that
will house tribal courts, domestic violence services, a charter school where at-risk youth can learn their native language, a safe
house and a family wellness court. The three-story, 65,000 square-feet building could also have an IMAX
theater, an underground lecture hall, a computer lab and a performance amphitheater. Native plants and spaces for tepees would be set outside, and a fire
pit would be placed in the round middle building. Tribal Planner Nate St. Pierre said the tribe could break ground on
the $10 million to $20 million building in the spring. The tribe is developing the plan as one of eight in the country
chosen to be part of the federal Substance Abuse and Mental Health Services Administration’s Indian Country Meth Initiative.
SAMHSA Deputy Administrator Eric Broderick is visiting the Rocky Boy’s Reservation Monday and today to hear the tribe’s ideas for how
to address addiction and other health problems. “It makes a lot of sense to bring all the parties involved with
treatment and recovery together,” Broderick said. “Family-based treatment is very effective.”

As one of the eight tribes in the Indian Country Meth Initiative, the Chippewa Cree get to share ideas and successes with the other tribes
and get $50,000 in seed money to develop their program. The initiative is just getting off the ground. Five tribes, including
the Crow in Montana, have been developing programs for the last year. The Chippewa Cree were invited to join the fall of 2007.
Being a part of the program opens the door to future federal funding.  Broderick said the tribe can compete for $1 billion in federal
substance abuse grants. Windy Boy hopes to use a mix of tribal, federal, state and private funding to pay for construction and, more importantly, sustain
operation once the Bear Spirit Cultural & Learning Lodge is complete.
Gov. Brian Schweitzer is visiting the reservation today as part of the two-day health conference.
Key to getting federal money is getting tribal leaders and the community behind the program, Broderick said.
The tribal council did its part Thursday, creating an Ojibwa Ne-i-yah-w tribal advisory committee and cultural resource tribal department.
“No amount of resources is going to solve this problem unless the community says ‘enough,’” Broderick said.

Warning Signs: Is Your Child Using Meth?

Click on a State to access a profile of treatment facilities (N-SSATS data)

Researchers zero in on brain effects, treatment approaches

The spread of methamphetamine production and abuse has sparked a flurry of research on the drug’s health effects and possible new ways for treating the addiction.
Until a few years ago, methamphetamine was considered a regional problem. Largely confined to the West Coast and Southwest, it was off the radar of federal drug offices in Washington, D.C. But as the drug swept into rural Midwestern communities in the mid-1990s, catching hospitals and treatment centers unprepared for its devastating effects, steps were taken to gain a better understanding of meth’s toll on the body.
Meth addiction gained a reputation as being untreatable when the drug began to spread into small communities in the Midwest. These rural areas had not been very affected by cocaine or heroin so when they had to start dealing with meth users they had no idea what to do with them, said Richard Rawson, executive director of the Matrix Institute, a non–profit addiction research organization in Los Angeles, and co-principal investigator at the Methamphetamine Treatment Project along with Anglin. “Patients were coming in psychotic, so you started hearing these horror stories that meth was untreatable. For those of us who’ve been dealing with heroin and crack users, it was more manageable.”
Though not impossible, meth addiction is a difficult disorder to treat, according to Anglin. “There’s not severe physical withdrawal with methamphetamine, but rather a feeling of anhedonia, an inability to experience pleasure, that can last for months and which leads to a lot of relapse at six months,” he said. The anhedonia appears to correspond with the period when the brain is recovering and producing abnormally low levels of dopamine.
“When you think of treatment of drugs like methamphetamine, you have to think of it like fixing a broken leg—treatment provides a structure to allow their brain chemistry to return to normal. Their brain is out of tune, it’s not working very well, and it takes a while to recover,” Rawson said.
Read more about Beating an Addiction to Meth

Treatment

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.

The brain scan on the left is from a control subject who has never used Meth. The red areas show dopamine activity. The scan on the right is from a Meth abuser - after 80 days of detoxification. The areas of dopamine are still fragmented and reduced.

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 http://www.Hazelden.org, http://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. 

Meth Treatment Numbers Explode
A new report from SAMHSA shows the number of people seeking treatment for Meth use or addiction quadrupled from 1993 through 2003, from 13 per 100,000 to 56 admissions per 100,000 population aged 12 or older.  South Dakota jumped from 5 to 90 per 100,000.  Access the entire report and analysis here.

Related Links:

Drug Rehab and Treatment Centers in Washington State
www.methamphetamine.org
ACCBO--The Addiction Counselor Certification Board of Oregon
OPERA-Oregon Prevention Education Recovery Association
Principles of Drug Addiction Treatment