Hi, I'm Derek Blevins. I'm an addiction psychiatrist and assistant professor of psychiatry at Columbia University and the title of this webinar series is Integrating Screening, Brief Interventions and Treatment for Stimulant Use Disorder During Buprenorphine Treatment for Opioid Use Disorder in Primary Care. And this is funded by the Opioid Response Network, which assists states, organizations and individuals by providing the education and training they need locally to address the opioid crisis and stimulant use. Technical assistance is available to support the evidence-based harm reduction, prevention, treatment and recovery of opioid use disorders and stimulant use disorders. The ORN provides local, experienced consultants in prevention, treatment and recovery to communities and organizations to help address the opioid crisis and stimulant use. ORN accepts requests for education and training and each state or territory has a designated team led by a regional coordinator who is an expert in implementing evidence-based practices. To ask questions or submit a technical assistance request, you can visit the Opioid Response Network website, email ORN at tripleap.org or call 401-270-5900. And here is the funding statement. Funding comes from SAMHSA. And the overall mission of ORN is to provide training and education via local experts to enhance harm reduction, prevention, treatment, especially medications like buprenorphine, naltrexone and methadone and recovery efforts across the country addressing state and local specific needs. And this is the third of four topics in this series, which will focus on behavioral treatment approaches. In an overview of this talk, so we'll talk about the principles of behavioral treatments, evidence-based behavioral therapies for stimulant use disorder and some practical use of behavioral therapies in primary care settings. So first, the principles of substance use disorder psychotherapy is that they pretty much all share in common are we want to increase patient motivation, increase their coping skills, increase their interpersonal functioning and increase the treatment alliance while also reducing their substance use and related consequences, reducing negative affect and reducing maladaptive behaviors. And this was a meta-analysis that looked at psychosocial treatments for substance use disorders. And what they showed overall was that they have a moderate effect size. The strongest effect was for contingency management, which we will talk about. And for cocaine, the trials that were included in this meta-analysis were on contingency management, CBT or relapse prevention and group drug counseling. About a third of the patients, this is noteworthy, did drop out of behavioral treatment when they were in these research studies that were included in this analysis. So here's a list of some of the evidence-based behavioral treatments, a list of the evidence-based behavioral treatments for substance use disorders, many of which have some evidence in treating stimulant use disorders. So first, contingency management, motivational enhancement therapy, cognitive behavioral therapy, which includes relapse prevention as sort of an offshoot of cognitive behavioral therapy that focuses on substance use. There's also a gay specific cognitive behavioral therapy that was designed for methamphetamine use disorder, also community reinforcement approach. And this approach can be combined with CM or contingency management, 12-step facilitation, medical management, mindfulness-based interventions, individual drug counseling, network therapy, and the matrix model. And for this talk, I'm going to focus on this, the list here in bold. And the reason for that is two things. One, that some of these have more evidence for stimulant use disorders, and also that these therapies have some practices that can be done in primary care settings that could potentially be helpful, especially for patients that maybe can't access behavioral treatment based off of their location or resources. But first we'll talk about contingency management. So contingency management is giving tangible rewards, usually money, to reinforce positive behaviors like negative urine drug testing. And this is based off of principles of operant conditioning. There are a couple of different types. One is a voucher-based reinforcement, where a voucher is given per drug-free urine sample. Vouchers usually have a monetary value, so they could be movie passes or for food. And you typically start with a low value and increase the value with a number of consecutive negative urine samples. A positive urine sample would then reset the value to that initial lower value. Another method is through prize incentives. So you give cash prizes instead of vouchers. And typically this is done with the fishbowl method. So every negative urine test would put their name into the fishbowl and give them the chance to win something between $1 and $100 when the name is drawn at some sort of defined interval. It can also incentivize attending counseling or other goal-related activities. There have been concerns raised about whether this could contribute to gambling, but studies have actually evaluated this and shown that it doesn't contribute to gambling behavior. But there are significant implementation challenges with contingency management, despite the fact that it is one of the more robust evidence-based practices for stimulant use disorder treatment. The first question is who pays? There's not an insurance model that is set up for incentivizing patients to have negative urine drug screens. And there are some issues related to federal or CMS kickback statutes that are a significant limitation for patients who have Medicaid or Medicare, where this would not really be possible to incentivize in a way that would be at the level necessary to promote behavior change. This could change in the future, but as the policies stand currently, it would limit this practice for patients with Medicaid or Medicare. It is effective at abstinence initiation, although not all patients respond to this method. So in summary, really more guidance and policy and regulations are needed to implement contingency management effectively in clinical settings. The second type of therapy I'm going to talk about is motivational enhancement therapy. But first I wanted to remind people what motivational interviewing is. This we talked about in the screening brief intervention talk. So motivational interviewing is really a style of conversational style with patients that has these three main components of engagement, motivation, and planning. It's a non-judgmental approach that really provides patient education. This ORS, that stands for open-ended questions, affirmations, reflections, and summaries, is the way to engage patients in conversations about substance use. It encourages problem-solving, reflects patients' commitment to change, is a very empathetic conversational style, focuses on developing a treatment alliance with the patient, and it's collaborative. It allows patient contribution, allows patient agreement, and appeals to their goals and values. And really, we should consider motivational interviewing the foundation for all treatment-related conversations. This will typically lead to better outcomes, whether you're doing just medication management or also trying to integrate some of these behavioral treatment approaches. So motivational enhancement therapy was designed based off of principles of motivational interviewing. It's a systematic approach for evoking change that was used in a project, or Project MATCH, which was a study for alcohol use disorder. It does involve an extensive initial assessment, and then that's followed by four individualized sessions over 12 weeks. Those four sessions are giving feedback based off of that initial assessment, building motivation and consolidating commitment to change, and then a couple of sessions to monitor and encourage progress. This was based off of the FRAMES acronym, so this is very similar to what I just mentioned in the motivational interviewing slide, providing feedback of personal risk and impairment, focusing on the personal responsibility, that's the R for change, giving clear advice to change, menu of alternative change options, therapist empathy, and facilitation of client self-efficacy or optimism. And it does use the stages of change, which we talk about sometimes in motivational interviewing, but wasn't really a component of MI initially, was integrated into motivational enhancement therapy when it was manualized for this alcohol use disorder treatment study. And this is just a reminder of the stages of change. So pre-contemplation is when patients don't have any interest or motivation or plans to make any change. Contemplation would be thinking about making a change in this context related to substance use. Preparation is making some plans to actually change. Action would be putting those plans into action. And then maintenance is once someone has achieved whatever their goal is, whether it's reduction or abstinence, what they need to do to maintain that. And then relapse is of course sometimes an outcome. And a patient doesn't have to enter back at pre-contemplation stage after relapse. They could enter contemplation, preparation, or action, and most often will. But this is sort of the image you'll usually see when talking about stages of change. So this was a practical thing that I think could be integrated into primary care settings. This was the change plan worksheet that comes from the motivational enhancement therapy manual. And you can just see this is something that you could potentially hand to a patient and say, fill this out and let's talk about maybe just one of these things when you come back for your appointment. And then the context, understanding that they would be coming in for buprenorphine for opioid use disorder, but this may focus on there's, stimulant use that may persist if their opioid use is in remission or under better control. So the change plan worksheet, these are some of the questions that are asked. So the changes I want to make are, the most important reasons I want to make these changes, the steps I plan to take in changing, the ways other people can help me and enlisting the person and the possible ways that particular person might help, how they would know if their plan is working, and some things that could potentially interfere with that plan. So pretty practical. Again, I think that this doesn't have to be something done in a 15 or 30 minute appointment, but if they bring this back to you and you could highlight a specific item on here, something that stands out to you, in particular, the reasons why they want to make a change and what sort of things are going to be challenges or things that are going to support them in that process. And now moving on to cognitive behavioral therapy, which many people have probably heard of. It is based on the theory that perception of a situation is more closely related to emotions or behaviors in the situation itself. It's a very structured type of therapy. It's time limited, very goal oriented. It can be flexible depending on what the patient's circumstances are and how much they're progressing in therapy. And it is designed to be synergistic or can be synergistic with medications. So medication adherence itself can be a skill that you talk about in cognitive behavioral therapy. There is some possibility of a delayed or what's sometimes called a sleeper effect, where patients may not initially seem to benefit from CBT, but then after they've actually finished the CBT, they may see some improvements in their substance use. And this is in comparison to contingency management, where we see that CM is maybe better at initiating abstinence, so helping earlier on. The two critical components of CBT are functional analysis and skills training. So the functional analysis focuses on identifying thoughts, feelings, or circumstances surrounding substance use. And then the skills training focuses on unlearning maladaptive feelings or behaviors and learning or relearning healthier skills and habits. And this is what a nine session CBT therapy might look like. So you'd start off with talking about coping with craving, understanding it, describing it, how to really identify it, you know, what does it feel like in the body? What are the thoughts that come along with it? And then coping with it. The second session might be shoring up motivation and commitment to stop. So really clarifying goals, addressing any ambivalence and noting ambivalence and that it's normal. Refusal skills or assertiveness is talks about handling or assessing availability of substances and assertiveness refusal skills. So kind of how to say no. Seemingly irrelevant decisions, how to identify them and practice safe decision making. And what we're talking about here is things like, you know, passing by the bar or the drug dealers block and avoiding doing that. And avoiding doing that, that it may seem like an irrelevant decision or going into the bodega and to buy a pack of cigarettes where you know that they sell or the person may sell drugs or that you may encounter someone who sells drugs. That's what is meant by a seemingly irrelevant decision. Developing an all purpose coping plan, anticipating high risk situations and developing a plan around them and then problem solving skills. So developing them out, recognizing, identifying, brainstorming, selecting a skill and evaluating its effectiveness. And then a few other things that are included in CBT are case management, HIV risk reduction and potentially a significant other session. And you hear in this that there are similarities with motivational enhancement therapy. So a couple of example exercises, again, that I think could be implemented in primary care practices, patients that are taking buprenorphine for OUD. So first is a functional analysis and the second is a decisional balance exercise. And these are commonly used in CBT. So I'm going to demonstrate a functional analysis, what it would look like. So we want the patient, we give them this handout that has kind of a graph that they identify a trigger, thoughts and feelings associated with the trigger, the actual behavior, a positive consequence and a negative consequence of that behavior. And the patient can really start anywhere here. So typically in the first three columns, right? Trigger thoughts and feelings or behavior and then work their way in any direction. It doesn't have to be, they don't have to understand the trigger first. They might have the behavior of substance use, right? And then to think back what thoughts and feelings preceded that behavior and was there a trigger that led to those thoughts and feelings and then the behavior. And then once a patient has been able to identify these pretty well, you wanna add on this additional column of alternative thought or coping skill. And I'm gonna show you what this could look like for a patient. So let's say that, again, let's say that the patient doesn't really identify the thoughts and feelings initially but that they first have this behavior of bought enough cocaine for a Friday night. The thought and feeling that could come with that would be after work will be more fun with cocaine and the feeling might be excited. The trigger would be the bus stop on their way home from work where the dealer sits on Fridays. A positive consequence would be had a good time while high and drinking beer, but a negative consequence would be had a hangover the next day and not enough money to pay the electric bill. And again, once they have this part of the functional analysis pretty good, then you can add on this alternative thought or coping skill. So the alternative thought would be the next day I will feel better and the alternative or the coping skill would be to walk to the next bus stop. Again, another process that could be used with a short period of time. And again, you could hand the patient this kind of graph or chart and have them come back and talk through it with you for just a couple of minutes. It's called a decisional balance exercise. So there's this grid where you have changing and not changing on the top and benefits and costs on the side. And what that might look like. So benefits of changing would be saving money, having better blood pressure and making my children proud. The benefits of not changing could be keeping the same friends, having fun times, feeling young. And then cost of changing would be losing friends, having nothing to do, feeling old and boring. And cost of not changing would be spending money, high blood pressure and children will be ashamed. So when I say this out loud, you can hear that there are similarities. So the green, the text that's in green are reasons to change and the text that's in red are reasons to not change. And what you're trying to get out here is different ways to say kind of the same thing. So that this benefits and costs of changing or not changing is more clear to the patient. And as I mentioned, there is a specific manual for gay specific CBT for methamphetamine use disorder that I did want to mention because we're talking about stimulant use disorder treatment with the idea being that attention to issues specific to certain subpopulations may improve psychotherapy outcomes. So gay specific CBT has been evaluated. So it was developed and evaluated and shown to significantly reduce sexual behaviors compared to the standard CBT, but had comparable reductions in methamphetamine use. And I included here the sessions with some of the titles so you can see some of the differences. You can see there's a focus on safe space. There's more focus on sexual activities and what it might be like to have sex without using methamphetamine. And some other modules about coming out all over again, restructuring your identity. So some significant differences from the standard CBT modules. And then the next evidence-based approach that I will talk a little bit about is community reinforcement approach. This also like contingency management is based on operant conditioning. It has elements of CBT like the functional analysis and problem solving with additional focus on lifestyle change and relationships. The purpose of CRA community reinforcement is to really rearrange the lifestyle so that healthy drug-free living becomes rewarding and competes with alcohol or drug use. It encourages alternative social activities to enhance enjoyment with family and or one's job. And it has been shown to be most effective when it's combined with a voucher program as part of contingency management, but it does not have to include contingency management. This is what, if you look at the SAMHSA website, this is kind of what CRA looks like. So functional analysis of substance use, relationship counseling, vocational guidance and job skills training, therapy focused on building social and drug refusal skills and new recreational activities and social networks. So a bit broader, more kind of all-encompassing approach to thinking about treating substance use. And like I showed for CBT, if you look at a standard, this will be a 24 week treatment, but what I put in bold were just some of the differences compared to CBT. So this focus on employment counseling, social and relational counseling is different than in CBT. Some of the other elements are similar. We also see that there's some emphasis on sleep hygiene and relaxation training that may be a little bit different than standard CBT. So the lifestyle change components that are included in community reinforcement approach are time management, which focuses on planning, scheduling and prioritizing events or activities, social and recreational activities, re-engaging with old or start new non-drug related activities, problem solving, and this is the same process as in CBT, vocational satisfaction. So having a focus on gaining employment or improving one's current job satisfaction, social skills, so assertiveness and other interpersonal skills and focusing on meeting non-drug using peers. And then again, HIV or AIDS prevention as it is talked about in CBT. The relationship counseling element, which I understand certainly is probably gonna be less of a component for a primary care provider, but just to understand sort of what this would look like if a patient were going to a behavioral health provider, it evaluates relationship happiness. There's this kind of idea of a daily reminder to be nice to each other, understanding how they define a perfect relationship. So both the person who is the patient and their spouse or significant other, teaching how to make requests of one another, teaching other communication skills. And it can also include medication contracts. And I've included a sample here from the manual, which is a disulfiram contract. So this would be more likely for someone with alcohol use disorder who's prescribed disulfiram. And there's this kind of a mutual agreement between the significant others and what it would look like for the patient to take this medication and how their significant other could support them. And then 12-step facilitation. So first, just to note that 12-step programs, 12-step mutual support groups like, well, the more common are Alcoholics Anonymous and Narcotics Anonymous, although they do exist for most substances, including cocaine and crystal meth. So there is CA and CMA, so Cocaine Anonymous and Crystal Meth Anonymous. And these are not manualized. They're not standardized types of therapy. They're mutual support groups. And they're difficult to study because there are many of them. And again, there's not a manual for how each session should look. There is this spiritual aspect to 12-step programs, this idea of turning oneself or turning over to a higher power, and a pretty strong emphasis on abstinence, not harm reduction and not moderation. But 12-step facilitation is manualized and has been studied and evaluated in research studies. And it focuses more on providing tools to the patient. It emphasizes connecting with a peer who's also in recovery, having a sponsor and to attending meetings. In each session of 12-step facilitation, you would review the 12-step journal that you provide a patient, talk about any slips they would have had and encourage sober days. And you can review steps one through five in succession and you elicit patient reactions. These are some of the processes of 12-step facilitation. And they did include a link here where you can actually see the list of the 12 steps. I do think this can be helpful for providers who are treating patients with addictions, sort of understand where they are in the process, kind of what they're going through and what they're hearing about in meetings. And then the last modality that I'm going to talk about is medical management. And medical management was designed for an alcohol use disorder clinical trial. And these are sessions that really focus on enhancing medication adherence and abstinence. And the idea, the reason it was really designed was to be adaptable to primary care settings. So you have in medical management an initial session and follow-up sessions. So at the initial session, you review and take results. This can include lab results, EKG, any other types of testing that are done in an evaluation appointment. Present them with a diagnosis. So in the case of a substance use disorder, a cocaine use disorder, a methamphetamine use disorder, set treatment goals around that diagnosis, provide medication information if you're prescribing a medication for it, develop medication adherence plan, discuss mutual support groups and encourage their attendance at 12-step or for SMART Recovery, which is another type of mutual support that's different than 12-step. Summarize all of the things that you talked about and then addressing any of their specific concerns. So that's gonna be that initial session, which may be a bit longer and could be in the evaluation appointment, although most likely you'd be ordering labs or having other testing done and you might have them come back to review these things. In the follow-up sessions, you assess their medical status and medication safety. Again, if you're prescribing for that particular substance use disorder, assess their medication adherence, assess substance use and troubleshoot and make recommendations. And the troubleshooting can be around their substance use, abstinence or reduction, as well as medication adherence issues. Medical management could be adapted for other substances. Again, it was designed for alcohol use disorder, though some of the personalized feedback like an AST or ALT may be less applicable for stimulant use disorder. And there's no FDA approved medication. So you might be talking about say, to peer mate for treating cocaine use disorder. And there may be some differences here in terms of what would be included. What I showed here on the screen is a medical management checklist for follow-up appointments and it's really just kind of a structured interview that walks through just kind of an opening, open-ended question, some of the personalized feedback that you might be able to provide to patients like vitals or labs, and then asking about their status with substance use, alcohol or drug use, and their medication adherence. This is frequently used in substance use disorder or medication clinical trials. So often when researchers are studying medications for cocaine use disorder, methamphetamine use disorder, the patient may be having this very similar conversation with the research clinician. And some other modalities that I wanna make sure to mention, again, mostly because you may be referring patients to behavioral treatment, and they may tell you that they're receiving this type of treatment, or you may be interested in referring a patient to a particular type of provider who would provide a specific type of treatment based off of your knowledge of the patient's kind of interests and their past experiences in therapy. So the first I wanted to mention is mindfulness-based relapse prevention. This is a little bit more broadly, mindfulness-based interventions, but mindfulness-based relapse prevention is probably one of the newer manualized psychotherapies for substance use disorders. The goal is to increase awareness of triggers, destructive habitual patterns, and automatic reactions, and to learn ways to create pause, change relationship with discomfort, respond more skillfully, and increase self-compassion. And another type of psychotherapy that's been around for quite a bit longer is individual drug counseling. In this type of therapy, the provider would be monitoring drug use behavior, craving, encouraging abstinence, encouraging 12-step participation, talking about relapse prevention and providing a lot of education. In network therapy, this focuses on involvement of the significant other in sessions with the aim of improving communication between the patient and the significant other, diffusing conflict between them, and praising drug avoidance skills. The significant other also acts as a monitor. So to provide information to the therapist, and this can be for medication. So if we're talking about disulfiram, for alcohol use disorder, or to Pyramate if it's being used off-label for cocaine use disorder. And then last, I just want to mention the MATRIX model. It really combines lots of different types of therapies. So it combines relapse prevention, self-help, family and group therapy, and psychoeducation. And a patient is most likely to encounter this type of therapy in an intensive outpatient or residential setting. And it has been evaluated and shown to be effective for stimulant use disorders. So in summary, behavioral treatments are moderately effective for treating stimulant use disorders, but dropout rates are high. In clinical trials, manualized therapies are generally administered by highly trained psychotherapists. However, elements of these treatments like functional analysis, decisional balance, lifestyle change, and 12-step encouragement may still be beneficial in primary care settings, particularly for patients without access to behavioral treatment. And then lastly, medical management was very specifically designed for primary care and integrates practices from other modalities with sort of less intensity and less necessity for additional more advanced training. All right, and that is the end of topic three. And we will follow up with our final discussion on pharmacologic treatment approaches for stimulant use disorders.

Behavioral Treatment Approaches

Derek Blevins

MD

Columbia University

behavioral treatments

evidence-based therapies

stimulant use disorder