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e Based Practice in the Treatment of Addiction Treatment of Addiction.
History of Addiction Treatment • Incarceration
What We Learned These didn’t work Needed to change from a “moral model” Emergence of the Disease Model Advances in understanding of neurochemistry’s role in addiction • Drug Court Model • Evidence Based Practices
Evidence-based practices (EBPs) refer to interventions that have been rigorously tested,
Treatment plans must be assessed and modified continually to meet changing needs 5.
Counseling and other behavioral therapies are critical components of effective treatment 7.
Medical detox is only the first stage of treatment 10.
Treatment does not need to be voluntary to be effective
Treatment programs should assess for HIV/AIDS,
Hepatitis B & C,
Brief intervention Social skills training Motivational enhancement Community reinforcement Behavioral contracting Miller et al.,
Hester & W.
Cognitive–behavioral interventions Community reinforcement Motivational enhancement therapy 12-step facilitation Contingency management Pharmacological therapies Systems treatment
What Does All This Mean
? • We have an opportunity to improve treatment services.
• There are effective and cost-efficient treatments available for alcohol and drug dependence.
Moral Reconation Therapy (MRT) 2.
Living in Balance 3.
Recovery Training & Self Help 5.
Brief Strategic Family Therapy (BSFT) Family Behavior Therapy (FBT) Moral Reconation Therapy (MRT) Multidimensional Family Therapy (MDFT) Family Support Network Multi-Systemic Therapy (MST) for Juvenile offenders Adolescent Community Reinforcement Approach (A-CRA)
Generic Counseling AOD Education Confrontational Interventions Psychodynamic Therapy Solution-focused Therapy Mindfulness-based Stress Reduction 7.
Effective Treatment for Offenders 1.
Cognitive Behavioral Therapy: Moral Reconation Therapy 4.
Relapse Prevention: Relapse Prevention Therapy (RPT) 5.
The Best way to choose an EBP
Based on valid theory of change
Reviewed and approved by experts
Manualized Treatment Protocols
Best Things About Manualized Treatment Protocols • Counselors and Clients like the structure and consistency • Easy to use • They help focus a session
A Free Resource for Treatment Manuals
SAMHSA’s National Clearinghouse for Alcohol and Drug Information (NCADI):
Limitations With Using Treatment Manuals • •
Cognitive Behavioral Interventions
A 1991 RCT comparing urban severe cocaine abusers receiving CBT versus those receiving interpersonal therapy found that those receiving CBT were more likely to: complete treatment sustain abstinence during treatment sustain abstinence immediately after treatment continue gains at 1 year follow-up
Moral Reconation Therapy (MRT®).
! I want to see you in my office first thing tomorrow
Do program participants have relapse prevention plans completed before leaving the first phase of treatment
The Facts and Figures
A 2008 meta-analysis of five relapse prevention effectiveness studies found RP was 2nd most effective intervention (behind CBT combined with contingency management)
Understand relapse as a process Identify and cope effectively with high-risk situations such as negative emotional states,
and social pressure Cope with urges and craving Implement damage control procedures during a lapse to minimize negative consequences Stay engaged in treatment even after a relapse Learn how to create a more balanced lifestyle
? • Insight – What to change
? • Skills – How to change
motivation waxes and wanes • Increasing motivation helps prevent relapse • Drug Courts provide external (incentives & sanctions) motivators • Participants will hopefully become internally motivated (it’s the right thing to do,
I feel good when I’m clean,
• Participants do not automatically know what to do to stay sober and why.
• Helping them understand behavioral patterns.
• Getting them to think outside of their “box”
I’ve never done one of these before.
But I did talk about it in group… and I stayed at a Holiday Inn Express
• Knowing what to do doesn’t mean you’ll do it (right) when it counts.
• Keys to skill building: – Practice,
practice – Reward the behavior you are trying to encourage
Treatment must address
People are Complex Multiple treatment interventions capable of addressing each of these domains will be required for effective outcomes.
“Treatment should be tailored to the needs of the individual and guided by an individualized treatment plan that is developed in consultation with the patient” American Society of Addiction Medicine’s Patient Placement Criteria
? For the BEST OUTCOMES Provide a Puzzle of Evidence Based Approaches
Community Reinforcement Case Management
Motivational approaches • Motivational approaches focus on engaging substance users in considering,
initiating and continuing substance abuse treatment while stopping their use of alcohol and other drugs.
• “Being where the client is” – what they are motivated by.
• Motivational approaches involve combining “motivational interviewing” with a stages-ofchange model.
pre-contemplation regarding change,
Cognitive Behavioral Therapy (CBT) approaches • A research review of meta-analyses found that cognitive behavioral approaches consistently appear to be among the most effective treatment therapy for substance abusers (Taxman,
• CBT approaches suggest that unless offenders’ faulty thinking is addressed,
there is a reduced likelihood of long-term change.
• The three main cognitive models now utilized by criminal justice agencies are Reasoning and Rehabilitation (R&R),
Thinking for a Change and Moral Reconation Therapy (MRT®).
Community Reinforcement Approach plus Vouchers • Uses the community to reward non-using behavior so that the client makes healthy lifestyle changes • High levels of satisfaction in drug and alcohol free lifestyles are needed to compete with the reinforcement derived from substance use and the substance-using lifestyle • The CRA approach is analogous to helping a child conclude—through experience,
not talking—that it’s more satisfying to be good than to be naughty.
Rewarding the Behavior
Clinical Case Management Goals – Help ensure that the important needs of the participants are being responded to,
and that they maintain contact with the various providers.
Case management of other ancillary & ongoing services • • • • • • •
Wellness practices Acupuncture Nutrition Stress management Smoking cessation Health/Dental Care 12-Step,
– prevent drugs from working,
Pharmacological Approaches Methadone – Opiate addiction – reduces craving,
helps restore normal functioning Buprenorphine – similar to methadone,
may be prescribed by an MD with special training) Acamprosate – reduction of alcohol cravings Antabuse – produces adverse reaction with alcohol use
changes alcohol action for some – reduction in relapse Neurontin – helps with insomnia in early recovery Clonidine – reduction of withdrawal symptoms – possible reduction in cravings Baclofen – possible reduction in cocaine cravings
plus transfer to MMT post release Assessed at intake and at 1,
drug test for opiates and cocaine,
self report of criminal activity and employment Those in MMT remained in treatment significantly longer than others.
Those who began MMT in prison had the lowest positive rates.