Transcript Evidence-Based Practice: Psychosocial Interventions

Evidence-Based Practice:
Psychosocial Interventions
Maxine Stitzer, Ph.D.
Johns Hopkins Univ SOM
NIDA Blending Conference
June 3, 2008
Cincinnati, Ohio
Talk Outline
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What is an evidence-based practice?
What practices are evidence-based?
Why should these be used?
How to decide which one(s) to use?
What Is An Evidence-Based
Practice?
• Developed by researchers
• Subjected to controlled evaluation
• Shown efficacious in 2 or more trials
Compared to Usual Care
Practices
• Therapy specified in a detailed manual
• Therapists trained to proficiency
• Therapists monitored for adherence
– presence of specified and absence of nonspecified elements
• Clients meet inclusion and exclusion criteria
– may be less complicated cases
• Detailed data collected on outcomes
Efficacy research shows that
practices can work under ideal
conditions
Do Evidence-Based Practices
Work in Real World Settings?
• Research conducted by NIDA CTN has
verified effectiveness of some evidencebased practices
– Motivational Interviewing
– Contingency Management
• Others are yet to be tested
– 12-step Facilitation
– Cognitive-Behavioral Therapy
What Psychosocial Therapies
are Evidence-based?
• Motivational Interviewing (MI/MET)
• Contingency Management (CM)
• Cognitive-behavioral therapy (CBT)
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MI/MET: What Is It
• Style of therapist-client interaction
• Utilizes basic counseling skills for rapport
– Reflective listening, open-ended questions,
avoid arguments and lectures
• Provide feedback and develop discrepancies
to motivate “change talk” and hopefully,
behavior change
MI/MET Techniques
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O
A
R
S
open ended questions
affirmation
reflective listening
summary statements
MI/MET: Evidence For Efficacy
• Improved compliance in medical patients
• Reduced drinking in alcoholics
• Drug users contacted in a medical setting
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
MI in Drug Treatment Settings
• Evidence mixed
– Some studies find benefits
– Others find no benefits
CTN MI Study Methods
• 418 patients randomized at 5 sites
• 375 were exposed to protocol
• Counselors trained in MI conducted intake
session as a MI “sandwich”
– Client-centered discussion with reflection,
open-ended questions, etc before & after intake
questionnaires
Patients assigned to MI completed more sessions
than those in standard treatment
Number of
sessions/ 28 6
days
5
5.02
4.03
4
3
MI
Standard treatment
2
1
0
Treatment condition
More MI patients were retained
at 1-month
100.00
84
74
MI
Standard
0.00
Treatment condition
No differences in retention at
the 84-day follow-up
Percent
retained at
100
CTP
MI
Standard
0
Treatment
No differences in drug use
during first 28 days
Days of
primary drug 7
use/28 days
6
5
4
MI
Standard
3
2
1
0
Treatment condition
Alcohol users (n=172)
were the ones who benefited
Averge 6
number of
sessions/
first 28 days 5
4
MI
Standard
3
2
1
0
Treatment condition
If a little MI is good (improved
attendance and retention)
would more be better?
Second CTN MI study delivered
3 sessions of MI-style therapy vs
3 sessions of individual TAU
MET Study Outcomes
MET
TAU
Significance
Days Enrolled
72
69
ns
Retained 4 mos (%)
41
46
ns
Positive UA
(% in 28 days)
21
28
ns
MET: Effectiveness in Alcoholics
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
MI Overview
• Excellent foundation for counseling skills
• Builds client internal motivation for change
• Evidence-based practice with good data
supporting use with alcoholics
• Jury still out on effectiveness with drug users
especially in treatment settings
CBT: What Is It
• Structured skills training lessons
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Manage cravings
Avoid triggers
Drug refusal
Coping/problem solving
• Lectures, practice, homework
• Manualized
– NIDA Therapy Manual for Drug Addiction #1
CBT Efficacy Evaluation
• Many studies have demonstrated efficacy
• Some show during treatment effects
• Some show benefits only after treatment
ends (“sleeper” effects)
IOP Treatment: CBT vs 12-Step
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
Maude Griffin et al., 1998
CBT vs Clinical Management: 1x per week
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
Carroll et al., 1994
CBT Overview
• Provides structured content for DA therapy
• Potential for building highly useful skills
– Coping, problem solving, drug avoidance, etc
• Potential limitations
– Do clients learn what is taught?
– Do clients put learning into practice?
Contingency Management
Motivational Incentives:
What Is It
• Provides tangible positive reinforcement for
specified behavior
– Behavior can be attendance, drug abstinence,
goal achievement
– Reinforcers can be cash-value vouchers or prizes
$10
Voucher Point System
Increasing magnitude, bonus, up to $1000
$2.50
$3.75
$5.00 +$10
$6.25
$7.50
$8.75 + $10
$10.00
$11.25
$12.50 + $10
$13.75
$15.00
$16.25 + $10
Advantages: demonstrated efficacy, accommodate personal
preferences, less likely to exchange for drugs
Disadvantages: cost, staffing for management, delay to receipt of
some items, worth less than cash?
Voucher Incentives in Outpatient
Drug-free Treatment
Higgins et al. Am. J. Psychiatry, 1993
Cocaine negative urines
Intermittent schedule/prize system
 Draws from a fishbowl
 Advantages: can be less expensive than vouchers; cost can be controlled
by varying size and cost of prizes and percentage of winning chips
Retention:
Alcoholics in Outpatient Psychosocial Treatment
STD
CM
120
% Retained
100
80
60
40
20
0
2
4
6
8
weeks
Petry et al., 2000
Time to first heavy drinking episode
STD
CM
% Not Relapsed
100
80
60
p<.05
40
20
0
2
4
6
8
Weeks
Petry et al., 2000
CTN MIEDAR Study
• Stimulant abusers randomly assigned to usual care with or
without abstinence incentives
– 415 psychosocial counseling
– 388 methadone maintained
• Drug-free urines earn draws from an abstinence bowl during a
3-month study
• Negative for cocaine, methamphet and alcohol ---> escalating
draws
• Also negative for opiates, THC ---> bonus draws
Total Earnings
• $400 in prizes could be earned on average
– If participant tested negative for all targeted
drugs over 12 consecutive weeks
Incentives Improve Retention in Counseling Treatment
100
Incentive
Control
Percentage Retained
80
60
50%
40
35%
20
0
RH = 1.6 CI=1.2,2.0
2
4
6
8
Study Week
10
12
Percent of Submitted Samples Testing Stimulant
and Alcohol Negative
Percentage negative samples
100
80
60
40
Abstinence Incentive
Usual Care
20
0
1
3
5
7
9
11
13
15
Study Visit
17
19
21
23
Abstinence Incentives in
Psychosocial Counseling Tx
• Incentives lengthened duration of drug-free treatment
participation
– Presumably improving long-term outcomes
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• May be useful for all clients as relapse prevention
– Suggests clinic-wide implementation
• Attendance incentive may achieve same goal
– If clients remain abstinent during treatment
Combination of treatments may
be best for long-term recovery
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
Why Should Evidence-Based
Practices Be Used?
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Enhance counseling skills and proficiency
Engage in culture of CQI
Improve treatment outcomes
Satisfy accreditation boards; federal and
insurance payers
Which Evidence-Based Practices
Should Be Used?
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Selected by needs of the clinic?
Selected by needs of the clients?
Selected by research effect sizes?
All used in some logical adoption sequence?
Sequential Adoption Plan
• Motivational Interviewing
• Contingency Management
• Cognitive-Behavior Therapy
Needs of Clinic and Clients
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Improve early engagement (MI/MET)
Improve retention (CM)
Stop on-going drug use (CM)
Prevent relapse (CM/CBT)
Build alternative non-drug reinforcers (CBT)
Evidence-Based Practices
Summary
• Shown efficacious in clinical trials and
effective in real world settings
• Adoption improves care quality and
outcomes
• Three recommended are MI, CM and CBT
• Sequential adoption and combined use may
be optimal strategy
Benefits of EBP Adoption
• Counselors will like it
– New counseling skills (MI), structured content
(CBT) and behavior change tools (CM)
• Clients will like it
– Therapy may be more engaging and useful
• Funders will like it
– Pathway to better outcomes