Transcript CBT with Women Substance Users or Not all gender differences are

THE BRAVE NEW WORLD OF
COMPUTERIZED INTERVENTIONS
FOR ADDICTION
[email protected]
PSYCHOTHERAPY DEVELOPMENT CENTER WEBSITE: PDC.YALE.EDU
NIDA R3715969, K05-DA00457, U10 - 015831
& P50 DA09241
DISCLOSURE: DR. CARROLL IS A MEMBER IN TRUST OF CBT4CBT LLC
OVERVIEW
1.
2.
Development and of computerized CBT
How could web-based interventions improve how we
treat addiction?
• Dissemination and accessibility
• Tailored treatments
THE NIH STAGE MODEL, 2014
ONKEN, CARROLL, SHOHAM, CUTHBERT & RIDDLE;
PSYCHOLOGICAL SCIENCE, 2, 22-24.
COGNITIVE-BEHAVIORAL THERAPY
CBT
• Based on functional analysis of substance use
• Emphasis on learning/implementation of coping
skills
• Functional analysis and patterns of use
• Coping with craving
• Addressing ambivalence and coping with thoughts
• Refusal skills
• Seemingly irrelevant decisions
• Problem solving skills
CARROLL ET AL (1994) Arch Gen Psychiatry,
121 cocaine users, 1 year follow-up
0.7
Clinical
mgmnt.
ASI Composite Scores
0.6
CBT
0.5
0.4
0.3
0.2
Delayed emergence
Of effects
0.1
0
Pretreatment Point (0)
End
2
4
6
Months After Treatment
8
10
12
HOW SUCCESSFUL HAVE WE BEEN IN
MOVING EVIDENCE BASED THERAPIES
INTO CLINICAL PRACTICE?
• Programs, clinicians report high levels of use of
empirically supported approaches, including CBT
• Increased pressure to do so by payors
• NO actual data from session tapes
….till now…
ANALYSIS OF 379 TAPES OF “STANDARD TREATMENT”
WHAT INTERVENTIONS NEVER OCCURRED IN TAU?
Emphasize abstinence
Spirituality
Cognition
Ambivalence
% rated
NEVER
Risk reduction training
Skills training
0 10 20 30 40 50 60 70 80 90 10
0
Percent of sessions where adherence score =1
FREQUENCY OF ‘CHAT’ BY TREATMENT
CONDITION: CTN MET VS TAU
4
3.5
3
2.5
MET
TAU
2
1.5
1
0.5
0
Session 1
Session 2
Session 3
STAGE III LEADS BACK TO STAGE I:
DISSEMINATION BACK TO
DEVELOPMENT
Manualized
Treatment
(CBT)
Delivered
through
clinician
Low ‘dose’ of CBT
WHY COMPUTER FACILITATED DELIVERY
OF EVIDENCED BASED TREATMENTS?
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**Effective implementation of CBT very rare in clinical practice
Only a small fraction of people with addiction-related problems
access treatment
• Save clinicians time, use as clinician extenders
• Broadly accessible, available 24/7
• Facilitated delivery via multimedia presentation
• Standardization, quality control
• Individualization, repetition, flexibility
• Facilitation of systematic evaluation of components (moderators
& mechanisms of action)
CORE PRINCIPLES:
CBT4CBT DEVELOPMENT
• Highly engaging-capture attention of substance users, retain
them in treatment
• Deliver potent dose of evidence based cognitive and
behavioral strategies-focus on key generalizable skills
• Durability of effects-skills practice
• Modeling-demonstration of skills in realistic situations under
stress
• Breadth of users-all drugs, balance of gender and ethnicity
• Security- NO identifying information or protected
informantion
‘CBT 4 CBT’
COMPUTER BASED TRAINING FOR CBT
•
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•
•
•
•
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7 modules, ~1 hour each, high flexibility
Highly user friendly, no text to read, linear navigation
Based on NIDA CBT manual
Multiple strategies for presenting skills
Video examples of characters struggling real life situations
Repeat movie with character using skills to change ‘ending’
Interactive exercises, quizzes
Multiple examples of ‘homework’
OVERVIEW: FIRST RANDOMIZED
CLINICAL TRIAL
• 8 week randomized clinical trial
• Outpatient community treatment program
• Standard treatment (weekly individual + group
therapy) (TAU) vs. CBT4CBT + TAU
• CBT4CBT offered in up to 2 weekly sessions
• 6 month follow-up
Carroll et al., Am J Psychiatry, 2008
PARTICIPANTS, FIRST TRIAL,
N=77
“All comers”: few restriction on participation, only
require some drug use in past 30 days
• 43% female
• 45% African American, 12% Hispanic
• 23% employed
• 37% on probation/parole
• 59% primary cocaine problem, 18% alcohol, 16%
opioids, 7% marijuana
• 79% users of more than one drug or alcohol
PRIMARY OUTCOME (% DRUGPOSITIVE URINE TOXICOLOGY
SCREENS), 8 WEEKS
80
70
53
60
50
40
34
CBT4CBT + TAU
TAU
30
20
10
0
% drug positive urines
Carroll et al., 2008, Am J Psychiatry
PRIMARY OUTCOME: LONGEST
CONSECUTIVE ABSTINENCE, IN
DAYS, AT 8 WEEKS BY TREATMENT
30
22
20
15
CBT4CBT + TAU
TAU
10
0
Longest continuous abstinence
Carroll et al., 2008, Am J Psychiatry
SKILL LEVEL THOUGH 6 MONTH FOLLOW-UP:
QUALITY OF BEST RESPONSE BY CONDITION
6
5
CBT4CBT
TAU
4
3
Baseline
End of tx-8 wks
Follow-up 20
weeks
Kiluk et al, Addiction, 2010
DURABILITY OF EFFECTS:
6 MONTH FOLLOW-UP
Estimated Days of Any Drug Use from Treatment
Endpoint to Follow- Up Month 6
8
7
6
5
4
3
2
1
0
0
1
4
3
2
CBT
5
6
TAU
Carroll et al., 2009, Drug & Alcohol Depend
QUALITY OF COPING SKILLS AS MEDIATOR
OF OUTCOME IN CBT4CBT
Coping Skills
(2) b=.3*
(3) b=8.3**
% positive urine
CBT v TAU
(1) b=5.2*
(4) b=3.3
Kiluk et al, Addiction, 2010
COST EFFECTIVENESS: COMPARISON ACROSS
TREATMENTS AND STUDIES, OLMSTEAD ET AL., DAD,
2010
(OUTCOME=LONGEST DAYS ABSTINENCE (LDA) INCREMENTAL COST
EFFECTIVENESS RATIOS (ICERS)
Treatment
Base Case
($)
Favorable
Scenario
($)
CBT4CBT
50
-31
MET/CBTa
102
77
Prize CM – MMb
141
115
Prize CM – DFc
258
163
aMET/CBT
= motivational enhancement therapy + clinician-delivered CBT
bPrize CM – MM = prize-based contingency management in methadone clinics
cPrize CM – DF = prize-based contingency management in drug free clinics
OVERVIEW: SECOND
RANDOMIZED TRIAL
• 101 DSM-IV cocaine-dependent methadone maintained opioid
users population
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Standard methadone maintenance (TAU) vs. CBT4CBT + TAU
CBT4CBT offered in up to 2 weekly sessions,
6 month follow-up
Sample: 60% female, 40% minority, 89% unemployed, higher
levels psychiatric comorbidity (29% depressive disorder, 30%
anxiety disorder), multiple other substance use
Carroll et al., Am J Psych. 2014
PRIMARY POST TREATMENT
OUTCOMES: COCAINE-MMP SAMPLE
Carroll et al., AJP, 2014
STATUS: CBT4CBT
• Completed:
2 RCTs indicating efficacy and durability of CBT4CBT
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No treatment related adverse effects
Variety of populations: Outpatient, methadone maintenance, and VA
Demonstration of skill acquisition, cost effectiveness and durability
• Ongoing:
• P50 Center: Enhance CBT4CBT outcome with galantamine
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(placebo controlled RCT), fMRI, neurocog, genetics
Evaluation of HIV module on drug/sex risk reduction
Man versus Machine: CBT4CBT versus traditional therapist
delivery
Neural mechanisms of the Sleeper Effect
Validation of alcohol-only version
Randomized trial of Spanish version
DEMO: CBT4CBT.com
INNOVATORS/EARLY ADOPTERS, JUNE
2014-PRESENT
• Clinical: Mass General Hospital; IOP
• Clinical: Mercy Hospital, Springfield Mo
• Pilot; Montana Drug Courts
• RCT pilot, Zuni of New Mexico
• RCT pilot, UCLA primary care practice
• RCT, Prince Edward Island
• RCT (pending), Columbia U HIV clinics
POTENTIAL APPLICATIONS OF COMPUTERASSISTED THERAPIES
• ‘Clinician extenders’
• Extending treatment benefits/ links to aftercare
• ‘Extending clinician expertise (e.g., dual diagnoses)
• Address overlooked issues (smoking)
• Linking systems of care (SBIRT)
• Behavioral platforms for pharmacotherapies
• Reaching rural opioid users (tele-buprenorphine)
• Homework apps for coaching
• Early intervention/prevention for mild cases
• TARGETING FUNDAMENTAL PROCESSES
NEW DIRECTIONS-PDC YEARS 21-26
“NEUROPLASTICITY REPRESENTS A PLAUSIBLE BIOLOGICAL MECHANISM
THROUGH WHICH PSYCHOLOGICAL INTERVENTIONS MAY EXERT SOME OF THEIR
THERAPEUTIC EFFECTS”
• Project 1: Kiluk/Carroll;
Does cognitive control training
prior to CBT enhance learning & outcome?
Preparation
(4 week)
Neurocog
+
fMRI
Neurocog
1. TAU
2. CM/abstinence
3. CM+cognitive
control training
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+
fMRI
Treatment
(8weeks)
CBT4CBT
Neurocog
+ fMRI+
6 month
follow-up
Changes in brain activity via fMRI:
Comparison of Post- to Pretreatment, CBT4CBT versus TAU
Stroop related activity dlPFC decreases from pre- to postCBT4CBT but not TAU
CBT Stroop Post > Pre
pFWE=.05
TAU Stroop Post > Pre
X-=21
CATEHOL-O-METHYLTRANSFERASE GENE
VAL158MET POLYMORPHISM (COMT) &
TREATMENT OUTCOME
N=82/101
EMOTIONAL (COCAINE) STROOP BY
TREATMENT CONDITION (N=101)
PROJECT 3: HEDY KOBER
CRAVING TASK  TREATMENT
Assessment only
Neurocog
+
fMRI
Regulation of
craving
Training-cognitive
3x/week
4 weeks
Regulation of
craving training
-mindfulness
3x/week
4 weeks
Neurocog
fMRI
1 month follow -up
RECONNECTING CBT WITH COGNITIVE
SCIENCE:
CBT=COGNITIVE CONTROL TRAINING
Concept
Target/Assesment
example
Intervention concept
Regulation of craving
Distress tolerance, ROC
ROC training
Attentional bias
IAT
Attentional bias training
Poor decision making
Impulsive
responding/BART/EDT
Delay discounting
Problem solving
CANTAB, PFC tasks
Problem solving, executive
function
Functional analysis
Self-monitoring
Working memory,
Cognitions
Cognitive/affective
awareness
PASAT
THANKS.
• Co-Investigators Luis Anez, Sam Ball, Dianne Duffey, Brian
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Kiluk, Donna LaPaglia, Steve Martino, Katie Nuro, Todd
Olmstead, Manny Paris, Nancy Petry, Julia Shi, Michelle
Silva, Caroline, Mehmet Sofuoglu, Dawn Sugarman, Kelly
Serafini, & Bruce Rounsaville
Team: Melissa Gordon, Theresa Babuscio, Matt Buck,
Donna Cofrancesco, Joanne Corvino, Karina Danvers, Kay
Debski, Kathleen Devore, Liz Doohan, Dorothy Eagan, Tami
Frankforter, Karen Hunkele, Dave Iamkis, Dan Marino, Cindy
Morgan, Charla Nich, Galina Portnoy, Liz Vollono,
fMRI component: Marc Potenza, Hedy Kober, Elise Devito,
Patrick Worhunsky, Iris Balodis, Jiansong Xu, Jud Brewer,
Sara Yip, Cameron DeLeone, Maggie Mae Mell, Todd
Constable
Yale Media: Rick Leone, Craig Tomlin, Thom Stylinski &
Lucas Swineford
Clinical performance sites: RNP: John Hamilton, Tina Klem,
Joanne Montgomery, APT: Lynn Madden, Nicole Belisle, Amanda
Shackle, CMHC: Bob Cole, Luis Anez, Donna LaPaglia