Transcript Kathleen M Carroll Professor of Psychiatry Yale University School of

What is the evidence for time limiting
addiction treatment?

Survey of treatment literature on
time limited treatment
 Few true randomized trials. .
Different conclusions based on
patient group (severity,
comorbidy problems, type of
substance)
 Implications for rebuilding a
treatment system







1271 index admissions to publicly funded clinics
(cocaine 64%, alcohol 44%, opioids 41%, marijuana
14%; 59% female, 87% AA)
3 year follow up (98% of those living, 35 died )
47% attain 12 months of abstinence
Mean time from first use to first treatment= 9 years
Median time from first to last use = 27 years.
Longer treatment career for males, those with earlier
first use (esp <15), multiple treatment episodes, and
mental distress.
Likely intensity/
Duration
of treatment
Duration of treatment
Should be proportional
to severity, chronicity
Of use and related problems
Intensity of
behavior
Level of
problems

Response generally happens early

More of a bad thing is rarely better.

More of a good thing is probably better

Its probably better to think about time to the
targeted outcome (abstinence)



If the good thing is an effective empirically
validated therapy.
Brief therapies effective first line for lower
severity individuals—Good evidence for
alcohol
Few well-done trials where a well-defined
cohort is randomized to different lengths of
an empirically validated therapy
%
of
Da
ys
Sm
oke
d
per
We
ek
1
Delayed Treatment
Brief Treatment
Extended Treatment
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
BL
4-mo
9-mo
15-mo
118 methamphetamine users, 4 month treatment


653 treatment seeking individuals dependent
on prescription opioids
Adaptive treatment model:
 Phase 1: 2 week buprenorphine/naloxone
stabilization + 2 week taper, 8 week follow up
 Successful patients (no opioid use at end of
tratment) complete
 Unsuccessful patients enter Phase II.
▪ 12 weeks bup/nal, 4 week taper, 8 week follow-up
653
randomized
5% successful
phase 1
50%
successful
Phase 2
9% successful at final week follow-up



Buprenorphine, naltrexone, methadone etc.
tend to be effective only while the individual
is taking it
Medications are opportunities to provide
treatment and services to support sustained
change
Stepwise discontinuation with
frequent monitoring.



CM very effective while contingencies in place
Dropoff after contingencies stop
But…..those who attain longer periods of abstinence
better outcomes in follow-up
Petry proposal-After care model, VI schedule of
reinforcement up to 6 months. If missing or positive,
frequency increases
 Likely to be less expensive and more acceptable to
patients than standard aftercare









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’







Highly engaging-capture attention of substance
users, retain them in treatment
Deliver potent dose of evidence based cognitive and
behavioral strategiesFocus 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 PHI
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
“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
Carroll et al., 2008, Am J Psychiatry
Carroll et al., 2008, Am J Psychiatry
6
5
CBT4CBT
TAU
4
3
Baseline
End of tx-8 wks
Follow-up 20
weeks
Kiluk et al, Addiction, 2010
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
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
2
3
CBT
4
5
6
TAU
Carroll et al., 2009, DAD





101 DSM-IV cocaine-dependent methadone
maintained opioid users population
Standard treatment (weekly group therapy)
(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., under review
Carroll et al., under review
Figure 2: STROOP task:
Comparison of Post- to Pretreatment, CBT4CBT versus TAU
Stroop activity decreases from pre- to postCBT4CBT but not TAU
CBT Stroop Post > Pre
pFWE=.05
TAU Stroop Post > Pre
X-=21

Self help for less severe cases/treatment entry
-Use until abstinent or treatment indicated


Medication platforms (office based buprenorphine)
Use until stabilized

Outpatient care
Endpoint-abstinence, demonstration of skills





SBIRT: Referral for treatment without
following through
Office based buprenorphine without assertive
care
Multiple admissions for the same ineffective
treatment (detoxification only)
Persisting in a treatment to which the patient
has not responded.
Discharging patients for being symptomatic
Assess
-Severity
- Comorbid problems
- Resources
Treat to criterion
Objective, clinically
meaningful outcome
Decrease
intensity
Taper
Support
monitor
Re-assess
Predetermined time
Clear feedback on criterion
Evaluation of mechanism
Increase intensity
Add medication
Add CM
Add support