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David Deitch, PhD, UCSD, ATTC 1

Notes:

UCSD ATTC

Treatment Models


The Treatment of IllicitDrug Taking

David A. Deitch, Ph.D.University of California San Diego

Clinical Professor of Psychiatry andDirector, Addiction Training Center

Alcohol Vs. Illicit Drugs and the History of Response Models developed to heroin Other general models Criteria Outcome data to major models Crime and drugs Using prisons Data on prison therapeutic community treatment Characteristics of therapeutic communities Pathways into addiction Personality disorders considerations

2David Deitch, PhD, UCSD, ATTC

David Deitch, PhD, UCSD, ATTC 31900 1920’s -30’s

A Policy Time LineA Policy Time Line1996

Development of the CriminalJustice Model

1986 & 1988

The War OnDrugs

1961 - Civil Addict Program1966 - NARA Act

1972 - Establishment of NIAA,NIDA and TASC

Development of Treatmentfrom a Social Perspective

Founding of AA, end of WWILexington& Fortworth

Harrison Narcotic Act( March 1, 1915)

Anti-Drug Abuse Act

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Notes:

UCSD ATTC

Treatment Models


Treatment of Heroin Addiction:Modalities/Philosophies

SELF-REGULATING COMMUNITY ( CHARACTER RESTRUCTURING)

PSYCHOTHERAPEUTIC ( SELF-MEDICATION; EGO DEFECT)

OPIOD MAINTENANCE ( SPECIFIC DEFECT CORRECTION)

NARCOTIC ANTAGONIST ( CONDITIONING; LEARNING)

MEDICAL DISTRIBUTION ( HARM REDUCTION)

SUPERVISORY-DETERRENT ( EUPHORIA-TEMPTATION)

FAITH AND DEDICATION ( SPIRITUAL VOID)

RELAPSE PREVENTION ( LEARNING, CRAVINGS, COPING)

MULTIMODALITY ( ETIOLOGICAL HETEROGENEITY)

J. Jaffe


Treatment Models

Detoxification Pharmacological Chemical Dependency Programs Therapeutic Communities Outpatient Model Social Model 12 Step


Social Criteriafor Treatment Success

Diminish crime in community Diminish tax consumptive behavior Diminish illicit substance abuse Increase tax productive behavior Increase personal well being

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UCSD ATTC

Treatment Models


Sociodemographic Characteristics of ClientsEntering Treatment by Modality

DARP


Outpatient Methadone Treatment (OMT)Changes From Before to After Treatment

IBR’S Quarterly Newsletter, Vol..7, Number 4, Winter 1997\98


Outpatient Drug Free (ODF) TreatmentChanges From Before to After Treatment


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UCSD ATTC

Treatment Models


Long-Term Residential (LTR) TreatmentChanges From Before to After Treatment



Short-Term ChangesFrom Before to After Treatment



Heroin

Psychology of Addictive Behaviors, Vol. 11:4, December 1997

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UCSD ATTC

Treatment Models


Crack Cocaine



Injecting



Sharing


ΚΕΘΕΑ-UCSD


Notes:

UCSD ATTC

Treatment Models


Effects of Long-Term Residential Treatment


Percent


Effects of Out Patient Drug Free Treatment


Percent


Drug Abuse Treatment Outcome Study (91-93)Characteristics of Drug Abuse Treatment Outcome Study

Follow-up Frame and Weighted Sample of Respondents Long Term ResidentialTherapeutic Community

Client Characteristics Frame Respondentsother behavior (N=2,293; %) (N=676; %)More than 30 yrs of age 47.8 49.9Male 67.4 65.0African American or Hispanic 61.7 60.1High School or generalequivalency diploma 57.1 58.8Married or living as married 22.5 21.6Criminal justice referral 33.1 34.7Previous drug treatment 60.0 59.8Private health insurance 5.6 3.6Treatment duration morethan 3 months 53.3 62.0

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UCSD ATTC

Treatment Models

Drug Use Preadmission year Follow-up yearother behavior (N=2,293; %) (N=676; %)Heroina 17.2 5.8Cocainea 66.4 22.1Marijuanaa 28.3 12.7Alcoholb 40.2 18.8Suicidal thoughts-attempts 23.6 13.2Predatory il legal activity 40.5 15.9Sexual behavior risk 47.8 28.4Less than full -time work 87.6 77.0Health limitations 29.1 24.9

Note. Preadmission year data are reported for the follow-up frame (N), and the follow-up year data are reported for the weighted sample of respondents(n).aWeekly or more frequent use of drug during the 1-year period. bWeekly or more frequent use with five or more drinks at a sitting.

1) Prevention or reduction of withdrawalsymptoms

2) Prevention or reduction of drug craving 3) Prevention of relapse to use of addictive drug 4) Restoration to or toward normalcy of any

physiological function disrupted by drug use


MethadoneL-AAM (L-alpha acetylmethadol)

Buprenophine

Center for Substance Abuse Treatment (CSAT)


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Notes:

UCSD ATTC

Treatment Models

Prevention of onset of withdrawalsyndrome for 24 hours or more

Reduction or elimination of drughunger or craving

Blockade of euphoric effects of illicitnarcotics



*Intake 2 Days

*Pre-Treatment 2 Weeks

Random Assignment of Patients: N = 112

*Post-Treatment At 6 & 12Month Points

ASISADS-LRisk of HIV behaviorUrine/breath tests

Stabilize @ 60mgHIV education andtest

ASIRisk of HIV behaviorUrine/breath tests


Experimental Group(methadone)

Control Group(no methadone)

H HH H

No drug abuseH Expelled from treatment

P P H1

H HHH

H HHH

H HH

2 3

1 Sepsis & endocarditis2 Leg amputation3 Sepsis

P In prison

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UCSD ATTC

Treatment Models


Experimental Group(methadone)

Control Group(no methadone)

P P

HH H

H

H


ADEQUATE DOSE

...BASED ON CLINICAL&

LABORATORY DATA


No Drug Effect(“Normal”)

DrugEffect

OverdoseIntoxication

Euphoria

Time in hours

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UCSD ATTC

Treatment Models

Early dose adjustments to “approximate” established“Tolerance Threshold”

REMEMBER STEADY-STATE PHARMACOLOGY Today’s dose repeated tomorrow will have a greater

effect and the next day, and the next… until steady-state is achieved Provide full relief and prevention of withdrawal signs

and symptoms and ensure reduction in drughunger/craving


David Deitch, PhD, UCSD, ATTC 29Daily Dose in MGS.


MethadoneDose Range

Less than 60 mg

60-70 mg

80+ mg

Relative Risk ofLeaving Treatment

100 (baseline)

47

21

Capelhorn & Bell, 1991

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UCSD ATTC

Treatment Models

Svikis et al. Johns Hopkins146 Cocaine Abusing, Pregnant Women Seeking Pre-Natal Care - Not Treatment 100 Received - 1-Week Residential Tx. Instill

Abstinence Orientation 46 Received - Standard Pre-Natal Care Costs and Complications of Delivery



46 Control Women

63%

100 Treated Women

*37%


46 Control Women

2534 gms

34 wks

100 Treated Women

*2939 gms

*39 wks

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UCSD ATTC

Treatment Models


46 Control Women

39 days

$46,700

100 Treated Women

*7 days

*$14,500


Therapeutic CommunityEnduring Principles

Concern for the state of our soul and our physical survival

Search for meaning: transcending truths

Challenge and admonish with love

Be invasive - accountable to the community

Public disclosure of acts, fears, hopes, guilts

Public expiation for wrongs done

Banishment is possible - - done with concern for survival

Leadership by elders - - by models

David Deitch, PhD, UCSD, ATTC 36University of California, San Diego Addictions Technology Transfer Center, 1997

It a is place that believes:• You can change - Unfold• The group can facilitate this change• The individual must take responsibility• There are structures to accommodate this• Act as if - Go through the motions

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UCSD ATTC

Treatment Models

Requisite/Pervasive T.C. is a Social Learning Model

- Learn through Challenge and Action- Learn through Universality of our Condition- Learn through Disclosure and Exposure- Fantasies, Angers, Fears, Hopes

37David Deitch, PhD, UCSD, ATTCUniversity of California, San Diego Addictions Technology Transfer Center, 1997

Structured Activities and Expectations- Ranges from groups of all types- Through conduct in all areas of community life (the way I make

my bed, keep my closet, dress, communicate, show concernfor others, etc.)

Environmental- Atmosphere of caring and respect for the person as well as

challenge- Unwritten philosophy - signs - visual aids- Symbols/Rituals (the way things are done)



Seminars andDiscussions/Reading

and Learning Every Day

Learn to Play Every Day

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UCSD ATTC

Treatment Models


Staffing

TC Trained leadershipTC Trained recovered peopleTC and academic trained people - MSW, PhD, RN, MD

Mix should be trained in transdisciplinary with crossskill abilitiesMust share - belief system

value systemModel - walk the walk not just talk the talk


GOALSTo learn:

Compassion

Achievement

Responsibility

XII

VI

IIIIX


T.C.COMMUNITY

Doctors

CounselorsSpecialists

Teacher

Psychologist

NurseFamily

Therapist

SocialWorker

MaintenanceCook

Administrator

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