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Evidence-Based Practice: Psychosocial Interventions

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Evidence-Based Practice: Psychosocial Interventions Maxine Stitzer, Ph.D. Johns Hopkins Univ SOM NIDA Blending Conference June 3, 2008 Cincinnati, Ohio – PowerPoint PPT presentation

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Title: Evidence-Based Practice: Psychosocial Interventions


1
Evidence-Based Practice Psychosocial
Interventions
Maxine Stitzer, Ph.D. Johns Hopkins Univ
SOM NIDA Blending Conference June 3, 2008
Cincinnati, Ohio
2
Talk Outline
  • What is an evidence-based practice?
  • What practices are evidence-based?
  • Why should these be used?
  • How to decide which one(s) to use?

3
What Is An Evidence-Based Practice?
  • Developed by researchers
  • Subjected to controlled evaluation
  • Shown efficacious in 2 or more trials

4
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
    non-specified elements
  • Clients meet inclusion and exclusion criteria
  • may be less complicated cases
  • Detailed data collected on outcomes

5
Efficacy research shows that practices can work
under ideal conditions
6
Do Evidence-Based Practices Work in Real World
Settings?
  • Research conducted by NIDA CTN has verified
    effectiveness of some evidence-based practices
  • Motivational Interviewing
  • Contingency Management
  • Others are yet to be tested
  • 12-step Facilitation
  • Cognitive-Behavioral Therapy

7
What Psychosocial Therapies are Evidence-based?
  • Motivational Interviewing (MI/MET)
  • Contingency Management (CM)
  • Cognitive-behavioral therapy (CBT)

8
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

9
MI/MET Techniques
  • O open ended questions
  • A affirmation
  • R reflective listening
  • S summary statements

10
MI/MET Evidence For Efficacy
  • Improved compliance in medical patients
  • Reduced drinking in alcoholics
  • Drug users contacted in a medical setting

11
(No Transcript)
12
MI in Drug Treatment Settings
  • Evidence mixed
  • Some studies find benefits
  • Others find no benefits

13
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

14
Patients assigned to MI completed more sessions
than those in standard treatment
15
More MI patients were retained at 1-month
16
No differences in retention at the 84-day
follow-up
17
No differences in drug use during first 28 days
18
Alcohol users (n172)were the ones who benefited
19
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
vs3 sessions of individual TAU
20
MET Study Outcomes
MET
TAU Significance Days Enrolled
72 69 ns Retained 4 mos ()
41 46 ns Positive UA 21
28 ns ( in 28 days)

21
MET Effectiveness in Alcoholics
22
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

23
CBT What Is It
  • Structured skills training lessons
  • Manage cravings
  • Avoid triggers
  • Drug refusal
  • Coping/problem solving
  • Lectures, practice, homework
  • Manualized
  • NIDA Therapy Manual for Drug Addiction 1

24
CBT Efficacy Evaluation
  • Many studies have demonstrated efficacy
  • Some show during treatment effects
  • Some show benefits only after treatment ends
    (sleeper effects)

25
IOP Treatment CBT vs 12-Step
Maude Griffin et al., 1998
26
CBT vs Clinical Management 1x per week
Carroll et al., 1994
27
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?

28
Contingency ManagementMotivational 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

29
Voucher Point System
  • Increasing magnitude, bonus, up to 1000
  • 2.50 10.00
  • 3.75 11.25
  • 5.00 10 12.50 10
  • 6.25 13.75
  • 7.50 15.00
  • 8.75 10 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?

30
Voucher Incentives in Outpatient Drug-free
Treatment
Higgins et al. Am. J. Psychiatry, 1993
Cocaine negative urines
31
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

32
Retention Alcoholics in Outpatient Psychosocial
Treatment
Petry et al., 2000
33
Time to first heavy drinking episode
plt.05
Petry et al., 2000
34
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 ---gt
    escalating draws
  • Also negative for opiates, THC ---gt bonus draws

35
Total Earnings
  • 400 in prizes could be earned on average
  • If participant tested negative for all targeted
    drugs over 12 consecutive weeks

36
Incentives Improve Retention in Counseling
Treatment
100
80
60
50
Percentage Retained
40
35
20
RH 1.6 CI1.2,2.0
0
2
4
6
8
10
12
Study Week
37
Percent of Submitted Samples Testing Stimulant
and Alcohol Negative
100
80
60
Percentage negative samples
40
Abstinence Incentive
Usual Care
20
0
1
3
5
7
9
11
13
15
17
19
21
23
Study Visit
38
Abstinence Incentives in Psychosocial Counseling
Tx
  • Incentives lengthened duration of drug-free
    treatment participation
  • Presumably improving long-term outcomes
  • 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

39
Combination of treatments may be best for
long-term recovery
40
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41
Why Should Evidence-Based Practices Be Used?
  • Enhance counseling skills and proficiency
  • Engage in culture of CQI
  • Improve treatment outcomes
  • Satisfy accreditation boards federal and
    insurance payers

42
Which Evidence-Based Practices Should Be Used?
  • Selected by needs of the clinic?
  • Selected by needs of the clients?
  • Selected by research effect sizes?
  • All used in some logical adoption sequence?

43
Sequential Adoption Plan
  • Motivational Interviewing
  • Contingency Management
  • Cognitive-Behavior Therapy

44
Needs of Clinic and Clients
  • Improve early engagement (MI/MET)
  • Improve retention (CM)
  • Stop on-going drug use (CM)
  • Prevent relapse (CM/CBT)
  • Build alternative non-drug reinforcers (CBT)

45
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

46
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
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