Military Personnel, Veterans and their Families: How Substance Abuse Treatment Research is Effecting Positive Change

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1 Military Personnel, Veterans and their Families: How Substance Abuse Treatment Research is Effecting Positive Change Kathleen M. Carroll PhD Albert E. Kent Professor of Psychiatry Yale University School of Medicine

2 Substance use is a pervasive and costly problem for VA and other service delivery systems High rates of substance use, especially alcohol and smoking Substance use co-occurs and greatly complicates other problems and disorders, especially PTSD, TBI, and depression Worsens treatment outcome AND increases costs for all other medical conditions Small proportion of those with addiction problems receive treatment 17% of smokers 20-30% of those with mental health problem 12% report alcohol misuse, only 0.2% referred, smaller fraction seen Effective substance use intervention reduces co-occurring problems and their costs

3 Three critical issues for being addressed by ongoing NIDA research 1. Addressing multiple problems (substance use, PTSD, depression, suicide, traumatic brain injury) effectively 2. Dissemination science: Delivering evidence based treatments in a large complex system 3. Increasing access to therapies with proven efficacy and their reducing costs

4 Three critical issues addressed in ongoing NIDA research Addressing multiple problems effectively Ismene Petrakis: Testing effective medications in veterans with substance use AND mental health disorders Sudie Back: Integrating PTSD and Substance use treatment Delivering evidence based treatments in a large complex system: Steve Martino-Stepped models to train VA clinicians Petry-National VA role-out of Contingency Management Increasing access to effective therapy and reducing costs using technology: Kathleen Carroll-Computerized delivery of Cognitive Behavioral therapy All supported in part through NIDA P50 DA0241 and/or VISN 1 MIRECC)

5 Behavioral Therapies Development Center at Yale: P50 DA09241 NIDA s only Center devoted to development of novel behavioral therapies and integration with effective medications National resource for development, evaluation and dissemination of novel therapies and dissemination science Source of the most effective (and cost-effective) therapies for substance use (CBT, CM, Twelve Step Facilitation) and pharmacotherapies (disulfiram, combined treatments) Resource for clinician training (manuals, training tapes, training, implementation science): 50+ trials, over 1000 peer-reviewed publications Close ties with VA Connecticut/ VISN1 MIRECC

6 Effective pharmacotherapies developed with NIDA/NIAAA support often developed and tested in VA settings Medication available? Effective in VA samples? Smoking Alcohol Opioids Comorbid psychiatric problems

7 Behavioral therapies are effective ACROSS types of substance abuse and populations Smoking Alcohol Opioids, heroin Cocaine Marijuana Co Occuring Motivational interviewing Contingency management Cognitive behavioral Behavioral couples, family *

8 OEF/OIF Veterans, PTSD, and substance use Of >6,000 U.S. OEF/OIF infantry soldiers, 30% returning home had a mental health disorder - most common was PTSD (Hoge et al., 2004). Of 88,000 Veterans serving in Iraq war, 16.7% had PTSD symptoms at 6 months post deployment (Milliken et al., 2007). Civilians and Veterans with PTSD are 2-4 times more likely than those to have substance use problem. PTSD + substance use= increased risk of medical and employment issues, homelessness, HIV risk behavior, and intimate partner violence.

9 Challenge- Do evidence based therapies maintain their efficacy when used with veterans with complex comorbid problems like substance use and PTSD?

10 Petrakis et al: Randomized trial of 254 veterans with alcohol + psychiatric disorder -Alcohol-using veterans with PTSD respond significantly better to evidence-based medications -PTSD symptoms improve when alcohol use reduced Petrakis et al, (2006) Biological Psychiatry

11 Integrative Model of PTSD/SUD Treatment Traditional model: Sequential care, target substance use first, then PTSD. -Concerns that focus on PTSD symptoms will worsen substance use treatment -But in many cases, PTSD symptoms lead to relapse -Separate or sequential treatments associated with lack of adherence, dropout Integrative model: -Address PTSD and substance use simultaneously -Focus on connections between PTSD & substance use

12 COPE: Integrated PTSD Substance Use Treatment Treat PTSD + SUD Manage PTSD without substance use Recovery from PTSD and SUD Long term Relief S. Back et al., NIDA RO1 DA030143

13 COPE among OEF/OIF Service Members ONGOING NIDA-Sponsored 5 yr trial Target=70 OEF/OIF veterans addiction + PTSD Typical Case Single, 24 yr old Marine, 4 years in OIF No history of mental health treatment Current PTSD and alcohol dependence Initial trauma: Witnessed friend being shot, rushed him to nearest base hospital, but died in pt s arms on the way. PTSD symptoms: nightmares and intrusive thoughts, isolation/distancing from family and friends, anger and aggression, extreme difficultly driving in traffic or being in crowded stores, avoidance of thoughts and memories through alcohol.

14 Cope: PTSD Checklist-Military Version (PCL-M) PCL-M Scores 60 Baseline 53 Week 1 51 Week 2 40 Week 3 46 Week 4 43 Week 5 39 Week 6 30 Week 7 36 Week 8 28 Week Week Week Week Back et al., R01 A

15 Time-Line Follow Back Avg. Amt. of Alcohol Used Per Day Baseline 12.5 Week Week Week Week 4 2 Week Week 6 2 Week Week 8 0 Week Week Week 11 0 Week Average No. of Standard Drinks Per Day Back et al., R01 DA

16 Beck Depression Inventory (BDI=II) BDI Score Baseline 17 Week 1 18 Week 2 15 Week 3 16 Week 4 14 Week 5 12 Week 6 10 Week 7 11 Week 8 8 Week 9 5 Week 10 4 Week 11 4 Week BDI-II Total Score Back et al., R01 DA

17 The science of bridging the gap

18 Problems: Training and supervision is costly, labor intensive, in small clinics can limit availability of services Assurance of clinician competence very difficult to do in large scale service Solutions: Recognize that all clinicians will not require the same level of training Provide training needed for each clinician s skill and fidelity level

19 A Criterion-Based Stepwise Training Approach Step 3: Competency-Based Supervision (Weeks 17-24) Step 2: Skill-Building Workshop (Weeks 9-16) Step 1: Web-Based Course (Weeks 1-8) Clinicians proceed to the next step of training if they fail to perform MI adequately after receiving a training step. Martino, S., Canning-Ball, M., Carroll, K.M., & Rounsaville, B.J. (2011). A criterion-based stepwise approach for training counselors in motivational interviewing. Journal of Substance Abuse Treatment, 40,

20 Key Findings (Martino et al., 2011) VA clinicians who showed inadequate MI performance immediately after taking the Web course and who subsequently participated in a workshop or supervision improved significantly over time Clinicians who performed MI adequately following the Web course continued to demonstrate similar levels of adherence and competence over a 24-week period without additional training Older certified alcohol and drug counselors who had been working in the field for many years were more likely to required additional training to meet adequate MI standards. 20

21 Problems: Contingency Management =Most powerful and flexible of empirically supported therapies for substance use Very slow acceptance in clinical community Barriers include cost of incentives, lack of top-down administrative support for implementation Solution: National, stepwise, supported implementation evaluation project

22 VA/Contingency Management Initiative (Petry, in press) February 2011, memo issued noting that only 1% of VA patients with substance use disorders had documented receipt of CM in 2010 Initiative involves provision of 2 critical components: Systematic training in CM (4 national trainings) Ongoing support for implementation

23 VA/Contingency Management Initiative Success to date: 187 VA clinicians trained; 4 locations nationally 113 stations represented, all 21 VISNs (Veteran Integrated Service Network) Guided implementation with budgeted support for incentives and ongoing telephone implementation support Clinicians initially skeptical, later enthusiastic proponents after seeing positive response in Veterans (first job, returning to school) To date, over 800 Veterans enrolled, over 9000 urines tested, and 91% test negative for drugs

24 Problem: - Delivery of evidence based therapies incurs some cost - training of therapists, monitoring fidelity - costs of novel medications - Many Veterans in rural locations don t have ready access to care Solutions: Use technology to deliver evidence-based therapies

25 How can we make science based therapies more available? Accessible to large numbers of those who need it,..including those reticent about identification Offers confidential access Cost-effective Flexibility, availability 24/7, rural and dispersed settings High capacity for individualization, repetition for those with cognitive limitations Compatible with existing VA, military systems Save clinicians time Provides standardization, high and consistent level of quality

26 CBT 4 CBT Computer Based training for CBT 7 modules, ~1 hour each, high flexibility Highly user friendly, no text to read, linear navigation Based on NIDA CBT manual Video examples of characters struggling real life situations Multimedia presentation of skills Interactive exercises, quizzes Multiple examples of homework to foster skills development

27 Web based: Drugs/alcohol; alcohol only, and Spanish

28 Efficacy of CBT4CBT versus TAU (treatment as usual) Percent drug-negative urine toxicology screens Carroll et al., 2008, Am J Psychiatry

29 Longest consecutive abstinence, in days, at 8 weeks by treatment condition Carroll et al., 2008, Am J Psychiatry

30 Durability of Effects of CBT4CBT: 6 month follow-up Estimated Days of Any Drug Use from Treatment Endpoint to Follow- Up Month CBT TAU Carroll et al., 2009, DAD

31 Co$t effectiveness of CBT4CBT: Outcome=Longest Days Abstinence (LDA) Incremental Cost Effectiveness Ratios (ICERS) Treatment As delivered in clinical trial ($) Taken to scale/favorable Scenario ($) CBT4CBT MET/CBT by clinician Olmstead et al., Drug and Alcohol Dependence, 2010

32 Is CBT4CBT effective with veterans? Just-completed randomized clinical trial at outpatient clinic at Newington CT VA (follow-ups ongoing) 72 substance using veterans (35% minority; 41% Army, 22% Marines, 17% Air Force; 15% Navy) 25 are current substance users (abstinence initiation arm) 47 released from inpatient treatment (relapse prevention arm) All comers = multiple substance use in most (63% primary alcohol users, 23% cocaine, 8% marijuana) VISN 1 MIRECC & NIDA P50 DA 09421

33 VA pilot, preliminary data: CBT4CBT+standard care versus standard care alone: 25 current users

34 Addressing complex co-occurring issues Addiction care Pharmacotherapy Computer-assisted therapy Screening Identification Brief treatment Ongoing Evaluation and Management Linkage to Services Cognitive rehabilitation PTSD, depression other mental health

35 Thank you- NIDA-supported treatments effective with Veterans Systematic, evidence-based dissemination ongoing Promise of technology to increase efficacy, reduce costs of prevention and treatment Please support continued NIH research efforts to improve the quality and access of treatment and prevention for military personnel, veterans and their families

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