Treatment Improvement Protocol (TIP) - Index
Chapter 3 - Approaches to Treatment (member's section)
Appendix A ~ Bibliography (member's section)
Chapter 4 ~ Practical Application of Treatment Strategies (member's section)
Appendix B ~ Worksheets (member's section)
Chapter 5 ~ Medical Aspects of Stimulant Use Disorders (member's section)
Appendix C ~ Screening Tests (member's section)
Chapter 6 ~ Treatment Issues for Special Groups (member's section)
Appendix D ~ Glossary (member's section)
Executive Summary ~ Negative Effects of Stimulant Use and How to Help!
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Treatment for Stimulant Use Disorders:
Methamphetamine & Cocaine - 1999 Treatment Improvement Protocol (TIP) Series 33
Richard A. Rawson, Ph.D. Center for Substance Abuse Treatment
This TIP, Treatment for Stimulant Use Disorders, supplies substance use disorder treatment providers with vital information on the effects of stimulant abuse and dependence, discusses the relevance of these effects to treating stimulant users, describes treatment approaches that are appropriate and effective for treating these clients, and makes specific recommendations on the practical application of these treatment strategies. Research on animals has demonstrated the profound effects that stimulants can have on the central nervous system, and new technologies have begun to document the stimulant-induced neurological impairments in humans. Researchers now believe that these impairments underlie the cognitive deficits that are often seen in chronic stimulant users.
Effective treatment strategies must recognize the impact that stimulant abuse and dependence have on the user's ability to respond to treatment. The treatment strategies that are described in this TIP have been scientifically validated as effective in treating people with stimulant use disorders. These strategies address the specific problems and needs that are inherent to chronic stimulant users.
This document discusses in detail the practical application of these treatment strategies and makes recommendations to improve treatment outcomes for stimulant abuse and dependence. The document also provides for clinicians and primary care providers an overview of the medical aspects of stimulant use. Furthermore, treatment issues for special groups and settings are reviewed.
Executive Summary and Recommendations:
Over the last 20 years, the use of stimulants has risen to national and international prominence. Stimulant use and its consequences have brought havoc to many communities across the United States and have prompted strong responses from Federal, State, and local governments and organizations. For example, the relatively minor problems of cocaine use in the 1960s and 1970s have grown to become major medical, legislative, and law enforcement issues in the 1990s. The devastation wrought by the crack cocaine epidemic is familiar to most Americans.
Similarly, the use and abuse of another stimulant, methamphetamine (MA), have risen dramatically in recent years. Widespread use and abuse of MA have led to a greater awareness of the problem and have inspired policymakers, legal officials, and service providers to focus increased efforts toward the personal and societal effects of this drug. Concerns that MA abuse may result in another epidemic led to passage of the Comprehensive Methamphetamine Control Act of 1996.
The explosive growth of stimulant use triggered a flurry of research. The results are tremendous advances in fundamental knowledge of stimulant use disorders and on the basic function of the brain and addictive disorders in general. Yet today, there are few reports that describe either the fundamentals of stimulant use disorder treatment or the success of various treatment interventions.
This Treatment Improvement Protocol (TIP) describes basic knowledge about the nature and treatment of stimulant use disorders. More specifically, it reviews what is currently known about treating the medical, psychiatric, and substance abuse/dependence problems associated with the use of two high-profile stimulants: cocaine and MA.
Scientifically-Based Information ~ Evidence-Based Information:
The scientifically based information in this TIP is presented in a manner that makes it available and relevant for clinicians and other "front line" substance use disorder treatment providers. It offers recommendations on treatment approaches, recommendations to maximize treatment engagement, strategies for planning and initiating treatment, and strategies for initiating and maintaining abstinence. Also included are recommendations for the medical management of stimulant users and recommendations regarding special groups and settings.
For purposes of this TIP, the substances included in the category of "stimulants" include the derivatives of the coca plant (cocaine hydrochloride and its freebase form, "crack") and the synthetically produced amphetamines, with a primary emphasis on illicitly produced Methamphetamine MA (and its smokable form, “Crystal or Jib”).
Summary of Recommendations:
Because of recent health care reforms, most individuals who seek help for stimulant dependence now receive treatment at structured outpatient treatment programs. Accordingly, this document provides recommendations for treatment strategies and techniques that are most relevant to the treatment of stimulant-dependent patients in structured outpatient treatment programs. However, many, if not most, of these strategies and techniques can be integrated into other types of programs, regardless of the setting or therapeutic orientation.
Psychosocial Treatment Approaches:
Psychosocial treatment approaches that incorporate well established psychological principles of learning are appropriate for and effective in treating stimulant users. In an effort to make these approaches consistently effective. However, the therapist's clinical judgment and flexibility are extremely important to the treatment process.
The Consensus Panel recommends a contingency management approach for treating stimulant users. A particularly successful version is the community-reinforcement-plus-vouchers approach in which couples: counseling, vocational training, and skills training are combined with rewards for negative drug tests (i.e., "clean" urinalysis results).
Relapse prevention systematically teaches clients: How to cope with substance craving, Substance refusal assertiveness skills, How seemingly irrelevant decisions may affect the probability of later substance use, General coping and problem-solving skills, How to apply strategies to prevent a full-blown relapse should an episode of substance use occur.
Other Interventions With Supportive Research:
Research indicates that the following may be appropriate interventions for stimulant users: Permitting women entering residential treatment to be accompanied by their children, Supportive-expressive psychotherapy, "Node-link mapping," which uses flowcharts and other methods to diagram relationships between clients' thoughts, actions, feelings, and substance use.
Other Models of Psychosocial Treatment:
A number of other psychosocial models and approaches have been described, and some used widely, for the treatment of stimulant use disorders, including: Network therapy, in which clients receiving individual psychotherapy develop a network of stable, nonsubstance-abusing support persons, such as family, partners, and close friends, Acupuncture, Therapeutic communities (the most common type of long-term residential treatment).
Maximizing Treatment Engagement & Make treatment accessible:
To maximize treatment engagement, programs must make treatment accessible. Having treatment programs in areas convenient to clients is associated with lower attrition rates. Treatment should be provided during the hours and on the days that are convenient for clients. Programs should be located near public transportation and in a part of town viewed as safe for evening visits.
Provide support for treatment participation:
Address clients' concrete needs, including transportation, housing, and finances. Some logistical barriers can be overcome by onsite services, through agreements with subcontractors, or by referrals. These can include onsite child care services, referrals to temporary shelters, vouchers for lunches, targeted financial assistance, assistance with paperwork regarding insurance, or filing for disability benefits.
Respond quickly and positively to initial telephone inquiries:
Because ambivalence about treatment is common among treatment-seeking stimulant users, methods to "screen out" those who are "in denial" are counterproductive and impede treatment entry. The initial interview should be scheduled within 24 hours after the client initially contacts the program.
Assessments and Orientations - Keep initial assessments brief:
Initial assessments should be brief, focused, and nonrepetitive.
Provide clear orientations:
Individuals need a thorough, clear, and realistic orientation about stimulant use disorder treatment. Clients should acquire a good understanding about the treatment process, the rules of the treatment program, expectations about their participation, and what they can expect the program to do for them and in what time frame.
Offer clients options:
Addiction treatment is more effective when a client chooses it from among alternatives than when it is assigned as the only option. Thus, it is important to provide clients with options and negotiate with them regarding the treatment approaches and strategies that are the most acceptable and promising.
Involve significant others:
Whenever possible, family and significant others who support the treatment goals should be involved in the treatment process.
Convey empathetic concern:
Counselors should be warm, friendly, engaging, empathetic, straightforward, and non-judgmental. Authoritarian and confrontational behavior by the staff can substantially increase the potential for violence.
To organize treatment strategies, it can be helpful to view the treatment process as consisting of: A treatment initiation period, An abstinence attainment period, An abstinence maintenance phase, A long-term abstinence support plan.
The Consensus Panel recommends treatment for 12 to 24 weeks followed by some type of support group participation.
The initial period of stimulant abstinence is characterized by symptoms of depression, difficulty concentrating, poor memory, irritability, fatigue, craving for cocaine/MA, and paranoia (especially for MA users). The duration of these symptoms varies; in general, symptoms typically last 3 to 5 days for cocaine users and 10 to 15 days for MA users.
The first several weeks of treatment have some relatively simple and straightforward priorities.
Establish treatment attendance:
During the first 2 or 3 weeks, clients should be scheduled for multiple weekly visits, even if the visits are 30 minutes in duration or less.
Discontinue use of psychoactive substances and initiate urinalysis schedule: Immediately upon entering the treatment program, clients should be placed on a mandatory, vigilant, and frequent urine testing schedule. This schedule should continue throughout the treatment process, although the frequency of testing can be tapered as treatment progresses. Urine samples should be taken every 3 or 4 days so as not to exceed the sensitivity limits of standard laboratory testing methods. Participation in self-help groups should be strongly encouraged but not required.
Assess psychiatric comorbidity:
During the initial 2 weeks of treatment, it is important to assess the possible existence of other psychiatric conditions and, if present, initiate appropriate treatment, including medication.
Assess stimulant-associated compulsive sexual behaviors:
Research has revealed an association between stimulant use and a variety of compulsive sexual behaviors. These behaviors include promiscuous sex, AIDS-risky behaviors, compulsive masturbation, compulsive pornographic viewing, and homosexual behavior for otherwise heterosexual individuals. In order for treatment to be effective, these issues must be discussed openly and nonjudgmentally.
Remediate stimulant "withdrawal" symptoms:
Remind clients that proper sleep and nutrition are necessary to allow the neurobiology of the brain to "recover." Giving them "permission" to sleep, eat, and gradually begin a program of exercise, can help establish some behaviors that will have long-term utility. These behaviors will help them begin to think more clearly and begin to feel some benefit from their initial efforts in treatment.
Establish structure and support. After the initial treatment engagement of 1 to 2 weeks, the focus is on the achievement of abstinence. Although there is no clear delineation between clients who are initiating abstinence and those maintaining abstinence, the initiating period occurs roughly from 2 to 6 weeks into treatment.
Establish structure and support:
Short-term goals should be set immediately and should be reasonably achievable. One such goal is complete abstinence from all substances for 1 week. Brief, frequent counseling sessions can reinforce the short-term goal of immediate abstinence and establish a therapeutic alliance between the client and counselor. Events of the past 24 hours are reviewed in each session and recommendations are provided for navigating the next 24 hours.
Address secondary drug use:
For many clients, their secondary substance use may not have been associated with adverse consequences or compulsive use. As a result, such clients need help to identify the connections between the use of other substances and their stimulant addiction. Clients should be encouraged to throw out all substance-related items. Family members, sober friends, or 12-Step sponsors should help with this task.
Initiate avoidance strategies:
Clients must develop specific action plans to break contacts with dealers and other stimulant users and to avoid high-risk places that are strongly associated with stimulant use.
Provide client education:
Educate clients about learning and conditioning factors associated with stimulant use and the impact of stimulants and other substances on the brain and behavior, such as cognitive impairments and forgetfulness.
Other steps to initiate abstinence include:
Identify cues and triggers, Develop action plan for cues and triggers, Enlist family participation, Establish social support systems, Address stimulant abuse-associated compulsive sexual behaviors.
Respond to early slips:
Early slips should not be considered tragic failures but rather simple mistakes. When slips occur, counselors can make a verbal or behavioral contract with clients regarding short-term achievable goals.
Maintaining Abstinence - Teach functional analysis of stimulant use:
The core components of a functional analysis are: Teaching clients to examine the types of circumstances, situations, thoughts, and feelings that increase the likelihood that they will use stimulants, Counseling clients to examine the positive, immediate, but short-term consequences of their stimulant use, Encouraging clients to review the negative and often delayed consequences of their stimulant use.
Teach relapse prevention techniques:
Relapse prevention techniques fall into the following categories: Psychoeducation about the relapse process and how to interrupt it, Identification of high-risk situations and relapse warning signs, Developing coping and stress management skills, Enhancing self-efficacy in dealing with potential relapse situations, Counteracting euphoric recall and the desire to test control over use, Developing a balanced lifestyle including healthy leisure and recreation activities, Responding safely to slips to avoid escalation into full-blown relapse, Establishing behavioral accountability for slips and relapse via urine monitoring and/or Breathalyzer.
Enhance self-efficacy regarding high-risk situations:
Once clients learn to identify, manage, and avoid high-risk situations, the counselor and client should try to determine if the client is confident in her ability to use those skills in the real world through role-playing and other therapeutic techniques.
Counteract euphoric recall and desire to test control:
So-called "war stories" that include euphoric recall and selective memory are powerful relapse triggers and should be strongly discouraged in recovery groups.
The following recommendations are for medical personnel to help them recognize and treat problems that may arise for stimulant users with acute or chronic intoxication or in various phases of withdrawal. The most common reasons for emergency room visits by cocaine users are cardiopulmonary symptoms (usually chest pains or palpitations); psychiatric complaints, ranging from altered mental states to suicidal ideation; and neurological problems, including seizures and delirium.
The major presenting symptoms for MA users pertain primarily to altered mental status, including confusion, delusions, paranoid reactions, hallucinations, and suicidal ideation. The rapid development of tolerance to its physiological effects among chronic MA users may explain the relative infrequency of cardiac complications in this group. The lethal dose of cocaine for 50 percent of novice users (LD50) is 1.5 grams. The LD50 for MA has not specifically been established, and there is significant individual variability to its toxicity. For example, doses of 30 milligrams (3 Points) can produce severe reactions, yet doses of 400 to 500 milligrams (1/2 Gram) are not necessarily fatal.
Management of stimulant intoxication:
Uncomplicated intoxication requires only observation and monitoring in a subdued environment until symptoms subside over several hours. Physical exertion and an overheated room can potentiate adverse effects because stimulants affect the body's heat-regulating mechanism at the same time that blood vessel constriction conserves heat. Indications that agitation is escalating and moving toward paranoia and potential psychosis (losing touch with reality), with increasing risk for violence, may warrant pharmacological intervention. Fast-acting benzodiazepines such as lorazepam (Ativan) or diazepam (Valium) are useful for calming an anxious, agitated client.
Management of potentially lethal overdose:
Manage hyperthermia by sedating to slow down and stop agitated movements and by rapidly cooling the client with body ice packs, mist and fan techniques, or cooling blankets. If restraints are required to start an intravenous administration, use mesh-type blankets only transiently to avoid interfering further with heat loss. Uncontrolled hypertension can be managed by intravenous administration of phentolamine (Regitine) or dopamine (Intropin). Treat seizures like status epilepticus with intravenous diazepam or other benzodiazepine. Diazepam is most effective if administered before or shortly after cocaine ingestion but is less effective after seizures begin.
Management of stimulant withdrawal:
The greatest risk from the distinctive stimulant abstinence syndrome is that one may do harm to oneself or others. Because withdrawal-related dysphoria and depression can be particularly severe in stimulant users, risk of suicide is intensified, and sensitive management is essential. Continuing agitation and persistent inability to fall asleep during withdrawal may also be treated symptomatically by using the antidepressant trazodone (Desyrel). Diphenhydramine (Benadryl) can also be used for its sedating properties.
Common physiological symptoms of chronic stimulant abuse/dependence:
Extreme fatigue--with physical and mental exhaustion and disrupted sleep patterns, Nutritional disorders--extreme weight loss, anemia, anorexia, cachexia (body wasting), Poor hygiene and self-care, Skin disorders and secondary skin infections--itching, lesions, hives, urticaria, Hair loss, Muscle pain/tenderness--may indicate rhabdomyolysis, Cardiovascular damage--from toxicity and contaminants in MA production, with concomitant renal and hepatic problems, Hypertensive crises with renal damage from sustained hypertension, Difficulty breathing--may reflect pulmonary edema, pneumonitis, obstructive airway disease, barotrauma, and other complications, Myocarditis, infarcts, Headaches, strokes, seizures, vision loss, Choreoathetoid (involuntary movement) disorders, Impaired sexual performance and reproductive functioning, Cerebrovascular changes, including evidence of cerebral hemorrhages and atrophy with associated cognitive deficits, Ischemic bowel, gastrointestinal complaints.
Common psychological/behavioral symptoms of chronic stimulant abuse / dependence:
Paranoia--with misinterpretation of environmental cues; psychosis with delusions, and hallucinations, Apprehension--with hopelessness and fear of impending doom that resembles a panic disorder, Depression--with suicidal thinking and behavior, Acute anxiety, Eating disorders.
Distinctive indicators of chronic stimulant abuse/dependence:
Nasal perforations and nose bleeds among snorters, Dental problems, including missing teeth, bleeding and infected gums, dental caries, Muscle cramping related to dehydration with low magnesium and potassium levels, Dermatitis around the mouth from smoking hydrochloride salt, Stale urine smell due to ammonia constituents used in manufacturing MA, Various dermatologic conditions, including excoriated skin lesions, Serious constipation due to dehydration and insufficient dietary fiber.
Reducing the risk of violence:
Medical personnel must be prepared for the paranoia, aggression, and violence that often accompany stimulant use. These personnel should: Keep the client in touch with reality by identifying themselves, using the client's name, and anticipating his concerns. Place the client in a quiet, subdued environment with only moderate stimuli. Ensure sufficient space so that the client does not feel confined. Have the door readily accessible to both the client and the interviewer, but do not let the client get between the interviewer and the door. Acknowledge agitation and potential for escalation into violence by reassuring the client that they are aware of his distress; asking clear, simple questions; tolerating repetitive replies; and remaining nonconfrontational. Foster confidence by listening carefully, remaining nonjudgmental, and reinforcing any progress made. Reduce risk by removing objects from the room that could be used as weapons and discreetly ensuring that the client has no weapons. Be prepared to show force if necessary by having a backup plan for help and having chemical and physical restraints immediately available. Train all medical or emergency staff to work as a team in managing volatile clients.
Associated Medical & Psychiatric Disorders:
There are a number of medical and psychiatric disorders that frequently accompany stimulant abuse and dependence. An awareness of these conditions is important for the safe and effective treatment of stimulant disorders. The conditions include: Cardiovascular system effects, Respiratory-pulmonary effects, Cerebrovascular complications, Muscular and renal toxicity, Gastrointestinal complaints, Infections, Effects on reproduction/formation of fetus/newborn children, HIV/AIDS and hepatitis, Toxic psychosis, Aggression and violence, Polysubstance abuse, Traumatic injury.
Assessment and diagnosis:
A diagnosis can be based on established DSM-IV criteria for amphetamine or cocaine use/abuse/dependence and other listed composites. An appropriate substance use history should include the substance(s) and medications used during the last 30 days; the specific substance(s) or combinations typically used with the usual dose, frequency, and route of administration; the duration of use/abuse; and the time and amount of last use as well as when the symptoms or complaints developed and how they have progressed. Stimulants typically can be detected in urine for approximately 24 to 48 hours following use and, maximally, for 3 days.
Special Groups and Settings:
The Consensus Panel feels strongly that cultural competence in treatment extends beyond racial/ethnic sensitivity to understanding the mores of groups bound together by gender, age, geography, sexual preferences, criminal activity, substance use, and medical and mental illnesses. The Consensus Panel therefore recommends the following: Counselors should be trained in cultural sensitivity and cultural competency issues to enhance the counselor's understanding and appreciation of both the client's background and his needs within that context. Intravenous drug users should have access to multicomponent HIV prevention programs, which include instruction on bleach disinfection along with skills training, counseling, and HIV testing. Needle exchange programs may also be helpful. Treatment for individuals in the criminal justice system is a rapidly expanding area of need. Stimulant users represent a substantial portion of the individuals in the court and prison treatment population. For rural populations, forming linkages between social service agencies, providing treatment services that are flexible in scope and structure, and using nontraditional outreach sites such as mobile or satellite offices are all important interventions. Counselors should be aware of the special needs of women and adolescents, including domestic issues, medical problems, child care needs, academic performance, and so on. Gender-specific treatment groups and school-based clinics can be helpful in reaching these particular groups.
In stimulant use disorder treatment today, providers have the opportunity to move the role of scientifically based approaches into the forefront of the treatment effort. Recent findings from basic and clinical research serve as the foundation of the evolving treatment system for stimulant use disorders and have yielded an entirely new set of strategies and tools to assist in the treatment of stimulant-related clinical disorders.
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