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Blending Clinical Practice and Research: Forging Partnerships to Enhance Drug Addiction Treatment



Plenary Session & Workshop Descriptions, Day 2

Contents


Science of Stress and Substance Abuse
David Vlahov, Ph.D., Center for Urban Epidemiologic Studies, New York Academy of Medicine


Coping in the Wake of Tragedy
Beny J. Primm, M.D., Addiction Research and Treatment Corporation


Assessment for Psychiatric Comorbidity in Addiction Treatment
Edward V. Nunes, M.D., Columbia University
Kathleen T. Brady, M.D., Ph.D., Medical University of South Carolina
Jerome F.X. Carroll, Ph.D., New York State Office of Alcoholism and Substance Abuse Services
Jeffrey Selzer, M.D., North Shore-Long Island Jewish Health System

Psychiatric disorders such as depression and anxiety are prevalent among patients being treated for substance dependence and have been associated with poor treatment outcome. A series of studies among alcoholics and opiate addicts suggest that depression can be treated and that improvement in depression may result in improved outcome of substance abuse treatment. Over the past decade there has been an increasing awareness in the treatment community of the importance of co-occurring disorders and the wide variety of disorders, including bipolar disorder, schizophrenia, panic disorder, phobias, posttraumatic stress disorder, eating disorders, pathological gambling, attention deficit disorder, and learning disabilities. Many challenges remain, including the fundamental challenge of how to accurately but efficiently identify these disorders among substance-dependent patients. This workshop will present the state of the research on the diagnosis and treatment of comorbid disorders and overview the challenges treatment providers confront in managing these disorders. Audience members will be asked to draw from their experience and knowledge in a discussion of how current research findings may be used to improve treatment and what shape future research should take.

Current Research Tells Us

  • Co-occurring disorders such as depression can be reliably identified using structured interviews with substance-dependent patients and can be improved with antidepressant treatment.

Considerations for Putting Research to Actual Use

  • Implement efficient methods for screening for these disorders and for treatment.

  • Meet the challenges of providing both the personnel and finances to make this happen.

Considerations for Future Research

  • Develop better screening instruments.

  • Expand diagnosis and treatment research beyond depression to other co-occurring disorders and to newer pharmacologic and behavioral treatments.

  • Determine the best systems of care for dually diagnosed patients.

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Buprenorphine/Naloxone Treatment of Opiate Dependence
Paul P. Casadonte, M.D., Department of Veterans Affairs and New York Harbor Healthcare System, Inc.
Leslie Amass, Ph.D., Friends Research Institute, Inc.
Paul J. Fudala, Ph.D., Philadelphia Veterans Affairs Medical Center and University of Pennsylvania School of Medicine
Terry Horton, M.D., Phoenix House Foundation, Inc.

This workshop will present an overview of more than two decades of research that have brought us to the point of adding a new medication to the treatment of opiate dependence. Integration of buprenorphine/naloxone into treatment will likely result in fundamental changes in the practice of addiction medicine in the United States. Buprenorphine/naloxone is likely to be approved for use in nonnarcotic treatment settings and in private medical offices. This workshop will include presentations on background pivotal research studies, the application of research evaluations to private-office opiate treatment, current detoxification studies in community settings, and an overview and discussion of some of the issues related to the integration of research and new treatments into an abstinence-based model.

Current Research Tells Us

  • There are 980,000 opiate-dependent individuals in the United States.

  • Approximately 200,000 are currently in treatment.

  • Buprenorphine/naloxone has been extensively studied in single-site and multisite clinical trials for more than 10 years and is of proven efficacy and safety.

Considerations for Putting Research to Actual Use

  • What adjustments need to be made to integrate an opiate-addicted population into nonnarcotic treatment settings?

  • What types of education programs do staff members need to incorporate this medication into treatment?

  • How can we educate the public and expand treatment opportunities?

Considerations for Future Research

  • Will the availability of buprenorphine/naloxone increase or decrease the number of untreated addicts?

  • Will buprenorphine/naloxone be readily accepted by staff members and patients in treatment settings?

  • Will buprenorphine/naloxone be a cost-effective treatment?

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Innovations in Methadone and LAAM Treatment
Mary Jeanne Kreek, M.D., Rockefeller University
Ronald Brady, M.D., Bridge Plaza Treatment and Rehabilitation Clinic
Ron Jackson, M.S.W., Evergreen Treatment Services
Edwin A. Salsitz, M.D., Beth Israel Medical Center

This workshop will describe important innovations in methadone and LAAM treatment and review the major successes, issues, and problems encountered over the 38 years of methadone maintenance treatment. Data will be presented from a 17-year experience of developing a novel model and treating approximately 300 patients in a medical maintenance program. To date, there have been no significant adverse events in this private, office-based pharmacotherapy model. The outcome data, medical comorbidity, and logistics of the program will be reviewed. The main issue encountered by the many successfully rehabilitated patients remains the widespread stigma and prejudice. Data also will be presented on the development of novel, office-based methadone treatment, including implementing methadone maintenance as part of primary care, as well as data related to the use of a mobile methadone treatment van to deliver care in diverse locations. Brief discussions may include different approaches to treatment outcome enhancement, including motivational enhancement and acupuncture intervention. An additional presentation will address the development and utilization of a computer model that automates the inventory of controlled substances, facilitates the accurate dispensing process for the delivery of methadone pharmacotherapy, and establishes a network for all the components of a methadone maintenance clinic. The computer model also collects and organizes data with efficiency, allowing examination of patient compliance and details of individual patient treatment. Another presentation will review issues, problems, and approaches to a community-based, urban methadone maintenance treatment program serving patients of cultural, ethnic, and economic diversity, including a brief discussion of the potential usefulness of LAAM in managing patients who have been less responsive to methadone maintenance treatment. A general discussion of these and other innovations will include the panelists and workshop participants.

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Smoking Cessation Treatment in Substance Abuse Rehabilitation Programs
Malcolm S. Reid, Ph.D., New York University School of Medicine
Steven Schwartz, Margaret A. Stutzman Addiction Treatment Center, New York State Office of Alcoholism and Substance Abuse Services
Steven Shoptaw, Ph.D., Friends Research Institute, Inc.

The problem of cigarette smoking among alcohol and other drug abusers has received increased attention in the past decade. Clinically important reasons for this include the high prevalence rate of smoking among substance abusers, markedly increased health risks and mortality rates, and evidence for greater alcohol or other drug addiction severity and health problems in substance abusers who smoke. Moreover, as social views about smoking in the United States have shifted toward viewing cigarette smoking as an addictive disease, substance abuse patients and their treatment providers have become more far more receptive to incorporating smoking cessation programs in their clinics. This workshop will review the pharmacological and behavioral treatment modalities for smoking cessation and examine the feasibility of smoking cessation treatment in substance abuse rehabilitation programs. The prevalence of cigarette smoking with other forms of substance abuse, nicotine neuropsychopharmacology, the relationship between nicotine dependence and other addictions, and the health consequences of smoking will be examined. Discussions will cover previous research on smoking cessation treatment in alcohol and other drug rehabilitation programs and its effects on alcohol and other drug abstinence and smoking quit rates and will address how to best integrate smoking cessation with substance abuse rehabilitation. The development of a smoking cessation program tailored to outpatient drug abuse treatment programs, designed in collaboration with treatment providers, will be presented. The challenges to implementing this and other smoking cessation programs, and investigating them across multiple modalities of substance abuse treatment, will be discussed.

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Family Network Therapy
Marc Galanter, M.D., New York University School of Medicine
Peter Steinglass, M.D., Ackerman Institute
José Szapocznik, Ph.D., University of Miami School of Medicine

This workshop will describe a variety of approaches to family and network therapy, focusing especially on the network approach. It will address basic approaches that can be used by the therapist to move a substance abuser toward recovery, employing the support of family or close friends. Video examples will be used to illustrate these approaches.

Current Research Tells Us

  • Family members can be engaged to ensure better attendance at treatment sessions.

  • Spouses are very important in improving treatment outcome.

  • Support from family members enhances the outcome of substance abuse treatment.

Considerations for Putting Research to Actual Use

  • What types of family and peer support can be targeted by family and network therapy?

  • How can family and network members be engaged in the treatment context?

  • What specific roles may family and network members play in the sessions?

Considerations for Future Research

  • What are effective ways for training physicians to engage family and network members in treatment?

  • Can family groups be used in substance abuse treatment?

  • How can family and network support be integrated into clinic settings?

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Trauma and Addiction
Denise Hien, Ph.D., Women's Health Project Treatment and Research Center, Columbia University School of Social Work, and St. Luke's-Roosevelt Hospital Center
Lisa Najavits, Ph.D., McLean Hospital and Harvard Medical School
Nancy J. Smyth, Ph.D., CSW, CASAC, State University of New York, Buffalo, School of Social Work

This workshop will focus on blending research and practice in treating comorbid trauma-related disorders and addiction. The workshop also will provide a research review of the epidemiology of trauma comorbidity and of new developments in the diagnosis of complex posttraumatic stress disorder and disorders of extreme stress. Included will be a review of empirically supported treatments that target trauma-related conditions among substance abusers, with a discussion of challenges to implementing such treatments in community-based addiction treatment programs. The complex pathways among trauma exposure, intimate partner violence, and risks for child maltreatment also will be explored in the context of discussing the challenges faced by clinicians working with substance abusers in recovery and their families.

Current Research Tells Us

  • Trauma exposure and trauma-related conditions are widespread among female substance abusers, and the rates are also very high for men in addiction treatment.

  • Childhood trauma may be a specific causal factor in the development of substance use disorders for women.

  • Integrated models of trauma and addiction treatment are more effective than treatments that target only the substance use disorder(s).

Considerations for Putting Research to Actual Use

  • What types of resources and supports do treatment programs and clinicians need to address trauma-related comorbidity?

  • What are "best practices" for individuals with trauma-related disorders presenting for addiction treatment?

  • Will existing and new treatments for trauma and addiction be sustainable at community-based treatment organizations?

Considerations for Future Research

  • What areas should be targeted for future behavioral and pharmacotherapeutic treatment development?

  • How do we best evaluate whether a treatment is effective?

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Substance Abuse and Coexisting Disabilities
Kenneth Perez, M.S., New York State Office of Alcoholism and Substance Abuse Services
Wayne A. Gordon, Ph.D., ACSW, CASAC, Mount Sinai School of Medicine
Deborah H. St. John, M.S., ACSW, CASAC, Private Practice
Dennis C. Moore, Ed.D., Wright State University School of Medicine

This workshop will describe issues related to providing substance use disorder treatment for persons with coexisting disabilities. It also will overview what is known about the prevalence of persons with coexisting disabilities in treatment and the challenges confronting treatment providers and researchers. Areas for future research will be suggested.

Current Research Tells Us

  • A significant percentage of persons entering substance use disorder treatment may experience coexisting disabilities.

  • Persons with the most severe disabilities may have few, if any, treatment alternatives.

  • Programmatic and policy changes may be necessary to adequately serve persons with disabilities in traditional substance use disorder treatment settings.

Considerations for Putting Research to Actual Use

  • Some functional impairments may necessitate changes in treatment approach, dosage intensity, or outcome expectations.

  • Previous substance use disorder research has tended to exclude persons with disabilities.

  • Monitoring outcomes may be more difficult for individuals with coexisting disabilities than for a general treatment population.

  • State and Federal databases contain inadequate information on which to make policy decisions.

Considerations for Future Research

  • How can we identify the accommodations most important for treatment success?

  • What are the average costs, in funding and other resources, for providing needed accommodations to persons with disabilities?

  • How can programs be modified within the existing community treatment systems?

  • How can we estimate the number of persons with disabilities in need of substance use disorder treatment?

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How Does the AOD Provider Prepare To Integrate the Use of Addiction Medicines and Clinical Behavioral Treatment?
Steven Kipnis, M.D., FACP, New York State Office of Alcoholism and Substance Abuse Services
Joy Davidoff, M.P.A., New York State Office of Alcoholism and Substance Abuse Services

This workshop will be an interactive exercise with full audience participation. The purpose of the workshop is to extract from the audience potential barriers that they have experienced or foresee in using medications as an adjunct to clinical behavioral treatment of substance abuse. Of significant importance is ensuring that addiction medicines will work with and enhance clinical behavioral treatment. This requires that program administrators and medical and clinical staff members work together to develop integrated protocols and systems.

Current Research Tells Us

  • Three major medications are under study for alcohol treatment: naltrexone, nalmephene, and acamprosate. Many medications are being studied for a wide range of addictions.

  • Psychological and pharmacological treatments are complementary and may be combined effectively.

  • Pharmacotherapy with aversive or anticraving medications may supplement behavioral treatment approaches.

Considerations for Putting Research to Actual Use

  • How do providers implement the use of addiction medicines?

  • What are the barriers to integrating addiction medicines into clinical treatment?

  • What current practices or systems need to be modified to incorporate delivery of medications to patients who may benefit from both counseling and addiction medications?

Considerations for Future Research

  • Is there an implementation process that can be developed to effectively integrate addiction medicines as an adjunct?

  • Do medications, when used in an adjunctive role, improve treatment outcomes?

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Treatment of Marijuana Abuse and Dependence
Frances R. Levin, M.D., New York State Psychiatric Institute and Columbia University
Margaret Haney, Ph.D., New York State Psychiatric Institute and Columbia University
Jonathan A. Spears, M.S.W., ACSW, Counseling Service of the Eastern District of New York

This workshop is designed to focus on treatment issues for marijuana-dependent individuals. The workshop will examine the extent of the problem, the potential impact of marijuana withdrawal on retention and treatment response, and therapeutic strategies that are currently practiced in the community or being empirically tested.

Current Research Tells Us

  • Marijuana abuse and dependence are significant problems.

  • Heavy users experience substantial withdrawal symptoms.

  • Treatment strategies that incorporate motivational enhancement and contingency management strategies may improve treatment outcome.

Considerations for Putting Research to Actual Use

  • What types of withdrawal symptoms can be expected to affect treatment outcome?

  • Can combined psychotherapeutic approaches be applied in community settings?

  • What types of outcome measures should be used to assess treatment improvement?

Considerations for Future Research

  • Are some treatment issues unique to marijuana-dependent individuals compared with other substance abusers seeking treatment?

  • What psychotherapeutic approaches need to be further tested?

  • Is there a role for pharmacotherapy for targeted subpopulations of marijuana-dependent individuals?

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Craving, Addiction, and the Brain: How Can We Apply This to Treatment?
Anna Rose Childress, Ph.D., University of Pennsylvania School of Medicine
Steven J. Grant, Ph.D., NIDA
Kevin Michael Wadalavage, M.A., CASAC, Outreach Project, Inc.

Accumulated evidence over the past 5 years shows that drug craving, particularly cue-induced drug craving, can be linked to activation of specific pathways in the brain, particularly those involved in reward and the anticipation of reward. The activation of this powerful "GO!" system may explain part of why patients struggle with craving and relapse. Another important piece of the puzzle is why some patients have so much more difficulty than others in "STOPPING," or managing, their craving. Recent brain findings show that some patients may have defects in the brain's "STOP!" circuitry, which is important in taking into account the future consequences of behavioral choice. These brain-based problems - plenty of GO! and not enough ability to STOP! - have important implications for how we view addiction and how we structure treatments to address craving and relapse.

Current Research Tells Us

  • Cues for cocaine, heroin, and nicotine activate powerful limbic GO! circuits in the brain.

  • Cocaine patients have hypoactivity and less gray matter density in regions that are important for STOPPING drug craving (and other impulses) and for making good decisions.

  • Cocaine patients show defects on tests of decisionmaking, and brain imaging data suggest that these patients may not even experience activation of the same brain circuits as nonusers when making decisions.

Considerations for Putting Research to Actual Use

  • These findings tell us that craving is not just a matter of "commitment" or "will" - it has a strong biologic basis, as does the ability to inhibit it.

  • Treatments need to address not only the triggers for craving (the GO! problem) but also the difficulty with inhibiting impulses (the STOP! problem).

  • Some of the strategies we use now - such as asking patients to consider future consequences when craving - can be effective, IF the patients have some STOPPING ability. But what if they do not?

  • Assessment of a patient's pull by cues (how much GO!) and ability to inhibit (how much STOP!) may be a useful part of pretreatment planning.

Considerations for Future Research

  • Can we use brain imaging or other nonimaging tests to characterize patients along the dimensions of GO! and STOP!? To determine whether treatment has improved either or both problems? To screen potential behavioral and medication treatments?

  • Can we screen at-risk populations for potential GO!-STOP! problems to help prevent the development of addiction?

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Naltrexone Revisited
Laura F. McNicholas, M.D., Ph.D., Philadelphia Veterans Affairs Medical Center and University of Pennsylvania School of Medicine
Sherri Gillette, M.S., CASAC, St. Lawrence Addiction Treatment Center, New York State Office of Alcoholism and Substance Abuse Services
Jami Rothenberg, Ph.D., New York State Psychiatric Institute and Columbia University
Maria A. Sullivan, M.D., Ph.D., New York State Psychiatric Institute and Columbia University

This workshop will discuss the use of naltrexone in the treatment of opioid dependence and in the treatment of alcohol dependence. It will describe methods of integrating naltrexone into treatment programs and the effective use of this medication in the treatment of patients. Barriers to integration will be discussed in the context of treating both opioid- and alcohol-dependent patients.

Current Research Tells Us

  • Naltrexone is an effective antagonist of the opioid mu-receptor.

  • Some alcohol-dependent patients respond to alcohol by releasing endogenous opioids.

  • Naltrexone can be effective in decreasing relapse to alcohol in alcohol-dependent patients.

Considerations for Putting Research to Actual Use

  • Models of integrating naltrexone into treatment programs will be discussed for the treatment of alcohol-dependent patients.

  • Models of integrating naltrexone into treatment programs will be discussed for the treatment of opioid-dependent patients.

  • Various behavioral approaches in the treatment of these patients, in conjunction with the use of naltrexone, will be discussed.

Considerations for Future Research

  • What barriers exist to the use of naltrexone, and how can they be addressed?

  • What role will new formulations of naltrexone play in integrating naltrexone into treatment?

  • Are there specific populations for whom naltrexone is particularly effective, and how do we identify them?

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Motivational Incentives/Contingency Management
Scott Kellogg, Ph.D., Rockefeller University
Joseph Krasnansky, CSW, Lower Eastside Service Center, Inc.
Marion Schwartz, M.S.W., CSW, New York University School of Medicine
Maxine Stitzer, Ph.D., Bayview Medical Center, Johns Hopkins University

Dr. B.F. Skinner believed that the best way to change behavior was through positive reinforcement. The contingency management or motivational incentive approach, using a structured yet straightforward design, seeks to reward patients for successfully abstaining from substance use. Using clear criteria, rapid onsite urine testing, and immediate reinforcement in terms of vouchers or gifts when patients present drug-free urine samples, motivational incentive programs have a powerful impact on retention and reduced substance use in both methadone and drug-free treatment centers. The goal of this workshop is to familiarize clinicians with (1) the behavioral principles involved in contingency management, (2) the exciting and creative research that has been done in this area, and (3) the challenges and successes that both researchers and clinicians are experiencing as they attempt to implement this program in two clinics in New York City.

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Methadone and Beyond: Medication and Its Role in Treating Addiction
Mary Jeanne Kreek, M.D., Professor and Head, Senior Physician, Rockerfeller University Hospital

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Where Will We Be in 5 to 10 Years
Mitchell S. Rosenthal, M.D., Phoenix House Foundation, Inc.

There is an assumption that research determines the direction in which practice moves. But funding and referral choices today are as likely to be influenced by policy and economic considerations as by what science has to say. Moreover, the influence of research in practice need not always be beneficial. Research tends to focus attention on what has most recently been illuminated, and this may not necessarily be what practitioners most need to address. Understanding how drug abuse changes brain chemistry, for example, has led to an understandable emphasis on -- and elevated expectations of -- pharmacological solutions to addiction. As a result, less attention has been paid to social and humanistic interventions, without which pharmacotherapies are of only limited utility. These two plenary presentations will explore what the future holds for the treatment of drug addiction. However, looking 5 or 10 years ahead, we should bear in mind that pharmacology is only a part of the picture. When dealing with most addictive disorders, the needs of the whole person must also be addressed.

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Sponsored by
National Institute on Drug Abuse
National Institutes of Health
Department of Health and Human Services

In partnership with
The New York CTN Node/New York University School of Medicine
The Long Island CTN Node/Columbia University and New York State Psychiatric Institute
New York State Office of Alcoholism and Substance Abuse Services
Alcoholism and Substance Abuse Providers of NYS
Northeast Addiction Technology Transfer Center (ATTC)
New York State Practice Improvement Collaborative (PIC)



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