Treatment for Individuals who Use Stimulants
A Protocol Using Empirically-Supported Behavioral Treatments for People with Stimulant Use Disorders
The authors of this manual have been involved in StimUD-related research, treatment, and training efforts for over 30 years. Over this period, the research on StimUD and its treatment has vastly increased and there is a great interest in better understanding StimUD and providing effective treatment for people who use cocaine and methamphetamine.
We have produced this manual to promote the use of research-supported strategies for StimUD treatment. The manual attempts to combine a number of strategies into a framework that is appropriate for use by clinicians in settings where people with StimUD receive treatment. This manual is not intended to be a cookbook and the materials used and the framework for their use are not intended to be an inflexible, one-size-fits-all prescription. At the end of the manual, we list a variety of treatment materials (see Appendix) that can be added or substituted for the ones we are recommending. We provide the contents of this manual and the framework for combining these treatment materials as one example for how research-supported strategies can be combined into a structured treatment experience.
The manual was developed at a time when CM with adequate incentives was considered impossible in the U.S. Hence, this manual was produced to offer a possible, albeit a non-evidence-based and certainly less effective alternative to CM.
As evidence-based CM protocols using adequate incentives are increasingly being developed and implemented in the U.S., there is interest in having CM delivered within a framework of other evidence-based behavioral support. The use of the materials in the TRUST Manual to augment CM treatment is another possible use of the manual, either in the form of a 12-week framework, or as ad hoc behavioral support materials.
The audience for the manual includes healthcare professionals who provide treatment services for individuals with StimUD. One category of these professionals who we particularly hope will benefit are therapists and other behavioral health clinicians who work in substance use disorder specialty care treatment programs. The manual has been written with this group in mind.
The manual intends to:
- Provide new information about the use and effects of cocaine and methamphetamine.
- Present several key clinical challenges that clinicians face when treating this population.
- Review the evidence-based treatment strategies for StimUD treatment.
- Discuss how motivational interviewing (MI) is central to the effective engagement of individuals in treatment and to assisting them with behavior change during treatment.
- Present how elements of community reinforcement approach (CRA) and cognitive behavioral therapy (CBT) can be used to assist individuals with StimUD to reduce/discontinue their drug use and prevent relapse.
- Describe a procedure for incorporating positive incentives into the treatment milieu and/or support the use of CM for the treatment of StimUD.
- Provide information and guidance for how physical exercise can benefit individuals who are attempting to reduce/discontinue their use of methamphetamine and cocaine.
- Describe a plan for providing continuing care to assist individuals to sustain the progress they have made in a structured treatment program.
- List an array of manuals and training resources for other research-supported substance use disorder treatment approaches.
For those working with people receiving care for Opioid Use Disorder, an adapted version is available
Treatment for Individuals who Use Stimulants while on MOUD
THERAPIST MANUAL & PATIENT WORKBOOK
The TRUST MOUD Manual is intended to be used with patients who are struggling with stimulant (cocaine/amphetamine) use while in treatment for OUD with methadone, buprenorphine, or naltrexone.
Working with patients presenting in MOUD treatment is a challenging, yet incredibly rewarding experience. While it is rewarding, it can also be frustrating. Stimulant use among these patients is common and many patients don’t see their use as problematic. In fact, for some patients who use stimulants sporadically, they may not need treatment. But certainly, for some patients on MOUD, cocaine/meth use is extremely detrimental to the effectiveness of their MOUD treatment and is a serious health problem. However, in many cases, regardless of the severity of use, the patients often don’t recognize their stimulant use as a problem, and they are not interested in intensive treatment.
The materials in the TRUST MOUD Manual attempt to provide this patient population with a useful set of information in a format that they find acceptable. The materials adopt CRA, CBT, and MI content and present it in a clear and relevant form that addresses the challenges they face while in MOUD treatment. We try to avoid long, didactic, lecturing materials, but rather try to create accessible topics and examples.
TRUST was developed with flexibility in mind to optimize patient engagement and retention. TRUST materials can be presented in 1:1 sessions and can be scheduled with patients or in on-going stimulant treatment groups. Topics can be presented in a sequence and frequency that lets therapists select content to meet patient needs. The 24 TRUST worksheets can be used in a flexible manner to be relevant and useful to patients.
Consistency is important when using the TRUST Manual. Set and adhere to meeting days and times. Start and end sessions on time. If used in a group format, have some group participation guidelines. Adhering to a specific session format and timing will enhance patients’ understanding of the group/individual session process and will allow them to focus on acquisition of new material.
Patients using stimulants will undoubtedly experience cognitive impairment as they participate in sessions and utilize the TRUST materials. Slowing down to allow patients to gather their thoughts and express themselves during group or individual sessions is important. In addition, using multi-media and repetition can be helpful for patients to grasp new concepts.
Use of Motivational Interviewing as a fundamental style and interpersonal approach is essential to success when using TRUST materials.
Ideally, TRUST session attendance should be paired with medication visit attendance to reduce the travel burden on patients. This is especially true in rural areas, where public transportation is non-existent, or when a patient has employment, education, or homemaking responsibilities. When possible, patients should have an opportunity to determine therapy visit days and times based upon their scheduling needs.
Research has shown that aerobic exercise improves cognitive capacity, reduces depression and anxiety, and improves cardiac and pulmonary function for individuals with stimulant use disorder. Several of the TRUST worksheets discuss the benefits of exercise as part of a treatment effort to reducing stimulant use. Encouraging patients to exercise will also help them to manage emotional highs and lows and help them structure their day. Getting patients to exercise is often difficult and requires ongoing encouragement and support.
The TRUST materials and their use with patients on MOUD should be used with a strong harm reduction foundation. The #1 priority for this group of patients is retention in treatment with MOUD. Participation in treatment activities with TRUST materials, when appropriate, should be encouraged, rewarded, and praised. In our opinion, requiring treatment attendance with TRUST materials, with a threat of MOUD discontinuation is never justified. In an era of lethal drugs including fentanyl, retention on MOUD is essential.
Other harm reduction activities should be combined with TRUST materials. Access to safe injection supplies, ready access to naloxone and fentanyl test strips, and as new drugs emerge (e.g., xylazine), it is critical to provide new information and test strips as they become available.
Many patients in MOUD treatment have multiple life challenges, including use of numerous drugs and alcohol, food insecurity, being unhoused, unemployment, as well as both mental health and physical health issues. To be successful, patients will need to be retained in treatment for a significant period of time, if not for a lifetime. These issues are not going to be resolved overnight, but rather through consistent and prolonged effort.
We hope these materials can be useful to your work with patients on MOUD.
Richard Rawson, PhD
Richard A. Rawson, PhD, is Professor Emeritus at the UCLA Department of Psychiatry and a Research Professor at the Vermont Center for Behavior and Health at the University of Vermont. He received a Ph.D. in experimental psychology from the University of Vermont in 1974. Dr. Rawson conducted numerous clinical trials on pharmacological and psychosocial addiction treatment and extensive system evaluation activities in a number of states and countries. He has led addiction research and training projects for the United Nations, the World Health Organization, and the U.S. State Department, exporting science-based knowledge to many parts of the world. Dr. Rawson has published 3 books, 40 book chapters, and over 250 peer-reviewed articles and has, for almost 50 years, conducted workshops, paper presentations, and training sessions in many areas of the world.
Albert Hasson, MSW
Albert L. Hasson received his MSW from UCLA and has worked in the field of addiction medicine as a researcher and a treatment provider since 1977. Mr. Hasson participated in the development of the evidence-based Matrix Model, a cognitive behavioral intervention for StimUD Treatment, and established the Matrix Institute on Addictions, Los Angeles opioid treatment program. Along with his administrative and clinical experience, Mr. Hasson has extensive experience in implementing and evaluating behavioral and pharmacologic interventions. He has served as a project director and trainer for the Pacific Southwest Addiction Technology Transfer Center at the UCLA Integrated Substance Abuse Programs.
Janice Stimson, PsyD
Janice Stimson, PsyD, has worked in the field of addiction treatment since 1998. For 20 years she has worked at the Matrix Institute on Addictions in the role of Clinic Director, overseeing and managing the clinic, seeing clients and supervising staff. At the clinic private adolescent and adult treatment programs coexisted along-side national research studies. Dr. Stimson held key positions in those studies and was responsible for ensuring the success of fulfilling recruitment, training, supervision, and protocol requirements.
Michael McCann, MA
Michael McCann, M.A., is one of the founders of the Matrix Institute on Addictions and creators of the Matrix Model. He has overseen the operation of Matrix clinics as well as the integration of many research projects within these sites. He has over 40 years of experience in substance use disorder treatment and research, and has authored or co-authored over 40 articles, books, and manuals. He has trained and lectured extensively on evidence-based behavioral interventions, pharmacologic treatments, methamphetamine dependence, opioid dependence, and on the implementation of evidence-based treatments into clinical practice
The authors would like to acknowledge the assistance provided by Thomas E. Freese, PhD, Beth Rutkowski, MPH, Gloria Miele, PhD, and Valerie P Antonini, MPH. Christine Morgan provided invaluable support with the production of the manual, along with editing support from Victoria T. Norith and Benjamin Nguyen, MSW, CPH.
The materials in this manual include content and worksheets from the Matrix Model Therapist Manual (SAMHSA, 2006); from the Community Reinforcement Approach, plus Vouchers Manual (NIDA, 2020).