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THE BRAVE NEW WORLD OF COMPUTERIZED INTERVENTIONS FOR ADDICTION [email protected] PSYCHOTHERAPY DEVELOPMENT CENTER WEBSITE: PDC.YALE.EDU NIDA R3715969, K05-DA00457, U10 - 015831 & P50 DA09241 DISCLOSURE: DR. CARROLL IS A MEMBER IN TRUST OF CBT4CBT LLC OVERVIEW 1. 2. Development and of computerized CBT How could web-based interventions improve how we treat addiction? • Dissemination and accessibility • Tailored treatments THE NIH STAGE MODEL, 2014 ONKEN, CARROLL, SHOHAM, CUTHBERT & RIDDLE; PSYCHOLOGICAL SCIENCE, 2, 22-24. COGNITIVE-BEHAVIORAL THERAPY CBT • Based on functional analysis of substance use • Emphasis on learning/implementation of coping skills • Functional analysis and patterns of use • Coping with craving • Addressing ambivalence and coping with thoughts • Refusal skills • Seemingly irrelevant decisions • Problem solving skills CARROLL ET AL (1994) Arch Gen Psychiatry, 121 cocaine users, 1 year follow-up 0.7 Clinical mgmnt. ASI Composite Scores 0.6 CBT 0.5 0.4 0.3 0.2 Delayed emergence Of effects 0.1 0 Pretreatment Point (0) End 2 4 6 Months After Treatment 8 10 12 HOW SUCCESSFUL HAVE WE BEEN IN MOVING EVIDENCE BASED THERAPIES INTO CLINICAL PRACTICE? • Programs, clinicians report high levels of use of empirically supported approaches, including CBT • Increased pressure to do so by payors • NO actual data from session tapes ….till now… ANALYSIS OF 379 TAPES OF “STANDARD TREATMENT” WHAT INTERVENTIONS NEVER OCCURRED IN TAU? Emphasize abstinence Spirituality Cognition Ambivalence % rated NEVER Risk reduction training Skills training 0 10 20 30 40 50 60 70 80 90 10 0 Percent of sessions where adherence score =1 FREQUENCY OF ‘CHAT’ BY TREATMENT CONDITION: CTN MET VS TAU 4 3.5 3 2.5 MET TAU 2 1.5 1 0.5 0 Session 1 Session 2 Session 3 STAGE III LEADS BACK TO STAGE I: DISSEMINATION BACK TO DEVELOPMENT Manualized Treatment (CBT) Delivered through clinician Low ‘dose’ of CBT WHY COMPUTER FACILITATED DELIVERY OF EVIDENCED BASED TREATMENTS? • • **Effective implementation of CBT very rare in clinical practice Only a small fraction of people with addiction-related problems access treatment • Save clinicians time, use as clinician extenders • Broadly accessible, available 24/7 • Facilitated delivery via multimedia presentation • Standardization, quality control • Individualization, repetition, flexibility • Facilitation of systematic evaluation of components (moderators & mechanisms of action) CORE PRINCIPLES: CBT4CBT DEVELOPMENT • Highly engaging-capture attention of substance users, retain them in treatment • Deliver potent dose of evidence based cognitive and behavioral strategies-focus on key generalizable skills • Durability of effects-skills practice • Modeling-demonstration of skills in realistic situations under stress • Breadth of users-all drugs, balance of gender and ethnicity • Security- NO identifying information or protected informantion ‘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 Multiple strategies for presenting skills Video examples of characters struggling real life situations Repeat movie with character using skills to change ‘ending’ Interactive exercises, quizzes Multiple examples of ‘homework’ OVERVIEW: FIRST RANDOMIZED CLINICAL TRIAL • 8 week randomized clinical trial • Outpatient community treatment program • Standard treatment (weekly individual + group therapy) (TAU) vs. CBT4CBT + TAU • CBT4CBT offered in up to 2 weekly sessions • 6 month follow-up Carroll et al., Am J Psychiatry, 2008 PARTICIPANTS, FIRST TRIAL, N=77 “All comers”: few restriction on participation, only require some drug use in past 30 days • 43% female • 45% African American, 12% Hispanic • 23% employed • 37% on probation/parole • 59% primary cocaine problem, 18% alcohol, 16% opioids, 7% marijuana • 79% users of more than one drug or alcohol PRIMARY OUTCOME (% DRUGPOSITIVE URINE TOXICOLOGY SCREENS), 8 WEEKS 80 70 53 60 50 40 34 CBT4CBT + TAU TAU 30 20 10 0 % drug positive urines Carroll et al., 2008, Am J Psychiatry PRIMARY OUTCOME: LONGEST CONSECUTIVE ABSTINENCE, IN DAYS, AT 8 WEEKS BY TREATMENT 30 22 20 15 CBT4CBT + TAU TAU 10 0 Longest continuous abstinence Carroll et al., 2008, Am J Psychiatry SKILL LEVEL THOUGH 6 MONTH FOLLOW-UP: QUALITY OF BEST RESPONSE BY CONDITION 6 5 CBT4CBT TAU 4 3 Baseline End of tx-8 wks Follow-up 20 weeks Kiluk et al, Addiction, 2010 DURABILITY OF EFFECTS: 6 MONTH FOLLOW-UP Estimated Days of Any Drug Use from Treatment Endpoint to Follow- Up Month 6 8 7 6 5 4 3 2 1 0 0 1 4 3 2 CBT 5 6 TAU Carroll et al., 2009, Drug & Alcohol Depend QUALITY OF COPING SKILLS AS MEDIATOR OF OUTCOME IN CBT4CBT Coping Skills (2) b=.3* (3) b=8.3** % positive urine CBT v TAU (1) b=5.2* (4) b=3.3 Kiluk et al, Addiction, 2010 COST EFFECTIVENESS: COMPARISON ACROSS TREATMENTS AND STUDIES, OLMSTEAD ET AL., DAD, 2010 (OUTCOME=LONGEST DAYS ABSTINENCE (LDA) INCREMENTAL COST EFFECTIVENESS RATIOS (ICERS) Treatment Base Case ($) Favorable Scenario ($) CBT4CBT 50 -31 MET/CBTa 102 77 Prize CM – MMb 141 115 Prize CM – DFc 258 163 aMET/CBT = motivational enhancement therapy + clinician-delivered CBT bPrize CM – MM = prize-based contingency management in methadone clinics cPrize CM – DF = prize-based contingency management in drug free clinics OVERVIEW: SECOND RANDOMIZED TRIAL • 101 DSM-IV cocaine-dependent methadone maintained opioid users population • • • • Standard methadone maintenance (TAU) vs. CBT4CBT + TAU CBT4CBT offered in up to 2 weekly sessions, 6 month follow-up Sample: 60% female, 40% minority, 89% unemployed, higher levels psychiatric comorbidity (29% depressive disorder, 30% anxiety disorder), multiple other substance use Carroll et al., Am J Psych. 2014 PRIMARY POST TREATMENT OUTCOMES: COCAINE-MMP SAMPLE Carroll et al., AJP, 2014 STATUS: CBT4CBT • Completed: 2 RCTs indicating efficacy and durability of CBT4CBT • • • No treatment related adverse effects Variety of populations: Outpatient, methadone maintenance, and VA Demonstration of skill acquisition, cost effectiveness and durability • Ongoing: • P50 Center: Enhance CBT4CBT outcome with galantamine • • • • • (placebo controlled RCT), fMRI, neurocog, genetics Evaluation of HIV module on drug/sex risk reduction Man versus Machine: CBT4CBT versus traditional therapist delivery Neural mechanisms of the Sleeper Effect Validation of alcohol-only version Randomized trial of Spanish version DEMO: CBT4CBT.com INNOVATORS/EARLY ADOPTERS, JUNE 2014-PRESENT • Clinical: Mass General Hospital; IOP • Clinical: Mercy Hospital, Springfield Mo • Pilot; Montana Drug Courts • RCT pilot, Zuni of New Mexico • RCT pilot, UCLA primary care practice • RCT, Prince Edward Island • RCT (pending), Columbia U HIV clinics POTENTIAL APPLICATIONS OF COMPUTERASSISTED THERAPIES • ‘Clinician extenders’ • Extending treatment benefits/ links to aftercare • ‘Extending clinician expertise (e.g., dual diagnoses) • Address overlooked issues (smoking) • Linking systems of care (SBIRT) • Behavioral platforms for pharmacotherapies • Reaching rural opioid users (tele-buprenorphine) • Homework apps for coaching • Early intervention/prevention for mild cases • TARGETING FUNDAMENTAL PROCESSES NEW DIRECTIONS-PDC YEARS 21-26 “NEUROPLASTICITY REPRESENTS A PLAUSIBLE BIOLOGICAL MECHANISM THROUGH WHICH PSYCHOLOGICAL INTERVENTIONS MAY EXERT SOME OF THEIR THERAPEUTIC EFFECTS” • Project 1: Kiluk/Carroll; Does cognitive control training prior to CBT enhance learning & outcome? Preparation (4 week) Neurocog + fMRI Neurocog 1. TAU 2. CM/abstinence 3. CM+cognitive control training - + fMRI Treatment (8weeks) CBT4CBT Neurocog + fMRI+ 6 month follow-up Changes in brain activity via fMRI: Comparison of Post- to Pretreatment, CBT4CBT versus TAU Stroop related activity dlPFC decreases from pre- to postCBT4CBT but not TAU CBT Stroop Post > Pre pFWE=.05 TAU Stroop Post > Pre X-=21 CATEHOL-O-METHYLTRANSFERASE GENE VAL158MET POLYMORPHISM (COMT) & TREATMENT OUTCOME N=82/101 EMOTIONAL (COCAINE) STROOP BY TREATMENT CONDITION (N=101) PROJECT 3: HEDY KOBER CRAVING TASK TREATMENT Assessment only Neurocog + fMRI Regulation of craving Training-cognitive 3x/week 4 weeks Regulation of craving training -mindfulness 3x/week 4 weeks Neurocog fMRI 1 month follow -up RECONNECTING CBT WITH COGNITIVE SCIENCE: CBT=COGNITIVE CONTROL TRAINING Concept Target/Assesment example Intervention concept Regulation of craving Distress tolerance, ROC ROC training Attentional bias IAT Attentional bias training Poor decision making Impulsive responding/BART/EDT Delay discounting Problem solving CANTAB, PFC tasks Problem solving, executive function Functional analysis Self-monitoring Working memory, Cognitions Cognitive/affective awareness PASAT THANKS. • Co-Investigators Luis Anez, Sam Ball, Dianne Duffey, Brian • • • • Kiluk, Donna LaPaglia, Steve Martino, Katie Nuro, Todd Olmstead, Manny Paris, Nancy Petry, Julia Shi, Michelle Silva, Caroline, Mehmet Sofuoglu, Dawn Sugarman, Kelly Serafini, & Bruce Rounsaville Team: Melissa Gordon, Theresa Babuscio, Matt Buck, Donna Cofrancesco, Joanne Corvino, Karina Danvers, Kay Debski, Kathleen Devore, Liz Doohan, Dorothy Eagan, Tami Frankforter, Karen Hunkele, Dave Iamkis, Dan Marino, Cindy Morgan, Charla Nich, Galina Portnoy, Liz Vollono, fMRI component: Marc Potenza, Hedy Kober, Elise Devito, Patrick Worhunsky, Iris Balodis, Jiansong Xu, Jud Brewer, Sara Yip, Cameron DeLeone, Maggie Mae Mell, Todd Constable Yale Media: Rick Leone, Craig Tomlin, Thom Stylinski & Lucas Swineford Clinical performance sites: RNP: John Hamilton, Tina Klem, Joanne Montgomery, APT: Lynn Madden, Nicole Belisle, Amanda Shackle, CMHC: Bob Cole, Luis Anez, Donna LaPaglia