1. Grounding Frequent Flyers Best Practices for recidivism reduction Presented by Tenesha L. Curtis, B.A. UNIVERSITY OF LOUISVILLE KENT SCHOOL OF SOCIAL WORK

2. Presentation Outline Evidence-based practice problem JADAC currently Question Methodology Interviews Practice Implications

3. Operating (JADAC, The Brook, etc.) based on evidence (as opposed to tradition, popularity, etc.) EBP brings together research from studies, client experience, and clinician experience and wisdom in order to formulate the best course of action to accomplish the goals of the agency, such as the best course of action to help keep addicts clean at JADAC. Evidence-Based Practice

4. Evidence-Based Practice

5. Evidence-Based Practice Steps 1. ID the problem/issue. 2. Formulate answerable question. 3. Find the best research relevant to the question. 4. Critically appraise findings for relevance, validity, etc. 5. Apply strongest method to practice. 6. Evaluate results of changes.

6. A Very Simplistic Example of Steps in Action ID the problem: “I’m out of pain pills!” Formulate Answerable Question: “What’s the easiest, fastest way for me to get more pain pills?” Find the best research: Magazine article says to fake pain at doctor’s office; doctor’s say pain they can’t detect means they prescribe more pain pills to people; other addicts say faking back pain works best Appraise research: “I think faking pain is good, but faking back pain sounds like my best bet!” Apply method: “Doc, I really got this terrible pain in my spine…” Evaluate: “I was only at the doctor’s office for ten minutes and got a 90-day supply of pain pills. This method works!”

7. The Problem Keeping addicts sober after they leave treatment.

8. The Question For chemically dependent adults, what are the most effective interventions for preventing post-inpatient detoxification recidivism? In other words, what can we do during the client’s time with us to help keep them clean once they leave treatment?

9. The JADAC Way Components of JADAC’s current operations Abstinence Only Mixed Gender 12-step facilitation and referral Cognitive Behavioral / Reality Therapy

10. TheEBPWay According to my research, the way JADAC “should” operate Pharmacological Assistance Cocaine “vaccine”, buprenorphine, methadone, antabuse Single-Gender Mixed gender facilities are counterproductive for females attempting to recover 12-step Facilitation and Referral Bring meetings in, send clients to meetings, and tell them to keep going to meetings after treatment Motivational Interviewing ( CBT/RT) Motivational interviewing sessions after each step of the CD treatment process. Session 1: Detox Prep; Session 2: Residential Prep; Session 3: Discharge Prep (to keep levels of motivation high through the treatment process). Cognitive Behavioral and Reality Therapy can come afterwards.

11. Methodology

12. Methodology

13. Methodology: Lit Review Searched a multitude of databases (via Minerva/Ebsco) Keywords: drug abuse; substance abuse; substance dependence; chemical dependency; recidivism; reduction Research from 1999 – 2009, only from peer-reviewed journal articles Each article appraised, scored, and ranked for rigor, reliability, and relevancy; only top ten chosen for use

14. Lit Review: Results Big Three Naltrexone Blocks ‘high’ only AFTER drug has been taken—therefore would eventually create a neutralization so that taking drug was about as interesting as watching paint dry. Weaning / life-long administration—like Antabuse, there is no true incentive for an addict to continue administering the drug since they know that if they don’t, they will get the high back. Because there is not internal motivation to stop using, naltrexone could possibly have to be administered for life. Drug Avoidance Skills Training Practicing avoiding common drug scenarios Practical application of tips and tricks—like the ones talked about in the relapse prevention lecture. Relapse prevention and subsequent release into the outside world is equivalent to reading the Kentucky driver’s manual to someone, and them telling them to practice driving on the highway between two semis in an ice storm. Whereas, adding DAST to the equation means the manual is read to the students, the students get a chance to practice driving around the neighborhood under various weather conditions, and THEN they get to go on the highway, given them a much better chance of not having an accident/relapsing. Motivational Interviewing Learn client’s motivations for behaviors Use client’s internal motivations to move them towards recovery If you can visualize our clients as wind-up toys, JADAC would be the type of facility that picks the toy up and makes it move forward, left, right, etc. Whereas, with MI, you are simply turning the key to set the mechanisms within the client to make them move forward on their own.

15. Methodology: Practitioner Interviews Six questions; Four CD Techs and Counselors Current Issues Themes Revolving Door: Especially rapidly readmitting those who have severely disturbed the treatment community in the (recent) past. Discipline: As it stands now, clients occasionally get ‘contracts’ or a ‘talking to’ from their counselor. Possible Changes Themes Waiting Period / Pre-requisite(s) for Readmission: Make the disruptive client showcase their commitment to following program guidelines by having specific assignments they must complete related to their previous behavior (making amends, in a sense) before they are allowed back into the program. Swift, Significant Consequences for Transgressions: Something meaningful to the client should be removed relatively quickly for breaking rules.

16. Methodology: Consumer Interviews Four questions; Four current clients Opiates; Benzodiazapines; Methadone; Marijuana; and Alcohol addicted persons were represented in this sample. Current Treatment Theme The clients feel that the overall treatment experience at JADAC is positive, with a few minor issues to be addressed such as having more recreation time and allowing there to be more activities for non-smokers to engage in while the nicotine addicts are smoking outside. Possible Change Themes Clients seemed to enjoy the prospects of having motivational interviewing or naltrexone added to their treatment (once these were explained to those who had not heard of them), but were fearful of drug avoidance skills training due to thinking they may be triggered strongly enough to leave. Which is interesting considering that they will definitely run into these scenarios in the outside world. I interpret that as them understanding that they believe they will definitely relapse if these situations come up once they leave treatment.

17. Evidence Consistency

18. Practice Implications For JADAC these results mean the agency ‘should’: Begin agency-wide use of MI and MI Principles Possibly incorporate DAST into curriculum, if it feels it can take steps to alleviate major client fears and guard against client departure from the program

19. Desired Outcomes Clinicians use MI principles throughout their interactions with clients (groups, classes, etc.) (Especially opiate) addicts stay in treatment longer Fewer clients relapse (instead of 85% relapsing, only 30% relapse) Clients relapse less (the average amount of times in treatment drops from 6 to 2) JADAC provides clients with top-level, research-supported treatment services

20. Comments? Teneshacurtis.com/jadac.html Questions?

21. References Brown, Thomas G.; Seraganian, Peter; Tremblay, Jacques; Annis, Helen. Process and outcome changes with relapse prevention versus 12-Step aftercare programs for substance abusers. Addiction, Jun2002, Vol. 97 Issue 6, p677 Farabee, David; Rawson, Richard; McCann, Michael. Adoption of drug avoidance activities among patients in contingency management and cognitive-behavioral treatments. Journal of Substance Abuse Treatment, Dec2002, Vol. 23 Issue 4, p343 Kakko, Johan; Svanborg, Kerstin Dybrandt; Kreek, Mary Jeanne; Heilig, Markus. 1-year retention and social function after buprenorphine-assited relapse prevention treatment for heroin dependence in Sweden: a randomised, placebo-controlled trial. Lancet, 2/22/2003, Vol. 361 Issue 9358, p662

22. References (page 2) Martell, Bridget A.; Mitchell, Ellen; Poling, James; Gonsai, Kishor; Kosten, Thomas R.. Vaccine Pharmacotherapy for the Treatment of Cocaine Dependence. Biological Psychiatry, Jul2005, Vol. 58 Issue 2, p158-164 Olmstead, Todd; White, William D.; Sindelar, Jody. The Impact of Managed Care on Substance Abuse Treatment Services. Health Services Research, Apr2004, Vol. 39 Issue 2, p319-344 Roll, John M.; Petry, Nancy M.; Stitzer, Maxine L.; Brecht, Mary L.; Peirce, Jessica M.; Mccann, Michael J.; Blame, Jack; MacDonald, Marilyn; Dimaria, Joan; Kellogg, Leroy Lucero Scott. Contingency Management for the Treatment of Methamphetamine Use Disorders. American Journal of Psychiatry, Nov2006, Vol. 163 Issue 11, p1993-1999

23. References (page 3) Schmitz, Joy M.; Stotts, Angela L.; Sayre, Shelly L.; DeLaune, Katherine A.; Grabowski, John. Treatment of Cocaine–Alcohol Dependence with Naltrexone and Relapse Prevention Therapy. American Journal on Addictions, Jul-Sep2004, Vol. 13 Issue 4, p333-341 Stein, L. A. R.; Lebeau-Craven, Rebecca. Motivational Interviewing and Relapse Prevention for DWI: A Pilot Study Journal of Drug Issues, Fall2002, Vol. 32 Issue 4, p1051-1069 Walton, M., Blow, F., & Booth, B. (2001). Diversity in relapse prevention needs: gender and race comparisons among substance abuse... American Journal of Drug & Alcohol Abuse, 27(2), 225. Wiesbeck, G. A.; Weijers, H. -G.; Wodarz, N.; Lesch, O. M.; Glaser, T.; Boening, J.. Gender-related differences in pharmacological relapse prevention with flupenthixoldecanoate in detoxified alcoholics. Archives of Women's Mental Health, 2003, Vol. 6 Issue 4, p259-262