Time for a treatment makeover?

Misuse of stimulants, including cocaine and methamphetamine, is on the rise, on their own and combined with opioids. Unlike opioids, there are no medications approved by the Food and Drug Administration (FDA) to treat addiction to cocaine or methamphetamine, or to any stimulants. This has resulted in increased interest in the Matrix Model, a behavioral treatment developed in the 1980s by Richard Rawson, PhD, professor emeritus of UCLA Integrated Substance Abuse Programs and research professor at the University of Vermont.

Rawson was executive director of the nonprofit Matrix Institute on Addictions from 1984-1988, and contributed to the development of the Matrix Model for outpatient stimulant addiction treatment. When Rawson officially went back to UCLA in 1997, he had to leave Matrix as a condition. The nonprofit was then run by Jeanne Obert until 2014, and it just recently merged with the Clare Foundation.

The model, delivered over 16 weeks of group sessions held three times a week, consists of relapse prevention, family therapy, group therapy and mutual support. The model has been shown to be effective in reducing sexual risk behaviors among people who use methamphetamine, decreasing the risk of HIV transmission. But Rawson tells Addiction Professional that the model badly needs to be updated. He now believes another treatment—a contingency management approach that provides rewards for desired behaviors—offers a better strategy for treating stimulant addiction.

The discussion of treatment strategies for stimulant dependence is taking on new urgency, amid concerns that history is repeating itself from the 1980s and 1990s when cocaine use increased dramatically in opioid use disorder (OUD) patients receiving medication-assisted treatment (MAT) with methadone.

In the past few months, Rawson says he has been getting calls from “all over the United States, where methamphetamine use is increasing, and where methamphetamine and cocaine use is interfering with the treatment of opioid use disorder patients on MAT. Based on what we saw in the methadone clinics of the 1980s and '90s, stimulant use could be a major public health problem for patients on MAT.”

But in an email to Addiction Professional, Rawson wrote in capital letters that “there is ZERO data from the use of the Matrix Model with this population” of MAT patients. “I would never recommend the application of the Matrix Model for treating this population.” Rather, he recommends contingency management.

“I do think some of the behavioral exercises from the Matrix manual could be useful to use together with contingency management, but contingency management is the [evidence-based practice],” he says.

He adds, “It’s time for people to find a way to use contingency management if they want to have meaningful impact in reducing stimulant use with primary stimulant users or especially with stimulant users on MAT for OUD.”

A look at the history

Here’s a historical perspective on Matrix, from Rawson.

He and partners developed the Matrix Model “as we tried to invent outpatient treatment for cocaine (and later methamphetamine users) in the 1980s,” he says. “We tried to apply the best current knowledge and used things like Alan Marlatt's work on relapse prevention. We developed a way of talking to patients about their brains and how addiction took control of their judgment and decision making, using the knowledge of cocaine effects at the time.”

This approach was interpersonal, emphasizing empathy, acceptance and a non-judgmental stance. The developers devised patient exercises emphasizing behavior change and cognitive strategies (such as “thought-stopping”), and tested these out with patients. After tracking treatment retention and urine test results, and with progress seemingly being made, the National Institutes of Health (NIH) started the Small Business Innovation Research (SBIR) grant program, under which small businesses could test products. This led to the Matrix manual, handouts, psychoeducation and instructions.

In the 1990s, after Barry McCaffrey took office as director of the Office of National Drug Control Policy (ONDCP), he convened a meeting on methamphetamine. Most of the presentations were derived from old data, or animal research, Rawson recalls. “We were the only ones with the new data,” he says. “We presented what we were doing. A decision was made to test the Matrix Model with a multi-site study.” That formed the basis for the Matrix Model being considered an evidence-based practice (EBP).

Changing the manual

The Matrix manual has been translated and disseminated widely, but perhaps not correctly, according to Rawson, who admits he has “been a big pain in the ass to my colleagues at Matrix.”

In Rawson’s mind, the manual was “always to be evolving and incorporating new knowledge and new findings,” he says. The point in developing it was to help stimulant users stop or reduce their use, but the simple application of a set of materials in 2018, in the same way they were delivered in 1988, isn't logical, he says.

“I think the materials have some useful clinical material for people working with stimulant users, but rather than fidelity, I would emphasize modifying and adapting the materials for new populations and settings, with new knowledge and new approaches,” Rawson says.

For at least a decade after he left Matrix, Rawson argues, Matrix training “became fixated on forcing people to use the materials in a very specific way.” This was done whether the work was in Beverly Hills, Calif. (where Matrix was developed) or in a rural village in Vietnam or South Africa, he says.

Around 2000 when the field started looking at behavioral treatment systematically, it became clear that even when discussing cognitive-behavioral therapy or motivational interviewing, it was important to ask how one knows that this is actually the service being delivered. “These are legitimate questions, and started the whole issue of fidelity to the model, and it advanced the way we studied psychosocial treatment,” says Rawson. “But it morphed into the large manuals, and this was a mistake.”

Rawson adds, “We didn’t develop the Matrix Model with the intention that it would be applied as a bible to stimulant users in all settings, with all types of stimulant users.”

Matrix had been developed in Southern California, with daily users of cocaine and methamphetamine, some of whom were injecting. “Over time, it became clear that stimulant users are a heterogeneous group,” he says.

The model, with three intensive sessions a week, and family involvement, just does not apply all over the world—even though that’s what happened. “For example, in Vietnam, amphetamine use is a tablet, which they take a few times a week,” he says. “To take this big intensive model and plop it down in a different culture with a different set of patients was a mistake.”

Obert, the former Matrix Institute CEO, tells Addiction Professional in a statement, “The Matrix model has been developed, researched and updated over decades. Published by both [the Center for Substance Abuse Treatment] and Hazelden, the model is an evidence-based approach to treating substance use disorders and its effectiveness is always enhanced when combined with contingency management and/or 12-Step involvement.”

Obert adds, “Within the last few years, Hazelden has published three updates and revisions to the Matrix Model. The most recent update, scheduled to be released soon, is a SAMHSA Matrix Manual that includes a section on medication-assisted treatment. The model continues to be adapted for specific populations and has trained over 6,000 medical professionals in 50 states and 21 countries.”

Stimulants vs. opioids

There is no good available data nationally on trends in stimulant use among patients receiving MAT for opioid use disorders. However, about 30% of patients on MAT in Vermont have positive urine tests for cocaine and about 5% have positive urine tests for methamphetamine, according to Rawson. There is agreement that stimulant use among patients on MAT is on the rise.

In a handful of patient interviews conducted in Vermont, Rawson discovered that patients found stimulants more “addicting” than opioids. This was a reflection of the fact that they used opioids to avoid withdrawal, while they used stimulants as a response to craving and a desire for drug effect.

Across the country, some patients on methadone and buprenorphine are also using cocaine or methamphetamine, says Rawson. “We’ve been so active getting people onto MAT for opioids, who are now turning around and using stimulants. What do we do about that?”

He sympathizes with physicians who want to prescribe buprenorphine. “They’ve been convinced that they should join the community effort to address opioid addiction, and they’re being heroes in primary care, doing wonderful work with these patients,” he says. And Vermont has had one of the most aggressive and effective models to treat opioid addiction: the hub and spoke model, which includes OTPs at the hub and buprenorphine prescribers, mostly in primary care, across the community.

“But nobody thought ahead,” says Rawson. “Here in Vermont, for example, the opioid market has shrunk with there being so many people on MAT.” In fact, between one-third and half of the people with opioid use disorders in Vermont are taking medications to treat it, so traffickers are looking for a way to try to keep their market, he says. “They had to switch from the opioid product to the stimulant product,” he says. And for patients on MAT, by definition they are at greater risk to develop future addiction than someone without a substance use disorder.

However, the investment in MAT is “worth every penny,” said Rawson, because it saves people from dying. “This just means we have to go back to the drawing board to provide assistance to address stimulant use with these patients,” he says. “It’s not like the story is over.”

Craving response

One of the biggest challenges in treating people dependent on stimulants is combating the Pavlovian trigger-craving response, in which triggers—people, places, and things that remind the person of the drug, as well as internal stimuli such as emotional states—provoke such a strong desire to use as to be almost insurmountable. Contingency management, however, has been shown to be one of the most effective ways to help stimulant users stay away from the drugs.

A good message to give patients involves education about conditioned cravings. The story of Pavlov’s dog, who drooled in response to the bell, is key. In response to triggers (such as the bell, which the dog had been conditioned to associate with food), the brain starts craving. This craving is automatic, and for many feels uncontrollable.

What doesn’t work for these patients, Rawson says: process group therapy, confrontation, medications, insight-oriented psychotherapy, generic cognitive-behavioral treatment, and kicking people out of treatment (“really, really bad idea,” one of Rawson’s slides states regarding the latter).

Details of contingency management

Research going back 25 years supports the use of contingency management to reduce cocaine and methamphetamine use, either for stimulant use disorders alone or for patients on MAT who are also dependent on stimulants, Rawson says. In all the meta-analyses of treatment for stimulant use disorders that have been conducted, only contingency management has demonstrated clear evidence of effectiveness, he says.

The incentives are typically vouchers, goods or privileges. The criminal justice system, including drug courts, uses negative reinforcement. But most patients prefer rewards. Punishment given as a consequence for a behavior just results in people dropping out of treatment, says Rawson.

For contingency management to work, the behavior must be followed immediately by the consequence. The target behavior is often negative drug tests. When these occur, the patient gets a reward, and continues not using. If there is a positive test, that reward is removed.

Here are some tips on implementing contingency management:

• Give frequent rewards.

• Make rewards easy to earn at first.

• Make sure rewards are useful and valuable to the patient.

• Connect the reward to specific, observable behavior.

• Give the reward speedily (the greater the delay, the weaker the effect).

• Reward any improvement; focus on small steps.

• Simple is better.

“The data on contingency management are incontrovertible,” says Rawson. He cites in particular a 2002 study he co-authored, published in the Archives of General Psychiatry, that found contingency management to be more effective than cognitive-behavioral therapy during methadone maintenance treatment for patients with stimulant dependence.

Rawson also considers exercise underused and useful. “Receptors recover more quickly with exercise,” he says. It helps patients with anhedonia, or the lack of pleasure they may experience in the early days of recovery while the body is repairing itself.

“It’s also a way of giving them something new to do,” says Rawson. Patients report that activities that keep them busy, and away from triggers, are important.

Role of medications

While there are medications, in particular Vyvanse, that are being looked at for stimulant use disorder, “Nothing has gone through the FDA process to make sure it’s safe and efficacious,” notes Rawson. But physicians are asking about how to help their MAT patients who are also using stimulants.

“We’re at a point where doctors in all these settings that are treating opioid users come to us and ask, ‘What can I use for them? I don’t want to kick them out of treatment,’” Rawson says.

Changing the patient’s dose of buprenorphine won’t have any effect on stimulant craving, he says. “Should they get counseling? It probably won’t hurt them.” But he added that there is no data on counseling for stimulant users who are in MAT for opioid use disorder.

Many providers’ response to contingency management is that it’s too expensive. “They say, ‘We don’t have money to set up a contingency management program,’ or ‘In our primary care clinic, where we use buprenorphine, we have no way to set up an elaborate contingency management program,’” Rawson says.

He adds, “All I ever hear is, ‘We would use contingency management but we can't figure out how to pay for it.’” His response? “Well, figure it out!”

Alison Knopf is a freelance writer based in New York.