Good morning, welcome to the Injury Control Research Center webcast of our
presentation entitled In the Pursuit of Innovative Treatments for Substance Use
Disorders: Is Mindfulness and Answer? My name is Keith Zullig, I'm with the
department of Social Behavioral Sciences at the School of Public Health.
My name is Megan Tuscano and I'm a second-year MPH student at WVU for the
School Public Health, and I'm Laura Lander such work faculty in the
department of Behavioral Medicine and Psychiatry and School of Medicine. And we
are all part of the main research team for our project. A couple acknowledgments,
we are supported by the Centers for Disease Control and Prevention through
our Injury Control Research Center for this research and we do not have any
conflicts of interest. We would also like to acknowledge other members of the
research team, our therapists Laurel Faulkenberry who leads our individual
mindfulness sessions for our intervention, and we also would like to
acknowledge Dr. Jerry Hobbs, who provides us some statistical support for the
project. Some of our learning objectives are to gain knowledge about the
prevalence of substance use disorders and overdose rates, nationally, and in
West Virginia, understand the disease model of addiction and how co-occurring
mental illness can impact treatment efficacy. We would like to learn about
mindfulness based relapse prevention and finally, gain knowledge about new
research using this intervention and outcomes of a recent study. So just a
little bit of background it's certainly been in the media, nationally, and in West
Virginia, the impact of the opioid epidemic on our citizens, so this is some
information about drug overdose deaths and one of the significant trends that
we're seeing is the increase in synthetic opioids so when we look at the
number of overdose deaths the vast majority of those, typically about 80%,
are as a result of ingestion of opioids and then most recently the emergence of
synthetic opioids such as carfentanil and fentanyl
being responsible for more and more of those deaths. The other trend that we are
seeing is cocaine and methamphetamine increases with regard to overdose deaths
and often these are mixtures so not just methamphetamine alone but methamphetamine mixed with synthetic opioids or other opioids that caused the
overdose deaths. Specifically in West Virginia, we have led the nation since
2010 in the national overdose death rates and in 2017 that trend persisted.
We had over 1,000 overdose deaths in 2017 and some of those are still being
counted, so it's not even the final result so this is a 15 percent increase
from 2016 despite the increase in awareness that this is happening,
the state has made major adjustments to prescribing practices and yet the deaths
continue. So one of the things that we're trying to address with this study is how
can we better develop treatments for individuals with the opioid use disorder
to better treat the disease so that we can reduce the overdose deaths in that
way. Just wanted to do a brief overview of the disease concept of addiction, so
this concept has been around for a long time the disease model is really about
identifying a defect, so a physical defect, which results in symptoms. The
physical defect in the disease of addiction is in the brain and the
symptoms are often behavioral, psychological in nature so when we think
about addiction it's a chronic disease so it's not one that can be treated in
12 weeks or in a short course of treatment, this is treatment over a
lifetime and it's typically characterized by an inability to abstain
from substances even if the person wants to. Behavioral problems, craving and
craving has both physiological and psychological components, diminished
recognition of problems and sometimes people refer to that as denial, so in the
face of significant problems people still identify "oh I don't really have a
problem I can stop when I want to", and then a dysfunctional emotional
response and that often emerges as psychiatric symptoms. These are the
current, kind of range of treatment options, so there's inpatient
detoxification for substance use disorders, which is typically short-term
so as we said it's a chronic disease, so detoxification is simply one
small piece of treatment. There are residential treatment programs ranging
in duration from two weeks to six months and those are much harder to
access for most people because there are not as many of those treatment
programs around. There's outpatient therapy and that can
be intensive therapy three times a week, or once a week, or even less often if
people don't have as intense a need, and then specifically for opioid use disorders there's medication assisted treatment with methadone,
buprenorphine, or naltrexone there are also medication assisted treatment
for other disorders such as alcohol use disorder using camp role or antabuse.
Specifically we're going to be more focused on talking about opioid use
disorders today. One of the things that makes treatment more complicated is when
someone has not only a single disorder like an opioid use disorder but has that
in combination with an additional mental health disorders such as anxiety, PTSD, or
depression and so you're treating two disorders at the same time and so it
makes sense, like with any disease, that if you have two disease processes going
on at the same time you need different kinds of treatments. And it's really
theorized that one of the reasons that treatment medication assisted treatment
or other behavioral treatments do not work for some people is because they
really have two disorders, and our study specifically was trying to get at this
issue of patients coming in and having two disorders and how do you treat two
disorders with a single treatment. The incidence is about it depends on
what year you look at but anywhere from 4.6 million and I've seen as high as
7 million American adults have both a substance use disorder and a mental
health disorder and among the population that I work with at Chestnut Ridge
Center, it's really about 60 to 70 percent of the individuals coming in
seeking treatment for their substance use disorder also have a co-occurring
mental health disorder so it's very high, higher than the national average. So the
components of good treatment have these three parts. There's a biological
component, and with medication assisted treatment that would be the medicine
addressed as the biological component which includes cravings and assistance with
withdrawal so people who suddenly stop using opioids who are physically
dependent on them will have withdrawal and so medications can help with that.
Then there's a psychological component and that's usually addressed
with the psychotherapy and that can be cognitive behavioral therapy, or what we
used in in our current study which is relapse is mindfulness based relapse
prevention and then the social component is usually community based supports such
as 12-step groups or any community based recovery groups such as smart recovery
or celebrate recovery. Other kinds of social supports are
family therapy and also spiritual community supports, so if someone is a
member of a church and is able to find support in that way so trying to foster
social connections is really part of what helps people become well.
And to give a little bit of background about mindfulness based relapse
prevention and what it is, so the term mindfulness and being mindful has been
thrown around a lot in recent years and I like to simplify it simply to say that
mindfulness is being in the present moment and being aware so present moment
awareness without judgment. While that sounds simple it can be very
difficult to do in our lives where we have lots of things pulling on our
attention, and lots of electronic things pulling on our attention, even
trying not to if you are physically awake trying not to look at your phone
for an entire hour can really be a challenge for people but when we go to
the phone it really pulls us out of the present moment. Its how practicing how to
be in in the now and while that seems odd to have to practice it's true many
of us really are often thinking about the past or thinking about what we need
to do in the future rather than being in the present moment. It's about increasing
awareness of your physical self, as well as your thoughts. So some of the
interventions have to do with focusing on breathing, focusing on physical space,
or focusing on what's happening inside your head. Increasing acceptance of
sensations, thoughts, and feelings so again working on that suspending
judgment. Just being an observer and curious as opposed to rendering judgment
on what you are doing or what you're thinking. Self-care is always a component
of recovery. Often people with substance use disorders have not taken good care
of themselves and sometimes need to relearn some of those skills. Mindfulness
based relapse prevention is also experiential so it's not a process group
per se where you sit around and talk about what happened in the last week or
talk about your childhood trauma. It's really engaging in
meditation, visualization, the practice of mindfulness, and then there's some
processing of how that's going and people's present experience of doing
that. It's very consistent with 12-step recovery principles as many
people note the principles are grounded in Buddhist teachings, as is mindfulness. So these are really compatible with with 12-step recovery principles.
And it's also compassionate and kind, which is always a bonus teaching people
how to be kind to themselves and that inevitably helps people be kinder
to others. Some of the misconceptions are that mindfulness is talking about your
problems and stress which it's really not. It's about it's talking about how to
be mindful and some of the struggles that we all have with that or
that another misconception is that it's thinking about nothing so I'm not very
good at thinking about nothing I can't shut off my mind well, that may
be something that occurs that's not necessarily the goal of mindfulness the
the goal of mindfulness again, is really about awareness in the present moment.
The other thing that's important and some of our participants in this study
have struggled with, is it's really not easy it really takes tremendous practice,
ideally daily practice, and it's not passive, it's an active process practice
that people hopefully integrate into their everyday life. So a little bit
about our effectiveness study and our study is an effectiveness study
because it is real-world naturalistic setting and that is one of the research
questions that we had, is can mindfulness based relapse prevention be incorporated
into an outpatient setting where people come and go?
Previously it has been people come in and go through the process, lock
step for eight weeks, so we're looking at this, can we see some similar results by
utilizing an outpatient setting which happens in a clinic and normal ways
where people come and go at any time. Participants are recruited from our
comprehensive opioid addiction treatment program at West Virginia University, who
are at least 90 days substance free. The reason why we're looking at 90 days
substance free as our initial experimental recruitment was with people
who are just coming into the clinic and they were just not stable, and so we
purposely are recruiting people that are a little bit more stable at this
time and are more receptive to the idea of engaging in mindfulness. We're using a
quasi experimental design where people self-select into the mindfulness group
or comparison groups and we'll call that a treatment as usual or a TAU and MBRP
respectively from here on forward. In the mindfulness group participants attend a
biweekly, 60-minute session for 24 weeks, so every other week for one hour, led by
our licensed therapist who we initially credited as Laurel Faulkenberry. We're
all part of the protocol the IRB approved protocol. Measures that we will
discuss here this morning are administered at baseline 12 weeks, 24
weeks, and 36 weeks post intervention. The comparison group also continue with
treatment and traditional cognitive behavioral therapy has our mindfulness
group similar sessions 60 minutes for also 24 weeks led by a licensed
therapist, so they just continue as they are. They also receive the same measures
at baseline, 12 weeks, 24 weeks, and 36 weeks post intervention. Some of the
outcomes that we're tracking are retention rates, we're interested in
understanding if folks who are in our intervention group that we retain them
at a higher rate than we see with treatment as usual. We are interested in
understanding if relapse, on any prohibited substance including
alcohol, occurs less in our mindfulness based relapse prevention group.
We are also tracking time to relapse and several self-report measures that we
also have include craving, anxiety, depression levels, and mindfulness. Our
measures of craving are a modified version of the desire for drugs questionnaire
where we have modified that questionnaire to expand it beyond
opioids to include alcohol. We are using the overall anxiety severity impairment
scale for our measure of anxiety, and that is a clinically based instrument.
And for measure of depression, we would look using the overall depression
severity impairment scale. And for our measure of mindfulness it's the five
facet mindfulness scale, that's a 39 item questionnaire. Our overall hypothesis is
participants in the mindfulness based relapse prevention group will
demonstrate increased retention rates in mindfulness and decreased relapse rates,
craving, anxiety, and depression. Some of our preliminary results to date because
we are an ongoing study we will continue to recruit through December 31st this
year and our project will end July 31st 2019 so these are subject to change.
Currently we have 47 people that have been recruited into the intervention
which approximates to about 21 in our mindfulness group and 26 in the
comparison group. Retention rates, or relapse rates excuse me, are lower in the
mindfulness group at 22% with about two relapses. In our comparison group, 43%
with six relapses. Importantly, for everyone to understand is that all
relapses were on substances other than opioids. We think that is a very strong
finding. Retention rates, mindfulness about 29 percent, six people have been
dismissed in comparison group of 23 percent, six people have been dismissed.
So dismissal from the clinic results in from patient non-compliance or need
for a right level of care. Turning to some of the self-report measures we
performed a mixed model analysis of variance ascertain the significance of
the MBRP intervention on changes in craving, anxiety, depression and
mindfulness between our two groups. In these analysis, we had 23 people who at
least 24 week data, so again we don't have everybody that has completed all
measures at this point. So that approximates into about 14 individuals
in the treatment as usual group, 9 in our intervention mindfulness based relapse
prevention group. Analyses suggest significant reduction were
observed in the mindfulness based relapse prevention group and reported
craving, anxiety, and depression compared to those in treatment as usual at this
point. And I will say that on our particular our anxiety and depression
measures where I don't have these data here for you today,
however, the clinical instruments of somebody receives a score
of 8 or higher on either of anxiety or depression measures, that is a measure of
clinical depression and our anxiety. We are reducing participants in the
mindfulness based relapse prevention group to below clinical levels in these
analyses, which is a significant finding. Interestingly, at this point time, we have
we have observed no changes in our mindfulness group. Our reported
mindfulness between our two groups, our hypothesis is that as people
participated in the intervention that they would report greater mindfulness
over time, however we are not seeing that at this point time. Again it's early,
preliminary, subject to change.
So some of the things that we're thinking about at this point: rates of
substance use disorder and overdose in West Virginia are among the highest in
the nation, medication assisted treatment is an
evidence-based treatment for substance use disorder, but for individuals
co-occurring disorder sometimes treatment alone is not sufficient. We
have a very high number of participants with co-occurring disorders as Miss
Lander indicated earlier. Preliminary study results suggest mindfulness based
relapse prevention can be successfully incorporated as a potential outpatient
therapy for the treatment of opioid use disorder with medication assisted
treatment, in our case with buprenorphine. This has not been explored previously
and we feel very good about this, that this is a possible option for treatment
for folks to give them a choice between traditional cognitive behavioral therapy
or mindfulness. Finally, integrating and adapting evidence-based treatments into
medication assisted treatment has a potential to improve outcomes and
decrease rates of relapse and overdose, especially those with co-occurring
disorders. Thank you for your time we've enjoyed providing this webcast and
hope it was helpful, hope it was helpful!
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