Oh Yeah, I use this as a as an
opportunity to get some stuff I've
been thinking about for awhile.
Kind of out there an especially
work that our group Brians there.
Yeah Corey, at least and others have been
doing trying to develop a phenotyping
project for nidus so that that got.
I got stalled and we hope it begins again,
but what came out of thinking about
sort of big big scale phenotyping of
people with substance use disorders
was if we ever really took on.
The heterogeneity of substance
use disorders and I'll talk about
what I mean like that in a minute.
What would it mean for for treatment
development? Where would we?
Where would we go for it and how
would we approach treatment for it?
So we're going to talk about is
too big given Switcher which are
kind of obvious to me after almost
40 years in this business.
First is that there isn't in probably
will never be a single approach that's
effective for treating all individuals
with substance use disorders.
There people are just too variable.
And second,
I've seen all kinds of characterizations of
substance use disorders kind of come and go,
so substance use disorders as
this or it's that.
You know none of them have ever
explained fully how are taken on
what substance use disorders can
be and how variable they have.
And I I don't think any has have
really led to the development
of a really broadly effective,
usable, usable treatment.
So what I'd like to do first is to review
the kind of dimensions of heterogeneity
that that I've been talking about.
What you know,
what's most important,
and especially in light,
of how we might start thinking about
personalized treatment approaches
for substance use disorders.
And then, once we kind of have that down,
what do we actually need to
treat this heterogeneity?
One of the things I'll
argue for is multivariate.
Tina typing,
not just measuring the stuff
that's easiest to mention that
the low hanging fruit will also
have to come up with interventions
that target that heterogeneity.
The core mechanisms of Sud,
and they're also going to have to
be things that you can really be
brought to scale and disseminated.
And at the end near the end of the talk,
I'll talk about our computerized
cognitive behavioral approach.
CBT for CBT as sort of a possible backbone.
Of of such an approach.
OK so.
These are just some of the conceptualizations
that have kind of come and gone,
and in in my time and you know,
they're all useful to a degree,
but they all fall short someplace,
so the old one was the old moral
failing people who have substance
use disorders or just plain bad.
Which lead,
of course to spectacularly ineffective,
could've models you know locking people up.
Counties in there have been,
especially in other countries,
some really disturbing treatment
approaches where people you know when
when treatment is isn't informed by
data. Some really creepy things can happen.
The other thing was sort of this
disease model, which is about
when I came into the field,
so this was really focusing
on really severe cases,
so these were people with alcohol
use disorder who hit rock bottom,
so they were really at the Sevier end.
And so a whole treatment system
sort of sprung up so long term,
residential kind of models
and people need to treatment.
But what I think this model did was
by focusing on those severe cases and
sort of the Minnesota model was like
pull the treatment system away from
the rest of the health care system and.
That was that was really unfortunate,
and we're still still dealing with
a lot of the problems associated
with that with that today.
So sort of the old treatment models have
been to a large extent, unwilling or so.
So about using evidence based
treatments and medical communications,
and and so forth.
So that was a thing.
Then we had chronically relapsing disorder,
which was.
Really, really nice,
because all of a sudden we realized
that you can't just treat a problem
that someone's had for years.
You know, with an 8 Week 12 week
treatment an expect a miracle,
we had to think about sort of
measurement and performance based care.
We had to think about more
chronic disease management,
so that was that was useful.
We learn from that,
but the other problem was that,
whoops, there's you know.
A lot of people who get a lot
better even without treatment,
so it's not one thing.
Self medication, which was also a.
An important concept and and still is.
It recognizes that work of actually
worked on here at Yale early on,
looked at defining rates of
psychiatric disorder among different
populations with cocaine use disorder,
opioid use disorder,
and so forth, and found very,
very high rates of psychiatric disorders.
So OK.
So then, if you treat the
underlying psychiatric disorder,
everything's going to be fine,
I accept.
Not so much,
it's it's if someone has a
comorbid psychiatric disorder.
Pay attention to it and treat it.
But just because you provide a
medication for depression or whatever,
the literature suggests that you're
going to kind of a variable outcome.
And then you know even the
good old brain disease model,
which is very much in Vogue.
So this is very useful because it
really you know it helps us all
understand that chronic substance use
usually can affect brain function.
It helps people understand that
once established it is very
very very hard to change.
It's very very hard to stop.
So I think that has helped
us a bit with stigma.
But again,
it's not just a brain disease.
And the example that I bring up
for this is if you know if it
was really only a brain disease,
continuously management wouldn't
work quite so well.
So you know continuously management
is treatment that is broadly
effective across virtually all
types of substance use disorder,
providing tangible rewards based on
targeted behaviors like abstinence.
It works consistently.
It works quickly.
It's pretty powerful, right? So you know,
if it was just the brain for brain disease,
it wouldn't work that well.
It wouldn't be like you could.
You know, you know,
here I've seen pretty serious cocaine users
change their lives or a pair of socks.
You know, it's just.
Is profound and if if substance use was
a brain disorder like schizophrenia or
bipolar illness or something like that,
I mean we wouldn't.
We wouldn't think we're going to reduce
psychotic symptoms or stop a manic
episode by offering people stuff.
It just doesn't follow through so.
Something so again, this is not everything.
All these concepts have something to offer,
but in in in my view,
all of them fall short.
An you know this heterogeneity
just kind of goes on and on.
So my my my mentor Bruce Rounsaville
told me very early on that you know
whatever it is that we're talking about,
people with substance use disorders
are always going to have more of it.
And there are lots and lots of
examples of that one I talked about
was comorbid psychopathology.
So rage,
the depression anxiety PTS di pretty much
all psychiatric disorders are elevated.
It's a good idea to pay attention
to them and treat them,
but not all individuals with
substance use disorders handsome.
Severity is another really
interesting dimension.
Again,
that the field kind of got
started with this focus on the
highly severe cases and then.
Among other things,
the 1990 Institute of Medicine
report on broadening the basis
of treatment for substance use
disorders highlighted that in fact,
most people with substance use disorders
have moderate to less severe cases.
In those it really, you know,
sort of high, severe, tightly,
sevier people at the top of the pyramid
was all that was getting treatment.
So what wonderful things came out of this?
Was that OK?
You can possibly intervene earlier
in the course of a disorder.
And prevent a less of your disorder
for becoming a more severe one.
It also kind of move the field,
you know,
sort of out of the severe and focus
with the residential system and said,
Hey,
you can find in treat people in all
kinds of systems in primary care systems,
medical system,
schools and so forth which led
to nice things like screening,
brief intervention and referral to treatment,
which demonstrated that brief.
Usually motivational approaches,
advice to change delivered in a range
of settings could have significant
effects on hazardous drinking.
You know, so that's, you know,
sort of codified and pain for now.
So that was great.
Except when we said Alright.
So now let's take SB Artie and do it
for more serious drug users in the
Ed and primary care, it didn't work.
It just felt felt felt flat again.
Kind of showing how this
heterogeneity is is almost always
there. It also shows up,
you know, kind of obviously in
terms of types of substances.
It's very, very hard to find an
individual who uses just one thing.
Just about all people with
alcohol use disorder.
Also smoke tobacco people with
drug use disorders usually use
alcohol and tobacco so that.
It's it's it's it's.
It's been really,
really hard to find in particular
medication targeting where
the one type of substance use,
with the exception of of naltrexone.
Because, Alright,
so your target you target
cocaine use disorder,
but some of those people are going
to have alcohol use disorder.
Some of them are.
It's really gonna get sort of
mess up your signal in terms of
of medication development so.
What do you do? What do you do about that?
And you know there's a variety of
other kinds of dimensions where
rates of whatever it is are elevated
in people with substance use disorders.
And what's nice is that from time
to time we've said OK cognitive
function is important.
So let's come up with interventions
that target cognitive function,
instinct for substance use,
disorder or attentional bias,
or affect or distress tolerance
or or whatever you have, well,
you know it's it's sort of interesting.
I'm going to come back to this.
'cause This Is This is, I think,
what we have to wrestle with.
People will vary into.
Some people will have distributed
this regulated cognitive functions,
some won't.
And then just because they have cognitive,
you know,
just treating cognitive function
only is not going to get at the
range of other kinds of problems
they may have to so you know,
sort of taking on this.
This heterogeneity is really important
and the other thing is that again.
Trying to get it causality with
any of these is with most of these
is relatively complicated 'cause
sometimes these things are sort
of risk factors and precede the
development of the substance use disorders.
Sometimes they develop after and
most of the time they kind of
get worse with substance use,
so it's it's the chicken and the egg
thing is is almost always a problem here.
Alright,
so I hope you're with me 'cause I
actually can't see the chat anyway,
so they they so people not only
differ in this hodgepodge of
various kind of comorbidities,
but various kinds of issues become.
More and less support important
at in terms of dynamics,
so one of the models that helped
our group really organize our
thinking about Phenotyping was the
functional model of addiction,
which I know many of you have seen before.
The Kuban and Bo called model,
but just to refresh you people
with substance use disorders.
Kind of go through different phases,
at which point these these these
different functions become, you know,
sort of more or less important so.
Sorry my my asthma is really bad
so forgive me.
Preoccupation is where you know people are,
are, you know,
start thinking about using
the substance executive
control, whether or not they can
kind of control their behavior
becomes very important and variables
that are particularly important.
I think at this stage our
attention, concentration,
working memory and delay discounting.
Can they sort of use the frontal
network to control what's going on?
If not, they tend to move into bins in it.
Binge intoxication, where incentive salience.
What they're getting rewarded for,
gets heightened,
and so concepts that are important there.
Cue, reactivity, attentional bias,
impulsive, iti, and so forth,
and after an episode of substance use,
people typically moved into withdrawal.
Negative affect. People feel really bad.
Depression, anxiety.
Anhedonia become important pain with OUD,
and you know that drives them back to you.
So so these variables.
Vary across individuals,
they vary across time. How?
How are we gonna deal with this stuff?
Times if we're going to take this on,
all we really need is.
Brief, reliable, inexpensive,
hopefully computerized battery for
phenotyping diverse individuals
with with SUDNI.
AAA is working on one of these calls.
The addiction neuroscience battery.
They're getting pretty far down
the line and have some evidence.
Sort of Validating the Model.
Katie Wicked Witch and her group
has have have done that as well.
Night night, as my does not sure
what it wants to do at this point,
but anyway, we'll get them.
Then once we have that,
we're gonna need really good algorithms
for selecting dog critical targets for
any given individual, you know that.
That seemed like a.
A difficult stretch,
but you know,
I think now with machine learning
and AI you know will and big enough
samples will will eventually get there,
and once we've got these algorithms,
we're actually going to need treatments
that are flexible enough that can be
tailored to the needs of individuals.
And,
you know,
have intervention that they're
really demonstrated to modify
those key targets underlying
substance use disorder alright?
So that's all you guys need
to do for the next 30 years.
No problem.
Yeah, but but I think if we
take on heterogeneity this is.
This is really what we're going to
have to do, and it's been difficult.
Um, yeah, so,
given all this heterogeneity
and where we have to go.
How are you thinking about
the current treatment system?
It's it's really,
really hard.
I hate to say it,
but even though evidence based
treatments are many more are available.
We have a lot more medications.
We have a lot more behavioral therapies.
We have all kinds of stuff,
but in most community treatment programs
you know we still have one size fits
all approach is outcome monitoring,
sort of performance based
care is incredibly rare.
Evidence based treatments are just
not used so that kind of thing
is starting to change though.
And so my group about.
Dark Ages bout tooth amount 2000.
So this was before.
Before YouTube,
this is where AOL still sounded like
the book poop on you've got Mail,
but we thought, OK,
let's computerize some evidence
based treatments and so why do this?
As I said, effective implementation of
CBT another based therapies is very rare.
In clinical practice.
We Steve Martino and Sambal and
others did a whole series of studies
within the clinical trials network,
demonstrating that the sort of
the dose of cognitive behavioral
therapy or any other evidence based
treatment that was being done in
clinical practice was incredibly,
incredibly low.
So people were sort of vaguely informed,
but they weren't doing it at
the at the dose that.
Was established in clinical trials
only a small fraction of people with
addiction related problems access
treatment for all kinds of reasons.
We still thought when doing this that.
That clinicians are are are important.
There's alot of things that clinicians do
that a computer program is never going to do,
so we can see this as the condition
still meets with the with the.
With the individual assesses their needs,
builds a relationship,
but they can kind of use the CBT for CBT to.
You know, sort of.
Provide an extra dose of
cognitive behavioral therapy.
They can kind of see it to them,
and there were some things that that
that got us very excited because there's
a lot of really cool things that you
can do with computers that you can't
do necessarily in this in in a session,
particularly multimedia presentation.
So we try to present the CBT concepts
in a range of formats people left,
listen and learn very, very differently.
So we went to to capitalize on that.
Obviously got the 24/7.
Availability, repetition,
flexibility, flexibility people
don't always learn the first time an.
And this is the point.
They want to come come, come back to is to.
Once you modular eyes it or computerize it.
It's sort of fixed.
So if we do.
A module on coping with craving.
We can actually deliver that and determine
if it has any effects on craving or not,
so we can actually begin to think
about whether this sort of package or
menu of stuff that we deliver it CBT,
which ones are actually associated with
an effect in which ones maybe or trivial,
trivial and.
And we can get rid of them.
And the other nice thing about it,
which we haven't really had before and
stuff just treating the standardized
delivery CBT provides sort of a high
and consistent level of skills training.
So these are the two chunks of it that
that still excite me very, very much.
Um?
And so when we started pulling this together,
we thought, OK, what are our core principles?
What are we going to have to
do to make CBT work?
An we first,
we're focusing primarily on
people with cocaine use disorder,
so we knew that if we had one of these.
You know,
take take,
take a take a CBT manual for therapist
and put it out on the web and
expect people to read it.
You know that wasn't going to work so
we needed to come up with something
that was really highly engaging and
capture the attention of substance
users and retain them in treatment
and those of you who worth work with
technology know how important that is to
get people to engage and stay engaged.
Most people kind of you,
something you know.
One thing once or twice and
you never see him again.
The other way we conceptualize CBT
for CBT was that this was going to be
essentially a skills training machine,
period.
All we were trying to do was provide
skills training in cognitive and
behavioral control strategies,
and at most we could focus on
a few key generalizable skill.
So we wanted to build a skill
training machine.
One of the other characteristics
of clinician delivered cognitive
behavioral therapy,
and in our hands at least,
has been durability of effects,
and we think that's because we
try to teach people these place
generalizable skills they carry
with them that has benefit for
them after they leave treatment.
So we really wanted to emphasize skills,
practice people practicing the skills
outside the outside the session.
So we built that and.
The I think the most important driver
of this was been modeling sort of
the opportunity not just to hear a
clinician describe a skill and put
it on a blackboard or something like that,
but actually see people use it in
realistic situations under stress
and I'll get to that in a second.
So as I understand it,
doctor kilic and Doctor Edens will be.
Sort of providing some exposure to CBT
for CBT for the Fellows later in this year.
So we're really excited to
get your feedback on it.
I think it's a.
It's a great way to learn CBT, but for
those of you who are familiar with it,
it's web based there bout 7 modules,
they take 35 minutes each.
Each one covers a core topic of CBT.
I'll show you that in a second,
but this is the thing we teach
via these movies.
We spent a lot of money in each version,
coming up with likable characters.
And a nice little story line.
We show the character and a
realistic setting, you know, bar.
Work home wherever.
Having trouble with with with with with,
with with with some conflict and
then we teach the skill and then we
kind of show that that individual
implementing the skill in that
realistic situation and you know I,
I think that's a really nice way
for people with substance use
disorders to to learn.
And it they tell us that too.
They like the movies the best.
If you're interested,
there's actually there's like 4 or
5 Movies Now on our new website,
cbtforcbt.com.
Oh, and I am a member of CBT for cpt.com.
It's an LLC that distributes it.
Essentially,
it cost to clinical providers
and I have a
conflict of interest management
scheme worked out with GAIL,
but just so you know that it's secure,
it collects no pH I,
it doesn't collect anything that
could get anyone in trouble,
so it's been used in prison systems,
probation systems, the VA, and and so forth.
The clinician doesn't really have
to be involved in this at all,
so it's really self guided and audio driven.
You don't have to really read.
We've had people who couldn't read use it,
they only have to do is, you know.
Essentially push, push up, push up button.
It's very self driven.
It works on all kinds of devices and
the clinician needs to be there in the
background 'cause there is an admin
system that tracks each users visits
to the various pages of the modules,
whether they're doing the homework.
Answers to quizzes that indicates
you know it is.
Is the person actually
comprehending the material,
which is really important,
so it works best when the clinician
says I really like it.
Use this and checks in every week
and praises them for doing homework
and all that good old stuff.
So we have different versions.
I'll talk about in a minute,
but we narrowed it down essentially to
6 or 7 quart kind of core skills and
the way we try to teach this in CBT is.
Here's something here's this idea.
This skill that you can use right
now to help control your substance.
Use whatever it is,
but if you think about it,
this skill can be used in a range
of situations that have nothing
to do with substance use.
Disorders can be used to make your life.
Just a lot easier on yourself so
you know functional analysis of
understanding patterns of substance use.
You can change them is, you know.
I think it's kind of dual process
thinking doing the first thing that
comes to your mind or stinking it
through doing Plan B coping with craving.
We teach as affect tolerance,
urge surfing,
distress tolerance comes comes to mind.
Refusal skills are basically
teaching assertiveness behavior
which is very useful for our people.
Recognizing coping and changing thoughts.
Cognitive flexibility.
Cognitive modification which
is a part of CBT for all kinds
of psychiatric disorders.
We teach decision making skills,
planful behaviors and so forth.
So it's this back and forth between
the movies showing the specific use
of this skill to control substance
use and then emphasizing this thing
can be used 'cause it's essentially a
part of being sort of an effective.
Sorry,
so this is a screenshot from our old version.
Essentially all that people need to
do is push these little blue buttons.
Set these things up so there's sort of
a sequence of common activities in each one,
but it would be what to expect.
We show the movie what would,
what would you do so you know
Sam's trying not to not to drink
before the football game in his
his old friend gets him in trouble.
The skill we show him using his skills.
We have various interactive
exercises where people kind of.
Toy around with the ideas.
We have homework and then exit the
crib ometer and stuff like that.
We tried to make this as generic as possible
so the actors are all like different ages,
different ethnicities,
different genders, you name it.
We mixed it all up so and so far
you know you know other than.
You know some there were some.
You know, sort of lumber.
Men in Montana didn't like it too much,
but no one has ever said no, you can't.
You know, this is not like me,
and in fact some of our first and best
customers have been groups of Native
Americans and 1st nation people,
which I think is important.
This is our newer version.
We get braver and braver as we go through.
This is HIV risk reduction.
You know,
if you if you if you come work with us,
you get to be an extra in in a scene,
but we really try to make these
engaging an real and fun and easy.
Most this is an example of the feedback
that a patient would get on the question,
so the questions that we ask
at the end of each module.
So if they didn't get it,
you know they can go back
and they can repeat it.
And I my my little screen with my people OK?
Now I'm going to go through
the evidence quickly.
We have now done 8 independent
clinical trials that show its efficacy,
durability and cost savings.
This is pretty obvious.
This was our very very first trial
where we did it in Bridgeport with a
mixed group of individuals with all
kinds of substance use disorders.
We took all comers and all we did
was people got regular treatment
as usual at liberation programs for
eight weeks or treatment as usual.
Plus the opportunity to interact with
CBT up in an office attic for eight
weeks and at the end of treatment
we got a 20% difference in positive
yarns and negative urine, so that was nice.
And then.
OK, and then a young man,
Brian kill it came along and he did
some very nice work demonstrating
that the CBT for CBT program actually
seemed to teach people skills.
So we had a.
A rather complicated role playing test,
but it was reliable and we could
rate peoples responses to high risk
situations in terms of quality.
And Brian demonstrated that skills
that we're trying to teach in
CBT state pretty flat.
If individuals were intiate
were in treatment as usual,
they went significantly up in CBT for CBT,
and you know a lot of that increase was
actually after people left treatment
so that you know again we're trying
to teach people these generalizable
skills and hopefully we did.
He also demonstrated.
We had a real mediation demonstrating
that essentially CBT versus T Au was
associated with an increase in coping skills.
That the increase in coping skills
was associated with positive
urine's after treatment an.
By accounting for this relationship
when looking at their relationship
for treatment in urine's that that
the acquisition of coping skills
essentially mediated that outcome.
So so that was nice.
We also got, you know,
so so it it works like CBT is.
You know it it teaches skills and we
got our sleeper effect in a six month
follow up with like 80% of that sample too.
So that was our first trial and you
know the rest of it has kind of been
interesting themes and variation.
We've tried to follow the stage model
of treatment development so starting.
With high internal validity and then
you know sort of focusing on mechanism,
but then.
Moving towards greater external
validity with all of these things.
So this was our second trial.
Sorry this was done in the app Foundation.
Methadone programs for people who
also had cocaine use disorder.
Much more challenging population,
but after 8 weeks we got essentially
this lower, less positive effects.
Overall in that in the sample,
but the effect size was that
was roughly the same,
so big differences and abstinence.
Drug free urine specimens.
We also got the nice durability
of effects for this one.
Brian lead developing a new
version of CBT for CBT.
So our first one was kind of drugs
and alcohol very generically we got
support from an I 888 to develop an
alcohol specific version so we did a.
Essentially pilot study.
Brian's doing a lot larger R 01 study now,
but again through the stage model we
kept kind of pushing the science on
this and so rather than just doing
a comparison of treatment as usual
to treatment as usual with CBT.
For CBT we said OK.
What happens if essentially all
the treatment that an individual
receives the CBT no groups,
no individual is what they did get was about?
10 minutes of week of sort
of individual monitoring.
Just making sure that this level
of care was sufficient for them and
they didn't need to go inpatient
or or have a higher level of care.
And.
You know, in terms of variety,
clinical outcomes,
percent no heavy drinking in
the last four weeks,
CBT with just monitoring,
did did almost as well as CBT for CBT.
So we got braver and braver.
This was our man versus machine study
which was done at Satu involved 137
outpatients with any substance use disorder
and so this one was treated as usual.
It's tattoo which is usually a
mix of groups and individuals.
Versus clinician delivered CBT.
So following the training model with the
day of training and supervised cases.
Or CBT for CBT with the brief monitoring
alone again since we took all comers.
We did look at days of
substance use overtime,
so here is a sample for this 175%
male. Alot of criminal justice referrals so
a lot of you know a fair amount of people
who kind of got pushed into treatment.
49% primary marijuana 29% primary cocaine,
alcohol a little bit of opioid in there.
We got a six month follow up from 83% of the
intention to treat sample and the way we set
this up and powered it was we figured both.
Forms of CBT delivered by clinician or
delivered by computer would both be
more effective than than treatment.
As usual we did not set this up as we did
not set this up as man versus machine,
except we call it that I'm sorry.
Essentially, you know this particular
population of CBT was was OK.
It was better than treatment as usual,
but the computerized.
Version clearly had the edge
and through the through the.
12 weeks of treatment and you know,
clearly clearly beyond so we sort of
built this little machine that you know,
essentially, you know,
beats a lot of what's what, what's,
what's out there so you know it's it's.
It's not intended to replace clinicians,
but there there's such access
problems in the United States.
So in in many places where there's
just no access to CBT for CBT this
is probably going to be good enough.
Um, this is some other nice work.
We looked at indicators of
clinical significance so.
As as Brian mentioned last week,
he's got a new project looking at the
DSM criteria as an outcome indicator.
So we all just diagnose people.
Once we look at it at the end of
treatment to Deceive had had an effect.
CBT for CBT was more effective than T AU,
and a little bit more effective than
than CBT delivered by clinician in terms
of the percentage of individuals who no
longer met DSM criteria for substance
use disorder at the end of treatment.
And you know people kinda like it.
But not every again the one of the
purposes of this study was figuring
out what kind of people you know,
like the computer versus what kind of
people you know really need that clinician
interaction and Therapeutic Alliance.
Lot of people kind of like this.
So we did try to make it entertaining.
Burn stuff the the interpersonal demand
isn't there, so that's interesting.
Look at my screen.
So.
You know, and we also think
learning is really interesting.
I, I've always interested in this idea,
like after a session,
but to patients really remember?
What do they take from it?
And so we have a pre post true false test.
I think there's about.
3550 I can't read minds, but again,
Tia you not a whole lot of change
from pre to post clinician CBT and.
Computer CBT both did pretty well,
and teaching people think so you know.
So now the next phase of this was saying,
OK, now we've got a nice systematic CBT.
Now can we kind of move it
towards populations that
don't really have access to care?
So working with many Paris and
Michelle Silva, Ann Lewis,
Sanyas and you Deligne,
Armillo from the Hispanic clinic.
We had we developed a nice culturally
adapted version for people who
primary language is Spanish.
We're trying to really get it.
People who can't have access to treatment
in English well aren't bilingual.
And then at this point we were
getting really brave and we we we,
the modules originally we
thought OK you can do it.
You can do it anywhere you want.
The weather dot dot dot and they
were sort of asynchronous and at
this point we realized people did
session 1234567 no matter what.
So we said Alright,
maybe we can get engagement
really up there by making my
making these videos into a story.
So we made a soap opera.
And it was.
It was really fun,
and we've done this ever since.
And instead of an aerator being for
the drug version is This guy, I don't know.
He's like a white guy who talks
like a like a weatherman.
It's, but instead we have this woman,
this this lovely woman who's warming kind.
So she's the narrator.
She's watching the soap opera and commenting
on the characters in doing the teaching.
And it's it's it's.
It's very sweet and very nicely.
Alot of fun making this one.
And again we finished a randomized
clinical trial for this with 92
Spanish speaking people with substance
use disorders because we were
doing this in a range of settings,
including the Hispanic clinic
where a lot of people have some
pretty serious mental illness.
We recognize that CBT for CBT
should not be offered alone,
so was offered as an add-on to treatment.
As usual, this was our.
Our sample,
which is kind of consistent with
people who seek treatment at
Hispanic clinic Moss and statute
where we also got people.
This was an interesting thing.
'cause this this kind of
answered the question was.
The question of.
Does CBT for CBT work with substance
use and substance use even with
populations with severe mental illness?
And the question was was really clearly yes.
And again,
our little soap opera theory
kind of really work.
So 56% of those in the intention to treat
sample actually completed all seven modules,
which is something you really don't
see with computerized treatment,
so.
Now the same team has developed a
version funded by in a AAA that's
focuses on alcohol use only,
and we're running a clinical trial of that.
And so where were We restarted
it and see see a hope to start.
It's at 2 pretty soon and you need patience.
And then again,
you know people morphine is A is A is
a really powerful treatment to get out there.
There's a number of people who can
do really well with office space.
Kind of just buprenorphine but
a lot of patients need more than
the medication themselves.
So we came up with a variation
to be used
in office space bupe.
So for that one we came up
with just a physician tutorial.
Here's what CBT is. Here's how it can.
Help your patience.
We work with Julia.
She and Jeanette Petro at CMU to kind
of figure out what would someone
who's just wavered really need.
So we had people norfin agreements,
progress notes, things to keep track of,
a nice dashboard.
And then we.
I just followed Julius year round
with a microphone for about 8 weeks
and recorded everything she said.
'cause she's just so awesome.
So I made one little video to
kind of help patients understand.
Poop videos of common problems
questions people would ask,
like why do I have to not use benzos Bubba?
Made sure they understood about Narcan,
maybe surely understood about safe storage.
We had a few knowledge quiz
and this five days tracker.
So every week people kind of
track their adherence to pupa,
tendencies, sessions, abstinence,
weather getting support
and doing other things.
And we finished a pilot awhile ago,
so this was only 2920.
People randomized to either standard
buprenorphine at CMU or CBT plus poop,
but again, even with a small sample
size we got some some really nice.
Difference is here.
So we are running now a trial.
We're trying to get to 100 patients at CMU.
So if you need if you know anyone.
It used to be on view.
Give Julia Shea call we need patience.
And so this is kind of where
we where we are right now.
And I have another talk that's
focused on the stage model.
But the stage model kind
of guided this process,
which has been good.
We have over,
I think 40 paste 40 papers out now,
including some of the fMRI data,
but we have a version for
drugs aversion for alcohol.
The Spanish drug version I
I've shown so that work for
everything except as a standalone.
the Spanish alcohol trial is on going now.
The Butte trials going on now.
We got some heel money to do version
for people who are on people morphine
or methadone who also had chronic
pain and so we're working on that.
The mic opie is Alishahi P and
will work on that with Steven.
Will Becker and man it.
Anne Ross McLean and the regular game and
through the American Heart Foundation.
So chicha gotta a wonderful
grant to focus on teen vaping.
And so we've just initiated a project
we're going to develop a CBT for.
CBT for teenagers who want to
Stop Vaping so we've done some
some good things and that now now
we're just having great fun so.
Many of you know Jordan,
so her project has been partnering
with the black churches as a
strategy to deliver substance
use treatment in psychiatric care
to the to the black community.
So we came up with the project where
treatment is delivered in groups by
church health workers or CCCH aizen.
So essentially this is capitalizing on.
The really rich network of black churches
in the United States as a real support too.
Black people who may not trust the
the traditional care system we did.
She got some money through why
CCI todo uncontrolled pilot.
So you know one other question.
People kept saying Oh yeah,
I know you can't do this.
It's not going to work.
People not going to show up.
You can't collect your end.
You can't do this.
You can't do that.
She did it all so.
We put out some Flyers.
200 people showed up one day and
volunteered for the 40 spaces that we had.
We at least we still have
people clamoring for it,
so we had 58% of individuals had
a severe substance use disorder.
So six or more on the on the DSM
when they came into treatment.
We did take.
We did take urine's every
single week in the church.
Nobody balked about it.
We were able to provide confidentiality
and Hi C was just fine with it.
But this was amazing.
78% of those who started completed
all sessions and graduated.
So the good news we have about this.
As we submitted an R1 back in January
and we have an IEEE support and we're
just waiting on the notice of award.
So we are.
This is one of the projects
that I'm most excited about.
The other thing that we've done,
I'm going to zip through these, though.
Working with Jeanette and Steve Holt at
the art clinic and at the Saint Rays.
Campus Yale,
New Haven.
We we wanted to see if CBT for
CBT could be used to deliver care
within the primary care settings.
Because with SPRT you know
so many people start and the
severe people get referred out.
And guess what?
You know 20% of only 20 at best
20% of those who are referred out
actually go to specialty care
people just not going to do it.
So what if you plop CBT for CBT instead?
Primary care that look great so we used.
We use that.
The addiction recovery clinic,
which is not your average primary
care clinic. It's it's staffed by.
Really dedicated addiction Medicine
Physicians an. It's a teaching clinic.
It's absolutely wonderful.
People. People love it.
But we did a nice little randomized
clinical trials without 58 individuals,
just to see if we plug CBT.
Would it help?
This one we we said you can do if you're
assigned to CPT you can do in anywhere.
Do we have some you can do?
You can do the modules at
home you can do at the clinic.
Interesting Lee,
like we didn't think this half of 'em
did it at the clinic just because.
You know their lives are really complicated.
They don't all have access to the thing,
so we could just, you know,
set them up in a little kiosk at the clinic.
And again,
this looks like a nice setting
for this
thing. 77% of those randomized
access to at least one module,
and of those 91% completed all
modules and substance use was the
substance use outcomes for the RC
clinic are just amazingly great.
It really is a model of care,
so we had a kind of a ceiling effect there.
But people like CBT.
So now in the in three minutes.
We've used,
you know we have manualized treatments
to be delivered through a clinician.
Hardly get any CBT.
Delivering it through the web.
You know I've talked a little bit
about dissemination, but can we get
back to this heterogeneity model?
BT is as we have it now.
You know is really a package.
It maybe addresses some of
those key features of Sud,
but it's not personalized treatment.
So could we look to see whether CBT
actually targeted those core features?
And this is the only grant I ever I ever
put in that the reviewers didn't like.
So one of the ways to do this would
be a fractional factorial design,
which capitalizes on the power of
factorial designs to kind of be able to.
Have reduced sample size and
so the idea of this is that.
With a large enough sample and by
turning on and off some of these modules,
you could actually test whether each
module had its desired desired effect.
By exposing some people to it and not others.
With a with a with a fractional design.
So this was brilliant, right?
And we only needed 500 patients to do it,
so the reviewer's all set up.
This is awesome.
This is so cool,
but CBT is sufficient enough.
Never mind you can't do it, so forget it.
Um, so we've been doing it.
Kind of the old fashion way,
thinking about.
To the degree to which CBT modules
can really map on to some of these
core pick features of addiction.
So if you think about it.
Executive functioning is kind of
targeted through the functional
analysis and problem solving.
Negative emotionality,
through coping with craving
incentive salience this way, too.
So you know, can we get a signal that?
CBT is affecting some of these things is
not the way we would want to do it, but.
You know it's not.
Give them this module.
Test it before and after kind of approach,
but you know it's it's OK.
So this is this is from work by
at least a veto which looked at
the emotional the cocaine stroup.
So this is like giving people cocaine
cues or neutral cues before an after
treatment and what we're looking for
is there essentially reaction time thinking,
you know,
react neutral cues.
You know I'm going to change
a whole lot peoples.
You know if you do a stroke
that you know has the word
table or something like that,
it's not gonna throw people but.
You know we saw a fairly big
decrease for CBT for CBT.
For the drug cues and Tia
you quiz with relatively
flat. The big news here though,
was that it wasn't so much that the
the treatment effect it was people who
would doost their reaction time most
from before to after treatment actually
had allowed abstinence. You know,
we don't really target affect in CVT.
You know we don't not as much as we can.
It's you know it's a piece
of when module but in.
Versus machine study Tia.
You stayed pretty flat overtime for the BS I,
while both versions of CBT
went down a little bit.
So anyway, this is where I want to go.
So CBT is not going to do it.
We're not going to do this alone,
but people have been
developing these nice targeted,
usually computerized interventions that.
Get at some of these core features,
delay discounting.
You there developing one that
changes it through episodic future
thinking alot of you will be familiar
with attentional bias retraining
as a component of treatment,
behavioral activation, mindfulness,
impulsive, decision making,
cognitive control training.
These are all nice components and my
wickedly oversimplified conclusion from
simplified reviews of these says you know,
OK, in general.
These interventions are pretty pretty
effective at modifying the specific target.
A specific target that
there are intended to do,
but it's kind of like really mixed or
weak effects on substance use itself
and what usually comes up with these
is that you know there's a lot of headroom.
Hedren, 80,
in this sample studied,
uh,
and these are generally not seen as
fully sufficient standalone treatments
on there only for active substance use.
But they could be components of
modularized approach is right so.
And This is why I think just focusing on
one comma ability doesn't make any sense.
'cause let's say you're targeting
delayed discounting.
You're dealing with,
you know some people are gonna
have all these other problems
and then wonder it's complicated.
Alright so.
You know my my thought is CBT
for CBT could really be a back
opponents of such an approach.
So down the line.
You got a woman with opioid use
disorder and your algorithm says hey,
she's got high negative effects.
She can't sleep.
She's got chronic pain.
So we kind of mix up a
treatment cocktail for her,
which includes, you know,
beautiful morphine maintenance
an she could have CBT for.
CBT for chronic pain with additional modules
that would focus on things like sleep,
hygiene, mood and pleasant activities.
It's it's it's.
It's at least a start for.
Personalized treatment and
here's another hypothetical,
so you've got a guy with
a udi very impulsive.
He is very reactive to cues he
doesn't make good decisions,
so there's something frontal going on there.
You know he gets naltrexone or compensate,
but he gets CBT for CBT.
Alcohol with some modules
looking at cognitive training,
attentional bias, decision making,
and distress tolerance.
So that's kind of my idea.
That's kind of my my blueprint
for the next umpteen years.
And so I'd like to thank you and my crew
who's been doing this for a long time.
Here's how to contact me and
I don't want to do that one,
so I'll stop my sharing and see.
If there are any questions in the chat.
So unmute yourself as some
questions do whatever.