Contingency Management Overview, Implementation, and ...… · Contingency Management • Based...

Contingency Management �Overview, Implementation, and Special Populations

David Lott, MDDanesh Alam, MD

DavidLott,MD,DFAPA,DFASAMNone

April8,2017

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Contingency Management �Overview, Implementation, and Special Populations

DaneshAlam,MD,DFAPA,FASAMResearchsupportfromNIDA,Alkermes,Allergan

At the conclusion of this session, participants should be able to: !  Explain the rationale for use of contingency management (CM) methods

!  Outline the methods and materials needed to start a CM program

!  Apply and anticipate the challenges faced when developing and implementing a successful CM program

!  explain how CM impacts treatment among physicians and other health care professionals as well as drug courts

!  Perhaps the most effective method of optimizing outcomes when combining with other forms of treatment

!  The scientific support for its efficacy is broad and growing

!  >170 studies!  >40 RCT’s

(Prendergast 2006)!  5 meta-analyses

Source:Dutra,etal.2008

!  Behavior Analysis and Behavioral Pharmacology"  Drugs of abuse are potent reinforcers"  Drug use is considered operant behavior"  Drug use is normal “learned” behavior"  Genetic and acquired characteristics that affect probability of abuse/dependence"  Environmental contexts and contingencies of reinforcement determine abuse

development

!  Drug taking maintained by “immediate” positive consequences that are consistent"  Feels good"  Social Reinforcement / Peer acceptance"  Short term improvement in mood"  “Relief” from adverse states (mood, thoughts, anxiety, withdrawal, etc)

Drugs have multiple positive effects

!  Negative consequences of use are “distant” and not consistent"  Employment or academic failure"  Medical problems"  Legal problems"  Relationship / family problems"  Psychiatric problems

!  Cost!  Availability of Drug (ease of access)!  Probability of Use affected by Environmental Cues…becomes

“habitual”!  Availability of Alternative Reinforcers

"  Other desirable materials, consumables, social or behavioral interactions or activities

!  Once drug abuse becomes well established (well learned), it is difficult to change

•  But, it is “learned behavior,” and therefore subject to change by same methods as other types of behavior

Behavior Change1) Decrease/eliminate drug use and drug-using behavior2) Increase incompatible, non-drug related, behavior that can replace or compete with drug use - Avoid contexts that set the occasion for use - Find alternative sources of reinforcement

AA slogans: - change people, places, things - HALT: don’t get Hungry, Angry, Lonely, Tired

Contingency Management

•  Based upon a simple operant principle -  if a behavior is reinforced or rewarded, it is more likely to occur in the future

•  This principle occurs naturally in our environments, and is purposely used in everyday life; it occurs whether you control it or not.

•  In the case of substance abuse treatment, drug abstinence, as well as other behaviors consistent with a drug-free lifestyle, can be reinforced using these principles.

!  CM arranges for delivery of systematic consequences for drug use, abstinence, or other therapeutic goals (e.g., counseling attendance, medication compliance)

!  Immediate consequences, sufficient magnitude

!  Reinforcement and punishment contingencies are effective, but reinforcement is preferred by clients and clinicians (and has fewer unexpected consequences)

Dutra et al., (2008)Stitzer & Petry (2006)Stitzer & Vandrey (2008)Plebani et al., (2006)Higgins et al., (2002)Higgins & Silverman (1999)Higgins et al.,(2008)Higgins & Petry (1999)

Forronato et al. (2013) CM vs. CBT Cocaine Dependence (Switzerland)Schierenberg A et al (2012) CM for Cocaine Dependence (Netherlands)Stanger & Budney (2010) AdolescentsLedgerwood (2008) Tobacco smoking

!  Series of randomized clinical trials

Higginsetal.,1991,1993,2001;2003;2004;2007....Silvermanetal.,1996;1998;2001;2003...

•  Weeks 1-12 earn points for each cocaine-negative urine specimen / self-report of no use (tested 4x/week)

•  Points have a monetary value•  Value increases with each consecutive cocaine sample•  $10 bonus for each cocaine-negative week•  Cocaine-positive specimens results in a reset of value to the initial

value•  Maximum earnings across treatment was $1090

(Higgins et al. 1991)

No cash providedCan spend vouchers on approved items any time after they are

earned Staff make available the retail items or services (gift cards,

restaurant gift certificates, sport equipment, movie passes, work clothes, etc.)

Integrated with CRA to facilitate lifestyle change and increased reinforcement from prosocial activities

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(Budney et al. 2006); replicated by Carroll et al, 2006 and Kadden et al., 2007

Higgins et al., 2007

Higgins et al., series of studies

Abstinence Rates�(S-R + biochemical verification)

(Higgins et al., 2004; Heil et al, 2008)

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!  Earn pulls from a “fishbowl” for meeting target goal (abstinence, completion of therapeutic activities, etc.)

!  Intermittent Reinforcement schedule: "  each pull has a “probability” of earning a prize

•  1/2chanceofwinningasmall$1-2prize

•  1/16chanceofwinningamedium$20-25prize

•  1/250chanceofwinningajumbo$100prize

Alcohol DependenceCocaine Dependence – Magnitude StudyMethamphetamine Dependence (also in SMI population)Therapy AttendanceTherapeutic, prosocial activities

Substances!  Cocaine!  Opiates!  Tobacco/Nicotine!  Marijuana!  Methamphetamine!  Alcohol!  Polysubstance!  Benzodiazepines

Related Targets /Consequences Used!  Medication Adherence !  Treatment Attendance!  Prosocial Activities or Treatment Goals!  Work Attendance and Performance!  Access to Housing!  Access to Disability Checks!  Risky sexual behavior

!  Reinforcement-based Workplace �Pregnant/postpartum; Injection drug users,; homeless alcoholics, welfare recipients �Silverman et al., DeFulio et al.(2001; 2004; 2006; 2007, 2009, 2011)

!  Target Treatment Plan Activities (Vouchers) !  Treatment Plan Activities vs. Abstinence Iguchi et al. (1997)

!  Target Participation with Juvenile Offenders (Vouchers) Sinha et al 2005; Carroll et al., 2007

!  Target Housing for Homeless Substance Abusers (Vouchers) Abstinent Contingent Housing > Usual care Milby et al. (1997, 1999)

!  Target Aftercare Attendance (Non-monetary, Social Reinforcement) Lash et al. (2004; 2005; 2007)

!  CM to increase Group Therapy Attendance (Ledgerwood et al., 2008)

Vouchers for Naltrexone Ingestion in Recently Detoxed Opiate-Dependent Patients

Preston et al., 1997 CM for Managing Disability Benefits with Severe, Chronic Mental

Illness and Substance Dependence Ries et al., 2004

Randomized Controlled Trial of Contingency Management for Stimulant Use in CMH Pts With SMI

(McDonnell et al., 2013)

CM for Compliance in Drug Court Participants (Marlowe et al, 1997)

CM to increase Treatment Attendance in Women receiving Temporary Assistance for Needy Families

Received vouchers to purchasing items (children’s toys, cosmetics, etc.) for attending treatment. (Morgenstern et al., 2006)

A) Clinic-based Incentive Program - Schedule of Reinforcement: escalating schedule; bonuses; reset for use (Weeks 3-14) - Magnitude of Reinforcement: $590 over 14 weeks

B) Home-based CM Program - Substance Monitoring Contract - reward for abstinence; punishment for use - use same monitoring procedures to determine abstinence - individualized magnitude and type of reward/consequence - weekly ~15 min. parent sessions (incentives for adherence)

Two-Pronged Abstinence-based CM Program

If ________________’s urine drug screen is negative [no drugs detected or reported] and there were no positive or refused alcohol breath tests since the last drug screen, I will:Praise their progress!Ask how I can help them keep up the good work.Celebrate their abstinence by:

Allowing them him use of the carTaking her out to dinnerContributing $5 toward Ipod purchase

If ____________’s urine drug screen is positive [drugs detected or reported] and/or there were positive or refused alcohol breath tests since the last drug screen, I will:

Remain calm! Not give a lecture. Ask how I can help Express confidence that they can do better next time Use the following consequence:

Chores Grounded till next test Loss of privileges (car, computer, cell phone)

!  PHPs extend the period of accountability for abstinence to five years

!  Physicians in PHPs transition from treatment to home, return to work, utilize the skills they learned in treatment, while knowing that any return to substance use produces serious consequences

!  Immersion in Alcoholics Anonymous (AA) and Narcotics Anonymous (NA)

DuPont, RL et al. 2009; JSAT 136: 159-171.

!  Zero tolerance for any substance use with frequent random drug tests and immediate, serious consequences for any missed or positive drug tests

!  Risk of losing their licenses to practice medicine !  Evaluation and intervention !  Monitoring contract, usually for 5 years !  Formal SUD treatment – plus treatment for comorbid

conditions !  Long-term monitoring and support/case management

!  904 physicians admitted to 16 PHP programs; 802 in 5-year follow-up:

64.2% (515) Completed contract 16.4% (132) Extended contract 19.3% (155) Failed to complete contract


!  Of all physicians at 5 year follow-up (n=802):

78% of sample were licensed or working 4% had retired or left practice voluntarily 11% had their licenses revoked 3% unknown status


!  Over the course of 5 years: "  78% of all physicians had

zero positive drug tests "  14% had only 1 positive

test "  3% had 2 positives tests "  5% had 3 or more positives

78%

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CourtesyofDr.RobertDuPont

!  Need long-term treatment !  Need ongoing monitoring !  Need contingencies - many sources of leverage can be used:

families workplace adjust frequency of visits/monitoring give smaller supplies of medication (esp. OAT)

!  Treatment as alternative to sentencing!  Frequent strict specimen testing!  Quick punishments for substance use (often return to jail)!  Some rewards for substance abstinence (e.g. remove felony

conviction from record)

!  nonviolent defendants charged with drug possession or related offenses committed as a result of the their drug use and/or addiction

!  First started in Miami in 1989!  integration of drug and alcohol treatment services with the judicial system!  a non-adversarial approach!  early identification and placement of eligible participants!  access to a full continuum of services; monitoring of abstinence!  coordination of strategies to address compliance issues!  judicial involvement and interaction with participants!  ongoing monitoring and evaluation of goals!  continuing educational opportunities for all drug court team members!  development of partnerships among courts, the community and related organizations

GuydishJR.JDrugIssues.2002Sep;32(4):1155-1172.

!  75% remain arrest-free after discharge !  Over 50% reduction in drug use compared to standard

treatment !  increase treatment program graduation rates by nearly 80%

Caveat:somecontrolledtrialsbutnotrandomized

(http://www.nadcp.org/learn/facts-and-figures)

!  Results vary widely and depend on how it is implemented !  Monitoring and quick delivery of contingencies are critical !  Has more of a focus on punishers (jail)

CM is highly variable:- Many different types of CM programs- Vary on: type of Rf

magnitude of Rf frequency of Rfduration target

!  Abstinence-based CM engenders sustained periods of abstinence (alcohol, tobacco, cocaine, opiates, marijuana, methamphetamine); sustained abstinence predicts future abstinence. Short-term, temporary periods of abstinence can be beneficial

!  Voucher and Prize-based CM are the two most researched types of CM with much evidence for their efficacy

!  Greater magnitude incentives engender greater rates of abstinence!  Longer duration program results in longer duration positive outcomes !  Maintenance / Relapse appears equivalent to other outpatient interventions (substantial

relapse)

!  Effective with special populations of substance abusers, including pregnant and recently postpartum women, adolescents, homeless, and those with serious mental illness

!  Cost Effectiveness / Return on Investment appears clear from a few studies, but more studies needed

1) Maintenance .... Challenge for all interventions - establish meaningful lifestyle change to compete with substance use2) Non-responders3) Reduced use / Harm reduction4) Schedules of Reinforcement (Incentives)5) Individual / cultural differences impact interventions - nature of Rf is that it is defined by its consequences6) Transportability / Dissemination

- Cost Effectiveness / Return on Investment- Payor Systems- Recognize barriers related to beliefs contrary to use of incentives (providers, administrators, policy makers, parents, general public) e.g., rewarding people for what they should be doing (or to stop doing what they should not be doing) is contrary to the beliefs of the masses

- Fidelity of Delivery incentive interventions are much more complex than they seem; details are important

•  Target(s) •  Monitoring •  Schedule of Reinforcement •  Magnitude of Reinforcement •  Type of Consequence

•  Abstinence should be primary target

•  Attendance or other therapeutic tasks can be targets but may not result in drug abstinence

•  Select achievable target (short period of abstinence, especially early in treatment).

•  Target must be verified using biochemical or other objective measure

•  Monitoring schedule must match schedule of reinforcement

•  Minimize delay between target behavior and reinforcement

•  Use frequent reinforcement especially early in treatment (weekly or even more often)

•  Creatively use of different schedules guided by behavioral principles of reinforcement

•  Higher magnitude incentives likely more potent than lesser magnitude

•  Some effective lower magnitude systems have used intermittent schedules (e.g., fishbowl)

•  Use a variety of reinforcers

•  Allow client choice when possible

•  Can include nonmonetary reinforcers (privileges, praise).

!  Using CM programs to motivate drug abstinence and support lifestyle change appear logical

!  Nonetheless, CM interventions have yet to pervade our community clinics? cost, expertise, conflicting philosophy

!  Be creative in development of reinforcement system

!  Consider reinforcement systems for prevention and treatment purposes

!  Clinical Population:"  (adults, adolescents, specific substance)

!  Type of Treatment: "  (Outpt, Intensive Outpt, Inpt)"  (group vs. individual)"  (Other)

!  CM Target Behavior:"  (drug abstinence, alcohol, all substances)"  (attendance, participation, medication

!  high relapse rates !  low motivation of many patients !  need to improve!! !  great results from CM

!  COST !  resources for education/training !  staff and administration concerns !  What types of prizes to use

!  food !  breaks !  a smile, positive words !  peer encouragement

!  probably already have enough of that !  discharge !  reset of prize escalation !  loss of privileges !  require more frequent visits

!  choose behaviors that are important for treatment and program success

!  choose behaviors you can objectively verify !  examples:

"  drug use (urine tests, breathalyzers) "  attendance "  completing assignments

!  system with established track record !  minimize cost !  minimize changes to existing program

!  Adolescent, ages 13-18 !  70% Male !  Referred by school, family, court system, or treatment

providers/facilities !  private health insurance and Medicaid

!  Intensive Outpatient (IOP, 3 hr per day) and Partial Hospital (PHP, 6 hr per day)

!  Substance Disorders programs and Dual Diagnosis programs

!  Group therapy based programming with individual sessions at least twice weekly

!  Elements of CBT, MET, and 12 step facilitation !  psychiatrist

!  2 - 4 weeks length of stay !  Referral to local individual therapist and psychiatrist

upon successful program completion !  Recommendation to continue self-help groups after

program completion

!  Use existing staff, urine testing, and attendance mechanisms already in operation !  Train staff in theory and techniques of CM with training manual (Petry, N.M. and M.L. Stitzer. 2002 Yale

University Psychotherapy Development Center)

!  Use plastic beads of different colors for drawing pieces !  Draw once weekly !  Therapist tabulates urine and attendance data each week

!  1 draw for a negative urine test !  increasing numbers of draws for each subsequent

consecutive negative urine !  Maximum of 6 draws per week !  Draws reset to 0 if a urine test is positive !  decrease by 50% or more from the previous specimen

quantitative value is considered negative for cannabis

!  1 draw for perfect attendance for the whole week !  Includes attendance at the Saturday family program

!  Counselors meet with all patients in large group !  Reiterate CM rules and goals !  Show and discuss some of the prizes !  Lively, fun atmosphere as patients take turns making their

awarded draws from the bag

!  50% Clear Beads No Value “Good Job” !  30% Red Beads Small Value $1 !  15% Green Beads Medium Value $5 !  5% Purple Beads Large Value $15

Prizes are gift certificates and gift cards to local area stores such as fast food restaurants, coffee shops, and a sports store, as well as cards redeemable for digital music downloads on the internet

Urinecollectionandtestingmethods

!  Indirect observation !  twice weekly testing, random !  Send-out test to commercial lab

!  ELISA with GC/MS confirmation !  Results in 1-3 days !  Tests for cannabinoids, opioids, cocaine, amphetamines, benzodiazepines;

other tests on request !  Integrity checks: pH, oxidizing adulterants, Cr, s.g., temperature

Results-Urines

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**p < 0.05, **p < 0.01 and †p < 0.005 Lott and Jencius, Drug Alcohol Depend 2009 102(1-3):162-5.

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!  Startup expenses: $9.58

!  Prizes: $1524.58

!  Mean cost per patient: $6.30 per patient (Additional $150 worth of prizes were donated by restaurants and hospital staff)

Summary

!  Very low monetary cost of CM program !  Significant decrease in urine positive rates for opioids,

cocaine, and all drugs !  Minimal change in attendance rate !  Increased retention

Discussion

!  Monetary cost is low but requires ongoing commitment from staff and institution

!  Significant positive effect on urine test outcomes !  later changes include addition of jumbo value prize

and removal of reinforcement for attendance !  Testing methods are opportunity for further

improvement

Patient Label

Date Test Result THC Ratio

Eligible # of draws

Comments Draw Date

□ NEGATIVE □ Marijuana ________ □ Cocaine □ Amphetamines □ Other _________________

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Example form for recording a patient’s drug test results,for the purpose of the Contingency Management program

Date Test Result THC Ratio

Eligible # of draws

Comments Draw Date

10-15-10 □ NEGATIVE X Marijuana 991 □ Cocaine □ Amphetamines □ Other _________________

695 0 * 1 3

6 (Max)

Creatinine: 142.4 mg/dL


↓ 279 0 1 *

3 6 (Max)

CRT: 107.1


↓ 119 0 1

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CRT: 191.9 Friday, 10-22


↑ 360 0 * 1 3

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CRT: 160.8


↑ 647 0 * 1 3

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CRT: 77.4

10-28-10 □ NEGATIVE X Marijuana 369 X Cocaine □ Amphetamines □ Other _________________

↓ 396 0 * 1 3

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CRT: 93.0


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Petry, N.M. and M.L. Stitzer. 2002 Yale University Psychotherapy Development CenterHiggins et al. (2008). Contingency management in substance abuse treatment. New York, NY: The Guilford Press.Lussier, J.P., Heil, S.H., Mongeon, J.A., Badger, G.J., & Higgins, S.T. (2006). A meta-analysis of voucher-based

reinforcement therapy for substance use disorders. Addiction, 101, 192-203. Petry, N. M. (2012). Contingency management for substance abuse treatment: A guide to implementing evidence-based

practice. New York, NY, US: Routledge/Taylor & Francis Group..Kellogg SH, et al. (2005). Something of value: the introduction of contingency management interventions into the NYC

Health and Hospital Addiction Treatment Service. J Subst Abuse Treat 28: 57-65.Budney et al., (2001). Contingency management: Using science to motivate change. In R. H. Coombs (Ed.), Addiction

Recovery Tools: (pp. 147-172). Thousand Oaks, CA: Sage Publications.Promoting Awareness of Motivational Incentives (PAMI) http://pami.nattc.orgPetry, N.M. (2013): http://contingencymanagement.uchc.edu/publications/index.html#cost_effectiveness0

Acknowledgements

!  Jessica Novak, Dan Phillips, Beth Sack, Paul Frerichs, and other staff

!  Simon Jencius !  Linden Oaks Hospital !  Various prize donors

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