practical application of contingency management

Practical Application of Practical Application of Contingency ManagementContingency Management

Michael J. McCann, MA

Matrix Institute on Addictions

Elements of Treatment: Elements of Treatment: Information, Persuasion, and MedicationInformation, Persuasion, and Medication

Information–Matrix Model – CBT– 12-Step

Persuasion–Motivational Interviewing– Confrontation– Contingency Management

Motivational InterventionsMotivational Interventions

If you build it they will not necessarily come.

And, if they do come, they may not come all of the time.

Hence:–Motivational Interviewing– Contingency Management

Contingency Management (CM)Contingency Management (CM)

CM: application of reinforcement contingencies to urine results or behaviors (attendance in treatment; completion of agreed upon activities).

Research consistently shows that it works.

Contingency Management: Contingency Management: OverviewOverview

1. Research findings

2. Application of CM in the Matrix Institute OTP

Research FindingsResearch Findings

Highlight efficacy

Raise questions about real-world applicability

Contingency Management: Contingency Management: Steve Higgins, Ph.D.Steve Higgins, Ph.D.

Community Reinforcement Approach (CRA)–Marital Therapy– Vocational Assistance– Skills Training– New social and recreational activities– Antabuse

Vouchers ($977)

Contingency Management: Contingency Management: Higgins et al., 1993Higgins et al., 1993

– 24-week treatment – 3 times per week urines

– Conditions• Standard treatment • CRA plus vouchers

Contingency Management: Contingency Management: Higgins et al., 1993Higgins et al., 1993

5%11%11%

42%

68%

58%

0%

10%20%

30%

40%50%

60%

70%

80%90%

100%

Completed Treatment 8 weeks continuousabstinence

16 weeks continuousabstinence

Standard TreatmentCRA & CM

Contingency Management: Contingency Management: Higgins et al., 1994Higgins et al., 1994

– How much of CRA effect is CM?

– 24-week treatment – 3 times per week urines

– Conditions• CRA only • CRA plus vouchers

Contingency Management: Contingency Management: Higgins et al., 1994Higgins et al., 1994

15%

40%

55%

75%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Completed Treatment 8 weeks continuous abstinence

CRACRA & CM

Contingency Management:Contingency Management: Rawson et al., 2002Rawson et al., 2002

Cocaine-using methadone patients16 weeks; 3 X per weekFour conditions:– CM – CBT – CBT & CM–Methadone only

Contingency Management: Contingency Management: Rawson et al., 2002Rawson et al., 2002

Cognitive-behavioral Treatment (CBT)– 90 minute groups– Cognitive/behavioral– Drug cessation– Lifestyle change– Relapse prevention

Contingency Management: Contingency Management: Rawson Rawson et al., 2002et al., 2002

Contingency Management – Vouchers for stimulant-free urines– Progressive schedule– Bonuses for 3 consecutive clean ($10)– Reset with 5 clean– Total earnings possible: $1277

Cocaine-free Urine Samples During StudyCocaine-free Urine Samples During StudyRawson et al., 2002Rawson et al., 2002

19.8

30.3

26.1

11

0

5

10

15

20

25

30

35

# c

oca

ine-f

ree

CBT CM CBT & CM MMP<.001

CM>MM

CBT & CM>MM

Percent Subjects Achieving 3 Consecutive Percent Subjects Achieving 3 Consecutive Weeks Cocaine-freeWeeks Cocaine-freeRawson et al., 2002Rawson et al., 2002

40%

63%57%

27%

0%

10%

20%

30%

40%

50%

60%

70%

% p

ts. 3-w

eeks

coca

ine fre

e

CBT CM CBT & CM MMP<.02

CM>MM

CBT & CM >MM

Days used cocaine in past month Days used cocaine in past month Rawson et al., 2002Rawson et al., 2002

0

3

6

9

12

15

Baseline Wk-17 Wk-26 Wk-52

# d

ays

use

d

MMCMCBT + CMCBT

Week 26: CM<MM; CBT<MM

Week 52: CBT<MM

CBT Group AttendanceCBT Group AttendanceRawson et al., 2002Rawson et al., 2002

17.9

24.7

0

5

10

15

20

25

30

# s

ess

ions

att

ended

CBT CBT & CMP<.04

Contingency Management in TreatmentContingency Management in Treatment

Conclusion: CM works

CM in PracticeCM in Practice

What to target?– Urine results?• Frequent enough? Results immediate?• Valid? Observed?

– Treatment goals • Can vary across patient and counselors• Verifiable?

– Attendance

CM in PracticeCM in Practice

Challenges– Addressing staff resistance• Patients should not have to be “paid”;

recovery is the reward • Motivation needs to come from within

CM in PracticeCM in Practice

Challenges–Must be simple• Easy to track—Need to keep a record of

attendance• Easy to figure rewards—no progressive

schedules, resets, etc.• Little burden on the counselor

CM in PracticeCM in Practice

Challenges–Must be inexpensive• A less expensive method may be a bit less

effective, but an expensive method will never be used.• A little reward goes a long way especially

combined with praise and recognition

CM in Practice in an OTPCM in Practice in an OTP

$5 per month for perfect group attendance

$5 per month for perfect medication attendance

Easy to trackLess expensive than CM in research

Perfect medication attendancePerfect medication attendancePre-post contingencies, n=49Pre-post contingencies, n=49

37%

52%

25%

30%

35%

40%

45%

50%

55%

% p

erf

ect

Pre-CM Post-CM

P<.05

Perfect group attendancePerfect group attendancePre-post contingencies, n=49Pre-post contingencies, n=49

58%

71%

40%

45%

50%

55%

60%

65%

70%

75%

% p

erf

ect

Pre-CM Post-CM

P<.01

Perfect group attendance in patients Perfect group attendance in patients missing pre-CM, n=20missing pre-CM, n=20

0%

65%

0%

10%

20%

30%

40%

50%

60%

70%

80%

% p

erf

ect

Pre-CM Post-CM

Groups attended in patients missing Groups attended in patients missing pre-CM, n=20pre-CM, n=20

58%

88%

0%10%20%30%40%50%60%70%80%90%

100%

% g

roups

Pre-CM Post-CM

P<.005

CM in an OTP: ConclusionsCM in an OTP: Conclusions

A simple, low cost CM intervention can improve patient attendance in groups and medication visits.

CM in an OTP: ModificationsCM in an OTP: Modifications

Recent data show diminished effectPerfection too difficult? More immediate effect; shaping:

McDonald’s coupons, once per week at group, first 30 days of treatment

CM in an OTP: ModificationsCM in an OTP: Modifications

Raffles – Voucher for 1-1 sessions– 2 vouchers qualifies for group raffle the

following month– Reinforces attendance in 1-1 and

groups– Relatively inexpensive– No tracking required

ConclusionsConclusions

CM can be effectively used in clinical settings

Low cost reinforcers can be effectiveSimple schedules can be effectiveIncreased attendance can offset cost

with fee-for-service billing