Contingency Management

• Contingency management (CM) refers to the systematic application of basic principles delineated by workers in the field of the Experimental Analysis of Behavior to assist individuals in changing their behavior. Primary emphasis is placed on the use of reinforcement and punishment to alter an individual’s day-to-day behavior.

Reinforcers in Health Care Reinforcers in Health Care

• Mammography screeningMammography screening

• Child immunizationChild immunization

BREAST CANCERBREAST CANCERMammography ScreeningMammography Screening

Recommendation for Women Ages 50 and older:Recommendation for Women Ages 50 and older:

ANNUAL MAMMOGRAMANNUAL MAMMOGRAM

With physician advice alone, few women receive With physician advice alone, few women receive an annual mammogram an annual mammogram (Stoner et al., 1998)(Stoner et al., 1998)

Mammogram ComplianceMammogram Compliance

0%

20%

40%

60%

Incentive No IncentiveRat

e of

Com

pli

ance

Rat

e of

Com

pli

ance

Rates of mammogram screening were 2.5 times higher for the Rates of mammogram screening were 2.5 times higher for the incentive as compared to the control women. incentive as compared to the control women. (Stoner et al., 1998)(Stoner et al., 1998)

ChildhoodImmunizations

In 1989-91, immunization rateswere as low as 23% for two-yearolds in the Chicago area.

Immunization Rates

0%

20%

40%

60%

80%

100%

Voucher Control

Rat

e

Rates increased when WIC food vouchers were given to those who had their children immunized. (Hoekstra et al., 1998)

How does CM work in treating drug abuse?

• Provide alternative sources of reinforcement.

Nader & Woolverton, 1991

0102030405060708090

100

0.3

cocaine dose mg/kg/inj

% Cocaine Choices

1 pellet

4 pellets

16 pellets

Higgins, Roll, & Bickel, 1996

0

2

4

6

8

10

$0.05 $1.00 $2.00

# of cocaine choices

Roll, & Newton, 2007

0

1

2

3

4

5

6

7

8

9

10

# of

methamphet

amine

choices

$0.05

$1.00

$5.00

CM has been used to treat a number of types of drug abuse

Opioids Benzodiazepines Marijuana MethamphetamineNicotine (tobacco smoking)AlcoholCocaine

Treatment of Cocaine Dependence in a Drug-Free Clinic

Higgins et al., 1994

Control Treatment–Psychosocial treatment–Urine testing 2x/week–No vouchers

Contingency Management–Psychosocial treatment–Urine testing 2x/week–Vouchers, escalating

0

25

50

75

100

CM Standard

%

>8 Weeks of Cocaine Abstinence

0

25

50

75

100

CM Standard

%

Retained Through Study

Higgins et al., 1994

Treatment of Cocaine Dependence

Treatment of Cocaine Abuse in Methadone Patients

Silverman et al., 1996

Contingency Management

3x weekly urine testing

received vouchers only if

urine samples were

cocaine negative

Control Group

3x weekly urine testing

received vouchers

regardless of urine test

results

0

25

50

75

100

%

CM Standard0

25

50

75

100

%

CM Standard

>8 Weeks of Cocaine Abstinence

Retained Through Study

Treatment of Cocaine Use in Methadone Patients

Silverman et al., 1996

• A recent meta-analysis reports that CM results in a successful treatment episode 61% of the time while other treatments with which it has been compared result in a successful treatment episode 39% of the time (Prendergast, Podus, Finney, Greenwell & Roll, 2006)

CTN 006 & 007

Random Assignment

• Standard care

• Standard care with prize CM

• 3-month evaluation

Draws escalate with Draws escalate with stimulant-free test resultsstimulant-free test results

Weeks Drug Free

# Draws

1

2

4

5

3

Total earningsTotal earningsOn average, patients could earn up to $400 in prizes if On average, patients could earn up to $400 in prizes if

they maintained abstinence for 12 weeks and submitted all 24 they maintained abstinence for 12 weeks and submitted all 24 negative samples. negative samples.

Actual earnings were $203 in psychosocial clinics and Actual earnings were $203 in psychosocial clinics and $130 in methadone clinics (e.g., half possible or less).$130 in methadone clinics (e.g., half possible or less).

CTN 006

Results from psychosocial clinicsResults from psychosocial clinics

Arapaho-Douglas (Rocky Mountain)

Charleston (South Carolina)

Circle Part (South Carolina)

Crossroads (Rocky Mountain)

Harbel (Mid Atlantic)

Jefferson (Delaware Valley)

Guenster LMG (New England)

Matrix (Pacific Region)

ResultsResults

0

20

40

60

%

Prize CM Standard

Remained 12 weeks in treatment

0

20

40

60

%

Prize CM Standard

>8 Weeks of stimulant abstinence

Petry et al. (2005). Archives of General Psychiatry

p<.05

p<.05

CM + TAUTAU

Comparing Cocaine and Methamphetamine Treatment Outcomes

Total Number of Negative Urines

0123456789

101112131415

Cocaine Methamphetamine

Mea

n N

umbe

r

CM +TAU

TAU

Longest Duration of Abstinence

0

1

2

3

4

5

Cocaine Methamphetamine

Mea

n W

eeks

CM +TAU

TAU

CTN 007

Eligible patientsEligible patients

Stimulant abusersStimulant abusers (cocaine or methamphetamine)(cocaine or methamphetamine)

enrolled in methadone or enrolled in methadone or outpatient psychosocial outpatient psychosocial treatmenttreatment

Participating methadone clinics

Act II (Delaware Valley) Aegis (Pacific Region)

Glenwood (Mid Atlantic)Greenwich (New York) LESC (New York)

Oasis (Mid Atlantic)

CTN methadone studies

Percent achieving > 8 weeks of stimulant abstinence

0

10

20

30

Prize CM Standard

%

p<.05

Peirce et al. (2006). Archives of General Psychiatry.

CMDE (N=120)

• TAU (16 weeks of CBT)

• TAU + 4 weeks of CM

• TAU + 8 weeks of CM

• TAU + 16 weeks of CM

n.s.

LTBC (N=118)

• TAU (16 weeks of CBT)

• Continuous = TAU + 12 weeks of CM FR1

• Predictable = TAU + 12 weeks of CM FR3

• Unpredictable = TAU + 12 weeks of CM VR3

Procedures

• Thrice weekly counseling and urine collection

• Negative urine resulted in delivery of a voucher utilizing an escalating scale of reinforcement procedure

.