How much would it cost me to How much would it cost me to buy a day’s abstinence? buy a day’s abstinence?

Behaviour therapies in the Behaviour therapies in the addictionsaddictions

John Marsden, Ph.D.John Marsden, Ph.D.Division of Psychological Medicine & Division of Psychological Medicine &

PsychiatryPsychiatry

National Addiction Centre,National Addiction Centre,

King’s College London, UKKing’s College London, UK

““Failure” Rates for AddictionsFailure” Rates for Addictions (reduction <50% in use after 6 (reduction <50% in use after 6

mos.)mos.)

5040

45

70

Alcohol Opiates Cocaine Nicotine

O’Brien & McLellan, 1996, The Lancet

Comparative Rates for Comparative Rates for

Treatment Compliance & RelapseTreatment Compliance & Relapse

50

40

30

55

30

70

Diabetes Hypertension Asthma

% Complied w Trt Plan% Relapsed (Mdn) in 1 Yr

O’Brien & McLellan, 1996, The Lancet

Behavioural Behavioural interventionsinterventions

► Theoretical foundationsTheoretical foundations► Laboratory and clinical foundationsLaboratory and clinical foundations► ReinforcementReinforcement

… …. . a process wherein a stimulus event a process wherein a stimulus event increases the future probability of drug increases the future probability of drug use by acting as a consequence.use by acting as a consequence.

► Effective interventionsEffective interventions► Combination therapiesCombination therapies► Key issues and future directionsKey issues and future directions

Theoretical foundationsTheoretical foundations

B.F. SkinnerB.F. Skinner

► Three-term contingencyThree-term contingency• Discriminative stimulusDiscriminative stimulus• Operant responseOperant response• Reinforcement (positive and negative)Reinforcement (positive and negative)

► Behaviour modified by consequencesBehaviour modified by consequences► Schedules of reinforcementSchedules of reinforcement► Drug self-adminstration at the coreDrug self-adminstration at the core► Drugs function as primary reinforcersDrugs function as primary reinforcers► Altering behavioural contingencies Altering behavioural contingencies

Laboratory Foundations Laboratory Foundations (1)(1)

► Opiates, psychostimulants, nicotine, alcohol and cannabis serve as reinforcers in a Opiates, psychostimulants, nicotine, alcohol and cannabis serve as reinforcers in a diverse range of speciesdiverse range of species

► Behaviours aimed at obtaining drugs exhibit strong motivational pressureBehaviours aimed at obtaining drugs exhibit strong motivational pressure► Animal drug use can be modified by manipulating variables that affect other operant Animal drug use can be modified by manipulating variables that affect other operant

behaviours:behaviours:• Increasing number of responses requiredIncreasing number of responses required• By blocking/eliminating the reinforcementBy blocking/eliminating the reinforcement

• By punishing the responses on which drug reinforcement is contingentBy punishing the responses on which drug reinforcement is contingent

Laboratory Foundations Laboratory Foundations (2)(2)

► Associative learning and memory Associative learning and memory processes underpin addiction processes underpin addiction

Treatment ProtocolTreatment Protocol ► Weeks 1-12Weeks 1-12

• 2x weekly counseling 2x weekly counseling • 3x weekly urine testing 3x weekly urine testing

► Weeks 13-24Weeks 13-24 • 1x weekly counseling 1x weekly counseling • 2x weekly urine testing 2x weekly urine testing

► Months 7-12Months 7-12 • Aftercare – 1x monthly check-in with counsellor Aftercare – 1x monthly check-in with counsellor • Random urine testing Random urine testing

Elements:Elements: Antabuse therapy (clinical punishment)Antabuse therapy (clinical punishment) Relationship counseling & skills training Relationship counseling & skills training Occupational assistanceOccupational assistance Vouchers for goods and servicesVouchers for goods and services

Vouchers (weeks 1-12 only)Vouchers (weeks 1-12 only)► Urine tests negative for benzoylecgoine Urine tests negative for benzoylecgoine

(BE) earned points worth $0.25. (BE) earned points worth $0.25.

► The first BE negative earns 10 pts @ The first BE negative earns 10 pts @ $0.25$0.25

► Voucher for each subsequent consecutive Voucher for each subsequent consecutive negative test increases by 5 pts.negative test increases by 5 pts.

► The equivalent of $10 bonus is earned for The equivalent of $10 bonus is earned for every 3 consecutive negative tests.every 3 consecutive negative tests.

Voucher protocol Voucher protocol ► BE-positive tests or failure to give a specimen BE-positive tests or failure to give a specimen

‘reset’ vouchers back to initial value.‘reset’ vouchers back to initial value.► BE-positive tests or failure to give a specimen BE-positive tests or failure to give a specimen

reset vouchers back to initial value.reset vouchers back to initial value.► 5 consecutive negative tests returned vouchers 5 consecutive negative tests returned vouchers

back to the value preceding a reset.back to the value preceding a reset.► Vouchers were exchangeable for retail items in Vouchers were exchangeable for retail items in

community; max. earnings possible = $997.50community; max. earnings possible = $997.50► All purchases were made by staff and had to be All purchases were made by staff and had to be

deemed by therapists to be recovery deemed by therapists to be recovery appropriate.appropriate.

Higgins et al. (1994) Incentives Improve Outcome Higgins et al. (1994) Incentives Improve Outcome in Outpatient Behavioral Treatment of Cocaine in Outpatient Behavioral Treatment of Cocaine Dependence. Arch. Gen. Psychiat, 51, 568-76Dependence. Arch. Gen. Psychiat, 51, 568-76

► 40 patients randomlized to two groups 40 patients randomlized to two groups ► Treatment lasts for 25 weeks.Treatment lasts for 25 weeks.► 2x weekly counseling and 3x weekly 2x weekly counseling and 3x weekly

urinalysis in weeks 1-12; reduced to 1x urinalysis in weeks 1-12; reduced to 1x weekly counseling and 2x weekly urinalysis weekly counseling and 2x weekly urinalysis in weeks 13-24.in weeks 13-24.

► Counseling in both groups based on the Counseling in both groups based on the Community Reinforcement Approach (CRA).Community Reinforcement Approach (CRA).

► Voucher group rewarded for BE-negative Voucher group rewarded for BE-negative results in weeks 1-12. During weeks 13-24, results in weeks 1-12. During weeks 13-24, both groups received only a single $1 lottery both groups received only a single $1 lottery ticket for each BE-negative test.ticket for each BE-negative test.

Higgins et al. (2000) Higgins et al. (2000) Contingent Reinforcement Contingent Reinforcement Increases Cocaine Abstinence During Outpatient Increases Cocaine Abstinence During Outpatient

Treatment and 1 Year of Follow-up. JCCP,Treatment and 1 Year of Follow-up. JCCP,

2000, 68, 64-722000, 68, 64-72

► 70 patients randomized to two groups.70 patients randomized to two groups.► Treatment over 24 weeks and 1 year Treatment over 24 weeks and 1 year

follow-upfollow-up► All get CRA + vouchersAll get CRA + vouchers► One group receives vouchers contingent One group receives vouchers contingent

on cocaine abstinenceon cocaine abstinence► Other group receives vouchers non-Other group receives vouchers non-

contingently (yoked control)contingently (yoked control)► 24 weeks treatment and 1 year of follow-24 weeks treatment and 1 year of follow-

upup

Iguchi et al. (1997) Reinforcing operants other Iguchi et al. (1997) Reinforcing operants other than abstinence in drug abuse treatment. JCCP, than abstinence in drug abuse treatment. JCCP,

65, 425-65, 425-

► 103 MMT patients who completed 6 weeks 103 MMT patients who completed 6 weeks of baseline testing to one of three of baseline testing to one of three conditions:conditions:(a) standard MMT(a) standard MMT

(b) MMT + up to $15/week in vouchers for (b) MMT + up to $15/week in vouchers for submitting drug-free urine samplessubmitting drug-free urine samples(c) MMT + up to $15/week in vouchers for (c) MMT + up to $15/week in vouchers for submitting treatment plan taskssubmitting treatment plan tasks

► Interventions over 12 weeksInterventions over 12 weeks► Follow-up over 6 monthsFollow-up over 6 months

TP InterventionTP Interventionhas greater time effect that other 2 has greater time effect that other 2

treatmerntstreatmernts

0

5

10

15

20

25

30

35

40

BaselineWeeks 1–6

InterventionWeeks 7–12

InterventionWeeks 13–18

Follow-UpWeeks 19–24

SC

TP

UA

% drug-free urine samples

Epstein et al. (2003) Epstein et al. (2003) Cognitive–Behavioral Therapy Cognitive–Behavioral Therapy Plus Contingency Management for Cocaine Use: Plus Contingency Management for Cocaine Use: Findings During Treatment and Across 12-Month Findings During Treatment and Across 12-Month

Follow-Up. Follow-Up.

Psychol Addict Behav; 17, 73–82. Psychol Addict Behav; 17, 73–82.

► 193 MMT outpatients randomized 193 MMT outpatients randomized totovoucher availability (contingent or not voucher availability (contingent or not contingent on cocaine-negative urine contingent on cocaine-negative urine testing.testing.

► Follow-ups at 3, 6 and 12 monthsFollow-ups at 3, 6 and 12 months

Patients abstinent from cocaine over 87 test Patients abstinent from cocaine over 87 test daysdays

Patients abstinent from cocaine over 87 test Patients abstinent from cocaine over 87 test daysdays

Patients abstinent from cocaine over 87 test Patients abstinent from cocaine over 87 test daysdays

A meta-analysis of voucher-A meta-analysis of voucher-based reinforcement therapy based reinforcement therapy for substance use disorders.for substance use disorders.

Jennifer Lussier et al. Jennifer Lussier et al. (2006) (2006)

Addiction, 101, 192-203Addiction, 101, 192-203

MethodsMethods► Effect sizes calculated for controlled studies Effect sizes calculated for controlled studies

VBRT published between 1/91 & 3/04VBRT published between 1/91 & 3/04► 65 studies reviewed, including 40 where 65 studies reviewed, including 40 where

effects of contingent vouchers were effects of contingent vouchers were experimentally isolatedexperimentally isolated

► Focus was on period when vouchers were Focus was on period when vouchers were availableavailable

► Studies grouped by moderator variables: Studies grouped by moderator variables: type of drug targeted, control, duration of type of drug targeted, control, duration of VBRT, voucher $ value, voucher delivery VBRT, voucher $ value, voucher delivery immediate or delayed, study settingimmediate or delayed, study setting

Experimental vs control Experimental vs control conditionsconditions

► Results as pearson correlation coefficient Results as pearson correlation coefficient where as a guide:where as a guide:r r = 0.10 (difference in effectiveness of 55% vs. 45%)= 0.10 (difference in effectiveness of 55% vs. 45%)

r r = 0.30 (65% vs. 35%) = 0.30 (65% vs. 35%) r r = 0.50 ( 75% vs. 25%)= 0.50 ( 75% vs. 25%)

► 65 studies reviewed, including 40 where 65 studies reviewed, including 40 where effects of contingent vouchers were effects of contingent vouchers were experimentally isolatedexperimentally isolated

► Studies grouped by moderator variables: type Studies grouped by moderator variables: type of drug targeted, control, duration of VBRT, of drug targeted, control, duration of VBRT, voucher $ value, voucher delivery immediate voucher $ value, voucher delivery immediate or delayed, study settingor delayed, study setting

Effects for different substances Effects for different substances

SubstanceSubstance N N studiestudiess

Mean Mean weighted weighted ESES

cocainecocaine 1212 0.350.35

opiatesopiates 33 0.390.39

cocaine & cocaine & opiates opiates

55 0.210.21

polydrugpolydrug 66 0.200.20

cannabiscannabis 11 0.570.57

alcoholalcohol 11 0.320.32

nicotinenicotine 22 0.480.48

2x2 factorial design2x2 factorial design

Group 1Group 1

Placebo Placebo medication & medication & control VBRTcontrol VBRT

Group 2Group 2

Active Active medication & medication & control VBRTcontrol VBRT

Group 3Group 3

Placebo Placebo medication & medication & active VBRTactive VBRT

Group 4Group 4

Active Active medication & medication & active VBRTactive VBRT

Lambeth Harbour StudyLambeth Harbour Study

► Randomised controlled trialRandomised controlled trial► Voucher-CM onlyVoucher-CM only► Synergistic voucher-CM + group based CBTSynergistic voucher-CM + group based CBT► 82 service users (primary cocaine) 82 service users (primary cocaine) ► 8 week intervention8 week intervention► 3 x weekly on-site, urine testing for cocaine3 x weekly on-site, urine testing for cocaine► 8 x 1.25 hr CBT with CM discussion focus8 x 1.25 hr CBT with CM discussion focus► All participants receive 8 x 1 hr keworkingAll participants receive 8 x 1 hr keworking► Follow-ups:Follow-ups:

At 1-month (week 12)At 1-month (week 12) At 3-months (week 24)At 3-months (week 24)

Outcome criteriaOutcome criteria

► (1) (1) Immediate abstinenceImmediate abstinence during weeks 7 & 8. during weeks 7 & 8.

Participants must provide at least 2 cocaine negative urine tests in Participants must provide at least 2 cocaine negative urine tests in each of weeks 7 and 8 and no positive tests. each of weeks 7 and 8 and no positive tests.

► (2) (2) Short-term abstinenceShort-term abstinence no reported use of cocaine during weeks 9- no reported use of cocaine during weeks 9-12 and provision of a negative urine test at the 12-week (1-month) 12 and provision of a negative urine test at the 12-week (1-month) follow-up; and follow-up; and

► (3) (3) Longer-term abstinenceLonger-term abstinence no reported use of cocaine during weeks no reported use of cocaine during weeks 21-24 and provision of a negative urine test at the 3-month follow-up.21-24 and provision of a negative urine test at the 3-month follow-up.

Statistical analysis by relative risk ratios for outcome criteria and NNT

Lambeth voucher-CMLambeth voucher-CM

► 24 tests on Monday, Wednesday & Friday24 tests on Monday, Wednesday & Friday► Escalating schedule starting at £1Escalating schedule starting at £1► Up by £0.5 for each successive –ive testUp by £0.5 for each successive –ive test► Bonus for each series of 6 –ive testsBonus for each series of 6 –ive tests► Re-set following +ive test or DNARe-set following +ive test or DNA► Return to previous level for 6 –ives (if time)Return to previous level for 6 –ives (if time)► Voucher for attending drop-in for 1.25 hoursVoucher for attending drop-in for 1.25 hours► Final bonus for attending for all 24 testsFinal bonus for attending for all 24 tests► Total voucher value possible = £323Total voucher value possible = £323► Harbour voucher credits exchanged for store gift certificates as Harbour voucher credits exchanged for store gift certificates as Argos, Argos,

Footlocker, Woolworths etc.Footlocker, Woolworths etc.

The Harbour StepsThe Harbour Steps

1

2

3

4

5

6

7

8

9

10

11

12

Week 1

Week 2

Week 3

Week 4

Week 5

Week 6

Week 7

Week 8

Lambeth CBTLambeth CBT► All CBT attenders receive CMAll CBT attenders receive CM► CBT has joint CM coaching and CBT skills training purposeCBT has joint CM coaching and CBT skills training purpose► Key themes:Key themes:

Showing you the ropesShowing you the ropes The CM rules!The CM rules! Clearance reassuranceClearance reassurance Personal voucher goalsPersonal voucher goals Getting rollingGetting rolling Brushing off a set-backBrushing off a set-back The crunch zoneThe crunch zone Helping othersHelping others CBT skills CBT skills

Key issues and future directionsKey issues and future directions

► Behavioural interventions using CM are effective Behavioural interventions using CM are effective at encouraging initial abstinence.at encouraging initial abstinence.

► When contingencies removed effects taper off.When contingencies removed effects taper off.► However, they are rarely used in routine However, they are rarely used in routine

treatment delivery settings and outside the USA.treatment delivery settings and outside the USA.► They may be particularly effective when They may be particularly effective when

combined/integrated with other interventions.combined/integrated with other interventions.► Further development of reinforcement schedules Further development of reinforcement schedules

is needed: non-abstinent reinforcement as initial is needed: non-abstinent reinforcement as initial step?step?