Low-Cost Contingency Management in Low-Cost Contingency Management in Community SettingsCommunity Settings

Low-Cost Contingency Management in Low-Cost Contingency Management in Community SettingsCommunity Settings

Nancy Petry, Ph.D.Nancy Petry, Ph.D.

University of Connecticut Health CenterUniversity of Connecticut Health Center

Farmington, CTFarmington, CT

Supported by NIH grants R01-DA13444, Supported by NIH grants R01-DA13444, RO1-DA016855, RO1-DA14618, RO1-DA016855, RO1-DA14618,

R29-DA12056, P50-DA09241 and P50-AA03510R29-DA12056, P50-DA09241 and P50-AA03510

Contingency management:Contingency management:

1.) Frequently monitor target behavior.1.) Frequently monitor target behavior.

2.) Provide tangible reinforcement when target 2.) Provide tangible reinforcement when target behavior occurs.behavior occurs.

3.) Remove reinforcement when target behavior does 3.) Remove reinforcement when target behavior does not occur.not occur.

$10

Voucher studiesVoucher studies

Treatment of Cocaine DependenceHiggins et al., 1994

Standard treatmentStandard treatment Community Community

Reinforcement Reinforcement Approach TherapyApproach Therapy

Urine testing 2x/weekUrine testing 2x/week No vouchersNo vouchers

$10

Contingency ManagementContingency Management Community Community

Reinforcement Reinforcement Approach TherapyApproach Therapy

Urine testing 2x/weekUrine testing 2x/week VouchersVouchers

Up to $1000 available

0

25

50

75

100

%

CM Std0

25

50

75

100

%

CM Std

>8 Weeks of Cocaine Abstinence

Retained throughout Trial

Higgins et al., 1994

Treatment of Cocaine Dependence

OpioidsOpioids (Stitzer et al various, Bickel et al., 1997)

Cocaine Cocaine (Higgins et al., 1991, 1993, 1994; Silverman et al., 1996; Shaner et al., 1997)

BenzodiazepinesBenzodiazepines (Stitzer et al., 1992)

MarijuanaMarijuana (Budney et al., 1991, 2000)

AlcoholAlcohol (Bigelow et al., 1975; Miller, 1975) Nicotine Nicotine (Crowley et al., 1991; Roll et al., 1996;

Shoptaw et al., 1996)

Voucher studiesVoucher studies

Addressing some of the practical concernsAddressing some of the practical concerns

1. Cost1. Cost

2. Generalization and Acceptability2. Generalization and Acceptability

Intermittent schedule of reinforcementIntermittent schedule of reinforcement

Implementation into standard clinic settingsImplementation into standard clinic settings

Standard VA clinic setting

Subjects:Subjects: 42 alcohol-dependent outpatients 42 alcohol-dependent outpatients

Standard treatment:Standard treatment:Intensive outpatient day program Intensive outpatient day program

5 hrs/day, 5 days/week, weeks 1-45 hrs/day, 5 days/week, weeks 1-4

Aftercare Aftercare 1-3 groups/week, weeks 4-81-3 groups/week, weeks 4-8

Treatment consisted of group sessions: 12 step, relapse Treatment consisted of group sessions: 12 step, relapse prevention, voc rehab, AIDS, coping skillsprevention, voc rehab, AIDS, coping skills

Standard treatment groupStandard treatment group

Received standard group treatment and Received standard group treatment and

BAC monitoring (daily during intensive, weekly BAC monitoring (daily during intensive, weekly during aftercare).during aftercare).

Additional 15 min ofAdditional 15 min of

education oneducation on

alcohol abuse weeklyalcohol abuse weekly

Contingent groupContingent group

Standard group treatment and BAC monitoringStandard group treatment and BAC monitoring

Reinforce alcohol abstinence:Reinforce alcohol abstinence: One draw for each negative BAC.One draw for each negative BAC. Five bonus draws for a week of consecutive abstinence.Five bonus draws for a week of consecutive abstinence.

128 draws possible128 draws possible

1/2 chance of winning a small $1 prize

1/16 chance of winning a medium $20 prize

1/250 chance of winning a jumbo $100 prize

Half the cards are winningHalf the cards are winning

RetentionRetention

0

20

40

60

80

100

120

2 4 6 8

weeks

% R

etai

ned

STDCM

Petry et al., 2000

0

20

40

60

80

100

2 4 6 8

Weeks

% N

ot R

elap

sed

STDCM

Time until first heavy drinking episodeTime until first heavy drinking episode

p<.05

Petry et al., 2000

Percent positive for any illicit drugPercent positive for any illicit drug

0

10

20

30

40

50

%

Intake Week 4 Week 8

STD

CM

Petry et al., 2000

SummarySummary

This variable ratio schedule of reinforcement This variable ratio schedule of reinforcement significantly increased retention and reduced significantly increased retention and reduced

alcohol use.alcohol use. On average, subjects earned $200 worth of prizes.On average, subjects earned $200 worth of prizes. Local retailers and stores were willing to donate Local retailers and stores were willing to donate

prizes.prizes.

Does this intermittent reinforcement system work as well as the voucher system?

Does this intermittent reinforcement system work as well as the voucher system?

Study designStudy design

Cocaine-dependent outpatients initiating Cocaine-dependent outpatients initiating intensive outpatient treatment.intensive outpatient treatment.

Randomly assigned to:Randomly assigned to: Standard treatmentStandard treatment Standard treatment plus voucher CMStandard treatment plus voucher CM Standard treatment plus prize CMStandard treatment plus prize CM

Vouchers vs. prizesVouchers vs. prizes

0

25

50

75

100

0 1 2 3 4 5 6 7 8 9 10 11 12

weeks

%

Standard

Voucher

Prize

Retention

p=.08p<.01

p<.01

Mean weeks of continuous cocaine abstinenceMean weeks of continuous cocaine abstinence

0

3

6

9

Standard Voucher Prize

wee

ks

p<.05

p<.01

How low can we go?How low can we go?

Treatment groupsTreatment groups

Cocaine-dependent patients entering intensive day Cocaine-dependent patients entering intensive day program randomly assigned to:program randomly assigned to:

1.) Standard treatment 1.) Standard treatment

2.) Standard treatment plus $80 CM2.) Standard treatment plus $80 CM

($0.33, $5, and $100 prizes)($0.33, $5, and $100 prizes)

3.) Standard treatment plus $240 CM3.) Standard treatment plus $240 CM

($1, $20, and $100 prizes)($1, $20, and $100 prizes)

Mean weeks of continuous cocaine abstinenceMean weeks of continuous cocaine abstinence

1

2

3

4

5

Mea

n

Standard $80 $240

Petry et al. 2004

Can it work in group settings?Can it work in group settings?

Cocaine abstinence

0

10

20

30

40

50

1 2 3 4 5 6 7 8 9 10 11 12

Weeks

% N

egat

ive

CMStandard

Group attendance

p<.01

0

20

40

60

80

100

1 2 3 4 5 6 7 8 9 10 11 12

Weeks

p<.01

Methadone maintenance clinicMethadone maintenance clinic

Petry et al., JCCP, in press

0

5

10

15

20

25

30

35

weeks

Clie

nts

ThursdayBoth daysTuesday

Baseline BaselineReinforcers

on TuesReinforcers

on Thurs

Lower reinforcerson Thurs

Attendance at groups at HIV centerAttendance at groups at HIV center

Petry, Martin, & Finocche, 2001

Community-based therapists providing the incentives for group attendanceCommunity-based therapists providing the incentives for group attendance

0

1

2

3

4

5

6

Standard CM

Wee

ks

Mean weeks of continuous cocaine and opioid abstinence

Mean days attended treatment

0

5

10

15

20

25

Standard CM

Day

s

SummarySummary

This lower-cost CM system is effective in This lower-cost CM system is effective in retaining patients in treatment. retaining patients in treatment.

It reduces substance use.It reduces substance use. Larger magnitude prizes seem more effective than Larger magnitude prizes seem more effective than

smaller magnitude prizes, but prizes work at least smaller magnitude prizes, but prizes work at least as well as vouchers.as well as vouchers.

This CM system can be implemented into group This CM system can be implemented into group treatment format.treatment format.

Additional studies should address:Additional studies should address:

Ways to further reduce costs without Ways to further reduce costs without compromising efficacy.compromising efficacy.

Patient subgroups who may require higher or Patient subgroups who may require higher or lower incentives.lower incentives.

What behaviors to target.What behaviors to target. Optimal durations of treatment.Optimal durations of treatment. Long-term efficacy.Long-term efficacy. Methods for training therapists to administer the Methods for training therapists to administer the

treatments.treatments.

AcknowledgementsAcknowledgements

Alcohol and Drug Recovery Centers, Inc. (Hartford, CT)Alcohol and Drug Recovery Centers, Inc. (Hartford, CT) Baystate Medical Center (Springfield, MA)Baystate Medical Center (Springfield, MA) Community Substance Abuse Centers, Inc. (Hartford, CT) Community Substance Abuse Centers, Inc. (Hartford, CT) The Living Center (Hartford, CT)The Living Center (Hartford, CT) Morris Foundation (Waterbury, CT)Morris Foundation (Waterbury, CT) St. Francis Behavioral Health (Hartford, CT)St. Francis Behavioral Health (Hartford, CT) VA Connecticut (Newington, CT)VA Connecticut (Newington, CT)

Sheila Alessi, Ph.D., Mark Austin, Ellen Cielieski, Marilyn Lewis, Sheila Alessi, Ph.D., Mark Austin, Ellen Cielieski, Marilyn Lewis, Ph.D., Bonnie Martin, Steve McKinnon, Sean Sierra, Michelle Tardiff, Ph.D., Bonnie Martin, Steve McKinnon, Sean Sierra, Michelle Tardiff, Jackie Tedford, M.S.W., and Mary WienersJackie Tedford, M.S.W., and Mary Wieners