Contingency Management An Evidence Based Approach to Improving Treatment Adherence Dr. John Mahan, MD, Addiction Psychiatrist Rhonda Spath, CADC Jackson County Mental Health

Disclosures Neither John Mahan, MD nor Rhonda Spath have any relevant financial disclosures to make No non-FDA approved uses for medications will be discussed

Learning Objectives Gain familiarity with the behavioral principles underpinning Contingency Management Learn about voucher-based vs. prize-based reinforcement paradigms, understand how an escalating schedule of reinforcement can be applied to either, and appreciate that these interventions do not cause or destabilize Gambling Disorder. Introduce how one ACT Team has implemented Contingency Management to reinforce desired pro-recovery behaviors, including A&D group attendance, meeting with medical providers, and presenting for long-acting injectable medication administration.

The Conundrum How to encourage clients to meet with clinicians, adhere to medications, or abstain from methamphetamine? Benefits: Better Physical and Mental Health Improved Relationships Social Productivity

The Conundrum To clients, the benefits of treatment plan adherence can be long-term, and therefore less immediate, than other competing factors Benefits: Better Physical and Mental Health Improved Relationships Social Productivity

Competing Priorities In service of Long Term Benefit Competing Forces Meeting with clinicians Medication adherence Abstinence from methamphetamine, cannabis, or other substances Competing Forces Negative symptoms, disruptive to daily life Avoiding side effects, a nuisance to remember Cravings, Avoidance of withdrawal, Desired alteration in perception of symptoms or difficult life circumstances

What is Contingency Management? A way to bring positive consequences for treatment adherence forward in time and to make them: More immediate More salient More predictable

What is Contingency Management? Based on Operant Behavioral Principles, also known as Instrumental Learning or Operant Conditioning If I do this, then that happens…

Operant vs. Classical Operant Conditioning Classical Conditioning Stimuli that are present when a behavior is rewarded (or punished) affect the likelihood of the behavior in the future – a thought process e.g., Getting to the ACT meeting early because you know there will be donuts and the best ones go fast! Stimuli that signal significant events produce reflexive behavior - often outside conscious awareness e.g., Salivating at the sight of your favorite treat!

but we are not the only ones who know this... A chance at free cannabis entices someone to enter a cannabis dispensary. Winning free cannabis makes it more likely an ACT client will return for another chance to win free cannabis

…so we should offer our own reinforcers Contingency Management uses immediate positive reinforcers to improve adherence to treatment plan elements that might otherwise have mostly long-term benefits.

Immediacy Target a behavior that you can reinforce in real time (not a delayed reward) Attending an appointment with a clinician Attending a group Successfully providing a laboratory sample (regardless of result) Appropriate Urine Drug Screen (point of care is best for immediacy of results)

Value The reinforcers have to be valuable to the participants (but they don’t have to be expensive). Ask participants what they want! Adolescents often don’t want CDs, for example I’d rather give health food, but participants often desire less nutritious snacks Can allow participants to “bank” points for larger items they would like

Fixed vs Intermittent Reinforcement “voucher-based” “Prize-based”

Fixed vs Intermittent Reinforcement “voucher-based” “Prize-based” Reinforcement is always the same, no chance involved Half the prizes are verbal encouragement, some are worth a little, a few are worth a bit more, and one can be pretty nice Works equally well as a fixed paradigm, and is cheaper to run Does NOT contribute to development or/ relapse to Gambling Disorder FUN!

Option: Escalating Schedule An Escalating Schedule can be applied to either Fixed or Intermittent reinforcement structures to improve efficacy (escalating works better!) Number of reinforcers increases with each successive successful behavior (up to a maximum), until participant misses an opportunity to display the desired behavior

Option: Escalating Schedule Constant escalating First: 1 Misses one: 0 Second in a row: 1 Third in a row: 1 Fourth in a row: 1 Fifth in a row: 1 Sixth in a row: 1 Seventh in a row: 1 First: 1 Misses one: 0 Second in a row: 2 Third in a row: 3 Fourth in a row: 4 Fifth in a row: 5 Sixth in a row: 5 Seventh in a row: 5

How long to continue? Continue to reinforce the behavior with contingency management at least until the long-term benefit of the behavior has been realized, and perhaps longer.

How long to continue? This might be a long time, but why not? If it was worth it to start, continuing is worth it Instead of stopping a reinforcer that is working, add a new behavioral target to a successful program for a given participant

How to Get it Funded Sell it to your administrators by showing how the cost of the program could be offset by a decrease in lost productivity: Missed appointments with your psychiatrist or other internal medical providers Low productivity due to missed groups or sessions with other providers

How to Make a Starting Budget Decide fixed vs intermittent (cheaper) Decide constant vs escalating (better) Decide how many will participate Decide how many target behaviors per participant How many chances per month for a participant to demonstrate a target behavior for a reinforcement? Calculate (average) value of reinforcement

How to Make a Starting Budget Fixed Value, Constant Schedule Initial Monthly Budget = Participants x Monthly Opportunities to show target behavior x Value E.g., 20 ACT clients can earn a $1 by meeting with their Psychiatrist twice a month, attending a weekly A&D group, or coming for their monthly long-acting injectable medication nurse appointment =20 x (2+4+1) x $1 = $140

How to Make a Starting Budget Fixed Value, Escalating Schedule Initial Monthly Budget = Participants x Monthly Opportunities to show target behavior x Value x highest consistency multiplier E.g., 20 ACT clients can earn a $1 by meeting with their Psychiatrist twice a month, attending a weekly A&D group, or coming for their monthly long-acting injectable medication nurse appointment. They can earn up to 5 $1 bills if they attend five or more in a row. =20 x (2+4+1) x $1 x 5 = $700

How to Make a Starting Budget Intermittent Value, Constant Schedule Initial Monthly Budget = Participants x Monthly Opportunities to show target behavior x Average Prize Value E.g., 20 ACT clients can earn a prize by meeting with their Psychiatrist twice a month, attending a weekly A&D group, or coming for their monthly long-acting injectable medication nurse appointment. The Average Prize value is $0.50 =20 x (2+4+1) x $0.50 = $70

Calculating Average Prize Value Divide the total value of all possible prizes by the total number of chances to win a prize. Ignore the “free spin” slots

Calculating Average Prize Value 16 terminal slots 8 are free 5 are worth 100 points 2 are worth 200 points 1 is worth 500 points (0+500+400+500)/16 =$0.87 average if 100 points is a dollar Ignore the “free spin” slots

How to Make a Starting Budget Intermittent Value, Escalating Schedule Initial Monthly Budget = Participants x Monthly Opportunities to show target behavior x highest consistency multiplier x Average Prize Value E.g., 20 ACT clients can earn a prize by meeting with their Psychiatrist twice a month, attending a weekly A&D group, or coming for their monthly long-acting injectable medication nurse appointment. They can earn up to 5 spins if they attend five or more in a row. The Average Prize value is $0.50. =20 x (2+4+1) x 5 x $0.50 = $350

How to Budget These calculations have given us an idea of where to start with an initial budget, but operating costs will be much lower (unless everyone is perfect all the time!) Use actual expenditures over the first several months to make future budgets. If you have more funding than you are spending, add more behavioral targets or improve value of prizes.

Jackson County ACT Team Medium sized ACT Team Methamphetamine, Cannabis, and Alcohol Use complicate response to treatment Tobacco-related illness will cause the death of most consumers of specialty mental health services We wanted to increase engagement in treatment