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 Mammography screening Mammography screening Child immunization Child immunization

BREAST CANCER Mammography Screening Recommendation for Women Ages 50 and older: ANNUAL MAMMOGRAM ANNUAL MAMMOGRAM With physician advice alone, few women receive an annual mammogram (Stoner et al., 1998)

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

Childhood Immunizations In , immunization rates were as low as 23% for two-year olds in the Chicago area.

Immunization Rates Rate 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

Higgins, Roll, & Bickel, 1996

Roll, & Newton, 2007

CM has been used to treat a number of types of drug abuse Opioids Benzodiazepines Marijuana Methamphetamine Nicotine (tobacco smoking) Alcohol Cocaine

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

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

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 stimulant-free test results Weeks Drug Free # Draws

Total earnings On average, patients could earn up to $400 in prizes if they maintained abstinence for 12 weeks and submitted all 24 negative samples. Actual earnings were $203 in psychosocial clinics and $130 in methadone clinics (e.g., half possible or less).

CTN 006

Results 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)

Results Petry et al. (2005). Archives of General Psychiatry p<.05

CM + TAU TAU

Comparing Cocaine and Methamphetamine Treatment Outcomes

Total Number of Negative Urines

Longest Duration of Abstinence

CTN 007

Eligible patients Stimulant abusers Stimulant abusers (cocaine or methamphetamine) (cocaine or methamphetamine) enrolled in methadone or enrolled in methadone or outpatient psychosocial treatment outpatient psychosocial treatment

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 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

Tests of Model Effects Source Type III Wald Chi- SquaredfSig. (Intercept) Index group Index1 * group Dependent Variable: meth Model: (Intercept), Index1, group, Index1 * group.