1. Luke Mitcheson Clinical Psychologist
Contingency Management Advanced Clinical Management of Addiction Module
Luke Mitcheson
Clinical Psychologist

2. Objectives Understand what CM is and aims to achieve
Understand the evidence base
Consider implementation issues

3. Introduction to Contingency Management
What is Contingency Management?
How has it been used in General Health Care?
 How has it been delivered in drug misuse?
BBV
Methadone Maintenance
What is the evidence for effectiveness?
CM in drug use (data from NICE)
What NICE had to say
Delivering CM in practice

4. Theory

6. What is Contingency Management?
Conditioning in which an operant (voluntary) response is brought under stimulus control by virtue of presenting reinforcement contingent upon the occurrence of the operant response OR
The basic process by which an individual's behaviour is shaped by reinforcement or by punishment
Based on operant conditioning principles (Skinner)

7. Application of operant conditioning
Add
Subtract
Positive
Positive reinforcement
increases behaviour
Extinction
decreases behaviour
Negative
Punishment
Negative reinforcement
Increases behaviour

8. Add Subtract Positive Negative
Extinction – ceasing any type of reinforcer
weakens behavioural response
Add
Subtract
Positive
Give voucher for drug free UDS
Stop giving praise for drug free UDS
Negative
Yell at client for drug free UDS
Lift daily supervised consumption for drug free UDSs

10. The Essential Elements
A discrete behaviour under voluntary control
Quantifiable targets – e.g. child does 15 minutes piano practice
Identified reinforcement (incentives, rewards) - e.g. praise, vouchers, prizes, privileges, cash
Clear contingent relationship between behaviour and reinforcement (schedules of reinforcement which are  consistent and immediate(at least initially) )
All reinforcement takes place in a context of already existing contingencies (AB-C)

11. Evidence

12. Use in General Health Care
Children – Star Charts (NICE – Nocturnal Enuresis)
Attendance for mammograms, cervical smears, TB screening/treatment (Giuffrida & Torgenson, 1997, BMJ)
Challenging behaviour in learning difficulties (Howlin et al 2009)
Depression (Martel et al, 2004)
The Quality and Outcomes Framework for primary care (Lester and Rowland, 2007)
Attendance at the gym (Charness & Gneezy 2009)
Smoking cessation (Volpp et al 2009)
Medication compliance (Claassen et al 2007)

13. NICE view of CM
An effective and cost-effective intervention for improving treatment outcomes for problem drug users (NICE, 2007)
The only recommended intervention for stimulant drug users

14. CM in Drug Misuse
Adherence to healthcare interventions – e.g. Hep B vaccinations
Stimulants – abstinence
Methadone – reduce illicit opiate/stimulant ‘use-on-top’
Detoxification – improved adherence

15. Adherence to Physical Health Interventions
2 x rate for TB test/Hep B vaccination, with £5-10 reward
Threefold for 6-month return rate (Seal et al, 2003)

16. Methadone Maintenance- CM for Illicit Drug Use
Most substantial evidence base
Large and consistent effect
Participants shown to remain abstinent for as long as 6 months
Cost effective
QALY health care costs alone = £15,000
QALY including criminal justice = £74
Forest plot on next slide relates to this slide

17. Contingency Management and MMT

18. CM for Opiate Detoxification
More likely to detox successfully
More likely to achieve abstinence

20. How ethical do you think it is to use offer service users vouchers ?
Discussion
How ethical do you think it is to use offer service users vouchers ?

21. So why isn’t CM routinely used?
In a survey of all NHS drug clinics for opiate users in England, NO SERVICE was identified as providing a structured CM programme (Weaver et al, 2007)

22. Concerns….
The acceptability and perceptions of CM to the general public and service users, the attitudes of staff and senior managers.
In particular, these concerns include:
The intervention may ‘reward’ illicit drug use
The effects will not be maintained long-term
The system is open to abuse as drug users may ‘cheat’ their drug tests

23. The unusual circumstances required to conduct RCTs and non-representativness of participants (exclusion criteria)
The costs associated with its implementation
Staff are not trained: major training programme required to implement
Cultural difference between US health care system and publicly funded English system
Incentive-based systems will not work outside the healthcare system (USA) in which they were developed
Differences in the welfare benefits systems between the USA and England (will UK users lose benefits?)

24. Implementation

25. Key issues in implementing a CM programme (Petry, 2006)
Robust, routine testing for drug misuse
Targets agreed in collaboration with service users
Incentives provided in a timely and consistent manner
Relationship between treatment goal and incentive schedule understood by service users
Incentives that are perceived to be reinforcing and support a drug-free lifestyle

26. 5 key aspects of implementing CM (Kellogg et al, 2005)
Rewards should be given frequently
Should be easy to earn rewards at the start
Rewards to include material goods and services that are of use and value to service users
Connection between reward and behaviour clear
Increased emphasis on reward-oriented not punishment-oriented approaches

27. Frequency and ease of earning rewards at the start
Closely linked
Frequent rewards = stronger connection to behaviour
Target behaviour must not be too difficult: ‘successive approximation’ (e.g. Elk et al, 1995)

28. Material goods and services
Rewards should be genuinely rewarding for service user
For example, vouchers and clinic privileges should all be chosen in conjunction with service user

29. Connection between reward and behaviour
Rewards are more effective if their distribution is directly connected to specific and observable behaviours
The greater the delay in receiving the reinforcement, the weaker its effect

30. Reward-oriented rather than punishment-oriented
Almost all trials showing efficacy of CM have been reward-oriented (e.g. Higgins et al, 1993; Stitzer et al, 1992)
Adding a punitive aspect to a CM reward-oriented treatment has not found to be effective (Iguchi et al, 1988)

31. Maintenance of behaviour after reinforcement
Don’t terminate a CM programme until target behaviour is stabilised
Reduce frequency and value of rewards towards end of programme (e.g. Higgins 1993, 1994; Petry 2004,2005)

32. Implementing CM in the NHS
Major studies of implementation in services where initially there was considerable resistance
Positive shifts in staff attitudes (McGovern et al, 2004; Kellogg et al, 2005; Kirby et al, 2006; Ritter and Cameron, 2006)

33. Endorsement of the programme by senior management and clinicians
Provision of a comprehensive education and training programme
Recognition by staff that CM is an intervention aimed at changing behaviours not simply reinforcing people for generally good behaviour
Shift in focus of service to one that is reward orientated
Kellogg et al (2005)

34. Factors to be considered when developing an programme in the NHS
Integration of CM with key working responsibilities of staff
Identification of groups of drug users who are most likely to benefit
Development of near patient testing
Impact of service users benefits

35. Reinforcement schedules
Clinic privileges (Stitzer et al, 1992; 1986)
Voucher reinforcement (Petry et al, 2000)
Cash (Malotte et al, 1998; Seal et al, 2003)
Prizes (Petry et al, 2005; Prendegast et al, 2006)

36. 3. Book first appointment with named worker
Incentivised attendance and completion of care plan programme for primary crack users
TRIAGE
Appt 1
Appt 2
Appt 3
Appt 4
TRIAGE
1. Ensure eligibility
2. Explain programme
3. Book first appointment with named worker
1. Work on full assessment and care-plan
2. Give £10 voucher
3. Explain reward schedule for session 2 and 3
1. Work on full assessment and care-plan
2. Give £10 voucher
3. Explain reward schedule for session 2 and 3
1. Work on full assessment and care-plan
2. Give £10 voucher
3. Give £10 bonus as per protocol
Treatment as usual
Eligibility Criteria:
Primary crack users
Not in treatment in past 12 weeks
Not in receipt of / seeking an opiate substitute prescription
Not having participated in this programme for I year

37. The Harbour Steps

38. Lambeth voucher-CM 24 tests on Monday, Wednesday & Friday
Escalating schedule starting at £1
Up by £0.5 for each successive –ive test
Bonus for each series of 6 –ive tests
Re-set following +ive test or DNA
Return to previous level for 6 –ives (if time)
£40 bonus if client attends all 24 sessions
Total voucher value possible = £282
Harbour voucher credits recorded in account book and withdrawn on treatment days

39. References
Higgins ST, Budney AJ, Bickel WK, Foerg FE, Donham R, Badger GJ. Incentives improve outcome in outpatient behavioral treatment of cocaine dependence. Arch Gen Psychiatry 1994; 51:
Lussier JP, Heil SH, Mongeon JA, Badger GJ, Higgins ST. A meta-analysis of voucher-based reinforcement therapy for substance use disorders. Addiction 2006; 101:  
Petry NM, Peirce JM, Stitzer ML, Blaine J, Roll JM, Cohen A, et al. Effect of prize-based incentives on outcomes in stimulant abusers in outpatient psychosocial treatment programs: A national drug abuse treatment clinical trials network study. Arch Gen Psychiatry ; 62:
Peirce JM, Petry NM, Stitzer ML, Blaine J, Kellogg S, Satterfield F, et al. Effects of lower-cost incentives on stimulant abstinence in methadone maintenance treatment: a National Drug Abuse Treatment Clinical Trials Network study. Arch Gen Psychiatry ; 63:201-8.
Kellogg SH, Burns M, Coleman P, Stitzer M, Wale JB, Kreek MJ. Something of value: the introduction of contingency management interventions into the New York City Health and Hospital Addiction Treatment Service. J Subst Abuse Treat 2005; 28: 57-65
Petry NM, Alessi SM, Hanson T, Sierra S. Randomized trial of contingent prizes versus vouchers in cocaine-using methadone patients. J Consult Clin Psychol 2007; 75:
Olmstead TA, Petry NM. The cost-effectiveness of prize-based and voucher-based contingency management in a population of cocaine- or opioid-dependent outpatients. Drug Alcohol Depend ; 102: