1. Practical Application of Contingency Management Michael J. McCann, MA Matrix Institute on Addictions

2. Elements of Treatment: Information, Persuasion, and Medication Information –Matrix Model –CBT –12-Step Persuasion –Motivational Interviewing –Confrontation –Contingency Management

3. Motivational Interventions If you build it they will not necessarily come. And, if they do come, they may not come all of the time. Hence: –Motivational Interviewing –Contingency Management

4. Contingency Management (CM) CM: application of reinforcement contingencies to urine results or behaviors (attendance in treatment; completion of agreed upon activities). Research consistently shows that it works.

5. Contingency Management: Overview 1. Research findings 2. Application of CM in the Matrix Institute NTP 3. Practical application of CM

6. Contingency Management: Research Findings Effective with wide variety of abused substances –Nicotine –Alcohol –Heroin –Benzodiazepines –Cocaine and Methamphetamine

7. Research Findings Highlight efficacy Raise questions about real-world applicability

8. Contingency Management: Steve Higgins, Ph.D. Community Reinforcement Approach (CRA) –Marital Therapy –Vocational Assistance –Skills Training –New social and recreational activities –Antabuse Vouchers ($977)

9. Contingency Management: Higgins et al., 1993 –24-week treatment –3 times per week urines –Conditions Standard treatment CRA plus vouchers

10. Contingency Management: Higgins et al., 1994 –24-week treatment –3 times per week urines –Conditions CRA only CRA plus vouchers

11. Contingency Management: Higgins et al., 1993

12. Contingency Management: Higgins et al., 1994 –How much of CRA effect is CM? –24-week treatment –3 times per week urines –Conditions CRA only CRA plus vouchers

13. Contingency Management: Higgins et al., 1994

14. Contingency Management: Rawson et al., 2002 Cognitive-Behavioral Treatment vs CM –Cocaine users –16 weeks –3 visits per week

15. Contingency Management: Rawson et al., 2002 Cognitive-behavioral Treatment (CBT) –90 minute groups –Cognitive/behavioral –Drug cessation –Lifestyle change –Relapse prevention

16. Contingency Management: Rawson et al., 2002 Contingency Management –Vouchers for stimulant-free urines –Progressive schedule –Bonuses for 3 consecutive clean ($10) –Reset with 5 clean –Total earnings possible: $1277

17. Contingency Management: Rawson et al., 2002 Cocaine-using methadone patients Four conditions: –CM –CBT –CBT & CM –Methadone only

18. Cocaine-free Urine Samples During Study Rawson et al., 2002 P<.001 CM>MM CBT & CM>MM

19. Percent Subjects Achieving 3 Consecutive Weeks Cocaine-free Rawson et al., 2002 P<.02 CM>MM CBT & CM >MM

20. Days used cocaine in past month Rawson et al., 2002 Week 26: CM<MM; CBT<MM Week 52: CBT<MM

21. CBT Group Attendance Rawson et al., 2002 P<.04

22. Contingency Management in Treatment Conclusion: CM works

23. Contingency Management in Treatment CM is not always popular with counselors. “Simply getting clean should be reward enough.” Other problems: Schedules are too complicated. Too expensive for the average clinic. The cost of vouchers exceeds what some clinics are reimbursed for a treatment episode.

24. CM in Practice in an NTP Treatment enhancements (RP groups, women’s groups, stimulant groups, HIV and Hep-C education, low cost CM) $5 per month for perfect group attendance $5 per month for perfect medication attendance

25. Perfect medication attendance Pre-post contingencies, n=49 P<.05

26. Perfect group attendance Pre-post contingencies, n=49 P<.01

27. Perfect group attendance in patients missing pre-CM, n=20

28. Groups attended in patients missing pre-CM, n=20 P<.005

29. CM in an NTP: Conclusions A simple, low cost CM intervention can improve patient attendance in groups and medication visits.

30. CM with Matrix Model Treatment May improve engagement of new patients May improve retention of patients May improve treatment outcomes

31. CM with Matrix Model Treatment Challenges –Must be simple Easy to track—Need to keep a record of attendance Easy to figure rewards—no progressive schedules, resets, etc. Little burden on the counselor

32. CM with Matrix Model Treatment Challenges –Must be inexpensive A less expensive method may be a bit less effective, but an expensive method will never be used. A little reward goes a long way especially combined with praise and recognition

33. CM with Matrix Model Treatment: Some examples Food available for 10 minutes after group starts Weekly reward for patients who attend all groups each week Monthly reward for patients who attend all groups each month

34. CM with Matrix Model Treatment: Some examples Raffles vs guaranteed reinforcement Certificates, plaques, food, goods, money, etc. Combine with social reinforcement

35. Conclusions CM can be effectively used in clinical settings Low cost reinforcers can be effective Simple schedules can be effective Increased attendance can offset cost with fee-for-service billing