1. Contingency Management in Problem Gambling Treatment Jeremiah Weinstock, Ph.D. University of Connecticut Health Center Farmington, CT USA

2. Overview 1.Pathological Gambling & Its Treatment 2.Background on Contingency Management (CM) 3.Applying CM to Gambling Treatment

3. Pathological Gambling Quick Review:  Pathological Gambling (PG) is characterized by maladaptive gambling behavior.  1% - 2% of general adult population meets DSM-IV diagnostic criteria for PG.  Vulnerable populations include: SUD, Forensic, Adolescents.  Availability of gambling is increasing dramatically.

4. Number of Gamblers Seeking Treatment in CT

5. Foxwoods Casino Opens

6. Number of Gamblers Seeking Treatment in CT Foxwoods Casino Opens Mohegan Sun Casino Opens

7. Gambling Treatment Treatment Options for PG 1.Gamblers Anonymous (12-Step) 2.Outpatient Counseling Cognitive Behavioral Therapy (CBT) Marital Therapy 3.Brief Interventions Motivational Enhancement Therapy 4.Pharmacotherapy (medication) 5.Inpatient Treatment No single treatment is appropriate for everyone.*

8. Gambling Treatment Obstacles to Effective Treatment:  Less than 8% of PG ever seek or get treatment (Slutske, 2006).  Many PGs drop-out of treatment prior to completion  33% - 50% (Leblonde et al. 2003; Ladouceur et al., 2001).  Adherence with treatment program.  Petry et al. (2006) – 40% completed less than 75% of intended treatment.  Best predictor of gambling abstinence was treatment adherence: number of CBT sessions/chapters completed.

9. Gambling Treatment 1 st Treatment Study at UConn Health Center:  231 Pathological Gamblers randomly assigned to: 1.Referral to Gamblers Anonymous 2.GA Referral + CBT self-help manual 3.GA Referral + CBT counseling. Petry et al., 2006

10. Gambling Treatment - Demos

11. Gambling Treatment - Adherence

12. Gambling Treatment - Results

13. Gambling Treatment WHAT CAN BE DONE?

14. Contingency Management Contingency Management:  Based upon principles of operant conditioning. Three behavioral tenets of CM: 1.Frequent monitoring of target behavior. 2.Providing tangible reinforcement for completion of target behaviors. 3.Remove reinforcement when target behavior does not occur. Typically, CM is added onto another SUD treatment.

15. Contingency Management Contingency Management Reinforcement: 1.Vouchers - $$$$  Silverman et al. (1996) = $1,155  Higgins et al. (2000) = $997.50 2.Prize Bowl – Lower cost alternative.  Not appropriate for PGs as it involves an element of chance somewhat similar to gambling.

16. Contingency Management Contingency Management SUD Tx Outcomes:  Participants stay in treatment longer  75% vs. 40% completed 24 weeks ( Higgins et al., 1994 ).  84% vs. 22% completed 8 weeks ( Petry et al., 2000 ).  Longer durations of continuous abstinence (LDA) during treatment  55% vs. 15% obtained 2-months of continuous abstinence.  2.7 and 4.5 times more likely to achieve 8 weeks and 12 weeks LDA, respectively (Petry et al., 2005).  Regardless of type of treatment, LDA during treatment is associated with long term success

17. Contingency Management CM reduces drug use:  Opioids (Bickel et al., 1999; Preston et al., 1998)  Cocaine (Higgins et al., 1994; Silverman et al., 1996)  Benzodiazepines (Stitzer et al., 1992)  Marijuana (Budney et al., 1991, 2000)  Nicotine (Shoptaw et al., 2002; Roll et al., 1996)  Alcohol (Petry, 2000)  Polydrug (Downey et al., 2000; Petry et al., 2005b)

18. Contingency Management CM increases treatment adherence:  Medication compliance (Carroll et al., 2001)  Complete activities consistent with treatment improves treatment outcome (Bickel et al., 1997; Iguchi et al., 1997)  Lewis & Petry (2005) found those completing family oriented activities:  Remained in treatment longer.  Longer durations of abstinence.  Reported greater reductions in family conflict.

19. CM for Gambling Treatment How do we apply CM to gambling treatment?  Cannot reinforce gambling abstinence, no objective measure.  Reinforce compliance with homework.  Reinforce GA attendance.  Reinforce behavioral activation. ONGOING STUDY @ UCHC:  Eight sessions of individual therapy.  Longer term (2 year) follow-ups included.

20. CM for Gambling Treatment Psycho-Education:  Provides educational materials about gambling.  Encourages attendance at GA. CBT:  Functional analysis of gambling behavior, coping skills training.  Encourages attendance at GA. CBT + CM:  Same content as CBT, and GA encouragement.  Earn up to $187 in vouchers for completing activity contracts.

21. Sample Activity Contract ActivityProofTo Be Done Potential Problems Done ? Go to GA Mtg. Signed Slip Wed 04/04 Don’t want to go. Go to churchChurch Bulletin Sun. 04/08 Over sleep! Have coffee with sister ReceiptSat. 04/07 She’s busy.

22. CM For Gambling Treatment 31 clients assigned to CBT+CM  Thus far, 493 activities contracted with 66% completed.  135 activities were completing CBT homework (27.4%)  43 activities were going to GA meeting (8.3%)

23. Preliminary Results - I

24. Preliminary Results - II

25. Preliminary Results - III

26. CM for Gambling Treatments How can I apply this to my clinic?  Reinforcement does not have to be vouchers:  Clinic privileges – parking spots, take-home bottles.  Donations from the community.

27. Summary 1.PG is associated with a host of adverse consequences. 2.Numerous treatment options are available, however few PGs seek treatment. 3.Current treatments can be effective, but there is room for improvement. 4.Contingency management is one way to improve treatment attendance and adherence. 5.With the recurrent nature of PG, it’s helpful for clients to have a positive experience with treatment – CM can be a positive addition to tx.

28. Acknowledgements Thank You:  Nancy M. Petry, Yola Ammerman, Anne Doersch, Heather Gay, Elise Kabela-Cormier, David M. Ledgerwood, Suzanne McColl, Ben Morasco, Betsy Parker, & Nicole Reilly. This study is supported by Nat’l Institute of Mental Health