1. Contingency management: Using principles of reinforcement to improve drug abuse treatment Nancy Petry, Ph.D. University of Connecticut Health Center Farmington, CT, USA Supported by National Institute of Health grants R01-DA13444, RO1-DA016855, RO1-DA14618, R01- DA018883, RO1-MH60417, RO1-MH60417-suppl, P50-DA09241, P50-AA03510 and M01-RR06192

2. Outline A. Background and efficacy Rewards and punishers in everyday life B. Voucher-based CM studies in research clinics C. The prize approach: Adaptation for community based clinics

3. A. Background Rewards used in everyday settings  Salaries, commission, awards, social praise  Children  Pets

4. Negative contingencies  Fines, tickets, jail  Poor evaluations, getting fired, negative social interactions  Detention, time out

5. Incentives in substance abuse treatment

6. Punishers often used with substance abusers Out-patient treatment programs  court mandated treatment  dismissed from treatment  inform probation officer Methadone maintenance  increase frequency of urine and breath testing  lower the dose  discontinue treatment

7. Positive incentives used in substance abuse treatment 12 Step treatment/AA  coffee, food  group recognition and approval  30-day pins/certificates  act as sponsor for others Out-patient treatment  certificates, praise Methadone maintenance  take-home doses  early dosing windows

8. B. Voucher-based contingency management studies in research settings The Three Principles of CM 1.) Frequently monitor target behavior. 2.) Provide tangible reinforcement when target behavior occurs. 3.) Remove reinforcement when target behavior does not occur.

9. Treatment of Cocaine Dependence Higgins et al., 1994 Standard Care Treatment  Community Reinforcement Approach Therapy  Urine testing 2x/week  No vouchers $10 Contingency Management  Community Reinforcement Approach Therapy  Urine testing 2x/week  Vouchers Up to $1000 available

10. Retained throughout Trial Higgins et al., 1994 Treatment of Cocaine Dependence

11. One-year Follow-up Results 60% in contingent group versus 45% in standard group were cocaine abstinent During-treatment abstinence predicts long-term abstinence (Higgins et al., 2000).

12. Treatment of Cocaine Abuse in Methadone Patients Contingent Incentives 3x weekly urine testing received vouchers only if urine samples were cocaine negative Up to $1155 available Average earnings of $426 Non-Contingent Incentives 3x weekly urine testing received vouchers regardless of urine test results Silverman et al., 1996

13. Retained Through Study Treatment of Cocaine Use in Methadone Patients Silverman et al., 1996

14. Contingency management reduces drug use  Opioids (Bickel et al., 1997; Preston et al., 1998)  Cocaine (Higgins et al., 1994, 2000, 2003; Silverman et al., 1996)  Benzodiazepines (Stitzer et al., 1992)  Marijuana (Budney et al., 2000, 2006)  Nicotine (Stitzer & Bigelow, 1984; Roll et al., 1996) (Stitzer & Bigelow, 1984; Roll et al., 1996)

15. Addressing some of the practical concerns 1. Cost 2. Generalization and acceptability

16. Prize CM Implementation into standard clinic settings

17. Standard VA clinic setting Subjects: 42 alcohol-dependent outpatients Standard treatment:  Intensive outpatient day program 5 hrs/day, 5 days/week, weeks 1-4  Aftercare 1-3 groups/week, weeks 4-8 Treatment consisted of group sessions: 12 step, relapse prevention, voc rehab, AIDS, coping skills

18. Standard treatment group Received standard group treatment and BAC monitoring (daily during intensive, weekly during aftercare). Additional 15 min of education on alcohol abuse weekly

19. Contingent group Standard group treatment and BAC monitoring Reinforce alcohol abstinence:  One draw for each negative BAC.  Bonus draws for a week of consecutive abstinence. 128 draws possible

20.  1/2 chance of winning a small $1 prize  1/16 chance of winning a large $20 prize  1/500 chance of winning a jumbo $100 prize Half the cards are winning

21. Retention Petry et al., 2000

22. Time until first heavy drinking episode p<.05 Petry et al., 2000

23. Percent positive for any illicit drug Petry et al., 2000

24. Summary  This variable ratio schedule of reinforcement significantly increased retention and reduced alcohol as well as other use.  On average, subjects earned $200 worth of prizes.  Local retailers and stores were willing to donate prizes.

25. Does this intermittent reinforcement system work as well as the voucher system?

26. Will it work for cocaine dependent outpatients?

27. Study design Cocaine-dependent outpatients initiating intensive outpatient treatment. Randomly assigned to: Standard treatment Standard treatment Standard treatment plus voucher CM Standard treatment plus voucher CM Standard treatment plus prize CM Standard treatment plus prize CM

28. Vouchers vs. prizes Retention p=.08 p<.01 Petry et al., 2005

29. Mean weeks of continuous cocaine abstinence p<.05 p<.01 Petry et al., 2005

30. How low can we go?

31. Treatment groups Cocaine-dependent patients entering intensive day program randomly assigned to: 1.) Standard treatment 2.) Standard treatment plus $80 CM ($0.33, $5, and $100 prizes) 3.) Standard treatment plus $240 CM ($1, $20, and $100 prizes)

32. Mean weeks of continuous cocaine abstinence Petry et al., 2004 p<.05 vs std care

33. Section summary  This lower-cost CM system is effective in retaining patients in outpatient treatment.  It ubiquitously lengthens abstinence (alcohol, cocaine, opioids, nicotine).  Larger magnitude prizes are more effective than smaller magnitude prizes, but prizes work as well as vouchers.  Durations of abstinence achieved are associated with long-term outcomes.

34. Longest duration of abstinence achieved during treatment is consistently associated with long-term abstinence (n=244) B p value OR (95% CI) Age0.06<.02 1.06 (1.01-1.11) Male gender -.45.19 Income0.00.83 Longest duration of abstinence (LDA).21<.001 1.19 (1.13-1.25) CM treatment.72<.05 2.05 (1.03-4.10) LDA x CM.09.53

35. National Drug Abuse Clinical Trials Network MD DE NE NY OR PR LI SC FL MI CO NC WA OH CT

36. Eligible Patients Stimulant Abusers Stimulant Abusers (cocaine or methamphetamine) (cocaine or methamphetamine) enrolled in methadone (n=398) enrolled in methadone (n=398) or outpatient psychosocial treatment (n=415)

37. Random Assignment Usual care Usual care enhanced with abstinence incentives 3-month evaluation

38. DRUG TARGETS ä PRIMARY TARGETS: ä Stimulants (cocaine; methamphetamine) ä Alcohol ä SECONDARY TARGETS: ä Opiates (Methadone patients) ä Opiates and marijuana (Psychosocial pts)

39. Draws Escalate with Stimulant-Free Test Results Weeks Drug Free # Draws 1 2 4 5 3

40. Bonus Draws for OPIATE (Methadone clinics) or OPIATE AND MARIJUANA (Psychosocial clinics) Abstinence Weeks Drug Free # Draws 22222

41. Total Earnings ä $400 in prizes could be earned on average If participant tested negative for all targeted drugs over 12 consecutive weeks

42. Results from Outpatient Psychosocial Clinics Arapaho-Douglas (Rocky Mountain) Charleston (South Carolina) Circle Park (South Carolina) Crossroads (Rocky Mountain) Harbel (Mid Atlantic) Jefferson (Delaware Valley) Guenster LMG (New England) Matrix (Pacific Region)

43. Percent Retained 0 20 40 60 80 100 24681012 CM Standard Study Week RETENTION IN TREATMENT 49% 35% RH = 1.6; CI = 1.2 - 2.1 Petry et al. Arch Gen Psychiatry, 2005 LONGEST DURATION OF ABSTINENCE p<.05

44. Participating Methadone Clinics Act II (Delaware Valley) Aegis (Pacific Region) Glenwood (Mid Atlantic) Greenwich (New York) LESC (New York) Oasis (Mid Atlantic)

45. 517192123 0 20 40 60 80 100 Study Visit (2/wk for 12 wks) % Urines Testing Negative Incentive Standard OR = 1.96 CI = 1.45 - 2.65 METHADONE: PERCENT STIMULANT NEGATIVE URINES Peirce, Petry, et al., Arch Gen Psychiatry, 2006

46. CTN methadone studies p<.05

47. CONCLUSIONS ä A large multi-site study of prize-based CM was successfully completed within CTN. ä Prize CM reduced stimulant use in methadone patients and improved retention and enhanced durations of abstinence in outpatient psychosocial treatment. ä Costs were reasonable. ä Further dissemination of CM interventions into usual care treatment is warranted.