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 OTP

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

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

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

9. Contingency Management: Higgins et al., 1993

10. 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

11. Contingency Management: Higgins et al., 1994

12. Contingency Management: Rawson et al., 2002 Cocaine-using methadone patients 16 weeks; 3 X per week Four conditions: –CM –CBT –CBT & CM –Methadone only

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

14. 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

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

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

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

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

19. Contingency Management in Treatment Conclusion: CM works

20. CM in Practice What to target? –Urine results? Frequent enough? Results immediate? Valid? Observed? –Treatment goals Can vary across patient and counselors Verifiable? –Attendance

21. CM in Practice Challenges –Addressing staff resistance Patients should not have to be “paid”; recovery is the reward Motivation needs to come from within

22. CM in Practice 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

23. CM in Practice 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

24. CM in Practice in an OTP $5 per month for perfect group attendance $5 per month for perfect medication attendance Easy to track Less expensive than CM in research

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

30. CM in an OTP: Modifications Recent data show diminished effect Perfection too difficult? More immediate effect; shaping: McDonald’s coupons, once per week at group, first 30 days of treatment

31. CM in an OTP: Modifications Raffles –Voucher for 1-1 sessions –2 vouchers qualifies for group raffle the following month –Reinforces attendance in 1-1 and groups –Relatively inexpensive –No tracking required

32. 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