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Practical Application of Practical Application of Contingency ManagementContingency Management
Michael J. McCann, MA
Matrix Institute on Addictions
Elements of Treatment: Elements of Treatment: Information, Persuasion, and MedicationInformation, Persuasion, and Medication
Information–Matrix Model – CBT– 12-Step
Persuasion–Motivational Interviewing– Confrontation– Contingency Management
Motivational InterventionsMotivational 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
Contingency Management (CM)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.
Contingency Management: Contingency Management: OverviewOverview1. Research findings
2. Application of CM in the Matrix Institute NTP
3. Practical application of CM
Contingency Management: Contingency Management: Research Findings Research Findings
Effective with wide variety of abused substances– Nicotine– Alcohol– Heroin– Benzodiazepines– Cocaine and Methamphetamine
Research FindingsResearch Findings
Highlight efficacy
Raise questions about real-world applicability
Contingency Management: Contingency Management: Steve Higgins, Ph.D.Steve Higgins, Ph.D.
Community Reinforcement Approach (CRA)–Marital Therapy– Vocational Assistance– Skills Training– New social and recreational activities– Antabuse
Vouchers ($977)
Contingency Management: Contingency Management: Higgins et al., 1993Higgins et al., 1993
– 24-week treatment – 3 times per week urines
– Conditions• Standard treatment • CRA plus vouchers
Contingency Management: Contingency Management: Higgins et al., 1994Higgins et al., 1994
– 24-week treatment – 3 times per week urines
– Conditions• CRA only • CRA plus vouchers
Contingency Management: Contingency Management: Higgins et al., 1993Higgins et al., 1993
5%11%11%
42%
68%
58%
0%
10%20%
30%
40%50%
60%
70%
80%90%
100%
Completed Treatment 8 weeks continuousabstinence
16 weeks continuousabstinence
Standard TreatmentCRA & CM
Contingency Management: Contingency Management: Higgins et al., 1994Higgins et al., 1994
– How much of CRA effect is CM?
– 24-week treatment – 3 times per week urines
– Conditions• CRA only • CRA plus vouchers
Contingency Management: Contingency Management: Higgins et al., 1994Higgins et al., 1994
15%
40%
55%
75%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Completed Treatment 8 weeks continuous abstinence
CRACRA & CM
Contingency Management: Contingency Management: Rawson et al., 2002Rawson et al., 2002
Cognitive-Behavioral Treatment vs CM– Cocaine users– 16 weeks– 3 visits per week
Contingency Management: Contingency Management: Rawson et al., 2002Rawson et al., 2002
Cognitive-behavioral Treatment (CBT)– 90 minute groups– Cognitive/behavioral– Drug cessation– Lifestyle change– Relapse prevention
Contingency Management: Contingency Management: Rawson Rawson et al., 2002et 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
Contingency Management:Contingency Management: Rawson et al., 2002Rawson et al., 2002
Cocaine-using methadone patientsFour conditions:– CM – CBT – CBT & CM–Methadone only
Cocaine-free Urine Samples During StudyCocaine-free Urine Samples During StudyRawson et al., 2002Rawson et al., 2002
19.8
30.3
26.1
11
0
5
10
15
20
25
30
35
# c
oca
ine-f
ree
CBT CM CBT & CM MMP<.001
CM>MM
CBT & CM>MM
Percent Subjects Achieving 3 Consecutive Percent Subjects Achieving 3 Consecutive Weeks Cocaine-freeWeeks Cocaine-freeRawson et al., 2002Rawson et al., 2002
40%
63%57%
27%
0%
10%
20%
30%
40%
50%
60%
70%
% p
ts. 3-w
eeks
coca
ine fre
e
CBT CM CBT & CM MMP<.02
CM>MM
CBT & CM >MM
Days used cocaine in past month Days used cocaine in past month Rawson et al., 2002Rawson et al., 2002
0
3
6
9
12
15
Baseline Wk-17 Wk-26 Wk-52
# d
ays
use
d
MMCMCBT + CMCBT
Week 26: CM<MM; CBT<MM
Week 52: CBT<MM
CBT Group AttendanceCBT Group AttendanceRawson et al., 2002Rawson et al., 2002
17.9
24.7
0
5
10
15
20
25
30
# s
ess
ions
att
ended
CBT CBT & CMP<.04
Contingency Management in TreatmentContingency Management in Treatment
Conclusion: CM works
Contingency Management in Treatment 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.
CM in Practice in an NTPCM 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
Perfect medication attendancePerfect medication attendancePre-post contingencies, n=49Pre-post contingencies, n=49
37%
52%
25%
30%
35%
40%
45%
50%
55%
% p
erf
ect
Pre-CM Post-CM
P<.05
Perfect group attendancePerfect group attendancePre-post contingencies, n=49Pre-post contingencies, n=49
58%
71%
40%
45%
50%
55%
60%
65%
70%
75%
% p
erf
ect
Pre-CM Post-CM
P<.01
Perfect group attendance in patients Perfect group attendance in patients missing pre-CM, n=20missing pre-CM, n=20
0%
65%
0%
10%
20%
30%
40%
50%
60%
70%
80%
% p
erf
ect
Pre-CM Post-CM
Groups attended in patients missing Groups attended in patients missing pre-CM, n=20pre-CM, n=20
58%
88%
0%10%20%30%40%50%60%70%80%90%
100%
% g
roups
Pre-CM Post-CM
P<.005
CM in an NTP: ConclusionsCM in an NTP: Conclusions
A simple, low cost CM intervention can improve patient attendance in groups and medication visits.
CM with Matrix Model Treatment CM with Matrix Model Treatment
May improve engagement of new patients
May improve retention of patients May improve treatment outcomes
CM with Matrix Model TreatmentCM 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
CM with Matrix Model TreatmentCM 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
CM with Matrix Model Treatment: CM with Matrix Model Treatment: Some examplesSome examplesFood available for 10 minutes after
group startsWeekly reward for patients who
attend all groups each weekMonthly reward for patients who
attend all groups each month
CM with Matrix Model Treatment: CM with Matrix Model Treatment: Some examplesSome examplesRaffles vs guaranteed reinforcementCertificates, plaques, food, goods,
money, etc. Combine with social reinforcement
ConclusionsConclusions
CM can be effectively used in clinical settings
Low cost reinforcers can be effectiveSimple schedules can be effectiveIncreased attendance can offset cost
with fee-for-service billing