Keeping It Positive:Keeping It Positive:Bringing Contingency Bringing Contingency

ManagementManagementTo New York CityTo New York City

Scott Kellogg, PhDNew York University/

New York Node

What Is What Is Contingency Contingency

Management?Management?

3

B. F. Skinner, PhD

Contingency Contingency ManagementManagement

Developed out of Skinner’s Operant Developed out of Skinner’s Operant Conditioning modelConditioning model

Typically involves the use of positive Typically involves the use of positive reinforcements to change behaviorreinforcements to change behavior

First applied to problems with alcoholism First applied to problems with alcoholism in the late 1960’sin the late 1960’s

Used in the treatment of drug addiction Used in the treatment of drug addiction beginning in the early 1970’sbeginning in the early 1970’s

One of the first protocols that were One of the first protocols that were considered for adoption by the NIDA considered for adoption by the NIDA Clinical Trials NetworkClinical Trials Network

Contingency Contingency ManagementManagement

In addiction treatment centers, CM In addiction treatment centers, CM has been primarily used to:has been primarily used to: Reduce or eliminate drug useReduce or eliminate drug use Increase group attendanceIncrease group attendance Facilitate compliance with medical Facilitate compliance with medical

treatmenttreatment Reinforce treatment goal Reinforce treatment goal

attainmentattainment

The Early Days of the The Early Days of the CTNCTN

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CTN Site Map – 2000CTN Site Map – 20006 Nodes 6 Nodes

                              

 

New York NodeNew York Node

The New York Node joined the The New York Node joined the Clinical Trials Network in 2000Clinical Trials Network in 2000

During the following monthsDuring the following months There would be at least two There would be at least two

conflictual Steering Committee conflictual Steering Committee meetingsmeetings

Then the CM protocol was Then the CM protocol was acceptedaccepted

Moving ForwardMoving Forward

The protocol then went into its The protocol then went into its development stage where it was development stage where it was renamed ….renamed ….

Motivational Incentives for Motivational Incentives for Enhanced Drug Abuse RecoveryEnhanced Drug Abuse Recovery

(MIEDAR)(MIEDAR)

Maxine Stitzer, PhDMaxine Stitzer, PhD

Nancy Petry, PhDNancy Petry, PhD

MIEDAR Protocol MIEDAR Protocol Overview Overview MaterialsMaterials

Who is Eligible?Who is Eligible?

Stimulant AbusersStimulant Abusers

Sample CollectionSample CollectionTwice WeeklyTwice Weekly

Abstinence BowlAbstinence Bowl

GoodJob

Good Job

Good Job

Small Small

Small

Large

Large

Jumbo

Good Job

Good Job

Good Job

Good Job

Good Job

Small

Good Job

Small

Examples ofExamples ofIncentive PrizesIncentive Prizes

SMALLSMALL($1($1--$5 items)$5 items)

LARGELARGE($20 items)($20 items)

JUMBOJUMBO($80($80--$100 items)$100 items)

Prize CabinetsPrize Cabinets

How Motivational Incentives How Motivational Incentives Could Work For YouCould Work For You

PatientPatientProvides CleanProvides Clean

UrineUrine IncentiveIncentivePatient EarnsPatient Earns PatientPatient

Provides MoreProvides MoreClean UrinesClean Urines

How do we expect this to How do we expect this to benefit clients and benefit clients and

counselors?counselors?

• • Better outcomes for your clientsBetter outcomes for your clients• • More time to do what you like to do More time to do what you like to do and what you do best in therapy and what you do best in therapy sessionssessions

New York Node TeamNew York Node Team

John Rotrosen, MD – New York Node John Rotrosen, MD – New York Node Principle InvestigatorPrinciple Investigator

Scott Kellogg, PhD – New York Node Scott Kellogg, PhD – New York Node MIEDAR Principle InvestigatorMIEDAR Principle Investigator

Marion Schwartz, CSW – Project Marion Schwartz, CSW – Project DirectorDirector

Agatha Kulaga, MSW – Research Agatha Kulaga, MSW – Research AssistantAssistant

Caroline Woo – Research AssistantCaroline Woo – Research Assistant

New York MIEDAR New York MIEDAR ClinicsClinics

New YorkNew York

Two methadone maintenance programs Two methadone maintenance programs joined the study:joined the study:

Lower Eastside Service CenterLower Eastside Service Center Under the leadership of Joe Under the leadership of Joe

Krasnansky, CSWKrasnansky, CSW Greenwich House MMTPGreenwich House MMTP

Under the leadership of Lolita Silva-Under the leadership of Lolita Silva-Vasquez, CSWVasquez, CSW

Up and RunningUp and Running

By late 2001, the protocol was up By late 2001, the protocol was up and running in New Yorkand running in New York

The Node then turned its attention The Node then turned its attention to the creation of the second to the creation of the second Blending ConferenceBlending Conference

Which was scheduled for March, Which was scheduled for March, 2002 2002

Meanwhile…Meanwhile…

New York City Health New York City Health and Hospitals Corporationand Hospitals Corporation

The largest provider of addiction The largest provider of addiction treatment in the United Statestreatment in the United States

Runs methadone programs in five major Runs methadone programs in five major hospitalshospitals Bellevue HospitalBellevue Hospital Kings County HospitalKings County Hospital Elmhurst HospitalElmhurst Hospital Lincoln HospitalLincoln Hospital Metropolitan HospitalMetropolitan Hospital

Mayor Rudolph GiulianiMayor Rudolph Giuliani

http://www.umich.edu/~ac213/student_projects07/global/rudygiuliani.jpg

Giuliani Orders 5 City Hospitals To Wean Addicts Off Methadone

By RACHEL L. SWARNSPublished: August 15, 1998, New York Times

Mayor Rudy Giuliani – Mayor Rudy Giuliani – Summer 1998Summer 1998

Mayor Giuliani shocked the world of Mayor Giuliani shocked the world of methadone treatmentmethadone treatment

Voiced his concern that methadone Voiced his concern that methadone patients were not being empowered to patients were not being empowered to find employmentfind employment

Proposed a plan in which opiate-Proposed a plan in which opiate-addicted individuals would only be able addicted individuals would only be able to get three-months of treatment to get three-months of treatment At City-run methadone facilitiesAt City-run methadone facilities

Mayor Rudy Giuliani and Mayor Rudy Giuliani and MethadoneMethadone

Eventually backed downEventually backed down But gave the HHC methadone But gave the HHC methadone

programs a mandate to get their programs a mandate to get their patients employedpatients employed

Funneled additional funds to these Funneled additional funds to these programs for Vocational Trainingprograms for Vocational Training

Vocational TrainingVocational Training

32

http://www.alaskacoinexchange.com/Stamps%2034/04c%20Apprenticeship.jpg

Vocational Training at Vocational Training at the HHCthe HHC

HHC developed high quality HHC developed high quality Vocational Centers in each of the Vocational Centers in each of the methadone clinicsmethadone clinics

Patients would not engage with the Patients would not engage with the services that were being offeredservices that were being offered

Vocational Training at Vocational Training at the HHCthe HHC

To increase participation,To increase participation, The HHC Leadership began The HHC Leadership began

considering using a reward programconsidering using a reward program Patients would receive gift Patients would receive gift

certificates and other desirable certificates and other desirable items if they met goals like:items if they met goals like:Getting a GEDGetting a GEDFinishing a phase of Vocational Finishing a phase of Vocational TrainingTraining

New York City HHC New York City HHC Meets NIDA CTN Meets NIDA CTN

At the New York Blending ConferenceAt the New York Blending Conference There was a panel on the MIEDAR There was a panel on the MIEDAR

protocolprotocol Maxine Stitzer, PhDMaxine Stitzer, PhD Joe Krasnansky, CSW, (LESC)Joe Krasnansky, CSW, (LESC) Scott Kellogg, PhDScott Kellogg, PhD Marion Schwartz, CSWMarion Schwartz, CSW

Each spoke about different aspects of Each spoke about different aspects of the MIEDAR protocolthe MIEDAR protocol

New York City HHC New York City HHC Meets NIDA CTN Meets NIDA CTN

Marylee Burns, MEd, MA, CRC from Marylee Burns, MEd, MA, CRC from the HHC was in the audiencethe HHC was in the audience

Recognized both the importance and Recognized both the importance and relevance of what we were doingrelevance of what we were doing

An alliance was formed to bring CM An alliance was formed to bring CM to the HHC addiction treatment to the HHC addiction treatment programsprograms

The HHC Addiction The HHC Addiction Treatment Leadership Treatment Leadership

TeamTeam Joyce Wale, CSW Joyce Wale, CSW Senior Assistant Vice President, New York Senior Assistant Vice President, New York

City Health and Hospitals Corporation, Office City Health and Hospitals Corporation, Office of Behavioral Health of Behavioral Health

Peter Coleman, MS, CASAC Peter Coleman, MS, CASAC Director, Office of Behavioral HealthDirector, Office of Behavioral Health

Marylee Burns, MEd, MA, CRC Marylee Burns, MEd, MA, CRC Assistant Director, Office of Behavioral Assistant Director, Office of Behavioral

HealthHealth

Forming the AllianceForming the Alliance Met with this HHC leadership team to Met with this HHC leadership team to

learn what they were trying to dolearn what they were trying to do Worked closely with Marylee Burns to Worked closely with Marylee Burns to

refine the Vocational Incentives that they refine the Vocational Incentives that they were beginning to implementwere beginning to implement

We eventually visited six clinics or We eventually visited six clinics or hospitals and presented the CM modelhospitals and presented the CM model

Each site then developed its own plan for Each site then developed its own plan for implementing CM with its patientsimplementing CM with its patients

They primarily reinforced group They primarily reinforced group attendanceattendance

Reward vs ReinforcementReward vs Reinforcement

This issue was at the heart of the This issue was at the heart of the HHC projectHHC project Probably a central issue in all CM Probably a central issue in all CM

dissemination effortsdissemination efforts

Reward vs ReinforcementReward vs Reinforcement

When you speak to staff or When you speak to staff or leadership about the use of leadership about the use of reinforcementsreinforcements

They almost universally talk about They almost universally talk about reinforcing patients for things like:reinforcing patients for things like: Holding a job for six monthsHolding a job for six months Being drug-free for 3 monthsBeing drug-free for 3 months Completing a GED or vocational Completing a GED or vocational

training programtraining program

Reward ProgramsReward Programs

This is what I call a Reward ProgramThis is what I call a Reward Program Acknowledging patients for achieving a Acknowledging patients for achieving a

goal or accomplishing something goal or accomplishing something noteworthynoteworthy Most likely give rewards to the best and Most likely give rewards to the best and

most motivated patientsmost motivated patients While often not changing the behavior While often not changing the behavior

of those patients who are struggling the of those patients who are struggling the most with drug use and treatment most with drug use and treatment compliancecompliance

Reinforcement ProgramsReinforcement Programs

Reinforcement ProgramReinforcement Program Breaks down each of the goals into Breaks down each of the goals into

very small steps very small steps Reinforces each of the steps along Reinforces each of the steps along

the waythe way Makes it easy to earn a Makes it easy to earn a

reinforcementreinforcement Distributes reinforcements with Distributes reinforcements with

fairly high frequencyfairly high frequency

Reinforcement ProgramsReinforcement Programs

Move from “You have done a good Move from “You have done a good job” tojob” to

““You have taken a step in the right You have taken a step in the right direction”direction”

This was the most important change This was the most important change in their program that we madein their program that we made

It was the difference that made the It was the difference that made the HHC Project successfulHHC Project successful

CTN ResultsCTN Results

Using Low-Using Low-Magnitude Magnitude

Reinforcements…Reinforcements…

47

o

o oo

o

oo

o

o

o o oo

oo

oo

o

o

o

o

o

o o

*

**

** *

*

*

**

* ** * *

**

**

*

*

* **

1 3 5 7 9 11 13 15 17 19 21 23

0

20

40

60

80

100

Study Visit

Per

cent

of

Sub

mit

ted

Uri

nes

Tes

ting

Neg

ativ

e

Incentive

Control

OR = 1.98 CI = 1.45 - 2.65

METHADONE: PERCENT STIMULANT NEGATIVE URINES

48

Per

cent

Ret

aine

d

0

20

40

60

80

100

2 4 6 8 10 12

o

o

o o oo

oo o

o oo

o

oo o

o

o o

o o o oo

2 4 6 8 10 12

0

20

40

60

80

100

Per

cent

Sub

mit

ting

At L

east

One

Sam

ple

Incentive

Control

Study Week

OR = 1.6; CI = 1.2 - 2.0

PSYCHOSOCIAL STUDY RETENTION

CM

TAU

Number of stimulant-negative samples

m = 13.9 (SEM = 1.2)

m = 9.9 (SEM = 1.0)

Length of abstinence m = 9.3 (SEM = 1.2)

m = 5.6 (SEM = 0.9)

Abstinent throughout entire trial

18% 6%

CTN Methamphetamine Sub-Study

(Matrix Clinics; n = 113)

Roll et al., 2006 in Roll & Newton, 2008

Insights from the Insights from the HHC ExperienceHHC Experience

Leadership is Leadership is CrucialCrucial

52

LeadershipLeadership

The successful introduction of The successful introduction of contingency management usually contingency management usually comes from two forcescomes from two forces The top leadership has made the The top leadership has made the

decision to implement itdecision to implement it Idea champions emerge from Idea champions emerge from

among the staff membersamong the staff members

53

LeadershipLeadership

No site successfully adopted CM No site successfully adopted CM without strong, clear, and persevering without strong, clear, and persevering endorsement and support from the endorsement and support from the head of the organizationhead of the organization

ResistanceResistance

ResistanceResistance

Counselors are initially resistant or Counselors are initially resistant or indifferent to the introduction of CMindifferent to the introduction of CM

ResistanceResistance

““I wasn’t a big fan.I wasn’t a big fan. I thought that people should go to I thought that people should go to

treatment because they wanted to treatment because they wanted to be well.” (Counselor)be well.” (Counselor)

Patients are Patients are EnthusiasticEnthusiastic

58

Patient ExperiencesPatient Experiences ““Clients were saying…Clients were saying… In Russia, we were forced into In Russia, we were forced into

treatment – treatment – Now (crying), my God, I’m getting Now (crying), my God, I’m getting

treatment and $25.00!”treatment and $25.00!”

59

Patient ExperiencesPatient Experiences ““Clients are proud and are having Clients are proud and are having

fun. fun. Early in treatment, when their Early in treatment, when their

name is called out, they are name is called out, they are feeling good that they are being feeling good that they are being acknowledged. acknowledged.

For once in their life, they are For once in their life, they are being rewarded for something.”being rewarded for something.”

The Reinforcements The Reinforcements Get Them to Go to Get Them to Go to

GroupGroup

The Bonding Gets The Bonding Gets Them to StayThem to Stay

61

Patient ExperiencesPatient Experiences

““The staff have heard clients say that they The staff have heard clients say that they had come to realize that there are had come to realize that there are rewards just in being with each other in rewards just in being with each other in group. group.

There are so many traumatized and There are so many traumatized and sexually abused patients who are only told sexually abused patients who are only told negative things. negative things.

So, when they hear something good – that So, when they hear something good – that helps to build their self-esteem and ego.” helps to build their self-esteem and ego.” (Director)(Director)

Family HealingFamily Healing

63

Family HealingFamily Healing

Patients used their gift certificates Patients used their gift certificates to buy presents or needed items for to buy presents or needed items for their children or other family their children or other family membersmembers

In a number of cases, these actions In a number of cases, these actions began a process of reconciliationbegan a process of reconciliation

Socializing Socializing and Generosityand Generosity

65

Socializing and Socializing and GenerosityGenerosity

Patients began to socialize with each Patients began to socialize with each otherother

They would use their coupons and They would use their coupons and go to movies together in groupsgo to movies together in groups

There were also reports that they There were also reports that they were taking care of each other and were taking care of each other and giving each other gifts giving each other gifts

InternalizationInternalization

67

Internalization Internalization As one counselor put it, As one counselor put it, They went from “You are forcing They went from “You are forcing

me” to “I choose”me” to “I choose”

Counselor Counselor Acceptance and Acceptance and

MoraleMorale

69

Counselor Acceptance Counselor Acceptance

Once they overcame their Once they overcame their resistance, resistance,

Counselors reported that they Counselors reported that they loved the intervention loved the intervention That it was energizing and That it was energizing and

excitingexciting

70

Counselor Experiences Counselor Experiences

““It gives me a great deal of It gives me a great deal of pleasure to know I’m part of a pleasure to know I’m part of a state-of-the-art methadone state-of-the-art methadone treatment program.” (Counselor)treatment program.” (Counselor)

Understanding Understanding the the

Reinforcement Reinforcement ProcessProcess

72

Understanding Understanding Reinforcement Reinforcement

““We came to see that we need to We came to see that we need to reward people where rewards in reward people where rewards in their lives were few and far between. their lives were few and far between.

We use the rewards as a clinical tool We use the rewards as a clinical tool – not as bribery, but for recognition. – not as bribery, but for recognition.

The really profound rewards will The really profound rewards will come later.”come later.”

Patient GratitudePatient Gratitude

74

Patient GratitudePatient Gratitude

When patients publicly, and When patients publicly, and sometimes tearfully, acknowledge sometimes tearfully, acknowledge the counselor’s help in public, the the counselor’s help in public, the staff felt a sense of gratitudestaff felt a sense of gratitude

““In the last two award ceremonies, In the last two award ceremonies, clients said, ‘I want to thank the clients said, ‘I want to thank the staff….’ staff….’

That sounded real good – we feel That sounded real good – we feel appreciated.”appreciated.”

Inaugurating Inaugurating Phase II at the Phase II at the

HHCHHC

NYC HEALTH AND HOSPITALS CORPORATION

OFFICE OF BEHAVIORAL HEALTH

PRESENTS

EpilogueEpilogue

Would eventually spread to 22 Units – Would eventually spread to 22 Units – 6 methadone 6 methadone 8 medication-free8 medication-free 6 detoxification units6 detoxification units

Thousands of patients became the Thousands of patients became the recipients and beneficiaries of recipients and beneficiaries of positive reinforcementspositive reinforcements

The largest clinical adoption of this The largest clinical adoption of this technique in historytechnique in history

NIDA CTN/NIDA CTN/HHC Project HHC Project IntegrationIntegration

http://www.moodyscollectibles.com/pixfiles/15024.jpg

NIDA Contingency Management Meeting, Burlington, VT, October 7, 2004

Northeast ATTC – NIDA CTN – New York City HHC – New York Veterans Administration Hospital –

NYSPA Division on Addictions Co-Sponsored CM Training

October 18, 2005

Promoting Awareness of Promoting Awareness of Motivational Incentives Motivational Incentives

(PAMI)(PAMI)

The work of the NIDA-CSAT Blending Team

Integrated the experiences of the NIDA CTN and the HHC Project

ConclusionConclusion

One model of disseminationOne model of dissemination A mixture of science, clinical A mixture of science, clinical

practice, and institutional realitiespractice, and institutional realities An example of principle-based An example of principle-based

disseminationdissemination

AcknowledgmentsAcknowledgments

Maxine Stitzer, PhDMaxine Stitzer, PhD Marylee Burns, MEd, MA, CRCMarylee Burns, MEd, MA, CRC John Rotrosen, MDJohn Rotrosen, MD Mary Jeanne Kreek, MDMary Jeanne Kreek, MD

87

AcknowledgementsAcknowledgements

Marion Schwartz, CSWMarion Schwartz, CSW Agatha Kulaga, MSWAgatha Kulaga, MSW Caroline WooCaroline Woo Joe Krasnansky, CSWJoe Krasnansky, CSW Lolita Silva-Vaszquez, CSWLolita Silva-Vaszquez, CSW Joyce B. Wale, CSWJoyce B. Wale, CSW Peter Coleman, MA, CASACPeter Coleman, MA, CASAC

88

AcknowledgementsAcknowledgements

Lonetta AlbrightLonetta Albright Amy Shanahan, MS, CASACAmy Shanahan, MS, CASAC Nancy Petry, PhDNancy Petry, PhD The leadership, staff, and patients The leadership, staff, and patients

of the New York City HHC Drug of the New York City HHC Drug Treatment ProgramsTreatment Programs

NIH-NIDA Grants P60-DA05130, NIH-NIDA Grants P60-DA05130, DA13046-04DA13046-04