Low-Cost Contingency Management in Community Settings Nancy Petry, Ph.D. University of Connecticut...
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Low-Cost Contingency Management in Low-Cost Contingency Management in Community SettingsCommunity Settings
Low-Cost Contingency Management in Low-Cost Contingency Management in Community SettingsCommunity Settings
Nancy Petry, Ph.D.Nancy Petry, Ph.D.
University of Connecticut Health CenterUniversity of Connecticut Health Center
Farmington, CTFarmington, CT
Supported by NIH grants R01-DA13444, Supported by NIH grants R01-DA13444, RO1-DA016855, RO1-DA14618, RO1-DA016855, RO1-DA14618,
R29-DA12056, P50-DA09241 and P50-AA03510R29-DA12056, P50-DA09241 and P50-AA03510
Contingency management:Contingency management:
1.) Frequently monitor target behavior.1.) Frequently monitor target behavior.
2.) Provide tangible reinforcement when target 2.) Provide tangible reinforcement when target behavior occurs.behavior occurs.
3.) Remove reinforcement when target behavior does 3.) Remove reinforcement when target behavior does not occur.not occur.
$10
Voucher studiesVoucher studies
Treatment of Cocaine DependenceHiggins et al., 1994
Standard treatmentStandard treatment Community Community
Reinforcement Reinforcement Approach TherapyApproach Therapy
Urine testing 2x/weekUrine testing 2x/week No vouchersNo vouchers
$10
Contingency ManagementContingency Management Community Community
Reinforcement Reinforcement Approach TherapyApproach Therapy
Urine testing 2x/weekUrine testing 2x/week VouchersVouchers
Up to $1000 available
0
25
50
75
100
%
CM Std0
25
50
75
100
%
CM Std
>8 Weeks of Cocaine Abstinence
Retained throughout Trial
Higgins et al., 1994
Treatment of Cocaine Dependence
OpioidsOpioids (Stitzer et al various, Bickel et al., 1997)
Cocaine Cocaine (Higgins et al., 1991, 1993, 1994; Silverman et al., 1996; Shaner et al., 1997)
BenzodiazepinesBenzodiazepines (Stitzer et al., 1992)
MarijuanaMarijuana (Budney et al., 1991, 2000)
AlcoholAlcohol (Bigelow et al., 1975; Miller, 1975) Nicotine Nicotine (Crowley et al., 1991; Roll et al., 1996;
Shoptaw et al., 1996)
Voucher studiesVoucher studies
Addressing some of the practical concernsAddressing some of the practical concerns
1. Cost1. Cost
2. Generalization and Acceptability2. Generalization and Acceptability
Intermittent schedule of reinforcementIntermittent schedule of reinforcement
Implementation into standard clinic settingsImplementation into standard clinic settings
Standard VA clinic setting
Subjects:Subjects: 42 alcohol-dependent outpatients 42 alcohol-dependent outpatients
Standard treatment:Standard treatment:Intensive outpatient day program Intensive outpatient day program
5 hrs/day, 5 days/week, weeks 1-45 hrs/day, 5 days/week, weeks 1-4
Aftercare Aftercare 1-3 groups/week, weeks 4-81-3 groups/week, weeks 4-8
Treatment consisted of group sessions: 12 step, relapse Treatment consisted of group sessions: 12 step, relapse prevention, voc rehab, AIDS, coping skillsprevention, voc rehab, AIDS, coping skills
Standard treatment groupStandard treatment group
Received standard group treatment and Received standard group treatment and
BAC monitoring (daily during intensive, weekly BAC monitoring (daily during intensive, weekly during aftercare).during aftercare).
Additional 15 min ofAdditional 15 min of
education oneducation on
alcohol abuse weeklyalcohol abuse weekly
Contingent groupContingent group
Standard group treatment and BAC monitoringStandard group treatment and BAC monitoring
Reinforce alcohol abstinence:Reinforce alcohol abstinence: One draw for each negative BAC.One draw for each negative BAC. Five bonus draws for a week of consecutive abstinence.Five bonus draws for a week of consecutive abstinence.
128 draws possible128 draws possible
1/2 chance of winning a small $1 prize
1/16 chance of winning a medium $20 prize
1/250 chance of winning a jumbo $100 prize
Half the cards are winningHalf the cards are winning
RetentionRetention
0
20
40
60
80
100
120
2 4 6 8
weeks
% R
etai
ned
STDCM
Petry et al., 2000
0
20
40
60
80
100
2 4 6 8
Weeks
% N
ot R
elap
sed
STDCM
Time until first heavy drinking episodeTime until first heavy drinking episode
p<.05
Petry et al., 2000
Percent positive for any illicit drugPercent positive for any illicit drug
0
10
20
30
40
50
%
Intake Week 4 Week 8
STD
CM
Petry et al., 2000
SummarySummary
This variable ratio schedule of reinforcement This variable ratio schedule of reinforcement significantly increased retention and reduced significantly increased retention and reduced
alcohol use.alcohol use. On average, subjects earned $200 worth of prizes.On average, subjects earned $200 worth of prizes. Local retailers and stores were willing to donate Local retailers and stores were willing to donate
prizes.prizes.
Does this intermittent reinforcement system work as well as the voucher system?
Does this intermittent reinforcement system work as well as the voucher system?
Study designStudy design
Cocaine-dependent outpatients initiating Cocaine-dependent outpatients initiating intensive outpatient treatment.intensive outpatient treatment.
Randomly assigned to:Randomly assigned to: Standard treatmentStandard treatment Standard treatment plus voucher CMStandard treatment plus voucher CM Standard treatment plus prize CMStandard treatment plus prize CM
Vouchers vs. prizesVouchers vs. prizes
0
25
50
75
100
0 1 2 3 4 5 6 7 8 9 10 11 12
weeks
%
Standard
Voucher
Prize
Retention
p=.08p<.01
p<.01
Mean weeks of continuous cocaine abstinenceMean weeks of continuous cocaine abstinence
0
3
6
9
Standard Voucher Prize
wee
ks
p<.05
p<.01
How low can we go?How low can we go?
Treatment groupsTreatment groups
Cocaine-dependent patients entering intensive day Cocaine-dependent patients entering intensive day program randomly assigned to:program randomly assigned to:
1.) Standard treatment 1.) Standard treatment
2.) Standard treatment plus $80 CM2.) Standard treatment plus $80 CM
($0.33, $5, and $100 prizes)($0.33, $5, and $100 prizes)
3.) Standard treatment plus $240 CM3.) Standard treatment plus $240 CM
($1, $20, and $100 prizes)($1, $20, and $100 prizes)
Mean weeks of continuous cocaine abstinenceMean weeks of continuous cocaine abstinence
1
2
3
4
5
Mea
n
Standard $80 $240
Petry et al. 2004
Can it work in group settings?Can it work in group settings?
Cocaine abstinence
0
10
20
30
40
50
1 2 3 4 5 6 7 8 9 10 11 12
Weeks
% N
egat
ive
CMStandard
Group attendance
p<.01
0
20
40
60
80
100
1 2 3 4 5 6 7 8 9 10 11 12
Weeks
p<.01
Methadone maintenance clinicMethadone maintenance clinic
Petry et al., JCCP, in press
0
5
10
15
20
25
30
35
weeks
Clie
nts
ThursdayBoth daysTuesday
Baseline BaselineReinforcers
on TuesReinforcers
on Thurs
Lower reinforcerson Thurs
Attendance at groups at HIV centerAttendance at groups at HIV center
Petry, Martin, & Finocche, 2001
Community-based therapists providing the incentives for group attendanceCommunity-based therapists providing the incentives for group attendance
0
1
2
3
4
5
6
Standard CM
Wee
ks
Mean weeks of continuous cocaine and opioid abstinence
Mean days attended treatment
0
5
10
15
20
25
Standard CM
Day
s
SummarySummary
This lower-cost CM system is effective in This lower-cost CM system is effective in retaining patients in treatment. retaining patients in treatment.
It reduces substance use.It reduces substance use. Larger magnitude prizes seem more effective than Larger magnitude prizes seem more effective than
smaller magnitude prizes, but prizes work at least smaller magnitude prizes, but prizes work at least as well as vouchers.as well as vouchers.
This CM system can be implemented into group This CM system can be implemented into group treatment format.treatment format.
Additional studies should address:Additional studies should address:
Ways to further reduce costs without Ways to further reduce costs without compromising efficacy.compromising efficacy.
Patient subgroups who may require higher or Patient subgroups who may require higher or lower incentives.lower incentives.
What behaviors to target.What behaviors to target. Optimal durations of treatment.Optimal durations of treatment. Long-term efficacy.Long-term efficacy. Methods for training therapists to administer the Methods for training therapists to administer the
treatments.treatments.
AcknowledgementsAcknowledgements
Alcohol and Drug Recovery Centers, Inc. (Hartford, CT)Alcohol and Drug Recovery Centers, Inc. (Hartford, CT) Baystate Medical Center (Springfield, MA)Baystate Medical Center (Springfield, MA) Community Substance Abuse Centers, Inc. (Hartford, CT) Community Substance Abuse Centers, Inc. (Hartford, CT) The Living Center (Hartford, CT)The Living Center (Hartford, CT) Morris Foundation (Waterbury, CT)Morris Foundation (Waterbury, CT) St. Francis Behavioral Health (Hartford, CT)St. Francis Behavioral Health (Hartford, CT) VA Connecticut (Newington, CT)VA Connecticut (Newington, CT)
Sheila Alessi, Ph.D., Mark Austin, Ellen Cielieski, Marilyn Lewis, Sheila Alessi, Ph.D., Mark Austin, Ellen Cielieski, Marilyn Lewis, Ph.D., Bonnie Martin, Steve McKinnon, Sean Sierra, Michelle Tardiff, Ph.D., Bonnie Martin, Steve McKinnon, Sean Sierra, Michelle Tardiff, Jackie Tedford, M.S.W., and Mary WienersJackie Tedford, M.S.W., and Mary Wieners