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![Page 1: Practical Application of Contingency Management Michael J. McCann, MA Matrix Institute on Addictions.](https://reader036.fdocuments.us/reader036/viewer/2022070607/5a4d1b887f8b9ab0599bd66b/html5/thumbnails/1.jpg)
Practical Application of Practical Application of Contingency ManagementContingency Management
Michael J. McCann, MAMatrix Institute on Addictions
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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
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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
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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.
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Contingency Management: Contingency Management: OverviewOverview
1. Research findings2. Application of CM in the Matrix
Institute OTP
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Research FindingsResearch Findings
Highlight efficacy
Raise questions about real-world applicability
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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)
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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
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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
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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
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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
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Contingency Management:Contingency Management: Rawson et al., 2002Rawson et al., 2002Cocaine-using methadone patients16 weeks; 3 X per weekFour conditions:– CM – CBT – CBT & CM–Methadone only
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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
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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
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Cocaine-free Urine Samples During StudyCocaine-free Urine Samples During StudyRawson et al., 2002Rawson et al., 2002
19.8
30.326.1
11
0
5
10
15
20
25
30
35
# c
ocai
ne-f
ree
CBT CM CBT & CM MMP<.001 CM>MMCBT & CM>MM
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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
-wee
ks c
ocai
ne fr
ee
CBT CM CBT & CM MMP<.02 CM>MMCBT & CM >MM
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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 u
sed
MMCMCBT + CMCBT
Week 26: CM<MM; CBT<MMWeek 52: CBT<MM
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CBT Group AttendanceCBT Group AttendanceRawson et al., 2002Rawson et al., 2002
17.9
24.7
0
5
10
15
20
25
30
# s
essi
ons
atte
nded
CBT CBT & CMP<.04
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Contingency Management in TreatmentContingency Management in Treatment
Conclusion: CM works
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CM in PracticeCM in Practice
What to target?– Urine results?• Frequent enough? Results immediate?• Valid? Observed?
– Treatment goals • Can vary across patient and counselors• Verifiable?
– Attendance
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CM in PracticeCM in Practice
Challenges– Addressing staff resistance• Patients should not have to be “paid”;
recovery is the reward • Motivation needs to come from within
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CM in PracticeCM 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
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CM in PracticeCM 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
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CM in Practice in an OTPCM in Practice in an OTP
$5 per month for perfect group attendance
$5 per month for perfect medication attendance
Easy to trackLess expensive than CM in research
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Perfect medication attendancePerfect medication attendancePre-post contingencies, n=49Pre-post contingencies, n=49
37%
52%
25%
30%
35%
40%
45%
50%
55%
% p
erfe
ct
Pre-CM Post-CM
P<.05
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Perfect group attendancePerfect group attendancePre-post contingencies, n=49Pre-post contingencies, n=49
58%
71%
40%
45%
50%
55%
60%
65%
70%
75%
% p
erfe
ct
Pre-CM Post-CM
P<.01
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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
erfe
ct
Pre-CM Post-CM
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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
roup
s
Pre-CM Post-CM
P<.005
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CM in an OTP: ConclusionsCM in an OTP: Conclusions
A simple, low cost CM intervention can improve patient attendance in groups and medication visits.
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CM in an OTP: ModificationsCM in an OTP: Modifications
Recent data show diminished effectPerfection too difficult? More immediate effect; shaping:
McDonald’s coupons, once per week at group, first 30 days of treatment
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CM in an OTP: ModificationsCM 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
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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