contingency management: using principles of reinforcement to improve drug abuse treatment nancy...
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Contingency management:Using principles of reinforcement to
improve drug abuse treatment
Contingency management:Using principles of reinforcement to
improve drug abuse treatmentNancy Petry, Ph.D.Nancy Petry, Ph.D.
University of Connecticut Health CenterUniversity of Connecticut Health Center
Farmington, CT, USAFarmington, CT, USA
Supported by National Institute of Health grants R01-DA13444, Supported by National Institute of Health grants R01-DA13444, RO1-DA016855, RO1-DA14618, R01-RO1-DA016855, RO1-DA14618, R01-DA018883DA018883, , RO1-MH60417RO1-MH60417, , RO1-MH60417RO1-MH60417-suppl, P50-DA09241, P50-AA03510 and -suppl, P50-DA09241, P50-AA03510 and M01-RR06192M01-RR06192
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OutlineOutline
A. Background and efficacyA. Background and efficacyRewards and punishers in everyday lifeRewards and punishers in everyday life
B. Voucher-based CM studies in research clinicsB. Voucher-based CM studies in research clinics
C. The prize approach: Adaptation for community C. The prize approach: Adaptation for community based clinicsbased clinics
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A. BackgroundRewards used in everyday settingsA. BackgroundRewards used in everyday settings
Salaries, commission, awards, social praiseSalaries, commission, awards, social praise
ChildrenChildren
Pets Pets
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Negative contingenciesNegative contingencies
Fines, tickets, jailFines, tickets, jail
Poor evaluations, getting fired, negative Poor evaluations, getting fired, negative social interactionssocial interactions
Detention, time outDetention, time out
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Incentives in substance abuse treatmentIncentives in substance abuse treatment
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Punishers often used with substance abusersPunishers often used with substance abusers
Out-patient treatment programsOut-patient treatment programs court mandated treatmentcourt mandated treatment dismissed from treatmentdismissed from treatment inform probation officerinform probation officer
Methadone maintenanceMethadone maintenance increase frequency of urine and breath testingincrease frequency of urine and breath testing lower the doselower the dose discontinue treatmentdiscontinue treatment
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Positive incentives used in substance abuse treatmentPositive incentives used in substance abuse treatment
12 Step treatment/AA12 Step treatment/AA coffee, foodcoffee, food group recognition and approvalgroup recognition and approval 30-day pins/certificates30-day pins/certificates act as sponsor for othersact as sponsor for others
Out-patient treatmentOut-patient treatment certificates, praisecertificates, praise
Methadone maintenanceMethadone maintenance take-home dosestake-home doses early dosing windowsearly dosing windows
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B. Voucher-based contingency management studies in research settingsB. Voucher-based contingency management studies in research settings
The Three Principles of CMThe Three Principles of CM
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.
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Treatment of Cocaine DependenceHiggins et al., 1994
Standard Care TreatmentStandard Care 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
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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
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One-year Follow-up Results
• 60% in contingent group versus 45% in standard group were cocaine abstinent
• During-treatment abstinence predicts long-term abstinence (Higgins et al., 2000).
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Treatment of Cocaine Abuse in Methadone PatientsTreatment of Cocaine Abuse in Methadone Patients
Contingent IncentivesContingent Incentives
3x weekly urine testing3x weekly urine testing
received vouchers received vouchers only ifonly if urine urine samples were cocaine samples were cocaine negativenegative
Up to $1155 available Up to $1155 available
Average earnings of $426Average earnings of $426
Non-Contingent IncentivesNon-Contingent Incentives
3x weekly urine testing3x weekly urine testing
received vouchers received vouchers regardlessregardless of of urine test resultsurine test results
Silverman et al., 1996
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0
25
50
75
100
%
CM Std/Yoked0
25
50
75
100
%
CM Std/Yoked
>8 Weeks of Cocaine Abstinence
Retained Through Study
Treatment of Cocaine Use in Methadone Patients
Silverman et al., 1996
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Contingency management reduces drug use
OpioidsOpioids (Bickel et al., 1997; Preston et al., 1998)(Bickel et al., 1997; Preston et al., 1998)
CocaineCocaine(Higgins et al., 1994, 2000, 2003; Silverman et al., 1996)(Higgins et al., 1994, 2000, 2003; Silverman et al., 1996)
BenzodiazepinesBenzodiazepines(Stitzer et al., 1992)(Stitzer et al., 1992)
MarijuanaMarijuana (Budney et al., 2000, 2006)(Budney et al., 2000, 2006)
NicotineNicotine (Stitzer & Bigelow, 1984; Roll et al., 1996)(Stitzer & Bigelow, 1984; Roll et al., 1996)
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Addressing some of the practical concernsAddressing some of the practical concerns
1. Cost1. Cost
2. Generalization and acceptability2. Generalization and acceptability
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Prize CMPrize CMPrize CMPrize CM
Implementation into standard clinic settingsImplementation into standard clinic settings
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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
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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
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Contingent groupContingent group
Standard group treatment and BAC monitoringStandard group treatment and BAC monitoringReinforce alcohol abstinence:Reinforce alcohol abstinence:
One draw for each negative BAC.One draw for each negative BAC. Bonus draws for a week of consecutive abstinence.Bonus draws for a week of consecutive abstinence.
128 draws possible 128 draws possible
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1/2 chance of winning a small $1 prize
1/16 chance of winning a large $20 prize
1/500 chance of winning a jumbo $100 prize
Half the cards are winningHalf the cards are winning
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RetentionRetention
0
20
40
60
80
100
120
2 4 6 8
weeks
% R
etai
ned
STDCM
Petry et al., 2000
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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
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Percent positive for any illicit drugPercent positive for any illicit drug
0
10
20
30
40
50
%
Intake Week 4 Week 8
STDCM
Petry et al., 2000
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SummarySummary
This variable ratio schedule of reinforcement This variable ratio schedule of reinforcement significantly increased retention and reduced significantly increased retention and reduced
alcohol as well as other use.alcohol as well as other 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.
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Does this intermittent reinforcement system work as well as the voucher system?
Does this intermittent reinforcement system work as well as the voucher system?
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Will it work for cocaine dependent outpatients?Will it work for cocaine dependent outpatients?
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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
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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
Petry et al., 2005
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Mean weeks of continuous cocaine abstinenceMean weeks of continuous cocaine abstinence
0
3
6
9
Standard Voucher Prize
wee
ks
p<.05
p<.01
Petry et al., 2005
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How low can we go?How low can we go?
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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)
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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
p<.05 vs std care
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Section summarySection summary
This lower-cost CM system is effective in This lower-cost CM system is effective in retaining patients in outpatient treatment. retaining patients in outpatient treatment.
It ubiquitously lengthens abstinence (alcohol, It ubiquitously lengthens abstinence (alcohol, cocaine, opioids, nicotine).cocaine, opioids, nicotine).
Larger magnitude prizes are more effective than Larger magnitude prizes are more effective than smaller magnitude prizes, but prizes work as well smaller magnitude prizes, but prizes work as well as vouchers.as vouchers.
Durations of abstinence achieved are associated Durations of abstinence achieved are associated with long-term outcomes. with long-term outcomes.
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Longest duration of abstinence achieved during treatment is consistently associated with long-term abstinence (n=244)
Longest duration of abstinence achieved during treatment is consistently associated with long-term abstinence (n=244)
BB p valuep value OR (95% CI)OR (95% CI)
AgeAge 0.060.06 <.02<.02 1.06 (1.01-1.11)1.06 (1.01-1.11)
Male genderMale gender -.45-.45 .19.19
IncomeIncome 0.000.00 .83.83
Longest duration of Longest duration of abstinence (LDA)abstinence (LDA)
.21.21 <.001<.001 1.19 (1.13-1.25)1.19 (1.13-1.25)
CM treatmentCM treatment .72.72 <.05<.05 2.05 (1.03-4.10)2.05 (1.03-4.10)
LDA x CMLDA x CM .09.09 .53.53
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National Drug Abuse Clinical Trials Network
National Drug Abuse Clinical Trials Network
MDMDDEDENENENYNY
OROR
PRPR
LILI
SCSC
FLFL
MIMI
COCO NCNC
WAWA
OHOH
CTCT
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Eligible PatientsEligible Patients
Stimulant AbusersStimulant Abusers (cocaine or methamphetamine)(cocaine or methamphetamine)
enrolled in methadone (n=398) enrolled in methadone (n=398) or outpatient psychosocial treatment (n=415)or outpatient psychosocial treatment (n=415)
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Random AssignmentRandom Assignment
• Usual care
• Usual care enhanced with abstinence incentives
• 3-month evaluation
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DRUG TARGETSDRUG TARGETS
PRIMARY TARGETS:PRIMARY TARGETS: Stimulants (cocaine; methamphetamine)Stimulants (cocaine; methamphetamine) Alcohol Alcohol
SECONDARY TARGETS:SECONDARY TARGETS: Opiates (Methadone patients)Opiates (Methadone patients) Opiates and marijuana (Psychosocial pts)Opiates and marijuana (Psychosocial pts)
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Draws Escalate with Draws Escalate with Stimulant-Free Test ResultsStimulant-Free Test Results
Weeks Drug Free
# Draws
1
2
4
5
3
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Bonus Draws for OPIATE (Methadone clinics) orBonus Draws for OPIATE (Methadone clinics) orOPIATE AND MARIJUANA (Psychosocial clinics) AbstinenceOPIATE AND MARIJUANA (Psychosocial clinics) Abstinence
Weeks Drug Free
# Draws2 2 2 2 2
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Total EarningsTotal Earnings
$400 in prizes could be earned on average$400 in prizes could be earned on averageIf participant tested negative for all targeted If participant tested negative for all targeted
drugs over 12 consecutive weeksdrugs over 12 consecutive weeks
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Results from Outpatient Psychosocial Clinics
Results from Outpatient Psychosocial Clinics
Arapaho-Douglas (Rocky Mountain) Arapaho-Douglas (Rocky Mountain) Charleston (South Carolina)Charleston (South Carolina)Circle Park (South Carolina) Circle Park (South Carolina)
Crossroads (Rocky Mountain) Crossroads (Rocky Mountain) Harbel (Mid Atlantic) Harbel (Mid Atlantic)
Jefferson (Delaware Valley)Jefferson (Delaware Valley)Guenster LMG (New England)Guenster LMG (New England)
Matrix (Pacific Region)Matrix (Pacific Region)
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Per
cent
Ret
aine
d
0
20
40
60
80
100
2 4 6 8 10 12
CM
Standard
Study Week
RETENTION IN TREATMENT
49%
35%
RH = 1.6; CI = 1.2 - 2.1
Petry et al. Arch Gen Psychiatry, 2005
0
3
6
9
Standard CM
Mea
n w
eeks
LONGEST DURATIONOF ABSTINENCE
p<.05
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Participating Methadone ClinicsParticipating Methadone Clinics
Act II (Delaware Valley) Act II (Delaware Valley) Aegis (Pacific Region)Aegis (Pacific Region)
Glenwood (Mid Atlantic)Glenwood (Mid Atlantic)Greenwich (New York) Greenwich (New York) LESC (New York) LESC (New York)
Oasis (Mid Atlantic) Oasis (Mid Atlantic)
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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 (2/wk for 12 wks)
% U
rine
s T
estin
g N
egat
ive
Incentive
Standard
OR = 1.96 CI = 1.45 - 2.65
METHADONE: PERCENT STIMULANT NEGATIVE URINES
Peirce, Petry, et al., Arch Gen Psychiatry, 2006
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CTN methadone studiesCTN methadone studies
Longest duration of abstinence
0
3
6
9
Standard Prize CM
Wee
ks
p<.05
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CONCLUSIONSCONCLUSIONS
A large multi-site study of prize-based CM was A large multi-site study of prize-based CM was successfully completed within CTN.successfully completed within CTN.
Prize CM reduced stimulant use in methadone Prize CM reduced stimulant use in methadone patients and improved retention and enhanced patients and improved retention and enhanced durations of abstinence in outpatient psychosocial durations of abstinence in outpatient psychosocial treatment.treatment.
Costs were reasonable.Costs were reasonable.
Further dissemination of CM interventions into Further dissemination of CM interventions into usual care treatment is warranted.usual care treatment is warranted.