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

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

A. BackgroundRewards used in everyday settingsA. BackgroundRewards used in everyday settings

Salaries, commission, awards, social praiseSalaries, commission, awards, social praise

ChildrenChildren

Pets Pets

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

Incentives in substance abuse treatmentIncentives in substance abuse treatment

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

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

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.

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

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

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).

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

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

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)

Addressing some of the practical concernsAddressing some of the practical concerns

1. Cost1. Cost

2. Generalization and acceptability2. Generalization and acceptability

Prize CMPrize CMPrize CMPrize CM

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 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

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

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

STDCM

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 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.

Does this intermittent reinforcement system work as well as the voucher system?

Does this intermittent reinforcement system work as well as the voucher system?

Will it work for cocaine dependent outpatients?Will it work for cocaine dependent outpatients?

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

Petry et al., 2005

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

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

p<.05 vs std care

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.

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

National Drug Abuse Clinical Trials Network

National Drug Abuse Clinical Trials Network

MDMDDEDENENENYNY

OROR

PRPR

LILI

SCSC

FLFL

MIMI

COCO NCNC

WAWA

OHOH

CTCT

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)

Random AssignmentRandom Assignment

• Usual care

• Usual care enhanced with abstinence incentives

• 3-month evaluation

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)

Draws Escalate with Draws Escalate with Stimulant-Free Test ResultsStimulant-Free Test Results

Weeks Drug Free

# Draws

1

2

4

5

3

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

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

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)

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

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)

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

CTN methadone studiesCTN methadone studies

Longest duration of abstinence

0

3

6

9

Standard Prize CM

Wee

ks

p<.05

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.