Improving Outcomes Improving Outcomes in in

Methadone TreatmentMethadone Treatment Cognitive/Behavioral Treatment Cognitive/Behavioral Treatment

Contingency ManagementContingency Management

Michael J. McCann, MAMichael J. McCann, MAMatrix Institute on AddictionsMatrix Institute on Addictions

SSeptember 25, 2008ptember 25, 2008

Overview of Presentation Overview of Presentation

Methadone treatment Methadone treatment effectivenesseffectiveness

Some general issues in treating Some general issues in treating opioid dependent patients opioid dependent patients

Some behavioral approaches to Some behavioral approaches to improve treatment improve treatment

Methadone Treatment Methadone Treatment WorksWorks

Methadone treatment is often Methadone treatment is often portrayed in a negative light.portrayed in a negative light.

We need to remind ourselves and We need to remind ourselves and educate others about our treatment.educate others about our treatment.

We provide lifesaving, effective We provide lifesaving, effective treatment. treatment.

Treatment outcomes are affected by Treatment outcomes are affected by your attitude about methadone.your attitude about methadone.

Reduction of Heroin Use by Length of Reduction of Heroin Use by Length of Stay in Methadone Maintenance Stay in Methadone Maintenance

TreatmentTreatment(Ball and Ross, 1991)(Ball and Ross, 1991)

97%

67%

23%

8%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Per

cen

t U

sin

g H

eroi

n

Pretreatment Less Than 6 Months 6 Months to 4.5 Years 4.5 Years or More

N = 617

Longer treatment = better outcomes

Methadone treatment efficacyMethadone treatment efficacyn=727, Hubbard et al. 1997n=727, Hubbard et al. 1997

42%

89%

22%28%

0%10%20%30%40%50%60%70%80%90%

100%

Heroin use (weekly) Cocaine use (weekly)

% o

f sa

mple

PretreatmentPosttreatment

Crime among 491 patients Crime among 491 patients before and during MMT at 6 before and during MMT at 6

programsprograms240

22

0

50

100

150

200

250

300

A B C D E F Average

Before TXDuring TX

Adapted from Ball & Ross - The Effectiveness of Methadone Maintenance Treatment, 1991

Cri

me

Day

s P

er Y

ear

Opioid Agonist Treatment of Addiction - Payte - 1998

Relapse to IV drug use after Relapse to IV drug use after MMTMMT

105 male patients who left treatment105 male patients who left treatment

28.9

45.5

57.6

72.282.1

0%

20%

40%

60%

80%

100%

In tx 1 to 3 4 to 6 7 to 9 10 to 12

Pe

rce

nt

IV U

se

rs

Months Since Stopping Treatment

Opioid Agonist Treatment of Addiction - Payte - 1998

Adapted from Ball & Ross - The Effectiveness of Methadone Maintenance Treatment, 1991

Mortality Rates in Treatment Mortality Rates in Treatment and 12 Months after and 12 Months after

DischargeDischargeZanis and Woody, 1998Zanis and Woody, 1998

8.2%

1.0%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

In Treatment (n=397)

Discharged (n=110)

% Died

Role of Psychosocial Services in Reducing Role of Psychosocial Services in Reducing Illicit Opioid UseIllicit Opioid Use

(Adapted From McLellan et al., 1993)(Adapted From McLellan et al., 1993)

0

20

40

60

80

0 4 8 12 16 20 24

Treatment Week

% Opiate-PositiveUrine Samples

MMS - Minimum Methadone Services SMS - Standard Methadone Services EMS - Enhanced Methadone Services

Minimum (Avg.= 59) (Methadone only)

Standard (Avg.= 38)

Enhanced (Avg.= 21)(Psychiatric, employment, family counseling)

Methadone OverdoseMethadone Overdose Methadone deaths rose 500% between 1999 Methadone deaths rose 500% between 1999

and 2005.and 2005.

Most ODs are related to the increase in Most ODs are related to the increase in prescribing methadone for pain.prescribing methadone for pain.

““While deaths involving methadone While deaths involving methadone increased, experiences in several states increased, experiences in several states show that show that addiction treatment programs are addiction treatment programs are not the culpritsnot the culprits” (Westley Clark, MD, JD, ” (Westley Clark, MD, JD, MPH, director, CSAT. MPH, director, CSAT.

Counseling Opioid Counseling Opioid Dependent Patients: Some Dependent Patients: Some

General Issues General Issues

1.1. Recovery and pharmacotherapyRecovery and pharmacotherapy

2.2. Patient orientation towards Patient orientation towards recovery recovery

3.3. Cognitive/Behavioral Cognitive/Behavioral approachesapproaches

Counseling IssuesCounseling Issues

Recovery and pharmacotherapyRecovery and pharmacotherapy

The Focus on “Getting The Focus on “Getting off”off”

Patients (and counselors) may Patients (and counselors) may have ambivalence regarding have ambivalence regarding medicationmedication

Focus on “getting off” medication Focus on “getting off” medication may convey taking medication is may convey taking medication is “bad”“bad”

Suggesting recovery requires Suggesting recovery requires cessation of medication is wrong.cessation of medication is wrong.

Recovery and Recovery and PharmacotherapyPharmacotherapy

Support patient’s medication-Support patient’s medication-takingtaking

Not this:Not this:

The Recovery Community may The Recovery Community may Ostracize Patients Taking Ostracize Patients Taking

MedicationMedication NA Board of Trustees Bulletin #29 NA Board of Trustees Bulletin #29

Regarding Methadone and other Drug Regarding Methadone and other Drug Replacement:Replacement: ““Members on drug replacement programs such Members on drug replacement programs such

as methadone are encouraged to attend NA as methadone are encouraged to attend NA meetings.”meetings.”

““It is a common practice for NA groups to It is a common practice for NA groups to encourage these members (or any other addict encourage these members (or any other addict who is still using), to participate only by who is still using), to participate only by listening.”listening.”

Note: Not all meetings take this approachNote: Not all meetings take this approach However, this reflects a common attitude.However, this reflects a common attitude.

Naltrexone Sample Naltrexone Sample AttritionAttrition

Is “getting off” realistic?Is “getting off” realistic?

28

81

167

233

0

50

100

150

200

250

Pogram Applicants Began Detoxification(72% )

Inducted ontoNaltrexone (35% )

Opioid-free at 12months (12% )

Naltrexone and OverdoseNaltrexone and OverdoseMiotto and McCann, 1997Miotto and McCann, 1997

13 of 81 Ss overdosed in a 12-month period13 of 81 Ss overdosed in a 12-month period

4 were fatal; 9 nonfatal4 were fatal; 9 nonfatal

Texas patients…..Texas patients…..

““Just substituting one drug for Just substituting one drug for another” another”

““Patients are still addicted”Patients are still addicted” But, But,

MedicationsMedications are legal are legalOral vs injectedOral vs injectedTaken under medical supervisionTaken under medical supervision Inexpensive Inexpensive

Recovery and Recovery and Pharmacotherapy: Facts Pharmacotherapy: Facts

and Mythsand Myths

““Patients are getting high”Patients are getting high” But,But,

Long acting, slow onsetLong acting, slow onsetMatches level of addictionMatches level of addiction

Recovery and Recovery and Pharmacotherapy: Facts Pharmacotherapy: Facts

and Mythsand Myths

Counseling IssuesCounseling Issues

Patient orientation towards Patient orientation towards recoveryrecovery

““Denial” in the usual sense is Denial” in the usual sense is virtually nonexistent in our patientsvirtually nonexistent in our patients

But, often a narrow focus (physical But, often a narrow focus (physical relief is sufficient)relief is sufficient)

Focus is often on not using illicit Focus is often on not using illicit opiates vs. developing new behaviors opiates vs. developing new behaviors (“Recovery” is not using heroin)(“Recovery” is not using heroin)

Patient orientation towards Patient orientation towards recoveryrecovery

Other drug, or alcohol use Other drug, or alcohol use may not be seen as a problem may not be seen as a problem or relevant to treatmentor relevant to treatment

Counseling may be viewed as Counseling may be viewed as an unnecessary impositionan unnecessary imposition

Patient orientation towards Patient orientation towards recoveryrecovery

Patient orientation towards Patient orientation towards recoveryrecovery

Patient orientation, counselor Patient orientation, counselor responseresponse Impatience, confrontation, “you’re Impatience, confrontation, “you’re

not ready for treatment”not ready for treatment”or,or,

Deal with patients at their stage of Deal with patients at their stage of acceptance and readinessacceptance and readiness

Motivational InterviewingMotivational Interviewing approachapproach

Patients not ready for treatment? Patients not ready for treatment? Or, are treatments not ready for Or, are treatments not ready for

patients?patients?

What works: The Matrix What works: The Matrix ModelModel Generally delivered in a 16-week, Generally delivered in a 16-week,

non-medication-assisted non-medication-assisted treatmenttreatment

Can be adapted for medication-Can be adapted for medication-assisted treatmentassisted treatment

Matrix Model in Matrix Model in Medication-assisted Medication-assisted

Treatment Treatment Can use group topics independent Can use group topics independent

of program structureof program structure

Provide weekly Early Recovery Provide weekly Early Recovery Groups for the first 30 days of Groups for the first 30 days of treatment treatment

Provide ongoing Relapse Provide ongoing Relapse Prevention groupsPrevention groups

Matrix Model GroupsMatrix Model Groups Focus on the presentFocus on the present

Focus on behavior vs. feelingsFocus on behavior vs. feelings

Structured, topics, information, analysis of Structured, topics, information, analysis of behaviorbehavior

Drug cessation skills and relapse preventionDrug cessation skills and relapse prevention

Lifestyle change in addition to not usingLifestyle change in addition to not using

Matrix Model GroupsMatrix Model Groups

Therapist frequently pursues less Therapist frequently pursues less motivated clientsmotivated clients

Non-confrontational; must be safe Non-confrontational; must be safe

Goal is abstinence; relapse is Goal is abstinence; relapse is toleratedtolerated

Matrix Model Key Matrix Model Key ComponentComponent

Information

The Brain Premise

Information: ConditioningInformation: Conditioning

Pavlov’s Dog

Information: ConditioningInformation: Conditioning

Pavlov’s Dog

Development of Craving Development of Craving ResponseResponseAddiction Phase

Thinking of Using

Mild Physiological Response

Entering Using Site

Heart Rate

Breathing Rate

Energy

Adrenaline Effects

Powerful Physiological Response

Use of AODs AOD Effects

Heart Rate

Breathing Rate

Energy

Adrenaline Effects

Heart

Blood Pressure

Energy

Conditioning and the Brain: Conditioning and the Brain: Message to PatientsMessage to Patients

Will power, good intentions are Will power, good intentions are not enoughnot enough

Behavior needs to changeBehavior needs to change

Deal with cravings: avoid triggersDeal with cravings: avoid triggers Deal with cravings: thought-Deal with cravings: thought-

stoppingstopping SchedulingScheduling

Early Recovery Skills Group Early Recovery Skills Group TopicsTopics

Cravings and SchedulingCravings and Scheduling Triggers, paraphernaliaTriggers, paraphernalia Thought-stoppingThought-stopping

Relapse Prevention GroupRelapse Prevention Group

What happens in group:What happens in group:

Introduction of new membersIntroduction of new members Review topic 30-45 minutes and Review topic 30-45 minutes and

discussdiscuss Discuss problems, progress, and Discuss problems, progress, and

plans for 30-45 minutesplans for 30-45 minutes Focus on the recent past and Focus on the recent past and

immediate futureimmediate future

Relapse Prevention Relapse Prevention GroupsGroups

Relapse PreventionRelapse Prevention Patients need to develop new Patients need to develop new

behaviorsbehaviors Learn to monitor signs of Learn to monitor signs of

vulnerability to relapsevulnerability to relapse Recovery is more than not using Recovery is more than not using

heroin or other illicit opioids.heroin or other illicit opioids. Recovery is more than not using Recovery is more than not using

drugs and alcoholdrugs and alcohol

Relapse Prevention Relapse Prevention TopicsTopics

Relapse PreventionRelapse Prevention Overview of the concept; things Overview of the concept; things

don’t “just happendon’t “just happen”” Using BehaviorUsing Behavior

Old behaviors need to changeOld behaviors need to change Re-emergence signals relapse risk Re-emergence signals relapse risk

(it’s a duck)(it’s a duck) Relapse JustificationRelapse Justification

““Stinking thinking”Stinking thinking” Recognize and stopRecognize and stop

Relapse AnalysisRelapse Analysis

Session to be done when relapse occurs Session to be done when relapse occurs after a period of sobrietyafter a period of sobriety

Functional analysisFunctional analysis

Continued drug use is better addressed Continued drug use is better addressed with Early Recovery topicswith Early Recovery topics

Relapse should be framed as a learning Relapse should be framed as a learning experienceexperience

A Good Counseling A Good Counseling SessionSession

Patients ultimately may need to Patients ultimately may need to understand why they became understand why they became addictedaddicted

More important early on:More important early on: Understanding the addiction disorderUnderstanding the addiction disorder Making changes in day-to-day lifeMaking changes in day-to-day life

A good session: the patients leaves A good session: the patients leaves knowing more about addiction and knowing more about addiction and recoveryrecovery

Elements of Treatment: Elements of Treatment:

Information, Persuasion, and Information, Persuasion, and MedicationMedication InformationInformation

Matrix Model Matrix Model CBTCBT 12-Step12-Step

PersuasionPersuasion Motivational InterviewingMotivational Interviewing ConfrontationConfrontation Contingency ManagementContingency Management

What works:What works:Contingency Contingency ManagementManagement

Contingency Contingency Management (CM)Management (CM)

CM: application of reinforcement CM: application of reinforcement contingencies to urine results or contingencies to urine results or behaviors (attendance in behaviors (attendance in treatment; completion of agreed treatment; completion of agreed upon activities).upon activities).

TermsTerms

Rewards vs reinforcementRewards vs reinforcement

Bribe vs reinforcementBribe vs reinforcement

Contingency Contingency Management: OverviewManagement: Overview

1.1. Research findingsResearch findings

2.2. Application of CM in NTPsApplication of CM in NTPs

Contingency ManagementContingency Management Steve Higgins, Ph.D., 1994Steve Higgins, Ph.D., 1994

Community Reinforcement Community Reinforcement Approach (CRA)Approach (CRA) Marital TherapyMarital Therapy Vocational AssistanceVocational Assistance Skills TrainingSkills Training New social and recreational activitiesNew social and recreational activities AntabuseAntabuse

CRA plus Vouchers ($977)CRA plus Vouchers ($977) 3 visits per week; 24 weeks3 visits per week; 24 weeks

Contingency Contingency Management: 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

Contingency Contingency ManagementManagement

It works, but…It works, but…

It is too expensive.It is too expensive.

It is too complex.It is too complex.

CM in Practice: Lower CM in Practice: Lower CostCost

Petry et al, 2000Petry et al, 2000

Drawing procedureDrawing procedure One draw for each negative One draw for each negative

breath alcohol testbreath alcohol test 5 negative tests in a week= 5 bonus 5 negative tests in a week= 5 bonus

drawsdraws

One draw for completion of One draw for completion of treatment goal activitytreatment goal activity

3 activities in a week= 5 bonus draws3 activities in a week= 5 bonus draws

CM in Practice: Low CostCM in Practice: Low CostPetry et al, 2000Petry et al, 2000

Drawing procedureDrawing procedure 250 slips (25%, “Sorry, try again”)250 slips (25%, “Sorry, try again”) 169 worth $1169 worth $1 17 worth $2017 worth $20 1 worth $1001 worth $100

Average cost per patient was Average cost per patient was $240 compared to $600 in the $240 compared to $600 in the Higgins studiesHiggins studies

CM in Practice: Lower CostCM in Practice: Lower CostPetry et al, 2000Petry et al, 2000

22%

84%

0%

20%

40%

60%

80%

100%

Standard Standard& CM

Retained for 8 weeks

39%

69%

0%

20%

40%

60%

80%

100%

Standard Standard &CM

% Abstinent at Week 8

CM in the “Real World”CM in the “Real World”

CM Training in NYC Health CM Training in NYC Health and Hospital Addiction and Hospital Addiction

Treatment ServiceTreatment Service Scott Kellogg et al., in the Scott Kellogg et al., in the

Journal of Substance Abuse Journal of Substance Abuse Treatment, 2005Treatment, 2005

Through the NIDA Clinical Trials Through the NIDA Clinical Trials Network, 5 clinics (4 NTPs) were Network, 5 clinics (4 NTPs) were trained in CM principlestrained in CM principles

Core Principles of CMCore Principles of CM Give reinforcement frequentlyGive reinforcement frequently Easy to earn initially (set the bar low)Easy to earn initially (set the bar low) Reinforcers should be items of use Reinforcers should be items of use

and value to patients and value to patients Reinforcement should be connected Reinforcement should be connected

to specific, observable behaviorto specific, observable behavior Minimize delay in reinforcement Minimize delay in reinforcement

delivery; greater delay, weaker effectdelivery; greater delay, weaker effect Focus on small steps; any Focus on small steps; any

improvementimprovement

CM Training in NYC: CM Training in NYC: Program 1Program 1

Piece of candy and a raffle ticket Piece of candy and a raffle ticket for each groupfor each group

Raffle for “metro card” at the end Raffle for “metro card” at the end of groupof group

Or, save raffle tickets for a raffle Or, save raffle tickets for a raffle with a bigger prizewith a bigger prize

CM Training in NYC: CM Training in NYC: Program 2Program 2

Token for attending a vocational Token for attending a vocational groupgroup

4 groups = $25 gift certificate4 groups = $25 gift certificate 8 groups = $25 gift certificate8 groups = $25 gift certificate 5 drug-free urines = McDonald’s 5 drug-free urines = McDonald’s

couponscoupons

CM Training in NYC: CM Training in NYC: Program 3Program 3

Points are earned for each group Points are earned for each group attendedattended

Points are entered in a computerPoints are entered in a computer Patients can log in and see total Patients can log in and see total

points earned every daypoints earned every day Patients can see what they can Patients can see what they can

earn for different point levelsearn for different point levels Points can be redeemed at any Points can be redeemed at any

timetime

CM Training in NYC: CM Training in NYC: Program 4Program 4

Target was attendance at Target was attendance at vocational or GED classvocational or GED class

Each class attended earned $5 in Each class attended earned $5 in an accountan account

After five classes, patients After five classes, patients receive $25 gift certificatereceive $25 gift certificate

Reinforcement ExamplesReinforcement Examples

Donuts, cookies, pizzaDonuts, cookies, pizza Start of group goodiesStart of group goodies Calendars, date books, booksCalendars, date books, books Tools, clothes, toiletries Tools, clothes, toiletries Water bottlesWater bottles SunglassesSunglasses

Reinforcement ExamplesReinforcement Examples

Preferred parkingPreferred parking ChipsChips Certificates or plaques for Certificates or plaques for

accomplishmentsaccomplishments Donations from local restaurants Donations from local restaurants

and storesand stores

CM in Practice: Low Cost & CM in Practice: Low Cost & SimpleSimple

Matrix Institute OTPMatrix Institute OTP $5 per month for perfect group $5 per month for perfect group

attendanceattendance $5 per month for perfect medication $5 per month for perfect medication

attendanceattendance Easy to track at the expense of less Easy to track at the expense of less

potencypotency Less expensive than CM in researchLess expensive than CM in research

Perfect medication Perfect medication attendanceattendance

n=49n=49

52%

37%

25%

30%

35%

40%

45%

50%

55%

Pre-CM Post-CM

% p

erf

ect

P<.05

Perfect group attendancePerfect group attendancen=49n=49

71%

58%

40%

45%

50%

55%

60%

65%

70%

75%

Pre-CM Post-CM

% p

erf

ect

P<.01

ConclusionsConclusions

CM can be effectively used in CM can be effectively used in clinical settingsclinical settings

CM can be a powerful tool to CM can be a powerful tool to assist counselors in helping assist counselors in helping patients achieve treatment goalspatients achieve treatment goals

Low cost reinforcers can be Low cost reinforcers can be effectiveeffective

Simple schedules can be effectiveSimple schedules can be effective