keeping it positive: bringing contingency management to new york city scott kellogg, phd new york...
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Keeping It Positive:Keeping It Positive:Bringing Contingency Bringing Contingency
ManagementManagementTo New York CityTo New York City
Scott Kellogg, PhDNew York University/
New York Node
Contingency Contingency ManagementManagement
Developed out of Skinner’s Operant Developed out of Skinner’s Operant Conditioning modelConditioning model
Typically involves the use of positive Typically involves the use of positive reinforcements to change behaviorreinforcements to change behavior
First applied to problems with alcoholism First applied to problems with alcoholism in the late 1960’sin the late 1960’s
Used in the treatment of drug addiction Used in the treatment of drug addiction beginning in the early 1970’sbeginning in the early 1970’s
One of the first protocols that were One of the first protocols that were considered for adoption by the NIDA considered for adoption by the NIDA Clinical Trials NetworkClinical Trials Network
Contingency Contingency ManagementManagement
In addiction treatment centers, CM In addiction treatment centers, CM has been primarily used to:has been primarily used to: Reduce or eliminate drug useReduce or eliminate drug use Increase group attendanceIncrease group attendance Facilitate compliance with medical Facilitate compliance with medical
treatmenttreatment Reinforce treatment goal Reinforce treatment goal
attainmentattainment
The Early Days of the The Early Days of the CTNCTN
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New York NodeNew York Node
The New York Node joined the The New York Node joined the Clinical Trials Network in 2000Clinical Trials Network in 2000
During the following monthsDuring the following months There would be at least two There would be at least two
conflictual Steering Committee conflictual Steering Committee meetingsmeetings
Then the CM protocol was Then the CM protocol was acceptedaccepted
Moving ForwardMoving Forward
The protocol then went into its The protocol then went into its development stage where it was development stage where it was renamed ….renamed ….
Motivational Incentives for Motivational Incentives for Enhanced Drug Abuse RecoveryEnhanced Drug Abuse Recovery
(MIEDAR)(MIEDAR)
Abstinence BowlAbstinence Bowl
GoodJob
Good Job
Good Job
Small Small
Small
Large
Large
Jumbo
Good Job
Good Job
Good Job
Good Job
Good Job
Small
Good Job
Small
Examples ofExamples ofIncentive PrizesIncentive Prizes
SMALLSMALL($1($1--$5 items)$5 items)
LARGELARGE($20 items)($20 items)
JUMBOJUMBO($80($80--$100 items)$100 items)
How Motivational Incentives How Motivational Incentives Could Work For YouCould Work For You
PatientPatientProvides CleanProvides Clean
UrineUrine IncentiveIncentivePatient EarnsPatient Earns PatientPatient
Provides MoreProvides MoreClean UrinesClean Urines
How do we expect this to How do we expect this to benefit clients and benefit clients and
counselors?counselors?
• • Better outcomes for your clientsBetter outcomes for your clients• • More time to do what you like to do More time to do what you like to do and what you do best in therapy and what you do best in therapy sessionssessions
New York Node TeamNew York Node Team
John Rotrosen, MD – New York Node John Rotrosen, MD – New York Node Principle InvestigatorPrinciple Investigator
Scott Kellogg, PhD – New York Node Scott Kellogg, PhD – New York Node MIEDAR Principle InvestigatorMIEDAR Principle Investigator
Marion Schwartz, CSW – Project Marion Schwartz, CSW – Project DirectorDirector
Agatha Kulaga, MSW – Research Agatha Kulaga, MSW – Research AssistantAssistant
Caroline Woo – Research AssistantCaroline Woo – Research Assistant
New YorkNew York
Two methadone maintenance programs Two methadone maintenance programs joined the study:joined the study:
Lower Eastside Service CenterLower Eastside Service Center Under the leadership of Joe Under the leadership of Joe
Krasnansky, CSWKrasnansky, CSW Greenwich House MMTPGreenwich House MMTP
Under the leadership of Lolita Silva-Under the leadership of Lolita Silva-Vasquez, CSWVasquez, CSW
Up and RunningUp and Running
By late 2001, the protocol was up By late 2001, the protocol was up and running in New Yorkand running in New York
The Node then turned its attention The Node then turned its attention to the creation of the second to the creation of the second Blending ConferenceBlending Conference
Which was scheduled for March, Which was scheduled for March, 2002 2002
New York City Health New York City Health and Hospitals Corporationand Hospitals Corporation
The largest provider of addiction The largest provider of addiction treatment in the United Statestreatment in the United States
Runs methadone programs in five major Runs methadone programs in five major hospitalshospitals Bellevue HospitalBellevue Hospital Kings County HospitalKings County Hospital Elmhurst HospitalElmhurst Hospital Lincoln HospitalLincoln Hospital Metropolitan HospitalMetropolitan Hospital
Mayor Rudolph GiulianiMayor Rudolph Giuliani
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Giuliani Orders 5 City Hospitals To Wean Addicts Off Methadone
By RACHEL L. SWARNSPublished: August 15, 1998, New York Times
Mayor Rudy Giuliani – Mayor Rudy Giuliani – Summer 1998Summer 1998
Mayor Giuliani shocked the world of Mayor Giuliani shocked the world of methadone treatmentmethadone treatment
Voiced his concern that methadone Voiced his concern that methadone patients were not being empowered to patients were not being empowered to find employmentfind employment
Proposed a plan in which opiate-Proposed a plan in which opiate-addicted individuals would only be able addicted individuals would only be able to get three-months of treatment to get three-months of treatment At City-run methadone facilitiesAt City-run methadone facilities
Mayor Rudy Giuliani and Mayor Rudy Giuliani and MethadoneMethadone
Eventually backed downEventually backed down But gave the HHC methadone But gave the HHC methadone
programs a mandate to get their programs a mandate to get their patients employedpatients employed
Funneled additional funds to these Funneled additional funds to these programs for Vocational Trainingprograms for Vocational Training
Vocational TrainingVocational Training
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Vocational Training at Vocational Training at the HHCthe HHC
HHC developed high quality HHC developed high quality Vocational Centers in each of the Vocational Centers in each of the methadone clinicsmethadone clinics
Patients would not engage with the Patients would not engage with the services that were being offeredservices that were being offered
Vocational Training at Vocational Training at the HHCthe HHC
To increase participation,To increase participation, The HHC Leadership began The HHC Leadership began
considering using a reward programconsidering using a reward program Patients would receive gift Patients would receive gift
certificates and other desirable certificates and other desirable items if they met goals like:items if they met goals like:Getting a GEDGetting a GEDFinishing a phase of Vocational Finishing a phase of Vocational TrainingTraining
New York City HHC New York City HHC Meets NIDA CTN Meets NIDA CTN
At the New York Blending ConferenceAt the New York Blending Conference There was a panel on the MIEDAR There was a panel on the MIEDAR
protocolprotocol Maxine Stitzer, PhDMaxine Stitzer, PhD Joe Krasnansky, CSW, (LESC)Joe Krasnansky, CSW, (LESC) Scott Kellogg, PhDScott Kellogg, PhD Marion Schwartz, CSWMarion Schwartz, CSW
Each spoke about different aspects of Each spoke about different aspects of the MIEDAR protocolthe MIEDAR protocol
New York City HHC New York City HHC Meets NIDA CTN Meets NIDA CTN
Marylee Burns, MEd, MA, CRC from Marylee Burns, MEd, MA, CRC from the HHC was in the audiencethe HHC was in the audience
Recognized both the importance and Recognized both the importance and relevance of what we were doingrelevance of what we were doing
An alliance was formed to bring CM An alliance was formed to bring CM to the HHC addiction treatment to the HHC addiction treatment programsprograms
The HHC Addiction The HHC Addiction Treatment Leadership Treatment Leadership
TeamTeam Joyce Wale, CSW Joyce Wale, CSW Senior Assistant Vice President, New York Senior Assistant Vice President, New York
City Health and Hospitals Corporation, Office City Health and Hospitals Corporation, Office of Behavioral Health of Behavioral Health
Peter Coleman, MS, CASAC Peter Coleman, MS, CASAC Director, Office of Behavioral HealthDirector, Office of Behavioral Health
Marylee Burns, MEd, MA, CRC Marylee Burns, MEd, MA, CRC Assistant Director, Office of Behavioral Assistant Director, Office of Behavioral
HealthHealth
Forming the AllianceForming the Alliance Met with this HHC leadership team to Met with this HHC leadership team to
learn what they were trying to dolearn what they were trying to do Worked closely with Marylee Burns to Worked closely with Marylee Burns to
refine the Vocational Incentives that they refine the Vocational Incentives that they were beginning to implementwere beginning to implement
We eventually visited six clinics or We eventually visited six clinics or hospitals and presented the CM modelhospitals and presented the CM model
Each site then developed its own plan for Each site then developed its own plan for implementing CM with its patientsimplementing CM with its patients
They primarily reinforced group They primarily reinforced group attendanceattendance
Reward vs ReinforcementReward vs Reinforcement
This issue was at the heart of the This issue was at the heart of the HHC projectHHC project Probably a central issue in all CM Probably a central issue in all CM
dissemination effortsdissemination efforts
Reward vs ReinforcementReward vs Reinforcement
When you speak to staff or When you speak to staff or leadership about the use of leadership about the use of reinforcementsreinforcements
They almost universally talk about They almost universally talk about reinforcing patients for things like:reinforcing patients for things like: Holding a job for six monthsHolding a job for six months Being drug-free for 3 monthsBeing drug-free for 3 months Completing a GED or vocational Completing a GED or vocational
training programtraining program
Reward ProgramsReward Programs
This is what I call a Reward ProgramThis is what I call a Reward Program Acknowledging patients for achieving a Acknowledging patients for achieving a
goal or accomplishing something goal or accomplishing something noteworthynoteworthy Most likely give rewards to the best and Most likely give rewards to the best and
most motivated patientsmost motivated patients While often not changing the behavior While often not changing the behavior
of those patients who are struggling the of those patients who are struggling the most with drug use and treatment most with drug use and treatment compliancecompliance
Reinforcement ProgramsReinforcement Programs
Reinforcement ProgramReinforcement Program Breaks down each of the goals into Breaks down each of the goals into
very small steps very small steps Reinforces each of the steps along Reinforces each of the steps along
the waythe way Makes it easy to earn a Makes it easy to earn a
reinforcementreinforcement Distributes reinforcements with Distributes reinforcements with
fairly high frequencyfairly high frequency
Reinforcement ProgramsReinforcement Programs
Move from “You have done a good Move from “You have done a good job” tojob” to
““You have taken a step in the right You have taken a step in the right direction”direction”
This was the most important change This was the most important change in their program that we madein their program that we made
It was the difference that made the It was the difference that made the HHC Project successfulHHC Project successful
47
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
Per
cent
of
Sub
mit
ted
Uri
nes
Tes
ting
Neg
ativ
e
Incentive
Control
OR = 1.98 CI = 1.45 - 2.65
METHADONE: PERCENT STIMULANT NEGATIVE URINES
48
Per
cent
Ret
aine
d
0
20
40
60
80
100
2 4 6 8 10 12
o
o
o o oo
oo o
o oo
o
oo o
o
o o
o o o oo
2 4 6 8 10 12
0
20
40
60
80
100
Per
cent
Sub
mit
ting
At L
east
One
Sam
ple
Incentive
Control
Study Week
OR = 1.6; CI = 1.2 - 2.0
PSYCHOSOCIAL STUDY RETENTION
CM
TAU
Number of stimulant-negative samples
m = 13.9 (SEM = 1.2)
m = 9.9 (SEM = 1.0)
Length of abstinence m = 9.3 (SEM = 1.2)
m = 5.6 (SEM = 0.9)
Abstinent throughout entire trial
18% 6%
CTN Methamphetamine Sub-Study
(Matrix Clinics; n = 113)
Roll et al., 2006 in Roll & Newton, 2008
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LeadershipLeadership
The successful introduction of The successful introduction of contingency management usually contingency management usually comes from two forcescomes from two forces The top leadership has made the The top leadership has made the
decision to implement itdecision to implement it Idea champions emerge from Idea champions emerge from
among the staff membersamong the staff members
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LeadershipLeadership
No site successfully adopted CM No site successfully adopted CM without strong, clear, and persevering without strong, clear, and persevering endorsement and support from the endorsement and support from the head of the organizationhead of the organization
ResistanceResistance
Counselors are initially resistant or Counselors are initially resistant or indifferent to the introduction of CMindifferent to the introduction of CM
ResistanceResistance
““I wasn’t a big fan.I wasn’t a big fan. I thought that people should go to I thought that people should go to
treatment because they wanted to treatment because they wanted to be well.” (Counselor)be well.” (Counselor)
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Patient ExperiencesPatient Experiences ““Clients were saying…Clients were saying… In Russia, we were forced into In Russia, we were forced into
treatment – treatment – Now (crying), my God, I’m getting Now (crying), my God, I’m getting
treatment and $25.00!”treatment and $25.00!”
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Patient ExperiencesPatient Experiences ““Clients are proud and are having Clients are proud and are having
fun. fun. Early in treatment, when their Early in treatment, when their
name is called out, they are name is called out, they are feeling good that they are being feeling good that they are being acknowledged. acknowledged.
For once in their life, they are For once in their life, they are being rewarded for something.”being rewarded for something.”
The Reinforcements The Reinforcements Get Them to Go to Get Them to Go to
GroupGroup
The Bonding Gets The Bonding Gets Them to StayThem to Stay
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Patient ExperiencesPatient Experiences
““The staff have heard clients say that they The staff have heard clients say that they had come to realize that there are had come to realize that there are rewards just in being with each other in rewards just in being with each other in group. group.
There are so many traumatized and There are so many traumatized and sexually abused patients who are only told sexually abused patients who are only told negative things. negative things.
So, when they hear something good – that So, when they hear something good – that helps to build their self-esteem and ego.” helps to build their self-esteem and ego.” (Director)(Director)
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Family HealingFamily Healing
Patients used their gift certificates Patients used their gift certificates to buy presents or needed items for to buy presents or needed items for their children or other family their children or other family membersmembers
In a number of cases, these actions In a number of cases, these actions began a process of reconciliationbegan a process of reconciliation
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Socializing and Socializing and GenerosityGenerosity
Patients began to socialize with each Patients began to socialize with each otherother
They would use their coupons and They would use their coupons and go to movies together in groupsgo to movies together in groups
There were also reports that they There were also reports that they were taking care of each other and were taking care of each other and giving each other gifts giving each other gifts
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Internalization Internalization As one counselor put it, As one counselor put it, They went from “You are forcing They went from “You are forcing
me” to “I choose”me” to “I choose”
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Counselor Acceptance Counselor Acceptance
Once they overcame their Once they overcame their resistance, resistance,
Counselors reported that they Counselors reported that they loved the intervention loved the intervention That it was energizing and That it was energizing and
excitingexciting
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Counselor Experiences Counselor Experiences
““It gives me a great deal of It gives me a great deal of pleasure to know I’m part of a pleasure to know I’m part of a state-of-the-art methadone state-of-the-art methadone treatment program.” (Counselor)treatment program.” (Counselor)
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Understanding Understanding Reinforcement Reinforcement
““We came to see that we need to We came to see that we need to reward people where rewards in reward people where rewards in their lives were few and far between. their lives were few and far between.
We use the rewards as a clinical tool We use the rewards as a clinical tool – not as bribery, but for recognition. – not as bribery, but for recognition.
The really profound rewards will The really profound rewards will come later.”come later.”
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Patient GratitudePatient Gratitude
When patients publicly, and When patients publicly, and sometimes tearfully, acknowledge sometimes tearfully, acknowledge the counselor’s help in public, the the counselor’s help in public, the staff felt a sense of gratitudestaff felt a sense of gratitude
““In the last two award ceremonies, In the last two award ceremonies, clients said, ‘I want to thank the clients said, ‘I want to thank the staff….’ staff….’
That sounded real good – we feel That sounded real good – we feel appreciated.”appreciated.”
EpilogueEpilogue
Would eventually spread to 22 Units – Would eventually spread to 22 Units – 6 methadone 6 methadone 8 medication-free8 medication-free 6 detoxification units6 detoxification units
Thousands of patients became the Thousands of patients became the recipients and beneficiaries of recipients and beneficiaries of positive reinforcementspositive reinforcements
The largest clinical adoption of this The largest clinical adoption of this technique in historytechnique in history
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NIDA Contingency Management Meeting, Burlington, VT, October 7, 2004
Northeast ATTC – NIDA CTN – New York City HHC – New York Veterans Administration Hospital –
NYSPA Division on Addictions Co-Sponsored CM Training
October 18, 2005
Promoting Awareness of Promoting Awareness of Motivational Incentives Motivational Incentives
(PAMI)(PAMI)
The work of the NIDA-CSAT Blending Team
Integrated the experiences of the NIDA CTN and the HHC Project
ConclusionConclusion
One model of disseminationOne model of dissemination A mixture of science, clinical A mixture of science, clinical
practice, and institutional realitiespractice, and institutional realities An example of principle-based An example of principle-based
disseminationdissemination
AcknowledgmentsAcknowledgments
Maxine Stitzer, PhDMaxine Stitzer, PhD Marylee Burns, MEd, MA, CRCMarylee Burns, MEd, MA, CRC John Rotrosen, MDJohn Rotrosen, MD Mary Jeanne Kreek, MDMary Jeanne Kreek, MD
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AcknowledgementsAcknowledgements
Marion Schwartz, CSWMarion Schwartz, CSW Agatha Kulaga, MSWAgatha Kulaga, MSW Caroline WooCaroline Woo Joe Krasnansky, CSWJoe Krasnansky, CSW Lolita Silva-Vaszquez, CSWLolita Silva-Vaszquez, CSW Joyce B. Wale, CSWJoyce B. Wale, CSW Peter Coleman, MA, CASACPeter Coleman, MA, CASAC
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AcknowledgementsAcknowledgements
Lonetta AlbrightLonetta Albright Amy Shanahan, MS, CASACAmy Shanahan, MS, CASAC Nancy Petry, PhDNancy Petry, PhD The leadership, staff, and patients The leadership, staff, and patients
of the New York City HHC Drug of the New York City HHC Drug Treatment ProgramsTreatment Programs
NIH-NIDA Grants P60-DA05130, NIH-NIDA Grants P60-DA05130, DA13046-04DA13046-04