Practical Application of Contingency Management Michael J. McCann, MA Matrix Institute on...
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Transcript of Practical Application of Contingency Management Michael J. McCann, MA Matrix Institute on...
Practical Application of Practical Application of Contingency ManagementContingency Management
Michael J. McCann, MAMatrix Institute on Addictions
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
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
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.
Contingency Management: Contingency Management: OverviewOverview
1. Research findings2. Application of CM in the Matrix
Institute OTP
Research FindingsResearch Findings
Highlight efficacy
Raise questions about real-world applicability
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)
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
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
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
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
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
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
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
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
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
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
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
Contingency Management in TreatmentContingency Management in Treatment
Conclusion: CM works
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
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
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
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
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
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
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
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
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
CM in an OTP: ConclusionsCM in an OTP: Conclusions
A simple, low cost CM intervention can improve patient attendance in groups and medication visits.
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
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
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