Practical Application of Contingency Management

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Practical Application of Contingency Management

• Michael J. McCann, MA
• Matrix Institute on Addictions

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Elements of Treatment Information, Persuasion,
and Medication

• Information
• Matrix Model
• CBT
• 12-Step
• Persuasion
• Motivational Interviewing
• Confrontation
• Contingency Management

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Motivational 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

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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.

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Contingency Management Overview

• Research findings
• Application of CM in the Matrix Institute NTP
• Practical application of CM

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Contingency Management Research Findings

• Effective with wide variety of abused substances
• Nicotine
• Alcohol
• Heroin
• Benzodiazepines
• Cocaine and Methamphetamine

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Research Findings

• Highlight efficacy
• Raise questions about real-world applicability

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Contingency Management Steve Higgins, Ph.D.

• Community Reinforcement Approach (CRA)
• Marital Therapy
• Vocational Assistance
• Skills Training
• New social and recreational activities
• Antabuse
• Vouchers (977)

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Contingency Management Higgins et al., 1993

• 24-week treatment
• 3 times per week urines
• Conditions
• Standard treatment
• CRA plus vouchers

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Contingency Management Higgins et al., 1994

• 24-week treatment
• 3 times per week urines
• Conditions
• CRA only
• CRA plus vouchers

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Contingency Management Higgins et al., 1993
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Contingency Management Higgins et al., 1994

• How much of CRA effect is CM?
• 24-week treatment
• 3 times per week urines
• Conditions
• CRA only
• CRA plus vouchers

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Contingency Management Higgins et al., 1994
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Contingency Management Rawson et al., 2002

• Cognitive-Behavioral Treatment vs CM
• Cocaine users
• 16 weeks
• 3 visits per week

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Contingency Management Rawson et al., 2002

• Cognitive-behavioral Treatment (CBT)
• 90 minute groups
• Cognitive/behavioral
• Drug cessation
• Lifestyle change
• Relapse prevention

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Contingency Management Rawson et 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

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Contingency Management Rawson et al., 2002

• Cocaine-using methadone patients
• Four conditions
• CM
• CBT
• CBT CM
• Methadone only

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Cocaine-free Urine Samples During StudyRawson et
al., 2002
Plt.001 CMgtMM CBT CMgtMM
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Percent Subjects Achieving 3 Consecutive Weeks
Cocaine-freeRawson et al., 2002
Plt.02 CMgtMM CBT CM gtMM
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Days used cocaine in past month Rawson et al.,
2002
Week 26 CMltMM CBTltMM Week 52 CBTltMM
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CBT Group AttendanceRawson et al., 2002
Plt.04
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Contingency Management in Treatment

• Conclusion CM works

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Contingency Management in Treatment

• CM is not always popular with counselors.
• Simply getting clean should be reward enough.
• Other problems
• Schedules are too complicated.
• Too expensive for the average clinic. The cost of
  vouchers exceeds what some clinics are reimbursed
  for a treatment episode.

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CM in Practice in an NTP

• Treatment enhancements (RP groups, womens
  groups, stimulant groups, HIV and Hep-C
  education, low cost CM)
• 5 per month for perfect group attendance
• 5 per month for perfect medication attendance

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Perfect medication attendancePre-post
contingencies, n49
Plt.05
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Perfect group attendancePre-post contingencies,
n49
Plt.01
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Perfect group attendance in patients missing
pre-CM, n20
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Groups attended in patients missing pre-CM, n20
Plt.005
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CM in an NTP Conclusions

• A simple, low cost CM intervention can improve
  patient attendance in groups and medication
  visits.

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CM with Matrix Model Treatment

• May improve engagement of new patients
• May improve retention of patients
• May improve treatment outcomes

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CM with Matrix Model Treatment

• Challenges
• Must be simple
• Easy to trackNeed to keep a record of attendance
• Easy to figure rewardsno progressive schedules,
  resets, etc.
• Little burden on the counselor

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CM with Matrix Model Treatment

• 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

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CM with Matrix Model Treatment Some examples

• Food available for 10 minutes after group starts
• Weekly reward for patients who attend all groups
  each week
• Monthly reward for patients who attend all groups
  each month

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CM with Matrix Model Treatment Some examples

• Raffles vs guaranteed reinforcement
• Certificates, plaques, food, goods, money, etc.
• Combine with social reinforcement

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Conclusions

• CM can be effectively used in clinical settings
• Low cost reinforcers can be effective
• Simple schedules can be effective
• Increased attendance can offset cost with
  fee-for-service billing