Transcript Contingency Management Advanced Clinical Management of

Contingency Management
Advanced Clinical Management of Addiction Module
Luke Mitcheson
Clinical Psychologist
Objectives
• Understand what CM is and aims to achieve
• Understand the evidence base
• Consider implementation issues
Introduction to Contingency Management
• What is Contingency Management?
• How has it been used in General Health Care?
• How has it been delivered in drug misuse?
• BBV
• Methadone Maintenance
• What is the evidence for effectiveness?
• CM in drug use (data from NICE)
• What NICE had to say
• Delivering CM in practice
THEORY
What is Contingency Management?
Conditioning in which an operant (voluntary)
response is brought under stimulus control by
virtue of presenting reinforcement contingent upon
the occurrence of the operant response
OR
The basic process by which an individual's
behaviour is shaped by reinforcement or by
punishment
Based on operant conditioning principles (Skinner)
Application of operant conditioning
Positive
Negative
Add
Subtract
Positive
reinforcement
Extinction
increases behaviour
decreases behaviour
Punishment
Negative
reinforcement
decreases behaviour
Increases behaviour
Extinction – ceasing any type of reinforcer
weakens behavioural response
Add
Subtract
Positive
Give voucher for drug
free UDS
Stop giving praise
for drug free UDS
Negative
Yell at client for drug
free UDS
Lift daily supervised
consumption for
drug free UDSs
The Essential Elements
– A discrete behaviour under voluntary control
– Quantifiable targets – e.g. child does 15 minutes piano
practice
– Identified reinforcement (incentives, rewards) - e.g.
praise, vouchers, prizes, privileges, cash
– Clear contingent relationship between behaviour and
reinforcement (schedules of reinforcement which
are consistent and immediate(at least initially) )
– All reinforcement takes place in a context of already
existing contingencies (AB-C)
EVIDENCE
Use in General Health Care
– Children – Star Charts (NICE – Nocturnal Enuresis)
– Attendance for mammograms, cervical smears, TB
screening/treatment (Giuffrida & Torgenson, 1997, BMJ)
– Challenging behaviour in learning difficulties (Howlin
et al 2009)
– Depression (Martel et al, 2004)
– The Quality and Outcomes Framework for primary
care (Lester and Rowland, 2007)
– Attendance at the gym (Charness & Gneezy 2009)
– Smoking cessation (Volpp et al 2009)
– Medication compliance (Claassen et al 2007)
NICE view of CM
An effective and cost-effective intervention for
improving treatment outcomes for problem drug users
(NICE, 2007)
–The only recommended intervention for stimulant
drug users
CM in Drug Misuse
• Adherence to healthcare interventions – e.g. Hep
B vaccinations
• Stimulants – abstinence
• Methadone – reduce illicit opiate/stimulant ‘useon-top’
• Detoxification – improved adherence
Adherence to Physical Health Interventions
• 2 x rate for TB test/Hep B vaccination, with £5-10 reward
• Threefold for 6-month return rate (Seal et al, 2003)
Review:
Comparison:
Outcome:
Study
or sub-category
DMP TG2 - 02: CM for improving concordance with physical healthcare
02 One-off CM vs Control
01 Returned for TB test or HBV vaccination (pooled)
CM
n/N
Control
n/N
RR (random)
95% CI
Weight
%
01 CM ($10-20 cash) vs Minimal control/outreach
186/200
33/100
Malotte 1998
206/217
106/215
Malotte 1999
46/48
30/48
Seal 2003
465
363
Subtotal (95% CI)
Total events: 438 (CM), 169 (Control)
Test for heterogeneity: Chi² = 12.54, df = 2 (P = 0.002), I² = 84.0%
Test for overall effect: Z = 4.45 (P < 0.00001)
29.96
37.13
32.91
100.00
0.1
0.2
0.5
Favours control
1
2
5
Favours CM
10
RR (random)
95% CI
2.82
1.93
1.53
2.00
[2.13,
[1.68,
[1.22,
[1.48,
3.74]
2.21]
1.92]
2.72]
Methadone MaintenanceCM for Illicit Drug Use
• Most substantial evidence base
• Large and consistent effect
• Participants shown to remain abstinent for as long
as 6 months
• Cost effective
• QALY health care costs alone
• QALY including criminal justice
= £15,000
= £74
13/29
PRESTON2000
19/30
RAWSON2002
163
Subtotal (95% CI)
Total events: 80 (MMT + CM), 40 (MMT+ Control)
Test for heterogeneity: Chi² = 11.07, df = 5 (P = 0.05), I² = 54.8%
Test for overall effect: Z = 2.99 (P = 0.003)
6/28
8/30
165
17.95
21.09
100.00
2.09 [0.92, 4.73]
2.38 [1.24, 4.56]
2.19 [1.31, 3.65]
4/23
10/40
0/19
0/28
110
31.45
52.77
7.97
7.81
100.00
1.82
3.00
21.90
18.37
3.74
[0.60,
[1.66,
[1.38,
[1.12,
[1.41,
5.51]
5.43]
347.62]
301.32]
9.92]
12.20
28.22
13.93
17.54
20.30
4.04
3.77
100.00
5.34
3.17
1.21
7.92
2.00
20.00
8.70
3.51
[1.34,
[1.86,
[0.35,
[2.86,
[0.83,
[1.25,
[0.49,
[1.99,
21.25]
5.42]
4.21]
21.92]
4.81]
319.22]
154.49]
6.19]
45.76
27.31
13.38
6.25
7.29
100.00
2.66
1.21
10.56
3.00
6.67
2.61
[1.27,
[0.35,
[1.38,
[0.13,
[0.37,
[1.46,
5.56]
4.21]
80.97]
70.42]
121.07]
4.68]
Contingency Management and MMT
06 6 weeks
6/19
PETRY2002
15/20
SCHOTTENFELD2005
11/20
SILVERMAN1998
9/29
PRESTON2000
88
Subtotal (95% CI)
Total events: 41 (MMT + CM), 14 (MMT+ Control)
Test for heterogeneity: Chi² = 5.80, df = 3 (P = 0.12), I² = 48.3%
Test for overall effect: Z = 2.65 (P = 0.008)
08 8 weeks
9/16
2/19
CHUTUAPE2001: Weekly
29/32
10/35
MCCLELLAN1993
4/19
4/23
PETRY2002
33/198
4/190
PIERCE2006
12/40
6/40
SCHOTTENFELD2005
10/20
0/19
SILVERMAN1998
4/29
0/28
PRESTON2000
354
354
Subtotal (95% CI)
Total events: 101 (MMT + CM), 26 (MMT+ Control)
Test for heterogeneity: Chi² = 10.04, df = 6 (P = 0.12), I² = 40.2%
Test for overall effect: Z = 4.34 (P < 0.0001)
09 12 weeks
17/32
MCCLELLAN1993
4/19
PETRY2002
11/198
PIERCE2006
1/26
SILVERMAN2004
3/20
SILVERMAN1998
295
Subtotal (95% CI)
Total events: 36 (MMT + CM), 12 (MMT+ Control)
Test for heterogeneity: Chi² = 3.97, df = 4 (P = 0.41), I² = 0%
Test for overall effect: Z = 3.22 (P = 0.001)
7/35
4/23
1/190
0/26
0/19
293
CM for Opiate Detoxification
• More likely to detox successfully
• More likely to achieve abstinence
Review:
Comparison:
Outcome:
Study
or sub-category
DMD 8: Detoxification + psychosocial intervention
02 (Detoxification + CM) versus (detoxification + control)
01 Completion of detoxification
CM
n/N
01 CM
10/19
Bickel 1997: CM+CRA
25/40
Hall 1979: CM
5/9
Higgins 1984: CM
9/13
Higgins 1986: CMmeth
7/10
McCaul 1984: CM
91
Subtotal (95% CI)
Total events: 56 (CM), 36 (control)
Test for heterogeneity: Chi² = 5.40, df = 4 (P = 0.25), I² = 25.9%
Test for overall effect: Z = 3.07 (P = 0.002)
control
n/N
RR (fixed)
95% CI
Weight
%
4/20
21/41
2/10
7/13
2/10
94
10.97
58.37
5.33
19.70
5.63
100.00
0.01
0.1
Favours control
1
10
Favours CM
100
RR (fixed)
95% CI
2.63
1.22
2.78
1.29
3.50
1.60
[0.99,
[0.83,
[0.71,
[0.69,
[0.95,
[1.18,
6.98]
1.79]
10.94]
2.39]
12.90]
2.16]
Discussion
How ethical do you think it is to use offer
service users vouchers ?
So why isn’t CM routinely used?
• In a survey of all NHS drug clinics for opiate
users in England, NO SERVICE was identified
as providing a structured CM programme
(Weaver et al, 2007)
21
Concerns….
1. The acceptability and perceptions of CM to the
general public and service users, the attitudes
of staff and senior managers.
In particular, these concerns include:
•
The intervention may ‘reward’ illicit drug use
•
The effects will not be maintained long-term
•
The system is open to abuse as drug users may
‘cheat’ their drug tests
22
2. The unusual circumstances required to conduct RCTs
and non-representativness of participants (exclusion
criteria)
3. The costs associated with its implementation
4. Staff are not trained: major training programme
required to implement
5. Cultural difference between US health care system
and publicly funded English system
6. Incentive-based systems will not work outside the
healthcare system (USA) in which they were
developed
7. Differences in the welfare benefits systems between
the USA and England (will UK users lose benefits?)
23
IMPLEMENTATION
Key issues in implementing a CM
programme (Petry, 2006)
• Robust, routine testing for drug misuse
• Targets agreed in collaboration with service
users
• Incentives provided in a timely and
consistent manner
• Relationship between treatment goal and
incentive schedule understood by service
users
• Incentives that are perceived to be
reinforcing and support a drug-free lifestyle
25
5 key aspects of implementing CM
(Kellogg et al, 2005)
1. Rewards should be given frequently
2. Should be easy to earn rewards at the
start
3. Rewards to include material goods and
services that are of use and value to
service users
4. Connection between reward and
behaviour clear
5. Increased emphasis on reward-oriented
not punishment-oriented approaches
26
Frequency and ease of earning
rewards at the start
• Closely linked
• Frequent rewards = stronger connection to
behaviour
• Target behaviour must not be too difficult:
‘successive approximation’ (e.g. Elk et al, 1995)
27
Material goods and services
• Rewards should be genuinely rewarding for
service user
• For example, vouchers and clinic privileges
should all be chosen in conjunction with
service user
28
Connection between reward and
behaviour
• Rewards are more effective if their
distribution is directly connected to specific
and observable behaviours
• The greater the delay in receiving the
reinforcement, the weaker its effect
29
Reward-oriented rather than
punishment-oriented
• Almost all trials showing efficacy of CM have
been reward-oriented (e.g. Higgins et al, 1993; Stitzer
et al, 1992)
• Adding a punitive aspect to a CM rewardoriented treatment has not found to be
effective (Iguchi et al, 1988)
30
Maintenance of behaviour after
reinforcement
• Don’t terminate a CM programme until target
behaviour is stabilised
• Reduce frequency and value of rewards
towards end of programme (e.g. Higgins 1993, 1994;
Petry 2004,2005)
31
Implementing CM in the NHS
• Major studies of implementation in services
where initially there was considerable
resistance
• Positive shifts in staff attitudes (McGovern et al,
2004; Kellogg et al, 2005; Kirby et al, 2006; Ritter and
Cameron, 2006)
32
1. Endorsement of the programme by senior
management and clinicians
2. Provision of a comprehensive education
and training programme
3. Recognition by staff that CM is an
intervention aimed at changing
behaviours not simply reinforcing people
for generally good behaviour
4. Shift in focus of service to one that is
reward orientated
Kellogg et al (2005)
33
Factors to be considered when developing
an programme in the NHS
• Integration of CM with key working
responsibilities of staff
• Identification of groups of drug users who are
most likely to benefit
• Development of near patient testing
• Impact of service users benefits
34
Reinforcement schedules
• Clinic privileges (Stitzer et al, 1992; 1986)
• Voucher reinforcement (Petry et al, 2000)
• Cash (Malotte et al, 1998; Seal et al, 2003)
• Prizes (Petry et al, 2005; Prendegast et al, 2006)
35
TRIAGE
Incentivised attendance and completion of care plan programme for primary crack users
TRIAGE
Appt 1
Appt 2
Appt 3
1. Work on full
assessment
and care-plan
2. Give £10
voucher
3. Explain
reward
schedule for
session 2 and 3
1. Work on full
assessment
and care-plan
2. Give £10
voucher
3. Explain
reward
schedule for
session 2 and 3
1. Work on full
assessment
and care-plan
2. Give £10
voucher
3. Give £10
bonus as per
protocol
Appt 4
TRIAGE
1. Ensure
eligibility
2. Explain
programme
3. Book first
appointment
with named
worker
Eligibility Criteria:
Primary crack users
Not in treatment in past 12 weeks
Not in receipt of / seeking an opiate substitute prescription
Not having participated in this programme for I year
Treatment as
usual
The Harbour Steps
Lambeth voucher-CM
►
24 tests on Monday, Wednesday & Friday
►
Escalating schedule starting at £1
►
Up by £0.5 for each successive –ive test
►
Bonus for each series of 6 –ive tests
►
Re-set following +ive test or DNA
►
Return to previous level for 6 –ives (if time)
►
£40 bonus if client attends all 24 sessions
►
Total voucher value possible = £282
►
Harbour voucher credits recorded in account book and
withdrawn on treatment days
References
•
•
•
•
•
•
•
Higgins ST, Budney AJ, Bickel WK, Foerg FE, Donham R, Badger GJ. Incentives improve
outcome in outpatient behavioral treatment of cocaine dependence. Arch Gen
Psychiatry 1994; 51: 568-76.
Lussier JP, Heil SH, Mongeon JA, Badger GJ, Higgins ST. A meta-analysis of voucherbased reinforcement therapy for substance use disorders. Addiction 2006; 101:192203.
Petry NM, Peirce JM, Stitzer ML, Blaine J, Roll JM, Cohen A, et al. Effect of prize-based
incentives on outcomes in stimulant abusers in outpatient psychosocial treatment
programs: A national drug abuse treatment clinical trials network study. Arch Gen
Psychiatry 2005. ; 62:1148-56
Peirce JM, Petry NM, Stitzer ML, Blaine J, Kellogg S, Satterfield F, et al. Effects of lowercost incentives on stimulant abstinence in methadone maintenance treatment: a
National Drug Abuse Treatment Clinical Trials Network study. Arch Gen Psychiatry 2006.
; 63:201-8.
Kellogg SH, Burns M, Coleman P, Stitzer M, Wale JB, Kreek MJ. Something of value: the
introduction of contingency management interventions into the New York City Health
and Hospital Addiction Treatment Service. J Subst Abuse Treat 2005; 28: 57-65
Petry NM, Alessi SM, Hanson T, Sierra S. Randomized trial of contingent prizes versus
vouchers in cocaine-using methadone patients. J Consult Clin Psychol 2007; 75: 983-91
Olmstead TA, Petry NM. The cost-effectiveness of prize-based and voucher-based
contingency management in a population of cocaine- or opioid-dependent outpatients.
Drug Alcohol Depend 2009. ; 102:108-15.