Transcript Open slides - CTN Dissemination Library

Contingency Management
• Contingency management (CM) refers to
the systematic application of basic
principles delineated by workers in the field
of the Experimental Analysis of Behavior to
assist individuals in changing their
behavior. Primary emphasis is placed on
the use of reinforcement and punishment to
alter an individual’s day-to-day behavior.
Reinforcers in Health Care
• Mammography screening
• Child immunization
BREAST CANCER
Mammography Screening
Recommendation for Women Ages 50 and older:
ANNUAL MAMMOGRAM
With physician advice alone, few women receive
an annual mammogram
(Stoner et al., 1998)
Mammogram Compliance
60%
40%
20%
0%
Incentive
No Incentive
Rates of mammogram screening were 2.5 times higher for the
incentive as compared to the control women.
(Stoner et al., 1998)
Childhood
Immunizations
In 1989-91, immunization rates
were as low as 23% for two-year
olds in the Chicago area.
Immunization Rates
100%
80%
60%
40%
20%
0%
Voucher
Control
Rates increased when WIC food vouchers were given to those
who had their children immunized.
(Hoekstra et al., 1998)
How does CM work in treating drug
abuse?
• Provide alternative sources of
reinforcement.
Nader & Woolverton, 1991
100
90
80
70
60
% Cocaine
50
Choices
40
30
20
10
0
1 pellet
4 pellets
16 pellets
0.3
cocaine dose mg/kg/inj
Higgins, Roll, & Bickel, 1996
10
8
# of cocaine 6
choices 4
2
0
$0.05
$1.00
$2.00
Roll, & Newton, 2007
10
9
8
7
# of
6
methamphet
5
amine
4
choices
3
2
1
0
$0.05
$1.00
$5.00
CM has been used to treat a number
of types of drug abuse
Opioids
Benzodiazepines
Marijuana
Methamphetamine
Nicotine (tobacco smoking)
Alcohol
Cocaine
Treatment of Cocaine Dependence
in a Drug-Free Clinic
Higgins et al., 1994
Contingency Management
–Psychosocial treatment
–Urine testing 2x/week
–Vouchers, escalating
Control Treatment
–Psychosocial treatment
–Urine testing 2x/week
–No vouchers
Treatment of Cocaine Dependence
Retained Through
Study
>8 Weeks of Cocaine
Abstinence
100
100
75
75
% 50
% 50
25
25
0
0
CM
Standard
CM
Standard
Higgins et al., 1994
Treatment of Cocaine Abuse in Methadone
Patients
Silverman et al., 1996
Contingency Management
3x weekly urine testing
received vouchers only if
urine samples were
cocaine negative
Control Group
3x weekly urine testing
received vouchers
regardless of urine test
results
Treatment of Cocaine Use in Methadone Patients
Retained Through
Study
>8 Weeks of Cocaine
Abstinence
100
100
75
75
% 50
% 50
25
25
0
0
CM
Standard
CM
Standard
Silverman et al., 1996
• A recent meta-analysis reports that CM
results in a successful treatment episode
61% of the time while other treatments with
which it has been compared result in a
successful treatment episode 39% of the
time (Prendergast, Podus, Finney,
Greenwell & Roll, 2006)
CTN 006 & 007
Random Assignment
• Standard care
• Standard care with
prize CM
• 3-month evaluation
Draws escalate with
stimulant-free test results
5
4
3
2
1
Weeks Drug Free
# Draws
Total earnings
On average, patients could earn up to $400 in prizes if
they maintained abstinence for 12 weeks and submitted all 24
negative samples.
Actual earnings were $203 in psychosocial clinics and
$130 in methadone clinics (e.g., half possible or less).
CTN 006
Results from psychosocial
clinics
Arapaho-Douglas (Rocky Mountain)
Charleston (South Carolina)
Circle Part (South Carolina)
Crossroads (Rocky Mountain)
Harbel (Mid Atlantic)
Jefferson (Delaware Valley)
Guenster LMG (New England)
Matrix (Pacific Region)
Results
>8 Weeks of stimulant
abstinence
Remained 12 weeks in
treatment
60
60
40
p<.05
40
%
%
20
20
0
0
Prize CM Standard
p<.05
Prize CM Standard
Petry et al. (2005). Archives of General Psychiatry
CM + TAU
TAU
Comparing Cocaine and Methamphetamine
Treatment Outcomes
Mean Number
Total Number of Negative Urines
15
14
13
12
11
10
9
8
7
6
5
4
3
2
1
0
CM +TAU
TAU
Cocaine
Methamphetamine
Longest Duration of Abstinence
5
Mean Weeks
4
3
CM +TAU
TAU
2
1
0
Cocaine
Methamphetamine
CTN 007
Eligible patients
Stimulant abusers
(cocaine or methamphetamine)
enrolled in methadone or
outpatient psychosocial
treatment
Participating methadone clinics
Act II (Delaware Valley)
Aegis (Pacific Region)
Glenwood (Mid Atlantic)
Greenwich (New York)
LESC (New York)
Oasis (Mid Atlantic)
CTN methadone studies
30
Percent achieving > 8 weeks of
stimulant abstinence
%
20
10
p<.05
0
Prize CM
Standard
Peirce et al. (2006). Archives of General Psychiatry.
CMDE (N=120)
• TAU (16 weeks of CBT)
• TAU + 4 weeks of CM
• TAU + 8 weeks of CM
• TAU + 16 weeks of CM
n.s.
LTBC (N=118)
• TAU (16 weeks of CBT)
• Continuous = TAU + 12 weeks of CM FR1
• Predictable = TAU + 12 weeks of CM FR3
• Unpredictable = TAU + 12 weeks of CM
VR3
Procedures
• Thrice weekly counseling and urine
collection
• Negative urine resulted in delivery of a
voucher utilizing an escalating scale of
reinforcement procedure
.