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Low-Cost Contingency Management in Community Settings

Low-Cost Contingency Management in Community Settings. Nancy Petry, Ph.D. University of Connecticut Health Center Farmington, CT Supported by NIH grants R01-DA13444, RO1-DA016855, RO1-DA14618, R29-DA12056, P50-DA09241 and P50-AA03510. Contingency management:.

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Low-Cost Contingency Management in Community Settings

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  1. Low-Cost Contingency Management in Community Settings Nancy Petry, Ph.D. University of Connecticut Health Center Farmington, CT Supported by NIH grants R01-DA13444, RO1-DA016855, RO1-DA14618, R29-DA12056, P50-DA09241 and P50-AA03510

  2. Contingency management: 1.) Frequently monitor target behavior. 2.) Provide tangible reinforcement when target behavior occurs. 3.) Remove reinforcement when target behavior does not occur.

  3. Voucher studies $10

  4. Treatment of Cocaine DependenceHiggins et al., 1994 Contingency Management • Community Reinforcement Approach Therapy • Urine testing 2x/week • Vouchers Standard treatment • Community Reinforcement Approach Therapy • Urine testing 2x/week • No vouchers $10 Up to $1000 available

  5. Treatment of Cocaine Dependence Retained throughout Trial Higgins et al., 1994

  6. Voucher studies • Opioids(Stitzer et al various, Bickel et al., 1997) • Cocaine (Higgins et al., 1991, 1993, 1994; Silverman et al., 1996; Shaner et al., 1997) • Benzodiazepines(Stitzer et al., 1992) • Marijuana(Budney et al., 1991, 2000) • Alcohol(Bigelow et al., 1975; Miller, 1975) • Nicotine (Crowley et al., 1991; Roll et al., 1996; Shoptaw et al., 1996)

  7. Addressing some of the practical concerns 1. Cost 2. Generalization and Acceptability

  8. Intermittent schedule of reinforcement Implementation into standard clinic settings

  9. Standard VA clinic setting Subjects: 42 alcohol-dependent outpatients Standard treatment: • Intensive outpatient day program 5 hrs/day, 5 days/week, weeks 1-4 • Aftercare 1-3 groups/week, weeks 4-8 Treatment consisted of group sessions: 12 step, relapse prevention, voc rehab, AIDS, coping skills

  10. Standard treatment group Received standard group treatment and BAC monitoring (daily during intensive, weekly during aftercare). Additional 15 min of education on alcohol abuse weekly Just say no

  11. Contingent group Standard group treatment and BAC monitoring Reinforce alcohol abstinence: • One draw for each negative BAC. • Five bonus draws for a week of consecutive abstinence. 128 draws possible

  12. Half the cards are winning • 1/2 chance of winning a small $1 prize • 1/16 chance of winning a medium $20 prize • 1/250 chance of winning a jumbo $100 prize

  13. Retention Petry et al., 2000

  14. Time until first heavy drinking episode p<.05 Petry et al., 2000

  15. Percent positive for any illicit drug Petry et al., 2000

  16. Summary • This variable ratio schedule of reinforcement significantly increased retention and reduced alcohol use. • On average, subjects earned $200 worth of prizes. • Local retailers and stores were willing to donate prizes.

  17. Does this intermittent reinforcement system work as well as the voucher system?

  18. Study design • Cocaine-dependent outpatients initiating intensive outpatient treatment. • Randomly assigned to: • Standard treatment • Standard treatment plus voucher CM • Standard treatment plus prize CM

  19. Vouchers vs. prizes Retention p<.01 p=.08 p<.01

  20. Mean weeks of continuous cocaine abstinence p<.01 p<.05

  21. How low can we go?

  22. Treatment groups Cocaine-dependent patients entering intensive day program randomly assigned to: 1.) Standard treatment 2.) Standard treatment plus $80 CM ($0.33, $5, and $100 prizes) 3.) Standard treatment plus $240 CM ($1, $20, and $100 prizes)

  23. Mean weeks of continuous cocaine abstinence Petry et al. 2004

  24. Can it work in group settings?

  25. Methadone maintenance clinic Group attendance Cocaine abstinence p<.01 p<.01 Petry et al., JCCP, in press

  26. Attendance at groups at HIV center Lower reinforcers on Thurs Reinforcers on Tues Reinforcers on Thurs Baseline Baseline Petry, Martin, & Finocche, 2001

  27. Community-based therapists providing the incentives for group attendance Mean weeks of continuous cocaine and opioid abstinence Mean days attended treatment

  28. Summary • This lower-cost CM system is effective in retaining patients in treatment. • It reduces substance use. • Larger magnitude prizes seem more effective than smaller magnitude prizes, but prizes work at least as well as vouchers. • This CM system can be implemented into group treatment format.

  29. Additional studies should address: • Ways to further reduce costs without compromising efficacy. • Patient subgroups who may require higher or lower incentives. • What behaviors to target. • Optimal durations of treatment. • Long-term efficacy. • Methods for training therapists to administer the treatments.

  30. Acknowledgements • Alcohol and Drug Recovery Centers, Inc. (Hartford, CT) • Baystate Medical Center (Springfield, MA) • Community Substance Abuse Centers, Inc. (Hartford, CT) • The Living Center (Hartford, CT) • Morris Foundation (Waterbury, CT) • St. Francis Behavioral Health (Hartford, CT) • VA Connecticut (Newington, CT) • Sheila Alessi, Ph.D., Mark Austin, Ellen Cielieski, Marilyn Lewis, Ph.D., Bonnie Martin, Steve McKinnon, Sean Sierra, Michelle Tardiff, Jackie Tedford, M.S.W., and Mary Wieners

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