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.
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Contingency Management Contingency management (CM) refers to the systematic application of basic principles delineated by workers in the field of the Experimental.
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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 Reinforcers in Health Care
• Mammography screeningMammography screening
• Child immunizationChild immunization
BREAST CANCERBREAST CANCERMammography ScreeningMammography Screening
Recommendation for Women Ages 50 and older:Recommendation for Women Ages 50 and older:
ANNUAL MAMMOGRAMANNUAL MAMMOGRAM
With physician advice alone, few women receive With physician advice alone, few women receive an annual mammogram an annual mammogram (Stoner et al., 1998)(Stoner et al., 1998)
Mammogram ComplianceMammogram Compliance
0%
20%
40%
60%
Incentive No IncentiveRat
e of
Com
pli
ance
Rat
e of
Com
pli
ance
Rates of mammogram screening were 2.5 times higher for the Rates of mammogram screening were 2.5 times higher for the incentive as compared to the control women. incentive as compared to the control women. (Stoner et al., 1998)(Stoner et al., 1998)
ChildhoodImmunizations
In 1989-91, immunization rateswere as low as 23% for two-yearolds in the Chicago area.
Immunization Rates
0%
20%
40%
60%
80%
100%
Voucher Control
Rat
e
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
0102030405060708090
100
0.3
cocaine dose mg/kg/inj
% Cocaine Choices
1 pellet
4 pellets
16 pellets
Higgins, Roll, & Bickel, 1996
0
2
4
6
8
10
$0.05 $1.00 $2.00
# of cocaine choices
Roll, & Newton, 2007
0
1
2
3
4
5
6
7
8
9
10
# of
methamphet
amine
choices
$0.05
$1.00
$5.00
CM has been used to treat a number of types of drug abuse
• 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 Draws escalate with stimulant-free test resultsstimulant-free test results
Weeks Drug Free
# Draws
1
2
4
5
3
Total earningsTotal earningsOn average, patients could earn up to $400 in prizes if On average, patients could earn up to $400 in prizes if
they maintained abstinence for 12 weeks and submitted all 24 they maintained abstinence for 12 weeks and submitted all 24 negative samples. negative samples.
Actual earnings were $203 in psychosocial clinics and Actual earnings were $203 in psychosocial clinics and $130 in methadone clinics (e.g., half possible or less).$130 in methadone clinics (e.g., half possible or less).
CTN 006
Results from psychosocial clinicsResults 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)
ResultsResults
0
20
40
60
%
Prize CM Standard
Remained 12 weeks in treatment
0
20
40
60
%
Prize CM Standard
>8 Weeks of stimulant abstinence
Petry et al. (2005). Archives of General Psychiatry
p<.05
p<.05
CM + TAUTAU
Comparing Cocaine and Methamphetamine Treatment Outcomes
Total Number of Negative Urines
0123456789
101112131415
Cocaine Methamphetamine
Mea
n N
umbe
r
CM +TAU
TAU
Longest Duration of Abstinence
0
1
2
3
4
5
Cocaine Methamphetamine
Mea
n W
eeks
CM +TAU
TAU
CTN 007
Eligible patientsEligible patients
Stimulant abusersStimulant abusers (cocaine or methamphetamine)(cocaine or methamphetamine)
enrolled in methadone or enrolled in methadone or outpatient psychosocial outpatient psychosocial treatmenttreatment
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
Percent achieving > 8 weeks of stimulant abstinence
0
10
20
30
Prize CM Standard
%
p<.05
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