# Presentation: 168550

## 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:

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

## Voucher studies

- $10

## Treatment of Cocaine DependenceHiggins et al., 1994

- Standard treatment
- Community Reinforcement Approach Therapy
- Urine testing 2x/week
- No vouchers

- $10

- Contingency Management
- Community Reinforcement Approach Therapy
- Urine testing 2x/week
- Vouchers

- Up to $1000 available

## Treatment of Cocaine Dependence

- Retained throughout
-            Trial

- Higgins et al., 1994

## Voucher studies

**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)

## Addressing some of the practical concerns

- 1. Cost
- 2. Generalization and Acceptability

## Intermittent schedule of reinforcement

- Implementation into standard clinic settings

## 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

## 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

## 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

## Half the cards are winning

- 1/16 chance of winning a medium $20  prize
- 1/250 chance of winning a jumbo $100 prize

## Retention

- Petry et al., 2000

## Time until first heavy drinking episode

- p<.05

- Petry et al., 2000

## Percent positive for any illicit drug

- Petry et al., 2000

## 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.

## Does this intermittent reinforcement system work as well as the voucher system?

## Study design

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

## Vouchers vs. prizes

- Retention

- p=.08

- p<.01

- p<.01

## Mean weeks of continuous cocaine abstinence

- p<.05

- p<.01

## How low can we go?

## 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)

## Mean weeks of continuous cocaine abstinence

- Petry et al. 2004

## Can it work in group settings?

## Methadone maintenance clinic

- Group attendance

- p<.01

- p<.01

- Petry et al., JCCP, in press

## Attendance at groups at HIV center

- Baseline

- Baseline

- Reinforcers
- on Tues

- Reinforcers
- on Thurs

- Lower
- reinforcers
- on Thurs

- Petry, Martin, & Finocche, 2001

## Community-based therapists providing the incentives for group attendance

**Mean weeks of continuous **
**cocaine and opioid abstinence**

**Mean days attended treatment**

## 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.

## 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.

## 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