1. Methadone maintenance in Michigan: Five years of data using a contingency management approach Gary Rhodes, M.A., L.L.P. Golfo Tzilos, M.A. Mark Greenwald, Ph.D. Wayne State University

2. Abstract Aims This program description presents an ongoing inner-city Detroit methadone maintenance treatment (MMT) program. Implemented in March 2002, several factors contributed to this Maintenance to Abstinence (MtoA) program’s design and development. First, Michigan State regulations require that methadone treatment providers encourage clients to complete MMT within two years. Second, budget cuts for publicly funded treatment reduced by more than half the amount of therapy authorized for a typical patient. To compensate for budget reductions and to enhance therapeutic outcomes, this program was designed as an evidence-based approach relying heavily on the use of contingency management techniques. Data will be presented on program elements such as overall abstinence rates when weekly additional “bonus” take-home medication is contingent upon providing drug-free urine specimens, cocaine abstinence rates following mandatory CBT group attendance for cocaine-positive urine specimens, and treatment retention.

3. Abstract (Cont.) Conclusions To date, 525 MtoA patients have enrolled. For comparison, we present outcome data from 105 Standard Treatment (ST) patients admitted just prior to MtoA program implementation. In ST abstinence was a treatment goal, but not required for continued enrollment. In contrast, MtoA is a performance-based program. Additionally, in ST dose adjustments arose from a patient requesting to see the doctor. In MtoA, automatic dose increases occur over the first two weeks of treatment. Compared to ST, MtoA abstinence rates improved (22% vs. 64% opiate- negative drug screens at 90 days) and treatment retention improved (24% vs. 46% retained in treatment at least one year). Data also show that abstinence-contingent take-home medication has been an effective therapeutic strategy. Finally, data on our combined CBT/contingency management approach for crack cocaine use will be presented. Support Joseph Young, Sr. Funds (State of Michigan)

4. The challenge was to create a methadone treatment program that improved on existing rates of abstinence and treatment retention, as well as prepare patients for successful dose reductions and eventual completion of the methadone phase of treatment within two years. M to A is an evidence-based treatment for opiate dependence with contingency management as its basic “operating system.” The most important elements of the M to A program are: Clear expectations for clinic attendance, counseling attendance, and abstinence Use of behavioral contracting whenever minimal expectations are not met Use of incentives – additional take-home privileges to reinforce abstinence, reduced counseling to reinforce ongoing abstinence, additional counseling for cocaine use Use of evidence-based therapies – therapists are trained in CBT, MET, and 12-Step Facilitation The outcome variables are treatment retention rates and abstinence rates by treatment week for illicit opiates, benzodiazapines and cocaine. A treatment week compares each patient's first week, second week, etc., regardless of date of admission. Retention rates are the percentage of total patients remaining in treatment at the end of each successive thirteen-week period. Introduction (cont.)

5. Clinic Demographics Current Population145 (50% M. to A., 50% M.E.) Publicly funded95% (Medicaid & Block Grant) Gender55% male, 45% female Race85% A.A., 13% White, 2% Hisp. Number of years using20.8 (s.d. 10.8) Amount per day$40.00 (s.d. $25.00) Method of use50% injection Cocaine Use at Intake48% Total admissions258

6. Maintenance to Abstinence Program After Two Years Percent of Negative Drug Screens by Treatment Week Beginning N=171

7. Maintenance to Abstinence Program After Five Years Percent of Negative Drug Screens by Treatment Week Beginning N=525

8. Comparison of Maintenance to Abstinence and Standard Methadone Treatment on Percentage of Opiate-Negative Urine Drug Screens

9. Comparison of Maintenance to Abstinence and Standard Methadone Treatment on Percentage of Cocaine-Negative Urine Drug Screens

10. Bonus Take-Homes: Persons in Treatment 90 Days or Longer, But Not Yet Earning Take-Home Privileges. Week 1 is First Week of Intervention

11. Cocaine Group Cocaine use among methadone patients remains one of the most difficult treatment issues. Cocaine use in Detroit is almost exclusively in the form of crack. Cocaine use has an overall negative impact on treatment outcomes. At intake over the past five years, 48% of new patients have tested positive for cocaine. Of all treatment dropouts, 88% used cocaine Of all those not meeting minimum abstinence requirements, 78% used cocaine. New patients are informed during the intake/orientation process that if their urine drug screen reveals cocaine use, they will be assigned to the mandatory cocaine group until they achieve six consecutive six consecutive weekly urine drugs screens.

12. Cocaine Group (cont) The M to A program conducts the cocaine group as a straightforward cognitive behavioral group therapy. Weekly topics include a handout and homework assignment. Missing a cocaine group results in a 30- day behavioral contract. Missing a second cocaine group during the contract period results in the initiation of a 30-day dose reduction to continue until all therapy sessions are attended for one week. These are the results we get. 39% of those assigned to cocaine group achieved the six consecutive cocaine-negative weekly urine drug screens and “graduate” In a clinic population averaging 150 patients, the weekly average of cocaine-positive urine drug screens is 10.5.

13. Behavioral Contracting 2007N Dose reduction initiated Resulting in discharge Ind. Counseling2030%5% Group Counseling140% Cocaine Group6414%0% Abstinence (no contracts before 90 days in treatment) 6848%21% Tampering825% Total174

14. Standard Methadone Treatment: Cumulative Percentages of Treatment Loss Over 52 Weeks (Beginning N = 105)

15. Maintenance to Abstinence: Cumulative Percentages of Treatment Loss Over 104 Weeks (Beginning N = 171)

16. Maintenance to Abstinence: Cumulative Percentages of Treatment Loss Over 104 Weeks (After Five Years, Beginning N=525)

17. Results/Discussion The contingency management techniques of the M to A methadone treatment program combined with effective therapies demonstrate a clear improvement over previous treatment practices. M-to-A rate of treatment retention is improved over SMT M-to-A opiate-negative drug screens show marked improvement over SMT M-to-A cocaine-negative drug screens show some improvement over SMT Bonus take-home privileges produced immediate and significant improvement in abstinence for all illicit drugs The number of M to A patients undergoing successful dose-reduction prior to discharge is much improved over SMT However, the percentage of patients successfully completing treatment has been disappointing. And, of those completing treatment, follow-up data has been difficult to obtain. Funder – State of Michigan (Joe Young Sr.)