2. Improving Outcomes in Methadone Treatment Cognitive/Behavioral Treatment Contingency Management Michael J. McCann, MA Matrix Institute on Addictions COMP Symposium September 11, 2007

3. Overview of Presentation Some general issues in treating opioid dependent patients Some general issues in treating opioid dependent patients Some behavioral approaches to improve treatment Some behavioral approaches to improve treatment

4. But first, let’s look at what we do… Methadone treatment is often portrayed in a negative light. Methadone treatment is often portrayed in a negative light. We need to remind ourselves and educate others about our treatment. We need to remind ourselves and educate others about our treatment. We provide lifesaving, effective treatment We provide lifesaving, effective treatment Numbers don’t lie…. Numbers don’t lie….

5. Reduction of Heroin Use by Length of Stay in Methadone Maintenance Treatment (Ball and Ross, 1991) N = 617

6. Methadone treatment efficacy n=727, Hubbard et al. 1997

7. Crime among 491 patients before and during MMT at 6 programs Adapted from Ball & Ross - The Effectiveness of Methadone Maintenance Treatment, 1991 Crime Days Per Year Opioid Agonist Treatment of Addiction - Payte - 1998

8. Patient Status Before and After Methadone Maintenance Treatment (Composite Average of Three Treatment Programs for 2 Years) (Adapted from McGlothlin and Anglin, 1981)

9. Relapse to IV drug use after MMT 105 male patients who left treatment Percent IV Users Months Since Stopping Treatment Opioid Agonist Treatment of Addiction - Payte - 1998 Adapted from Ball & Ross - The Effectiveness of Methadone Maintenance Treatment, 1991

10. Mortality Rates in Treatment and 12 Months after Discharge Zanis and Woody, 1998

11. Role of Psychosocial Services in Reducing Illicit Opioid Use (Adapted From McLellan et al., 1993) Minimum Standard Enhanced

12. Treatment Outcome Data-Summary Methadone treatment is incredibly effective Methadone treatment is incredibly effective Be proud of the work you do Be proud of the work you do Inform, educate, advocate. Inform, educate, advocate.

13. Counseling Opioid Dependent Patients: Some General Issues 1.Recovery and pharmacotherapy 2.Patient orientation towards recovery 3.12-Step meetings 4.Cognitive/Behavioral approaches

14. Counseling Issues Recovery and pharmacotherapy Recovery and pharmacotherapy

15. Recovery and Pharmacotherapy Patients (and counselors) may have ambivalence regarding medication Patients (and counselors) may have ambivalence regarding medication The recovery community may ostracize patients taking medication The recovery community may ostracize patients taking medication Counselors need to have accurate information Counselors need to have accurate information

16. Recovery and Pharmacotherapy Focus on “getting off” medication may convey taking medication is “bad” Focus on “getting off” medication may convey taking medication is “bad” Suggesting recovery requires cessation of medication is wrong Suggesting recovery requires cessation of medication is wrong Support patient’s medication-taking Support patient’s medication-taking

17. “Just substituting one drug for another” “Just substituting one drug for another” “Patients are still addicted” “Patients are still addicted” But, But, Medications are legal Medications are legal Oral vs injected Oral vs injected Taken under medical supervision Taken under medical supervision Inexpensive Inexpensive Recovery and Pharmacotherapy: Facts and Myths

18. “Patients are getting high” “Patients are getting high” But, But, Long acting, slow onset Long acting, slow onset Matches level of addiction Matches level of addiction Recovery and Pharmacotherapy: Facts and Myths

19. Counseling Issues Patient orientation towards recovery Patient orientation towards recovery

20. “Denial” in the usual sense is virtually nonexistent in our patients “Denial” in the usual sense is virtually nonexistent in our patients But, often a narrow focus (physical relief is sufficient) But, often a narrow focus (physical relief is sufficient) Focus is often on not using illicit opiates vs. developing new behaviors (“Recovery” is not using heroin) Focus is often on not using illicit opiates vs. developing new behaviors (“Recovery” is not using heroin) Patient orientation towards recovery

21. Other drug, or alcohol use may not be seen as a problem or relevant to treatment Other drug, or alcohol use may not be seen as a problem or relevant to treatment Counseling may be viewed as an unnecessary imposition Counseling may be viewed as an unnecessary imposition Patient orientation towards recovery

22. Patient orientation, counselor response Patient orientation, counselor response Impatience, confrontation, “you’re not ready for treatment” Impatience, confrontation, “you’re not ready for treatment”or, Deal with patients at their stage of acceptance and readiness Deal with patients at their stage of acceptance and readiness Motivational Interviewing approach Motivational Interviewing approach Patients not ready for treatment? Patients not ready for treatment? Or, are treatments not ready for patients? Or, are treatments not ready for patients?

23. Counseling Issues 12-Step Meetings 12-Step Meetings

24. Medication and the 12-Step program Medication and the 12-Step program Program policy Program policy “The AA Member: Medications and Other Drugs” “The AA Member: Medications and Other Drugs” NA: “The ultimate responsibility for making medical decisions rests with each individual” NA: “The ultimate responsibility for making medical decisions rests with each individual” Some meetings are more accepting of medications than others Some meetings are more accepting of medications than others On-site meetings On-site meetings 12-Step Meetings

25. Behavioral Treatments: What Works? Motivational Interviewing-(Engagement) Motivational Interviewing-(Engagement) Contingency Management-(Engagement, retention, treatment) Contingency Management-(Engagement, retention, treatment) CBT/Matrix Model-(Treatment) CBT/Matrix Model-(Treatment)

26. What works: The Matrix Model

27. Treatment Components of the Matrix Model Individual Sessions Individual Sessions Early Recovery Groups Early Recovery Groups Relapse Prevention Groups Relapse Prevention Groups Family Education Group Family Education Group 12-Step Meetings 12-Step Meetings Social Support Groups Social Support Groups Urine Testing Urine Testing

28. Matrix Program Schedule (Sample) MondayWednesday Friday Weeks 1-4 Early Recovery Skills Weeks 1-12 Family/Education Weeks 1-4 Early Recovery Skills Weeks 1-16 Relapse Prevention Weeks 13-16 Social Support Weeks 1-16 Relapse Prevention Urine and breath alcohol tests once per week, weeks 1-16 Ten Individual/Conjoint sessions during 1 st 16 weeks

29. Matrix Model in Medication-assisted Treatment Can use group topics independent of program structure Can use group topics independent of program structure Provide weekly Early Recovery Groups for the first 30 days of treatment Provide weekly Early Recovery Groups for the first 30 days of treatment Provide ongoing Relapse Prevention groups Provide ongoing Relapse Prevention groups

30. Matrix Model Groups Focus on the present Focus on the present Focus on behavior vs. feelings Focus on behavior vs. feelings Structured, topics, information, analysis of behavior Structured, topics, information, analysis of behavior Drug cessation skills and relapse prevention Drug cessation skills and relapse prevention Lifestyle change in addition to not using Lifestyle change in addition to not using

31. Matrix Model Groups  Therapist frequently pursues less motivated clients  Non-confrontational; must be safe  Goal is abstinence; relapse is tolerated

32. Matrix Model Key Component Information The Brain Premise

33. Information: Conditioning Pavlov’s Dog

34. Information: Conditioning Pavlov’s Dog

35. Triggers and Cravings DRUG

36. Conditioning Process During Addiction Social Phase Triggers Parties Special Occasions Responses Pleasant Thoughts about AOD No Physiological Response Infrequent Use Strength of Conditioned Connection Mild

37. Development of Craving Response Addiction Phase Thinking of Using Mild Physiological Response Entering Using Site  Heart Rate  Breathing Rate  Energy  Adrenaline Effects Powerful Physiological Response Use of AODs AOD Effects  Heart Rate  Breathing Rate  Energy  Adrenaline Effects Heart Blood Pressure Energy

38. Trigger Thought Craving Use Triggers & Cravings

39. Conditioning and the Brain: Message to Patients Will power, good intentions are not enough Will power, good intentions are not enough Behavior needs to change Behavior needs to change Deal with cravings: avoid triggers Deal with cravings: avoid triggers Deal with cravings: thought-stopping Deal with cravings: thought-stopping Scheduling Scheduling

40. Early Recovery Skills Group What happens in group: Introduction of new members Introduction of new members Orientation to ERS groups Orientation to ERS groups Review of topic Review of topic Each member discusses topic via handout Each member discusses topic via handout

41. Early Recovery Skills Group Topics Cravings and Scheduling Cravings and Scheduling Triggers, paraphernalia Triggers, paraphernalia Thought-stopping Thought-stopping

42. Relapse Prevention Group What happens in group: Introduction of new members Introduction of new members Review topic 30-45 minutes and discuss Review topic 30-45 minutes and discuss Discuss problems, progress, and plans for 30- 45 minutes Discuss problems, progress, and plans for 30- 45 minutes Focus on the recent past and immediate future Focus on the recent past and immediate future

43. Relapse Prevention Groups Relapse Prevention Relapse Prevention Patients need to develop new behaviors Patients need to develop new behaviors Learn to monitor signs of vulnerability to relapse Learn to monitor signs of vulnerability to relapse Recovery is more than not using heroin or other illicit opioids. Recovery is more than not using heroin or other illicit opioids. Recovery is more than not using drugs and alcohol Recovery is more than not using drugs and alcohol

44. Relapse Prevention Topics Relapse Prevention Relapse Prevention Overview of the concept; things don’t “just happen ” Overview of the concept; things don’t “just happen ” Using Behavior Using Behavior Old behaviors need to change Old behaviors need to change Re-emergence signals relapse risk (it’s a duck) Re-emergence signals relapse risk (it’s a duck) Relapse Justification Relapse Justification “Stinking thinking” “Stinking thinking” Recognize and stop Recognize and stop

45. Relapse Prevention Topics Dangerous Emotions Dangerous Emotions Loneliness, anger, deprivation Loneliness, anger, deprivation Be Smart, not Strong Be Smart, not Strong Avoid the dangerous people and places Avoid the dangerous people and places Don’t rely on will power Don’t rely on will power Avoiding Relapse Drift Avoiding Relapse Drift Identify “mooring lines” Identify “mooring lines” Monitor drift Monitor drift

46. Relapse Prevention Topics Total Abstinence Total Abstinence Other drug/alcohol use impedes recovery growth Other drug/alcohol use impedes recovery growth Development of new dependencies is possible Development of new dependencies is possible Taking Care of Business Taking Care of Business Addiction is full-time Addiction is full-time Normal responsibilities often neglected Normal responsibilities often neglected Taking Care of Yourself Taking Care of Yourself Health, grooming Health, grooming New self-image New self-image

47. Relapse Analysis Session to be done when relapse occurs after a period of sobriety Session to be done when relapse occurs after a period of sobriety Functional analysis Functional analysis Continued drug use is better addressed with Early Recovery topics Continued drug use is better addressed with Early Recovery topics Relapse should be framed as a learning experience Relapse should be framed as a learning experience

48. A Good Counseling Session Patients ultimately may need to understand why they became addicted Patients ultimately may need to understand why they became addicted More important early on: More important early on: Understanding the addiction disorder Understanding the addiction disorder Making changes in day-to-day life Making changes in day-to-day life A good session: the patients leaves knowing more about addiction and recovery A good session: the patients leaves knowing more about addiction and recovery

49. Elements of Treatment: Information, Persuasion, and Medication Information Information Matrix Model Matrix Model CBT CBT 12-Step 12-Step Persuasion Persuasion Motivational Interviewing Motivational Interviewing Confrontation Confrontation Contingency Management Contingency Management

50. What works: Contingency Management

51. Contingency Management (CM) CM: application of reinforcement contingencies to urine results or behaviors (attendance in treatment; completion of agreed upon activities). CM: application of reinforcement contingencies to urine results or behaviors (attendance in treatment; completion of agreed upon activities).

52. Engagement and Retention Strategies for engaging and retaining Strategies for engaging and retaining Warmth and empathy Warmth and empathy Flexibility Flexibility A safe environment A safe environment Motivational interviewing approach Motivational interviewing approach Contingency management Contingency management

53. Contingency Management: Overview 1.Research findings 2.Application of CM in the Matrix Institute clinics

54. Contingency Management Steve Higgins, Ph.D., 1993 Community Reinforcement Approach (CRA) Community Reinforcement Approach (CRA) Marital Therapy Marital Therapy Vocational Assistance Vocational Assistance Skills Training Skills Training New social and recreational activities New social and recreational activities Antabuse Antabuse Vouchers ($977) Vouchers ($977) Standard Treatment Standard Treatment

55. Contingency Management: Higgins et al., 1993

56. Contingency Management: Higgins et al., 1994 How much of CRA effect is CM? How much of CRA effect is CM? 24-week treatment 24-week treatment 3 times per week urines 3 times per week urines Conditions Conditions CRA only CRA only CRA plus vouchers CRA plus vouchers

57. Contingency Management: Higgins et al., 1994

58. Contingency Management It works, but… It works, but… It is too expensive. It is too expensive. It is too complex. It is too complex.

59. CM in Practice: Lower Cost Petry et al, 2000 42 alcohol dependent patients 42 alcohol dependent patients Standard treatment (12-Step, life skills, coping skills, RP, AIDS education, social-recreational); 4-week intensive Standard treatment (12-Step, life skills, coping skills, RP, AIDS education, social-recreational); 4-week intensive Standard treatment plus CM Standard treatment plus CM Target behaviors: breath alcohol test; 3 treatment goal activities Target behaviors: breath alcohol test; 3 treatment goal activities

60. CM in Practice: Lower Cost Petry et al, 2000 Drawing procedure Drawing procedure 250 slips (25%, “Sorry, try again”) 250 slips (25%, “Sorry, try again”) 169 worth $1 169 worth $1 17 worth $20 17 worth $20 1 worth $100 1 worth $100 Average cost per patient was $240 compared to $600 in the Higgins studies Average cost per patient was $240 compared to $600 in the Higgins studies

61. CM in Practice: Lower Cost Petry et al, 2000

62. CM in Practice: Still Lower Cost Petry et al, 2004 Standard treatment Standard treatment CM $80 max ($36 actually earned, $3/week) CM $80 max ($36 actually earned, $3/week) CM $240 max($68 actually earned, $5.67/week) CM $240 max($68 actually earned, $5.67/week) Cocaine-users Cocaine-users

63. CM in Practice: Still Lower Cost Petry et al, 2004 Drawing procedure—250 slips Drawing procedure—250 slips 50% “Good job” both groups 50% “Good job” both groups 109 worth $.33 or $1.00 109 worth $.33 or $1.00 15 worth $5 or $20 15 worth $5 or $20 1 worth $100 both groups 1 worth $100 both groups

64. CM in Practice: Still Lower Cost Petry et al, 2004 Results Results $80 group was not as effective as $240 $80 group was not as effective as $240 $80 did result in improvement $80 did result in improvement Only patients who gave positive urines at start were affected by the intervention Only patients who gave positive urines at start were affected by the intervention

65. 61 % were Cocaine-negative at intake

66. Other CM Examples Raffles to lower expense Raffles to lower expense Donuts, cookies, pizza Donuts, cookies, pizza Start of group goodies Start of group goodies Preferred parking Preferred parking Chips Chips Certificates or plaques for accomplishments Certificates or plaques for accomplishments Donations from local restaurants and stores Donations from local restaurants and stores

67. CM in Practice: Low Cost & Simple Matrix Institute OTP Matrix Institute OTP $5 per month for perfect group attendance $5 per month for perfect group attendance $5 per month for perfect medication attendance $5 per month for perfect medication attendance Easy to track at the expense of less potency Easy to track at the expense of less potency Less expensive than CM in research Less expensive than CM in research

68. Perfect medication attendance n=49 P<.05

69. Perfect group attendance n=49 P<.01

70. Perfect group attendance in patients missing pre-CM, n=20

71. Groups attended in patients missing pre-CM, n=20 P<.005

72. CM in Practice in an OTP Cost per patient per month Cost per patient per month Group attendance: $3.50/patient Group attendance: $3.50/patient Medication attendance: $2.50/patient Medication attendance: $2.50/patient

73. CM in an OTP: Conclusions A simple, low cost CM intervention can improve patient attendance in groups and medication visits. A simple, low cost CM intervention can improve patient attendance in groups and medication visits.

74. CM in an OTP: Modifications After a while data showed diminished effect After a while data showed diminished effect Perfection too difficult? Perfection too difficult? Miss one and the month is lost Miss one and the month is lost

75. CM in an OTP: Modifications More immediate effect; shaping: McDonald’s coupons, once per week at group, first 30 days of treatment More immediate effect; shaping: McDonald’s coupons, once per week at group, first 30 days of treatment Quarterly bonuses: Quarterly bonuses: 80% attendance = certificate and $5 80% attendance = certificate and $5 100% attendance = certificate and $10 100% attendance = certificate and $10 Attendance displayed in group Attendance displayed in group

76. Conclusions CM can be effectively used in clinical settings CM can be effectively used in clinical settings Low cost reinforcers can be effective Low cost reinforcers can be effective Simple schedules can be effective Simple schedules can be effective