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 Dependence Higgins 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
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
Cocaine abstinence
Group attendance
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. Mean weeks of continuous cocaine and opioid abstinence
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