2. Improving Outcomes in Methadone Treatment Cognitive/Behavioral Treatment Contingency Management Michael J. McCann, MA Matrix Institute on Addictions Sptember 25, 2008 September 25, 2008

3. Overview of Presentation Methadone treatment effectiveness Methadone treatment effectiveness 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. Methadone Treatment Works 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. Treatment outcomes are affected by your attitude about methadone. Treatment outcomes are affected by your attitude about methadone.

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

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. 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

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

10. Role of Psychosocial Services in Reducing Illicit Opioid Use (Adapted From McLellan et al., 1993) Minimum (Avg.= 59) (Methadone only) Standard (Avg.= 38) Enhanced (Avg.= 21) (Psychiatric, employment, family counseling)

11. Methadone Overdose Methadone deaths rose 500% between 1999 and 2005. Methadone deaths rose 500% between 1999 and 2005. Most ODs are related to the increase in prescribing methadone for pain. Most ODs are related to the increase in prescribing methadone for pain. “While deaths involving methadone increased, experiences in several states show that addiction treatment programs are not the culprits” (Westley Clark, MD, JD, MPH, director, CSAT. “While deaths involving methadone increased, experiences in several states show that addiction treatment programs are not the culprits” (Westley Clark, MD, JD, MPH, director, CSAT.

12. Counseling Opioid Dependent Patients: Some General Issues 1.Recovery and pharmacotherapy 2.Patient orientation towards recovery 3.Cognitive/Behavioral approaches

13. Counseling Issues Recovery and pharmacotherapy Recovery and pharmacotherapy

14. The Focus on “Getting off” Patients (and counselors) may have ambivalence regarding medication Patients (and counselors) may have ambivalence regarding medication 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.

15. Recovery and Pharmacotherapy Support patient’s medication-taking Support patient’s medication-taking Not this: Not this:

16. The Recovery Community may Ostracize Patients Taking Medication NA Board of Trustees Bulletin #29 Regarding Methadone and other Drug Replacement: NA Board of Trustees Bulletin #29 Regarding Methadone and other Drug Replacement: “Members on drug replacement programs such as methadone are encouraged to attend NA meetings.” “Members on drug replacement programs such as methadone are encouraged to attend NA meetings.” “It is a common practice for NA groups to encourage these members (or any other addict who is still using), to participate only by listening.” “It is a common practice for NA groups to encourage these members (or any other addict who is still using), to participate only by listening.” Note: Not all meetings take this approach Note: Not all meetings take this approach However, this reflects a common attitude. However, this reflects a common attitude.

17. Naltrexone Sample Attrition Is “getting off” realistic?

18. Naltrexone and Overdose Miotto and McCann, 1997 13 of 81 Ss overdosed in a 12-month period 13 of 81 Ss overdosed in a 12-month period 4 were fatal; 9 nonfatal 4 were fatal; 9 nonfatal Texas patients….. Texas patients…..

19. “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

20. “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

21. Counseling Issues Patient orientation towards recovery Patient orientation towards recovery

22. “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

23. 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

24. 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?

25. What works: The Matrix Model Generally delivered in a 16-week, non- medication-assisted treatment Generally delivered in a 16-week, non- medication-assisted treatment Can be adapted for medication-assisted treatment Can be adapted for medication-assisted treatment

26. 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

27. 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

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

29. Matrix Model Key Component Information The Brain Premise

30. Information: Conditioning Pavlov’s Dog

31. Information: Conditioning Pavlov’s Dog

32. 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

33. 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

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

35. 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

36. 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

37. 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

38. 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

39. 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

40. 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

41. What works: Contingency Management

42. 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).

43. Terms Rewards vs reinforcement Rewards vs reinforcement Bribe vs reinforcement Bribe vs reinforcement

44. Contingency Management: Overview 1.Research findings 2.Application of CM in NTPs

45. Contingency Management Steve Higgins, Ph.D., 1994 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 CRA plus Vouchers ($977) CRA plus Vouchers ($977) 3 visits per week; 24 weeks 3 visits per week; 24 weeks

46. Contingency Management: Higgins et al., 1994

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

48. CM in Practice: Lower Cost Petry et al, 2000 Drawing procedure Drawing procedure One draw for each negative One draw for each negative breath alcohol test 5 negative tests in a week= 5 bonus draws 5 negative tests in a week= 5 bonus draws One draw for completion of treatment goal activity One draw for completion of treatment goal activity 3 activities in a week= 5 bonus draws 3 activities in a week= 5 bonus draws

49. CM in Practice: Low 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

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

51. CM in the “Real World”

52. CM Training in NYC Health and Hospital Addiction Treatment Service Scott Kellogg et al., in the Journal of Substance Abuse Treatment, 2005 Scott Kellogg et al., in the Journal of Substance Abuse Treatment, 2005 Through the NIDA Clinical Trials Network, 5 clinics (4 NTPs) were trained in CM principles Through the NIDA Clinical Trials Network, 5 clinics (4 NTPs) were trained in CM principles

53. Core Principles of CM Give reinforcement frequently Give reinforcement frequently Easy to earn initially (set the bar low) Easy to earn initially (set the bar low) Reinforcers should be items of use and value to patients Reinforcers should be items of use and value to patients Reinforcement should be connected to specific, observable behavior Reinforcement should be connected to specific, observable behavior Minimize delay in reinforcement delivery; greater delay, weaker effect Minimize delay in reinforcement delivery; greater delay, weaker effect Focus on small steps; any improvement Focus on small steps; any improvement

54. CM Training in NYC: Program 1 Piece of candy and a raffle ticket for each group Piece of candy and a raffle ticket for each group Raffle for “metro card” at the end of group Raffle for “metro card” at the end of group Or, save raffle tickets for a raffle with a bigger prize Or, save raffle tickets for a raffle with a bigger prize

55. CM Training in NYC: Program 2 Token for attending a vocational group Token for attending a vocational group 4 groups = $25 gift certificate 4 groups = $25 gift certificate 8 groups = $25 gift certificate 8 groups = $25 gift certificate 5 drug-free urines = McDonald’s coupons 5 drug-free urines = McDonald’s coupons

56. CM Training in NYC: Program 3 Points are earned for each group attended Points are earned for each group attended Points are entered in a computer Points are entered in a computer Patients can log in and see total points earned every day Patients can log in and see total points earned every day Patients can see what they can earn for different point levels Patients can see what they can earn for different point levels Points can be redeemed at any time Points can be redeemed at any time

57. CM Training in NYC: Program 4 Target was attendance at vocational or GED class Target was attendance at vocational or GED class Each class attended earned $5 in an account Each class attended earned $5 in an account After five classes, patients receive $25 gift certificate After five classes, patients receive $25 gift certificate

58. Reinforcement Examples Donuts, cookies, pizza Donuts, cookies, pizza Start of group goodies Start of group goodies Calendars, date books, books Calendars, date books, books Tools, clothes, toiletries Tools, clothes, toiletries Water bottles Water bottles Sunglasses Sunglasses

59. Reinforcement Examples 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

60. 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

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

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

63. Conclusions CM can be effectively used in clinical settings CM can be effectively used in clinical settings CM can be a powerful tool to assist counselors in helping patients achieve treatment goals CM can be a powerful tool to assist counselors in helping patients achieve treatment goals Low cost reinforcers can be effective Low cost reinforcers can be effective Simple schedules can be effective Simple schedules can be effective