Keeping It Positive: Bringing Contingency Management To New York City

1. Keeping It Positive:Bringing Contingency ManagementTo New York City Scott Kellogg, PhD New York University/ New York Node

2. What Is Contingency Management?

3. B. F. Skinner, PhD 3

4. Contingency Management • Developed out of Skinner’s Operant Conditioning model • Typically involves the use of positive reinforcements to change behavior • First applied to problems with alcoholism in the late 1960’s • Used in the treatment of drug addiction beginning in the early 1970’s • One of the first protocols that were considered for adoption by the NIDA Clinical Trials Network

5. Contingency Management • In addiction treatment centers, CM has been primarily used to: • Reduce or eliminate drug use • Increase group attendance • Facilitate compliance with medical treatment • Reinforce treatment goal attainment

6. The Early Days of the CTN http://images-eu.amazon.com/images/P/B0002PC31M.02.LZZZZZZZ.jpg

7. CTN Site Map – 20006 Nodes

8. New York Node • The New York Node joined the Clinical Trials Network in 2000 • During the following months • There would be at least two conflictual Steering Committee meetings • Then the CM protocol was accepted

9. Moving Forward • The protocol then went into its development stage where it was renamed ….

11. Maxine Stitzer, PhD

12. Nancy Petry, PhD

13. MIEDAR Protocol Overview Materials

15. Sample Collection Twice Weekly

19. Patient Patient Patient Earns Provides Clean Provides More Incentive Urine Clean Urines How Motivational Incentives Could Work For You

20. How do we expect this to benefit clients and counselors? • Better outcomes for your clients • More time to do what you like to do and what you do best in therapy sessions

21. New York Node Team • John Rotrosen, MD – New York Node Principle Investigator • Scott Kellogg, PhD – New York Node MIEDAR Principle Investigator • Marion Schwartz, CSW – Project Director • Agatha Kulaga, MSW – Research Assistant • Caroline Woo – Research Assistant

22. New York MIEDAR Clinics

23. New York • Two methadone maintenance programs joined the study: • Lower Eastside Service Center • Under the leadership of Joe Krasnansky, CSW • Greenwich House MMTP • Under the leadership of Lolita Silva-Vasquez, CSW

24. Up and Running • By late 2001, the protocol was up and running in New York • The Node then turned its attention to the creation of the second Blending Conference • Which was scheduled for March, 2002

25. Meanwhile…

27. New York City Health and Hospitals Corporation • The largest provider of addiction treatment in the United States • Runs methadone programs in five major hospitals • Bellevue Hospital • Kings County Hospital • Elmhurst Hospital • Lincoln Hospital • Metropolitan Hospital

28. Mayor Rudolph Giuliani http://www.umich.edu/~ac213/student_projects07/global/rudygiuliani.jpg

29. Giuliani Orders 5 City Hospitals To Wean Addicts Off Methadone By RACHEL L. SWARNS Published: August 15, 1998, New York Times

30. Mayor Rudy Giuliani – Summer 1998 • Mayor Giuliani shocked the world of methadone treatment • Voiced his concern that methadone patients were not being empowered to find employment • Proposed a plan in which opiate-addicted individuals would only be able to get three-months of treatment • At City-run methadone facilities

31. Mayor Rudy Giuliani and Methadone • Eventually backed down • But gave the HHC methadone programs a mandate to get their patients employed • Funneled additional funds to these programs for Vocational Training

32. Vocational Training http://www.alaskacoinexchange.com/Stamps%2034/04c%20Apprenticeship.jpg 32

33. Vocational Training at the HHC • HHC developed high quality Vocational Centers in each of the methadone clinics • Patients would not engage with the services that were being offered

34. Vocational Training at the HHC • To increase participation, • The HHC Leadership began considering using a reward program • Patients would receive gift certificates and other desirable items if they met goals like: • Getting a GED • Finishing a phase of Vocational Training

36. New York City HHC Meets NIDA CTN • At the New York Blending Conference • There was a panel on the MIEDAR protocol • Maxine Stitzer, PhD • Joe Krasnansky, CSW, (LESC) • Scott Kellogg, PhD • Marion Schwartz, CSW • Each spoke about different aspects of the MIEDAR protocol

37. New York City HHC Meets NIDA CTN • Marylee Burns, MEd, MA, CRC from the HHC was in the audience • Recognized both the importance and relevance of what we were doing • An alliance was formed to bring CM to the HHC addiction treatment programs

38. The HHC Addiction Treatment Leadership Team • Joyce Wale, CSW • Senior Assistant Vice President, New York City Health and Hospitals Corporation, Office of Behavioral Health • Peter Coleman, MS, CASAC • Director, Office of Behavioral Health • Marylee Burns, MEd, MA, CRC • Assistant Director, Office of Behavioral Health

39. Forming the Alliance • Met with this HHC leadership team to learn what they were trying to do • Worked closely with Marylee Burns to refine the Vocational Incentives that they were beginning to implement • We eventually visited six clinics or hospitals and presented the CM model • Each site then developed its own plan for implementing CM with its patients • They primarily reinforced group attendance

40. Reward vs Reinforcement • This issue was at the heart of the HHC project • Probably a central issue in all CM dissemination efforts

41. Reward vs Reinforcement • When you speak to staff or leadership about the use of reinforcements • They almost universally talk about reinforcing patients for things like: • Holding a job for six months • Being drug-free for 3 months • Completing a GED or vocational training program

42. Reward Programs • This is what I call a Reward Program • Acknowledging patients for achieving a goal or accomplishing something noteworthy • Most likely give rewards to the best and most motivated patients • While often not changing the behavior of those patients who are struggling the most with drug use and treatment compliance

43. Reinforcement Programs • Reinforcement Program • Breaks down each of the goals into very small steps • Reinforces each of the steps along the way • Makes it easy to earn a reinforcement • Distributes reinforcements with fairly high frequency

44. Reinforcement Programs • Move from “You have done a good job” to • “You have taken a step in the right direction” • This was the most important change in their program that we made • It was the difference that made the HHC Project successful

45. CTN Results

46. Using Low-Magnitude Reinforcements…

47. o o o o o o o o o o o o o o o o o o o o o o o * * * * * * * * * * * * * * * * * * * * * * * o * 1 3 5 7 9 1 1 1 3 1 METHADONE: PERCENT STIMULANT NEGATIVE URINES 1 0 0 Incentive Control 8 0 6 0 Percent of Submitted Urines Testing Negative 4 0 2 0 OR = 1.98 CI = 1.45 - 2.65 0 5 1 7 1 9 2 1 2 3 Study Visit 47

48. PSYCHOSOCIAL STUDY RETENTION 100 o o 100 Incentive 80 80 Control o o o o o o o o o 60 60 o Percent Retained o o Percent Submitting At Least One Sample o o o o o o o o 40 40 o o 20 OR = 1.6; CI = 1.2 - 2.0 20 0 0 2 4 6 8 10 12 2 4 6 8 10 12 48 Study Week

49. CTN Methamphetamine Sub-Study (Matrix Clinics; n = 113) Roll et al., 2006 in Roll & Newton, 2008

50. Insights from the HHC Experience