Peter Coleman, M.S., CASAC Marylee Burns, M.Ed., M.A., CRC Scott Kellogg, Ph.D.

1. CONTINGENCY MANAGEMENT APPROACH: IMPLEMENTATION AND OUTCOMES Peter Coleman, M.S., CASAC Marylee Burns, M.Ed., M.A., CRC Scott Kellogg, Ph.D.

2. Workshop Outline • Overview of NYC Health and Hospitals and the Foundations of Change • The Latest Research on Contingency Management • The HHC Experience: Implementation and Outcomes

3. Overview of NYC Health and Hospitals Corporation and the Foundations of Change

4. Largest municipal health care provider in United States Provides services to 1.3 million NYC residents Offers full array of health, mental health, and chemical dependency services 8 Inpatient Detox Units 8 Methadone Treatment Programs 19 Outpatient Chemical Dependency Programs 2 Halfway Houses 4 Hospital Intervention Programs, and Case Management Program NYC Health and Hospitals Corporation (HHC)

5. Contingency ManagementWhy Should We Change Anything? We’ve been providing drug treatment for years and our patients do fine!

6. Addiction is a major public health issue – providing effective treatment a major challenge • It is estimated that only 20% of those addicted to opiates are engaged in treatment. • 50% of non-funded MTP programs in NYS report that fewer than 54% of those entering treatment are retained for more than 1 year. • 50% of non-funded MTP programs in NYS report that less than 32% of patients discharged have discontinued use of heroin.

7. Addiction May be Considered a Medical Condition, but… • It is often viewed as a moral weakness that is self inflicted and best dealt with through the criminal justice system. • While it is a chronic disorder, it is often treated as an acute condition with expectations of immediate resolution. • Patients are often stigmatized by society, medical providers and treatment program staff, and by family, friends and peers.

8. External Pressures for Change • Increased focus on program accountability, measurement of progress and clinical outcomes • Welfare reform and related financial ramifications • Demand for individualized treatment, respectful of patient rights • CSAT program accreditation requirements

9. The Truth About Change • Change typically requires a systems approach • Change is not easy and is a long-term process • Change requires a vision and commitment on behalf of the entire organization • Change involves trial and error as well as ongoing evaluation • Change requires strong leadership, but it is best accomplished when done with input and participation of patients and staff

10. 1998 OASAS Vocational Initiative 1999 mayoral scrutiny of methadone treatment 2000 OASAS/HRA Vocational Initiative 2001 New CSAT regulations for opioid treatment Desire to incorporate self sufficiency and employment as major treatment goals Conscious decision to improve quality of care, patient satisfaction, and treatment outcomes Foundations of Change at HHC

11. Initial Actions: Vocational Rehab staff added and Career Centers established MTP Workgroup established Practice Guidelines and Manuals developed Reporting mechanisms put in place Initial Results: Nature of clinics changed but culture didn’t Treatment approach had punitive feel Patients did not respond and retention declined Staff disenchanted Improvements unsustained Initial Actions and Results

12. Workgroups expanded and continued to meet Administrative support increased Staff polled regarding attitudes and needs Patient satisfaction surveys undertaken Training Initiatives: “Thinking Outside the Box” Transtheoretical Model of Behavioral Change Project Invest Management Training: “Successfully Supervising People” Reinvigorating the Process

13. Moving in the Right Direction:- Leadership invigorated- Staff attitudes improved- Treatment began to shift away from punitive policies- Improved therapeutic environment But patient outcomes, particularly in relation to self sufficiency and employment, had still not improved to desired levels

14. Patient Motivation and Recognition Initiative • Based on research which supported use of tokens to encourage and motivate patients towards treatment goals • Used recognition of patient achievements as mechanism for improving self image and peer support • Focused on advancement in treatment and attainment of goals as well as vocational issues

15. Specific, measurable objective benchmarks Description of motivational supports Description of patient recognition activities Timeline for implementation and integration Mechanism for staff training and patient education Proposed methods for supplemental and ongoing support Method of tracking outcomes and accounting for supports Programs were required to submit a plan that included:

16. 9 programs responded and were ultimately awarded an average of $12,900 each plus a supply of Metrocards and gift certificates Contingency Management was on it’s way!

17. Science Meets Practice • As an outgrowth of a Contingency Management Panel (Kellogg and Stitzer) presented at the NIDA Blending Conference held in New York in March, 2002 • As a direct result of the Blending Conference, a collaboration developed between Ms. Marylee Burns and Mr. Peter Coleman of the Office of Behavioral Health of the New York City Health and Hospitals Corporation (HHC), and Scott Kellogg, PhD of The Rockefeller University and the CTN.

18. The Collaboration • Staff were provided with papers by Drs. Stitzer, Petry, and Higgins • Dr. Kellogg presented research on contingency management to Substance Abuse Directors Meeting • Ms. Burns and Dr. Kellogg went to participating programs to meet with staff, speak about the research, and critique the initial efforts to develop Contingency Management components within the programs

19. Where are we in 2004? • 8 of the original 9 programs (6 MTPs and 2 O/P) were allocated additional funds which averaged $19,166 • 5 additional O/P programs were allocated funds which averaged $10,000 • Additional training resources were provided • Day-long Contingency Management Conference: Science in the Trenches

20. Successful implementation of Contingency Management at HHC reflects the sum of the various parts

21. Commitment of the system to long term process for treatment improvement Availability of initial funding and potential for additional funds The adoption of science for the clinical paradigm and framework Leadership direction and oversight Setting the Stage:Factors In Success

22. Teamwork between program leadership and line staff which empowered staff and encouraged creativity • Patient participation, recognition, enthusiasm and empowerment • Therapeutic environment which focused on positives and moved from sanctions to rewards • Individualization of care; particularly the matching of patient treatment needs to motivations

23. Ongoing process of review, revision and improvement • Integration of contingency management into overall structure of treatment approach • Staff training initiatives • Networking and collaborating with NIDA CTN affiliated researchers

24. Research on Contingency Management Approaches in Substance Abuse Settings

25. Contingency Management • An approach that has been in use since the late 1970’s • Developed by Dr. Maxine Stitzer at Johns Hopkins University • Further developed by Dr. Stephen Higgins at the University of Vermont, by Dr. Nancy Petry at the University of Connecticut, and by Dr. Ken Silverman at Johns Hopkins University • Based on the work of B. F. Skinner • Behavior is determined by its consequences • Reinforcement -- Increases the likelihood of a behavior occurring • Punishment -- Decreases the likelihood of a behavior occurring

26. THE FANTASY Patients Recognize that they have a Problem They Know they Need Help with that Problem They come to treatment ready for change

27. REALITY CHECK……. What REALLY makes patients come to treatment?

28. Negative Consequences of Drug Use Treatment

29. External Negative Consequences Family Members Employers Parole/Probation Child Protective Services

30. Personal Negative Consequences Many Patients Come to Treatment Because BAD Things are Happening, Others are Angry with Them, They are Tired and Depressed, They have run out of money, They Want Life to Change BUT……...

31. Drugs are Positive Reinforcers They Make People Feel Good.

32. Abstinence Continued Use Drug Abusers Straddle the Fence

33. Behavioral Results of Ambivalence Some patients stop using Some patients continue to use drugs during treatment Some patients drop out of treatment early

34. Methodsare needed to: Continued Drug Use Drug Abstinence - counteract ambivalence- increase motivation for change

35. What are Motivational Incentives and How Can They Help

36. Motivational Incentives In Everyday Life • Child rearing • Praise and discipline • Education • Grades/honors and detention/suspension • Business organizations • Bonuses; promotions and sanctions/demotions • Criminal justice • Arrest/incarceration and early release

37. Examples of Rewards Vouchers and Gift Certificates Attention, Pat on the Back Prizes and Gifts Privileges Services

38. Examples of Punishers • Fines • Tickets • Restrictions • Sanctions • Displeasure

39. It is the CONTINGENCY that matters………. BEHAVIOR REWARD • Giving things away for free • does NOT change behavior • The closer in time, the more • powerful the reinforcement

40. Punishments • Do not teach what to do; only what not to do • Promote harsh and demeaning atmosphere • May also do harm (e.g. promote aggression) • Are necessary under limited circumstances

41. Rewards • Teach new behaviors and promote growth • Promote positive atmosphere & communication • Promote self-esteem and self-confidence • Sustainable over time

42. Rewards versus Punishments Which is used more frequently?

43. Punishments!

44. Application to Drug Abuse:Intervention Targets • Improved Therapy Attendance • Decreased Drug Use • Treatment Plan Goal Attainment

45. Common Naturally Occurring Rewards and Punishers In Drug Abuse Treatment PositiveNegative - take-homes - time restriction - award ceremonies - missed services - certificates; key chains - probation - status/recognition - dismissal

46. Motivational Incentives Research • Clients earn vouchers for drug-free urines • usually cocaine-free urines • Vouchers are worth money • Vouchers are exchanged for • retail items (e.g. clothing, sports equipment) • services (e.g. rent; bill payments)

47. Research on Motivational Incentives Cocaine abusers in drug-free treatment Cocaine abusers in methadone treatment

48. Treatment of Cocaine Dependence in a Drug-Free ClinicHiggins et al., 1994 Incentive Treatment Community Reinforcement Approach Therapy Urine testing 2x/week Vouchers Control Treatment Community Reinforcement Approach Therapy Urine testing 2x/week No vouchers $10 Can earn over $1000 Actual earnings: 600

49. Treatment of Cocaine Dependence Retained Through 6 month Study Higgins et al., 1994

50. One-year Follow-up Results • 60% of incentive group were cocaine abstinent • While 45% of the control group were abstinent • During-treatment abstinence predicts long-term abstinence