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Overcoming addiction, step by step
'Contingency management' study rekindles interest
in a deceptively low-tech treatment for heroin users
BY KRISTINE KELLY
Before Rockefeller’s Scott Kellogg got
involved, many of the clinics that treat New York City’s
200,000 heroin addicts were struggling to come up with better ways
to motivate their patients.
Methadone, a drug developed at Rockefeller in
the 1960s, helps eliminate the need for heroin, but for many
it’s only one part of their recovery process. Though the
clinics rely on methadone to counter the biology of addiction,
sometimes they need something more.
“For years, there has been just such a
system, one that, like methadone, has been scientifically tested
and documented over a period of decades,” says Kellogg, who
is a clinical psychologist and research associate in Mary Jeanne Kreek’s
Laboratory of the Biology of Addiction. “It just hadn’t
ever been widely adopted by clinics.”
It’s known as contingency management,
and it works by giving patients a series of immediate rewards to
encourage small steps towards recovery. Now a new study, one of the
largest ever done to examine the role of motivational incentives in
drug users, has convinced many in New York’s clinics that
contingency management works.
Contingency management, or, as it is
increasingly called, motivational incentives, was first used in the
1960s, and is based on the work of behaviorist B. F.
Skinner’s idea of operant conditioning, which proposes that
behavior is more likely to continue if it is reinforced. At its
core, the contingency management approach to drug addiction is
based on the idea that people use drugs because they are
reinforcing — they provide pleasure. The way to counter this
and to help people recover is to provide reinforcements for not
using drugs.
In the mid 1970s, Maxine Stitzer from Johns
Hopkins University began to test its effectiveness on patients
addicted to drugs. “Dr. Stitzer started to look at drug
addictions, methadone patients in particular, to see if she could
make changes in their behavior,” says Kellogg. “She
consistently worked throughout the late 1970s and 1980s, doing this
research and publishing papers; this was basically ignored by the
mainstream addiction treatment field.”
The history of contingency management
underlines a basic rift in addiction treatment between the
scientists and the treatment specialists. Addiction, said the
specialists, is a disease and, as such, would be unresponsive to
external conditions.
But study after study, published by Stitzer
and others, argued that this was not the case. Addicts could change
their behavior if given the right incentive or set of incentives.
The National Institute of Drug Abuse (NIDA) saw that contingency
management, as well as other science-based addiction treatments,
were being under-utilized. In response, they developed the Clinical
Trials Network to both test and publicize the various treatment
approaches.
In 2002, Kellogg, who is scientific director
for the NIDA contingency management intervention in New York,
joined with the New York City Health and Hospitals Corporation to
launch contingency management programs in seven city addiction
clinics, one of the largest contingency management adoptions ever
attempted.
“Scott developed the concept of a modified,
practical but formal contingency management intervention within a
community-based treatment setting,” says Kreek, the Patrick E.
and Beatrice M. Haggerty Professor, “and he educated people at
the HHC so they could implement it.”
“Clinics, including New York’s,
have experimented with rewards systems over the years, but they
have tended to focus on long-term rewards — giving out prizes
only to those who achieve major milestones which may take weeks or
months of consistent effort to reach,” says Kellogg.
“But that sets the bar too high and runs the risk of
rewarding only the best patients, when it’s the struggling
patients that need the most motivation.”
Kellogg suggested to them that they could
achieve a better outcome if they didn’t simply reward the
attainment of goals, but, instead, reinforced each of the steps
along the way.
Those steps include celebrating each
attendance at a group meeting or each drug-free test result. Later,
larger achievements like stable housing are rewarded. The prizes
are easy-to-earn material goods, such as movie passes and food
vouchers; and they help to both initiate and maintain positive
changes. It is the reinforcement of the small steps that is the key
for tapping into the power of the approach, especially with
patients who have not been doing well in treatment. The program is
not a substitute for counseling or pharmacotherapy, but it serves
to keep the patients motivated and reaffirm the benefits they make
in treatment.
Kellogg’s study, published in the
January issue of The Journal of
Substance Abuse Treatment, is based on
clinical data and progress reports submitted by each of the seven
clinics involved, as well as staff interviews and patient
testimonials. The paper shows that combining contingency management
with other treatments increases patient motivation to stay in
treatment and enhances their therapeutic progress. In addition, the
staff and administrators observed increased attendance at group and
individual counseling sessions, more drug-free tests, higher levels
of employment-related activities, better school attendance, and a
markedly improved treatment atmosphere.
It was not always a smooth collaboration. Many
staff were at first hesitant to even try contingency management
treatment. Eventually, however, most changed their minds, spurred
on by the sight of positive and, in some cases, dramatic changes in
their patients.
“I remember one patient saying ‘I
felt like I was going down the drain with drug use, that I was
going to die soon. And this got me connected, got me involved in
groups and back into things. Now I’m clean and
sober,’” says Kellogg. “It is so powerful to
hear, so powerful to witness. I would love to see the whole
treatment system adopt this intervention.”
Thanks in large part to Kellogg’s work,
the use of contingency management has already been extended to
several additional treatment centers and plans are in the works for
further expansion in New York City and beyond.
May 13, 2005
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