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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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