The new study is one of the largest ever done to examine the merits of contingency management, a positive-reinforcement treatment method in which patients are given rewards for constructive actions taken towards their recovery, for treating addiction.
"This type of behavior research will help us understand what type of treatments and interventions, often used in conjunction with targeted specific pharmacotherapies such as methadone for opiate addiction, are effective and how they can be translated into real life," says Kreek, Patrick E. and Beatrice M. Haggerty Professor and head of the Laboratory on the Biology of Addictive Disease.
The Journal of Substance Abuse Treatment paper tells the story of a transformation within the system, says Kellogg, who is a clinical psychologist in Kreek's laboratory
"We are hoping this study, which describes the experience of using contingency management from the vantage point of each group of participants, will inspire other people to think that this is something that they might want to bring into their clinic or their treatment system," he says. "To transform the field, we need to have both numbers and the stories. Together, this is a powerful mechanism for change."
The intervention was first used in the addiction field in the mid-60s with alcoholic patients. The treatment was partially based on the behaviorist B. F. Skinner's idea of operant conditioning, which proposes that behavior is more likely to continue if it is reinforced. In the mid-70's, Maxine Stitzer, Ph.D., from Johns Hopkins University and a co-author of this paper, began to test the effectiveness of this theory and intervention method on patients addicted to drugs.
"There was a debate between the scientific and the traditional worlds of drug treatment," says Kellogg. "At first, the traditionalists were not able to take in a behavioral perspective as they saw addiction as an innate disease; therefore external circumstances should not affect an addicted person's behavior. But those ideas are changing now, and that change is part of our story."
The National Institute of Drug Addiction (NIDA) developed the Clinical Trials Network to both test and publicize various science-based addiction treatments, and the contingency management program was one of the first chosen to study. At a conference sponsored by NIDA, Kellogg, who is the scientific director for the contingency management intervention in New York, met Peter Coleman and Marylee Burns, from the Office of Behavioral Health at the HHC, who are contributing authors to the paper. Their meeting produced one of the largest adoptions ever done of contingency management, which involved five addiction clinics in New York City.
"The Health and Hospitals Corporation was already preparing to apply something similar to the contingency management approach," Kellogg says. "They were thinking of giving people rewards when they reached significant treatment benchmarks, such as holding a job for six months. Using the science of operant conditioning, we suggested to them that you could achieve a better outcome if you don't simply reward the attainment of goals, but, instead, you reinforce all of the steps along the way."
"Scott developed the concept of a modified, practical but formal contingency management intervention within a community-based treatment setting," Kreek says, "and he educated people at the HHC so they could implement it."
Contingency management is designed to reinforce small steps, especially at the beginning, like celebrating each attendance at a group meeting or each drug-free test result. Later, patients can move on to larger achievements like stable housing. Easy-to-earn material goods, such as movie passes and food vouchers, help to both initiate and maintain positive changes. The program is not thought of as a substitute for counseling or pharmacotherapy, but something that adds to the therapy.
Documentation for the study included not only collected data, but also letters from patients and videotaped interviews with staff and patients. Kellogg remembers one patient saying, "I felt like I was going down the drain with drug use, that I was going to die soon. This [intervention] got me connected, got me involved in groups and back into things. Now I'm clean and sober."
"We did have some opposition at first from the staff, people who come from different therapeutic traditions," Kellogg says. "In general, we tend to punish people for doing things that are wrong, so it's not necessarily intuitive to reinforce positive behavior when it does occur in our patients. But once the patients began to respond to the reinforcements, it changed the counselors. The counselors want the patients to get better, and when they saw the patients get better, it was really persuasive."
"I've heard several patients say 'My life has changed, I'm feeling better,'" he says. "It is so powerful to hear, so powerful to witness. I would love to see the whole treatment system adopt this intervention."
This research was supported in part by the National Institute on Drug Abuse. Joyce B. Wale from the New York Health and Hospitals Corporation also contributed to this paper.