We'll get at least most of this part in. Okay, let's see what other questions like the breakdown of showing how substances affect the dopamine receptors. The reason why we have to use more and more drugs, um, has become apparent to that person. Oh, just contingency management. Oh, so increased tolerance, does it apply to contingency management? That's a fair question. Well, it makes a whole lot of sense, Larry, because when we, when we take a substance, that is contingency management right there. When we take a substance, it makes us feel good. We want to take more. It makes us feel good. And there's a reward in our brain. And that's the really important tie to why contingency management is helpful to counteract the need to want to have to take, as you can imagine, especially a stimulant is stimulating all parts of our brain. Yeah, great thing. Great thoughts. People have here. We've talked a lot about how the brain responds to dopamine and what increases, um, this, the brain in the brain at different times and stigma. It's still very hard to get some people to understand how addiction really does affect the brain. Um, and so a lot of the work to combat stigma has focused on, uh, you know, talking about substance use disorders and addiction as, um, persistent and reoccurring health conditions that have their origins in our brain and in our human biology. Um, so yeah, it is hard to get folks to understand that. Do we need greater reward with case management or with a contingency management over time? Like, do you have to keep increasing the reward amount, Amy? Yeah. That's why when you see the types of contingency management programs, there's escalating and we'll get into that when I cover the slides too, but really good, uh, connection again, Larry, that, yeah, if you keep giving someone, you know, a $2 gift card or a $5 gift card to the gas station or wherever they, it's just not gonna, it's going to lose its luster for a while. So escalating, escalating incentives is more powerful for sure. Someone else said that this covered this information has been covered in some trainings that they've had before. It's important to understand how substances affect the brain and how having another reward system to replace those effects is important. And then Rhonda says she uses this concept with clients to help them understand why they demonstrate these behaviors, um, and the things that they do to help with self-loathing, right? Self-loathing, shame, um, embarrassment, humiliation are all, um, emotions that our clients are really used to feeling and helping folks understand what's going on in their brain and body and why they are acting the way they are, because it is also baffling to them, um, can really help people understand what's happening and maybe lift some of that self-blame and self-loathing off their shoulders. Something's happening, happening biologically. Yeah. That's it from the chat. Yeah. Thanks, Sherry. I appreciate it. Thanks folks for offering up your comments and your questions, um, helps me understand where you are and what you're thinking about as well. So I realized we have about 20 some odd minutes left, so I'm going to go through my slides again, but please, uh, consider questions as we go along, Sherry, we'll keep a watch on those. And if we don't have time to answer them today, we have our follow-up sessions as well. So even when you leave today and you start to think about, hmm, how would this work? How does this work? How can this work in the work that I do? Um, that's what we will talk about when we meet again. So considering contingency management, you know, it, it's, um, often considered, and I, I used to train this 20 years ago and I would talk about motivational incentives in, as synonymous to contingency management. And I'm going to start to separate those two out. Contingency management works because it's an evidence-based program. Offering incentives for someone to go to a 12-step support group or go to their doctor's appointment or, um, some, uh, getting a certificate for completing a group, um, is a type of reward, um, but it's not based on the science. There's a lot of things to follow when it comes to the science of contingency management. Uh, the green box, it can be delivered by any provider. That's true. And SAMHSA has an advi- in their advisory adds that it has to be implemented by a program that's licensed, people that are licensed. And the reason for that is because it's a treatment modality. So this comes up a lot in conversation about case management and peer recovery specialists that they shouldn't be delivering contingency management. That's part, partly true. And what's powerful is that the whole team could be involved in helping, but the actual delivery and the documentation of contingency management is done by the counselor of record or the clinician of record. It is brief. As you saw in the polling question, you can do contingency management in a short 12 weeks to help people engage in the recovery process in, in a treatment program, um, to help keep them engaged in higher levels of care, like intensive outpatient or partial hospitalization. It can be low cost depending on what method you use, lower cost, um, and it can be combined with what you're already doing. And you know, the big thing for me is it is fun. Boy, we do some heavy lifting and we do a lot of heavy work with folks that are struggling and it, and it can feel tough and a heavy load. Contingency management can make treatment fun. And I've seen it. I have stories to tell, but I don't want to start them now lest I get through my slides. So there's lots of stories and I bet you have some too. So we'd love to hear your stories about what you think. So I have some slides on the research that I know was covered in some of the healthy knowledge courses. So here's one that compares using contingency management with folks who use stimulants. So you'll see those blue boxes. Those are higher numbers of folks who had negative urine drug tests as a result compared with the non-contingent control group. Here's a couple pieces related to alcohol use and legal problems compared with people who are getting contingency management. Look at that bar graph. So people who are using alcohol reduced significantly by 62% using contingency management. And you can see that the other bar shows negative cocaine tox screens at six months and also did a cross comparison of when they weren't using cocaine, they also reduced their number of legal problems. So you see some ripple effect there. One thing that surprised me when I first started learning about the research, when Dr. Petrie was starting to study the fishbowl method, she would target, for example, stimulant use. She wouldn't target other drugs necessarily, and only the drugs that the person had a problem with. So if someone tested positive, for example, for using marijuana, they would still get the incentive for the negative cocaine use. What Drs. Petrie and others have done is you could use a bonus incentive if they don't use other substances that they've been using. There's no sense in spending a whole lot of money on the 12-panel substances. If you use a 12-panel drug screen and give them an incentive for all of those, you'd lose a lot of your money and it wouldn't be effective because the folks aren't using those other substances. So there's just a little insert there about implementation that you can target one substance of use and not all of them, and definitely can target a bonus for another substance use if they're agreeing. Again, I'm going to underscore that again, the person has to agree to this. If a person does not want to stop using, let's say marijuana, for example, we're not going to use contingency management to get them to stop using marijuana. It's not effective when we do it that way. I put my motivational interviewing hat on and say, it's not effective when we force people to do something they don't want to do anyway. They typically will go back to it or, yeah, do something opposite what we want them to do. Any comments or questions yet in the chat, folks? Nothing in the chat yet, Amy. All right. And then here's an example of smoking cessation with contingency management. And you'll see that the comparison was cognitive behavioral therapy and nicotine replacement compared with that and contingency management. So those darker bars show the significant reduction in smoking with contingency management as well. It also shows the synergy of the different types of treatment. Look at end of treatment, pretty big effect size. 50% of the folks were doing much better when they added contingency management over the long haul. So we talked about what CM is in the definition in the chat or in the polling question. And just putting it simply, it's a behavioral therapy where individuals are reinforced or rewarded for exhibiting a behavior change. And again, that behavior change is done in collaboration with them and the clinical team, the clinical person. We talked briefly about negative reinforcement that you'll see with the green symbol. It's to avoid things like fines or going to jail, societal sanctions, or any kind of conflict or displeasure. Um, we don't really focus on that when we're doing contingency management, we focus on more of the positive things, the smaller things that the steps that people take to change that behavior. It helps in the short term versus waiting for someone to become abstinent if that's their goal or if that's our goal with them together, or if your program is an abstinence-based program, that would be ineffective if we waited until they achieved that final outcome when it comes to contingency management. Is somebody coming off of mute to have a question? Hello? Hello? Okay. There we go. All right. No question. All right. Keep them coming if you have a question. Write them in the chat. So here's the core elements, or I refer to them sometimes as the seven principles. We do have a reference sheet where we have the core elements listed, the seven principles listed, where you can check and use that as a checks and balance in your implementation. So I start on the top right, the behavior, excuse me, the behavior of focus, and the common behaviors of focus in contingency management programs are attendance to treatment, attendance to sessions, or substance use, not using. So those are the two common ones. I think in my, well, I know in my experience where folks can misunderstand contingency management is wanting to target a lot of different behaviors and want to target them all at once, and it diminishes the results, and it's not backed by evidence to do that. So for example, some people want to target them completing other treatment goals, and contingency management can help with that. What I'm telling you, though, is that there's not specific science that says if you target all these things, that will work. I've noticed when people try to focus too many behaviors, as you can imagine, if you have five different behaviors that we're targeting to change and you get lost in the shuffle of it. Sorry, I have a tickle in my throat. A population of focus, I'm going to give you an example with this one. When I was overseeing a methadone clinic, for example, we had out of about 450 people, 60 people that were not participating in the clinical care. They were just coming for the medicine and they were leaving. So we were trying to invite them to participate in contingency management, so we just targeted that group of people, people that weren't showing up for their clinical care. So we used contingency management for that small group of folks. And again, back to the point of they have to be part of it and collaborate, we had a sheet that told them what contingency management was, they agreed or not to be a part of it, and 10 out of 60 people decided they didn't want to be a part of it. So we did not include them in the contingency management program. So we had 50 folks, they signed the agreement understanding what contingency management was, and then the clinician knew to write that in their treatment intervention, in their treatment plan, and off they went as part of the program. Larry, very important pieces that you brought up in the chat. The type and the value of the incentive is very important, it depends on the socioeconomic status of the folks that you're serving, what they want, what they find enticing, how often you reinforce them, do you give them a reinforcement every time, and then the timing. The timing is very important, it has to be done as close to the behavior as possible. So what we do know is that if you target attendance, for example, in intensive outpatient, which typically is three group sessions a week, right, in many programs, if you wait until the end of the week, three is that magic number. If you go beyond three, it seems to lose its effectiveness, so that timing and frequency is really important. What I like about vouchers and the prize-based model of contingency management is you can reinforce the behavior every time it happens by virtue of them pulling from the fishbowl or earning a voucher that they then later cash in. So you're not always giving the tangible good in real time, they may cash it in. So Dr. Petrie's group in Connecticut, for example, folks would pull from the fishbowl and cash in their ticket from the fishbowl on Friday, because they had a fishbowl Friday group. We talked about the duration of reinforcement, we certainly know that the behavior can drift back when the incentives are taken away. So more science needs to be done on that, but 12 to 24 weeks is the number so far that research has focused on, not beyond that 24-week program. Amy, just a time check, we got about 10 minutes left and I need to save two minutes for the evaluation. Great, thank you for that. All right, so here's some summary of the principles that it has to be provided consistently. When it's inconsistent, it starts to get ineffective. When the behavior is not demonstrated, it's withheld. We don't take incentives away once they're earned, but if the person is targeting, let's say abstinence and they test positive, they just don't get the incentive that time. They don't get kicked out of the program, they don't get kicked out of contingency management, they just get withheld. Or Larry, as you mentioned, if we escalate and we're escalating and let's say a person earned five vouchers because they've been consistently negative five times and they use or they test positive, they just start back at one the next time. So the incentive is withheld and it starts back in it. When you think about the video, it makes very good sense that we have to, we're not just shaping behavior over time, we're helping to reshape that brain. Okay. And if it's inconsistent, the brain gets a little confused about that. These are the two on the right that are mostly used. We didn't talk much about this, but already we know there's some privileges and other reinforcements that happen within programs. You probably can share in the chat what types of reinforcements you're familiar with that are happening already within clinical privileges. For example, I shared take-home doses and methadone is a privilege, is a clinic privilege. Voucher-based is what SAMHSA will endorse, not cash. They're not condoning the use of cash, but fake money, if you will. I didn't say I'm in Pittsburgh, but I'm in Pittsburgh, Pennsylvania, and we have a maternal program here where moms earned baby bucks when they did certain things. So, voucher-based. And then prize incentives are typically around that fishbowl model where you pull from the fishbowl and it offers you a specific prize, a small, medium, or a jumbo prize. So, those are the types of contingency management programs. So, when you start to think about, when I went through it very quickly, those seven principles, this is how it's put into play. You pick that particular population or group of folks. Maybe in your program, you would pick folks who are using stimulants. In other programs, I've seen them target pregnant women who are smoking. So, it has to be a behavior that you're able to measure, you're able to see it, and then also be able to provide that immediate reward. And as Larry asked earlier, the size of the reinforcement escalates each time. So, I'll give you an example. With a fishbowl, the prize-based, a person gets one pull from the fishbowl if they test negative. They get two the second time they test. They get three the third time. So, there's that escalation. And it resets back to one if the person tests positive. Okay. So, there's that escalation and how to navigate that, and of course, that withholding when they use test positive. So, here are some examples. I mentioned one already. The methadone clinic, we targeted attendance. They got points for their attendance. The staff identified that those points were worth $1. So, they had points that they collected. So, it's a modified type of voucher-based program. The outpatient, an outpatient clinic targeted attendance in intensive outpatient and offered bus tickets to and from the clinic and other incentives at the end of their three days of care. So, there's so many different ways that you could do this. And people think about residential programs. Residential programs have a lot of privileges internally, privilege-based contingency management. And, you know, you can target attendance to groups or activities on the unit, things of that nature. So, those are some examples. And you may have some that you'd want to share as well. Well, this one could take us to the end. So, I'm not going to say too much about what people say, but the clients were like, wow, I can't believe that people were, you know, noticing what I did do instead of what I didn't do and focusing on the positives. The clinical staff were collaborating together. I could tell you a story from our methadone clinic where the support staff were involved in keeping the prize cabinets stocked and helped us with the inventory. And they felt finally involved in the care and the treatment. Administrators found that the folks were having fun. I love the story in the methadone clinic where the dad wanted to win the jumbo prize, which was a small TV and the other clients were rooting him on. They weren't competing with him. They wanted him to succeed and they helped him get to the clinic by driving him, by ride-sharing, things of that nature. So, there's where the fun and the positiveness comes in when you start to hear those stories. So, we have a lot that could go wrong and that's based on the seven principles. And instead of me going through this slide, and I know Sherry will share the slides with you, we also have the list of the seven, the seven principles, the seven guidelines around contingency management. And it identifies some specifications like this that says, huh, if the, if it feels like it's not working, it's usually because some of these things are happening. And we certainly know that there are concerns. There's cultural concerns where people think it's not fair. It's not fair to give some, use it for some and not others. There's financial concerns. How do we handle this? The time, the money, where's the money coming from? Who tracks it? How are you going to navigate that? How are you going to help people have the protected time to do it? And the logistical pieces around giving it good time to implement, making sure the staff understand the policies and the procedures and the documentation expectations. And I already mentioned the philosophical things. Does it, do people feel like they, you know, what are their concerns about it? Do they think it's tricking people? We have implemented contingency management across the board when folks are still wondering and concerned. Amy, we have a question in the chat, but we only have three minutes left and we need to save at least that for the evaluation. Would you like to finish out the slides now or answer the question? Let me go ahead and answer the question because I think we're almost done with what I need to share at this point anyway. I think so. Okay. What happens outcome when they are done with treatment and no rewards are being given to them for doing what they're supposed to be doing anyway as adults? Ah, well, there's that philosophical issue. And that's a great question that comes up a lot. So it's like we, what we typically do with folks in care, connect them to contingencies in their life. Their relationships get better. Perhaps they have found a friend group, maybe in 12-step recovery or in other means where folks have built up contingencies in their community. So should do, well, you know, that's our judgment, what people should or shouldn't be doing. Recovery is a journey for everyone and everyone has their own struggles. So tying that into contingencies in their community and in their home life. Thank you, Amy. I also want to share just a personal quick story. I use Weight Watchers and Weight Watchers consistently uses contingency management. I lost weight, contingency management helped me do that. I kept the weight off because I learned everything I needed to do to stay within my weight range. So just as a personal story of someone who has used contingency management, it kept me going to the meetings. It kept me connecting with people there. And I didn't need it when I left to keep eating the way I knew I needed to eat. So I don't know, that's just a really quick personal story I thought I'd share about how contingency management has impacted me. I want to thank Amy Shanahan for sharing her expertise with us here today. And I want to thank you all for your attention and participation today. Thank you. You've helped make this presentation interactive and a little bit fun. So thank you for that. Please, if you have not already, use your camera phone or the link that I dropped into the chat to complete our evaluation survey. This is how we are judged. This is how we are funded. And I'd really be grateful to everybody if you all could take the time to complete our survey evaluation. Thank you guys so much. I'll send it out to you after the fact. We will see you all again here in what, about a month, couple weeks? When are we meeting again? Oh, let me find my event alert I pulled up. Do I have it? Oh, I don't have a date here. Who can tell me the date? There it is. Hold on. I'm sorry, guys. I had this up earlier, but I'm shifting screens. So our second session is set for Tuesday, March the 25th from 10 to 11. And we will look forward to seeing you all there again on that date and time. Thank you so much for coming today and we'll see you soon. Thanks, everybody. Thanks, Sherry. Bring your questions and your stories when you come. That'd be great. Yeah, questions and stories. Thanks, guys. Have a great rest of your day. Bye-bye.

contingency management

addiction treatment

dopamine receptors

incentives

voucher-based systems

substance use disorders