International Journal of the Addictions
ISSN: 0020-773X (Print) (Online) Journal homepage: http://www.tandfonline.com/loi/isum19
Contingency Management in a Methadone Maintenance Program: Availability of Reinforcers Maxine Stitzer & George Bigelow To cite this article: Maxine Stitzer & George Bigelow (1978) Contingency Management in a Methadone Maintenance Program: Availability of Reinforcers, International Journal of the Addictions, 13:5, 737-746, DOI: 10.3109/10826087809039299 To link to this article: http://dx.doi.org/10.3109/10826087809039299
Published online: 03 Jul 2009.
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The International Journal of the Addictions, 13(5), 737-746, 1978
Contingency Management in a Methadone Maintenance Program: Availability of Reinforcers Maxine Stitzer," Ph.D. George Bigelow, Ph.D. Department of Psychiatry Baltimore City Hospitals; and Department of Psychiatry and Behavioral Sciences The Johns Hopkins University School of Medicine Baltimore, Maryland 2 I224
Abstract
A survey was conducted t o identify clinic privileges that might serve as reinforcers for a group of methadone maintenance clients. Fifty-three clients ranked nine clinic privileges according to their desirability. The opportunity to take medication home from the clinic on 4 days of the week was ranked as most desirable, on the average, followed by receiving cash payments *To whom requests for reprints should be addressed at Department of Psychiatry, Baltimore City Hospitals, Baltimore, Maryland 21224. 7 37
Copyright @ 1978 by Marcel Dekker, Inc. All Rights Reserved. Neither this work nor any part may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, microfilming, and recording, or by any information storage and retrieval system, without permission in writing from the publisher.
STITZER AND BIGELOW
73x
Downloaded by [RMIT University Library] at 20:50 01 April 2016
(630 and $10) and the opportunity for limited dosage self-control. Medication take-home privileges appear to be the most potent potential reinforcer available in the context of a methadone clinic. Contingency management therapy, which operates by scheduling positive reinforcement as a consequence to desirable behaviors, has been used with a variety of populations in the treatment of disorders of selfcontrol, such as smoking (Elliot and Tighe, 1968), overeating (Mann, 1972), and alcoholism (Miller, 1972). These techniques may be useful as well for promoting improved behaviors in narcotics-dependent clients enrolled in a methadone maintenance program. The availability of suitable reinforcers could be a limiting factor in the use of contingency management techniques. However, a variety of potential reinforcers are available in the context of the operation of a methadone clinic including medication take-home privileges, methadone dose increases, detoxification from methadone, removal of split-dose schedules, prescriptions for other drugs, letters to probation officers, monetary
Table 1 Client Characteristics
% of clients (N Male Female Race: White Black Marital status: Married Single Divorced or separated Employment : Full-time Part-time Unemployed
a
53)
79.2 20.8 75.5 24.5 37.7 45.3 17 54.7 3.8 41.5
Sex:
Age (years) Education (years) Length of addiction (years) Known time in any methadone maintenance treatment (months)
=
Median 26 12 7 27
Range 20-42 6-1 8 2-25 0-121"
Five respondents to the survey were new admissions to methadone maintenance.
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139
payments, and alterations of urinalysis and counseling attendance requirements. There is little systematic information, however, about which of these privileges could be effectively utilized as reinforcers in contingency management procedures with a population of methadone maintenance clients. Yen (1974) recently surveyed a group of 25 methadone maintenance clients, asking them to rank-order the desirability of several program privileges in order to identify privileges which might serve as reinforcers. Medication take-home days were ranked as most desirable, followed by a decrease in number of urinalysis tests, and recommendations for shortening length of probation. Items such as holding a monthly party and taking a “field trip” were ranked much lower. These results should be expanded and replicated in other programs to be meaningful. We have conducted a questionnaire survey which was similar to the one used by Yen (1974) in that it assessed the potential reinforcing value of several privileges which can be offered to clients in a methadone maintenance program.
METHODS Subjects
Fifty-three clients, the entire enrollment of this methadone maintenance treatment-research program, completed questionnaires. Table 1 presents characteristics of the surveyed clients who were primarily drawn from a White working class community in Southeast Baltimore. Questionnaire
The questionnaire was designed to assess relative desirability of program privileges which might be used as incentives in contingency management procedures. A nine-item “reinforcement menu” was presented, as shown in Table 2, which included most privilleges which could reasonably be offered in a methadone maintenance clinic. Clients were asked to rank-order these privileges according to their relative desirability. Reliability of rank-orderings of the menu items was assessed in a separate question which asked clients to assign a monetary value to medication take-home privileges. The question asked, “If the program would pay you to give up all your take-home days, how much would you sell them for?”
STITZER AND BIGELOW
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Table 2 Items Included in the Reinforcer Menu Chance to give fewer urines Chance to play pool in the TEP rec room No requirements for counseling Receiving $10.00 per week from the program Having maximum number of take-home days (4) Chance to serve as client representative to the drug program Chance to select your own methadone dose occasionally Receiving $30.00 per week from the program Monthly TEP party
Another series of questions were designed to assess the desirability of an option for limited dosage self-control. Clients were asked: (1) “If you had a chance to change your dose (up or down) for a single duy, would you do i t ? ” (yes or no); ( 2 ) “If yes, would you increase/decrease your dose?”; (3) “By how much (mg)‘?”;(4) “If you had a chance to change your dose (up or down) for a single day several times, about how often do you think you would do it?” (every day, every other day, twice a week, once a week, every other week, once a month, less often). The full questionnaire also included items concerning symptomatology and methadone dosage adequacy, the results of which are reported separately (Stitzer and Bigelow. 1976). Procedures
All questionnaires were completed during an eight-day period in May 1975. Clients received the forms from counselors or other staff members, who explained the questionnaire and who remained available to answer any questions.
R ESU LTS Relative Desirability of Program Privileges
Figure 1 shows the average ranks assigned by clients to the program privileges presented in the reinforcer menu. Maximum number of takehome days (4 days) received the highest rank (2.2). There were only nine clients (17y0) who gave take-home days a rank of 4 or lower, and eight of these clients currently had 3 or more take-home days, suggesting that they
CONTINGENCY MANAGEMENT
MAXIMUM TAKE -HOMES
5 30 PER WEEK
-
~'
741
AVERAGE RANK
2.2 3.0
S 10 PER WEEK
J
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t, 2 c
SELF SELECT DOSE
7
L
FEWER URINES
6
REPRESENTATIVE
Ly
NO COUNSELING
PLAY POOL
MONTHLY PARTY
PERCENT OF CLIENTS RANKING ITEM 1 , 2 0 R 3
Fig. 1. Nine items on a reinforcer menu were rank-ordered by 53 methadone maintenance clients (see Table 1 for complete questionnaire items). A rank of 1 indicated the item was most desirable, while a rank of 9 indicated the item was least desirable. Percent of clients who ranked each item in the three most desirable categories are shown, as well as the average rank order for each item.
may have interpreted the question differently from other clients who did not already receive substantial take-home privileges. Receiving $30 per week from the program was the next most desirable privilege, followed by receiving $10 per week and the opportunity for limited dosage selfcontrol. Playing pool in the recreation room and holding a monthly party received the lowest average ranks. Monetary Value of Medication Take-Home Days
Table 3 shows the monetary value (sell-price) placed on take-home days by clients who were currently receiving any take-home privileges.
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142
Table 3 Monetary Value of Medication Take-Home Days for a Group of Methadone Maintenance Clients
% of clients responding
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Sell price per take-home day (S) 0-5.00 5.01-10.00 10.01-15.00 15.01-20.00 20.01-25.00 25.01-30.00 95.00-100.00 Would not sell
(N
=
38)
10.5 15.8 13.2 5.3 1.9 2.6 5.3 39.5
The high desirability of take-home days is indicated by the fact that 44.7",, of the clients who had any take-home days said they would not sell at any price or asked an absurdly high price (over $95.00 per day). The median sell-price for the clients who said they were willing to sell was $12.50 per day. Since most of these clients received 2 to 4 take-home days (with a total subjective value between $25 and $SO), this is in line with data from the reinforcer menu where 62'!, of all clients ranked take-home days as more desirable than receiving $30 per week from the program. Thus there was substantial internal consistency in patients' valuations of take-home privileges. Limited Dosage Self-Control as a Reinforcer
The opportunity for single-day dosage self-control was ranked fourth, on the average, by our clients, with money and maximum number of takehomes ranked higher. Nevertheless. 667" of the clients answered in the affirmative when asked whether they would like to have the option of changing their dose for a single day, and 38% gave limited dosage selfcontrol a rank of 1, 2, or 3 on the reinforcer menu. Not surprisingly, 94", of those who said they would like to change their dose indicated they would opt for an increase rather than a decrease. Table 4 shows the distribution of client choices for the size of a dose increase. Median size of the suggested dose increase was 20 mg. Table 5 shows the distribution of client choices for the frequency of exercising the dosage self-control option. About 5004 of client choices were for the twice-per-week, once-
CONTINGENCY MANAGEMENT
143
Table 4 Size of Dose Increases Selected for the Limited Dosage Self-Control Option
% of clients
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Size of dose increase (mg)
(N = 31)
0-10 11-20 2 1 4 41-60 61-80 81-100
25.8 29.0 16.0 19.4 6.5 3.2
per-week, and every-other-week options, while the every-day option was chosen by 22.6% of clients. The every-day dose increase option is equivalent to a permanent dose increase. Presumably, clients who picked this frequency would exercise the limited dosage self-control option if it were offered less frequently than every day.
DISCUSSION The results of the reinforcer menu survey generally correspond very well with those obtained by Yen (1974), when 25 methadone maintenance clients ranked the desirability of nine program privileges. As in the present study, Yen’s clients ranked the opportunity to “take methadone home occasionally” as most desirable (average rank was 1.24), while “use of recreational facilities in the center,” “serve as representative to the drug program,” and “monthly party” were ranked much lower (average ranks of 5.32, 5.76 and 6.08, respectively). Table 5 Frequencies Selected for Exercising the Dosage Self- Control Option
% of clients Frequency of dose change
(N = 31)
Every day Every other day Twice per week Once per week Every other week Once per month Less often
22.6 6.5 16.1 19.3 16.1 9.1 9.1
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On the basis of questionnaire surveys, methadone take-home privileges appear to be the most powerful reinforcer that can be offered to methadone maintenance clients. However, the efficacy of a reinforcer can only be validated by its effect upon behavior when offered in a contingent arrangement. Although Baldridge et al. (1974) report using methadone take-home privileges as a reward for clients who are employed, free of supplementary drugs and maintaining a high level of participation in the program, there has been only one systematic behavioral demonstration that the take-home privilege can serve as a reinforcer for a group of methadone maintenance clients. Stitzer et al. (1976) showed that attendance rates at weekly counseling sessions were higher when weekend takehome privileges were delivered contingent upon counseling attendance than when take-home privileges were delivered noncontingently. The extent to which contingent take-home privileges can be effectively used to influence a broader range of clients’ behavior remains to be determined. The opportunity for limited dosage self-control is a privilege which is not generally utilized in methadone maintenance clinics. The reinforcer menu survey indicates that limited dosage self-control may not generally be as potent a reinforcer as the medication take-home privilege. However, a majority of clients indicated that they would like the opportunity to increase their dose occasionally, and therefore this opportunity might serve as a powerful reinforcer for some clients. There is some reason to believe that limited dosage self-control would be a safe procedure (Goldstein et al., 1974), but its efficacy as a reinforcer has yet to be demonstrated behaviorally. Although contingency management techniques have been effectively applied in many disorders of self-control, they are only beginning to be utilized in the treatment of substance abuse other than alcoholism. Boudin (1974) has designed a model program to achieve and maintain abstinence in a population of drug-abusing clients, but there has been little systematic application of contingency management techniques with methadone maintenance clients. Bigelow et al. (1974) have described a methadone maintenance program utilizing contingent reinforcement procedures and presented case studies suggesting the efficacy of the procedures. Liebson et al. (1973) have demonstrated the efficacy of contingency management in treating alcoholism among methadone patients, and Stitzer et al. (1976) have demonstrated the efficacy of contingent methadone take-home privileges in enhancing counseling attendance. Thus the use of contingency management techniques in methadone maintenance programs would seem to be expedient and worthwhile since program privileges
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which are available in the context of a methadone maintenance clinic can serve as potent incentives to influence client behaviors in a positive direction. Contingencies involving program privileges could be focused on clinic behavior and compliance with clinic rules such as medication pick-up, giving of urine samples, and counseling attendance. Alternatively, contingency management could focus on specific problem areas of individual clients in the areas of employment, illicit drug use, or social adjustment. The selection of specific goals to be pursued might differ in different clinics, and should be based on the needs and goals of specific programs, their clients, and the communities they serve. Whatever the focus of contingencies, staff training and supervision in the use of contingency management techniques would be important to achieve the consistent and appropriate delivery of rewards which are so essential to the success of these procedures. If contingency management procedures utilizing methadone program privileges as reinforcers prove to be effective in altering a variety of client behaviors, this could be a fruitful new adjunct to treatment of this drug-abusing population. ACKNOWLEDGMENTS
Special thanks are extended to the entire staff of the Treatment Evaluation Project and of the Southeast Baltimore Drug Abuse Program for their many contributions to this study. Financial support was provided by contract No. HSM 42-73-217 from the National Institute on Drug Abuse. REFERENCES BALDRIDGE, P., McCORMACK, M . , THOMPSON, L., ZARROW, A . , and PRIMM, B.J. Providing incentives to successful methadone patients-Experimental program. N . Y. Srate J . Med. 74: 111- 114, 1974. BIGELOW, G., HARRIS, A,, LAWRENCE, C., and D’LUGOFF, B. Contingency Management and Behavior Therapy in a Methadone Maintenance Program. Presented at the meeting of the American Psychological Association, New Orleans, September 1974. BOUDIN, H . Contingency Contracting with Heroin Addicts in the Natural Environment. Presented at the meeting of the American Psychological Association, New Orleans, September 1974. ELLIOT, R., and TIGHE, T. Breaking the cigarette habit: Effects of a technique involving threatened loss of money. Psychol. Rec. 18: 503-513, 1968. GOLDSTEIN, A,, HANSTEEN, R.W., HORNS, W.H., and RADE, M. Control of methadone dosage by patients. In Proceedings of the 1st National Drug Abuse Conference. New York: NAPAN, 1974
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LIEBSON. I . , BIGELOW, G., and FLAMER, R. Aicoholism among methadone patients: A specific treatment method. A m . J . PsJ,chiutry 130: 483-485, 1973. MANN, R.A. The behavior-therapeutic use of contingency contracting to control an adult behavior problem: Weight control. J . Appl. Behar. A n d . 5 : 99- 109. 1972. M1LLER.P. The use of behavioral contracting in the treatment of alcoholism: A case report. Behai.. Tlzer. 3: 593-596, 1972. STITZEK. M.. and BIGELOW, G . Stabhzation on methadone: Symptomatology and discriminability of methadone dose alterations. In Proceedings u / rhe Commirter on Problems qfDnrg Dependence. National Academy of Sciences, Washington, D.C., 1976. pp. 1000-1002. STITZER, M . , BIGELOW, G . . LAWRENCE, C., COHEN. J . , D’LUGOFF, B., and HAWTHORNE, J. Medication take-home as a reinforcer in a methadone maintenance program. Addict. Behac. In press. YEN. S . Akailability of activity reinforcers in a drug abuse clinic: A preliminary report. Psl.c~hol.Rep. 34: 1021-1022, 1974.
ISSN: 0020-773X (Print) (Online) Journal homepage: http://www.tandfonline.com/loi/isum19
Contingency Management in a Methadone Maintenance Program: Availability of Reinforcers Maxine Stitzer & George Bigelow To cite this article: Maxine Stitzer & George Bigelow (1978) Contingency Management in a Methadone Maintenance Program: Availability of Reinforcers, International Journal of the Addictions, 13:5, 737-746, DOI: 10.3109/10826087809039299 To link to this article: http://dx.doi.org/10.3109/10826087809039299
Published online: 03 Jul 2009.
Submit your article to this journal
Article views: 8
View related articles
Citing articles: 7 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=isum19 Download by: [RMIT University Library]
Date: 01 April 2016, At: 20:50
Downloaded by [RMIT University Library] at 20:50 01 April 2016
The International Journal of the Addictions, 13(5), 737-746, 1978
Contingency Management in a Methadone Maintenance Program: Availability of Reinforcers Maxine Stitzer," Ph.D. George Bigelow, Ph.D. Department of Psychiatry Baltimore City Hospitals; and Department of Psychiatry and Behavioral Sciences The Johns Hopkins University School of Medicine Baltimore, Maryland 2 I224
Abstract
A survey was conducted t o identify clinic privileges that might serve as reinforcers for a group of methadone maintenance clients. Fifty-three clients ranked nine clinic privileges according to their desirability. The opportunity to take medication home from the clinic on 4 days of the week was ranked as most desirable, on the average, followed by receiving cash payments *To whom requests for reprints should be addressed at Department of Psychiatry, Baltimore City Hospitals, Baltimore, Maryland 21224. 7 37
Copyright @ 1978 by Marcel Dekker, Inc. All Rights Reserved. Neither this work nor any part may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, microfilming, and recording, or by any information storage and retrieval system, without permission in writing from the publisher.
STITZER AND BIGELOW
73x
Downloaded by [RMIT University Library] at 20:50 01 April 2016
(630 and $10) and the opportunity for limited dosage self-control. Medication take-home privileges appear to be the most potent potential reinforcer available in the context of a methadone clinic. Contingency management therapy, which operates by scheduling positive reinforcement as a consequence to desirable behaviors, has been used with a variety of populations in the treatment of disorders of selfcontrol, such as smoking (Elliot and Tighe, 1968), overeating (Mann, 1972), and alcoholism (Miller, 1972). These techniques may be useful as well for promoting improved behaviors in narcotics-dependent clients enrolled in a methadone maintenance program. The availability of suitable reinforcers could be a limiting factor in the use of contingency management techniques. However, a variety of potential reinforcers are available in the context of the operation of a methadone clinic including medication take-home privileges, methadone dose increases, detoxification from methadone, removal of split-dose schedules, prescriptions for other drugs, letters to probation officers, monetary
Table 1 Client Characteristics
% of clients (N Male Female Race: White Black Marital status: Married Single Divorced or separated Employment : Full-time Part-time Unemployed
a
53)
79.2 20.8 75.5 24.5 37.7 45.3 17 54.7 3.8 41.5
Sex:
Age (years) Education (years) Length of addiction (years) Known time in any methadone maintenance treatment (months)
=
Median 26 12 7 27
Range 20-42 6-1 8 2-25 0-121"
Five respondents to the survey were new admissions to methadone maintenance.
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CONTINGENCY MANAGEMENT
139
payments, and alterations of urinalysis and counseling attendance requirements. There is little systematic information, however, about which of these privileges could be effectively utilized as reinforcers in contingency management procedures with a population of methadone maintenance clients. Yen (1974) recently surveyed a group of 25 methadone maintenance clients, asking them to rank-order the desirability of several program privileges in order to identify privileges which might serve as reinforcers. Medication take-home days were ranked as most desirable, followed by a decrease in number of urinalysis tests, and recommendations for shortening length of probation. Items such as holding a monthly party and taking a “field trip” were ranked much lower. These results should be expanded and replicated in other programs to be meaningful. We have conducted a questionnaire survey which was similar to the one used by Yen (1974) in that it assessed the potential reinforcing value of several privileges which can be offered to clients in a methadone maintenance program.
METHODS Subjects
Fifty-three clients, the entire enrollment of this methadone maintenance treatment-research program, completed questionnaires. Table 1 presents characteristics of the surveyed clients who were primarily drawn from a White working class community in Southeast Baltimore. Questionnaire
The questionnaire was designed to assess relative desirability of program privileges which might be used as incentives in contingency management procedures. A nine-item “reinforcement menu” was presented, as shown in Table 2, which included most privilleges which could reasonably be offered in a methadone maintenance clinic. Clients were asked to rank-order these privileges according to their relative desirability. Reliability of rank-orderings of the menu items was assessed in a separate question which asked clients to assign a monetary value to medication take-home privileges. The question asked, “If the program would pay you to give up all your take-home days, how much would you sell them for?”
STITZER AND BIGELOW
740
Downloaded by [RMIT University Library] at 20:50 01 April 2016
Table 2 Items Included in the Reinforcer Menu Chance to give fewer urines Chance to play pool in the TEP rec room No requirements for counseling Receiving $10.00 per week from the program Having maximum number of take-home days (4) Chance to serve as client representative to the drug program Chance to select your own methadone dose occasionally Receiving $30.00 per week from the program Monthly TEP party
Another series of questions were designed to assess the desirability of an option for limited dosage self-control. Clients were asked: (1) “If you had a chance to change your dose (up or down) for a single duy, would you do i t ? ” (yes or no); ( 2 ) “If yes, would you increase/decrease your dose?”; (3) “By how much (mg)‘?”;(4) “If you had a chance to change your dose (up or down) for a single day several times, about how often do you think you would do it?” (every day, every other day, twice a week, once a week, every other week, once a month, less often). The full questionnaire also included items concerning symptomatology and methadone dosage adequacy, the results of which are reported separately (Stitzer and Bigelow. 1976). Procedures
All questionnaires were completed during an eight-day period in May 1975. Clients received the forms from counselors or other staff members, who explained the questionnaire and who remained available to answer any questions.
R ESU LTS Relative Desirability of Program Privileges
Figure 1 shows the average ranks assigned by clients to the program privileges presented in the reinforcer menu. Maximum number of takehome days (4 days) received the highest rank (2.2). There were only nine clients (17y0) who gave take-home days a rank of 4 or lower, and eight of these clients currently had 3 or more take-home days, suggesting that they
CONTINGENCY MANAGEMENT
MAXIMUM TAKE -HOMES
5 30 PER WEEK
-
~'
741
AVERAGE RANK
2.2 3.0
S 10 PER WEEK
J
Downloaded by [RMIT University Library] at 20:50 01 April 2016
t, 2 c
SELF SELECT DOSE
7
L
FEWER URINES
6
REPRESENTATIVE
Ly
NO COUNSELING
PLAY POOL
MONTHLY PARTY
PERCENT OF CLIENTS RANKING ITEM 1 , 2 0 R 3
Fig. 1. Nine items on a reinforcer menu were rank-ordered by 53 methadone maintenance clients (see Table 1 for complete questionnaire items). A rank of 1 indicated the item was most desirable, while a rank of 9 indicated the item was least desirable. Percent of clients who ranked each item in the three most desirable categories are shown, as well as the average rank order for each item.
may have interpreted the question differently from other clients who did not already receive substantial take-home privileges. Receiving $30 per week from the program was the next most desirable privilege, followed by receiving $10 per week and the opportunity for limited dosage selfcontrol. Playing pool in the recreation room and holding a monthly party received the lowest average ranks. Monetary Value of Medication Take-Home Days
Table 3 shows the monetary value (sell-price) placed on take-home days by clients who were currently receiving any take-home privileges.
STITZER AND BIGELOW
142
Table 3 Monetary Value of Medication Take-Home Days for a Group of Methadone Maintenance Clients
% of clients responding
Downloaded by [RMIT University Library] at 20:50 01 April 2016
Sell price per take-home day (S) 0-5.00 5.01-10.00 10.01-15.00 15.01-20.00 20.01-25.00 25.01-30.00 95.00-100.00 Would not sell
(N
=
38)
10.5 15.8 13.2 5.3 1.9 2.6 5.3 39.5
The high desirability of take-home days is indicated by the fact that 44.7",, of the clients who had any take-home days said they would not sell at any price or asked an absurdly high price (over $95.00 per day). The median sell-price for the clients who said they were willing to sell was $12.50 per day. Since most of these clients received 2 to 4 take-home days (with a total subjective value between $25 and $SO), this is in line with data from the reinforcer menu where 62'!, of all clients ranked take-home days as more desirable than receiving $30 per week from the program. Thus there was substantial internal consistency in patients' valuations of take-home privileges. Limited Dosage Self-Control as a Reinforcer
The opportunity for single-day dosage self-control was ranked fourth, on the average, by our clients, with money and maximum number of takehomes ranked higher. Nevertheless. 667" of the clients answered in the affirmative when asked whether they would like to have the option of changing their dose for a single day, and 38% gave limited dosage selfcontrol a rank of 1, 2, or 3 on the reinforcer menu. Not surprisingly, 94", of those who said they would like to change their dose indicated they would opt for an increase rather than a decrease. Table 4 shows the distribution of client choices for the size of a dose increase. Median size of the suggested dose increase was 20 mg. Table 5 shows the distribution of client choices for the frequency of exercising the dosage self-control option. About 5004 of client choices were for the twice-per-week, once-
CONTINGENCY MANAGEMENT
143
Table 4 Size of Dose Increases Selected for the Limited Dosage Self-Control Option
% of clients
Downloaded by [RMIT University Library] at 20:50 01 April 2016
Size of dose increase (mg)
(N = 31)
0-10 11-20 2 1 4 41-60 61-80 81-100
25.8 29.0 16.0 19.4 6.5 3.2
per-week, and every-other-week options, while the every-day option was chosen by 22.6% of clients. The every-day dose increase option is equivalent to a permanent dose increase. Presumably, clients who picked this frequency would exercise the limited dosage self-control option if it were offered less frequently than every day.
DISCUSSION The results of the reinforcer menu survey generally correspond very well with those obtained by Yen (1974), when 25 methadone maintenance clients ranked the desirability of nine program privileges. As in the present study, Yen’s clients ranked the opportunity to “take methadone home occasionally” as most desirable (average rank was 1.24), while “use of recreational facilities in the center,” “serve as representative to the drug program,” and “monthly party” were ranked much lower (average ranks of 5.32, 5.76 and 6.08, respectively). Table 5 Frequencies Selected for Exercising the Dosage Self- Control Option
% of clients Frequency of dose change
(N = 31)
Every day Every other day Twice per week Once per week Every other week Once per month Less often
22.6 6.5 16.1 19.3 16.1 9.1 9.1
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On the basis of questionnaire surveys, methadone take-home privileges appear to be the most powerful reinforcer that can be offered to methadone maintenance clients. However, the efficacy of a reinforcer can only be validated by its effect upon behavior when offered in a contingent arrangement. Although Baldridge et al. (1974) report using methadone take-home privileges as a reward for clients who are employed, free of supplementary drugs and maintaining a high level of participation in the program, there has been only one systematic behavioral demonstration that the take-home privilege can serve as a reinforcer for a group of methadone maintenance clients. Stitzer et al. (1976) showed that attendance rates at weekly counseling sessions were higher when weekend takehome privileges were delivered contingent upon counseling attendance than when take-home privileges were delivered noncontingently. The extent to which contingent take-home privileges can be effectively used to influence a broader range of clients’ behavior remains to be determined. The opportunity for limited dosage self-control is a privilege which is not generally utilized in methadone maintenance clinics. The reinforcer menu survey indicates that limited dosage self-control may not generally be as potent a reinforcer as the medication take-home privilege. However, a majority of clients indicated that they would like the opportunity to increase their dose occasionally, and therefore this opportunity might serve as a powerful reinforcer for some clients. There is some reason to believe that limited dosage self-control would be a safe procedure (Goldstein et al., 1974), but its efficacy as a reinforcer has yet to be demonstrated behaviorally. Although contingency management techniques have been effectively applied in many disorders of self-control, they are only beginning to be utilized in the treatment of substance abuse other than alcoholism. Boudin (1974) has designed a model program to achieve and maintain abstinence in a population of drug-abusing clients, but there has been little systematic application of contingency management techniques with methadone maintenance clients. Bigelow et al. (1974) have described a methadone maintenance program utilizing contingent reinforcement procedures and presented case studies suggesting the efficacy of the procedures. Liebson et al. (1973) have demonstrated the efficacy of contingency management in treating alcoholism among methadone patients, and Stitzer et al. (1976) have demonstrated the efficacy of contingent methadone take-home privileges in enhancing counseling attendance. Thus the use of contingency management techniques in methadone maintenance programs would seem to be expedient and worthwhile since program privileges
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which are available in the context of a methadone maintenance clinic can serve as potent incentives to influence client behaviors in a positive direction. Contingencies involving program privileges could be focused on clinic behavior and compliance with clinic rules such as medication pick-up, giving of urine samples, and counseling attendance. Alternatively, contingency management could focus on specific problem areas of individual clients in the areas of employment, illicit drug use, or social adjustment. The selection of specific goals to be pursued might differ in different clinics, and should be based on the needs and goals of specific programs, their clients, and the communities they serve. Whatever the focus of contingencies, staff training and supervision in the use of contingency management techniques would be important to achieve the consistent and appropriate delivery of rewards which are so essential to the success of these procedures. If contingency management procedures utilizing methadone program privileges as reinforcers prove to be effective in altering a variety of client behaviors, this could be a fruitful new adjunct to treatment of this drug-abusing population. ACKNOWLEDGMENTS
Special thanks are extended to the entire staff of the Treatment Evaluation Project and of the Southeast Baltimore Drug Abuse Program for their many contributions to this study. Financial support was provided by contract No. HSM 42-73-217 from the National Institute on Drug Abuse. REFERENCES BALDRIDGE, P., McCORMACK, M . , THOMPSON, L., ZARROW, A . , and PRIMM, B.J. Providing incentives to successful methadone patients-Experimental program. N . Y. Srate J . Med. 74: 111- 114, 1974. BIGELOW, G., HARRIS, A,, LAWRENCE, C., and D’LUGOFF, B. Contingency Management and Behavior Therapy in a Methadone Maintenance Program. Presented at the meeting of the American Psychological Association, New Orleans, September 1974. BOUDIN, H . Contingency Contracting with Heroin Addicts in the Natural Environment. Presented at the meeting of the American Psychological Association, New Orleans, September 1974. ELLIOT, R., and TIGHE, T. Breaking the cigarette habit: Effects of a technique involving threatened loss of money. Psychol. Rec. 18: 503-513, 1968. GOLDSTEIN, A,, HANSTEEN, R.W., HORNS, W.H., and RADE, M. Control of methadone dosage by patients. In Proceedings of the 1st National Drug Abuse Conference. New York: NAPAN, 1974
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LIEBSON. I . , BIGELOW, G., and FLAMER, R. Aicoholism among methadone patients: A specific treatment method. A m . J . PsJ,chiutry 130: 483-485, 1973. MANN, R.A. The behavior-therapeutic use of contingency contracting to control an adult behavior problem: Weight control. J . Appl. Behar. A n d . 5 : 99- 109. 1972. M1LLER.P. The use of behavioral contracting in the treatment of alcoholism: A case report. Behai.. Tlzer. 3: 593-596, 1972. STITZEK. M.. and BIGELOW, G . Stabhzation on methadone: Symptomatology and discriminability of methadone dose alterations. In Proceedings u / rhe Commirter on Problems qfDnrg Dependence. National Academy of Sciences, Washington, D.C., 1976. pp. 1000-1002. STITZER, M . , BIGELOW, G . . LAWRENCE, C., COHEN. J . , D’LUGOFF, B., and HAWTHORNE, J. Medication take-home as a reinforcer in a methadone maintenance program. Addict. Behac. In press. YEN. S . Akailability of activity reinforcers in a drug abuse clinic: A preliminary report. Psl.c~hol.Rep. 34: 1021-1022, 1974.
