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Contingency Management
in
Substance Misuse Services
Andy Moore
Locality Director
What is it ?
• The principle behind CM is that desired behaviours are
systematically reinforced while undesired behaviours are
discouraged
• The theories underpinning CM are well over 50 years
old.
• In terms of the drug field, the 2007 Clinical Guidelines
provide the following explanation:
“Contingency management operates by providing a variety
of incentives in the form of vouchers, privileges, prizes or
modest financial incentives to modify a person’s drug
misuse or to increase health promoting behaviours”
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Evidence base
• The evidence for the effectiveness of CM is substantial.
In fact, according to NICE, it constitutes:
“the largest single body of evidence for the effectiveness
of psychosocial interventions in drug misuse”
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Evidence base
• In July 2007 NICE published two clinical guidelines – one on
psychosocial interventions and one on detoxification. Both included
recommendations that CM be introduced to drug services as part of
an NTA-led implementation programme:
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Putting it into practice
• The keyworker’s attitude is as important as the incentive
– Praise is as vital as the incentive
– Talk up the importance of the incentives available
– Help clients see how continued positive behaviour can help
change their lives
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Drug free CM
• 12 week programme.
• Reset to week 1 for positive test
• Maximum of £108
Week
1
Week
2
Week
3
Week
4
Week
5
Week
6
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You can earn £2 per negative urine
i.e. £6.
You can earn £3 per negative urine
i.e. £9
You can earn £4 per negative urine e.g.
£12
You can earn £5 per negative urine
e.g. £10
You can earn £6 per negative urine
e.g. £12
You can earn £7 per negative urine
e.g. £14
Week
7
Week
8
Week
9
Week
10
Week
11
Week
12
You can earn £8
You can earn £9
You can earn £10
You can earn £8
You can earn £6
You can earn £4
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Drug free CM
• 28 yr old man stable on Buprenorphine but using £50+
crack per week
• 4/4 previous tests positive to Cocaine
• Could not see a way forward until we mentioned CM
• Completed the programme earned £75
• Transferred to primary care team, working full time used
Crack 1-2 in last 6 months
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Attendance CM
• 27 year old single parent had dna’d or cancelled last 6/9
appointments
• Attended all 12 of CM programme
• Behaviour generalised to attendance at dentist, diabetic
clinic
• Enrolled on and completed evening class
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Rewards
• Clothes
• Gifts for their children
• Uniform for college course
• Health/fitness club passes
• Fridge, coffee maker, rug
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Issues for staff
• Attitude to rewards
• Ability to give positive verbal rewards
• Organisation of diary and work
• Paperwork and maths
• Practicalities of purchasing the incentives
• Are we better set up to punish than reward?
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Issues for service users
• They understood the underlying principles and only 2
refused on “ethical grounds”
• Very little complaint from those not on the programme
• People still talk about what they spent their
money/vouchers on
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