Peter Coleman, M'S', CASAC

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CONTINGENCY MANAGEMENT APPROACH IMPLEMENTATION
AND OUTCOMES

• Peter Coleman, M.S., CASAC
• Marylee Burns, M.Ed., M.A., CRC
• Scott Kellogg, Ph.D.

2
Workshop Outline

• Overview of NYC Health and Hospitals and the
  Foundations of Change
• The Latest Research on Contingency Management
• The HHC Experience Implementation and Outcomes

3
Overview of NYC Health and Hospitals
Corporation and the Foundations of Change
4
NYC Health and Hospitals Corporation (HHC)

• Largest municipal health care provider in United
  States
• Provides services to 1.3 million NYC residents
• Offers full array of health, mental health, and
  chemical dependency services

• 8 Inpatient Detox Units
• 8 Methadone Treatment Programs
• 19 Outpatient Chemical Dependency Programs
• 2 Halfway Houses
• 4 Hospital Intervention Programs, and
• Case Management Program

5
Contingency ManagementWhy Should We Change
Anything?

• Weve been providing drug treatment for years and
  our patients do fine!

6
Addiction is a major public health issue
providing effective treatment a major challenge

• It is estimated that only 20 of those addicted
  to opiates are engaged in treatment.
• 50 of non-funded MTP programs in NYS report that
  fewer than 54 of those entering treatment are
  retained for more than 1 year.
• 50 of non-funded MTP programs in NYS report that
  less than 32 of patients discharged have
  discontinued use of heroin.

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Addiction May be Considered a Medical Condition,
but

• It is often viewed as a moral weakness that is
  self inflicted and best dealt with through the
  criminal justice system.
• While it is a chronic disorder, it is often
  treated as an acute condition with expectations
  of immediate resolution.
• Patients are often stigmatized by society,
  medical providers and treatment program staff,
  and by family, friends and peers.

8
External Pressures for Change

• Increased focus on program accountability,
  measurement of progress and clinical outcomes
• Welfare reform and related financial
  ramifications
• Demand for individualized treatment, respectful
  of patient rights
• CSAT program accreditation requirements

9
The Truth About Change

• Change typically requires a systems approach
• Change is not easy and is a long-term process
• Change requires a vision and commitment on behalf
  of the entire organization
• Change involves trial and error as well as
  ongoing evaluation
• Change requires strong leadership, but it is best
  accomplished when done with input and
  participation of patients and staff

10
Foundations of Change at HHC

• 1998 OASAS Vocational Initiative
• 1999 mayoral scrutiny of methadone treatment
• 2000 OASAS/HRA Vocational Initiative
• 2001 New CSAT regulations for opioid treatment

• Desire to incorporate
• self sufficiency and
• employment as major
• treatment goals
• Conscious decision to
• improve quality of care,
• patient satisfaction, and
• treatment outcomes

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Initial Actions and Results

• Initial Actions
• Vocational Rehab staff added and Career Centers
  established
• MTP Workgroup
• established
• Practice Guidelines and Manuals developed
• Reporting mechanisms put in place

• Initial Results
• Nature of clinics changed but culture didnt
• Treatment approach had punitive feel
• Patients did not respond and retention declined
• Staff disenchanted
• Improvements unsustained

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Reinvigorating the Process

• Workgroups
• expanded and
• continued to meet
• Administrative support increased
• Staff polled regarding attitudes and needs
• Patient satisfaction surveys undertaken

• Training Initiatives
• Thinking Outside the Box
• Transtheoretical Model
• of Behavioral Change
• Project Invest
• Management Training Successfully
• Supervising People

13
Moving in the Right Direction- Leadership
invigorated- Staff attitudes improved-
Treatment began to shift away from punitive
policies- Improved therapeutic environment

• But patient outcomes, particularly in relation to
  self sufficiency and employment, had still not
  improved to desired levels

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Patient Motivation and Recognition Initiative

• Based on research which supported use of tokens
  to encourage and motivate patients towards
  treatment goals
• Used recognition of patient achievements as
  mechanism for improving self image and peer
  support
• Focused on advancement in treatment and
  attainment of goals as well as vocational issues

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Programs were required to submit a plan that
included

• Specific, measurable objective benchmarks
• Description of motivational supports
• Description of patient recognition activities
• Timeline for implementation and integration

• Mechanism for staff training and patient
  education
• Proposed methods for supplemental and ongoing
  support
• Method of tracking outcomes and accounting for
  supports

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9 programs responded and were ultimately awarded
an average of 12,900 each plus a supply of
Metrocards and gift certificates

• Contingency Management
• was on its way!

17
Science Meets Practice

• As an outgrowth of a Contingency Management Panel
  (Kellogg and Stitzer) presented at the NIDA
  Blending Conference held in New York in March,
  2002
• As a direct result of the Blending Conference, a
  collaboration developed between Ms. Marylee Burns
  and Mr. Peter Coleman of the Office of Behavioral
  Health of the New York City Health and Hospitals
  Corporation (HHC), and Scott Kellogg, PhD of The
  Rockefeller University and the CTN.

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The Collaboration

• Staff were provided with papers by Drs. Stitzer,
  Petry, and Higgins
• Dr. Kellogg presented research on contingency
  management to Substance Abuse Directors Meeting
• Ms. Burns and Dr. Kellogg went to participating
  programs to meet with staff, speak about the
  research, and critique the initial efforts to
  develop Contingency Management components within
  the programs

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Where are we in 2004?

• 8 of the original 9 programs (6 MTPs and 2 O/P)
  were allocated additional funds which averaged
  19,166
• 5 additional O/P programs were allocated funds
  which averaged 10,000
• Additional training resources were provided
• Day-long Contingency Management Conference
  Science in the Trenches

20
Successful implementation of Contingency
Management at HHC reflects the sum of the
various parts
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Setting the StageFactors In Success

• Commitment of the system to long term process for
  treatment improvement
• Availability of initial funding and potential for
  additional funds

• The adoption of science for the clinical paradigm
  and framework
• Leadership direction and oversight

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• Teamwork between program leadership and line
  staff which empowered staff and encouraged
  creativity
• Patient participation, recognition, enthusiasm
  and empowerment
• Therapeutic environment which focused on
  positives and moved from sanctions to rewards
• Individualization of care particularly the
  matching of patient treatment needs to
  motivations

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• Ongoing process of review, revision and
  improvement
• Integration of contingency management into
  overall structure of treatment approach
• Staff training initiatives
• Networking and collaborating with NIDA CTN
  affiliated researchers

24
Research on Contingency Management Approaches in
Substance Abuse Settings
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Contingency Management

• An approach that has been in use since the late
  1970s
• Developed by Dr. Maxine Stitzer at Johns Hopkins
  University
• Further developed by Dr. Stephen Higgins at the
  University of Vermont, by Dr. Nancy Petry at the
  University of Connecticut, and by Dr. Ken
  Silverman at Johns Hopkins University
• Based on the work of B. F. Skinner
• Behavior is determined by its consequences
• Reinforcement -- Increases the likelihood of a
  behavior occurring
• Punishment -- Decreases the likelihood of a
  behavior occurring

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THE FANTASY Patients Recognize that they have
a Problem They Know they Need Help with that
Problem They come to treatment ready for change
27
REALITY CHECK.
What REALLY makes patients come to treatment?
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Negative Consequences of Drug Use
Treatment
29
External Negative Consequences
Family Members Employers Parole/Probation Child
Protective Services
30
Personal Negative Consequences Many Patients
Come to Treatment Because BAD Things are
Happening, Others are Angry with Them, They are
Tired and Depressed, They have run out of money,
They Want Life to Change BUT...
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Drugs are Positive Reinforcers
They Make People Feel Good.
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Abstinence
Continued Use
Drug Abusers Straddle the Fence
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Behavioral Results of Ambivalence
Some patients stop using
Some patients continue to use drugs
during treatment
Some patients drop out of treatment early
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Methods are needed to
Continued Drug Use
Drug Abstinence
- counteract ambivalence- increase motivation
for change
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What are Motivational Incentives and How Can They
Help
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Motivational Incentives In Everyday Life

• Child rearing
• Praise and discipline
• Education
• Grades/honors and detention/suspension
• Business organizations
• Bonuses promotions and sanctions/demotions
• Criminal justice
• Arrest/incarceration and early release

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Examples of Rewards
Vouchers and Gift Certificates
Attention, Pat on the Back
Prizes and Gifts
Privileges
Services
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Examples of Punishers

• Fines
• Tickets
• Restrictions
• Sanctions
• Displeasure

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It is the CONTINGENCY that matters.
BEHAVIOR
REWARD

• Giving things away for free
• does NOT change behavior
• The closer in time, the more
• powerful the reinforcement

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Punishments

• Do not teach what to do only what not to do
• Promote harsh and demeaning atmosphere
• May also do harm (e.g. promote aggression)
• Are necessary under limited circumstances

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Rewards

• Teach new behaviors and promote growth
• Promote positive atmosphere communication
• Promote self-esteem and self-confidence
• Sustainable over time

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Rewards versus Punishments

• Which is used
• more frequently?

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Punishments!
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Application to Drug AbuseIntervention Targets

• Improved Therapy Attendance
• Decreased Drug Use
• Treatment Plan Goal Attainment

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Common Naturally Occurring Rewards and Punishers
In Drug Abuse Treatment

• Positive Negative
• - take-homes - time restriction
• - award ceremonies - missed services
• - certificates key chains - probation
• - status/recognition - dismissal

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Motivational Incentives Research

• Clients earn vouchers for drug-free urines
• usually cocaine-free urines
• Vouchers are worth money
• Vouchers are exchanged for
• retail items (e.g. clothing, sports equipment)
• services (e.g. rent bill payments)

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Research on Motivational Incentives
Cocaine abusers in drug-free treatment
Cocaine abusers in methadone treatment
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Treatment of Cocaine Dependence in a Drug-Free
ClinicHiggins et al., 1994
Control Treatment Community Reinforcement
Approach Therapy Urine testing 2x/week No vouchers
Incentive Treatment Community Reinforcement
Approach Therapy Urine testing 2x/week Vouchers
10
Can earn over 1000 Actual earnings 600
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Treatment of Cocaine Dependence
Retained Through 6 month Study
Higgins et al., 1994
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One-year Follow-up Results

• 60 of incentive group were cocaine abstinent
• While 45 of the control group were abstinent
• During-treatment abstinence predicts long-term
  abstinence

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Treatment of Cocaine Abuse in Methadone
PatientsSilverman et al., 1996

• Contingent Incentives
• 3x weekly urine testing
• received vouchers only if urine samples were
  cocaine negative
• Up to 1155 available
• Average earnings of 426

• Non-Contingent Incentives
• 3x weekly urine testing
• received vouchers regardless of urine test
  results

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Treatment of Cocaine Use in Methadone Patients
Retained Through Study
Silverman et al., 1996
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Patient Ratings of Helpfulness
Overall helpfulness of treatment
Silverman et al., 1996
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Adaptation into Standard Clinic Settings

• Intermittent reward for good behavior
• reduces cost

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Intermittent Incentive Study with
Alcoholic-Dependent Outpatients

• Subjects alcohol-dependent outpatients
• Standard treatment
• Intensive outpatient day program
• 5 hrs/day, 5 days/week, weeks 1-4
• Aftercare
• 1-3 groups/week, weeks 4-8
• Treatment consisted of group sessions 12 step,
• relapse prevention, vocational rehab, AIDS,
  coping skills

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Intermittent Reward

• Instead of getting reinforced every time they are
  drug-free,
• The drug-free patient draws from the fishbowl
• 50 of the draws are verbal reinforcements that
  say good job
• And 50 of draws are winners

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Control Group

• Received standard group treatment and
• Breath Alcohol (BAC) monitoring
• (daily during intensive, weekly during
  aftercare).
• Additional 15 min of
• education on
• alcohol abuse weekly

Just say no
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Incentives Group

• Standard group treatment and BAC monitoring
• Incentives for alcohol abstinence
• One draw for each negative BAC.
• Five bonus draws for a week of consecutive
  abstinence.

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Half the cards are winning
42 of the cards are worth a small prize (i.e.
toiletries, food) 7 are worth a medium prize
(i.e., cordless phone, CD) And less than 1 are
worth a jumbo prize (i.e., TV, video)
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Retention
Retained
Petry et al., 2000
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Time Until First Drinking Episode
Abstinent
Weeks
Petry et al., 2000
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Percent Positive for Any Illicit Drug
Petry et al., 2000
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Summary of Research

• This intermittent schedule of incentives
  significantly increased retention and reduced
  alcohol, as well as other drug, use.
• On average, subjects earned 200 worth of prizes.
• Local retailers and stores were willing to donate
  prizes.

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The Original Plan

• When I first became a part of this project, each
  HHC clinic was expected to create a plan for
  distributing reinforcements in an appropriate and
  systematic way to their patients
• The idea was that when patients reached various
  benchmarks, they would receive a prize or reward
  (i.e., a gift certificate)

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Potential Shortcomings

• After our dialogue about CM, it became clear that
  there might be a shortcoming to this plan
• My thought was that they were creating a reward
  program rather than a reinforcement program

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Reward Vs. Reinforcement

• The reward program can be seen as one that is
  set up to acknowledge major accomplishments
  maintaining abstinence for 1 month holding a job
  for 3 or 6 months or completing a one-year
  program in a sense, it is a program to reward
  virtue
• The greatest concern was that it would result in
  the distribution of prizes to the best or most
  successful patients
• While having little or no impact on those who
  were having serious problems attaining or
  maintaining abstinence and sobriety

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Reinforcement ProgramsContingency management
programs have the ability to

• Reinforce each of the steps and each of the
  components that are involved in reaching the
  goal, not just the attainment of the goal
• Be more gradualistic, and, while not value-free,
  they are not as overtly value-oriented
• Focus more on initiating and maintaining behavior
  change

• Allow us to go from You
• have done a good job to
• You have taken a step in the
• right direction
• Help not only the most
• motivated patients, but also
• those who are more troubled
• and/or more severely
• addicted have the opportunity
• to benefit (Petry et al., 2001)

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Definitions and Constructs

• Technically, reward and reinforcement, as
  used here, are the same thing the issue is the
  criteria for reinforcement (Kazdin, 1994 Wolpe,
  1982)
• However, clinically, the social constructs of
  reward and reinforcement were quite meaningful
  to the staff and the leadership

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Definitions and Constructs (2)

• Giving things to people on the way to
  accomplishing a goal seemed fundamentally
  different from giving to them only when they
  achieved it
• It was this difference that played a crucial role
  in reorienting the HHC clinics and making this
  project a success

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Reinforcement StrategiesA number of guidelines
about the use of contingencies were emphasized
(see also Kirby et al., 1999)

• Reinforcements should be given very frequently
• 2. It should be very easy to earn reinforcements
  at the start the bar should be kept low
• 3. An example of this is that when the trainers
  at Sea World begin to teach the whales to jump
  over the hoops, they start with the hoop being
  under the water the whales are reinforced for
  simply swimming over it (Coonradt, 1996)

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Reinforcement Strategies (2)
4. To be as effective as possible, the
reinforcements should include material goods and
services and these need to be of use and value to
the patients 5. Social reinforcement alone is
not likely to be sufficient -- especially for
patients who are disconnected or socially
phobic 6. Reinforcements will be most effective
if their distribution is connected to specific
and observable behaviors and they receive them
immediately after exhibiting the behavior (i.e.,
attending the group) 7. The greater the delay in
receiving the reinforcement, the weaker its
effect is likely to be
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Clinical Considerations

• Emphasize the positive
• Focus on the good things the patients did -- not
  their failings
• Any steps in the right direction is a cause for
  celebration
• In the face of setbacks, patients should be
  encouraged, not criticized
• Reinforcement criteria should be clear to both
  the patients and the staff if they meet the
  criteria, they must receive the reinforcement --
  regardless of their drug use status

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Social Aspects

• There are powerful social reinforcement processes
  at work when the counselor gives the
  reinforcement to the patient
• Counselors who are not enthusiastic might
  inadvertently have a damaging impact on its
  efficacy
• A congratulatory approach is seen as the most
  appropriate one

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Implications for Counseling

• It was emphasized that CM is not a substitute for
  counseling
• Reinforcements do not directly teach people how
  to abstain nor do they provide skills -- they
  simply strengthen behaviors that lead to that
  outcome
• Counselors have a valuable therapeutic
  opportunity to explore with their patients what
  actions they took to avoid using drugs this can
  be used to develop future coping strategies
  (Morral, Iguchi, Belding, 1999)

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The HHC ExperienceImplementation and Outcomes
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Implementation

• 7 out of 9 clinics implemented programs
• Contingency management programs varied some
  used points/tickets, others the fishbowl
• Many plans changed along the way
• Group attendance as well as goal attainment were
  reinforced - material and social reinforcements
  were used

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Implementation - continued

• Reinforcements were distributed in both group and
  individual settings.
• Programs expanded upon existing award ceremonies.

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Benchmarks Reinforcements

• Benchmarks included
• Group attendance
• Goal attainment
• Negative toxicologies
• Completion of medical and psychosocial history
• Higher levels of reinforcement were used for
  groups that involved exploring careers, education
  and other work related issues.

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Reinforcements

• Range of prizes some matched with program
  issues e.g. job interview
• McDonalds coupons, movie passes,
  transportation vouchers (metro cards),
  calendars, gift certificates from major
  department stores and music outlets, date books,
  tools, clothes, books, tee-shirts, microwaves,
  water bottles, sunglasses, things for children,
  toiletries, food, and candy

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Implementation Process

• At first, there was a fair amount of staff
  resistance
• This was a long and hard process and there
  were lots of fights. Staff saw it as a negative
  at first,. As the director, I allowed the staff
  to ventilate. The Vocational staff started the
  whole process because their orientation is far
  more receptive to this kind of thing. (Program
  Director)

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Patients Reactions

• Some patients needed tangible evidence of such
  prizes
• Eventually patients were very enthusiastic
• Their self esteem seemed to increase as seen in
  their improved appearance and their attendance to
  and interest in groups.
• They also began to become more empowered as seen
  in their development of goals

89
Patients Reactions - Continued

• Clients were sayingIn Russia, we were forced
  into treatment -- Now (crying), my God, Im
  getting treatment and 25.00!
• Clients are proud and are having fun. Early in
  treatment, when their name is called out, they
  are feeling good that they are being
  acknowledged. For once in their life, they are
  being rewarded for something.
• When the client signs onto the computer, they
  see Dust-off Your Dreams Treatment Works. We
  know that clients dreams were lost to drug
  addiction. Now, clients are able to go to Macys
  and J.C. Penney. This is big time for them
  theyre able to shop at prestigious stores.

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Patients Reactions - continued

• A core issue here was the profound emotional and
  economic deprivation that these patients had
  experienced and continued to experience.
• The reinforcements and awards were so powerful
  because some patients believed that the staff did
  not care about them, and others, in their 30s
  and 40s, had never received a certificate for
  anything.
• Because of their high levels of economic
  deprivation, the gift certificates frequently
  made a significant difference in their lives.

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Patients Reactions - continued

• The basic process was that the reinforcements got
  them to the groups and motivated them to stay,
  and then the power of the group began to have its
  impact.
• As has been noted elsewhere (Petry et al., 2001),
  patients first came for external reasons and then
  chose to stay because of their internal
  motivations.

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Patients Reactions - continued

• Patients who participated in the program often
  began to become more socially integrated and
  began to socialize with each other
• They would use their coupons and go to movies
  together in groups
• There were also reports that they were taking
  care of each other and giving each other gifts

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Patients Reactions - continued

• Their sense of connection to the program grew and
  they participated more freely in its events
• The staff heard clients say that they came to
  realize that there are rewards just in being with
  each other in group. There are so many
  traumatized and sexually abused patients who are
  only told negative things. So, when they hear
  something good that helps to build their
  self-esteem and ego. As one patient put it, I
  used to think the drug dealer cared for me but
  this is really caring. (Counselor)
• In many cases, the prizes became a vehicle for
  family healing

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Patient Reactions - Internalization

• They developed increased sense of ownership
  and responsibility for their program and their
  recovery.
• You are forcing me to I choose.
• In one striking example, patients who felt that
  methadone initially made them drowsy, delayed the
  taking of their medication until after their
  group so they could be more alert and alive..
• Clients also began to speak privately to their
  counselors about individuals who were dealing
  drugs or otherwise engaging in anti-therapeutic
  behavior.

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Counselor Experiences

• Morale improved
• Identification with evidence-based practice
• It gives me a great deal of pleasure to know
  Im part of a state-of-the-art methadone
  treatment program.
• Public gratitude -
• In the last two award ceremonies, clients said,
  I want to thank the staff. That sounded real
  good we feel appreciated.

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Counselor Experiences - continued

• Communication Improved
• Staff designed, evaluated and changed CM programs
• Staff spoke more of patient changes and made more
  team decisions regarding treatment
• Staff Attitude Improved
• I love coming to work now.

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Counselor Experiences - continued

• Relationships among the different staff services
  improved
• Last year, the staff were not positive. They
  were very territorial, and somebody was always
  waiting to attack this idea. Perhaps they were
  feeling very threatened Now, the staff are
  more cohesive.
• (Program Director)

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Counselor Experiences - continued

• There has been a major acceptance now for
  vocational counseling and activities, and we now
  have a Wall of Fame. A bulletin board with
  pictures of employed patients. Before, the
  rehabiliation counselors were the brunt of
  sarcasm, now clients are asking that their
  pictures could be added to the board.

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Counselor Experiences - continued

• Perception of the use of reinforcements began to
  change.
• We came to see that we need to reward people
  where rewards in their lives were few and far
  between. We use the rewards as a clinical tool
  not as bribery, but for recognition. The really
  profound rewards will come later.
• Even small steps were recognized and celebrated.
• I felt resistant at first. But, as it caught
  on, I began to like giving points to clients. I
  saw that my client wasnt using dope, only coke,
  and Id say give him a point! So, now Im very
  involved.

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Kings County HospitalVocational Outcome Data

• Kings County did a comparison between a group of
  patients who were enrolled in a series of
  vocational groups and received incentives and
  another group of patients that were involved with
  the vocational groups before the incentives were
  introduced.
• 25 of the non-incentive group (n 20) completed
  the series while 61 of the incentive group (n
  18) completed the series of groups.

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Before C.M. After C.M.
N 20 N 18

• The two groups were compared at a six-month
  follow-up.
• 40 of the non-incentive group were
  vocationally engaged while
• 89 of the incentive group were vocationally
  engaged.

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Harlem Hospital Vocational Outcome Data

Before C.M. After C.M.
(Census stable at 350)
as of 12/02 as of 4/03

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Clinic Changes - Mood and Culture

• Marked decrease in conflicts and disruptive
  behavior in some of the clinics
• The mood has changed in the last 6 months
  there has been less disciplinary action in
  fact, no fights at all. There has been no need
  for escorting people out of the building as has
  been the case in the past.
• Before, the clients would yell and curse, and
  now things are calm. Amazing. Clients are
  more pleasant its an easier place to exist
  in.

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Clinic Changes - Mood and Culture

• I think it does strengthen the alliance with the
  team, not just one counselor. The program has
  become nurturing.
• Communication Improved
• Staff spoke more of patient changes and made more
  team decisions regarding treatment.
• Staff designed, evaluated and changed CM
  programs.
• Staff Attitude Improved
• I love coming to work now.

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Staff, Patient, and Clinic Overall Impressions

• One year later, the contingency management
  programs were a reported success and valued by
  both staff and patients.
• The patients loved it, and some reported that it
  had saved their lives. They felt that their drug
  use had been getting worse and worse, and it was
  the contingencies that encouraged their choosing
  a different life direction.

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Staff, Patient, and Clinic Overall Impressions -
continued

• The staff and leadership were very excited about
  and proud of their reinforcement programs. As
  one counselor put it,
• I dont know who invented it, but it was a
  stroke of genius.

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Acknowledgements
108

• Collaborators of this project were
• Marylee Burns, MEd, MA, CRC, Assistant Director,
  HHC Office of Behavioral Health
• Peter Coleman, MS, CASAC, Senior Director, HHC,
  Office of Behavioral Health
• Scott Kellogg, Ph.D., Clinical Psychologist,
  Laboratory of the Biology of the Addictive
  Diseases, The Rockefeller University

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• Development, implementation and support of this
  project is due to the efforts of the leadership,
  staff, and patients of the New York City HHC
  Chemical Dependency Programs.
• Wed like to thank specifically
• HHCs Office of Behavioral Health
• Joyce B. Wale, Senior Assistant Vice President
• Michael Norman Haynes, Sr. Management Consultant,
  and
• Antonio Webb, Sr. Management Consultant

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• Ludwig Hauser, CSW and the staff of Bellevue
  Hospitals Methadone Treatment Program,Jaime
  Rosario, CSW and the staff of Coney Island
  Hospitals Outpatient Chemical Dependency
  Treatment Program, Martin Gaffney, CSW and the
  staff of Elmhurst Hospitals Methadone Treatment
  Program,Aisha Muhammad, CSW and Curtis Saunders
  and the staff Harlem Hospitals Methadone
  Treatment Program,Janet Aiyeku, CASAC and Dayo
  Alalade, Ph.D and the staff of Kings County
  Hospitals Methadone Treatment Program
• All the patients at HHC programs who have
  supported the development of contingency
  management and have evolved into some of the
  strongest advocates.

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• And a special thanks to the researchers
  associated with the NIDA CTN Project
• John Rotrosen, MD, NYU School of Medicine
• Maxine Stitzer, Ph.D., John Hopkins University
• Dr. Mary Jeanne Kreek at the Rockefeller
  University
• NIH-NIDA Grants P60-DA05130 (Kreek),
• DA13046-04 (Rotrosen)

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CONTACT INFORMATION

• Marylee Burns, MEd, MA,, CRC
• Assistant Director,
• NYC Health and Hospitals Corp.
• 212-788-3458 burnsm_at_nychhc.org
• Peter Coleman, MS, CASAC
• Senior Director,
• NYC Health and Hospitals Corp.
• 212-442-3993 colemanp_at_nychhc.org
• Scott Kellogg, Ph.D.,
• Clinical Psychologist,
• The Rockefeller University
• 212-327-8282 kellogs_at_rockefeller.edu