Contingency Management in Problem Gambling Treatment

1
Contingency Management in Problem Gambling
Treatment

• Jeremiah Weinstock, Ph.D.
• University of Connecticut Health Center
• Farmington, CT USA

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Overview

1. Pathological Gambling Its Treatment
2. Background on Contingency Management (CM)
3. Applying CM to Gambling Treatment

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Pathological Gambling

• Quick Review
• Pathological Gambling (PG) is characterized by
  maladaptive gambling behavior.
• 1 - 2 of general adult population meets DSM-IV
  diagnostic criteria for PG.
• Vulnerable populations include SUD, Forensic,
  Adolescents.
• Availability of gambling is increasing
  dramatically.

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Number of Gamblers Seeking Treatment in CT
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Number of Gamblers Seeking Treatment in CT
Foxwoods Casino Opens
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Number of Gamblers Seeking Treatment in CT
Mohegan Sun Casino Opens
Foxwoods Casino Opens
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Gambling Treatment

• Treatment Options for PG
• Gamblers Anonymous (12-Step)
• Outpatient Counseling
• Cognitive Behavioral Therapy (CBT)
• Marital Therapy
• Brief Interventions
• Motivational Enhancement Therapy
• Pharmacotherapy (medication)
• Inpatient Treatment
• No single treatment is appropriate for everyone.

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Gambling Treatment

• Obstacles to Effective Treatment
• Less than 8 of PG ever seek or get treatment
  (Slutske, 2006).
• Many PGs drop-out of treatment prior to
  completion
• 33 - 50 (Leblonde et al. 2003 Ladouceur et
  al., 2001).
• Adherence with treatment program.
• Petry et al. (2006) 40 completed less than 75
  of intended treatment.
• Best predictor of gambling abstinence was
  treatment adherence number of CBT
  sessions/chapters completed.

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Gambling Treatment

• 1st Treatment Study at UConn Health Center
• 231 Pathological Gamblers randomly assigned to
• Referral to Gamblers Anonymous
• GA Referral CBT self-help manual
• GA Referral CBT counseling.

Petry et al., 2006
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Gambling Treatment - Demos
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Gambling Treatment - Adherence
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Gambling Treatment - Results
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Gambling Treatment

• WHAT CAN BE DONE?

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Contingency Management

• Contingency Management
• Based upon principles of operant conditioning.
• Three behavioral tenets of CM
• Frequent monitoring of target behavior.
• Providing tangible reinforcement for completion
  of target behaviors.
• Remove reinforcement when target behavior does
  not occur.
• Typically, CM is added onto another SUD treatment.

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Contingency Management

• Contingency Management Reinforcement
• Vouchers -
• Silverman et al. (1996) 1,155
• Higgins et al. (2000) 997.50
• Prize Bowl Lower cost alternative.
• Not appropriate for PGs as it involves an
  element of chance somewhat similar to gambling.

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Contingency Management

• Contingency Management SUD Tx Outcomes
• Participants stay in treatment longer
• 75 vs. 40 completed 24 weeks (Higgins et al.,
  1994).
• 84 vs. 22 completed 8 weeks (Petry et al.,
  2000).
• Longer durations of continuous abstinence (LDA)
  during treatment
• 55 vs. 15 obtained 2-months of continuous
  abstinence.
• 2.7 and 4.5 times more likely to achieve 8 weeks
  and 12 weeks LDA, respectively (Petry et al.,
  2005).
• Regardless of type of treatment, LDA during
  treatment is associated with long term success

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Contingency Management

• CM reduces drug use
• Opioids (Bickel et al., 1999 Preston et al.,
  1998)
• Cocaine (Higgins et al., 1994 Silverman et al.,
  1996)
• Benzodiazepines (Stitzer et al., 1992)
• Marijuana (Budney et al., 1991, 2000)
• Nicotine (Shoptaw et al., 2002 Roll et al.,
  1996)
• Alcohol (Petry, 2000)
• Polydrug (Downey et al., 2000 Petry et al.,
  2005b)

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Contingency Management

• CM increases treatment adherence
• Medication compliance (Carroll et al., 2001)
• Complete activities consistent with treatment
  improves treatment outcome (Bickel et al., 1997
  Iguchi et al., 1997)
• Lewis Petry (2005) found those completing
  family oriented activities
• Remained in treatment longer.
• Longer durations of abstinence.
• Reported greater reductions in family conflict.

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CM for Gambling Treatment

• How do we apply CM to gambling treatment?
• Cannot reinforce gambling abstinence, no
  objective measure.
• Reinforce compliance with homework.
• Reinforce GA attendance.
• Reinforce behavioral activation.
• ONGOING STUDY _at_ UCHC
• Eight sessions of individual therapy.
• Longer term (2 year) follow-ups included.

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CM for Gambling Treatment

• Psycho-Education
• Provides educational materials about gambling.
• Encourages attendance at GA.
• CBT
• Functional analysis of gambling behavior, coping
  skills training.
• Encourages attendance at GA.
• CBT CM
• Same content as CBT, and GA encouragement.
• Earn up to 187 in vouchers for completing
  activity contracts.

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Sample Activity Contract
Activity Proof To Be Done Potential Problems Done?
Go to GA Mtg. Signed Slip Wed 04/04 Dont want to go.
Go to church Church Bulletin Sun. 04/08 Over sleep!
Have coffee with sister Receipt Sat. 04/07 Shes busy.
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CM For Gambling Treatment

• 31 clients assigned to CBTCM
• Thus far, 493 activities contracted with 66
  completed.
• 135 activities were completing CBT homework
  (27.4)
• 43 activities were going to GA meeting (8.3)

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Preliminary Results - I
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Preliminary Results - II
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Preliminary Results - III
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CM for Gambling Treatments

• How can I apply this to my clinic?
• Reinforcement does not have to be vouchers
• Clinic privileges parking spots, take-home
  bottles.
• Donations from the community.

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Summary

1. PG is associated with a host of adverse
   consequences.
2. Numerous treatment options are available, however
   few PGs seek treatment.
3. Current treatments can be effective, but there is
   room for improvement.
4. Contingency management is one way to improve
   treatment attendance and adherence.
5. With the recurrent nature of PG, its helpful for
   clients to have a positive experience with
   treatment CM can be a positive addition to tx.

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Acknowledgements

• Thank You
• Nancy M. Petry, Yola Ammerman, Anne Doersch,
  Heather Gay, Elise Kabela-Cormier, David M.
  Ledgerwood, Suzanne McColl, Ben Morasco, Betsy
  Parker, Nicole Reilly.
• This study is supported by Natl Institute of
  Mental Health