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"Because Addiction interferes with motivation even patients in the most desperate of circumstances will refuse treatment. It is therefore not surprising that despite the UK spending over £7 Billion on imprisoning and over £1 Billion on treating the addicted, less than 10% are recorded as recovering. Indeed it has has been calculated that it takes about  9 years to come off Class A drugs. For chaotic addicts, their families bereaved by addiction and the taxpayer there is clearly an urgent need to find alternative strategies of proven efficacy.
Surprisingly, one such strategy already exists but regrettably it has still not been widely used. This strategy is called Contingency Management and involves giving small incentives to encourage addicts to change their behaviour.  This simple technique now has had over fifty years of research evidence testifying to its effectiveness and because of these good results it is recommended by NICE the UK National Institute for Clinical Excellence. This site is for people who want to try our new comprehensive "earning version" of Contingency Management which has been remarkably successful in helping people with serious addictions"   

Contingency self-management- a new approach to Addiction using Carecreds with mobile phone prompting 

Dr Michael D’Souza MD FRCGP FFPHM

 Summary

 Contingency Self-management is a new approach to help people with all types of addiction. It is based on the proposition that addiction has hitherto been so difficult to treat because sufferers have to gain release from four locked in states. The first is due to a chronic personality state that is perversely and adversely reinforced by ordinary clinical care. The second is a chemical craving to obtain the Dopamine rewards generated by their addiction. The third is the stress relief also produced by the addiction. The fourth is entrapment in a subculture of fellow users that infect, prompt recidivism and provide the supplies and financial basis for its continuation.

Our idea is to offer a Carecreds service, which has already been shown to help the majority of severe opiate users, via premium number mobile phone support. This will provide a self-funded, contingency management service to reinforce patient resolve to break each of these locks. We believe that such a service is worth testing to see if it is both more effective and less expensive than current approaches.

  

 INTRODUCTION 

It is recognized that Addiction is one of the principal causes of modern disease and when extreme can generate widespread social distress. We know that a wide range of activities such as perversions and gambling can become addictive and many totally different substances such as food, tobacco, alcohol and opiates seem to be much more liable to cause it than others. There are abundant psychological theories about its causes and many approaches to preventing and controlling it. Yet until recently it has been a mystery as to how behavior that is essentially so self-destructive can override the basic animal instinct to survive. In the UK, on the naïve assumption that it is prompted by willful criminality, we currently spend over £10 billion a year on imprisoning addicts ignoring the fact that even legally irresponsible experimental animals can become addicted.  Yet it increasingly clear that this ill-conceived policy is not only ineffective and wasteful but may actually be counterproductive. Sadly the £2 billion we spend on the humane alternative of treating addiction clinically also has a poor success record and as a consequence, a large part of the £93 billion spent on the NHS is devoted to picking up the pieces of our failure to treat addiction satisfactorily.

 

During the last five years there have been some interesting developments. Brain research has at last identified that probably all causes of addiction stimulate the direct production of larger amounts of central Dopamine. This hormone is responsible for generating pleasure and most importantly of directing motivation in all higher animal life. Indeed experimental rodents will starve to death rather than stop pressing a lever that delivers them central dopamine rewards. Clearly this helps explain the self-destructiveness seen in severe human addicts.

 

However probably because human beings possess such exceptional intellect, people with addiction also can exhibit changes in their personalities i.e. the role their consciousness assumes when conversing with itself and with its fellow men.  This usually manifests itself as inappropriate and uncooperative thought or behavior such as crime and poor social bonding.  Interestingly recovered addicts describe the only thing that helped them was when they  “hit rock bottom” and changed their own dependant behavior so that they began caring more for themselves and others. The idea behind this paper is that it is now possible link all these different observations and to devise a new approach to addiction that might have a better chance of success. It is perhaps useful to explain how we have arrived at our present conclusions of what this treatment should be.

 

In 2005 disheartened by the difficulty of getting effective help for our severely addicted Class A addicts in General Practice, we instinctively felt that relying on a non-judgmental approach to persuade them to adopt a healthier low stress lifestyle might, in the circumstances, be the best we could do. Although it proved clinically challenging to engage with these patients, just taking just this simple measure did seem to calm and then alter their personality state and produced much more encouraging results than referring them on to local services. It seemed that when engaging in a long-term (>9 month) non-judgmental adult dialogue, our addicts began adopting an adult personality state themselves and it was this that produced the beneficial effects.  It was as if the really basic position that has evolved for the purpose of survival is to co-operate with ones social group from which stems trusting and moral behavior etc. The personality problems and addiction were pathological responses to stress.

 

We then came across one clinical intervention that had been consistently reported by the literature as being really useful in controlling addictive behavior. This was Contingency Management (i.e. the provision of rewards contingent on improved behavior). Furthermore, although advocated as being effective by NICE, it was not in widespread use in the UK. The reason seemed to be that many experts felt it was a conceptually undesirable form of bribery that tended to encourage patients who had no desire to be helped to become manipulative and dependent on these rewards for self-gain, furthermore there was little evidence about how long the period incentives should be kept up and they also had considerable anxiety that the media would be very critical of spending NHS resources on rewarding “blameworthy” addicts.

 

HOW CARECREDS HAVE EVOLVED

Notwithstanding these objections, indeed accepting that they might be the reverse of treating patients as adults, in 2009 we designed and got some modest local funding to try a comprehensive form of Contingency management, which incentivized our patients to do a range of self-caring activities such as exercise and relaxation and to social re-integrate via caring for others. The idea was to use this approach for just a short time on poorly motivated patients. We called our scheme “CareCreds” and we offered participating patients earnings related store (Boots) vouchers i.e. they increased in value in proportion to the number of CareCreds gained. We were very gratified with results and after 18 months over 87% of our patients had become street clean.  See the full results as published on the NICE website. Last year the scheme won the GP magazine award for clinical innovation. However, possibly because of the "bribery objection" it did not receive any further public funding until 2012. Therefore in the intervening period we have met these objections by devising a new version of the scheme that requires a much more adult approach and operates on all degrees and all forms of addiction. 

We call our new scheme Contingency self-management because the process is entirely under the control of the addicted person. Indeed we now suspect that ordinary clinical care does not work as well as it should precisely because, particularly kindly relationships, accidentally encourage such patients to stay in a dependent personality state. Although it is clear that addiction is linked with many things that are difficult to change such as genetic inheritance and misfortune, it is equally clear that many people with similar genes and even worse luck do not develop damaging habits. It is also evident that there are many addicts who recover quite quickly. Why not everyone? The key difference seems that persistent addicts get caught up in a world of recurrent major or minor pleasurable experiences to which they are constantly chemically prompted to return. Their experience is that both their personality state and their use of addiction enables them to avoid remembered or recurrent stress; even the stress of the guilt of being an addict! Sadly it achieves this in an effective but disastrous way. Because they get such a powerful relief from stress many addicts panic about whether can survive without maintaining their addiction. It is a way of thinking similar to Obsessional Compulsive Disorder, somewhat irrational but the more it is done the easier the habit is to repeat. However it is mainly because they have unconsciously escaped irksome reality by entering into this parallel, usually immature, personality state they pursue a “selfish” life narrative that seeks this instant gratification rather than help. In this way any locally available addictive substance or learned behavior can become their poison of "choice".

 To summarize they have become triple locked in by personality problems, stress relief and pleasure seeking motivation. Furthermore for some others further entrapment is possible. Because their addictive behavior often starts as a reaction to stressful trauma, such as bereavement, shame or exclusion from normal community life, it may drive them into a subculture of fellow addicts. Indeed such a community may have introduced them to addiction in the first place. After a time “the friends” in this subculture are all they have left and they mutually support and finance their shared addictive lifestyle. With four or more locks on the door it is clear now why addiction is so difficult to escape.

Contingency self-management has been redesigned to tackle addiction on the basis of this theory. It is open to anyone with any form of addiction who feels that they are harming themselves or others.  It explains to them what they are up against and then how they can use Carecreds to unpick as many of these four locks, as they need to by themselves, in confidence, in their own time and without any externally generated pressure. It is surprising how sometimes even small incentives produce big changes. Like the last straw that breaks the camel's back they can create a tipping point that suddenly results in change.

Tackling the first lock i.e. being in the wrong frame of mind is the most important and most challenging. CareCreds incentivizes adherents to self-manage by helping them remain in an adult, cooperative personality state rather than remaining regressed state and feeling like “a patient” or a victim of addiction. Unlike Alcoholics anonymous it opposes meaningless self-labeling like “I am an alcoholic”.  Instead it encourages them to be positive about themselves and their capabilities. This is aided by our having a dialogue only with their adult side and enlisting this to help others.

To help with the chemical predicament the second lock initially we ignore the addiction itself but focus on reducing stress by developing healthier life habits, problem solving and financial control. Only then does the scheme incentivize addiction reduction using delaying tactics in response to cravings to allow spontaneous hormonal adjustment. It uses regular mobile phone texting rather than face-to-face contact. This allows their phone number to be used as their sole identity. This maintains complete confidentiality and lack of embarrassment in participating throughout the period of self-treatment. The duration of which (or if necessary recommencing a course of treatment) is entirely up to each participant.  Furthermore there is little or no financial barrier to using the service.  Because the main cost is only text messaging this can be provided for just a token cost while each person sees if Carecreds actually helps him or her.  Only then and only if they want to, they can put extra pressure on themselves by paying in a more realistic stake via a premium phone number. This should be a variable stake (e.g. based on 5% of their monthly addiction costs), which they can then try to earn back by gaining sufficient CareCreds.

 Procedure for making patients aware of ECBC (Earn Credit By Caring)

                  With the agreement of local commissioners ALL GPs are sent an ECBC pack of explanatory forms with attached plastic cards with our contact website, email and mobile contact number. They can hand these out to patients with ANY sort of harmful addiction but particularly to those who are not doing well. These leaflets can be offered to distressed family members who are paying for the habits of unmotivated relatives as a useful tool to introduce an element of earning into their relationship, pointing out the section relevant to them.

 

The ECBC Plastic Card that Patients to carry has on it

 Instant Yoga instructions etc


Contact info. Website; email and our 5 premium numbers

 

The handout leaflet text

"If you have ever wished, like most people, for a chance of losing your addictions, improving your relationships, finding more peace, self-respect and a means of being more use to yourself and others, then please read further about ECBC (Earn Credit by Caring). This is a proven way you can help yourself get free and deserve to be so. ECBC will give you the confidential support you require to do this via a non- judgmental service.

ECBC is self-directed treatment aimed getting you to reduce your own stress as the best way of escaping addiction. To participate, all you need to do is contact us by text. The act of doing this enables you to put up a small financial stake via our premium number, most of which you can soon earn back by acquiring sufficient CareCreds*. We suggest you start by using our lowest (25p) rate. However, the higher you make your stake the more it will increase your resolve to help yourself. Indeed many people prefer eventually to increase their stake so that approaches 5% of their monthly addiction costs because this then becomes a useful way of accumulating savings at the same time as they reducing the costs of their habit. 

If you are helping someone else

If you do not have a problem yourself but are financially supporting a friend or relative who does, we suggest that rather than continually giving them handouts you offer to subsidized them (at least in part) according to how many Carecreds they earn each month. This system operates by you choosing the premium rate phone to use. The weekly contact texts enquiring about CareCred earnings are sent to both your mobile phone and the patients. Your replies will validate the claims and be converted into CareCreds earned. At the end of each month you are at liberty to move up or down the premium rating or to stop if you feel it is not helping or that the patient is ready to do DIY CareCreds."

 

 

         *CARECREDS ARE EARNED by

  1.    Safe eating 5/day + Food of calorific strength averaging 1cal/1gm

2.     Exercising body daily till SOB/sweat provided it is medically OK to do so

        3.     Exercising mind – skill courses, crosswords, reading arts & science in the media

4.     Exercising emotion flexibility to more easily adopt an adult frame of mind

5.     Not damaging others    

6.     Not damaging yourself

7.   Not using tobacco

  8.    Practicing Safe sex

9.    Safe alcohol use

      10.    Following medical advice

      11.    Reducing addictive habits on own – delaying responses to craving

      12.    Undergoing a planned cure e.g. Detoxification 

      13.    Stopping addictive practices

      14.   Helping research

      15.   Helping others

      16.   One CareCred is automatically added for each consecutive month that ECBC is continued to a maximum of 3 months

 

Thus in total you can gradually earn a combined total of 95 CareCreds. This is equivalent to getting 95% of your monthly stake back. The minimum of 5% that is retained by ECBC is to cover the running costs of the scheme and to fund “Free” CareCred earnings for some cases, who are very impoverished and considered to be so stuck that they need some start up encouragement to participate.There is an option for relatives,friends or services to pay and supervise this service. In this option the carer's mobile will contact the premium number and their while the patients number will also be contacted via a free service. Only the carers' record of earned CareCreds will be used for repayment.

            N.B. All our contact with you will be handled confidentially and anonymously in that only your mobile phone number will identify you. This number will be used to text you weekly both to give you support and to prompt you to report back on how many Carecreds you are earning. 

So START OFF BY TEXTING US NOW using the word - CareCreds - followed by an estimate about how much your addiction actually cost you to the nearest pound yesterday.

E.g. if it cost £5 Text to the premium number of your choice: Carecreds5

 

N.B. If you're not troubled by the financial cost of your addiction but only by shame it causes,

We suggest you text the daily amount you would be prepared to pay to remove this embarrassment.

 

 

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