Contingency ManagementMotivational Incentives: Past, Present and Future

Maxine Stitzer, Ph.D.Johns Hopkins University SOM

NIDA/CTN Regional Dissemination Conference

Baltimore, MDJune 3, 2010

What you will hear today

• CM/Incentives Background – Development and efficacy research

• Effectiveness testing – National Drug Abuse Clinical Trials Network

• Implications for future – Pathway for adoption by treatment providers

Drug User’s DilemmaDrug User’s Dilemma

Get a jobTime with familyBetter health

Easy moneyHang with friendsGet high

Motivational Incentives Can Motivational Incentives Can Counteract AmbivalenceCounteract Ambivalence

Make sober living a more Make sober living a more attractive option through attractive option through positive reinforcement of positive reinforcement of abstinence and otherabstinence and otherbehavior changebehavior change

People Respond to Consequences

• Behavior can be changed by consequences– Rewards increase desired behavior– Punishment and sanctions decrease undesired

behavior

Contingency Management: Application in Drug Abuse

• Measurable target behavior

• Rewarding consequence

Application in Drug Abuse Treatment: Early Studies

• Behavioral targets:– Counseling attendance– Drug use during treatment– On-time fee payment

• Reinforcing consequences:– Money (or vouchers) – Privileges (e.g. methadone take-home doses)

Incentive Effects on Benzodiazepine Use

3-month intervention with methadone maintained benzo users; incentive is take-home or money

Percent benzo negative urines– Before incentives 9%– During incentives 53%– After incentives 11%

Stitzer et al., 1982

Voucher Reinforcement making cocaine abstinence a more

attractive option • Intensive counseling plus

• Points earned for cocaine negative urine results– Escalating schedule with reset penalty

– Trade in points for goods

– $1000 available in first 3 months Steve Higgins

Voucher Incentives in Outpatient Drug-free Treatment

0

20

40

60

80

100

2 4 6 8 10 12 14 16 18 20 22 24

BehavioralStandard

Weeks of Treatment

Perc

ent

of S

ubje

cts

Higgins et al. Am. J. Psychiatry, 1993

Cocaine negative urines

Perc

ent

Coca

ine N

egati

ve

Baseline Intervention Weeks

Control

Vouchers

0

20

40

60

80

100

2 4 6 8 10 121 2 3 4 5

** * * * *

* *

Voucher Incentives in Cocaine Abusing

Methadone Patients Silverman et al., 1996

Voucher Reinforcement

• Elegantly incorporates behavioral principles designed to initiate & sustain abstinence

• Demonstrated efficacy in controlled trials BUT• Sample sizes are small• Costs were high ($1000 per client could be earned)

$1000???

You’ve got to be kidding!!!

Nancy Petry’s Fishbowl: Intermittent Reinforcement Schedule

For cost reduction in community clinic settings

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Fishbowl Method

Incentive = draws from a bowl

- Draws earned for each negative urine or BAC- Number of draws can escalate- Bonus draws can be given for consecutive weeks of abstinence

largest chance of winning a small $1 prize

moderate chance of winning a large $20 prize

small chance of winning a jumbo $100 prize

Half the slips are winnersWin frequency inversely related to cost

Retention: Alcoholics in Outpatient Psychosocial Treatment

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40

60

80

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120

2 4 6 8

weeks

STDCM

Petry et al., 2000

Percent positive for any illicit drug

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10

20

30

40

50

%

Intake Week 4 Week 8

STDCM

Petry et al., 2000

Efficacy of abstinence reinforcement demonstrated

Drug-free and methadone

treatment populations

Voucher and prize draw methods

Generality of Abstinence Reinforcement Effects Across Abused Substances

Cocaine (Higgins et al., 1994; Silverman et al., 1996, 2004; Petry & Martin, 2002)

Alcohol (Petry et al., 2000)

Opioids (Bickel et al., 1997; Silverman et al., 1996)

Marijuana (Budney et al., 1991, 2000, 2006)

Nicotine (Tobacco smoking) (Stitzer & Bigelow, 1984; Roll et al., 1996; Shoptaw et al., 2002)

National Drug Abuse Treatment Clinical Trials Network

Bridging the gap between research and practice

Clinicians Researchers

CTN Mission

• Conduct effectiveness research with community treatment partners– Do interventions developed and studied in research

clinics work when tested in the real world settings?– If so, how can we make these new treatments part

of usual care?

How do abstinence incentives fit into the clinical picture?

• Add-on to counseling as usual– Special intervention to enhance motivation for

sustained abstinence – Focuses on the positive to recognize and celebrate

success– Allows counselors to work on life-style changes

that can sustain abstinence beyond incentives

CTN MIEDAR StudyCTN MIEDAR Study

Participants = 800 stimulant users (cocaine or methamphetamine)

Conducted in:

6 methadone and

8 drug-free programs

Random Assignment

• Usual care

• Usual care enhanced with abstinence incentives

• 3-month evaluation

Sample CollectionSample CollectionTwice WeeklyTwice Weekly

Intermittent Reinforcement Schedule:Intermittent Reinforcement Schedule: Draws from the Abstinence BowlDraws from the Abstinence Bowl

Good

JobGood

Job

Good Job

Small Small

Small

Large

Large

Jumbo

Good Job

Good Job

Good Job

Good Job

Good Job

Small

Good Job

Small

Draws Escalate with Draws Escalate with Stimulant- and Alcohol-Free Test ResultsStimulant- and Alcohol-Free Test Results

Weeks Drug Free

# Draws

1

2

4

5

3

Bonus Draws for Bonus Draws for Opiate and Marijuana AbstinenceOpiate and Marijuana Abstinence

Weeks Drug Free

# Draws2 2 2 2 2

Half the chips are winners Half the chips are winners Examples of PrizesExamples of Prizes

SMALLSMALL ($1-$5 items)($1-$5 items)

LARGELARGE($20 items)($20 items)

JUMBOJUMBO($80-$100 items)($80-$100 items)

42% 8%

Total Earnings

• $400 in prizes could be earned on average– If participant tested negative for all targeted

drugs over 12 consecutive weeks

MIEDAR: Who participated and how did it turn out?

PATICIPANT DEMOGRAPHICS

METH PSYCH

(N=388) (N=415)

FEMALE (%) 45 55MINORITY (%) 49 58AGE (mean yrs) 42 36EDUC (mean yrs) 12 12EMPLOYED (%) 32 35PROB/PAROLE (%) 16 36METH DOSE(mg) 86 ---TIME IN TX (mos) 9 1

METHADONE PROGRAM STUDY RESULTS

Per

cen

tage

Ret

ain

ed

0

20

40

60

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2 4 6 8 10 12

RH = 1.1 CI = 0.8,1.6

Study Retention in Methadone Treatment

Control

Incentive

Percent Stimulant Negative Urines

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20

40

60

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100

1 3 5 7 9 11 13 15 17 19 21 23

Study Visit

Per

cen

tag

e o

f st

imu

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egat

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uri

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sam

ple

s

Abstinence IncentiveUsual Care

OR=1.91 (1.4-2.6)

Individual Subject Performance

21% Incentive vs

8% control

had prolonged abstinence outcome (19-24 Stimulant Negative Urines)

Outpatient Psychosocial Clinics: Contrasting Outcomes

Percent Stimulant Negative Urines

0

20

40

60

80

100

1 3 5 7 9 11 13 15 17 19 21 23

Study Visit

Per

cen

tag

e o

f st

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sam

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Abstinence Incentive

Usual Care

Study Week

Per

cen

tage

Ret

ain

ed

0

20

40

60

80

100

2 4 6 8 10 12

RH = 1.6 CI=1.2,2.0

Incentives Improve Retention in Counseling Treatment

Control

Incentive

50%

35%

Psychosocial Site Differences: Raising Performance

• Abstinence incentives worked best in clinics with lower retention – Control mean = 3.6 - 6.8 weeks

• Clinics where clients were usually retained for 8 weeks didn’t show improved retention with incentives

Individual Subject Performance

19% incentive vs 5% control had 12 weeks of stimulant negative samples

RESEARCH CONCLUSIONS

Incentives can improve client outcomes on retention and drug use when implemented in community treatment programs

Dissemination/Adoption

• Clearly recognized as one evidence-based practice advocated by program funders and licensers

• 1/4 - 1/3 of clinics are currently using incentives- mostly to reinforce attendance (Roman et al., 2010)

• Information on what it is and how to do it increasingly available– e.g. PAMI materials at www.nattc.org– programs such as this one today

Should Kids Be Bribed To Do Well In School?

TIMEMAGAZINE

April 8, 2010

Why Adopt Motivational Incentives?

from Kellogg et al., Something of Value, JSAT, 2005

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Counselors Come to Understand Reinforcement

• “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”

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Clients Like it• “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”

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Contributes to Positive Clinician-Client Interaction

• When patients publicly, and sometimes tearfully, acknowledged the counselor’s help in public, the staff felt a sense of gratitude

• “In the last two award ceremonies, clients said, ‘I want to thank the staff….’ That sounded real good – we felt appreciated”

Looking Into the Future

Peace, Prosperity and…

Prizes in every clinic!

Motivational Incentive Workshops

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Fourth Visit

Date:

Second Visit

Date:

Third Visit

Date:

Task:

3 NegativeUAs

First VisitDate:

Task:

ProbationOfficeVisit

Task:

Negative UA

Task:

Negative UA14 DayAnniversary!

Christine HigginsDissemination SpecialistCTN Mid Atlantic Node

Incentive Approaches for Clinicians

Ashli Sheidow, Ph.D.Associate Professor PsychiatryFamily Services Research CtrMedical Univ South Carolina

Incentive Contracting for Adolescents

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Jim BeitingExecutive DirectorCommunity Behavioral HealthHamilton, Ohio

Incentive Implementation for Administrators

Salon A