motivational incentives in the ctn: results, clinical implications, and dissemination christine...
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MOTIVATIONAL INCENTIVES IN THE CTN:RESULTS, CLINICAL IMPLICATIONS, AND DISSEMINATION
CHRISTINE HIGGINS,DISSEMINATION SPECIALIST,CTN-MID-ATLANTIC NODE
Greetings from
Dr. Stitzer!
Faculty, Johns Hopkins University, School of MedicinePrincipal Investigator,NIDA/CTN Mid-Atlantic Node
What you will hear today
CM/Incentives Background – Development and efficacy research
Effectiveness testing – National Drug Abuse Clinical Trials Network
Dissemination Efforts -- Blending Products, workshops and websites
Should Kids Be Bribed To Do Well In School?
TIMEMAGAZINE
April 8, 2010
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
Drug User’s DilemmaDrug User’s Dilemma
Get a jobTime with familyBetter health
Easy moneyHang with friendsGet high
CONTINUED USE
SOBERLIVING
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 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
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 MEIDAR StudyCTN MEIDAR 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
MEIDAR: Who participated and how did it turn out?
METHADONE PROGRAM STUDY RESULTS
Per
cen
tage
Ret
ain
ed
0
20
40
60
80
100
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
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
imu
lan
t n
egat
ive
uri
ne
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
imu
lan
t n
egat
ive
uri
ne
sam
ple
s
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
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
Why Adopt Motivational Incentives?
from Kellogg et al., Something of Value, JSAT, 2005
40
Counselors Come to Understand Reinforcement
• “We came to see that we need to reward people where rewards (reinforcers) in their lives were few and far between
• We use the rewards (reinforcers) as a clinical tool – not as bribery, but for recognition
• The really profound rewards will come later”
41
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”
42
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!
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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
Some applications….
A fan of the tic-tac-toe board
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
Craftsman Tool Cart
Blending Product
Helpful websites
www.nattc.org• Visit here to find on-line/downloadable
NIDA/SAMSHA blending products
www.bettertxoutcomes.org
Visit here to register for the on-line course on motivational incentives
www.motivationaincentives.org
Visit here for creative ideas and tips for implementation of contingency management.
Christine Higgins chiggin2@jhmi.edu
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