Regional Dissemination Conference Contingency Management Motivational Incentives: Past, Present and Future Maxine Stitzer, Ph.D. Johns Hopkins University SOM NIDA/CTN Regional Dissemination Conference Baltimore, MD June 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 Dilemma Sober Living Continued Use Get a job Easy money Time with family Better health Easy money Hang with friends Get high Sober Living Continued Use

Motivational Incentives Can Counteract Ambivalence Make sober living a more attractive option through positive reinforcement of abstinence and other behavior 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 Higgins et al. Am. J. Psychiatry, 1993 Cocaine negative urines

Voucher Incentives in Cocaine Abusing Methadone Patients Silverman et al., 1996 100 Control Vouchers 80 Percent Cocaine Negative 60 * * * * * * * * 40 20 1 2 3 4 5 2 4 6 8 10 12 Baseline Intervention Weeks

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

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

Half the slips are winners Win frequency inversely related to cost largest chance of winning a small $1 prize moderate chance of winning a large $20 prize small chance of winning a jumbo $100 prize

Retention: Alcoholics in Outpatient Psychosocial Treatment Petry et al., 2000

Percent positive for any illicit drug 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 Study Participants = 800 stimulant users (cocaine or methamphetamine) Conducted in: 6 methadone and 8 drug-free programs

Random Assignment • Usual care enhanced with abstinence incentives 3-month evaluation

Sample Collection Twice Weekly

Intermittent Reinforcement Schedule: Draws from the Abstinence Bowl Good Job Small Jumbo Good Job Large Small Small Large Small Good Job Good Job Good Job Good Job Good Job Good Job Small Good Job

Stimulant- and Alcohol-Free Test Results Draws Escalate with Stimulant- and Alcohol-Free Test Results Weeks Drug Free # Draws 1 2 4 5 3

Opiate and Marijuana Abstinence Bonus Draws for Opiate and Marijuana Abstinence # Draws 2 2 2 2 2 Weeks Drug Free

Half the chips are winners Examples of Prizes 42% 8% SMALL ($1-$5 items) LARGE ($20 items) JUMBO ($80-$100 items)

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

METHADONE PROGRAM STUDY RESULTS

Study Retention in Methadone Treatment 100 80 Percentage Retained 60 Control Incentive 40 20 RH = 1.1 CI = 0.8,1.6 2 4 6 8 10 12

Percent Stimulant Negative Urines 1 A b s t i n e c I v U u a l C r 8 6 Percentage of stimulant negative urine samples 4 2 OR=1.91 (1.4-2.6) 1 3 5 7 9 1 1 1 3 1 5 1 7 1 9 2 1 2 3 S t u d y V i s i t

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

Incentives Improve Retention in Counseling Treatment 100 Control Incentive 80 60 50% Percentage Retained 40 35% 20 RH = 1.6 CI=1.2,2.0 2 4 6 8 10 12 Study Week

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? TIME MAGAZINE April 8, 2010

Why Adopt Motivational Incentives. from Kellogg et al Why Adopt Motivational Incentives? from Kellogg et al., Something of Value, JSAT, 2005

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” 49 49

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” 50 50

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” 51 51

Looking Into the Future Peace, Prosperity and… Prizes in every clinic!

Motivational Incentive Workshops

Incentive Approaches for Clinicians Christine Higgins Dissemination Specialist CTN Mid Atlantic Node

Incentive Contracting for Adolescents Ashli Sheidow, Ph.D. Associate Professor Psychiatry Family Services Research Ctr Medical Univ South Carolina

Incentive Implementation for Administrators Salon A Jim Beiting Executive Director Community Behavioral Health Hamilton, Ohio