1. 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

3. 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

4. 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

5. Motivational Incentives Can Counteract Ambivalence
Make sober living a more
attractive option through
positive reinforcement of
abstinence and other
behavior change

7. People Respond to Consequences
Behavior can be changed by consequences
Rewards increase desired behavior
Punishment and sanctions decrease undesired behavior

8. Contingency Management: Application in Drug Abuse
Measurable target behavior
Rewarding consequence

9. 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)

10. 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

11. 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

12. Voucher Incentives in Outpatient Drug-free Treatment
Higgins et al. Am. J. Psychiatry, 1993
Cocaine negative urines

13. 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

14. 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)

15. $1000???
You’ve got to be kidding!!!

16. Nancy Petry’s Fishbowl: Intermittent Reinforcement Schedule
For cost reduction in community clinic settings

17. 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

18. 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

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

20. Percent positive for any illicit drug
Petry et al., 2000

21. Efficacy of abstinence reinforcement demonstrated
Drug-free and methadone
treatment populations
Voucher and prize draw methods

22. 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)

23. National Drug Abuse Treatment Clinical Trials Network
Bridging the gap between
research and practice
Clinicians
Researchers

24. 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?

25. 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

26. CTN MIEDAR Study
Participants = 800 stimulant users (cocaine or methamphetamine)
Conducted in:
6 methadone and
8 drug-free programs

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

28. Sample Collection
Twice Weekly

29. 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

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

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

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

33. Total Earnings $400 in prizes could be earned on average
If participant tested negative for all targeted drugs over 12 consecutive weeks

34. MIEDAR: Who participated and how did it turn out?

35. PATICIPANT DEMOGRAPHICS
METH PSYCH
(N=388) (N=415)
FEMALE (%)
MINORITY (%)
AGE (mean yrs)
EDUC (mean yrs)
EMPLOYED (%)
PROB/PAROLE (%)
METH DOSE(mg)
TIME IN TX (mos)

36. METHADONE PROGRAM STUDY RESULTS

37. 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

38. Percent Stimulant Negative Urines1 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 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

39. Individual Subject Performance
21% Incentive vs
8% control
had prolonged abstinence outcome
(19-24 Stimulant Negative Urines)

40. Outpatient Psychosocial Clinics: Contrasting Outcomes

41. Percent Stimulant Negative Urines

42. 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

43. Psychosocial Site Differences: Raising Performance
Abstinence incentives worked best in clinics with lower retention
Control mean = weeks
Clinics where clients were usually retained for 8 weeks didn’t show improved retention with incentives

44. Individual Subject Performance
19% incentive vs 5% control
had 12 weeks of
stimulant negative samples

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

46. 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
programs such as this one today

47. Should Kids Be Bribed To Do Well In School?
TIME
MAGAZINE
April 8, 2010

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

49. 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

50. 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

51. 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

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

53. Motivational Incentive Workshops

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

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

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