1. Motivational Incentives: Utility in Health Care Settings Maxine Stitzer, Ph.D. Johns Hopkins Univ SOM Christiana Care Health Systems Conference Addressing Substance Use in Hospitals April 9, 2013

2. Presentation Outline Define Motivational Incentives Review utility in substance abuse treatment –Service access and entry –Repeated service access –Abstinence from abused substances Discuss application in health care settings

3. Motivational Incentives = Contingency Management What are they? –Positive reinforcement for desired behaviors –Can be social (attention; praise) or tangible items What’s the goal? –Counter ambivalence and barriers to service access –Guide people to better health and well-being by encouraging healthful and pro-social behaviors –Individual benefits and societal costs may be reduced

4. Motivational Incentives positive reinforcement to promote desirable behavior change

5. Reward programs Acknowledges patients for achieving a major goal or completing significant progress Rewards usually given to the “ best ” and most motivated patients They don ’ t change the behavior of those struggling the most with drug use and treatment compliance

6. Reinforcement programs on the other hand, use incentives to … Break down goals into very small steps Reinforce each step along the way Make it easy to learn & earn Give reinforcements early and often Include the most troubled and difficult to reach most troubled & difficult to reach patients Reinforcement programs

7. Reward vs Reinforcement Reward goals Completing treatment Get a job Complete GED 30 days abstinent Reinforcement goals Attend treatment session Submit a job application Sign up for GED One negative urine

8. Why pay people to do what they should be doing anyway? Because they aren’t doing it! Incentives are a practical fix to a therapeutic conundrum They change the therapeutic dynamic for difficult patients toward acknowledging and celebrating success rather than blaming or dwelling on failure

9. Incentives in Substance Abuse Treatment: Efficacy Review Service access and entry Repeated service access Drug use cessation and relapse prevention

10. Service Access and Entry Examples from Substance Abuse Treatment

11. Vouchers for Free Methadone Treatment (Sorensen et al., 2005) Opioid abusers (N = 126) receiving care in a hospital Randomly assigned to 4 conditions –Usual care referral –Case management for 6 months –Voucher for 6-months free methadone Tx –Combined voucher and case management

12. Vouchers for Free Methadone Treatment (Sorensen et al., 2006) Percent Receiving Services Six-Month Outcomes

13. Care Continuity: Detox to OP Chutuape et al. 2001 Participants (N = 196) from a 3-day detox invited to enroll at an outpatient Tx program Randomly assigned to: –Usual care control –$13 incentive –Van ride + incentive

14. Care Continuity: Detox to OP Chutuape et al. 2001 Percent Contacting Treatment *

15. Care Continuity: Residential to OP (Aquavita et al., JSAT, 2013) Tested 3 methods of transition from 28-day residential to outpatient aftercare treatment (N = 260) –Usual care –Client incentive –Residential in-reach

16. Care Continuity Interventions Usual care –Select program; fax referral; make appt (optional) Client Incentive –$25 to show up; $75 more for continued attendance Residential in-reach –In-person meeting with OP counselor; sign contract; next day appt

17. Residential-To-Outpatient Transition Rates 84%* 74%*

18. Incentives for Treatment Entry Follow-Through (Corrigan et al., 2005) Substance users with traumatic brain injury (N = 195) with intake completed at an OP treatment program Outcome = return to sign an individual service plan (ISP) within 30 days Randomly assigned via phone delivered intervention –Attention control –Motivational interview –Barrier reduction- pay for taxi, bus, parking, etc –Incentives- $20 gift certificate upon ISP completion

19. Traumatic Brain Injured Sample Percent Signing ISP

20. Services Access Getting People to the Door Financial incentives can motivate people to take advantage of substance abuse treatment services –vouchers for free treatment –money or gift cards for showing/returning –“barrier reduction” incentives addressing transportation Personal contact may also add value –Case management –Counselor “warm hand-offs”

21. Attendance Incentives: Encouraging People to Stay

22. Attendance Incentives in an HIV Drop-In Center (Petry et al., 2001) Average Attendance per Session Baseline CM intervention 0.7 7 (range 0-3) (range 2-12) Prize draws escalate with weeks of consecutive attendance during a 14 week intervention (n = 43)

23. Attendance: Group Therapy for Methadone Patients (Sigmon & Stitzer, 2005) Patients were assigned to attend orientation (N = 44) or cocaine (N = 58) groups 2X per week for 12 wks Prize draws could be earned on an escalating schedule for attendance; max earnings = $170

24. Cocaine Group Attendance in Methadone Maintenance Transition Clients Consistent Clients Percent Sessions Attended

25. Attendance in OP Treatment (Petry et al., 2012) Participants (N = 215) were cocaine abusers urine negative at entry to outpatient psychosocial counseling treatment Randomly assigned –Usual care –Escalating prize draws over 12 weeks; max earnings = $250

26. Attendance in OP Treatment $250 in prize draws (Petry et al., 2012) Sessions attended

27. Care Continuity Study: Client Incentive Increased OP Attendance First 30 Days *

28. Incentives for Session Attendance Positive incentives have clearly been useful for increasing rates of attendance in substance abuse treatment settings

29. Abstinence Incentives: Initiating and Sustaining Drug Abstinence Majority of research has used drug abstinence during treatment as target by reinforcing drug negative urine tests

30. Voucher Reinforcement for abstinence initiation and maintenance in cocaine abusers Principle of alternative reinforcement: –Benefits of abstinence are long-term –Making abstinence today a more attractive option Points earned for cocaine negative urine results –Escalating schedule of point earnings –Trade in points for goods –$1000 available over 3 months

31. Draws Escalate With Drug-Neg Test Results and Reset With Positive Weeks Drug Free # Draws 1 2 4 5 3

32. Voucher Incentives for Outpatient Drug-free Treatment of Cocaine Abusers Higgins et al. Am. J. Psychiatry, 1993 Cocaine negative urines

33. Intermittent schedule/prize system  Draws from a fishbowl  Advantages: may be more fun and less expensive than vouchers; cost can be controlled via number and cost of prizes and percentage of winning chips

34.  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 winners Win frequency inversely related to cost

35. CTN MIEDAR Study ( Stitzer, Petry, Peirce et al., 2005) Participants in OP drug-free Tx could earn up to $400 in prizes on average during 12-week study if they tested negative for cocaine, methamphetamine alcohol, opiates, and marijuana

36. Study Week Percentage Retained 0 20 40 60 80 100 24681012 RH = 1.6 CI=1.2,2.0 Incentives Improved Retention in Counseling Treatment Control Incentive 50% 35%

37. Percent of Submitted Samples Testing Stimulant and Alcohol Negative 0 20 40 60 80 100 1357911131517192123 Study Visit Percentage negative samples Abstinence Incentive Usual Care

38. Methadone Maintenance Sample: Percent Stimulant Negative Urines 0 20 40 60 80 100 1357911131517192123 Study Visit Percentage of stimulant negative urine samples Abstinence Incentive Usual Care OR=1.98 (1.4-2.8)

39. 048 0481216202428323640444852 Intervention Evaluation Period Study Weeks Baseline Usual Care Control (N = 26) Take-Homes Only (n = 26) Take-Homes Plus Vouchers (n = 26) Random Assignment Long-term effects on Cocaine Use in Methadone Maintenance Silverman et al., JCCP, 2004

40. Reducing Cocaine Use in Methadone Patients Silverman et al., 2004 58% 36% 15%

41. Abstinence Incentives Promotes initial abstinence when drug use is on-going Promotes increased duration of drug-free treatment participation after drug use stops –i.e. works for relapse prevention Positive impact on long-term outcomes –Longer during-treatment abstinence translates into better long-term outcome

42. Cross-Substance Generality CocaineOpioids Methamphetamine Alcohol Marijuana Nicotine (Tobacco smoking)

43. Abstinence incentives as an add-on to counseling promote retention and drug-free participation This is the building block for long- term recovery

44. Summary Positive incentives in the form of vouchers or prize draws can be therapeutically helpful in several ways to promote: –services access and entry –continued involvement in services –abstinence and relapse prevention

45. Potential Application in Health Care Access specialty services –e.g. vaccinations; prenatal and pediatric care Keep follow-up medical appointments Address drug use as a barrier Take prescribed medicines Promote lifestyle change

46. Immunization Rates Rate Rates increased when WIC food vouchers were given to those who had their children immunized (Hoekstra et al., 1998) Percent Immunized

47. Receipt of HIV Test Results (Thornton R, Am. Econ Rev, 2008) PERCENT Rural Malawi residents (N = 2812) offered free HIV testing All participated in a drawing where there could earn from $0 to $3 if they returned for HIV test results INCENTIVES

48. Pregnancy-Focused Incentive Schemes In Developing Nations Bangladesh –Food, cash, baby gifts for pre and post-natal care and delivery in a health clinic Uganda –Motorcyclists paid to transport pregnant women to maternity clinic Rwanda –Health teams paid for baby deliveries, family planning and vaccinations

49. Incentive Applications at Christiana Care 100 mothers per year go through opioid detox But may not have optimal outcomes due to fragmented care and lack of follow-through

50. Can you do it here? Traditional barriers to implementation are coming down Attitudes Cost/financing Training resources

51. Incentives can help overcome barriers and move patients along a motivational continuum What’s in it for them to attend medical visits and/or stop their drug use? Drug users especially like immediate gratification Long-term benefits to health are theoretical, largely intangible and in the future Incentives bring benefits forward in time and make them tangible

52. Does everyone need incentives? Principle of “justice” suggests incentives should be given to everyone but- Incentives have best application for those who struggle with adherence despite lower-intensity interventions such as appointment reminders

53. Financing Ideally, incentives would be built into the budget and offset by health care cost savings Meanwhile, there are some work-arounds –Community donations (women and children) –Staff donations of goods and/or money –Small grants or agency-funded pilot projects

54. Dollar Stores are full of great things! Incentive prizes don’t need to be costly but do need to be desirable know your audience Ask patients what they want!

55. Implementation Needs Planning Who will be offered incentives? How will program be structured? –How much and for how long? Who will manage and coordinate the program? How will incentives be purchased and financed? Where can staff get training and advice? How will impact be evaluated?

56. Training Resources CTN Blending Products provide principles, advice and examples for structuring an incentive program –Identifying effective reinforcers –Constructing fishbowls –Escalating schedules Expert consultants are also available through CTN and ATTC

57. Training Resources NIDA Blending Products –PAMI –MI PRESTO (includes CD) –www.ctndisseminationlibrary.org Petry Manual –Contingency Management for Substance Abuse Treatment. A guide to Implementing This Evidence- Based Practice (Taylor & Francis, 2012)

58. Incentive programs can be implemented And they will make a difference!

59. Moving Forward Let’s talk about applying motivational incentives in this hospital!

60. Addressing Christiana Care Goals For Pregnant Women Regular pediatric and post-natal appointments –Consider offering gift cards or prize draws Remove drug use as a barrier –Consider treatment entry vouchers –Consider case management or “warm hand-offs”