Transcript Open slides - CTN Dissemination Library

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
Medicine
Principal 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?
TIME
MAGAZINE
April 8, 2010
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
Drug User’s Dilemma
CONTINUED
USE
Easy money
Hang with friends
Get high
SOBER
LIVING
Get a job
Time with family
Better health
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
– During incentives
– After incentives
Stitzer et al., 1982
9%
53%
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
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
QuickTime™ and a
Pho to - JPEG de com press or
are nee ded to s ee this picture.
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
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 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 Collection
Twice Weekly
Intermittent Reinforcement Schedule:
Draws from the Abstinence Bowl
Good
Job
Small
Small
Large
Small
Good
Job
Good
Job
Good
Job
Good
Job
Good
Job
Good
Job
Small
Good
Job
Draws Escalate with
Stimulant- and Alcohol-Free Test Results
5
4
3
2
1
Weeks Drug Free
# Draws
Bonus Draws for
Opiate and Marijuana Abstinence
2
2
2
Weeks Drug Free
2
2
# Draws
Half the chips are winners
Examples of Prizes
42%
SMALL
($1-$5 items)
8%
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
MEIDAR: Who participated and
how did it turn out?
METHADONE PROGRAM
STUDY RESULTS
Study Retention in Methadone Treatment
Percentage Retained
100
80
60
Incentive
Control
40
20
0
RH = 1.1
CI = 0.8,1.6
2
4
6
8
10
12
Percentage of stimulant negative
urine samples
Percent Stimulant Negative Urines
100
Abstinence Incentive
Usual Care
80
60
40
20
OR=1.91 (1.4-2.6)
0
1
3
5
7
9
11 13
15 17 19 21 23
Study Visit
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
Percentage of stimulant negative
urine samples
100
80
60
40
Abstinence Incentive
Usual Care
20
0
1
3
5
7
9
11 13 15 17 19 21 23
Study Visit
Incentives Improve Retention in Counseling Treatment
100
Incentive
Control
Percentage Retained
80
60
50%
40
35%
20
0
RH = 1.6 CI=1.2,2.0
2
4
6
8
Study Week
10
12
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 incentivesmostly 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
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”
40
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”
41
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”
42
Looking Into the Future
Peace, Prosperity and…
Prizes in every clinic!
Some applications….
Fourth Visit Second Visit Third Visit
Date:
Date:
Task:
QuickTime™ and a
Photo - JPEG decompressor
are needed to see this picture.
3 Negative
UAs
Date:
Task:
First
Visit
Probation
OfficeVisit
Date:
Task:
Task:
Negative UA Negative UA 14 Day
Anniversary!
Christine Higgins
Dissemination Specialist
CTN Mid Atlantic Node
A fan of the tic-tac-toe board
Incentive Contracting for Adolescents
Ashli Sheidow, Ph.D.
Associate Professor Psychiatry
Family Services Research Ctr
Medical Univ South Carolina
QuickTime™ and a
Photo - JPEG decompressor
are needed to see this picture.
Jim Beiting
Executive Director
Community Behavioral Health
Hamilton, 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
[email protected]