Transcript Stitzer - CTN Dissemination Library

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
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
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
Motivational Incentives
positive reinforcement to promote desirable behavior change
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
Reinforcement programs
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
Reward vs Reinforcement
Reward goals
Reinforcement goals
Completing treatment
Attend treatment session
Get a job
Submit a job application
Complete GED
Sign up for GED
30 days abstinent
One negative urine
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
Incentives in Substance Abuse
Treatment: Efficacy Review
• Service access and entry
• Repeated service access
• Drug use cessation and relapse prevention
Service Access and Entry
Examples from Substance Abuse
Treatment
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
Vouchers for Free Methadone
Treatment (Sorensen et al., 2006)
Six-Month Outcomes
100
80
60
40
20
0
Usual Care
Case Mgt
Vouchers
Combined
Tx
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
Care Continuity: Detox to OP
Percent Contacting Treatment
Chutuape et al. 2001
100
*
80
60
40
20
0
usual care
Incentive
ride + incentive
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
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
Residential-To-Outpatient
Transition Rates
84%*
74%*
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
Percent Returning in 30 days
Traumatic Brain Injured Sample
Percent Signing ISP
100
80
60
40
20
0
Attention
MI
BR
Study Condition
Incentive
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”
Attendance Incentives:
Encouraging People to Stay
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
Attendance Incentives in an
HIV Drop-In Center
(Petry et al., 2001)
Prize draws escalate with weeks of consecutive
attendance during a 14 week intervention (n = 43)
Average Attendance per Session
Baseline
0.7
(range 0-3)
CM intervention
7
(range 2-12)
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
Cocaine Group Attendance in
Methadone Maintenance
Transition
Clients
Consistent
Clients
100
80
60
40
20
0
No Incentives Incentives
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
Attendance in OP Treatment
$250 in prize draws
(Petry et al., 2012)
Sessions attended
20
15
10
5
0
Usual Care
Incentive
Care Continuity Study: Client Incentive
Increased OP Attendance First 30 Days
*
Incentives for Session
Attendance
Positive incentives have clearly been
useful for increasing rates of attendance
in substance abuse treatment settings
QuickTime™ and a
TIFF (Uncompressed) decompressor
are needed to see this picture.
Abstinence Incentives:
Initiating and Sustaining Drug
Abstinence
Majority of research has used drug
abstinence during treatment as target
by reinforcing drug negative
urine tests
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
Draws Escalate With
Drug-Neg Test Results and Reset With Positive
5
4
3
2
1
Weeks Drug Free
# Draws
Voucher Incentives for Outpatient
Drug-free Treatment of Cocaine Abusers
Higgins et al. Am. J. Psychiatry, 1993
Cocaine negative urines
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
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
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
Incentives Improved 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
Percentage negative samples
Percent of Submitted Samples Testing Stimulant
and Alcohol Negative
100
80
60
40
Abstinence Incentive
Usual Care
20
0
1
3
5
7
9
11
13
15
Study Visit
17
19
21
23
Percentage of stimulant negative
urine samples
Methadone Maintenance Sample:
Percent Stimulant Negative Urines
100
Abstinence Incentive
Usual Care
80
60
40
20
OR=1.98 (1.4-2.8)
0
1
3
5
7
9
11 13
15 17 19 21 23
Study Visit
Long-term effects on Cocaine Use
in Methadone Maintenance
Take-Homes Plus Vouchers (n = 26)
Random
Assignment
Take-Homes Only (n = 26)
Usual Care Control (N = 26)
0
4
8
Baseline
0
4
8
12 16
20 24 28
32 36
40
Intervention Evaluation Period
Study Weeks
Silverman et al., JCCP, 2004
44 48
52
Reducing Cocaine Use in Methadone Patients
Silverman et al., 2004
100
75
58%
50
36%
25
15%
0
0
5 10
Baseline
4
8 12 16 20 24 28 32 36 40 44 48 52
Intervention Weeks
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
Cross-Substance Generality
Cocaine
Opioids
Methamphetamine
Alcohol
Marijuana
Nicotine (Tobacco smoking)
Abstinence incentives as an add-on
to counseling promote retention and
drug-free participation
This is the building block for longterm recovery
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
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
Immunization Rates
100
80
60
40
20
0
YES
NO
Rates increased when WIC food vouchers were
given to those who had their children immunized
(Hoekstra et al., 1998)
Receipt of HIV Test Results
(Thornton R, Am. Econ Rev, 2008)
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
100
80
60
40
20
0
YES
NO
INCENTIVES
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
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
Can you do it here?
Traditional barriers to
implementation are coming down
• Attitudes
• Cost/financing
• Training resources
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
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
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
Incentive prizes don’t
need to be costly but do
need to be desirable
know your audience
Dollar Stores are full of great things!
Ask patients
what they want!
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?
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
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 EvidenceBased Practice (Taylor & Francis, 2012)
Incentive programs
can be implemented
And they will make
a difference!
Moving Forward
Let’s talk about applying motivational
incentives in this hospital!
QuickTi me™ and a
TIFF (U ncompressed) decompressor
are needed to see this picture.
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”