Greetings from Dr. Stitzer!

1. Motivational Incentives IN THE CTN:Results, clinical Implications, and disseminationChristine Higgins,Dissemination Specialist,CTN-Mid-Atlantic Node

2. Greetings from Dr. Stitzer! Faculty, Johns Hopkins University, School of Medicine Principal Investigator, NIDA/CTN Mid-Atlantic Node

4. 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

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

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

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

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

10. Drug User’s Dilemma CONTINUED USE SOBER LIVING Get a job Time with family Better health Easy money Hang with friends Get high

11. 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)

12. 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

13. 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

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 winnersWin 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. 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

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

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

22. Sample Collection Twice Weekly

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

24. 5 4 # Draws 3 2 1 Weeks Drug Free Draws Escalate with Stimulant- and Alcohol-Free Test Results

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

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

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

28. MEIDAR: Who participated and how did it turn out?

29. METHADONE PROGRAM STUDY RESULTS

30. Incentive Control Study Retention in Methadone Treatment 100 80 Percentage Retained 60 40 20 RH = 1.1 CI = 0.8,1.6 0 2 4 6 8 10 12

31. A b s t i n e n c e I n c e n t i v e U s u a l C a r e Percent Stimulant Negative Urines 1 0 0 8 0 6 0 Percentage of stimulant negative urine samples 4 0 2 0 OR=1.91 (1.4-2.6) 0 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

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

33. Outpatient Psychosocial Clinics: Contrasting Outcomes

34. Percent Stimulant Negative Urines

35. Control Incentive Incentives Improve Retention in Counseling Treatment 100 80 60 50% Percentage Retained 40 35% 20 RH = 1.6 CI=1.2,2.0 0 2 4 6 8 10 12 Study Week

36. 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

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

38. 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

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

40. 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

41. 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

42. 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

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

44. Some applications…. Christine Higgins Dissemination Specialist CTN Mid Atlantic Node A fan of the tic-tac-toe board

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

46. Jim Beiting Executive Director Community Behavioral Health Hamilton, Ohio Craftsman Tool Cart

47. Blending Product

48. 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.

49. Christine Higgins chiggin2@jhmi.edu