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 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
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
Why pay people to do what they should be doing anyway?
Because they aren’t doing it!
Incentives are a practical fix to atherapeutic 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)
0
20
40
60
80
100
Usual Care Case Mgt Vouchers CombinedTx
Per
cent
Rec
eivi
ng S
ervi
ces
Six-Month Outcomes
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 Chutuape et al. 2001
0
20
40
60
80
100
usual care Incentive ride + incentivePer
cent
Con
tact
ing
Tre
atm
ent
*
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
Traumatic Brain Injured Sample Percent Signing ISP
0
20
40
60
80
100
Attention MI BR IncentivePerc
ent R
etur
ning
in 3
0 da
ys
Study Condition
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
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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 consecutiveattendance during a 14 week intervention (n = 43)
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
0
20
40
60
80
100
No Incentives IncentivesPer
cent
Se s
sion
s A
tte n
d ed
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)
0
5
10
15
20
Usual Care Incentive
Ses
sion
s at
tend
ed
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
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Abstinence Incentives:Initiating and Sustaining Drug
Abstinence
Majority of research has used drug abstinence during treatment as target
by reinforcing drug negativeurine 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 Draws Escalate With Drug-Neg Test Results and Reset With PositiveDrug-Neg Test Results and Reset With Positive
Weeks Drug Free
# Draws
1
2
4
5
3
Voucher Incentives for Outpatient Drug-free Treatment of Cocaine Abusers
0
20
40
60
80
100
2 4 6 8 10 12 14 16 18 20 22 24
BehavioralStandard
Weeks of Treatment
Perc
ent
of S
ubje
cts
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
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 winnersWin frequency inversely related to cost
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
Study Week
Per
cen
tage
Ret
ain
ed
0
20
40
60
80
100
2 4 6 8 10 12
RH = 1.6 CI=1.2,2.0
Incentives Improved Retention in Counseling Treatment
Control
Incentive
50%
35%
Percent of Submitted Samples Testing Stimulant and Alcohol Negative
0
20
40
60
80
100
1 3 5 7 9 11 13 15 17 19 21 23
Study Visit
Per
cen
tag
e n
egat
ive
sam
ple
s
Abstinence Incentive
Usual Care
Methadone Maintenance Sample:Percent Stimulant Negative Urines
0
20
40
60
80
100
1 3 5 7 9 11 13 15 17 19 21 23
Study Visit
Per
cen
tag
e o
f st
imu
lan
t n
egat
ive
uri
ne
sam
ple
s
Abstinence IncentiveUsual Care
OR=1.98 (1.4-2.8)
0 4 8 0 4 8 12 16 20 24 28 32 36 40 44 48 52
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
Baseline Intervention Weeks
Perc
ent
Coc
aine
Neg
ativ
e Take-Home Plus VoucherTake-Home OnlyControl
0 10 4 8 12 16 20 24 28 32 36 40 44 48 520
25
50
75
100
5
Reducing Cocaine Use in Methadone PatientsSilverman et al., 2004
58%
36%
15%
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 long-term 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
Rate
Rates increased when WIC food vouchers were given to those who had their children immunized
(Hoekstra et al., 1998)
0
20
40
60
80
100
YES NO
Per
cent
Im
mun
ized
Receipt of HIV Test Results (Thornton R, Am. Econ Rev, 2008)
0
20
40
60
80
100
YES NO
PE
RC
EN
T
Rural Malawi residents (N = 2812) offered free HIV testingAll participated in a drawing where there could earnfrom $0 to $3 if they returned for HIV test results
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
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!
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 Evidence-Based Practice (Taylor & Francis, 2012)
Incentive programs can be implemented
And they will make a difference!
Moving Forward
Let’s talk about applying motivational Let’s talk about applying motivational incentives in this hospital!incentives in this hospital!
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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”