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”