The opportunity to win rewards worth as little as $1 for abstinence can help motivate outpatients to stay in behavioral therapy and remain drug-free, according to a NIDA Clinical Trials Network (CTN) study. At eight community-based addiction treatment programs across the United States, stimulant abusers who could earn a chance to win a prize by providing drug-free urine samples were four times as likely as peers who were not offered this incentive to attain 12 weeks of continuous abstinence. Prizes for the incentive intervention cost the programs about $200, or $2.42 a day per participant.
Many addiction treatment clinics face the challenge of high patient dropout rates. Reinforcing abstinence helps keep patients interested in attending treatment for longer periods, which can facilitate behavioral changes to keep them off drugs for the long haul," says Dr. Nancy Petry of the University of Connecticut School of Medicine, coleader of the study. Prior research has found that, no matter how it is achieved, duration of abstinence during treatment is one of the best predictors of abstinence 1 year later. "More patients achieve this therapeutic milestone with a boost from incentive programs," says the study's other coleader, Dr. Maxine Stitzer of The Johns Hopkins University School of Medicine.
The CTN investigators randomly assigned 415 treatment-seeking stimulant abusers (see chart) to one of two conditions: usual care or usual care plus abstinence-based incentives for 12 weeks. Usual care typically consisted of group counseling, although some patients received individual and family therapy. Patients gave urine and breath samples twice weekly. Research assistants tested the urine samples for stimulants, opiates, and marijuana, and tested the breath samples for alcohol.
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Each participant in the incentive condition received immediate feedback on his or her samples. After submitting stimulant- and alcohol-negative samples, the patient could draw from an opaque container with 500 chips, each with words of encouragement or an assigned value: Half of the chips simply said, "good job;" 209 could be traded for $1 prizes, 40 for $20 prizes, and 1 for a $100 prize. Prizes were conferred immediately and included many options, ranging from toiletries, snacks, and bus tokens to kitchen items, telephones, and retail store certificates for televisions, music players, and DVD players. The number of draws earned increased by one each week in which all the patient's samples were stimulant- and alcohol-negative, but fell back to one following a positive sample or an unexcused absence. When a participant first achieved two consecutive weeks of abstinence, he or she received a $20 prize. Participants who submitted stimulant- and alcohol-negative samples could earn two bonus draws a week if their urine samples were also opioid- and marijuana-negative.
More patients in the incentive program (49 percent) than in usual care (35 percent) completed 12 weeks of counseling. Patients in the incentive group achieved an average duration of sustained abstinence of 4.4 consecutive weeks, compared with only 2.6 weeks among counseling-only patients. Nineteen percent of patients receiving the incentive intervention attained 12 weeks of continuous abstinence compared with 5 percent of those in usual care. Intervention patients also attended more counseling sessions (19 versus 16) and submitted more stimulant-negative urine samples during treatment than patients in usual care (48 versus 36 percent).
Blending Initiative Disseminates Information on Low-Cost Incentives
Clinicians and administrators who wish to learn more about using low-cost incentives to motivate patients to stay off drugs can get information through the Blending Initiative, a program established by NIDA and the Substance Abuse and Mental Health Services Administration to speed the adoption of scientific findings into drug abuse treatment. The Blending Initiative has developed an awareness program that disseminates practical information on low-cost incentive programs and a summary of research evidence that supports their use as an adjunct to addiction treatment.
A DVD/CD-ROM describes the principles underlying incentive programs, the range of behaviors that clinics can target, and findings from studies of the intervention with a variety of patient populations. In the video component, clinicians, patients, and managers describe their experiences with the use of low-cost incentives in Manhattan and Connecticut outpatient methadone treatment programs. Viewers observe a group of Connecticut clients participating in a prize draw and a panel of directors and clinical managers discussing implementation challenges, ways to overcome problems, and the reasons they think the low-cost incentive program is effective. The CD-ROM component includes a flexible PowerPoint presentation suited for executive briefings or a 3-hour workshop. The Blending Initiative expects to release the information package in fall 2006, and it will be posted on NIDA's Web site, and on the Addiction Technology Transfer Center (ATTC) Web site, www.nattc.org.
"We anticipate that the awareness campaign will leave the addiction treatment community wanting more, for example, Web-based training and workshops on how to implement low-cost incentive programs," says Ms. Lonnetta Albright, director of the Great Lakes ATTC and leader of the Promoting Awareness of Motivational Incentives Blending Team. The 2006 Blending Initiative program, "Bridges to the Future," was held October 16 and 17, 2006 in Seattle, Washington (see http://www.seiservices.com/blendingseattle/topics.htm).
Incentives Accentuate the Positive
"Incentive programs, including low-cost ones, add excitement and additional reasons to attend substance abuse treatment. Many substance abusers are ambivalent about treatment, and rewards may help them stay involved in counseling," says Dr. Petry. Extending retention in treatment may prolong abstinence, in part, because it gives counselors more time to help patients re-engage in a drug-free lifestyle, says Dr. Stitzer. Helping patients sustain abstinence once they leave therapy is a challenge for all treatments, including incentive programs.
Some previous clinical trials of voucher-based incentive programs showed benefits of the treatment persisting for 1 to 2 years, but others found no added value over the long term compared with usual care. Further research will focus on followup with patients to determine the conditions under which incentive interventions, particularly as applied by community-based treatment programs, support extended abstinence.
Other relatively small, often single-site NIDA-funded clinical trials over the past 15 years have demonstrated that motivational incentives are an effective adjunct to standard therapy for opiate-, marijuana-, alcohol-, and cocaine-addicted patients. Patients in most of those early studies always received vouchers exchangeable for goods or services, rather than chances to win prizes, for positive behaviors; costs typically ran to about $1,000 per patient over 3 months, with the result that few community programs adopted the motivational incentive approach. Dr. Petry developed her prize-drawing system to make incentives affordable for community programs. She has tested it successfully in several Connecticut treatment programs, and now its effectiveness is confirmed by the CTN trial. NIDA is collaborating with the Substance Abuse and Mental Health Services Administration's Addiction Technology Transfer Center to promote awareness of the low-cost motivational incentive technique (see textbox).
The CTN researchers note that some community-based treatment providers resist the idea of motivational incentives based on a belief that clinicians should not reward patients for behaviors "that they are supposed to do anyway." In response, the researchers point out that groups and individuals often use external incentives to motivate others—from employees' bonuses to children's allowances for household chores. Dr. Stitzer advocates a shift in perspective from punishing lapses to celebrating successes. She observes that counselors have often changed their views when they have seen incentives help revolving-door patients stay in therapy. "Incentive programs—the idea of catching people being good and rewarding the behavior—can infuse addiction treatment with a positive outlook and reinvigorate patients and counselors," says Dr. Stitzer.
Petry, N.M., et al. Effect of prize-based incentives on outcomes in stimulant abusers in outpatient psychosocial treatment programs: A National Drug Abuse Treatment Clinical Trials Network Study. Archives of General Psychiatry 62(10):1148-1156, 2005. [Abstract]