1
|
Kim YG, Brandt L, Cheung K, Nunes EV, Roll J, Luo SX, Liu Y. Optimizing Contingency Management with Reinforcement Learning. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.03.28.24305031. [PMID: 38585900 PMCID: PMC10996730 DOI: 10.1101/2024.03.28.24305031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/09/2024]
Abstract
Contingency Management (CM) is a psychological treatment that aims to change behavior with financial incentives. In substance use disorders (SUDs), deployment of CM has been enriched by longstanding discussions around the cost-effectiveness of prized-based and voucher-based approaches. In prize-based CM, participants earn draws to win prizes, including small incentives to reduce costs, and the number of draws escalates depending on the duration of maintenance of abstinence. In voucher-based CM, participants receive a predetermined voucher amount based on specific substance test results. While both types have enhanced treatment outcomes, there is room for improvement in their cost-effectiveness: the voucher-based system requires enduring financial investment; the prize-based system might sacrifice efficacy. Previous work in computational psychiatry of SUDs typically employs frameworks wherein participants make decisions to maximize their expected compensation. In contrast, we developed new frameworks that clinical decision-makers choose actions, CM structures, to reinforce the substance abstinence behavior of participants. We consider the choice of the voucher or prize to be a sequential decision, where there are two pivotal parameters: the prize probability for each draw and the escalation rule determining the number of draws. Recent advancements in Reinforcement Learning, more specifically, in off-policy evaluation, afforded techniques to estimate outcomes for different CM decision scenarios from observed clinical trial data. We searched CM schemas that maximized treatment outcomes with budget constraints. Using this framework, we analyzed data from the Clinical Trials Network to construct unbiased estimators on the effects of new CM schemas. Our results indicated that the optimal CM schema would be to strengthen reinforcement rapidly in the middle of the treatment course. Our estimated optimal CM policy improved treatment outcomes by 32% while maintaining costs. Our methods and results have broad applications in future clinical trial planning and translational investigations on the neurobiological basis of SUDs.
Collapse
Affiliation(s)
- Young-Geun Kim
- Mailman School of Public Health, Department of Biostatistics, New York, NY, USA
- Columbia University Irving Medical Center, Department of Psychiatry, New York, NY, USA
| | - Laura Brandt
- City College of New York, Department of Psychology, New York, NY, USA
| | - Ken Cheung
- Mailman School of Public Health, Department of Biostatistics, New York, NY, USA
| | - Edward V Nunes
- Columbia University Irving Medical Center, Department of Psychiatry, New York, NY, USA
- New York State Psychiatric Institute, Division on Substance Use Disorders, New York, NY, USA
| | - John Roll
- Washington State University, Department of Community and Behavioral Health, Spokane, WA, USA
- Washington State University, Program of Excellence in Addictions Research, Spokane, WA, USA
| | - Sean X Luo
- Columbia University Irving Medical Center, Department of Psychiatry, New York, NY, USA
- New York State Psychiatric Institute, Division on Substance Use Disorders, New York, NY, USA
| | - Ying Liu
- Columbia University Irving Medical Center, Department of Psychiatry, New York, NY, USA
| |
Collapse
|
2
|
Dallery J, Ives L, Knerr A. Toward an era of impact of digital contingency management in the treatment of substance use disorders. Prev Med 2023; 176:107518. [PMID: 37080501 DOI: 10.1016/j.ypmed.2023.107518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 04/03/2023] [Accepted: 04/15/2023] [Indexed: 04/22/2023]
Abstract
Digital contingency management entails remote methods to obtain biochemical confirmation of drug status and provide desirable, tangible consequences contingent on abstinence. Advances in digital CM suggest that it may be on the cusp of making a public health impact. Specific advances include technological capabilities and affordability, companies that specialize in digital CM, policies and reimbursement models, and the increasing availability of resources related to CM. Digital CM has expanded from cigarette smoking to alcohol and illicit substance misuse, and to include a diverse range of underserved and high-risk groups (e.g., pregnant and postpartum women, socioeconomically disadvantaged individuals, adolescents, and rural populations). Although the digital divide continues to narrow, culturally responsive methods may increase uptake and engagement with digital CM. The promise of digital CM is widescale access to an evidence-based treatment with low staff burden, no side effects, high fidelity engagement, acceptability, and effectiveness, and greater equity. We may be close to realizing this promise.
Collapse
|
3
|
Orme S, Zarkin GA, Luckey J, Dunlap LJ, Novak MD, Holtyn AF, Toegel F, Silverman K. Cost and cost-effectiveness of abstinence contingent wage supplements. Drug Alcohol Depend 2023; 244:109754. [PMID: 36638680 PMCID: PMC10207811 DOI: 10.1016/j.drugalcdep.2022.109754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 12/14/2022] [Accepted: 12/19/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Substance use disorders are correlated with unemployment and poverty. However, few interventions aim to improve substance use, unemployment, and, distally, poverty. The Abstinence-Contingent Wage Supplement (ACWS) randomized controlled trial combined a therapeutic workplace with abstinence-contingent wage supplements to address substance use and unemployment. The ACWS study found that abstinence-contingent wage supplements increased the percentage of participants who had negative drug tests, who were employed, and who were above the poverty line during the intervention period. This study presents the cost of ACWS and calculates the cost-effectiveness of ACWS compared with usual care. METHODS To calculate the cost and cost-effectiveness of ACWS, we used activity-based costing methods to cost the intervention and calculated the costs from the provider and healthcare sector perspective. We calculated incremental cost-effectiveness ratios and cost-effectiveness acceptability curves for negative drug tests and employment. RESULTS ACWS cost $11,310 per participant over the 12-month intervention period. Total intervention and healthcare costs per participant over the intervention period were $20,625 for usual care and $30,686 for ACWS. At the end of the intervention period an additional participant with a negative drug test cost $1437 while an additional participant employed cost $915. CONCLUSIONS ACWS increases drug abstinence and employment and may be cost-effective at the end of the 12-month intervention period if decision makers are willing to pay the incremental cost associated with the intervention.
Collapse
Affiliation(s)
- Stephen Orme
- RTI International, Research Triangle Park, NC, United States.
| | - Gary A Zarkin
- RTI International, Research Triangle Park, NC, United States
| | - Jackson Luckey
- RTI International, Research Triangle Park, NC, United States
| | - Laura J Dunlap
- RTI International, Research Triangle Park, NC, United States
| | - Matthew D Novak
- Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - August F Holtyn
- Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Forrest Toegel
- Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Kenneth Silverman
- Johns Hopkins University School of Medicine, Baltimore, MD, United States
| |
Collapse
|
4
|
Coughlin LN, Bonar EE, Walton MA, Fernandez AC, Duguid I, Nahum-Shani I. New Directions for Motivational Incentive Interventions for Smoking Cessation. Front Digit Health 2022; 4:803301. [PMID: 35310552 PMCID: PMC8931767 DOI: 10.3389/fdgth.2022.803301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 01/31/2022] [Indexed: 11/13/2022] Open
Abstract
Background Motivational incentive interventions are highly effective for smoking cessation. Yet, these interventions are not widely available to people who want to quit smoking, in part, due to barriers such as administrative burden, concern about the use of extrinsic reinforcement (i.e., incentives) to improve cessation outcomes, suboptimal intervention engagement, individual burden, and up-front costs. Purpose Technological advancements can mitigate some of these barriers. For example, mobile abstinence monitoring and digital, automated incentive delivery have the potential to lower the clinic burden associated with monitoring abstinence and administering incentives while also reducing the frequency of clinic visits. However, to fully realize the potential of digital technologies to deliver motivational incentives it is critical to develop strategies to mitigate longstanding concerns that reliance on extrinsic monetary reinforcement may hamper internal motivation for cessation, improve individual engagement with the intervention, and address scalability limitations due to the up-front cost of monetary incentives. Herein, we describe the state of digitally-delivered motivational incentives. We then build on existing principles for creating just-in-time adaptive interventions to highlight new directions in leveraging digital technology to improve the effectiveness and scalability of motivational incentive interventions. Conclusions Technological advancement in abstinence monitoring coupled with digital delivery of reinforcers has made the use of motivational incentives for smoking cessation increasingly feasible. We propose future directions for a new era of motivational incentive interventions that leverage technology to integrate monetary and non-monetary incentives in a way that addresses the changing needs of individuals as they unfold in real-time.
Collapse
Affiliation(s)
- Lara N. Coughlin
- Addiction Center, Department of Psychiatry, University of Michigan, Ann Arbor, MI, United States
- Injury Prevention Center, University of Michigan, Ann Arbor, MI, United States
- *Correspondence: Lara N. Coughlin
| | - Erin E. Bonar
- Addiction Center, Department of Psychiatry, University of Michigan, Ann Arbor, MI, United States
- Injury Prevention Center, University of Michigan, Ann Arbor, MI, United States
| | - Maureen A. Walton
- Addiction Center, Department of Psychiatry, University of Michigan, Ann Arbor, MI, United States
- Injury Prevention Center, University of Michigan, Ann Arbor, MI, United States
| | - Anne C. Fernandez
- Addiction Center, Department of Psychiatry, University of Michigan, Ann Arbor, MI, United States
| | - Isabelle Duguid
- Addiction Center, Department of Psychiatry, University of Michigan, Ann Arbor, MI, United States
| | - Inbal Nahum-Shani
- Institute for Social Research, University of Michigan, Ann Arbor, MI, United States
| |
Collapse
|
5
|
McCurdy AJ, Normand MP. The effects of a group‐deposit prize draw on the step counts of sedentary and low active adults. BEHAVIORAL INTERVENTIONS 2022. [DOI: 10.1002/bin.1869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Alex J. McCurdy
- Department of Psychology University of the Pacific Stockton California USA
| | - Matthew P. Normand
- Department of Psychology University of the Pacific Stockton California USA
| |
Collapse
|
6
|
Koffarnus MN, Kablinger AS, Kaplan BA, Crill EM. Remotely administered incentive-based treatment for alcohol use disorder with participant-funded incentives is effective but less accessible to low-income participants. Exp Clin Psychopharmacol 2021; 29:555-565. [PMID: 34110885 PMCID: PMC8943847 DOI: 10.1037/pha0000503] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The delivery of monetary incentives contingent on verified abstinence is an effective treatment for alcohol use disorder. However, incentive cost has often been cited as a barrier to delivering this type of treatment. In the present randomized parallel groups trial, we systematically replicated a previous trial we conducted that employed remote alcohol monitoring and incentive delivery to promote abstinence from alcohol, but with the additional requirement for participants to partially self-fund their abstinence incentives. Treatment-seeking participants with alcohol use disorder (n = 92) who met inclusion criteria (n = 36) were randomized to either a Contingent or Noncontingent group (n = 18 each). Those not meeting inclusion criteria included 15 participants who agreed to the deposit requirement but failed to make the deposit payment. The Contingent group received nearly immediate monetary incentives each day they remotely provided negative breathalyzer samples. The Noncontingent group received matched incentives each day they successfully provided samples independent of alcohol content. Days abstinent in the Contingent group were 86%, which was significantly higher than the 44% recorded in the Noncontingent group, corresponding to an odds ratio of 8.2. Exploratory analyses revealed that the deposit requirement prevented participation in those with lower incomes and those with greater alcohol use. These results support the efficacy of this remotely deliverable alcohol abstinence reinforcement incentive intervention with a deposit requirement. However, the requirement to provide a monetary deposit to self-fund abstinence incentives may prevent those with greater alcohol use and/or those experiencing extreme poverty from participating in the intervention. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
Collapse
Affiliation(s)
- Mikhail N. Koffarnus
- Department of Family and Community Medicine, University of Kentucky College of Medicine
| | - Anita S. Kablinger
- Psychiatry and Behavioral Medicine, Virginia Tech Carilion School of Medicine
| | - Brent A. Kaplan
- Department of Family and Community Medicine, University of Kentucky College of Medicine
| | - Elisa M. Crill
- Department of Family and Community Medicine, University of Kentucky College of Medicine
| |
Collapse
|
7
|
A Novel Adaptation of Peer Health Navigation and Contingency Management for Advancement Along the HIV Care Continuum Among Transgender Women of Color. AIDS Behav 2021; 25:40-51. [PMID: 31187355 DOI: 10.1007/s10461-019-02554-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Transgender women, particularly racial/ethnic minority transgender women, evidence disproportionately high rates of untreated HIV infection and disproportionately low rates of HIV viral suppression. The Alexis Project was a combined peer health navigation (PHN) and contingency management (CM) intervention that targeted HIV milestones associated with advancement along the HIV care continuum. From February 2014 through August 2016, 139 transgender women of color (TWOC) enrolled and received unlimited PHN sessions and an escalating CM rewards schedule for confirmed achievement of both behavioral (e.g., HIV care visits) and biomedical (e.g., viral load reductions and achieved/sustained viral suppression) HIV milestones. Results demonstrated that increased attendance to PHN sessions was associated with significant achievement of both behavioral (coef. range 0.12-0.38) and biomedical (coef. = 0.10) HIV milestones (all p ≤ 0.01); 85% were linked to HIV care, and 83% who enrolled detectable and achieved the minimum 1 log viral load reduction advanced to full viral suppression. The combined PHN and CM intervention successfully promoted advancement along the HIV Care Continuum, with particularly robust effects for behavioral HIV milestones.
Collapse
|
8
|
Fraser ER, Hill-Kapturczak N, Jett J, Beck R, Oluwoye O, Kriegel LS, Alcover KC, McPherson S, Cabassa LJ, Javors M, McDonell MG. Mixed-methods trial of a phosphatidylethanol-based contingency management intervention to initiate and maintain alcohol abstinence in formerly homeless adults with alcohol use disorders. Contemp Clin Trials Commun 2021; 22:100757. [PMID: 33763620 PMCID: PMC7973861 DOI: 10.1016/j.conctc.2021.100757] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 01/27/2021] [Accepted: 03/01/2021] [Indexed: 12/03/2022] Open
Abstract
Background Contingency management (CM) is an intervention where incentives are provided in exchange for biochemically confirmed alcohol abstinence. CM is effective at initiating alcohol abstinence, but it is less effective at maintaining long-term abstinence. Phosphatidylethanol (PEth), collected via a finger-stick, can detect alcohol use for 14–28 days. PEth allows for the development of a CM model that includes increasingly less frequent monitoring of abstinence to assist high risk groups, such as formerly homeless individuals, maintain long-term abstinence. Aims Investigate whether PEth-based CM intervention targeting alcohol abstinence in formerly homeless, currently housed individuals with alcohol use disorders is: (1) acceptable and feasible for housing program tenants and personnel; and is associated with increased (2) alcohol abstinence and (3) housing tenure. Methods Acceptability and feasibility will be assessed using a QUAL+quant mixed-methods design using qualitative interviews and quantitative measures of satisfaction and attrition. Effectiveness will be evaluated through a randomized pilot trial of 50 study participants who will receive 6 months of either treatment as usual (TAU) including incentives (e.g., gift cards) for providing blood samples (Control Condition) or TAU and incentives for negative PEth results (PEth-CM Condition). Outcomes will be assessed during the intervention and at a three-month follow-up visit. The trial will be conducted via telehealth as a result of COVID-19. Discussion This protocol seeks to utilize a novel alcohol biomarker to evaluate the acceptability, feasibility, and initial effectiveness of a CM model that encourages long-term abstinence in a high-risk group.
Collapse
Affiliation(s)
- Elizabeth R Fraser
- Behavioral Health Innovations, Washington State University, Spokane, WA, USA
| | - Nathalie Hill-Kapturczak
- Biological Psychiatry Analytical Lab, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Julianne Jett
- Behavioral Health Innovations, Washington State University, Spokane, WA, USA.,Elson S. Floyd College of Medicine, Washington State University, Spokane, WA, USA
| | - Rachael Beck
- Behavioral Health Innovations, Washington State University, Spokane, WA, USA
| | - Oladunni Oluwoye
- Behavioral Health Innovations, Washington State University, Spokane, WA, USA.,Elson S. Floyd College of Medicine, Washington State University, Spokane, WA, USA
| | - Liat S Kriegel
- Behavioral Health Innovations, Washington State University, Spokane, WA, USA.,Elson S. Floyd College of Medicine, Washington State University, Spokane, WA, USA
| | - Karl C Alcover
- Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Sterling McPherson
- Elson S. Floyd College of Medicine, Washington State University, Spokane, WA, USA
| | - Leopoldo J Cabassa
- Brown School of Social Work, Washington University in St. Louis, St. Louis, MO, USA
| | - Martin Javors
- Biological Psychiatry Analytical Lab, University of Texas Health San Antonio, San Antonio, TX, USA
| | - Michael G McDonell
- Behavioral Health Innovations, Washington State University, Spokane, WA, USA.,Elson S. Floyd College of Medicine, Washington State University, Spokane, WA, USA
| |
Collapse
|
9
|
A Pilot Study of Youth With Type 1 Diabetes Initiating Use of a Hybrid Closed-Loop System While Receiving a Behavioral Economics Intervention. Endocr Pract 2020; 27:545-551. [PMID: 34120699 DOI: 10.1016/j.eprac.2020.11.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 10/22/2020] [Accepted: 11/07/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Many youth do not use the hybrid closed-loop system for type 1 diabetes effectively. This study evaluated the impact of financial incentives for diabetes-related tasks on use of the 670G hybrid closed-loop system and on glycemia. METHODS At auto mode initiation and for 16 weeks thereafter, participants received a flat rate for wearing and calibrating the sensor ($1/day), administering at least 3 mealtime insulin boluses per day ($1/day), and uploading ($5/week). Weekly bonuses were given for maintaining at least 70% of the time in auto mode, which were increased for persistent auto mode use from $3/week to a maximum of $13/week. If a participant failed to maintain auto mode for a week, the rewards were reset to baseline. Data from 17 participants aged 15.9 years ± 2.5 years (baseline hemoglobin A1c [HbA1c] 8.6% ± 1.1%) were collected at 6, 12, and 16 weeks. The reinforcers were withdrawn at 16 weeks, with a follow-up assessment at 24 weeks. RESULTS With reinforcers, the participants administered an average of at least 3 mealtime insulin boluses per day and wore the sensor over 70% of the time. However, auto mode use waned. HbA1c levels decreased by 0.5% after 6 weeks, and this improvement was maintained at 12 and 16 weeks (P < .05). Upon withdrawal of reinforcers, HbA1c levels increased back to baseline at 24 weeks. CONCLUSION Compensation for diabetes-related tasks was associated with lower HbA1c levels, consistent administration of mealtime insulin boluses, and sustained sensor use. These results support the potential of financial rewards for improving outcomes in youth with type 1 diabetes.
Collapse
|
10
|
Breen RJ, Ferguson SG, Palmer MA. Higher incentive amounts do not appear to be associated with greater quit rates in financial incentive programmes for smoking cessation. Addict Behav 2020; 110:106513. [PMID: 32590220 DOI: 10.1016/j.addbeh.2020.106513] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 05/27/2020] [Accepted: 06/08/2020] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Financial incentive (FI) programmes can promote smoking cessation. While foundational research suggests higher FI amounts may better produce outcomes, confirmation is needed. Further, the optimal amount(s) needed to cost-effectively promote change is unclear. Our objective was to reconfirm whether higher amounts are associated with greater quitting through review of previous programmes, before assessing whether non-linear trends and obvious inflections in this relationship exist which may highlight optimal amounts. METHODS Four databases were searched for controlled or randomised controlled studies which detailed FI programmes for smoking cessation in adults. RESULTS Twenty-six studies were included. Programmes varied in length (3.0-52.0 weeks, median = 12.0), FI provision timing, and longest follow-up (5.5-24.0 months, median = 6.0). The odds ratio of quitting at longest follow-up ranged from 0.32 to 5.89. Maximum FI amounts were between US$106.19 and $4,027.92. Quit rates and amounts were not significantly correlated. Subsequent comparisons to reduce between-study variations were non-significant. Further analyses revealed no evidence of non-linear fits, changes in inflection, or cut-points. CONCLUSIONS While higher FI amounts were not associated with greater quitting within this review, the limited data available and variations in target populations and programme designs unrelated to the amount have undoubtedly influenced results. Findings suggest information on this relationship and optimal FI amounts are not determinable through current evidence. As this information is important for cost-effectiveness evaluations and real-world viability, further investigation is necessary. Laboratory research could provide valuable initial insight. Trials comparing programme efficacy under the identified amounts could then be implemented.
Collapse
Affiliation(s)
- Rachel J Breen
- College of Health and Medicine, University of Tasmanian, Australia.
| | | | - Matthew A Palmer
- College of Health and Medicine, University of Tasmanian, Australia
| |
Collapse
|
11
|
Vulimiri M, Bleser WK, Saunders RS, Madanay F, Moseley C, McGuire HF, Ubel PA, McKethan A, McClellan M, Wong CA. Engaging Beneficiaries In Medicaid Programs That Incentivize Health-Promoting Behaviors. Health Aff (Millwood) 2020; 38:431-439. [PMID: 30830831 DOI: 10.1377/hlthaff.2018.05427] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Medicaid programs are increasingly adopting incentive programs to improve health behaviors among beneficiaries. There is limited evidence on what incentives are being offered to Medicaid beneficiaries, how programs are engaging beneficiaries, and how programs are evaluated. In 2017-18 we synthesized available information on these programs and interviewed eighty policy stakeholders to identify the rationale behind key program design decisions and stakeholders' recommendations for beneficiary engagement and program evaluation. Key underlying program rationales included improving the use of preventive services and promoting personal responsibility. Beneficiary engagement strategies emphasized meeting members where they are and offering prizes or services customized for certain groups. Stakeholders recommended collaborating with external evaluators to design and conduct robust evaluations of incentive programs. Finally, stakeholders recommended aligning beneficiary incentives with provider incentives and other payment reforms through the use of common meaningful measures to streamline program evaluation.
Collapse
Affiliation(s)
- Madhulika Vulimiri
- Madhulika Vulimiri is a senior Medicaid strategist at the North Carolina Department of Health and Human Services, in Raleigh, North Carolina. She was a master of public policy student in the Sanford School of Public Policy, Duke University, in Durham, North Carolina, at the time this work was conducted
| | - William K Bleser
- William K. Bleser is a research associate in the Duke-Margolis Center for Health Policy, Duke University, in Washington, D.C
| | - Robert S Saunders
- Robert S. Saunders is a research director in the Duke-Margolis Center for Health Policy, Duke University, in Washington, D.C
| | - Farrah Madanay
- Farrah Madanay is a PhD student in public policy in the Sanford School of Public Policy, Duke University, in Durham
| | - Connor Moseley
- Connor Moseley is a medical student in the Duke University School of Medicine in Durham
| | - Hunter F McGuire
- Hunter F. McGuire is a master of public health student in the Gillings School of Global Public Health, University of North Carolina at Chapel Hill. He was a research assistant in the Duke Clinical Research Institute in Durham at the time this work was conducted
| | - Peter A Ubel
- Peter A. Ubel is the Madge and Dennis T. McLawhorn Professor of Business, Public Policy, and Medicine at Duke University in Durham
| | - Aaron McKethan
- Aaron McKethan is an assistant professor in the Department of Population Health Sciences and a senior fellow in the Duke-Margolis Center for Health Policy, both in the Duke University School of Medicine in Durham
| | - Mark McClellan
- Mark McClellan is director of the Duke-Margolis Center for Health Policy in Washington, D.C., and the Robert J. Margolis Professor of Business, Medicine, and Policy at Duke University in Durham
| | - Charlene A Wong
- Charlene A. Wong ( ) is an assistant professor of pediatrics and public policy, and faculty in the Duke-Margolis Center for Health Policy and the Duke Clinical Research Institute, all at Duke University in Durham
| |
Collapse
|
12
|
Moss AC, De Silva D, Cox S, Notley C, Nanda M. Measuring the impact of the Capital Card®, a novel form of contingency management, on substance misuse treatment outcomes: A retrospective evaluation. PLoS One 2020; 15:e0229905. [PMID: 32155186 PMCID: PMC7064232 DOI: 10.1371/journal.pone.0229905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 02/14/2020] [Indexed: 11/30/2022] Open
Abstract
Background The Capital Card, developed by WDP, is a digital innovation which acts as a form of contingency management, and aims to significantly improve service user outcomes. WDP is a substance misuse treatment provider commissioned by local authorities across the UK to support service users and their families affected by addiction. The Capital Card, much like commercial loyalty cards, uses a simple earn-spend points system which incentivises and rewards service users for engaging with services e.g. by attending key work sessions, Blood Borne Virus appointments or group-work sessions. The Spend activities available to service users are designed to improve overall wellbeing and build social and recovery capital, and include activities such as educational classes, fitness classes, driving lessons, and cinema tickets. Methods and findings We compared successful completion rates of 1,545 service users accessing one of WDP’s London based community services over a two-year period; before and after the Capital Card was introduced. Client demographics (age, sex and primary substance) were controlled for during the analysis. Once client demographics were controlled for, analysis showed that clients with a Capital Card were 1.5 times more likely to successfully complete treatment than those who had not had the Capital Card (OR = 1.507, 95% CI = 1.194 to 1.902). Conclusions The results of this initial evaluation are of particular interest to commissioners and policy makers as it indicates that the Capital Card can be used effectively as a form of contingency management to enhance recovery outcomes for service users engaging in community-based substance misuse services.
Collapse
Affiliation(s)
- Antony C. Moss
- Centre for Addictive Behaviours Research, School of Applied Sciences, London South Bank University, London, United Kingdom
- * E-mail:
| | | | - Sharon Cox
- Centre for Addictive Behaviours Research, School of Applied Sciences, London South Bank University, London, United Kingdom
| | - Caitlin Notley
- Centre for Addictive Behaviours Research, School of Applied Sciences, London South Bank University, London, United Kingdom
- Norwich Medical School, University of East Anglia, Norwich, United Kingdom
| | - Manish Nanda
- Innovation Research Unit, WDP, London, United Kingdom
| |
Collapse
|
13
|
Wagner JA, Petry NM, Weyman K, Tichy E, Cengiz E, Zajac K, Tamborlane WV. Glucose management for rewards: A randomized trial to improve glucose monitoring and associated self-management behaviors in adolescents with type 1 diabetes. Pediatr Diabetes 2019; 20:997-1006. [PMID: 31271239 PMCID: PMC6786915 DOI: 10.1111/pedi.12889] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 06/04/2019] [Accepted: 06/18/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND This randomized, controlled trial evaluated a monetary-based reinforcement intervention for increasing self-monitoring of blood glucose (SMBG) among youth with poorly controlled type 1 diabetes. METHODS After a 2-week baseline, 60 participants were randomized to enhanced usual care (EUC) or Reinforcers. The Reinforcers group earned monetary rewards for SMBG and associated behaviors such as uploading glucose meters. Reinforcers were withdrawn at 24 weeks. A follow-up evaluation occurred at 36 weeks. RESULTS Participants in the reinforcers group increased the proportion of days they completed ≥4 SMBG from 14.6% at baseline to 64.4%, 47.5%, and 37.8% at 6, 12, and 24 weeks, respectively. In contrast, EUC participants declined from 22.7% at baseline to 17.5%, 10.5%, and 11.1% (Ps < .01 vs EUC at all time points). Group differences were attenuated but remained significant after withdrawal of reinforcers. Effect sizes for SMBG were very large during reinforcement and large after withdrawal of reinforcers. In the reinforcers group, mean A1c dropped from 9.5% ± 1.2% at baseline to 9.0% ± 1.3% at week 6 and 9.0% ± 1.4% at week 12. For EUC, A1c was 9.2% ± 0.2% at baseline and ranged from 9.2% ± 1.5% to 9.6% ± 1.6% throughout the study (P < .05 vs EUC). Group differences in A1c were no longer significant at weeks 24 and 36. Effect sizes for A1c were small during reinforcement and also after withdrawal of reinforcement. CONCLUSIONS Monetary-based reinforcement of adolescents with type 1 diabetes caused durable increases in SMBG. Modification of the reinforcement structure may be needed to sustain improved metabolic control in this challenging age group.
Collapse
Affiliation(s)
- Julie A. Wagner
- University of Connecticut School of Dental Medicine,University of Connecticut School of Medicine
| | | | | | | | | | | | | |
Collapse
|
14
|
Rash CJ, DePhilippis D. Considerations for Implementing Contingency Management in Substance Abuse Treatment Clinics: The Veterans Affairs Initiative as a Model. Perspect Behav Sci 2019; 42:479-499. [PMID: 31976446 DOI: 10.1007/s40614-019-00204-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Contingency management (CM) is an efficacious intervention for the treatment of substance use disorders that is widely applicable across a range of client populations and characteristics. Despite its strong evidence base, CM remains underutilized in real world practice. This article introduces CM for clinicians interested in adopting CM and briefly reviews this research evidence. In addition, CM protocols are described, with emphasis on the specific design considerations important to CM's efficacy. The recent Department of Veterans Affairs (VA) initiative, which represents the first successful large-scale implementation effort, is presented. It provides a model for the training and supervision components that may be critical to implementation with fidelity. Continued research in this area, as well as further demonstrations of successful dissemination and implementation, will be critical for improving the adoption of this intervention in clinical, nonresearch settings.
Collapse
Affiliation(s)
- Carla J Rash
- 1Calhoun Cardiology Center, University of Connecticut Health School of Medicine, 263 Farmington, Avenue (MC 3944), Farmington, CT 06030-3944 USA
| | - Dominick DePhilippis
- 2Center of Excellence in Substance Addiction Treatment and Education, Corporal Michael J. Crescenz Veterans Administration Medical Center, Perelman School of Medicine, Department of Veterans Affairs, Pennsylvania, PA USA
| |
Collapse
|
15
|
Forster SE, DePhilippis D, Forman SD. "I's" on the prize: A systematic review of individual differences in Contingency Management treatment response. J Subst Abuse Treat 2019; 100:64-83. [PMID: 30898330 DOI: 10.1016/j.jsat.2019.03.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 01/30/2019] [Accepted: 03/06/2019] [Indexed: 01/02/2023]
Abstract
Contingency Management is an evidence-based treatment for substance use disorders with strong potential for measurement-based customization. Previous work has examined individual difference factors in Contingency Management treatment response of potential relevance to treatment targeting and adaptive implementation; however, a systematic review of such factors has not yet been conducted. Here, we summarize and evaluate the existing literature on patient-level predictors, mediators, and moderators of Contingency Management treatment response in stimulant and/or opioid using outpatients - clinical populations most frequently targeted in Contingency Management research and clinical practice. Our search strategy identified 648 unique, peer-reviewed publications, of which 39 met full inclusion criteria for the current review. These publications considered a variety of individual difference factors, including (1) motivation to change and substance use before and during treatment (8/39 publications), (2) substance use comorbidity and chronicity (8/39 publications), (3) psychiatric comorbidity and severity (8/39 publications), (4) medical, legal, and sociodemographic considerations (15/39 publications), and (5) cognitive-behavioral variables (1/39 publications). Contingency Management was generally associated with improved treatment outcomes (e.g., longer periods of continuous abstinence, better retention), regardless of individual difference factors; however, specific patient-level characteristics were associated with either an enhanced (e.g., more previous treatment attempts, history of sexual abuse, diagnosis of antisocial personality disorder) or diminished (e.g., complex post-traumatic stress symptoms, pretreatment benzodiazepine use) response to Contingency Management. Overall, the current literature is limited but existing evidence generally supports greater benefits of Contingency Management in patients who would otherwise have a poorer prognosis in standard outpatient care. It was also identified that the majority of previous work represents a posteriori analysis of pre-existing clinical samples and has therefore rarely considered pre-specified, hypothesis-driven individual difference factors. We therefore additionally highlight patient-level factors that are currently understudied, as well as promising future directions for measurement-based treatment adaptations that may directly respond to patient traits and states to improve Contingency Management effectiveness across individuals and over time.
Collapse
Affiliation(s)
- Sarah E Forster
- VISN 4 Mental Illness Research, Education, and Clinical Center, VA Pittsburgh Healthcare System, United States of America; University of Pittsburgh, Department of Psychiatry, United States of America.
| | - Dominick DePhilippis
- Center of Excellence in Substance Addiction Treatment and Education, Corporal Michael J. Crescenz VA Medical Center, United States of America; Perelman School of Medicine, University of Pennsylvania, United States of America
| | - Steven D Forman
- VISN 4 Mental Illness Research, Education, and Clinical Center, VA Pittsburgh Healthcare System, United States of America; University of Pittsburgh, Department of Psychiatry, United States of America
| |
Collapse
|
16
|
Koffarnus MN, Bickel WK, Kablinger AS. Remote Alcohol Monitoring to Facilitate Incentive-Based Treatment for Alcohol Use Disorder: A Randomized Trial. Alcohol Clin Exp Res 2018; 42:2423-2431. [PMID: 30335205 PMCID: PMC6286218 DOI: 10.1111/acer.13891] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Accepted: 09/13/2018] [Indexed: 11/29/2022]
Abstract
Background The delivery of monetary incentives contingent on verified abstinence is an effective treatment for alcohol use disorder. However, technological barriers to accurate, frequent biochemical verification of alcohol abstinence have limited the dissemination of this technique. Methods In the present randomized parallel trial, we employed a breathalyzer that allows remote, user‐verified collection of a breath alcohol sample, text messaging, and reloadable debit cards for remote delivery of incentives to evaluate a contingency management treatment for alcohol use disorder that can be delivered with no in‐person contact. Treatment‐seeking participants with alcohol use disorder (n = 40) were recruited from the community and randomized to either a contingent or a noncontingent group (n = 20 each). The contingent group received nearly immediate monetary incentives each day they remotely provided negative breathalyzer samples. The noncontingent group received matched monetary payments each day they successfully provided samples independent of alcohol content. Groups were not masked as awareness of group contingencies was an essential intervention component. Results The primary outcome of the intent‐to‐treat analyses (analyzed n = 40) was percent days abstinent as measured by the remote breathalyzer samples. Abstinence rates in the contingent group were 85%, which was significantly higher than the 38% recorded in the noncontingent group, corresponding to an odds ratio of 9.4 (95% CI = 4.0 to 22.2). Breathalyzer collection adherence rates were over 95%, and participant ratings of acceptability were also high. Conclusions These results support the efficacy, acceptability, and feasibility of this remotely deliverable abstinence reinforcement incentive intervention for the initiation and near‐term maintenance of abstinence from alcohol in adults with alcohol use disorder. Due to low provider and participant burden, this procedure has the potential for broad dissemination.
Collapse
Affiliation(s)
| | - Warren K Bickel
- Virginia Tech Carilion Research Institute, Virginia Tech, Roanoke, Virginia
| | - Anita S Kablinger
- Psychiatry and Behavioral Sciences, Virginia Tech Carilion School of Medicine, Roanoke, Virginia
| |
Collapse
|
17
|
Petry NM, Alessi SM, Rash CJ, Barry D, Carroll KM. A randomized trial of contingency management reinforcing attendance at treatment: Do duration and timing of reinforcement matter? J Consult Clin Psychol 2018; 86:799-809. [PMID: 30265039 PMCID: PMC6166435 DOI: 10.1037/ccp0000330] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Contingency management (CM) interventions that reinforce attendance have rarely been evaluated in terms of reducing drug use. Using a sequential randomized design, this study examined the efficacy of three attendance CM conditions compared to usual care (UC) on drug use outcomes. It evaluated whether the duration (6 vs. 12 weeks) and timing (early vs. later treatment) of CM delivery impact treatment response. METHOD Upon initiating outpatient treatment, patients with cocaine use disorders (N = 360) were randomized to UC or CM for attending treatment for 6 weeks. At week 6, patients (n = 308) were rerandomized to UC or CM for another 6 weeks, with assignment stratified on current functioning. Samples were screened for illicit drugs twice weekly for 12 weeks. RESULTS Patients randomized to CM at both time-points attended more sessions and achieved more abstinence than those never randomized to CM. Relative to UC, receiving attendance CM in weeks 1-6 only was not efficacious, but those receiving attendance CM in weeks 7-12 only evidenced some benefits compared to those who never received CM. Twelve weeks of attendance CM was more efficacious than 6 weeks. No between-groups differences in drug use were noted at follow-ups, but days attended treatment and proportion negative samples during treatment were associated with long-term cocaine abstinence. CONCLUSIONS Attendance-based CM increases treatment participation and reduces drug use, with beneficial effects noted when CM is delivered over longer durations and during later phases of outpatient care. (PsycINFO Database Record (c) 2018 APA, all rights reserved).
Collapse
Affiliation(s)
| | | | | | - Danielle Barry
- University of Connecticut Health Center
- Edith Nourse Rogers Memorial VA Hospital
| | | |
Collapse
|
18
|
McDonell MG, Leickly E, McPherson S, Skalisky J, Srebnik D, Angelo F, Vilardaga R, Nepom JR, Roll JM, Ries RK. A Randomized Controlled Trial of Ethyl Glucuronide-Based Contingency Management for Outpatients With Co-Occurring Alcohol Use Disorders and Serious Mental Illness. Am J Psychiatry 2017; 174:370-377. [PMID: 28135843 PMCID: PMC5378651 DOI: 10.1176/appi.ajp.2016.16050627] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The authors examined whether a contingency management intervention using the ethyl glucuronide (EtG) alcohol biomarker resulted in increased alcohol abstinence in outpatients with co-occurring serious mental illnesses. Secondary objectives were to determine whether contingency management was associated with changes in heavy drinking, treatment attendance, drug use, cigarette smoking, psychiatric symptoms, and HIV-risk behavior. METHOD Seventy-nine (37% female, 44% nonwhite) outpatients with serious mental illness and alcohol dependence receiving treatment as usual completed a 4-week observation period and were randomly assigned to 12 weeks of contingency management for EtG-negative urine samples and addiction treatment attendance, or reinforcement only for study participation. Contingency management included the variable magnitude of reinforcement "prize draw" procedure contingent on EtG-negative samples (<150 ng/mL) three times a week and weekly gift cards for outpatient treatment attendance. Urine EtG, drug test, and self-report outcomes were assessed during the 12-week intervention and 3-month follow-up periods. RESULTS Contingency management participants were 3.1 times (95% CI=2.2-4.5) more likely to submit an EtG-negative urine test during the 12-week intervention period, attaining nearly 1.5 weeks of additional alcohol abstinence compared with controls. Contingency management participants had significantly lower mean EtG levels, reported less drinking and fewer heavy drinking episodes, and were more likely to submit stimulant-negative urine and smoking-negative breath samples, compared with controls. Differences in self-reported alcohol use were maintained at the 3-month follow-up. CONCLUSIONS This is the first randomized trial utilizing an accurate and validated biomarker (EtG) to demonstrate the efficacy of contingency management for alcohol dependence in outpatients with serious mental illness.
Collapse
Affiliation(s)
- Michael G. McDonell
- Initiative for Research and Education to Advance Community Health, Washington State University, Spokane WA,Elson S. Floyd College of Medicine, Washington State University, Spokane WA,Program for Excellence in Addiction Research, Washington State University, Spokane WA
| | - Emily Leickly
- Initiative for Research and Education to Advance Community Health, Washington State University, Spokane WA,Program for Excellence in Addiction Research, Washington State University, Spokane WA
| | - Sterling McPherson
- Elson S. Floyd College of Medicine, Washington State University, Spokane WA,Program for Excellence in Addiction Research, Washington State University, Spokane WA,Providence Medical Research Center, Providence Health Care, Spokane WA
| | - Jordan Skalisky
- Initiative for Research and Education to Advance Community Health, Washington State University, Spokane WA,Program for Excellence in Addiction Research, Washington State University, Spokane WA
| | - Debra Srebnik
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle WA
| | - Frank Angelo
- School of Public Health, University of Washington, Seattle WA
| | - Roger Vilardaga
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle WA
| | - Jenny R. Nepom
- Initiative for Research and Education to Advance Community Health, Washington State University, Spokane WA,Program for Excellence in Addiction Research, Washington State University, Spokane WA
| | - John M. Roll
- Elson S. Floyd College of Medicine, Washington State University, Spokane WA,Program for Excellence in Addiction Research, Washington State University, Spokane WA
| | - Richard K. Ries
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle WA
| |
Collapse
|
19
|
Rash CJ, Stitzer M, Weinstock J. Contingency Management: New Directions and Remaining Challenges for An Evidence-Based Intervention. J Subst Abuse Treat 2017; 72:10-18. [PMID: 27746057 PMCID: PMC5154900 DOI: 10.1016/j.jsat.2016.09.008] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Accepted: 09/23/2016] [Indexed: 12/24/2022]
Abstract
This article introduces the special issue on contingency management (CM), an efficacious intervention for the treatment of substance use disorders with low uptake in clinical settings that is not commensurate with evidence for efficacy. In this special issue of the Journal of Substance Abuse Treatment, we present 16 articles representing the latest research in efficacy, implementation, and technological advances related to CM. Combined, this collection of articles highlights the diverse populations, settings, and applications of CM in the treatment of substance use disorders. We conclude by highlighting directions for future research, particularly those that may increase CM's appeal and uptake in routine clinical care.
Collapse
Affiliation(s)
- Carla J Rash
- Calhoun Cardiology Center - Behavioral Health, UConn Health Center, 263 Farmington Avenue (MC 3944), Farmington, CT 06030-3944.
| | - Maxine Stitzer
- Department of Psychiatry and Behavioral Science, Johns Hopkins University School of Medicine, Hopkins Bayview Medical Center, 5510 Nathan Shock Drive, Baltimore, MD 21224
| | - Jeremiah Weinstock
- Department of Psychology, Saint Louis University, 3700 Lindell Boulevard, Morrissey Hall Rm 2735, St. Louis, MO 63108
| |
Collapse
|
20
|
Barry CL, Epstein AJ, Fiellin DA, Fraenkel L, Busch SH. Estimating demand for primary care-based treatment for substance and alcohol use disorders. Addiction 2016; 111:1376-84. [PMID: 26899802 PMCID: PMC4940268 DOI: 10.1111/add.13364] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Revised: 11/23/2015] [Accepted: 02/11/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND AIMS While there is broad recognition of the high societal costs of substance use disorders (SUD), treatment rates are low. We examined whether, in the United States, participants with substance or alcohol use disorder would report a greater willingness to enter SUD treatment located in a primary care setting (primary care) or more commonly found specialty care setting in the United States (usual care). DESIGN Randomized survey-embedded experiment. SETTING US web-based research panel in which participants were randomized to read one-paragraph vignettes describing treatment in usual care (specialty drug or alcohol treatment center), primary care or collaborative care within a primary care setting. PARTICIPANTS A total of 42 451 panelists aged 18+ were screened for substance or alcohol use disorder using validated diagnostic criteria. Participants included 344 with a substance use disorder and 634 with an alcohol use disorder not in treatment with no prior treatment history. MEASURES Willingness to enter treatment across vignettes by condition. FINDINGS Among participants with a substance use disorder, 24.6% of those randomized to usual care reported being willing to enter drug treatment compared with 37.2% for primary care [12.6 percentage point difference; 95% confidence interval (CI) = 0.8, 24.4) and 34.0% for collaborative care (9.4 percentage point difference; 95% CI = -2.0, 20.8). Among participants with an alcohol use disorder, 17.6% of those randomized to usual care reported being willing to enter alcohol treatment compared with 20.3% for primary care (2.6 percentage point difference; 95% CI = -4.9, 10.1) and 20.8% for collaborative care (3.1 percentage point difference; 95% CI = -4.3, 10.6). The most common reason for not being willing to enter drug (63%) and alcohol (78%) treatment was the belief that treatment was not needed. CONCLUSIONS In the United States, people diagnosed with substance or alcohol use disorders appear to be more willing to enter treatment in a primary care setting than in a specialty drug treatment center. Expanding availability of primary care-based substance use disorder treatment could increase treatment rates in the United States.
Collapse
Affiliation(s)
- Colleen L. Barry
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Andrew J. Epstein
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Department of Veterans Affairs’ Center for Health Equity Research and Promotion, Philadelphia Veterans Affairs Medical Center, Philadelphia, PA
| | - David A. Fiellin
- Department of General Internal Medicine, Yale School of Medicine, New Haven, CT
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT
| | - Liana Fraenkel
- Department of General Internal Medicine, Yale School of Medicine, New Haven, CT
- VA Connecticut Healthcare System
| | - Susan H. Busch
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT
| |
Collapse
|
21
|
Efficacy of cocaine contingency management in heroin-assisted treatment: Results of a randomized controlled trial. Drug Alcohol Depend 2016; 164:55-63. [PMID: 27177805 DOI: 10.1016/j.drugalcdep.2016.04.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Revised: 04/16/2016] [Accepted: 04/17/2016] [Indexed: 11/23/2022]
Abstract
AIMS To determine the efficacy of contingency management (CM), targeting cocaine use, as an add-on intervention for heroin dependent patients in supervised heroin-assisted treatment (HAT) with frequent cocaine use. DESIGN Multi-center, open-label, parallel group, randomized controlled trial. SETTING Twelve specialized addiction treatment centers for HAT in The Netherlands; April 2006-January 2011. PARTICIPANTS 214 chronic, treatment-refractory heroin dependent patients in HAT, with frequent cocaine use. INTERVENTIONS Routine, daily supervised diacetylmorphine treatment, co-prescribed with oral methadone (HAT), with and without 6 months contingency management for cocaine use as an add-on intervention; HAT+CM and HAT-only, respectively. MEASUREMENTS Primary outcome was the longest, uninterrupted duration of cocaine abstinence, based upon laboratory urinalysis. Secondary outcome measures included other cocaine-related measures, treatment retention in HAT, and multi-domain health-related treatment response. FINDINGS In an intention-to-treat analysis, HAT+CM was more effective than HAT-only in promoting longer, uninterrupted duration of cocaine abstinence (3.7 weeks versus 1.6 weeks; negative binomial regression: Exp(B)=2.34, 95%-CI: 1.70-3.23; p<0.001). This result remained significant in sensitivity analyses and was supported by all secondary, cocaine-related outcome measures. Treatment retention in HAT was high (91.6%) with no difference between the groups. The improvement in multi-domain health-related treatment response during the trial was numerically higher in HAT+CM (from 37.4% to 53.1%; +15.7%) than in HAT-only (from 44.5% to 46.5%; +2.0%), but this difference was statistically not significant. CONCLUSIONS Contingency management is an effective add-on intervention to promote longer, uninterrupted periods of cocaine abstinence in chronic, treatment-refractory heroin dependent patients in heroin-assisted treatment with frequent cocaine use. The trial has been registered in The Netherlands National Trial Register under clinical trial registration number NTR4728.
Collapse
|
22
|
Secades-Villa R, García-Rodríguez O, Fernández-Hermida JR. Contingency management for substance use disorders in Spain: Implications for research and practice. Prev Med 2015; 80:82-8. [PMID: 26164071 DOI: 10.1016/j.ypmed.2015.07.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Revised: 06/25/2015] [Accepted: 07/02/2015] [Indexed: 11/18/2022]
Abstract
OBJECTIVE We provide a narrative review of published studies evaluating voucher-based contingency management (CM) treatment for cocaine, nicotine and cannabis use disorders in Spain and discuss the concerns and future challenges. METHOD Published studies between 2008 and 2015 that evaluated the impact of incentives for SUD in Spain and included an appropriate control or comparison condition were identified and reviewed. RESULTS Adding voucher-based CM to standard treatments obtained better treatment retention and cocaine abstinence than standard care alone. CM also improved psychosocial functioning. Economic status or depressive symptoms did not affect the results of CM treatment for cocaine dependence. The addition of a CM protocol to cognitive behavioral treatment (CBT) also improved treatment effectiveness for smoking cessation. Available data on the effect of CM on cannabis use disorders (CUD) with young people did not allow confirmation of its superiority to date. CONCLUSION The research conducted to date in Spain confirms and expands the findings of studies conducted in the US supporting the effectiveness of CM in the context of community settings with cocaine- and nicotine-dependents. However, CM has not yet been readily adopted into general clinical practice in Spain or the rest of Europe. The limited effectiveness of CM for CUD is likely due to the scarcity of data and may change with more studies, taking into account recent research on this topic in the US. Continued efforts are warranted to further develop and disseminate incentive-based treatments for SUD across clinical settings and populations in Spain.
Collapse
Affiliation(s)
- Roberto Secades-Villa
- Department of Psychology, University of Oviedo, Plaza Feijoo s/n, 33003 Oviedo, Spain.
| | | | | |
Collapse
|
23
|
López-Núñez C, Alonso-Pérez F, Pedrosa I, Secades-Villa R. Cost-effectiveness of a voucher-based intervention for smoking cessation. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2015; 42:296-305. [PMID: 26484869 DOI: 10.3109/00952990.2015.1081913] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Contingency management (CM) has been shown to be effective in reducing smoking consumption, but has traditionally been criticized for its costs. OBJECTIVES This study assessed the cost-effectiveness of using a voucher-based CM protocol added to a cognitive behavioral treatment (CBT) for smoking cessation among treatment-seeking patients from the general population. METHODS A total of 92 patients were randomly assigned to CBT or CBT plus CM for abstinence. Incremental cost-effectiveness ratios (ICERs) were calculated by dividing the increase in costs by the increase in effects (continuous abstinence, longest duration of abstinence at 6-month follow-up and cotinine results during the treatment). An acceptability curve illustrated the statistical uncertainty surrounding the cost-effectiveness estimate. We also determined the optimum cost per participant for predicting the smoking status at 6-month follow-up. RESULTS The average cost per participant in the CBT condition was €138.73 (US$ 150.23) as opposed to €411.61 (US$ 445.73) in the CBT plus CM condition (p < 0.01). The incremental cost of using voucher-based CM to increase the number of participants that maintained abstinence at 6-month follow-up by one extra participant was €68.22 (US$ 73.88), and to lengthen the longest duration of abstinence by 1 week was €53.92 (US$ 58.39). The incremental cost to obtain an extra cotinine-negative result was €181.90 (US$ 196.98). CONCLUSION Compared with CBT alone, the voucher-based protocol required additional costs but achieved significantly better outcomes. These results will allow stakeholders to make policy decisions about CM implementation for smoking cessation in the broader community.
Collapse
Affiliation(s)
| | | | - Ignacio Pedrosa
- a Department of Psychology , University of Oviedo , Oviedo , Spain
| | | |
Collapse
|
24
|
Murphy SM, McDonell MG, McPherson S, Srebnik D, Angelo F, Roll JM, Ries RK. An economic evaluation of a contingency-management intervention for stimulant use among community mental health patients with serious mental illness. Drug Alcohol Depend 2015; 153:293-9. [PMID: 26026494 PMCID: PMC4509830 DOI: 10.1016/j.drugalcdep.2015.05.004] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2014] [Revised: 04/22/2015] [Accepted: 05/04/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND This study examines the cost-effectiveness of contingency-management (CM) for stimulant dependence among community mental health patients with serious mental illness (SMI) METHODS: Economic evaluation of a 12-week randomized controlled trial investigating the efficacy of CM added to treatment-as-usual (CM+TAU), relative to TAU without CM, for treating stimulant dependence among patients with a SMI. The trial included 176 participants diagnosed with SMI and stimulant dependency who were receiving community mental health and addiction treatment at one community mental health center in Seattle, Washington. Participants were also assessed during a 12-week follow-up period. Positive and negative syndrome scale (PANSS) scores were used to calculate quality-adjusted life-years (QALYs) for the primary economic outcome. The primary clinical outcome, the stimulant-free year (SFY) is a weighted measure of time free from stimulants. Two perspectives were adopted, those of the provider and the payer. RESULTS At 12-weeks neither the provider ($2652, p=0.74) nor the payer ($2611, p=0.99) cost differentials were statistically significant. This was also true for the payer at 24-weeks (-$125, p=1.00). QALYs gained were similar across groups, resulting in small, insignificant differences (0.04, p=0.23 at 12-weeks; 0.01, p=0.70 at 24 weeks). CM+TAU experienced significantly more SFYs, 0.24 (p<0.001) at 12 weeks and 0.20 (p=0.002) at 24 weeks, resulting in at least an 85% chance of being considered cost-effective at a threshold of $200,000/SFY. CONCLUSION Contingency management appears to be a wise investment for both the provider and the payer with regard to the clinical outcome of time free from stimulants.
Collapse
Affiliation(s)
- Sean M. Murphy
- Program of Excellence in Addictions Research, Washington State University, Spokane, Washington 99210, USA,Corresponding author at: Department of Health Policy & Administration, P.O. Box 1495, Spokane, WA 99210-1495. Phone: 509-358-7949. Fax: 509-358-7984509-358-7949.
| | - Michael G. McDonell
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, Washington 98195, USA
| | - Sterling McPherson
- Program of Excellence in Addictions Research, Washington State University, Spokane, Washington 99210, USA
| | - Debra Srebnik
- King County Mental Health, Chemical Abuse and Dependency Services Division, Seattle, Washington 98104, USA
| | - Frank Angelo
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, Washington 98195, USA
| | - John M. Roll
- Program of Excellence in Addictions Research, Washington State University, Spokane, Washington 99210, USA
| | - Richard K. Ries
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, Washington 98195, USA
| |
Collapse
|
25
|
Patients Undergoing Substance Abuse Treatment and Receiving Financial Assistance for a Physical Disability Respond Well to Contingency Management Treatment. J Subst Abuse Treat 2015; 58:67-71. [PMID: 26184649 DOI: 10.1016/j.jsat.2015.06.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Revised: 06/10/2015] [Accepted: 06/10/2015] [Indexed: 11/21/2022]
Abstract
Physical illness and disability are common in individuals with substance use disorders, but little is known about the impact of physical disability status on substance use treatment outcomes. This study examined the main and interactive effects of physical disability payment status on substance use treatment. Participants (N = 1,013) were enrolled in one of six prior randomized clinical trials comparing contingency management (CM) to standard care; 79 (7.8%) participants reported receiving disability payments, CM improved all three primary substance use outcomes: treatment retention, percent negative samples and longest duration of abstinence. There was no significant main effect of physical disability payment status on treatment outcomes; however, a significant treatment condition by physical disability status interaction effect emerged in terms of retention in treatment and duration of abstinence achieved. Patients who were receiving physical disability payments responded particularly well to CM, and their time in treatment and durations of drug and alcohol abstinence increased even more markedly with CM than did that of their counterparts who were not receiving physical disability assistance. These findings suggest an objectively defined cohort of patients receiving substance use treatment who respond particularly well to CM.
Collapse
|
26
|
Dougherty DM, Karns TE, Mullen J, Liang Y, Lake SL, Roache JD, Hill-Kapturczak N. Transdermal alcohol concentration data collected during a contingency management program to reduce at-risk drinking. Drug Alcohol Depend 2015; 148:77-84. [PMID: 25582388 PMCID: PMC5505238 DOI: 10.1016/j.drugalcdep.2014.12.021] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2014] [Revised: 12/08/2014] [Accepted: 12/15/2014] [Indexed: 11/26/2022]
Abstract
BACKGROUND Recently, we demonstrated that transdermal alcohol monitors could be used in a contingency management procedure to reduce problematic drinking; the frequency of self-reported heavy/moderate drinking days decreased and days of no to low drinking increased. These effects persisted for three months after intervention. In the current report, we used the transdermal alcohol concentration (TAC) data collected prior to and during the contingency management procedure to provide a detailed characterization of objectively measured alcohol use. METHODS Drinkers (n=80) who frequently engaged in risky drinking behaviors were recruited and participated in three study phases: a 4-week Observation phase where participants drank as usual; a 12-week Contingency Management phase where participants received $50 each week when TAC did not exceed 0.03g/dl; and a 3-month Follow-up phase where self-reported alcohol consumption was monitored. Transdermal monitors were worn during the first two phases, where each week they recived $105 for visiting the clinic and wearing the monitor. Outcomes focused on using TAC data to objectively characterize drinking and were used to classify drinking levels as either no, low, moderate, or heavy drinking as a function of weeks and day of week. RESULTS Compared to the Observation phase, TAC data indicated that episodes of heavy drinking days during the Contingency Management phase were reduced and episodes of no drinking and low to moderate drinking increased. CONCLUSIONS These results lend further support for linking transdermal alcohol monitoring with contingency management interventions. Collectively, studies to date indicate that interventions like these may be useful for both abstinence and moderation-based programs.
Collapse
Affiliation(s)
- Donald M. Dougherty
- Department of Psychiatry, The University of Texas Health Science Center at San Antonio, San Antonio, TX,Corresponding Author: Donald M. Dougherty, Department of Psychiatry, The University of Texas Health Science Center at San Antonio, NRLC MC 7793, 7703 Floyd Curl Drive, San Antonio, TX 78229-3900, USA, , Phone: 210-567-2745, Fax: 210-567-2748
| | - Tara E. Karns
- Department of Psychiatry, The University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - Jillian Mullen
- Department of Psychiatry, The University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - Yuanyuan Liang
- Department of Epidemiology and Biostatistics, The University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - Sarah L. Lake
- Department of Psychiatry, The University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - John D. Roache
- Department of Psychiatry, The University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - Nathalie Hill-Kapturczak
- Department of Psychiatry, The University of Texas Health Science Center at San Antonio, San Antonio, TX
| |
Collapse
|
27
|
Shearer J, Tie H, Byford S. Economic evaluations of contingency management in illicit drug misuse programmes: A systematic review. Drug Alcohol Rev 2015; 34:289-98. [PMID: 25659953 DOI: 10.1111/dar.12240] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2014] [Accepted: 11/04/2014] [Indexed: 11/26/2022]
Abstract
ISSUES UK clinical guidelines published in 2007 recommended contingency management (CM) as an adjunct to opiate substitution therapy. However, CM has not been adopted in the UK despite evidence of clinical effectiveness. Evidence for the cost-effectiveness of CM is less clear and will need to be explored if CM is to be adopted by national health systems in countries such as the UK. APPROACH Systematic review and descriptive synthesis of published economic evaluations. KEY FINDINGS The review identified nine published studies that could be classified as economic evaluations. These were all based within US treatment settings, and five were conducted by the same group of authors. All studies found that the addition of CM to usual care increased both costs and effects (commonly drug abstinence or medication adherence). IMPLICATIONS This review confirms that the existing evidence base for cost-effectiveness has limited generalisability beyond the original research clinical settings and populations. CONCLUSION The data were not sufficiently strong to make any conclusion about the cost-effectiveness of CM. More relevant and comprehensive evidence for cost-effectiveness than currently exists is needed.
Collapse
Affiliation(s)
- James Shearer
- Centre for the Economics of Mental and Physical Health, Institute of Psychiatry, King's College London, London, UK
| | | | | |
Collapse
|
28
|
Walter KN, Petry NM. Patients with diabetes respond well to contingency management treatment targeting alcohol and substance use. PSYCHOL HEALTH MED 2014; 20:916-26. [PMID: 25531935 PMCID: PMC4668112 DOI: 10.1080/13548506.2014.991334] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Alcohol and drug use contribute to the pathogenesis of diabetes and are associated with adverse health outcomes, but little research exists on treatments for substance use disorders (SUDs) in patients with diabetes. The aim of this study was to evaluate contingency management (CM) treatments targeting substance use in patients with diabetes. A secondary analysis evaluated the main and interactive effects of diabetes status and treatment condition on outcomes of 681 substance abusers. All participants were enrolled in randomized clinical trials comparing CM to standard care (SC). Overall, CM treatment improved outcomes. There was also a significant treatment condition X diabetes status interaction effect in terms of duration of abstinence achieved and proportion of negative samples submitted; patients with diabetes responded even more favorably than their counterparts without diabetes when receiving CM. Analyses of post-treatment effects revealed that patients with diabetes, regardless of the type of SUD treatment to which they were earlier assigned, were more likely than those without diabetes to be abstinent at the nine-month follow-up. The findings suggest CM may be an effective treatment for this vulnerable subgroup of substance-abusing patients.
Collapse
Affiliation(s)
- Kimberly N. Walter
- Department of Medicine, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Nancy M. Petry
- Department of Medicine, University of Connecticut School of Medicine, Farmington, CT, USA
| |
Collapse
|
29
|
Bickel WK, Johnson MW, Koffarnus MN, MacKillop J, Murphy JG. The behavioral economics of substance use disorders: reinforcement pathologies and their repair. Annu Rev Clin Psychol 2014; 10:641-77. [PMID: 24679180 DOI: 10.1146/annurev-clinpsy-032813-153724] [Citation(s) in RCA: 385] [Impact Index Per Article: 38.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The field of behavioral economics has made important inroads into the understanding of substance use disorders through the concept of reinforcer pathology. Reinforcer pathology refers to the joint effects of (a) the persistently high valuation of a reinforcer, broadly defined to include tangible commodities and experiences, and/or (b) the excessive preference for the immediate acquisition or consumption of a commodity despite long-term negative outcomes. From this perspective, reinforcer pathology results from the recursive interactions of endogenous person-level variables and exogenous environment-level factors. The current review describes the basic principles of behavioral economics that are central to reinforcer pathology, the processes that engender reinforcer pathology, and the approaches and procedures that can repair reinforcement pathologies. The overall goal of this review is to present a new understanding of substance use disorders as viewed by recent advances in behavioral economics.
Collapse
Affiliation(s)
- Warren K Bickel
- Virginia Tech Carilion Research Institute, Roanoke, Virginia 24016; ,
| | | | | | | | | |
Collapse
|
30
|
Dallery J, Kurti A, Erb P. A New Frontier: Integrating Behavioral and Digital Technology to Promote Health Behavior. THE BEHAVIOR ANALYST 2014; 38:19-49. [PMID: 27347477 DOI: 10.1007/s40614-014-0017-y] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Modifiable behavioral risk factors such as cigarette smoking, physical inactivity, and obesity contribute to over 40 % of premature deaths in the USA. Advances in digital and information technology are creating unprecedented opportunities for behavior analysts to assess and modify these risk factors. Technological advances include mobile devices, wearable sensors, biomarker detectors, and real-time access to therapeutic support via information technology. Integrating these advances with behavioral technology in the form of conceptually systematic principles and procedures could usher in a new generation of effective and scalable behavioral interventions targeting health behavior. In this selective review of the literature, we discuss how technological tools can assess and modify a range of antecedents and consequences of healthy and unhealthy behavior. We also describe practical, methodological, and conceptual advantages for behavior analysts that stem from the use of technology to assess and treat health behavior.
Collapse
Affiliation(s)
- Jesse Dallery
- Department of Psychology, University of Florida, P. O. Box 112250, Gainesville, FL 32611 USA
| | - Allison Kurti
- Department of Psychology, University of Florida, P. O. Box 112250, Gainesville, FL 32611 USA
| | - Philip Erb
- Department of Psychology, University of Florida, P. O. Box 112250, Gainesville, FL 32611 USA
| |
Collapse
|
31
|
Reback CJ, Shoptaw S. Development of an evidence-based, gay-specific cognitive behavioral therapy intervention for methamphetamine-abusing gay and bisexual men. Addict Behav 2014; 39:1286-91. [PMID: 22169619 DOI: 10.1016/j.addbeh.2011.11.029] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2011] [Revised: 11/01/2011] [Accepted: 11/21/2011] [Indexed: 10/15/2022]
Abstract
This study compared outcomes in methamphetamine use and sexual risk behaviors from a modified gay-specific, cognitive behavioral therapy (GCBT) combined with a low-cost contingency management (CM; [GCBT+CM]) intervention to prior findings from clinical trials of the original GCBT. Effect sizes for primary outcomes were compared using meta analysis. Comparisons of effect sizes at end of treatment showed the modified GCBT+CM produced significantly fewer consecutive weeks of methamphetamine abstinence (-0.44, CI: -0.79, -0.09) and fewer male sexual partners (-0.36, CI: -0.71, -0.02) than the first trial of GCBT, and more days of methamphetamine use (0.35, CI: 0.02, 0.68) than the second trial of GCBT. At 26-week follow-up, the modified GCBT+CM produced greater effects in reducing the number of male sexual partners (-0.54, CI: -0.89, -0.19; -0.51, CI: -0.84, -0.18). The original GCBT produced more and mostly short-term beneficial drug use outcomes, though sexual behavior changes consistently favored the modified GCBT+CM. On balance, most benefits are retained with the modified GCBT+CM intervention.
Collapse
|
32
|
Hand DJ, Heil SH, Sigmon SC, Higgins ST. Improving medicaid health incentives programs: lessons from substance abuse treatment research. Prev Med 2014; 63:87-9. [PMID: 24613792 PMCID: PMC4043298 DOI: 10.1016/j.ypmed.2014.03.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2013] [Revised: 02/25/2014] [Accepted: 03/02/2014] [Indexed: 11/29/2022]
Abstract
This commentary addresses the efforts of Medicaid programs in several US states to employ financial incentives to increase healthy behavior among their beneficiaries. While these Medicaid incentive programs have been successful at boosting rates of less effortful behaviors, like semiannual dental visits, they have fallen short in promoting more complex behaviors, like smoking cessation, drug abstinence, and weight management. Incentives have been extensively studied as a treatment for substance use disorders for over 20years, with good success. We identify two variables shown by meta-analysis to moderate the efficacy of incentive interventions in substance abuse treatment, the immediacy of incentive delivery and size (or magnitude) of the incentive, that are lacking in current Medicaid incentive program. We also offer some guidance on how these moderating variables could be addressed within Medicaid programs. This is a critical time for such analysis, as more than 10 states are employing incentives in their Medicaid programs, and some are currently reevaluating their incentive strategies.
Collapse
Affiliation(s)
- Dennis J Hand
- Vermont Center on Behavior and Health, University of Vermont, 1 So. Prospect St., UHC Room 1415, Burlington, VT 05401, USA; Department of Psychiatry, University of Vermont, 1 So. Prospect St., UHC Room 1415, Burlington, VT 05401, USA.
| | - Sarah H Heil
- Vermont Center on Behavior and Health, University of Vermont, 1 So. Prospect St., UHC Room 1415, Burlington, VT 05401, USA; Department of Psychiatry, University of Vermont, 1 So. Prospect St., UHC Room 1415, Burlington, VT 05401, USA; Department of Psychology, University of Vermont, 1 So. Prospect St., UHC Room 1415, Burlington, VT 05401, USA
| | - Stacey C Sigmon
- Vermont Center on Behavior and Health, University of Vermont, 1 So. Prospect St., UHC Room 1415, Burlington, VT 05401, USA; Department of Psychiatry, University of Vermont, 1 So. Prospect St., UHC Room 1415, Burlington, VT 05401, USA; Department of Psychology, University of Vermont, 1 So. Prospect St., UHC Room 1415, Burlington, VT 05401, USA
| | - Stephen T Higgins
- Vermont Center on Behavior and Health, University of Vermont, 1 So. Prospect St., UHC Room 1415, Burlington, VT 05401, USA; Department of Psychiatry, University of Vermont, 1 So. Prospect St., UHC Room 1415, Burlington, VT 05401, USA; Department of Psychology, University of Vermont, 1 So. Prospect St., UHC Room 1415, Burlington, VT 05401, USA
| |
Collapse
|
33
|
Srebnik D, Sugar A, Coblentz P, McDonell MG, Angelo F, Lowe JM, Ries RK, Roll J. Acceptability of contingency management among clinicians and clients within a co-occurring mental health and substance use treatment program. Am J Addict 2014; 22:432-6. [PMID: 23952887 DOI: 10.1111/j.1521-0391.2013.00333.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2011] [Revised: 01/09/2012] [Accepted: 02/24/2012] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Emerging evidence supports the effectiveness of contingency management (CM) for addictions treatment among individuals with co-occurring serious mental illness (SMI). Addiction treatment for people with SMI generally occurs within community mental health centers (CMHCs) and it is not known whether CM is acceptable within this context. Client views regarding CM are also unknown. OBJECTIVES This study is the first to describe CM acceptability among CMHC clinicians, and the first to explore client views. Clinician-level predictors of CM acceptability are also examined. METHODS This study examined views about CM among 80 clinicians and 29 clients within a CMHC within the context of a concurrent CM study. RESULTS Three-quarters of clinicians reported they would use CM if funding were available. Clinicians and clients affirmed that incentives enhance abstinence motivation. Clinician CM acceptability was related to greater years of experience, and identifying as an addictions or co-occurring disorders counselor, more than a mental health clinician. CONCLUSIONS The findings provide preliminary evidence that CMHC clinicians, serving clients with addictions and complicating SMI, and client participants in CM, view CM as motivating and a positive tool to facilitate recovery. SCIENTIFIC SIGNIFICANCE As an evidence-based intervention, CM warrants further efforts toward funding and dissemination in CMHCs.
Collapse
Affiliation(s)
- Debra Srebnik
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington 98104-2499, USA.
| | | | | | | | | | | | | | | |
Collapse
|
34
|
Hartzler B, Jackson TR, Jones BE, Beadnell B, Calsyn DA. Disseminating contingency management: impacts of staff training and implementation at an opiate treatment program. J Subst Abuse Treat 2013; 46:429-38. [PMID: 24462242 DOI: 10.1016/j.jsat.2013.12.007] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2013] [Revised: 12/02/2013] [Accepted: 12/10/2013] [Indexed: 12/15/2022]
Abstract
Guided by a comprehensive implementation model, this study examined training/implementation processes for a tailored contingency management (CM) intervention instituted at a Clinical Trials Network-affiliate opioid treatment program (OTP). Staff-level training outcomes (intervention delivery skill, knowledge, and adoption readiness) were assessed before and after a 16-hour training, and again following a 90-day trial implementation period. Management-level implementation outcomes (intervention cost, feasibility, and sustainability) were assessed at study conclusion in a qualitative interview with OTP management. Intervention effectiveness was also assessed via independent chart review of trial CM implementation vs. a historical control period. Results included: 1) robust, durable increases in delivery skill, knowledge, and adoption readiness among trained staff; 2) positive managerial perspectives of intervention cost, feasibility, and sustainability; and 3) significant clinical impacts on targeted patient indices. Collective results offer support for the study's collaborative intervention design and the applied, skills-based focus of staff training processes. Implications for CM dissemination are discussed.
Collapse
Affiliation(s)
- Bryan Hartzler
- Alcohol & Drug Abuse Institute, University of Washington, Seattle, WA 98105.
| | - T Ron Jackson
- School of Social Work, University of Washington, Seattle, WA 98105; Evergreen Treatment Services, Seattle, WA 98134
| | - Brinn E Jones
- Alcohol & Drug Abuse Institute, University of Washington, Seattle, WA 98105
| | - Blair Beadnell
- School of Social Work, University of Washington, Seattle, WA 98105
| | - Donald A Calsyn
- Alcohol & Drug Abuse Institute, University of Washington, Seattle, WA 98105; Psychiatry & Behavioral Sciences, University of Washington, Seattle, WA 98105
| |
Collapse
|
35
|
Stanger C, Budney AJ, Bickel WK. A developmental perspective on neuroeconomic mechanisms of contingency management. PSYCHOLOGY OF ADDICTIVE BEHAVIORS 2013; 27:403-15. [PMID: 22663343 PMCID: PMC3443497 DOI: 10.1037/a0028748] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
This paper provides a developmental overview of relevant theory and research on delay discounting and neuroeconomics, and their implications for contingency management (CM) approaches to treatment. Recent advances in the neuroscience of decision making have the potential to inform treatment development for adolescent substance use in general, and CM treatments in particular. CM interventions may be informed by research on delay discounting, a type of decision making that reflects how individuals value immediate versus delayed rewards. Delay discounting reliably distinguishes substance abusers from nonabusers and is a significant predictor of individual differences in response to substance use treatments. Discounting may also be important in predicting response to CM, as CM attempts to directly influence this decision-making process, shifting the preference from the immediate rewards of use to delayed rewards for choosing not to use. Multiple neural processes underlie decision making, and those processes have implications for adolescent substance abuse. There are significant neurodevelopmental processes that differentiate adolescents from adults. These processes are implicated in delay discounting, suggesting that adolescence may reflect a period of plasticity in temporal decision making. Understanding the neural mechanisms of delay discounting has led to promising working memory interventions directly targeting the executive functions that underlie individual choices. These interventions may be particularly helpful in combination with CM interventions that offer immediate rewards for brief periods of abstinence, and may show particular benefit in adolescence due to the heightened neural plasticity of systems that underlie temporal discounting in adolescence.
Collapse
Affiliation(s)
- Catherine Stanger
- Department of Psychiatry, Geisel School of Medicine at Dartmouth, Lebanon, NH 03756, USA.
| | | | | |
Collapse
|
36
|
Abstract
Abstract
We present a generally applicable theory of focusing based on the hypothesis that a person focuses more on, and hence overweights, attributes in which her options differ more. Our model predicts that the decision maker is too prone to choose options with concentrated advantages relative to alternatives, but maximizes utility when the advantages and disadvantages of alternatives are equally concentrated. Applying our model to intertemporal choice, these results predict that a person exhibits present bias and time inconsistency when—such as in lifestyle choices and other widely invoked applications of hyperbolic discounting—the future effect of a current decision is distributed over many dates, and the effects of multiple decisions accumulate. But unlike in previous models, in our theory (1) present bias is lower when the costs of current misbehavior are less dispersed, helping explain why people respond more to monetary incentives than to health concerns in harmful consumption; and (2) time inconsistency is lower when a person commits to fewer decisions with accumulating effects in her ex ante choice. In addition, a person does not fully maximize welfare even when making decisions ex ante: (3) she commits to too much of an activity—for example, exercise or work—that is beneficial overall; and (4) makes “future-biased” commitments when—such as in preparing for a big event—the benefit of many periods’ effort is concentrated in a single goal.
Collapse
|
37
|
Reback CJ, Peck JA, Fletcher JB, Nuno M, Dierst-Davies R. Lifetime substance use and HIV sexual risk behaviors predict treatment response to contingency management among homeless, substance-dependent MSM. J Psychoactive Drugs 2012; 44:166-72. [PMID: 22880545 DOI: 10.1080/02791072.2012.684633] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Homeless, substance-dependent men who have sex with men (MSM) continue to suffer health disparities, including high rates of HIV. One-hundred and thirty one homeless, substance-dependent MSM were randomized into a contingency management (CM) intervention to increase substance abstinence and health-promoting behaviors. Participants were recruited from a community-based, health education/risk reduction HIV prevention program and the research activities were also conducted at the community site. Secondary analyses were conducted to identify and characterize treatment responders (defined as participants in a contingency management intervention who scored at or above the median on three primary outcomes). Treatment responders were more likely to be Caucasian/White (p < .05), report fewer years of lifetime methamphetamine, cocaine, and polysubstance use (p < or = .05), and report more recent sexual partners and high-risk sexual behaviors than nonresponders (p < .05). The application of evidence-based interventions continues to be a public health priority, especially in the effort to implement effective interventions for use in community settings. The identification of both treatment responders and nonresponders is important for intervention development tailored to specific populations, both in service programs and research studies, to optimize outcomes among highly impacted populations.
Collapse
Affiliation(s)
- Cathy J Reback
- Friends Research Institute, University of California, Los Angeles, USA.
| | | | | | | | | |
Collapse
|
38
|
Olmstead TA, Cohen JP, Petry NM. Health-care service utilization in substance abusers receiving contingency management and standard care treatments. Addiction 2012; 107:1462-70. [PMID: 22296262 PMCID: PMC3634865 DOI: 10.1111/j.1360-0443.2012.03831.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
AIM To determine the impact of standard care and contingency management treatments on the utilization of general health-care services by substance abusers. PARTICIPANTS, DESIGN AND MEASUREMENTS: This secondary analysis pooled 1028 treatment-seeking substance abusers from five randomized clinical trials that compared the effects of standard care (SC, n = 362) to standard care plus contingency management (CM, n = 666). In each trial, subjects in the CM condition showed significantly greater reductions in substance use than their SC counterparts. For each subject, utilization of 15 general health-care services was measured 1 year prior to treatment intake and up to 9 months following treatment intake. Post-intake utilization data were pro-rated to be comparable to the 1-year pre-intake data. Paired t-tests evaluated changes in service utilization pre- and post-intake, and difference-in-differences regression models were used to estimate the impact of CM, compared to SC, on changes in the utilization of each of the 15 health services. SETTING Out-patient community substance abuse clinics in Connecticut and Massachusetts, USA. FINDINGS Utilization of several types of out-patient services increased significantly between the pre- and post-intake periods [e.g. dental visits (0.47, P < 0.001), community health center visits (0.50, P < 0.001), visits to a mental health professional office (1.03, P = 0.001)], while in-patient hospital care for mental health problems decreased significantly (-3.50 nights, P < 0.001). A substantial portion of these changes occurred during the treatment period. No significant differences were found between the two treatment conditions. CONCLUSIONS Initiating out-patient substance abuse treatment is associated with changes in general health-care service utilization, independent of the type of treatment offered.
Collapse
Affiliation(s)
- Todd A. Olmstead
- George Mason University, School of Public Policy, 3401 Fairfax Drive, Arlington, VA 22201, USA
| | - Jeffrey P. Cohen
- University of Hartford, Barney School of Business, 200 Bloomfield Ave., West Hartford, CT, 06117, USA
| | - Nancy M. Petry
- University of Connecticut Health Center, Department of Medicine, 263 Farmington Avenue, Farmington, CT 06030, USA
| |
Collapse
|
39
|
Financial incentives for smoking cessation in low-income smokers: study protocol for a randomized controlled trial. Trials 2012; 13:88. [PMID: 22721577 PMCID: PMC3526393 DOI: 10.1186/1745-6215-13-88] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2012] [Accepted: 05/25/2012] [Indexed: 11/29/2022] Open
Abstract
Background Tobacco smoking is the leading avoidable cause of death in high-income countries. The smoking-related disease burden is borne primarily by the least educated and least affluent groups. Thus, there is a need for effective smoking cessation interventions that reach to, and are effective in this group. Research suggests that modest financial incentives are not very effective in helping smokers quit. What is not known is whether large financial incentives can enhance longer-term (1 year) smoking cessation rates, outside clinical and workplace settings. Trial design A randomized, parallel groups, controlled trial. Methods Participants: Eight hundred low-income smokers in Switzerland (the less affluent third of the population, based on fiscal taxation). Intervention: A smoking cessation program including: (a) financial incentives given during 6 months; and (b) Internet-based counseling. Financial rewards will be offered for biochemically verified smoking abstinence after 1, 2, and 3 weeks and 1, 3, and 6 months, for a maximum of 1,500 CHF (1,250 EUR, 1,500 USD) for those abstinent at all time-points. All participants, including controls, will receive Internet-based, individually-tailored, smoking cessation counseling and self-help booklets, but there will be no in-person or telephone counseling, and participants will not receive medications. The control group will not receive financial incentives. Objective: To increase smoking cessation rates. Outcome: Smoking abstinence after 6 and 18 months, not contradicted by biochemical tests. We will assess relapse after the end of the intervention, to test whether 6-month effects translate into sustained abstinence 12 months after the incentives are withdrawn. Randomization: Will be done using sealed envelopes drawn by participants. Blinding: Is not possible in this context. Discussion Smoking prevention policies and interventions have been least effective in the least educated, low-income groups. Combining financial incentives and Internet-based counseling is an innovative approach that, if proven acceptable and effective, could be later implemented on a large scale at a reasonable cost, decrease health disparities, and save many lives. Trial registration Current Controlled Trials ISRCTN04019434.
Collapse
|
40
|
Affiliation(s)
- Bruce A. Christiansen
- CORRESPONDING AUTHOR: Bruce A. Christiansen, PhD, Center for Tobacco Research and Intervention, School of Medicine and Public Health, University of Wisconsin, 1930 Monroe St, Suite 200, Madison, WI 53711,
| |
Collapse
|
41
|
Hartzler B, Lash SJ, Roll JM. Contingency management in substance abuse treatment: a structured review of the evidence for its transportability. Drug Alcohol Depend 2012; 122:1-10. [PMID: 22153943 PMCID: PMC3307900 DOI: 10.1016/j.drugalcdep.2011.11.011] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2011] [Revised: 11/14/2011] [Accepted: 11/16/2011] [Indexed: 10/14/2022]
Abstract
AIMS Extant literature on contingency management (CM) transportability, or its transition from academia to community practice, is reviewed. The Consolidated Framework for Implementation Research (CFIR; Damschroder et al., 2009) guides the examination of this material. METHODS PsychInfo and Medline database searches identified 27 publications, with reviewed reference lists garnering 22 others. These 49 sources were examined according to CFIR domains of the intervention, outer setting, inner setting, clinicians, and implementation processes. RESULTS Intervention characteristics were focal in 59% of the identified literature, with less frequent focus on clinicians (34%), inner setting (32%), implementation processes (18%), and outer setting (8%). As intervention characteristics, adaptability and trialability most facilitate transportability whereas non-clinical origin, perceived inefficacy or disadvantages, and costs are impediments. Clinicians with a managerial focus and greater clinic tenure and CM experience are candidates to curry organizational readiness for implementation, and combat staff disinterest or philosophical objection. A clinic's technology comfort, staff continuity, and leadership advocacy are inner setting characteristics that prompt effective implementation. Implementation processes in successful demonstration projects include careful fiscal/logistical planning, role-specific staff engagement, practical adaptation in execution, and evaluation via fidelity-monitoring and cost-effectiveness analyses. Outer setting characteristics-like economic policies and inter-agency networking or competition-are salient, often unrecognized influences. CONCLUSIONS As most implementation constructs are still moving targets, CM transportability is in its infancy and warrants further scientific attention. More effective dissemination may necessitate that future research weight emphasis on external validity, and utilize models of implementation science.
Collapse
Affiliation(s)
- Bryan Hartzler
- Alcohol and Drug Abuse Institute, University of Washington, 1107 NE 45th Street, Seattle, WA 98105, USA.
| | | | | |
Collapse
|
42
|
Ruger JP, Abdallah AB, Luekens C, Cottler L. Cost-effectiveness of peer-delivered interventions for cocaine and alcohol abuse among women: a randomized controlled trial. PLoS One 2012; 7:e33594. [PMID: 22448255 PMCID: PMC3308978 DOI: 10.1371/journal.pone.0033594] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2011] [Accepted: 02/13/2012] [Indexed: 11/18/2022] Open
Abstract
Aims To determine whether the additional interventions to standard care are cost-effective in addressing cocaine and alcohol abuse at 4 months (4 M) and 12 months (12 M) from baseline. Method We conducted a cost-effectiveness analysis of a randomized controlled trial with three arms: (1) NIDA's Standard intervention (SI); (2) SI plus a Well Woman Exam (WWE); and, (3) SI, WWE, plus four Educational Sessions (4ES). Results To obtain an additional cocaine abstainer, WWE compared to SI cost $7,223 at 4 M and $3,611 at 12 M. Per additional alcohol abstainer, WWE compared to SI cost $3,611 and $7,223 at 4 M and 12 M, respectively. At 12 M, 4ES was dominated (more costly and less effective) by WWE for abstinence outcomes. Conclusions To our knowledge, this is the first cost-effectiveness analysis simultaneously examining cocaine and alcohol abuse in women. Depending on primary outcomes sought and priorities of policy makers, peer-delivered interventions can be a cost-effective way to address the needs of this growing, underserved population. Trial Registration ClinicalTrials.gov NCT01235091
Collapse
Affiliation(s)
- Jennifer Prah Ruger
- Department of Public Health, Yale University School of Medicine, New Haven, Connecticut, United States of America.
| | | | | | | |
Collapse
|
43
|
Petry NM, Weinstock J, Alessi SM. A randomized trial of contingency management delivered in the context of group counseling. J Consult Clin Psychol 2012; 79:686-96. [PMID: 21806297 DOI: 10.1037/a0024813] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Contingency management (CM) is efficacious in reducing drug use. Typically, reinforcers are provided on an individual basis to patients for submitting drug-negative samples. However, most treatment is provided in a group context, and poor attendance is a substantial concern. This study evaluated whether adding CM to group-based outpatient treatment would increase attendance and drug abstinence relative to standard care. METHOD Substance abusing patients (N = 239) initiating outpatient treatment at 2 community-based clinics were randomized to standard care with frequent urine sample monitoring for 12 weeks (SC) or that same treatment with CM delivered in the context of group counseling sessions. In the CM condition, patients earned opportunities to put their names in a hat based on attendance and submission of drug-negative samples. At group counseling sessions, therapists selected names randomly from the hat, and individuals whose names were drawn won prizes ranging from $1 to $100. RESULTS Patients assigned to CM earned a median of $160 in prizes, and they attended significantly more days of treatment (d = 0.25), remained in treatment for more continuous weeks (d = 0.40), and achieved longer durations of drug abstinence (d = 0.26) than patients randomized to SC. Group adherence and therapeutic alliance also improved with CM. In addition, HIV risk behaviors were significantly lower in CM relative to SC patients during early phases of treatment and at the 12-month follow-up. CONCLUSIONS These data demonstrate that CM delivered in the context of outpatient group counseling can increase attendance and improve drug abstinence.
Collapse
Affiliation(s)
- Nancy M Petry
- Calhoun Cardiology Center, University of Connecticut School of Medicine, Farmington, CT 06030-3944, USA.
| | | | | |
Collapse
|
44
|
Petry NM, Barry D, Alessi SM, Rounsaville BJ, Carroll KM. A randomized trial adapting contingency management targets based on initial abstinence status of cocaine-dependent patients. J Consult Clin Psychol 2012; 80:276-85. [PMID: 22229758 DOI: 10.1037/a0026883] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Contingency management (CM) reduces drug use, but questions remain regarding optimal targets and magnitudes of reinforcement. We evaluated the efficacy of CM reinforcing attendance in patients who initiated treatment with cocaine-negative samples, and of higher magnitude abstinence-based CM in patients who began treatment positive. METHOD Initially cocaine-negative patients (n = 333) were randomized to standard care (SC), SC + CM reinforcing submission of negative samples with $250 in prizes ($250Abs), or SC + CM reinforcing attendance ($250Att). Initially cocaine-positive patients (n = 109) were randomized to SC, $250Abs, or higher magnitude CM ($560Abs). RESULTS For initially cocaine-negative patients, $250Abs and $250Att were equally efficacious to SC in enhancing longest duration of abstinence (LDA); $250Att patients submitted lower proportions of negative samples when missing samples were considered missing, but these patients also attended more study sessions, provided more samples, and submitted a higher proportion of negative samples than SC patients when expected samples were analyzed, ps < .05. In initially cocaine-positive patients, both CM conditions increased proportions of negative samples relative to SC when missing samples were excluded from analyses, but only $560Abs was efficacious in increasing LDA and proportion of negative samples when expected samples were analyzed, ps < .05. Follow-ups revealed no differences among groups, but LDA was consistently associated with abstinence during follow-up, p < .05. CONCLUSIONS High magnitude abstinence-based reinforcement improved all abstinence outcomes in patients who began treatment while using cocaine. For patients initiating treatment abstinent, both attendance- and abstinence-based CM resulted in improvements on some measures.
Collapse
Affiliation(s)
- Nancy M Petry
- Calhoun Cardiology Center, Department of Medicine, University of Connecticut Health Center MC-3944, 263 Farmington Avenue, Farmington, CT 06030-3944, USA.
| | | | | | | | | |
Collapse
|
45
|
Kirby KC, Carpenedo CM, Stitzer ML, Dugosh KL, Petry NM, Roll JM, Saladin ME, Cohen AJ, Hamilton J, Reese K, Sillo GR, Stabile PQ, Sterling RC. Is exposure to an effective contingency management intervention associated with more positive provider beliefs? J Subst Abuse Treat 2011; 42:356-65. [PMID: 22116009 DOI: 10.1016/j.jsat.2011.09.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2011] [Revised: 08/25/2011] [Accepted: 09/15/2011] [Indexed: 10/15/2022]
Abstract
This study empirically examined opinions of treatment providers regarding contingency management (CM) programs while controlling for experience with a specific efficacious CM program. In addition to empirically describing provider opinions, we examined whether the opinions of providers at the sites that implemented the CM program were more positive than those of matched providers at sites that did not implement it. Participants from 7 CM treatment sites (n = 76) and 7 matched nonparticipating sites (n = 69) within the same nodes of the National Institute of Drug Abuse Clinical Trials Network completed the Provider Survey of Incentives (PSI), which assesses positive and negative beliefs about incentive programs. An intent-to-treat analysis found no differences in the PSI summary scores of providers in CM program versus matched sites, but correcting for experience with tangible incentives showed significant differences, with providers from CM sites reporting more positive opinions than those from matched sites. Some differences were found in opinions regarding costs of incentives, and these generally indicated that participants from CM sites were more likely to see the costs as worthwhile. The results from the study suggest that exposing community treatment providers to incentive programs may itself be an effective strategy in prompting the dissemination of CM interventions.
Collapse
Affiliation(s)
- Kimberly C Kirby
- Treatment Research Institute, 150 S. Independence Mall West, Philadelphia, PA19106, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
46
|
Petry NM, Barry D, Pescatello L, White WB. A low-cost reinforcement procedure improves short-term weight loss outcomes. Am J Med 2011; 124:1082-5. [PMID: 21851917 PMCID: PMC3200484 DOI: 10.1016/j.amjmed.2011.04.016] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2011] [Revised: 04/08/2011] [Accepted: 04/08/2011] [Indexed: 10/17/2022]
Abstract
OBJECTIVE Reinforcement-based treatments, based on behavioral economics models, can improve outcomes of medical conditions with behavioral components. This study evaluated the efficacy of a low-cost reinforcement intervention to produce initial weight loss. METHODS Overweight individuals (n=56) were randomized to one of two 12-week treatments: Lifestyle, Exercise, Attitudes, Relationships, Nutrition manual with supportive counseling or that same treatment with opportunities to win $1 to $100 prizes for losing weight and completing weight-loss activities. RESULTS Patients receiving reinforcement lost significantly more weight (6.0% ± 4.9% baseline bodyweight) than patients in the non-reinforcement condition (3.5% ± 4.1%; P=.04). Moreover, 64.3% of patients receiving reinforcement achieved weight loss of ≥ 5% baseline bodyweight versus 25.0% of those in the non-reinforcement condition (P=.003). Proportional weight loss was significantly related to reductions in total cholesterol and 24-hour ambulatory heart rate. CONCLUSION This reinforcement-based intervention substantially enhances short-term weight loss, and reductions in weight are associated with important changes in clinical biomarkers. Larger-scale evaluation of reinforcement-based treatments for weight loss is warranted.
Collapse
Affiliation(s)
- Nancy M Petry
- University of Connecticut School of Medicine, Farmington, CT, USA
| | | | | | | |
Collapse
|
47
|
Carroll KM, Ball SA, Jackson R, Martino S, Petry NM, Stitzer ML, Wells EA, Weiss RD. Ten take home lessons from the first 10 years of the CTN and 10 recommendations for the future. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2011; 37:275-82. [PMID: 21854269 PMCID: PMC3232679 DOI: 10.3109/00952990.2011.596978] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND The first 10 years of the National Institute on Drug Abuse's Clinical Trials Network (CTN) yielded a wealth of data on the effectiveness of a number of behavioral, pharmacological, and combined approaches in community-based settings. METHODS We summarize some of the methodological contributions and lessons learned from the behavioral trials conducted during its first ten years, including the capacity and enormous potential of this national research infrastructure. RESULTS The CTN made contributions to the methodology of effectiveness research; new insights from secondary analyses; the extent to which approaches with strong evidence bases, such as contingency management, extend their effectiveness to real world clinical settings; new data on 'standard treatment' as actually practiced in community programs, the extent to which retention remains a major issue in the field; important data on the safety of specific behavioral therapies for addiction; and heightened the importance of continued sustained attention to bridging the gap between treatment and research. CONCLUSIONS Areas of focus for the CTN's future include defining common outcome measures to be used in treatment outcome studies for illicit drugs; incorporating performance indicators and measures of clinical significance; conducting comparative outcome studies; contributing to the understanding of effective treatments of comorbidity; reaching underserved populations; building implementation science; understanding long-term outcomes of current treatments and sustaining treatment effects; and conducting future trials more efficiently.
Collapse
Affiliation(s)
- Kathleen M Carroll
- Division of Substance Abuse, Department of Psychiatry, Yale University School of Medicine, West Haven, CT, USA.
| | | | | | | | | | | | | | | |
Collapse
|
48
|
Embry DD. Behavioral vaccines and evidence-based kernels: nonpharmaceutical approaches for the prevention of mental, emotional, and behavioral disorders. Psychiatr Clin North Am 2011; 34:1-34. [PMID: 21333837 PMCID: PMC3064963 DOI: 10.1016/j.psc.2010.11.003] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
In the United States the rates for some mental, emotional, and behavioral problems (MEBs) have objectively increased over the past 20 to 50 years. The attributes of a public health approach to the treatment of MEBs are defined in this article. Multiple examples of how public health approaches might reduce or prevent MEBs using low-cost evidence-based kernels, which are fundamental units of behavior, are discussed. Such kernels can be used repeatedly, which then act as "behavioral vaccines" to reduce morbidity or mortality and/or improve human wellbeing. The author calls for 6 key policy actions to improve MEBs in young people.
Collapse
|
49
|
Abstract
Information technology represents an excellent medium to deliver contingencies of reinforcement to change behavior. Recently, we have linked the Internet with a science-based, behavioral treatment for cigarette smoking: abstinence reinforcement therapy. Under abstinence reinforcement interventions, incentives are provided for objective evidence of abstinence. Several studies suggest that the intervention is effective in initiating abstinence. The intervention addresses limitations (access, cost, sustainability, and dissemination potential) inherent in traditional abstinence reinforcement delivery models. It can also be applied to vulnerable, at-risk populations, and to other behavior to promote health. Information technologies offer unprecedented and rapidly expanding opportunities to facilitate behavior change.
Collapse
Affiliation(s)
- Jesse Dallery
- Department of Psychology, University of Florida, Gainesville, FL 32611, USA.
| | | |
Collapse
|
50
|
Maciejewski ML, Farley JF, Parker J, Wansink D. Copayment Reductions Generate Greater Medication Adherence In Targeted Patients. Health Aff (Millwood) 2010; 29:2002-8. [DOI: 10.1377/hlthaff.2010.0571] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Matthew L. Maciejewski
- Matthew L. Maciejewski ( ) is a research career scientist in the Center for Health Services Research in Primary Care at the Durham Veterans Affairs (VA) Medical Center and an associate professor in the Division of General Medicine, Department of Medicine, at Duke University Medical Center, both in Durham, North Carolina
| | - Joel F. Farley
- Joel F. Farley is an assistant professor in the Division of Pharmaceutical Outcomes and Policy, University of North Carolina, in Chapel Hill
| | - John Parker
- John Parker is a senior informatics analyst at Blue Cross Blue Shield of North Carolina, in Durham
| | - Daryl Wansink
- Daryl Wansink is the director of research and evaluation at Blue Cross Blue Shield of North Carolina
| |
Collapse
|