Motivational incentives research in the National Drug Abuse Treatment Clinical Trials Network

The purpose of this article is to review both main findings and secondary analyses from studies of abstinence incentives conducted in the National Drug Abuse Treatment Clinical Trials Network (CTN). Previous research has supported the efficacy of tangible incentives provided contingent on evidence of recent drug abstinence. CTN conducted the first multisite effectiveness trial of this novel intervention. Study participants were stimulant abusers (N = 803) participating in treatment at 14 clinical sites and randomly assigned to treatment as usual with or without a prize draw incentive program. Study participants could earn up to $400 over 3 months for submission of drug-free urine and breath (BAL) specimens. Three-month retention was significantly improved by incentives offered to psychosocial counseling clients (50% incentive vs. 35% control retained), whereas ongoing stimulant drug use was significantly reduced in methadone maintenance clients (54.4% incentive vs. 38.7% control samples testing stimulant-negative). In both settings, duration of continuous abstinence achieved was improved in the incentive condition. These studies support effectiveness of one abstinence incentive intervention and highlight the different outcomes that can be expected with application in methadone maintenance versus psychosocial counseling treatment settings. Secondary analyses have shown the importance of early treatment positive versus negative urine screens in moderating the outcome of abstinence incentives and have explored both safety and cost-effectiveness of the intervention. Implications for the use of motivational incentive methods in clinical practice are discussed.     

Client incentives versus contracting and staff incentives: How care continuity interventions in substance abuse treatment can improve residential to outpatient transition

Interventions for improving transition from short-term residential to outpatient treatment were examined. Usual care (UC; n = 114) was referral to a preferred outpatient program with advance appointment optional. Client incentive (CI; n = 97) offered up to $100 in gift cards for intake and attendance during the first 30 days of treatment. Contracting with staff incentives (CSI; n = 49) consisted of meeting with an outpatient counselor prior to residential discharge, signing an attendance contract, receiving an appointment and payment to staff if clients attended. CSI significantly improved rates of successful transition (84%) and admission (74%) compared to UC (64% contact; 49% admitted). CI did not result in significantly improved outcomes (74%; 60%). CSI was likely mediated by the reliability (92 versus 52% in UC) and immediacy (1.0 versus 3.9 days) of appointment scheduling. This study supports use of CSI for improving rates of transition between residential and outpatient continuing care treatment.     

Public policy,attitudes and willingness to pay for treatment of substance dependence in Iran

BackgroundEvaluation of costs and benefits of substance use treatment programs through a standard economic framework is necessary for optimal policy making. However, drug policy making is seldom supported by economic justification. Measurement of willingness to pay is a tool to provide better understanding of intangible substance use treatment outcomes and to help a balanced policy in treatment of substance use between maintenance treatment and abstinence-based approach.AimTo assess the reciprocal association between economic indexes and attitudes about substance use and its treatment as indicators of tendency toward the two different treatment.MethodWillingness to pay for treatment was measured by contingency valuation method among 109 treatment cost payers of which 78 subjects were from outpatient methadone maintenance clinics and 31 were from abstinence-based residential facilities. To analyze predictors of willingness to pay, we used income to capture heterogeneity of purchasing power among subjects. Further, we checked bivariate correlation of different attitudes of cost payers with willingness to pay. In the next step using backward regression equation we tried to reach the best specification of the model. Selected variables include cost payers’ attitudes toward substance use and its treatment, effectiveness of treatment, social attitude toward the condition of substance use in Iran, fairness of treatment prices, and government financial support for addiction treatment.ResultsIn methadone maintenance clinics the payers’ income had a pivotal role in determining willingness to pay for substance use treatment by 50% (p<0.001 ). On the other hand, in abstinence-based residential facilities positive attitude toward substance use (61%, p<0.01) was the major direct determinant of willingness to pay for treatment. Attitude to public financial support for substance use treatment (55%, p<0.01 ) and consumption experience (45%, p<0.01 ) showed an inverse association with WTP in regression equation.ConclusionThis study expanded the understanding of the nature of payment in different substance use treatment modalities. The suggestion to policy makers is that before taking position on different types of treatment services, it is necessary to pay attention to factors that determine values cost payers put on treatment. In other words, economic indexes, payers’ views about substance use and its treatment, and their opinion about effectiveness of substance use treatment programs may jeopardize the success of the policy.     

Use of a low-cost incentive intervention to improve counseling attendance among methadone-maintained patients

Despite the importance of counseling in methadone maintenance treatment, many patients do not take advantage of these services. Incentives for attending group counseling were offered to methadone-maintained patients during an orientation phase of treatment or during required attendance at a relapse group later in treatment. Upon attending each counseling session, patients could draw for prizes under an escalating draw system with a 50% probability that draws would result in a prize. Incentives included small ($1), moderate ($5), and large ($20) prizes, with chances of winning inversely related to prize costs, and a maximum possible total of $160 per patient. It was anticipated that this policy would provide a relatively low-cost approach to improving counseling attendance in our methadone clinic. The incentive policy significantly increased the percent of counseling sessions attended (52% vs. 76%) and promoted periods of continuous attendance. These data further support the effectiveness of low-cost incentive programs in enhancing counseling attendance among methadone patients.     

Reinforcing integrated psychiatric service attendance in an opioid-agonist program: A randomized and controlled trial

Background

The benefits of integrating substance abuse and psychiatric care may be limited by poor service utilization. This randomized clinical trial evaluated the efficacy of using contingency management to improve utilization of psychiatric services co-located and integrated within a community-based methadone maintenance treatment program.

Methods

Opioid-dependent outpatients (n = 125) with any current psychiatric disorder were randomly assigned to: (1) reinforced on-site integrated care (ROIC), with vouchers (worth $25.00) contingent on full adherence to each week of scheduled psychiatric services; or (2) standard on-site integrated care (SOIC). All participants received access to the same schedule of psychiatrist and mental health counseling sessions for 12-weeks.

Results

ROIC participants attended more overall psychiatric sessions at month 1 (M = 7.53 vs. 3.97, p < .001), month 2 (M = 6.31 vs. 2.81, p < .001), and month 3 (M = 5.71 vs. 2.44, p < .001). Both conditions evidenced reductions in psychiatric distress (p < .001) and similar rates of drug-positive urine samples. No differences in study retention were observed.

Conclusions

These findings suggest that contingency management can improve utilization of psychiatric services scheduled within an on-site and integrated treatment model. Delivering evidenced-based mental health counseling, or modifying the contingency plan to include illicit drug use, may be required to facilitate greater changes in psychiatric and substance abuse outcomes.     

Patient retention in mobile and fixed-site methadone maintenance treatment

The retention of patients (n = 399) enrolled in mobile health services (MHS), a Baltimore outpatient mobile methadone treatment program, was compared to patient retention (n = 1588) in six Baltimore fixed-site programs. Mobile program patients were retained for a median of 15.53 months in treatment in comparison to 3.90 for fixed-site patients (n = 664) from the MHS served zip codes (MHSZIPS) and 6.27 for fixed-site patients (n = 924) from zip codes other than those served by MHS (OTHERZIPS), (P < 0.001). Using Cox regression, the characteristics of patients associated with earlier discharge were (1) higher number of arrests, (2) more frequent cocaine use and (3) lower family income. These predictors of shorter retention were generally more prevalent among patients from the MHS served zip codes. Therefore, the longer retention in treatment of MHS patients as compared to OTHERZIPS fixed-site program patients is even more striking. Consistent with these differences in retention, were findings in a prior study suggesting that the mobile program provided greater access to services in reducing patient transportation cost and travel time. Thus, mobile methadone maintenance treatment appears to be a useful means of providing services.     

Small financial incentives increase smoking cessation in homeless smokers: A pilot study

Although over 70% of homeless individuals smoke, few studies have examined the effectiveness of smoking cessation interventions in this vulnerable population. The purpose of this pilot study was to compare the effectiveness of shelter-based smoking cessation clinic usual care (UC) to an adjunctive contingency management (CM) treatment that offered UC plus small financial incentives for smoking abstinence. Sixty-eight homeless individuals in Dallas, Texas (recruited in 2012) were assigned to UC (n = 58) or UC plus financial incentives (CM; n = 10) groups and were followed for 5 consecutive weeks (1 week pre-quit through 4 weeks post-quit). A generalized linear mixed model regression analysis was conducted to compare biochemically-verified abstinence rates between groups. An additional model examined the interaction between time and treatment group. The participants were primarily male (61.8%) and African American (58.8%), and were 49 years of age on average. There was a significant effect of treatment group on abstinence overall, and effects varied over time. Follow-up logistic regression analyses indicated that CM participants were significantly more likely than UC participants to be abstinent on the quit date (50% vs. 19% abstinent) and at 4 weeks post-quit (30% vs. 1.7% abstinent). Offering small financial incentives for smoking abstinence may be an effective way to facilitate smoking cessation in homeless individuals.     

Retention in methadone and buprenorphine treatment among African Americans

Methadone has been the most commonly used pharmacotherapy for the treatment of opioid dependence in U.S. public sector treatment, but availability of buprenorphine as an alternative medication continues to increase. Drawing data from two community-based clinical trials that were conducted nearly contemporaneously, this study examined retention in methadone versus buprenorphine treatment over 6 months among urban African Americans receiving treatment in one of four publicly-funded programs (N = 478; 178 methadone; 300 buprenorphine). Adjusting for confounds related to medication selection, survival analysis revealed that buprenorphine patients are at substantially higher risk of dropout compared to methadone patients (HR = 2.43; p < .001). Buprenorphine's retention disadvantage appears to be concentrated in the earlier phases of treatment (approximately the first 50 days), after which risk of subsequent dropout becomes similar for the two medications. These findings confirm a retention disparity between methadone and buprenorphine in this population, and suggest potential avenues for future research to enhance retention in buprenorphine treatment.     

Methadone maintenance and the cost and utilization of health care among individuals dependent on opioids in a commercial health plan

Background

Few health plans provide maintenance medication for opioid dependence. This study assessed the cost of treating opioid-dependent members in a commercial health plan and the impacts of methadone maintenance on costs of care.

Methods

Individuals with diagnoses of opioid dependence (two or more diagnoses per year) and at least 9 months of health plan eligibility each year were extracted from electronic health records for the years 2000 through 2004 (1,518 individuals and 2,523 observations across the study period—some individuals were in multiple years). Analyses examined the patterns and costs of health care for three groups of patients: (1) one or more methadone visits during the year (n = 1,298; 51%); (2) no methadone visits and 0 or 1 visits in the Addiction Medicine Department (n = 370; 15%); (3) no methadone visits and 2 or more visits in addiction medicine (n = 855; 34%).

Results

Primary care (86%), emergency department (48%) and inpatient (24%) visits were common. Mean total annual costs to the health plan were $11,200 (2004 dollars) per member per year. The health plan's costs for members receiving methadone maintenance were 50% lower ($7,163) when compared to those with two or more outpatient addiction treatment visits but no methadone ($14,157) and 62% lower than those with one or zero outpatient addiction treatment visits and no methadone treatment ($18,694).

Conclusions

Use of opioid maintenance services was associated with lower total costs of care for opioid-dependent members in a commercial health plan.     

A treatment reengagement intervention for syringe exchangers

Poor sustained treatment engagement limits the effectiveness of all modalities of substance abuse treatment. This study evaluated the efficacy of a novel treatment reengagement intervention for a subset of syringe-exchange program (SEP) participants (N = 113) that had enrolled in treatment as part of a 4-month clinical trial (M. Kidorf et al., 2009). Three reengagement conditions for participants leaving treatment were compared. Motivational referral condition (MRC) participants (n = 31) could attend group sessions that focused on renewing treatment interest. MRC plus incentive (MRC + I) participants (n = 49) could receive modest monetary incentives for attending these sessions and reenrolling in treatment. Standard referral condition participants (n = 33) could not attend groups or receive incentives. Across a 1-year observation window, almost all study participants (86%) were discharged from treatment. MRC + I participants attended more group sessions than MRC participants and were considerably more likely to reenroll in treatment than participants in the other study conditions. Reengagement strategies can further enhance the public health benefits of SEPs by increasing rates of treatment participation over time.     

Criminal justice referral and incentives in outpatient substance abuse treatment

A substantial number of substance abusers entering outpatient psychosocial counseling treatment are referred from the criminal justice (CJ) system. This secondary analysis of previously published findings from a large (N = 415) multi-site trial of a prize-based abstinence incentive intervention ( Petry et al., 2005) examined the influence of CJ referral on usual care outcomes and response to the incentive procedure. CJ referrals (n = 138) were more likely than those not CJ referred (n = 277) to provide stimulant negative urine samples whether missing samples were counted as positive (50 versus 41%, p = .016) or as missing (96 versus 91%, p < .001). A significant interaction term was found only for percentage of treatment completers (p = .027). However, on that retention variable, and three additional drug use measures, significant incentive effects were confined to participants who entered treatment without referral from the criminal justice system. The study suggests that abstinence incentives should be offered as a first priority to stimulant users entering treatment without criminal justice referral. However, incentives can be considered for use with CJ-referred stimulant users based on the observation that best outcomes were obtained in CJ referrals who also received the abstinence incentive program.     

The brief abstinence test: effects of continued incentive availability on cocaine abstinence

This study compared the effects of 4 voucher incentive conditions of a brief abstinence test on continuous cocaine abstinence. In 3 conditions, cocaine-abusing methadone patients could earn $100 for 2 days of cocaine abstinence; 2 of these conditions offered, on either a continuous or interrupted schedule, an additional $300 for evidence of sustained abstinence over the next 9 days. In the 4th condition, no incentives were available. In incentive conditions, 70-80% of patients initiated abstinence, compared with 48% in the no-incentive condition. Both continuing reinforcement conditions produced higher rates of sustained abstinence than the single and no-voucher conditions. The study confirmed the utility of quantitative urine-testing methods combined with high valued incentives to promote cocaine abstinence initiation in methadone maintenance patients.     

Web-based behavioral treatment for substance use disorders as a partial replacement of standard methadone maintenance treatment

This study is the first experimental trial to evaluate the effectiveness of a Web-based behavioral intervention when deployed in a model where it partially substituted for standard counseling in a community-based specialty addiction treatment program. New opioid-dependent intakes in methadone maintenance treatment (n = 160) were randomly assigned for 12 months to either: (1) standard treatment or (2) reduced standard treatment plus a Web-based psychosocial intervention, the Therapeutic Education System (TES). Results demonstrated that replacing a portion of standard treatment with TES resulted in significantly greater rates of objectively measured opioid abstinence (48% vs. 37% abstinence across all study weeks; F(1, 158) = 5.90, p < .05 and 59% vs. 43% abstinence on weeks participants provided urine samples for testing; F(1, 158) = 8.81, p < .01). This result was robust and was evident despite how opioid abstinence was operationally defined and evaluated. The potential implications for service delivery models within substance abuse treatment programs and other healthcare entities are discussed.     

A randomized controlled trial of fluoxetine in the treatment of cocaine dependence among methadone-maintained patients

Background

Cocaine abuse and dependence continue to be widespread. Currently, there are no pharmacotherapies shown to be effective in the treatment of cocaine dependence.

Methods

A 33-week outpatient clinical trial of fluoxetine (60 mg/day, po) for cocaine dependence that incorporated abstinence-contingent voucher incentives was conducted. Participants (N = 145) were both cocaine and opioid dependent and treated with methadone. A stratified randomization procedure assigned subjects to one of four conditions: fluoxetine plus voucher incentives (FV), placebo plus voucher incentives (PV), fluoxetine without vouchers (F), and placebo without vouchers (P). Dosing of fluoxetine/placebo was double blind. Primary outcomes were treatment retention and cocaine use based on thrice-weekly urine testing.

Results

The PV group had the longest treatment retention (M = 165 days) and lowest probability of cocaine use. The adjusted predicted probabilities of cocaine use were 65% in the P group, 60% in the F group, 56% in the FV group, and 31% in the PV group.

Conclusions

Fluoxetine was not efficacious in reducing cocaine use in patients dually dependent on cocaine and opioids.     

Comparison of Pregnancy-Specific Interventions to a Traditional Treatment Program for Cocaine-Addicted Pregnant Women

Alcohol and drug use in pregnancy is a significant concern. There is a paucity of treatment programs for substance-abusing pregnant women, especially if indigent. Futhermore, treatment retention is compromised when the drug of choice is crack-cocaine. This paper reports the results of a study comparing treatment retention of cocaine-abusing indigent pregnant women before and after incorporating pregnancy-specific interventions. Audits were performed on 603 charts of women enrolled between 1988 and 1994 in either a traditional treatment program (n = 114) or in the Pregnancy Substance Abuse Program (PSAP) (n = 489). Differences in treatment retention were found between the two treatment groups. Drop-out rates from the inpatient component of treatment were significantly lower in the PSAP group than in the control group (11.3% vs. 38.6%, p < .001). There was a higher rate of completion of outpatient treatment in the PSAP compared to the control group (34.4% vs. 13.5%, p < .005). These results were achieved with a 2-day decreased inpatient stay. Treatment retention improved when specialized interventions were provided, at minimal additional cost. These results have implications for other publicly funded treatment programs.     

Predictors and Outcome of Aftercare Participation of Alcohol and Drug Users Completing Residential Treatment

This study attempts to identify factors associated with greater aftercare participation for 367 adults who completed abstinence-based residential addiction treatment between and at Bellwood Health Services in Toronto, Canada. Pre-treatment substance use, number of days spent in residential treatment, motivation, treatment satisfaction, and demographics were used to determine which characteristics predicted greater aftercare participation. The duration of residential treatment and treatment satisfaction emerged as significant predictors of aftercare attendance. Regular aftercare attendance was associated with lower levels of substance use at 6-month follow-up. Results suggest that a longer duration of residential treatment can influence continuing care engagement and highlight the importance of initial treatment retention for long-term recovery.     

The SUMMIT Trial:: A field comparison of buprenorphine versus methadone maintenance treatment

This prospective patient-preference study examined the effectiveness in practice of methadone versus buprenorphine maintenance treatment and the beliefs of subjects regarding these drugs. A total of 361 opiate-dependent individuals (89% of those eligible, presenting for treatment over 2 years at a drug service in England) received rapid titration then flexible dosing with methadone or buprenorphine; 227 patients chose methadone (63%) and 134 buprenorphine (37%). Participants choosing methadone had more severe substance abuse and psychiatric and physical problems but were more likely to remain in treatment. Survival analysis indicated those prescribed methadone were over twice as likely to be retained (hazard ratio for retention was 2.08 and 95% confidence interval [CI] = 1.49–2.94 for methadone vs. buprenorphine), However, those retained on buprenorphine were more likely to suppress illicit opiate use (odds ratio = 2.136, 95% CI = 1.509–3.027, p < .001) and achieve detoxification. Buprenorphine may also recruit more individuals to treatment because 28% of those choosing buprenorphine (10% of the total sample) stated they would not have accessed treatment with methadone.     

Organizational determinants of outpatient substance abuse treatment duration in women

Longer treatment duration has consistently been related to improved substance use outcomes. This study examined how tailored women's programming and organizational characteristics were related to duration in outpatient substance abuse treatment in women. Data were from two waves of a national outpatient substance abuse treatment unit survey (n = 571 in 1999/2000, n = 566 in 2005). Analyses were conducted separately for methadone and nonmethadone programs. Negative binomial regressions tested associations between organizational determinants, tailored programming, and women's treatment duration. Of the tailored programming services, childcare was significantly related to longer duration in the nonmethadone programs, but few other organizational factors were. Tailored programming was not associated to treatment duration in methadone programs, but ownership, affiliation, and accreditation were related to longer duration. Study findings suggest evidence for how external relationships related to resources, treatment constraints, and legitimacy may influence women's treatment duration. Methadone programs may be more vulnerable to external influences.     

Challenges and Outcomes of Parallel Care for Patients With Co-Occurring Psychiatric Disorder in Methadone Maintenance Treatment

Objective: Most opioid users seeking treatment in community-based substance abuse treatment programs have at least one co-occurring psychiatric disorder, and the presence of psychiatric comorbidity in this population is associated with increased psychological distress, poorer quality of life, and reduced response to substance abuse treatment. This observational study describes clinical outcomes of referring patients receiving methadone maintenance with at least one co-occurring psychiatric disorder to a community psychiatry program located on the same hospital campus. Methods: Participants (n = 156) were offered priority referrals to a community psychiatry program that included regularly scheduled psychiatrist appointments, individual and group therapy, and enhanced access to psychiatric medications for 1 year. Psychiatric distress was measured with the Symptom Checklist (SCL-90-R), which participants completed monthly. Results: While about 80% of the sample (n = 124) initiated psychiatric care, the average length of treatment was only 128.2 days (SD = 122.8), participants attended only 33% of all scheduled appointments (M = 14.9 sessions, SD = 14.1), and 84% (n = 104) did not complete a full year of care. Of those who did not complete a full year, over half (55%, n = 68) left psychiatric care while still receiving substance abuse treatment. Exploratory negative binomial regression showed that baseline cocaine and alcohol use disorder (p =.002 and.022, respectively) and current employment (p =.034) were associated with worse psychiatric treatment retention. Modest reductions in psychiatric distress over time were observed (SCL-90-R Global Severity Index change score = 2.5; paired t = 3.54, df = 121, p =.001). Conclusions: Referral of patients with co-occurring psychiatric disorders receiving methadone maintenance to a community psychiatry program is often ineffective, even after reducing common barriers to care. Service delivery models designed to improve attendance and retention, such as integrated care models, should be evaluated. This study is part of a larger clinical trial, registered at www.clinicaltrials.gov under #NCT00787735.     

Field Test of a Dialectical Behavior Therapy Skills Training–Based Intervention for Smoking Cessation and Opioid Relapse Prevention in Methadone Treatment

Objective: Almost all individuals in methadone treatment for opioid dependence smoke cigarettes, and half of people in methadone treatment have an opioid relapse within six months. Dialectical behavior therapy (DBT) skills training has shown promise for addressing substance use and a variety of health behaviors and conditions; however, it has never been evaluated for smoking cessation in any population. The objective of this study was to field test a DBT skills training–based intervention for tobacco dependence and opioid relapse prevention (DBT-Quit) among people in methadone treatment.

Methods: We recruited seven individuals in methadone treatment to participate in a field test of DBT-Quit. Participants attended 12 weekly 90-minute DBT skills training groups, focusing on mindfulness, emotion regulation, and distress tolerance skills. Participants received nicotine patches for eight?weeks and completed assessments at baseline, 6 weeks (mid-treatment), and 12 weeks (post-treatment).

Results: All but one participant (86%, n?=?6) attended at least 50% of intervention sessions. Participants were “very” or “mostly” satisfied with the intervention. At 12 weeks, all but one (86%, n?=?6) had made a quit attempt, and one (14%) had seven-day point prevalence abstinence. Participants were smoke-free for 24?hours (14%, n?=?1), 7 to 14?days (43%, n?=?3), and 30 to 59?days (29%, n?=?2). Participants smoked significantly fewer cigarettes per day at 6 weeks and 12 weeks as compared to baseline. No participants used illicit drugs. As compared to baseline, at follow-up there were no significant differences in difficulties with emotion regulation, distress tolerance, or mindfulness.

Conclusions: A DBT skills training–based intervention for individuals who smoke and have an opioid use disorder is feasible and acceptable in methadone treatment and may help this population prevent drug relapse, attempt to quit smoking, experience smoke-free days, and cut down on their smoking. More research is needed to determine the optimal structure and components of a DBT skills–based intervention for drug relapse prevention and smoking cessation. Further, a randomized controlled trial of DBT-Quit is needed to determine the efficacy of DBT skills training for smoking cessation and drug relapse prevention in this population.