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This paper reports on a cost-effectiveness study of protocol CTN-0007, designed to determine if prize-based contingency management (CM), which has been shown to improve treatment outcomes over usual care (UC) alone, is worth the additional cost to treatment agencies. Six methadone maintenance community-based treatment programs (CTPs) in the CTN participated, with a study sample of 388 participants, 190 in the UC condition and 198 in the CM condition (which combined usual care with contingency management).

The authors found that prize-based contingency management provided better patient outcomes than usual care, but required additional costs. Compared to usual care, the incremental cost of using prize-based contingency management to lengthen the longest duration of abstinence (LDA) by one week was $141. The incremental cost to obtain an additional stimulant-negative urine sample was $70. Whether this extra expenditure is worthwhile depends upon the value placed on these outcomes. Using only the benefit of averted crime, an acceptability curve developed by the authors demonstrates a cost-effectiveness benefit of 90%. However, this estimate is quite conservative because averted crime is only one of the many potential benefits of a reduction in substance abuse. By comparing this study to a companion study, the authors also found that adding prize-based contingency management to usual care may be more cost-effective in methadone maintenance clinics than in counseling-based drug-free clinics. Further empirical analyses are needed to help policy makers decide whether CM is worth the extra expense; this paper helps to build an empirical basis for these important decisions.

Related protocols: CTN-0007-A-2

Despite research demonstrating its effectiveness, use of contingency management (CM) in substance use disorder treatment has been limited. Given the vital role that counselors play as arbiters in the use of therapies, examination of their use of and attitudes toward CM could provide insight into how to better promote further use of the intervention. This paper examines 731 counselors’ attitudes toward the effectiveness and acceptability of CM in treatment, as well as their specific attitudes toward both unspecified and tangible incentives for treatment attendance and abstinence. Compared to cognitive behavioral therapy, motivational interviewing, and community reinforcement approach, counselors rated CM as the least effective and least acceptable psychosocial intervention. Exposure through use of CM in a counselor’s employing organization was positively associated with perceptions of acceptability, agreement that incentives have a positive effect on the client-counselor relationship, and endorsement of tangible incentives for abstinence. Endorsement of tangible incentives for treatment attendance was significantly greater among counselors with more years in the treatment field, and counselors who held at least a Master’s degree. Counselors’ adaptability or openness to innovations was also positively associated with attitudes toward CM. Further, female counselors and counselors with a greater 12-step philosophy were less likely to endorse the use of incentives.

A highlight of this study is that it offers the first specific assessment of the impact of “Promoting Awareness of Motivational Incentives” (PAMI), a web-based tool based on findings of CM protocols tested within the Clinical Trials Network (CTN), on counselors employed outside the CTN. We found that 10% of counselors had accessed PAMI, and those who had accessed PAMI were more likely to report a higher degree of perceived effectiveness of CM than those who had not.

Conclusions: The effectiveness of SUD treatment will be enhanced by the breadth of the menu of treatment offerings that are offered by providers, assuming appropriate fidelity to the design of these interventions. Given the barriers to CM adoption, identifying predictors of positive CM attitudes among counselors can help diffuse CM into routine clinical practice. Exposure is important in ensuring proper delivery of such treatment, and training could help decrease the reluctance of paying individuals for treatment attendance or abstinence. This study lays in the groundwork for vital research on the impact of multiple web-based educational strategies. Future research should focus on differential effectiveness of different educational strategies, consider the attitudes of patients themselves, and explore the orientations toward practices such as CM among third-party payers. Given the barriers to CM adoption, identifying predictors of positive attitudes among counselors can help diffuse CM into routine clinical practice.

Related protocols: CTN-0006, CTN-0007

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 National Drug Abuse Treatment Clinical Trials Network (CTN) protocol CTN-0006 (Motivational Incentives for Enhanced Drug Abuse Recovery: Drug Free Clinics), a large, multi-site trial of a prize-based abstinence incentive intervention, 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 or as missing. A significant interaction term was found only for percentage of treatment completers (p=0.27). 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. Nevertheless, there were trends toward better retention and less drug use in CJ referrals who received abstinence incentives as well.

Conclusions: This study suggests that abstinence incentives should be offered as a first priority to stimulant users entering treatment without criminal justice referral. However, incentives can also be considered for use with criminal justice-referred stimulant users, based on the observation that best outcomes were obtained in CJ referrals who also received the abstinence incentive program.

Related protocols: CTN-0006

Substance abusers who enter treatment require a combination of motivation, skills and opportunities to make the behavior changes needed that will advance their recovery. One technique that has been helpful in boosting and sustaining motivation for successful participation and behavior change during treatment involves the use of tangible incentives that are awarded to clients by clinic staff contingent upon objective evidence of goal attainment. Contingency Management and Motivational Incentives are synonymous names for this technique. A large body of research provides evidence that motivational incentives, when implemented appropriately, can increase length of treatment participation and promote sustained periods of drug abstinence. Further, the technique has been shown efficacious when applied to users of a variety of abused substances including cocaine, alcohol and marijuana.

A large multi-site clinical trial conducted within the National Drug Abuse Treatment Clinical Trials Network supported effectiveness for treatment of stimulant users when abstinence-contingent incentives were added to usual care in community treatment programs that provided either psychosocial counseling alone or opiate substitution therapy (methadone) as well. Data from this trial will be used to demonstrate the magnitude and generality of these effects. Motivational incentives have been well accepted and widely adopted by substance abuse treatment researchers including those in CTN, to support adequate participation and/or to promote abstinence among research volunteers. The technique can also improve substance abuse treatment outcomes but has been less well accepted and widely adopted within the realm of clinical practice, despite being one of the most effective known behavioral interventions available for use in these settings. Nevertheless, adoption is gradually increasing as more training and dissemination materials become available and as solutions to perceived adoption impediments are addressed. During this presentation, dissemination resources will be provided and lessons learned about adoption discussed.

Related protocols: CTN-0006, CTN-0007

Stimulant users who sought treatment in a psychosocial outpatient treatment program participated in a multi-site 12-week randomized controlled trial (n=415) of a prize-based abstinence incentive intervention. Primary study outcomes were published previously (Petry et al., 2005); the present analysis examined the influence of criminal justice referral on treatment retention and stimulant use. In this study, participants were categorized based on study condition (incentives vs. usual care) and whether they were referred to treatment by the criminal justice system. Analyses assessed the separate and interactive effects of these factors on retention and stimulant use. Participants referred from the criminal justice system were more likely to be retained in treatment and to provide stimulant negative urine samples than those not referred from criminal justice. There was a significant interaction of criminal justice referral and incentives on treatment retention. Among voluntary referrals, those receiving abstinence incentives submitted 11.2 negative urines on average vs. 7.8 submitted by those in usual care. Among criminal justice referrals, mean number of negative urines submitted was 12.5 in those who received abstinence incentives vs. 10.3 in usual care.

Conclusions: Abstinence incentives significantly improved outcomes in voluntary but not in criminal justice referred admissions to outpatient treatment, probably due to higher base rates of retention and abstinence in the CJ referrals. Nevertheless, an additive effect of external motivation sources was seen with best outcomes in those exposed to both positive (abstinence incentives) and negative (CJ monitoring and sanctions) motivators and worst outcomes in those with neither source of external motivation.

This is the Results Article for CTN-0007-A-1.

This CTN platform 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, the researchers 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 non-participating sites (n=69) within the same nodes of the National Drug Abuse Treatment Clinical Trials Network (CTN) 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 programs versus matched sites, but correcting for experience with tangible incentives showed significant differences, with providers from CM sites reporting more positive opinions that 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 this evidence-based practice, one of the goals of NIDA’s CTN.

Related protocols: CTN-0006, CTN-0007, CTN-0007-A-1

THIS PRODUCT IS NO LONGER AVAILABLE. The Motivational Incentives Implementation Software (MIIS) is available at no cost. This platform, developed by the National Institute on Drug Abuse, provides the mechanisms to: assist researchers, clinicians, and counselors in utilizing and applying Motivational Incentives for treating patients with substance use disorders; and maintain information about clinic patients as well as in the implementation and calculation of incentives based on the defined parameters. MIIS is secure, easy to use, and easy to implement. The user interface allows patient information and activities to be stored and can manage patient appointments and supply detailed reports about patient progress. Patients are automatically awarded draws as an incentive for attendance and abstinence. MIIS can be configured to select prizes and provide draws in varying escalation schedules that are sensitive to patient history of compliance and relapse. The software also maintains a record of prizes awarded to patients.

This product has been combined with two other MI Blending Team Products, PAMI and MI:PRESTO to form a “Motivational Incentives (MI) Package.” MIIS has been discontinued; the other two products are available here: https://collaborativeforhealth.org/bettertxoutcomes/.

Related protocols: CTN-0006, CTN-0007

Motivational Incentives: Positive Reinforcers to Enhance Successful Treatment Outcomes (MI:PRESTO) is an interactive on-line course that focuses on the process of adopting Motivational Incentives in a clinical setting. By design, this course builds upon the Addiction Technology Transfer Center Network’s Technology Transfer Conceptual Model. Highlighted within this model is a multidimensional process that promotes the use of an innovation, in this case Motivational Incentives.

This free, self-guided, online learning tool assists Clinical Supervisors and other behavioral healthcare practitioners to learn and experience how to utilize the 7 Principles of Motivational Incentives introduced in PAMI, to facilitate the adoption of Motivational Incentives as an effective evidence-based practice aimed at reducing drug abuse and promoting positive outcomes for patients.

Related protocols: CTN-0006, CTN-0007

Researchers involved in the CTN protocols NIDA-CTN-0006 and NIDA-CTN-0007 (Motivational Incentives for Enhanced Drug Abuse Recovery in Drug Free Clinics and Methadone Clinics) have shown that motivational incentive programs using low-cost reinforcement (prizes, vouchers, clinic privileges, etc.), delivered in conjunction with onsite urine screening promotes higher rates of treatment retention and abstinence from drug abuse. This Blending Team product focuses on informing the field about successful approaches in the use of motivational incentives (also referred to as contingency management). The package includes an instructional CD-ROM, loaded with a video featuring conversations from top researchers to clinicians to patients in the field of addiction and recovery; sample documents that are customizable to your needs; PowerPoint presentations; research articles; and various additional resources. The PAMI Product was distributed to Research Utilization Committee (RUC) members in May 2007. It can also be downloaded from the ATTC web site.

This product was updated in 2011, providing tools designed to build awareness of Motivational Incentives as an effective therapeutic strategy within the addiction treatment field. It has been combined with two other MI Blending Team Products, MI:PRESTO and MIIS, to form a “Motivational Incentives (MI) Package.” MIIS has been discontinued; the other two products can be found here: https://collaborativeforhealth.org/bettertxoutcomes/.

Related protocols: CTN-0006, CTN-0007

This presentation begins with an overview of the two CTN MIEDAR projects, which examined the use of a low-cost incentive program to increase abstinence rates among patients in both methadone and drug-free substance abuse treatment programs. The studies showed that patients assigned to the incentive program remained in treatment longer and submitted a greater percentage of substance-free urine samples than patients in usual care, in both types of community treatment programs. Because of the positive outcomes of these two trials, NIDA and SAMHSA adapted the protocol for the Blending Team Product, “Promoting Awareness of Motivational Incentives” (PAMI), the materials for which are all available in both the CTN Dissemination Library.

The presentation concludes with a series of suggested “next steps” for clinicians looking for more help on how to implement incentives in their own treatment programs. A second MIEDAR Blending Team Product is currently being developed; it will take advantage of modern technology by offering computer-based trainings and implementation support. Watch for this product to be released as early as Spring 2011.

Related protocols: CTN-0006, CTN-0007

This presentation provides an overview of motivational incentives, with a focus on the Promoting Awareness of Motivational Incentives (PAMI) Blending Team Product and practical methods clinicians can use to smoothly adopt MI in their organizations. Challenges of motivational incentive, including cost of incentives, on-site testing, and counselor resistance are addressed in detail.

The presentation ends with a description of Nancy Petry’s checklist on motivational incentive implementation procedures, taken from her Drug and Alcohol Dependence article published in 2000. For a copy of that article, please contact the CTN Dissemination Librarians.

Counselor attitudes toward evidence-based practices, such as motivational incentives/contingency management (MI/CM), are important in bridging the gap between research and practice. Mailed surveys from 1,959 substance abuse treatment counselors showed ambivalence toward MI/CM and strong disagreement with using monetary rewards for achievement of treatment goals. Attitudes were associated with counselors’ educational attainment, a 12-step treatment ideology, affiliation with NIDA’s Clinical Trials Network (where two multi-site clinical trials of MI/CM have been conducted, in both drug-free outpatient programs and opioid treatment programs), and working in opioid treatment programs. Exposure to MI/CM via training was more strongly associated with attitudes when counselors worked in programs that had adopted MI/CM, but overall, the extent to which counselors have received such training was relatively low. While there is substantial resistance to MI/CM, dissemination and training about the essential elements of MI/CM may enhance counselors’ receptivity toward the intervention.

This research contributes to the growing literature about the value of research networks in influencing attitudes toward evidence-based treatment practices.

Related protocols: CTN-0006, CTN-0007

Prize-based contingency management (CM) is efficacious in treating cocaine abuse, and the chance-based procedures of prize CM may be appealing to those who gamble. Using data from three randomized trials, including National Drug Abuse Treatment Clinical Trials Network protocol CTN-0007 (Motivational Incentives for Enhanced Drug Abuse Recovery: Methadone Clinics), researchers evaluated whether cocaine-abusing patients who had wagered in the month before treatment (n=62) responded more favorably to prize CM than those who had not (n=278). Participants were randomized to standard care (SC) or SC plus prize CM. Although prize CM was related to better outcomes overall, recent gambling was not associated with outcomes across or within treatment conditions. Gambling participation before treatment entry was associated with reductions in gambling over time, and this effect was more pronounced among those assigned to CM.

Although these results are limited by the short timeframe over which gambling was evaluated and the overall low rates of gambling in this sample, these data suggest that prize CM is efficacious in substance-abusing patients who do and those who do not gamble before entering substance abuse treatment, and they extend prior studies indicating that prize CM does not increase gambling.

Related protocols: CTN-0007

This presentation begins with the history of contingency management (CM), an intervention that originally developed out of B.F. Skinner’s Operant Conditioning model. CM typically involves the use of positive reinforcements to change behavior and was first applied to problems with alcoholism in the late 1960’s. The New York Node joined the CTN in 2000 and participated in one of the two MIEDAR studies (“Motivational Incentives for Enhanced Drug Abuse Recovery: Methadone Clinics,” CTN-0007). This purpose and outcomes of this study are described in the presentation along with details about the specific involvement of two CTPs from the New York Node in the protocol (Lower Eastside Service Center and Greenwich House MMPT). In 2008, threatened changes in methadone maintenance policy led the New York City Health and Hospitals Corporation (HHC), the largest provider of addiction treatment in the U.S., to adopt new vocational rehabilitation programs. When patients refused to participate in the offered programs, the HHC adopted CM as a technique to increase involvement. The HHC eventually formed an alliance with the CTN to help develop a Vocational Incentives Program. Results from both the CM-related CTN protocols and the HHC’s VIP program are presented. The HHC has maintained its connection to the CTN via co-sponsored CM trainings and other workshops and conference, a perfect example of the CTN’s ability to help foster the dissemination of evidence-based practices in to real-world settings.

This study applies a latent variable approach to examine gender and racial/ethnic differences in cocaine dependence, to determine the presence of differential item functioning (DIF) or item-response bias to diagnostic questions of cocaine dependence, and to explore the effects of DIF on the predictor analysis of cocaine dependence. The analysis sample included 682 cocaine users enrolled in two national multisite studies of the National Drug Abuse Treatment Clinical Trials Network (CTN) (protocols CTN-0006 and CTN-0007, Motivational Incentives for Enhanced Drug Abuse Recovery in Drug Free/Methadone Clinics, respectively). Participants were recruited from 14 community-based substance abuse treatment programs associated with the CTN, including 6 methadone and 8 outpatient non-methadone programs. Factor and multiple indicators-multiple causes (MIMIC) procedures evaluated the latent continuum of cocaine dependence and is correlates. MIMIC analysis showed that men exhibited lower odds of cocaine dependence than women, controlling for the effects of DIF, years of cocaine use, addiction treatment history, comorbid drug dependence diagnoses, and treatment setting. There were no racial/ethnic differences in cocaine dependence; however, DIF by race/ethnicity was noted. Within the context of multiple community-based addiction treatment settings, women were more likely than men to exhibit cocaine dependence. Addiction treatment research needs to further evaluate gender-related differences in drug dependence in treatment entry and to investigate how these differences may affect study participation, retention, and treatment response to better serve this population.

Supported by the Duke Clinical Research Institute (CTN DSC 1).

Related protocols: CTN-0006, CTN-0007