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Program Profile: Prize-Based Incentive Contingency Management for Substance Abusers

Evidence Rating: Effective - More than one study Effective - More than one study

Date: This profile was posted on June 08, 2011

Program Summary

A version of contingency management that provides adult substance abusers in community-based treatment with an opportunity to win prizes if they remain drug free. The program is rated Effective. The incentive group had the longest drug use abstinence, study retention, and attended more counseling sessions compared with those who received usual care.

This program’s rating is based on evidence that includes at least one high-quality randomized controlled trial.

Program Description

Program Goals

Prize-based Incentives Contingency Management for Substance Abusers is a version of contingency management (CM) that provides adult substance abusers in community-based treatment with an opportunity to win prizes if they remain drug free. The intervention is based on the psychological theory of operant conditioning, which relies on the use of consequences to modify the occurrence and form of specific behavior. In this instance, the intervention provides reinforcement of positive behaviors that will lead to behavioral change (mainly, abstinence from drug use). Participation lasts anywhere from 2 to 4 weeks for the intensive outpatient therapy to 12 months or longer with aftercare services.

 

CM interventions attempt to increase positive behavior in substance abusers by offering vouchers that are redeemable for retail goods and services but are contingent on behavior change. Prize-based CM reinforces positive abstinent behavior in substance-abusing clients in treatment by providing them an opportunity to win various prizes when they provide negative urine and breath samples or complete treatment-related activities.

 

For example, one abstinence incentive procedure used with cocaine and methamphetamine users in community clinics invited clients who provided negative tests to draw plastic chips from a bowl, which could result in winning a prize valued from $1 to $100. Chips worth $1 allowed clients to select from a variety of popular items such as bus tokens, snacks, and fast-food gift certificates. The more valuable the dollar amount on the chip, the more valuable the items that a client could select from. A chip worth $20 allowed clients to choose from items such as compact disc players, telephones, and retail store gift certificates. Chips worth $80 to $100 allowed clients to choose from items such as televisions, stereos, and DVD players. The number of chips a participant was permitted to draw was determined on a schedule that was responsive to test outcomes.

 

CM systems using vouchers have not been directly compared with CM systems that use prizes.

 

Target Population

The prize-based CM system is used in addition to intensive outpatient substance abuse treatment program services in community treatment clinics. The target population is adult patients who primarily abuse stimulants (such as cocaine) or opioids (such as heroin) or who may have multiple substance abuse problems.

Evaluation Outcomes

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Study 1

Quality of Life Inventory Total Scores (QOLI)

Petry, Alessi, and Hanson (2007) found that Quality of Life Inventory (QOLI) total scores increased significantly over time for study participants who received contingency management. The total scores did not increase significantly for study participants who received standard care. Looking at the subscale scores, Civic Action, Home, Relationship with Relatives, Self-Regard, Standard of Living, and Work scores significantly increased over time for the CM group. These scores generally remained unchanged in the standard care group. For the Love Relationships subscale, the scores significantly decreased for the standard care group.

 

The number of scales that participants rated as at least important was greater in the CM group compared with the standard care group at the month 9 assessment. However, there were no significant differences between the groups at the remaining assessment periods.

 

Longest Duration of Abstinence (LDA)

The analysis of the relationship between CM and LDA found that group assignment (CM versus standard care) made a significant impact on LDA. Standard care group members achieved 3.5 weeks (± 3 weeks) of abstinence, compared with 5.8 weeks (± 4.5 weeks) for those in the CM group. The final step of this analysis found that LDA was a significant predictor of changes in QOLI scores over time, indicating that LDA at least partially mediates the relationship between type of treatment and changes over time in QOLI scores.

 

Study 2

Study Retention

Petry and colleagues (2005) found that participants randomly assigned to the incentive condition were significantly more likely to be retained than those assigned to receive usual care. By the end of 12 weeks, 49 percent of participants in the incentive condition were still retained, compared with 35 percent of the usual care participants. Incentive participants were also more likely to submit weekly samples than usual care participants.

 

Counseling Use

Participants in the incentive group attended an average of 19.2 counseling sessions (± 16.8 sessions) during the 12-week study period, compared with 15.7 counseling sessions (± 14.4 sessions) attended by participants who received usual care.

 

Drug Use

The general estimating equation analysis (which assumed that missing samples were negative if they were preceded and followed by negative samples) showed nonsignificant differences between the incentive group and usual care group in terms of urine samples free of the primary and secondary target drugs. General estimating equation analysis (which coded missing samples as positive) showed a significantly higher proportion of stimulant-free samples in the incentive group. Most urine samples were stimulant free in both conditions. The rates of negative alcohol breath samples were also extremely high for both groups. Rates did not differ by condition, except when missing data was treated as positive.

 

Analysis of LDA measures showed that the usual care group had an average number of 5.2 visits with confirmed abstinence (± 6.9 visits) and the incentive group had an average number of 8.6 visits with confirmed abstinence (± 9.2 visits). This translated into roughly 2.6 weeks of consecutive abstinence for the usual care group and 4.4 weeks for the incentive group. The incentive group had about twice as many participants with at least 4 weeks and 8 weeks of documented sustained abstinence. The percentage of participants with 12 weeks of documented abstinence was nearly four times as great for the incentive group as for the usual care participants.

 

Negative Samples Submitted

The proportion of participants who had very good outcomes (19 to 24 negative samples of stimulants and alcohol) was significantly higher in the incentive group than in the usual care group. Conversely, the proportion with relatively poor outcomes (one to six negative samples) was lower in the incentive group than in the usual care group.

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Evaluation Methodology

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Study 1

Petry, Alessi, and Hanson (2007) combined data from three randomized clinical trials of contingency management to determine whether the quality of life of cocaine abusers who received contingency management (CM) differed significantly from patients who received standard care. The study included 393 individuals who participated in one of three CM studies from 1999 to 2003 (Petry et al. 2006; Petry et al. 2005; Petry et al. 2004). The three studies occurred at four drug abuse treatment clinics in Connecticut and Massachusetts. Recruitment for the studies occurred between September 1998 and January 2004, and follow-ups of study participants occurred between October 1998 and September 2004.

 

Substance users were eligible to participate in the study if they were initiating intensive outpatient treatment at one of the four clinics and met the Diagnostic and Statistical Manual of Mental Disorders (DSM–IV) criteria for cocaine abuse or dependence. Substance abusers were ineligible to participate if they were unable to comprehend the study, had an active psychotic disorder, were currently suicidal, or were in recovery for pathological gambling.

 

There were 278 patients randomly assigned to receive CM and 115 patients randomly assigned to receive standard treatment across the three studies. The CM treatment group was 48 percent male, and 53.0 percent African American, 33.5 percent European American, 11.2 percent Hispanic/Latino, and 2.5 percent other. Age averaged 36.1 years. The standard care control group was 54.8 percent male and 51.3 percent African American, 37.4 percent European American, 11.3 percent Hispanic/Latino, with an average age of 36.4 years. There were no significant differences between the groups.

 

Study participants completed a 2-hour interview that captured demographic information and assessed drug use diagnoses and pathological gambling based on the Structured Clinical Interview from DSM–IV. Breath and urine samples were also collected and screened for alcohol, cocaine, and opioid use. The Quality of Life Inventory (QOLI) assessed the importance and satisfaction in 17 life areas. The total scale score is obtained by averaging all subscale scores for each domain that is rated as important or extremely important by participants. The QOLI total score reflects subjective well-being in life domains considered of some importance to participants. The QOLI was administered again at 1, 3, 6, and 9 months after treatment began.

 

The standard treatment condition included group therapy sessions that involved relapse prevention, coping and life skills training, AIDS education, and 12-step treatment. Intensive case (up to 5 hours a day, 5 days a week) lasted 2 to 4 weeks. Aftercare consisted of one group session a week for up to 12 months. Study participants who received standard care submitted breath and urine samples 3 days a week in weeks 1 to 3, 2 days a week in weeks 4 to 6, and once a week in weeks 7 to 12 of the studies.

 

CM treatment consisted of the same standard care that the control group received plus the chance to earn prizes or vouchers for submitting negative samples and/or completing goal-related activities. Each of the three studies included in the analysis evaluated two CM procedures that differed by magnitude of prizes available (Petry et al. 2004), type of reinforcement (Petry et al. 2005), or behaviors reinforced (Petry et al. 2006). In two of the studies (Petry et al. 2005; Petry et al. 2004), patients received reinforcements for two behaviors—submission of negative samples and completion of goal-related activities. The number of draws earned started at one draw per one negative sample or activity completed, with bonuses of five draws or a $10 voucher for a full week of negative samples or three activities completed within a week. During the third study (Petry et al. 2004), participants earned draws associated with $1, $20, and $100 prizes, with an expected maximal earning of about $240.

 

For this study, participants from all three studies were combined into one group, and participants who did not receive CM were combined into the standard treatment group. Hierarchical linear modeling was used to evaluate changes in the QOLI total scores from baseline through month 9. The study also included examination of drug abstinence as a mediated effect of CM on QOLI total scores. The main outcome measure in each study was longest duration of abstinence (LDA) achieved during treatment. LDA was defined as consecutive weeks in which all samples tested negative for opioids, cocaine, and alcohol, ranging from 0 to 12 weeks.

 

There were four steps of mediation analyses also conducted. Step 1 evaluated whether CM engendered significant improvements relative to standard treatment on QOLI scores over time. Step 2 examined whether CM significantly improved durations of abstinence. Step 3 evaluated partial corrections between LDA and posttreatment QOLI scores. Step 4 assessed whether inclusion of LDA as a between-participants predictor rendered the relationship found in step 1 nonsignificant.

 

Study 2

Petry and colleagues (2005) evaluated the efficacy of prize-based incentives contingency management intervention as an addition to usual care in community treatment settings. The study included 415 cocaine or methamphetamine users from eight outpatient community clinics located in urban, suburban, and rural settings through the country.

 

Patients at the clinics were enrolled between April 30, 2001, and Feb. 28, 2003. Patients were eligible to participate if: they reported stimulant use within 2 weeks of study entry; exited a controlled environment (detoxification unit, hospital, or correctional facility) within 2 weeks of study entry and reported stimulant use within 2 weeks of entering the controlled environment; or submitted a stimulant-positive urine sample as treatment entry without self-reporting stimulant use. Eligible participants completed a 90-minute interview before random assignment. Information was gathered on demographics, psychosocial problems, and lifetime and current drug use, including DSM–IV substance use diagnoses. Participants also provided first-study urine samples. Participants were then randomly assigned to either usual care or usual care plus abstinence-based incentives for 12 weeks.

 

The usual care condition consisted primarily of group counseling, and possibly individual and family counseling as well. Participants received immediate feedback on urinalysis results, and staff congratulated participants if they tested negative. The abstinence incentives group earned the chance to win prizes when their test results were negative for cocaine, amphetamine, methamphetamine, and alcohol (primary target drug). Participants with negative tests were allowed to draw 1 to 12 chips from a container that had 500 chips. The number of chips a participant was permitted to draw was determined on a schedule that was responsive to test outcomes. Draws increased by one each week in which all submitted samples were free of the primary target drugs. Each chip had a different reward value, ranging from Good Job (worth no reward), to Small (worth $1 in prizes), to Large (worth $20 in prizes), to Jumbo (worth $80 to $100 in prizes).

 

The usual care group was 44.7 percent male, and 40.3 percent African American, 39.3 percent White, 12.1 percent Hispanic, and 8.3 percent other, with an average age of 35.7 years. The incentives group was 44.5 percent male, and 31.6 percent African American, 45.0 percent White, 12.9 percent Hispanic, 10.5 percent other, with an average age of 35.9 years. There were no significant differences between the groups, except on marital status (the incentives group had a higher percentage of participants who had never been married and a lower percentage who were married or cohabitating).

 

The outcome measures of interest were retention, study compliance, treatment participation, and substance use. Retention was measured as the number of days that elapsed between the first and last study urine samples that were submitted. Study compliance was the percentage of participants who submitted at least one sample per week during the study. Treatment participation was defined as the number of counseling sessions attended during the 12-week study, including individual, group, and family counseling sessions.

 

To account for missing or incomplete data, substance use was evaluated in several ways: overall percentage of submitted samples that were free of each target drug (stimulants, alcohol, opioids, and marijuana), percentage of samples submitted that were free of stimulants and alcohol at each of the 24 study visits, total number of stimulant- and alcohol-free samples submitted by each participant, and longest duration of abstinence from the primary target drug for each participant.

 

The study used t–tests for continued variables and chi-square tests for dichotomous variables when examining between-group differences on baseline measures. Study retention was examined using the Cox proportional hazards model. Binary variables that repeated across time were analyzed using generalized estimating equations. Results from this analysis were reported as odds ratios. Individual differences in outcomes were measured using t–tests, Mann–Whitney tests, and chi-square tests.

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Cost

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The outcome results from the Petry and colleagues (2005) study found that patients in the treatment group who received prize incentives earned an average of 76.5 draws. The average total cost of the incentive procedure was $203 per participant, or $2.42 per participant per day.
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Evidence-Base (Studies Reviewed)

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These sources were used in the development of the program profile:

Study 1
Petry, Nancy M., Sheila M. Alessi, and Tressa Hanson. 2007. “Contingency Management Improves Abstinence and Quality of Life in Cocaine Abusers.” Journal of Consulting and Clinical Psychology 75(2):307–15.

Study 2
Petry, Nancy M., Jessica M. Peirce, Maxine L. Stitzer, Jack Blaine, John M. Roll, Allan Cohen, Jeanne Obert, Therese Killeen, Michael E. Saladin, Mark Cowell, Kimberly C. Kirby, Robert Sterling, Charlotte Royer–Malvestuto, John Hamilton, Robert E. Booth, Marilyn Macdonald, Marc Liebert, Linda Rader, Raynetta Burns, Joan DiMaria, Marc L. Copersino, Patricia Quinn Stabile, Ken Kolodner, and Rui Li. 2005. “Effect of Prize-Based Incentives on Outcomes in Stimulant Abusers in Outpatient Psychosocial Treatment Programs: A National Drug Abuse Treatment Clinical Trials Network Study.” Archives of General Psychiatry 62:1148–56.
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Additional References

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These sources were used in the development of the program profile:

Peirce, Jessica M., Nancy M. Petry, Maxine L. Stitzer, Jack Blaine, S. Kellogg, F. Satterfield, M. Schwartz, J. Krasnansky, E. Pencer, L. Silva–Vazquez, Kimberly C. Kirby, Charlotte Royer–Malvestuto, John M. Roll, Allan Cohen, Marc L. Copersino, Ken Kolodner, and Rui Li. 2006. “Effects of Lower-Cost Incentives on Stimulant Abstinence in Methadone Maintenance Treatment: A National Drug Abuse Treatment Clinical Trials Network Study.” Archives of General Psychiatry 63:201–08.

Petry, Nancy M., Sheila Alessi, Kathleen M. Carroll, Tressa Hanson, S. McKinnon, Bruce Rounsaville, and S. Sierra. 2006. “Contingency Management Treatment of Substance Abusers Versus Prizes: Contingency Management Treatment of Substance Abusers in Community Settings.” Journal of Consulting and Clinical Psychology 74:592–601.

Petry, Nancy M., Sheila M. Alessi, Jacqueline Marx, Mark Austin, and Michelle Tardif. 2005. “Vouchers Versus Prizes: Contingency Management Treatment of Substance Abusers in Community Settings.” Journal of Consulting and Clinical Psychology 73(6):1005–14.

Petry, Nancy M., Bonnie Martin, and Francis Simcic Jr. 2005. “Prize Reinforcement Contingency Management for Cocaine Dependence: Integration With Group Therapy in a Methadone Clinic.” Journal of Consulting and Clinical Psychology 73(2):354–59.

Petry, Nancy M., Jacqueline Tedford, Mark Austin, Charla Nich, Kathleen M. Carroll, and Bruce J. Rounsaville. 2004. “Prize Reinforcement Contingency Management for Treating Cocaine Users: How Low Can We Go, and With Whom?” Addiction 99:349–60.
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Related Practices

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Following are CrimeSolutions.gov-rated practices that are related to this program:

Contingency Management Interventions for Substance Use Disorders
This is an intervention strategy designed to reduce substance use disorders by rewarding positive behavior (e.g., negative drug tests) and withholding rewards when undesired behavior is exhibited (e.g., positive drug screens). The overall goal is abstinence from substance use. The practice is rated Effective for reducing alcohol, tobacco, and illicit drug use.

Evidence Ratings for Outcomes:
Effective - More than one Meta-Analysis Drugs & Substance Abuse - Multiple substances
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Program Snapshot

Age: 18+

Gender: Both

Race/Ethnicity: Black, Hispanic, White, Other

Geography: Rural, Suburban, Urban

Setting (Delivery): Inpatient/Outpatient, Other Community Setting

Program Type: Alcohol and Drug Therapy/Treatment, Family Therapy, Group Therapy, Individual Therapy, Residential Treatment Center

Targeted Population: Alcohol and Other Drug (AOD) Offenders

Current Program Status: Active

Listed by Other Directories: National Registry of Evidence-based Programs and Practices

Program Developer:
Nancy Petry
Professor
University of Connecticut Health Center, Department of Medicine
263 Farmington Avenue
Farmington CT 06030–3944
Website
Email

Training and TA Provider:
Nancy Petry
Professor
University of Connecticut Health Center, Department of Medicine
263 Farmington Avenue
Farmington CT 06030–3944
Website
Email