Treatment With a Payoff

Both the general medical world and the insurance industry have used direct financial incentives to promote positive behavior change in individuals. While the concept has been slower to catch on in the addiction treatment community, a growing body of research evidence and practice experience is boosting the notion that rewarding individuals' recovery-affirming behaviors can have benefits.

The concept surfaced for the addiction community during the crack cocaine epidemic of the 1980s, when new clients were posing tough challenges for treatment programs. “All these people were abusing cocaine, and substance abuse treatment programs all over the country had no idea what to do with them,” says Nancy Petry, PhD, professor at the University of Connecticut Health Center's Department of Psychiatry and Neuropsychiatry Institute. “But they knew that they were not engaging in treatment and not doing well.”

Stephen Higgins, PhD, professor of psychiatry and psychology at the University of Vermont, developed an incentive approach to treatment that used vouchers to reward cocaine treatment outpatients for meeting predetermined therapeutic targets. Higgins and colleagues wrote in a 2002 report published in Addictive Behaviors that vouchers could prove helpful since psychosocial treatments for cocaine addiction at the time were not working and pharmacotherapies were not showing great promise in clinical trials.

Higgins' initial study compared the use of vouchers combined with an intensive behavioral therapy known as the Community Reinforcement Approach with lower-intensity drug abuse counseling. Clients in the voucher group were awarded points with monetary values for submitting negative urine specimens. Accumulated points could be used to purchase retail items, with treatment staff conducting the actual purchases.

“The voucher system that Steve developed worked incredibly well in his initial publications, really engaging the patients in treatment longer and reducing their cocaine use,” says Petry, who subsequently worked with Higgins on other studies. “It had a major impact, at least in the scientific world.”

Moving the positive results from Higgins' work to the greater treatment community proved somewhat problematic, however. Higgins' studies showed encouraging treatment results through the use of vouchers, but at a relatively high price. In his initial study, patients qualifying for the maximum amount in vouchers and bonus points earned nearly $1,000. Average earnings among patients in this study were about half that amount, but that still represents a significant cost for the average treatment center.

As part of the National Institute on Drug Abuse's Clinical Trials Network initiative, Petry developed an alternative voucher system that dramatically reduced the cost of implementing an incentive program. She developed a prize system built on the same principles as Higgins' voucher system, but instead of earning a concrete monetary value for every negative urinalysis sample, patients would draw slips of paper from a fishbowl and win a prize under her approach.

“The technique has shown equivalent efficacy, perhaps even better than the voucher system in some of my studies that have recently been published, and it seems to have all of the benefits of vouchers,” says Petry. She has been implementing her research at more than a dozen community-based clinic sites in Connecticut.

Under Petry's prize system, clients usually win small prizes worth about $1—items such as bus tokens, fast-food gift certificates, or toiletries. On half of the slips is written: “Sorry, try again.”

About once a week, clients can win items worth about $20. “They usually choose things like watches, handheld CD players, or pot-and-pan sets,” says Petry. The fishbowl contains one slip for a jumbo prize, such as a television, a DVD player, or a microwave oven.

An entire week of negative urinalysis samples earns bonus draws, with the number of draws increasing in successive weeks of clean urine samples.

“I think the reason why this technique works as well or better than the voucher system is that there is a possibility of winning something big, which is appealing and I think more fun for the patients because all of the prizes are right here on-site and they're working for different things,” says Petry.

A 12-week trial of Petry's approach among cocaine-using methadone patients resulted in a higher percentage of negative urinalysis results compared to a control group that received no incentives. The patients in the incentive group earned an average of $137 in prizes during the 12-week period—a much more reasonable cost for community treatment programs.

A tailored approach

At WestBridge, an addiction treatment provider agency in New Hampshire, incentives have been used on a case-by-case basis for the past three years, says CEO Mary Woods, who is also president of NAADAC, The Association for Addiction Professionals. “As an addiction professional, I see the use of incentives as a real adjunct to treatment,” says Woods. “It's a way to pay people to be well—that's the way we characterize it.”

WestBridge specializes in treating clients with co-occurring substance abuse and mental health disorders. “It's a way to reinforce the behaviors you want to support as opposed to punishing the ones you don't want to have—we find it to be very effective,” says Woods.

The effort at WestBridge starts when staff members sit down with individuals and ask them to engage in a wellness plan. Staffers ask clients to tell them what they are really struggling with, says Woods. “They may say, ‘It's hard for me to get to a meeting,’ or ‘It's hard for me to take my meds,’ or ‘It's hard for me to call my sponsors,’ so we'll look at some type of positive reinforcement,” she says. The reinforcement may be a straight monetary value, or it may be going out for coffee, or it may be a CD or points toward a video game, says Woods. All the while, clients are still receiving counseling and other essential services, she says.

WestBridge has found that while incentives don't work for everyone, the positive behaviors that may ensue from them become internalized.

The first client for whom West-Bridge implemented incentives was psychiatrically impaired and not doing well in treatment, Woods recalls. “We asked him what his goals were, and he said it was to find a job; we asked him what he needed to do to find a job, and he said, ‘need to take my meds,’” says Woods. So every time he took his meds, he earned $5.

Once this approach began to work, it was applied to the client's attendance at AA meetings. “He had to get there on time, he had to stay for the whole meeting, he couldn't leave for too long during groups, and he had to be at AA appropriately—it wasn't just going to be showing up and sitting down,” says Woods.

After a while, the client started going on his own; the meetings became part of his routine, and the program was able to praise the client for achieving this change.

Petry believes that while substance abuse treatment programs also can be slow to change in embracing ideas such as incentives, the concept appears to be gaining interest steadily. “I've been working in the field for 10 years and no one had even heard of this 10 years ago, despite the fact that there has been research on it for the last 20 to 30 years,” says Petry. “Now everywhere I go, people have heard of it—they might not be doing it, but more and more places are starting to do it.”

A well-researched technique

In a meta-analysis of voucher-based initiatives for substance abuse disorders published in the February 2006 issue of Addiction, Higgins and colleagues identified 63 controlled studies on the subject that were published in peer-reviewed journals between 1991 and 2004. The vast majority of these studies examined abstinence outcomes.

One such study showed improved cocaine abstinence among methadone clients in a major metropolitan area, but found that a poststudy abstinence effect was lacking. Researchers led by Kenneth Silverman, PhD, of Johns Hopkins University were able to achieve a one-year abstinence effect in this group, for both cocaine and opiates, with vouchers approximating $5,000 in value.

Silverman also was involved in creation of a “therapeutic workplace” intervention with pregnant and postpartum cocaine- and opiate-dependent women. The researchers developed a data entry business that employed the women and raised money to pay for the vouchers. The intervention resulted in an increase in negative urine samples among the participants.

Petry's prize method has been shown to be effective in alcohol-dependent male veterans receiving outpatient services, although Higgins has written that these findings will need to be replicated elsewhere. In addition, preliminary studies have indicated that vouchers have promise in reducing cigarette smoking among methadone maintenance patients.

Limited studies have been conducted on the effect of vouchers on addicted clients with mental illness. In one effort, two men with schizophrenia were paid $25 per cocaine-negative urinalysis test, with the frequency of these desired results increasing. A study of 11 outpatients with schizophrenia who were heavy smokers found that monetary incentives could reduce cigarette smoking in this population.

Vouchers also have been used to increase compliance with medication regimens, Higgins has reported. Vouchers have been used to increase naltrexone compliance among opiate addicts, although more research is needed on the question of the most appropriate value of vouchers for achieving optimal results, according to Higgins.

Perhaps most importantly, some incentive programs have shown effectiveness that lasts beyond the duration of the trials. The key to this positive effect is retaining clients in treatment. In his voucher initiative, Higgins found a positive effect on cocaine abstinence 12 months poststudy. The addiction treatment community may find that a strategy still unfamiliar to many agencies could bring a long-term payoff for clients.