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Transcript of Conditional Cash Transfers and Contingency Management Strategies in Substance Users Mark Hull MD,...
![Page 1: Conditional Cash Transfers and Contingency Management Strategies in Substance Users Mark Hull MD, MHSc, FRCPC Clinical Assistant Professor, University.](https://reader036.fdocuments.in/reader036/viewer/2022062407/56649e035503460f94aeec9e/html5/thumbnails/1.jpg)
Conditional Cash Transfers and Contingency Management
Strategies in Substance Users
Mark Hull MD, MHSc, FRCPCClinical Assistant Professor, University of
British ColumbiaResearch Scientist, BC Centre for Excellence
in HIV/AIDS
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Objectives
• Substance use (DU) and barriers to HAART
• Incentives in the setting of DU• Contingency Management in DU
– Applications to treatment and prevention of HIV
• Adherence
• Limitations
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Introduction
Mathers, B et al. Lancet 2008; 372:1733.
HIV Prevalence among DU
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Barriers to CareStructural Individual-level Provider-level
Criminalization of behaviour
Addiction-related instability
Physician perceptions
Marginalization Comorbid conditions
Incarceration Homelessness/ food insecurity
Adapted from Wood, E. et al AIDS 2008;22:1247
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Barriers to careDiminished response Similar mortality outcomes
Wood, E et al. CMAJ 2003;169: 656. Wood, E et al. JAMA 2008;300: 550.
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Interventions to improve HAART adherence
• Directly observed therapy (DOT)– A recent meta-analysis did not identify a clear
benefit over self-administration (pooled relative risk 1.04; 95% CI 0.91 – 1.20) Ford, N et al. Lancet 2009;374:2064.
• Links to methadone maintenance programs Palepu, A et al. Drug Alcohol Depend 2006;84:188.
• Intensive case management strategies Kushel, M et al. Clin Infect Dis 2006;43: 234.
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Incentive-based Programs in DU
• Client or patient-targeted conditional cash transfers (CCT) have become a means to achieve performance-based results.– Smoking cessation programs Volpp, K et al NEJM 2009;360:699.
– Weight-loss programs Volpp, K et al. JAMA 2008;300:2631.
• In DU CCT has taken the form of:– 1. Limited incentives for completion of specific health-
related tasks.– 2. Contingency management interventions designed
to shape long-term behaviours for reduction in substance use.
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Incentive-based Programs in DU
• Limited incentives have been used to increase uptake of preventative health activities:– Small ($5-25) monetary incentives– Food vouchers
• Improved rates of completion of TB screening processes– Return for PPD screening Chaisson, R et al. JAIDS 1996;11:455 ; FitzGerald JM et al. Int
J Tuberc Lung Dis 1999;3:153.
– Completion of screening chest X-ray Perlman, D et al J. Urban Health 2003;80:428.
• Completion of hepatitis B vaccine series– Randomized trial of monetary incentive vs. outreach nurses,
69% vs. 23% completion. Seal, K et al. Drug and Alcohol Depend 2003; 71:127.
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Contingency Management
• Key features to CM programs:
– Identification of clinically relevant behaviour– Objective measurement of the behaviour– Selection of a reinforcer desirable to the
target population– Linking target behaviour to the application of
the reinforcer
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Contingency Management
• Strategies for reinforcement should take into account a number of principles:– Escalation of the reinforcer
• The longer the desired behaviour occurs, the more the reinforcer is increased to maintain the behaviour
– Reset features• If the behaviour does not occur, the reinforcer is reset to
lower levels
– Immediacy of the reinforcer• Reinforcement should occur as soon as possible after the
desired behaviour is observed.
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Contingency Management Strategies
• Voucher-based Higgins, ST et al . Life Sci 1994;55:159. Higgins, ST et al. Addiction 2007;192:271. Silverman, K et al. Drug and Alcohol Depend 1996;41:197.
• Fishbowl prize draw Petry, N et al. J Consult Clin Psychol 2000;68:250-7 ; Petry, N et al. J Consult Clin Psychol 2005;73:1005.
• CM can be used to target substance abstinence – opiates and stimulants, attendance, and goal-directed activities.
• Meta-analyses of CM show clear benefit for improved abstinence and attendance Lussier, JP et al. Addiction 2006;102:192. ; Prendergast, M et al. Addiction 2006;101:1546.
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Incentives for HIV treatment and prevention.
• Improved HIV screening– Improved uptake of followup for HIV testing in the ER
Kelen, GD et al. Ann Emerg Med 1996;27:687. Haukoos, JS et al. Acad Emerg Med 2005;12:617.
• Attendance at HIV risk reduction group session Deren, S et al. Public Health Reports 1994;109:549.
• Change in HIV risk behaviours (CM)– Methamphetamine use and URAI Shoptaw, S et al. Drug and
Alchol Depend 2005; 78:125.
– Cocaine use and risk behaviours Schroeder, JR et al. Addictive Behaviours 2006;31:868.
– CM arms superior to CBT, but majority of effects due to the impact on decreased substance use.
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Incentives for HIV prevention and treatment - Adherence
Sorensen 2007 Rosen 2007 Javanbakht 2006
Voucher based CM (n=66)
Prizebowl CM (n= 56)
Incentive (n=90)
MEMS adherence
MEMS adherence
Viral load suppression
12 weeks 16 weeks 48 weeks78% vs. 58% adherent Not sustained
61% → 76%adherentNot sustained
55% vs. 28% had 1 log reduction
• Sorensen. Drug and Alcohol Depend. 2007 • Rosen. AIDS Pt Care and STD’s 2007 • Javanbakht, M et al. JIAPAC 2006
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Limitations• Limited evidence for durability of HIV-related CM
interventions– Longer period of CM likely needed.
• ?cost-effectiveness• Care provider aversion
– Increased drug use with monetary incentive• Not seen in studies Riley, E. J Urban Health 2005;82:142.
– Issues of fairness – Coercion in marginalized populations
• Not seen when assessed Festinger D, et al. Drug Alcohol Depend. 2008;96:128.
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The Future
• Use of CM has been advocated as a component of the UK NICE policy guideline for substance use treatments.– Adapted by some sites in Australia.
• Evaluation of incentives for HIV Treatment and Prevention underway:– HPTN 065 TLC Plus
• RCT of financial incentive for linkage to care and viral load suppression.
– BC CFE Seek and Treat • RCT of CM for linkage to care and viral load suppression in
DU.
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Acknowledgements
• Dr Nancy Petry PhD – University of Connecticut Health Center
• Shoshana Kahana PhD – National Institute on Drug Abuse
• National Institute on Drug Abuse