MIEDAR, PAMI and BEYOND

Maxine Stitzer, Ph.D.

Johns Hopkins SOM

APHA Symposium

Denver , CO

November 10, 2010

Stitzer Disclosures

I have no financial or commercial interests to disclose

Outline

• Motivational Incentives study: MIEDAR

• Blending Product: PAMI

• Next steps in dissemination

CTN MIEDAR Study

• Strength of evidence for efficacy of contingent incentives led to a CTN clinical trial

• Purpose– Test effectiveness of an abstinence incentive

intervention for stimulant abusers using a clinically feasible lower-cost fishbowl method

CTN MIEDAR Study Design

• Parallel studies (006, 007) – psychosocial counseling (N = 416) – methadone (N = 399)

• Target: stimulant negative urines • Random assignment to UC with or without incentives• Escalating prize draws for stimulant and alcohol-

negative specimens• $400 in prizes could be earned over 12 weeks

Points Escalate with Drug-Free Test Points Escalate with Drug-Free Test Results & Reset with PositivesResults & Reset with Positives

Weeks Drug Free

# Draws

1

2

4

5

3

Study Week

Per

cent

age

Ret

ain

ed

0

20

40

60

80

100

2 4 6 8 10 12

RH = 1.6 CI=1.2,2.0

Incentives Improve Retention in Counseling Treatment

Control

Incentive

50%

35%

Incentives Reduce During-Treatment Stimulant Usein Methadone Patients

0

20

40

60

80

100

1 3 5 7 9 11 13 15 17 19 21 23

Study Visit

Per

cen

tag

e o

f st

imu

lan

t n

egat

ive

uri

ne

sam

ple

s

Abstinence IncentiveUsual Care

OR=1.98 (1.4-2.8)

Abstinence Incentives are Effective

• Therefore dissemination is warranted

• NIDA and CTN are committed to dissemination with ATTC as partners

• First team assembled to consider features and messages of a Blending Product

Dissemination Considerations

• A particular intervention was found to be effective in two particular study samples

• Should this exact protocol form the basis for a blending product?

• If not, what should be disseminated?

Dissemination Considerations: Where are we starting?

• Clinicians have had limited exposure to concept of positive incentives

• Little systematic training available

• Practice not wide-spread- few models

Dissemination Considerations

• Needs include:– better understanding of advantages– more familiarity with principles– more knowledge about techniques– access to resources and support materials

• Awareness enhancement is a first step

Promoting Awareness of Motivational Incentives

SUCCESSFUL TREATMENT OUTCOMES

Find PAMI Blending Products

• nattc.org

• CTNdisseminationlibrary.org

PAMI Materials

• Video– history, principles, testimonials

• Slide shows (2) – history, principles, research background

• Resources and support materials– 7 principles, order manual, research papers,

funding ideas, client tracking forms

Good Job Good Job Good Job

Good Job

Small

Good JobSmall

JumboLarge

Support Materials: DRAW TICKETS

PAMI

• Strengths– Lots of good information – Much is consistent with awareness goal– Useful materials that go beyond awareness goal

• Limitations– No actual training on principles or practice– No directions on how to use materials

Next Steps:What Clinicians Want & Need

• More help on how to implement– Formal training – Practical guidance & coaching– Hands-on experience & practice

Second MIEDAR Blending Product

Let’s take advantage of modern technology!

Training

Implementation

Part 1: Computer-Based Training

• Teaches theoretical principles– didactics and case examples– Self-paced; self-correcting

• Case scenarios and hands-on exercises• with feedback for appropriate choices

• Includes quizzes and CME credit

Part 2: Computer-Based Implementation Support

• Principle is to be user-friendly

• Goal is to provide a basic program with flexible options for individual client tailoring

Computer-Based Implementation

• Improve feasibility

• Improve consistency and fidelity

• Facilitate use of more complicated schedules (e.g. escalating)

Computer-Based Incentives

• Two TREATMENT PLANS– Attendance– Abstinence

• Client can be assigned to one or both and assignment can change over time– e.g. an active drug user could start with

attendance then move to abstinence

Computer-Based Incentives: Counselor Jobs

• Set schedule and duration of Tx visits

• Select target drug(s) and urine test frequency

• Provide client with feedback and incentives

• Alter Tx plan as needed

Computer-Based Incentives: Computer’s Jobs

• Track and display client progress

• Calculate number of draws to award under an escalating schedule

• Determine and display prize winnings according to pre-programmed probabilities

Treatment Plan Examples

• Joe S can earn up to $300 in prizes if he attends all scheduled sessions (2X per week) for 8 weeks

• Wanda P. can earn up to $400 in prizes if she tests negative for opiates, cocaine and MJ in 1X per week random urine testing during first 12 weeks of treatment

Treatment Plan Examples

• Mark W can earn up to $200 in prizes if he attends 2X per week for the first 6 Tx weeks

• In weeks 7 - 18, he can earn up to $400 if he tests negative for cocaine and alcohol during 1X per week random testing

Features of Computer-Based Treatment Plans

• Clearly specifies target behavior, frequency of assessment, amount that can be earned and duration of the program

• Allows flexibility in all parameters and ability to change Tx plan based on client progress

Development Timeline

• Work in-progress by all partners– NIDA Office of Policy & Communications – Great Lakes ATTC, – NIDA Intramural Research Group

• Products to be released next spring?• Look for products @ nattc.org or

ctndisseminatonlibrary.org

Future Directions

• Promotion of new blending product

• Adoption by a large number of clinics

• More research to answer key clinician queries– How much is enough (prize value)?– How long is enough (incentive exposure)?– How can use of two targets be optimized?

Your Personal

Counseling Program

Urine Test Results

OPS

COC

METH

Pos Neg

Fingerprint

ID Scan

Call CustomerService

Take Your

Pills

Future of Techno Treatment?

Activate Computer TherapyProgram

Take MoneyOr Gift Card

Place Urine

Sample Here