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.