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

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

Introduction

Mathers, B et al. Lancet 2008; 372:1733.

HIV Prevalence among DU

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

Barriers to careDiminished response Similar mortality outcomes

Wood, E et al. CMAJ 2003;169: 656. Wood, E et al. JAMA 2008;300: 550.

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.

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.

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.

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

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.

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.

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.

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

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.

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.

Acknowledgements

• Dr Nancy Petry PhD – University of Connecticut Health Center

• Shoshana Kahana PhD – National Institute on Drug Abuse

• National Institute on Drug Abuse