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 alcoholnegative specimens
• $400 in prizes could be earned over 12 weeks
Points Escalate with Drug-Free Test Results
& Reset with Positives
5
4
3
2
1
Weeks Drug Free
# Draws
Incentives Improve Retention in Counseling Treatment
100
Incentive
Control
Percentage Retained
80
60
50%
40
35%
20
RH = 1.6 CI=1.2,2.0
0
2
4
6
8
Study Week
10
12
Percentage of stimulant negative
urine samples
Incentives Reduce During-Treatment Stimulant Use
in Methadone Patients
100
Abstinence Incentive
Usual Care
80
60
40
20
OR=1.98 (1.4-2.8)
0
1
3
5
7
9
11 13
15 17 19 21 23
Study Visit
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
Support Materials: DRAW TICKETS
Good Job
Good Job
Good Job
Good Job
Small
Good Job
Small
Large
Jumbo
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?
Future of Techno Treatment?
Call
Customer
Service
Urine Test Results
Pos
OPS
Neg
Your
Personal
Counseling
Program
Activate
Computer
Therapy
Program
Take Money
Or Gift Card
COC
Fingerprint
ID Scan
METH
Place Urine
Sample Here
Take Your
Pills