Nancy M. Petry on Incentive Intervention for Substance Abusers

Emerging Research FRonts Commentary, February 2011

Nancy M. Petry

Article: Effect of prize-based incentives on outcomes in stimulant abusers in outpatient psychosocial treatment programs - A national drug abuse treatment clinical trials network study

Authors: Petry, NM, et al.
Journal: ARCH GEN PSYCHIAT, 62 (10): 1148-1156, OCT 2005
Addresses: Univ Connecticut, Ctr Hlth, Dept Psychiat, Sch Med, 263 Farmington Ave, Farmington, CT 06030 USA.
Univ Connecticut, Ctr Hlth, Dept Psychiat, Sch Med, Farmington, CT 06030 USA.
(Addresses have been truncated)
(Commentary for December 2010 [late entry])

Nancy M. Petry talks with and answers a few questions about this month's Emerging Research Front paper in the field of Psychiatry/Psychology.

SW: Why do you think your paper is highly cited?

I think the paper has been well-cited because it is the first large scale, multi-site study evaluating the efficacy of an incentive (or reinforcement) intervention for substance use disorders. This type of approach represents a paradigm shift for the treatment of substance use disorders, which can be punitive in nature. This paper brought an intervention that is built upon positive reinforcement techniques to the wider attention of researchers, community-based providers, and public payors.

SW: Does it describe a new discovery, methodology, or synthesis of knowledge?

This paper demonstrated that a relatively low-cost incentive procedure, in which patients earn the opportunity to win prizes, can substantially increase abstinence in substance abusing patients. In this report and additional studies that further investigated this technique, we found that this incentive intervention is efficacious across a range of substance use disorders and in a variety of clinical settings. Furthermore, the intervention appears to be cost effective and can improve outcomes at a cost as low as $100-200 in prizes per patient.

SW: Would you summarize the significance of your paper in layman's terms?

This study demonstrates that providing patients with the chance to win low cost, monetary-based prizes for achieving and maintaining abstinence can substantially improve drug abuse treatment outcomes.

SW: How did you become involved in this research and were any particular problems encountered along the way?

"Those afflicted by substance use disorders are among the most disenfranchised and underprivileged."

I was trained in the experimental analysis of behavior and behavioral pharmacology at Harvard University. Early on, I became interested in applied behavioral approaches, and the treatment of substance use disorders was a natural extension of this work. Much treatment in substance use disorders, however, is not empirically based, and translational research has been difficult.

I have always conducted studies of this approach in community-based clinics, and I try to remain attuned to problems and challenges faced in these settings. I devised the intervention and the specific studies to address clinical needs. Through these projects, I developed excellent working relationships with clinicians, and their first-hand observations of the benefits of this intervention has swayed providers about the importance of providing incentives to improve outcomes in this difficult-to-treat patient population.

This work continues to be hampered by skepticism on one hand, and naiveté on the other. Both these issues may impede the ultimate adoption of this treatment. Skeptics continue to apply different standards to this intervention than to pharmaceutical ones. For example, this intervention is criticized about its long-term efficacy, when similar concerns are not raised about pharmaceutical approaches for other chronic relapsing conditions. Costs are raised as a barrier for this intervention, yet the costs of prizes pale in comparison to those associated with many pharmacotherapies.

Conversely, many well-meaning providers attempt to implement incentive approaches without fully understanding them. Although providing incentives for positive behavior change is straightforward in theory, a number of important issues need to be considered for the procedures to be effective. Appropriate training and oversight will need to be arranged prior to effective wide-scale implementation.

SW: Where do you see your research leading in the future?

I am interested in applying this approach to the treatment of other disorders that have behavioral components, such as improving outcomes among diabetic or overweight patients. It can also be useful to increase adherence to exercise and medication regimens across a range of conditions.

SW: Do you foresee any social or political implications for your research?

Some critics have likened this intervention to "paying" or "bribing" substance abusers for abstinence (see also Common Q&A). Unfortunately, these attitudes are a sad reflection of disparities. Those afflicted by substance use disorders are among the most disenfranchised and underprivileged.

Incentives for performance are a part of everyday life, and efficacious treatments that incorporate such universal principles should not be intentionally withheld from substance abusing patients. If provision of $200 worth of prizes can improve engagement in treatment and outcomes of substance abusers, this is an intervention that we as a society perhaps cannot afford to oppose.End

Nancy M. Petry, Ph.D.
University of Connecticut Health Center
Farmington, CT, USA




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