miedar, pami and beyond maxine stitzer, ph.d. johns hopkins som apha symposium denver, co november...
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MIEDAR, PAMI and BEYOND
Maxine Stitzer, Ph.D.
Johns Hopkins SOM
APHA Symposium
Denver , CO
November 10, 2010
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
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
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
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?
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