Impact of an Incentive Program on Treatment Outcomes for Veterans with Alcohol or Stimulant Dependence

Hagedorn HJ, Noorbaloochi S. Impact of an Incentive Program on Treatment Outcomes for Veterans with Alcohol or Stimulant Dependence. Paper presented at: AcademyHealth Annual Research Meeting; 2012 Jun 24; Orlando, FL.

Related HSR&D Project(s)

• IIR 03-120 – Effectiveness of Contingency Management in VA Addictions Treatment

Research Objectives: Evaluate the effect of adding an Incentive Program (IP) to outpatient usual care (UC) on outcomes for Veterans entering substance use disorders treatment with a diagnosis of alcohol dependence (AD) only and those with a diagnosis of stimulant dependence (SD) with or without concurrent AD. Study Design: Study participants were randomized to receive either UC or the IP intervention plus UC. All participants consented to breath alcohol and rapid result urine drug screening twice per week for eight weeks. Each time they submitted negative screens, IP participants earned chances to draw for coupons which could be used in the VA cafeteria or gift shop. The primary outcome was the number of negative urine drug and breath alcohol tests out of the 16 possible during the intervention period. Secondary outcomes include study retention and longest duration of abstinence. Population Studied: Participants were Veterans presenting for treatment with AD only (n = 191) or SD with or without AD (n = 139) at the Minneapolis or the Seattle VA Medical Center addiction treatment clinics. Participants were predominantly male (98%) and White (52.5%) or African American (35.2%) with a mean age of 50. Principal Findings: For the primary outcome of number of negative samples submitted, a generalized linear mixed model demonstrated that in the AD only subgroup, IP participants submitted significantly more negative samples (M = 13.2) compared to UC participants (M = 10.8). For the SD subgroup, there were no significant differences between the IP and UC participants on negative samples (M = 10.4 vs. 9.8). In the AD only subgroup, the IP participants were retained in the intervention significantly longer (M = 7.2 weeks) compared to the UC participants (M = 6.2 weeks) and demonstrated a significantly longer duration of abstinence (M = 12.5 visits) compared to the UC participants (M = 9.6 visits). In the SD subgroup, there were no significant differences between the IP and the UC participants on study retention (M = 6.1 vs. 6.0 weeks) or longest duration of abstinence (M = 9.4 vs. 8.3 visits). Within the IP condition, the AD subgroup earned a significantly higher value of vouchers throughout the intervention (M = $123) compared to the SD subgroup (M = $76). Conclusions: The IP increased number of negative screens submitted, study retention, and longest duration of abstinence achieved for the AD subgroup. This is the first large randomized trial to demonstrate the effectiveness of an IP with AD only participants. However, these effects were not seen in the SD subgroup which is inconsistent with prior trials. This lack of an effect may be attributable to low levels of dependence, as evidenced at baseline by low rates of stimulant positive urine tests (12%) and self-reported percent days of stimulant use (41%) compared to other similar trials, resulting in better prognosis for the UC group compared to similar trials. Implications for Policy, Delivery, and Practice: The IP is a low cost adjunctive intervention that improves outcomes in early recovery for alcohol dependent patients. While multiple trials support the effectiveness of IPs among patients with severe stimulant dependence, the effectiveness in patients with less severe stimulant dependence may be questionable.