Pubdate: Fri, 10 Mar 2006
Source: Detroit Free Press (MI)
Copyright: 2006 Detroit Free Press
Author: Virginia A. Smith, Knight Ridder Newspapers
Bookmark: (Treatment)


Studies: Rewards Enhance Treatment

PHILADELPHIA -- It's a proposition as old as parenthood: Do this 
thing you don't want to do -- "please?" -- and you'll get something 
nice for your trouble.

Now, the idea that we can influence adult behavior by offering 
meaningful incentives -- gift cards, bus tokens, CD players and rent 
subsidies -- is slowly catching on in drug and alcohol treatment.

More than 60 studies in the United States and in Europe show that 
rewarding substance abusers for staying clean helps keep them 
enrolled in the crucial early weeks of outpatient rehab, when dropout 
rates can hit 40% or more.

It's also helped double abstinence rates later on to about 60%.

"Many of us recognize this as one of the most important and effective 
tools we have," said Charles R. Schuster, director of the National 
Institute on Drug Abuse under Presidents Ronald Reagan and George 
Bush, now head of addictions research at Wayne State University 
School of Medicine.

"But we've done a lousy job of selling it," he added.

Costs of goods weighed

"Contingency management," as this system is called, is all about 
stimulating the brain's natural reward centers with something other 
than drugs or alcohol.

And while offering goods and services to addicts can get expensive, 
think of it this way: Untreated addiction costs this country $400 
billion a year, more than heart disease, diabetes and cancer combined.

Consider, too, that two centuries of collective knowledge and 
treatment history have brought us no closer to a cure for addiction. 
Only a small percentage of addicts ever achieve complete and 
sustained recovery.

Scientists began looking at the reinforcing effects of drugs in 
laboratory animals as early as the 1940s. In the 1960s, studies 
showed that normal monkeys offered intravenous cocaine anytime they 
pressed a lever quickly began acting like drug-crazed humans. The 
animals pressed and pressed and would have overdosed or starved to 
death had they not been forced to stop.

Research waned as interest in new medications and talk therapies for 
addiction emerged.

Then, in the 1980s, Stephen T. Higgins, a behavioral psychologist, 
began looking for a way to keep cocaine addicts -- a particularly 
tough group -- in rehab long enough for the inherent rewards of being 
drug-free to kick in.

He knew he couldn't use cash. "For many cocaine users, that's a cue 
for drug use," he said.

Higgins settled on vouchers to augment standard treatment.

That can include time in a residential facility, an intensive 
outpatient program, Alcoholics Anonymous-style group therapy, 
individual counseling and medication, followed by years in AA support 
groups. With some variation, this has been the model for treating 
addiction for decades.

Values of vouchers increase

Higgins' idea was simple. If addicts in treatment produce a drug-free 
urine specimen, they get vouchers ultimately redeemable for things 
like camera equipment, passes to local gyms, McDonald's gift 
certificates and fishing licenses.

The vouchers start small -- $2.50 -- and build up over the 12-week 
program, for a possible total of $1,000.

But produce one dirty sample and you're back to square one.

A lot of these decisions to use drugs are spontaneous, said Higgins, 
professor of psychiatry at the University of Vermont. "All we wanted 
to do was give them reason to pause." His studies found that with 
vouchers, retention rates in his rehab programs increased fivefold, to 50%.

James R. McKay, an addictions expert at the University of 
Pennsylvania, is wrapping up a five-year, 170-patient voucher study 
funded by a $2.5-million federal grant. Cocaine addicts with alcohol 
and other problems earned up to $1,150 in vouchers redeemable for 
rent and utility subsidies or gift cards from stores like Target and Wal-Mart.

McKay's results, now being analyzed, show vouchers having a modest, 
not huge, effect in keeping addicts in outpatient treatment and 
reducing cocaine use. But he's intrigued.

"I think this taps into some sense of achievement, giving people 
clearly measurable goals: Clean urine equals progress," he said.

Even so, the idea may be a tough sell on a large scale.

Incentives cost money and treatment programs are notoriously underfunded.

The AA 12-step philosophy is deeply entrenched. The idea of rewarding 
people to stay off drugs offends those who think abstinence should be 
its own reward, said Tyrone Thomas, a drug counselor who works with McKay.

"They say, 'You're paying people to stay clean,' which isn't 
necessarily accurate, but that's the perception," he said.
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