Phase 1 Numerous studies have tested whether providing incentives to encourage abstinence
from drugs can further reduce drug abuse in a drug-treatment setting. The results are
promising: Incentives to reduce opioid abuse increase the average duration of abstinence
by 25 - 60% relative to medication and counseling alone (Petry et al., 2006; Schottenfeld
et al., 2005). Similar effects have been demonstrated repeatedly across a wealth of
populations, substance-abuse disorders, and payment methodologies (see Lussier et al.,
2006; Higgins et al., 2011; Davis et al., 2016; and Higgins et al., 2016 for reviews of
providing incentives for managing addiction).
Despite evidence that incentives are effective and the increasing need for effective
approaches to combat the addiction crisis, incentive programs have not been widely
implemented. A key barrier is that while the benefits are largely borne by patients and
taxpayers, there are large logistical costs that must be borne by clinics: most existing
incentive programs involve manual, in-person measurement of behaviors, and prize or
voucher purchase and delivery by clinic staff. The significant clinic-level legwork
necessary to set up these programs, including setting up behavioral and payment tracking
systems, training staff, etc., have prevented the programs from scaling widely (Benishek
et al., 2014). In sum, prior experience has consistently shown that incentives increase
duration of treatment and decrease substance abuse, but the logistical complications
remain a hurdle to implementation.
The investigators propose to conduct the first randomized evaluation of an innovative,
scalable incentives program for drug addiction delivered through a mobile application.
The application, which was developed by DynamiCare Health (henceforth "DynamiCare"),
provides a "turnkey" solution that health clinics can easily prescribe. The app enables
remote monitoring of behavior; for example, drug tests can be administered in patients'
homes, as patients submit "selfie-videos" showing them taking saliva drug tests, which
are then verified by trained remote staff. Treatment adherence can similarly be checked
through GPS tracking for on-site methadone pharmacotherapy. The efficacy of this approach
has not been tested rigorously before.
This study phase will address two key knowledge gaps in the logistics of existing
incentive program design for drug addiction. First, the study will test technology for
remote monitoring of abstinence behavior for drug use. Remote monitoring of abstinence
from cigarettes and alcohol has been integral in reducing the costs and extending the
potential reach of incentive programs for people with nicotine/tobacco and alcohol use
disorders (e.g. to vulnerable or rural populations), and the study promises to do the
same for illicit drug addiction (see for a review of remote monitoring technologies for
incentive delivery). The second gap is in remote delivery of incentives. After a behavior
is verified, the app will deliver incentives to patients as cash available on a linked
debit card. The delay between monitoring of the target behavior and the delivery of
financial incentives has been shown to be a significant moderator of treatment effect
size (Lussier, Heil, Mongeon, Badger, & Higgins, 2006). The technology allows patients to
receive incentives almost immediately following the undertaking of the incentivized
behavior: a first in incentives for drug addiction.
The second question is how to optimize the size of incentives over time to maximize
incentive effectiveness. This will be performed by randomly varying the size and timing
of incentives offered to participants across groups. The variation in incentive amounts
will vary across participants and time to fit a structural model of abstinence behaviors
over time. This model will be used to describe the optimal shape of incentives over time.
Phase 2 Combating the epidemic of overdose deaths is a central challenge of U.S. health
care policy, and substance use disorder (SUD) is increasingly harming older adults. One
approach to treating SUD, incentivizing abstinence from substance use, has repeatedly
proven effective but has limited evidence base in older populations. A uniquely scalable
modality - of increasing interest to policymakers - for implementing this approach is
with a mobile application (app) that delivers incentives for abstinence from opioids and
stimulants. However, one concern about using an app for incentives is that it may hinder
take-up and viability among older populations. Thus, testing the app specifically among
older adults is of critical policy importance.
This phase will focus on the effectiveness of the app for older adults (aged 55 and
over), and on understanding whether the acceptability and effectiveness of the app is
decreasing with older age. Specifically, the primary research aim is to assess whether
app-based incentives are effective for older adults. The secondary research aims are to
understand whether older adults have lower take-up and engagement with the app than
younger adults, and if app effectiveness is mediated by age, thus shedding light on the
necessity of age-specific app design features. Effects on abstinence outcomes will be
measured for all participants who engage with the app (N=59), and take-up and engagement
outcomes will be measured for all participants who are eligible for the randomized
controlled trial even if they do not enroll (N=98). It is expected that 15 percent of
participants will be older adults. In order to complete the research aims, data will be
jointly analyzed from the Roybal-funded study phase and the previous study phase.
The OVERALL AIM is to assess whether app-based incentives are effective for older adults
and to quantify the associations between age and both the efficacy and take-up of
app-based incentives. This will allow us to determine if older adults with substance use
disorders are willing to engage with app-based incentives and whether they perform
similarly to their younger counterparts. Because the study will leverage data from an
existing study on app-based incentives, a small add-on study is sufficient to address
these three aims. This aim will be achieved while simultaneously gathering data that will
shed light on the two aims of the first phase of the study: whether app-based incentives
are effective overall, and how to optimize the size of incentives over time to maximize
their effectiveness.
The results of this intervention will be directly relevant for potential users of this or
similar mobile applications for incentive provision among people with substance use
disorders, including insurers, treatment facilities, and governments.