Full length articleAn economic evaluation of a contingency-management intervention for stimulant use among community mental health patients with serious mental illness
Introduction
Contingency management (CM) is a well-established intervention for drug and alcohol use disorders. CM employs positive reinforcers (e.g., vouchers or prizes) when individuals demonstrate drug or alcohol abstinence. Meta-analyses of CM have found it to be associated with higher rates of treatment retention and abstinence, relative to standard care (Benishek et al., 2014, Dutra et al., 2008, Lussier et al., 2006, Prendergast et al., 2006). CM has demonstrated efficacy as a treatment for stimulants (cocaine, amphetamine, methamphetamine), marijuana, opioids, nicotine, and alcohol use disorders. Importantly, Dutra et al. (2008) compared CM approaches to all other psychosocial treatments and found that they had the highest rates of in-treatment abstinence. However, the relatively high in-treatment abstinence rates of CM are not typically sustained (Dutra et al., 2008, Rawson et al., 2006, Rawson et al., 2002).
Emerging literature has demonstrated the effectiveness of CM for individuals with substance use disorders (SUDs) who also suffer from severe mental illnesses (SMI; Bellack et al., 2006, McDonell et al., 2013, Roll et al., 2004). Adults with SMI, such as schizophrenia, bipolar and re-occurring major depressive disorders suffer from high rates of SUDs, with lifetime rates as high as 50% (Regier et al., 1990). Relative to people with only one of these conditions, individuals with co-occurring SMIs and SUDs have more severe substance use and psychiatric symptoms (RachBeisel et al., 1999), poorer treatment adherence (Bennett et al., 2001), increased homelessness (Galanter et al., 1998), and higher rates of smoking (de Leon et al., 2007), HIV infection (RachBeisel et al., 1999), psychiatric hospitalization (Haywood et al., 1995), emergency room use (Bartels et al., 1993) and incarceration (Abram and Teplin, 1991). The high rates of SUDs among individuals with SMI, and the consequences of this comorbidity, directly contribute to the high economic cost of SMI in the U.S., which is estimated to be well over $400 billion (2013 USD) annually (Insel, 2008).
Many people with comorbid SUD and SMI do not receive concurrent treatment for the disorders (Substance Abuse and Mental Health Services Administration, 2002, Watkins et al., 2001a), although integrated treatments have been shown to reduce drug use (Baker et al., 2006, Barrowclough et al., 2010, Bellack et al., 2006, Drake et al., 1998, Epstein et al., 2004, Watkins et al., 2001b, Weiss et al., 2009). While the results pertaining to reductions in psychiatric severity associated with many integrated treatments are mixed (Drake et al., 2008), two randomized, controlled trials (RCTs) have shown that CM alone (McDonell et al., 2013), or as part of a cognitive behavioral treatment (Bellack et al., 2006) can reduce drug and alcohol use, improve psychiatric symptoms, and reduce inpatient hospitalizations in adults who suffer from co-occurring SUDs and SMI. Moreover, a recent Cochrane Collaboration review reported that CM is a promising treatment for SUDs in outpatients with SMI (Hunt et al., 2013).
Despite the apparent promise of CM interventions in treating co-occurring SMI and SUD, perceived cost and an inability to bill for urine tests and tangible reinforcers present a significant barrier to implementation (Kirby et al., 1999, McGovern et al., 2004, Petry and Simcic, 2002, Srebnik et al., 2013). Information regarding the cost-effectiveness of CM is needed to inform policymakers who are increasingly making decisions about the availability of such treatments based on their clinical and cost effectiveness (Petry et al., 2014). Previous cost-effectiveness analyses (CEAs) on CM have been favorable, but have focused on its application to the treatment of specific drugs rather than co-occurring SMI and SUD, and have focused solely on clinical measures for the effectiveness outcome, such as abstinence or treatment completion (Olmstead and Petry, 2009, Olmstead et al., 2007a, Olmstead et al., 2007b, Olmstead et al., 2007c, Sindelar et al., 2007a, Sindelar et al., 2007b). No studies to date have investigated the cost-effectiveness of CM for individuals with comorbid SMI and SUD, a particularly costly population.
Given that substance misuse affects most areas of functioning and SUDs are generally chronic conditions, quality-of-life is increasingly viewed as an important component of long-term recovery (Laudet, 2011); despite that, it is rarely included as an outcome in contingency-management CEAs. A cost-utility analysis (CUA) assesses the relative cost-effectiveness of an intervention; however, the outcome includes a measure of utility (i.e., satisfaction), and is often expressed as quality-adjusted life years (QALYs). QALYs are beneficial as a measure of effectiveness, in that they reflect the combined preference for length and quality of life. The purpose of this study is to conduct an economic evaluation of a CM intervention as an add-on to treatment-as-usual (TAU) for treating stimulant use disorders among 176 outpatients with a SMI.
Section snippets
CM intervention
McDonell et al. (2013) conducted a 12-week randomized controlled trial of CM with treatment-as-usual (CM + TAU) relative to TAU with non-contingent rewards for 176 individuals with SMI and stimulant dependence who were receiving community mental health and addiction treatment at one community mental health center in Seattle, Washington. Participants were assessed during the intervention as well as during a 12-week follow-up period. Eligibility criteria for the study included using stimulants in
Results
Descriptive statistics for patients’ demographic information, healthcare utilization (both intervention and follow-up) and direct medical costs for the 12-weeks prior to randomization, by study group, can be viewed in Table 1. The only significant difference between the two treatment groups was the number of inpatient days in the follow-up period, with the noncontingent-control group experiencing 4 and the CM group 0.
Discussion
The contingency management add-on to treatment as usual for patients with comorbid substance-use and serious-mental disorders costs an estimated $396 per individual over a 12-week treatment episode. Although the total direct medical cost differentials are all highly insignificant, due to the variability in the outpatient and non-study service variables, the results highlight some points worth of consideration for future CM studies. After adding outpatient mental-health and chemical-dependency
Conclusion
CM added to TAU appears to be a wise investment for providers and payers for treating SUDs among the very costly and difficult-to-manage population of individuals with a co-occurring SMI. CM plus TAU significantly improved time free from stimulants relative to TAU, an effect that was sustained over the follow-up period, with no significant difference in direct-medical costs or health-related quality-of-life.
Role of funding source
Supported by National Institute on Drug Abuse grant R01 DA022476-01 (principal investigator, Dr. Ries). The funding agency had no further role in study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the paper for publication.
Contributors
Authors SMM, MGM and SM conceived the study, and managed the literature searches and summaries of previous related work. MGM, SM and FA were responsible for obtaining and cleaning the data. SMM performed the statistical analyses and wrote the first draft of the manuscript. All authors provided input on the statistical approach, performed critical reviews and collaborated with SMM on manuscript revisions. All authors have approved the final manuscript.
Conflict of interest
Drs. McPherson and Roll have received research funding from the Bristol-Myers Squibb Foundation. Dr. Ries has been on the speakers bureaus of Alkermes and Janssen. The other authors report no financial relationships with commercial interests.
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