Give them prizes, and they will come: contingency management for treatment of alcohol dependence

Prevention, screening, and treatment for heavy drinking and alcohol use disorder

Heavy drinking and alcohol use disorder are major public health problems. Practitioners not specialising in alcohol treatment are often unaware of the guidelines for preventing, identifying, and treating heavy drinking and alcohol use disorder. However, a consensus exists that clinically useful and valuable tools are available to address these issues. Here, we review existing information and developments from the past 5 years in these areas. We also include information on heavy drinking and alcohol use disorder among individuals with co-occurring psychiatric disorders, including drug use disorders. Areas covered include prevention; screening, brief intervention, and referral for treatment; evidence-based behavioural interventions; medication-assisted treatment; technology-based interventions (eHealth and mHealth); and population-level interventions. We also discuss the key topics for future research.

The treatment of cocaine use disorder

Cocaine use continues to be a serious worldwide public health problem. Cocaine abuse is associated with substantial morbidity and mortality. Cocaine overdose deaths are increasing in the United States and, in certain populations, outnumber heroin and opiate overdose deaths. Psychosocial treatments remain the treatments of choice for cocaine use disorder (CUD), with standard approaches including contingency management and cognitive behavioral therapy. However, the effect sizes of these treatments are not large, and they are not effective for most patients. Consequently, investigators have sought to develop pharmacological agents to augment the efficacy of psychosocial treatments. Despite these efforts, no medications have yet been proven to be safe and effective for the treatment of CUD. The most promising pharmacological strategies for CUD treatment thus far include the use of dopamine agonists, such as long-acting amphetamine and modafinil or glutamatergic and GABAergic agents such as topiramate. Combination drugs may be especially promising.

The dissemination and implementation of contingency management for substance use disorders: A systematic review

Contingency management is one of the most effective behavioral interventions for substance use. However, the implementation of contingency management has not been as widespread as might be expected given its efficacy. This review summarizes literature that examines the dissemination and implementation of contingency management for substance use in community (e.g., specialized substance use treatment) and clinical (e.g., primary care) settings. A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Databases including Google Scholar, World of Knowledge, PsycINFO, and PubMed were searched. Search results yielded 100 articles and after the screening of titles and abstracts 44 were identified. Full-text articles were examined for eligibility and yielded 24 articles that were included in this review. Of the 24 articles included in the review, the majority (n = 11) focused on implementing contingency management in methadone clinics and opioid treatment programs. Training methods, implementation strategies, fidelity assessments, and attitudes toward the implementation of contingency management are discussed in greater detail. These findings highlight the importance of organizational input and ongoing supervision and consultation, and the need for additional research that is guided by theoretical frameworks and use rigorous study designs. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Considerations for Implementing Contingency Management in Substance Abuse Treatment Clinics: The Veterans Affairs Initiative as a Model

Contingency management (CM) is an efficacious intervention for the treatment of substance use disorders that is widely applicable across a range of client populations and characteristics. Despite its strong evidence base, CM remains underutilized in real world practice. This article introduces CM for clinicians interested in adopting CM and briefly reviews this research evidence. In addition, CM protocols are described, with emphasis on the specific design considerations important to CM's efficacy. The recent Department of Veterans Affairs (VA) initiative, which represents the first successful large-scale implementation effort, is presented. It provides a model for the training and supervision components that may be critical to implementation with fidelity. Continued research in this area, as well as further demonstrations of successful dissemination and implementation, will be critical for improving the adoption of this intervention in clinical, nonresearch settings.

Timeline Followback Self-Reports Underestimate Alcohol Use Prior to Successful Contingency Management Treatment

AIMS

Alcohol consumption is a modifiable and plausible risk factor for age-related cognitive decline but more longitudinal studies investigating the association are needed. Our aims were to estimate associations of adult-life alcohol consumption and consumption patterns with age-related cognitive decline.

METHODS

We investigated the associations of self-reported adult-life weekly alcohol consumption and weekly extreme binge drinking (≥10 units on the same occasion) with changes in test scores on an identical validated test of intelligence completed in early adulthood and late midlife in 2498 Danish men from the Lifestyle and Cognition Follow-up study 2015. Analyses were adjusted for year of birth, retest interval, baseline IQ, education and smoking.

RESULTS

Men with adult-life alcohol consumption of more than 28 units/week had a larger decline in IQ scores from early adulthood to late midlife than men consuming 1-14 units/week (B29-35units/week = -3.6; P < 0.001). Likewise, a 1-year increase in weekly extreme binge drinking was associated with a 0.12-point decline in IQ scores (P < 0.001). Weekly extreme binge drinking explained more variance in IQ changes than average weekly consumption. In analyses including mutual adjustment of weekly extreme binge drinking and average weekly alcohol consumption, the estimated IQ decline associated with extreme binge drinking was largely unaffected, whereas the association with weekly alcohol consumption became non-significant.

CONCLUSIONS

Adult-life heavy alcohol consumption and extreme binge drinking appear to be associated with larger cognitive decline in men. Moreover, extreme binge drinking may be more important than weekly alcohol consumption in relation to cognitive decline.

Sex differences in stress-related alcohol use

Rates of alcohol use disorder (AUD) have increased in women by 84% over the past ten years relative to a 35% increase in men. This substantive increase in female drinking is alarming given that women experience greater alcohol-related health consequences compared to men. Stress is strongly associated with all phases of alcohol addiction, including drinking initiation, maintenance, and relapse for both women and men, but plays an especially critical role for women. The purpose of the present narrative review is to highlight what is known about sex differences in the relationship between stress and drinking. The critical role stress reactivity and negative affect play in initiating and maintaining alcohol use in women is addressed, and the available evidence for sex differences in drinking for negative reinforcement as it relates to brain stress systems is presented. This review discusses the critical structures and neurotransmitters that may underlie sex differences in stress-related alcohol use (e.g., prefrontal cortex, amygdala, norepinephrine, corticotropin releasing factor, and dynorphin), the involvement of sex and stress in alcohol-induced neurodegeneration, and the role of ovarian hormones in stress-related drinking. Finally, the potential avenues for the development of sex-appropriate pharmacological and behavioral treatments for AUD are identified. Overall, women are generally more likely to drink to regulate negative affect and stress reactivity. Sex differences in the onset and maintenance of alcohol use begin to develop during adolescence, coinciding with exposure to early life stress. These factors continue to affect alcohol use into adulthood, when reduced responsivity to stress, increased affect-related psychiatric comorbidities and alcohol-induced neurodegeneration contribute to chronic and problematic alcohol use, particularly for women. However, current research is limited regarding the examination of sex in the initiation and maintenance of alcohol use. Probing brain stress systems and associated brain regions is an important future direction for developing sex-appropriate treatments to address the role of stress in AUD.

Protective Effects of Pregnancy on Risk of Alcohol Use Disorder

OBJECTIVE

The authors sought to clarify the etiology of the association between pregnancy and reduced risk of alcohol use disorder.

METHODS

The authors used data from longitudinal population-wide Swedish medical, pharmacy, and criminal registries to evaluate whether rates of alcohol use disorder are lower during pregnancy. They compared pregnant women born between 1975 and 1992 (N=322,029) with matched population controls, with female relatives discordant for pregnancy, and with pre- and postpregnancy periods within individuals. They further compared rates of alcohol use disorder between pregnant women and their partners.

RESULTS

Pregnancy was inversely associated with alcohol use disorder across all analyses (odds ratios, 0.17-0.32). In co-relative analyses, the strength of the association increased among more closely related individuals. Within individuals, rates of alcohol use disorder were substantially decreased during pregnancy relative to the prepregnancy period (odds ratios, 0.25-0.26), and they remained reduced during postpartum periods (odds ratios, 0.23-0.31). Results were similar for second pregnancies (odds ratio, 0.23). The partners of pregnant women also exhibited reductions in alcohol use disorder (odds ratio, 0.45). Among women who became pregnant at earlier ages and those with a history of criminal behavior, the negative association between pregnancy and alcohol use disorder was especially pronounced, but no moderation was observed for a personal or maternal parental history of alcohol use disorder.

CONCLUSIONS

The findings suggest that pregnancy plays a critical, and likely causal, motivational role in reducing alcohol use disorder risk among women and, to a lesser extent, their partners. These results extend our understanding of the relationship between pregnancy and alcohol use, demonstrating that even a severe condition such as alcohol use disorder is subject to the protective effects of pregnancy.

A Randomized Trial Comparing Extended-Release Injectable Suspension and Oral Naltrexone, Both Combined With Behavioral Therapy, for the Treatment of Opioid Use Disorder

OBJECTIVE

The oral formulation of the opioid antagonist naltrexone has shown limited effectiveness for treatment of opioid use disorder due to poor adherence. Long-acting injection naltrexone (XR-naltrexone), administered monthly, circumvents the need for daily pill taking, potentially improving adherence, and has been shown to be superior to placebo in reducing opioid use over 6 months of treatment. This open-label trial compared the outcomes of patients with opioid use disorder treated with XR-naltrexone or oral naltrexone in combination with behavioral therapy.

METHOD

Sixty opioid-dependent adults completed inpatient opioid withdrawal and were transitioned to oral naltrexone. They were stratified by severity of opioid use (six or fewer bags versus more than six bags of heroin per day) and randomly assigned (1:1) to continue treatment with oral naltrexone (N=32) or XR-naltrexone (N=28) for 24 weeks. The first dose of XR-naltrexone (380 mg) was administered prior to discharge, with monthly doses thereafter, and oral naltrexone was given in a 50-mg daily dose. All participants received weekly behavioral therapy to support treatment and adherence to naltrexone.

RESULTS

A Cox proportional hazards model adjusting for race, gender, route of use, and baseline opioid use severity indicated that significantly more patients were retained in treatment for 6 months in the XR-naltrexone group (16 of 28 patients, 57.1%) than in the oral naltrexone group (nine of 32 patients, 28.1%) (hazard ratio=2.18, 95% CI=1.07, 4.43).

CONCLUSIONS

Patients receiving XR-naltrexone had twice the rate of treatment retention at 6 months compared with those taking oral naltrexone. These results support the use of XR-naltrexone combined with behavioral therapy as an effective treatment for patients seeking opioid withdrawal and nonagonist treatment for preventing relapse to opioid use disorder.

Association between alcoholic interventions and abstinence rates for alcohol use disorders: A meta-analysis

OBJECTIVE

The aim of present study is to quantitatively evaluate the association between different interventions and abstinence rates based on network meta-analysis.

METHOD

Following PRISMA guidelines, randomized clinical trials that compared different alcoholic interventions for alcohol use disorders associated with abstinence rates in treatment sessions or/and follow-up sessions were recruited. Main data synthesis was performed by Bayesian random-effects network meta-analyses, and the relative ranking of interventions was estimated by cumulative probability P values (SUCRA). Funnel plot symmetry was used to detect publication bias. Moreover, pair-wised comparison was also conducted to determine the statistical difference and forest plots were generated to calculate the differences between the groups. The Grades of Recommendations Assessment, Development and Evaluation (GRADE) criteria were utilized for the recommendations of evidence from pairwise direct comparisons.

RESULTS

A total of 137 RCTs containing 27,282 participants and 8 variations of psychotherapy, pharmacotherapy, contingency management, and brief intervention used as treatment interventions were included. In summary, contingency management plus psychotherapy was demonstrated to be effective and possessed the best rank of achieving the highest abstinence rate in treatment sessions (SUCRA, 0.61). Pharmacotherapy plus psychotherapy also revealed its efficacy and was associated with the highest abstinence rate in follow-up sessions (SUCRA, 0.40). More importantly, psychotherapy alone was demonstrated not to be associated with higher abstinence rates in both treatment (OR, 1.052; 95% CI, 0.907-1.220) and follow-up sessions (OR, 0.967; 95% CI, 0.552-1.693), yet pharmacotherapy seemed to be the only intervention associated with higher abstinence rates compared to controls in both sessions (treatment session: OR, 1.074; 95% CI, 1.002-1.152) (follow-up session: OR, 1.442; 95% CI, 1.094-1.900).

CONCLUSIONS

Contingency management plus psychotherapy and pharmacotherapy plus psychotherapy were demonstrated to be associated with the highest abstinence rates in treatment sessions and follow-up sessions, respectively. However, contingency management and pharmacotherapy seemed to be the substantial crucial factors allowing for the maintenance of the highest abstinence rates in respective sessions, although we need more evidence for further validation.

Alcohol family history moderates the association between evening substance-free reinforcement and alcohol problems

Behavioral economic theories of substance abuse posit that deficits in substance-free reward increase risk for substance misuse, but little research has examined potential moderators of this relationship, including dispositional risk factors. Here, we tested the hypothesis that young adult heavy drinkers with family histories of alcohol misuse would show a stronger association specifically between low evening substance-free reinforcement and alcohol problems compared to those without a family history of alcohol misuse. Participants were 317 college students reporting heavy episodic drinking (Mage = 18.8, SD = 1.1, 61% female, 79% White) who completed a questionnaire about engagement and enjoyment in rewarding activities not involving substance use after 7 p.m., along with measures of personal and parental alcohol use/problems. Evening substance-free reinforcement was negatively associated with typical drinking level for women, but not for men. Family history status did not show a significant association with typical alcohol consumption or evening substance-free reinforcement (operationalized as activity participation × enjoyment), but did show a significant association with alcohol problems. Evening substance-free reinforcement was significantly negatively related to alcohol problems for both men and women. However, the presence of a family history of alcohol misuse moderated this relationship, such that only individuals with familial risk for alcohol misuse who reported lower evening substance-free reinforcement evidenced greater alcohol-related problems. These findings suggest that lower evening substance-free reinforcement is associated with alcohol misuse among young adults, and that this association is exacerbated among individuals with familial risk for developing alcohol problems. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

The Healthy Weigh study of lottery-based incentives and environmental strategies for weight loss: Design and baseline characteristics

Identifying effective strategies for treating obesity is a clinical challenge and a public health priority. The present study is an innovative test of the relative effectiveness of lottery-based financial incentives and environmental strategies on weight loss and maintenance. The Healthy Weigh study is evaluating the comparative effectiveness of behavioral economic financial incentives and environmental strategies, separately and together, in achieving initial weight loss and maintenance of weight loss, in obese urban employee populations. Healthy Weigh is a multi-site, 4-arm randomized controlled trial (RCT) in which 344 employed participants were randomized to one of four arms. The study arms are: 1) standard employee wellness benefits and weigh-ins every 6 months (control arm/usual care); and the control/usual care plus either: 2) daily lottery incentives tied to achievement of weight loss goals (incentive arm); 3) individually tailored environmental strategies around food intake and physical activity (environmental arm); or 4) a combination of incentives and environmental strategies (combined arm). This trial used a web-based platform to enroll, communicate with, and track participant weight change. Wireless scales were used by participants in the three treatment group arms to digitally transmit daily/weekly weights. For females, the baseline median (interquartile range, IQR) for BMI and weight were 37.0 (33.5, 40.6) and 219.9 (198.1, 248.6), respectively; and for males, they were 36.0 (32.8, 39.8) and 247.9 (228.1, 279.5), respectively. The population was generally well-educated. This study demonstrated that multi-site employee-based recruitment for a weight-control intervention study is feasible but may need additional time for coordination between diverse environments.

Remote Alcohol Monitoring to Facilitate Incentive-Based Treatment for Alcohol Use Disorder: A Randomized Trial

Background

The delivery of monetary incentives contingent on verified abstinence is an effective treatment for alcohol use disorder. However, technological barriers to accurate, frequent biochemical verification of alcohol abstinence have limited the dissemination of this technique.

Methods

In the present randomized parallel trial, we employed a breathalyzer that allows remote, user‐verified collection of a breath alcohol sample, text messaging, and reloadable debit cards for remote delivery of incentives to evaluate a contingency management treatment for alcohol use disorder that can be delivered with no in‐person contact. Treatment‐seeking participants with alcohol use disorder (n = 40) were recruited from the community and randomized to either a contingent or a noncontingent group (n = 20 each). The contingent group received nearly immediate monetary incentives each day they remotely provided negative breathalyzer samples. The noncontingent group received matched monetary payments each day they successfully provided samples independent of alcohol content. Groups were not masked as awareness of group contingencies was an essential intervention component.

Results

The primary outcome of the intent‐to‐treat analyses (analyzed n = 40) was percent days abstinent as measured by the remote breathalyzer samples. Abstinence rates in the contingent group were 85%, which was significantly higher than the 38% recorded in the noncontingent group, corresponding to an odds ratio of 9.4 (95% CI = 4.0 to 22.2). Breathalyzer collection adherence rates were over 95%, and participant ratings of acceptability were also high.

Conclusions

These results support the efficacy, acceptability, and feasibility of this remotely deliverable abstinence reinforcement incentive intervention for the initiation and near‐term maintenance of abstinence from alcohol in adults with alcohol use disorder. Due to low provider and participant burden, this procedure has the potential for broad dissemination.

A randomized trial of contingency management reinforcing attendance at treatment: Do duration and timing of reinforcement matter?

OBJECTIVE

Contingency management (CM) interventions that reinforce attendance have rarely been evaluated in terms of reducing drug use. Using a sequential randomized design, this study examined the efficacy of three attendance CM conditions compared to usual care (UC) on drug use outcomes. It evaluated whether the duration (6 vs. 12 weeks) and timing (early vs. later treatment) of CM delivery impact treatment response.

METHOD

Upon initiating outpatient treatment, patients with cocaine use disorders (N = 360) were randomized to UC or CM for attending treatment for 6 weeks. At week 6, patients (n = 308) were rerandomized to UC or CM for another 6 weeks, with assignment stratified on current functioning. Samples were screened for illicit drugs twice weekly for 12 weeks.

RESULTS

Patients randomized to CM at both time-points attended more sessions and achieved more abstinence than those never randomized to CM. Relative to UC, receiving attendance CM in weeks 1-6 only was not efficacious, but those receiving attendance CM in weeks 7-12 only evidenced some benefits compared to those who never received CM. Twelve weeks of attendance CM was more efficacious than 6 weeks. No between-groups differences in drug use were noted at follow-ups, but days attended treatment and proportion negative samples during treatment were associated with long-term cocaine abstinence.

CONCLUSIONS

Attendance-based CM increases treatment participation and reduces drug use, with beneficial effects noted when CM is delivered over longer durations and during later phases of outpatient care. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Smartphone-Based Contingency Management Intervention to Improve Pre-Exposure Prophylaxis Adherence: Pilot Trial

Background

Pre-exposure prophylaxis (PrEP) provides a strong preventative benefit to individuals at risk for HIV. While PrEP adherence is highly correlated with its efficacy, adherence rates are variable both across and within persons.

Objective

The objective of this study was to develop and pilot-test a smartphone-based intervention, known as mSMART, that targets PrEP adherence. mSMART provides contingency management in the form of monetary incentives for daily PrEP adherence based on a real-time adherence assessment using a camera-based medication event-monitoring tool as well as medication reminders, PrEP education, individualized behavioral strategies to address PrEP adherence barriers, and medication adherence feedback.

Methods

This was a 4-week open-label, phase I trial in a community sample of young men who have sex with men already on PrEP (N=10).

Results

Although adherence composite scores corresponding to PrEP biomarkers indicated that 90% (9/10) of the sample already had an acceptable baseline adherence in the protective range, by the end of the 4-week period, the scores improved for 30% (3/10) of the sample—adherence did not worsen for any participants. Participants reported mean PrEP adherence rates of 91% via daily entries in mSMART. At the end of the 4-week period, participants indicated acceptable ratings of satisfaction, usability, and willingness to recommend mSMART to others. There were no technical difficulties associated with smartphone compatibility, user misunderstandings about mSMART features that interfered with daily use, or study attrition.

Conclusions

This study is the first to apply contingency management to PrEP adherence. Findings indicated that mSMART is feasible and acceptable. Such an adherence intervention administered via a user-friendly smartphone app can allow for widespread dissemination. Future efficacy trials are needed.

Trial Registration

ClinicalTrials.gov NCT02895893; https://clinicaltrials.gov/ct2/show/NCT02895893 (Accessed by Webcite at http://www.webcitation.org/72JskjDJq)

Contingency management intervention targeting co-addiction of alcohol and drugs among American Indian adults: Design, methodology, and baseline data

BACKGROUND/AIMS

American Indian adults have some of the highest alcohol abstinence rates compared to the overall US population. Despite this, many American Indian people are more likely to concurrently use alcohol and illicit drugs and are less likely to participate and remain in outpatient treatment for alcohol and other drug use compared to the general US population. There is limited knowledge about effective interventions targeting alcohol and drug co-addiction among American Indian adults. Contingency management is a behavioral intervention designed to increase drug abstinence by offering monetary incentives in exchange for drug and alcohol negative urine samples. We aim to evaluate and describe a culturally tailored contingency management intervention to increase alcohol and other drug abstinence among American Indian adults residing in a Northern Plains reservation.

METHODS

This 2 × 2 factorial, randomized controlled trial currently includes 114 American Indian adults with alcohol and/or drug dependence who are seeking treatment. Participants were randomized into one of four groups that received (1) contingency management for alcohol, (2) contingency management for other drug, (3) contingency management for both substances, or (4) no contingency management for either substance. We present descriptive, baseline data to characterize the sample and describe the modified contingency management approach that is specific to the community wherein this trial was being conducted.

RESULTS

The sample is 49.1% male, with an average age of 35.8 years (standard deviation = 10.4 years). At baseline, 43.0% of the sample tested positive for ethyl glucuronide, 50.9% of participants self-reported methamphetamine as their most used drug, 36.8% self-reported cannabis, and 12.3% self-reported prescription opiates as their most used drug. Among randomized participants, 47.4% tested positive for cannabis, 28.1% tested positive for methamphetamine, 16.7% tested positive for amphetamines, and 2.1% tested positive for opiates.

CONCLUSION

This is the first study to examine a culturally tailored contingency management intervention targeting co-addiction of two substances among American Indian adults. By establishing a tribal-university partnership to adapt, implement, and evaluate contingency management, we will increase the literature on evidence-based addiction treatments and research, while improving trust for addiction interventions among American Indian communities through ongoing collaboration. Moreover, results have implications for the use of contingency management as an intervention for co-addiction in any population.

Smoking Cessation for Those Pursuing Recovery from Substance Use Disorders

This article summarizes the literature regarding the similar biopsychosocial mechanisms of tobacco use and alcohol and substance use disorders, and the evidence for and against the provision of tobacco cessation for those in treatment for alcohol and substance use disorders. The practicality of treatment, focusing on methods, timing, and breadth of intervention strategies, are also presented. Common methodologies that may be used across tobacco use and alcohol and substance use disorder to prevent lapse and relapse are discussed. Physicians can and should adhere to the policy that tobacco use is a common and dangerous comorbid condition that demands concomitant treatment.

Medicaid Incentives for Preventing Chronic Disease: Effects of Financial Incentives for Smoking Cessation

OBJECTIVE

To test the effectiveness of financial incentives for smoking cessation in the Medicaid population.

DATA SOURCES

Secondary data from the Medicaid Incentives for Prevention of Chronic Disease (MIPCD) program and Medicaid claims/encounter data from 2010 to 2015 for five states.

STUDY DESIGN

Beneficiaries were randomized into receipt or no receipt of financial incentives. We ran multivariate regression models testing the impact of financial incentives on the use of counseling services, smoking behavior, and Medicaid expenditures and utilization.

DATA EXTRACTION

Participating states provided Medicaid eligibility, claims and encounters, program enrollment, and incentivized service use data.

PRINCIPAL FINDINGS

Participants who received incentives were more likely to call the Quitline and complete counseling sessions. Incentive receipt was positively associated with self-reported quit attempts, self-reported quits, or passing cotinine tests of smoking cessation in most programs, although results were only statistically significant in a subset. There was no systematic evidence that incentives affected health care use or spending.

CONCLUSIONS

Financial incentives are a promising policy lever to motivate behavioral change in the Medicaid population, but more evidence is needed regarding optimal incentive size, effectiveness of process-versus outcome-based incentives, targeting of incentives, and long-run cost-effectiveness.

Role of the discriminative properties of the reinforcer in resurgence

In three experiments with rat subjects, we examined the effects of the discriminative effects of reinforcers that were presented during or after operant extinction. Experiments 1 and 2 examined resurgence, in which an extinguished operant response (R1) recovers when a second behavior (R2) that has been reinforced to replace it is also placed in extinction. The results of Experiment 1 suggest that the amount of R1's resurgence is a decreasing linear function of the interreinforcement interval used during the reinforcement of R2. In Experiment 2, R1 was reinforced with one outcome (O1), and R2 was then reinforced with a second outcome (O2) while R1 was extinguished. In resurgence tests, response-independent (noncontingent) presentations of O2 prevented resurgence of R1, which otherwise occurred when testing was conducted with either no reinforcers or noncontingent presentations of O1. In Experiment 3, we then examined the effects of noncontingent O1 and O2 presentations after simple extinction in either the presence or the absence of noncontingent presentations of O2. Overall, the results are consistent with a role for the discriminative properties of the reinforcer in controlling operant behavior. In resurgence, the reinforcer used during response elimination provides a distinct context that controls the inhibition of R1. The results are less consistent with an alternative view emphasizing the disrupting effects of alternative reinforcement.

Working Memory Training for Adolescents With Cannabis Use Disorders: A Randomized Controlled Trial

Adolescent cannabis use is associated with working memory impairment. The present randomized controlled trial assigned adolescents ages 14 to 21 enrolled in cannabis use treatment to receive either working memory training (experimental group) or a control training (control group) as an adjunctive treatment. Cognitive function, drug use, and other outcomes were assessed before and after training. We observed few differences in cognitive, functional, or self-reported drug use outcomes as a function of training group, although tetrahydrocannabinol (THC) urinalysis results favored the experimental group. These findings are similar to previous studies in substance users, which have shown limited transfer effects for working memory training.

The national implementation of Contingency Management (CM) in the Department of Veterans Affairs: Attendance at CM sessions and substance use outcomes

BACKGROUND

In 2011, the Department of Veterans Affairs launched an initiative to expand patients' access to contingency management (CM) for the treatment of substance use disorders, particularly stimulant use disorder. This study evaluates the uptake and effectiveness of the VA initiative by presenting data on participation in coaching, fidelity to key components of the CM protocol, and clinical outcomes (CM attendance and substance use).

METHODS

Fifty-five months after the first VA stations began offering CM to patients in June 2011, 94 stations had made CM available to 2060 patients. As those 94 VA stations began delivering CM to Veterans, their staff participated in coaching calls to maintain fidelity to CM procedures. As a part of the CM coaching process, those 94 implementation sites provided data describing the setting and structure of their CM programs as well as their fidelity practices. Additional data on patients' CM attendance and urine test results also were collected from the 94 implementation sites.

RESULTS

The mean number of coaching calls the 94 programs participated in was 6.5. The majority of sites implemented CM according to recommended standard guidelines and reported high fidelity with most CM practices. On average, patients attended more than half their scheduled CM sessions, and the average percent of samples that tested negative for the target substance was 91.1%.

CONCLUSION

The VA's CM implementation initiative has resulted in widespread uptake of CM and produced attendance and substance use outcomes comparable to those found in controlled clinical trials.

Crack cocaine users views regarding treatment with contingency management in Brazil

BACKGROUND

Contingency management (CM) has recently shown efficacy in promoting abstinence and retention in treatment among crack cocaine users in Brazil. However, partially because of unawareness and resistance among health care providers, CM has not been widely employed. The objective of this study was to conduct a secondary analysis in order to evaluate how CM participants perceive their treatment experience.

METHODS

Twenty-seven crack cocaine users, previously assigned to 12 weeks of CM treatment, were assessed with a structured questionnaire designed to assess their personal opinion of, difficulty in understanding, and acceptance of the CM intervention, as well as their opinion regarding its impact on their treatment responses.

RESULTS

Descriptive analyses showed that 92.6% of the participants found it very easy to understand the CM protocol. All participants reported liking their CM experience quite a bit. For the perceived effects of CM on their treatment response, 81.5% of the participants stated that CM helped them considerably, the mean score for the impact of CM on treatment response (out of a maximum of 10) being 9 (SD = 1.5). When asked if they believed CM could help other people with crack cocaine dependence, 92.6% of the participants stated that CM could help such people a lot and 7.4% stated that it could help them a little.

CONCLUSIONS

From the perspective of the patients, CM was easily assimilated, easily accepted, and had a direct positive effect on treatment response. These findings provide additional support for the incorporation of CM into substance abuse treatment services in Brazil.

Comparison of focused cognitive training and portable "brain-games" on functional outcomes for vocational rehabilitation participants

Cognitive remediation performed in a cognitive laboratory was compared with a sham control using portable brain games to study effects on vocational, neurocognitive, and functional outcomes for participants with psychotic disorders in vocational rehabilitation (VR). Seventy-seven participants (61% schizophrenia, 39% other psychosis) in transitional (45.5%) or supported employment (54.5%) were randomly assigned to 6 months of portable cognitive-games (CG) or cognitive remediation (CR) plus a weekly goal-setting group, and evaluated during training, post-training and at 12 months. Overall rates of employment did not differ significantly at 12-month follow-up; however, VR + CG attained employment more rapidly during training. A significant time by condition interaction favored VR + CR on Quality of Life Total Score and Instrumental Functioning over 12 months. Neurocognitive outcomes favored VR + CR, particularly on attention. Training hours related significantly to neurocognitive improvement regardless of condition. No differences were found in training adherence despite portability for VR + CG. Results indicate that VR + CR had significantly greater effect than VR + CG on neurocognition and community functioning, but not on employment outcome. Job attainment rates during the training period revealed a potential advantage for portable training raising new questions concerning how cognitive remediation can be most effectively integrated with VR.

What works in alcohol use disorders?

Treatment of alcohol use disorders typically involves a combination of pharmacotherapy and psychosocial interventions. About one-quarter of people with alcohol dependence (‘alcoholics’) who seek treatment remain abstinent over 1 year. Research has consistently shown that less intensive, community treatment (particularly brief interventions) is just as effective as intense, residential treatment. Many psychosocial treatments are probably equally effective. Techniques for medically assisted detoxification are widespread and effective. More recent evidence provides some support for the use of drugs such as acamprosate to prevent relapse in the medium to long term.

Duration of therapy - Does it matter?: A systematic review and meta-regression of the duration of psychosocial treatments for alcohol use disorder

BACKGROUND

The recommendations in clinical guidelines for duration of therapy for alcohol use disorder (AUD) are based on consensus decisions. In reality, we do not know the optimal duration of an alcohol treatment course.

METHODS

A systematic review and meta-regression of randomized controlled trials of psychosocial treatment in alcohol outpatient treatment centers. The population consisted of adults suffering from AUD, treated in an outpatient facility with at least two sessions of therapy. Meta-regression analysis was performed with treatment outcome as a function of duration of therapy across studies. Treatment outcome was defined as long-term alcohol use measured in percentage of days abstinent (PDA), percentage of heavy days drinking (PHD), and/or proportion of participants abstinent (ABS).

RESULTS

48 studies encompassing 8984 participants. Mean planned duration of therapy: 18 (8-82) weeks and 14 (2-36) sessions. Mean actual attended sessions: 9 (1-26). Mean follow-up time: 43 (8-104) weeks with a mean of 6 (2-18) research assessments. Neither planned weeks, duration of sessions, frequency of sessions per week, nor actual attended sessions were associated with long-term alcohol use outcomes. However, frequency of research assessments was positively associated with PDA and PHD.

CONCLUSION

No associations between long-term alcohol use outcomes and planned or actual attended duration of psychosocial treatment in outpatient care. Research assessments and, accordingly, the research project in itself may influence outcome in studies of psychosocial treatment for alcohol use disorder.

Is the concept of compulsion useful in the explanation or description of addictive behaviour and experience?

The concept of compulsion, in which addictive behaviour is said to be carried out against the will, is central to the disease theory of addiction and ubiquitous in modern definitions. The aims of this article are: (i) to describe various meanings of compulsion in the literature; (ii) to compare the part thought to be played by compulsion in addiction with its suggested role in obsessive-compulsive disorder; (iii) to critically examine the place of compulsion in influential neurobiological accounts of addiction; (iv) to summarise the empirical evidence bearing on the usefulness of the compulsion concept, evidence that seems at first sight incompatible with the notion of compulsion. This is followed by a discussion of which possible meanings of compulsion can survive an empirical test and what role they might play in understanding addiction, paying particular attention to a distinction between strong and weak senses of compulsion. A conclusion is that addictive behaviour cannot be considered compulsive at the time it is carried out, though other possible meanings of compulsion as an explanation or description of addictive behaviour and experience are discussed. Among other conclusions, it is suggested that, although in some senses of the term it may seem arbitrary whether or not 'compulsion' should be retained, its use has important consequences for the public understanding of addiction, and is likely to deter people's attempts to overcome their addictions and their chances of success.

Contingency management treatment for substance use disorders: How far has it come, and where does it need to go?

Contingency management (CM) interventions consistently improve substance abuse treatment outcomes, yet CM remains a highly controversial intervention and is rarely implemented in practice settings. This article briefly outlines the evidence base of CM and then describes 4 of the most often-cited concerns about it: philosophical, motivational, durability, and economic. Data supporting and refuting each of these issues are reviewed. The article concludes with suggestions to address these matters and other important areas for CM research and implementation, with the aims of improving uptake of this efficacious intervention in practice settings and outcomes of patients with substance use disorders. (PsycINFO Database Record

A Novel Therapy for cocaine dependence during abstinence: A randomized clinical trial

Background

Topiramate is an anticonvulsant drug and an ideal candidate for reducing the craving in people relying on cocaine. Contingency management is one of the common therapies in the domain of addiction.

Objective

The present study aimed to evaluate and compare three medication methods of Topiramate (TPM), Contingency Management (CM) and the combined TPM treatment and cash intervention on craving during abstinence.

Methods

This randomized clinical trial was conducted at Bijan Center for Substance Abuse Treatment in Tehran, Iran, from December 15, 2014 to November 20, 2015. One hundred males (Age range=18–34; SD=4.11) undergoing abstinence were assigned randomly to four groups (n=25) of Topiramate (TPM), Contingency Management (CM) and the Combined Method plus a placebo control group. Treatment was provided for twelve weeks for the experiment groups, and only the control group received the placebo. Participants in the Cash-based and CM Condition had an identical 12-week escalating schedule of reinforcement (cash-based incentives worth $0, $20, $40, and $80). Also, in the Topiramate group, participants’ dosage ranged between 25–300 mg/day in escalating doses) 25, 50, 100, 150, 200, 250, 300). In addition, all subjects received brief behavioral compliance enhancement treatment (BBCET). Participants took a urine test twice a week, with a given threshold of > 300 ng/ml, and indicators of cocaine craving (response rate= 91%) was evaluated in two phases of pre-test and post-test. We used Chi square, ANCOVA Univariate Model and Scheffe’s post hoc to analyze the primary and secondary outcomes. Also, the qualitative data resulted from demographic evaluations were coded and analyzed by the instrument of analysis of qualitative data i.e. Atlas.ti, Version 5.2.

Results

The results showed that all three types of treatment played a significant efficacy in reducing the craving. The mean (95% CI) scores of craving was 12.04 (p=0.05) with TPM, 13.89 (p=0.05) with CM, 10.92 (p=0.01) with Mix and 16.89 (p>0.05) with control. Moreover, the highest variance explaining the changes in craving was assigned to the combined treatment (p<0.01).

Conclusions

The findings of this study, while having applicable aspects in this domain, can be helpful in planning supplementary remedial procedures.

Trial registration

The trial was registered at the Thai Clinical Trial Registration Center with the TCR ID: TCTR20170112001.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Experiences with SCRAMx alcohol monitoring technology in 100 alcohol treatment outpatients

BACKGROUND

Transdermal alcohol monitoring technology allows for new research on alcohol use disorders. This study assessed feasibility, acceptability, and adherence with this technology in the context of two clinical research trials.

METHODS

Participants were the first 100 community-based alcohol treatment outpatients enrolled in randomized studies that monitored drinking with the secure continuous remote alcohol monitor (SCRAMx®) for 12 weeks. Study 1 participants were randomized to usual care (n=36) or usual care with contingency management incentives for treatment attendance (CM-Att; n=30). Study 2 participants were randomized to usual care (n=17) or usual care with CM for each day of no drinking per SCRAMx (CM-Abst; n=17). After 12 weeks, participants completed a survey about the bracelet.

RESULTS

Nine percent of individuals screened (54 of 595) declined participation because of the bracelet. Of participants, 84% provided 12weeks of data, and 96% of bracelets were returned fully intact. Ninety-four equipment tampers occurred, affecting 2% of monitoring days; 56% (67) of tampers coincided with detected drinking. Common concerns reported by participants were skin marks (58%), irritation (54%), and interfered with clothing choices (51%), but severity ratings were generally mild (60%-94%). Eighty-one percent of participants reported that the bracelet helped them reduce drinking, and 75% indicated that they would wear it for longer. A common suggestion for improvement was to reduce the size of the bracelet.

CONCLUSIONS

Results support the viability of transdermal monitoring in voluntary substance abuse treatment participants for an extended duration. Issues to consider for future applications of this technology are discussed.

Pretreatment ethyl glucuronide levels predict response to a contingency management intervention for alcohol use disorders among adults with serious mental illness

BACKGROUND AND OBJECTIVES

This study investigated if pretreatment ethyl glucuronide (EtG) levels corresponding to light (100 ng/mL), heavy (500 ng/mL), and very heavy (1,000 ng/mL) drinking predicted longest duration of alcohol abstinence (LDA) and proportion of EtG-negative urine tests in outpatients receiving a 12-week EtG-based contingency management (CM) intervention for alcohol dependence.

METHODS

Participants were 40 adults diagnosed with alcohol use disorders and serious mental illness who submitted up to 12 urine samples for EtG analysis during a 4-week observation period and were then randomized to 12-weeks of CM for alcohol abstinence and addiction treatment attendance. Alcohol use outcomes during CM as assessed by EtG and self-report were compared across those who did and did not attain a pre-treatment average EtG level of 500 ng/mL-a level that equates to frequent heavy drinking.

RESULTS

Only the 500 ng/mL cutoff was associated with significant differences in LDA and proportion of EtG-negative samples during CM. Those with a pre-treatment EtG < 500 ng/mL attained a LDA 2.3 (alcohol) to 2.9 (drugs) weeks longer than pre-treatment heavy drinkers.

DISCUSSION AND CONCLUSIONS

The EtG biomarker can be used to determine who will respond to a CM intervention for alcohol use disorders and could inform future trials that are designed to be tailored to individual patients.

SCIENTIFIC SIGNIFICANCE

Results suggest pre-treatment EtG cutoffs equivalent to heavy and very heavy drinking predict outcomes in CM. (Am J Addict 2017;26:673-675).

Choice between variable and fixed cocaine injections in male rhesus monkeys

RATIONALE

The schedule of drug availability may enhance choice of a drug. In non-human subjects, reinforcers are chosen more often when available under variable schedules of reinforcement relative to fixed schedules.

OBJECTIVE

To determine whether variable-drug access is an important determinant of cocaine choice by manipulating the schedule, drug dose, and combination of schedule + dose.

METHOD

Four male rhesus monkeys chose between cocaine doses (0.025-0.4 mg/kg/injection). In control conditions, the schedule and dose of each drug delivery were fixed. In other conditions, the reinforcement schedule (i.e., variable-ratio schedule), dose of each cocaine delivery, or both were variable on one lever while all aspects on the other lever remained fixed.

RESULTS

When cocaine dose was equal on average (0.1 mg/kg/injection), 2 of 4 subjects chose cocaine associated with the variable schedule more than the fixed schedule. All subjects chose the variable dose that was equal on average to the fixed dose, and this difference was statistically significant. Three of 4 subjects chose cocaine associated with the variable combination over the fixed option (when the dose was equal on average). During dose-response determinations (when dose on the variable and fixed options were not equal), making the schedule, dose, or both variable generally did not alter cocaine's potency as a reinforcer.

CONCLUSION

While many factors contribute to drug choice, unpredictable drug access is a feature that may be common in the natural environment and could play a key role in the allocation of behavior to drug alternatives by patients with substance-use disorders.

Functional neural changes following behavioral therapies and disulfiram for cocaine dependence

A growing literature exists on neural correlates of treatment outcome. However, different types-or components of-treatment have distinct theorized mechanisms of action. And it is not yet known how changes in neural activity across treatment relate to engagement in different treatment components. Participants with cocaine use disorders in a randomized clinical trial received cognitive-behavioral therapy (CBT) plus, in a 2 × 2 design, contingency management (CM) or no CM, and disulfiram or placebo. Participants performed a functional MRI Stroop task, a measure of cognitive control, at the beginning of and after the 12-week treatment. Analyses assessed changes in Stroop-related neural activity within the sample overall and assessed how changes in Stroop-related activity correlated with measures of treatment process specific to each form of treatment (i.e., participation in CBT sessions, receipt of CM prizes, administration of disulfiram pills). Within the sample overall, compared with beginning of treatment, posttreatment Stroop-related neural activity was diminished in the hippocampus, thalamus, cingulate, precentral, post- and precentral gyrus, and precuneus and culmen regions (pFWE < .05). In separate whole-brain correlation analyses, greater reductions in Stroop-related activity were associated with more treatment engagement-"CBT sessions" with the precentral gyrus, inferior parietal lobule, and middle and medial frontal gyrus; "CM prizes" with the postcentral frontal gyrus. Disulfiram "medication days" were not associated with changes in Stroop-related activity. Findings suggest that key process indicators of CBT and CM may be associated with functional changes in cognitive-control-related neurocircuitry. (PsycINFO Database Record

Pilot investigation of a phosphatidylethanol-based contingency management intervention targeting alcohol use

Phosphatidylethanol (PEth) can be detected in blood from 14 to as many as 28 days after alcohol consumption, depending on the amount and frequency of alcohol consumed. PEth may have utility for verifying abstinence in a contingency management (CM) intervention for alcohol use, particularly in settings where frequent verification of abstinence is impossible or impractical. Five nontreatment-seeking heavy drinkers (40% men) participated in an 11-week, ABA-phased within-subject experiment for which they submitted blood spots for PEth measurement, urine samples for ethyl glucuronide (EtG) testing, and self-report drinking data weekly. Participants received reinforcers for submitting samples throughout the A phases. During the B phase (CM phase), they received additional reinforcers when their PEth level was reduced from the previous week and was verified by a negative EtG (<150 ng/ml) urine test and self-report. PEth, EtG, and self-report outcomes were compared between A phases (Weeks 1-3, 8-11) and B phases (Weeks 4-7). During the A phases, 23% of PEth results indicated alcohol abstinence, whereas 53% of PEth samples submitted during the CM (B phase) indicated alcohol abstinence. Participants were more likely to submit EtG-negative urine samples and report lower levels of drinking and heavy drinking during the B phase, relative to the A phases. We also explored the ability of PEth to detect self-reported drinking. The combined PEth homologs (16:0/18:1 and 16:0/18:2) predicted self-reported drinking with area under the curve from 0.81 (1 week) to 0.80 (3 weeks). Results support the initial feasibility of a Peth-based CM intervention. (PsycINFO Database Record

Practical issues regarding implementing a randomized clinical trial in a homeless population: strategies and lessons learned

Abstract

There is a critical need for objective data to guide effective health promotion and care for homeless populations. However, many investigators exclude homeless populations from clinical trials due to practical concerns about conducting research with this population. This report is based on our experience and lessons learned while conducting two large NIH-funded randomized controlled trials targeting smoking cessation among persons who are homeless. The current report also addresses challenges when conducting clinical trials among homeless populations and offers potential solutions. Homeless individuals face several challenges including the need to negotiate daily access to food, clothing, and shelter. Some of the critical issues investigators encounter include recruitment and retention obstacles; cognitive impairment, mental health and substance abuse disorders; transportation and scheduling challenges; issues pertaining to adequate study compensation; the need for safety protocols for study staff; and issues related to protecting the wellbeing of these potentially vulnerable adults. Anticipating realistic conditions in which to conduct studies with participants who are homeless will help investigators to design efficient protocols and may improve the feasibility of conducting clinical trials involving homeless populations and the quality of the data collected by the researchers.

Trial registration

ClinicalTrials.gov, ID: NCT00786149. Registered on 5 November 2008;

ClinicalTrials.gov, ID: NCT01932996. Registered on 20 November 2014.

A preliminary randomized controlled trial of contingency management for alcohol use reduction using a transdermal alcohol sensor

AIMS

We tested the efficacy of daily contingent reinforcement for reducing alcohol use compared with (yoked) non-contingent reinforcement (NR) using a transdermal alcohol sensor to detect alcohol use.

DESIGN

Pilot randomized controlled design with 1 baseline week, 3 intervention weeks and 1-month follow-up.

SETTING

New England, USA.

PARTICIPANTS

Heavy drinking adults (46.7% female) not seeking treatment were randomized to (1) an escalating schedule of cash reinforcement (CR; n = 15) for days on which alcohol was neither reported nor detected or (2) yoked NR (n = 15).

INTERVENTION AND COMPARATOR

Reinforcement for CR participants started at $5 and increased $2 every subsequent day on which alcohol was not detected or reported, to a maximum of $17. Participants received no reinforcement for days on which alcohol use was detected or reported, and the reinforcer value was re-set to $5 the day after a drinking day. NR participants were yoked to the daily reinforcer value of an individual in the CR condition, in order of enrollment. Paired participants in CR and NR therefore received the same amount of money, but the amount for the NR participant was not behavior-related.

MEASUREMENTS

The primary outcome was percentage of days without sensor-detected drinking. Secondary outcomes were number of consecutive days with no detected drinking, peak transdermal alcohol concentration (TAC), self-reported drinks per week and drinking below NIH low-risk guidelines.

FINDINGS

Controlling for baseline, CR had a higher percentage of days with no drinking detected (54.3%) than NR (31.2%) during intervention weeks [P = 0.05, Cohen's d = 0.74; 95% confidence interval (CI) = 0.007-1.47]. The longest period of consecutive days with no drinking detected was 8.0 for CR versus 2.9 for NR (P = 0.03, d = 0.85; 95% CI = 0.08-1.61). Peak TAC during intervention showed a non-significant group difference (P = 0.20; d = 0.48; 95% CI = 0.00-1.18); a similar result was found for drinks per week (P = 0.12; d = 0.59; 95% CI = 0.00-1.30). Four times more participants in CR drank below NIH low-risk drinking guidelines during intervention than did participants in NR: 31.1 versus 7.1% (P = 0.07; d = 0.71; 95% CI = -0.04 to 1.46). At 1-month follow-up, the highest number of consecutive days without drinking (self-report) did not differ significantly between conditions (P = 0.26), but showed a medium effect size (d = 0.44; 95% CI = -0.32 to 1.18).

CONCLUSIONS

Cash incentives linked to a transdermal alcohol sensor can reduce heavy alcohol consumption while the incentives are in operation.

A Randomized Controlled Trial of Ethyl Glucuronide-Based Contingency Management for Outpatients With Co-Occurring Alcohol Use Disorders and Serious Mental Illness

OBJECTIVE

The authors examined whether a contingency management intervention using the ethyl glucuronide (EtG) alcohol biomarker resulted in increased alcohol abstinence in outpatients with co-occurring serious mental illnesses. Secondary objectives were to determine whether contingency management was associated with changes in heavy drinking, treatment attendance, drug use, cigarette smoking, psychiatric symptoms, and HIV-risk behavior.

METHOD

Seventy-nine (37% female, 44% nonwhite) outpatients with serious mental illness and alcohol dependence receiving treatment as usual completed a 4-week observation period and were randomly assigned to 12 weeks of contingency management for EtG-negative urine samples and addiction treatment attendance, or reinforcement only for study participation. Contingency management included the variable magnitude of reinforcement "prize draw" procedure contingent on EtG-negative samples (<150 ng/mL) three times a week and weekly gift cards for outpatient treatment attendance. Urine EtG, drug test, and self-report outcomes were assessed during the 12-week intervention and 3-month follow-up periods.

RESULTS

Contingency management participants were 3.1 times (95% CI=2.2-4.5) more likely to submit an EtG-negative urine test during the 12-week intervention period, attaining nearly 1.5 weeks of additional alcohol abstinence compared with controls. Contingency management participants had significantly lower mean EtG levels, reported less drinking and fewer heavy drinking episodes, and were more likely to submit stimulant-negative urine and smoking-negative breath samples, compared with controls. Differences in self-reported alcohol use were maintained at the 3-month follow-up.

CONCLUSIONS

This is the first randomized trial utilizing an accurate and validated biomarker (EtG) to demonstrate the efficacy of contingency management for alcohol dependence in outpatients with serious mental illness.

The Efficacy of Contingency Management on Cocaine Craving, using Prize-based Reinforcement of Abstinence in Cocaine Users

Introduction

Contingency management (CM) is one of the most common therapies in the domain of drug addiction. This study has been carried out with the purpose of evaluating the efficacy of contingency management intervention.

Method

In an experimental design, between December 15, 2014 and November 20, 2015, fifty men (between 18 and 31 with an average age of 24.6) with a history of cocaine use, were selected voluntarily and were randomly assigned into two groups of CM and control group. The CM group were awarded coupons for negative urine tests, over a period of twelve weeks. The urine tests were taken from the participants twice per week, with cutoff concentrations for positive set at 300 ng/ml and self-reporting index of cocaine craving (response rate = 96%) were evaluated in two phase, through pretest and posttest measures. The data were analyzed by parametric covariance test. Additionally, the qualitative data, resulted from demographic measures, were coded and were analyzed with the help of an analysis instrument of qualitative data i.e. ATLAS.ti-5.2.

Results

The primary outcome was the number of negative urine tests and the secondary outcome included the cocaine usage craving index over twelve weeks. The mean of (95% of confidence) number of negative cocaine urine tests was 15.4 (13.1–17.8) in the CM group and 19.7 (17.7–21.6) in the control group (P = 0.049). Also, results showed that CM has a significant effect on reducing craving (p<0.01).

Conclusion

The findings of this study, while having practical aspects in this domain, can be valuable in planning remedial procedures.

Using Bayes factors for testing hypotheses about intervention effectiveness in addictions research

BACKGROUND AND AIMS

It has been proposed that more use should be made of Bayes factors in hypothesis testing in addiction research. Bayes factors are the ratios of the likelihood of a specified hypothesis (e.g. an intervention effect within a given range) to another hypothesis (e.g. no effect). They are particularly important for differentiating lack of strong evidence for an effect and evidence for lack of an effect. This paper reviewed randomized trials reported in Addiction between January and June 2013 to assess how far Bayes factors might improve the interpretation of the data.

METHODS

Seventy-five effect sizes and their standard errors were extracted from 12 trials. Seventy-three per cent (n = 55) of these were non-significant (i.e. P > 0.05). For each non-significant finding a Bayes factor was calculated using a population effect derived from previous research. In sensitivity analyses, a further two Bayes factors were calculated assuming clinically meaningful and plausible ranges around this population effect.

RESULTS

Twenty per cent (n = 11) of the non-significant Bayes factors were < ⅓ and 3.6% (n = 2) were > 3. The other 76.4% (n = 42) of Bayes factors were between ⅓ and 3. Of these, 26 were in the direction of there being an effect (Bayes factor > 1 and < 3); 12 tended to favour the hypothesis of no effect (Bayes factor < 1 and > ⅓); and for four there was no evidence either way (Bayes factor = 1). In sensitivity analyses, 13.3% of Bayes Factors were < ⅓ (n = 20), 62.7% (n = 94) were between ⅓ and 3 and 24.0% (n = 36) were > 3, showing good concordance with the main results.

CONCLUSIONS

Use of Bayes factors when analysing data from randomized trials of interventions in addiction research can provide important information that would lead to more precise conclusions than are obtained typically using currently prevailing methods.

The behavioral economics of young adult substance abuse

Alcohol and drug use peaks during young adulthood and can interfere with critical developmental tasks and set the stage for chronic substance misuse and associated social, educational, and health-related outcomes. There is a need for novel, theory-based approaches to guide substance abuse prevention efforts during this critical developmental period. This paper discusses the particular relevance of behavioral economic theory to young adult alcohol and drug misuse, and reviews of available literature on prevention and intervention strategies that are consistent with behavioral economic theory. Behavioral economic theory predicts that decisions to use drugs and alcohol are related to the relative availability and price of both alcohol and substance-free alternative activities, and the extent to which reinforcement from delayed substance-free outcomes is devalued relative to the immediate reinforcement associated with drugs. Behavioral economic measures of motivation for substance use are based on relative levels of behavioral and economic resource allocation towards drug versus alternatives, and have been shown to predict change in substance use over time. Policy and individual level prevention approaches that are consistent with behavioral economic theory are discussed, including brief interventions that increase future orientation and engagement in rewarding alternatives to substance use. Prevention approaches that increase engagement in constructive future-oriented activities among young adults (e.g., educational/vocational success) have the potential to reduce future health disparities associated with both substance abuse and poor educational/vocational outcomes.

A contingency management method for 30-days abstinence in non-treatment seeking young adult cannabis users

BACKGROUND

Rates of young adult cannabis use are rising, perceived harm is at its historical nadir, and most users do not want to quit. Most studies evaluating effects of cannabis use in young adults are cross-sectional, limiting causal inference. A method to reliably induce abstinence periods in cannabis users would allow assessment of the effects of abstinence and resumption of use on a variety of outcomes in a within-subjects, repeated measures design.

METHODS

We examined the efficacy and feasibility of a voucher-based contingency management procedure for incentivizing one month of continuous cannabis abstinence among young adults who reported at least weekly cannabis use, volunteered to participate in a laboratory study, and did not express a desire to discontinue cannabis use long-term. Continuous cannabis abstinence was reinforced with an escalating incentive schedule, and self-report of abstinence was confirmed by frequent quantitative assays of urine cannabis metabolite (THCCOOH) concentration. New cannabis use during the abstinence period was determined using an established algorithm of change in creatinine-adjusted cannabis metabolite concentrations between study visits.

RESULTS

Thirty-eight young adults, aged 18-25 years, enrolled and 34 (89.5%) attained biochemically confirmed 30-day abstinence. Among those who attained abstinence, 93.9% resumed regular use within two-weeks of incentive discontinuation.

CONCLUSION

Findings support the feasibility and efficacy of contingency management to elicit short-term, continuous cannabis abstinence among young adult, non-treatment seeking, regular cannabis users. Further work should test the effectiveness of this contingency management procedure for cannabis abstinence in periods longer than one month, which may be required to evaluate some effects of abstinence.

Treatment of alcohol use disorders in patients with alcoholic liver disease

Alcohol use disorders (AUDs) is one of the leading causes of disease and disability in almost all European countries. Among the alcohol-related diseases, alcoholic liver disease (ALD) is the most common. At present, alcohol is the most frequent cause of liver cirrhosis in the Western world. The cornerstone of treatment for ALD is achieving total alcohol abstinence and preventing relapse; medical and surgical treatments for ALD are limited when drinking continues. This narrative review summarizes current treatments for AUDs with a particular emphasis to the treatment of AUDs in patients with ALD. Medical management, psychosocial and pharmacological interventions are analyzed, underlying limits and options in AUD patients. Finally, this review discusses the most appropriate setting for the management of AUD patients with advanced liver disease as well as the indications for liver transplantation in AUD patients.

The Core of Care Management: The Role of Authentic Relationships in Caring for Patients with Frequent Hospitalizations

In the movement to improve the health of patients with multiple chronic conditions and vulnerabilities, while reducing the need for hospitalizations, care management programs have garnered wide attention and support. The qualitative data presented in this paper sheds new light on key components of successful chronic care management programs. By going beyond a task- and temporal-based framework, this analysis identifies and defines the importance of "authentic healing relationships" in driving individual and systemic change. Drawing on the voices of 30 former clients of the Camden Coalition of Healthcare Providers, the investigators use qualitative methods to identify and elaborate the core elements of the authentic healing relationship-security, genuineness, and continuity-a relationship that is linked to patient motivation and active health management. Although not readily found in the traditional health care delivery system, these authentic healing relationships present significant implications for addressing the persistent health-related needs of patients with frequent hospitalizations. (Population Health Management 2016;19:248-256).

The Behavioral Economics and Neuroeconomics of Alcohol Use Disorders

BACKGROUND

Behavioral economics and neuroeconomics bring together perspectives and methods from psychology, economics, and cognitive neuroscience to understand decision making and choice behavior. Extending an operant behavioral theoretical framework, these perspectives have increasingly been applied to understand the alcohol use disorders (AUDs), and this review surveys the theory, methods, and findings from this approach. The focus is on 3 key behavioral economic concepts: delay discounting (i.e., preferences for smaller immediate rewards relative to larger delayed rewards), alcohol demand (i.e., alcohol's reinforcing value), and proportionate alcohol-related reinforcement (i.e., relative amount of psychosocial reinforcement associated with alcohol use).

FINDINGS

Delay discounting has been linked to AUDs in both cross-sectional and longitudinal studies and has been investigated cross-sectionally using neuroimaging. Alcohol demand and proportionate alcohol-related reinforcement have both been robustly associated with drinking and alcohol misuse cross-sectionally, but not over time. Both have also been found to predict treatment response to brief interventions. Alcohol demand has also been used to enhance the measurement of acute motivation for alcohol in laboratory studies. Interventions that focus on reducing the value of alcohol by increasing alternative reinforcement and response cost have been found to be efficacious, albeit in relatively small numbers of randomized controlled trials (RCTs). Mediators and moderators of response to these interventions have not been extensively investigated.

FUTURE DIRECTIONS

The application of behavioral economics and neuroeconomics to AUDs has given rise to an extensive body of empirical work, although significant gaps in knowledge remain. In particular, there is a need for more longitudinal investigations to clarify the etiological roles of these behavioral economic processes, especially alcohol demand and proportionate alcohol reinforcement. Additional RCTs are needed to extend and generalize the findings for reinforcement-based interventions and to investigate mediators and moderators of treatment success for optimization. Applying neuroeconomics to AUDs remains at an early stage and has been primarily descriptive to date, but has high potential for important translational insights into the future. The same is true for using these behavioral economic indicators to understand genetic influences on AUDs.

Using contingency management procedures to reduce at-risk drinking in heavy drinkers

BACKGROUND

Treatments for alcohol use disorders typically have been abstinence based, but harm reduction approaches that encourage drinkers to alter their drinking behavior to reduce the probability of alcohol-related consequences, have gained in popularity. This study used a contingency management procedure to determine its effectiveness in reducing alcohol consumption among heavy drinkers.

METHODS

Eighty-two nontreatment-seeking heavy drinkers (ages 21 to 54, M = 30.20) who did not meet diagnostic criteria for alcohol dependence participated in the study. The study had 3 phases: (i) an Observation phase (4 weeks) where participants drank normally; (ii) a Contingency Management phase (12 weeks) where participants were paid $50 weekly for not exceeding low levels of alcohol consumption as measured by transdermal alcohol concentrations, <0.03 g/dl; and (iii) a Follow-up phase (12 weeks) where participants (n = 66) returned monthly for 3 months to self-report drinking after the contingencies were removed. Transdermal alcohol monitors were used to verify meeting contingency requirements; all other analyses were conducted on self-reported alcohol use.

RESULTS

On average 42.3% of participants met the contingency criteria and were paid an average of $222 during the Contingency Management phase, with an average $1,998 in total compensation throughout the study. Compared to the Observation phase, the percent of any self-reported drinking days significantly decreased from 59.9 to 40.0% in the Contingency Management and 32.0% in the Follow-up phases. The percent of self-reported heavy drinking days reported also significantly decreased from 42.4% in the Observation phase to 19.7% in the Contingency Management phase, which was accompanied by a significant increase in percent days of self-reported no (from 40.1 to 60.0%) and low-level drinking (from 9.9 to 15.4%). Self-reported reductions in drinking either persisted, or became more pronounced, during the Follow-up phase.

CONCLUSIONS

Contingency management was associated with a reduction in self-reported episodes of heavy drinking among nontreatment-seeking heavy drinkers. These effects persisted even after incentives were removed, indicating the potential utility of contingency management as a therapeutic intervention to reduce harmful patterns of drinking.