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

A randomized trial of contingency management delivered by community therapists

OBJECTIVE

Contingency management (CM) is an evidence-based treatment, but few clinicians deliver this intervention in community-based settings.

METHOD

Twenty-three clinicians from 3 methadone maintenance clinics received training in CM. Following a didactics seminar and a training and supervision period in which clinicians delivered CM to pilot patients, a randomized trial evaluated the efficacy of CM when delivered entirely by clinicians. Sixteen clinicians treated 130 patients randomized to CM or standard care. In both conditions, urine and breath samples were collected twice weekly for 12 weeks. In the CM condition, patients earned the opportunity to win prizes ranging in value from $1 to $100 for submitting samples negative for cocaine and alcohol. Primary treatment outcomes were retention, longest continuous period of abstinence, and proportion of negative samples submitted.

RESULTS

Patients randomized to CM remained in the study longer (9.5 ± 3.6 vs. 6.7 ± 5.0 weeks), achieved greater durations of abstinence (4.7 ± 4.7 vs. 1.7 ± 2.7 weeks), and submitted a higher proportion of negative samples (57.7% ± 40.0% vs. 29.4% ± 33.3%) than those assigned to standard care.

CONCLUSIONS

These data indicate that, with appropriate training, community-based clinicians can effectively administer CM. This study suggests that resources ought to be directed toward training and supervising community-based providers in delivering CM, as patient outcomes can be significantly improved by integrating CM in methadone clinics.

Decision-making capacities and affective reward anticipation in DWI recidivists compared to non-offenders: a preliminary study

OBJECTIVES

Impaired decision making is seen in several problem behaviours including alcoholism and problem gambling. Decision-making style may contribute to driving while impaired with alcohol (DWI) in some offenders as well. The Somatic Marker Framework theorizes that decision making is the product of two interacting affective neural systems, an impulsive, rapid, amygdala-dependent process for emotionally signalling the immediate negative or positive consequences of an option, and a reflective, longer-lasting, ventral medial prefrontal cortex dependent system for emotionally signalling the future negative or positive prospects of an option. This study tested the hypothesis that offenders who showed disadvantageous decision-making would be at higher risk for recidivism than those who showed more advantageous decision-making. In addition, in line with the Somatic Marker Hypothesis, offenders who showed disadvantageous decision-making would exhibit a distinct pattern of somatic activation compared to offenders who showed more advantageous decision-making.

METHODS

A sample of 21 DWI offenders with from 2 to 7 past DWI convictions and a reference group consisting of 19 non-offender (N-O) drivers were recruited and administered the Iowa Gambling Task (IGT), as well as evaluated on sociodemographic, driving and alcohol use dimensions. In addition, anticipatory skin conductance response (aSCR) was measured in the 5s prior to each of a 100 card draws on the IGT.

RESULTS

Median split of the DWI offender sample based upon overall performance on the IGT yielded two subgroups (IGT-R Hi and IGT-R Lo). Hypothesis 1 was supported, as the IGT-R Lo group possessed significantly greater frequency of past DWI convictions and severity of past drinking. Descriptive analyses revealed that on the IGT, IGT-R Hi group performed similarly to the N-O reference group while the IGT-R Lo group performed significantly worse. Hypothesis 2 was not supported.

CONCLUSIONS

Decision making is a plausible explanatory neurocognitive pathway to severer forms of DWI. The role of emotional processing in DWI risk is uncertain. Subtyping DWI offenders using neurocognitive criteria seems a promising avenue for improving clinically meaningful methods of DWI risk assessment and intervention.

Baseline trajectories of heavy drinking and their effects on postrandomization drinking in the COMBINE Study: empirically derived predictors of drinking outcomes during treatment

The Combined Pharmacotherapies and Behavioral Interventions (COMBINE) Study sought to answer questions about the benefits of combining behavioral and pharmacological interventions (naltrexone and acamprosate) in alcohol-dependent patients. Our goals were to identify trajectories of heavy drinking before randomization in COMBINE, to characterize patients in these trajectories, and to assess whether prerandomization trajectories predict drinking outcomes. We analyzed daily indicators of heavy drinking 90 days before randomization using a trajectory-based approach. Each patient was assigned to the most likely prerandomization heavy-drinking trajectory, and the baseline characteristics of participants in the baseline trajectories were compared. The main and interactive effects of these trajectories and treatment factors (acamprosate, naltrexone, or combined behavioral intervention) on summary drinking measures during active treatment (16 weeks) were assessed. We identified five trajectories of heavy drinking prerandomization: "T1: frequent heavy drinkers"; "T2: very frequent heavy drinkers"; "T3: nearly daily heavy drinkers"; "T4: daily heavy drinkers"; and "T5: daily heavy drinkers stopping early" before randomization. Trajectory membership was significantly associated with all drinking outcomes. Patients in "T5: daily heavy drinkers stopping early" had comparable drinking outcomes to those in "T1: frequent heavy drinkers," whereas the remaining trajectories were associated with significantly worse outcomes. The baseline trajectory did not interact significantly with the treatment condition. These exploratory analyses confirmed the hypothesis that baseline trajectories predict postrandomization drinking outcomes. Interestingly, "T5: daily heavy drinkers stopping early" had outcomes that were comparable to the least severe baseline trajectory "T1: frequent heavy drinkers," and baseline trajectories of heavy drinking did not moderate the treatment effects.

Identifying provider beliefs related to contingency management adoption using the contingency management beliefs questionnaire

BACKGROUND

Contingency management (CM) is a widely recognized empirically-supported addiction treatment; however, dissemination and adoption of CM into routine clinical practice has been slow. Assessment of beliefs about CM may highlight key barriers and facilitators of adoption and inform dissemination efforts. In the present study, we developed a 35-item questionnaire (contingency management beliefs questionnaire; CMBQ) assessing CM beliefs and examined the relation of these beliefs to clinician characteristics and clinical practices.

METHODS

The web-based study was completed by 617 substance abuse treatment providers. We examined the factor structure using exploratory factor analysis (EFA) in a randomly selected half-sample (n=318) and evaluated the generalizability of the solution using confirmatory factor analysis (CFA) in the second half-sample (n=299).

RESULTS

EFA results suggested a 3-factor solution with 32 items retained; factors represented general barriers, training-related barriers, and pro-CM items. CFA results supported the solution, and reliability was good within each half-sample (α=0.88 and 0.90). Therapeutic approach, years experience in addictions field, perception of CM's research support, prior CM training, and CM adoption interest were significantly associated with the factors.

CONCLUSIONS

Overall, participants viewed CM favorably yet endorsed barriers, indicating a need for more extensive and targeted response to the most common misperceptions in dissemination efforts.

A randomized trial adapting contingency management targets based on initial abstinence status of cocaine-dependent patients

OBJECTIVE

Contingency management (CM) reduces drug use, but questions remain regarding optimal targets and magnitudes of reinforcement. We evaluated the efficacy of CM reinforcing attendance in patients who initiated treatment with cocaine-negative samples, and of higher magnitude abstinence-based CM in patients who began treatment positive.

METHOD

Initially cocaine-negative patients (n = 333) were randomized to standard care (SC), SC + CM reinforcing submission of negative samples with $250 in prizes ($250Abs), or SC + CM reinforcing attendance ($250Att). Initially cocaine-positive patients (n = 109) were randomized to SC, $250Abs, or higher magnitude CM ($560Abs).

RESULTS

For initially cocaine-negative patients, $250Abs and $250Att were equally efficacious to SC in enhancing longest duration of abstinence (LDA); $250Att patients submitted lower proportions of negative samples when missing samples were considered missing, but these patients also attended more study sessions, provided more samples, and submitted a higher proportion of negative samples than SC patients when expected samples were analyzed, ps < .05. In initially cocaine-positive patients, both CM conditions increased proportions of negative samples relative to SC when missing samples were excluded from analyses, but only $560Abs was efficacious in increasing LDA and proportion of negative samples when expected samples were analyzed, ps < .05. Follow-ups revealed no differences among groups, but LDA was consistently associated with abstinence during follow-up, p < .05.

CONCLUSIONS

High magnitude abstinence-based reinforcement improved all abstinence outcomes in patients who began treatment while using cocaine. For patients initiating treatment abstinent, both attendance- and abstinence-based CM resulted in improvements on some measures.

Overview of special sub-section on money management articles: cross-disciplinary perspectives on money management by addicts

BACKGROUND

How addicts manage their funds can be understood from the studies of impulsive spending, contingency management, self-reported expenditures, behavioral economics, and anthropology.

OBJECTIVE

To show how these differing perspectives can provide theoretical explanations for substance abuse, they were applied to the question of when extra "windfall" funds are spent on substances of abuse. Treatment implications of these perspectives were examined.

METHODS

Relevant literature was reviewed.

RESULTS

Behavioral economics and related approaches provide the basis for money-management-based interventions targeting substance abuse, informed configuration of reinforcers to compete with substances, and therapeutically framing the choice between abstinence and substance use.

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

A cross-discipline consideration of how addicts manage their funds has the potential to inform and improve substance abuse treatment.

Re-envisioning Addiction Treatment: A Six-Point Plan

This article is focused on improving the quality of addiction treatment. Based on observations that patients are leaving treatment too early and/or are continuing to use substances during their care, the authors propose six actions that could help reorient and revitalize this kind of clinical work: (1) conceptualize and treat addictive disorders within a psychiatric/mental health framework; (2) make the creation of a strong therapeutic alliance a core part of the healing process; (3) understand patients' addictions and other problems using models based on multiple internal parts, voices, or modes; (4) make contingency management and the use of positive reinforcement systems a standard and central practice in all treatment settings; (5) envision long-term change and healing through the lens of identity theory; and (6) integrate the growing developments in recovery culture with formal treatment.

Monetary-based consequences for drug abstinence: methods of implementation and some considerations about the allocation of finances in substance abusers

Conceptualizing drug abuse within the framework of behavioral theories of choice highlights the relevance of environmental variables in shifting behavior away from drug-related purchases. Choosing to use drugs results in immediate and certain consequences (e.g., drug high and relief from withdrawal), whereas choosing abstinence typically results in delayed, and often uncertain, consequences (e.g., improved health, interpersonal relationships, money).

METHODS

This is a selective review of the literature on Contingency management (CM).

RESULTS

We highlight a variety of methods to deliver CM in practical, effective, and sustainable ways. We consider a number of parameters that are critical to the success of monetary-based CM, and the role of the context in influencing CM's effects. To illustrate the broad range of applications of CM, we also review different methods for arranging contingencies to promote abstinence and other relevant behavior. Finally, we discuss some considerations about how drug-dependent individuals allocate their finances in the context of CM interventions.

CONCLUSIONS

Contingency management (CM) increases choice for drug abstinence via the availability of immediate, financial-based gains, contingent on objective evidence of abstinence.

Exercise as an adjunct treatment for opiate agonist treatment: review of the current research and implementation strategies

Opiate dependence is a significant public health concern linked to poor quality of life, comorbid psychiatric disorders, and high costs to society. Current opiate agonist treatments are an effective but limited intervention. Adjunctive interventions could improve and augment opiate agonist treatment outcomes, including drug abstinence, quality of life, and physical health. This article reviews exercise as an adjunctive intervention for opiate agonist treatment, especially in regards to improving mood and overall quality of life, while reducing other substance use. Poor adherence and dropout frequently prevent many individuals from garnering the many physical and mental health benefits of exercise. Strategies for implementing an exercise intervention, including safety considerations, are discussed.

A behavioral economic supplement to brief motivational interventions for college drinking

Basic behavioral and neurobiological research has demonstrated that deficiencies in naturally occurring substance-free rewards are both a cause and a consequence of substance abuse that are due in part to the systematic discounting of delayed substance-free rewards. Existing brief motivational interventions (BMIs) for alcohol abuse do not target this mechanism of change. The goal of this uncontrolled pilot study was to evaluate a behavioral economic Substance-Free Activity Session (SFAS) to traditional alcohol BMIs. Participants were 13 college freshmen who reported two or more heavy drinking episodes (>5/4 drinks in an occasion for men/ women) in the past month. All participants completed a baseline assessment and a BMI that addressed alcohol use. In addition, participants received the SFAS, a 50-min individual session that attempts to increase engagement in constructive alternatives to drinking by enhancing the salience of delayed rewards (academic and career success) and the patterns of behavior (academic and extracurricular engagement) leading to these outcomes. At the 1-month follow-up assessment, participants reported significant reductions in heavy drinking, and moderate to large effect size reductions in weekly drinking and peak blood alcohol levels. The results of this pilot study provide preliminary support for the efficacy of this behavioral economic intervention session as a supplement to traditional alcohol BMIs.

Contingency management for the treatment of antipsychotic-induced weight gain: a randomized controlled pilot study

OBJECTIVE

Weight gain is common for individuals with serious mental illness (SMI) receiving antipsychotic drug therapy. Contingency management (CM) is a behavioral intervention that rewards positive performance and has demonstrated effectiveness in reducing drug use in SMI populations. This study evaluated the feasibility of using CM to promote weight loss in individuals with SMI over 8 weeks.

METHOD

30 individuals (BMI ≥ 28 kg/m(2)) were randomized to one of three conditions: i) The combination of a standardized lifestyle modification (LM) program for individuals with SMI and payment for group attendance (CM(attendance)), ii) The combination of LM and payment for weight loss (CM(weight)), and iii) waitlist control (CON). After the waitlist period, those participants joined a LM group and received payment for behavioral change (CM(behavior)).

RESULTS

Subjects in the CM(attendance) and in the CM(weight) group lost a mean of 1.16 kg and 1.23 kg, respectively, while subjects in the CON gained a mean of 0.68 kg. Subjects receiving CM(behavior), lost a mean of 2.54 kg, which was a significant weight loss compared to the control period.

CONCLUSION

LM supplemented with CM may facilitate weight loss in patients taking antipsychotic medications; financial reimbursement for behavioral change may be particularly effective in this population.

Adaptability of contingency management in justice settings: survey findings on attitudes toward using rewards

Contingency management (CM) is widely recognized as an evidence-based practice, but it is not widely used in either treatment settings or justice settings. CM is perceived as adaptable in justice settings given the natural inclination to use contingencies to improve compliance to desired behaviors. In the Justice Steps implementation study, 5 federal district court jurisdictions agreed to consider implementing CM in specialized problem-solving courts or probation settings. A baseline survey (N = 186) examined the acceptance and feasibility of using rewards as a tool to manage offender compliance. The results of the survey revealed that most of the respondents believe that rewards are acceptable, with little difference between social and material rewards. Survey findings also showed that female justice workers and those who were not probation officers were more accepting of material rewards than their counterparts. Findings are consistent with prior research in drug treatment settings where there is little concern about using rewards.

Attrition in web-based treatment for problem drinkers

Background

Web-based interventions for problem drinking are effective but characterized by high rates of attrition. There is a need to better understand attrition rates in order to improve the completion rates and the success of Web-based treatment programs.

Objective

The objectives of our study were to (1) examine attrition prevalence and pretreatment predictors of attrition in a sample of open-access users of a Web-based program for problem drinkers, and (2) to further explore attrition data from our randomized controlled trial (RCT) of the Web-based program.

Methods

Attrition data from two groups of Dutch-speaking problem drinkers were collected: (1) open-access participants enrolled in the program in 2009 (n = 885), and (2) RCT participants (n = 156). Participants were classified as noncompleters if they did not complete all 12 treatment sessions (9 assignments and 3 assessments). In both samples we assessed prevalence of attrition and pretreatment predictors of treatment completion. Logistic regression analysis was used to explore predictors of treatment completion. In the RCT sample, we additionally measured reasons for noncompletion and participants’ suggestions to enhance treatment adherence. The qualitative data were analyzed using thematic analysis.

Results

The open-access and RCT group differed significantly in the percentage of treatment completers (273/780, 35.0% vs 65/144, 45%, χ²₁ = 5.4, P = .02). Logistic regression analysis revealed a significant contribution of treatment readiness, gender, education level, age, baseline alcohol consumption, and readiness to change to predict treatment completion. The key reasons for noncompletion were personal reasons, dissatisfaction with the intervention, and satisfaction with their own improvement. The main suggestions for boosting strategies involved email notification and more flexibility in the intervention.

Conclusions

The challenge of Web-based alcohol treatment programs no longer seems to be their effectiveness but keeping participants involved until the end of the treatment program. Further research should investigate whether the suggested strategies to improve adherence decrease attrition rates in Web-based interventions. If we can succeed in improving attrition rates, the success of Web-based alcohol interventions will also improve and, as a consequence, their public health impact will increase.

Trial

International Standard Randomized Controlled Trial Number (ISRCTN): 39104853; http://www.controlled-trials.com/ISRCTN39104853 (Archived by WebCite at http://www.webcitation.org/63IKDul1T)

Amount of earnings during prize contingency management treatment is associated with posttreatment abstinence outcomes

Contingency management (CM) treatments that provide patients with the opportunity to earn chances of winning prizes of varying magnitudes are becoming increasingly popular. In the CM literature, magnitude of reinforcement is linked with effect sizes, such that CM treatments that provide larger magnitude reinforcement are more efficacious than those that provide lower magnitude reinforcement. With prize CM, even when magnitudes of overall expected prize earnings are constant, some patients win more prizes than others. Thus, patients who win larger overall amounts of prizes during treatment may have better outcomes than those who win fewer prizes. This study evaluated the impact of overall amounts of prizes won on long-term abstinence outcomes. The dollar amount of prizes won during prize CM treatments was determined from 78 cocaine-abusing methadone-maintenance patients who were randomized to prize CM treatments in three clinical trials. Abstinence three months following the end of the CM intervention was the primary dependent variable. The dollar amount of prizes won during CM treatment was a significant predictor of submission of cocaine-negative urine samples and self-reports of cocaine abstinence at the follow-up evaluation, even after controlling for other variables associated with long-term abstinence, such as pretreatment urinalysis results and longest duration of abstinence achieved during treatment. These results suggest that magnitudes of earnings during prize CM may impact outcomes and call for further experimentation of parameters related to the efficacy of prize CM.

The impact of contingency management on quality of life among cocaine abusers with and without alcohol dependence

The use of quality of life (QOL) measures in substance abuse treatment research is important because it may lead to a broader understanding of patients' health status and effects of interventions. Despite the high rates of comorbid cocaine and alcohol use disorders, little is known about the QOL of this population, and even less about the impact of an efficacious behavioral treatment, contingency management (CM), on QOL. In this study, data from three clinical trials were retrospectively analyzed to examine QOL in outpatient cocaine abusers with and without alcohol dependence (AD) and the impact of CM on QOL over time as a function of AD status. Patients were randomized to standard care (n = 115) or standard care plus CM (n = 278) for 12 weeks. QOL was assessed at baseline and Months 1, 3, 6, and 9. At treatment initiation, AD patients had lower QOL total scores and they scored lower on several subscale scores than those without AD. CM treatment was associated with improvement in QOL regardless of AD status. These data suggest that CM produces benefits that go beyond substance abuse outcomes, and they support the use of QOL indexes to capture information related to treatment outcomes. 

Contingency management for alcohol use reduction: a pilot study using a transdermal alcohol sensor

BACKGROUND

Contingency management (CM) has not been thoroughly evaluated as a treatment for alcohol abuse or dependence, in part because verification of alcohol use reduction requires frequent in-person breath tests. Transdermal alcohol sensors detect alcohol regularly throughout the day, providing remote monitoring and allowing for rapid reinforcement of reductions in use.

METHODS

The purpose of this study was to evaluate the efficacy of CM for reduction in alcohol use, using a transdermal alcohol sensor to provide a continuous measure of alcohol use. Participants were 13 heavy drinking adults who wore the Secure Continuous Remote Alcohol Monitoring (SCRAM) bracelet for three weeks and provided reports of alcohol and drug use using daily web-based surveys. In Week 1, participants were asked to drink as usual; in Weeks 2 and 3, they were reinforced on an escalating schedule with values ranging from $5 to $17 per day on days when alcohol use was not reported or detected by the SCRAM.

RESULTS

Self-reports of percent days abstinent and drinks per week, and transdermal measures of average and peak transdermal alcohol concentration and area under the curve declined significantly in Weeks 2-3. A nonsignificant but large effect size for reduction in days of tobacco use also was found. An adjustment to the SCRAM criteria for detecting alcohol use provided an accurate but less conservative method for use with non-mandated clients.

CONCLUSION

Results support the efficacy of CM for alcohol use reductions and the feasibility of using transdermal monitoring of alcohol use for clinical purposes.

Parent training plus contingency management for substance abusing families: a Complier Average Causal Effects (CACE) analysis

BACKGROUND

Children of substance abusers are at risk for behavioral/emotional problems. To improve outcomes for these children, we developed and tested an intervention that integrated a novel contingency management (CM) program designed to enhance compliance with an empirically-validated parent training curriculum. CM provided incentives for daily monitoring of parenting and child behavior, completion of home practice assignments, and session attendance.

METHODS

Forty-seven mothers with substance abuse or dependence were randomly assigned to parent training+incentives (PTI) or parent training without incentives (PT). Children were 55% male, ages 2-7 years.

RESULTS

Homework completion and session attendance did not differ between PTI and PT mothers, but PTI mothers had higher rates of daily monitoring. PTI children had larger reductions in child externalizing problems in all models. Complier Average Causal Effects (CACE) analyses showed additional significant effects of PTI on child internalizing problems, parent problems and parenting. These effects were not significant in standard Intent-to-Treat analyses.

CONCLUSION

Results suggest our incentive program may offer a method for boosting outcomes.

Using a NIATx based local learning collaborative for performance improvement

Local governments play an important role in improving substance abuse and mental health services. The structure of the local learning collaborative requires careful attention to old relationships and challenges local governmental leaders to help move participants from a competitive to collaborative environment. This study describes one county's experience applying the NIATx process improvement model via a local learning collaborative. Local substance abuse and mental health agencies participated in two local learning collaboratives designed to improve client retention in substance abuse treatment and client access to mental health services. Results of changes implemented at the provider level on access and retention are outlined. The process of implementing evidence-based practices by using the Plan-Do-Study-Act rapid-cycle change is a powerful combination for change at the local level. Key lessons include: creating a clear plan and shared vision, recognizing that one size does not fit all, using data can help fuel participant engagement, a long collaborative may benefit from breaking it into smaller segments, and paying providers to offset costs of participation enhances their engagement. The experience gained in Onondaga County, New York, offers insights that serve as a foundation for using the local learning collaborative in other community-based organizations.

Design considerations for a study to evaluate the impact of smoking cessation treatment on stimulant use outcomes in stimulant-dependent individuals

Cigarette smoking is prevalent in cocaine/methamphetamine-dependent patients and associated with significant morbidity and mortality, yet, the provision of smoking cessation treatment in conjunction with substance use disorder (SUD) treatment is not standard practice. This is due, in part, to clinician concern that combining smoking cessation treatment with SUD treatment could lead to poorer SUD outcomes. The NIDA Clinical Trials Network is conducting a 10-week, two-group, randomized trial to evaluate the impact of providing smoking cessation treatment (SCT) with SUD treatment as usual (TAU), compared to TAU alone, in smokers who are in outpatient treatment for cocaine or methamphetamine dependence. Approximately 528 participants, recruited from 12 community treatment programs, will be randomized into the trial. The present paper describes key design decisions made during protocol development. The trial is designed to evaluate the relationship between cigarette smoking and stimulant use, which prior research suggests is linked, and should contribute to our understanding of how best to address the co-occurring problems of nicotine dependence and cocaine/methamphetamine-dependence. Unique aspects of the trial include the primary question of interest, which concerns the impact of providing SCT on SUD outcomes rather than on smoking outcomes, and the intensity of the SCT chosen, which includes bupropion, nicotine replacement, and two psychosocial interventions.

Compensation effects on clinical trial data collection in opioid-dependent young adults

BACKGROUND

Attrition in studies of substance use disorder treatment is problematic, potentially introducing bias into data analysis.

OBJECTIVES

This study aimed to determine the effect of participant compensation amounts on rates of missing data and observed rates of drug use.

METHODS

We performed a secondary analysis of a clinical trial of buprenorphine/naloxone among 152 treatment-seeking opioid-dependent subjects aged 15-21 during participation in a randomized trial. Subjects were randomized to a 2-week detoxification with buprenorphine/naloxone (DETOX; N = 78) or 12 weeks buprenorphine/naloxone (BUP; N = 74). Participants were compensated $5 for weekly urine drug screens and self-reported drug use information and $75 for more extensive assessments at weeks 4, 8, and 12.

RESULTS

Though BUP assignment decreased the likelihood of missing data, there were significantly less missing data at 4, 8, and 12 weeks than other weeks, and the effect of compensation on the probability of urine screens being positive was more pronounced in DETOX subjects.

CONCLUSION

These findings suggest that variations in the amount of compensation for completing assessments can differentially affect outcome measurements, depending on treatment group assignment.

SCIENTIFIC SIGNIFICANCE

Adequate financial compensation may minimize bias when treatment condition is associated with differential dropout and may be a cost-effective way to reduce attrition. Moreover, active users may be more likely than non-active users to drop out if compensation is inadequate, especially in control groups or in groups who are not receiving active treatment.

Concurrent alcohol dependence among methadone-maintained cocaine abusers is associated with greater abstinence

Concurrent alcohol dependence (AD) among polysubstance abusers has been associated with negative consequences, although it may not necessarily lead to poor treatment outcomes. One of the most efficacious treatments for cocaine abuse is contingency management (CM), but little research has explored the impact of AD on abstinence outcomes, particularly among patients in methadone maintenance. Using data from three trials of CM for cocaine use, we compared baseline characteristics and posttreatment and follow-up cocaine outcomes between methadone-maintained, cocaine-dependent patients (N = 193) with and without concurrent AD, randomized to standard care (SC) with or without CM. Patients with and without concurrent AD had similar baseline characteristics, with the exception that AD patients reported more alcohol use. AD patients achieved longer durations of cocaine abstinence and were more likely to submit a cocaine-negative sample at follow-up than non-AD patients. Patients randomized to CM achieved better outcomes than those randomized to SC, but there was no interaction between treatment condition and AD status. These findings suggest that cocaine-using methadone patients with AD achieve greater cocaine abstinence than their non-AD counterparts and should not necessarily be viewed as more difficult to treat.

Behavioral vaccines and evidence-based kernels: nonpharmaceutical approaches for the prevention of mental, emotional, and behavioral disorders

In the United States the rates for some mental, emotional, and behavioral problems (MEBs) have objectively increased over the past 20 to 50 years. The attributes of a public health approach to the treatment of MEBs are defined in this article. Multiple examples of how public health approaches might reduce or prevent MEBs using low-cost evidence-based kernels, which are fundamental units of behavior, are discussed. Such kernels can be used repeatedly, which then act as "behavioral vaccines" to reduce morbidity or mortality and/or improve human wellbeing. The author calls for 6 key policy actions to improve MEBs in young people.

Contingency management in the 21st century: technological innovations to promote smoking cessation

Information technology represents an excellent medium to deliver contingencies of reinforcement to change behavior. Recently, we have linked the Internet with a science-based, behavioral treatment for cigarette smoking: abstinence reinforcement therapy. Under abstinence reinforcement interventions, incentives are provided for objective evidence of abstinence. Several studies suggest that the intervention is effective in initiating abstinence. The intervention addresses limitations (access, cost, sustainability, and dissemination potential) inherent in traditional abstinence reinforcement delivery models. It can also be applied to vulnerable, at-risk populations, and to other behavior to promote health. Information technologies offer unprecedented and rapidly expanding opportunities to facilitate behavior change.

Diffusion of contingency management and attitudes regarding its effectiveness and acceptability

Substance abuse counselors are critical as the key arbiters of clients' acceptance and use of innovative treatment techniques, with their potential support embedded in their knowledge of and attitudes towards particular innovations. In this analysis the authors examine the role of substance abuse counselors in the adoption of a psychosocial treatment innovation, contingency management (CM). Using data collected from 1140 counselors employed in a national sample of 318 public treatment centers, the authors examine theoretical predictors of counselors' knowledge of CM, and their attitudes regarding CM's effectiveness and acceptability. Findings suggest that lack of exposure to CM through program use and innovation-specific training is the most salient barrier to CM adoption and diffusion. The study also highlights the importance of social networks in the diffusion and acceptance of treatment innovations.

Contingency management treatments: controversies and challenges

While ideology, politics, and economics will impact the eventual expansion or failure to implement contingency management in countries around the world, the scientific data clearly indicate that this is an intervention worthy of continued investment.

Cognitive behavioral therapy for substance use disorders

Cognitive behavioral therapy (CBT) for substance use disorders has shown efficacy as a monotherapy and as part of combination treatment strategies. This article provides a review of the evidence supporting the use of CBT, clinical elements of its application, novel treatment strategies for improving treatment response, and dissemination efforts. Although CBT for substance abuse is characterized by heterogeneous treatment elements such as operant learning strategies, cognitive and motivational elements, and skills-building interventions, across protocols several core elements emerge that focus on overcoming the powerfully reinforcing effects of psychoactive substances. These elements, and support for their efficacy, are discussed.

Prize-based contingency management is efficacious in cocaine-abusing patients with and without recent gambling participation

Prize-based contingency management (CM) is efficacious in treating cocaine abuse, and the chance-based procedures of prize CM may be appealing to those who gamble. Using data from three randomized trials, we evaluated whether cocaine-abusing patients who had wagered in the month before treatment (n = 62) responded more favorably to prize CM than those who had not (n = 278). Participants were randomized to standard care (SC) or SC plus prize CM. Although prize CM was related to better outcomes overall, recent gambling was not associated with outcomes across or within treatment conditions. Gambling participation before treatment entry was associated with reductions in gambling over time, and this effect was more pronounced among those assigned to CM. These data suggest that prize CM is equally efficacious for substance-abusing patients who do and do not gamble, and they extend prior studies indicating that prize CM does not increase gambling.

Using a novel alternative to drug choice in a human laboratory model of a cocaine binge: a game of chance

Human laboratory studies have shown that, once initiated, cocaine self-administration is difficult to disrupt using non-drug alternatives. This inpatient study examined whether binge self-administration of cocaine could be altered by an immediate, non-drug reinforcer. Ten cocaine-dependent participants completed 5 consecutive laboratory session days with 2 sessions per day (a model binge), 9 days where cocaine was not available, and subsequent 2 laboratory session days where cocaine was again available (a second model binge). In each laboratory session, participants could choose to either self-administer smoked cocaine or play a game of chance by drawing a pre-determined number of balls from a bingo wheel. Balls were worth monetary amounts from $0 to $20. Participants' choice to smoke cocaine varied as a function of number of balls drawn. Thus, this game of chance served as an alternative reinforcer to smoking cocaine. Choice varied lawfully as a function of the number of opportunities to earn money indicating that an immediate behavioral alternative can reduce cocaine self-administration after initiation of use. The current model could be used to evaluate whether behavioral and pharmacological manipulations shift choice from cocaine to a non-drug alternative.

Contingency Management Approaches for Adolescent Substance Use Disorders

The addition of contingency management (CM) to the menu of effective treatments for adolescent substance abuse has generated excitement in the research and treatment communities. CM interventions are based on extensive basic science and clinical research evidence demonstrating that drug use is sensitive to systematically applied consequences. This article provides (a) a review of basic CM principles, (b) implementation guidelines, (c) a review of the clinical CM research targeting adolescent substance abuse, and (d) a discussion of implementation successes and challenges. Although the research base for CM with adolescents is in its infancy, there are multiple reasons for high expectations.

Partnerships and pathways of dissemination: the National Institute on Drug Abuse-Substance Abuse and Mental Health Services Administration Blending Initiative in the Clinical Trials Network

Since 2001, the National Drug Abuse Treatment Clinical Trials Network (CTN) has worked to put the results of its trials into the hands of community treatment programs, in large part through its participation in the National Institute on Drug Abuse-Substance Abuse and Mental Health Services Administration Blending Initiative and its close involvement with the Center for Substance Abuse Treatment's Addiction Technology Transfer Centers. This article describes (a) the CTN's integral role in the Blending Initiative, (b) key partnerships and dissemination pathways through which the results of CTN trials are developed into blending products and then transferred to community treatment programs, and (c) three blending initiatives involving buprenorphine, motivational incentives, and motivational interviewing. The Blending Initiative has resulted in high utilization of its products, preparation of more than 200 regional trainers, widespread training of service providers in most U.S. States, Puerto Rico, and the U.S. Virgin Islands and movement toward the development of Web-based implementation supports and technical assistance. Implications for future directions of the Blending Initiative and opportunities for research are discussed.

The first decade of the National Drug Abuse Treatment Clinical Trials Network: bridging the gap between research and practice to improve drug abuse treatment

The National Institute on Drug Abuse established the National Drug Abuse Treatment Clinical Trials Network (CTN) in 1999 to improve the quality of addiction treatment using science as the vehicle. The network brings providers from community-based drug abuse treatment programs and scientists from university-based research centers together in an alliance that fosters bidirectional communication and collaboration. Collaboration enhanced the relevance of research to practice and facilitated the development and implementation of evidence-based treatments in community practice settings. The CTN's 20 completed trials tested pharmacological, behavioral, and integrated treatment interventions for adolescents and adults; more than 11,000 individuals participated in the trials. This article reviews the rationale for the CTN, describes the translation of its guiding principles into research endeavors, and anticipates the future evolution of clinical research within the Network.

Motivational incentives research in the National Drug Abuse Treatment Clinical Trials Network

The purpose of this article is to review both main findings and secondary analyses from studies of abstinence incentives conducted in the National Drug Abuse Treatment Clinical Trials Network (CTN). Previous research has supported the efficacy of tangible incentives provided contingent on evidence of recent drug abstinence. CTN conducted the first multisite effectiveness trial of this novel intervention. Study participants were stimulant abusers (N = 803) participating in treatment at 14 clinical sites and randomly assigned to treatment as usual with or without a prize draw incentive program. Study participants could earn up to $400 over 3 months for submission of drug-free urine and breath (BAL) specimens. Three-month retention was significantly improved by incentives offered to psychosocial counseling clients (50% incentive vs. 35% control retained), whereas ongoing stimulant drug use was significantly reduced in methadone maintenance clients (54.4% incentive vs. 38.7% control samples testing stimulant-negative). In both settings, duration of continuous abstinence achieved was improved in the incentive condition. These studies support effectiveness of one abstinence incentive intervention and highlight the different outcomes that can be expected with application in methadone maintenance versus psychosocial counseling treatment settings. Secondary analyses have shown the importance of early treatment positive versus negative urine screens in moderating the outcome of abstinence incentives and have explored both safety and cost-effectiveness of the intervention. Implications for the use of motivational incentive methods in clinical practice are discussed.

Psychometric properties of the contingency management competence scale

Contingency management (CM) is an evidence-based treatment, and clinicians are beginning to implement this intervention in practice. However, little research exists on methods for assuring appropriate implementation of CM. This study describes the development and psychometric properties of the 12-item CM Competence Scale (CMCS). Thirty-five therapists from nine community-based clinics participated; following a training period, a randomized trial evaluated the efficacy of CM in cocaine abusing patients. Analyses of the CMCS are based on ratings from 1613 audiotapes of therapist interactions with 78 patients enrolled in the training phase and 103 patients in the randomized phase. Inter-rater reliability from 11 raters and internal consistency of items on the CMCS was good to excellent. Items loaded onto two factors: one contained items specific to discussions of the outcomes of urine testing and reinforcement, and the other contained general items related to use of praise, communication of confidence, empathy, skillfulness, and maintaining session structure, as well as discussions of self-reports of drug use when they occurred. During the training phase in CM delivery, scores on the CMCS rose significantly between earlier and later training sessions, and during the randomized phase, CM sessions were rated more highly than non-CM sessions. Scores on the subscale assessing general items were significantly correlated with indices of the therapeutic alliance and predictive of durations of cocaine abstinence achieved. These data suggest that the CMCS is reliable and valid in assessing delivery of CM and that competence in CM delivery is associated with improved patient outcomes.

A review of exercise as intervention for sedentary hazardous drinking college students: rationale and issues

College students have high rates of alcohol problems despite a number of intervention initiatives designed to reduce alcohol use. Substance use, including heavy drinking, often occurs at the expense of other, substance-free, activities. This review examines the promotion of one specific substance-free activity-exercise-as an intervention for hazardous drinking. Exercise has numerous physical and mental health benefits, and data suggest that students who engage in exercise regularly are less likely to drink heavily. However, the adherence to exercise necessary to achieve these benefits and possibly reduce drinking is poor, and improved exercise adherence interventions are needed. A novel combination of motivational enhancement therapy and contingency management is discussed as a means to address the critical issue of exercise adherence.

Group-based randomized trial of contingencies for health and abstinence in HIV patients

OBJECTIVE

Contingency management (CM) treatments are usually applied individually for drug abstinence, but CM can also be targeted toward health behaviors and implemented in groups. This study evaluated effects of a group-based CM intervention that focused on reinforcing health behaviors.

METHOD

HIV-positive patients with cocaine or opioid use disorders (n = 170) were randomized to weekly CM or 12-step (TS) groups for 24 weeks (mean attendance was 10.8 +/- 8.1 sessions for CM participants and 9.0 +/- 6.9 session for TS participants). During the treatment period, both groups received compensation for attendance ($10 per session) and submission of urine samples (about $2 per sample). In addition, participants received $25 for submitting samples and completing evaluations at Months 1, 3, 6, 9, and 12; 65-75 of the 81 participants assigned to TS and 71-80 of the 89 participants assigned to CM completed these evaluations. During the treatment period, patients in the CM group received chances to win prizes contingent upon completing health activities and submitting substance-free specimens (M = $260, SD = $267).

RESULTS

Mean attendance was 10.8 +/- 8.1 sessions for CM participants and 9.0 +/- 6.9 sessions for TS participants. CM participants submitted a significantly greater number of consecutive drug-free specimens than did TS participants (5.2 +/- 6.0 vs. 3.7 +/- 5.6), but proportions of negative samples did not differ between groups during treatment or at follow-up evaluations. From pre- to posttreatment, CM participants showed greater reductions in viral loads and HIV-risk behaviors than did TS participants, but these effects were not maintained throughout the follow-up period.

CONCLUSIONS

These data suggest the efficacy of group-based CM for HIV-positive substance abusers, but more research is needed to extend the long-term benefits.

Craving's place in addiction theory: contributions of the major models

We examine in this paper the unfolding of craving concepts within 18 models that span roughly 60 years (1948-2009). The amassed evidence suggests that craving is an indispensable construct, useful as a research area because it has continued to destabilize patients seeking treatment for substances. The models fall into four categories: the conditioning-based models, the cognitive models, the psychobiological models, and the motivation models. In the conditioning models, craving is assumed to be an automatic, unconscious reaction to a stimulus. In the cognitive models, craving arises from the operation of information processing systems. In the psychobiological models, craving can be explained at least in part by biological factors with an emphasis on motivational components. Finally, in the motivation models, craving is viewed as a component of a larger decision-making framework. It is well accepted that no single model explains craving completely, suggesting that a solid understanding of the phenomenon will only occur with consideration from multiple angles. A reformulated definition of craving is proposed.

A randomized trial of contingency management for adolescent marijuana abuse and dependence

An initial efficacy test of an innovative behavioral outpatient treatment model for adolescents with problematic use of marijuana enrolled 69 adolescents, aged 14-18, and randomly assigned them to one of two treatment conditions. Both conditions received individualized Motivational Enhancement and Cognitive Behavioral Therapy (MET/CBT) and a twice-weekly drug-testing program. The experimental contingency management condition involved a clinic-delivered, abstinence-based incentive program, and weekly behavioral parent training sessions that included a parent-delivered, abstinence-based, substance monitoring contract. The comparison condition included an attendance-based incentive program, and weekly psychoeducational parent sessions. Follow-up assessments were performed at 3, 6, and 9 months post-treatment. The experimental condition showed greater marijuana abstinence during treatment, e.g., 7.6 vs. 5.1 continuous weeks and 50% vs. 18% achieved > or = 10 weeks of abstinence. Improvements were found in parenting and youth psychopathology across treatment conditions, and improvements in negative parenting uniquely predicted post-treatment abstinence. The outcomes observed in the experimental condition are consistent with adult substance-dependence treatment literature, and suggest that integrating CM abstinence-based approaches with other empirically based outpatient interventions provides an alternative and efficacious treatment model for adolescent substance abuse/dependence. Replication and continued development of more potent interventions remain needed to further advance the development of effective substance abuse treatments for adolescents.

Incentives for retention of pregnant substance users: a secondary analysis

Retention of pregnant substance users in treatment is challenging. In a multisite clinical trial, 200 pregnant substance users entering outpatient treatment at one of four programs were randomized to either three individual sessions of Motivational Enhancement Therapy for Pregnant Substance users or three individual sessions normally provided. Retail scrip from $25 to $30 was provided for attendance of research visits but not treatment visits. A post hoc analysis of the non-methadone-maintained participants (n = 175) evaluated the hypotheses that monetary reinforcement for attendance would result in more consecutive, and overall, weeks of attendance of research versus nonincentivized treatment visits. Findings indicate participants were nearly three times as likely to attend 4 consecutive weeks of research visits versus treatment sessions. There was no effect for income while fewer dependents were associated with more consecutive weeks of attendance. Incentives in the $25-to-$30 range may serve to significantly increase attendance and retention.

The Washington Circle continuity of care performance measure: predictive validity with adolescents discharged from residential treatment

This study examined the predictive validity of the Washington Circle (WC) continuity of care after long-term residential treatment performance measure, as well as the impact of assertive continuing care interventions on achieving continuity of care. This measure is a process measure that focuses on timely delivery of a minimal floor of services that are necessary to provide sufficient quality of treatment but should not be construed to be the optimal continuity of care after residential treatment for any specific adolescent. Participants included 342 adolescents who were admitted to long-term residential treatment and randomly assigned to either standard continuing care or an assertive continuing care condition. Overall, results provide initial support for the WC continuity of care after residential treatment performance measure as a useful predictor of 3-month recovery status. In addition, assignment to an assertive continuing care condition was found to significantly increase the likelihood of achieving continuity of care.

Should personality traits be considered when refining substance misuse treatment programs?

The interplay between stable personality characteristics and environmental factors is emphasised in most contemporary approaches to individual differences. This interaction appears to be important in understanding the development of substance use and misuse. Impulsivity related personality traits such as sensation-seeking, novelty seeking, reward-sensitivity and behavioural disinhibition, are strongly linked to adolescent and adult substance use and misuse. The role of anxiety-related traits, in the development of substance misuse is less clear. Nonetheless, anxiety disorders are very common amongst adult substance misusers and almost certainly play a critical role in the maintenance of a substance use disorder and influence treatment effectiveness. The data suggest that personality influences treatment outcomes and yet these individual differences are generally not addressed in treatment. We argue in this review that interventions which are matched to these relevant personality traits may improve treatment outcomes for substance misusers.

Contingency management promotes smoking reductions in residential substance abuse patients

Rates and consequences of cigarette smoking are more severe in substance abusers. In this 12-week pilot study, residential substance abuse treatment patients received standard care for smoking cessation (n=12) or prize contingency management (n=12) for expired carbon monoxide (CO) tests < or =8 ppm and salivary cotinine <10 ng/ml, which are indicative of smoking abstinence. Percentage of negative CO tests and the highest number of consecutive negative CO tests were greater in contingency management compared to standard care.

Contingency management for attendance to group substance abuse treatment administered by clinicians in community clinics

Contingency management (CM) is effective in enhancing retention in therapy. After an 8-week baseline, four community-based substance abuse treatment clinics were exposed in random order to 16 weeks of standard care with CM followed by 16 weeks of standard care without CM or vice versa. In total, 75 outpatients participated. Patients who were enrolled in the clinics when the CM treatment phase was in effect attended a significantly greater percentage of therapy sessions than patients who were enrolled in treatment when CM was not in effect. This study is one of the first to investigate CM in community settings implemented entirely by community clinicians, and results suggest that CM is effective in improving therapy attendance.

Intangibility in intertemporal choice

Since the advent of the discounted utility (DU) model, economists have thought about intertemporal choice in very specific terms. DU assumes that people make explicit trade-offs between costs and benefits occurring at different points in time. While this explicit trade-off perspective is simple and tractable, and has stimulated productive research, it does not provide a very realistic representation of a wide range of the most important intertemporal trade-offs that people face in daily life. If one considers the most important and commonly discussed examples of intertemporal choices, a striking pattern emerges: in almost all cases, early outcomes tend to be concrete (e.g. purchasing this latte), but later outcomes tend to be much less tangible (e.g. the unknown item that could have been purchased later with the money spent on this latte). We propose that people rely on anticipatory emotions as a proxy for intangible outcomes when trade-offs are implicit. This paper reviews neuroeconomic evidence that has begun to elucidate the role of anticipatory emotions in decisions involving intangible outcomes. Although most progress has been made in the domain of spending and saving, we discuss how the existing neuroeconomic research could be extended to other domains where trade-offs are ill defined.

Evidence-based kernels: fundamental units of behavioral influence

This paper describes evidence-based kernels, fundamental units of behavioral influence that appear to underlie effective prevention and treatment for children, adults, and families. A kernel is a behavior-influence procedure shown through experimental analysis to affect a specific behavior and that is indivisible in the sense that removing any of its components would render it inert. Existing evidence shows that a variety of kernels can influence behavior in context, and some evidence suggests that frequent use or sufficient use of some kernels may produce longer lasting behavioral shifts. The analysis of kernels could contribute to an empirically based theory of behavioral influence, augment existing prevention or treatment efforts, facilitate the dissemination of effective prevention and treatment practices, clarify the active ingredients in existing interventions, and contribute to efficiently developing interventions that are more effective. Kernels involve one or more of the following mechanisms of behavior influence: reinforcement, altering antecedents, changing verbal relational responding, or changing physiological states directly. The paper describes 52 of these kernels, and details practical, theoretical, and research implications, including calling for a national database of kernels that influence human behavior.

Contingency management reduces drug-related human immunodeficiency virus risk behaviors in cocaine-abusing methadone patients

AIM

Contingency management (CM) is efficacious in reducing drug use. This study examined whether CM also reduces human immunodeficiency virus (HIV) risk behaviors and if these effects are mediated by longest duration of abstinence achieved during treatment.

DESIGN

Data were analyzed from a subset of participants in a combined data set of three published randomized controlled trials of CM treatments.

SETTING

A community-based methadone maintenance clinic.

PARTICIPANTS

One-hundred and sixty-five cocaine-abusing methadone maintenance patients.

INTERVENTION

Participants received either standard methadone treatment or standard methadone treatment with CM for 3 months.

MEASUREMENTS

The HIV Risk Behavior Scale (HRBS) was administered prior to randomization to a study condition and 3 months after the study treatments ended. The primary objective indicator of drug use was longest duration of cocaine and opioid abstinence achieved during treatment.

FINDINGS

Relative to those assigned to standard care, participants receiving CM significantly decreased overall HIV risk behaviors and injection drug use risk behaviors. CM participants also achieved longer durations of consecutive cocaine and opioid abstinence during treatment. Duration of abstinence achieved mediated the relationship between treatment condition and HRBS difference scores.

CONCLUSIONS

These results suggest that CM treatment reduces HIV drug use risk behaviors in cocaine-abusing methadone maintenance patients.

Increasing retention of African-American women on welfare in outpatient substance user treatment using low-magnitude incentives

Contingency management (CM) has been found to be effective in increasing treatment retention in various outpatient substance user treatment populations; however, the costs of established CM protocols often exceed the financial resources of community-based, nonprofit treatment programs. The results of the present study provide initial evidence that a low-magnitude contingency management protocol can be effective in increasing both treatment attendance and completion rates in a sample of 54 urban, African-American, substance-using women on welfare, without creating undue financial or logistical burden on the treatment agency. The study's limitations and future research are noted.