A comprehensive guide to the application of contingency management procedures in clinical settings

Vouchers versus prizes: contingency management treatment of substance abusers in community settings

Contingency management (CM) interventions usually use vouchers as reinforcers, but a new technique awards chances of winning prizes. This study compares these approaches. In community treatment centers, 142 cocaine- or heroin-dependent outpatients were randomly assigned to standard treatment (ST), ST with vouchers, or ST with prizes for 12 weeks. CM patients remained in treatment longer and achieved greater durations of objectively confirmed abstinence than did ST patients; CM conditions did not differ significantly. Although abstinence at 6- and 9-month follow-ups did not differ by group, the best predictor of abstinence was longest duration of abstinence achieved during treatment. Thus, prize and voucher CM systems are equally efficacious in promoting long durations of abstinence, which in turn are associated with benefits posttreatment.

Contingency Management for Treatment of Substance Abuse

Clinical research trials demonstrate the efficacy of contingency management procedures in treating substance use disorders. Usually, reinforcement, in the form of vouchers exchangeable for retail goods and services, is provided for drug abstinence in patients treated in psychosocial or methadone maintenance clinics. Recently, the types of reinforcers have been adapted to include lower cost alternatives, and reinforcement is being expanded to alter other target behaviors such as attendance at treatment, adherence to treatment goals, and compliance with medication. This chapter provides an overview of the populations and behaviors to which contingency management approaches have been applied. It also reviews design features that appear critical in the successful adaptation of the techniques. In addition, areas for future research are described.

A meta-analysis of voucher-based reinforcement therapy for substance use disorders

AIMS

To systematically investigate the effectiveness of voucher-based reinforcement therapy for the treatment of substance use disorders.

METHODS

Effect sizes and 95% confidence intervals were calculated for studies published between January 1991 and March 2004 that utilized voucher-based reinforcement therapy (VBRT) or related monetary-based incentives to treat substance use disorders (SUDs).

FINDINGS

Thirty studies involved interventions targeting abstinence from drug use using experimental designs where effects on treatment outcome could be attributed to the VBRT intervention. The estimated average effect size (r) for those studies was 0.32 (95% CI 0.26-0.38). Analyses of variables thought to moderate VBRT effect sizes revealed that more immediate voucher delivery and greater monetary value of the voucher were associated with larger effect sizes. Additional studies were identified wherein VBRT was used to target clinic attendance (n = 6) or medication compliance (n = 4). VBRT studies targeting attendance produced average effect sizes of 0.15 (95% CI 0.02-0.28), while those that targeted medication compliance produced an average effect of 0.32 (95% CI 0.15-0.47). No significant moderators were identified for these 10 studies.

CONCLUSIONS

Overall, VBRT generated significantly better outcomes than did control treatments. These results further support the efficacy of VBRT, quantify the magnitude of its effects, identify significant moderators and suggest potential directions for future research.

The impact of enhanced incentives on vocational rehabilitation outcomes for dually diagnosed veterans

This study evaluated the efficacy of adding contingency management techniques to vocational rehabilitation (VR) to improve treatment outcome as measured by entry into competitive employment. Nineteen dually diagnosed veterans who entered VR in the Veterans' Administration's compensated work therapy (CWT) program were randomly assigned to CWT (n = 8) or to CWT with enhanced incentives (n = 11). Over the first 16 weeks of rehabilitation, those in the incentives condition could earn up to dollar 1,006 in cash for meeting two sets of clinical goals: (a) remaining abstinent from drugs and alcohol and (b) taking steps to obtain and maintain a competitive job. Results indicate that relative to participants in the CWT-only group, those in the incentives condition engaged in more job-search activities, were more likely to remain abstinent from drugs and alcohol, were more likely to obtain competitive employment, and earned an average of 68% more in wages. These results suggest that rehabilitation outcomes may be enhanced by restructuring traditional work-for-pay contingencies to include direct financial rewards for meeting clinical goals.

Interventions to increase use of nicotine gum: a randomized, controlled, single-blind trial

Medication noncompliance with smoking cessation pharmacotherapies is a significant problem in both research and clinical settings. This randomized, controlled, single-blind study compared three single-session psychological interventions to increase use of nicotine gum during a 15-day treatment period. A total of 97 adult smokers were randomized to receive standard treatment (ST, n = 31), brief feedback (BF, n = 32) plus ST, or contingency management (CM; i.e., payment for chewing at least 12 pieces/day on 10 of 15 intervention days, n = 34) plus ST and BF. Only the CM condition led to significantly greater average daily gum use (pieces/day: ST, 6.17; BF, 7.81; CM, 10.17 [p values <.05]) and higher rates of compliance (ST, 13.6%; BF, 25.2%; CM, 65.6% [p values <.001]). No differences were observed in smoking abstinence, nicotine withdrawal, or urinary cotinine as a function of treatment. Implications of the present findings are discussed, including application to clinical trials and extension to real-world use of nicotine gum.

Drugs and alcohol: treating and preventing abuse, addiction and their medical consequences

Recent advances in the fields of genetics, molecular biology, behavioral neuropharmacology, and brain imaging have dramatically changed our understanding of the addictive process and why relapse occurs even in the face of catastrophic consequences. Addiction is now recognized as a chronic brain disease that involves complex interactions between repeated exposure to drugs, biological (i.e., genetic and developmental), and environmental (i.e., drug availability, social, and economic variables) factors. Its treatment, therefore, requires, in general, not only a long-term intervention but also a multipronged approach that addresses the psychiatric, medical, legal, and social consequences of addiction. Also, because addiction usually starts in adolescence or early adulthood and is frequently comorbid with mental illness, we need to expand our treatment interventions in this age group both for substance abuse and psychiatric disorders.

A comparison of voucher exchanges between criminal justice involved and noninvolved participants enrolled in voucher-based contingency management drug abuse treatment programs

This report compares requests for goods or services made by participants in two clinical trials of contingency management for the treatment of substance abuse. One trial was for participants involved with the criminal justice system and one was for participants who were not involved with the criminal justice system. In both trials, participants earned vouchers that could be exchanged for goods or services. Results indicated that the criminal justice group used the majority of their vouchers for paying fees or fines related to the criminal justice system while the other group used only a small portion of their vouchers for paying costs related to the criminal justice system. However, when the costs for the criminal justice system are removed, the proportion of vouchers exchanged for various goods and services are similar between the two groups. The results suggest that for those substance abusers involved in the criminal justice system, assistance in paying fines and fees related to their criminal justice system involvement may be a potentially powerful source of reinforcement that could be used in creative treatment strategies.

Incentive program decreases no-shows in nontreatment substance abuse research

This study examined the use of a low-cost incentive program to decrease the rate of unanticipated no-shows in a nontreatment study of the genetics of substance dependence. Low-cost retail items (such as calling cards or gift certificates) were offered contingent on attendance at the first scheduled research appointment. Although the intervention did not result in an increase in the rate of attendance at appointments, it reduced the likelihood of unanticipated no-shows by almost 50%. This reduction was accompanied by a significant increase in advance cancellations. Despite limitations due to the study's A-B design, this research demonstrates that it may be possible to use modest incentives to increase the efficiency of research enrollment and increase service provision for substance abusers.

Motivationally enhanced group counseling for substance users in a soup kitchen: a randomized clinical trial

Soup kitchens tend to serve residentially unstable adults characterized by a high prevalence of substance abuse. In this study, 289 soup kitchen guests who reported drug or alcohol problems were randomly assigned to information and referral (I&R) plus peer advocacy (peers encouraging subjects to participate in other services) (N = 139) or to an experimental 12-session motivational group (three sessions per week for 4 weeks) followed by a 36-session cognitive-behavioral group (three sessions per week for 12 weeks), plus I&R and peer advocacy. Mean age was 42; 82% male; 68% African-American; 81% unstable residence; 14% HIV+. Experimentals were significantly more likely than the controls to have increased their participation in some type of substance abuse intervention during the follow-up period. In addition, experimentals were significantly more likely than controls to have reduced both drinking and heavy drinking at follow-up (there was no difference between groups in reduction of cocaine use). Interaction analysis indicated that the experimental intervention was more effective for participants with higher rather than lower substance abuse severity at baseline. These results support the concept that motivationally enhanced group counseling, provided as a low-threshold outreach intervention, can help to increase participation in formal treatment and 12-step groups and to reduce substance abuse, particularly for those starting with high severity of use.

A combined cognitive and behavioral intervention for cocaine-using methadone clients

Treating cocaine use by opiate-dependent clients in methadone programs is a well-documented challenge. Both behavioral (contingency management) and cognitive (relapse prevention) interventions have shown promise in helping engage these clients in treatment. In this study, the effectiveness of combining contingency management with a cocaine-specific relapse prevention counseling module was examined. Sixty-one cocaine-using methadone clients were randomly assigned to one of four treatment conditions to participate in the eight-week intervention and eight-week follow-up period. Using analysis of variance (ANOVA), differences in cocaine use and treatment retention were examined. Contingency management was significantly related to reductions in cocaine use and the counseling module was positively related to six-month retention rates. Both interventions were associated with positive treatment response but the effects were reflected in different behavioral outcomes.

A comparison of voucher-delivery schedules for the initiation of cocaine abstinence

Studies on the use of shaping procedures to increase rates of cocaine abstinence have produced promising results. This study used a Brief Abstinence Test to examine the impact of reinforcement for initial reductions in cocaine use on a subsequent abstinence reinforcement test. Methadone maintenance patients showing evidence of cocaine use were exposed to two 1-week reinforcement conditions. During the shaping condition, participants could earn $50 vouchers on Wednesday and Friday for meeting quantitative urinalysis criteria and a $100 voucher on the following Monday for meeting the more stringent qualitative criteria. During the terminal condition, only the $100 earning opportunity for meeting the qualitative criteria was provided. Participants were more likely to meet the qualitative reinforcement criteria on Wednesday and Friday in the shaping condition than in the terminal condition. However, contrary to the initial hypothesis, the shaping reinforcement condition did not increase rates of abstinence on the final abstinence test.

Something of value: the introduction of contingency management interventions into the New York City Health and Hospital Addiction Treatment Service

This paper explores the impact of the adoption of the contingency management approach by the Chemical Dependency Treatment Services of the New York City Health and Hospitals Corporation (HHC). The utilization of this approach grew out of an alliance between NIDA Clinical Trials Network-affiliated clinicians and researchers and a leadership team at the HHC. Interviews and dialogues with administrators, staff, and patients revealed a shared sense that the use of contingency management had: (1) increased patient motivation for treatment and recovery; (2) facilitated therapeutic progress and goal attainment; (3) improved the attitude and morale of many staff members and administrators; and (4) developed a more collegial and affirming relationship not only between patients and staff, but also among staff members.

Treatment of cocaine dependence and depression

In common with all other classes of substance use disorders, cocaine dependence has been shown to be strongly associated with depression by community and clinical surveys. Diagnosing depression in cocaine abusers can be challenging because it is difficult to distinguish transient symptoms caused by cocaine from enduring depression syndromes. Nonetheless, both "substance-induced" and "independent" depression syndromes require clinical attention, especially when symptoms have been persistent and severe before entering treatment. Use of antidepressant medications for combined cocaine dependence and depression is supported by a preponderance of evidence from 4 randomized clinical trials (RCTs) that prospectively targeted both depression and cocaine dependence and 7 RCTs in which a post hoc analyses demonstrated efficacy in the subgroup of cocaine abusers with comorbid depression. Notably, most negative studies have evaluated SSRIs while positive studies have used agents such as desipramine or buproprion. A substantial clinical trials literature supports the efficacy of behavioral treatments for general populations of cocaine abusers and of patients with depression but few studies have addressed patients with both disorders. Treatment development and research are needed on models of care that truly integrate strategies for addressing both cocaine use and depression. Recent advances have paved the way for a new generation of research. These include validation of efficacious cocaine treatments, improved diagnostic methods, organization of the Clinical Trials Network and development of guidelines for managing methodological challenges posed by high rates of current medication use and polysubstance abuse in treatment entering cocaine abusers.

Abstinence incentive effects in a short-term outpatient detoxification program

Despite being widely available, outpatient detoxification has limited efficacy as a stand-alone treatment. This study examined whether abstinence-contingent incentives would improve outcomes for patients entering outpatient opiate detoxification. Participants (N = 211) received a 100 US dollars voucher on the last day of detoxification either contingent on opiate and cocaine abstinence or noncontingently. Urine samples were collected at intake, on Wednesday, Friday (the last day of detoxification), and the following Monday. Among contingent-voucher participants, 31% were drug-free on Friday compared with 18% of noncontingent controls (Z = 2.4, p < .05). Few (12-13%) participants tested negative on Monday. Results support the ability of vouchers to produce modest improvements in abstinence initiation rates during brief detoxification but suggest that additional interventions are needed to sustain improvements.

Choosing a behavioral therapy platform for pharmacotherapy of substance users

Behavioral therapy platforms have become virtual requirements in pharmacotherapy trials due to their utility in reducing noise variability, preventing differential medication adherence and protocol attrition, enhancing statistical power and addressing ethical issues in placebo-controlled trials. Selecting an appropriate behavioral platform for a particular trial requires study-specific tailoring, taking into account both the stage of development of the medication being evaluated, as well as the specific strengths and weaknesses of a broad array of available empirically supported behavioral therapies and the range of their possible targets (e.g., enhancing medication adherence, preventing attrition, addressing co-morbid problems, fostering abstinence, and targeting specific weaknesses of the pharmacologic agent). Choosing a suitable behavioral platform also requires consideration of the characteristics of the population to be treated, stage of scientific knowledge regarding the medication's effects, appropriate balance of internal and external validity, and consideration of potential ceiling effects. Available manualized behavioral treatments are reviewed, noting their strengths and limitations as behavioral therapy platforms for pharmacotherapy trials and as potential concomitant therapies in clinical practice.

The role of psychosocial treatments in pharmacotherapy for alcoholism

Medication treatment for alcohol use disorders often includes a psychotherapy component. The most appropriate psychotherapy to use may depend upon characteristics of the patient, the medication, the setting, and the experiences of the provider. To date, little empirical research has investigated these issues with respect to outcomes in clinical trials that combine pharmacotherapy and psychotherapy. This paper reviews seven major types of psychotherapy for treatment of alcohol use disorders: brief interventions, motivational enhancement therapy, cognitive-behavioral therapy, cue exposure therapy, behavioral treatments, behavioral marital therapy, and twelve-step therapy. The theoretical basis for and empirical evidence supporting the efficacy of the therapies are reviewed, with an emphasis on studies that provided pharmacotherapy in conjunction with psychotherapy. Directions for future research in this area are also suggested.

A tale of two cities: financing two voucher programs for substance abusers through community donations

Voucher-based reinforcement therapy (VBRT) is an effective drug abuse treatment, but the cost of VBRT rewards has limited its dissemination. Obtaining VBRT incentives through donations may be one way to overcome this barrier. Two direct mail campaigns solicited donations for use in VBRT for pregnant, postpartum, and parenting drug users in Toronto, Ontario, Canada, and in Los Angeles, California. In Toronto, 19% of those contacted over 2 months donated 8,000 dollars (4,000 dollars/month) of goods and services. In Los Angeles, nearly 26% of those contacted over 34 months donated 161,000 dollars (4,472dollars/month) of goods and services. Maintaining voucher programs by soliciting donations is feasible and sustainable. The methods in this article can serve as a guide for successful donation solicitation campaigns. Donations offer an alternative for obtaining VBRT rewards for substance abuse treatment and may increase its dissemination.

Heroin and cocaine abusers have higher discount rates for delayed rewards than alcoholics or non-drug-using controls

AIMS

To test a prediction of the discounting model of impulsiveness that discount rates would be positively associated with addiction. The delay-discount rate refers to the rate of reduction in the present value of a future reward as the delay to that reward increases.

DESIGN AND MEASUREMENTS

We estimated participants' discount rates on the basis of their pattern of choices between smaller immediate rewards ($11-80) and larger, delayed rewards ($25-85; at delays from 1 week to 6 months) in a questionnaire format. Participants had a one-in-six chance of winning a reward that they chose on one randomly selected trial.

PARTICIPANTS AND SETTING

Heroin (n = 27), cocaine (n = 41) and alcohol (n = 33) abusers and non-drug-using controls (n = 44) were recruited from advertisements. They were tested in a drug abuse research clinic at a medical school.

FINDINGS

On average, the cocaine and heroin groups had higher rates than controls (both P < 0.001), but alcoholics did not (P = 0.44). Abstinence was associated with lower rates for heroin abusers (P = 0.03), but not for cocaine or alcohol abusers (both P > 0.50).

CONCLUSIONS

These data suggest that discount rates vary with the preferred drug of abuse, and that high discount rates should be considered in the development of substance abuse prevention and treatment efforts.

Prize reinforcement contingency management for treating cocaine users: how low can we go, and with whom?

AIMS

This study evaluated the efficacy of a low-cost, prize reinforcement contingency management (CM) intervention for reducing cocaine use.

SETTING

Community-based treatment centers.

PARTICIPANTS AND DESIGN

Cocaine-abusing out-patients (n = 120) were assigned randomly to one of three 12-week conditions: standard treatment, standard treatment plus CM with an expected maximum of $80 of reinforcement or standard treatment plus CM with an expected maximum of $240 of reinforcement.

INTERVENTION

In the CM conditions, patients earned the opportunity to win prizes for submitting negative urine samples and completing goal-related activities.

MEASUREMENTS

Drug use was measured at intake and throughout a 3-month treatment period.

FINDINGS

Patients in the $240 CM condition achieved more abstinence than patients in the standard condition. Patients who initiated treatment with positive urinalysis results were most responsive to the CM intervention, with the $240 CM condition engendering the best effects in this subgroup. In contrast, patients who initiated treatment with negative urinalysis results generally remained abstinent during treatment, regardless of treatment assignment. On average, patients in the two CM conditions earned $36 and $68 in prizes.

CONCLUSIONS

This study suggests that prize reinforcement CM may be suitable for community-based settings, and beneficial effects may be magnitude-dependent in more severe patients.

Investigating the use of contingency management in the treatment of cocaine abuse among individuals with schizophrenia: a feasibility study

This small-scale study was conducted to examine the feasibility of using voucher-based reinforcement therapy (VBRT) as a treatment modality for cocaine abuse among individuals with schizophrenia. Cocaine use was reduced in three individuals with a diagnosis of schizophrenia during a VBRT intervention. Interestingly, all of the abstinence occurred during the first half of the intervention. This early period of sobriety may represent a clinically relevant window of opportunity during which intensive psychosocial or social work interventions might have a greater chance for success.

Improving On‐Time Counseling Attendance in a Methadone Treatment Program: A Contingency Management Approach

Two studies were conducted to investigate the effectiveness of contingency management techniques in promoting punctual counseling attendance among methadone maintenance patients. In Study 1, 50 participants were recruited from an inner-city methadone maintenance program. Study 1 used an A-B-A design with baseline, intervention, and return-to-baseline phases. On-time attendance was reinforced during the intervention phase with a voucher that was redeemable for a draw out of a box containing 100 tokens with values varying from 0.00 dollars to 100.00 dollars. Methadone maintenance patients who exhibited poor attendance during baseline showed a significant positive response during the contingency management intervention phase. Study 2 used the same design as Study 1 except that the 52 participants were randomized into reinforcement groups that received either the variable rate of reinforcement as in Study 1 or a fixed value reinforcer of 3.25 dollars. As in Study 1, Poor Attenders significantly improved counseling attendance during the intervention. There were no differences between the variable and fixed reinforcement groups. Overall, results suggest that targeting Poor Attenders with contingency management techniques may be a cost-effective method of improving counseling attendance. Targeting Poor Attenders early in treatment may be especially important for improving treatment outcomes.

Single- versus dual-drug target: effects in a brief abstinence incentive procedure

The number of drugs targeted may have an important influence on the ability of drug abusers to abstain during motivational incentive procedures. The authors investigated outcomes in methadone maintenance patients (n = 58), who had evidence of both opiate and cocaine use, when continuous abstinence from cocaine only (single target) or from both cocaine and heroin (dual target) was required to earn US dollars 200 in voucher incentives over a 4-day period. Study patients were equally likely to initiate and sustain abstinence from cocaine under the single- versus the dual-drug target. They were more likely to initiate opiate abstinence under the dual-target condition, demonstrating sensitivity to reinforcer effects. Results suggest that adding a second drug target does not impede short-term cocaine abstinence initiation.

Reinforcement of counseling attendance and alcohol abstinence in a community-based dual-diagnosis treatment program: A feasibility study

This study evaluated the effectiveness of a community-based contingency management (CM) protocol reinforcing punctual dual-diagnosis group counseling attendance and negative breath alcohol levels. Participants were 20 dual-diagnosis patients. The A-B-A within-subjects reversal design included a 4-week baseline phase (BL), a 12-week CM intervention, and a 4-week return-to-baseline phase (R-BL). Group counseling was provided twice weekly, with breath tests before each session. CM attendance rates were significantly higher (65%+-28%) than BL (45%+-32%, p<.05) and remained elevated in the R-BL phase (68%+-29%). Despite clinical reports of frequent intoxication, during the study all breath test results were negative, regardless of study phase. Thus, no contingency effect on alcohol use could be determined. Results suggest that CM interventions can be effective in increasing attendance in a community treatment program for the dually diagnosed.

Antisocial personality in treatment-seeking cocaine abusers: Psychosocial functioning and HIV risk

Antisocial personality disorder (ASP) is common in substance abusers and may be associated with increased severity of psychosocial problems and risk of HIV infection. This study compared 174 treatment-seeking cocaine abusers with and without ASP on Addiction Severity Index (ASI) scores and the HIV risk behavior scale. Patients with ASP comprised 35% of the sample. These patients evidenced more severe problems than non-ASP patients on alcohol, legal, and psychiatric indices of the ASI. Patients with ASP also reported greater participation in lifetime sexual risk behaviors, including number of casual sexual partners, inconsistent condom use, and frequency of anal sex. This study suggests the importance of screening for ASP when patients initiate treatment. Specific and more intensive treatment may be necessary to improve outcomes in this patient population.

Day treatment for cocaine dependence: incremental utility over outpatient counseling and voucher incentives

Urban, poor, crack cocaine-dependent clients were randomly assigned to outpatient addiction counseling (n=39) or day treatment (n=40). Participants in both conditions received equivalent individual cognitive-behavioral counseling and earned equivalent payment vouchers for providing cocaine-negative urine samples. However, day treatment participants attended significantly more psychoeducational and recreational groups and received two meals per day. Prior to random assignment, more participants expressed a preference for day treatment and participants were more likely to return for an initial appointment following assignment to day treatment. However, no significant between-groups differences in tenure or abstinence were detected during the 3-month course of treatment. These null findings were attributable to an absence of a dose-response effect for the group interventions in the day treatment condition. In addition, there may have been a ceiling effect from the vouchers, which masked the influence of the additional day treatment components.

Cognitive-behavioral therapy plus contingency management for cocaine use: findings during treatment and across 12-month follow-up

Contingency management (CM) rapidly reduces cocaine use, but its effects subside after treatment. Cognitive-behavioral therapy (CBT) produces reductions months after treatment. Combined, the 2 might be complementary. One hundred ninety-three cocaine-using methadone-maintained outpatients were randomly assigned to 12 weeks of group therapy (CBT or a control condition) and voucher availability (CM contingent on cocaine-negative urine or noncontingent). Follow-ups occurred 3, 6, and 12 months posttreatment. Primary outcome was cocaine-negative urine (urinalysis 3 times/week during treatment and once at each follow-up). During treatment, initial effects of CM were dampened by CBT. Posttreatment, there were signs of additive benefits, significant in 3- versus 12-month contrasts. Former CBT participants were also more likely to acknowledge cocaine use and its effects and to report employment.

On beyond urine: clinically useful assessment instruments in the treatment of drug dependence

Although there are a wealth of clinically useful, brief, and low-cost assessment instruments available for use with drug-dependent populations, relatively few are broadly used in clinical practice. With an emphasis on: (1). the multidimensional nature of drug users' problems; and (2). assessments that can be integrated into empirically validated treatments, clinically useful assessments in four general categories (evaluation and diagnosis of drug dependence, identifying concurrent disorders and problems, treatment planning, and evaluation of treatment outcome) are briefly summarized. Progress in the field of drug abuse treatment has been significantly hampered by the failure to adopt, across research and clinical settings, a common set of assessments.

Recent advances in the dissemination of contingency management techniques: clinical and research perspectives

Research studies have demonstrated the efficacy of contingency management procedures in treating substance use disorders. However, these procedures have only recently been adapted to and tested within community-based clinical settings. This article reviews recent advances in the field of contingency management, with attention to dissemination issues. Counselor's reactions to the implementation of these techniques in individual and group treatment modalities are detailed. Suggestions are made for areas in which more research is needed, from both a counselor's and researcher's perspective.

Low-cost contingency management for treating cocaine- and opioid-abusing methadone patients

This study evaluated the efficacy of a low-cost contingency management (CM) procedure in reducing concurrent cocaine and opioid use among methadone patients. Forty-two patients were randomly assigned to 12 weeks of standard treatment or standard treatment plus CM. CM patients eamed the opportunity to draw from a bowl and win prizes ranging from $1 to $ 100 in value for submitting samples negative for cocaine and opioids. Patients in the CM condition achieved longer durations of continuous abstinence than patients in the standard treatment condition, and these effects were maintained throughout a 6-month follow-up period. On average, patients in the CM condition earned $137 of prizes. These data suggest that this prize reinforcement procedure may be suitable for community-based settings.

Contingency management to enhance naltrexone treatment of opioid dependence: a randomized clinical trial of reinforcement magnitude

Fifty-five detoxified opioid-dependent individuals were randomly assigned to 1 of 3 treatments delivered over 12 weeks: standard naltrexone maintenance, standard naltrexone plus low-value contingency management (CM), or standard naltrexone plus high-value CM. Results suggest that (a) assignment to either CM condition was associated with significant reductions in opioid use over time compared with standard naltrexone treatment; (b) contrasts of high- versus low-value reinforcement magnitude were not significant, suggesting no relative benefit of higher over lower value incentives in this population; (c) participants assigned to either CM group reported significant reductions in readiness to change compared with participants assigned to standard naltrexone treatment. These findings suggest that targeted behavioral therapies can play a substantial role in broadening the utility of available pharmacotherapies.

Contingency management in group treatment: a demonstration project in an HIV drop-in center

This study describes a contingency management intervention applied in group treatment. In an HIV drop-in center, groups were held on Tuesdays and Thursdays for 35 weeks. An ABB'CA design was used, in which reinforcers were available in non-A phases. In the initial B phase, reinforcers were available only on Tuesdays, and they switched to Thursdays in the B' and C phases. The reinforcer was a drawing that was associated with the possibility of winning a prize. Reinforcers were provided for attending group and completing steps related to treatment goals. The number of drawings escalated with weeks of consecutive attendance and activity completion in the B phases; in the C phase, a fixed number of draws were provided. Overall, the procedure increased attendance, with an average of 0.7 clients (range 0-4) per session in the initial baseline phase to an average of seven clients (range 2-12) during reinforcement phases. The percentage of activities completed also rose from 25% during baseline to 65% during reinforcement phases. These data suggest the feasibility of a group-based contingency management intervention.

Innovations in treatment for drug abuse: solutions to a public health problem

Illicit drug use is an important public health problem with broad social costs. The low effectiveness of prevention efforts leaves treatment of drug dependence as one of the most powerful means of fighting illicit drug use. Treatment reduces drug use and crime and increases individuals' functioning. However, programs that treat drug dependence have high dropout rates and low completion rates. In addition, some individuals continue to use drugs while in treatment, and relapse is common. Furthermore, only a fraction of those who need treatment receive it. Recently, there have been important innovations that reduce barriers and increase effectiveness of treatment. These innovations include new pharmacological agents, novel counseling strategies, promising ways to motivate, and treatment in new settings. This paper describes standard treatments and recent innovations designed to increase (a) effectiveness of treatment, (b) motivation to seek care, (c) access, (d) retention, and (e) cost-effectiveness. We provide criteria on how these innovations should be evaluated in order to determine which should be adopted, funded, and transferred to existing and future treatment programs.

Reinforcing compliance with non-drug-related activities

Contingency management (CM) procedures, that provide incentives for specific behaviors, are efficacious in treating substance use disorders. Typically, CM interventions reinforce submission of urine specimens negative for the targeted drug(s) of abuse, but other behaviors can be reinforced as well, such as compliance with non-drug-related activities. This article describes 1,059 activities chosen by 46 subjects participating in one of two CM studies. The most frequently chosen activities were related to recreational activities (going to movies, library, or church) and sobriety (attending Alcoholics Anonymous meetings, completing worksheets). Over 95% of subjects participated in at least one of these types of activities, and together they accounted for over 70% of the activities selected. Over half the subjects participated in at least one activity related to employment, health, family, and personal improvement, such as applying for a job, attending a medical appointment, taking their child to an event, or creating weekly to-do lists. A detailed description of activity selection and verification procedures may assist in developing consistent approaches across treatment settings, and future research may evaluate further the efficacy of this contingency management approach in treating substance abusers.