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

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.

Contingency management: utility in the treatment of drug abuse disorders

Contingency management (CM) is a strategy that uses positive reinforcement to improve the clinical outcomes of substance abusers in treatment, especially sustained abstinence from drugs of abuse. Further, CM has been adopted to improve methodology and interpretation of outcomes in clinical trials testing new pharmacotherapies and to improve adherence to efficacious medications in substance abuse patients. Thus, CM has proven to be widely useful as a direct therapeutic intervention and as a tool in treatment development.

On blending practice and research: the search for commonalities in substance abuse treatment

There has been a growing interest in the substance abuse treatment field in bringing together the treatment and research communities. While dialogues about logistical and philosophical issues are important, the development of shared core concepts could potentially be quite helpful in facilitating communication and creating common treatment and research goals. It is the contention of this paper that all psychosocial and, potentially, pharmacological treatments ideally address, in part or in full, three aspects of the self--the capacity to regulate emotional and behavioral expression, the ability to engage in future-oriented, goal-directed behavior, and the development of nonaddict and/or recovery-oriented identities. Examples from the research and treatment literature are provided.

Cultural differences in access to care

As high-profile reviews have appeared and international interest has grown, sophisticated studies of the U.S. population continue to document racial and ethnic disparities in initiation of mental health care and in continuity of care. Many explanations focus on cultural factors: trust and treatment receptiveness, stigma, culturally distinctive beliefs about mental illness and mental health, culturally sanctioned ways of expressing mental health-related suffering and coping styles, and client preferences for alternative interventions and treatment-seeking pathways, as well as unresponsive programs and providers. The research itself has become more rigorous and informative, but it continues to lack theoretical focus and does not yet yield cumulative findings. Too few studies have addressed community and regional differences or differences between mental health treatment programs and systems, or considered mental health-related policies that are very likely linked to disparities. Theoretically well-formulated studies on representative samples can provide a comprehensive explanation of access disparities in cultural and culture-related terms that inform a broad-based plan of remedial intervention.

Cost-effectiveness of prize-based contingency management in methadone maintenance treatment programs

AIM

To determine if prize-based contingency management (CM), which has been shown to improve treatment outcomes over usual care (UC) alone, is cost-effective.

DESIGN

A cost-effectiveness study of a multi-site clinical trial. Data on the outcome measures came from the original effectiveness trial. Cost data were gathered by clinic survey specifically for this cost-effectiveness analysis.

SETTING

Six methadone maintenance community clinics participating in the National Drug Abuse Treatment Clinical Trials Network.

PARTICIPANTS

Participants were recruited from six methadone maintenance community treatment programs. The study sample consisted of 388 participants: 190 in the UC condition and 198 in the CM condition. Participants were randomized at each site to either the UC or the CM condition based on the presence of stimulants (cocaine, amphetamine or methamphetamine) and opioids in their baseline urine sample.

INTERVENTION

Prize-based contingency management added to usual care.

MEASUREMENTS

Longest duration of abstinence (LDA), number of stimulant-negative urine samples and costs of treatment.

FINDINGS

Compared to usual care, the incremental cost of using prize-based CM to lengthen the LDA by 1 week was $141 [95% confidence interval (CI), $105-$193]. The incremental cost to obtain an additional stimulant-negative urine sample was $70 (95% CI, $53-$117).

CONCLUSIONS

By comparing this study to a companion study, we found that adding prize-based CM to usual care may be more cost-effective in methadone maintenance clinics than in counseling-based drug-free clinics.

A perfect platform: combining contingency management with medications for drug abuse

Contingency management (CM) procedures, which provide concrete reinforcers or rewards contingent on verification of discrete targeted behaviors, such as drug-free urines, have been demonstrated to be effective in a number of clinical trials. However, to date there have been only a few that have capitalized on the unique strengths and capabilities of CM as an ideal platform to improve response to or address weaknesses of many pharmacotherapies used in the treatment of drug abuse. In this review, we describe the multiple potential uses of CM as a platform for pharmacotherapy, including reducing illicit drug use in the context of agonist therapies; fostering medication compliance with antagonists, aversive agents and HIV medications; fostering a period of abstinence prior to initiation of agents used to treat comorbid psychiatric conditions or in the context of vaccines to foster adequate periods of abstinence while titer levels are building; and to enhance the effectiveness of anticraving agents through additive or synergistic effects. Although its multiple strengths render it an almost perfect platform, CM does have some weaknesses that have limited its use to date, including cost, the short-term nature of its effects, and need for training. Future treatment development of CM as a medication platform needs to counter these issues by focusing on CM applications with large potential benefit, developing simple or automated methods for CM delivery and placing greater emphasis on the process of transitioning away from formal CM treatment.

Contingency management in cocaine abusers: a dose-effect comparison of goods-based versus cash-based incentives

Goods-based contingency management interventions (e.g., those using vouchers or prizes as incentives) have demonstrated efficacy in reducing cocaine use, but cost has limited dissemination to community clinics. Recent research suggests that development of a cash-based contingency management approach may improve treatment outcomes while reducing operational costs of the intervention. However, the clinical safety of providing cash-based incentives to substance abusers has been a concern. The present 16-week study compared the effects of goods-based versus cash-based incentives worth $0, $25, $50, and $100 on short-term cocaine abstinence in a small sample of cocaine-dependent methadone patients (N = 12). A within-subject design was used; a 9-day washout period separated each of 8 incentive conditions. Higher magnitude ($50 and $100) cash-based incentives (checks) produced greater cocaine abstinence compared with the control ($0) condition, but a magnitude effect was not seen for goods-based incentives (vouchers). A trend was observed for greater rates of abstinence in the cash-based versus goods-based incentives at the $50 and $100 magnitudes. Receipt of $100 checks did not increase subsequent rates of cocaine use above those seen in control conditions. The efficacy and safety data provided in this and other recent studies suggest that use of cash-based incentives deserves consideration for clinical applications of contingency management, but additional confirmation in research using larger samples and more prolonged periods of incentive delivery is needed.

Contingency Management to reduce substance use in individuals who are homeless with co-occurring psychiatric disorders

Homeless shelters provide a unique opportunity to intervene with occupants who have substance abuse problems, as not addressing these issues may lead to continuation of problems playing a contributing role in homelessness. Attempts to implement Contingency Management (CM) with this population have often been complex, costly, and not straightforward to replicate in community settings. We conducted a randomized trial evaluating a simple, low-cost 4-week CM program for 30 individuals seeking shelter in a community-based homeless shelter who had both current substance and psychiatric disorders. Behavioral assessments were performed at baseline, weekly, and termination of the study. Overall retention in the trial was high; participants assigned to CM reduced their cocaine and alcohol use more than those in assessment-only. This pilot trial suggests that application of low-cost CM procedures is feasible within this novel setting and may decrease substance use.

Abstinence rates following behavioral treatments for marijuana dependence

Previous studies have noted particular difficulty in achieving abstinence among those who are marijuana dependent. The present study employed a dismantling design to determine whether adding contingency management (ContM) to motivational enhancement therapy plus cognitive behavioral therapy (MET+CBT), an intervention used in prior studies of treatment for marijuana dependence, would enhance abstinence outcomes. 240 marijuana dependent participants were recruited via advertisements and assigned to either MET+CBT, ContM-only, MET+CBT+ContM, or to a case-management control condition. All interventions involved 9 weekly 1-h sessions, except for the ContM-only condition whose sessions lasted about 15 min. ContM provided reinforcement for marijuana-free urine specimens, in the form of vouchers redeemable for goods or services. Follow-up data were collected at posttreatment and at 3-month intervals for 1 year. The two ContM conditions had superior abstinence outcomes: ContM-only had the highest abstinence rates at posttreatment, and the MET+CBT+ContM combination had the highest rates at later follow-ups. The roles of contingency management and coping skills training in the treatment of marijuana dependence are discussed.

Theory-based active ingredients of effective treatments for substance use disorders

This paper describes four related theories that specify common social processes that protect individuals from developing substance use disorders and may underlie effective psychosocial treatments for these disorders: social control theory, behavioral economics and behavioral choice theory, social learning theory, and stress and coping theory. It then provides an overview of the rationale and evidence for four effective psychosocial treatments for substance use disorders: motivational interviewing and motivational enhancement therapy, 12-step facilitation treatment, cognitive-behavioral treatment and behavioral family counseling, and contingency management and community reinforcement approaches. The presumed active ingredients of these treatments are described in terms of how they exemplify the social processes highlighted by the four theories. The identified common components of effective treatment include support, goal direction, and structure; an emphasis on rewards that compete with substance use, a focus on abstinence-oriented norms and models, and attempts to develop self-efficacy and coping skills. Several issues that need to be addressed to enhance our understanding of the active ingredients involved in effective treatment are discussed, including how to develop measures of these ingredients, how well the ingredients predict outcomes and influence conceptually comparable aspects of clients' life contexts, and how much their influence varies depending upon clients' demographic and personal characteristics.

Therapeutic alliance and treatment progress in couple psychotherapy

This study examined the ability of the therapeutic alliance to predict treatment progress on individual- and relationship-level variables from the early to middle phase of couple treatment. Although alliance did not predict progress in individual functioning, it accounted for 5-22% of the variance in improvement in marital distress. Women's mid-treatment alliance uniquely predicted improvement in marital distress, over and above early treatment alliance. When men's alliances with the therapist were stronger than their partners' at session 8, couples showed more improvement in marital distress. Treatment response was also positively associated with women's ratings of their partners' alliance. Results confirm that the therapeutic alliance in conjoint treatment is composed of distinct client subsystems that are useful predictors of treatment progress.

Relapse and Relapse Prevention

Most psychological disorders and problem behaviors are characterized by very high rates of postremittance relapse. Thus, advances in the long-term efficacy of psychological interventions require understanding the causes and processes of relapse, with the ultimate goal of developing strategies that reduce the probability of relapse. Existing psychological theory and interventions relevant to relapse and relapse prevention (RP) are reviewed, with a focus on addictive behaviors. The past two decades have produced increased attention toward the relapse problem and important advances in the conceptualization of relapse (i.e., as a process rather than a discrete event). Further progress will require the translation of basic theory into applied theory, the development of integrative theories of relapse, and the design and testing of theory-based, multimodal RP interventions.

Contingency management: an evidence-based component of methamphetamine use disorder treatments

AIMS

To review briefly some of the available evidence regarding the utility of contingency management in treating methamphetamine use disorders.

DESIGN

A literature review was conducted to locate relevant studies for the review.

FINDINGS

The review suggests that contingency management is likely to be a useful component of treatment strategies designed to address methamphetamine use disorders. Results suggest that contingency management can increase the likelihood of providing methamphetamine-free urine samples during treatment.

CONCLUSIONS

Evidence suggests that contingency management is a good candidate for inclusion in treatment strategies for methamphetamine addiction.

A pilot double-blind treatment trial of memantine for alcohol dependence

BACKGROUND

There is growing evidence that N-methyl-d-aspartate (NMDA) receptor antagonists may have potential for the treatment of alcohol disorders. Memantine is a selective noncompetitive NMDA receptor antagonist that has been shown to decrease alcohol craving in moderate drinkers. This 16-week double-blind outpatient pilot clinical trial determined if memantine was more effective than placebo at reducing alcohol use in actively drinking alcohol-dependent patients.

METHODS

Forty-four treatment-seeking alcohol-dependent individuals were enrolled, with 34 patients stratified to either the memantine group (n=19; maximum dose of 40 mg/d) or the placebo (PBO; n=15) group. The primary outcome measures were related to alcohol use (average drinks per day, average drinks per drinking day, percentage of heavy drinking days, and percentage of days abstinent) based on the timeline follow-back (TLFB). Secondary outcome measures included the Obsessive Compulsive Drinking Scale, Clinical Global Impression ratings, and gamma-glutamyltransferase (GGT), a biomarker of recent alcohol use. To enhance retention, patients received voucher incentives for clinic attendance.

RESULTS

Of those randomized, approximately 80% (27) completed the entire 16-week trial. Longitudinal analysis of drinks per day and drinks per drinking day showed a significant reduction in alcohol use, but no difference between the 2 groups. Further, the percentage of heavy drinking days indicated that both groups showed a significant decrease in drinking behavior, but there was significant treatment effect in favor of the PBO group. Similarly, for the percentage of days abstinent, the PBO group achieved a significantly greater percentage of days abstinent at a faster rate than the memantine group. Lastly, the memantine group reported a greater number of side effects compared with the PBO group, such that 26% of patients had their drug dose decreased or discontinued due to memantine-related side effects.

CONCLUSIONS

The results of this double-blind placebo-controlled pilot trial do not support the use of memantine for the treatment of actively drinking alcohol-dependent patients. However, voucher incentives did facilitate retention.

Cost-effectiveness of prize-based incentives for stimulant abusers in outpatient psychosocial treatment programs

OBJECTIVE

To evaluate the cost-effectiveness of a prize-based intervention as an addition to usual care for stimulant abusers.

METHODS

This cost-effectiveness analysis is based on a randomized clinical trial implemented within the National Drug Abuse Treatment Clinical Trials Network. The trial was conducted at eight community-based outpatient psychosocial drug abuse treatment clinics. Four hundred and fifteen stimulant abusers were assigned to usual care (N=206) or usual care plus abstinence-based incentives (N=209) for 12 weeks. Participants randomized to the incentive condition earned the chance to draw for prizes for submitting substance negative samples; the number of draws earned increased with continuous abstinence time. Incremental cost-effectiveness ratios were estimated to compare prize-based incentives relative to usual care. The primary patient outcome was longest duration of confirmed stimulant abstinence (LDA). Unit costs were obtained via surveys administered at the eight participating clinics. Resource utilizations and patient outcomes were obtained from the clinical trial. Acceptability curves are presented to illustrate the uncertainty due to the sample and to provide policy relevant information.

RESULTS

The incremental cost to lengthen the LDA by 1 week was 258 US dollars (95% confidence interval, 191-401 US dollars). Sensitivity analyses on several key parameters show that this value ranges from 163 to 269 US dollars.

CONCLUSIONS

Compared with the usual care group, the incentive group had significantly longer LDAs and significantly higher costs.

Innovation adoption in substance abuse treatment: exposure, trialability, and the Clinical Trials Network

Researchers and policymakers are increasingly focusing on factors that facilitate or impede the diffusion of evidence-based treatment techniques into routine clinical practice. One potentially fruitful avenue of research is the influence of involvement in research networks as a predictor of organizational innovation. The Clinical Trials Network (CTN) is examining a number of behavioral and pharmacological treatment techniques in controlled multisite studies. Using data from participating CTN treatment programs and large samples of programs outside the CTN, these analyses examine the influence of exposure to clinical trials on the subsequent adoption of buprenorphine and voucher-based motivational incentives. The analyses show that, controlling for a variety of organizational characteristics, direct exposure to buprenorphine clinical trials in the CTN significantly increased the odds of subsequent adoption. By contrast, the adoption of motivational incentives was entirely explained by organizational characteristics. The findings suggest that adoption of treatment innovations is a function of exposure, organizational resources, nature of innovations, and stage of the diffusion process.

Efficacy of an individualized adherence support program with contingent reinforcement among nonadherent HIV-positive patients: results from a randomized trial

OBJECTIVE

To evaluate the efficacy of a program designed to improve adherence to antiretroviral therapy among patients with poor adherence.

METHODS

A randomized intervention trial was conducted among 90 HIV-positive patients experiencing treatment failure as a result of noncompliance with their medication regimen. Eligible participants were randomly assigned to an adherence case management intervention with monetary reinforcement (CM) or to a standard of care group (SC). The CM participants met regularly with a treatment advocate for individualized adherence support. Efficacy was measured in terms of reductions in viral load and improvements in immune function at weeks 12, 24, and 48.

RESULTS

After 48 weeks, 55% (n=26) of those in the CM achieved at least a 1-log10 drop in viral load as compared to 28% (n=12) in the SC group (P=.0089). Furthermore, the mean CD4 count was 209 cells/mm3 for the CM group as compared to 150 cells/mm3 in the SC group (P=.0333). Based on logistic regression analysis, being in the CM was an independent predictor of reduction in viral load (odds ratio=2.49; P=.0514).

CONCLUSION

The individualized adherence intervention is feasible and effective in reducing viral load and improving immune function.

Adolescent and young adult heroin patients: drug use and success in methadone maintenance treatment

This study examined the impact of methadone maintenance treatment on an inclusive group of adolescent and young adult opiate-dependent patients, ages 15-23, admitted over a 6-year period, during their first year in the program. Retention in treatment was the primary outcome variable, and at 12 months, 48% were still in treatment. The findings were: (a) a stepwise discriminant function analysis revealed that patients who consistently used heroin were at a greater risk of leaving treatment within the first 12 months; (b) the use of cocaine was an indicator of higher levels of heroin use in those who reached the one-year mark; (c) among patients who stayed in treatment for one year, there was a significant reduction in heroin use, a trend toward a reduction in cocaine use, and no significant impact on benzodiazepine use; and (d) the group that stayed in treatment was slightly younger than the group that left before the first year ended. There were no gender or ethnic differences between the two groups. Suggestions for interventions that might improve treatment outcome are presented.

What do we get for our money? Cost-effectiveness of adding contingency management

AIMS

To assess the relative cost-effectiveness of lower versus higher cost prize-based contingency management (CM) treatments for cocaine abuse.

DESIGN

Cost-effectiveness analyses based on resource utilization, unit costs and outcomes from a previous CM efficacy trial.

SETTING

Two community-based treatment centers.

PARTICIPANTS

Patients (n = 120) enrolled in out-patient treatment for cocaine abuse.

INTERVENTION

Random assignment to one of three 12-week treatment conditions: standard treatment (STD) alone or two variants of STD combined with prize based CM. In CM, drawing for prizes was available to those submitting drug-free urine samples and completing goal-related activities. There were two levels of pay-out (referred to as $80 versus $240) based on the potential value of prizes won.

MEASUREMENTS

Costs per participant associated with counseling utilization, urine and breathalyzer testing, and operation of the prize-drawing procedure were derived from a survey conducted at 16 clinics that had participated in CM studies. The three measures of effectiveness were: (1) longest duration of consecutive abstinence; (2) percentage completing treatment; and (3) percentage of samples drug-free.

FINDINGS

The higher magnitude CM produced outcomes at a lower per unit cost than did the lower magnitude prize CM treatment. This was the case for all three outcome measures examined and held across various assumptions in the sensitivity analysis.

CONCLUSIONS

Cost-effectiveness analyses can inform policy decisions regarding selection of one treatment model over another. Decisions on adoption of new evidence-based treatments would be aided by more information on society's willingness to pay for incremental gains in effectiveness.

HAART adherence strategies for methadone clients who are HIV-positive: a treatment manual for implementing contingency management and medication coaching

Research demonstrates that injection drug users with HIV and/or AIDS have difficulty adhering to complex regimens of HIV medications. Because of the risk of increased viral resistance associated with irregular medication adherence, there is considerable clinical need to assist clients who abuse substances in taking their antiretroviral medications on time and as directed. This article outlines intervention strategies to improve medication adherence among clients who are in methadone maintenance. In this treatment manual, the authors delineate contingency management procedures, including voucher incentives and a fishbowl lottery prize system. They also describe intervention elements and adherence tools for medication coaching. The purpose of this manual is to describe the intervention procedures for clinicians and to serve as a resource for drug abuse treatment programs that serve clients who are HIV-positive.

Contingency management interventions for HIV-related behaviors

Contingency management (CM) is a scientifically based treatment approach typically employed in substance abuse treatment settings to reinforce drug abstinence, counseling attendance, completion of activities, or other treatment goals. Although the application of CM to HIV management has few published studies, it shows promise as an intervention for HIV-related behaviors. CM interventions such as voucher reinforcement, prize systems, and cash incentives can be used to reduce HIV risk behaviors and to improve HIV medication adherence. CM programs have wide applicability to HIV prevention and management in clinical and community settings and can be implemented as stand-alone techniques or in combination with other interventions.

Trends in the adoption of medications for alcohol dependence

Increasing attention is being paid to the development and dissemination of effective pharmacotherapies for the treatment of alcohol and other drug dependence. However, numerous structural and philosophical barriers impede the widespread adoption of these treatment approaches in everyday clinical practice. Research is needed to understand and overcome this gap. Drawing upon data collected from 2 large samples of substance abuse treatment providers at multiple time points, this article examines the prevalence and correlates of the adoption of the currently available pharmacotherapies for alcohol dependence: disulfiram, oral naltrexone, and acamprosate. These data suggest that the proportion of treatment programs using pharmacotherapies for alcohol dependence has been declining over time. In addition, the proportion of patients to whom these medications are prescribed is notably low. The adoption of disulfiram and naltrexone is significantly more likely in programs that are accredited, employ at least 1 physician, offer integrated care for patients with co-occurring psychiatric conditions, derive proportionately more revenue from commercial insurance payers, and have fewer linkages with the criminal justice system. Preliminary data suggest that the early adoption of acamprosate is following a similar pattern. Recommendations for addressing challenges to the diffusion of pharmacotherapies for alcohol dependence are presented.

Contingency management for treatment of substance use disorders: a meta-analysis

AIMS

To examine the effectiveness of contingency management (CM) techniques in treating substance use disorders (i.e. illicit drugs, alcohol, tobacco).

DESIGN

Meta-analysis was used to determine the average effect size and potential moderators in 47 comparisons of the effectiveness of CM from studies based on a treatment-control group design and published between 1970 and 2002.

FINDINGS

The mean effect size (ES) of CM was positive, with a magnitude of d = 0.42 using a fixed effects model. The magnitude of the ES declined over time, following treatment. CM was more effective in treating opiate use (d = 0.65) and cocaine use (d = 0.66), compared with tobacco (d = 0.31) or multiple drugs (d = 0.42). Larger effect sizes were associated with higher researcher involvement, earlier studies and shorter treatment duration.

CONCLUSIONS

Study findings suggest that CM is among the more effective approaches to promoting abstinence during the treatment of substance use disorders. CM improves the ability of clients to remain abstinent, thereby allowing them to take fuller advantage of other clinical treatment components.

Contingency management treatments: Reinforcing abstinence versus adherence with goal-related activities

Contingency management (CM) interventions usually reinforce submission of drug-negative specimens, but they can also reinforce adherence with goal-related activities. This study compared the efficacy of the 2 approaches. Substance-abusing outpatients (N = 131) were randomly assigned to 1 of 3 12-week treatments: standard treatment (ST), ST with CM for submitting negative urine toxicology screens, or ST with CM for completing goal-related activities. CM patients remained in treatment longer and achieved more abstinence than ST patients, but the CM condition that reinforced submission of negative samples resulted in better outcomes than the CM condition that reinforced goal-related activities. Abstinence at 6- and 9-month follow-ups did not differ by group, but longest duration of abstinence achieved during treatment was associated with abstinence posttreatment.

Needs and scientific opportunities for research on substance abuse treatment among Hispanic adults

The results of a focused search of the literature on empirical studies of substance abuse treatment outcomes with Hispanic adults are reviewed. Also provided are key research opportunities and recommendations on substance abuse treatment for Hispanics. The paper is divided into two major sections: the first focuses on behavioral drug treatment studies on Hispanic adults, and the second identifies published original articles in pharmacotherapy, namely that more empirical research is needed to determine which treatments are efficacious with Hispanic populations. For treatment modalities not associated with promising effect sizes with Hispanic samples, cultural modifications may be needed to improve the compatibility of the treatment with Hispanic culture. For those treatments found to have promising effect sizes with various Hispanic subgroups, with Hispanics at different levels of acculturation, and with Hispanics from various socioeconomic backgrounds. The authors stress the need for theory-driven interventions to be developed specifically for well-characterized Hispanic subgroups (e.g., suburban middle-income Puerto Ricans living in the Northeast).

Depot naltrexone in lieu of incarceration: a behavioral analysis of coerced treatment for addicted offenders

This article is part of a series of articles examining a proposal to offer depot naltrexone to certain nonviolent opiate-addicted criminal offenders in exchange for release from incarceration or diversion from prosecution. This "negative-reinforcement" behavioral paradigm could have a better chance of success than what has heretofore been attempted with drug-abusing offenders. Traditional correctional efforts have been largely unsuccessful due to the complexities of implementation and the side effects of punishment. Although positive reinforcement can be more efficacious, it has often been strenuously resisted on the ground that it is inequitable to reward antisocial individuals for doing what is minimally expected of most citizens. Negative reinforcement steers between these hurdles by avoiding the iatrogenic effects of punishment, while also being palatable to stakeholders. More research is needed to identify the effects, costs, and side effects of negative-reinforcement arrangements for drug offenders. The current proposal provides an excellent platform for conducting this research because the target intervention (depot naltrexone) is demonstrably efficacious, nonpsychoactive, and has few, if any, side effects. Therefore, use of this medication would be unlikely to invoke the same types of legal and ethical objections that have traditionally been levied against the use of psychoactive medications with vulnerable populations of institutionalized offenders. Specific recommendations are offered for questions that must be addressed in future research studies.

Contingency management treatments

Contingency management is highly efficacious in improving outcomes in substance misuse. Whereas a great deal of research has evaluated these interventions empirically, few treatment providers integrate this approach in practice. The rationale for contingency management is described, with a call for expansion of this technique outside the USA.

Prize-based contingency management does not increase gambling

A contingency management (CM) intervention that provides drug-abstinent patients a chance to win prizes of varying magnitudes is efficacious in retaining patients in treatment and reducing drug use. However, this intervention has been criticized as possibly increasing gambling because it contains an element of chance. Gambling behaviors before, during and 3 months after participation in a multi-site study of CM were compared for stimulant users randomly assigned to 12 weeks of standard care with (N=407) or without (N=396) prize-based CM. Among study participants enrolled in outpatient non-methadone drug abuse treatment (N=415), 26% reported gambling during the observation period, and this rate was 37% among participants (N=388) enrolled in methadone maintenance programs. No differences in gambling over time were noted between those assigned to the prize CM versus standard care conditions, indicating that this prize CM procedure does not adversely impact gambling behavior among stimulant abusers.

The therapy alliance: a moderator in therapy outcome for families dealing with child abuse and neglect

The role of the therapy alliance in therapy outcome for families dealing with child abuse and neglect was examined using the family as the unit of analysis. The alliance was tested as a moderator in relationship to posttreatment levels of symptom distress and physical violence. Results show that the bonds, goals, and tasks subscale scores are significantly related to posttreatment levels of symptom distress and that the goals subscale score is significantly related to posttreatment level of violence. There is an interaction between bonds and level of violence at intake, suggesting that the greater the level of violence at intake, the more important the bonds domain.

Use of a low-cost incentive intervention to improve counseling attendance among methadone-maintained patients

Despite the importance of counseling in methadone maintenance treatment, many patients do not take advantage of these services. Incentives for attending group counseling were offered to methadone-maintained patients during an orientation phase of treatment or during required attendance at a relapse group later in treatment. Upon attending each counseling session, patients could draw for prizes under an escalating draw system with a 50% probability that draws would result in a prize. Incentives included small (1dollar), moderate (5 dollars), and large (20 dollars) prizes, with chances of winning inversely related to prize costs, and a maximum possible total of 160 dollars per patient. It was anticipated that this policy would provide a relatively low-cost approach to improving counseling attendance in our methadone clinic. The incentive policy significantly increased the percent of counseling sessions attended (52% vs. 76%) and promoted periods of continuous attendance. These data further support the effectiveness of low-cost incentive programs in enhancing counseling attendance among methadone patients.

A comparison between low-magnitude voucher and buprenorphine medication contingencies in promoting abstinence from opioids and cocaine

This study compared the relative efficacy of low-magnitude, contingent monetary vouchers, contingent buprenorphine medication, and standard counseling in promoting abstinence from illicit opioids and cocaine among opioid-dependent adults. Following an 8-week baseline period during which participants received buprenorphine maintenance treatment with no contingencies in place, 60 participants were randomly assigned to one of 3 treatment groups for 12 weeks: (a) Participants in the voucher group earned vouchers for each opioid- and cocaine-negative urine sample, in accordance with an escalating schedule. Continuous abstinence resulted in voucher earnings equivalent to a total of 269 US dollars, which participants could exchange for material reinforcers of their choice. (b) Participants in the medication contingency group received half their scheduled buprenorphine dose for clinic attendance and the other half for remaining abstinent from opiates and cocaine. Thus, they received only half of their scheduled dose on submission of an opioid- and/or cocaine-positive urine sample. (c) Participants in standard treatment did not receive programmed consequences contingent on urinalysis results. All participants were maintained with buprenorphine according to a 3-times-per-week dosing regimen and participated in behavioral drug counseling. Retention rate did not significantly differ across the groups; however, participants in the medication contingency group achieved significantly more weeks of continuous abstinence from opiates and cocaine compared with participants in the voucher group (Ms = 5.95 and 2.90, respectively). Results suggest that the use of medication-based contingencies in combination with behavioral therapy in promoting drug abstinence may have clinical utility. Limitations of the study are discussed.

Annotation: the therapeutic alliance--a significant but neglected variable in child mental health treatment studies

BACKGROUND

There has been relatively little research into therapeutic alliance in child and adolescent mental health and virtually no incorporation of alliance measures as a variable in treatment trials in Child and Adolescent Mental Health Services (CAMHS).

METHOD

A selective literature review on studies in therapeutic alliance in adulthood and childhood along with a theoretical formulation of possible mechanisms of alliance.

RESULTS

Therapeutic alliance is reliably measurable both by observation and questionnaire methods at all points in the treatment cycle. In both adult and child studies it shows a consistent, albeit modest, association with treatment outcome. In specific adult studies it has shown a high predictive validity in relation to outcome compared to other variables. In child studies alliance is particularly salient in externalising disorder and predicts outcome of inpatient treatment. Child alliance and parental alliance are independent factors. Theoretical models of alliance outlined in this paper suggest testable hypotheses regarding predictors for positive and negative alliance.

CONCLUSIONS

Therapeutic alliance in CAMHS is measurable and worth measuring. It is likely to be an important variable for treatment outcome studies and should be included in future trial designs.

A qualitative investigation of changes in the belief systems of families of children with autism or Down syndrome

BACKGROUND

There have been few reports of the world views, values and priorities of families of children with autism or Down syndrome, despite the fact that family belief systems are considered to be among the most important factors affecting the adaptation and resilience of families.

METHODS

Transcripts from three focus groups involving 19 key informants (15 parents of children with autism or Down syndrome, and 4 service providers) were analysed using qualitative methods.

RESULTS

The themes indicated that raising a child with a disability can be a life-changing experience that spurs families to examine their belief systems. Parents can come to gain a sense of coherence and control through changes in their world views, values and priorities that involve different ways of thinking about their child, their parenting role, and the role of the family. Although parents may grapple with lost dreams, over time positive adaptations can occur in the form of changed world views concerning life and disability, and an appreciation of the positive contributions made by children to family members and society as a whole. Parents' experiences indicate the importance of hope and of seeing possibilities that lie ahead.

CONCLUSIONS

The information from this study may be used to provide families with an advance understanding of the changes in beliefs that they might undergo, and assists service providers in providing individualized and family-centred services and supports to families.

The use of contingency management to reduce cigarette smoking among college students

The current study tested the feasibility of using contingency management to reduce cigarette smoking among college students. Eighty-eight undergraduate smokers were enrolled in a 3-week ABA study. During the baseline weeks, participants earned noncontingent monetary payments for attending data collection sessions. During the intervention week, participants earned monetary payments contingent on demonstrating recent abstinence. Participants were randomly assigned to either a low- or a high-reinforcer magnitude condition that controlled the amount of money that could be earned during the intervention week. Cigarette smoking was significantly reduced during the intervention week relative to the baseline weeks, and greater reductions were achieved under the high-reinforcer magnitude condition. These results suggest that cigarette smoking among college students is responsive to contingency management procedures.

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.

Effects of an Internet-based voucher reinforcement program for smoking abstinence: a feasibility study

The present study tested the feasibility of an Internet-based method to obtain objective evidence of smoking abstinence and to deliver vouchers for evidence of abstinence. Four heavy smokers participated in this 4-week study. Twice daily, participants made video recordings of themselves providing a breath carbon monoxide (CO) sample with a Web camera. The video was sent electronically to the smoking clinic. Participants could earn vouchers for gradual reductions in breath CO during an initial shaping condition, and then for achieving abstinence (CO < or = 4 ppm). Vouchers could be exchanged for merchandise at select Internet vendors. Relative to baseline conditions, participants substantially reduced their smoke intake, and 3 achieved sustained periods of abstinence. The study suggests that an Internet-based voucher reinforcement program is a feasible method to promote abstinence from cigarette smoking.