Behavioral treatment of cocaine-dependent pregnant women and TB-exposed patients

Prescribing Opioids as an Incentive to Retain Patients in Medical Care: A Qualitative Investigation into Clinician Awareness and Perceptions

HIV treatment retention remains a significant public health concern. Our qualitative analysis used emergent data from a larger HIV treatment study to explore clinician perspectives on prescribing opioids to incentivize retention in HIV care. Data from individual interviews with 29 HIV and substance use clinicians were analyzed using thematic analysis. Prescribing opioids as a retention strategy emerged as a theme. Nine of 11 HIV clinicians reported prior knowledge of this practice; only one of 12 substance use clinicians indicated prior knowledge. Positive perceptions included: harm reduction approach, increased appointment attendance, and sustained engagement in HIV care. Negative perceptions included: addiction potential, increased engagement not leading to better health outcomes, and prescriptions becoming the appointment focus. Some clinicians used prescriptions as a strategy to improve treatment retention, which may be particularly problematic in light of the current opioid epidemic. Understanding motives, outcomes, and clinical decision-making processes is needed.

Contingency management interventions for tobacco and other substance use disorders in pregnancy

Contingency management (CM) is an effective intervention for reducing use of licit and illicit substances in a variety of populations. Pregnant women are a vulnerable population with much to gain from effective interventions for substance use disorders, and for whom CM interventions may be especially well-suited. We reviewed the literature on CM interventions among pregnant women with tobacco and other substance use disorders with 3 aims: (a) describe the effectiveness of CM for reducing use of tobacco and other substances during pregnancy, (b) describe the effects of CM interventions on infant outcomes, and (c) identify needs for future research on CM in pregnancy. Our search strategy revealed 27 primary studies of CM in pregnancy. CM was effective in the majority of studies targeting nicotine abstinence, and results were mixed in studies targeting illicit substances. A variety of methodologies were used within the relatively small number of studies making it difficult to identify underlying mechanisms. Also, very few studies reported maternal and infant outcomes, and significant effects of CM were only apparent when secondary analyses pooled data from multiple studies. Furthermore, there is extremely limited data on the cost effectiveness of CM interventions in pregnancy. Future research should address these 3 areas to better determine the ultimate value of CM as an efficacious treatment for pregnant women with substance use disorders. (PsycINFO Database Record

Newborn birth-weight of pregnant women on methadone or buprenorphine maintenance treatment: A national contingency management approach trial

BACKGROUND AND OBJECTIVES

Methadone maintenance treatment (MMT) is the gold standard for pregnant women with opioid use disorders. Still, low birth-weights were reported, in particular of mothers who became pregnant before admission to MMT. We studied whether an escalating incentive contingency-management approach may contribute to better newborn birth-weights.

METHODS

A nationwide controlled randomized trial among all Israeli methadone/buprenorphine maintenance treatment (MBMT), newly or already in treatment pregnant women was performed. A modified contingency-management protocol with coupons of escalating value depending upon reduction of drug use, cigarette smoking, and alcohol consumption was compared to standard care arm. Drugs in urine, smoking (Fagerstrom score), alcohol use, and depression were monitored.

RESULTS

Thirty-five women had 46 pregnancies. In their first pregnancy, 19 from the contingency-management and 16 from the standard care arms were studied. Contingency-management group as compared to the standard care arm included more newly admitted women (36.8% vs. 6.3%, p = .05), with benzodiazepine and cannabis onset at a younger age, and higher proportion of any drug abuse while pregnant (100% vs. 68.8%, p = .01). Fifteen of the contingency-management and 14 of the control arm gave birth (78.9% vs. 87.5%, p = .3) with similar proportions of normal (>2,500 g) birth-weight (71.4% vs. 61.5%, p = .8).

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

Newborns' birth-weight was comparable among the two study arms indicating no contribution of the contingency-management approach. Small sample and baseline differences between arms might have influenced results. Intensive intervention should be evaluated on a larger scale of participants. (Am J Addict 2017;26:167-175).

Psychosocial interventions for pregnant women in outpatient illicit drug treatment programs compared to other interventions

BACKGROUND

Illicit drug use in pregnancy is a complex social and public health problem. The consequences of drug use in pregnancy are high for both the woman and her child. Therefore, it is important to develop and evaluate effective treatments. There is evidence for the effectiveness of psychosocial interventions in drug treatment but it is unclear whether they are effective in pregnant women. This is an update of a Cochrane review originally published in 2007.

OBJECTIVES

To evaluate the effectiveness of psychosocial interventions in pregnant women enrolled in illicit drug treatment programmes on birth and neonatal outcomes, on attendance and retention in treatment, as well as on maternal and neonatal drug abstinence. In short, do psychosocial interventions translate into less illicit drug use, greater abstinence, better birth outcomes, or greater clinic attendance?

SEARCH METHODS

We conducted the original literature search in May 2006 and performed the search update up to January 2015. For both review stages (original and update), we searched the Cochrane Drugs and Alcohol Group Trial's register (May 2006 and January 2015); the Cochrane Central Register of Trials (CENTRAL; the Cochrane Library 2015, Issue 1); PubMed (1996 to January 2015); EMBASE (1996 to January 2015); and CINAHL (1982 to January 2015).

SELECTION CRITERIA

We included randomized controlled trials comparing any psychosocial intervention vs. a control intervention that could include pharmacological treatment, such as methadone maintenance, a different psychosocial intervention, counselling, prenatal care, STD counselling and testing, transportation, or childcare.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by the Cochrane Collaboration. We performed analyses based on three comparisons: any psychosocial intervention vs. control, contingency management (CM) interventions vs. control, and motivational interviewing based (MIB) interventions vs.

MAIN RESULTS

In total, we included 14 studies with 1298 participants: nine studies (704 participants) compared CM vs. control, and five studies (594 participants) compared MIB interventions vs.

CONTROL

We did not find any studies that assessed other types of psychosocial interventions. For the most part, it was unclear if included studies adequately controlled for biases within their studies as such information was not often reported. We assessed risk of bias in the included studies relating to participant selection, allocation concealment, personnel and outcome assessor blinding, and attrition.The included trials rarely captured maternal and neonatal outcomes. For studies that did measure such outcomes, no difference was observed in pre-term birth rates (RR 0.71, 95% confidence interval (CI) 0.34 to 1.51; three trials, 264 participants, moderate quality evidence), maternal toxicity at delivery (RR 1.18, 95% CI 0.52 to 2.65; two trials, 217 participants, moderate quality evidence), or low birth weight (RR 0.72, 95% CI 0.36 to 1.43; one trial, 160 participants, moderate quality evidence). However, the results did show that neonates remained in hospital for fewer days after delivery in CM intervention groups (RR -1.27, 95% CI -2.52 to -0.03; two trials, 103 participants, moderate quality evidence). There were no differences observed at the end of studies in retention or abstinence (as assessed by positive drug test at the end of treatment) in any psychosocial intervention group compared to control (Retention: RR 0.99, 95% CI 0.93 to 1.06, nine trials, 743 participants, low quality evidence; and Abstinence: RR 1.14, 95% CI 0.75 to 1.73, three trials, 367 participants, low quality evidence). These results held for both CM and MIB combined. Overall, the quality of the evidence was low to moderate.

AUTHORS' CONCLUSIONS

The present evidence suggests that there is no difference in treatment outcomes to address drug use in pregnant women with use of psychosocial interventions, when taken in the presence of other comprehensive care options. However, few studies evaluated obstetrical or neonatal outcomes and rarely did so in a systematic way, making it difficult to assess the effect of psychosocial interventions on these clinically important outcomes. It is important to develop a better evidence base to evaluate psychosocial modalities of treatment in this important population.

The use of incentives to reinforce medication adherence

OBJECTIVE

Poor medication adherence is a longstanding problem, and is especially pertinent for individuals with chronic conditions or diseases. Adherence to medications can improve patient outcomes and greatly reduce the cost of care. The purpose of the present review is to describe the literature on the use of incentives as applied to the problem of medication adherence.

METHODS

We conducted a systematic review of peer-reviewed empirical evaluations of incentives provided to patients contingent upon medication adherence.

RESULTS

This review suggests that incentive-based medication adherence interventions can be very effective, but there are few controlled studies. The studies on incentive-based medication adherence interventions most commonly feature patients taking medication for drug or alcohol dependence, HIV, or latent tuberculosis. Across studies that reported percent adherence comparisons, incentives increased adherence by a mean of 20 percentage points, but effects varied widely. Cross-study comparisons indicate a positive relationship between the value of the incentive and the impact of the intervention. Post-intervention evaluations were rare, but tended to find that adherence effects diminish after the interventions are discontinued.

CONCLUSIONS

Incentive-based medication adherence interventions are promising but understudied. A significant challenge for research in this area is the development of sustainable and cost-effective long-term interventions.

Lessons learned from a randomized trial of fixed and escalating contingency management schedules in opioid-dependent pregnant women

BACKGROUND

Contingency management (CM) has shown promise for treating substance use disorders in pregnant women.

METHODS

A randomized clinical trial compared the relative efficacy of three conditions on the measures of opioid and cocaine abstinence and days retained in treatment. A total of 133 pregnant patients attending treatment for substance use disorders were randomized either to an escalating reinforcement condition, a fixed reinforcement condition, or an attendance control condition. Conditions were compared on drug abstinence rates and days retained in treatment.

RESULTS

As expected, the pooled escalating + fixed conditions received a greater total amount of voucher money than the control condition mean [M = 392.40 (SE = 40.47) vs. 219.74 (SE = 39.78)], respectively; p < .001. However, the escalating and fixed conditions did not differ on the outcome variables of drug abstinence and treatment retention.

CONCLUSIONS

The CM conditions examined in the current study did not emerge as superior to the control condition. The lack of significant differences among study conditions may be attributed, in part, to study sample size. Additionally, methodological issues related to the CM intervention may also have compromised outcomes, including delay in reinforcement following the target behavior and limited contact with the reinforcer.

SCIENTIFIC SIGNIFICANCE

This study highlights the importance of key CM implementation features, including immediate reinforcement, and adequate access to the reinforcer. It may also be that the reset feature for missing samples in CM interventions is an essential contingency for promoting behavior change.

Maternal substance use and integrated treatment programs for women with substance abuse issues and their children: a meta-analysis

BACKGROUND

The rate of women with substance abuse issues is increasing. Women present with a unique constellation of risk factors and presenting needs, which may include specific needs in their role as mothers. Numerous integrated programs (those with substance use treatment and pregnancy, parenting, or child services) have been developed to specifically meet the needs of pregnant and parenting women with substance abuse issues. This synthesis and meta-analysis reviews research in this important and growing area of treatment.

METHODS

We searched PsycINFO, MedLine, PubMed, Web of Science, EMBASE, Proquest Dissertations, Sociological Abstracts, and CINAHL and compiled a database of 21 studies (2 randomized trials, 9 quasi-experimental studies, 10 cohort studies) of integrated programs published between 1990 and 2007 with outcome data on maternal substance use. Data were summarized and where possible, meta-analyses were performed, using standardized mean differences (d) effect size estimates.

RESULTS

In the two studies comparing integrated programs to no treatment, effect sizes for urine toxicology and percent using substances significantly favored integrated programs and ranged from 0.18 to 1.41. Studies examining changes in maternal substance use from beginning to end of treatment were statistically significant and medium sized. More specifically, in the five studies measuring severity of drug and alcohol use, the average effect sizes were 0.64 and 0.40, respectively. In the four cohort studies of days of use, the average effect size was 0.52. Of studies comparing integrated to non-integrated programs, four studies assessed urine toxicology and two assessed self-reported abstinence. Overall effect sizes for each measure were not statistically significant (d = -0.09 and 0.22, respectively).

CONCLUSIONS

Findings suggest that integrated programs are effective in reducing maternal substance use. However, integrated programs were not significantly more effective than non-integrated programs. Policy implications are discussed with specific attention to the need for funding of high quality randomized control trials and improved reporting practices.

Increasing prenatal care and healthy behaviors in pregnant substance users

Evidence suggests that prenatal care, healthy behaviors such as exercise and nutrition, and general stress level are associated with fetal and maternal health but there is a relative dearth of research on interventions to improve these factors in pregnant substance users. Two hundred pregnant substance users entering outpatient substance abuse treatment were randomized to receive either three individual sessions of Motivational Enhancement Therapy for pregnant substance users (MET-PS) or the first three individual sessions normally provided by the program. The present study evaluated the relative efficacy of MET-PS, compared to treatment as usual, on modifiable healthy behaviors and the impact of treatment when the groups were pooled. The results suggest that MET-PS was not more effective than treatment as usual in improving modifiable healthy behaviors. When the treatment groups were pooled, the results suggest that there were significant increases in prenatal care utilization and prenatal/multi-vitamin and water consumption, and a significant decrease in stress. Limitations and recommendations for further research are discussed.

Incentives for retention of pregnant substance users: a secondary analysis

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

Tuberculosis and illicit drug use: review and update

Illicit drug users continue to be a group at high risk for tuberculosis (TB). Here, we present an updated review of the relationship between TB and illicit drug use, and we summarize more than a decade of new research. Drug users, and injection drug users in particular, have driven TB epidemics in a number of countries. The successful identification and treatment of TB among illicit drug users remain important components of a comprehensive TB strategy, but illicit drug users present a unique set of challenges for TB diagnosis and control. New diagnostic modalities, including interferon-gamma-release assays, offer potential for improved diagnosis and surveillance among this group, along with proven treatment strategies that incorporate the use of directly observed therapy with treatment for drug abuse. Special considerations, including coinfection with viral hepatitis and the rifampin-methadone drug interaction, warrant clinical attention and are also updated here.

A randomized trial of 6-month methadone maintenance with standard or minimal counseling versus 21-day methadone detoxification

BACKGROUND

Important questions remain regarding the necessary duration and intensity for methadone treatment to be effective.

METHODS

As part of a clinical trial of tuberculosis chemoprophylaxis [Batki, S.L., Gruber, V.A., Bradley, J.M., Bradley, M., Delucchi, K., 2002. A controlled trial of methadone treatment combined with directly observed isoniazid for tuberculosis prevention in injection drug users. Drug Alcohol Depend. 66 283-293. doi:10.1016/S0376-8716(01)00208-3], patients with opioid dependence were recruited from an outpatient 21-day methadone detoxification program and were randomly assigned to one of three treatment conditions: (1) continuation in 21-day methadone detoxification; (2) transfer to 6-month methadone maintenance with only minimal counseling; or (3) transfer to 6-month methadone maintenance with standard twice monthly counseling and as-needed social work and psychiatric services. Both the 6-month maintenance treatments were followed by 1.5 months of detoxification. Urine drug tests and self-report measures were collected at baseline, months 1-6, and month 8.5.

RESULTS

Compared to 21-day methadone detoxification, 6-month methadone maintenance with either minimal or standard counseling resulted in fewer opiate positive urine tests and days of self-reported heroin and alcohol use. There was no change in cocaine use or other outcome measures. The increased counseling available in the standard counseling condition did not appear to reduce heroin use further than the minimal counseling condition, in contrast to the effect found for more structured counseling in long-term methadone maintenance (McLellan et al., 1993).

CONCLUSIONS

Six months of methadone maintenance, even with minimal counseling, reduces heroin and alcohol use more than 21-day methadone detoxification.

Psychosocial interventions for pregnant women in outpatient illicit drug treatment programs compared to other interventions

BACKGROUND

Illicit drug use in pregnancy is a complex social and public health problem. It is important to develop and evaluate effective treatments. There is evidence for the effectiveness of psychosocial in this population; however, to our knowledge, no systematic review on the subject has been undertaken.

OBJECTIVES

To evaluate the effectiveness of psychosocial interventions in pregnant women enrolled in illicit drug treatment programs on birth and neonatal outcomes, on attendance and retention in treatment, as well as on maternal and neonatal drug abstinence. In short, do psychosocial interventions translate into less illicit drug use, greater abstinence, better birth outcomes, or greater clinic attendance.?

SEARCH STRATEGY

We searched the Cochrane Drugs and Alcohol Group's trial register (May 2006), the Cochrane Central Register of Trials (Central- The Cochrane Library, Issue 3, 2005); MEDLINE (1.1996-8.2006); EMBASE (1.1996-8.2006); CINAHL (1.1982-8.2006), and reference lists of articles.

SELECTION CRITERIA

Randomised studies comparing any psychosocial intervention versus pharmacological interventions or placebo or non-intervention or another psychosocial intervention for treating illicit drug use in pregnancy.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality and extracted data.

MAIN RESULTS

Nine trials involving 546 pregnant women were included. Five studies considered contingency management (CM), and four studies considered manual based interventions such as motivational interviewing (MI). The main finding was that contingency management led to better study retention. There was only minimal effect of CM on illicit drug abstinence. In contrast, motivational interviewing led towards poorer study retention, although this did not approach statistical significance. For both, no difference in birth or neonatal outcomes was found, but this was an outcome rarely captured in the studies.

AUTHORS' CONCLUSIONS

The present evidence suggests that CM strategies are effective in improving retention of pregnant women in illicit drug treatment programs as well as in transiently reducing illicit drug use. There is insufficient evidence to support the use of MI. Overall the available evidence has low numbers and, therefore, it is impossible to accurately assess the effect of psychosocial interventions on obstetrical and neonatal outcomes. It is important to develop a better evidence base to evaluate psychosocial modalities of treatment in this important population.

Voucher reinforcement improves medication adherence in HIV-positive methadone patients: a randomized trial

This clinical trial evaluated a contingency management intervention designed to improve medication adherence among HIV-positive methadone maintenance patients. After a 4-week baseline observation phase, eligible participants (N=66) were randomly assigned to: (a) medication coaching sessions every other week to assist with adherence strategies (comparison group) or (b) medication coaching plus voucher reinforcement for opening electronic medication caps on time (voucher group). Baseline adherence (percent doses taken/percent total possible doses) was 51% using electronic measurement, 75% using self-report and 75% using pill count. The intervention was provided for 12 weeks, with a 4-week follow-up. The primary outcome results of the clinical trial indicated effectiveness during the intervention, with significant mean adherence differences between voucher and comparison groups using electronic measurement (78% versus 56%), pill count (86% versus 75%), and self-report (87% versus 69%). Differences between groups faded after vouchers were discontinued. Contingency management shows promise as a strategy to promote antiretroviral medication adherence in this population.

Substance abuse treatment entry, retention, and outcome in women: a review of the literature

This paper reviews the literature examining characteristics associated with treatment outcome in women with substance use disorders. A search of the English language literature from 1975 to 2005 using Medline and PsycInfo databases found 280 relevant articles. Ninety percent of the studies investigating gender differences in substance abuse treatment outcomes were published since 1990, and of those, over 40% were published since the year 2000. Only 11.8% of these studies were randomized clinical trials. A convergence of evidence suggests that women with substance use disorders are less likely, over the lifetime, to enter treatment compared to their male counterparts. Once in treatment, however, gender is not a significant predictor of treatment retention, completion, or outcome. Gender-specific predictors of outcome do exist, however, and individual characteristics and treatment approaches can differentially affect outcomes by gender. While women-only treatment is not necessarily more effective than mixed-gender treatment, some greater effectiveness has been demonstrated by treatments that address problems more common to substance-abusing women or that are designed for specific subgroups of this population. There is a need to develop and test effective treatments for specific subgroups such as older women with substance use disorders, as well as those with co-occurring substance use and psychiatric disorders such as eating disorders. Future research on effectiveness and cost-effectiveness of gender-specific versus standard treatments, as well as identification of the characteristics of women and men who can benefit from mixed-gender versus single-gender treatments, would advance the field.

Psychosocial approaches to psychostimulant dependence: A systematic review

This review examines the nature and evidence for the effectiveness of psychosocial interventions for psychostimulant dependence. Psychostimulant dependence and related harms continue to increase in many parts of the world, while treatment responses are predominantly limited to psychosocial interventions. The effectiveness of psychosocial interventions is compromised by poor rates of treatment induction and retention. As with other substance use disorders, increasing the diversity of treatment options is likely to improve treatment coverage and outcomes across a broader range of users. Identifying medications that might enhance treatment induction and retention would also enhance the effectiveness of psychosocial programs. It is concluded that psychosocial interventions are moderately effective in reducing psychostimulant use and related harms among psychostimulant-dependent persons.

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.

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.

Cash value of voucher reinforcers in pregnant drug-dependent women

This study examined the relative reinforcing potency of vouchers and cash in drug-dependent pregnant women (N = 48) across voucher values (US 10 dollars, US 50 dollars, and US 100 dollars) by use of a series of choices to understand how exchange-delay features of voucher reinforcers influence their reinforcing potency compared with cash. The study also examined a no delay vs. 2-day delay of the cash alternative. Generally, cash was selected at 80%-90% of voucher face values. Vouchers were also discounted less when a 2-day delay was imposed on the cash option compared to the immediately available cash. These results suggest that voucher discounting does occur among patients in drug treatment. However, vouchers retain 80%-90% of their cash value and thus remain relatively potent reinforcers.

Shaping cocaine abstinence by successive approximation

Cocaine-using methadone-maintenance patients were randomized to standard contingency management (abstinence group, n = 49) or to a contingency designed to increase contact with reinforcers (shaping group, n = 46). For 8 weeks, both groups earned escalating-value vouchers based on thrice-weekly urinalyses: The abstinence group earned vouchers for cocaine-negative urines only; the shaping group earned vouchers for each urine specimen with a 25% or more decrease in cocaine metabolite (first 3 weeks) and then for negative urines only (last 5 weeks). Cocaine use was lower in the shaping group, but only in the last 5 weeks, when the response requirement was identical. Thus, the shaping contingency appeared to better prepare patients for abstinence. A 2nd phase of the study showed that abstinence induced by escalating-value vouchers can be maintained by a nonescalating schedule, suggesting that contingency management can be practical as a maintenance treatment.

Fetal effects of cocaine: an updated meta-analysis

BACKGROUND

A very large number of women in the reproductive age group consume cocaine, leading to grave concerns regarding the long term health of millions of children after in utero exposure. The results of controlled studies have been contradictory, leading to confusion, and, possible, misinformation and misperception of teratogenic risk.

OBJECTIVE

To systematically review available data on pregnancy outcome when the mother consumed cocaine.

METHODS

A meta-analysis of all epidemiologic studies based on a priori criteria was conducted. Comparisons of adverse events in subgroups of exposed vs. unexposed children were performed. Analyses were based on several exposure groups: mainly cocaine, cocaine plus polydrug, polydrug but no cocaine, and drug free.

RESULTS

Thirty three studies met our inclusion criteria. For all end points of interest (rates of major malformations, low birth weight, prematurity, placental abruption, premature rupture of membrane [PROM], and mean birth weight, length and head circumference), cocaine-exposed infants had higher risks than children of women not exposed to any drug. However, most of these adverse effects were nullified when cocaine exposed children were compared to children exposed to polydrug but no cocaine. Only the risk of placental abruption and premature rupture of membranes were statistically associated with cocaine use itself.

CONCLUSIONS

Many of the perinatal adverse effects commonly attributed to cocaine may be caused by the multiple confounders that can occur in a cocaine using mother. Only the risk for placental abruption and PROM could be statistically related to cocaine. For other adverse effects, additional studies will be needed to ensure adequate statistical power.

The effectiveness of incentives in enhancing treatment attendance and drug abstinence in methadone-maintained pregnant women

This study examined the effectiveness of short-term contingency management for eliminating cocaine use and increasing full day treatment attendance with pregnant methadone-maintained women randomly assigned to either an escalating voucher incentive schedule (n=44) or non-incentive (n=36) conditions. Full day treatment attendance and urine toxicology for cocaine and heroin were assessed and consequated for 14 days. The escalating voucher incentive schedule significantly increased full day treatment attendance and drug abstinence compared to the non-incentive schedule. These results suggest that reinforcing the co-occurrence of two required behaviors (treatment attendance and abstinence from illicit drug use) is effective, and may be an important adjunct to methadone pharmacotherapy for treating pregnant drug dependent women.

Improving treatment outcomes for pregnant drug-dependent women using low-magnitude voucher incentives

The aim of this study was to examine the effectiveness of low-magnitude behavioral incentives in improving attendance for abstinence-treated patients and sustaining illicit-drug abstinence for methadone-treated patients. Subjects were randomly assigned to either incentive or control conditions, with target behaviors differing for the two patient groups (attendance for abstinence-treated and abstinence for methadone-treated patients). Controls received no incentives, whereas incentive subjects could earn $5/day in vouchers during the first 7 days of an intensive outpatient treatment. Results showed that $5/day did not significantly improve attendance in abstinence-treated patients or impact drug abstinence in methadone-treated patients. The data suggest that low-magnitude voucher incentives enhanced treatment attendance by methadone-treated subjects. Although modest monetary incentives had some utility in improving attendance in methadone-treated patients, more potent interventions are needed to improve attendance and maintain abstinence in this high-risk population.

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

Controlled clinical research has demonstrated the efficacy of contingency management procedures in treating substance use disorders. Now is the time to begin introducing these procedures into standard clinical practice. This article reviews the rationale of contingency management interventions and provides a review of representative scientific work in the area. It also discusses behaviors that can be modified, reinforcers that can be used, and behavioral principles that can be adapted to improve outcomes. This paper provides practical advice and a guideline for clinicians and researchers to use when designing and administering contingency management interventions. The recommendations are based on empirically validated manipulations. Areas in which more research is needed are suggested as well.

Smoked cocaine self-administration in females and voucher incentives for abstinence

There are three purposes for this study: (1) To extend the laboratory study of heavy smoked cocaine use to women, (2) to assess cocaine withdrawal symptoms and (3) to assess the utility of voucher incentives for achieving and maintaining cocaine and other drug abstinence in female cocaine abusers.

METHODS

Ten non-treatment seeking female cocaine smokers resided inpatient for 4-5 days and could smoke up to 6 doses of cocaine base (50 mg each) twice a day (at 1200 h and again at 1600 h) for 2 consecutive days. During the following 2-week outpatient phase, women were given US $40 in merchandise vouchers if urinalysis indicated lower drug levels from the previous day.

RESULTS

Women self-administered 20.4 out of 24 possible doses. Compared to the 1200 session, heart rate and blood pressure, but not subjective effects, were still significantly increased prior to the 1600 session. Nine women completed the outpatient phase, attending 98% of their appointments. Using the One-Half Rule, 56% of urines indicated no new cocaine or other drug use.

IMPLICATIONS

Although a US $40 voucher incentive for a "clean" urine was not sufficient to eliminate cocaine use, the possibility of earning the voucher was sufficient to maintain nearly perfect attendance.

Cessation of cocaine use during pregnancy: effects of contingency management interventions on maintaining abstinence and complying with prenatal care

Previous studies have reported cessation of cocaine use in pregnant women prior to treatment entry. This study examined the relative effectiveness of adjunctive contingency management interventions in maintaining abstinence and enhancing compliance with prenatal care in this unique population. Pregnant cocaine-dependent women who had used the drug during this pregnancy but had ceased use prior to study entry (N = 12) were randomly assigned to one of two treatment groups. All patients received a multifaceted treatment including behaviorally based drug counseling and weekly prenatal visits. Patients in the experimental condition also received contingent reinforcement for cocaine abstinence and attendance at prenatal visits. There was a high rate of retention and abstinence from cocaine in both groups. However, patients in the experimental group had a higher rate of attendance at prenatal visits, and none of the patients in this group experienced adverse perinatal outcome(s), compared to 80% of patients in the control group. This finding has important implications for cost-effective treatments and prevention of illness.

Attendance incentives for outpatient treatment: effects in methadone- and nonmethadone-maintained pregnant drug dependent women

The effectiveness of behavioral incentives for improving treatment participation and retention in samples of methadone-maintained (n = 66) and nonmethadone-maintained (n = 76) pregnant drug dependent women was examined. Subjects were randomly assigned to receive $0 (standard care) and $1, $5, or $10/day for attending at least 4 h of interdisciplinary treatment programming during the first 7 consecutive days after transfer from residential to outpatient care, with payment dispensed in the form of gift certificates. Methadone-maintained women attended nearly twice as many full treatment days as those not receiving methadone (5.2 vs 2.8 days; P < 0.001) and were retained in treatment significantly longer (86.4 vs 28.9% active in treatment at 30 days). There was no main effect of incentives and no effect on attendance in methadone patients. However, nonmethadone patients offered higher magnitude incentives ($5/$10) attended 3.3 days out of 7 on average, compared to 2.3 days for those offered $0 or $1 per day (t = 1.73; P < 0.05). The study confirmed that methadone maintenance is a powerful therapeutic adjunct which is associated with significantly better treatment retention and participation in ancillary programming than is abstinence-based treatment. It was also found that modest financial incentives can facilitate treatment participation for abstinence-based patients. However, more potent interventions would be needed to match the effectiveness of methadone in this regard.

Behavioral Interventions: Effective and Adaptable for the Treatment of Pregnant Cocaine-Dependent Women

We examined the effectiveness of behavioral interventions in the treatment of cocaine-dependent pregnant women. The study was carried out in four stages: (1) the unique needs of substance-abusing women were examined to identify effective treatment factors, (2) behavioral interventions found to be effective in other cocaine-dependent populations were identified, (3) strategies from these two elements were combined in an ongoing treatment-study of cocaine-dependent pregnant women (the Pregnancy Project), and (4) outcome data in a group of 35 women who participated in the Pregnancy Project were examined. The rate of retention in treatment was high, as was compliance with prenatal care for those women who remained in treatment. A high rate of compliance with prenatal care was associated with good perinatal outcome. There was a relatively high rate of cocaine abstinence during treatment, at birth, and in the early period following birth of the baby. Many of the patients especially appreciated the individually based, self-empowering aspects of the behavioral counseling interventions. We concluded that behavioral interventions, within a woman-friendly treatment program, are an important treatment option to consider.

Drug treatment for women: traditional models and new directions

Drug treatment is a diverse field in which a variety of treatment frameworks and formats exist, few of which have been tailored to women's circumstances and needs. Most drug treatment is based on insight-oriented and behavioral approaches, often accompanied by pharmacologic treatments. Complementary approaches such as acupuncture and biofeedback also are available. Feminist criticisms of traditional therapy have prompted development of woman-centered treatment, which provides a safe environment for empowerment and building relationship skills. Nurses can provide supportive interventions using mutuality and avoiding confrontation, and can advocate for access to woman-centered drug treatment and harm reduction measures to minimize the damage caused by alcohol and drugs.