Contingency Management for Treatment of Substance Abuse

Contingency Management for Dually Diagnosed Inpatients with Psychosis

Contingency management (CM) is an evidence-based treatment method in substance abuse treatment. However, little is known about its efficacy in dually diagnosed patients with psychosis and in inpatient settings. Therefore, the aim of this study is to investigate the efficacy of CM for dually diagnosed patients with psychosis in an inpatient setting. Furthermore, we investigate the effect of the nature of the reward used (cash vs. prize) on the efficacy of CM. We made use of an 8-week fish-bowl CM intervention by means of a within-subject reversal design with three treatment phases (baseline-intervention-follow-up). Sixty-seven patients were included in this study, of whom thirty-four completed the protocol. The results show no effect of CM on abstinence nor an interaction with clinical or demographic variables. Cash money is as effective as prizes. Future research should further investigate the effect of psychosis and treatment setting on the efficacy of CM, with special attention for Patient Report Experience and Outcome Measures (PREM/PROM).

Voucher incentives to improve viral suppression among HIV-positive people who inject drugs and men who have sex with men in India: a cluster randomised trial

BACKGROUND

Progress on HIV treatment outcomes for people who inject drugs and men who have sex with men in India has been slow compared with that in other populations. We assessed whether HIV treatment incentives would improve outcomes among these groups.

METHODS

We did a matched-pair, cluster randomised trial in 16 sites (eight for people who inject drugs and eight for men who have sex with men) across 15 cities in India. We recruited cohorts of HIV-positive people who inject drugs or men who have sex with men who were antiretroviral therapy (ART)-naive or had less than 12 months of ART exposure. We randomised sites to provide incentives or usual care. At intervention sites, we provided incentive vouchers, which could be exchanged for food or household goods, for attending motivational interviewing sessions and timely appointments at government ART clinics. An ART-naive participant meeting all targets could earn the equivalent to 14 days' wages over 12 months. The primary outcome was survival with viral suppression at 12 months. We used an intention-to-treat analytic approach appropriate for matched-pair cluster randomised trials, adjusting for baseline viral suppression. This study was registered with ClinicalTrials.gov, NCT02969915, and is complete.

FINDINGS

Between Oct 30, 2017, and Oct 12, 2018, we recruited 1200 people who inject drugs and 1114 men who have sex with men living with HIV. Among people who inject drugs, 154 (12·8%) identified as female gender and 1046 (87·2%) as male. The site median percentage of participants earning one or more incentives was 96·1% (IQR 93·7-98·1). At 12 months, HIV viral suppression was 31·9% (n=383) among people who inject drugs and 52·1% (n=580) among men who have sex with men. The incentive intervention was not associated with significantly improved survival with viral suppression compared with usual care (adjusted prevalence difference 9·6 percentage points, 95% CI -4·4 to 23·7).

INTERPRETATION

Despite high intervention engagement, incentives did not improve survival with viral suppression among people who inject drugs and men who have sex with men living with HIV in India. The poor outcomes overall underscore the need for innovative, multilevel approaches to engage marginalised people living with HIV in low-income and middle-income settings.

FUNDING

US National Institutes of Health, Elton John AIDS Foundation.

Comparison of transdermal alcohol concentration and self-reported alcohol consumption in people with alcohol dependence attending community alcohol treatment services

AIM

We aimed to assess the accuracy and wearability of a transdermal alcohol sensor (TAS) (BACtrack Skyn) with people currently receiving treatment at alcohol services.

METHOD

A mixed methods observational study involving three NHS alcohol services in south London was conducted. All participants (7=male, 9=female) wore a TAS for 1 week and met with the researcher every other weekday to complete the TAS data download and a TimeLine Follow Back (TLFB). At the end of the week, a post-wear survey was completed. Transdermal Alcohol Concentration (TAC) from the TAS was compared to the TLFB. Post-wear survey responses, attendance voucher incentives and descriptive TAS data (removals, missing and skin temperature data) were analysed. We investigated different drinking event thresholds changing the criteria of TAC level and length of time TAC was increased and analysed each drinking threshold sensitivity, specificity, positive and negative predicative values, and percentage accuracy classification.

RESULTS

The TAS recorded the number of alcohol-drinking days with a high degree of accuracy compared to the TLFB as gold-standard. However, of the participation time of the 16 participants, 14.5% of the TAS data was missing in output and 16.4% of the recorded data suggests the TAS was not currently being worn. Of the data recorded, in line with the drinking event threshold of >15 ug/l TAC, >15minutes, we found that sensitivity = 93%, specificity = 84% and a Pearson correlation of r(16) =.926, p = <.001, BCa 95% CI [.855 -.981]. The threshold with the highest accuracy was TAC>15 ug/l, >60minutes which classified alcohol events with 90% accuracy, AUC =.910, sensitivity = 90%, specificity = 96%. The post-wear survey reported that most participants found it comfortable and that wearing it did not interfere with daily activities. Six participants reported side effects, including itching and a rash, but these would not deter them from wearing it again with all six reporting they would wear the TAS again and for longer than one week.

CONCLUSIONS

The TAS did not capture every drinking event that was self-reported but maintained a high correlation. There were instances of missing TAS data and TAS removals. Overall, our findings would support the acceptability and feasibility of TAS as a tool that could be used in clinical settings for objective alcohol monitoring with patients being responsible for the TAS.

Accuracy of transdermal alcohol monitoring devices in a laboratory setting

The development of transdermal alcohol sensors (TASs) presents a new method to monitor alcohol consumption with the ability to objectively measure data 24/7. We aimed to evaluate the accuracy of two TASs (BACtrack Skyn and Smart Start BARE) in a laboratory setting. Thirty-two adults received a dose of ethanol 0.56 g/kg body weight as a 20% solution while wearing the two TASs and provided Breath Alcohol Concentration (BrAC) measurements for 3.5 h postalcohol consumption. Pearson's correlations and repeated measures analysis of variance tests were conducted on the peak, time-to-peak, and area under the curve data. Bland-Altman plots were derived. A time series analysis and cross-correlations were conducted to adjust for time lag. Both TASs were able to detect alcohol and increase within 20 min. BrAC peaked significantly quicker than Skyn and BARE. BrAC and Skyn peaks were negatively significantly correlated (r = -0.381, P = .035, n = 31), while Skyn and BARE peaks were positively significantly correlated (r = 0.380, P = .038, n = 30). Repeated measures analysis of variance found a significant difference between BrAC, Skyn, and BARE (F(1.946, 852.301) = 459.873, P < .001)). A time series analysis found when BrAC-Skyn and BrAC-BARE were adjusted for the delay to peak, and there was still a significant difference. Failure rates: 1.7% (Skyn) and 4.8% (BARE). Some evidence was obtained for TAS validity as both consistently detected alcohol. Failure rates and time lag show improvements in older device generations. However, neither TAS presented strong equivalence to the breathalyser even when the lag time was adjusted. With further testing and technology advancements, TAS could be a potential alcohol monitoring tool. Two of the newest TAS devices were worn in laboratory conditions for one afternoon to compare their accuracy of alcohol monitoring to a breathalyser. Findings suggest that the two TASs (BACtrack Skyn and SmartStart BARE) recorded significantly similar data postalcohol consumption, but not with the breathalyser.

IUPHAR-review: The integration of classic psychedelics into current substance use disorder treatment models

Substance use disorders (SUDs) have an enormous impact on public health. With classic psychedelic-assisted therapies showing initial promise in treating multiple SUDs, it is possible that these treatments will become legally available options for patients with SUDs in the future. This article highlights how classic psychedelic-assisted therapies might be integrated into current clinical practice. We first describe contemporary evidence-based treatments for SUDs and highlight how classic psychedelic-assisted therapies might fit within each treatment. We suggest that classic psychedelic-assisted therapies can be integrated into most mainstream evidence-based SUD treatments that are currently used in clinical settings, indicating broad compatibility of classic psychedelics with contemporary SUD treatment paradigms.

Culturally tailored digital therapeutic for substance use disorders with urban Indigenous people in the United States: A randomized controlled study

INTRODUCTION

Indigenous people experience health disparities, including higher rates of substance use disorders (SUDs). Digital therapeutics are a growing platform for treatment services and have the potential to expand access to culturally responsive interventions for Indigenous people. As one of the first randomized controlled trials for SUDs for American Indian and Alaska Native (AI/AN) adults, the aim of this study was to pilot test the efficacy of a culturally tailored intervention among urban Indigenous adults.

METHODS

The study used a randomized controlled parallel design of 12 weeks of treatment-as-usual (TAU) (n = 26) versus TAU + Therapeutic Education System-Native Version (TES-NAV) (n = 27) with follow-up assessments at end of treatment and week 24 in an urban outpatient addiction treatment program for Native American adults. TAU consisted of individual/group counseling and cultural activities. The TES-NAV arm comprised TAU + 26 self-directed culturally tailored digital skills-based modules grounded in the community reinforcement approach with contingency management for abstinence and module completion. Primary outcome was longest consecutive weeks of abstinence from drugs and heavy drinking measured using self-report (Timeline Followback) and urine alcohol and drug toxicology screen during 12 weeks of treatment. Secondary outcomes were percent days abstinence during and posttreatment, coping strategies, social connectedness, and substance use and sexual risk behaviors.

RESULTS

The study enrolled fifty-three (52.8 % male) AI/AN adults seeking treatment for a SUD. Although the study did not detect a benefit of TAU+TES-NAV over TAU on the primary outcome (Median = 2 consecutive weeks of abstinence for both arms) at end of treatment (treatment effect: Z = -0.78, p = 0.437), TAU+TES-NAV participants did demonstrate significantly greater percent days of abstinence at the week 24 follow-up (69.3 % versus 49.0 % for TAU; t = 2.08, p = 0.045) and significantly greater change in social connectedness mean score, baseline to week 12 (Z = -2.66, p = 0.011), compared to TAU. The study detected no differences between treatment arms for coping strategies or risk behaviors.

CONCLUSION

The addition of TES-NAV to TAU did not significantly improve consecutive weeks of abstinence from drugs or heavy drinking; however, several secondary findings suggest promise for a culturally tailored digital therapeutic SUD intervention among urban Indigenous people.

CLINICAL TRIALS

GOV REGISTRATION: #NCT03363256.

The fourth wave of the overdose crisis: Examining the prominent role of psychomotor stimulants with and without fentanyl

The current overdose and broader public health crisis involving illicit drug use is often referred to as the "opioid" or "fentanyl" crisis. Clearly there is extensive data on the profound damage done by opioids over the past 20 years and specifically by fentanyl in the past 5 years. However, there is an extensive array of data that suggests there is more to the current crisis than opioids/fentanyl. Much recent evidence indicates that methamphetamine and cocaine are playing a substantial and increasing role in the illicit drug crisis in the US-the 4th wave. This paper reviews data that illustrate the role of psychomotor stimulants in fatal overdoses, nonfatal overdoses, and emergency department visits. Despite the major detrimental role that stimulants are having on the public health in the US in 2023, there is virtually no evidence-based treatment available in practice for people with stimulant use disorder (StimUD). Although there are no medications with FDA-approval for the treatment of StimUD, there is a behavioral treatment, contingency management (CM), with over 3 decades of robust research supporting its efficacy for individuals with StimUD. Despite the overwhelming evidence supporting CM, it is not being widely used in routine treatment outside the VA healthcare system. This paper reviews some of the (a) evidence for CM, (b) CM protocol design elements that require consideration, (c) current obstacles to the widespread implementation of CM, and (d) strategies for addressing these obstacles. Overcoming these obstacles is a priority to allow routine use of CM as a treatment for StimUD.

Prescription digital therapeutics: A new frontier for pharmacists and the future of treatment

Within digital health, digital therapeutics (DTx) are increasingly used to provide clinical treatment. DTx are evidence-based, U.S. Food and Drug Administration-authorized software to treat or manage medical conditions and are available either via prescription or as nonprescription products. DTx that require clinician initiation and oversight are called prescription DTx (PDTs). DTx and PDTs have unique mechanisms of action and are expanding treatment options beyond traditional pharmacotherapy. They may be implemented on their own or used in combination with a drug and in some cases may be the only treatment option for a particular disease state. This article explains how DTx and PDTs function and how these technologies can be incorporated by pharmacists as they attend to their patients' care.

Contingency Management for Stimulant Use Disorder: Progress, Challenges, and Recommendations

The United States is currently in the fourth wave of the overdose crisis wherein stimulants together with fentanyl are the major drivers of overdose deaths. To date, there has been limited effort outside the US Veterans Administration Health System health system to disseminate evidence-based treatment for people with stimulant use disorder. Contingency management, a behavioral intervention in which positive reinforcement is provided for a target behavior indicating treatment progress, has decades of empirical support but limited implementation in real-world, non-US Veterans Administration Health System settings. The purpose of the report is to provide an overview of contingency management, the barriers to adoption, and recommendations for overcoming these barriers.

Testing the efficacy of real-time fMRI neurofeedback for training people who smoke daily to upregulate neural responses to nondrug rewards

Although the use of nondrug rewards (e.g., money) to facilitate smoking cessation is widespread, recent research has found that such rewards may be least effective when people who smoke cigarettes are tempted to do so. Specifically, among people who smoke, the neural response to nondrug rewards appears blunted when access to cigarettes is anticipated, and this blunting is linked to a decrease in willingness to refrain from smoking to earn a monetary incentive. Accordingly, methods to enhance the value of nondrug rewards may be theoretically and clinically important. The current proof-of-concept study tested if real-time fMRI neurofeedback training augments the ability to upregulate responses in reward-related brain areas relative to a no-feedback control condition in people who smoke. Adults (n = 44, age range = 20-44) who reported smoking >5 cigarettes per day completed the study. Those in the intervention group (n = 22, 5 females) were trained to upregulate brain responses using feedback of ongoing striatal activity (i.e., a dynamic "thermometer" that reflected ongoing changes of fMRI signal intensity in the striatum) in a single neurofeedback session with three training runs. The control group (n = 22, 5 females) underwent a nearly identical procedure but received no neurofeedback. Those who received neurofeedback training demonstrated significantly greater increases in striatal BOLD activation while attempting to think about something rewarding compared to controls, but this effect was present only during the first training run. Future neurofeedback research with those who smoke should explore how to make neurofeedback training more effective for the self-regulation of reward-related brain activities.

A Prescription Digital Therapeutic to Support Unsupervised Buprenorphine Initiation for Patients With Opioid Use Disorder: Protocol for a Proof-of-Concept Study

BACKGROUND

Home-based (unsupervised) buprenorphine initiation is considered safe and effective, yet many patients report barriers to successful treatment initiation. Prescription digital therapeutics (PDTs) are software-based disease treatments regulated by the US Food and Drug Administration (FDA). The reSET-O PDT was authorized by the FDA in 2018 and delivers behavioral treatment for individuals receiving buprenorphine for opioid use disorder (OUD). A prototype PDT (PEAR-002b) designed for use with reSET-O was developed to assist in unsupervised buprenorphine initiation.

OBJECTIVE

The primary objective of this pilot study is to evaluate the acceptability of PEAR-002b in individuals with OUD who use it to support buprenorphine initiation, their unsupervised buprenorphine initiation success rate, and their medication adherence.

METHODS

Ten adults with OUD will be recruited for acceptability and feasibility testing. Outcomes will be assessed using week-1 visit attendance, participant interviews and satisfaction surveys, and urine drug screening (UDS). Three tools will be used in the study: PEAR-002b, reSET-O, and EmbracePlus. PEAR-002b includes a new set of features designed for use with reSET-O. The mechanism of action for the combined PEAR-002b and reSET-O treatment is a program of medication dosing support during week 1 of the initiation phase, cognitive behavioral therapy, and contingency management. During the medication initiation phase, participants are guided through a process to support proper medication use. PEAR-002b advises them when to take their buprenorphine based on provider inputs (eg, starting dose), self-reported substance use, and self-reported withdrawal symptoms. This study also administers the EmbracePlus device, a medical-grade smartwatch, to pilot methods for collecting physiologic data (eg, heart rate and skin conductance) and evaluate the device's potential for use along with PDTs that are designed to improve OUD treatment initiation. Home buprenorphine initiation success will be summarized as the proportion of participants attending the post-buprenorphine initiation visit (week 1) and the proportion of participants who experience buprenorphine initiation-related adverse events (eg, precipitated withdrawal). Acceptability of PEAR-002b will be evaluated based on individual participants' ratings of ease of use, satisfaction, perceived helpfulness, and likelihood of recommending PEAR-002b. Medication adherence will be evaluated by participant self-report data and confirmed by UDS. UDS data will be summarized as the mean of individual participants' proportion of total urine samples testing positive for buprenorphine or norbuprenorphine over the 4-week study.

RESULTS

This project was funded in September 2019. As of September 2022, participant enrollment is ongoing.

CONCLUSIONS

This is the first study to our knowledge to develop a PDT that assists with unsupervised buprenorphine initiation with the intent to better support patients and prescribers during this early phase of treatment. This pilot study will assess the acceptability and utility of a digital therapeutic to assist individuals with OUD with unsupervised buprenorphine initiation.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05412966; https://clinicaltrials.gov/ct2/show/NCT05412966.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/43122.

Oxycodone self-administration and reinstatement in male and female squirrel monkeys: Effects of alternative reinforcer availability

The use of non-drug alternative reinforcers has long been utilized as a component of therapeutic interventions for the management of substance use disorder; however, the conditions under which alternative reinforcers are most effective are not well characterized. This study evaluated the impact of varying the magnitude of an alternative reinforcer on oxycodone self-administration and reinstatement in male and female squirrel monkeys. Subjects (n=4/sex) were trained under concurrent second-order schedules of reinforcement for intravenous oxycodone (0.001-0.1mg/kg/inj) on one lever, and sweetened condensed milk (5, 10, 20, 30% in water) on another. Oxycodone-primed reinstatement was evaluated by administering 0.32mg/kg oxycodone prior to sessions in which saline was available on the drug-paired lever. During oxycodone self-administration sessions, milk availability decreased oxycodone self-administration and preference in a concentration-dependent manner; low milk concentrations were more effective at decreasing oxycodone’s reinforcing potency in males. During reinstatement tests, milk significantly attenuated oxycodone-primed responding in both males and females; low milk concentrations were more effective at decreasing the priming effects of oxycodone in females. That alternative reinforcers differentially impacted self-administration and reinstatement in a sex-dependent manner suggests that treatment strategies that utilize alternative reinforcers may be more effective in males or females depending on when they are implemented.

Addressing stimulant use disorder through state opioid response grants from the substance abuse and mental health services administration: Missouri's initial approach

Background: The alarming growth of stimulant-involved deaths underscores the urgent need for states to expand existing opioid-specific approaches to intentionally reach and serve people who use stimulants. Recent permission from federal agencies has allowed states to spend grant funding that was previously restricted to opioid-related activities on approaches addressing stimulant use.Objectives: This manuscript describes the rationale, methods, and initial results supporting the implementation of Missouri's recent stimulant-focused efforts - including previously-prohibited activities such as Contingency Management and fentanyl test strip distribution.Methods: Missouri's State Opioid Response team facilitated the design and implementation of Contingency Management pilot programming abiding by federal spending limits of no more than $75 of incentives per client, mass distribution of fentanyl test strips, and publicly accessible harm reduction trainings and materials specific to stimulant use. Data sources used for initial evaluations included state-level treatment claims, fentanyl test strip distribution counts by type and region of organizations receiving them, and qualitative feedback from stakeholders.Results: Six substance use treatment agencies developed Contingency Management programs, serving 29 individuals in the first nine months. Over 20,000 fentanyl test strips were distributed using a prioritization system designed to reach those most likely to benefit from their use.Conclusions: Recent federally funded efforts to better address stimulant use in Missouri have increased access to evidence-based treatment and harm reduction resources. Lessons learned from early implementation, especially those regarding time allowed for program development and how best to ensure equitable resource distribution, will inform future stimulant-focused program efforts.

Additive roles of tobacco and cannabis co-use in relation to delay discounting in a sample of heavy drinkers

RATIONALE

Alcohol use disorder (AUD) is associated with steeper delay discounting rates; however, it is unknown whether substance co-use, particularly cannabis use, has an additive effect on discounting rates among heavy drinkers. Furthermore, it is unclear whether substance co-use and delay discounting are independently associated with AUD severity.

OBJECTIVES

The purpose of this study was to determine whether alcohol, tobacco, and cannabis co-use impacts delay discounting rates. We also sought to determine whether substance co-use and delay discounting were associated with AUD symptom counts.

METHODS

The study sample was culled from several human laboratory studies and consisted of 483 heavy drinking individuals who completed a baseline visit (prior to experimental procedures). Participants were divided into groups based on self-reported alcohol, tobacco, and cannabis use during the past 30 days: alcohol only (n = 184), alcohol + cigarettes (n = 89), alcohol + cannabis (n = 82), and tri-use (n = 128). We examined discounting rates across the 4 groups and used multiple linear regression to test whether co-use and delay discounting were associated with AUD symptoms.

RESULTS

After adjusting for covariates, individuals in the alcohol + cannabis group and the tri-use group had steeper discounting rates relative to the alcohol-only group. In addition, tri-use and delay discounting rates were independently correlated with a greater number of AUD symptoms.

CONCLUSIONS

Delay discounting rates were significantly greater among subgroups reporting cannabis use providing partial support for an additive effect, while also highlighting the importance of co-use substance type. Both tri-use and delay discounting were associated with greater AUD severity, which may provide relevant intervention targets.

Mobile contingency management for smoking cessation among socioeconomically disadvantaged adults: Protocol for a randomized trial

BACKGROUND

Smoking rates remain high among socioeconomically disadvantaged adults. Offering small escalating financial incentives for abstinence (i.e., contingency management [CM]), alongside clinic-based treatment dramatically increases cessation rates in this vulnerable population. However, innovative approaches are needed for those who are less able to attend office visits. The current study will evaluate an automated mobile phone-based CM approach that will allow socioeconomically disadvantaged individuals to remotely earn financial incentives for smoking cessation.

METHODS

The investigators have previously combined technologies, including 1) carbon monoxide monitors that connect with mobile phones to remotely verify abstinence, 2) facial recognition software to confirm identity during breath sample submissions, and 3) automated delivery of incentives triggered by biochemical abstinence confirmation. This automated CM approach will be evaluated in a randomized controlled trial of 532 low-income adults seeking cessation treatment. Participants will be randomly assigned to telephone counseling and nicotine replacement therapy (standard care [SC]) or SC plus mobile financial incentives (CM) for abstinence.

RESULTS

Biochemically-verified 7-day point prevalence abstinence at 26 weeks post-quit is the primary outcome. The cost-effectiveness of the interventions will be evaluated. Potential treatment mechanisms, including self-efficacy, motivation, and treatment engagement, will be explored to optimize future interventions.

DISCUSSION

Automated mobile CM may offer a low-cost approach to smoking cessation that can be combined with telephone counseling and pharmacological interventions. This approach represents a critical step toward the widespread dissemination of CM treatment to real-world settings, to reduce tobacco-related disease and disparities.

Examining Ways to Improve Weight Control Programs' Population Reach and Representativeness: A Discrete Choice Experiment of Financial Incentives

BACKGROUND

Both theoretical and empirical evidence supports the potential of modest financial incentives to increase the reach of evidence-based weight control programs. However, few studies exist that examine the best incentive design for achieving the highest reach and representativeness at the lowest cost and whether or not incentive designs may be valued differentially by subgroups that experience obesity-related health disparities.

METHODS

A discrete choice experiment was conducted (n = 1232 participants; over 90% of them were overweight/obese) to collect stated preference towards different financial incentive attributes, including reward amount, program location, reward contingency, and payment form and frequency. Mixed logit and conditional logit models were used to determine overall and subgroup preference ranking of attributes. Using the National Health and Nutrition Examination Survey data sample weights and the estimated models, we predicted US nationally representative participation rates by subgroups and examined the effect of offering more than one incentive design. External validity was checked by using a completed cluster randomized control trial.

RESULTS

There were significant subgroup differences in preference toward incentive attributes. There was also a sizable negative response to larger incentive amounts among African Americans, suggesting that higher amounts would reduce participation from this population. We also find that offering participants a menu of incentive designs to choose from would increase reach more than offering higher reward amounts.

CONCLUSIONS

We confirmed the existence of preference heterogeneity and the importance of subgroup-targeted incentive designs in any evidence-based weight control program to maximize population reach and reduce health disparities.

Engagement in Digital Mental Health Interventions: Can Monetary Incentives Help?

Digital mental health interventions (DMHI) are scalable and cost-effective strategies for increasing access to mental health care; however, dropout rates associated with digital interventions are high, particularly for open-access digital interventions. While some studies have focused on predictors of dropout from digital mental health programs, few studies have focused on engagement features that might improve engagement. In this perspective article, we discuss whether monetary incentives (MI) are one avenue to increasing user engagement in DMHI. We begin by reviewing the literature on the effects of MI for behavior change in health domains (e.g., dietary behaviors, substance use, and medication adherence). Then, drawing on a pilot study we conducted to test the effects of different levels of MI on usage and improvement in subjective well-being among users of a DMHI (Happify), we discuss the potential applications of MI for DMHI, the potential drawbacks of financial incentives in this context, and open questions for future research.

Feasibility and Acceptability of reSET-O®: Patient and Provider Reported Experiences in a Pilot Study of a Mobile Novel Digital Therapeutic in People with Opioid Use Disorder (Preprint)

Background

Objective

Methods

Results

Conclusions

A Behavior-Analytic Approach to Antivaccination Practices

In recent years, there has been an increase in outbreaks of diseases that are preventable by vaccination. As vaccination involves behavior, behavior analysts are uniquely positioned to contribute solutions to this socially significant problem. The present article explores a behavior-analytic approach to understanding the function of the behavior of both people who have their children vaccinated and those who do not have their children vaccinated, and potential interventions to increase vaccination rates. An introduction to the problem is followed by a brief history of the antivaccination movement. In our analysis, a failure to vaccinate is conceptualized as a noncompliance response (i.e., medical nonadherence), and conditions giving rise to that noncompliance are evaluated. In this process, the roles of avoidance, the functional-altering impact of rule-governed behavior, relational frames, and countercontrol are considered. Potential solutions informed by applied behavior-analytic literature, including contingency management and behavioral safety, are discussed.

Self-efficacy as a mediator of patient navigation interventions to engage persons living with HIV and substance use

BACKGROUND

People living with HIV who report substance use (PLWH-SU) face many barriers to care, resulting in an increased risk for poor health outcomes and the potential for ongoing disease transmission. This study evaluates the mechanisms by which Patient Navigation (PN) and Contingency Management (CM) interventions may work to address barriers to care and improve HIV outcomes in this population.

METHODS

Mediation analysis was conducted using data from a randomized, multi-site trial testing PN interventions to improve HIV care outcomes among 801 hospitalized PLHW-SU. Direct and indirect effects of PN and PN + CM were evaluated through five potential mediators-psychosocial conditions, healthcare avoidance, financial hardship, system barriers, and self-efficacy for HIV treatment adherence-on engagement in HIV care and viral suppression.

RESULTS

The PN + CM intervention had an indirect effect on improving engagement in HIV care at 6 months by increasing self-efficacy for HIV treatment adherence (β = 0.042, 95% CI = 0.008, 0.086). PN + CM also led to increases in viral suppression at 6 months (β = 0.090, 95% CI = 0.023, 0.168) and 12 months (β = 0.069, 95% CI = 0.009, 0.129) via increases in self-efficacy, although the direct effects were not significant. No mediating effects were observed for PN alone.

CONCLUSION

PN + CM interventions for PLWH-SU can increase an individual's self-efficacy for HIV treatment adherence, which in turn improves engagement in care at 6 months and may contribute to viral suppression over 12 months. Building self-efficacy may be a key factor in the success of such interventions and should be considered as a primary goal of PN + CM in practice.

Safety and efficacy of a prescription digital therapeutic as an adjunct to buprenorphine for treatment of opioid use disorder

OBJECTIVES

To evaluate the safety and efficacy of a digital therapeutic in treatment-seeking individuals with opioid use disorder (OUD) in an analysis of randomized clinical trial (RCT) data (ClinicalTrials.gov identifier: NCT00929253).

METHODS

Secondary analysis of an RCT including 170 adults meeting DSM-IV criteria for OUD. Participants were randomized to 12-weeks of treatment-as-usual (TAU) or TAU plus a digital therapeutic providing 67 digital, interactive educational modules based on the Community Reinforcement Approach. TAU consisted of buprenorphine maintenance therapy, 30 min biweekly clinician interaction, and abstinence-based contingency management. Primary endpoints were treatment retention and abstinence (negative urine drug screen) during weeks 9-12 of treatment. Safety was assessed by evaluating adverse events.

RESULTS

Participants randomized to TAU plus a digital therapeutic had significantly greater odds of opioid abstinence during weeks 9-12 compared to TAU: 77.3 versus 62.1%, respectively (p=.02), OR 2.08, 95% CI 1.10-3.95. The risk of patients leaving treatment was significantly lower in the digital therapeutic group (HR 0.49, 95% CI 0.26-0.92). No significant difference was observed in the rate of adverse events between groups (p=.42).

CONCLUSIONS

A prescription digital therapeutic (PDT) in combination with buprenorphine therapy improves clinically significant patient outcomes including abstinence from illicit opioids and retention in treatment compared with treatment as usual.

The use of financial incentives to prevent unhealthy behaviors: A review

Behaviors that are putting people's health at risk are widespread and some of them are on the rise. Some of these behaviors can be prohibited or prevented by taxation. But financial incentives such as conditional cash transfers are also increasingly proposed and tested to discourage such behaviors, in domains as varied as HIV/AIDS, drugs, alcohol, smoking, and obesity. This paper presents the theoretical justification for using such incentives, distinguishing between the price, income effects, and the nudge effects. The growing literature about the effectiveness of financial incentives to prevent undesirable behaviors is reviewed in detail for each type of harmful behavior. Finally, the paper discusses the long-term sustainability of such incentives, a key issue if they are to be scaled up beyond pilot programs and research projects. The current evidence on whether such incentives have an impact after they are discontinued is mixed. Some design features, like lotteries or commitment devices, could induce savings as well as increase effectiveness, therefore improving sustainability.

Relative expected value of drugs versus competing rewards underpins vulnerability to and recovery from addiction

Behavioural economic theories of addiction contend that greater expected value of drug relative to alternative non-drug rewards is the core mechanism underpinning vulnerability to and recovery from addiction. To evaluate this claim, we exhaustively review studies with human drug users that have measured concurrent choice between drugs vs. alternative rewards, and explored individual differences. These studies show that drug choice can be modulated by drug cues, drug devaluation, imposition of costs/punishment and negative mood induction. Regarding individual differences, dependence severity was reliably associated with overall drug preference, and self-reported drug use to cope with negative affect was reliably associated with greater sensitivity to mood induced increases in drug choice. By contrast, there were no reliable individual differences in sensitivity to the effect of drug cues, drug devaluation or punishment on drug choice. These findings provide insight into the mechanisms that underpin vulnerability to dependence: vulnerability is conferred by greater relative value ascribed to drugs, and relative drug value is further augmented by negative affective states in those who report drug use coping motives. However, dependence does not appear to be characterised by abnormal cue-reactivity, habit learning or compulsion. We then briefly review emerging literature which demonstrates that therapeutic interventions and recovery from addiction might be attributed to changes in the expected relative value of drug versus alternative rewards. Finally, we outline a speculative computational account of the distortions in decision-making that precede action selection in addiction, and we explain how this account provides a blueprint for future research on the determinants of drug choice, and mechanisms of treatment and recovery from addiction. We conclude that a unified economic decision-making account of addiction has great promise in reconciling diverse addiction theories, and neuropsychological evaluation of the underlying decision mechanisms is a fruitful area for future research and treatment.

Automated Mobile Delivery of Financial Incentives for Smoking Cessation Among Socioeconomically Disadvantaged Adults: Feasibility Study

BACKGROUND

Socioeconomic disadvantage is associated with a reduced likelihood of smoking cessation. Smartphone ownership is increasing rapidly, including among low-income adults, and smartphone interventions for smoking cessation may increase access to smoking cessation treatment among socioeconomically disadvantaged adults.

OBJECTIVE

This study aimed to evaluate the feasibility of an automated smartphone-based approach to delivering financial incentives for smoking cessation.

METHODS

Socioeconomically disadvantaged adults initiating tobacco cessation treatment were followed from 1 week before a scheduled quit attempt through 26 weeks after the quit date. Participants received telephone counseling and nicotine replacement therapy. Smoking cessation was verified 5 times per week via smartphone prompts to self-report smoking status and submit a breath sample via a portable carbon monoxide (CO) monitor that was connected with participants' smartphones. Identity was verified during smoking status assessments using smartphone-based facial recognition software. When smoking abstinence and identity were verified, an automated credit card payment was triggered. Participants were incentivized for abstinence on the quit date and up to five days per week during the first 4 weeks after the scheduled quit date, with additional incentives offered during postquit weeks 8 and 12. In total, participants had the opportunity to earn up to US $250 in abstinence-contingent incentives over the first 12 weeks of the quit attempt.

RESULTS

Participants (N=16) were predominantly female (12/16, 75%) and non-Hispanic white (11/16, 69%), black (4/16, 25%), or Hispanic of any race (1/16, 6%). Most participants (9/16, 56%) reported an annual household income of <US $11,000. During the first 4 weeks after the scheduled quit date, participants completed a median of 16 (out of 21; range 1-21) mobile smoking status assessments, and they earned a median of US $28 in abstinence-contingent incentives (out of a possible US $150; range US $0-US $135). Median earnings did not change during the 8- and 12-week incentivized follow-up periods (total median earnings over 12 weeks=US $28; range US $0-US $167). During the first 4 weeks after the scheduled quit date, participants abstained from smoking on a median of 5 (out of 21) assessment days (range 0-20). At the in-person follow-up visits, the expired CO-confirmed 7-day point prevalence abstinence rates were 19% (3/16) and 13% (2/16) at 12 and 26 weeks postquit, respectively. Overall, most participants reported that the system was easy to use and that they would recommend this treatment to their friends and family.

CONCLUSIONS

Preliminary data suggest that this smartphone-based approach to verifying identity and smoking status and automating the delivery of abstinence-contingent incentives to a credit card is feasible for use among socioeconomically disadvantaged adults. However, continued refinement is warranted.

Parallel modeling of pain and depression in prediction of relapse during buprenorphine and naloxone treatment: A finite mixture model

BACKGROUND

Relapse is common in treatment for opioid use disorders (OUDs). Pain and depression often co-occur during OUD treatment, yet little is known about how they influence relapse among patients with a primary diagnosis of prescription opioid use disorder (POUD). Advanced statistical analyses that can simultaneously model these two conditions may lead to targeted clinical interventions.

METHOD

The objective of this study was to utilize a discrete survival analysis with a growth mixture model to test time to prescription opioid relapse, predicted by parallel growth trajectories of depression and pain, in a clinical sample of patients in buprenorphine/naloxone treatment. The latent class analysis characterized heterogeneity with data collected from the National Institute of Drug Abuse Clinical Trials Network project (CTN-0030).

RESULTS

Results suggested that a 4-class solution was the most parsimonious based on global fit indices and clinical relevance. The 4 classes identified were: 1) low relapse, 2) high depression and moderate pain, 3) high pain, and 4) high relapse. Odds ratios for time-to-first use indicated no statistically significant difference in time to relapse between the high pain and the high depression classes, but all other classes differed significantly.

CONCLUSION

This is the first longitudinal study to characterize the influence of pain, depression, and relapse in patients receiving buprenorphine and naloxone treatment. These results emphasize the need to monitor the influence of pain and depression during stabilization on buprenorphine and naloxone. Future work may identify appropriate interventions that can be introduced to extend time-to-first prescription opioid use among patients.

Randomized controlled trial of d-cycloserine in cocaine dependence: Effects on contingency management and cue-induced cocaine craving in a naturalistic setting

Cocaine dependence constitutes a significant public health concern. This randomized, double-blind, placebo-controlled trial tested a novel approach to reducing cocaine use among cocaine-dependent individuals with d-cycloserine, a drug known to enhance learning and some learning-based therapies. Urine samples and cocaine craving were assessed across three phases: induction (Weeks 1-2), treatment (Weeks 3-5; urinalysis-based contingency management plus exposure therapy), and posttreatment (Weeks 6-7). During the treatment phase, either 50 mg of d-cycloserine or placebo was administered after delivery of urinalysis feedback with potential monetary reward and before exposure therapy sessions in naturalistic contexts individually associated with cocaine use. d-cycloserine significantly improved learning on an operant laboratory task. Contingency management significantly reduced cocaine use and craving. d-cycloserine did not significantly affect cocaine use or craving in the treatment phase. Craving significantly increased for the d-cycloserine group during the post treatment phase. Therefore, although the study showed that d-cycloserine was capable of improving learning, enhancement of learning-based therapy was not observed. Moreover, no differences in behavioral measures of cocaine demand (cocaine purchasing task) or monetary or sexual delay discounting were observed across phases or between groups in any phase. These results are somewhat consistent with previous findings suggesting that d-cycloserine administration increases cocaine craving, although they differ from other findings showing that d-cycloserine administration reduces alcohol or nicotine cravings. Methodological variables (e.g., guided vs. unguided exposure therapy sessions, length of extinction exposure) likely play a role in dissimilar findings observed across studies. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

An operant social self-administration and choice model in rats

It is difficult to translate results from animal research on addiction to an understanding of the behavior of human drug users. Despite decades of basic research on neurobiological mechanisms of drug addiction, treatment options remain largely unchanged. A potential reason for this is that mechanistic studies using rodent models do not incorporate a critical facet of human addiction: volitional choices between drug use and non-drug social rewards (e.g., employment and family). Recently, we developed an operant model in which rats press a lever for rewarding social interaction with a peer and then choose between an addictive drug (heroin or methamphetamine) and social interaction. Using this model, we showed that rewarding social interaction suppresses drug self-administration, relapse to drug seeking, and brain responses to drug-associated cues. Here, we describe a protocol for operant social interaction using a discrete-trial choice between drugs and social interaction that causes voluntary abstinence from the drug and tests for incubation of drug craving (the time-dependent increase in drug seeking during abstinence). This protocol is flexible but generally requires 8-9 weeks for completion. We also provide a detailed description of the technical requirements and procedures for building the social self-administration and choice apparatus. Our protocol provides a reliable way to study the role of operant social reward in addiction and addiction vulnerability in the context of choices. We propose that this protocol can be used to study brain mechanisms of operant social reward and potentially impairments in social reward in animal models of psychiatric disorders and pain.

Non-pharmacological factors that determine drug use and addiction

Based on their pharmacological properties, psychoactive drugs are supposed to take control of the natural reward system to finally drive compulsory drug seeking and consumption. However, psychoactive drugs are not used in an arbitrary way as pure pharmacological reinforcement would suggest, but rather in a highly specific manner depending on non-pharmacological factors. While pharmacological effects of psychoactive drugs are well studied, neurobiological mechanisms of non-pharmacological factors are less well understood. Here we review the emerging neurobiological mechanisms beyond pharmacological reinforcement which determine drug effects and use frequency. Important progress was made on the understanding of how the character of an environment and social stress determine drug self-administration. This is expanded by new evidence on how behavioral alternatives and opportunities for drug instrumentalization generate different patterns of drug choice. Emerging evidence suggests that the neurobiology of non-pharmacological factors strongly determines pharmacological and behavioral drug action and may, thus, give rise for an expanded system's approach of psychoactive drug use and addiction.

Are animal models of addiction useful?

BACKGROUND

Pre-clinical research involving non-human animals has made important contributions to our understanding of risk factors for addiction, neuroadaptations that follow chronic drug exposure and to the development of some efficacious pharmacotherapies for addiction. Despite these contributions, we argue that animal models of addiction have impeded progress in our understanding of addiction and its treatment in humans.

ARGUMENT

First, the majority of pharmacological treatments that were initially developed using animal models have failed to prove effective for the treatment of addiction in humans, resulting in a huge waste of resources. Secondly, we demonstrate that prevailing animal models that portray addiction as a disorder of compulsion and habit cannot be reconciled with observations that psychoactive drug use in humans is a goal-directed operant behaviour that remains under the control of its consequences, even in people who are addicted. Thirdly, addiction may be a uniquely human phenomenon that is dependent on language, which necessarily limits the validity of animal models. Finally, we argue that addicted brains must be understood as one component of broader networks of symptoms and environmental and social factors that are impossible to model in laboratory animals.

CONCLUSIONS

A case can be made that animal models of addiction have not served us well in understanding and treating addiction in humans. It is important to reconsider some widely held beliefs about the nature of addictive behaviour in humans that have arisen from the zeal to translate observations of laboratory animals.

Interventions to Reduce Drug Use Among Methamphetamine Users at Risk for HIV

PURPOSE OF REVIEW

This paper reports on the results of a study comparing two behavioral treatments for methamphetamine users. The outcome was the effectiveness of the interventions in reducing meth use. The interventions were contingency management (CM) and contingency management plus strengths-based case management (CM/SBCM).

RECENT FINDINGS

CM/SBCM was found to be associated with attending more sessions for people who reported being in a couple. Also, participants who earned more money in the first part of the study were more likely to have more clean urinalysis in the second part of the study. Latent class analysis identified a class of participants who were in a couple, without sexual abuse history, and less meth use at baseline. This class tended to have more clean urinalysis in the CM/SBCM intervention. These results indicate that incentive-based interventions with case management may be useful for helping meth users reduce their drug use.

Advances in behavioral animal models of alcohol use disorder

Alcohol use disorder (AUD) is a multifaceted neuropsychiatric disease that combines behavioral, psychosocial, and neurobiological aspects. Over the previous decade, animal models have advanced in modeling the major psychological constructs that characterize AUD. These advances pave the road for more sophisticated behavioral models that capture addiction-related aspects, such as alcohol craving, compulsive seeking and intake, dependence, and relapse. In this review, we survey the recent progress in behavioral animal modeling of five aspects of AUD: alcohol consumption, dependence, and seeking; compulsivity in alcohol intake despite adverse outcomes; vulnerability and resilience factors in alcohol addiction; relapse despite treatment; and relapse prevention by manipulating alcohol-associated memory reconsolidation. These advances represent a general attempt to grasp the complexity and multidimensional nature of AUD, and to focus on behavioral characteristics that better reflect and model this disorder.

Understanding the link between contingency management and smoking cessation: The roles of sex and self-efficacy

INTRODUCTION

Little is known about the mechanisms linking contingency management (CM) treatment with smoking cessation, and recent research suggests that the CM approach is associated with better smoking cessation outcomes among females than males. The current study investigated self-efficacy as a potential mechanism through which CM treatment influences smoking cessation, and explored whether these relationships differed by sex.

METHODS

Participants (N = 139) were primarily Black (63.3%) and female (57.6%) adults enrolled in a safety-net hospital smoking cessation program. Participants received usual care (UC), which included pharmacotherapy and counseling sessions (n = 66) or a CM intervention (UC + 4 weeks of small, abstinence contingent financial incentives; n = 73). Self-efficacy for quitting was measured on the day after quitting with the Self-Efficacy Scale/Confidence (SESC) questionnaire. Mediation analyses were conducted to evaluate the indirect effects of treatment group on biochemically-verified abstinence (4-weeks post-quit) via self-efficacy, and moderated mediation analyses were conducted to evaluate the moderating role of sex.

RESULTS

Self-efficacy was not found to mediate the relations between CM treatment and smoking cessation in the overall sample. However, analyses indicated a significant moderating effect of sex on the indirect effect of treatment group on smoking cessation through self-efficacy (each of the 3 SESC subscales). Specifically, there was a stronger association between CM and greater self-efficacy among females than males.

CONCLUSION

Findings suggest that CM treatment had a differing impact on self-efficacy among males and females, which in turn influenced the likelihood of smoking cessation.

Free will in addictive behaviors: A matter of definition

Certain people are at risk for using alcohol or other drugs excessively and for developing problems with their use. Their susceptibility might arise from a variety of factors, including their genetic make-up, brain chemistry, family background, personality and other psychological variables, and environmental and sociocultural variables. Moreover, after substance use has become established, there are additional cognitive-motivational variables (e.g., substance-related attentional bias) that contribute to enacting behaviors consistent with the person's motivation to acquire and use the substance. People who are at such risk are likely to choose to use addictive substances even though doing so entails negative consequences. In the sense of complete freedom from being determined by causal factors, we believe that there is no such thing as free will, but defined as ability to make choices from among multiple options, even though the choices are ultimately governed by natural processes, addicted individuals are free to choose. Although they might appear unable to exercise this kind of free will in decisions about their substance use, addictive behaviors are ultimately always goal-directed and voluntary. Such goal pursuits manifest considerable flexibility. Even some severely addicted individuals can cease their use when the value of continuing the use abruptly declines or when the subjective cost of continuing the use is too great with respect to the incentives in other areas of their lives. Formal treatment strategies (e.g., contingency management, Systematic Motivational Counseling, cognitive training) can also be used to facilitate this reversal.

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

Influencing quality of outpatient SUD care: Implementation of alerts and incentives in Washington State

Financial incentives for quality improvement and feedback on specific clients are two approaches to improving the quality of treatment for individuals with substance use disorders. We examined the impacts of these interventions in Washington State by randomizing outpatient substance use treatment agencies into intervention and control groups. From October 2013 through December 2015, agencies could earn financial incentives for meeting performance goals incorporating both achievement relative to a benchmark and improvement from agencies' own baselines. Weekly feedback was e-mailed to agencies in the alert or alert plus incentives arms. Difference-in difference regressions controlling for client and agency characteristics showed that none of the interventions significantly affected client engagement after outpatient admissions, overall or for sub-groups based on race/ethnicity, age, rural residence, or agency baseline performance. Treatment agencies offered insights related to several themes: delivery system context (e.g., agency time and resources needed during transition to a managed behavioral healthcare system), implementation (e.g., data lag), agency issues (e.g., staff turnover), and client factors (e.g., motivation). Interventions took place during a time of Medicaid expansion and planning for statewide integration of mental health and substance use disorder treatment into a managed care model, which may have resulted in agencies not responding to the interventions. Moreover, incentives and alerts at the agency-level may not be effective when factors are at play beyond the agency's control.

An open-label pilot study of an intervention using mobile phones to deliver contingency management of tobacco abstinence to high school students

This pilot study assessed the feasibility, acceptability, and preliminary efficacy of a smoking cessation intervention that used mobile phones to remotely deliver reinforcements contingent on tobacco abstinence (contingency management [CM]) and weekly in-person cognitive-behavioral therapy to adolescent smokers. Daily adolescent smokers (N = 15; 12 completed study procedures, 3 dropped out) were recruited to participate in a 4-week study. During the first 2 weeks, daily text messages sent at random times prompted participants to transmit a video of themselves providing a carbon monoxide (CO) sample. During the last 2 weeks, text messages sent on 3 randomly chosen days each week prompted participants to transmit a video of themselves providing a saliva sample. Negative samples (CO ≤8 ppm; cotinine ≤100 ng/ml) were reinforced with monetary incentives. Feasibility was assessed using the number of on-time, valid videos, and acceptability was determined using participant perceptions of the intervention. Seven-day point-prevalence (PP) abstinence (self-reported abstinence, cotinine <100 ng/ml) was assessed at end of treatment (EOT) and at a 1-month follow-up. The study findings indicate that remote delivery of CM using mobile phones was feasible (85.8% of the CO videos and 67% of the saliva cotinine videos were on time) and acceptable (positive perceptions of the CM procedures). Seven-day PP was 60% at EOT and 46.7% at the follow-up. Although larger randomized controlled trials are needed to evaluate efficacy, this pilot study suggests that the use of mobile phones to deliver CM for smoking cessation among adolescent smokers was acceptable and feasible. (PsycINFO Database Record

Incentivizing attendance to prolonged exposure for PTSD with opioid use disorder patients: A randomized controlled trial

OBJECTIVE

To determine whether contingent monetary incentives increase opioid use disorder patients' attendance to Prolonged Exposure (PE) therapy and whether attendance is associated with improvement in posttraumatic stress disorder (PTSD) and substance use disorder (SUD) outcomes.

METHOD

Patients (N = 58) with PTSD were offered PE or PE with incentives (PE + I; max $480) to attend PE sessions. Participants were assessed at baseline and weeks 6, 12, and 24 postrandomization.

RESULTS

Participants were mostly women (79%) and Caucasian (71%); mean age 37.43 years (SD = 11.33). PE + I participants attended a median of 9 (of 12) sessions compared to 1 session for PE participants (p < .001), which included more exposure sessions (PE + I mdn = 6; PE mdn = 0; p < .001). A Time × treatment condition interaction indicated that PE + I participants exhibited a greater decrease in PTSD severity over time than PE participants (OR = 3.1; 95% CI = 0.4-5.7; p = .024). PE + I participants remained in substance use treatment longer than PE participants (mdn days = 262 vs. 192; p = .039). There were no group differences in drug use.

CONCLUSIONS

Monetary incentives increased SUD patients' attendance to an otherwise poorly attended treatment for PTSD. Better attendance in the incentivized group was associated with greater PTSD improvement, better SUD treatment retention, and no increased drug use. Incentives are well supported for improving adherence to substance use treatment goals and promising as a means to improve therapy attendance, which may improve the effectiveness of existing psychotherapies in difficult-to-treat populations. (PsycINFO Database Record

Neuroscience-Inspired, Behavioral Change Program for University Students

It is clear that environmental influences impact the structure and function of the human brain, and thus, thoughts, actions, and behaviors. These in turn influence whether an individual engages in high-risk (drugs, alcohol, violence) or health-promoting (exercise, meditation, music) activities. The developmental mismatch between cortical and subcortical maturation of the transitional age brain places college students at risk for negative outcomes. This article argues that the prescription of incentive-based behavioral change and brain-building activities simply make good scientific, programmatic, and financial sense for colleges and universities. The authors present University of Vermont Wellness Environment as an example.

Incubation of Methamphetamine but not Heroin Craving After Voluntary Abstinence in Male and Female Rats

We recently introduced an animal model of incubation of methamphetamine craving after choice-based voluntary abstinence in male rats. Here we studied the generality of this phenomenon to (1) female rats, and (2) male and female rats with a history of heroin self-administration. We first trained rats to self-administer palatable food pellets for 6 days (6 h per day) for either methamphetamine (0.1 mg/kg/infusion) or heroin (0.1 mg/kg/infusion) for 12 days (6 h/day). We then assessed relapse to drug seeking under extinction conditions after 1 and 21 abstinence days. Between tests, the rats underwent either voluntary abstinence (achieved via a discrete choice procedure between drug and palatable food; 20 trials/day) or home-cage forced abstinence. We found no sex differences in methamphetamine self-administration or in the strong preference for the palatable food over methamphetamine during the choice-based voluntary abstinence. In both sexes, methamphetamine seeking in the relapse tests was higher after 21 days of either voluntary or forced abstinence than after 1 day (incubation of methamphetamine craving). We also found no sex differences in heroin self-administration or the strong preference for the palatable food over heroin during the choice-based voluntary abstinence. However, male and female rats with a history of heroin self-administration showed incubation of heroin craving after forced but not voluntary abstinence. Our results show that incubation of methamphetamine craving after voluntary abstinence generalizes to female rats. Unexpectedly, prolonged voluntary abstinence prevented the emergence of incubation of heroin craving in both sexes.

Insights from Preclinical Choice Models on Treating Drug Addiction

Substance-use disorders are a global public health problem that arises from behavioral misallocation between drug use and more adaptive behaviors maintained by nondrug alternatives (e.g., food or money). Preclinical drug self-administration procedures that incorporate a concurrently available nondrug reinforcer (e.g., food) provide translationally relevant and distinct dependent measures of behavioral allocation (i.e., to assess the relative reinforcing efficacy of the drug) and behavioral rate (i.e., to assess motor competence). In particular, preclinical drug versus food 'choice' procedures have produced increasingly concordant results with both human laboratory drug self-administration studies and double-blind placebo-controlled clinical trials. Accordingly, here we provide a heuristic framework of substance-use disorders based on a behavioral-centric perspective and recent insights from these preclinical choice procedures.

Contingency Management Interventions for HIV, Tuberculosis, and Hepatitis Control Among Individuals With Substance Use Disorders: A Systematized Review

Hepatitis, HIV and tuberculosis are significant and costly public health problems that disproportionately affect individuals with substance use disorders (SUDs). Incentive-based treatment approaches (i.e., contingency management; CM) are highly effective at reducing drug use. The primary aim of this report is to review the extant literature that examines the efficacy of CM interventions for the prevention, diagnosis and treatment of hepatitis, HIV and tuberculosis among individuals with SUDs. A literature search identified 23 controlled studies on this topic. In approximately 85% of the studies, CM produced significantly better adherence to prevention, diagnosis and treatment-related medical services, with adherence rates averaging almost 35% higher among patients receiving incentives vs. control condition participants. Findings from these studies parallel the results of a meta-analysis of CM interventions for the treatment of SUDs. The results also suggest that the principles that underlie the efficacy of CM generalize across infectious disease and substance abuse treatment behaviors. The application of additional principles from the literature on CM for treatment of SUDs to interventions targeting infectious disease control would be beneficial. Further development and dissemination of these interventions has the potential to greatly impact public health.

A Preliminary Investigation of a Relapse Prevention Mobile Application to Maintain Smoking Abstinence Among Individuals With Posttraumatic Stress Disorder

OBJECTIVES

Smokers with posttraumatic stress disorder (PTSD) have increased difficulty achieving and maintaining abstinence. Contingency management approaches to smoking cessation interventions have demonstrated short-term efficacy but are limited by high rates of relapse. The goal of this pilot study was to evaluate the usability and feasibility of a smartphone-based smoking cessation application (Stay Quit Coach) designed to prevent relapse among individuals with PTSD.

METHODS

Smokers (N = 11) were randomized to (1) QUIT4EVER, an intervention combining mobile contingency management smoking cessation counseling and medications, and Stay Quit Coach or (2) a contact control condition that was identical to QUIT4EVER except Stay Quit Coach was not included. The primary outcome was prolonged smoking abstinence.

RESULTS

Among those queried during the follow-up periods, average Stay Quit Coach helpfulness ratings were high and ranged from 7.25 to 10 on a 10-point Likert scale (with higher scores corresponding to greater helpfulness). The Stay Quit Coach was rated by participants as being most effective at helping to quit smoking, helping to remain quit, and providing support and relevant information about quitting. Among the three quitters in the QUIT4EVER group, all reported abstinence at 3 and 6 months; however, abstinence was only bioverified for one quitter at 6 months. Among the four quitters in the contact control condition group, three reported abstinence at 3 and 6 months, but abstinence was not confirmed by bioverification.

CONCLUSIONS

Smokers with PTSD express interest in and helpfulness of Stay Quit Coach for remaining abstinent after a quit attempt. Combined use of mobile contingency management and Stay Quit Coach is a feasible and acceptable adjunctive smoking cessation treatment for reducing smoking among smokers with PTSD. Adequately powered clinical trials are needed to demonstrate the long-term efficacy of this combined approach to smoking cessation. This study [Use of Technological Advances to Prevent Smoking Relapse among Smokers with PTSD (QUIT4EVER)] was registered on www.clinicaltrials.gov . clinicaltrials.gov identifier: NCT01990079.

Exercise as an Adjunctive Treatment for Substance Use Disorders: Rationale and Intervention Description

Substance use disorders (SUDs) are maladaptive patterns of substance use that are associated with psychiatric comorbidity, unhealthy lifestyle choices, and high rates of relapse. Exercise is associated with a wide range of acute and long-term benefits for both mental and physical health and is presently being investigated as a promising adjunctive treatment for SUD. Despite positive effects of regular physical activity on treatment outcomes and risk factors for relapse, low adherence and high attrition rates limit the benefits derived from exercise interventions. Lack of motivation is one of many perceived barriers to initiating exercise that contributes to poor adherence to interventions. In the present article, we describe the protocol for a novel, integrated exercise intervention that combines motivational interviewing (MI), a client-centered approach designed to enhance intrinsic motivation and resolve ambivalence toward change, and contingency management (CM), a behavioral treatment that provides monetary incentives for the completion of target behaviors. The protocol seeks to address the challenges surrounding initiation and maintenance of an exercise program at a level consistent with public health guidelines, particularly for sedentary patients. We conclude with considerations for the implementation of the intervention in SUD specific clinics.

Contingency Management: New Directions and Remaining Challenges for An Evidence-Based Intervention

This article introduces the special issue on contingency management (CM), an efficacious intervention for the treatment of substance use disorders with low uptake in clinical settings that is not commensurate with evidence for efficacy. In this special issue of the Journal of Substance Abuse Treatment, we present 16 articles representing the latest research in efficacy, implementation, and technological advances related to CM. Combined, this collection of articles highlights the diverse populations, settings, and applications of CM in the treatment of substance use disorders. We conclude by highlighting directions for future research, particularly those that may increase CM's appeal and uptake in routine clinical care.

Synthetic cannabinoids to avoid urine drug screens: Implications for contingency management and other treatments for drug dependence

Contingency management (CM) is an effective treatment for substance use dependence. Within CM, rewards or vouchers promote continued abstinence by acting as alternative reinforcers to substance use. However, CM relies on the use of accurate biochemical verification methods, such as urinalysis, to verify abstinence. Synthetic cannabinoids (SCs) pose a risk for CM treatment because they are not easily detected by common urinalysis techniques. Although SCs pose a risk, there is limited information regarding current rates of SC use within substance dependent populations as well as rates of substance use and psychiatric disorders among those who use SCs in treatment. We discuss emerging research on these topics and potential implications for CM treatments. Findings suggest CM researchers should test for and query SC use among those being treated for cannabis and cocaine use problems as well as among younger populations of substance users. Implications of other novel psychoactive substances for drug treatment and drug urinalysis are also discussed.

Behavioral Impulsivity Does Not Predict Naturalistic Alcohol Consumption or Treatment Outcomes

OBJECTIVE

The purpose of this study was to determine if behavioral impulsivity under multiple conditions (baseline, after alcohol consumption or after serotonin depletion) predicted naturalistic alcohol use or treatment outcomes from a moderation-based contingency management intervention.

METHOD

The current data analysis pulls information from three phases of a large study: 1) Phase 1 examined baseline and the effects of alcohol use and serotonin depletion on three types of behavioral impulsivity: response initiation (IMT task), response inhibition (GoStop task), and delay discounting (SKIP task); 2) Phase 2 involved 28 days of naturalistic drinking; and 3) Phase 3 involved 3 months of contingency management. During phases 2 and 3 alcohol use was measured objectively using transdermal alcohol monitors. The results of each individual phase has been previously published showing that at a group level the effects of alcohol consumption on impulsivity were dependent on the component of impulsivity being measured and the dose of alcohol consumed but serotonin depletion had no effect on impulsivity, and that a moderation-based contingency management intervention reduced heavy drinking.

RESULTS

The current analysis combining data from those who completed all three phases (n = 67) showed that impulsivity measured at baseline, after alcohol consumption, or after serotonin depletion did not predict naturalistic drinking or treatment outcomes from a moderation-based CM treatment.

CONCLUSIONS

Contingency management interventions may prove to be an effective intervention for impulsive individuals, however, normal variations in measured impulsivity do not seem to relate to normal variations in drinking pattern or response to moderation-based contingency management.

The Effectiveness of Ultra-Low Magnitude Reinforcers: Findings From a "Real-World" Application of Contingency Management

BACKGROUND

Research has consistently found contingency management (CM) to be an effective tool in increasing desired patient behaviors in substance use disorder (SUD) treatment. Despite the strong evidence for the effectiveness of this intervention, practical issues and the cost of implementing CM in treatment programs have been significant barriers to adoption.

OBJECTIVES

To evaluate the impact of a CM program designed and implemented by university-affiliated methadone clinic staff to increase patient group attendance. The CM program consisted of a weekly raffle for patients attending clinician-led group counseling and/or in-clinic Methadone Anonymous (MA) groups in which slips with patient ID#s were entered and one ID slip was drawn per week with a fee credit for a dose of methadone ($15) as the prize.

METHODS

The CM program continued for 12 months. Group attendance was tracked before, during, and after CM implementation as part of ongoing clinic service utilization monitoring.

RESULTS

Following the implementation of CM, attendance at any clinician-led or MA groups increased significantly from baseline to month 1 (X²=5.78, p<0.05) but this increase was not sustained beyond month 6. Analysis of attendance by type of group revealed that clinician-led group attendance did not increase significantly but there was a significant increase in in-clinic MA group attendance from baseline to month 1 (X²=20.27, p<0.001), which was sustained through the 12-month implementation period (X²=11.21, p<0.001) and through 3 months post-implementation (X²=14.73; p<0.001).

CONCLUSIONS

A low-cost, simple CM intervention implemented by clinic staff was associated with significant increases in the target behavior of increasing group attendance.

The Behavioral Economics and Neuroeconomics of Alcohol Use Disorders

BACKGROUND

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

FINDINGS

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

FUTURE DIRECTIONS

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

Noninvasive brain stimulation treatments for addiction and major depression

Major depressive disorder (MDD) and substance use disorders (SUDs) are prevalent, disabling, and challenging illnesses for which new treatment options are needed, particularly in comorbid cases. Neuroimaging studies of the functional architecture of the brain suggest common neural substrates underlying MDD and SUDs. Intrinsic brain activity is organized into a set of functional networks, of which two are particularly relevant to psychiatry. The salience network (SN) is crucial for cognitive control and response inhibition, and deficits in SN function are implicated across a wide variety of psychiatric disorders, including MDD and SUDs. The ventromedial network (VMN) corresponds to the classic reward circuit, and pathological VMN activity for drug cues/negative stimuli is seen in SUDs/MDD. Noninvasive brain stimulation (NIBS) techniques, including rTMS and tDCS, have been used to enhance cortico–striatal–thalamic activity through the core SN nodes in the dorsal anterior cingulate cortex, dorsolateral prefrontal cortex, and anterior insula. Improvements in both MDD and SUD symptoms ensue, including in comorbid cases, via enhanced cognitive control. Inhibition of the VMN also appears promising in preclinical studies for quenching the pathological incentive salience underlying SUDs and MDD. Evolving techniques may further enhance the efficacy of NIBS for MDD and SUD cases that are unresponsive to conventional treatments.

The Computational Complexity of Valuation and Motivational Forces in Decision-Making Processes

The concept of value is fundamental to most theories of motivation and decision making. However, value has to be measured experimentally. Different methods of measuring value produce incompatible valuation hierarchies. Taking the agent's perspective (rather than the experimenter's), we interpret the different valuation measurement methods as accessing different decision-making systems and show how these different systems depend on different information processing algorithms. This identifies the translation from these multiple decision-making systems into a single action taken by a given agent as one of the most important open questions in decision making today. We conclude by looking at how these different valuation measures accessing different decision-making systems can be used to understand and treat decision dysfunction such as in addiction.