Predictors of Suicidal Ideation and Continued Substance Use Problems Among Patients Receiving Methadone Maintenance Treatment Who Have Co-Occurring Cocaine Use Disorder

BACKGROUND

Persons with polysubstance use problems are at high suicide risk, which may complicate substance use treatment. The purpose of this study was to a) examine cross-sectional and longitudinal risk factors for suicidality among persons in methadone maintenance treatment who present with co-occurring cocaine use disorder and b) evaluate whether suicidality impacts substance use outcomes independently and differentially depending on treatment type (i.e. standard methadone care [SC] vs. contingency management plus standard care [CM + SC]).

METHODS

Data come from five randomized controlled trials of CM conducted within methadone clinics (N = 562). Participants were categorized (mutually exclusive) as no history of suicidality (56.4%, n=317), past suicidal ideation (SI; 11%, n=62), recent SI (3.6%, n=20), or lifetime suicide attempt (29%, n=163).

RESULTS

Suicidality groups differed by sex and baseline employment, income, trauma history, and psychosocial functioning. Suicide attempt history was positively associated with years of polysubstance use, prior drug treatments, and unintentional overdose history. Baseline psychological problem severity and emotional abuse history were associated with SI likelihood 12 weeks later. Past SI was associated with longer durations of abstinence than no suicidality. Unexpectedly, those with recent SI reported lower drug use severity at 12 week if they received SC compared to CM + SC. Effects were small to medium.

CONCLUSIONS

Despite greater polysubstance use history, patients with suicide attempts did not show worse substance use outcomes than persons without suicidality. Patients with past SI fared better than those without suicidality on abstinence over 12 wk. Methadone clinics could be key points of entrance and continued services for suicide prevention.

Mindfulness as an early intervention for hazardous alcohol use among non-treatment seeking Latine emerging adults: A mini-review

The age cohort referred to as emerging adults (ages 18-29 years old) demonstrates the most hazardous alcohol use in the United States (U.S.) Approximately one-third of emerging adults regularly engage in heavy episodic drinking (4/5 drinks in two hours females/males). Compared to their non-Latine White peers, Latine emerging adults in the U.S. report lower rates of heavy episodic drinking (HED) yet are at greater risk of developing a substance use disorder and experience more severe negative consequences from drinking alcohol. Despite their high-risk status, Latine emerging adults are less likely to seek treatment and have less access to innovative health-promoting resources, further exacerbating health inequities. Research has shown that practicing mindfulness can interrupt habituated cognitions, intrusive thinking, and automatic behaviors associated with hazardous drinking. However, Latine representation in MBI trials is minimal. This mini-review explores the potential value of mindfulness as an early intervention for hazardous alcohol use among Latine emerging adults. The review provides future directions for research, highlighting the need to design culturally and developmentally tailored MBIs that can provide a respectful, non-judgmental, and discrimination-free environment that appeals to Latine emerging adults. Additionally, conclusions are drawn regarding the possible benefits of pairing MBI with contingency management strategies to decrease attrition rates in MBI trials.

Percentage of negative urine drug screens as a clinically meaningful endpoint for RCTs evaluating treatment for cocaine use

BACKGROUND

This study examined a threshold based on the percentage of cocaine-negative (CN) urine drug screens (UDS) collected during treatment as a potential meaningful endpoint for clinical trials. We hypothesized that individuals providing at least 75% CN UDS would have better long-term outcomes than those providing less than 75% CN UDS.

METHODS

Two separate pooled datasets of randomized clinical trials conducted at different institutions were used for analyses: one composed of eight trials (N = 760) and the other composed of three trials (N = 416), all evaluating behavioral and/or pharmacological treatments for cocaine use. UDS were collected at least once per week (up to three times per week) during the 8- or 12-week treatment period across all trials, with substance use and psychosocial functioning measured up to 12 months following treatment. Chi-squares and ANOVAs compared within-treatment and follow-up outcomes between the groups.

RESULTS

Compared to those who did not achieve the threshold, participants who achieved the 75%-CN threshold were retained in treatment longer and had a longer period of continuous abstinence, and were more likely to report problem-free functioning. Additionally, participants who achieved the 75%-CN threshold were more likely to report sustained abstinence and better psychosocial functioning throughout a follow-up period up to 12 months than those who did not achieve the threshold.

CONCLUSIONS

A threshold of 75%-CN UDS is associated with short- and long-term clinical benefits. Future clinical trials may consider this a meaningful threshold for defining treatment responders.

Most recent, modal, or median heroin purchase: Does it matter when estimating market size?

BACKGROUND

Assessing the size of illicit drug markets is an important activity of many government agencies; however, the expenditure-based method for estimating market size relies on the relatively untested assumption that the cash value of the most recent purchase is representative of the average purchase amount. Using panel data, we test the representativeness of the most recent, modal and median purchase compared to the average purchase amount.

METHODS

Data were drawn from a prior study that collected daily transaction-level purchase data from a sample of 120 people who were using heroin regularly. The same study participants completed two distinct two-week waves of data collection, separated by six months. T-tests and bootstrapping were used to detect differences within each wave between the average cash value of participant heroin purchases and the cash value of their most recent, modal and median heroin purchases.

RESULTS

In both waves, we found (a) no evidence that the expected value of the most recent purchase differs from the expected value of the average purchase, and (b) the expected values of the modal and median purchases are smaller than the expected value of the average purchase. These results imply that estimates of total market size based on the modal or median purchase will suffer from a significant downward bias, but that estimates based on the most recent purchase will be unbiased.

CONCLUSIONS

We provide evidence in support of using the most recent (but not the modal or the median) purchase to estimate market size for heroin.

Tobacco use patterns and clinical outcomes in the T1D exchange

AIMS

This study examined associations between tobacco use and diabetes outcomes using the T1D Exchange Registry.

METHODS

Adult participants (N = 933) completed standardized questionnaires including self-reported outcomes: past year serious hypoglycemic and diabetic ketoacidosis episodes, diabetes self-care, diabetes distress, and self-monitoring of blood glucose. Chart-extracted outcomes included HbA1c, nephrology and neuropathy diagnoses, and BMI. We examined the relation of tobacco use status (never, former, current) and frequency of use (daily versus less than daily) to these outcomes.

RESULTS

The majority had never used tobacco (55%, n = 515); 27% (n = 252) were former users and 18% (n = 166) were current users (with 31% using daily). Tobacco status was associated with HbA1c, BMI, self-care, distress, and blood glucose monitoring frequency. Across most outcomes, current users evidenced worse values relative to never users, and former users were largely similar to never users. Daily use was associated with significantly worse outcomes on HbA1c, diabetes self-care, and distress scores relative to less than daily use.

CONCLUSIONS

These cross-sectional comparisons suggest that current tobacco use is associated with worse status on important clinical diabetes indicators. Former users did not evidence these deleterious associations. Findings point to potential diabetes-specific motivators that could inform tobacco cessation interventions.

The impact of marijuana use on cocaine use outcomes among patients in methadone maintenance treatment across five trials of contingency management

OBJECTIVE

Cocaine use is prevalent among patients in methadone maintenance and a risk factor for poor treatment outcomes. Contingency management (CM) decreases cocaine use in this population, but little is known about its efficacy when marijuana use is present prior to or during treatment.

METHOD

Data from five randomized CM trials (N = 557) were used to evaluate whether: (a) marijuana frequency (none, low, or high) prior to or during treatment impacts cocaine use outcomes and (b) marijuana use differentially impacts cocaine outcomes with standard care (SC) + CM versus SC alone.

RESULTS

Relative to no marijuana use, low (β = .28, p < .01) and high marijuana use (β = .32, p < .05) during treatment were associated with roughly 1 week shorter duration of cocaine abstinence on average. Low marijuana use (β = .71, p < .05) during treatment was associated with a lower proportion of negative cocaine samples during treatment relative to no marijuana use. Treatment group by marijuana use (before or during treatment) interactions on duration and proportion of cocaine abstinence during treatment were not significant. For longer term outcomes, in SC + CM, marijuana use during treatment did not impact cocaine abstinence 6 months post-baseline. In SC, low (OR = .44, p < .05) and high (OR = .26, p < .001) marijuana use during treatment decreased odds of cocaine abstinence at 6 months post-baseline relative to no use.

CONCLUSIONS

Findings highlight the benefits of SC + CM and abstaining from marijuana use during active treatment. At 6 months postbaseline, SC + CM evidenced similar cocaine abstinence regardless of marijuana use levels during treatment, while those with low and high marijuana use showed decreased abstinence rates in SC only. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Deep Brain Stimulation Compared With Contingency Management for the Treatment of Cocaine Use Disorders: A Threshold and Cost-Effectiveness Analysis

OBJECTIVES

Cocaine is the second most frequently used illicit drug worldwide (after cannabis), and cocaine use disorder (CUD) related deaths increased globally by 80% from 1990 to 2013. There is yet to be a regulatory-approved treatment. Emerging preclinical evidence indicates that deep brain stimulation (DBS) of the nucleus accumbens may be a therapeutic option. Prior to expanding the costly investigation of DBS for treatment of CUD, it is important to ensure societal cost-effectiveness.

AIMS

We conducted a threshold and cost-effectiveness analysis to determine the success rate at which DBS would be equivalent to contingency management (CM), recently identified as the most efficacious therapy for treatments of CUDs.

MATERIALS AND METHODS

Quality of life, efficacy, and safety parameters for CM were obtained from previous literature. Costs were calculated from a societal perspective. Our model predicted the utility benefit based on quality-adjusted-life-years (QALYs) and incremental-cost-effectiveness-ratio resulting from two treatments on a one-, two-, and five-year timeline.

RESULTS

On a one-year timeline, DBS would need to impart a success rate (i.e., cocaine free) of 70% for it to yield the same utility benefit (0.492 QALYs per year) as CM. At no success rate would DBS be more cost-effective (incremental-cost-effectiveness-ratio <$50,000) than CM during the first year. Nevertheless, as DBS costs are front-loaded, DBS would need to achieve success rates of 74% and 51% for its cost-effectiveness to exceed that of CM over a two- and five-year period, respectively.

CONCLUSIONS

We find DBS would not be cost-effective in the short-term (one year) but may be cost-effective in longer timelines. Since DBS holds promise to potentially be a cost-effective treatment for CUDs, future randomized controlled trials should be performed to assess its efficacy.

Alcohol Use Disorder in the Age of Technology: A Review of Wearable Biosensors in Alcohol Use Disorder Treatment

Biosensors enable observation and understanding of latent physiological occurrences otherwise unknown or invasively detected. Wearable biosensors monitoring physiological constructs across a wide variety of mental and physical health conditions have become an important trend in innovative research methodologies. Within substance use research, explorations of biosensor technology commonly focus on identifying physiological indicators of intoxication to increase understanding of addiction etiology and to inform treatment recommendations. In this review, we examine the state of research in this area as it pertains to treatment of alcohol use disorders specifically highlighting the gaps in our current knowledge with recommendations for future research. Annually, alcohol use disorders affect approximately 15 million individuals. A primary focus of existing wearable technology-based research among people with alcohol use disorders is identifying alcohol intoxication. A large benefit of wearable biosensors for this purpose is they provide continuous readings in a passive manner compared with the gold standard measure of blood alcohol content (BAC) traditionally measured intermittently by breathalyzer or blood draw. There are two primary means of measuring intoxication with biosensors: gait and sweat. Gait changes have been measured via smart sensors placed on the wrist, in the shoe, and mobile device sensors in smart phones. Sweat measured by transdermal biosensors detects the presence of alcohol in the blood stream correlating to BAC. Transdermal biosensors have been designed in tattoos/skin patches, shirts, and most commonly, devices worn on the ankle or wrist. Transdermal devices were initially developed to help monitor court-ordered sobriety among offenders with alcohol use disorder. These devices now prove most useful in continuously tracking consumption throughout clinical trials for behavioral treatment modalities. More recent research has started exploring the uses for physical activity trackers and physiological arousal sensors to guide behavioral interventions for relapse prevention. While research has begun to demonstrate wearable devices' utility in reducing alcohol consumption among individuals aiming to cutdown on their drinking, monitoring sustained abstinence in studies exploring contingency management for alcohol use disorders, and facilitating engagement in activity-based treatment interventions, their full potential to further aid in understanding of, and treatment for, alcohol use disorders has yet to be explored.

Alcohol Use and Clinical Outcomes in Adults in the Type 1 Diabetes Exchange

OBJECTIVES

Alcohol consumption has serious potential consequences for persons with type 1 diabetes. This cross-sectional study examined associations between drinking status and diabetes-related outcomes.

METHODS

Participants included 934 adults at Type 1 Diabetes Exchange Registry clinics who responded to an e-mail invitation to complete an electronic survey with items on alcohol consumption; glycated hemoglobin (A1C) and body mass index (BMI) were extracted from medical charts. Participants were an average 38±16 years of age, 61% were women and 90% were non-Hispanic white; A1C was 7.8%±1.5%. The sample was made up of 11% (n=103) never drinkers, 9% (n=89) former drinkers, 61% (n=567) current (past year) nonbinge drinkers and 19% (n=174) current binge drinkers.

RESULTS

After controlling for covariates, diabetes distress was lower among never drinkers compared with former and nonbinge drinkers (p<0.009). Never drinkers compared with former drinkers had lower odds of past-year severe hypoglycemia (p=0.001) and lower odds of a neuropathy diagnoses (p=0.006). There were omnibus model trends toward associations between drinking status and diabetes self-care (p=0.10) and between drinking status and BMI (p=0.06). Never drinkers did not differ from other groups on daily frequency of blood glucose self-monitoring, A1C or past-year diabetic ketoacidosis (p>0.05).

CONCLUSIONS

These results suggest complex relationships between drinking and diabetes-related distress, and that recent severe hypoglycemia and the presence of neuropathy may motivate some to stop drinking. Prospective studies may improve understanding of these findings.

Objective continuous monitoring of alcohol consumption for three months among alcohol use disorder treatment outpatients

BACKGROUND

Transdermal alcohol sensing technology allows for objective continuous monitoring of alcohol use. The purpose of this study was to characterize alcohol consumption measured with this technology among alcohol use disorder treatment outpatients in two clinical trials.

METHODS

Participants were community-based alcohol treatment outpatients in usual care (N = 63) during the first three years of studies that monitored drinking with the secure continuous remote alcohol monitor (SCRAMx®) ankle bracelet. Research visits for uploading SCRAMx data occurred every other week in Study 1 (n = 43) and once weekly in Study 2 (n = 20), for 3 months. Staff used timeline follow-back procedures to collect self-reports of drinking frequency and magnitude at each research visit.

RESULTS

In the 90 days before intake, 85.7% (n = 54) of participants reported consuming alcohol, and consumption occurred on a median (interquartile range) 35.7% (29.0%) of days. During the treatment period, per SCRAMx versus self-report, the percentage who drank was 92.1% (n = 58) versus 46.6% (n = 30), p = .03, and consumption occurred on 16.5% (36.5%) versus 0.0% (21.4%) of days, respectively, p < .001. Median longest duration of abstinence was 26.0 (25.0) versus 39.0 (58.0) days, respectively, p < .001. Breath alcohol concentration, estimated from SCRAMx data, ranged from 0.02 to 0.91 g/dL.

CONCLUSIONS

This is the first study to quantify alcohol consumption among alcohol treatment outpatients using transdermal sensor technology. Results indicate that most patients drank while in outpatient care. Issues to consider for future applications of this technology and implications for alcohol treatment are discussed.

Monitoring alcohol use in heavy drinking soup kitchen attendees

Rates of heavy alcohol use in soup kitchen attendees range from 30% to 38%, but these data are based entirely on self-reported drinking. Little is known about the intensity or frequency of drinking in this population. We assessed alcohol use transdermally every 30 min over a 3-week period among heavy drinkers who attended local soup kitchens. In addition to transdermal alcohol monitoring, participants were randomly assigned to daily breath alcohol monitoring with or without reinforcement for alcohol-negative breath samples (BrAC). Analyses assessed feasibility of transdermal monitoring and examined alcohol use based on BrAC, transdermal, and self-report data, as well as effect sizes for these metrics based on group assignment. Nineteen participants completed the 21-day monitoring period in full; three persons removed the anklet 3-16 days early due to hospitalization, impending hospitalization, or incarceration. Participants reported minimal impacts of the monitors, and severity ratings of side effects were mild. When using BrAC, transdermal, and self-report data, the percentage of non-drinking days was 93%, 58%, and 57%, and the longest duration of consecutive non-drinking days averaged 10.3, 7.2, and 5.7 days, respectively. About half of drinking days involved heavy drinking (5 + drinks). Self-report and transdermal drinking days correlated significantly, p < .001, but neither index was associated with BrAC. Group comparisons indicate small-to-moderate sized effects of reinforcement compared to no reinforcement for increasing the proportion of alcohol-negative breath samples and durations of consecutive non-drinking samples during the study when BrAC was the metric. Transdermal data and self-report data indicated a more complex pattern. Reinforcement participants drank more often but at lower quantities than monitoring (control) participants per both transdermal and self-report data. These data suggest that transdermal monitors are well tolerated and document substantial heavy drinking in this population. Soup kitchens users are in need of alcohol interventions, and soup kitchens may represent a novel opportunistic setting for intervention delivery for an important and growing health disparities population.

Reinforcing exercise to improve drug abuse treatment outcomes: A randomized controlled study in a substance use disorder outpatient treatment setting

Exercise holds potential to reduce substance use, but engaging patients in exercise regimens is challenging. Contingency management (CM) interventions can directly address adherence by targeting initiation and maintenance of exercise behavior. This study evaluated the efficacy of a CM-reinforced exercise intervention as an adjunct to standard outpatient substance use disorder treatment. Participants were 120 patients with substance use disorders who were randomly assigned to standard care with CM for completing exercise goals or CM for completing general nonexercise goals weekly for a 4-month treatment period. Urine samples were tested for evidence of illicit substance use up to twice a week during treatment and at follow-ups through month 12. Results found that the CM-exercise condition demonstrated during-treatment improvements on several physical activity and relevant psychosocial functioning indices (e.g., self-efficacy for exercise). The CM-exercise condition had no advantage relative to the CM-general condition in decreasing substance use. Overall, this study adds to a small body of well-powered trials assessing effects of exercise interventions as adjunct treatment for substance use disorders and finds no benefit over an alternate CM approach in terms of drug abstinence. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Examining implementation of contingency management in real-world settings

Very little is known about how reward programs are implemented in real-world substance use treatment settings and whether training in contingency management (CM), an empirically supported rewards-based intervention, impacts their design quality. Providers (N = 214) completed surveys assessing CM beliefs, training, and practices related to use of tangible rewards in treatment. For providers reporting they had not used rewards in treatment previously (54%, n = 116), we assessed beliefs about and interest in adopting a reward-based program. For those endorsing prior reward experience (46%, n = 98), we assessed the features and delivery of rewards and the relation of reward-based intervention training to 4 parameters related to CM efficacy: reinforcement magnitude, immediacy, frequency, and escalation. Among providers without reward experience, endorsement of supportive statements about CM predicted interest in adopting a rewards-based program. Providers with reward experience most often targeted treatment attendance and engaged in behaviors likely to decrease the effectiveness of the intervention, including use of low magnitudes (≤ $25/client), delayed reinforcement, failure to escalate reward values, and offering reward opportunities less than weekly. Providers with longer durations of training were more likely to engage in behaviors consistent with effective CM, including larger magnitude rewards and immediate delivery of rewards. Results indicate that real-world treatment clinics are using reward-based programs but not in ways consistent with research protocols. Longer training exposure is associated with greater adherence to some aspects of CM protocol design. Other evidence-based design features are not being implemented as recommended, even with training. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

A randomized trial of contingency management reinforcing attendance at treatment: Do duration and timing of reinforcement matter?

OBJECTIVE

Contingency management (CM) interventions that reinforce attendance have rarely been evaluated in terms of reducing drug use. Using a sequential randomized design, this study examined the efficacy of three attendance CM conditions compared to usual care (UC) on drug use outcomes. It evaluated whether the duration (6 vs. 12 weeks) and timing (early vs. later treatment) of CM delivery impact treatment response.

METHOD

Upon initiating outpatient treatment, patients with cocaine use disorders (N = 360) were randomized to UC or CM for attending treatment for 6 weeks. At week 6, patients (n = 308) were rerandomized to UC or CM for another 6 weeks, with assignment stratified on current functioning. Samples were screened for illicit drugs twice weekly for 12 weeks.

RESULTS

Patients randomized to CM at both time-points attended more sessions and achieved more abstinence than those never randomized to CM. Relative to UC, receiving attendance CM in weeks 1-6 only was not efficacious, but those receiving attendance CM in weeks 7-12 only evidenced some benefits compared to those who never received CM. Twelve weeks of attendance CM was more efficacious than 6 weeks. No between-groups differences in drug use were noted at follow-ups, but days attended treatment and proportion negative samples during treatment were associated with long-term cocaine abstinence.

CONCLUSIONS

Attendance-based CM increases treatment participation and reduces drug use, with beneficial effects noted when CM is delivered over longer durations and during later phases of outpatient care. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

A randomized trial of contingency management for smoking cessation in the homeless

Smoking-cessation services are an unmet need among the homeless, who smoke at rates more than 4 times the national estimate. Successful interventions have high potential for improving tobacco-related health disparities among homeless smokers. Contingency management (CM) is a behavioral intervention with efficacy in a number of substance-use disorder populations, including smokers. However, no randomized studies have evaluated the effect of CM in homeless smokers. We examined smoking-related outcomes in homeless smokers (N = 70) randomized to standard-care (SC) smoking cessation involving transdermal nicotine-replacement therapy (NRT), standard counseling, and carbon monoxide (CO) monitoring or the same SC plus CM for negative CO sample submissions. Participants randomized to CM achieved significantly longer durations of consecutive abstinence and submitted a significantly higher proportion of CO-negative samples relative to standard-care participants. At 4 weeks postquit day, 22% were abstinent in the CM condition and 9% were abstinent in the SC condition. At the 6-month follow-up, about 10% of smokers in both conditions were abstinent. This study demonstrates that CM is an efficacious option to increase initial quit rates in homeless smokers, but methods to extend effects are needed. (PsycINFO Database Record

A Randomized Trial of Adjunct mHealth Abstinence Reinforcement With Transdermal Nicotine and Counseling for Smoking Cessation

Introduction

Abstinence reinforcement is efficacious for improving smoking treatment outcomes, but practical constraints related to the need for multiple in-person carbon monoxide (CO) breath tests daily to verify smoking abstinence have limited its use. This study tested an mHealth procedure to remotely monitor and reinforce smoking abstinence in individuals' natural environment.

Methods

Eligible treatment-seeking smokers (N = 90) were randomized to (1) usual care and ecological monitoring with abstinence reinforcement (mHealth reinforcement) or (2) without reinforcement (mHealth monitoring). Usual care was 8 weeks of transdermal nicotine and twice-weekly telephone counseling. Following training, an interactive voice response system prompted participants to conduct CO tests 1-3 daily at pseudorandom times (7 am to 10 pm) for 4 weeks. When prompted, participants used a study cell phone and CO monitor to complete a CO self-test, video record the process, and submit videos using multimedia messaging. mHealth reinforcement participants could earn prizes for smoking-negative on-time CO tests. The interactive voice response generated preliminary earnings immediately. Earnings were finalized by comparing video records against participants' self-reports.

Results

mHealth reinforcement was associated with a greater proportion of smoking-negative CO tests, longest duration of prolonged abstinence, and point-prevalence abstinence during the monitoring/reinforcement phase compared to mHealth monitoring (p < .01, d = 0.8-1.3). Follow-up (weeks 4-24) analyses indicated main effects of reinforcement on point-prevalence abstinence and proportion of days smoked (p ≤ .05); values were comparable by week 24.

Conclusions

mHealth reinforcement has short-term efficacy. Research on methods to enhance and sustain benefits is needed.

Implications

This study suggests that mHealth abstinence reinforcement is efficacious and may present temporal and spatial opportunities to research, engage, and support smokers trying to quit that do not exist with conventional (not technology-based) reinforcement interventions.

Experiences with SCRAMx alcohol monitoring technology in 100 alcohol treatment outpatients

BACKGROUND

Transdermal alcohol monitoring technology allows for new research on alcohol use disorders. This study assessed feasibility, acceptability, and adherence with this technology in the context of two clinical research trials.

METHODS

Participants were the first 100 community-based alcohol treatment outpatients enrolled in randomized studies that monitored drinking with the secure continuous remote alcohol monitor (SCRAMx^®) for 12 weeks. Study 1 participants were randomized to usual care (n=36) or usual care with contingency management incentives for treatment attendance (CM-Att; n=30). Study 2 participants were randomized to usual care (n=17) or usual care with CM for each day of no drinking per SCRAMx (CM-Abst; n=17). After 12 weeks, participants completed a survey about the bracelet.

RESULTS

Nine percent of individuals screened (54 of 595) declined participation because of the bracelet. Of participants, 84% provided 12weeks of data, and 96% of bracelets were returned fully intact. Ninety-four equipment tampers occurred, affecting 2% of monitoring days; 56% (67) of tampers coincided with detected drinking. Common concerns reported by participants were skin marks (58%), irritation (54%), and interfered with clothing choices (51%), but severity ratings were generally mild (60%-94%). Eighty-one percent of participants reported that the bracelet helped them reduce drinking, and 75% indicated that they would wear it for longer. A common suggestion for improvement was to reduce the size of the bracelet.

CONCLUSIONS

Results support the viability of transdermal monitoring in voluntary substance abuse treatment participants for an extended duration. Issues to consider for future applications of this technology are discussed.

Contingency management treatment for substance use disorders: How far has it come, and where does it need to go?

Contingency management (CM) interventions consistently improve substance abuse treatment outcomes, yet CM remains a highly controversial intervention and is rarely implemented in practice settings. This article briefly outlines the evidence base of CM and then describes 4 of the most often-cited concerns about it: philosophical, motivational, durability, and economic. Data supporting and refuting each of these issues are reviewed. The article concludes with suggestions to address these matters and other important areas for CM research and implementation, with the aims of improving uptake of this efficacious intervention in practice settings and outcomes of patients with substance use disorders. (PsycINFO Database Record

A randomized controlled trial of brief interventions for problem gambling in substance abuse treatment patients

OBJECTIVE

This study evaluated the efficacy of brief gambling treatments in patients attending substance abuse treatment clinics.

METHOD

Substance abuse treatment patients with gambling problems (N = 217) were randomly assigned to a 10- to 15-min brief psychoeducation gambling intervention; a 10- to 15-min brief advice intervention addressing gambling norms, risk factors, and methods to prevent additional problems; or 4 50-min sessions of motivational enhancement therapy plus cognitive behavior therapy for reducing gambling (MET + CBT). Gambling and related problems were assessed at baseline and throughout 24 months.

RESULTS

In the sample as a whole, days and dollars wagered and gambling problems decreased markedly from baseline through Month 5; thereafter, reductions in dollars wagered and gambling problems continued to decrease modestly but significantly, and days gambled remained constant. Brief advice significantly reduced days gambled between baseline and Month 5 relative to brief psychoeducation. The MET + CBT condition engendered no benefit beyond brief advice in terms of days gambled but did lead to more precipitous reductions in dollars gambled and problems experienced in the initial 5 months, and greater clinically significant improvements in gambling in both the short and long term. MET + CBT also resulted in initial decreases in self-reported alcohol use and problems but did not differentially impact self-reported illicit drug use or submission of positive samples.

CONCLUSIONS

Gambling problems tend to dissipate over time regardless of the intervention applied, but offering MET + CBT was more efficacious in decreasing gambling than providing a brief single session intervention. (PsycINFO Database Record

Treatment Satisfaction in a Randomized Clinical Trial of mHealth Smoking Abstinence Reinforcement

The importance of patient satisfaction in modern healthcare is widely recognized, but research on satisfaction in the context of smoking cessation has not kept pace. The purpose of this study was to explore treatment satisfaction in a sample of smokers (N=84) randomized to one of two smoking cessation treatment interventions (mHealth reinforcement and mHealth monitoring) that used cell phone-based procedures to monitor smoking status in individuals' natural environments for 4 weeks. Starting on the target quit date, participants received usual care smoking cessation treatment consisting of 8 weeks of transdermal nicotine and 4 weeks of twice-weekly telephone counseling were also prompted 1 to 3 times daily (with exact number and timing not disclosed beforehand) to use a study cell phone and CO monitor to complete a CO self-test, video-record the process, and submit videos using multimedia messaging within 2 hours. mHealth reinforcement participants could earn prizes for smoking-negative on-time CO tests. A treatment satisfaction survey was completed at the end of the 4-week monitoring/reinforcement phase. Results indicate that participants overwhelmingly endorsed high levels of overall satisfaction in both conditions. Treatment adherence did not differ between conditions, but was positively associated with endorsing the highest satisfaction with help quitting with the intervention (p<.01 to .03). mHealth reinforcement was associated with increased longest duration of abstinence (p<.01). Controlling for relevant participant characteristics and treatment adherence, longest duration of abstinence robustly predicted highest satisfaction with help quitting and mediated the effect of treatment condition on that satisfaction. Further research on treatment satisfaction may aid the development of effective abstinence reinforcement and other smoking cessation interventions.

Smartphone applications to reduce alcohol consumption and help patients with alcohol use disorder: a state-of-the-art review

Hazardous drinking and alcohol use disorder (AUD) are substantial contributors to USA and global morbidity and mortality. Patient self-management and continuing care are needed to combat these public health threats. However, services are rarely provided to patients outside of clinic settings or following brief intervention. Smartphone applications (“apps”) may help narrow the divide between traditional health care and patient needs. The purpose of this review is to identify and summarize smartphone apps to reduce alcohol consumption or treat AUD that have been evaluated for feasibility, acceptability, and/or efficacy. We searched two research databases for peer-reviewed journal articles published in English that evaluated smartphone apps to decrease alcohol consumption or treat AUD. We identified six apps. Two of these apps (A-CHESS and LBMI-A) promoted self-reported reductions in alcohol use, two (Promillekoll and PartyPlanner) failed to promote self-reported reductions in alcohol use, and two (HealthCall-S and Chimpshop) require further evaluation and testing before any conclusions regarding efficacy can be made. In summary, few evaluations of smartphone apps to reduce alcohol consumption or treat AUD have been reported in the scientific literature. Although advances in smartphone technology hold promise for disseminating interventions among hazardous drinkers and individuals with AUD, more systematic evaluations are necessary to ensure that smartphone apps are clinically useful.

The price elasticity of demand for heroin: Matched longitudinal and experimental evidence

This paper reports estimates of the price elasticity of demand for heroin based on a newly constructed dataset. The dataset has two matched components concerning the same sample of regular heroin users: longitudinal information about real-world heroin demand (actual price and actual quantity at daily intervals for each heroin user in the sample) and experimental information about laboratory heroin demand (elicited by presenting the same heroin users with scenarios in a laboratory setting). Two empirical strategies are used to estimate the price elasticity of demand for heroin. The first strategy exploits the idiosyncratic variation in the price experienced by a heroin user over time that occurs in markets for illegal drugs. The second strategy exploits the experimentally induced variation in price experienced by a heroin user across experimental scenarios. Both empirical strategies result in the estimate that the conditional price elasticity of demand for heroin is approximately -0.80.

Reinforcing adherence to antihypertensive medications

This pilot study evaluated a reinforcement intervention to improve adherence to antihypertensive therapy. Twenty-nine participants were randomized to standard care or standard care plus financial reinforcement for 12 weeks. Participants in the reinforcement group received a cell phone to self-record videos of adherence, for which they earned rewards. These participants sent videos demonstrating on-time adherence 97.8% of the time. Pill count adherence differed significantly between the groups during treatment, with 98.8%±1.5% of pills taken during treatment in the reinforcement condition vs 92.6%±9.2% in standard care (P<.002). Benefits persisted throughout a 3-month follow-up, with 93.8%±9.3% vs 78.0%±18.5% of pills taken (P<.001). Pill counts correlated significantly (P<.001) with self-reports of adherence, which also differed between groups over time (P<.01). Systolic blood pressure decreased modestly over time in participants overall (P<.01) but without significant time-by-group effects. These results suggest that reinforcing medication adherence via cellular phone technology and financial reinforcement holds potential to improve adherence.

Smoking reductions and increased self-efficacy in a randomized controlled trial of smoking abstinence-contingent incentives in residential substance abuse treatment patients

INTRODUCTION

Individuals with substance use disorders (SUDs) experience increased smoking-related morbidity and mortality but severely compromised smoking treatment benefits. Residential SUD treatment settings may be particularly positioned to target smoking, with ever-increasing smoking bans and culture shifts, but most smokers continue smoking. This study examined the effects of contingency management (CM) for increasing smoking abstinence in residential patients.

METHODS

Smokers interested in quitting were recruited from a residential SUD program for men and were randomized to frequent smoking monitoring with behavioral support (monitoring; n = 21) or that plus smoking abstinence-contingent (expired carbon monoxide [CO] ≤ 6 ppm; urinary cotinine ≤ 30ng/ml) incentives (CM, n = 24) for 4 weeks. After setting a quit date, procedures included daily behavioral support and smoking self-reports, 2 CO samples (a.m./p.m.) Monday through Friday, and cotinine tests on Mondays. CM participants received escalating draws for prizes ($1, $20, and $100 values) for negative tests; positive and missed samples reset draws. Follow-ups involved samples, self-reported smoking, and self-efficacy (weeks 4, 8, 12, and 24).

RESULTS

Percent days CO-negative was higher with CM (median [interquartile range] 51.7% [62.8%]) compared to monitoring (0% [32.1%]) (p = .002). Cigarettes per day declined and point-prevalence abstinence increased through follow-up (p < .01), without significant group by time effects (p > .05). Abstinence self-efficacy increased overall during the intervention and more with CM compared to monitoring and was associated with abstinence across conditions through follow-up.

CONCLUSIONS

CM improved some measures of response to smoking treatment in residential SUD patients.

Standard magnitude prize reinforcers can be as efficacious as larger magnitude reinforcers in cocaine-dependent methadone patients

OBJECTIVE

Contingency management (CM) reduces cocaine use in methadone patients, but only about 50% of patients respond to CM interventions. This study evaluated whether increasing magnitudes of reinforcement will improve outcomes.

METHOD

Cocaine-dependent methadone patients (N = 240) were randomized to 1 of 4 12-week treatment conditions: usual care (UC); UC plus standard prize CM, in which average expected prize earnings were about $300; UC plus high magnitude prize CM, in which average expected prize earnings were about $900; or UC plus voucher CM, with an expected maximum of about $900 in vouchers.

RESULTS

All 3 CM conditions yielded significant reductions in cocaine use relative to UC, with effect sizes (d) ranging from 0.38 to 0.59. No differences were noted between CM conditions, with at least 55% of patients in each CM condition achieving 1 week or more of cocaine abstinence versus 35% in UC. During the 12 weeks after the intervention ended, CM increased time until relapse relative to UC, but the effects of CM were no longer significant at a 12-month follow-up.

CONCLUSIONS

Providing the standard magnitude of $300 in prizes was as effective as larger magnitude CM in cocaine-dependent methadone patients in this study. Given its strong evidence base and relatively low costs, standard magnitude prize CM should be considered for adoption in methadone clinics to encourage cocaine abstinence, but new methods need to be developed to sustain abstinence.

The effects of alcohol problems and smoking on delay discounting in individuals with gambling problems

Problem gambling is an addictive behavior with high comorbidity with alcohol problems and smoking. A common feature shared by these conditions is impulsivity. Past research shows that individuals with any of these addictions discount delayed money at higher rates than those without, and that the presence of gambling and substance use lead to additive effects on discounting. To date, however, no study examined the impact of smoking on these associations. The goals of this study were to compare the discounting rates of gamblers with and without histories of alcohol problems and smoking, and assess the associations these addictions might have on discounting. We analyzed the discounting rates of treatment-seeking gamblers categorized into four groups based on their histories of alcohol and smoking. Results revealed effects of history of alcohol problems, and an interaction between smoking and alcohol problems, on discounting. Never smokers with histories of alcohol problems discounted money less steeply than the other groups of gamblers. These results suggest that smoking does not produce additional increases on discounting rates in individuals with other addiction problems and the small subpopulation of gamblers with alcohol problems who never smoked is less impulsive and may have unique risk and/or protective behaviors.

A randomized study of cellphone technology to reinforce alcohol abstinence in the natural environment

AIMS

Contingency management (CM) uses tangible incentives to systematically reinforce abstinence and is among the most efficacious psychosocial substance abuse treatments. This study assessed the feasibility and initial efficacy of a portable CM procedure designed to address technical limitations for detecting drinking that have prevented using CM for alcohol problems.

DESIGN

Participants received a cellphone, breathalyzer and training on video-recording alcohol breath tests (BrACs) and texting results. For 4 weeks, staff texted participants one to three times daily indicating that a breath alcohol concentration test (BrAC) was due within the hour. Participants were randomized to (1) modest compensation for submitting dated time-stamped BrAC videos regardless of results or (2) the same plus CM with escalating vouchers for on-time alcohol-negative tests (n-BrAC; <02 g/dl). 'Thank-you' texts were sent, with CM patients also informed of results-based earnings.

SETTING

Participants' natural environment.

PARTICIPANTS

Adults (n = 30; ≥ 21 years) who drank frequently but were not physiologically dependent.

MEASUREMENTS

Drinking and related problems were assessed at intake and week 4. BrACs and self-reports of drinking were collected throughout. The primary outcome was the percentage of n-BrACs. Other outcomes were the longest duration of consecutive n-BrACs (longest duration of abstinence) and self-reports of drinking.

FINDINGS

On average, 88.6% (10.4%) of BrACs were submitted on time, without group differences (P = 0.18). The percentage of n-BrACs and LDA were greater with CM, and there was an interaction effect on drinking frequency and negative consequences, with decreases over time with CM (P = 0.00; effect sizes d = 0.52-0.62).

CONCLUSION

Cellphone technology may be useful for extending contingency management to treatment for alcohol problems.

Contingency management treatments decrease psychiatric symptoms

OBJECTIVE

Contingency management (CM) is an empirically validated treatment for substance use disorders, but its effects on psychiatric symptoms have not been systematically examined. The purpose of this study was to examine the impact of CM on psychiatric symptoms of cocaine dependent patients receiving CM with standard care versus standard care alone.

METHOD

Psychiatric symptoms were evaluated in 393 patients participating in 1 of 3 randomized trials of CM at treatment initiation and 1, 3 (posttreatment), 6, and 9 months later.

RESULTS

Patients randomized to CM evidenced significant reductions in psychiatric symptoms over time throughout the 9-month follow-up. In contrast, psychiatric symptoms remained stable relative to baseline in patients randomized to standard care. A significant time by treatment condition effect was noted (p < .05) for overall psychiatric distress as well as for specific indices of depression, hostility, interpersonal sensitivity, phobic anxiety and psychoticism symptoms. Reductions in drug use mediated the effects of CM on psychiatric symptoms.

CONCLUSIONS

These data demonstrate that the effects of CM extend beyond their impact on drug use behaviors and the period in which reinforcers are in effect.

A randomized trial of contingency management delivered by community therapists

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

A randomized trial of contingency management delivered in the context of group counseling

OBJECTIVE

Contingency management (CM) is efficacious in reducing drug use. Typically, reinforcers are provided on an individual basis to patients for submitting drug-negative samples. However, most treatment is provided in a group context, and poor attendance is a substantial concern. This study evaluated whether adding CM to group-based outpatient treatment would increase attendance and drug abstinence relative to standard care.

METHOD

Substance abusing patients (N = 239) initiating outpatient treatment at 2 community-based clinics were randomized to standard care with frequent urine sample monitoring for 12 weeks (SC) or that same treatment with CM delivered in the context of group counseling sessions. In the CM condition, patients earned opportunities to put their names in a hat based on attendance and submission of drug-negative samples. At group counseling sessions, therapists selected names randomly from the hat, and individuals whose names were drawn won prizes ranging from $1 to $100.

RESULTS

Patients assigned to CM earned a median of $160 in prizes, and they attended significantly more days of treatment (d = 0.25), remained in treatment for more continuous weeks (d = 0.40), and achieved longer durations of drug abstinence (d = 0.26) than patients randomized to SC. Group adherence and therapeutic alliance also improved with CM. In addition, HIV risk behaviors were significantly lower in CM relative to SC patients during early phases of treatment and at the 12-month follow-up.

CONCLUSIONS

These data demonstrate that CM delivered in the context of outpatient group counseling can increase attendance and improve drug abstinence.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

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

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

Contingency management is efficacious and improves outcomes in cocaine patients with pretreatment marijuana use

BACKGROUND

Marijuana use is common in patients seeking treatment for cocaine use. Nevertheless, few studies have examined effects of marijuana use on treatment outcomes in general, and even fewer with respect to contingency management (CM) treatment, which has been criticized for potentially increasing non-reinforced drug use.

METHODS

Data from three randomized clinical trials of CM versus standard treatment (ST) in cocaine-abusing patients were examined (Petry et al., 2004, 2005a, 2006a; N=393) to assess effects of pretreatment marijuana use on outcomes. Patients were divided into two groups: (1) no self-reported marijuana use (No Pre-M; n=315) and (2) any self-reported marijuana use (Pre-M; n=78) in the 30 days pretreatment.

RESULTS

CM was especially efficacious in enhancing retention in Pre-M patients such that retention nearly doubled among Pre-M patients assigned to CM versus those assigned to ST. In contrast, CM exerted only modest benefits on retention in No Pre-M patients. Pretreatment marijuana use was not related to during-treatment abstinence from cocaine, opioids, and alcohol, or abstinence at a Month 9 follow-up. However, CM treatment and longest duration of abstinence achieved during treatment were significant predictors of Month 9 abstinence. Pre-M patients also evidenced more improvements in drug problems over time when randomized to CM.

CONCLUSIONS

CM was especially efficacious in facilitating retention and improving severity of drug-related problems in those who used marijuana in the month before initiating treatment.

Psychometric properties of the contingency management competence scale

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

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Behavioral assessment of impulsivity in pathological gamblers with and without substance use disorder histories versus healthy controls

Pathological gamblers (PGs) may have high levels of impulsivity, and a correlation between substance use disorders (SUDs) and impulsivity is well established. However, only a handful of studies have attempted to assess impulsivity and other impulse-spectrum traits (e.g., sensation seeking) using a variety of behavioral and self-report measures in PGs and few examined the independent impact of SUDs. We compared 30 PGs without SUD histories, 31 PGs with SUD histories and 40 control participants on self-reported impulsivity, delayed discounting, attention/memory, response inhibition, risk taking, sensation seeking and distress tolerance measures. PGs, regardless of SUD history, discounted delayed rewards at greater rates than controls. PGs also reported acting on the spur of the moment, experienced trouble planning and thinking carefully, and noted greater attention difficulties than controls. PGs with SUD took greater risks on a risk-taking task than did PGs without SUD histories, but the two groups did not differ on any other measures of impulsivity. We conclude that PGs are more impulsive than non-problem gamblers in fairly specific ways, but PGs with and without SUD histories differ on few measures. More research should focus on specific ways in which PGs exhibit impulsivity to better address impulsive behaviors in treatment.

Contingency management promotes smoking reductions in residential substance abuse patients

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

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

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

Contingency management is efficacious for cocaine abusers with prior treatment attempts

Efforts are underway to detect subgroups who may be more or less responsive to contingency management (CM) substance abuse treatments. This study examined the impact of prior treatment attempts on primary and posttreatment outcomes in a combined sample of cocaine abusers randomized to standard care substance abuse outpatient treatment (SC) or SC plus CM. Participants (N = 393) were categorized according to self-reported prior treatment attempts (0-1, >or=2). Participants with multiple prior treatment attempts were older, had more severe alcohol and cocaine use disorders, and had greater employment-related problems. Participants with 0?1 prior treatment attempts had comparable treatment retention, regardless of treatment condition; however, among participants with multiple prior treatment attempts, retention was greater for CM than SC. A similar, but nonsignificant (p = .08) pattern was evident for longest duration of abstinence (LDA). LDA was a significant predictor of negative (for cocaine, alcohol, and opiates) specimen results at Month 9. The results provide support for CM as an advantageous option for individuals with multiple prior treatment attempts, as well as for substance abuse treatment patients in general.

Cocaine abusers with and without alcohol dependence respond equally well to contingency management treatments

Contingency management (CM) treatments are efficacious in treating cocaine abuse. Despite high prevalence rates of alcohol dependence (AD) among individuals with cocaine use disorders, relatively little data are available regarding whether comorbid AD is associated with poorer treatment outcomes in general, or in response to CM in particular. Using data from 3 randomized trials of CM for cocaine abuse, we compared cocaine abusers (N = 393) with and without AD in terms of abstinence and psychosocial problems during treatment and follow-up. Alcohol dependent participants had more lifetime years of cocaine and alcohol use and greater severity of alcohol and psychiatric problems. CM was positively and significantly associated with longer durations of abstinence, regardless of AD status. Although not significantly associated with abstinence, the presence of AD was related to improvement in medical and alcohol-related problems during treatment, and these gains were maintained posttreatment. The results suggest that cocaine abusers benefit equally well from CM treatments, regardless of AD status. Further, alcohol dependent participants are able to offset greater baseline severity in psychosocial functioning and maintain these improvements with CM.

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

AIM

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

DESIGN

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

SETTING

A community-based methadone maintenance clinic.

PARTICIPANTS

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

INTERVENTION

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

MEASUREMENTS

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

FINDINGS

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

CONCLUSIONS

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

Randomized trial of contingent prizes versus vouchers in cocaine-using methadone patients

Contingency management (CM) interventions frequently utilize vouchers as reinforcers, but a prize-based system is also efficacious. This study compared these approaches. Seventy-four cocaine-dependent methadone outpatients were randomly assigned to standard treatment (ST), ST plus a maximum of $585 in contingent vouchers, or ST plus an expected average maximum of $300 in contingent prizes for 12 weeks. CM participants achieved longer durations of abstinence (LDA) than ST participants, and CM conditions did not differ significantly in outcomes or amount of reinforcement earned. Although long-term abstinence did not differ by group, LDA during treatment was the best predictor of abstinence at 9 months. Thus, reinforcement with prizes was similar to voucher CM in promoting LDA, which is associated with posttreatment benefits.

Contingency management improves abstinence and quality of life in cocaine abusers

Contingency management (CM) treatments enhance drug abstinence. This study evaluated whether CM also improves quality of life and if these effects are mediated by abstinence. Across 3 independent trials, cocaine abusers in intensive outpatient treatment (n = 387) were randomly assigned to 12 weeks of standard treatment as usual or standard treatment with CM. The Quality Of Life Inventory (QOLI) was administered at baseline and at Months 1, 3, 6, and 9. Changes in QOLI scores over time differed significantly by treatment, with QOLI scores rising over time in CM participants and remaining stable in standard treatment participants. CM participants also achieved greater durations of abstinence, and duration of abstinence was correlated with posttreatment QOLI scores. During-treatment abstinence mediated the relationship between treatment condition and QOLI scores over time.

Low-cost contingency management in community clinics: delivering incentives partially in group therapy

This study examined the feasibility and effectiveness of prize-based contingency management (CM) when incentives for attendance were administered in group therapy and incentives for abstinence were administered in individual meetings. Three community substance abuse treatment programs participated in this two-phase, crossover design study. Outpatients (N = 103) entering treatment who met diagnostic criteria for cocaine, opiate, and alcohol abuse or dependence were recruited. During the standard condition, participants received standard treatment and submitted breath and urine samples that were tested for alcohol, cocaine, and opiates twice weekly during Weeks 1-6 and once weekly during Weeks 7-12. During the CM condition, participants received the same standard treatment and sample and attendance monitoring, plus the opportunity to win prizes for negative samples and treatment attendance. Demographic information and substance abuse history were evaluated at intake, and posttreatment substance use (toxicology results and self-report) was evaluated at Month 6 and Month 9 follow-up interviews. Primary outcomes were weeks retained in treatment and longest duration of sustained abstinence (LDA). LDA was significantly greater in CM-condition participants, but weeks retained did not differ between groups. Rates of substance use were lower in CM participants at Month 9 but not at Month 6. This study suggests that it is feasible to deliver incentives for attendance in group therapy, but that further research is needed to understand the modest effects on attendance. Strengths and limitations of this study are discussed.

Regardless of psychiatric severity the addition of contingency management to standard treatment improves retention and drug use outcomes

The relationship between psychiatric severity and substance use disorders treatment outcome was assessed in 393 individuals who received either standard treatment or standard treatment plus contingency management. The sample was divided into groups of low, moderate, and high psychiatric severity based upon baseline Addiction Severity Index psychiatric composite scores. Participants in the high psychiatric severity group reported a greater prevalence of psychiatric hospitalization, psychiatric medications, and suicide attempts, as well as poorer baseline psychosocial functioning. In terms of treatment outcome, a significant interaction between psychiatric severity and treatment modality was found in relation to treatment retention. Participants in the standard treatment condition were more likely to dropout of treatment earlier as psychiatric severity increased, while retention was similar across the psychiatric severity groups in the contingency management condition. Psychiatric severity was not linked to longest duration of abstinence achieved during treatment or adherence with contingency management procedures. Overall, these findings suggest contingency management is an efficacious and appropriate intervention for substance use disordered individuals across a range of psychiatric problems.

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

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

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

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

An experimental examination of the initial weeks of abstinence in cigarette smokers

Gaining experimental control over abstinence may help define processes that change during abstinence that may be related to the association between initial abstinence and relapse risk often noted in clinical trials. Adult smokers (n = 34) were randomly assigned to receive monetary incentives contingent on abstinence (CO +/- 4 ppm) or noncontingent for 12 days. Carbon monoxide (CO) tests were conducted 3 times per day, saliva samples were collected on Days 5 and 12, and all other measures were collected 1 time per day. In the contingent group, 59% of participants abstained throughout the study versus 0% in the control condition. Abstinence was associated with increases in participant-rated ease of abstaining and confidence in abstinence; nicotine withdrawal severity and craving decreased over time. Results indicate that it is feasible to experimentally manipulate smoking abstinence and that doing so can enhance understanding of the relationship between early abstinence and relapse risk.

An experimental test of the influence of prior cigarette smoking abstinence on future abstinence

Significant positive associations between early and later abstinence are often reported in clinical trials on smoking cessation, but those relationships do not permit causal inferences. The present study was conducted to examine experimentally whether prior smoking abstinence histories can directly facilitate later abstinence, using a contingency management procedure to manipulate prior abstinence. A total of 40 adult cigarette smokers who were not trying to quit were randomly assigned to one of two conditions: Contingent ALL (C-ALL), who earned monetary incentives contingent on smoking abstinence during three 5 day experimental periods; or Contingent LAST (C-LAST), who earned incentives independent of abstinence during the first two periods (i.e., noncontingent payments) and contingent on abstinence during the final period. The contingency management procedure was effective in establishing different abstinence histories in the two conditions during the first two periods. Comparison of abstinence levels between the C-ALL and C-LAST conditions during the third period showed significantly greater abstinence in the C-ALL condition, although nicotine withdrawal and other subject ratings generally did not differ significantly between the two conditions. These results provide experimental evidence that prior abstinence histories can directly influence subsequent efforts to abstain from smoking.