Contingent take-home incentive: Effects on drug use of methadone maintenance patients.

Examined contingent methadone take-home privileges for effectiveness in reducing on-going supplemental drug use of methadone maintenance patients. 53 new intakes were randomly assigned to begin receiving take-home privileges after 2 consecutive weeks of drug-free urines or to a noncontingent procedure in which take-homes were delivered independently of urine test results. The contingent procedure produced more individuals with at least 4 consecutive weeks of abstinence (32 vs 8%); 28% of noncontingent Ss also achieved abstinence after shifting to the contingent procedure. Lower baseline rate of drug-free urines was strongly associated with successful outcome, whereas the type of drug abused (cocaine vs benzodiazepines) did not influence outcomes. Findings support a recommendation for using contingent take-home incentives to motivate abstinence during methadone maintenance treatment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A Randomized Trial of Long-Term Reinforcement of Cocaine Abstinence in Methadone-Maintained Patients Who Inject Drugs.

This study determined whether long-term abstinence reinforcement could maintain cocaine abstinence throughout a yearlong period. Patients who injected drugs and used cocaine during methadone treatment (n = 78) were randomly assigned to 1 of 2 abstinence-reinforcement groups or to a usual care control group. Participants in the 2 abstinence-reinforcement groups could earn take-home methadone doses for providing opiate- and cocaine-free urine samples; participants in 1 of those groups also could earn $5,800 in vouchers for providing cocaine-free urine samples over 52 weeks. Both abstinence-reinforcement interventions increased cocaine abstinence, but the addition of the voucher intervention resulted in the largest and most sustained abstinence. Therefore, voucher-based reinforcement of cocaine abstinence in methadone patients can be a highly effective maintenance intervention. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Contingent reinforcement increases cocaine abstinence during outpatient treatment and 1 year of follow-up.

This study assessed whether contingent incentives can be used to reinforce cocaine abstinence in dependent outpatients. Seventy cocaine-dependent outpatients were randomized into 2 conditions. All participants received 24 weeks of treatment and 1 year of follow-up. The treatment provided to all participants combined counseling based on the community reinforcement approach with incentives in the form of vouchers exchangeable for retail items. In 1 condition, incentives were delivered contingent on cocaine-free urinalysis results, whereas in the other condition incentives were delivered independent of urinalysis results. Abstinence-contingent incentives significantly increased cocaine abstinence during treatment and 1 year of follow-up compared with noncontingent incentives. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Broad beneficial effects of cocaine abstinence reinforcement among methadone patients

Escalating reinforcement for sustained abstinence has been effective in treating cocaine abuse. Under this schedule, patients receive vouchers for cocaine-free urine samples; vouchers have monetary values that increase with the number of consecutive cocaine-free urine samples. Cocaine-abusing methadone patients were randomly assigned to receive vouchers for 12 weeks under (a) an escalating schedule (n = 20), (b) an escalating schedule with start-up bonuses (n = 20), or (c) a noncontingent schedule (n = 19). Start-up bonuses were designed to provide added reinforcement for initiating abstinence; however, they did not improve outcomes. Both contingent interventions significantly increased cocaine abstinence. In addition, the contingent interventions increased abstinence from opiates and decreased reports of cocaine craving. These results replicate the efficacy of cocaine abstinence reinforcement and show that it can have broad beneficial effects.     

Vocher-based reinforcement of opiate plus cocaine abstinence in treatment-resistant methadone patients: Effects of reinforcer magnitude.

The study tested a voucher-based abstinence reinforcement procedure for reducing opiate and cocaine use in a population of treatment-resistant opiate- and cocaine-abusing methadone patients. Vouchers exchangeable for goods and services were contingent on abstinence from both opiates and cocaine. In two conditions, participants could earn up to $374 or $3,369 in vouchers for providing opiate- and cocaine-free urine samples. Participants received a daily 60-mg dose of methadone. The dose was increased in a second phase, and the voucher conditions were replicated. Analyses of both phases revealed trends toward greater abstinence under the high voucher condition and suggested that higher doses may enhance the efficacy of voucher reinforcement. The results show that reinforcement for abstinence from 2 drugs simultaneously can be effective even in a treatment-resistant population. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Medication take-home doses and contingency management.

Two studies examined contingent take-home medication doses during treatment of opiate or cocaine dependence. In the first study, methadone maintenance patients were randomly assigned to one of two 8-week baseline take-home (TH) conditions differing in frequency of clinic visits per week. This was followed by a 12-week contingency management (CM) procedure in which frequent THs resulted from drug-free urines. Participants receiving more frequent THs during baseline had lower illicit drug use during the first 6 weeks of CM. In the second study, fluoxetine (0-, 20-, 40-mg) TH doses were similarly contingent in treatment of cocaine dependence. The 40-mg group used less cocaine during contingency than did other groups. The combination of fluoxetine and environmental contingencies may produce benefit where neither alone is sufficient. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A randomized controlled trial of the therapeutic workplace for community methadone patients: A partial failure to engage.

The Therapeutic Workplace is an employment-based treatment for drug addiction that uses wages for work to reinforce drug abstinence. The Therapeutic Workplace has promoted abstinence from heroin and cocaine in treatment-resistant mothers in methadone treatment. This study attempted to replicate that effect in crack cocaine users recruited from community-based methadone programs. Participants were randomly assigned to a Therapeutic Workplace (n=22) or usual care control (n=25) group. Therapeutic Workplace participants were invited to work in the workplace and earn vouchers every weekday for 9 months contingent on documented opiate and cocaine abstinence. The two groups did not differ significantly on measures of cocaine or opiate use collected during study participation. Daily attendance and urinalysis results of the Therapeutic Workplace group were analyzed, and only 7 of the 22 participants initiated consistent periods of abstinence and workplace attendance. Two individuals gained access to the workplace on a few days, and 9 participants attempted to gain access to the workplace but never provided a drug-negative urine sample. Possible reasons for differences between the current study and the previous Therapeutic Workplace study are considered. Procedures that increase participant contact with the Therapeutic Workplace and its reinforcement contingencies might increase the likelihood of these individuals being successful in the treatment program. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Predicting cocaine group treatment outcome in cocaine-abusing methadone patients.

The authors examined predictors of cocaine group treatment outcome in methadone maintenance treatment (MMT) patients, including cocaine urinalysis at intake and demographic variables. Clinic policy is that patients identified as using cocaine must attend a weekly cocaine-focused, cognitive–behavioral therapy (CBT) group. Cocaine treatment is based on a behavioral (escape) contingency model whereby completers must attend group-counseling sessions and produce cocaine-negative urinalysis results. Among the 113 patients enrolled in the cocaine group, 43 (38%) were treatment completers (who attended 6 consecutive weeks of group and produced 6 consecutive weeks of cocaine-free urine tests) and 70 (62%) were treatment noncompleters. Treatment completion (i.e., cocaine abstinence) was significantly associated with baseline cocaine-free urinalysis and higher methadone dose. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The brief abstinence test: Effects of continued incentive availability on cocaine abstinence.

This study compared the effects of 4 voucher incentive conditions of a brief abstinence test on continuous cocaine abstinence. In 3 conditions, cocaine-abusing methadone patients could earn $100 for 2 days of cocaine abstinence; 2 of these conditions offered, on either a continuous or interrupted schedule, an additional $300 for evidence of sustained abstinence over the next 9 days. In the 4th condition, no incentives were available. In incentive conditions, 70-80% of patients initiated abstinence, compared with 48% in the no-incentive condition. Both continuing reinforcement conditions produced higher rates of sustained abstinence than the single and no-voucher conditions. The study confirmed the utility of quantitative urine-testing methods combined with high valued incentives to promote cocaine abstinence initiation in methadone maintenance patients. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Initial abstinence and success in achieving longer term cocaine abstinence.

This study's goals were to characterize the relationship between early and longer term cocaine abstinence and assess whether increasing early abstinence increases longer term abstinence. Results from 190 cocaine-dependent outpatients were analyzed. Participants were divided into 2 conditions: (a) those treated with community reinforcement approach (CRA) plus contingent vouchers (n?=?125) and (b) those treated with control treatments (n?=?65). A period of sustained abstinence during treatment was associated with significantly greater odds of posttreatment abstinence, with no evidence of differences between the 2 treatment conditions in that regard. Treatment conditions differed in that CRA plus contingent vouchers increased the proportion of participants who sustained a period of during-treatment abstinence and increased abstinence during 6-month posttreatment follow-up. Devising interventions that increase the proportion of individuals who achieve an early period of sustained abstinence may be key to increasing longer term cocaine abstinence. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Contingency contracting with monetary reinforcers for abstinence from multiple drugs in a methadone program.

Positive monetary contingencies for treating opioid dependence complicated by other drug use were examined. Participants (N?=?102) entered 6-month methadone transition treatment (MTT) and were randomized into experimental conditions: 51 entered MTT with contingency contracts using monetary reinforcers and targeting abstinence from illicit drug and alcohol use, and 51 entered MTT without contingency contracts targeting abstinence. Outcomes were evaluated by random urinalysis and breath analysis. After 4 months of treatment, individuals in the contingency condition had longer periods of continuous abstinence (p?     

Contingency management for cocaine use in methadone maintenance patients: When does abstinence happen?

Contingency management (CM) is an efficacious intervention for cocaine abusing methadone patients, but typically only about half of patients respond. By investigating time to onset of cocaine abstinence and factors associated with abstinence, we may be able to more efficiently direct CM approaches to patients most likely to benefit. Onset of cocaine abstinence was evaluated in cocaine abusing methadone maintenance patients (N = 193) enrolled in one of three randomized clinical trials of CM. Participants received standard treatment with frequent urine toxicology monitoring or standard treatment plus CM during the trials. Slightly more than half the sample obtained at least 1 week of cocaine abstinence, and approximately a third of the sample obtained at least 4 weeks of cocaine abstinence. Discrete-time survival and hazard analyses found Weeks 1 and 2 of the intervention period had the greatest probability for the initiation of abstinence, and few participants initiated any period of abstinence after Week 4. Patients randomized to CM, those with more years of cocaine use, and those with less recent cocaine use were more likely to achieve abstinence. Overall, these results indicate onset of cocaine abstinence is likely to occur early in treatment and in individuals with less severe cocaine use. Practical implications of these results for designing and implementing CM interventions in methadone maintenance clinics are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

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. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

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

This study compared the relative efficacy of low-magnitude, contingent monetary vouchers, contingent buprenorphine medication, and standard counseling in promoting abstinence from illicit opioids and cocaine among opioid-dependent adults. Following an 8-week baseline period during which participants received buprenorphine maintenance treatment with no contingencies in place, 60 participants were randomly assigned to one of 3 treatment groups for 12 weeks: (a) Participants in the voucher group earned vouchers for each opioid- and cocaine-negative urine sample, in accordance with an escalating schedule. Continuous abstinence resulted in voucher earnings equivalent to a total of $269, which participants could exchange for material reinforcers of their choice. (b) Participants in the medication contingency group received half their scheduled buprenorphine dose for clinic attendance and the other half for remaining abstinent from opiates and cocaine. Thus, they received only half of their scheduled dose on submission of an opioid- and/or cocaine-positive urine sample. (c) Participants in standard treatment did not receive programmed consequences contingent on urinalysis results. All participants were maintained with buprenorphine according to a 3-times-per-week dosing regimen and participated in behavioral drug counseling. Retention rate did not significantly differ across the groups; however, participants in the medication contingency group achieved significantly more weeks of continuous abstinence from opiates and cocaine compared with participants in the voucher group (Ms = 5.95 and 2.90, respectively). Results suggest that the use of medication-based contingencies in combination with behavioral therapy in promoting drug abstinence may have clinical utility. Limitations of the study are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

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

Goods-based contingency management interventions (e.g., those using vouchers or prizes as incentives) have demonstrated efficacy in reducing cocaine use, but cost has limited dissemination to community clinics. Recent research suggests that development of a cash-based contingency management approach may improve treatment outcomes while reducing operational costs of the intervention. However, the clinical safety of providing cash-based incentives to substance abusers has been a concern. The present 16-week study compared the effects of goods-based versus cash-based incentives worth $0, $25, $50, and $100 on short-term cocaine abstinence in a small sample of cocaine-dependent methadone patients (N = 12). A within-subject design was used; a 9-day washout period separated each of 8 incentive conditions. Higher magnitude ($50 and $100) cash-based incentives (checks) produced greater cocaine abstinence compared with the control ($0) condition, but a magnitude effect was not seen for goods-based incentives (vouchers). A trend was observed for greater rates of abstinence in the cash-based versus goods-based incentives at the $50 and $100 magnitudes. Receipt of $100 checks did not increase subsequent rates of cocaine use above those seen in control conditions. The efficacy and safety data provided in this and other recent studies suggest that use of cash-based incentives deserves consideration for clinical applications of contingency management, but additional confirmation in research using larger samples and more prolonged periods of incentive delivery is needed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Contingent reinforcement of marijuana abstinence among individuals with serious mental illness: A feasibility study.

The feasibility of using monetary incentives to promote abstinence from marijuana use among individuals with serious mental illness was examined by using a within-subjects experimental design. Participants were 18 adults with schizophrenia or other serious mental illness who reported regular marijuana use. During 2 baseline conditions, participants received payment for submitting urine specimens independent of urinalysis results. During 3 incentive conditions, participants received varying amounts of money if urinalysis results were negative for recent marijuana use. The number of marijuana-negative specimens obtained was significantly greater during incentive than baseline conditions. These results provide evidence that marijuana use among at least some mentally ill individuals is sensitive to contingent reinforcement and support the potential feasibility of using contingency management interventions to reduce substance abuse among the mentally ill. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Single- Versus Dual-Drug Target: Effects in a Brief Abstinence Incentive Procedure.

The number of drugs targeted may have an important influence on the ability of drug abusers to abstain during motivational incentive procedures. The authors investigated outcomes in methadone maintenance patients (n = 58), who had evidence of both opiate and cocaine use, when continuous abstinence from cocaine only (single target) or from both cocaine and heroin (dual target) was required to earn $200 in voucher incentives over a 4-day period. Study patients were equally likely to initiate and sustain abstinence from cocaine under the single- versus the dual-drug target. They were more likely to initiate opiate abstinence under the dual-target condition, demonstrating sensitivity to reinforcer effects. Results suggest that adding a second drug target does not impede short-term cocaine abstinence initiation. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Concurrent alcohol dependence among methadone-maintained cocaine abusers is associated with greater abstinence.

Concurrent alcohol dependence (AD) among polysubstance abusers has been associated with negative consequences, although it may not necessarily lead to poor treatment outcomes. One of the most efficacious treatments for cocaine abuse is contingency management (CM), but little research has explored the impact of AD on abstinence outcomes, particularly among patients in methadone maintenance. Using data from three trials of CM for cocaine use, we compared baseline characteristics and posttreatment and follow-up cocaine outcomes between methadone-maintained, cocaine-dependent patients (N = 193) with and without concurrent AD, randomized to standard care (SC) with or without CM. Patients with and without concurrent AD had similar baseline characteristics, with the exception that AD patients reported more alcohol use. AD patients achieved longer durations of cocaine abstinence and were more likely to submit a cocaine-negative sample at follow-up than non-AD patients. Patients randomized to CM achieved better outcomes than those randomized to SC, but there was no interaction between treatment condition and AD status. These findings suggest that cocaine-using methadone patients with AD achieve greater cocaine abstinence than their non-AD counterparts and should not necessarily be viewed as more difficult to treat. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

A controlled smoking cessation trial for substance-dependent inpatients.

Smoking treatment for newly recovering drug and alcohol-dependent smokers in a residential rehabilitation program was examined. The randomly assigned conditions (n?=?50 each) were multicomponent smoking treatment (MST), MST plus generalization training of smoking cessation to drug and alcohol cessation (MST+G), or usual care (UC). Fifty participants who declined smoking treatment (treatment refusers) also were studied. Both treatment conditions achieved continuous smoking abstinence rates (MST: 12%. MST+G: 10%, at 12-month follow-up) that were significantly higher than in the UC condition (0%). The MST condition had a continuous drug and alcohol abstinence rate that was significantly higher than that of the MST+G condition (40% vs. 20% at 12-month follow-up) although neither differed significantly from that of the UC condition (33%). These results support the feasibility of smoking treatment for this population and provide information regarding appropriate treatment components. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Comparison of the frequency and enjoyability of pleasant events in cocaine abusers vs. non-abusers using a standardized behavioral inventory

AIMS: To examine whether cocaine abusers differ from non-abusers in their frequency and enjoyability of engaging in various "pleasant events", in order to approximate the density of positive reinforcement experienced in their natural environment. DESIGN: Comparisons of cocaine abusers to normative data and matched controls. SETTING: An outpatient substance abuse treatment center in Burlington, Vermont, USA. PARTICIPANTS: Subjects included 100 individuals enrolled in outpatient treatment for cocaine abuse or dependence and 50 community volunteers without histories of drug abuse or other major psychiatric illness and matched to cocaine-dependent patients on age, sex and SES. MEASUREMENTS: Diagnostic assessments were based upon clinical interviews using the DSM-III-R checklist. The primary focus of this study was the Pleasant Events Schedule (PES), a self-rated behavioral inventory of the frequency and enjoyability of engaging in "pleasant" activities. Cocaine use history, treatment outcome and other relevant variables were also assessed. FINDINGS: Cocaine abusers reliably reported lower frequency of non-social, introverted, passive outdoor and mood-related activities than controls. These differences remained after controlling for demographic and life-style differences between groups, with the exception of mood-related activities. Perceived enjoyability of the activities did not differ across groups. Intravenous cocaine use and prior treatment for cocaine abuse predicted particularly low frequency of pleasant activities. Greater frequency of non-social activities predicted better treatment outcome. CONCLUSIONS: Drug abuse is associated with low density of certain types of non-drug reinforcement. Systematic increases in these activities may improve treatment outcome.