A reinforcement-based Therapeutic Workplace for the treatment of drug abuse: Six-month abtinence outcomes.

This study evaluated a novel drug abuse treatment, the Therapeutic Workplace. In this treatment, patients are paid to perform jobs or to participate in job training. Salary is linked to abstinence by requiring patients to provide drug-free urine samples to gain access to the workplace. Pregnant and postpartum drug abuse patients (N ?=?40) were randomly assigned to a Therapeutic Workplace or usual care control group. Therapeutic Workplace participants were invited to work 3 hr every weekday for 6 months and could earn up to $4,030 in vouchers for abstinence, workplace attendance, and performance. On average, 45% of participants attended the workplace per day. Relative to controls, the Therapeutic Workplace nearly doubled patients' abstinence from opiates and cocaine (33% vs. 59% of thrice-weekly urine samples drug negative, respectively, p ?     

A reinforcement-based Therapeutic Workplace for the treatment of drug abuse: Three-year abstinence outcomes.

Long-term Therapeutic Workplace effects were evaluated in heroin- and cocaine-dependent, unemployed, treatment-resistant young mothers. Participants were paid to work or to train in the Therapeutic Workplace but had to provide drug-free urine samples to gain daily access. Participants (N=40) were randomly assigned to a Therapeutic Workplace or usual care control group. Therapeutic Workplace participants could work for 3 years. Relative to controls, Therapeutic Workplace participants increased cocaine (28% vs. 54% negative; p=.04) and opiate (37% vs. 60% negative; p=.05) abstinence on the basis of monthly urine samples collected until 3 years after intake. The Therapeutic Workplace can be an effective long-term treatment of cocaine and heroin addiction in poor and chronically unemployed young mothers. (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)     

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)     

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

Toward application of the Therapeutic Workplace: Reply to Higgins (2001), Marlatt (2001), McLellan (2001), and Petry (2001).

Responds to comments by N. M. Petry, S. T. Higgins, A. T. McLellan, and G. A. Marlatt (see records 2001-14365-003, 2001-14365-004, 2001-14365-005, 2001-14365-006 respectively) on the article by K. Silverman et al. (see record 2001-14365-002). The Therapeutic Workplace appears effective at initiating abstinence from heroin and cocaine in pregnant and postpartum women. However, the cost and complexity of the intervention must be reduced before it is ready for widespread application. This treatment is designed to train and employ drug abuse patients, and to use the salary that they earn for working to reinforce abstinence. Limiting teaching to only critical skills can reduce the costs of training. Computerizing the intervention also can reduce its cost and complexity. Major cost efficiencies should be realized when participants become employed in Therapeutic Workplace businesses; these businesses could provide a self-sustaining means of arranging long-term employment and salary-based abstinence reinforcement. Studies are required that simultaneously demonstrate the effectiveness and cost efficiencies of using salary for real work to reinforce drug abstinence. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Comparable efficacy of contingency management for cocaine dependence among African American, Hispanic, and White methadone maintenance clients.

Cocaine use is a significant problem among methadone maintenance clients. Contingency management (CM) is a reinforcement-based approach with demonstrated efficacy for reducing cocaine use. This study examines whether the efficacy of CM treatment for cocaine-dependent individuals receiving methadone maintenance for opioid dependence differs by ethnicity. Participants were 191 African American, Hispanic, and White cocaine-dependent methadone maintenance clients, randomly assigned to standard methadone treatment or standard methadone treatment plus CM for 12 weeks. Hispanic participants were younger, less educated, and reported fewer years of cocaine use than did African American and White participants and reported fewer years of heroin use than did African American participants. African American participants were less likely to report a history of psychiatric symptoms or treatment in comparison with Hispanic and White participants. While CM was associated with longer duration of continuous cocaine abstinence and a greater proportion of submitted urine samples negative for cocaine, ethnicity was not related to treatment outcomes, and there was no significant interaction between treatment and ethnicity. CM appears to be an efficacious treatment for cocaine dependence among methadone maintenance clients, regardless of ethnicity. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

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)     

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)     

Contingency Management of Reliable Attendance of Chronically Unemployed Substance Abusers in a Therapeutic Workplace.

The Therapeutic Workplace is an effective drug abuse treatment that integrates abstinence reinforcement into a work setting by using a salary that drug abusers earn for work. Drug abuse patients are trained and hired to become data entry operators in a Therapeutic Workplace business. Despite the opportunity to earn a high wage, participants frequently arrive at work late and fail to work complete shifts. In the present study, a contingency management intervention to promote consistent and reliable attendance was evaluated in 4 participants. Participants were not allowed to work on days that they arrived late, and their pay was temporarily reduced each time they arrived late at work or failed to complete a work shift. A within-subject reversal design showed that the intervention increased the frequency with which participants arrived at work on time and completed work shifts. (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)     

Treatment of immunologic nervous system diseases by using anti-adhesion molecule antibodies

In this evaluation of baseline drug use as a predictor of treatment outcome, cocaine use during a 5-week baseline was compared in methadone maintenance patients who had < 5 (n = 10) versus > or = 5 (n = 9) weeks of abstinence during an experimental cocaine abstinence reinforcement treatment. Cocaine use was evaluated at the 1st and last visit and the 1st and last week of baseline and as a mean across the 5-week baseline treatment; response was calculated as a mean across 12 weeks of experimental treatment. Those who had successful outcomes (abstainers) used significantly less cocaine in the 5-week baseline than those with less successful outcomes (nonabstainers). Differences in cocaine use were not evident in the 1st baseline visit or week, but the abstainers used significantly less cocaine in the last visit and week of baseline compared with the nonabstainers. Cocaine use during baseline provided critical predictors of response to the experimental treatment.     

Cocaine use early in treatment predicts outcome in a behavioral treatment program.

In this evaluation of baseline drug use as a predictor of treatment outcome, cocaine use during a 5-week baseline was compared in methadone maintenance patients who had n?=?10) versus ≥5 (n?=?9) weeks of abstinence during an experimental cocaine abstinence reinforcement treatment. Cocaine use was evaluated at the 1st and last visit and the 1st and last week of baseline and as a mean across the 5-week baseline treatment; response was calculated as a mean across 12 weeks of experimental treatment. Those who had successful outcomes (abstainers) used significantly less cocaine in the 5-week baseline than those with less successful outcomes (nonabstainers). Differences in cocaine use were not evident in the 1st baseline visit or week, but the abstainers used significantly less cocaine in the last visit and week of baseline compared with the nonabstainers. Cocaine use during baseline provided critical predictors of response to the experimental treatment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

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)     

Effects of reinforcer magnitude on data-entry productivity in chronically unemployed drug abusers participating in a therapeutic workplace.

The Therapeutic Workplace is a substance abuse treatment wherein patients are hired and paid to work in a job contingent on daily drug-free urine samples. The present study examined data-entry productivity of 6 unemployed methadone patients who demonstrated relatively variable and low data-entry response rates. A within-subject reversal design was used to determine whether increasing reinforcement magnitude tenfold could increase response rates. Four of the 6 participants showed the highest rates of responding in the high magnitude reinforcement condition. Two participants, who had the lowest overall response rates, showed less robust changes to the magnitude manipulation. The results suggest that reinforcement magnitude can be used to improve productivity in Therapeutic Workplace participants. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Predictors of outcome in LAAM, buprenorphine, and methadone treatment for opioid dependence.

This study examined (1) predictors of treatment outcome for opioid-dependent participants in a single-site controlled trial comparing methadone, buprenorphine, and LAAM treatments and (2) the extent to which various subpopulations of patients may have more successful outcomes with each medication. The relationships between patient demographics, drug use history, and psychological status and outcome measures of treatment retention, opiate use, and cocaine use were assessed. We believe this study to be the first to demonstrate that predictors of treatment success appear to be largely similar in LAAM, buprenorphine, and methadone treatment for opioid dependence. We did not find any factors that would strongly guide selection of one medication over others. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Prize Reinforcement Contingency Management for Cocaine Dependence: Integration With Group Therapy in a Methadone Clinic.

In this study, the authors evaluated a low-cost contingency management (CM) procedure for reducing cocaine use and enhancing group therapy attendance in 77 cocaine-dependent methadone patients. Patients were randomly assigned to 12 weeks of standard treatment or standard treatment with CM, in which patients earned the opportunity to win prizes ranging from $1 to $100 for submitting cocainenegative samples and attending therapy. Patients in the CM condition submitted more cocaine-negative samples and attended more groups than patients in standard treatment. The best predictor of cocaine abstinence at follow-up was duration of abstinence during treatment. On average, patients in the CM condition earned $117 in prizes. Data from this study suggest that some aspects of reinforcement can be implemented in group therapy in community-based clinics. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Abstinence-contingent reinforcement and engagement in non-drug-related activities among illicit drug abusers.

Methadone-maintained cocaine abusers (N = 78) were randomly assigned to 1 of the following 52-week interventions: (a) usual care only (UC), (b) take-home methadone doses contingent on cocaine- and opiate-negative results (THM), or (c) take-home methadone doses for cocaine- and opiate-negative results and monetary-based vouchers contingent on cocaine-negative urinalysis results (THM + V). Cocaine use was assessed by urinalysis on a thrice-weekly schedule. Frequency and enjoyability of non-drug-related activities were assessed with the Pleasant Events Schedule (PES) at baseline, midtreatment, and end of treatment. The THM + V condition achieved the greatest abstinence from cocaine and opiate use, followed by the THM and UC conditions. The THM + V condition had the highest PES frequency ratings at midtreatment and at the end of treatment, followed by the THM and UC conditions. There were significant differences between the THM + V and UC conditions on 10 of 12 PES-derived subscales. Analyses revealed that abstinence mediated the effects of treatment condition on frequency ratings. There were no significant differences in enjoyability ratings. These results suggest that when contingency-management interventions increase abstinence from drug abuse, they also increase engagement in non-drug-related activities in naturalistic settings. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Non-prescribed drug use during methadone treatment by clinic- and community-based patients

We investigated the efficacy of methadone maintenance treatment in clinic-based (n = 10) and community-based (n = 10) patients by studying the relationships between dose, plasma concentrations of methadone and non-prescribed drug-use using logistic regression. We found that clinic-based patients had significantly reduced odds of having a urine sample test positive for illicit drugs when compared to community-based patients (OR = 0.20; 95% confidence interval 0.10-0.38: p < 0.001). There was no relationship between either methadone dose or plasma methadone concentration and testing positive for non-prescribed drugs (including cocaine, cannabis, amphetamine, ecstasy, benzodiazepines). We looked specifically at the misuse of opiate drugs. Location was again important and clinic-based patients had significantly reduced odds of having a urine sample test positive for opiate drugs (OR = 0.36, 95% confidence interval 0.18-0.71: p approximately 0.004). Opiate drug use in our patients was also significantly related to plasma methadone concentration, increasing noticeably when the drug concentration < 0.48 nmol/L (p approximately 0.04). We found no relationship between methadone dose and odds of having a positive urine drug test in either clinic- or community-based patients.     

Contingent reinforcement of group participation versus abstinence in a methadone maintenance program.

This study compared the effectiveness of 2 types of contingency management interventions on reducing unauthorized drug use among methadone maintenance patients. Take-home medications were used to reinforce either the provision of drug-free urines (UA) or attendance of groups providing training in interpersonal problem solving (TIPS). Newly enrolled patients were randomly assigned to either the TIPS (n?=?34) or the UA (n?=?32) condition after a 12-week stabilization period. During the course of the 24-week intervention period, UA participants showed greater improvement than TIPS participants in rates of abstinence from unauthorized drugs. Also, a greater proportion of UA participants met a priori criteria for clinical improvement, whereas a greater proportion of TIPS participants met a priori criteria for clinical deterioration. The results support the efficacy of contingency interventions targeted specifically at drug-using behavior. (PsycINFO Database Record (c) 2010 APA, all rights reserved)