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CORK Bibliography: Behavioral Contingencies and Contingency Management

28 citations. January 2009 to present

Prepared: March 2010

Barnett PG; Sorensen JL; Wong W; Haug NA; Hall SM. Effect of incentives for medication adherence on health care use and costs in methadone patients with HIV. Drug and Alcohol Dependence 100(1-2): 115-121, 2009. (49 refs.)

Background: The potential benefits of anti-retroviral therapy for HIV is not fully realized because of difficulties in adherence with demanding treatment regimens, especially among injection drug users. Methods: HIV-positive methadone patients who were less than 80% adherent with their primary anti-retroviral therapy were randomized to a trial of incentives for on-time adherence. Adherence was rewarded with an escalating scale of vouchers redeemable for goods. Both intervention and control group visited a medication coach twice a month. The cost of the intervention was determined by micro-costing. Other costs were obtained from administrative data and patient report of out-of-system care. Results: During the 12-week intervention period, the incremental direct cost of the intervention, including treatment vouchers, was $942. The Voucher group incurred $2572 in anti-retroviral drug cost, significantly' more than the $1973 incurred by the comparison group (p<.01). Adherence, as measured by on-time openings of an electronically monitored vial was 78% in the intervention group and 56% in the control group. Conclusions: The incremental direct cost of voucher incentives was $292 per month. If the observed increase in adherence from voucher incentives can be sustained in the long-term, the literature suggests that disease progression will be slowed. Further research is needed to evaluate if the improvement can be sustained or achieved at lower cost. Mitigation of treatment resistance and reduction in HIV transmission are additional benefits that favor adoption.

Brigham G; Winhusen T; Lewis D; Kropp F. Incentives for retention of pregnant substance users: A secondary analysis. Journal of Substance Abuse Treatment 38(1): 90-95, 2010. (27 refs.)

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

Businelle MS; Rash CJ; Burke RS; Parker JD. Using vouchers to increase continuing care participation in Veterans: Does magnitude matter? American Journal on Addictions 18(2): 122-129, 2009. (34 refs.)

The present study examined the comparative effects of adding contingency management (CM) schedules to an existing substance abuse continuing care program, with the goal of increasing attendance. We retrospectively examined the attendance of 135 veterans enrolled in one of three CM programs and a quasi-control condition of 55 veterans. Results indicated that participants enrolled in the two higher magnitude CM voucher programs increased both continuing care attendance and length of participation. Findings support the use of CM to increase continuing care attendance among veterans with substance use disorders, and suggest that voucher magnitude and bonuses both had a positive impact.

Chopra MP; Landes RD; Gatchalian KM; Jackson LC; Buchhalter AR; Stitzer ML et al. Buprenorphine medication versus voucher contingencies in promoting abstinence from opioids and cocaine. Experimental and Clinical Psychopharmacology 17(4): 226-236, 2009. (37 refs.)

During a 12-week intervention, opioid dependent participants (N = 120) maintained on thrice-a-week (M, W, F) buprenorphine plus therapist and computer-based counseling were randomized to receive: (a) medication contingencies (MC = thrice weekly dosing schedule vs. daily attendance and single-day 50% dose reduction imposed upon submission of an opioid and/or cocaine positive urine sample); (b) voucher contingency (VC = escalating schedule for opioid and/or cocaine negative samples with reset for drug-positive samples); or (c) standard care (SC), with no programmed consequences for urinalysis results. VC resulted in better 12-week retention (85%) compared to MC (58%; p = 0.009), but neither differed from SC (76% retained). After adjusting for baseline differences in employment, and compared to SC, the MC group achieved 1.5 more continuous weeks of combined opioid/cocaine abstinence (p = 0.030). while the VC group had 2 more total weeks of abstinence (p = 0.048). Drug use results suggest that both the interventions were efficacious, with effects primarily in opioid rather than cocaine test results. Findings should be interpreted in light of the greater attrition associated with medication-based contingencies versus the greater monetary costs of voucher-based contingencies.

DeFulio A; Donlin WD; Wong CJ; Silverman K. Employment-based abstinence reinforcement as a maintenance intervention for the treatment of cocaine dependence: A randomized controlled trial. Addiction 104(9): 1530-1538, 2009. (46 refs.)

Context: Due to the chronic nature of cocaine dependence, long-term maintenance treatments may be required to sustain abstinence. Abstinence reinforcement is among the most effective means of initiating cocaine abstinence. Practical and effective means of maintaining abstinence reinforcement programs over time are needed. Objective: To determine whether employment-based abstinence reinforcement can be an effective long-term maintenance intervention for cocaine dependence. Design: Participants (n = 128) were enrolled in a 6-month job skills training and abstinence initiation program. Participants who initiated abstinence, attended regularly and developed needed job skills during the first 6 months were hired as operators in a data entry business and assigned randomly to an employment-only (control, n = 24) or abstinence-contingent employment (n = 27) group. Setting: A non-profit data entry business. Participants Unemployed welfare recipients who used cocaine persistently while enrolled in methadone treatment in Baltimore. Intervention: Abstinence-contingent employment participants received 1 year of employment-based contingency management, in which access to employment was contingent upon provision of drug-free urine samples under routine and then random drug testing. If a participant provided drug-positive urine or failed to provide a mandatory sample, then that participant received a temporary reduction in pay and could not work until urinalysis confirmed recent abstinence. Main outcome measure: Cocaine-negative urine samples at monthly assessments across 1 year of employment. Results: During the 1 year of employment, abstinence-contingent employment participants provided significantly more cocaine-negative urine samples than employment-only participants [79.3% and 50.7%, respectively; P = 0.004, odds ratio (OR) = 3.73, 95% confidence interval (CI) = 1.60-8.69]. Conclusions: Employment-based abstinence reinforcement that includes random drug testing is effective as a long-term maintenance intervention, and is among the most promising treatments for drug dependence. Work-places could serve as therapeutic agents in the treatment of drug dependence by arranging long-term employment-based contingency management programs.

Diaz SA; Perez JME. Use of small incentives for increasing participation and reducing dropout in a family drug-use prevention program in a Spanish sample. Substance Use & Misuse 44(14): 1990-2000, 2009. (33 refs.)

Poor participation rates represent one of the most serious problems facing family-based drug-use prevention programs. Strategies involving incentives have been used to increase recruitment and retention of the target population of such interventions, but in Spain, such strategies for modifying behavior are unusual. The goal of the research was to study the use of small financial incentives ((sic)10 voucher) as a strategy to increase attendance and reduce dropout in a family drug-prevention program applied in the school context. Participants were 211 pupils (aged 12-13) and their parents. The results show that small financial incentives can be useful to increase the attendance of families in prevention programs and to reduce dropout.

Dunn KE; Sigmon SC; Reimann EF; Badger GJ; Heil SH; Higgins ST. A contingency-management intervention to promote initial smoking cessation among opioid-maintained patients. Experimental and Clinical Psychopharmacology 18(1): 37-50, 2010. (79 refs.)

Prevalence of cigarette smoking among opioid-maintained patients is more than threefold that of the general population and associated with increased morbidity and mortality. Relatively few studies have evaluated smoking interventions in this population. The purpose of the present study was to examine the efficacy of contingency management for promoting initial smoking abstinence. Forty methadone- or buprenorphine-maintained cigarette smokers were randomly assigned to a contingent (n = 20) or noncontingent (n = 20) experimental group and visited the clinic for 14 consecutive days. Contingent participants received vouchers based on breath carbon monoxide levels during Study Days 1 to 5 and urinary cotinine levels during Days 6 to 14. Voucher earnings began at $9.00 and increased by $1.50 with each subsequent negative sample for maximum possible of $362.50. Noncontingent participants earned vouchers independent of smoking status. Although not a primary focus, participants who were interested and medically eligible could also receive bupropion (Zyban). Contingent participants achieved significantly more initial smoking abstinence, as evidenced by a greater percentage of smoking-negative samples (55% vs. 17%) and longer duration of continuous abstinence (7.7 vs. 2.4 days) during the 2 week quit attempt than noncontingent participants, respectively. Bupropion did not significantly influence abstinence outcomes. Results from this randomized clinical trial support the efficacy of contingency management interventions in promoting initial smoking abstinence in this challenging population.

Dunn KE; Sigmon SC; Reimann E; Heil SH; Higgins ST. Effects of smoking cessation on illicit drug use among opiod maintenance patients: A pilot study. Journal of Drug Issues 39(2): 313-327, 2009. (49 refs.)

Opioid treatment program patients and staff often have concerns that smoking cessation may jeopardize abstinence from illicit drug use. In this study, we evaluated whether smoking abstinence produced with a two-week contingency-management (CM) intervention was associated with relapse to illicit drug use among patients enrolled in opioid maintenance. Opioid-maintenance patients who were stable in treatment and abstinent from illicit drugs were enrolled in a 14-day smoking-cessation study. Participants were dichotomized into Abstainers (> 90% smoking-negative samples, n=12) and Smokers (< 10% smoking-negative samples, n=16). Illicit drug assays included opioids, oxycodone, propoxyphene, cannabis, amphetamines, cocaine, and benzodiazepines. There were no differences between the Abstainers and Smokers, with 99% and 96% of samples testing negative for all illicit drugs in each group, respectively. Data from this study provide no evidence that smoking cessation among stable opioid-maintained patients undermines drug abstinence and lend support for programs that encourage smoking cessation during drug abuse treatment.

Epstein DH; Schmittner J; Umbricht A; Schroeder JR; Moolchan ET; Preston KL. Promoting abstinence from cocaine and heroin with a methadone dose increase and a novel contingency. Drug and Alcohol Dependence 101(1-2): 92-100, 2009. (43 refs.)

To test whether a combination of contingency management and methadone dose increase would promote abstinence from heroin and cocaine, we conducted a randomized controlled trial using a 2 x 3 (dose x contingency) factorial design in which dose assignment was double-blind. Participants were 252 heroin- and cocaine-abusing outpatients on methadone maintenance. The were randomly assigned to methadone dose (70 or 100 mg/day, double-blind) and voucher condition (noncontingent, contingent on cocaine-negative urines, or "split"). The "split" contingency was a novel contingency that reinforced abstinence from either drug while doubly reinforcing simultaneous abstinence from both: the total value of incentives was "split" between drugs to contain costs. The main outcome measures were percentages of urine specimens negative for heroin. cocaine, and both simultaneously; these were monitored during a 5-week baseline of standard treatment (to determine Study eligibility), a 12-week intervention, and a 10-week maintenance phase (to examine intervention effects in return-to-baseline conditions). DSM-IV criteria for ongoing drug dependence were assessed at study exit. Urine-screen results showed that the methadone dose increase reduced heroin use but not cocaine use. The split 100 mg group was the only group to achieve a longer duration of simultaneous negatives than its same-dose noncontingent control group. The frequency of DSM-IV opiate and cocaine dependence diagnoses decreased in the active intervention groups. For a split contingency to promote simultaneous abstinence from cocaine and heroin, a relatively high dose of methadone appears necessary but not sufficient; an increase in overall incentive amount may also be required.

Garcia-Rodriguez O; Secades-Villa R; Higgins ST; Fernandez-Hermida JR; Carballo JL; Perez JME et al. Effects of voucher-based intervention on abstinence and retention in an outpatient treatment for cocaine addiction: A randomized controlled trial. Experimental and Clinical Psychopharmacology 17(3): 131-138, 2009. (26 refs.)

The aims of this study were to assess whether voucher magnitude improved cocaine abstinence and retention in an Outpatient treatment for cocaine dependence, and to determine the effectiveness of a contingency management intervention in a European cultural context. A randomized controlled trial was conducted in which 96 participants who were randomly assigned to I of 3 treatment conditions in a community setting: standard outpatient treatment, community reinforcement approach (CRA) plus low monetary value vouchers (each point earned was equivalent to 0.125(sic), US$ 0.18), and CRA plus high monetary value vouchers (each point was worth 0.25(sic), US$ 0.36). In the standard treatment group, mean percentage of cocaine-negative samples was 88.45%, versus 96.09% in the CRA plus low-vouchers group, and 97.07% in the CRA plus high-vouchers group. Retention rate at 6 months was 36.5% in the standard treatment group, 53.3% in the CRA plus low-vouchers group, and 69.0% in the CRA plus high-vouchers group. The CRA plus vouchers groups obtained better results than the standard program. This study showed that treating cocaine addiction by combining CRA with vouchers was more effective than standard treatment in community outpatient programs in Spain.

Hall EA; Prendergast ML; Roll JM; Warda U. Reinforcing abstinence and treatment participation among offenders in a drug diversion program: Are vouchers effective. Criminal Justice and Behavior 36(9): 935-953, 2009. (52 refs.)

This study assessed a 26-week voucher-based intervention to reinforce abstinence and participation in treatment-related activities among substance-abusing offenders court referred to outpatient treatment under drug diversion legislation (California's Substance Abuse and Crime Prevention Act). Standard treatment consisted of criminal justice supervision and an evidence-based model for treating stimulant abuse. Participants were randomly assigned to four groups, standard treatment (ST) only, ST plus vouchers for testing negative, ST plus vouchers for performing treatment plan activities, and ST plus vouchers for testing negative and/or performing treatment plan activities. Results indicate that voucher-based reinforcement of negative urines and of treatment plan tasks (using a flat reinforcement schedule) showed no statistically significant effects on measures of retention or drug use relative to the standard treatment protocol. It is likely that punishment and reinforcement operating within the criminal justice context had a stronger impact on participants' treatment retention and drug use than the relatively low-value vouchers awarded as part of the treatment protocol.

Hjorthoj C; Fohlmann A; Nordentoft M. Treatment of cannabis use disorders in people with schizophrenia spectrum disorders: A systematic review. Addictive Behaviors 34(6-7): 520-525, 2009. (67 refs.)

Background: Cannabis use disorders (CUD) are prevalent among people with schizophrenia spectrum disorders (SSD). with a range of detrimental effects, e.g. reduced compliance to medication and psychosocial interventions, and increased level of psychotic-dimension symptoms. The aim of this study was to review literature on treatments of CUD in SSD-patients. Methods: PubMed, PsycINFC, EMBASE, and The Cochrane Central Register of Controlled Trials were searched. Results: 41 articles were selected, 11 treating cannabis as a separate outcome. Contingency management was only effective while active. Pharmacological interventions appeared effective, but lacked randomized controlled trials (RCTs). Psychosocial interventions. e.g. motivational interviewing and cognitive behavior therapy (CBT), were ineffective in most studies with cannabis as a separate outcome, but effective in studies that grouped cannabis together with other substance use disorders. Conclusions: Insufficient evidence exists on treating this form of dual-diagnosis patients. Studies grouping several types of substances as a single outcome may overlook differential effects. Future RCTs should investigate combinations of psychosocial, pharmacological, and contingency management.

Hjorthoj C; Fohlmann A; Nordentoft M. Treatment of cannabis use disorders in people with schizophrenia spectrum disorders - A systematic review (Reprinted from Addictive Behaviours, vol 34, pg 520-525, 2009). Addictive Behaviors 34(10, Special Issue): 846-851, 2009. (69 refs.)

Background: Cannabis use disorders (CUD) are prevalent among people with schizophrenia spectrum disorders (SSD), with a range of detrimental effects, e.g. reduced compliance to medication and psychosocial interventions, and increased level of psychotic-dimension symptoms. The aim of this study was to review literature on treatments of CUD in SSD-patients. Methods: PubMedicine, PsycINFO, EMBASE, and The Cochrane Central Register of Controlled Trials were searched. Results: 41 articles were selected, 11 treating cannabis as a separate outcome. Contingency management was only effective while active. Pharmacological interventions appeared effective, but lacked randomized controlled trials (RCTs). Psychosocial interventions. e.g. motivational interviewing and cognitive behavior therapy (CBT), were ineffective in most studies with cannabis as a separate outcome, but effective in studies that grouped cannabis together with other substance use disorders. Conclusions: Insufficient evidence exists on treating this form of dual-diagnosis patients. Studies grouping several types of substances as a single outcome may overlook differential effects. Future RCTs should investigate combinations of psychosocial, pharmacological, and contingency management.

Kidorf M; King VL; Neufeld K; Peirce J; Kolodner K; Brooner RK. Improving substance abuse treatment enrollment in community syringe exchangers. Addiction 104(5): 786-795, 2009. (29 refs.)

Aims: The present study evaluated the effectiveness of an intervention combining motivational enhancement and treatment readiness groups, with and without monetary incentives for attendance and treatment enrollment, on enhancing rates of substance abuse treatment entry among new registrants at the Baltimore Needle Exchange Program (BNEP). Design Opioid-dependent study participants (n = 281) referred by the BNEP were assigned randomly to one of three referral interventions: (i) eight individual motivational enhancement sessions and 16 treatment readiness group sessions (motivated referral condition-MRC); (ii) the MRC intervention with monetary incentives for attending sessions and enrolling in treatment-MRC+I); or (iii) a standard referral condition which directed participants back to the BNEP for referral ( standard referral-SRC). Participants were followed for 4 months. Findings MRC+I participants were more likely to enroll in any type of treatment than MRC or SRC participants (52.1% versus 31.9% versus 35.5%; chi(2) = 9.12, P = 0.01), and more likely to enroll in treatment including methadone than MRC or SRC participants (40.4% versus 20.2% versus 16.1%; chi(2) = 16.65, P < 0.001). MRC+I participants also reported less heroin and injection use than MRC and SRC participants. Conclusions: Syringe exchange sites can be effective platforms to motivate opioid users to enroll in substance abuse treatment and ultimately reduce drug use and number of drug injections.

Lamb RJ; Kirby KC; Morral AR; Galbicka G; Iguchi MY. Shaping smoking cessation in hard-to-treat smokers. Journal of Consulting and Clinical Psychology 78(1): 62-71, 2010. (26 refs.)

Objective: Contingency management (CM) effectively treats addictions by providing abstinence incentives. However, CM fails for many who do not readily become abstinent and earn incentives. Shaping may improve outcomes in these hard-to-treat (HTT) individuals. Shaping sets intermediate criteria for incentive delivery between the present behavior and total abstinence. This should result in HTT individuals having improving, rather than poor, outcomes. We examined whether shaping improved outcomes in HTT smokers (never abstinent during a 10-visit baseline). Method: Smokers were stratified into HTT (n = 96) and easier-to-treat (ETT [abstinent at least once during baseline]; n = 50) and randomly assigned to either CM or CM with shaping (CMS). CM provided incentives for breath carbon monoxide (CO) levels <4 ppm (approximately I day of abstinence). CMS shaped abstinence by providing incentives for COs lower than the 7th lowest of the participant's last 9 samples or <4 ppm. Interventions lasted for 60 successive weekday visits. Results: Cluster analysis identified 4 groups of participants: stable successes, improving, deteriorating, and poor outcomes. In comparison with ETT, HTT participants were more likely to belong to I of the 2 unsuccessful clusters (odds ratio [OR] = 8.1, 95% CI [3.1, 21]). This difference was greater with CM (OR = 42, 95% Cl [5.9, 307]) than with CMS, in which the difference between HTT and ETT participants was not significant. Assignment to CMS predicted membership in the improving (p = .002) as compared with the poor outcomes cluster. Conclusion: Shaping can increase CM's effectiveness for HTT smokers.

Leeks KD; Hopkins DP; Soler RE; Aten A; Chattopadhyay SK. Worksite-based incentives and competitions to reduce tobacco use: A systematic review. (review). American Journal of Preventive Medicine 38(2, Supplement 2): S263-S274, 2010. (55 refs.)

The Guide to Community Preventive Service (Community Guide) methods for systematic reviews were used to evaluate the evidence of effectiveness of worksite-based incentives and competitions to reduce tobacco use among workers. These interventions offer a reward to individuals or to teams of individuals on the basis of participation or success in a specified smoking behavior change (such as abstaining from tobacco use for a period of time). The review team identified a total of 26 published studies, 14 of which met study design and quality of execution criteria for inclusion in the final assessment. Only one study, which did not qualify for review, evaluated the use of incentives when implemented alone. All of the 14 qualifying studies evaluated incentives and competitions when implemented in combination with a variety of additional interventions, such as client education, smoking cessation groups, and telephone cessation support. Of the qualifying studies, 13 evaluated differences in tobacco-use cessation among intervention participants, with a median follow-up period of 12 months. The median change in self-reported tobacco-use cessation was an increase of 4.4 percentage points (a median relative percentage improvement of 67%). The present evidence is insufficient to determine the effectiveness of incentives or competitions, when implemented alone, to reduce tobacco use. However, the qualifying studies provide strong evidence, according to Community Guide rules, that worksite-based incentives and competitions in combination with additional interventions are effective in increasing the number of workers who quit using tobacco. In addition, these multicomponent interventions have the potential to generate positive economic returns over investment when the averted costs of tobacco-associated illnesses are considered. A concurrent systematic review identified four studies with economic evidence. Two of these studies provided evidence of net cost savings to employers when program costs are adjusted for averted healthcare expenses and productivity losses, based on referenced secondary estimates.

Lott DC; Jencius S. Effectiveness of very low-cost contingency management in a community adolescent treatment program. Drug and Alcohol Dependence 102(1/3): 162-165, 2009. (17 refs.)

Controlled studies have shown that motivational incentives reduce drug use, but community implementation has been limited. This observational study examines the effect of a contingency management (CM) Program on urine, attendance, and cost measures in a community substance abuse treatment program for adolescents. Treatment included elements of 12-step facilitation, cognitive behavioral therapy, and motivational enhancement. All urine tests included cannabinoids, opioids, benzodiazepines, cocaine, and amphetamines. Patients with negative urines or perfect attendance earned chances to draw weekly from a bag for prizes of varying value, and the number of draws increased with each consecutive negative urine test. Data were collected for those patients (age 12-18) treated immediately before (n = 83) and after (n = 264) the CM program was introduced to the treatment center, and positive urine rates were compared using chi-square tests. Patients treated with the CM program had lower rates of urines positive for opioids (p < 0.005) and cocaine (p < 0.05), and non-significantly but consistently lower rates of urines positive for all other drug classes. Altogether, the proportion Of urines positive for any drug decreased from 33.3% to 23.4% (p < 0.01). Pre- and post-CM comparisons of attendance reveal lower daily attendance rates but longer retention in treatment. Expenses were minimal at $0.39 per patient per day. These data yield additional evidence for the feasibility and effectiveness of CM methods in community adolescent treatment programs.

Mckay JR; Lynch KG; Coviello D; Morrison R; Cary MS; Skalina L et al. Randomized trial of continuing care enhancements for cocaine-dependent patients following initial engagement. Journal of Consulting and Clinical Psychology 78(1): 111-120, 2010. (57 refs.)

Objective: The effects of cognitive-behavioral relapse prevention (RP), contingency management (CM), and their combination (CM + RP) were evaluated in a randomized trial with 100 cocaine-dependent patients (58% female, 89% African American) who were engaged in treatment for at least 2 weeks and had an average of 44 days of abstinence at baseline. Method: The participants were from intensive outpatient programs, which provide 10 hr per week of group counseling. The CM protocol provided gift certificates (maximum value $1,150; mean received = $740) for cocaine-free urines over 12 weeks on an escalating reinforcement schedule, and weekly individual RP sessions were offered for up to 20 weeks. Average number of RP sessions attended was 3 in RP and 13 in CM + RP. Results: Generalizing estimation equation analyses over 18 months postrandomization showed significant effects for CM (but not RP) on urine toxicology and self-reported cocaine use (p = .05), with no significant CM x RP interactions. Secondary analyses indicated CM + RP produced better cocaine urine toxicology outcomes at 6 months than treatment as usual, odds ratio [OR] = 3.96 (1.33, 11.80), p < .01, and RP, OR = 4.89 (1.51, 15.86), p < .01, and produced better cocaine urine toxicology outcomes at 9 months than treatment as usual, OR = 4.21 (1.37, 12.88), p < .01, and RP, OR = 4.24 (1.32, 13.65), p < .01. Trends also favored CM + RP over CM at 6 months, OR = 2.93 (0.94, 9.07), p = .06, and 9 months, OR = 2.93 (0.94, 9.10), p = .06. Differences between the conditions were not significant after 9 months. Conclusions: These results suggest CM can improve outcomes in cocaine-dependent patients in intensive outpatient programs who have achieved initial engagement, particularly when it is combined with RP.

Monterosso J; Ainslie G. The picoeconomic approach to addictions: Analyzing the conflict of successive motivational states. (review). Addiction Research & Theory 17(2): 115-134, 2009. (104 refs.)

The branch of behavioral economics called picoeconomics (Ainslie 1986) models behavior as the competition between successive motivational states within the individual. This approach is particularly well suited for investigating addiction and recovery from addiction. We begin by outlining behavioral findings that provide the foundation for picoeconomics. Next we discuss strategies of self-control available to the individual guarding against her own anticipated preference reversals, and also consider negative side effects of these self-control strategies. These generally overlooked side effects include the tendency for lapses to lead to binges - the abstinence violation effect. Finally, we describe the relative effectiveness of contingency management and 12-step treatments for substance dependence from the perspective of picoeconomics, and discuss other implications of picoeconomics for the field of addiction.

Olmstead TA; Petry NM. The cost-effectiveness of prize-based and voucher-based contingency management in a population of cocaine- or opioid-dependent outpatients. Drug and Alcohol Dependence 102(1/3): 108-115, 2009. (33 refs.)

Objective: To evaluate the cost-effectiveness of using prize-based and Voucher-based contingency management (CM) as additions to standard treatment for cocaine- or heroin-dependent outpatients in community treatment centers. Methods: This cost-effectiveness analysis is based on a randomized clinical trial conducted at three community-based outpatient psychosocial substance abuse treatment clinics. A total of 142 cocaine- or heroin-dependent outpatients were randomly assigned to one of three treatment conditions: standard treatment (ST), ST with prizes (prize CM), or ST with vouchers (voucher CM) for 12 weeks. The primary patient outcome was the longest duration of confirmed abstinence (LDA) from cocaine, opioids and alcohol during treatment. Unit costs were collected from the three participating clinics. Resource utilizations and patient outcomes were obtained from the clinical trial. Incremental cost-effectiveness ratios (ICERs) and acceptability Curves were used to evaluate the relative cost-effectiveness of the interventions. Results: Based on the ICERs and acceptability curves, ST is likely to be the most cost-effective intervention when the threshold Value to decision makers of lengthening the LDA during treatment by I week is less than approximately $166, and prize CM is likely to be the most cost-effective intervention when the threshold value is greater than approximately $166. Conclusions: Prize CM was found likely to be the most cost-effective intervention over a comparatively wide range of threshold Values for lengthening the LDA during treatment by I week. However, additional studies with alternative incentive parameters are required to determine the generalizability of our results.

Rasha CJ; Olmstead TA; Petry NM. Income does not affect response to contingency management treatments among community substance abuse treatment-seekers. Drug and Alcohol Dependence 104(3): 249-253, 2009. (28 refs.)

The present study examined a commonly held belief that contingency management (CM) may be less effective for substance abusers with relatively more economic resources compared to those with relatively few resources. Using a combined sample of 393 treatment-seeking cocaine abusers from three clinical trials involving randomization to standard care or standard care plus CM conditions, we assessed the impact of past year income, alone and in combination with treatment condition, as well as income type (i.e., earned, illegal, unstable) on the longest duration of continuous verified abstinence (LDA) achieved during treatment. Results suggested that income had no effect on LIDA in either condition, and that CM's effectiveness did not deteriorate among those with better economic resources in the present sample. This finding may be of value to clinicians and administrators who are considering the addition of CM to standard care treatments in community outpatient substance abuse clinics and have concerns about the generalizability of CM across clients with various economic resources.

Romanowich P; Lamb RJ. The relationship between in-treatment abstinence and post-treatment abstinence in a smoking cessation treatment. Experimental and Clinical Psychopharmacology 18(1): 32-36, 2010. (14 refs.)

Previous research has indicated that abstinence early in a smoking cessation program is predictive of successful posttreatment abstinence. However, it has not been established whether or not this effect is independent of other in-treatment abstinence patterns. In this paper the relationship between three potentially important aspects of in-treatment smoking abstinence and posttreatment smoking abstinence are examined: early abstinence, extended abstinence, and end-of-treatment abstinence. We examined the relationship between smoking behavior measured each weekday over 70 visits (approximately 14 weeks) of a contingency management smoking cessation program and at a follow-up visit 6 months after study entry (3 months after the scheduled end of treatment). Ninety-five of 102 participants were successfully followed-up. Seven of these 95 participants were confirmed abstinent. Early abstinence, defined as abstinence during the first 10 treatment visits, was significantly and independently related to follow-up abstinence (OR = 56.67 [7.29-440.63]). Extended abstinence and end-of-treatment abstinence were related to follow-up abstinence, but not independent of early abstinence based on multiple regression models. Inclusion of a variety of demognaphic and environmental characteristics did not significantly alter this relationship. Thus, consistent with the previous literature, the establishment of early abstinence appears to be crucial to establishing longer-term abstinence, independent of other in-treatment abstinence patterns.

Romero V; Donohue B; Allen DN. Treatment of concurrent substance dependence, child neglect and domestic violence: A single case examination involving family behavior therapy. Journal of Family Violence 25(3): 287-295, 2010. (16 refs.)

Although child neglect and substance abuse co-occur in greater than 60% of child protective service cases, intervention outcome studies are deplorably lacking. Therefore, a home-based Family Behavior Therapy is described in the treatment of a woman evidencing child neglect, substance dependence, domestic violence and other co-occurring problems. Treatment included contingency management, self control, stimulus control, communication and child management skills training exercises, and financial management components. Results indicated improvements in child abuse potential, home hazards, domestic violence, and drug use, which were substantiated by objective urinalysis testing, and tours of her home. Validity checks indicated the participant was being truthful in her responses to standardized questionnaires, and assessors were "blind" to study intent. Limitations (i.e., lack of experimental control and follow-up data collection) of this case example are discussed in light of these results.

Roozen HG. Legitimizing 'The medical prescription of money' (commentary). Addiction 104(9): 1512-1518, 2009. (16 refs.)

This is a commentary on the use of contingency management in the treatment of substance abuse problems, a reflection on the article in this issue "Employment-based abstinence reinforcement as a maintenance intervention for the treatment of cocaine dependence: a randomized controlled trial" by DeFulio et al.

Schmitz JM; Lindsay JA; Green CE; Herin DV; Stotts AL; Moeller FG. High-dose naltrexone therapy for cocaine-alcohol dependence. American Journal on Addictions 18(5): 356-362, 2009. (36 refs.)

This randomized, double-blind, placebo-controlled study compared the effects of high-dose (100 mg/d) naltrexone versus placebo in a sample of 87 randomized subjects with both cocaine and alcohol dependence. Medication conditions were crossed with two behavioral therapy platforms that examined whether adding contingency management (CM) that targeted cocaine abstinence would enhance naltrexone effects compared to cognitive behavioral therapy (CBT) without CM. Primary outcome measures for cocaine (urine screens) and alcohol use (timeline followback) were collected thrice-weekly during 12 weeks of treatment. Retention in treatment and medication compliance rates were low. Rates of cocaine use and drinks per day did not differ between treatment groups; however naltrexone did reduce frequency of heavy drinking days, as did CBT without CM. Notably, adding CM to CBT did not enhance treatment outcomes. These weak findings suggest that pharmacological and behavioral interventions that have shown efficacy in the treatment of a single drug dependence disorder may not provide the coverage needed when targeting dual drug dependence.

Stoops WW; Dallery J; Fields NM; Nuzzo PA; Schoenberg NE; Martin CA; Casey B; Wong CJ. An Internet-based abstinence reinforcement smoking cessation intervention in rural smokers. Drug and Alcohol Dependence 105(1/2): 56-62, 2009. (43 refs.)

The implementation of cigarette smoking abstinence reinforcement programs may be hindered by the time intensive burden placed on patients and treatment providers. The use of remote monitoring and reinforcement of smoking abstinence may enhance the accessibility and acceptability of this intervention, particularly in rural areas where transportation can be unreliable and treatment providers distant. This study determined the effectiveness of an Internet-based abstinence reinforcement intervention in initiating and maintaining smoking abstinence in rural smokers. Sixty-eight smokers were enrolled to evaluate the efficacy of an Internet-based smoking cessation program. During the 6-week intervention period, all participants were asked to record 2 videos of breath carbon monoxide (CO) samples daily. Participants also typed the value of their CO readings into web-based software that provided feedback and reinforcement based on their smoking status. Participants (n=35) in the Abstinence Contingent (AC) group received monetary incentives contingent on recent smoking abstinence (i.e., CO of 4 parts per million or below). Participants (n=33) in the Yoked Control (YC) group received monetary incentives independent of smoking status. Participants in the AC group were significantly more likely than the YC group to post negative CO samples on the study website (OR=4.56; 95% CI=2.18-9.52). Participants assigned to AC were also significantly more likely to achieve some level of continuous abstinence over the 6-week intervention compared to those assigned to YC. These results demonstrate the feasibility and short-term efficacy of delivering reinforcement for smoking abstinence over the Internet to rural populations.

Tevyaw TO; Colby SM; Tidey JW; Kahler CW; Rohsenow DJ; Barnett NP et al. Contingency management and motivational enhancement: A randomized clinical trial for college student smokers. Nicotine & Tobacco Research 11(6): 739-749, 2009. (58 refs.)

The efficacy of contingency-management (CM) and motivational enhancement therapy (MET) for college student smoking cessation was examined. Nontreatment-seeking daily smokers (N = 110) were randomly assigned to 3 weeks of CM versus noncontingent reinforcement (NR) and to three individual sessions of MET versus a relaxation control in a 2 x 2 experimental design. Expired carbon monoxide (CO) samples were collected twice daily for 3 weeks. Participants earned U.S.$5 for providing each sample; additionally, those randomized to CM earned escalating monetary rewards based on CO reductions (Week 1) and smoking abstinence (Weeks 2-3). Compared with NR, CM resulted in significantly lower CO levels and greater total and consecutive abstinence during the intervention. Those in the CM and MET groups reported greater interest in quitting smoking posttreatment, but rates of confirmed abstinence at follow-up were very low (4% at 6-month follow-up) and did not differ by group. Findings support the short-term efficacy of CM for reducing smoking among college students. Future research should explore enhancements to CM in this population, including a longer intervention period and the recruitment of smokers who are motivated to quit.