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CORK Bibliography: Behavioral Contingencies and Contingency Management

108 citations. January 2003 to present

Prepared: March 2008

Alessi SM; Badger GJ; Higgins ST. An experimental examination of the initial weeks of abstinence in cigarette smokers. Experimental and Clinical Psychopharmacology 12(4): 276-287, 2004. (48 refs.)

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

Brooner RK; Kidorf MS; King VL; Stoller KB; Peirce JM; Bigelow GE et al. Behavioral contingencies improve counseling attendance in an adaptive treatment model. Journal of Substance Abuse Treatment 27(3): 223-232, 2004. (56 refs.)

Poor patient adherence remains a serious obstacle to improving the effectiveness of many drug abuse therapies and the overall quality of care delivered in programs. The present study evaluated the utility and efficacy of incorporating behavioral contingencies in a stepped care treatment approach to motivate patient attendance to the varying amounts of prescribed weekly counseling. Study participants were opioid-dependent patients (n = 127) newly admitted to an ambulatory treatment program that provides methadone. Participants were randomly assigned to a Motivated Stepped Care condition (MSC; n = 65) with behavioral contingencies to specifically motivate counseling attendance vs. a Standard Stepped Care condition (SSC; n = 62) without these contingencies. The MSC vs. SSC condition was associated with a higher rate of counseling attendance (83% vs. 44%, p < .001) and a lower rate of poor treatment response (46% vs. 79%, p < .001). The behavioral contingencies were well tolerated and strongly associated with excellent attendance across both lower and higher doses of weekly counseling.

Budney AJ; Moore B; Sigmon SC; Higgins ST. Contingency-management interventions for cannabis dependence. IN: Roffman RA; Stephens RS, eds. Cannabis Dependence: Its Nature, Consequences and Treatment. London: Cambridge University Press, 2006. pp. 155-179

This chapter provides an introduction to a clinical approach which is less well known, contingency management. It sets forth the basic principles, effectiveness, and what is required for effective implementation. Discussion then turns to the description of a study using contingency management voucher program in the treatment of those with cannabis dependence. The study design, participants, treatments, and results are provided. The use of contingency management to engage probation-referred marijuana abusers into treatment and use among adolescent abusers is then presented. The chapter concludes with discussion of marijuana as a secondary drug of abuse -- particularly among those who primary drug is cocaine or those involved in methadone maintenance, as well as those with severe psychiatric illness.

Budney AJ; Moore BA; Rocha HL; Higgins ST. Clinical trial of abstinence-based vouchers and cognitive-behavioral therapy for cannabis dependence. Journal of Consulting and Clinical Psychology 74(2): 307-316, 2006. (31 refs.)

Ninety cannabis-dependent adults seeking treatment were randomly assigned to receive cognitive-behavioral therapy, abstinence-based voucher incentives, or their combination. Treatment duration was 14 weeks, and outcomes were assessed for 12 months posttreatment. Findings suggest that (a) abstinence-based vouchers were effective for engendering extended periods of continuous marijuana abstinence during treatment, (b) cognitive-behavioral therapy did not add to this during-treatment effect, and (c) cognitive-behavioral therapy enhanced the posttreatment maintenance of the initial positive effect of vouchers on abstinence. This study extends the literature on cannabis dependence, indicating that a program of abstinence-based vouchers is a potent treatment option. Discussion focuses on the strengths of each intervention, the clinical significance of the findings, and the need to continue efforts toward development of effective interventions.

Calsyn DA; DeMarco FJ; Saxon AJ; Sloan KL; Gibbon KE. Evaluation of a minimal services treatment track for noncompliant patients in opioid substitution treatment. American Journal of Public Health 93(7): 1086-1088, 2003. (12 refs.)

Opioid substitution treatment (OST) is the most widely used treatment for opiate dependence. The preponderance of evidence suggests that retention in OST is associated with decreased opiate use and criminality. However, continued illicit drug use among patients in OST is common. Program responses to ongoing use vary widely, though discharge is a frequent response. Unfortunately, outcomes for out-of-treatment opiate addicts are very poor. Recently published OST guidelines recommend that programs find alternatives to treatment termination for ongoing drug use. Such a policy poses certain dilemmas. While benefiting that sub-set of patients, possibly it may be associated with increased illicit use among other patients. In April 1998, the OST program at the Veterans Affairs Puget Sound Health Care System (VAPSHCS) in Seattle, Washington, instituted a minimal services (MS) treatment track as an alternative to discharge for patients who continued to use illicit drugs. MS was designed to retain these patients in treatment. MS also was designed to introduce additional contingencies that 1) encouraged abstinence and 2) simultaneously minimized demands on clinic and staff resources and opened additional treatment slots to reduce the waiting list for new patients. The new policy's impact on both MS patients and the clinic population at large was assessed at one year. The findings suggest that retention of drug-using patients in modified OST can benefit those patients without an associated significant increase in harm to the larger clinic population. Nearly three quarters of the patients placed in MS were retained in treatment, and more than 1 third of those retained improved sufficiently to return to the regular OST program. As a group, MS patients cut their detectable benzodiazepine, cocaine, and opiate use roughly in half, with more than 1 third showing significant reductions in positive UA results 6 months after placement in MS. These results were obtained with little evidence of an associated increase in clinicwide harm as measured by positive UA results.

Carpenter KM; Nunes EV. Behavior therapy for depression in drug dependence (BTDD): Results of a stage Ia therapy development pilot. American Journal of Drug and Alcohol Abuse 32(4): 541-548, 2006. (15 refs.)

Limited access to positive reinforcers is a central feature in behavioral formulations of substance use and depression, and evidence suggests both disorders share similar environmental contexts. The Behavioral Therapy for Depression in Drug Dependence (BTDD) was developed to target the density of potential reinforcers in a patient's environment to reduce both depression and illicit substance use using therapeutic techniques from three operant based treatment programs, Community Reinforcement Approach, Changing Reinforcement Events, and Treatment-plan Contingency Management. Results of an uncontrolled Stage Ia trial (n = 29), indicated 48% of the participants demonstrated at least a 50% reduction in baseline depression scores during the 16-session treatment program. Those designated as treatment responders completed more out-of-session behavioral activities, attended more treatment sessions, and demonstrated less benzodiazepine use during the program than non-responders. There were no changes in opiate and cocaine use. BTDD may be a useful adjunct to methadone maintenance for treating comorbid depressive disorders.

2006, Marcel Dekker, Inc.

Carroll K; Sinha R; Easton C. Engaging young probation-referred cannabis-abusing individuals in treatment. IN: Roffman RA; Stephens RS, eds. Cannabis Dependence: Its Nature, Consequences and Treatment. London: Cambridge University Press, 2006. pp. 297-314

This chapter, one of several dealing with adolescent cannabis problems, addresses efforts to involve adolescents who are probation-referred into treatment. It begins by consideration of the rationale for targeting young adult marijuana users, and similarly, the rationale for focusing upon those referred by the legal system. The chapter then deals with the question of why evaluation a motivational enhancement approach with this latter population. and why test a contingency management approach. The remainder of the chapter outlines intervention research which uses these techniques, the results, and what is entailed to train therapists to provide this treatment.

Carroll KM. Matching and differtial therapies. IN: Frances RJ; Miller SI; Mack AH, eds. Clinical Textbook of Addictive Disorders, 3rd edition. New York: Guilford Press, 2005. pp. 637-662. (117 refs.)

Despite the emergence of new treatment approaches, including drug therapies, the goal of matching treatment and client characteristics remains in its infancy. There is discussion of these efforts in terms of alcohol dependence, cocaine dependence, and opiate dependence and newer modalities such as contingency management and manualized approaches.

Carroll KM; Easton CJ; Nich C; Hunkele KA; Neavins TM; Sinha R et al. The use of contingency management and motivational/skills-building therapy to treat young adults with marijuana dependence. Journal of Consulting and Clinical Psychology 74(5): 955-966, 2006. (70 refs.)

Marijuana-dependent young adults (N = 136), all referred by the criminal justice system, were randomized to I of 4 treatment conditions: a motivational/skills-building intervention (motivational enhancement therapy/cognitive-behavioral therapy; MET/CBT) plus incentives contingent on session attendance or submission of marijuana-free urine specimens (contingency management; CM), MET/CBT without CM, individual drug counseling (DC) plus CM, and DC without CM. There was a significant main effect of CM on treatment retention and marijuana-free urine specimens. Moreover, the combination of MET/CBT plus CM was significantly more effective than MET/CBT without CM or DC plus CM, which were in turn more effective than DC without CM for treatment attendance and percentage of marijuana-free urine specimens. Participants assigned to MET/CBT continued to reduce the frequency of their marijuana use through a 6-month follow-up.

Correia CJ; Sigmon SC; Silverman K; Bigelow G; Stitzer ML. Comparison of voucher-delivery schedules for the initiation of cocaine abstinence. Experimental and Clinical Psychopharmacology 13(3): 253-258, 2005. (30 refs.)

Studies on the use of shaping procedures to increase rates of cocaine abstinence have produced promising results. This study used a Brief Abstinence Test to examine the impact of reinforcement for initial reductions in cocaine use on a subsequent abstinence reinforcement test. Methadone maintenance patients showing evidence of cocaine use were exposed to two 1-week reinforcement conditions. During the shaping condition, participants could earn $50 vouchers on Wednesday and Friday for meeting quantitative urinalysis criteria and a $100 voucher on the following Monday for meeting the more stringent qualitative criteria. During the terminal condition, only the $100 earning opportunity for meeting the qualitative criteria was provided. Participants were more likely to meet the qualitative reinforcement criteria on Wednesday and Friday in the shaping condition than in the terminal condition. However, contrary to the initial hypothesis, the shaping reinforcement condition did not increase rates of abstinence on the final abstinence test.

Dallery J; Glenn IM. Effects of an Internet-based voucher reinforcement program for smoking abstinence: A feasibility study. Journal of Applied Behavior Analysis 38(3): 349-357, 2005. (30 refs.)

The present study tested the feasibility of an Internet-based method to obtain objective evidence of smoking abstinence and to deliver vouchers for evidence of abstinence. Four heavy smokers participated in this 4-week study. Twice daily, participants made video recordings of themselves providing a breath carbon monoxide (CO) sample with a Web camera. The video was sent electronically to the smoking clinic. Participants could earn vouchers for gradual reductions in breath CO during an initial shaping condition, and then for achieving abstinence (CO 4 ppm). Vouchers could be exchanged for merchandise at select Internet vendors. Relative to baseline conditions, participants substantially reduced their smoke intake, and 3 achieved sustained periods of abstinence. The study suggests that an Internet-based voucher reinforcement program is a feasible method to promote abstinence from cigarette smoking.

Dallery J; Glenn IM; Raiff BR. An Internet-based abstinence reinforcement treatment for cigarette smoking. Drug and Alcohol Dependence 86(2/3): 230-238, 2007. (60 refs.)

Although voucher reinforcement has been shown to promote abstinence from smoking, more practical methods are needed to obtain objective evidence of smoking status on a frequent and sustained basis. Using a within-subject reversal design, the present study tested an Internet-based method to obtain objective evidence of smoking status and to deliver voucher incentives for evidence of abstinence. Twenty (10 females) heavy smokers completed this 4-week study. Twice daily, participants made video recordings of themselves providing a breath carbon monoxide (CO) sample with a web camera. The video was made at home and sent electronically to the smoking clinic. Participants could earn vouchers for gradual reductions in breath CO during a 4-day shaping condition, and then for achieving abstinence (CO <= 7 ppm) during a 10-day abstinence induction phase. Vouchers could be exchanged for merchandise at select Internet vendors. Relative to baseline conditions, significant decreases in CO were observed during treatment, and many participants achieved sustained periods of abstinence. The study suggests that an Internet-based voucher reinforcement program is a feasible and effective method to promote abstinence from cigarette smoking.

2007, Elsevier Science

Donny EC; Brasser SM; Bigelow GE; Stitzer ML; Walsh SL. Methadone doses of 100 mg or greater are more effective than lower doses at suppressing heroin self-administration in opioid-dependent volunteers. Addiction 100(10): 1496-1509, 2005. (39 refs.)

Aims: Methadone maintenance has been an effective pharmacotherapy for the treatment of heroin dependence for nearly four decades. Recent clinical research suggests that methadone doses larger than those used in most clinics are more effective at suppressing illicit heroin use. This greater efficacy may result from greater cross-tolerance to the reinforcing effects of heroin. Design: The purpose of this double-blind, within-subject study was to examine the relationship between methadone maintenance dose and the reinforcing effects of heroin. Setting: Participants were stabilized on 50, 100 and 150 mg methadone (ascending order) during separate outpatient periods before being admitted to an inpatient research unit for testing at each maintenance dose. Participants: Five opiate-dependent volunteers completed the study. Measurements: During each 4-week inpatient testing period, participants sampled three doses of heroin (0, 10, or 20 mg; random order; one dose per week) and were subsequently allowed seven opportunities to choose between another injection of that week's heroin dose and varying amounts of money ($2-38). Findings: The number of heroin injections chosen decreased as methadone dose was increased. Larger alternative monetary reinforcers were required to suppress heroin self-administration during maintenance on 50 compared to 100 or 150 mg methadone. Larger methadone doses also completely blocked the subjective effects of heroin and produced greater withdrawal suppression during the outpatient periods. Conclusions: These results support other clinical and laboratory-based research indicating that persistent heroin use may be reduced by providing larger methadone maintenance doses that produce more effective cross-tolerance to heroin.

Epstein DH; Hawkins WE; Covi L; Umbricht A; Preston KL. Cognitive-behavioral therapy plus contingency management for cocaine use: Findings during treatment and across 12-month follow-Up. Psychology of Addictive Behaviors 17(1): 73-82, 2003. (35 refs.)

Contingency management (CM) rapidly reduces cocaine use, but its effects subside after treatment. Cognitive-behavioral therapy (CBT) produces reductions months after treatment. Combined, the 2 might be complementary. One hundred ninety-three cocaine-using methadone-maintained outpatients were randomly assigned to 12 weeks of group therapy (CBT or a control condition) and voucher availability (CM contingent on cocaine-negative urine or noncontingent). Follow-ups occurred 3, 6, and 12 months posttreatment. Primary outcome was cocaine-negative urine (urinalysis 3 times/week during treatment and once at each follow-up). During treatment, initial effects of CM were dampened by CBT. Posttreatment, there were signs of additive benefits, significant in 3- versus 12-month contrasts. Former CBT participants were also more likely to acknowledge cocaine use and its effects and to report employment.

Festinger DS; Marlowe DB; Croft JR; Dugosh KL; Mastro NK; Lee PA et al. Do research payments precipitate drug use or coerce participation? Drug and Alcohol Dependence 78(3): 275-281, 2005. (47 refs.)

Providing high-magnitude cash incentives to substance abuse clients to participate in research is frequently viewed as unethical based on the concerns that this might precipitate new drug use or be perceived as coercive. We randomly assigned consenting drug abuse outpatients to receive payments of $10, $40, or $70 in either cash or gift certificate for attending a 6-month research follow-up assessment. At the 6-month follow-up, participants received their randomly determined incentive and were then scheduled for a second follow-up appointment 3 days later to detect new instances of drug use. Findings indicated that neither the magnitude nor mode of the incentives had a significant effect on rates of new drug use or perceptions of coercion. Consistent with the contingency management literature, higher payments and cash payments were associated with increased follow-up rates. Finally, the results suggest that higher magnitude payments may be more cost-effective by reducing the need for more intensive follow-up efforts.

Fournier AK; Ehrhart IJ; Glindemann KE; Geller ES. Intervening to decrease alcohol abuse at university parties: Differential reinforcement of intoxication level. Behavior Modification 28(2): 167-181, 2004. (34 refs.)

This quasi-experimental field study assessed whether an incentive/reward intervention can change the drinking behavior and the subsequent levels of intoxication among college students attending fraternity parties. A total of 356 blood alcohol concentration (BAC) assessments, using hand-held breathalyzers, were obtained at two baseline and at two intervention parties at the same fraternity house. At the intervention parties, the students were informed they could win a cash prize if their BAC was below .05, and they were given nomograms to aid in monitoring their levels of intoxication. Mean BAC and the percentage of partiers with intoxication levels above .05 were significantly lower at the two intervention parties. More than twice as many partygoers were legally intoxicated (i.e., BAC > .08) at the two baseline parties than at the two intervention parties, indicating a clinically significant impact of the incentive/reward intervention. Greek-life students, in particular, were significantly less intoxicated at intervention parties, compared to baseline parties (p < .001).

Futterman R; Sapadin K; Silverman S. Transferring psychological technology into substance abuse treatment: Substance abuse as a psychiatric illness. Addiction Research & Theory 14(3): 265-274, 2006. (11 refs.)

A model of transferring psychological technology into substance abuse treatment programs based on viewing substance abuse as a psychiatric illness and treating it as such is presented. This theoretical framework integrates disparate technical developments, such as relapse prevention, harm reduction, motivational interviewing/motivational enhancement, and contingency management. Implications for treatment and outcome measurement are described, and an example of how one program used this model is presented.

Glindemann KE; Ehrhart IJ; Drake EA; Geller ES. Reducing excessive alcohol consumption at university fraternity parties: A cost-effective incentive/reward intervention. Addictive Behaviors 32(1): 39-48, 2007. (28 refs.)

The impact of an incentive/reward intervention on college students' intoxication from alcohol consumption at fraternity parties was explored using a group-randomized trial. Participants included 702 college students (447 men, 225 women) attending fraternity parties in Blacksburg, VA. Six fraternities were randomly assigned to a control or experimental group, and each of these fraternities hosted two parties. The three fraternities in the experimental group hosted a baseline party first and then hosted an intervention party at which those having a blood alcohol concentration (BAC) level below 0.05 were entered in a $100 cash lottery. The three fraternities in the control group hosted two control (non-intervention) parties. For the experimental fraternities, mean BAC levels were significantly lower at the intervention parties (M = 0.079) than the baseline parties (M = 0.098) and the percentage of partygoers with a BAC below 0.08 was significantly higher at intervention parties (40.1%) than at baseline parties (30.6%). This field study supports the efficacy of differential reinforcement in controlling student intoxication at party settings.

Hawk LW; Higbee C; Hyland A; Alford T; O'Connor R; Cummings KM. Concurrent quit & win and nicotine replacement therapy voucher giveaway programs: Participant characteristics and predictors of smoking abstinence. Journal of Public Health Management and Practice 12(1): 52-59, 2006. (29 refs.)

This study compares the participant characteristics, program costs, and outcomes of a Quit & Win contest and a nicotine replacement therapy (NRT) voucher giveaway promotion. Both programs were conducted simultaneously so that smokers could enroll in either one program alone (n = 849 and 690, respectively) or both programs (Combination group; n = 230). A follow-up telephone survey of a random sample of participants was conducted 4 to 7 months after enrollment to evaluate smoking status. At enrollment, participants in the three groups were comparable on most smoking and demographic variables, although Quit & Win participants were, on average, younger than those who signed up to get the NRT voucher. Compared with the characteristics of smokers in the region, those who enrolled in the intervention programs were heavier smokers and had more years of formal education. At follow-up, the self-reported quit rates were similar across the three intervention groups, ranging between 25 percent and 30 percent. The only evidence for a higher quit rate among those in the Combination group was among younger smokers. On a simple estimated cost per quit basis, the Quit & Win ($130) and NRT ($179) voucher interventions appear roughly comparable. In all groups, abstinence rates were higher among lighter smokers (< 21 cigarettes per day), participants who did not live with another smoker, and those who were married, Both the Quit & Win and NRT voucher giveaway programs were effective in recruiting smokers to make a quit attempt, although combining both interventions did not generally increase abstinence rates.

Heil SH; Tidey JW; Holmes HW; Badger GJ; Higgins ST. A contingent payment model of smoking cessation: Effects on abstinence and withdrawal. Nicotine & Tobacco Research 5(2): 205-213, 2003. (34 refs.)

The present study was designed to characterize nicotine withdrawal during a 5-day period in which smokers who were not trying to quit were offered monetary incentives to abstain while residing in their usual environments. Participants were randomly assigned to one of three groups. In two groups, monetary payment was delivered contingent on breath carbon monoxide levels (CO less than or equal to 8ppm) indicating recent smoking abstinence, with the amount of payment differing between the two groups. The third group was a control group in which payment was delivered independent of smoking status. Participants provided CO samples three times per day (morning, afternoon- and evening) for 5 days (Monday-Friday). At each evening visit, all participants completed a nicotine withdrawal questionnaire and other questionnaires. Contingent payment significantly decreased expired-air CO and salivary cotinine levels as compared with the control group. No significant differences in abstinence were noted as a function of the amount paid. Participants in both contingent payment groups reported significantly more withdrawal symptoms than those in the noncontingent control group, including increases in anxiety and nervousness, impatience and restlessness, hunger, and desire to smoke. Such contingent payment procedures may provide an effective method for studying nicotine withdrawal in smokers that does not require the costly and inconvenient practice of housing research participants on a closed ward to prevent smoking.

Helmus TC; Saules KK; Schoener EP; Roll JM. Reinforcement of counseling attendance and alcohol abstinence in a community-based dual-diagnosis treatment program: A feasibility study. Psychology of Addictive Behaviors 17(3): 249-251, 2003. (16 refs.)

This study evaluated the effectiveness of a community-based contingency management (CM) protocol reinforcing punctual dual-diagnosis group counseling attendance and negative breath alcohol levels. Participants were 20 dual-diagnosis patients. The A-B-A within-subjects reversal design included a 4-week baseline phase (BL), a 12-week CM intervention, and a 4-week return-to-baseline phase (R-BL). Group counseling was provided twice weekly, with breath tests before each session. CM attendance rates were significantly higher (65% +/- 28%) than BL (45% +/- 32%, p < .05) and remained elevated in the R-BL phase (68% +/- 29%). Despite clinical reports of frequent intoxication, during the study all breath test results were negative, regardless of study phase. Thus, no contingency effect on alcohol use could be determined. Results suggest that CM interventions can be effective in increasing attendance in a community treatment program for the dually diagnosed.

Higgins ST. Extending contingency management to the treatment of methamphetamine use disorders. (editorial). American Journal of Psychiatry 163(11): 1870-1872, 2006. (9 refs.)

Higgins ST; Heil SH; Solomon LJ; Bernstein IM; Lussier JP; Abel RL et al. A pilot study on voucher-based incentives to promote abstinence from cigarette smoking during pregnancy and postpartum. Nicotine & Tobacco Research 6(6): 1015-1020, 2004. (20 refs.)

We report results from a pilot study examining the use of vouchers redeemable for retail items as incentives for smoking cessation during pregnancy and postpartum. Of 100 study-eligible women who were still smoking upon entering prenatal care, 58 were recruited from university-based and community, obstetric practices to participate in a smoking cessation study. Participants were assigned to either contingent or noncontingent voucher conditions. Vouchers were available during pregnancy and for 12 weeks postpartum. In the contingent condition, vouchers were earned for biochemically verified smoking abstinence. In the noncontingent condition. vouchers were earned independent of smoking status. Abstinence monitoring and associated voucher delivery was conducted daily during the initial 5 days of the cessation effort, gradually decreased to every other week antepartum, increased to once weekly during the initial 4 weeks postpartum, and then decreased again to every other week for the remaining 8 weeks of the postpartum intervention period. Contingent vouchers increased 7-day point-prevalence abstinence at the end-of-pregnancy (37% vs. 9%) and 12-week postpartum (33% vs. 0%) assessments. That effect was sustained through the 24-week postpartum assessment (27% vs. 0%), which was 12 weeks after discontinuation of the voucher program. Total mean voucher earnings across antepartum and postpartum were US$397 (SD = US$414) and US$313 (SD = $142) in the contingent and noncontingent conditions respectively. The magnitude of these treatment effects exceed levels typically observed with pregnant and recently postpartum smokers, and the maintenance of effects through 24 weeks postpartum extends the duration beyond those reported previously.

Higgins ST; Sigmon SC; Wong CJ; Heil SH; Badger GJ; Donham R et al. Community reinforcement therapy for cocaine-dependent outpatients. Archives of General Psychiatry 60(10): 1043-1052, 2003. (48 refs.)

Objective: To examine the contributions of community reinforcement therapy to outcome in the community reinforcement approach (CRA) + vouchers outpatient treatment for cocaine dependence. Methods: One hundred cocaine-dependent outpatients were randomly assigned to one of 2 treatment conditions: CRA + vouchers or vouchers only. All patients earned incentives in the form of vouchers exchangeable for retail items contingent on cocaine-free urinalysis results during treatment weeks 1 to 12. Incentives were combined with a 24-week course of CRA therapy designed to promote healthy lifestyle changes in the CRA + vouchers condition, while incentives represented the primary treatment in the vouchers-only condition. Patient drug use and psychosocial functioning were assessed at intake and at least every 3 months for 2 years after treatment entry. Results: Patients treated with CRA + vouchers were retained better in treatment, used cocaine at a lower frequency during treatment but not follow-up, and reported a lower frequency of drinking to intoxication during treatment and follow-up compared with patients treated with vouchers only. Patients treated with CRA + vouchers also reported a higher frequency of days of paid employment during treatment and the initial 6 months of follow-up, decreased depressive symptoms during treatment only, and fewer hospitalizations and legal problems during follow-up. Conclusions: Combining CRA with vouchers had therapeutic effects on substance abuse and psychosocial functioning during treatment and posttreatment follow-up in cocaine-dependent outpatients, although effects on cocaine use appear to be limited to the treatment period.

Hilarski C, ed. Addiction, Assessment, and Treatment with Adolescents, Adults, and Families. New York: Haworth Social Work Practice Press, 2005. (Chapter refs.)

This volume with 13 chapters covers a broad range of issues ranging from counselor's belief's about confrontation, faith-based recovery programs, the use of contingency management, motivational interviewing, family based treatment, behavioral therapy, and treatment of juvenile offenders.

Hogarth L; Dickinson A; Duka T. Explicit knowledge of stimulus-outcome contingencies and stimulus control of selective attention and instrumental action in human smoking behaviour. Psychopharmacology 177(4): 428-437, 2005. (43 refs.)

Rationale: External stimuli (S+) that reliably signal that addictive drugs are available command the focus of selective attention and control instrumental action that procures the drug. According to incentive salience theory, as the contingency between the S+ and the drug is learned the magnitude of attentional orienting towards the S+ increases. By contrast, alternative theories propose that processing of the S+ becomes more efficient with training such that the measured attentional orienting response elicited by the S+ decreases. Objectives: The aim of the present study was to prompt half of participants to acquire explicit knowledge of the stimulus-reinforcer contingencies arranged in training, to examine the impact of this manipulation on the magnitude of attentional orienting towards the S+. Methods: Smokers (n=32) completed an instrumental discrimination training procedure in which a set of stimuli were established as differential predictors that an instrumental response would yield tobacco-smoke reinforcement. During training, attention for the stimuli and performance of the instrumental tobacco-seeking response were measured in parallel. One group (n=16) was prompted to develop explicit knowledge of the discriminative contingencies in training whereas another group (n=16) underwent discrimination training without prompting. Results: The prompted group reported accurate knowledge of the contingencies and showed no attentional orienting response towards the S+. By contrast, the unprompted group reported inaccurate knowledge of the contingencies and showed an attentional orienting response towards the S+. The S+ appeared to control the instrumental tobacco-seeking response in both groups equally. Conclusions: The results suggest that attention for drug paired S+ is associated with the process of learning about the relationship between those cues and the drug.

Jang SM; Schoppelrey SL. Implementation of contingency management substance abuse treatment in community settings. IN: Hilarski C, ed. Addiction, Assessment, and Treatment with Adolescents, Adults, and Families. New York: Haworth Social Work Practice Press, 2005. pp. 41-54. (51 refs.)

Considerable evidence exists regarding the efficacy and cost-effectiveness of contingency management (CM) and related approaches to treating substance use disorders. Despite more than 25 years of research, these interventions are presently under-utilized, especially in community settings. This article examines potential barriers related to cost, appropriateness, and effectiveness that may explain the low levels of utilization and proposes strategies for overcoming these barriers. Implications for further research and implementation efforts are also discussed.

Johansson BA; Berglund M; Lindgren A. Efficacy of maintenance treatment with naltrexone for opioid dependence: A meta-analytical review. (review). Addiction 101(4): 491-503, 2006. (42 refs.)

Aims: To determine the efficacy of naltrexone in reducing illicit opioid use and the potential moderating role of treatment retention. Design: First, randomized controlled trials (RCTs) comparing the regimens of treatment using the opioid antagonist, naltrexone, with controls were analysed by meta-analysis for treatment effect with regard to a range of outcome criteria. The degree of heterogeneity was also determined. The moderating effect of other interventions during naltrexone maintenance was then estimated, particularly with regard to their effect on treatment retention. Participants: Fifteen studies involving 1071 patients were found. Measurements: All available outcomes were analysed in 10 studies of naltrexone versus control (seven placebo) and six studies of randomized psychosocial/psychopharmacological interventions. Findings: Significant heterogeneity was found in the efficacy of naltrexone. Level of retention in treatment was found to be a moderator, explaining most of the heterogeneity found. Overall, naltrexone was significantly better than control conditions in reducing the number of opioid-positive urines. This effect was only present in the high retention subgroup for differences in retention. Contingency management (CM) increased retention and naltrexone use, resulting in a reduced number of opioid-positive urines. Conclusion: Retention is important to the effect of naltrexone in treating opioid dependence. Contingency management is a promising method of increasing retention.

Jones HE; Johnson RE; Bigelow GE; Silverman K; Mudric T; Strain EC. Safety and efficacy of L-tryptophan and behavioral incentives for treatment of cocaine dependence: a randomized clinical trial. American Journal on Addictions 13(5): 421-437, 2004. (44 refs.)

L-tryptophan (ie, tryptophan) has shown promise as a pharmacotherapy in cocaine addiction treatment. Abstinent contingent voucher incentives have shown efficacy in abstinence initiation and maintenance for treatment of cocaine dependence. The present study evaluated these two approaches singly and in combination in a relapse prevention+treatment design. A double-blind, parallel-group, placebo-controlled design was used. Cocaine-dependent patients (N = 199) were stratified and randomized to one of four groups: tryptophan + contingent vouchers, tryptophan + non-contingent vouchers, placebo + contingent vouchers, and placebo + non-contingent vouchers. The study included residential stabilization (4-9 days), where patients achieved initial cocaine abstinence; outpatient treatment evaluation (16 weeks), where patients received medication, vouchers, and urine testing thrice weekly; and disposition. Main outcomes were retention in treatment, urinalysis, self-reported drug use, and self-reported side effects. Tryptophan did not significantly prevent relapse to cocaine use or attenuate cocaine use after relapse. Contingent vouchers significantly increased the time to cocaine relapse and produced less cocaine use relative to non-contingent vouchers. Results demonstrate the sensitivity of this methodology for detecting decreases in cocaine use, as evidenced by significant changes of the contingent voucher conditions; this suggests that tryptophan's lack of efficacy was not due to model insensitivity for detecting significant differences in cocaine use. This study also showed that contingent vouchers were effective in the novel experimental model of relapse prevention.

Kadden RM. Behavioral and cognitive-behavioral treatments for alcoholism: Research opportunities. IN: Galanter M, ed. Recent Developments in Alcoholism. Volume 16: Research on Alcoholism Treatment. Methodology/Psychosocial Treatment/Selected Treatment Topics/Research Priorities. New York: Kluwer Academic, 2003. pp. 165-182. (74 refs.)

A review of research on learning-based interventions is presented, which addresses both "behavioral" and "cognitive-behavioral" studies. It is noted that behavioral approaches emphasize external antecedents and consequences affecting behavior, without referencing mediational states, cognitions or other private events. Cognitive-behavioral approaches, on the other hand, include cognitive processes and emotions among that factors that may affect behavior and use both behavioral and cognitive methods to promote behavioral change. Section headings in this book chapter include: (1) cue exposure; (2) gaps in knowledge; (3) research opportunities; (4) contingency management; (5) coping skills training; (6) relapse prevention; and (7) behavioral marital therapy.

Kamon J; Budney A; Stanger C. A contingency management intervention for adolescent marijuana abuse and conduct problems. Journal of the American Academy of Child and Adolescent Psychiatry 44(6): 513-521, 2005. (38 refs.)

Objective: To describe an innovative treatment for adolescent marijuana abuse and provide initial information about its feasibility, acceptability, and potential efficacy. Method: Provided an intervention composed of (1) a clinic-administered, abstinence-based incentive program; (2) parent-directed contingency management targeting substance use and conduct problems; (3) a clinic-administered incentive program for parent participation; and (4) individual cognitive-behavioral therapy for adolescents. Data are presented for 19 adolescents, age 15-18 years. Measures of substance use, psychopathology, and parenting were collected before and after the 14-week treatment. Substance use measures were also collected 1 month post-treatment. Substance use was monitored by twice-weekly urine and breath testing. An intent-to-treat model was used. Results: Adolescents and parents attended an average of 10.3 and 10.6 of 14 sessions, respectively. Substance use, externalizing behaviors, and negative parenting behaviors decreased by treatment end. Urine testing indicated that abstinence increased from 37% at intake to 74% at treatment end (z value = 2.28, p = .02) and that 53% of adolescents were abstinent 30 days post-treatment. Conclusions: Preliminary data provide support for the feasibility and acceptability of a family-based, contingency management model to treat adolescent substance use and conduct problems. Controlled efficacy studies with larger samples are needed.

Katz EC; Chutuape MA; Jones H; Jasinski D; Fingerhood M; Stitzer M. Abstinence incentive effects in a short-term outpatient detoxification program. Experimental and Clinical Psychopharmacology 12(4): 262-268, 2004. (39 refs.)

Despite being widely available, outpatient detoxification has limited efficacy as a stand-alone treatment. This study examined whether abstinence-contingent incentives would improve outcomes for patients entering outpatient opiate detoxification. Participants (N = 211) received a $100 voucher on the last day of detoxification either contingent on opiate and cocaine abstinence or noncontingently. Urine samples were collected at intake, on Wednesday, Friday (the last day of detoxification), and the following Monday. Among contingent-voucher participants, 31% were drug-free on Friday compared with 18% of noncontingent controls (Z = 2.4, p < .05). Few (12-13%) participants tested negative on Monday. Results support the ability of vouchers to produce modest improvements in abstinence initiation rates during brief detoxification but suggest that additional interventions are needed to sustain improvements.

Kellogg SH; Burns M; Coleman P; Stitzer M; Wale JB; Kreek MJ. Something of value: The introduction of contingency management interventions into the New York City Health and Hospital Addiction Treatment Service. Journal of Substance Abuse Treatment 28(1): 57-65, 2005. (15 refs.)

This paper explores the impact of the adoption of the contingency management approach by the Chemical Dependency Treatment Services of the New York City Health and Hospitals Corporation (HHC). The utilization of this approach grew out of an alliance between NIDA Clinical Trials Network-affiliated clinicians and researchers and a leadership team at the HHC. Interviews and dialogues with administrators, staff, and patients revealed a shared sense that the use of contingency management had: (1) increased patient motivation for treatment and recovery; (2) facilitated therapeutic progress and goal attainment; (3) improved the attitude and morale of many staff members and administrators; and (4) developed a more collegial and affirming relationship not only between patients and staff, but also among staff members.

Kellogg SH; Kreek MJ. Gradualism, identity, reinforcements, and change. International Journal of Drug Policy 16(6): 369-375, 2005. (54 refs.)

This paper reflects the ongoing development of gradualism, a drug treatment perspective that seeks to make use of the full array of effective, creative, and innovative harm reduction and abstinence-oriented treatments available to help addicted individuals move along a continuum from active/chaotic use to abstinence or moderation, as appropriate. The essence of gradualism is an emphasis on positive change and transformation as therapeutic goals. The paper first looks at manifestations of gradualism in harm reduction treatment facilities. Following this is a discussion of the role of identity transformation in the change process. The final section explores how contingency management or motivational incentive interventions could be used in harm reduction settings to facilitate this kind of therapeutic movement.

Kirby KC; Benishek LA; Dugosh KL; Kerwin ME. Substance abuse treatment providers' beliefs and objections regarding contingency management: Implications for dissemination. Drug and Alcohol Dependence 85(1): 19-27, 2006. (28 refs.)

Contingency management (CM) interventions are among the most effective methods for initiating drug abstinence, but they infrequently have been adopted by community drug and alcohol treatment programs. The primary purpose of this investigation was to determine the prevalence of specific beliefs that community treatment providers hold regarding contingency management interventions. We surveyed 383 treatment providers from three geographical areas of the United States regarding moral or ethical objections, negative side effects, practicality, limitations and positive opinions regarding tangible and social CM interventions. Results indicate that positive beliefs were surprisingly prevalent, with providers agreeing with an average of 67% of the positive statements regarding CM using tangible incentives and 54% indicating that they would be in favor of adding a tangible CM intervention to their treatment program. The most prevalent objections to incentive programs were that they cost too much, fail to address the underlying problems of addiction, and do not address multiple behaviors. Social incentives were viewed more favorably than tangible incentives and both were viewed more positively by providers who were supervisors, had advanced degrees, had more addictions experience, and had previous experience with tangible incentives. These findings have implications for improving the dissemination of this empirically-supported treatment.

Kosten T; Poling J; Oliveto A. Effects of reducing contingency management values on heroin and cocaine use for buprenorphine- and desipramine-treated patients. Addiction 98(5): 665-671, 2003. (37 refs.)

Aims: During 3 months where contingency management (CM) had an escalating value for each consecutive drug-free urine (escalating CM), cocaine- and heroin-abusing patients significantly increased drug-free urines. The 'escalating CM' was eliminated during months 4-6 to assess any reduction in drug-free urines. Design Patients who completed a 3-month, randomized, double-blind, trial evaluating CM versus non-CM and desipramine (DMI) versus placebo, had an escalating CM' eliminated during months 4-6. The CM and non-CM groups were compared using thrice-weekly urine samples. Setting Out-patient buprenorphine maintenance for 6 months. Participants All 75 of the 160 original study patients who completed month 3 of the clinical trial. Intervention The 'escalating CM' was eliminated for all 3 months and during months 5 and 6 the response requirement was also increased to two and then three consecutive drug-free urines in order to obtain a voucher. Measurements Urine toxicology for opiates and cocaine. Findings After eliminating the 'escalating CM', the CM group showed a decline in combined opioid- and cocaine-free urines. This decline within the CM group was greater in those treated with DMI than placebo. Conclusions: Buprenorphine with DMI maintained drug abstinence after eliminating the 'escalating CM', but not after increasing the response requirement, suggesting the need for more intensive psychosocial interventions during CM.

Lamb RJ; Kirby KC; Morral AR; Galbicka G; Iguchi MY. Improving contingency management programs for addiction. Addictive Behaviors 29(3): 507-523, 2004. (26 refs.)

Contingency management interventions effectively reduce or eliminate some individuals' problem substance use. Typically, those who do not benefit never experience the reward or planned contingency available through the intervention because they never produce the behavior (often abstinence) on which the reward is contingent. With two analog studies, we examine whether the effectiveness contingency management interventions improves when contingencies are arranged in ways that improve the likelihood of all participants experiencing the available reward. Participants were smokers not planning to quit. In Study 1, smokers were paid $0, 1, 3, 10, or 30 each day for 5 days for delivery of breath carbon monoxide (CO) levels either 4 ppm or below half the median of their baseline levels. Higher payment amounts and the easier target criterion resulted in a higher likelihood of participants meeting criterion. Once participants met the 4 ppm criterion, however, they often maintained this behavior even in the absence of payments for reduced breath CO levels. An ineffective contingency management system was made effective based on these results. Study 2 examined the effectiveness of percentile schedules at reducing breath CO levels. Percentile schedules shaped lower breath CO levels. The effectiveness of percentile schedules in shaping abstinence was tested in treatment seekers, and percentile schedules were found to be effective at shaping abstinence.

Lamb RJ; Morral AR; Kirby KC; Iguchi MY; Galbicka G. Shaping smoking cessation using percentile schedules. Drug and Alcohol Dependence 76(3): 247-259, 2004. (37 refs.)

Behavioral interventions that provide incentives contingent upon abstinence are effective addiction treatments. Nevertheless, these treatments often fail for individuals whose recent behaviors are very different from those reinforced. These hard-to-treat individuals may require shaping to achieve abstinence. We used percentile schedules to shape smokers' delivery of breath samples indicative of recent smoking abstinence (breath carbon monoxide (BCO) <4 ppm). Percentile schedules deliver incentives to current behaviors proximal to the target. Participants (N = 102) were assigned to treatments delivering incentives for breath COs at or below the 10th, 30th, 50th, or 70th percentile of recent breath COs. Each condition effectively ensured contact with available contingencies, and resulted in BCO <4 ppm in >90% of the 30th, 50th and 70th percentile groups versus 63% in the 10th percentile. The 30th, 50th and 70th percentiles were especially effective in a sub-sample of hard-to-treat participants who did not deliver a breath CO <4 ppm during an initial abstinence test or during a nine-visit baseline period, suggesting the value of shaping for this important sub-sample.

Ledgerwood DM; Petry NM. Does contingency management affect motivation to change substance use? Drug and Alcohol Dependence 83(1): 65-72, 2006. (32 refs.)

Although substantial evidence favors the efficacy of contingency management (CM) for substance use disorders, few studies have examined the effect of CM on one's motivation to change substance use. One way of conceptualizing motivation to change is by using the stages of change model [Prochaska. J.O., DiClemente, C.C., 1983. Stages and processes of self-change of smoking: toward an integrative model of change. J. Consult. Clin. Psychology. 51, 390-395]. We assessed motivation to change substance use as conceptualized by the stages of change model using the University of Rhode Island Change Assessment (URICA [McConnaughy, E.A., Prochaska, J.O., Velicer, W.F., 1983. Stages of change in psychotherapy: measurement and sample profiles. Psychother. Theor. Research. 20, 368-375]) in 115 patients in community treatment clinics before they were randomized to receive standard treatment or standard treatment plus CM. Motivation was also assessed 3 months later. Patients in both conditions evidenced significant decreases in their motivation scores from pre- to post-treatment. CM neither increased nor decreased motivation relative to the standard treatment condition. Pre-treatment motivation scores were also not related to treatment outcome. Assignment to the CM condition was associated with better treatment outcome as defined by longest duration of abstinence during treatment (LDA). Higher post-treatment motivation was also modestly associated with LDA, but not in all analyses. These findings suggest that CM neither increases nor decreases motivation to change substance use in outpatients receiving treatment at community-based drug-free clinics. Future studies should further examine motivation change in CM treatment using different assessment tools and conceptualizations of motivation, extending these effects to other treatment settings and populations.

Leland DS; Paulus MP. Increased risk-taking decision-making but not altered response to punishment in stimulant-using young adults. Drug and Alcohol Dependence 78(1): 83-90, 2005. (50 refs.)

Stimulant-using and stimulant-naive young adults performed the "risky gains" decision-making task [Paulus, M.P., Rogalsky, C., Simmons, A., Feinstein, J.S., Stein, M.B., 2003. Increased activation in the right insula during risk-taking decision making is related to harm avoidance and neuroticism. Neuroimage 19(4), 1439-1448]. On each trial, the numbers 20, 40, and 80 are presented individually in ascending order. Subjects press a button to receive the displayed number in points. The 20 is always associated with a gain of 20 points (safe response). There is a chance that waiting to select a 40 or 80 will result in punishment of 40 or 80 points, respectively (risky response). All subjects made fewer risky responses immediately following punished trials (p <.001). Stimulant-users made more risky responses than never-users overall (p <.02) but showed the same inhibition effect of punishment on next-trial risky responding. Risk-taking in the task correlated with measures of sensation-seeking and impulsivity, but not other personality measures, anxiety, or tendency toward alcohol use disorders. Results are consistent with the hypothesis that stimulant-users show increased risk-taking but are not less sensitive to punishments than controls. By requiring selection from a sequence of individual options presented according to a fixed schedule, rather than allowing deliberation between simultaneously available options, the risky gains task may model a different sort of risk-taking than other tasks.

Lewis MW; Petry NM. Contingency management treatments that reinforce completion of goal-related activities: Participation in family activities and its association with outcomes. Drug and Alcohol Dependence 79(2): 267-271, 2005. (17 refs.)

Contingency management (CM) techniques that reinforce completion of nondrug related activities may be efficacious in treating substance dependence. No studies to date have evaluated whether involvement in particular types of activities reduces problems in those domains. One hundred fifty-nine cocaine-abusing adults who had been randomized to a CM intervention were categorized based on whether or not they engaged in three or more family related activities during the 12-week treatment period. Differences between the groups were evaluated with respect to treatment retention, length of continuous abstinence, and changes from baseline to the end of the intervention in ASI-family scores and days of family conflict. Participants who engaged in family activities (N=29) remained in treatment longer, were abstinent for more weeks, and reported greater reduction in family conflict compared to participants who did not engage in family activities (N= 130). These data suggest that participants who elect to complete family related activities during CM treatments may evidence improved outcomes and reduced family conflict.

Lussier JP; Heil SH; Mongeon JA; Badger GJ; Higgins ST. A meta-analysis of voucher-based reinforcement therapy for substance use disorders. (review). Addiction 101(2): 192-203, 2006. (81 refs.)

Aims: To systematically investigate the effectiveness of voucher-based reinforcement therapy for the treatment of substance use disorders. Methods: Effect sizes and 95% confidence intervals were calculated for studies published between January 1991 and March 2004 that utilized voucher-based reinforcement therapy (VBRT) or related monetary-based incentives to treat substance use disorders (SUDs). Findings: Thirty studies involved interventions targeting abstinence from drug use using experimental designs where effects on treatment outcome could be attributed to the VBRT intervention. The estimated average effect size (r) for those studies was 0.32 (95% CI 0.26-0.38). Analyses of variables thought to moderate VBRT effect sizes revealed that more immediate voucher delivery and greater monetary value of the voucher were associated with larger effect sizes. Additional studies were identified wherein VBRT was used to target clinic attendance (n = 6) or medication compliance (n = 4). VBRT studies targeting attendance produced average effect sizes of 0.15 (95% CI 0.02-0.28), while those that targeted medication compliance produced an average effect of 0.32 (95% CI 0.15-0.47). No significant moderators were identified for these 10 studies. Conclusions: Overall, VBRT generated significantly better outcomes than did control treatments. These results further support the efficacy of VBRT, quantify the magnitude of its effects, identify significant moderators and suggest potential directions for future research.

Marlowe DB; Kirby KC; Festinger DS; Merikle EP; Tran TQ; Platt JJ. Day treatment for cocaine dependence: Incremental utility over outpatient counseling and voucher incentives. (rapid communication). Addictive Behaviors 28(2): 387-398, 2003. (23 refs.)

Urban, poor, crack cocaine-dependent clients were randomly assigned to outpatient addiction counseling (n=39) or day treatment (n=40). Participants in both conditions received equivalent individual cognitive-behavioral counseling and earned equivalent payment vouchers for providing cocaine-negative urine samples. However, day treatment participants attended significantly more psychoeducational and recreational groups and received two meals per day. Prior to random assignment, more participants expressed a preference for day treatment and participants were more likely to return for an initial appointment following assignment to day treatment. However, no significant between-groups differences in tenure or abstinence were detected during the 3-month course of treatment. These null findings were attributable to an absence of a dose-response effect for the group interventions in the day treatment condition. In addition, there may have been a ceiling effect from the vouchers, which masked the influence of the additional day treatment components.

Milby JB; Schumacher JE; Vuchinich RE; Wallace D. Transitions during effective treatment for cocaine-abusing homeless persons: Establishing abstinence, lapse, and relapse, and reestablishing abstinence. Psychology of Addictive Behaviors 18(3): 250 -256, 2004. (26 refs.)

Data are reported on drug use among cocaine-dependent homeless persons who participated in a clinical trial that compared day treatment only (DT, n = 69) with day treatment plus abstinent-contingent housing and work (DT+, n = 72). Drug use was measured with multiple weekly urine toxicologies. Compared with DT participants, more DT+ participants established abstinence, maintained abstinence for longer durations, were marginally significantly more likely to lapse, and significantly less likely to relapse. Of all participants who established abstinence and then relapsed, DT+ participants relapsed later and were more likely to reestablish abstinence. These analyses yield information on the processes involved in the, manner in which drug use changes as a result of abstinent-contingent housing and work.

Milby JB; Schumacher JE; Wallace D; Freedman MJ; Vuchinich RE. To house or not to house: The effects of providing housing to homeless substance abusers in treatment. American Journal of Public Health 95(7): 1259-1265, 2005. (35 refs.)

Objectives. Housing typically is not provided to homeless persons during drug abuse treatment. We examined how treatment outcomes were affected under 3 different housing provision conditions. Methods. We studied 196 cocaine-dependent participants who received day treatment and no housing (NH) housing contingent on drug abstinence (ACH), or housing not contingent on abstinence (NACH). Drug use was monitored with urine testing. Results, The ACH group had a higher prevalence of drug abstinence than the NACH group (after control for treatment attendance), which in turn had a higher prevalence than the NH group. All 3 groups showed significant improvement in maintaining employment and housing. Conclusions. The results of this and previous trials indicate that providing abstinence-contingent housing to homeless substance abusers in treatment is an efficacious, effective, and practical intervention. Programs to provide such housing should be considered in policy initiatives.

O'Connor R; Fix B; Celestino P; Carlin-Menter S; Hyland A; Cummings KM. Financial incentives to promote smoking cessation: Evidence from 11 Quit and Win Contests. Journal of Public Health Management and Practice 12(1): 44-51, 2006. (20 refs.)

In an effort to motivate smokers across New York State to stop smoking, tobacco control programs across the state held "Quit and Win" incentive-based stop-smoking contests. These contests encouraged smokers to make a quit attempt by offering a chance to win cash prize (usually $1,000) for successfully stopping smoking for at least 1 month. Between 2001 and 2004, 11 different Quit and Win Contests involving 5,504 adult smokers were sponsored in different communities across New York State. Follow-up surveys were conducted 4 to 6 months after each contest ended to evaluate participants' success in quitting smoking, Expenditures for promoting contests varied from a high of $91,441 to a low of $4,345, with a median of $25,928. An average of 0.55 percent of smokers was recruited to join contests across the 11 communities. Among smokers who enrolled in a contest, 9 out of 10 reported making a quit attempt, and between 53 percent and 72 percent reported quitting for the full month of the contest. At 4 to 6 months follow-up, self-reported quit rates (7-day point prevalence) among contestants ranged from 22 percent to 49 percent, with an average of 31 percent. Based on a statewide population survey, 8 of the 11 programs showed quit rates that were significantly higher (P <.001 by Wilcoxon rank-sum test) than the estimated quit rate of 21 percent seen among smokers making a quit attempt in the past year. This study shows that for a relatively modest investment of resources, thousands of smokers can be recruited to make a serious quit attempt, with many remaining smoke-free months later.

Pantalon MV; Ferro G; Chawarski MC; LaPaglia DM; Pakes JP; Schottenfeld RS. Voucher purchases in contingency management interventions for women with cocaine dependence. Addictive Disorders and Their Treatment 3(1): 27-35, 2004. (25 refs.)

Objective: Voucher-based Contingency Management (CM) has been shown to be effective in treating cocaine dependence, but the relative impact of extensive voucher purchase guidelines has not been evaluated. Consequently, our objective was to investigate the effect of purchase guidelines on voucher purchases. Methods: We evaluated voucher purchases made by 94 cocaine dependent women who were enrolled in a randomized clinical trial of the Community Reinforcement Approach (CRA) versus Twelve-Step Facilitation (TSF), where extensive purchase guidelines were only part of CRA. Results: In CRA, 70% of the purchases were consistent with the guidelines offered. The most frequent purchases were for social/recreational activities (30%), the participant's child (non-basic needs; 17%), and household items (15%). There were no significant differences in percentages of purchases between CRA and TSF. Additionally, preliminary findings on the relationship between voucher purchase patterns and cocaine abstinence are presented. Conclusion: The findings suggest that extensive purchase guidelines may not be a critical aspect of voucher reward programs.

Paul CL; Wiggers J; Daly JB; Green S; Walsh RA; Knight J et al. Direct telemarketing of smoking cessation interventions: Will smokers take the call? Addiction 99(7): 907-913, 2004. (32 refs.)

Aims: Few smokers currently make use of available and effective cessation strategies, despite their expressed desire to quit and reported interest in cessation support. This study aimed to explore the feasibility of a telephone-based direct-marketing approach to delivering cessation strategies. Design, setting, measurements and participants: A community survey was conducted to explore the views of current adult smokers regarding the acceptability, likely uptake and barriers to uptake of smoking cessation services offered by direct telephone marketing. Findings:Three quarters (73.8%) of smokers contacted agreed to be surveyed. Of the 194 study participants, 75.3% reported that they would utilize vouchers for discount nicotine replacement therapy (NRT), 66.5% would use a mailed self-help booklet, 57.2% would take up the offer of regular mailings of personalized letters and self-help materials and 46.4% would utilize a 'we-call-you' telephone counselling service. The characteristics of those indicating likely uptake of these services were also explored. The two major barriers to uptake of services were preferring to quit without help and a belief that a particular service would not help the participant. Conclusions: The data suggest strong support for the direct marketing of smoking cessation strategies; they also highlight the need for further study of the cost-effectiveness of telephone-based direct marketing of smoking cessation strategies as a population-based strategy for reducing the prevalence of smoking in the community.

Peirce JM; Petry NM; Stitzer ML; Blaine J; Kellogg S; Satterfield F et al. Effects of lower-cost incentives on stimulant abstinence in methadone maintenance treatment: A national drug abuse treatment clinical trials network study. Archives of General Psychiatry 63(2): 201-208, 2006. (33 refs.)

Background: Contingency management interventions that provide tangible incentives based on objective indicators of drug abstinence have improved treatment outcomes of substance abusers, but have not been widely implemented in community drug abuse treatment settings. Objective: To compare outcomes achieved when a lower-cost prize-based contingency management treatment is added to usual care in community methadone hydrochloride maintenance treatment settings. Design: Random assignment to usual care with (n = 198) or without (n = 190) abstinence incentives during a 12-week trial. Setting: Six community-based methadone maintenance drug abuse treatment clinics in locations across the United States. Participants: Three hundred eighty-eight stimulant-abusing patients enrolled in methadone maintenance programs for at least 1 month and no more than 3 years. Intervention: Participants submitting stimulant- and alcohol-negative samples earned draws for a chance to win prizes; the number of draws earned increased with continuous abstinence time. Main Outcome Measures: Total number of stimulant- and alcohol-negative samples provided, percentage of stimulant- and alcohol-negative samples provided, longest duration of abstinence, retention, and counseling attendance. Results: Submission of stimulant- and alcohol-negative samples was twice as likely for incentive as for usual care group participants (odds ratio, 1.98; 95% confidence interval, 1.42-2.77). Achieving 4 or more, 8 or more, and 12 weeks of continuous abstinence was approximately 3, 9, and 11 times more likely, respectively, for incentive vs usual care participants. Groups did not differ on study retention or counseling attendance. The average cost of prizes was $120 per participant. Conclusion: An abstinence incentive approach that paid $120 in prizes per participant effectively increased stimulant abstinence in community-based methadone maintenance treatment clinics.

Petry NM; Alessi SM; Marx J; Austin M; Tardif M. Vouchers versus prizes: Contingency management treatment of substance abusers in community settings. Journal of Consulting and Clinical Psychology 73(6): 1005-1014, 2005. (45 refs.)

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

Petry NM; Bohn MJ. Fishbowls and candy bars: Using low-cost incentives to increase treatment retention. Science & Practice Perspectives 2(1), 2003. (0 refs.)

Contingency management approaches that reward patients for meeting their drug abuse treatment objectives have demonstrated effectiveness in cocaine dependence clinical trials nationwide. The cost of such programs, however, was considered prohibitive for most community based treatment providers. In this article, Drs. Nancy Petry, a researcher, and Michael Bohn, Medical Director of a community substance abuse treatment program, discuss researching and implementing interventions designed to produce the benefits of contingency management at a fraction of the cost.

Public Domain

Petry NM; Martin B; Simcic F. Prize reinforcement contingency management for cocaine dependence: Integration with group therapy in a methadone clinic. Journal of Consulting and Clinical Psychology 73(2): 354-359, 2005. (31 refs.)

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 cocaine-negative 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.

Petry NM; Peirce JM; Stitzer ML; Blaine J; Roll JM; Cohen A et al. Effect of prize-based incentives on outcomes in stimulant abusers in outpatient psychosocial treatment programs: A national drug abuse treatment clinical trials network study. Archives of General Psychiatry 62(10): 1148-1156, 2005. (45 refs.)

Context: Contingency management interventions that provide tangible incentives based on objective indicators of drug abstinence are efficacious in improving outcomes in substance abusers, but these treatments have rarely been implemented, in community-based settings. Objective: To evaluate the efficacy of an abstinence-based contingency management intervention as an addition to usual care in community treatment settings. Design: Random assignment to usual care or usual care plus abstinence-based incentives for 12 weeks. Setting: Eight community-based outpatient psychosocial drug abuse treatment programs. Participants: A total of 415 cocaine or methamphetamine users beginning outpatient substance abuse treatment. Intervention: All participants received standard care, and those assigned to the abstinence-based incentive condition also earned chances to win prizes for submitting substance-free urine samples; the chances of winning prizes increased with continuous time abstinent. Main Outcome Measures: Retention, counseling attendance, total number of substance-free samples provided, percentage of stimulant- and alcohol-free samples submitted, and longest duration of confirmed stimulant abstinence. Results: Participants assigned to the abstinence-based incentive condition remained in treatment for a mean +/- SD of 8.0 +/- 4.2 weeks and attended a mean +/- SD of 19.2.+/- 16.8 counseling sessions compared with 6.9 +/- 4.4 weeks and 15.7 +/- 14.4 sessions for those assigned to the usual care condition (P <.02 for all). Participants in the abstinence-based incentive condition also submitted significantly more stimulant- and alcohol-free samples (P <.001). The abstinence-based incentive group was significantly more likely to achieve 4, 8, and 12 weeks of continuous abstinence than the control group, with odds ratios of 2.5, 2.7, and 4.5, respectively. However, the percentage of positive samples submitted was low overall and did not differ between conditions. Conclusion: The abstinence-based incentive procedure, which provided a mean of $203 in prizes per participant, was efficacious in improving retention and associated abstinence outcomes.

Petry NM; Tedford J; Austin M; Nich C; Carroll KM; Rounsaville BJ. Prize reinforcement contingency management for treating cocaine users: How low can we go, and with whom? Addiction 99(3): 349-360, 2004. (44 refs.)

Aims This study evaluated the efficacy of a low-cost, prize reinforcement contingency management (CM) intervention for reducing cocaine use. Setting Community-based treatment centers. Participants and design Cocaine-abusing out-patients (n = 120) were assigned randomly to one of three 12-week conditions: standard treatment, standard treatment plus CM with an expected maximum of $80 of reinforcement or standard treatment plus CM with an expected maximum of $240 of reinforcement. Intervention In the CM conditions, patients earned the opportunity to win prizes for submitting negative urine samples and completing goal-related activities. Measurements Drug use was measured at intake and throughout a 3-month treatment period. Findings Patients in the $240 CM condition achieved more abstinence than patients in the standard condition. Patients who initiated treatment with positive urinalysis results were most responsive to the CM intervention, with the $240 CM condition engendering the best effects in this subgroup. In contrast, patients who initiated treatment with negative urinalysis results generally remained abstinent during treatment, regardless of treatment assignment. On average, patients in the two CM conditions earned $36 and $68 in prizes. Conclusions This study suggests that prize reinforcement CM may be suitable for community-based settings, and beneficial effects may be magnitude-dependent in more severe patients.

Pollastri AR; Pokrywa ML; Walsh SJ; Kranzler HR; Gelernter J. Incentive program decreases no-shows in nontreatment substance abuse research. Experimental and Clinical Psychopharmacology 13(4): 376-380, 2005. (16 refs.)

This study examined the use of a low-cost incentive program to decrease the rate of unanticipated no-shows in a nontreatment study of the genetics of substance dependence. Low-cost retail items (such as calling cards or gift certificates) were offered contingent on attendance at the first scheduled research appointment. Although the intervention did not result in an increase in the rate of attendance at appointments, it reduced the likelihood of unanticipated no-shows by almost 50%. This reduction was accompanied by a significant increase in advance cancellations. Despite limitations due to the study's A-B design, this research demonstrates that it may be possible to use modest incentives to increase the efficiency of research enrollment and increase service provision for substance abusers.

Prendergast M; Podus D; Finney J; Greenwell L; Roll J. Contingency management for treatment of substance use disorders: a meta-analysis. (review). Addiction 101(11): 1546-1560, 2006. (109 refs.)

Aims: To examine the effectiveness of contingency management (CM) techniques in treating substance use disorders (i.e. illicit drugs, alcohol, tobacco). Design: Meta-analysis was used to determine the average effect size and potential moderators in 47 comparisons of the effectiveness of CM from studies based on a treatment-control group design and published between 1970 and 2002. Findings: The mean effect size (ES) of CM was positive, with a magnitude of d = 0.42 using a fixed effects model. The magnitude of the ES declined over time, following treatment. CM was more effective in treating opiate use (d = 0.65) and cocaine use (d = 0.66), compared with tobacco (d = 0.31) or multiple drugs (d = 0.42). Larger effect sizes were associated with higher researcher involvement, earlier studies and shorter treatment duration. Conclusion: Study findings suggest that CM is among the more effective approaches to promoting abstinence during the treatment of substance use disorders. CM improves the ability of clients to remain abstinent, thereby allowing them to take fuller advantage of other clinical treatment components.

Prendergast ML; Podus D; Chang E; Urada D. The effectiveness of drug abuse treatment: A meta-analysis of comparison group studies (vol 67, pg 53, 2002) (correction). Drug and Alcohol Dependence 84(1): 133-133, 2006. (1 refs.)

Rawson RA; McCann MJ; Flammino F; Shoptaw S; Miotto K; Reiber C et al. A comparison of contingency management and cognitive-behavioral approaches for stimulant-dependent individuals. Addiction 101(2): 267-274, 2006. (34 refs.)

Aims: Previous research has reported that both contingency management (CM) and cognitive-behavioral therapy (CBT) are efficacious interventions for the treatment of stimulant abusers. The present study sought to directly compare the effectiveness of (CM) and (CBT) alone and in combination in reducing stimulant use. Design: Randomized clinical trial. Participants Stimulant-dependent individuals (n = 171). Intervention CM, CBT or combined CM and CBT, 16-week treatment conditions. CM condition participants received vouchers for stimulant-free urine samples. CBT condition participants attended three 90-minute group sessions each week. Measurements: Participants were interviewed at baseline and weeks 17, 26 and 52. Measures included psychiatric disorders and alcohol and drug use and concomitant social problems. Findings CM procedures produced better retention and lower rates of stimulant use during the study period. Self-reported stimulant use was reduced from baseline levels at all follow-up points for all groups and urinalysis data did not differ between groups at follow-up. While CM produced robust evidence of efficacy during treatment application, CBT produced comparable longer-term outcomes. There was no evidence of an additive effect when the two treatments were combined. Conclusions: This study suggests that CM is an efficacious treatment for reducing stimulant use and is superior during treatment to a CBT approach. CM is useful in engaging substance abusers, retaining them in treatment and helping them achieve abstinence from stimulant use. CBT also reduces drug use from baseline levels and produces comparable outcomes on all measures at follow-up.

Rhodes GL; Saules KK; Helmus TC; Roll J; BeShears RS; Ledgerwood DM et al. Improving on-time counseling attendance in a methadone treatment program: A contingency management approach. American Journal of Drug and Alcohol Abuse 29(4): 759-773, 2003. (27 refs.)

Two studies were conducted to investigate the effectiveness of contingency management techniques in promoting punctual counseling attendance among methadone maintenance patients. In Study 1, 50 participants were recruited from an inner-city methadone maintenance program. Study I used an A-B-A design with baseline, intervention, and return-to-baseline phases. On-time attendance was reinforced during the intervention phase with a voucher that was redeemable for a draw out of a box containing 100 tokens with values varying from $0.00 to $100.00. Methadone maintenance patients who exhibited poor attendance during baseline showed a significant positive response during the contingency management intervention phase. Study 2 used the same design as Study I except that the 52 participants were randomized into reinforcement groups that received either the variable rate of reinforcement as in Study I or a fixed value reinforcer of $3.25. As in Study 1, Poor Attenders significantly improved counseling attendance during the intervention. There were no differences between the variable and fixed reinforcement groups. Overall, results suggest that targeting Poor Attenders with contingency management techniques may be a cost-effective method of improving counseling attendance. Targeting Poor Attenders early in treatment may be especially important for improving treatment outcomes.

Ries RK; Dyck DG; Short R; Srebnik D; Fisher A; Comtois KA. Outcomes of managing disability benefits among patients with substance dependence and severe mental illness. Psychiatric Services 55(4): 445-447, 2004. (10 refs.)

To evaluate the feasibility, and efficacy of a program to manage Social Security disability benefits in a clinical sample of patients with severe mental illness and co-occurring substance dependence, 41 patients were randomly assigned to have their benefits either contingently or noncontingently managed through their mental health center. Contingent management involved adjustments to the type or frequency (not amount) of disability benefits and payments for study participation based on ratings of substance use, money management, And treatment follow-through. The patients with contingent management used significantly less alcohol and drugs and showed much better money management than those with noncontingent management. Patients and case managers who participated in the study reported that they found the management strategy to be acceptable and useful.

Robles E; Crone CC; Whiteside-Mansell L; Conners NA; Bokony PA; Worley LLM et al. Voucher-based incentives for cigarette smoking reduction in a women's residential treatment program. Nicotine & Tobacco Research 7(1): 111-117, 2005. (38 refs.)

Participants were women (N=16) living with their children in a residential substance abuse treatment facility. In this within-subjects repeated measures study, a 1-week baseline was followed by a 4-week intervention and a 2-week follow-up (same as the baseline). The intervention consisted of exposure to an educational video and a smoking cessation workbook, brief individual support meetings, and an escalating schedule of voucher-based reinforcement of abstinence. Throughout the study, three daily breath samples (8 A.M., noon, and 4 P.M.) were collected Monday through Friday to determine carbon monoxide (CO) concentration. In addition, urine cotinine (COT) was assessed on Monday mornings to monitor weekend tobacco use. Participants received vouchers of escalating value for CO-negative breath and COT-negative urine samples. Positive samples reset the voucher value. Significantly more negative tests were submitted during the intervention than during baseline and follow-up. The intensive behavioral intervention evaluated in this study produced a substantial reduction in cigarette smoking, and 25% of participants remained abstinent 2 weeks after the intervention was suspended. Nevertheless, the percentage of CO-negative samples submitted during the follow-up returned to baseline levels. While retaining many real-world characteristics, residential treatment facilities provide important opportunities for smoking cessation treatment and research.

Roffman RA; Stephens RS, eds. Cannabis Dependence: Its Nature, Consequences and Treatment. London: Cambridge University Press, 2006. (Chapter refs.)

Cannabis is the most widely used illicit drug in the U.S. In respect to public policy, there are a number of questions that have been raised, from review of its legal status, with some proposing legalization or de-criminalization of small quantities, to making provision for medical use for those with chronic illness. There has also been increasing research on cannabis, its relationship to the emergence of schizophrenia, to clarification of the existence and nature of withdrawal phenomenon with abstinence after long-term heavy use. This edited volume, with 15 chapters and 26 contributors, is intended as a comprehensive review of cannabis use, the associated problems, and related policy questions. It is organized into five parts. The first part deals with cannabis dependence: the pharmacological basis, epidemiology, diagnosis, and associated medical and psychological morbidity. Part II considers interventions with cannabis dependent adults. Five different approaches are reviewed: cognitive-behavioral and motivational enhancement therapies, contingency-management, the marijuana check-up, guided self-change (a brief motivational technique), and supportive-expressive psychotherapy. Part III addresses interventions with cannabis-dependent adolescents and young adults. One chapter reviews the findings and treatment models from the 'Cannabis Youth Treatment Study', another describes the teen cannabis check-up and strategies for reaching young marijuana users, and another deals with probation-referred cannabis-abusing young adults. Part IV is directed to the policy implications of cannabis dependence; and Part V deals with the implications for research and policy.

Roll JM. Assessing the feasibility of using contingency management to modify cigarette smoking by adolescents. Journal of Applied Behavior Analysis 38(4): 463-467, 2005. (21 refs.)

Cigarette smoking is a leading cause of preventable death in the United States. Many smokers initiate this dangerous behavior during adolescence. This report describes a contingency management intervention designed to initate and maintain a period of abstinence from cigarettes by adolescent smokers. Results suggest that the intervention was generally successful and that further investigation of this topic is warranted.

Roll JM; Chermack ST; Chudzynski JE. Investigating the use of contingency management in the treatment of cocaine abuse among individuals with schizophrenia: A feasibility study. Psychiatry Research 125(1): 61-64, 2004. (13 refs.)

This small-scale study was conducted to examine the feasibility of using voucher-based reinforcement therapy (VBRT) as a treatment modality for cocaine abuse among individuals with schizophrenia. Cocaine use was reduced in three individuals with a diagnosis of schizophrenia during a VBRT intervention. Interestingly, all of the abstinence occurred during the first half of the intervention. This early period of sobriety may represent a clinically relevant window of opportunity during which intensive psychosocial or social work interventions might have a greater chance for success.

Roll JM; Chudzynski JE; Richardson G. Potential sources of reinforcement and punishment in a drug-free treatment clinic: Client and staff perceptions. American Journal of Drug and Alcohol Abuse 31(1): 21-33, 2005. (42 refs.)

Contingency management interventions are quite successful at initiating abstinence from drugs of abuse. However, these approaches to drug abuse treatment are often criticized because of their perceived cost. One way to reduce the cost of contingency management interventions would be to use nonmonetary sources of reinforcement or punishment. A number of reports have discussed the availability of potential sources of reinforcement in opiate replacement clinics. This report describes the availability of potential sources of reinforcement and punishment available in drug-free treatment programs. Both clients and clinic staff rated a number of items in terms of their potential reinforcing and punishing efficacy. Results suggest that there are several sources of reinforcement and punishment available in drug-free clinics, which could be used in contingency management programs. The results also suggest that the clinic staff perceives potential sources of punishment as more aversive than do the clients.

Roll JM; Huber A; Sodano R; Chudzynski JE; Moynier E; Shoptaw S. A comparison of five reinforcement schedules for use in contingency management-based treatment of methamphetamine abuse. Psychological Record 56(1): 67-81, 2006. (45 refs.)

One variation of contingency management involves providing vouchers with monetary value for the provision of a biological sample indicating no recent drug use. These vouchers can be exchanged for goods or services. The schedule with which the vouchers are disbursed has been studied and results suggest that those schedules that incorporate escalating magnitude of reinforcement for consecutive instances of abstinence and a reset contingency, which reduces the value of the vouchers for instances of use, seem to provide the best treatment outcome. In this paper we explore several other scheduling arrangements while using the escalating schedule with a reset contingency as the comparator. The comparator schedule generally outperformed the other schedules in initiating and in maintaining abstinence from methamphetamine.

Roll JM; Petry NM; Stitzer ML; Brecht ML; Peirce JM; McCann MJ et al. Contingency management for the treatment of methamphetamine use disorders. American Journal of Psychiatry 163(11): 1993-1999, 2006. (42 refs.)

Objective: Theory and some preliminary evidence suggest that contingency management may be an effective treatment strategy or adjunct to psychosocial treatment for methamphetamine use disorders. An experimentally rigorous investigation on the topic was provided by a large multisite trial conducted under the auspices of the Clinical Trials Network of the National Institute on Drug Abuse. Method: The authors report data on 113 participants who were diagnosed with methamphetamine abuse or dependence. They were randomly assigned to receive 12 weeks of either treatment as usual or treatment as usual plus contingency management. Urine samples were tested for illicit drugs, and breath samples were tested for alcohol. The reinforcers for drug-negative samples were plastic chips, some of which could be exchanged for prizes. The number of plastic chips drawn increased with each week of negative samples but was reset to one after a missed or positive sample. Results: The participants in both groups remained in treatment for equivalent times, but those receiving contingency management in addition to usual treatment submitted significantly more negative samples, and they were abstinent for a longer period of time (5 versus 3 weeks). Conclusions: These results suggest that contingency management has promise as a component in treatment strategies for methamphetamine use disorder.

2006, American Psychiatric Association

Roll JM; Prendergast ML; Sorensen K; Prakash S; Chudzynski JE. A comparison of voucher exchanges between criminal justice involved and noninvolved participants enrolled in voucher-based contingency management drug abuse treatment programs. American Journal of Drug and Alcohol Abuse 31(3): 393-401, 2005. (38 refs.)

This report compares requests for goods or services made by participants in two clinical trials of contingency management for the treatment of substance abuse. One trial was for participants involved with the criminal justice system and one was for participants who were not involved with the criminal justice system. In both trials, participants earned vouchers that could be exchanged for goods or services. Results indicated that the criminal justice group used the majority of their vouchers for paying fees or fines related to the criminal justice system while the other group used only a small portion of their vouchers for paying costs related to the criminal justice system. However, when the costs for the criminal justice system are removed, the proportion of vouchers exchanged for various goods and services are similar between the two groups. The results suggest that for those substance abusers involved in the criminal justice system, assistance in paying fines and fees related to their criminal justice system involvement may be a potentially powerful source of reinforcement that could be used in creative treatment strategies.

Roll JM; Shoptaw S. Contingency management: Schedule effects. Psychiatry Research 144(1): 91-93, 2006. (9 refs.)

Contingency management interventions provide reinforcement for abstaining from drugs and withhold reinforcement when drug use is detected. Previous work demonstrates that the reinforcement schedule with which reinforcement is delivered modulates the efficacy of the intervention. This pilot study explores the effects of reinforcement in methamphetamine-dependent individuals. Results suggest that schedules incorporating an increasing magnitude of reinforcement for consecutive abstinences with a reset in reinforcer magnitude for a positive drug test produce superior results.

Rosado J; Sigmon SC; Jones HE; Stitzer ML. Cash value of voucher reinforcers in pregnant drug-dependent women. Experimental and Clinical Psychopharmacology 13(1): 41-47, 2005. (21 refs.)

This study examined the relative reinforcing potency of vouchers and cash in drug-dependent pregnant women (N = 48) across voucher values ($10, $50, and $ 100) by use of a series of choices to understand how exchange-delay features of voucher reinforcers influence their reinforcing potency compared with cash. The study also examined a no delay vs. 2-day delay of the cash alternative. Generally, cash was selected at 80%-90% of voucher face values. Vouchers were also discounted less when a 2-day delay was imposed on the cash option compared to the immediately available cash. These results suggest that voucher discounting does occur among patients in drug treatment. However, vouchers retain 80%-90% of their cash value and thus remain relatively potent reinforcers.

Rosen MI; Bailey M; Rosenheck RR. Principles of money management as a therapy for addiction. (editorial). Psychiatric Services 54(2): 171-173, 2003. (8 refs.)

Money is a well-recognized cue for drug use. There is evidence of an increase in substance abuse and in its adverse effects around the beginning of the month, when income checks are typically received. The authors propose a conceptualization of money management as a specific therapy that targets drug addiction and involves 3 functions. The 1st is an administrative, or "teller," function, whereby mismanagement of funds is curtailed by controlling access to the client's bank account. The 2nd function involves training the client to make a budget and plan expenditures. The 3rd function incorporates behavioral principles by using discretionary spending to reinforce constructive activities and sobriety. These 3 money management functions involve fundamentally rehabilitative rather than restrictive activities. There is a need to determine the efficacy of money management as a therapy. On the basis of the principles outlined, the authors have developed an intervention that they refer to as ATM (advisor-teller-mone y manager) that has been successfully implemented and is currently being tested in a clinical trial.

Rotgers F; Morgenstern; Walters ST. Treating Substance Abuse: Theory and Techniques. 2nd edition. New York: The Guilford Press, 2003

This book focuses on the most widely used treatment theories and also addresses the application. Each of the theoretical perspectives on treatment has paired chapters: the first focuses on theory, and the second translates the theory into practice. The focus is upon evidence-based treatments, including cognitive-behavioral theories of substance abuse, behavioral-economic principles, and the use of contingency management techniques.

Rowan-Szal GA; Bartholomew NG; Chatham LR; Simpson DD. A combined cognitive behavioral intervention for cocaine-using methadone clients. Journal of Psychoactive Drugs 37(1): 75-84, 2005. (54 refs.)

Treating cocaine use by opiate-dependent clients in methadone programs is a well documented challenge. Both behavioral (contingency management) and cognitive (relapse prevention) interventions have shown promise in helping engage these clients in treatment. In this study, the effectiveness of combining contingency management with a cocaine-specific relapse prevention counseling module was examined. Sixty-one cocaine-using methadone clients were randomly assigned to one of four treatment conditions to participate in the eight-week intervention and eight-week follow-up period. Using analysis of variance (ANOVA), differences in cocaine use and treatment retention were examined. Contingency management was significantly related to reductions in cocaine use and the counseling module was positively related to six-month retention rates. Both interventions were associated with positive treatment response but the effects were reflected in different behavioral outcomes.

Schroeder JR; Gupman AE; Epstein DH; Umbricht A; Preston KL. Do noncontingent vouchers increase drug use? Experimental and Clinical Psychopharmacology 11(3): 195-201, 2003. (26 refs.)

Data from 2 contingency management trials, targeting opiate or cocaine use, were used to investigate whether noncontingent vouchers inadvertently reinforce drug use. The control group in each trial received noncontingent vouchers matched in value and frequency to those received by experimental groups, but independent of urinalysis. Vouchers were offered thrice weekly for 8 weeks (opiates) or 12 weeks (cocaine). Both dose-response and temporal associations of noncontingent voucher receipt with drug-positive urines were assessed. Drug use was unrelated to frequency of noncontingent voucher delivery and noncontingent voucher receipt when being drug positive was unassociated with risk of subsequent drug use, with one exception: cocaine use in the cocaine study (relative risk = 1.05, 95% confidence interval: 1.01-1.09). Overall, results do not indicate a causal relationship between noncontingent voucher receipt and increased drug use.

Seal KH; Kral AH; Lorvick J; McNees A; Gee L; Edlin BR. A randomized controlled trial of monetary incentives vs. outreach to enhance adherence to the hepatitis B vaccine series among injection drug users. Drug and Alcohol Dependence 71(2): 127-131, 2003. (25 refs.)

Background: Injection drug users (IDUs) are at high-risk for hepatitis B virus (HBV) and HIV. Due to concerns about non-adherence to multi-dose vaccine regimens however, IDUs are severely under-immunized against HBV and have been excluded from phase III trials of multi-dose candidate HIV vaccines in the United States. Methods: Through a randomized controlled trial, we compared the effectiveness of monetary incentives versus outreach to improve IDUs' adherence to the 3-dose hepatitis B vaccine. In 1998-1999, HBV-susceptible IDUs were recruited from San Francisco streets. Eligible participants received their first dose of vaccine and were randomized to either receive monthly monetary incentives (n=48) or maintain weekly contact with an outreach worker (n=48) during the 6-month vaccine series. Results: All 3 doses of vaccine were received by 33 (69%) of IDUs in the monetary incentive arm and 11 (23%) in the outreach arm (odds RATIO=13.8; 95% confidence interval, 2.9, 128; P<0.0001). In a multivariate model, receiving monetary incentives was independently associated with vaccine completion (AOR=10.3; 95% CI=3.7, 29.0). Conclusions: Among IDUs, monetary incentives are superior to outreach in achieving adherence to the multi-dose hepatitis B vaccine series. Monetary incentives may be adapted to future multi-dose candidate HIV vaccine trials in IDUs.

Shoptaw S; Huber A; Peck J; Yang XW; Liu JM; Dang J et al. Randomized, placebo-controlled trial of sertraline and contingency management for the treatment of methamphetamine dependence. Drug and Alcohol Dependence 85(1): 12-18, 2006. (29 refs.)

Background: Methamphetamine dependence and associated medical and psychiatric concerns are significant public health issues. This project evaluated the efficacy of sertraline (50 mg bid) and contingency management (CM) for the treatment of methamphetamine dependence. Method: In this randomized, placebo-controlled, double-blind trial, participants completed a 2-week non-medication baseline and were randomized to one of four conditions for 12 weeks: sertraline plus CM (n = 6 1), sertraline-only (n = 59), matching placebo plus CM (n = 54), or matching placebo-only (n = 55). All participants attended clinic thrice-weekly for data collection, medication dispensing, and relapse prevention groups. Outcomes included methamphetamine use (urine drug screening and self-reported days of use), retention (length of stay), drug craving (visual analogue scale), and mood symptoms (Beck Depression Inventory). Results: No statistically significant main or interaction effects for sertraline or CM in reducing methamphetamine use were observed using a generalized estimating equation (GEE), although post hoc analyses showed the sertraline-only condition had significantly poorer retention than other conditions (chi(2) (3) = 8.40, p < 0.05). Sertraline conditions produced significantly more adverse events than placebo conditions. A significantly higher proportion of participants in CM conditions achieved three consecutive weeks of methamphetamine abstinence than those in non-CM conditions. Conclusions: These data do not demonstrate improved outcomes for sertraline versus placebo for treatment of methamphetamine dependence; indeed, they suggest sertraline is contraindicated for methamphetamine dependence. Findings provide support for the use of contingency management for treatment of methamphetamine dependence.

Shoptaw S; Klausner JD; Reback CJ; Tierney S; Stansell J; Hare CB et al. A public health response to the methamphetamine epidemic: The implementation of contingency management to treat methamphetamine dependence. BMC Public Health 6(article 214), 2006. (11 refs.)

Background: In response to increases in methamphatemine-associated sexually transmitted diseases, the San Francisco Department of Public Health implemented a contingency management (CM) field program called the Positive Reinforcement Opportunity Project (PROP). Methods: Methamphetamine-using men who have sex with men (MSM) in San Francisco qualified for PROP following expressed interest in the program, provision of an observed urine sample that tested positive for methamphetamine metabolites and self-report of recent methamphetamine use. For 12 weeks, PROP participants provided observed urine samples on Mondays, Wednesdays and Fridays and received vouchers of increasing value for each consecutive sample that tested negative to metabolites of methamphetamine. Vouchers were exchanged for goods and services that promoted a healthy lifestyle. No cash was provided. Primary outcomes included acceptability (number of enrollments/time), impact (clinical response to treatment and cost-effectiveness as cost per patient treated). Results: Enrollment in PROP was brisk indicating its acceptability. During the first 10 months of operation, 143 men sought treatment and of these 77.6% were HIV-infected. Of those screened, 111 began CM treatment and averaged 15 (42%) methamphetamine-free urine samples out of a possible 36 samples during the 12-week treatment period; 60% completed 4 weeks of treatment; 48% 8 weeks and 30% 12 weeks. Across all participants, an average of $159 (SD = $165) in vouchers or 35.1% of the maximum possible ($453) was provided for these participants. The average cost per participant of the 143 treated was $800. Conclusion: Clinical responses to CM in PROP were similar to CM delivered in drug treatment programs, supporting the adaptability and effectiveness of CM to non-traditional drug treatment settings. Costs were reasonable and less than or comparable to other methamphetamine outpatient treatment programs. Further expansion of programs like PROP could address the increasing need for acceptable, feasible and cost-effective methamphetamine treatment in this group with exceptionally high rates of HIV-infection.

Sigmon SC; Correia CJ; Stitzer ML. Cocaine abstinence during methadone maintenance: Effects of repeated brief exposure to voucher-based reinforcement. Experimental and Clinical Psychopharmacology 12(4): 269-275, 2004. (19 refs.)

This study determined whether abstinence engendered by intermittent reinforcement might generalize to nonreinforced periods and enhance overall rates of cocaine abstinence among methadone maintenance patients. Participants were randomized to 1 of 3 groups. The quantitative group (n = 14) earned incentives for a 50% decrease in urine benzoylecgonine concentrations; the qualitative group (n = 13) earned incentives for providing urines with concentrations <300 ng/ml. Both reinforced groups received 12 random opportunities to earn $100 in vouchers for abstinence. The control group (n = 15) was encouraged to abstain on 12 occasions under the same schedule. Incentive participants achieved significantly more cocaine abstinence on earning than on nonearning days, with no difference between quantitative and qualitative groups. The study supports brief abstinence test efficacy but did not find that unpredictable opportunities to earn incentives generalized to nonreinforced days.

Sigmon SC; Higgins ST. Voucher-based contingent reinforcement of marijuana abstinence among individuals with serious mental illness. Journal of Substance Abuse Treatment 30(4): 291-295, 2006. (13 refs.)

Previous studies by our group have used money given contingent on abstinence to reduce drug use by individuals with schizophrenia. In this study, we examined the sensitivity of marijuana use by individuals with serious mental illness to voucher-based contingent reinforcement. which represents the first study to date investigating the efficacy of voucher incentives with this population. This within subject reversal design consisted of three conditions: 4-week baseline, 12-week voucher intervention, and 4-week baseline. During baseline periods. subjects received US$10 vouchers per urine specimen, independent Of urinalysis results. During voucher intervention, only specimens testing negative for marijuana earned vouchers, with total possible earnings of US$930. Seven adults with schizophrenia or other serious mental illnesses participated in the study. The percentage of marijuana-negative specimens was significantly greater during voucher intervention than during baseline periods. These results provide evidence that marijuana use among individuals with serious mental illness is sensitive to voucher-based incentives and further support the potential feasibility of using voucher-based contingency management to reduce substance abuse in this challenging population.

Sigmon SC; Stitzer ML . Use of a low-cost incentive intervention to improve counseling attendance among methadone-maintained patients. Journal of Substance Abuse Treatment 29(4): 253-258, 2005. (14 refs.)

Despite the importance of counseling in methadone maintenance treatment, many patients do not take advantage of these services. Incentives for attending group counseling were offered to methadone-maintained patients during an orientation phase of treatment or during required attendance at a relapse group later in treatment. Upon attending each counseling session, patients could draw for prizes under an escalating draw system with a 50% probability that draws would result in a prize. Incentives included small ($1), moderate ($5), and large ($20) prizes, with chances of winning inversely related to prize costs, and a maximum possible total of $160 per patient. It was anticipated that this policy would provide a relatively low-cost approach to improving counseling attendance in our methadone clinic. The incentive policy significantly increased the percent of counseling sessions attended (52% vs. 76%) and promoted periods of continuous attendance. These data further support the effectiveness of low-cost incentive programs in enhancing counseling attendance among methadone patients.

Silverman K. Exploring the limits and utility of operant conditioning in the treatment of drug addiction. Behavior Analyst 27(2): 209-230, 2004. (68 refs.)

This article describes a research program to develop an operant treatment for cocaine addiction in low-income, treatment-resistant. methadone patients. The treatment's central feature is an abstinence reinforcement contingency in which patients earn monetary reinforcement for providing cocaine-free urine samples. Success and failure of this contingency appear to be an orderly function of familiar parameters of operant conditioning. Increasing reinforcement magnitude and duration can increase effectiveness, and sustaining the contingency can prevent relapse. Initial development of a potentially practical application of this technology suggests that it may be possible to integrate abstinence reinforcement into employment settings using salary for work to reinforce drug abstinence. This research illustrates the potential utility and current limitations of an operant approach to the treatment of drug addiction. Similar research programs are needed to explore the limits of the operant approach and to develop practical applications that can be used widely in society for the treatment of drug addiction.

Silverman K; Robles E; Mudric T; Bigelow GE; Stitzer ML. A randomized trial of long-term reinforcement of cocaine abstinence in methadone-maintained patients who inject drugs. Journal of Consulting and Clinical Psychology 72(5): 839 -854, 2004. (42 refs.)

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.

Sorensen JL; Masson CL; Delucchi K; Sporer K; Barnett PG; Mitsuishi F et al. Randomized trial of drug abuse treatment-linkage strategies. Journal of Consulting and Clinical Psychology 73(6): 1026-1035, 2005. (39 refs.)

A clinical trial contrasted 2 interventions designed to link opioid-dependent hospital patients to drug abuse treatment. The 126 out-of-treatment participants were randomly assigned to (a) case management, (b) voucher for free methadone maintenance treatment (MMT), (c) case management plus voucher, or (d) usual care. Services were provided for 6 months. MMT enrollment at 3 months was 47% (case management), 89% (voucher), 93% (case management plus voucher), and 11% (usual care); at 6 months enrollment was 48%, 68%, 79%, and 21%, respectively. Case management and vouchers can be valuable in health settings to link substance abusers with medical problems to drug abuse treatment.

Stitzer M. Contingency management and the addictions. (editorial). Addiction 101(11): 1536-1537, 2006. (5 refs.)

Strona FV; McCright J; Hjord H; Ahrens K; Tierney S; Shoptaw S et al. The acceptability and feasibility of the Positive Reinforcement Opportunity Project, a community-based contingency management methamphetamine treatment program for gay and bisexual men in San Francisco. Journal of Psychoactive Drugs Supplement 3: 377-383, 2006. (12 refs.)

The Positive Reinforcement Opportunity Project (PROP) was a pilot program developed to build on the efficacy of contingency management (CM) using positive reinforcement to address the treatment needs of gay and bisexual men currently using crystal methamphetamines (meth). It was hypothesized that a version of CM could be implemented in San Francisco that was less costly than traditional treatment methods and reached gay and other MSM using meth who also engaged in high-risk sexual activity. Of the 178 men who participated in PROP from December 2003 to December 2005, many self-reported behaviors for acquiring and spreading sexually transmitted diseases including HIV infection. During the initial intake, 73% reported high-risk sexual behavior in the prior three months, with 60% reporting anal receptive and/or insertive sex without condoms. This report describes the implementation of PROP and suggest both its limitations and potential strengths. Initial findings suggest that PROP was a useful and low cost substance use treatment option that resulted in a 35% 90-day completion rate, which is similar to graduation rates from traditional, more costly treatment options. Further evaluation of the limited data from three- and six-month follow-up of those who completed PROP is currently ongoing.

2006, Haight-Ashbury Publications

Volpp KG; Levy AG; Asch DA; Berlin JA; Murphy JJ; Gomez A et al. A randomized controlled trial of financial incentives for smoking cessation. Cancer Epidemiology, Biomarkers & Prevention 15(1): 12-18, 2006. (40 refs.)

Background: Although 435,000 Americans die each year of tobacco-related illness, only similar to 3% of smokers quit each year. Financial incentives have been shown to be effective in modifying behavior within highly structured settings, such as drug treatment programs, but this has not been shown in treating chronic disease in less structured settings. The objective of this study was to determine whether modest financial incentives increase the rate of smoking cessation program enrollment, completion, and quit rates in a outpatient clinical setting. Methods: 179 smokers at the Philadelphia Veterans Affairs Medical Center who reported smoking at least 10 cigarettes per day were randomized into incentive and nonincentive groups. Both groups were offered a free five-class smoking cessation program at the Philadelphia Veterans Affairs Medical Center. The incentive group was also offered $20 for each class attended and $100 if they quit smoking 30 days post program completion. Self-reported smoking cessation was confirmed with urine cotinine tests. Results: The incentive group had higher rates of program enrollment (43.3% versus 20.2%; P < 0.001) and completion (25.8% versus 12.2%; P = 0.02). Quit rates at 75 days were 16.3% in the incentive group versus 4.6% in the control group (P = 0.01). At 6 months, quit rates in the incentive group were not significantly higher (6.5%) than in the control group (4.6%; P > 0.20). Conclusion: Modest financial incentives are associated with significantly higher rates of smoking cessation program enrollment and completion and short-term quit rates. Future studies should consider including an incentive for longer-term cessation.

Wong CJ; Dillon EM; Sylvest C; Silverman K. Evaluation of a modified contingency management intervention for consistent attendance in therapeutic workplace participants. [rapid communication]. Drug and Alcohol Dependence 74(3): 319-323, 2004. (10 refs.)

In a therapeutic workplace business, drug abuse patients are hired as data entry operators and paid to perform data entry work contingent upon documented drug abstinence. Reliable attendance has been difficult to maintain despite the opportunity for operators to earn a living wage, 6 h per day, 5 days per week. A within-subject reversal design experiment evaluated a contingency management intervention that allowed for flexibility regarding when operators could arrive to work, yet maintained a contingency for reliable workplace attendance. Results from a within-subject reversal design experiment demonstrated the contingency management intervention to be effective in increasing the frequency of completed work shifts in four of five operators. Repeated measures ANOVA and Tukey's post-hoc tests of grouped data showed that the contingency management intervention significantly (P<0.05) increased the mean percent of days that operators completed work shifts (5% baseline; 63% contingency management; 7% baseline). This study demonstrates an effective procedure for maintaining attendance in therapeutic workplace participants.