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CORK Bibliography: Behavioral Contingencies and Contingency Management

74 citations. January 2007 to present

Prepared: March 2009

Alessi SM; Hanson T; Wieners M; Petry NM. Low-cost contingency management in community clinics: Delivering incentives partially in group therapy. Experimental and Clinical Psychopharmacology 15(3): 293-300, 2007. (26 refs.)

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

Alessi SM; Petry NM; Urso J. Contingency management promotes smoking reductions in residential substance abuse patients. Journal of Applied Behavior Analysis 41(4): 617-622, 2008. (21 refs.)

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

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

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

Bride BE; Humble MN. Increasing retention of African-American women on welfare in outpatient substance user treatment using low-magnitude incentives. Substance Use & Misuse 43(8/9): 1016-1026, 2008. (35 refs.)

Contingency management (CM) has been found to be effective in increasing treatment retention in various outpatient substance user treatment populations; however, the costs of established CM protocols often exceed the financial resources of community-based, nonprofit treatment programs. The results of the present study provide initial evidence that a low-magnitude contingency management protocol can be effective in increasing both treatment attendance and completion rates in a sample of 54 urban, African-American, substance-using women on welfare, without creating undue financial or logistical burden on the treatment agency. The study's limitations and future research are noted.

Brooner RK; Kidorf MS; King VL; Stoller KB; Neufeld KJ; Kolodner K. Comparing adaptive stepped care and monetary-based voucher interventions for opioid dependence. Drug and Alcohol Dependence 88(Supplement 2): S14-S23, 2007. (49 refs.)

This 6-month randomized clinical trial (with 3-month follow-up) used a 2 x 2 design to compare the independent and combined effectiveness of two interventions designed to improve outcomes in treatment-seeking opioid-dependent patients (n=236): motivated stepped care (MSC) and contingent voucher incentives (CVI). MSC is an adaptive treatment strategy that uses principles of negative, reinforcement and avoidance to motivate both attendance to varying levels of counseling services and brief periods of abstinence [Brooner, R.K., Kidorf, M., 2002. Using behavioral reinforcement to improve methadone treatment participation. Sciences. Pract. Perspect. 1, 38-46; Brooner, R.K., Kidorf, M.S., King, V.L., Peirce, J.M., Bigelow, G.E., Kolodner, K., 2004. A modified "stepped care" approach to improve attendance behavior in treatment seeking opioid abusers. J. Substance. Abuse Treat. 27, 223-232]. In contrast, CVI [Higgins, S., Delaney, D.D., Budney, A.J., Bickel, W.K., Hughes, J.R., Foerg, B.A., Fenwick, J.W., 1991. A behavioral approach to achieving initial cocaine abstinence. Am. Psychiatr. 148, 1218-1224] relies on positive reinforcement to motivate drug abstinence. The results showed that the combined approach (MSC + CVI) was associated with the highest proportion of drug-negative urine samples during both the randomized and 3-month follow-up arms of the evaluation. The CVI-only and the MSC-only conditions evidenced similar proportions of drug-negative urine samples that were both significantly greater than the standard care (SC) comparison group. Voucher-based reinforcement was associated with better retention, while adaptive stepped-based care was associated with better adherence to scheduled counseling sessions. These results suggest that both CVI and MSC are more effective than routine care for reducing drug use in opioid dependent outpatients, and that the overall benefits of MSC are enhanced further by adding positive reinforcement.

Cahill K; Perera R. Competitions and incentives for smoking cessation. (review). Cochrane Database of Systematic Reviews (review) 3(article CD004307), 2008. (96 refs.)

Background: Material or financial incentives may be used in an attempt to reinforce behaviour change, including smoking cessation. They have been widely used in workplace smoking cessation programmes, and to a lesser extent within community programmes. Quit and Win contests are the subject of a companion review. Objectives: To determine whether competitions and incentives lead to higher long-term quit rates. We also set out to examine the relationship between incentives and participation rates. Search strategy: We searched the Cochrane Tobacco Addiction Group Specialized Register, with additional searches of MEDLINE, EMBASE, CINAHL and PsycINFO. Search terms included incentive*, competition*, contest*, reward*, prize*, contingent payment*, deposit contract*. The most recent searches were in December 2007. Selection criteria We considered randomized controlled trials, allocating individuals, workplaces, groups within workplaces, or communities to experimental or control conditions. We also considered controlled studies with baseline and post-intervention measures. Data collection and analysis Data were extracted by one author and checked by the second. We contacted study authors for additional data where necessary. The main outcome measure was abstinence from smoking at least six months from the start of the intervention. We used the most rigorous definition of abstinence in each trial, and biochemically validated rates where available. Where possible we performed meta-analysis using a generic inverse variance model, grouped by timed endpoints, but not pooled across the subgroups. Main results: Seventeen studies met our inclusion criteria. None of the studies demonstrated significantly higher quit rates for the incentives group than for the control group beyond the six-month assessment. There was no clear evidence that participants who committed their own money to the programme did better than those who did not, or that different types of incentives were more or less effective. There is some evidence that although cessation rates have not been shown to differ significantly, recruitment rates can be improved by rewarding participation, which may be expected to deliver higher absolute numbers of successful quitters. Cost effectiveness analysis is not appropriate to this review, since the efficacy of the intervention has not been demonstrated.

Cameron J; Ritter A. Contingency management: Perspectives of Australian service providers. Drug and Alcohol Review 26(2): 183-189, 2007. (43 refs.)

Given the very positive and extensive research evidence demonstrating efficacy and effectiveness of contingency management, it is important that Australia explore whether contingency management has a role to play in our own treatment context. Qualitative interviews were conducted with 30 experienced alcohol and drug practitioners, service managers and policymakers in Victoria. Interviewees were selected to represent the range of drug treatment services types and included rural representation. A semi- structured interview schedule, covering their perceptions and practices of contingency management was used. All interviews were transcribed verbatim and analysed using N2 qualitative data analysis program. The majority of key informants were positively inclined toward contingency management, notwithstanding some concerns about the philosophical underpinnings. Concerns were raised in relation to the use of monetary rewards. Examples of the use of contingency management provided by key informants demonstrated an over- inclusive definition: all the examples did not adhere to the key principles of contingency management. This may create problems if a structured contingency management were to be introduced in Australia. Contingency management is an important adjunctive treatment intervention and its use in Australia has the potential to enhance treatment outcomes. No unmanageable barriers were identified in this study.

Carroll KM; Rounsaville BJ. A perfect platform: Combining contingency management with medications for drug abuse. (review). American Journal of Drug and Alcohol Abuse 33(3): 343-365, 2007. (113 refs.)

Contingency management (CM) procedures, which provide concrete reinforcers or rewards contingent on verification of discrete targeted behaviors, such as drug-free urines, have been demonstrated to be effective in a number of clinical trials. However, to date there have been only a few that have capitalized on the unique strengths and capabilities of CM as an ideal platform to improve response to or address weaknesses of many pharmacotherapies used in the treatment of drug abuse. In this review, we describe the multiple potential uses of CM as a platform for pharmacotherapy, including reducing illicit drug use in the context of agonist therapies; fostering medication compliance with antagonists, aversive agents and HIV medications; fostering a period of abstinence prior to initiation of agents used to treat comorbid psychiatric conditions or in the context of vaccines to foster adequate periods of abstinence while titer levels are building; and to enhance the effectiveness of anticraving agents through additive or synergistic effects. Although its multiple strengths render it an almost perfect platform, CM does have some weaknesses that have limited its use to date, including cost, the short-term nature of its effects, and need for training. Future treatment development of CM as a medication platform needs to counter these issues by focusing on CM applications with large potential benefit, developing simple or automated methods for CM delivery and placing greater emphasis on the process of transitioning away from formal CM treatment.

Cavallo DA; Cooney JL; Duhig AM; Smith AE; Liss TB; McFetridge AK et al. Combining cognitive behavioral therapy with contingency management for smoking cessation in adolescent smokers: A preliminary comparison of two different CBT formats. American Journal on Addictions 16(6): 468-474, 2007. (29 refs.)

This pilot study evaluated the optimal format of cognitive behavioral therapy (CBT) to combine with contingency management (CM) in a four-week, high school-based smoking cessation program. Thirty-four adolescent smokers received a standard weekly version of CBT or a frequent brief behavioral intervention. Results indicate a trend toward a higher seven-day point prevalence end-of-treatment abstinence rate and percent days abstinent during treatment in the CBT condition. In addition, significantly more participants in the CBT group completed treatment. These preliminary results suggest that when combined with CM, the standard weekly format of CBT is more acceptable to adolescent smokers.

Chawarski MC; Mazlan M; Schottenfeld RS. Behavioral drug and HIV risk reduction counseling (BDRC) with abstinence-contingent take-home buprenorphine: A pilot randomized clinical trial. Drug and Alcohol Dependence 94(1/3): 281-284, 2008. (20 refs.)

This pilot randomized clinical trial evaluated whether the efficacy of office-based buprenorphine maintenance treatment (BMT), provided with limited counseling or oversight of medication adherence is improved by the addition of individual drug counseling and abstinence-contingent take-home doses of buprenorphine. After a 2-week buprenorphine and stabilization period, heroin dependent individuals (n = 24) in Muar, Malaysia were randomly assigned to Standard Services BMT (physician administered advice and support, and weekly, non-contingent medication pick-up) or Enhanced Services (nurse-delivered manual-guided behavioral drug and HIV risk reduction counseling (BDRC) and abstinence-contingent take-home buprenorphine (ACB), 7 day supply maximum). Outcomes included retention, proportion of opioid-negative urine tests, self-reported drug use, and self-reported HIV risk behaviors. 12/12 (100%) of Enhanced Services and 11/12 (92%) of Standard Services participants completed the entire protocol. The proportion of opioid-negative urine tests increased significantly over time for both groups (p < 0.001), and the reductions were significantly greater in the Enhanced Services group (p < 0.05); Enhanced Services group achieved higher overall proportions of opiate negative urine toxicology tests (87% vs. 69%, p = 0.04) and longer periods of consecutive abstinence from opiates (10.3 weeks vs. 7.8 weeks, p = 0.154). Both groups significantly reduced HIV risk behaviors during treatment (p < 0.05), but the difference between Enhanced and Standard Services (26% vs. 17% reductions from the baseline levels, respectively) was not statistically significant (p = 0.9). Manual-guided behavioral drug and HIV risk reduction counseling and abstinence-contingent take-home buprenorphine appear promising for adding to the efficacy of office-based BMT provided with limited drug counseling and medication oversight.

Corrigan JD; Bogner J. Interventions to promote retention in substance abuse treatment. Brain Injury 21(4): 343-356, 2007. (63 refs.)

Objectives: Compare two methods of improving retention in substance abuse treatment for persons with traumatic brain injury. Design: Randomized clinical trial with control group comparison. Interventions: Provision of a financial incentive and reduction of logistical barriers. Outcome measures: Treatment attendance, perceived therapeutic alliance, premature termination. Results: Provision of a financial incentive was highly effective for facilitating early attendance and appeared to promote eventual successful treatment completion. Reduction of logistical barriers did not significantly improve attendance or successful discharge. The hypothesized role of improved therapeutic alliance as a consequence of intervention and a mediator for preventing premature termination was not supported. However, results suggested that intervention, particularly financial incentives, promoted congruence between counsellor and client perceived therapeutic alliance. Conclusions: For clients with traumatic brain injuries, provision of a financial incentive at an early point in substance abuse treatment substantially improves attendance and reduces the likelihood of premature termination. The basis for this effect appears to involve more than enhancement of the therapeutic alliance. We posit that concrete incentives can provide an opportunity for successful rule- governed behaviour that may generalize to other areas of improved impulse control.

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.

Dallery J; Meredith S; Glenn IM. A deposit contract method to deliver abstinence reinforcement for cigarette smoking. Journal of Applied Behavior Analysis 41(4): 609-615, 2008. (23 refs.)

Eight smokers were randomly assigned to a deposit contract ($50.00) or to a no-deposit group. Using a reversal design, participants could recoup their deposit (deposit group) or earn vouchers (no-deposit group) for smoking reductions and abstinence (breath carbon monoxide [CO] <= 4 parts per million) during treatment phases. Treatment was delivered via a novel Internet-based method to monitor smoking status. Although equivalent decreases in breath CO and abstinence were observed during treatment in both groups, $178.50 in vouchers were distributed to participants in the no-deposit group, whereas a small surplus remained in the deposit group. A deposit contract method may represent a cost-effective model to deliver abstinence reinforcement for cigarette smoking.

Donlin WD; Knealing TW; Needham M; Wong CJ; Silverman K. Attendence rates in a workplace predict subsequent outcome of employment-based reinforcement of cocaine abstinence in methadone patients. Journal of Applied Behavior Analysis 41(4): 499-516, 2008. (32 refs.)

This study, assessed whether attendance rates in a workplace predicted subsequent outcome of employment-based reinforcement of cocaine abstinence. Unemployed adults in Baltimore methadone programs who used cocaine (N = 111) could work in a workplace for 4 hr every weekday and earn $10.00 per hour in vouchers for 26 weeks. During an induction period, participants provided urine samples but could work independent of their urinalysis results. After the induction period, participants had to provide urinalysis evidence of cocaine abstinence to work and maintain maximum pay. A multiple regression analysis showed that induction period attendance was independently associated with urinalysis evidence of cocaine abstinence under the employment-based abstinence reinforcement contingency. Induction period attendance may measure the reinforcing value of employment and could be used to guide the improvement of employment-based abstinence reinforcement.

Drebing CE; Van Ormer EA; Mueller L; Hebert M; Phd WEP; Petry NM et al. Adding contingency management intervention to vocational rehabilitation: Outcomes for dually diagnosed veterans. Journal of Rehabilitation Research and Development 47(6): 851-865, 2007. (39 refs.)

In this random-assignment trial, we evaluated the efficacy of using a contingency management (CM) intervention to enhance job acquisition and tenure among participants of a vocational rehabilitation (VR) program. The CM intervention offered participants cash incentives up to $1,170 for completing tasks related to sobriety and job search and maintenance. Participants were 100 veterans with comorbid psychiatric disorders and substance dependence who were randomly assigned either to VR only or VR + CM. Relative to participants in the VR-only group, those in the VR + CM group showed more intense job searches and transitioned to competitive employment faster and at higher rates. No significant difference was found in job tenure, though this may be due to the limited follow-up period. Abstinence rates were significantly better in the VR + CM group during the first 16 weeks of follow-up but not significantly different in subsequent follow-ups. No relationship was found between relapse and employment. These results suggest that rehabilitation outcomes may be enhanced by adding CM to current programming or by restructuring traditional work-for-pay contingencies to include direct financial rewards for achievement of clinical goals.

Dunn KE; Sigmon SC; Thomas CS; Heil SH; Higgins ST. Voucher-based contingency reinforcement of smoking abstinence among methadone-maintained patients: A pilot study. Journal of Applied Behavior Analysis 41(4): 527-538, 2008. (49 refs.)

This study, evaluated the efficacy, of a contingency management (CM) intervention to promote smoking cessation in methadone-maintained patients. Twenty participants, randomized into contingent (n = 10) or noncontingent (n = 10) experimental conditions, completed the 14-day, study. Abstinence was determined using breath carbon monoxide and urine cotinine levels. Contingent participants received voucher-based incentives for biochemical evidence of smoking, abstinence. Noncontingent participants earned vouchers independent of smoking status. Contingent participants achieved significantly more smoking abstinence and longer durations of continuous smoking abstinence than did noncontingent participants. These results support the potential efficacy of using voucher-based CM to promote smoking cessation among methadone-maintained patients.

Ford JD; Hawke J; Alessi S; Ledgerwood D; Petry N. Psychological trauma and PTSD symptoms as predictors of substance dependence treatment outcomes. Behaviour Research and Therapy 45(10): 2417-2431, 2007. (56 refs.)

Psychological trauma and post-traumatic stress disorder (PTSD) may complicate and reduce the effectiveness of treatment for substance use disorders (SUDs). This study assessed trauma history and symptoms of simple and complex PTSD at baseline in a randomized trial of contingency management (CM) compared to standard treatment (ST) with 142 cocaine- or heroin-dependent outpatients. History of exposure to each of eight types of psychological trauma was unrelated to treatment outcome, except for witnessed assaults and emotional abuse. Complex PTSD symptoms were inversely associated with short-term treatment outcomes, and PTSD symptoms were positively related to long-term outcome, independent of the effects of demographics, psychological distress, baseline substance use status, and treatment modality. Complex PTSD symptoms warrant further study as a potential negative prognostic factor in SUD interventions.

Gallagher SM; Penn PE; Schindler E; Layne W. A comparison of smoking cessation treatments for persons with schizophrenia and other serious mental illnesses. Journal of Psychoactive Drugs 39(4): 487-497, 2007. (42 refs.)

Adults with any DSM-IV diagnosed mental illness smoke nearly half of the cigarettes consumed in the U.S. (Lasser et al. 2000). This study compared two smoking cessation interventions for persons with schizophrenia or other serious mental illness because national data suggests that: (1) they smoke at two to three times the rate of the general population; (2) cessation interventions for this population are understudied; (3) most cessation studies exclude persons with serious mental illness; and (4) cessation results in public health care savings and disposable income savings for clients. This study included a large number of persons with serious mental illness (N = 181) who were randomly assigned to one of three groups: contingent reinforcement (CR), CR plus nicotine patch (21 mg, CR+NRT) for 16 weeks, and a minimal intervention, self-quit control group. These participants were followed for 36 weeks. CR was accomplished with escalating financial compensation for achieving and maintaining abstinence as verified by expired carbon monoxide (CO). Quit rates, as measured by expired CO, were higher and discordant with saliva cotinine quit rates. Cotinine showed lower quit rates and small differences between intervention and control participants at weeks 20 and 36. There was, however, evidence of reduced smoking and importantly, no evidence of psychiatric exacerbation.

Garica-Rodriguez O; Secades-Villa R; Higgins ST; Fernandez-Herminda JR; Carballo JL. Financing a voucher program for cocaine abusers through community donations in Spain. Journal of Applied Behavior Analysis 41(4): 623-628, 2008. (25 refs.)

This study analyzed the viability of financing a voucher program for cocaine addicts in Spain through public and private donations. Of the 136 companies contacted, 52 (38%) provided donations. The difference between the benefits (15,670(sic)/$20,371) and the costs (3,734,(sic)/$4,854) was 11,936(sic)/$15,517. The type of reinforcer a company call offer, the size of the company. and the time elapsed before responding may be determining variables in a company's decision whether to collaborate.

Ghitza UE; Epstein DH; Preston KL. Contingency management reduces injection-related HIV risk behaviors in heroin and cocaine using outpatients. Addictive Behaviors 33(4): 593-604, 2008. (39 refs.)

Intravenous drug use is a major vector of HIV transmission. We assessed whether contingency management (CM), in which participants cam reinforcers for drug abstinence, reduces HIV risk behaviors in methadone-maintained opiate- and cocaine-using outpatients. Participants (n = 116) were randomly assigned to prize-based CM or to receipt of prize draws noncontingently on a schedule yoked to the CM group. Both groups received methadone and individual counseling throughout treatment. The HIV-Risk Taking Behaviour Scale was administered in written questionnaire form at 2-week intervals (HRBS; [Darke, S., Hall, W, Heather, N., Ward, J., & Wodak, A. (1991). The reliability and validity of a scale to measure HIV risk-taking behaviour among intravenous drug users. AIDS, 5, 181-185]). A mediation analysis was conducted to determine whether abstinence from opiates and cocaine mediated the effect of CM on HRBS scores. Changes in HRBS scores over time differed significantly by treatment (F(9,334)=2.4,p<0.05), with HRBS scores decreasing over time in the CM group to a greater extent than in the noncontingent control group. Participants in the CM group had significantly lower rates of simultaneous cocaine/opiate-positive urine specimens than those in the noncontingent control group during CM treatment (F(1,1 1 1)=6.8, p=0.01). The relationship between treatment condition and HRBS scores was mediated by abstinence. CM targeted toward cocaine and heroin use produces significant reductions in injection-related drug-taking behaviors associated with heightened risk for getting or transmitting HIV.

Ghitza UE; Epstein DH; Schmittner J; Vahabzadeh M; Lin JL; Preston KL. Effect of reinforcement probability and prize size on cocaine and heroin abstinence in prize-based contingency management. Journal of Applied Behavior Analysis 41(4): 539-549, 2008. (37 refs.)

Although treatment outcome in prize-based contingency management has been shown to depend on reinforcement schedule, the optimal schedule is still unknown. Therefore, we conducted a retrospective analysis of data from a randomized clinical trial (Ghitza et al., 2007) to determine the effects of the probability of winning a prize (low vs. high) and the size of the prize won (small, large, or jumbo) on likelihood of abstinence until the next urine-collection day for heroin and cocaine Users (N = 116) in methadone maintenance. Higher probability of winning, but not the size of individual prizes, was associated with a greater percentage of cocaine-negative, but not opiate-negative, urines.

Ghitza UE; Epstein DH; Schmittner J; Vahabzadeh M; Lin JL; Preston KL. Randomized trial of prize-based reinforcement density for simultaneous abstinence from cocaine and heroin. Journal of Consulting and Clinical Psychology 75(5): 765-774, 2007. (44 refs.)

To examine the effect of reinforcer density in prize-based abstinence reinforcement, heroin/cocaine users (N = 116) in methadone maintenance (100 mg/day) were randomly assigned to a noncontingent control group (NonC) or to I of 3 groups that earned prize draws for abstinence: manual drawing with standard prize density (MS) or computerized drawing with standard (CS) or high (CH) density. Probabilities (prizes/draw) were standard (50%) and high (78%); prize density was double blind. Mean prize values were CH, $286; CS, $167; MS, $139; and NonC, $171. Outcomes were % opioid/cocaine-negative urines during the 12-week intervention and then 8 weeks postintervention as well as diagnosis of dependence up to 6 months poststudy. CH had significantly more negative specimens than did NonC during intervention and had more than all groups during postintervention treatment: Mean % negative (95% confidence interval) during postintervention treatment adjusted for baseline drug use and dropout were CH, 55% (14%-90%); CS, 7% (1%-27%); MS, 4% (1%-12%); and NonC, 3% (1%-10%). Current cocaine dependence diagnoses after treatment were significantly lower in contingent compared with noncontingent groups. Computerized drawing with higher-density prizes enhanced reduction of cocaine use; abstinence reinforcement had long-term therapeutic benefits.

Glenn IM; Dallery J. Effects of Internet-based voucher reinforcement and a transdermal nicotine patch on cigarette smoking. Journal of Applied Behavior Analysis 40(1): 1-13, 2007. (57 refs.)

Nicotine replacement products are commonly used to promote smoking cessation, but alternative and complementary methods may increase cessation rates. The current experiment compared the short-term effects of a transdermal nicotine patch to voucher-based reinforcement of smoking abstinence on cigarette smoking. Fourteen heavy smokers (7 men and 7 women) completed the four 5-day phases of the study: baseline, patch treatment, voucher treatment, and return to baseline. The order of the two treatment phases was counterbalanced across participants. In the patch treatment condition, participants wore a 14-mg transdermal nicotine patch every day. In the voucher treatment condition, participants received vouchers contingent on abstinence from smoking, defined as producing carbon monoxide (CO) readings of <= 4 parts per million. Participants e-mailed two video clips per day showing them breathing into a CO monitor and the resulting CO reading to clinic staff. In the voucher treatment, 24% of samples were negative, and 5% of samples were negative in the patch treatment. Results suggest that contingent vouchers were more effective than transdermal nicotine patches in promoting abstinence.

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.

Godley SH; Godley MD; Wright KL; Funk RR; Petry NM. Contingent reinforcement of personal goal activities for adolescents with substance use disorders during post-residential continuing care. American Journal on Addictions 17(4): 278-286, 2008. (26 refs.)

Contingency management (CM) is efficacious in improving outcomes of substance-abusing patients, but CM studies are relatively rare in adolescents. CM approaches can reinforce both abstinence and adherence to treatment-related goal areas. This paper describes 1,739 different activities in 10 goal areas (e.g., education, family/friends, and social/recreational) chosen by 86 adolescents who were participating in a multiple week CM study that reinforced both abstinence and adherence with goal-related activities. The mean activities selected was 20, and the mean completed was 13. Overall, 1,114 or 64% of chosen activities were completed. The clinical feasibility of activity incentive programs for adolescents is discussed.

Greenwald MK. Opioid abstinence reinforcement delays heroin lapse during buprenorphine dose tapering. Journal of Applied Behavior Analysis 41(4): 603-607, 2008. (14 refs.)

A positive reinforcement contingency increased opioid abstinence during Outpatient close tapering (4, 2, then 0 mg/day during weeks 1 through 3) in non-treatment-seeking heroin-dependent volunteers who had been maintained on buprenorphine (8 mg/day) during an inpatient research protocol. The control group (n = 12) received $4.00 for completing assessments at each thrice-weekly visit during dose tapering; 10 of 12 lapsed to heroin use 1 day after discharge. The abstinence reinforcement group (n = 10) received $30.00 for each consecutive opioid-free urine sample; this significantly delayed heroin lapse (median, 15 days).

Hanson T; Alessi SM; Petry NM. Contingency management reduces drug-related human immunodeficiency virus risk behaviors in cocaine-abusing methadone patients. Addiction 103(7): 1187-1197, 2008. (46 refs.)

Aim Contingency management (CM) is efficacious in reducing drug use. This study examined whether CM also reduces human immunodeficiency virus (HIV) risk behaviors and if these effects are mediated by longest duration of abstinence achieved during treatment. Design Data were analyzed from a subset of participants in a combined data set of three published randomized controlled trials of CM treatments. Setting A community-based methadone maintenance clinic. Participants One-hundred and sixty-five cocaine-abusing methadone maintenance patients. Intervention Participants received either standard methadone treatment or standard methadone treatment with CM for 3 months. Measurements The HIV Risk Behavior Scale (HRBS) was administered prior to randomization to a study condition and 3 months after the study treatments ended. The primary objective indicator of drug use was longest duration of cocaine and opioid abstinence achieved during treatment. Findings Relative to those assigned to standard care, participants receiving CM significantly decreased overall HIV risk behaviors and injection drug use risk behaviors. CM participants also achieved longer durations of consecutive cocaine and opioid abstinence during treatment. Duration of abstinence achieved mediated the relationship between treatment condition and HRBS difference scores. Conclusions These results suggest that CM treatment reduces HIV drug use risk behaviors in cocaine-abusing methadone maintenance patients.

Heil SH; Higgins ST; Bernstein IM; Solomon LJ; Rogers RE; Thomas CS et al. Effects of voucher-based incentives on abstinence from cigarette smoking and fetal growth among pregnant women. Addiction 103(6): 1009-1018, 2008. (35 refs.)

Aims: This study examined whether voucher-based reinforcement therapy (VBRT) contingent upon smoking abstinence during pregnancy is an effective method for decreasing maternal smoking during pregnancy and improving fetal growth. Design, setting and participants: A two-condition, parallel-groups, randomized controlled trial was conducted in a university-based research clinic. A total of 82 smokers entering prenatal care participated in the trial. Intervention Participants were assigned randomly to either contingent or non-contingent voucher conditions. Vouchers exchangeable for retail items were available during pregnancy and for 12 weeks postpartum. In the contingent condition, vouchers were earned for biochemically verified smoking abstinence; in the non-contingent condition, vouchers were earned independent of smoking status. Measurements Smoking outcomes were evaluated using urine-toxicology testing and self-report. Fetal growth outcomes were evaluated using serial ultrasound examinations performed during the third trimester. Findings Contingent vouchers significantly increased point-prevalence abstinence at the end-of-pregnancy (41% versus 10%) and at the 12-week postpartum assessment (24% versus 3%). Serial ultrasound examinations indicated significantly greater growth in terms of estimated fetal weight, femur length and abdominal circumference in the contingent compared to the non-contingent conditions. Conclusions: These results provide further evidence that voucher-based reinforcement therapy has a substantive contribution to make to efforts to decrease maternal smoking during pregnancy and provide new evidence of positive effects on fetal health.

Henggeler SW; Chapman JE; Rowland MD; Halliday-Boykins CA; Randall J; Shackelford J et al. If you build it, they will come: Statewide practitioner interest in contingency management for youths. Journal of Substance Abuse Treatment 32(2): 121-131, 2007. (45 refs.)

Addressing the science-service gap, we examined in this study the amenability of a large heterogeneous sample of community-based therapists in the state mental health and substance abuse treatment sectors to learn about an evidence-based practice (EBP) for adolescent substance abuse (i.e., contingency management [CM]) when such learning was supported administratively and logistically. Leadership in most (44 of 50) public sector agencies supported practitioner recruitment, and 432 of 543 eligible practitioners subsequently attended a 1-day workshop in contingency management. Workshop attendance was predicted by organizational factors but not by practitioner demographic characteristics, professional background, attitudes toward evidence-based practice, or service sector. Moreover, the primary reason for workshop attendance was to improve services for adolescent clients; the primary barriers to attendance, for those who did not attend, were practical in nature and not due to theoretical incompatibility. The findings demonstrate a considerable amount of interest practitioners showed in both the substance abuse and mental health sectors in learning about an evidence-based practice.

Henggeler SW; Chapman JE; Rowland MD; Halliday-Boykins CA; Randall J; Shackelford J et al. Statewide adoption and initial implementation of contingency management for substance-abusing adolescents. Journal of Consulting and Clinical Psychology 76(4): 556-567, 2008. (47 refs.)

Four hundred thirty-two public sector therapists attended a workshop in contingency management (CM) and were interviewed monthly for the following 6 months to assess their adoption and initial implementation of CM to treat substance-abusing adolescent clients. Results showed that 58% (n = 131) of the practitioners with at least one substance-abusing adolescent client (n = 225) adopted CM. Rates of adoption varied with therapist service sector (mental health vs. substance abuse), educational background, professional experience, and attitudes toward treatment manuals and evidence-based practices. Competing clinical priorities and client resistance were most often reported as barriers to adopting CM, whereas unfavorable attitudes toward and difficulty in implementing CM were rarely cited as barriers. The fidelity of initial CM implementation among adopters was predicted by organizational characteristics as well as by several demographic, professional experience, attitudinal, and service sector characteristics. Overall, the findings support the amenability of public sector practitioners to adopt evidence-based practices and suggest that the predictors of adoption and initial implementation are complex and multifaceted.

Higgins ST; Heil SH; Dantona R; Donham R; Matthews M; Badger GJ. Effects of varying the monetary value of voucher-based incentives on abstinence achieved during and following treatment among cocaine-dependent outpatients. Addiction 102(2): 271-281, 2007. (22 refs.)

Aims: This study examined whether increasing the amount of abstinence achieved during outpatient treatment for cocaine dependence is an effective method for increasing longer-term cocaine abstinence. Design A two-condition, parallel groups, randomized controlled trial was conducted. Setting The trial was conducted in a university-based research clinic. Participants A total of 100 cocaine-dependent outpatients participated in the trial. Intervention Participants were assigned randomly to receive treatment based on the community reinforcement approach (CRA) plus voucher-based incentives set at a relatively high monetary value (maximal value = $1995/12 weeks) or CRA with vouchers set at a relatively low monetary value (maximal value = $499/12 weeks). Vouchers were earned contingent on cocaine-negative urinalysis results during the initial 12 weeks of the 24-week outpatient treatment. Measurements Outcomes were evaluated using urine-toxicology testing, questionnaires and other self-report instruments. Findings Increasing voucher value increased the duration of continuous cocaine abstinence achieved during the 24-week treatment period. Point-prevalence cocaine abstinence assessed every 3 months throughout an 18-month follow-up period was greater in the high- than low-value voucher conditions. The duration of abstinence achieved during treatment predicted abstinence during follow-up, although that relationship weakened over time. Conclusions: Increasing the value of abstinence-contingent incentives during the initial weeks of treatment appears to represent an effective method for increasing during-treatment and longer-term cocaine abstinence, but the positive association of during-treatment abstinence with longer-term outcome dissipates with time.

Higgins ST; Silverman K; Heil SH, eds. Contingency Management in Substance Abuse Treatment. New York: Guilford Press, 2007. (chapter refs.)

This edited volume considers the applications of contingency management principles across a wide range of substance use disorders (cocaine, opioids, marijuana, tobacco, and alcohol) and in diverse populations (the homeless, pregnant and postpartum women, those with mental illness, and adolescents). Beyond dealing with clinical issues the volume also addresses what is entailed in establishing and funding contingency management programs.

Husky MM; Mazure CM; Carroli KM; Barry D; Petry NM. Using experience sampling method in the context of contingency management for substance abuse treatment. Journal of Applied Behavior Analysis 41(4): 635-644, 2008. (21 refs.)

Contingency management (CM) treatments have been shown to be effective in reducing substance use. This manuscript illustrates how the experience sampling method (ESM) can depict behavior and behavior change and can be used to explore CM treatment mechanisms. ESM characterizes idiosyncratic patterns of behavior and offers the potential to determine how behavioral patterns are affected by the operant conditioning principles that drive contingency management It may also lead to the identification of new target behaviors for contingency management in the context of substance abuse treatment.

Killeen T; Carter R; Colersino M; Petry N; Stitzer M. Effectiveness of motivational incentives in stimulant abusing outpatients with different treatment histories. American Journal of Drug and Alcohol Abuse 33(1): 129-137, 2007. (15 refs.)

Objective: To determine if prize-based abstinence incentives will differentially affect substance abuse outcomes in patients with different treatment histories. Design: Treatment seeking outpatients with more or less prior treatment episodes were randomized to receive either prize-based incentives plus treatment as usual (TAU) or TAU alone. Outcome variables included longest sustained period of abstinence, number of negative urine drug screens (UDS), and retention in treatment. Results: Treatment experienced participants were older, more likely to be female, African American, unemployed, and with more severe cocaine and psychiatric problems. The effectiveness of incentives did not differ significantly between the two treatment history groups with regard to the outcome measures.

Kinnaman JES; Slade E; Bennett ME; Bellack AS. Examination of contingency payments to dually-diagnosed patients in a multi-faceted behavioral treatment. Addictive Behaviors 32(7): 1480-1485, 2007. (12 refs.)

Contingency management (CM) may be a promising component of treatment to help dually-diagnosed patients reduce their substance use. However, most prior studies examining CM with these patients have not examined the relationships among patient variables and contingency rewards received. This study examined whether characteristics of dually-diagnosed patients were related to CM payments received in a multi-faceted program. Fifty-nine dually-diagnosed patients participated in a multimodal behavioral therapy for illicit substance use involving CM. Baseline demographic and clinical characteristics were examined as they related to receipt of payments. Demographic characteristics generally were not related to receipt of payments. Several clinical variables, including diagnosis of schizophrenia, current substance dependence, and co-morbid alcohol dependence were related to payment receipt. These results provide an important step toward understanding the characteristics of dually-diagnosed patients that predict their response to CM.

Kirby KC; Kerwin ME; Carpenedo CM; Rosenwasser BJ; Gardner RS. Interdependent group contingency management for cocaine-dependence methadone maintenance patients. Journal of Applied Behavior Analysis 41(4): 579-595, 2008. (54 refs.)

Contingency management (CM) for drug abstinence has been applied to individuals independently even when delivered in groups. We developed a group CM intervention in which the behavior of a single, randomly selected, anonymous individual determined reinforcement delivery for the entire group. We also compared contingencies placed only on cocaine abstinence (CA) versus one of four behaviors (CA, treatment attendance, group CM attendance, and methadone compliance) selected randomly at each drawing. Two groups were formed with 22 cocaine-dependent community-based methadone patients and exposed to both CA and multiple behavior (MB) conditions in a reversal design counterbalanced across groups for exposure order. The group CM intervention proved feasible and safe. The MB condition improved group CM meeting attendance relative to the CA condition.

Kosten TR. Pharmacotherapy for addictions: Partnering with contingency management. (editorial). American Journal of Drug and Alcohol Abuse 33(3): 341-342, 2007. (0 refs.)

Lederwood DM; Alessi SM; Hanson T; Godley MD; Petry NM. Contingency management for attendance to group substance abuse treatment administered by clinicians in community clinics. Journal of Applied Behavior Analysis 41(4): 517-526, 2008. (23 refs.)

Contingency management (CM) is effective in enhancing retention in therapy. After all 8-week baseline, four community-based substance abuse treatment clinics were exposed in random order to 16 weeks of standard care with CM followed by 16 weeks of standard care without CM or vice versa. In total, 75 outpatients participated. Patients who were enrolled in the clinics when the treatment phase was in effect attended a significantly greater percentage of therapy sessions than patients who were enrolled ill treatment when CM was nor in effect. This study is one of the first to investigate CM in community settings implemented entirely by community clinicians, and results suggest that CM is effective in improving therapy attendance.

Lee NK; Rawson RA. A systematic review of cognitive and behavioural therapies for methamphetamine dependence. (review). Drug and Alcohol Review 27(3): 309-317, 2008. (28 refs.)

Introduction and Aims. The use of methamphetamine is widespread and poses significant challenges for treatment providers. Much of the treatment knowledge about this group has been extrapolated from studies of treatment for cocaine dependence. Medications have been shown to be of limited effectiveness for methamphetamine users, making psychological interventions the treatment of choice. Approach. This paper describes a systematic review of cognitive-behavioural and behavioural interventions for methamphetamine users. A systematic search of published literature was undertaken focusing only on randomised trials. Key Findings. There were a relatively small number of intervention studies that compared cognitive -behavioural or behavioural interventions using randomised trial methodology. Most commonly, studies examined cognitive-behaviour therapy (CBT) and/or contingency management (CM). Treatment with CBT appears to be associated with reductions in methamphetamine use and other positive changes, even over very short periods of treatment (two and four sessions). CM studies found a significant reduction of methamphetamine during application of the procedure, but it is not clear if these gains are sustained at post-treatment follow-up. Implications. The review highlights that there are effective treatments for methamphetamine dependence. Alcohol and other drug (AOD) clinicians are familiar with these types of interventions and should use them and convey to clients that they are effective. Services and policy makers should ensure that best practice interventions are implemented within AOD services. Conclusion. Psychological intervention is effective in addressing methamphetamine use and dependence. CBT and contingency management are two accessible interventions that are implemented easily within current AOD services. There is still more work to conduct in improving methamphetamine treatment, however, and further research into cognitive-behavioural and behavioural treatments for methamphetamine users is required, with a focus on improving longevity of the effect of intervention and improving effectiveness among more complex presentations.

Litt MD; Kadden RM; Kabela-Cormier E; Petry N. Changing network support for drinking: Initial findings from the network support project. Journal of Consulting and Clinical Psychology 75(4): 542-555, 2007. (49 refs.)

The aim of this study was to determine whether a socially focused treatment can effect change in the patient's social network from one that reinforces drinking to one that reinforces sobriety. Alcohol dependent men and women (N = 210) recruited from the community were randomly assigned to 1 of 3 outpatient treatment conditions: network support (NS), network support + contingency management (NS + CM), or case management (CaseM; a control condition). Analysis of drinking rates for 186 participants at 15 months indicated a significant interaction effect of Treatment X Time, with both NS conditions yielding better outcomes than the CaseM condition. Analyses of social network variables at posttreatment indicated that the NS conditions did not reduce social support for drinking relative to the CaseM condition but did increase behavioral and attitudinal support for abstinence as well as Alcoholics Anonymous (AA) involvement. Both the NS variables and AA involvement variables were significantly correlated with drinking outcomes. These findings indicate that drinkers' social networks can be changed by a treatment that is specifically designed to do so, and that these changes contribute to improved drinking outcomes.

Litt MD; Kadden RM; Kabela-Cormier E; Petry NM. Coping skills training and contingency management treatments for marijuana dependence: Exploring mechanisms of behavior change. Addiction 103(4): 638-648, 2008. (48 refs.)

Aims Achieving abstinence in the treatment of marijuana dependence has been difficult. To date the most successful treatments have included combinations of motivation enhancement treatment (MET) plus cognitive-behavioral coping skills training (CBT) and/or contingency management (ContM) approaches. Although these treatment approaches are theoretically based, their mechanisms of action have not been explored fully. The purpose of the present study was to explore mechanisms of behavior change from a marijuana treatment trial in which CBT and ContM were evaluated separately and in combination. Design A dismantling design was used in the context of a randomized clinical trial. Setting: The setting was an out-patient treatment research facility located in a university medical center. Participants: Participants were 240 adult marijuana smokers, meeting criteria for cannabis dependence. Interventions: Participants were assigned to one of four 9-week treatment conditions: a case management control condition, MET/CBT coping skills training, ContM and MET/CBT + ContM. Measurements: Outcome measures were total 90-day abstinence, recorded every 90 days for 12 months post-treatment. Findings: Regardless of treatment condition, abstinence in near-term follow-ups was predicted most clearly by abstinence during treatment, but long-term abstinence was predicted by use of coping skills and especially by post-treatment self-efficacy for abstinence. Conclusions It was concluded that the most efficacious treatments for marijuana dependence are likely to be those that increase self-efficacy.

Marlowe DB; Festinger DS; Dugosh KL; Arabia PL; Kirby KC. An effectiveness trial of contingency mangement in a felony preadjudication drug court. Journal of Applied Behavior Analysis 41(4): 565-577, 2008. (29 refs.)

This study evaluated a contingency management (CM) program in a drug court. Gift certificates for compliance were delivered at 4- to 6-week intervals (total Value $390.00). Participants in one condition earned gift certificates that escalated by $5.00 increments. participants in a second condition began earning higher magnitude gift certificates, and the density of reinforcement was gradually decreased. No main effects of CM were detected, which appears to be attributable to a ceiling effect from the intensive contingencies already delivered in the drug court and the low density of reinforcement. Preplanned interaction analyses suggested that participants with more serious criminal backgrounds might have performed better in the CM conditions. This suggests that CM programs may be best suited for more incorrigible drug offenders.

McCarty D; Fuller BE; Arfken C; Miller M; Nunes EV; Edmundson E et al. Direct care workers in the national drug abuse treatment clinical trials network: Characteristics, opinions, and beliefs. Psychiatric Services 58(2): 181-190, 2007. (22 refs.)

Objective: Individuals with direct care responsibilities in 348 drug abuse treatment units were surveyed to obtain a description of the workforce and to assess support for evidence-based therapies. Methods: Surveys were distributed to 112 programs participating in the National Drug Abuse Treatment Clinical Trials Network (CTN). Descriptive analyses characterized the workforce. Analyses of covariance tested the effects of job category on opinions about evidence-based practices and controlled for the effects of education, modality (outpatient or residential), race, and gender. Results: Women made up two-thirds of the CTN workforce. One-third of the workforce had a master's or doctoral degree. Responses from 1,757 counselors, 908 support staff, 522 managers-supervisors, and 511 medical staff (71% of eligible participants) suggested that the variables that most were most consistently associated with responses were job category (19 of 22 items) and education (20 of 22 items). Managers-supervisors were the most supportive of evidence-based therapies, and support staff were the least supportive. Generally, individuals with graduate degrees had more positive opinions about evidence-based therapies. Support for using medications and contingency management was modest across job categories. Conclusions: The relatively traditional beliefs of support staff could inhibit the introduction of evidence-based practices. Programs initiating changes in therapeutic approaches may benefit from including all employees in change efforts.

Milby JB; Schumacher JE; Vuchinich RE; Freedman MJ; Kertesz S; Wallace D. Toward cost-effective initial care for substance-abusing homeless. Journal of Substance Abuse Treatment 34(2): 180-191, 2008. (40 refs.)

In a randomized controlled trial, behavioral day treatment, including contingency management (CM+), was compared to contingency management components alone (CM). All 206 cocaine-dependent homeless participants received a furnished apartment with food and work training/employment contingent on drug-negative urine tests. CM+ also received cognitive-behavioral therapy, therapeutic goal management, and other intervention components. Results revealed that CM, treatment attendance and abstinence were not significantly different from CM during 24 weeks of treatment. After treatment and contingencies ended, however, CM+ showed more abstinence than CM, indicating a delayed effect of treatment from 6 to 18 months. CM+ had more consecutive weeks abstinent across 52 weeks, but not during active treatment. We conclude that CM alone may be viable as initial care for cocaine-dependent homeless persons. That CM+ yields more durable abstinence indicates that it may be appropriate as stepped-up care for clients not responding to CM (Clinical Trials.gov, no. NCT00368524).

Olmstead TA; Sindelar JL; Petry NM. Clinic variation in the cost-effectiveness of contingency management. American Journal on Addictions 16(6): 457-460, 2007. (23 refs.)

This study determined whether, and by how much, the cost-effectiveness of contingency management (CM) varied across the eight clinics in the National Institute on Drug Abuse Clinical Trials Network MIEDAR trial. Incremental costs, incremental outcomes, and incremental cost-effectiveness ratios (ICERs) of CM compared to usual care were calculated, compared and contrasted for each of the clinics. Results showed that the incremental cost of using CM compared to usual care varied by a factor of 1.9 across the clinics, ranging from an additional $306 to an additional $582 per patient. The effect of CM on the longest duration of continuous stimulant abstinence (LDA) varied by a factor of 8.0 across the clinics, ranging from an additional 0.5 to an additional 4.0 weeks. The ICERs for the LDA varied by a factor of 4.6 across the clinics, ranging from $145 to $666. These results show that the cost-effectiveness of CM varied widely among the clinics in the MIEDAR trial. Future research should focus on identifying the sources of this variation, perhaps by identifying clinic-level best practices and/or identifying those subgroups of patients that respond the most cost-effectively, with the ultimate goal of improving the cost-effectiveness of CM overall.

Olmstead TA; Sindelar JL; Petry NA. Cost-effectiveness of prize-based incentives for stimulant abusers in outpatient psychosocial treatment programs. Drug and Alcohol Dependence 87(2/3): 175-182, 2007. (30 refs.)

Objective: To evaluate the cost-effectiveness of a prize-based intervention as an addition to usual care for stimulant abusers. Methods: This cost-effectiveness analysis is based on a randomized clinical trial implemented within the National Drug Abuse Treatment Clinical Trials Network. The trial was conducted at eight community-based outpatient psychosocial drug abuse treatment clinics. Four hundred and fifteen stimulant abusers were assigned to usual care (N = 206) or usual care plus abstinence-based incentives (N = 209) for 12 weeks. Participants randomized to the incentive condition earned the chance to draw for prizes for submitting substance negative samples; the number of draws earned increased with continuous abstinence time. Incremental cost-effectiveness ratios were estimated to compare prize-based incentives relative to usual care. The primary patient outcome was longest duration of confirmed stimulant abstinence (LDA). Unit costs were obtained via surveys administered at the eight participating clinics. Resource utilizations and patient outcomes were obtained from the clinical trial. Acceptability curves are presented to illustrate the uncertainty due to the sample and to provide policy relevant information. Results: The incremental cost to lengthen the LDA by 1 week was US$ 258 (95% confidence interval, US$ 191-401). Sensitivity analyses on several key parameters show that this value ranges from US$ 163 to 269. Conclusions: Compared with the usual care group, the incentive group had significantly longer LDAs and significantly higher costs.

Olmstead TA; Sindelar JL; Easton CJ; Carroll KM. The cost-effectiveness of four treatments for marijuana dependence. Addiction 102(9): 1443-1453, 2007. (41 refs.)

Aim: To analyze data from a randomized clinical trial to determine the cost-effectiveness of using contingency management (CM) and motivational/skills building therapy (motivational enhancement therapy/cognitive-behavioral therapy: MET/CBT) to treat young adults with marijuana dependence. Participants, design and measurements A total of 136 marijuana-dependent young adults, all referred by the criminal justice system, were randomized to one of four treatment conditions: MET/CBT with CM, MET/CBT without CM, drug counseling (DC) with CM and DC without CM. Patient outcome measures include the longest duration of confirmed marijuana abstinence (LDA) during treatment and the total number of marijuana-free urine specimens provided during treatment. Costs were collected retrospectively from the provider and include the costs of therapy, patient drug testing, and those associated with the incentives component (value of vouchers, time to administer the voucher system). Settings: Out-patient substance abuse clinic in New Haven, Connecticut. Findings: Which treatment is the most cost-effective depends on the threshold values of an additional week of LDA or an additional marijuana-free urine specimen. For example, the most effective treatment, MET/CBT with CM, was also the most cost-effective treatment at the highest threshold values, while the least effective treatment, DC, was the most cost-effective at the lowest values. Because consensus threshold values for these patient outcomes do not exist, results are presented showing the ranges of values over which each treatment would be considered cost-effective compared to the others. Acceptability curves are presented to show the decision uncertainty associated with these ranges. The results are shown to be robust to (i) sensitivity analyses on several key cost parameters and (ii) patient outcomes measured during the 6-month follow-up period. Conclusions: This study uses incremental cost-effectiveness ratios and acceptability curves to shed light on the relative cost-effectiveness of four interventions for treating young adults with marijuana dependence. Given the relatively small and specialized nature of our study sample, and the fact that we examined a CM procedure with a single reinforcement schedule, additional studies are warranted to determine the reliability and generalizability of our results both to alternative marijuana-using populations and to CM procedures with alternative incentive parameters. Nevertheless, the relative durability of effects of MET/CBT compared to DC through the 6-month follow-up, and its cost-effectiveness over a comparatively wide range of threshold values, underscores the promise of this approach.

Petry NM; Alessi SM; Hanson T. Contingency management improves abstinence and quality of life in cocaine abusers. Journal of Consulting and Clinical Psychology 75(2): 307-315, 2007. (53 refs.)

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

Petry NM; Lewis MW; Ostvik-White EM. Participation in religious activities during contingency management interventions is associated with substance use treatment outcomes. American Journal on Addictions 17(5): 408-413, 2008. (20 refs.)

Many drug abuse treatment programs encourage participation in religious activities, yet there is scant research regarding their effectiveness. Contingency management (CM) interventions sometimes reinforce the completion of non-drug related activities, and church attendance is a popular activity. Cocaine abusers (n = 184) randomized to CM interventions were categorized based on whether or not they engaged in three or more religious activities. Engagers in religious activities (n = 34) remained in treatment longer, were abstinent for longer durations, and submitted more substance-negative samples than non-engagers (n = 150), even after controlling for number of activities completed overall. Thus, encouraging religious involvement during CM treatment may improve during treatment outcomes.

Preston KL; Ghitza UE; Schmittner JP; Schroeder JR; Epstein DH. Randomized trial comparing two treatment strategies using prize-based reinforcement of abstinence in cocaine and opiate users. Journal of Applied Behavior Analysis 41(4): 551-563, 2008. (39 refs.)

We compared two strategies of prize-based contingency management (CM) in methadone-maintained outpatients. Urine was tested thrice weekly, for 5 weeks pre-CM, 12 weeks GM, and 8 weeks post-CM. Participants were randomly assigned to a cocaine contingency (four prize draws for each cocaine-negative urine, N = 29) or an opiate-cocaine contingency (one draw for each urine negative for opiates or cocaine, four draws if negative for both, N = 38). There were no group differences in cocaine abstinence during CM or post-CM and no differences in opiate abstinence during CM, opiate abstinence was greater in the opiate-cocaine group post-CM, and heroin craving was reduced in this group during and post-CM. Draws earned per cocaine-negative urine (four vs. one) did not affect cocaine use.

Rash CJ; Alessi SM; Petry NM. Cocaine abusers with and without alcohol dependence respond equally well to contingency management treatments. Experimental and Clinical Psychopharmacology 16(4): 275-281, 2008. (29 refs.)

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

Rash CJ; Alessi SM; Petry NM. Contingency management Is efficacious for cocaine abusers with prior treatment attempts. Experimental and Clinical Psychopharmacology 16(6): 547-554, 2008. (25 refs.)

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

Ritter A; Cameron J. Australian clinician attitudes towards contingency management: Comparing down under with America. Drug and Alcohol Dependence 87(2/3): 312-315, 2007. (9 refs.)

Background: Contingency management (CM) is an efficacious treatment intervention. Research from the US indicates that clinicians have both positive and negative attitudes towards CM. Concerns about the practicalities of implementation and potential philosophical differences have been identified in American samples. To date, no research has examined Australian clinicians attitudes towards CM nor assessed the extent to which Australian clinicians share the concerns of American clinicians. Method: The Provider Survey of Incentives was completed by 102 Australian drug and alcohol treatment providers. The survey assesses both positive and negative attitudes towards tangible and social incentives. Comparisons are made with published data on American samples. Results: The proportion of respondents agreeing with positive opinions about CM in this Australian sample was lower than that reported in the American sample. The average percentage agreement for positive aspects of tangible rewards was 41% whereas the average percent agreement for social rewards was 51% indicating more positive views towards social rewards. Objections to CM were similar between the two samples, but American respondents more strongly agreed with the idea that it would not be right to give incentives when clients are still using drugs, whereas the Australian sample had much less difficulty with this concept. Conclusions: There appears to be broad support for CM from about half of the clinicians surveyed. The areas of concern were highly similar between the Australian sample and published American data. Many Australian clinicians expressed neutral views about CM, indicating that the environment may be ripe for implementation of programs.

Rogers RE; Higgins ST; Silvertnan K; Thomas CS; Badger GJ; Bigelow G et al. Abstinence-contingent reinforcement and engagement in non-drug-related activities among illicit drug abusers. Psychology of Addictive Behaviors 22(4): 544-550, 2008. (28 refs.)

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

Roll JM. Contingency management: An evidence-based component of methamphetamine use disorder treatments. Addiction 102(Supplement 1): 114-120, 2007. (42 refs.)

Aims: To review briefly some of the available evidence regarding the utility of contingency management in treating methamphetamine use disorders. Design: A literature review was conducted to locate relevant studies for the review. Findings The review suggests that contingency management is likely to be a useful component of treatment strategies designed to address methamphetamine use disorders. Results suggest that contingency management can increase the likelihood of providing methamphetamine-free urine samples during treatment. Conclusions: Evidence suggests that contingency management is a good candidate for inclusion in treatment strategies for methamphetamine addiction.

Rosenthal RN; Brady KT; Levounis P; Willenbring ML. Advances in the treatment of alcohol dependence. Journal of Clinical Psychiatry 68(7): 1117-1128, 2007. (89 refs.)

This article presents the highlights of a series of teleconferences on "Advances in the Treatment of Alcohol Dependence." The first section corresponding to the first telecast discusses the neurobiological basis for current pharmacological treatment, with attention to the dominant neurotransmitter systems that are the treatment targets. The second section is focuses on the extended-release injectable suspension preparation of naltrexone, with attention to its efficacy, safety, and tolerability. The third section considers the integration of psychotherapy and pharmacotherapy in the treatment of alcohol dependence. The therapies briefly described include cognitive-behavioral therapy, motivational enhancement therapy, twelve-step facilitation therapy, and contingency management. The final section reviews the finding of the COMBINE Study, which examined the efficacy of combinations of pharmacologic and behavioral interventions. Overall, patients taking medications showed a significant increase in days abstinent over the 16 week study period, However, over a one year follow-up, unlike naltrexone, acamprosate results were not superior to placebo. It was also found that "medical management" in combination with naltrexone was as successful as "specialty alcohol counseling" (Note: Neither medical management nor specialty alcohol counseling are adequately defined.)

sBarry D; Weinstock J; Petry NM. Ethnic differences in HIV risk behaviors among methadone-maintained women receiving contingency management for cocaine use disorders. Drug and Alcohol Dependence 98(1/2): 144-153, 2008. (60 refs.)

To identify ethnic differences in HIV risk behaviors among cocaine using women receiving methadone maintenance for opioid dependence, and to evaluate the efficacy of contingency management (CM) for cocaine use disorders in reducing HIV risk behaviors. Methods: African American (N=47), Hispanic (N=47), and White women (N=29) were randomized to standard methadone treatment or standard methadone treatment plus a CM intervention. They completed the HIV Risk Behavior Scale (HRBS) indicating frequency of drug use and sexual behaviors across the lifetime, in the month before baseline, and in the 3 months following clinical trial participation. Ethnic group differences and the effect of CM on change in HIV risk behaviors between baseline and follow-up were evaluated.Results: White women reported significantly higher lifetime rates of risky drug use and sexual behaviors on the HRBS than African American women; neither group differed significantly from Hispanic women. No ethnic group differences in HIV risk behaviors were identified in the month prior to baseline. At follow-up, African American women reported fewer high-risk drug use behaviors than White or Hispanic women, and Hispanic women reported more high-risk sexual behaviors than White or African American women. CM was associated with reduction in high-risk drug use behaviors regardless of ethnicity, but did not affect high-risk sexual behaviors. Conclusions: White women receiving methadone maintenance engage in more lifetime HIV risk behaviors than African American women. CM for cocaine use reduces risky drug use behaviors, but certain ethnic groups may benefit from additional targeted HIV prevention efforts.

Schepis TS; Duhig AM; Liss T; McFetridge A; Wu R; Cavallo DA et al. Contingency management for smoking cessation: Enhancing feasibility through use of immunoassay test strips measuring cotinine. Nicotine & Tobacco Research 10(9): 1495-1501, 2008. (33 refs.)

Contingency management (CM) is a powerful behavioral intervention shown to reduce the use of a variety of substances including tobacco. Use of CM techniques for smoking cessation has been restricted by the use of multiple daily measurements of breath CO as the objective indicator to reinforce abstinence. Cotinine, with its longer half-life, may be a better marker. We evaluated the use of urinary cotinine (determined using once-daily semiquantitative immunoassay test strips and verified using quantitative GC/HPLC techniques) as an abstinence indicator in treatment-seeking adult and adolescent smokers participating in a CM-based intervention program. Both techniques of determining urinary cotinine were highly sensitive and moderately specific at detecting abstinence, and they were highly concordant. However, specificity was somewhat lower during the first few days of a quit attempt and improved over time. The results were similar in adults and adolescent smokers, and suggest that during the first few days of a quit attempt it would be advisable to continue to use daily multiple CO measurements to verify abstinence. However, once abstinence is achieved, once-daily immunoassay test strips could be used for continued monitoring of urinary cotinine levels. Immunoassay testing can identify individuals who relapse to smoking, though this study cannot evaluate whether the strips can identify resumption of abstinence. These results suggest that the use of cotinine as an abstinence indicator, by reducing the number of daily appointments, could significantly enhance the feasibility and utility of CM-based interventions for smoking cessation.

Schumacher JE; Milby JB; Wallace D; Meehan DC; Kertesz S; Vuchinich R; Dunning J; Usdan S. Meta-analysis of day treatment and contingency-management dismantling research: Birmingham homeless cocaine studies (1990-2006). Journal of Consulting and Clinical Psychology 75(5): 823-828, 2007. (15 refs.)

Four successive randomized clinical trials studying contingency management (CM), involving various treatment arms of drug-abstinent housing and work therapy and day treatment (DT) with a behavioral component, were compared on common drug abstinence outcomes at 2 treatment completion points (2 and 6 months). The clinical trials were conducted from 1990 to 2006 in Birmingham, Alabama, with a total of 644 homeless persons with primary crack cocaine addiction. The meta-analysis utilized the weighted least squares approach to integrate data encompassing 9 different treatment arms to assess the effects of CM and DT (neither, DT only, CM only, and CM + DT) on a common estimate of prevalence of drug abstinence. Taken together, the results show much stronger benefits from CM + DT and from CM only than for DT alone. Throughout all of the Birmingham Homeless Cocaine Studies, the CM + DT consistently produced higher abstinence prevalence than did no CM.

Silverman K; Roll JM; Higgins ST. Special issue on the behavioral analysis and treatment of drug addiction. (introduction). Journal of Applied Behavior Analysis 41(4): 471-480, 2008. (36 refs.)

Extensive evidence from the laboratory and the clinic suggests that drug addiction can be viewed as operant behavior and effectively treated through the application of principles of operant conditioning. Contingency management interventions that arrange for the direct reinforcement of drug abstinence or of other therapeutically important target behaviors (e.g., regular use of drug abuse treatment medications) are among the most studied type of operant treatments. Behavior analysts have contributed to the substantial and rapidly growing literature on operant treatments for drug addiction, but the Publications of this work usually appear in medical, clinical psychology, or drug abuse journals. This special issue of the Journal of Applied Behavior Analysis represents an effort to bring this important work to the attention of the behavior-analytic community. The articles in this special issue illustrate both the enormous potential of contingency management interventions to address the Serious and seemingly intractable problem of drug addiction as well as the real challenges involved in attempting to develop and disseminate treatments that will produce substantial and lasting changes in the lives of individuals plagued by the chronic problem of drug addiction.

Silverman K; Wong CJ; Needham M; Diemer KN; Knealing T; Crone-Todd D et al. A randomized trial of employment-based reinforcement of cocaine abstinence in injection drug users. Journal of Applied Behavior Analysis 40(3): 387-410, 2007. (51 refs.)

High-magnitude and long-duration abstinence reinforcement can promote drug abstinence but can be difficult to finance. Employment may be a vehicle for arranging high-magnitude and long-duration abstinence reinforcement. This study determined if employment-based abstinence reinforcement could increase cocaine abstinence in adults who inject drugs and use cocaine during methadone treatment. Participants could work 4 hr every weekday in a workplace where they could earn about $10.00 per hour in vouchers; they were required to provide routine urine samples. Participants who attended the workplace and provided cocaine-positive urine samples during the initial 4 weeks were invited to work 26 weeks and were randomly assigned to an abstinence-and-work (n = 28) or work-only (n = 28) group. Abstinence-and-work participants had to provide urine samples showing cocaine abstinence to work and maintain maximum pay. Work-only participants could work independent of their urinalysis results. Abstinence-and-work participants provided more (p = .004; OR = 5.80, 95% CI = 2.03-16.56) cocaine-negative urine samples (29%) than did work-only participants (10%). Employment-based abstinence reinforcement can increase cocaine abstinence.

Sindelar JL; Olmstead TA; Peirce JM. Cost-effectiveness of prize-based contingency management in methadone maintenance treatment programs. Addiction 102(9): 1463-1471, 2007. (26 refs.)

Aim: To determine if prize-based contingency management (CM), which has been shown to improve treatment outcomes over usual care (UC) alone, is cost-effective. Design: A cost-effectiveness study of a multi-site clinical trial. Data on the outcome measures came from the original effectiveness trial. Cost data were gathered by clinic survey specifically for this cost-effectiveness analysis. Setting: Six methadone maintenance community clinics participating in the National Drug Abuse Treatment Clinical Trials Network. Participants: Participants were recruited from six methadone maintenance community treatment programs. The study sample consisted of 388 participants: 190 in the UC condition and 198 in the CM condition. Participants were randomized at each site to either the UC or the CM condition based on the presence of stimulants (cocaine, amphetamine or methamphetamine) and opioids in their baseline urine sample. Intervention Prize-based contingency management added to usual care. Measurements Longest duration of abstinence (LDA), number of stimulant-negative urine samples and costs of treatment. Findings: Compared to usual care, the incremental cost of using prize-based CM to lengthen the LDA by 1 week was $141 [95% confidence interval (CI), $105-$193]. The incremental cost to obtain an additional stimulant-negative urine sample was $70 (95% CI, $53-$117). Conclusions: By comparing this study to a companion study, we found that adding prize-based CM to usual care may be more cost-effective in methadone maintenance clinics than in counseling-based drug-free clinics.

Sindelar, J.; Elbel, B.; Petry, NM. What do we get for our money? Cost-effectiveness of adding contingency management. Addiction 102(2): 309-316, 2007. (33 refs.)

To assess the relative cost-effectiveness of lower versus higher cost prize-based contingency management (CM) treatments for cocaine abuse. Design Cost-effectiveness analyses based on resource utilization, unit costs and outcomes from a previous CM efficacy trial. Setting Two community-based treatment centers. Participants Patients (n = 120) enrolled in out-patient treatment for cocaine abuse. Intervention Random assignment to one of three 12-week treatment conditions: standard treatment (STD) alone or two variants of STD combined with prize based CM. In CM, drawing for prizes was available to those submitting drug-free urine samples and completing goal-related activities. There were two levels of pay-out (referred to as $80 versus $240) based on the potential value of prizes won. Measurements Costs per participant associated with counseling utilization, urine and breathalyzer testing, and operation of the prize-drawing procedure were derived from a survey conducted at 16 clinics that had participated in CM studies. The three measures of effectiveness were: (1) longest duration of consecutive abstinence: (2) percentage completing treatment; and (3) percentage of samples drug-free. Findings : The higher magnitude CM produced outcomes at a lower per unit cost than did the lower magnitude prize CM treatment. This was the case for all three outcome measures examined and held across various assumptions in the sensitivity analysis. Conclusions Cost-effectiveness analyses can inform policy decisions regarding selection of one treatment model over another. Decisions on adoption of new evidence-based treatments would be aided by more information on society's willingness to pay for incremental gains in effectiveness.

Sorensen JL; Haug NA; Delucchi KL; Gruber V; Kletter E; Batki SL et al. Voucher reinforcement improves medication adherence in HIV-positive methadone patients: A randomized trial. Drug and Alcohol Dependence 88(1): 54-63, 2007. (43 refs.)

This clinical trial evaluated a contingency management intervention designed to improve medication adherence among HIV-positive methadone maintenance patients. After a 4-week baseline observation phase, eligible participants (N=66) were randomly assigned to: (a) medication coaching sessions every other week to assist with adherence strategies (comparison group) or (b) medication coaching plus voucher reinforcement for opening electronic medication caps on time (voucher group). Baseline adherence (percent doses taken/percent total possible doses) was 51% using electronic measurement, 75% using self-report and 75% using pill count. The intervention was provided for 12 weeks, with a 4-week follow-up. The primary outcome results of the clinical trial indicated effectiveness during the intervention, with significant mean adherence differences between voucher and comparison groups using electronic measurement (78% versus 56%), pill count (86% versus 75%), and self-report (87% versus 69%). Differences between groups faded after vouchers were discontinued. Contingency management shows promise as a strategy to promote antiretroviral medication adherence in this population.

Stevenson RJ. Payment for treatment adherence: Drug misusers are likely to abuse the system. (letter). British Medical Journal 335(7615): 317-317, 2007. (2 refs.)

Stitzer ML; Peirce J; Petry NM; Kirby K; Roll J; Krasnansky J et al. Abstinence-based incentives in methadone maintenance: Interaction with intake stimulant test results. Experimental and Clinical Psychopharmacology 15(4): 344-350, 2007. (22 refs.)

Baseline drug use detected in urine toxicology has been shown to predict drug abuse treatment outcome, including response to contingency management interventions with drug abstinence as their target. This study examined the association between baseline urine test result and treatment outcome in stabilized methadone maintenance patients with ongoing stimulant use to determine whether abstinence incentives were differentially effective in those testing stimulant negative versus positive at study entry. Participants were 386 methadone-maintained patients who took part in a National Drug Abuse Treatment Clinical Trials Network multisite study aimed at reducing stimulant abuse during treatment (J. M. Peirce et al., 2006). At study intake, 24% of participants tested stimulant negative and 76% tested positive. Those testing negative at entry submitted 82% negative urines during the study versus 36% for those testing positive at entry (odds ratio [OR] = 8.67; confidence interval [CI] = 5.81-12.94). Compared with those receiving usual care, the addition of abstinence incentives resulted in a significant increase in stimulant-negative urine samples submitted during the study both for those testing negative at study entry (OR = 2.27; CI = 1.13-4.75) and for those testing positive (OR = 1.84; CI = 1.25-2.71). These findings suggest that abstinence incentives have significant clinical benefits independent of initial drug use severity among methadone maintenance patients with ongoing stimulant drug use.

Stitzer ML; Vandrey R. Contingency management: Utility in the treatment of drug abuse disorders. Clinical Pharmacology and Therapeutics 83(4): 644-647, 2008. (34 refs.)

Contingency management (CM) is a strategy that uses positive reinforcement to improve the clinical outcomes of substance abusers in treatment, especially sustained abstinence from drugs of abuse. Further, CM has been adopted to improve methodology and interpretation of outcomes in clinical trials testing new pharmacotherapies and to improve adherence to efficacious medications in substance abuse patients. Thus, CM has proven to be widely useful as a direct therapeutic intervention and as a tool in treatment development.

Tevyaw TO; Gwaltney C; Tidey JW; Colby SM; Kahler CW; Miranda R et al. Contingency management for adolescent smokers: An exploratory study. Journal of Child & Adolescent Substance Abuse 16(4): 23-44, 2007. (40 refs.)

This exploratory study investigated the efficacy and feasibility of a contingency management (CM) protocol for adolescent smokers that included use of a reduction phase. Using a within-participants design, 19 adolescents completed three 7-day phases: (1) reinforcement for attendance and provision of breath samples (RA) phase, (2) a washout phase, (3) a CM phase, with order of CM and RA counterbalanced. In addition, participants were randomized to one of two reinforcement conditions during the CM phase: (1) CM-Abstinence condition (n = 9), wherein participants earned reinforcement only for carbon monoxide levels (CO) indicating abstinence; (2) CM-Reduction condition (n = 10), wherein participants earned reinforcement for reductions from baseline CO levels for the first half of the CM phase, followed by an abstinence contingency for the remainder of the phase. Compared with CM-Abstinence, adolescents in CM-Reduction demonstrated trends for more abstinent readings and had a significantly higher percentage of readings meeting criteria for reinforcement during the CM phase. Adolescents who received the RA phase first had lower CO readings during the subsequent CM phase than those who received CM first. Future research is warranted on the effects of introducing RA and other control conditions prior to administration of CM, on strengthening the magnitude of the reinforcement, on instituting reinforcement schedules that program more reinforcers and with longer duration to maximize the efficacy of CM-based interventions, and on increasing the exportability of CM for smoking through advances in biochemical data collection and assessment techniques.

Tracy K; Babuscio T; Nich C; Kiluk B; Carroll KM; Petry NM et al. Contingency management to reduce substance use in individuals who are homeless with co-occurring psychiatric disorders. American Journal of Drug and Alcohol Abuse 33(2): 253-258, 2007. (9 refs.)

Homeless shelters provide a unique opportunity to intervene with occupants who have substance abuse problems, as not addressing these issues may lead to continuation of problems playing a contributing role in homelessness. Attempts to implement Contingency Management (CM) with this population have often been complex, costly, and not straightforward to replicate in community settings. We conducted a randomized trial evaluating a simple, low-cost 4-week CM program for 30 individuals seeking shelter in a community-based homeless shelter who had both current substance and psychiatric disorders. Behavioral assessments were performed at baseline, weekly, and termination of the study. Overall retention in the trial was high; participants assigned to CM reduced their cocaine and alcohol use more than those in assessment-only. This pilot trial suggests that application of low-cost CM procedures is feasible within this novel setting and may decrease substance use.

Trujols J; Luquero E; Sinol N; Banuls E; Tejero A; Batlle F et al. Cognitive-behavioral therapy for the treatment of cocaine dependence. (review). Actas Esponolas de Psiquiatria 35(3): 190-198, 2007. (85 refs.)

The past two decades have been characterized by marked progress in the development of effective cognitive-behavioral therapies for cocaine dependence, for which no generally effective pharmacotherapies have been identified. The increasing literature on the efficacy of several types of cognitive-behavioral therapies (community reinforcement approach plus vouchers, cue exposure treatment, relapse prevention therapy and motivational interviewing) for cocaine use disorders is reviewed, followed by discussion of a number of issues that arise when integrating these cognitive-behavioral interventions into clinical practice. Overall, this review describes a vigorous area of research that has much to contribute to the treatment of cocaine use disorders.

Vandrey R; Bigelow GE; Stitzer ML. Contingency management in cocaine abusers: A dose-effect comparison of goods-based versus cash-based incentives. Experimental and Clinical Psychopharmacology 15(4): 338-343, 2007. (18 refs.)

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

Weinstock J; Alessi SM; Petry NM. Regardless of psychiatric severity the addition of contingency management to standard treatment improves retention and drug use outcomes. Drug and Alcohol Dependence 87(2/3): 288-296, 2007. (45 refs.)

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

Weinstock J; Barry D; Petry NM. Exercise-related activities are associated with positive outcome in contingency management treatment for substance use disorders. Addictive Behaviors 33(8): 1072-1075, 2008. (9 refs.)

Exercise has been proposed as an adjunct intervention for substance use disorders due to its many benefits in terms of mental and physical health. This study investigated the association between completion of exercise-related activities and substance use disorders treatment outcome in a sample of 187 participants undergoing intensive outpatient treatment with contingency management. The sample was divided into two groups based upon whether or not an individual completed an exercise-related activity. Individuals who engaged in exercise-related activities (n =45) were found to achieve longer durations of abstinence during treatment than individuals who did not complete an exercise-related activity (n = 142). Overall, these findings suggest that exercise may be of benefit to individuals undergoing substance use disorders treatment. Methods for implementing an exercise intervention within substance use disorders treatment are discussed.

Wong CJ; Silverman K. Establishing and maintaining job skills and professional behaviors in chronically unemployed drug abusers. Substance Use & Misuse 42(7): 1127-1140, 2007. (15 refs.)

The therapeutic workplace intervention is an employment-based drug user intervention that integrates abstinence reinforcement contingencies into an employment setting, intended for individuals manifesting chronic unemployment and drug addiction. Research on the therapeutic workplace intervention has provided a unique and rare opportunity to collect data and conduct fine-grained analyses of the training and work performance of participants. Results from a series of studies document that chronically unemployed drug users display behaviors that likely limit their success in conventional businesses. This article reviews a systematic line of research showing that targeted and intensive contingency management interventions and training programs have been effective in promoting consistent attendance and high rates of productivity and establishing job skills for employment.