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CORK Bibliography: Contingency Management

77 citations. January 2009 to present

Prepared: March 2012

Alessi SM; Rash C; Petry NM. Contingency management is efficacious and improves outcomes in cocaine patients with pretreatment marijuana use. Drug and Alcohol Dependence 118(1): 62-67, 2011. (41 refs.)

Background: Marijuana use is common in patients seeking treatment for cocaine use. Nevertheless, few studies have examined effects of marijuana use on treatment outcomes in general, and even fewer with respect to contingency management (CM) treatment, which has been criticized for potentially increasing non-reinforced drug use. Methods: Data from three randomized clinical trials of CM versus standard treatment (ST) in cocaine-abusing patients were examined (Petty et al., 2004, 2005a, 2006a; N = 393) to assess effects of pretreatment marijuana use on outcomes. Patients were divided into two groups: (1) no self-reported marijuana use (No Pre-M; n = 315) and (2) any self-reported marijuana use (Pre-M; n = 78) in the 30 days pretreatment. Results: CM� was especially efficacious in enhancing retention in Pre-M patients such that retention nearly doubled among Pre-M patients assigned to CM versus those assigned to ST. In contrast, CM exerted only modest benefits on retention in No Pre-M patients. Pretreatment marijuana use was not related to during-treatment abstinence from cocaine, opioids, and alcohol, or abstinence at a Month 9 follow-up. However, CM treatment and longest duration of abstinence achieved during treatment were significant predictors of Month 9 abstinence. Pre-M patients also evidenced more improvements in drug problems over time when randomized to CM. Conclusions: CM was especially efficacious in facilitating retention and improving severity of drug-related problems in those who used marijuana in the month before initiating treatment.

Barnett NP; Tidey J; Murphy JG; Swift R; Colby SM. Contingency management for alcohol use reduction: A pilot study using a transdermal alcohol sensor. Drug and Alcohol Dependence 118(2-3): 391-399, 2011. (27 refs.)

Background: Contingency management (CM) has not been thoroughly evaluated as a treatment for alcohol abuse or dependence, in part because verification of alcohol use reduction requires frequent in-person breath tests. Transdermal alcohol sensors detect alcohol regularly throughout the day, providing remote monitoring and allowing for rapid reinforcement of reductions in use. Methods: The purpose of this study was to evaluate the efficacy of CM for reduction in alcohol use, using a transdermal alcohol sensor to provide a continuous measure of alcohol use. Participants were 13 heavy drinking adults who wore the Secure Continuous Remote Alcohol Monitoring (SCRAM) bracelet for three weeks and provided reports of alcohol and drug use using daily web-based surveys. In Week 1, participants were asked to drink as usual; in Weeks 2 and 3, they were reinforced on an escalating schedule with values ranging from $5 to $17 per day on days when alcohol use was not reported or detected by the SCRAM. Results: Self-reports of percent days abstinent and drinks per week, and transdermal measures of average and peak transdermal alcohol concentration and area under the curve declined significantly in Weeks 2-3. A nonsignificant but large effect size for reduction in days of tobacco use also was found. An adjustment to the SCRAM criteria for detecting alcohol use provided an accurate but less conservative method for use with non-mandated clients. Conclusion: Results support the efficacy of CM for alcohol use reductions and the feasibility of using transdermal monitoring of alcohol use for clinical purposes.

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.

Bickel WK; Jones BA; Landes RD; Christensen DR; Jackson L; Mancino M. Hypothetical intertemporal choice and real economic behavior: Delay discounting predicts voucher redemptions during contingency-management procedures. Experimental and Clinical Psychopharmacology 18(6): 546-552, 2010. (40 refs.)

Delay discounting rates are predictive of drug use status, the likelihood of becoming abstinent, and a variety of health behaviors. Rates of delay discounting may also be related to other relevant behaviors associated with addiction, such as the frequency at which individuals redeem contingency management voucher earnings. This study examined the discounting rates of 152 participants in a buprenorphine treatment program for opioid abuse. Participants received up to 12 weeks of buprenorphine treatment combined with contingency management. Participant's drug use was measured via urine specimens submitted three times a week. Successive negative urine specimens were reinforced with increasing amounts of money. After each negative urine specimen, a participant could either redeem his or her earnings or accumulate it in an account Analysis of the frequency of redemptions showed that participants with higher rates of delay discounting at study intake redeemed their earnings significantly more often than participants with lower rates of discounting. Age and income also predicted redemption rates. We suggest that delay discounting rates can be used to predict redemption behaviors in a contingency management treatment program and that these findings are consistent with the recent theory of the competing neurobehavioral decision systems.

Bisaga A; Aharonovich E; Cheng WY; Levin FR; Mariani JJ; Raby WN et al. A placebo-controlled trial of memantine for cocaine dependence with high-value voucher incentives during a pre-randomization lead-in period. Drug and Alcohol Dependence 111(1-2): 97-104, 2010. (53 refs.)

Preclinical findings suggest that the inhibition of NMDA glutamatergic neurotransmission may have beneficial effects in the treatment of cocaine dependence. We hypothesized that memantine, a low potency, uncompetitive NMDA receptor antagonist, would be safe and effective in the treatment of cocaine dependence, particularly in preventing relapse to cocaine use in abstinent individuals. Cocaine dependent patients (N = 112) were enrolled. The trial began with a 2-week placebo lead-in period during which patients received high-value voucher contingency management to induce abstinence. Participants were then randomized to receive either memantine 20 mg bid (N = 39) or placebo (N = 42) for 12-weeks in combination with individual relapse-prevention therapy. The randomization was stratified by abstinence status during the lead-in period. The primary outcome was the weekly proportion of days of cocaine use. There were no significant differences in cocaine use outcome between the groups treated with memantine versus placebo. Thus, the efficacy of memantine 40 mg/d for the treatment of cocaine dependence was not supported. Urine-confirmed abstinence during the lead-in period was achieved by 44% of participants, and was a strong predictor of subsequent cocaine abstinence during the trial. This suggests that this clinical trial design, an intensive behavioral intervention during a lead-in period, resolves cocaine dependent patients into two subgroups, one that rapidly achieves sustained abstinence and may not need a medication, and another that displays persistent cocaine use and would most likely benefit from a medication to help induce abstinence. Targeting the latter subgroup may advance medication development efforts.

Bride BE; Abraham AJ; Roman PM. Diffusion of contingency management and attitudes regarding its effectiveness and acceptability. Substance Abuse 31(3): 127-135, 2010. (32 refs.)

Substance abuse counselors are critical as the key arbiters of clients' acceptance and use of innovative treatment techniques, with their potential support embedded in their knowledge of and attitudes towards particular innovations. In this analysis the authors examine the role of substance abuse counselors in the adoption of a psychosocial treatment innovation, contingency management (CM). Using data collected from 1140 counselors employed in a national sample of 318 public treatment centers, the authors examine theoretical predictors of counselors' knowledge of CM, and their attitudes regarding CM's effectiveness and acceptability. Findings suggest that lack of exposure to CM through program use and innovation-specific training is the most salient barrier to CM adoption and diffusion. The study also highlights the importance of social networks in the diffusion and acceptance of treatment innovations.

Bride BE; Abraham AJ; Roman PM. Organizational factors associated with the use of contingency management in publicly funded substance abuse treatment centers. Journal of Substance Abuse Treatment 40(1): 87-94, 2011. (54 refs.)

A promising area within technology transfer studies is the identification of organizational factors that influence the adoption of treatment innovations. Although studies have identified organizational factors associated with the adoption of pharmacological innovations, few studies have examined organizational factors in the adoption of psychosocial innovations, among which contingency management (CM) is a significant practice. Using data from a sample (N = 318) drawn from the population of publicly funded treatment centers in the United States, this study modeled organizational factors falling in the domains of structural characteristics, workforce variables, values and norms, and patient characteristics associated with the use of CM. Organizations were more likely to use CM if they embrace a supportive therapeutic approach, are research friendly, offer only outpatient levels of care, or serve drug-court patients. Implications for studying the diffusion and implementation of evidence-based psychosocial interventions are discussed.

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

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

Budney AJ; Fearer S; Walker DD; Stanger C; Thostenson J; Grabinski M et al. An initial trial of a computerized behavioral intervention for cannabis use disorder. Drug and Alcohol Dependence 115(1-2): 74-79, 2011. (34 refs.)

The most potent outcomes for cannabis use disorders have been observed with a combination of three evidence-based interventions, motivational enhancement therapy (MET), cognitive-behavioral therapy (CBT), and abstinence-based contingency-management (CM). Access to this intervention remains limited because of cost and service availability issues. This report describes the initial stages of a project designed to develop and test a computer-assisted version of MET/CBT/CM that could address, many of the current barriers to its dissemination. A nonrandomized, 12-week comparison study assigned 38 adults seeking treatment for a cannabis use disorder to either therapist-delivered (n = 22) or computer-delivered (n = 16) MET/CBT/CM. Attendance, retention, and cannabis use outcomes did not differ significantly between groups, and there were no indications of superior outcomes favoring therapist delivery. Participants provided positive ratings of the computer-delivered sessions. These preliminary findings suggest that computer-assisted delivery of MET/CBT/CM is acceptable to outpatients and does not adversely impact compliance or outcomes achieved during treatment with MET/CBT/CM for cannabis use disorders. Assessment of post-treatment outcomes and replication in randomized trials are needed to determine reliability and longer term effects. As observed in a growing number of studies, computerized therapies have the potential to increase access to, reduce costs, and enhance fidelity of providing evidence-based treatments without sacrificing and possibly enhancing effectiveness.

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

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

Cavallo DA; Nich C; Schepis TS; Smith AE; Liss TB; McFetridge AK et al. Preliminary examination of adolescent spending in a contingency management-based smoking-cessation program. Journal of Child & Adolescent Substance Abuse 19(4): 335-342, 2010. (14 refs.)

Contingency management (CM) utilizing monetary incentives is efficacious in enhancing abstinence in an adolescent smoking-cessation program, but how adolescents spend their money has not been examined. We assessed spending habits of 38 adolescent smokers in a CM-based smoking-cessation project prior to quitting and during treatment using a questionnaire about spending in a number of categories, including cigarettes, other addictive substances, durable goods, and disposable goods. Our preliminary results indicate that participation in a CM-based program for smoking cessation did not lead to greater spending on cigarettes and other substances and may have produced more socially acceptable spending.

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

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

Chung T; Geier C; Luna B; Pajtek S; Terwilliger R; Thatcher D; Clark DB. Enhancing response inhibition by incentive: Comparison of adolescents with and without substance use disorder. Drug and Alcohol Dependence 115(1-2): 43-50, 2011. (52 refs.)

Effective response inhibition is a key component of recovery from addiction. Some research suggests that response inhibition can be enhanced through reward contingencies. We examined the effect of monetary incentive on response inhibition among adolescents with and without substance use disorder (SLID) using a fast event-related fMRI antisaccade reward task. The fMRI task permits investigation of how reward (monetary incentive) might modulate inhibitory control during three task phases: cue presentation (reward or neutral trial), response preparation, and response execution. Adolescents with lifetime SUD (n = 12; 100% marijuana use disorder) were gender and age-matched to healthy controls (n = 12). Monetary incentive facilitated inhibitory control for SUD adolescents: for healthy controls, the difference in error rate for neutral and reward trials was not significant. There were no significant differences in behavioral performance between groups across reward and neutral trials, however, group differences in regional brain activation were identified. During the response preparation phase of reward trials, SUD adolescents, compared to controls, showed increased activation of prefrontal and oculomotor control (e.g., frontal eye field) areas, brain regions that have been associated with effective response inhibition. Results indicate differences in brain activation between SUD and control youth when preparing to inhibit a prepotent response in the context of reward, and support a possible role for incentives in enhancing response inhibition among youth with SUD.

Dallery J; Raiff BR. Contingency management in the 21st century: Technological innovations to promote smoking cessation. Substance Use & Misuse 46(1): 10-22, 2011. (90 refs.)

Information technology represents an excellent medium to deliver contingencies of reinforcement to change behavior. Recently, we have linked the Internet with a science-based, behavioral treatment for cigarette smoking: abstinence reinforcement therapy. Under abstinence reinforcement interventions, incentives are provided for objective evidence of abstinence. Several studies suggest that the intervention is effective in initiating abstinence. The intervention addresses limitations (access, cost, sustainability, and dissemination potential) inherent in traditional abstinence reinforcement delivery models. It can also be applied to vulnerable, at-risk populations, and to other behavior to promote health. Information technologies offer unprecedented and rapidly expanding opportunities to facilitate behavior change.

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

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

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

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

Ducharme LJ; Knudsen HK; Abraham AJ; Roman PM. Counselor attitudes toward the use of motivational incentives in addiction treatment. American Journal on Addictions 19(6): 496-503, 2010. (39 refs.)

Counselor attitudes toward evidence-based practices, such as motivational incentives/contingency management (MI/CM), are important in bridging the gap between research and practice. Mailed surveys from 1,959 substance abuse treatment counselors showed ambivalence toward MI/CM and strong disagreement with using monetary rewards for achievement of treatment goals. Attitudes were associated with counselors' educational attainment, a 12-step treatment ideology, affiliation with NIDA's Clinical Trials Network, and working in opioid treatment programs. Exposure to MI/CM via training was more strongly associated with attitudes when counselors worked in programs that had adopted MI/CM. While there is substantial resistance to MI/CM, dissemination and training about the essential elements of MI/CM may enhance counselors' receptivity toward this intervention.

Dunn KE; Saulsgiver KA; Sigmon SC. Contingency management for behavior change: Applications to promote brief smoking cessation among opioid-maintained patients. Experimental and Clinical Psychopharmacology 19(1): 20-30, 2011. (86 refs.)

Cigarette smoking is highly prevalent among patients who are being treated for opioid-dependence, yet there have been limited scientific efforts to promote smoking cessation in this population. Contingency management (CM) is a behavioral treatment that provides monetary incentives contingent upon biochemical evidence of drug abstinence. This paper discusses the results of two studies that utilized CM to promote brief smoking cessation among opioid-maintained patients. Participants in a pilot study were randomly assigned for a 2-week period to a Contingent group that earned monetary vouchers for providing biochemical samples that met criteria for smoking abstinence, or a Noncontingent group that earned monetary vouchers independent of smoking status (Dunn et al, 2008). Results showed Contingent participants provided significantly more smoking-negative samples than Noncontingent participants (55% vs. 5%, respectively). A second randomized trial that utilized the same 2-week intervention and provided access to the smoking cessation pharmacotherapy bupropion replicated the results of the pilot study (55% and 17% abstinence in Contingent and Noncontingent groups, respectively; Dunn et al, 2010). Relapse to illicit drug use was also evaluated prospectively and no association between smoking abstinence and relapse to illicit drug use was observed (Dunn et al, 2009). It will be important for future studies to evaluate participant characteristics that might predict better treatment outcome, to assess the contribution that pharmacotherapies might have alone or in combination with a CM intervention on smoking cessation and to evaluate methods for maintaining the abstinence that is achieved during this brief intervention for longer periods of time.

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

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

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

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

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

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

Everly JJ; DeFulio A; Koffarnus MN; Leoutsakos JMS; Donlin WD; Aklin WM et al. Employment-based reinforcement of adherence to depot naltrexone in unemployed opioid-dependent adults: A randomized controlled trial. Addiction 106(7): 1309-1318, 2011. (38 refs.)

Aims: Naltrexone can be used to treat opioid dependence, but patients refuse to take it. Extended-release depot formulations may improve adherence, but long-term adherence rates to depot naltrexone are not known. This study determined long-term rates of adherence to depot naltrexone and whether employment-based reinforcement can improve adherence. Design: Participants who were inducted onto oral naltrexone were assigned randomly to contingency (n = 18) or prescription (n = 17) groups. Participants were offered six depot naltrexone injections and invited to work at the therapeutic workplace on week days for 26 weeks, where they earned stipends for participating in job skills training. Contingency participants were required to accept naltrexone injections to maintain workplace access and to maintain maximum pay. Prescription participants could work independently of whether they accepted injections. Setting: The therapeutic workplace, a model employment-based intervention for drug addiction and unemployment. Participants Opioid-dependent unemployed adults. Measurements Depot naltrexone injections accepted and opiate-negative urine samples. Findings: Contingency participants accepted significantly more naltrexone injections than prescription participants (81% versus 42%), and were more likely to accept all injections (66% versus 35%). At monthly assessments (with missing urine samples imputed as positive), the groups provided similar percentages of samples negative for opiates (74% versus 62%) and for cocaine (56% versus 54%). Opiate-positive samples were more likely when samples were also positive for cocaine. Conclusions: Employment-based reinforcement can maintain adherence to depot naltrexone. Future research should determine whether persistent cocaine use compromises naltrexone's effect on opiate use. Workplaces may be useful for promoting sustained adherence to depot naltrexone.

Garcia-Fernandez G; Secades-Villa R; Garcia-Rodriguez O; Alvarez-Lopez H; Fernandez-Hermida JR; Fernandez-Artamendi S et al. Long-term benefits of adding incentives to the Community Reinforcement Approach for cocaine dependence. European Addiction Research 17(3): 139- 145, 2011. (40 refs.)

Background: The community reinforcement approach (CRA) with vouchers is a well-established program developed for the treatment of cocaine addiction. It involves an incentive program in which patients earn vouchers that can be exchanged for goods or services contingent upon abstinence from cocaine use. Aim: To examine the contributions of incentives to retention, abstinence, and psychosocial outcomes in the CRA + vouchers program at the 12-month follow-up. Methods: 58 cocaine addicts were randomly assigned to CRA treatment with or without an added incentive program in a community setting for cocaine dependence in Spain. Results: 65.5% of patients in the group with vouchers completed 12 months of treatment, versus 48.3% in the novoucher group. In the CRA + vouchers group, mean percentage of cocaine-negative samples was 95.76%, versus 79.31% in the group without vouchers. There were significant improvements in psychosocial functioning in both treatments, but when differences were observed, they supported CRA with vouchers over CRA alone. Conclusion: Combining CRA with incentives improves treatment outcomes in cocaine-dependent outpatients. Additive benefits of vouchers remain 6 months after the incentive program ends.

Garcia-Fernandez G; Secades-Villa R; Garcia-Rodriguez O; Alvarez-Lopez H; Sanchez-Hervas E; Fernandez-Hermida JR et al. Individual characteristics and response to contingency management treatment for cocaine addiction. Psicothema 23(1): 114-118, 2011. (39 refs.)

Voucher-based contingency management (CM) research has demonstrated efficacy for treating cocaine addiction, but few studies have examined associations between individual baseline characteristics and response to CM treatments. The aim of this study, involving 50 cocaine outpatients receiving CM for cocaine addiction, was to assess the impact of baseline characteristics on abstinence outcomes after six months of treatment. Patients who were abstinent after six months of treatment accounted for 58% of the sample. Patients with higher scores on the Alcohol area of the EuropASI and patients that were non-abstinent during the first month of treatment were less likely to achieve abstinence. These outcome predictors have implications both for treatment research and for clinical practice. Patients who do not respond early to treatment may need a more intensive intervention, and concomitant problematic alcohol use should be detected and treated. The remaining baseline variables examined were not statistically significant predictors of abstinence. This finding is important for the generalizability of CM across the range of individual characteristics of treatment-seeking cocaine abusers.

Garcia-Fernandez G; Secades-Villa R; Garcia-Rodriguez O; Sanchez-Hervas E; Fernandez-Hermida JR; Higgins ST. Adding voucher-based incentives to community reinforcement approach improves outcomes during treatment for cocaine dependence. American Journal on Addictions 20(5): 456-461, 2011. (20 refs.)

This study compares the efficacy of the Community Reinforcement Approach (CRA) with and without an incentive program for cocaine-dependent patients in Spain. A total of 58 patients were randomly assigned to the CRA or CRA plus vouchers condition. In the CRA plus vouchers group, mean percentage of cocaine-negative samples was 97.07%, versus 79.76% in the no-voucher group. Those treated in the CRA plus vouchers condition also achieved greater improvements in psychosocial functioning than those treated in the CRA condition. The present results show that treatment outcome is better if incentives are delivered contingent upon the submission of cocaine-free urine specimens.

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

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

Gifford EV; Tavakoli S; Weingardt KR; Finney JW; Pierson HM; Rosen CS et al. How do components of evidence-based psychological treatment cluster in practice? A survey and cluster analysis. Journal of Substance Abuse Treatment 42(1): 45-55, 2012. (66 refs.)

Evidence-based psychological treatments (EBPTs) are clusters of interventions, but it is unclear how providers actually implement these clusters in practice. A disaggregated measure of EBPTs was developed to characterize clinicians' component-level evidence-based practices and to examine relationships among these practices. Survey items captured components of evidence-based treatments based on treatment integrity measures. The Web-based survey was conducted with 75 U.S. Department of Veterans Affairs (VA) substance use disorder (SUD) practitioners and 149 non-VA community-based SUD practitioners. Clinician's self-designated treatment orientations were positively related to their endorsement of those EBPT components; however, clinicians used components from a variety of EBPTs. Hierarchical cluster analysis indicated that clinicians combined and organized interventions from cognitive-behavioral therapy, the community reinforcement approach, motivational interviewing, structured family and couples therapy, 12-step facilitation, and contingency management into clusters including empathy and support, treatment engagement and activation, abstinence initiation, and recovery maintenance. Understanding how clinicians use EBPT components may lead to improved evidence-based practice dissemination and implementation.

Haley SJ; Dugosh KL; Lynch KG. Performance contracting to engage detoxification-only patients into continued rehabilitation. Journal of Substance Abuse Treatment 40(2): 123-131, 2011. (48 refs.)

In 2006, only 18.7% of Delaware's detoxification patients were admitted to continuing recovery-oriented treatment within 30 days after discharge. In response, Delaware established financial contingencies to (1) maintain 90% detoxification occupancy, (2) make receipt of 10% of the facility's monthly reimbursement contingent on 25% of patients entering treatment, and (3) provide a $500 bonus for every patient with three or more prior detoxification visits who was retained in treatment. Under the performance contract, the detoxification provider (1) maintained the 90% occupancy requirement, (2) achieved the 25% treatment entry target for 7 of 12 months, and (3) observed only 8% (27/337) of detoxification completions that met the targeted length of stay. Continuation to and retention in treatment was even more constrained for patients with three or more prior detoxifications. Contrary to the policy intent, the number of patients with three or more detoxifications in fiscal year (FY) 2008 is nearly triple that of FY 2006. The modest gain in the transition rate was achieved without changes in patient access; the FY 2008 patient population reported significantly higher rates of homelessness and a younger age of first use than before the performance contract in FY 2006. Performance contracting may offer promise for improving transition to treatment rates. However, the unique needs of detoxification patients, the treatment capacity of each level of care to meet patient needs, and the structure of the performance contract must be carefully considered. Performance contracting efforts may be strengthened when service contracts across the system are tightly synchronized.

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

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

Higgins ST. Comments on contingency management and conditional cash transfers. Health Economics 19(10): 1255-1258, 2010. (21 refs.)

This essay discusses research on incentive-based interventions to promote healthy behavior change, contingency management (CM) and conditional cash transfers (CCT). The overarching point of the essay is that CM and CCT are often treated as distinct areas of inquiry when at their core they represent a common approach. Some potential bi-directional benefits of recognizing this commonality are discussed. Distinct intellectual traditions probably account for the separate paths of CM and CCT to date, with the former being rooted in behavioral psychology and the latter in microeconomics. It is concluded that the emerging field of behavioral economics, which is informed by and integrates principles of each of those disciplines, may provide the proper conceptual framework for integrating CM and CCT.

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

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

Hser YI; Li JH; Jiang HF; Zhang RM; Du J; Zhang CB et al. Effects of a randomized contingency management intervention on opiate abstinence and retention in methadone maintenance treatment in China. Addiction 106(10): 1801-1809, 2011. (25 refs.)

Aims: Methadone maintenance treatment has been made available in China in response to the rapid spread of human immunodeficiency virus (HIV), but high rates of dropout and relapse are problematic. The aim of this study was to apply and test if a contingency management (or motivational incentives) intervention can improve treatment retention and reduce drug use. Design: Random assignment to usual care with (n = 160) or without (n = 159) incentives during a 12-week trial. Incentives participants earned draws for a chance to win prizes on two separate tracks targeting opiate-negative urine sample or consecutive attendance; the number of draws increased with continuous abstinence or attendance. Setting: Community-based methadone maintenance clinics in Shanghai and Kunming. Participants: The sample was 23.8% female, mean age was 38, mean years of drug use was 9.4 and 57.8% had injected drugs in the past 30 days. Measurements: Treatment retention and negative drug urine. Findings Relative to the treatment-asusual (control) group, better retention was observed among the incentive group in Kunming (75% versus 44%), but no difference was found in Shanghai (90% versus 86%). Submission of negative urine samples was more common among the incentive group than the usual care (74% versus 68% in Shanghai, 27% versus 18% in Kunming), as was the longest duration of sustained abstinence (7.7 weeks versus 6.5 in Shanghai, 2.5 versus 1.6 in Kunming). The average total prize amount was 371 Yuan (or $55) per participant (527 for Shanghai versus 216 in Kunming). Conclusions: Contingency management improves treatment retention and drug abstinence in methadone maintenance treatment clinics in China, although there can be considerable site differences in magnitude of effects.

Jia ZR; Worhunsky PD; Carroll KM; Rounsaville BJ; Stevens MC; Pearlson GD et al. An initial study of neural responses to monetary incentives as related to treatment outcome in cocaine dependence. Biological Psychiatry 70(6): 553-560, 2011. (54 refs.)

Background: Although cocaine dependence (CD) involves abnormalities in drug-related, reward-based decision making, it is not well understood whether these abnormalities generalize to nondrug-related cues and rewards and how neural functions underlying reward processing in cocaine abusers relate to treatment outcome. Methods: Twenty CD patients before treatment and 20 matched healthy control (HC) subjects participated in functional magnetic resonance imaging while performing a monetary incentive delay task. Outcomes through 8 weeks were assessed via percent cocaine-negative urine toxicology, self-reported cocaine abstinence, and treatment retention. Results: Among the whole sample, anticipation of working for monetary reward (i.e., reward anticipation) was associated with activation in the ventral striatum (VS), medial frontal gyrus, thalamus, right subcallosal gyrus, right insula, and left amygdala. Cocaine dependence compared with HC participants exhibited greater activation during notification of rewarding outcome (i.e., reward receipt) in left and right VS, right caudate, and right insula. In CD participants during reward anticipation, activation in left and right thalamus and right caudate correlated negatively with percent cocaine-negative urine toxicology, activation in thalamus bilaterally correlated negatively with self-reported abstinence measures, and activation in left amygdala and parahippocampal gyrus correlated negatively with treatment retention. During reward notification, activation in right thalamus, right VS, and left culmen correlated negatively with abstinence and with urine toxicology. Conclusions: These findings suggest that in treatment-seeking CD participants, corticolimbic reward circuitry is relatively overactivated during monetary incentive delay task performance and specific regional activations related to reward processing may predict aspects of treatment outcome and represent important targets for treatment development in CD.

Kelly TM; Daley DC; Douaihy AB. Treatment of substance abusing patients with comorbid psychiatric disorders. (review). Addictive Behaviors 37(1): 11-24, 2012. (184 refs.)

Objective: To update clinicians on the latest in evidence-based treatments for substance use disorders (SUD) and non-substance use disorders among adults and suggest how these treatments can be combined into an evidence-based process that enhances treatment effectiveness in comorbid patients. Method: Articles were extracted from Pubmed using the search terms "dual diagnosis," "comorbidity" and "co-occurring" and were reviewed for evidence of effectiveness for pharmacologic and psychotherapeutic treatments of comorbidity. Results: Twenty-four research reviews and 43 research trials were reviewed. The preponderance of the evidence suggests that antidepressants prescribed to improve substance-related symptoms among patients with mood and anxiety disorders are either not highly effective or involve risk due to high side-effect profiles or toxicity. Second generation antipsychotics are more effective for treatment of schizophrenia and comorbid substance abuse and current evidence suggests clozapine, olanzapine and risperidone are among the best. Clozapine appears to be the most effective of the antipsychotics for reducing alcohol, cocaine and cannabis abuse among patients with schizophrenia. Motivational interviewing has robust support as a highly effective psychotherapy for establishing a therapeutic alliance. This finding is critical since retention in treatment is essential for maintaining effectiveness. Highly structured therapy programs that integrate intensive outpatient treatments, case management services and behavioral therapies such as Contingency Management (CM) are most effective for treatment of severe comorbid conditions. Conclusions: Creative combinations of psychotherapies, behavioral and pharmacological interventions offer the most effective treatment for comorbidity. Intensity of treatment must be increased for severe comorbid conditions such as the schizophrenia/cannabis dependence comorbidity due to the limitations of pharmacological treatments.

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

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

Koffarnus MN; Wong CJ; Diemer K; Needham M; Hampton J; Fingerhood M et al. A randomized clinical trial of a therapeutic workplace for chronically unemployed, homeless, alcohol-dependent adults. Alcohol and Alcoholism 46(5): 561-569, 2011. (48 refs.)

Aims: To assess the efficacy of the Therapeutic Workplace, a substance abuse intervention that promotes abstinence while simultaneously addressing the issues of poverty and lack of job skills, in promoting abstinence from alcohol among homeless alcoholics. Methods: Participants (n = 124) were randomly assigned to conditions either requiring abstinence from alcohol to engage in paid job skills training (Contingent Paid Training group), offering paid job skills training with no abstinence contingencies (Paid Training group) or offering unpaid job skill training with no abstinence contingencies (Unpaid Training group). Results: Participants in the Contingent Paid Training group had significantly fewer positive (blood alcohol level >= 0.004 g/dl) breath samples than the Paid Training group in both randomly scheduled breath samples collected in the community and breath samples collected during monthly assessments. The breath sample results from the Unpaid Training group were similar in absolute terms to the Contingent Paid Training group, which may have been influenced by a lower breath sample collection rate in this group and fewer reported drinks per day consumed at intake. Conclusion: Overall, the results support the utility of the Therapeutic Workplace intervention to promote abstinence from alcohol among homeless alcoholics, and support paid training as a way of increasing engagement in training programs.

Kollins SH; McClernon FJ; Van Voorhees EE. Monetary incentives promote smoking abstinence in adults with Attention Deficit Hyperactivity Disorder (ADHD). Experimental and Clinical Psychopharmacology 18(3): 221-228, 2010. (50 refs.)

Individuals with attention deficit hyperactivity disorder (ADHD) smoke at rates significantly higher than the general population and have more difficulty quitting than nondiagnosed individuals. Currently, there are no evidence-based approaches for reducing smoking specifically in individuals with ADHD. Adult regular smokers with or without ADHD participated in a study of extended smoking withdrawal where monetary incentives were used to promote abstinence. Participants were paid according to an escalating schedule for maintaining abstinence measured as self-report of no smoking and an expired air carbon monoxide (CO) level of 4 parts per million. Sixty-four percent (14/22) of smokers with ADHD and 50% (11/22) of smokers without ADHD maintained complete abstinence for the 2-week duration of the study. Twenty-two percent (5/22) and 9% (2/22) of smokers with ADHD and without ADHD, respectively, maintained continued abstinence for up to 10 days following the removal of the contingencies. Though abstinence rates were higher for the smokers with ADHD, the group differences were not statistically significant. Results suggest that monetary incentives may be a useful approach for promoting abstinence in adult smokers with ADHD, perhaps owing to altered reinforcement processes in these individuals.

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

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

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

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

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

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

Lubman DI; King JA; Castle DJ. Treating comorbid substance use disorders in schizophrenia. International Review of Psychiatry 22(2): 191-201, 2010. (74 refs.)

Aim: To review the literature on pharmacological and psychosocial treatment approaches for people with schizophrenia and comorbid substance use disorder(s) (SUD). Method: Selective literature review. Results: Despite the high prevalence of comorbid SUD among people with schizophrenia, there is a considerable paucity of rigorously conducted randomized controlled treatment trials. While there is some evidence for clozapine, and for the adjunctive use of agents such as naltrexone for comorbid alcohol dependence, the available literature largely comprises case studies, case series, open label studies and retrospective surveys. In terms of psychosocial approaches, there is reasonable consensus that integrated approaches are most appropriate. Regarding specific aspects of care, motivational interviewing, cognitive behavioural therapy and contingency management have an emerging supportive literature, as do family interventions. However, there is no 'one size fits all', and a flexible approach with the ability to apply specific components of care to particular individuals, is required. Group-based therapies and longer-term residential services have an important role for some patients, but further research is required to delineate more clearly which patients will benefit from these strategies. Conclusions: While there is growing (albeit limited) evidence that integrated and well articulated interventions that encompass pharmacological and psychosocial parameters can be beneficial for people with schizophrenia and comorbid SUD, there remains a considerable gap in the literature available to inform evidence-based practice.

Mancino MJ; McGaugh J; Feldman Z; Poling J; Oliveto A. Effect of PTSD diagnosis and contingency management procedures on cocaine use in dually cocaine- and opioid-dependent individuals maintained on LAAM: A retrospective analysis. American Journal on Addictions 19(2): 169-177, 2010. (49 refs.)

This randomized clinical trial retrospectively examined the effect of post-traumatic stress disorder (PTSD) and contingency management (CM) on cocaine use in opioid and cocaine dependent individuals maintained on high or low-dose LAAM randomly assigned to CM or a yoked-control condition. Cocaine-positive urines decreased more rapidly over time in those without PTSD versus those with PTSD in the noncontingency condition. In participants with PTSD, CM resulted in fewer cocaine-positive urines compared to the noncontingent condition. This suggests that CM may help improve the potentially worse outcomes in opioid- and cocaine-dependent individuals with PTSD compared to those without PTSD.

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

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

Menza TW; Jameson DR; Hughes JP; Colfax GN; Shoptaw S; Golden MR. Contingency management to reduce methamphetamine use and sexual risk among men who have sex with men: A randomized controlled trial. BMC Public Health 10: e-article 774, 2010. (45 refs.)

Background: Methamphetamine use is associated with HIV acquisition and transmission among men who have sex with men (MSM). Contingency management (CM), providing positive reinforcement for drug abstinence and withholding reinforcement when abstinence is not demonstrated, may facilitate reduced methamphetamine use and sexual risk. We compared CM as a stand-alone intervention to a minimal intervention control to assess the feasibility of conducting a larger, more definitive trial of CM; to define the frequency of behavioral outcomes to power such a trial; and, to compute preliminary estimates of CM's effectiveness. Methods: We randomly assigned 127 MSM from Seattle, WA who use methamphetamine to receive a 12-week CM intervention (n = 70) or referral to community resources (n = 57). Results: Retention at 24 weeks was 84%. Comparing consecutive study visits, non-concordant UAI declined significantly in both study arms. During the intervention, CM and control participants were comparably likely to provide urine samples containing methamphetamine (adjusted relative risk [aRR] = 1.09; 95% CI: 0.71, 1.56) and to report non-concordant UAI (aRR = 0.80; 95% CI: 0.47, 1.35). However, during post-intervention follow-up, CM participants were somewhat more likely to provide urine samples containing methamphetamine than control participants (aRR = 1.21; 95% CI: 0.95, 1.54, P = 0.11). Compared to control participants, CM participants were significantly more likely to report weekly or more frequent methamphetamine use and use of more than eight quarters of methamphetamine during the intervention and post-intervention periods. Conclusions: While it is possible to enroll and retain MSM who use methamphetamine in a trial of CM conducted outside drug treatment, our data suggest that CM is not likely to have a large, sustained effect on methamphetamine use.

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

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

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

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

Petry NM. Contingency management treatments: Controversies and challenges. (editorial). Addiction 105(9): 1507-1509, 2010. (19 refs.)

Petry NM; Alessi SM. Prize-based contingency management is efficacious in cocaine-abusing patients with and without recent gambling participation. Journal of Substance Abuse Treatment 39(3): 282-288, 2010. (45 refs.)

Prize-based contingency management (CM) is efficacious in treating cocaine abuse, and the chance-based Procedures of prize CM may be appealing to those who gamble. Using data from three randomized trials, we evaluated whether cocaine-abusing patients who had wagered in the month before treatment (n = 62) responded more favorably to prize CM than those who had not (n = 278). Participants were randomized to standard care (SC) or SC plus prize CM. Although prize CM was related to better outcomes overall, recent gambling was not associated with outcomes across or within treatment conditions. Gambling participation before treatment entry was associated with reductions in gambling over time, and this effect was more pronounced among those assigned to CM. These data suggest that prize CM is equally efficacious for substance-abusing patients who do and do not gamble, and they extend prior studies indicating that prize CM does not increase gambling.

Petry NM; Alessi SM; Ledgerwood DM; Sierra S. Psychometric properties of the Contingency Management Competence Scale. Drug and Alcohol Dependence 109(1-3): 167-174, 2010. (40 refs.)

Contingency management (CM) is an evidence-based treatment, and clinicians are beginning to implement this intervention in practice. However, little research exists on methods for assuring appropriate implementation of CM. This study describes the development and psychometric properties of the 12-item CM Competence Scale (CMCS). Thirty-five therapists from nine community-based clinics participated; following a training period, a randomized trial evaluated the efficacy of CM in cocaine abusing patients. Analyses of the CMCS are based on ratings from 1613 audiotapes of therapist interactions with 78 patients enrolled in the training phase and 103 patients in the randomized phase. Inter-rater reliability from 11 raters and internal consistency of items on the CMCS was good to excellent. Items loaded onto two factors: one contained items specific to discussions of the outcomes of urine testing and reinforcement, and the other contained general items related to use of praise, communication of confidence, empathy, skillfulness, and maintaining session structure, as well as discussions of self-reports of drug use when they occurred. During the training phase in CM delivery, scores on the CMCS rose significantly between earlier and later training sessions, and during the randomized phase, CM sessions were rated more highly than non-CM sessions. Scores on the subscale assessing general items were significantly correlated with indices of the therapeutic alliance and predictive of durations of cocaine abstinence achieved. These data suggest that the CMCS is reliable and valid in assessing delivery of CM and that competence in CM delivery is associated with improved patient outcomes.

Petry NM; Ford JD; Barry D. Contingency management is especially efficacious in engendering long durations of abstinence in patients with sexual abuse histories. Psychology of Addictive Behaviors 25(2): 293-300, 2011. (55 refs.)

Exposure to sexual victimization is prevalent among persons with substance use disorders (SUDs). Contingency management (CM) treatments utilize concrete and relatively immediate positive reinforcers to retain patients in treatment and reduce substance use, and CM may have particular benefits for patients with histories of sexual victimization. Using data from three randomized trials of CM (N = 393), this study evaluated main and interactive effects of sexual abuse history and treatment condition (standard care versus CM) with respect to during treatment outcomes (retention, proportion of negative urine samples submitted, and longest duration of abstinence) and abstinence at a nine-month follow-up. Compared to patients without sexual abuse histories (N = 316), those with sexual abuse histories (N = 77) submitted a significantly higher proportion of negative samples in treatment. In CM, but not in standard care, patients with sexual abuse histories achieved significantly longer durations of abstinence during treatment than those without sexual abuse histories. Although sexual abuse history was not associated with abstinence at nine-month follow-up evaluations, longest duration of abstinence during treatment was significantly associated with this long-term outcome. Results suggest that SUD patients with sexual abuse histories may accrue particular benefits during CM treatment that are associated with long-term abstinence.

Petry NM; Rash CJ; Easton CJ. Contingency management treatment in substance abusers with and without legal problems. Journal of the American Academy of Psychiatry and The Law 39(3): 370-378, 2011. (38 refs.)

Drug and alcohol abusers frequently have legal difficulties, and the legal system often provides negative reinforcement for substance abuse treatment. In contrast, contingency management (CM) treatments utilize positive reinforcement procedures to improve patient outcomes. This study evaluated whether substance-abusing patients with legal problems at treatment entry had differential outcomes, in general and in response to CM, compared with those without legal problems. Data from three randomized CM trials (n = 393) were used in an evaluation of main and interactive effects of legal status and treatment condition, with respect to retention and abstinence. Compared with patients without legal difficulties, those with legal problems remained in treatment for shorter durations and achieved shorter periods of abstinence. CM was positively and significantly associated with longer durations of abstinence, regardless of legal status. Results suggest that substance abusers with legal problems have generally poor outcomes, but that CM is effective regardless of the patient's legal status.

Petry NM; Weinstock J; Alessi SM. A randomized trial of contingency management delivered in the context of group counseling. Journal of Consulting and Clinical Psychology 79(5): 686-696, 2011. (67 refs.)

Objective: Contingency management (CM) is efficacious in reducing drug use. Typically, reinforcers are provided on an individual basis to patients for submitting drug-negative samples. However, most treatment is provided in a group context, and poor attendance is a substantial concern. This study evaluated whether adding CM to group-based outpatient treatment would increase attendance and drug abstinence relative to standard care. Method: Substance abusing patients (N = 239) initiating outpatient treatment at 2 community-based clinics were randomized to standard care with frequent urine sample monitoring for 12 weeks (SC) or that same treatment with CM delivered in the context of group counseling sessions. In the CM condition, patients earned opportunities to put their names in a hat based on attendance and submission of drug-negative samples. At group counseling sessions, therapists selected names randomly from the hat, and individuals whose names were drawn won prizes ranging from $1 to $100. Results: Patients assigned to CM earned a median of $160 in prizes, and they attended significantly more days of treatment (d = 0.25), remained in treatment for more continuous weeks (d = 0.40), and achieved longer durations of drug abstinence (d = 0.26) than patients randomized to SC. Group adherence and therapeutic alliance also improved with CM. In addition, HIV risk behaviors were significantly lower in CM relative to SC patients during early phases of treatment and at the 12-month follow-up. Conclusions: These data demonstrate that CM delivered in the context of outpatient group counseling can increase attendance and improve drug abstinence.

Promberger M; Brown RCH; Ashcroft RE; Marteau TM. Acceptability of financial incentives to improve health outcomes in UK and US samples. Journal of Medical Ethics 37(11): 682-687, 2011. (21 refs.)

In an online study conducted separately in the UK and the US, participants rated the acceptability and fairness of four interventions: two types of financial incentives (rewards and penalties) and two types of medical interventions (pills and injections). These were stated to be equally effective in improving outcomes in five contexts: (a) weight loss and (b) smoking cessation programmes, and adherence in treatment programmes for (c) drug addiction, (d) serious mental illness and (e) physiotherapy after surgery. Financial incentives (weekly rewards and penalties) were judged less acceptable and to be less fair than medical interventions (weekly pill or injection) across all five contexts. Context moderated the relative preference between rewards and penalties: participants from both countries favoured rewards over penalties in weight loss and treatment for serious mental illness. Only among US participants was this relative preference moderated by perceived responsibility of the target group. Overall, participants supported funding more strongly for interventions when they judged members of the target group to be less responsible for their condition, and vice versa. These results reveal a striking similarity in negative attitudes towards the use of financial incentives, rewards as well as penalties, in improving outcomes across a range of contexts, in the UK and the USA. The basis for such negative attitudes awaits further study.

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

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

Reback CJ; Peck JA; Dierst-Davies R; Nuno M; Kamien JB; Amass L. Contingency management among homeless, out-of-treatment men who have sex with men. Journal of Substance Abuse Treatment 39(3): 255-263, 2010. (33 refs.)

Homeless men who have sex with men are a particularly vulnerable population with high rates of substance dependence, psychiatric disorders, and HIV prevalence. Most need strong incentives to engage with community-based prevention and treatment programs. Contingency management (CM) was implemented in a community HIV prevention setting and targeted reduced substance use and increased health-promoting behaviors over a 24-week intervention period. Participants in the CM condition achieved greater reductions in stimulant and alcohol use (chi(2) = 27.36, p < .01) and, in particular, methamphetamine use (chi(2) = 21.78, p < .01) and greater increases in health-promoting behaviors (chi(2) = 37.83, p < .01) during the intervention period than those in the control group. Reductions in substance use were maintained to 9- and 12-month follow-up evaluations. Findings indicate the utility of CM for this high-risk population and the feasibility of implementing the intervention in a community-based HIV prevention program.

Reisinger HS; Brackett RH; Buzza CD; Paez MBW; Gourley R; Vander Weg MW et al. "All the Money in the World ..." patient perspectives regarding the influence of financial incentives. Health Services Research 46(6, part 1): 1986-2004, 2011. (39 refs.)

Objective. To analyze patient perspectives of the use of financial incentives in a hypertension intervention. Study Setting. Twelve Veterans Affairs primary care clinics over a 9-month period. Study Design. Qualitative semistructured interviews conducted with 54 hypertensive veterans participating in an intervention to promote guideline-consistent therapy. Intervention components included an intervention letter requesting patients talk with their providers, an offer of U.S.$20 to bring in the letter to their provider, and a health educator phone call. Data Collection Methods. Semistructured interviews were conducted. Transcripts were coded for thematic content. The financial incentive theme was then subcoded for more detailed analysis. Principle Findings. Most participants (n=48; 88.9 percent) stated the incentive had (or would have) no effect on their decision to initiate a discussion with their provider. Some participants articulated reservations about the effectiveness and/or appropriateness of financial incentives in health care decisions; however, a few expressed the opinion that there may be some potential benefits to the use of financial incentives if they encourage patients to be active in their health care. Conclusion. The findings of this study raise questions about the appropriateness and unintended consequences of employing patient-directed financial incentives in health care settings. [Note: contingency management is used in alcohol and drug use treatment.]

Romanowich P; Lamb RJ. Effects of escalating and descending schedules of incentives on cigarette smoking in smokers without plans to quit. Journal of Applied Behavior Analysis 43(3): 357-367, 2010. (41 refs.)

Contingent incentives can reduce substance abuse. Escalating payment schedules, which begin with a small incentive magnitude and progressively increase with meeting the contingency, increase smoking abstinence. Likewise, descending payment schedules can increase cocaine abstinence. The current experiment enrolled smokers without plans to quit in the next 6 months and compared escalating and descending payments schedules over 15 visits. In the larger incentive condition (LI, n = 39), the largest possible incentive was $100, and in the smaller incentive condition (SI, n = 18), the largest possible incentive was $32. In both conditions, more participants in the descending groups initiated abstinence. A higher proportion of participants in both the escalating and descending groups initiated abstinence in the LI than in the SI. Although participants in the descending groups had more abstinent visits during the first five contingent visits than those in the escalating groups, these differences were not maintained.

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

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

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

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

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

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

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

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

Schmitz JM; Lindsay JA; Stotts AL; Green CE; Moeller FG. Contingency management and levodopa-carbidopa for cocaine treatment: A comparison of three behavioral targets. Experimental and Clinical Psychopharmacology 18(3): 238-244, 2010. (32 refs.)

New data support use of levodopa pharmacotherapy with behavioral contingency management (CM) as one efficacious combination in cocaine dependence disorder treatment. A potential mechanism of the combined treatment effects may be related to dopamine-induced enhancement of the saliency of contingently delivered reinforcers. Evidence to support this mechanism was sought by evaluating levodopa-enhancing effects across distinct CM conditions that varied in behavioral targets. A total of 136 treatment-seeking, cocaine dependent subjects participated in this 12-week, randomized, placebo-controlled trial of levodopa (vs. placebo) administered in combination with one of three behavioral CM conditions. In the CM-URINE condition, subjects received cash-valued vouchers contingent on cocaine-negative urine toxicology results. In the CM-ATTEND condition, the same voucher schedule was contingent on attending thrice weekly clinic visits. In the CM-MEDICATION condition, the same voucher schedule was contingent on Medication Event Monitoring Systems- and riboflavin-based evidence of pill-taking behavior. Primary outcomes associated with each CM target behavior were analyzed using generalized linear mixed models for repeated outcomes. CM responding in the CM-ATTEND and CM-MEDICATION conditions showed orderly effects, with each condition producing corresponding changes in targeted behaviors, regardless of medication condition. In contrast, CM responding in the CM-URINE condition was moderated by medication, with levodopa-treated subjects more likely to submit cocaine-negative urines. These findings specify the optimal target behavior for CM when used in combination with levodopa pharmacotherapy.

Schottenfeld RS; Moore B; Pantalon MV. Contingency management with community reinforcement approach or twelve-step facilitation drug counseling for cocaine dependent pregnant women or women with young children. Drug and Alcohol Dependence 118(1): 48-55, 2011. (75 refs.)

Background: Cocaine abuse among women of child-bearing years is a significant public health problem. This study evaluated the efficacy of contingency management (CM), the community reinforcement approach (CRA), and twelve-step facilitation (TSF) for cocaine-dependent pregnant women or women with young children. Methods: Using a 2 x 2 study design, 145 cocaine dependent women were randomized to 24 weeks of CRA or TSF and to monetary vouchers provided contingent on cocaine-negative urine tests (CM) or non-contingently but yoked in value (voucher control, VC). Primary outcome measures included the longest consecutive period of documented abstinence, proportion of cocaine-negative urine tests (obtained twice-weekly), and percent days using cocaine (PDC) during treatment. Documented cocaine abstinence at baseline and 3, 6, 9 and 12 months following randomization was a secondary outcome. Findings: CM was associated with significantly greater duration of cocaine abstinence (p < .01), higher proportion of cocaine-negative urine tests (p < 0.01), and higher proportion of documented abstinence across the 3-, 6-, 9- and 12-month assessments (p < 0.05), compared to VC. The differences between CRA and TSF were not significant for any of these measures (all p values >= 0.75). PDC decreased significantly from baseline during treatment in all four groups (p < 0.001) but did not differ significantly between CM and VC (p = 0.10) or between TSF and CRA (p = 0.23). Interpretation: The study findings support the efficacy of CM for cocaine dependent pregnant women and women with young children but do not support greater efficacy of CRA compared to TSF or differential efficacy of CM when paired with either CRA or TSF.

Secades-Villa R; Garcia-Rodriguez O; Garcia-Fernandez G; Sanchez-Hervas E; Fernandez-Hermida JR; Higgins ST. Community Reinforcement Approach plus vouchers among cocaine-dependent outpatients: Twelve-month outcomes. Psychology of Addictive Behaviors 25(1): 174-179, 2011. (24 refs.)

The aims of this study were to assess the effectiveness of the Community Reinforcement Approach (CRA) plus vouchers treatment in a cohort of Spanish cocaine-dependent outpatients, and to examine the maintenance of treatment effects after the voucher intervention was discontinued. Sixty-four adult outpatients were randomly assigned to one of two treatment conditions, CRA plus vouchers or standard care. The vouchers program was implemented from weeks 1 to 24. Among patients assigned to the CRA plus vouchers condition, 65.5% completed 12 months of treatment versus 28.6% of those assigned to the standard care condition (p = .003). At the 12-month assessment, 58.6% of patients assigned to the CRA plus vouchers condition were abstinent, compared with 25.7% in the standard care condition (p = .008); furthermore, 34.5% of patients assigned to the CRA plus vouchers condition achieved twelve months of continuous cocaine abstinence, versus 17.1% in the standard care condition. Those treated in the CRA plus vouchers condition also achieved greater improvements in psychosocial functioning than those treated in the standard care condition. Overall, these results reveal an extension of the effectiveness of the CRA plus vouchers treatment to a community sample of cocaine-dependent outpatients, while also supporting the maintenance of treatment effects for 6 months after completion of the voucher program.

Stanger C; Budney AJ. Contingency management approaches for adolescent substance use disorders. Child and Adolescent Psychiatric Clinics of North America 19(3): 547-+, 2010. (44 refs.)

The addition of contingency management (CM) to the menu of effective treatments for adolescent substance abuse has generated excitement in the research and treatment communities. CM interventions are based on extensive basic science and clinical research evidence demonstrating that drug use is sensitive to systematically applied consequences. This article provides (a) a review of basic CM principles, (b) implementation guidelines, (c) a review of the clinical CM research targeting adolescent substance abuse, and (d) a discussion of implementation successes and challenges. Although the research base for CM with adolescents is in its infancy, there are multiple reasons for high expectations.

Stanger C; Ryan SR; Fu HY; Budney AJ. Parent training plus contingency management for substance abusing families: A Complier Average Causal Effects (CACE) analysis. Drug and Alcohol Dependence 118(2-3): 119-126, 2011. (50 refs.)

Background: Children of substance abusers are at risk for behavioral/emotional problems. To improve outcomes for these children, we developed and tested an intervention that integrated a novel contingency management (CM) program designed to enhance compliance with an empirically-validated parent training curriculum. CM provided incentives for daily monitoring of parenting and child behavior, completion of home practice assignments, and session attendance. Methods: Forty-seven mothers with substance abuse or dependence were randomly assigned to parent training + incentives (PTI) or parent training without incentives (PT). Children were 55% male, ages 2-7 years. Results: Homework completion and session attendance did not differ between PTI and PT mothers, but PTI mothers had higher rates of daily monitoring. PTI children had larger reductions in child externalizing problems in all models. Complier Average Causal Effects (CACE) analyses showed additional significant effects of PTI on child internalizing problems, parent problems and parenting. These effects were not significant in standard Intent-to-Treat analyses. Conclusion: Results suggest our incentive program may offer a method for boosting outcomes.

Stitzer ML; Polk T; Bowles S; Kosten T. Drug users' adherence to a 6-month vaccination protocol: Effects of motivational incentives. Drug and Alcohol Dependence 107(1): 76-79, 2010. (20 refs.)

Vaccines represent a new and promising avenue of treatment for drug abuse but pose new medication adherence challenges due to prolonged and widely spaced administration schedules. This study examined effects of prize-based incentives on retention and medication adherence among 26 cocaine users involved in a 6-month hepatitis B vaccination series. Participants could meet with research staff weekly for 24 weeks and receive 7 injections containing either the Hepatitis B vaccine or a placebo. All participants received $10 at each weekly visit (maximum of $240). Those randomly assigned to the incentive program received additional monetary payments on an escalating schedule for attendance at weekly monitoring and vaccination visits with maximum possible earnings of $751. Croup attendance diverged after study week 8 with attendance better sustained in the incentive than control group (group by time interaction, p=.035). Overall percent of weekly sessions attended was 82% for incentive versus 649 for control (p=.139). Receiving all scheduled injections were 77% of incentive versus 46% of control participants (p=.107). A significantly larger percentage (74% versus 51%; p=.016) of injections were received by incentive versus control participants on the originally scheduled day. Results suggest that monetary incentives can successfully motivate drug users to attend sessions regularly and to receive injected medications in a more reliable and timely manner than may be seen under usual care procedures. Thus, incentives may be useful for addressing adherence and allowing participants to reap the full benefits of newly developed medications.

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

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

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

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

Tidey JW; Rohsenow DJ; Kaplan GB; Swift RM; Reid N. Effects of contingency management and bupropion on cigarette smoking in smokers with schizophrenia. Psychopharmacology 217(2): 279-287, 2011. (61 refs.)

Individuals with schizophrenia have high smoking-related morbidity and mortality rates and need powerful and innovative smoking cessation interventions. This proof-of-concept study investigated the feasibility and initial efficacy of combining a contingency management intervention with bupropion to reduce smoking in people with schizophrenia. Using a double-blind, placebo-controlled, between-groups design, 57 non-treatment-seeking participants were randomized to receive 300 mg/day bupropion or placebo. One week later, participants were randomized to a contingency management (CM) intervention in which reductions in urinary cotinine levels were reinforced, or a non-contingent reinforcement (NR) condition in which session attendance was reinforced, regardless of cotinine level. Over the 22-day study period, participants visited the laboratory approximately three times per week to provide urine samples for analysis of cotinine levels, to give breath samples for analysis of carbon monoxide (CO) levels, and to report number of cigarettes smoked per day, nicotine withdrawal symptoms, cigarette craving, and psychiatric symptoms. Cotinine and CO levels significantly decreased during the study period in participants randomized to the CM condition, but not the NR condition. Bupropion did not reduce cotinine levels or increase the efficacy of CM. Cigarette craving and psychiatric symptom levels significantly decreased during the study in all groups. The results of this study indicate the efficacy and feasibility of this CM intervention for reducing smoking in individuals with schizophrenia.

Van Horn DHA; Drapkin M; Ivey M; Thomas T; Domis SW; Abdalla O et al. Voucher incentives increase treatment participation in telephone-based continuing care for cocaine dependence. Drug and Alcohol Dependence 114(2-3): 225- 228, 2011. (15 refs.)

Background:Telephone-based monitoring is a promising approach to continuing care of substance use disorders, but patients often do not engage or participate enough to benefit. Voucher incentives can increase retention in outpatient treatment and continuing care, but may be less effective when reinforcement is delayed, as in telephone-based care. We compared treatment utilization rates among cocaine-dependent patients enrolled in telephone continuing care with and without voucher incentives to determine whether incentives increase participation in telephone-based care. Method: Participants were 195 cocaine-dependent patients who completed two weeks of community-based intensive outpatient treatment for substance use disorders and were randomly assigned to receive telephone continuing care with or without voucher incentives for participation as part of a larger clinical trial. The 12-month intervention included 2 in-person orientation sessions followed by up to 30 telephone sessions. Incentivized patients could receive up to $400 worth of gift cards. Results: Patients who received incentives were not more likely to complete their initial orientation to continuing care. Incentivized patients who completed orientation completed 67% of possible continuing care sessions, as compared to 39% among non-incentivized patients who completed orientation. Among all patients randomized to receive incentives, the average number of completed sessions was 15.5, versus 7.2 for patients who did not receive incentives, and average voucher earnings were $200. Conclusions: Voucher incentives can have a large effect on telephone continuing care participation, even when reinforcement is delayed. Further research will determine whether increased participation leads to better outcome among patients who received incentives.

Versek BE; Carpenedo CM; Rosenwasser BJ; Dugosh KL; Bresani E; Kirby KC. Resets do not appear to increase the rate of adverse events or prolong relapse in voucher-based reinforcement therapy. Journal of Substance Abuse Treatment 39(2): 167-173, 2010. (32 refs.)

Voucher-based reinforcement therapy (VBRT) is an efficacious contingency management intervention for substance use disorders that provides escalating voucher values to reinforce continuous abstinence and typically resets escalated values to the initial low level upon detection of drug use. The objective of this study involving 130 methadone-maintained outpatients receiving VBRT was to investigate whether resets (a) increase risk for adverse events (AEs) and (b) delay return to abstinence in relation to magnitude of voucher reset. Weeks following resets were examined for increased likelihood of AEs using a Poisson regression. A Cox proportional hazards model was used to determine if higher resets increased the number of days until a negative urine specimen. Results showed that resets did not increase the likelihood of AEs nor were higher resets related to an increased delay to abstinence. Research involving larger samples is needed to produce sufficient data directly addressing safety concerns of various treatment stakeholders.

Vlahov D; Strathdee S. The bottom line on cash incentives with drug users. (editorial). Addiction 104(5): 796-797, 2009. (27 refs.)

Weinstock J. A review of exercise as intervention for sedentary hazardous drinking college students: Rationale and issues. (review). Journal of American College Health 58(6): 539-544, 2010. (76 refs.)

College students have high rates of alcohol problems despite a number of intervention initiatives designed to reduce alcohol use. Substance use, including heavy drinking, often occurs at the expense of other, substance-free, activities. This review examines the promotion of one specific substance-free activity exercise as an intervention for hazardous drinking. Exercise has numerous physical and mental health benefits, and data suggest that students who engage in exercise regularly are less likely to drink heavily. However, the adherence to exercise necessary to achieve these benefits and possibly reduce drinking is poor, and improved exercise adherence interventions are needed. A novel combination of motivational enhancement therapy and contingency management is discussed as a means to address the critical issue of exercise adherence.

West R. 'Payments by results' and smoking cessation support. (editorial). Addiction 106(10): 1730-1731, 2011. (4 refs.)

West R; Evans A; Michie S. Behavior change techniques used in group-based behavioral support by the English stop-smoking services and preliminary assessment of association with short-term quit outcomes. Nicotine & Tobacco Research 13(12): 1316-1320, 2011. (15 refs.)

Objective: To develop a reliable coding scheme for components of group-based behavioral support for smoking cessation, to establish the frequency of inclusion in English Stop-Smoking Service (SSS) treatment manuals of specific components, and to investigate the associations between inclusion of behavior change techniques (BCTs) and service success rates. Methods: A taxonomy of BCTs specific to group-based behavioral support was developed and reliability of use assessed. All English SSSs (n = 145) were contacted to request their group-support treatment manuals. BCTs included in the manuals were identified using this taxonomy. Associations between inclusion of specific BCTs and short-term (4-week) self-reported quit outcomes were assessed. Results: Fourteen group-support BCTs were identified with >90% agreement between coders. One hundred and seven services responded to the request for group-support manuals of which 30 had suitable documents. On average, 7 BCTs were included in each manual. Two were positively associated with 4-week quit rates: "communicate group member identities" and a "betting game" (a financial deposit that is lost if a stop-smoking "buddy" relapses). Conclusion: It is possible to reliably code group-specific BCTs for smoking cessation. Fourteen such techniques are present in guideline documents of which 2 appear to be associated with higher short-term self-reported quit rates when included in treatment manuals of English SSSs.

Winstanley EL; Bigelow GE; Silverman K; Johnson RE; Strain EC. A randomized controlled trial of fluoxetine in the treatment of cocaine dependence among methadone-maintained patients. Journal of Substance Abuse Treatment 40(3): 255-264, 2011. (31 refs.)

Background: Cocaine abuse and dependence continue to be widespread. Currently, there are no pharmacotherapies shown to be effective in the treatment of cocaine dependence. Methods: A 33-week outpatient clinical trial of fluoxetine (60 mg/day, po) for cocaine dependence that incorporated abstinence-contingent voucher incentives was conducted. Participants (N = 145) were both cocaine and opioid dependent and treated with methadone. A stratified randomization procedure assigned subjects to one of four conditions: fluoxetine plus voucher incentives (FV), placebo plus voucher incentives (PV), fluoxetine without vouchers (F), and placebo without vouchers (P). Dosing of fluoxetine/placebo was double blind. Primary outcomes were treatment retention and cocaine use based on thrice-weekly urine testing. Results: The PV group had the longest treatment retention (M = 165 days) and lowest probability of cocaine use. The adjusted predicted probabilities of cocaine use were 65% in the P group, 60% in the F group, 56% in the FV group, and 31% in the PV group. Conclusions: Fluoxetinc was not efficacious in reducing cocaine use in patients dually dependent on cocaine and opioids.