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.
Determine whether employment-based abstinence reinforcement can be an effective long-term maintenance intervention for cocaine dependence.
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 six months were hired as operators in a data entry business and randomly assigned to an employment only (Control, n = 24) or abstinence-contingent employment (n = 27) group.
A nonprofit data entry business.
Unemployed welfare recipients who persistently used cocaine while enrolled in methadone treatment in Baltimore.
Abstinence-contingent employment participants received one year of employment-based contingency management, in which access to employment was contingent on provision 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 one year of employment.
During the one-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, OR = 3.73, 95% CI = 1.60 – 8.69).
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. Workplaces could serve as therapeutic agents in the treatment of drug dependence by arranging long-term employment-based contingency management programs.
clinicaltrials.gov. Identifier: NCT00249496
Cocaine; Methadone; Employment; Contingency management; Abstinence reinforcement
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.
Participants who were inducted onto oral naltrexone were randomly assigned to Contingency (n=18) or Prescription (n=17) groups. Participants were offered six depot naltrexone injections and invited to work at the therapeutic workplace weekdays 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 independent of whether they accepted injections.
The therapeutic workplace, a model employment-based intervention for drug addiction and unemployment.
Opioid-dependent unemployed adults.
Depot naltrexone injections accepted and opiate-negative urine samples.
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.
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.
depot naltrexone; contingency management; heroin; substance abuse; employment-based reinforcement
Due to the chronicity of cocaine dependence, practical and effective maintenance interventions are needed to sustain long-term abstinence. We sought to assess the effects of long-term employment-based reinforcement of cocaine abstinence after discontinuation of the intervention.
Participants who initiated sustained opiate and cocaine abstinence during a 6-month abstinence reinforcement and training program worked as data entry operators and were randomly assigned to a group that could work independent of drug use (Control, n = 24), or an abstinence-contingent employment (n = 27) group that was required to provide cocaine- and opiate-negative urine samples to work and maintain maximum rate of pay.
A nonprofit data entry business.
Unemployed welfare recipients who persistently used cocaine while in methadone treatment.
Urine samples and self-reports were collected every six months for 30 months.
During the employment year, abstinence-contingent employment participants provided significantly more cocaine-negative samples than controls (82.7% and 54.2%; P = .01, OR = 4.61). During the follow-up year, the groups had similar rates of cocaine-negative samples (44.2% and 50.0%; P = .93), and HIV-risk behaviors. Participants’ social, employment, economic, and legal conditions were similar in the two groups across all phases of the study.
Employment-based reinforcement effectively maintains long-term cocaine abstinence, but many patients relapse to use when the abstinence contingency is discontinued, even after a year of abstinence-contingent employment. Relapse could be prevented in many patients by leaving employment-based abstinence reinforcement in place indefinitely, which could be facilitated by integrating it into typical workplaces.
Cocaine; Methadone; Employment; Contingency management; Abstinence reinforcement
In contingency management (CM), monetary incentives are contingent on evidence of drug abstinence. Typically, incentives (e.g., “vouchers” exchangeable for goods or services) are contingent on individual performance. We programmed vouchers contingent on group performance to investigate whether these contingencies would promote brief abstinence from cigarette smoking. Thirty-two participants were divided into small teams (n = 3 per team). During three 5-day within-subject experimental conditions, participants submitted video recordings of breath carbon monoxide (CO) measures twice daily via Mōtiv8 Systems™, an Internet-based remote monitoring application. During the interdependent contingency condition, participants earned vouchers each time they and their teammates submitted breath CO samples indicative of abstinence (i.e., negative samples). During the independent contingency condition, participants earned vouchers each time they submitted negative samples, regardless of their teammates' performance. During the no vouchers condition, no monetary incentives were contingent on abstinence. In addition, half of the participants (n = 16) could communicate with their teammates through an online peer support forum. Although forum access did not appear to promote smoking abstinence, monetary incentives did promote brief abstinence. Significantly more negative samples were submitted when vouchers were contingent on individual performance (56%) or team performance (53%) relative to when no vouchers were available (35%; F = 6.9, p = 0.002). The results show that interdependent contingencies can promote brief abstinence from cigarette smoking. Moreover, the results suggest that these contingencies may help lower treatment costs and promote social support.
contingency management; incentive; group contingency; cigarette; social support
We assessed the ability of a combined contingent reinforcement and intensive monitoring procedure to promote and sustain temporary smoking cessation among 34 hired research volunteers, and the ability of a smoking reduction test to predict the subsequent initiation of abstinence. During the 5-day cutdown test, subjects were paid from $0 to $6 per day depending on the extent of reduction from baseline CO levels. During the abstinence test, breath samples were obtained three times daily and subjects were paid $4 for each CO reading less than or equal to 11 ppm. Sixty-eight percent of subjects initiated abstinence. Of the breath samples collected during the abstinence test (91% of scheduled samples), 96.5% were less than or equal to 11 ppm and 80.5% were less than or equal to 8 ppm. Subjects who earned more money during the cutdown test were more likely to abstain (r = -0.51, p less than .001). Contingent reinforcement and intensive monitoring procedures appear to have usefulness for analog studies of smoking reduction and cessation.
The therapeutic workplace is a novel intervention that uses access to paid training and employment to reinforce drug abstinence within the context of standard methadone maintenance. We used the Drug Abuse Treatment Cost Analysis Program as a standard method of estimating the economic costs of this intervention. Over a one-year period, the therapeutic workplace served 122 methadone maintenance clients who had a median length of stay of 22 weeks. The workplace maintained a mean daily census of 48 clients. The combined cost of methadone maintenance and the therapeutic workplace was estimated at $362 per week. This cost is less than other treatments that might be used to promote abstinence in individuals who continue to use drugs during methadone treatment. Given prior evidence of effectiveness, these cost data may be useful to policymakers, social service agencies, and researchers interested in using or further developing the therapeutic workplace intervention.
Cost; Economics; DATCAP; substance abuse treatment; addiction treatment; unemployment
This study evaluated the efficacy of adding contingency management techniques to vocational rehabilitation (VR) to improve treatment outcome as measured by entry into competitive employment. Nineteen dually diagnosed veterans who entered VR in the Veterans' Administration's compensated work therapy (CWT) program were randomly assigned to CWT (n = 8) or to CWT with enhanced incentives (n = 11). Over the first 16 weeks of rehabilitation, those in the incentives condition could earn up to $1,006 in cash for meeting two sets of clinical goals: (a) remaining abstinent from drugs and alcohol and (b) taking steps to obtain and maintain a competitive job. Results indicate that relative to participants in the CWT-only group, those in the incentives condition engaged in more job-search activities, were more likely to remain abstinent from drugs and alcohol, were more likely to obtain competitive employment, and earned an average of 68% more in wages. These results suggest that rehabilitation outcomes may be enhanced by restructuring traditional work-for-pay contingencies to include direct financial rewards for meeting clinical goals.
vocational rehabilitation; contingency management
In a randomized controlled trial, behavioral day treatment, including contingency management (CM+), was compared to contingency management components alone (CM). All 206 cocaine dependent, homeless participants received a furnished apartment with food and work training/employment contingent on drug-negative urine tests. CM+ also received cognitive behavioral therapy, therapeutic goal management, and other intervention components. Results revealed that CM+ treatment attendance and abstinence were not significantly different from CM during 24 weeks of treatment. After treatment and contingencies ended, however, CM+ showed more abstinence than CM, indicating a delayed effect of treatment from 6 to 18 months. CM+ had more consecutive weeks abstinent across 52 weeks, but not during active treatment. We conclude that CM alone may be viable as initial care for cocaine dependent homeless persons. That CM+ yields more durable abstinence indicates it may be appropriate as stepped up care for clients not responding to CM. Clinical Trials.gov #NCT00368524
High-magnitude and long-duration abstinence reinforcement can promote drug abstinence but can be difficult to finance. Employment may be a vehicle for arranging high-magnitude and long-duration abstinence reinforcement. This study determined if employment-based abstinence reinforcement could increase cocaine abstinence in adults who inject drugs and use cocaine during methadone treatment. Participants could work 4 hr every weekday in a workplace where they could earn about $10.00 per hour in vouchers; they were required to provide routine urine samples. Participants who attended the workplace and provided cocaine-positive urine samples during the initial 4 weeks were invited to work 26 weeks and were randomly assigned to an abstinence-and-work (n = 28) or work-only (n = 28) group. Abstinence-and-work participants had to provide urine samples showing cocaine abstinence to work and maintain maximum pay. Work-only participants could work independent of their urinalysis results. Abstinence-and-work participants provided more (p = .004; OR = 5.80, 95% CI = 2.03–16.56) cocaine-negative urine samples (29%) than did work-only participants (10%). Employment-based abstinence reinforcement can increase cocaine abstinence.
contingency management; abstinence reinforcement; cocaine addiction; methadone; drug abuse treatment; employment
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.
contingency management; smoking cessation; methadone; buprenorphine; bupropion
Contingency management (CM) uses tangible incentives to systematically reinforce abstinence and is among the most efficacious psychosocial substance abuse treatments. This study assessed the feasibility and initial efficacy of a portable CM procedure designed to address technical limitations for detecting drinking that have prevented using CM for alcohol problems.
Participants received a cell phone, breathalyzer, and training on video-recording alcohol breath tests (BrACs) and texting results. For 4 weeks, staff texted participants 1–3 times daily indicating a BrAC was due within the hour. Participants were randomized to (1) modest compensation for submitting dated time-stamped BrAC videos regardless of results or (2) the same plus CM with escalating vouchers for on-time alcohol-negative tests (n-BrAC; <02 g/dL). Thank you texts were sent, with CM patients also informed of results-based earnings.
Participants’ natural environment.
Adults (N=30; ≥21 years) who drank frequently but not physiologically dependent.
Drinking and related problems were assessed at Intake and Week 4. BrACs and self-reports of drinking were collected throughout. The primary outcome was percent of n-BrACs. Other outcomes were longest duration of consecutive n-BrACs (LDA) and self-reports of drinking.
On average, 88.6% (10.4%) of BrACs were submitted on time, without group differences (p>.5). Percent of n-BrACs and LDA were greater with CM, and there was an interaction effect on drinking frequency and negative consequences, with decreases over time with CM (p=.00; effect sizes d=.52 to .62).
Cell phone technology may be useful for extending CM to treatment for alcohol problems.
alcohol; abstinence; cell phone; contingency management; mobile; reinforcement
This study assessed whether attendance rates in a workplace predicted subsequent outcome of employment-based reinforcement of cocaine abstinence. Unemployed adults in Baltimore methadone programs who used cocaine (N = 111) could work in a workplace for 4 hr every weekday and earn $10.00 per hour in vouchers for 26 weeks. During an induction period, participants provided urine samples but could work independent of their urinalysis results. After the induction period, participants had to provide urinalysis evidence of cocaine abstinence to work and maintain maximum pay. A multiple regression analysis showed that induction period attendance was independently associated with urinalysis evidence of cocaine abstinence under the employment-based abstinence reinforcement contingency. Induction period attendance may measure the reinforcing value of employment and could be used to guide the improvement of employment-based abstinence reinforcement.
abstinence reinforcement; cocaine addiction; contingency management; employment; methadone
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 (available in the form of vouchers) 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). A nonsignificant trend suggested bupropion may have contributed to smoking abstinence (Dunn et al, 2010). For both studies high rates of relapse to smoking were observed after the intervention ended; however, the results compare favorably to previous pharmacological and behavioral smoking cessation interventions and provide evidence that opioid-maintained patients can achieve a brief period of continuous smoking abstinence. Relapse to illicit drug use was also evaluated prospectively and no evidence that smoking abstinence was associated with a 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.
contingency management; smoking cessation; methadone; buprenorphine; smoking
To conduct a randomized, controlled trial of abstinence-contingent recovery housing delivered with or without intensive day treatment among individuals exiting residential opioid detoxification.
Random assignment to one of three conditions: Recovery housing alone (RH), abstinence-contingent recovery housing with RBT (RH+RBT), or usual care (UC). RH and RH+RBT participants received 12 weeks of paid recovery housing contingent upon drug abstinence. RH+RBT participants also received 26 weeks of RBT, initiated concurrently with recovery housing. Assessments were conducted at 1, 3, and 6 months after treatment enrollment.
Outpatient drug-free substance abuse treatment program in Baltimore, Maryland.
Patients (N = 243) who completed medication-assisted opioid detoxification.
Primary outcome was drug abstinence (opioid- and cocaine-negative urine and no self-reported opioid or cocaine use in the previous 30 days). Secondary outcomes included abstinence at all time points (1, 3, and 6 months), days in recovery housing, and employment.
Overall rates of drug abstinence were 50% for RH+RBT, 37% for RH, and 13% for UC (p < .001). At 6 months, RH+RBT participants remained more likely to meet abstinence criteria than UC participants (37% vs. 20%, p = .016). Length of stay in recovery housing mediated abstinence outcomes and was longer in RH+RBT (49.5 days) than in RH (32.2 days; p < .002).
Abstinence-contingent recovery housing improves abstinence in opioid-dependent adults following medication-assisted detoxification. The addition of intensive ‘reinforcement-based treatment’ behavioural counseling further improves treatment outcomes in part by promoting longer recovery house stays.
In contingency management (CM) interventions, monetary consequences are contingent on evidence of drug abstinence. Typically, these consequences are contingent on individual performance. Consequences contingent on group performance may promote social support (e.g., praise).
Thus, to combine social support with the monetary incentives of CM, we integrated independent and interdependent group contingencies of reinforcement into an Internet-based intervention to promote smoking abstinence. Breath carbon monoxide (CO) measures were compared between treatment conditions and a baseline control condition. Thirteen participants were divided into 5 groups or “teams” (n = 2–3 per team). Each participant submitted video recordings of CO measurement twice daily via the Internet. Teammates could monitor each other’s progress and communicate with one another through an online peer support forum. During a 4-day tapering condition, vouchers exchangeable for goods were contingent on gradual reductions in breath CO. During a 10-day abstinence induction condition, vouchers were contingent on abstinence (CO ≤4 ppm). In both treatment conditions, concurrent independent and interdependent group contingencies were arranged (i.e., a mixed contingency arrangement).
Less than 1% of CO samples submitted during baseline were ≤4 ppm, compared to 57% submitted during abstinence induction. Sixty-five percent of participants’ comments on the online peer support forum were rated as positive by independent observers. Participants rated the intervention favorably on a treatment acceptability questionnaire.
The results suggest that the intervention is feasible and acceptable for promoting abstinence from cigarette smoking.
Smoking; Cigarette; Internet; Group; Contingency management; Incentives
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. They 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 100mg 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.
contingency management; polydrug dependence; methadone dose; DSM diagnoses
Drug users in treatment or exiting treatment face many barriers to employment when entering the job market, such as low levels of education and technical skills, and low levels of interpersonal skills. As a result of these and other barriers, employment rates in these groups are generally low.
This article examines the existence and possible predictors of specific barriers to employment related to interpersonal and technical skills in a sample of participants enrolled in a therapeutic workplace intervention for substance abuse.
In Study I (N = 77), we characterized and examined predictors of participant scores on a staff-rated scale of interpersonal skills (Work Behavior Inventory). In Study II (N = 29), we examined whether participants had lower levels of computer knowledge than job seekers in the general population, and investigated possible predictors of computer knowledge in the sample.
In general, participants in Study I displayed low levels of interpersonal skills, and participants in Study II scored lower on the computer knowledge test than job seekers in the general population. Older participants tended to have lower levels of interpersonal skills and lower levels of computer knowledge.
Conclusions and Scientific Significance
These results suggest that providers of workforce development services for drug users in treatment or exiting treatment should attend to these specific barriers to employment, which may also be more pronounced among older clients.
computer skills; employment; employment barriers; social skills; substance abuse
An increasingly aging workforce and advances in technology are changing work environments and structures. The continued employability of older adults, particularly those of lower socioeconomic status (SES), requires them to participate in training programs to ensure their competence in today’s workplace. Focus groups with 37 unemployed adults (51–76 years old) were conducted to gather information about barriers and obstacles for returning to work, training needs and formats, work experiences, and perceptions of the characteristics of an ideal job. Overall, results indicated that participants experienced age discrimination and lack of technology skills. They also expressed a desire to receive additional training on technology and a preference for classroom training.
The purpose of this paper is to review both main findings and secondary analyses from studies of abstinence incentives conducted in the National Drug Abuse Treatment Clinical Trials Network (CTN). Previous research has supported the efficacy of tangible incentives provided contingent on evidence of recent drug abstinence. CTN conducted the first multi-site effectiveness trial of this novel intervention. Study participants were stimulant abusers (N = 803) participating in treatment at 14 clinical sites and randomly assigned to treatment as usual (TAU) with or without a prize draw incentive program. Study participants could earn up to $400 over 3 months for submission of drug- urine and breath (BAL) specimens. 3-month retention was significantly improved by incentives offered to psychosocial counseling clients (50% incentive vs 35% control retained) while on-going stimulant drug use was significantly reduced in methadone maintenance clients (54.4% incentive vs 38.7% control samples testing stimulant negative). In both settings, duration of continuous abstinence achieved was improved in the incentive condition. These studies support effectiveness of one abstinence incentive intervention and highlight the different outcomes that can be expected with application in methadone maintenance versus psychosocial counseling treatment settings. Secondary analyses have shown the importance of early treatment positive versus negative urine screens in moderating the outcome of abstinence incentives and have explored both safety and cost-effectiveness of the intervention. Implications for the use of motivational incentive methods in clinical practice are discussed.
This study assessed the effects of a contingency management (CM) intervention for alcohol consumption in 10 alcohol-dependent participants. An ABCA design was used. Vouchers were provided contingent on results of ethyl glucuronide (EtG) urine tests (an alcohol biomarker with a 2-day detection period) and alcohol breath tests during the C phase. The percentage of negative urines was 35% during the first baseline phase, 69% during the C phase, and 20% during the return-to-baseline phase. Results suggest that EtG urine tests may be a feasible method to deliver CM to promote alcohol abstinence.
addiction; alcohol; contingency management; biomarker; ethyl glucuronide
This study evaluated the efficacy of a contingency management (CM) intervention to promote smoking cessation in methadone-maintained patients. Twenty participants, randomized into contingent (n = 10) or noncontingent (n = 10) experimental conditions, completed the 14-day study. Abstinence was determined using breath carbon monoxide and urine cotinine levels. Contingent participants received voucher-based incentives for biochemical evidence of smoking abstinence. Noncontingent participants earned vouchers independent of smoking status. Contingent participants achieved significantly more smoking abstinence and longer durations of continuous smoking abstinence than did noncontingent participants. These results support the potential efficacy of using voucher-based CM to promote smoking cessation among methadone-maintained patients.
contingency management; methadone maintenance; smoking cessation
Unemployment is associated with negative outcomes both during and after drug abuse treatment. Interventions designed to increase rates of employment may also improve drug abuse treatment outcomes. The purpose of this multi-site clinical trial was to evaluate the Job Seekers’ Workshop (JSW), a three session, manualized program designed to train patients in the skills needed to find and secure a job.
Study participants were recruited through the NIDA Clinical Trials Network (CTN) from six psychosocial counseling (n=327) and five methadone maintenance (n=301) drug treatment programs. Participants were randomly assigned to either standard care (program-specific services plus brochure with local employment resources) (SC) or standard care plus JSW. Three 4-hr small group JSW sessions were offered weekly by trained JSW facilitators with ongoing fidelity monitoring.
JSW and SC participants had similar 12- and 24-week results for the primary outcome measure (i.e., obtaining a new taxed job or enrollment in a training program), Specifically, one-fifth of participants at 12 weeks (20.1 – 24.3%) and nearly one-third at 24 weeks (31.4–31.9%) had positive outcomes, with “obtaining a new taxed job” accounting for the majority of cases.
JSW group participants did not have higher rates of employment/training than SC controls. Rates of job acquisition were modest for both groups, suggesting more intensive interventions may be needed. Alternate targets (e.g., enhancing patient motivation, training in job-specific skills) warrant further study as well.
Substance Use Disorders; Vocational Rehabilitation; Treatment; Translational Research; Employment
Contingency management (CM) is an evidence-based treatment, but few clinicians deliver this intervention in community-based settings.
Twenty-three clinicians from three methadone maintenance clinics received training in CM. Following a didactics seminar and a training and supervision period in which clinicians delivered CM to pilot patients, a randomized trial evaluated the efficacy of CM when delivered entirely by clinicians. Sixteen clinicians treated 130 patients randomized to CM or standard care. In both conditions, urine and breath samples were collected twice weekly for 12 weeks. In the CM condition, patients earned the opportunity to win prizes ranging in value from $1 to $100 for submitting samples negative for cocaine and alcohol. Primary treatment outcomes were retention, longest continuous period of abstinence, and proportion of negative samples submitted.
Patients randomized to CM remained in the study longer (9.5 ± 3.6 versus 6.7 ± 5.0 weeks), achieved greater durations of abstinence (4.7 ± 4.7 versus 1.7 ± 2.7 weeks), and submitted a higher proportion of negative samples (57.7% ± 40.0% versus 29.4% ± 33.3%) than those assigned to standard care.
These data indicate that, with appropriate training, community-based clinicians can effectively administer CM. This study suggests that resources ought to be directed toward training and supervising community-based providers in delivering CM, as patient outcomes can be significantly improved by integrating CM in methadone clinics.
contingency management; therapist; community clinics; training
There is a need for safe medications that can effectively support recovery by treating symptoms of protracted abstinence in alcoholics that may precipitate relapse e.g., craving and disturbances in sleep and mood. This proof-of-concept study reports on the effectiveness of gabapentin 1200 mg for attenuating these symptoms in a non treatment-seeking sample of cue-reactive, alcohol-dependent individuals. Subjects were 33 paid volunteers with current DSM-IV alcohol dependence and a strength of craving rating 1σ or greater for alcohol than water cues. Subjects were randomly assigned to gabapentin or placebo for 1-week and then participated in a within-subjects trial where each was exposed to standardized sets of pleasant, neutral, and unpleasant visual stimuli followed by alcohol or water cues. We found a significant attenuating effect of gabapentin (vs. placebo) on several measures of subjective craving for alcohol as well as for affectively-evoked craving. Gabapentin was also found to significantly improve several measures of sleep quality. Side effects were minimal, and gabapentin effects were not found to resemble any major classes of abused drugs. Results suggest that gabapentin may be effective for treating the protracted abstinence phase in alcohol dependence and, hence, that a randomized clinical trial would be an appropriate next step. The study also suggests the value of cue reactivity studies as proof-of-concept screens for potential anti relapse drugs.
Affective stimuli; alcohol dependence; craving; cue reactivity; gabapentin; proof-of-concept
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.
contingency management; cigarette smoking; reinforcement schedules; smoking cessation