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1.  Employment-based abstinence reinforcement following inpatient detoxification in HIV-positive opioid and/or cocaine-dependent patients 
Employment-based reinforcement interventions have been used to promote abstinence from drugs among chronically unemployed injection drug users. The current study utilized an employment-based reinforcement intervention to promote opiate and cocaine abstinence among opioid-dependent, HIV-positive participants who had recently completed a brief inpatient detoxification. Participants (n=46) were randomly assigned to an Abstinence & Work group that was required to provide negative urine samples in order to enter the workplace and earn incentives for work (n=16), a Work Only group that was permitted to enter the workplace and earn incentives independent of drug use (n=15), and a No Voucher control group that did not receive any incentives for working (n=15) over a 26-week period. The primary outcome was urinalysis-confirmed opiate, cocaine, and combined opiate/cocaine abstinence. Participants were 78% male and 89% African American. Results showed no significant between-group differences in urinalysis-verified drug abstinence or HIV risk behaviors during the 6-month intervention. The Work Only group had significantly greater workplace attendance and worked more minutes per day when compared to the No Voucher group. Several features of the study design, including the lack of an induction period, setting the threshold for entering the workplace too high by requiring immediate abstinence from several drugs, and increasing the risk of relapse by providing a brief detoxification that was not supported by any continued pharmacological intervention, likely prevented the workplace from becoming established as a reinforcer that could be used to promote drug abstinence. However, increases in workplace attendance have important implications for adult training programs.
doi:10.1037/a0034863
PMCID: PMC4332775  PMID: 24490712
HIV; contingency management; therapeutic workplace; incentive; injection drug use
2.  Academic skills of chronically unemployed drug-addicted adults 
BACKGROUND
The strong association between unemployment and drug addiction suggests that employment interventions are an important and needed focus of drug-addiction treatment. The increasing necessity of possessing basic academic skills to function in the workplace may require that some individuals receive educational training along with vocational training.
OBJECTIVE
This study investigated the academic skills of drug-addicted and chronically-unemployed adults (N = 559) who were enrolled in one of six studies conducted at the Center for Learning and Health in Baltimore, MD.
METHODS
Upon study enrollment, academic skills in math, spelling, and reading were examined using the Wide Range Achievement Test (WRAT-3 or WRAT-4) and educational history was examined using the Addiction Severity Index–Lite.
RESULTS
Although participants completed an average of 11 years of education, actual academic skill level was at or below the seventh grade level for 81% of participants in math, 61% in spelling, and 43% in reading, and most participants were classified as Low Average or below based on age group norms. Despite the fact that participants in this analysis were studied across several years and were from diverse populations, rates of high school completion and academic skill levels were remarkably similar.
CONCLUSIONS
Programs designed to improve the long-term employment status of drug-addicted individuals may benefit from the inclusion of basic adult education; future research on the topic is needed. Although establishing basic skills does not directly address chronic unemployment, it may help individuals obtain the jobs they desire and function effectively in those jobs.
doi:10.3233/JVR-140724
PMCID: PMC4307804  PMID: 25635162
Academic skills; vocational training; employment; education; poverty; drug addiction; Therapeutic Workplace
3.  Randomized Clinical Trial Examining Duration of Voucher-Based Reinforcement Therapy for Cocaine Abstinence 
Drug and alcohol dependence  2013;132(3):639-645.
Background
This is the first study to systematically manipulate duration of Voucher-Based Reinforcement Therapy (VBRT) to see if extending the duration increases abstinence during and following VBRT.
Methods
We randomized cocaine-dependent methadone-maintained adults to Standard (12 weeks; n=62) or Extended (36 weeks; n=68) VBRT and provided escalating voucher amounts contingent upon urinalysis verification of cocaine abstinence. Urinalysis was scheduled at least every two weeks during the 48-week study and more frequently during VBRT (3/week) and 12 weeks of Aftercare (2/week).
Results
Extended VBRT produced longer durations of continuous cocaine abstinence during weeks 1–24 (5.7 vs 2.7 weeks; p=0.003) and proportionally more abstinence during weeks 24–36 (X2 =4.57, p=.03, OR=2.18) compared to Standard VBRT. Duration of VBRT did not directly predict after-VBRT abstinence; but longer continuous abstinence during VBRT predicted abstinence during Aftercare (p=0.001) and during the last 12 weeks of the study (p < 0.001). Extended VBRT averaged higher monthly voucher costs compared to Standard VBRT ($96 vs $43, p < .001); however, the average cost per week of abstinence attained was higher in the Standard group ($8.06 vs $5.88, p < .001). Participants in the Extended group with voucher costs exceeding $25 monthly averaged 20 weeks of continuous abstinence.
Conclusions
Greater abstinence occurred during Extended VBRT, but providing a longer duration was not by itself sufficient to maintain abstinence after VBRT. However, if abstinence can be captured and sustained during VBRT, then providing longer durations may help increase the continuous abstinence that predicts better long-term outcomes.
doi:10.1016/j.drugalcdep.2013.04.015
PMCID: PMC3770760  PMID: 23680075
VBRT; vouchers; reinforcement; cocaine abstinence; treatment duration
4.  Incentives and health: An introduction 
Preventive medicine  2012;55(0):S2-S6.
doi:10.1016/j.ypmed.2012.04.008
PMCID: PMC4107351  PMID: 22554884
5.  Propensity to Work Among Chronically Unemployed Adult Drug Users 
Substance use & misuse  2010;46(5):599-607.
Analyses were conducted to compare rates of employment before, during, and after employment at the therapeutic workplace, which is a novel employment-based treatment for drug misuse. Participants in two clinical trials attended the therapeutic workplace at higher rates than they worked before intake and six months after discharge. These data suggest that unemployed chronic drug misusers will attend work at higher rates at the therapeutic workplace than in the community when paid modest wages, and that the failure of chronic drug misusers to obtain employment in the community may not result from lack of interest in work.
doi:10.3109/10826084.2010.526982
PMCID: PMC3985271  PMID: 20964531
drug misuse; employment; therapeutic workplace; vocational training
6.  Motivating Ergonomic Computer Workstation Setup: Sometimes Training Is Not Enough 
Musculoskeletal disorders lead to pain and suffering and result in high costs to industry. There is evidence to suggest that whereas conventional ergonomics training programs result in knowledge gains, they may not necessarily translate to changes in behavior. There were 11 participants in an ergonomics training program, and a subsample of participants received a motivational intervention in the form of incentives for correct workstation setup. Training did not yield any changes in ergonomics measures for any participant. Incentives resulted in marked and durable changes in targeted workstation measures. The data suggest that improving worker knowledge about ergonomically correct workstation setup does not necessarily lead to correct workstation setup, and that motivational interventions may be needed to achieve lasting behavior change.
PMCID: PMC3985273  PMID: 22429527
computer workstations; incentives; injury prevention; musculoskeletal disorders; training
7.  Risk-Taking Propensity as a Predictor of Induction onto Naltrexone Treatment for Opioid Dependence 
The Journal of clinical psychiatry  2012;73(8):e1056-e1061.
Objective
Heroin addiction is a chronic relapsing disorder that has devastating social, medical, and economic consequences. Naltrexone is an antagonist that blocks opioid effects and could be an effective medication for the treatment of opioid dependence. However, its clinical utility has been limited partly because of poor adherence and acceptability. Given the importance of compliance to naltrexone treatment for opioid dependence, the goal of the current study was to examine predictors involved in successful induction onto naltrexone treatment.
Method
Parametric and nonparametric statistical tests were performed on data from a sample of 64 individuals entering treatment who met DSM-IV criteria for opioid dependence. The relationship between naltrexone induction (i.e., inducted- vs. not-inducted onto naltrexone) and risk-taking propensity, as indexed by riskiness on the Balloon Analogue Risk Task (BART) was examined. Participants were recruited from local detoxification programs, inpatient drug treatment, and other Baltimore programs that provided services to opioid dependent adults (e.g., Baltimore Needle Exchange Program) during the period from August 2007 to September 2008.
Results
Positive association between risk-taking propensity and odds of naltrexone induction. Specifically, each five point increase in the total BART score was associated with a 25% decrease in odds of naltrexone induction (OR=0.76, 95% CI: 0.58–0.99, p = .041). This association remained statistically significant even after adjusting for potential confounds, including injection drug use and cocaine positive urine results (p = .05). After adjusting for the covariates, each five point increase in BART score was associated with 28% decrease in the odds of achieving the maintenance dose (AOR=0.73, 95% CI: 0.54–0.99, p = .046).
Conclusions
Risk taking propensity was predictive of induction onto naltrexone treatment, above and beyond injection drug use and cocaine-positive urine samples.
doi:10.4088/JCP.09m05807
PMCID: PMC3985274  PMID: 22967782
Risk taking propensity; naltrexone; opioid dependence; substance abuse treatment
8.  Barriers to Employment among Unemployed Drug Users: Age Predicts Severity 
Background
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.
Objective
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.
Methods
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.
Results
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.
doi:10.3109/00952990.2011.643976
PMCID: PMC3985289  PMID: 22242680
computer skills; employment; employment barriers; social skills; substance abuse
9.  Employment-Based Reinforcement of Adherence to Oral Naltrexone Treatment in Unemployed Injection Drug Users 
Naltrexone has high potential for use as a relapse prevention pharmacotherapy for opiate dependence; however suffers from notoriously poor adherence when prescribed for oral self-administration. This study evaluated whether entry to a therapeutic workplace could be used to reinforce adherence with oral naltrexone. Opiate-dependent and cocaine-using injection drug users were detoxified, inducted onto oral naltrexone, and randomly assigned to a Contingency (n=35) or Prescription (n=32) group for a 26-week period. Contingency participants were required to ingest naltrexone under staff observation to gain access to the therapeutic workplace. Prescription participants received a take-home supply of naltrexone and could access the workplace independent of naltrexone ingestion. Primary outcome measures were percent of urine samples positive for naltrexone at 30-day assessments and negative for opiates and cocaine at 30-day assessments. Contingency participants provided significantly more urine samples that were positive for naltrexone compared to Prescription participants (72% vs. 21%, P<.01), however no effect of experimental group was observed on percent opiate-negative (71% vs. 60%, P=.19.) or cocaine-negative (56% vs. 53%, P=.82) samples in the Contingency and Prescription groups, respectively. Opiate-positive samples were significantly more likely to occur in conjunction with cocaine (P<.001), and when not protected by naltrexone (P<.02), independent of experimental group. Overall, these results show that contingent access to a therapeutic workplace significantly promoted adherence to oral naltrexone, and that the majority of opiate use occurred in conjunction with cocaine use, suggesting that untreated cocaine use may limit the effectiveness of oral naltrexone in promoting opiate abstinence.
doi:10.1037/a0030743
PMCID: PMC3641088  PMID: 23205722
naltrexone; contingency management; therapeutic workplace; incentive; injection drug use
10.  The use of incentives to reinforce medication adherence 
Preventive medicine  2012;55(Suppl):S86-S94.
Objective
Poor medication adherence is a longstanding problem, and is especially pertinent for individuals with chronic conditions or diseases. Adherence to medications can improve patient outcomes and greatly reduce the cost of care. The purpose of the present review is to describe the literature on the use of incentives as applied to the problem of medication adherence.
Methods
We conducted a systematic review of peer-reviewed empirical evaluations of incentives provided to patients contingent upon medication adherence.
Results
This review suggests that incentive-based medication adherence interventions can be very effective, but there are few controlled studies. The studies on incentive-based medication adherence interventions most commonly feature patients taking medication for drug or alcohol dependence, HIV, or latent tuberculosis. Across studies that reported percent adherence comparisons, incentives increased adherence by a mean of 20 percentage points, but effects varied widely. Cross-study comparisons indicate a positive relationship between the value of the incentive and the impact of the intervention. Post-intervention evaluations were rare, but tended to find that adherence effects diminish after the interventions are discontinued.
Conclusions
Incentive-based medication adherence interventions are promising but understudied. A significant challenge for research in this area is the development of sustainable and cost-effective long-term interventions.
doi:10.1016/j.ypmed.2012.04.017
PMCID: PMC3424340  PMID: 22580095
11.  Maintenance of reinforcement to address the chronic nature of drug addiction 
Preventive medicine  2012;55(Suppl):S46-S53.
Background
Drug addiction can be a chronic problem. Abstinence reinforcement can initiate drug abstinence, but as with other treatments many patients relapse after the intervention ends. Abstinence reinforcement can be maintained to promote long-term drug abstinence, but practical means of implementing long-term abstinence reinforcement are needed.
Methods
We reviewed 8 clinical trials conducted in Baltimore, MD from 1996 through 2010 that evaluated the therapeutic workplace as a vehicle for maintaining reinforcement for the treatment of drug addiction. The therapeutic workplace uses employment-based reinforcement in which employees must provide objective evidence of drug abstinence or medication adherence to work and earn wages.
Results
Employment-based reinforcement can initiate (3 of 4 studies) and maintain (2 studies) cocaine abstinence in methadone patients, although relapse can occur even after long-term exposure to abstinence reinforcement (1 study). Employment-based reinforcement can also promote abstinence from alcohol in homeless alcohol dependent adults (1 study), and maintain adherence to extended-release naltrexone in opioid dependent adults (2 studies).
Conclusion
Treatments should seek to promote life-long effects in patients. Therapeutic reinforcement may need to be maintained indefinitely to prevent relapse. Workplaces could be effective vehicles for the maintenance of therapeutic reinforcement contingencies for drug abstinence and adherence to addiction medications.
doi:10.1016/j.ypmed.2012.03.013
PMCID: PMC3437006  PMID: 22668883
Reinforcement; Incentives; Contingency Management; Cocaine; Heroin; Drug Addiction; Treatment; Employment; Poverty; Relapse
12.  Employment-based reinforcement of adherence to an FDA approved extended release formulation of naltrexone in opioid-dependent adults: A randomized controlled trial 
Drug and alcohol dependence  2011;120(1-3):48-54.
Background
Naltrexone provides excellent opioid blockade, but its clinical utility is limited because opioid-dependent patients typically refuse it. An injectable suspension of naltrexone for extended release (XR-NTX) was recently approved by the FDA for treatment of opioid dependence. XR-NTX treatment may require concurrent behavioral intervention to maximize adherence and effectiveness, thus we sought to evaluate employment-based reinforcement as a method of improving adherence to XR-NTX in opiate dependent adults.
Methods
Opioid-dependent adults (N = 38) were detoxified and inducted onto oral naltrexone, then randomly assigned to contingency or prescription conditions. Participants received up to six doses of XR-NTX at four-week intervals. All participants could earn vouchers for attendance and performance at a therapeutic workplace. Contingency participants were required to accept XRNTX injections to access the workplace and earn vouchers. Prescription participants could earn vouchers independent of their acceptance of XR-NTX injections.
Results
Contingency participants accepted significantly more naltrexone injections than prescription participants (87% versus 52%, p = .002), and were more likely to accept all injections (74% versus 26%, p = .004). Participants in the two conditions provided similar percentages of samples negative for opiates (72% versus 65%) and for cocaine (58% versus 54%).Opiate positivity was significantly more likely when samples were also cocaine positive, independent of naltrexone blockade (p = .002).
Conclusions
Long-term adherence to XR-NTX in unemployed opiate dependent adults is low under usual care conditions. Employment-based reinforcement can maintain adherence to XRNTX. Ongoing cocaine use appears to interfere with the clinical effectiveness of XR-NTX on opiate use.
doi:10.1016/j.drugalcdep.2011.06.023
PMCID: PMC3245785  PMID: 21782353
contingency management; incentives; therapeutic workplace; heroin; opioid pharmacotherapy; extended-release naltrexone
13.  A Randomized Clinical Trial of a Therapeutic Workplace for Chronically Unemployed, Homeless, Alcohol-Dependent Adults 
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.
doi:10.1093/alcalc/agr057
PMCID: PMC3156886  PMID: 21622676
14.  Employment-Based Reinforcement of Adherence to Depot Naltrexone in Unemployed Opioid-Dependent Adults: A Randomized Controlled Trial 
Addiction (Abingdon, England)  2011;106(7):1309-1318.
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 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.
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.
doi:10.1111/j.1360-0443.2011.03400.x
PMCID: PMC3107896  PMID: 21320227
depot naltrexone; contingency management; heroin; substance abuse; employment-based reinforcement
15.  USING WORDS INSTEAD OF JUMBLED CHARACTERS AS STIMULI IN KEYBOARD TRAINING FACILITATES FLUENT PERFORMANCE 
Keyboarding skill is an important target for adult education programs due to the ubiquity of computers in modern work environments. A previous study showed that novice typists learned key locations quickly but that fluency took a relatively long time to develop. In the present study, novice typists achieved fluent performance in nearly half the time when words rather than jumbled characters were used as stimuli. This suggests that using real words in the keyboarding program can enhance the efficiency of training.
doi:10.1901/jaba.2011.44-921
PMCID: PMC3251293  PMID: 22219541
typing; fluency; adult education; job skills; workforce development
16.  Employment-based abstinence reinforcement as a maintenance intervention for the treatment of cocaine dependence: post-intervention outcomes 
Addiction (Abingdon, England)  2011;106(5):960-967.
Aims
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.
Design
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.
Setting
A nonprofit data entry business.
Participants
Unemployed welfare recipients who persistently used cocaine while in methadone treatment.
Measurements
Urine samples and self-reports were collected every six months for 30 months.
Findings
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.
Conclusions
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.
doi:10.1111/j.1360-0443.2011.03364.x
PMCID: PMC3074032  PMID: 21226886
Cocaine; Methadone; Employment; Contingency management; Abstinence reinforcement
17.  A randomized controlled trial of fluoxetine in the treatment of cocaine dependence among methadone-maintained patients 
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, p.o.) for cocaine dependence was conducted that incorporated abstinence-contingent voucher incentives. 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 (mean of 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
Fluoxetine was not efficacious in reducing cocaine use in patients dually dependent on cocaine and opioids.
doi:10.1016/j.jsat.2010.11.010
PMCID: PMC3078567  PMID: 21266301
Cocaine; Contingency management; Fluoxetine; Methadone
18.  GENERALIZATION OF POSTURE TRAINING TO COMPUTER WORKSTATIONS IN AN APPLIED SETTING 
Improving employees' posture may decrease the risk of musculoskeletal disorders. The current paper is a systematic replication and extension of Sigurdsson and Austin (2008), who found that an intervention consisting of information, real-time feedback, and self-monitoring improved participant posture at mock workstations. In the current study, participants worked in an applied setting, and posture data were collected at participants' own workstations and a mock workstation. Intervention in the mock setting was associated with consistent improvement in safe posture at the mock workstation, but generalization to the actual workstation was limited.
doi:10.1901/jaba.2011.44-157
PMCID: PMC3050474  PMID: 21541108
ergonomics; musculoskeletal disorders; real-time feedback; self-monitoring
19.  Professional Demeanor of Chronically Unemployed Cocaine-Dependent Methadone Patients in a Therapeutic Workplace 
Substance use & misuse  2007;42(7):1141-1159.
This study assesses the frequency that users of illicit drugs display unprofessional behaviors in an employment setting. This research was conducted in the Therapeutic Workplace, a model employment-based treatment program for chronically unemployed adults with long-histories of illicit drug use. Unemployed adults in methadone treatment, who were opiate and cocaine dependent, showed signs of injection drug use, and recently used cocaine were hired to work for 4 hours every weekday for 7 months. Results show that while the overall incidence of many undesirable behaviors is low, a small percentage of participants had serious workplace behavior problems that might limit their success in community workplaces. This study suggests that unprofessional behavior in the workplace could contribute to chronic unemployment in this population.
doi:10.1080/10826080701410089
PMCID: PMC3072792  PMID: 17668330
Employment; Heroin Addiction; Cocaine Addiction; Contingency management; Reinforcement; Vocation rehabilitation
20.  Employment-Based Abstinence Reinforcement as a Maintenance Intervention for the Treatment of Cocaine Dependence: A Randomized Controlled Trial 
Addiction (Abingdon, England)  2009;104(9):1530-1538.
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:
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 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.
Setting:
A nonprofit data entry business.
Participants:
Unemployed welfare recipients who persistently used cocaine while enrolled in methadone treatment in Baltimore.
Intervention:
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.
Results:
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).
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. Workplaces could serve as therapeutic agents in the treatment of drug dependence by arranging long-term employment-based contingency management programs.
Trial Registration:
clinicaltrials.gov. Identifier: NCT00249496
doi:10.1111/j.1360-0443.2009.02657.x
PMCID: PMC2729763  PMID: 19686522
Cocaine; Methadone; Employment; Contingency management; Abstinence reinforcement
21.  MODIFICATION OF PERSEVERATIVE RESPONDING THAT INCREASED EARNINGS BUT IMPEDED SKILL ACQUISITION IN A JOB-SKILLS TRAINING PROGRAM 
Adults in a therapeutic workplace working on a computerized keyboarding training program earned vouchers for typing correct characters. Typing technique was evaluated on review steps. Participants could pass the review and earn a bonus, or skip the review and proceed with no bonus. Alternatively, participants could continue practicing on the same step. Participants persistently repeated the same step, which halted progress through the program but allowed them to increase their rate of responding and, as a result, their earnings. Blocking the initiation of practice on review steps and removing payment for practice initiated after prompts (extinction) both produced rapid progress through the program. These results underscore the importance of careful arrangement of the contingencies in adult education programs.
doi:10.1901/jaba.2009.42-627
PMCID: PMC2741061  PMID: 20190923
addiction; extinction; job skills training; response blocking; voucher reinforcement
22.  Abstinence-Contingent Reinforcement and Engagement in Non-drug Related Activities among Illicit Drug Abusers 
Methadone-maintained cocaine abusers (n = 78) were randomly assigned to a 52-week intervention of either (1) usual care only (UC), (2) take-home methadone doses contingent on cocaine- and opiate-negative results (THM), or (3) take-home methadone doses for cocaine- and opiate-negative results and monetary-based vouchers contingent on cocaine-negative urinalysis results (THM+V). Cocaine use was assessed by urinalysis on a thrice-weekly schedule. Frequency and enjoyability of non-drug related activities were assessed with the Pleasant Events Schedule (PES) at baseline, mid-, and end-of-treatment. The THM+V condition achieved the greatest abstinence from cocaine and opiate use, followed by the THM and UC conditions. The THM+V condition had the highest PES Frequency ratings at mid- and end-of-treatment, followed by the THM and UC conditions. There were significant differences between the THM+V and UC conditions on 10 of 12 PES subscales. Analyses revealed that abstinence mediated the effects of treatment condition on frequency ratings. There were no significant differences in Enjoyability ratings. These results suggest that when contingency-management interventions increase abstinence from drug abuse they also increase engagement in non-drug related activities in naturalistic settings.
doi:10.1037/0893-164X.22.4.544
PMCID: PMC2825151  PMID: 19071979
Substance Abuse; Treatment; Contingency Management; Pleasant Events; Cocaine
23.  Attendance Rates in A Workplace Predict Subsequent Outcome of Employment-Based Reinforcement of Cocaine Abstinence in Methadone Patients 
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.
doi:10.1901/jaba.2008.41-499
PMCID: PMC2606606  PMID: 19192855
abstinence reinforcement; cocaine addiction; contingency management; employment; methadone
24.  Introduction to The Special Issue on The Behavior Analysis and Treatment of Drug Addiction 
Extensive evidence from the laboratory and the clinic suggests that drug addiction can be viewed as operant behavior and effectively treated through the application of principles of operant conditioning. Contingency management interventions that arrange for the direct reinforcement of drug abstinence or of other therapeutically important target behaviors (e.g., regular use of drug abuse treatment medications) are among the most studied type of operant treatments. Behavior analysts have contributed to the substantial and rapidly growing literature on operant treatments for drug addiction, but the publications of this work usually appear in medical, clinical psychology, or drug abuse journals. This special issue of the Journal of Applied Behavior Analysis represents an effort to bring this important work to the attention of the behavior-analytic community. The articles in this special issue illustrate both the enormous potential of contingency management interventions to address the serious and seemingly intractable problem of drug addiction as well as the real challenges involved in attempting to develop and disseminate treatments that will produce substantial and lasting changes in the lives of individuals plagued by the chronic problem of drug addiction.
doi:10.1901/jaba.2008.41-471
PMCID: PMC2606609  PMID: 19192853
abstinence reinforcement; contingency management; drug abuse; drug addiction; operant conditioning
25.  Economic Cost of the Therapeutic Workplace Intervention Added to Methadone Maintenance 
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.
doi:10.1016/j.jsat.2007.04.013
PMCID: PMC2423275  PMID: 17614239
Cost; Economics; DATCAP; substance abuse treatment; addiction treatment; unemployment

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