A Comparison of Five Reinforcement Schedules for use in Contingency Management-Based Treatment of Methamphetamine Abuse

Contingency management for monosubstance use disorders: Systematic review and assessment of predicted versus obtained effects

Contingency management (CM) is notably successful as a substance use disorder treatment and is most effective when targeting monosubstance use. Evidence suggests the effects of CM exceed predictions based on the value of the incentives delivered for monosubstance abstinence. In this systematic review, we examine common variations of CM interventions applied to a single substance to determine what factors may contribute to the larger effect. Our results show that CM produced moderate to large effect sizes when single drugs were targeted, with stable effects over time. We also found that interventions targeting cocaine abstinence overwhelmingly outperformed their predicted effect, whereas interventions for smoking cessation did not. Thus, incentives alone may not account for the success of CM, at least when applied to stimulant use disorder. We propose other potential sources of the effect including social reinforcement and the specific parameters of the reinforcement schedule.

Study protocol for a sequential multiple assignment randomized trial to decrease alcohol use before and after surgery

BACKGROUND

High-risk alcohol consumption in the weeks before and after surgery poses significant risks for postoperative recovery. Despite this, elective surgical patients are rarely offered alcohol-focused education, interventions, or treatment. This paper describes the protocol of a research study designed to evaluate the effectiveness of brief, non-pharmacological, therapeutic approaches to reduce alcohol use before and after surgery.

METHODS

The Alcohol Screening and Preoperative Intervention Research (ASPIRE-2) study trial includes 440 elective, non-cancer, surgery patients ages 21-75 years-old who report high-risk alcohol use. This trial uses a Sequential, Multiple Assignment, Randomized Trial (SMART) design to test the effectiveness of adaptive interventions that include preoperative Virtual Health Coaching (VHC) or Enhanced Usual Care (EUC) followed by postoperative intervention strategies tailored to participant response to the preoperative study condition. Intervention "response" is defined as achieving low-risk alcohol use following the preoperative intervention. The primary aims of this study are to: 1) examine the effectiveness of adaptive interventions that begin with preoperative VHC compared to EUC in reducing high-risk alcohol use among elective surgical patients; and 2) identify the most effective postoperative strategy for lasting alcohol use reduction over a period of 12 months. Secondary and exploratory aims will identify the best performing pre-specified adaptive interventions, identify baseline and time-varying moderators of intervention effectiveness, and evaluate surgical outcomes.

CONCLUSION

The ASPIRE-2 study is an innovative approach to develop adaptive interventions to reduce alcohol use proximal to elective surgery when alcohol use poses short- and long-term risks to surgery and health.

Cocaine abstinence during the "critical period" of a contingency management trial predicts future abstinence in people with cocaine use disorder

BACKGROUND

Contingency Management (CM) is being piloted as a treatment for stimulant use disorder in several US states, highlighting the need for treatment optimization. One important goal of optimization is decreasing drug use during the early stages of treatment, which has predicted success in other interventions. However, this "critical period" has not been reported in CM trials. The purpose of this analysis was to determine if, after accounting for baseline abstinence and incentive condition, abstinence in a CM trial for people with Cocaine Use Disorder (CUD) could be predicted by cocaine use during a first-week critical period.

METHODS

Eighty-seven participants with CUD were randomized to receive contingent high or low value incentives for cocaine abstinence or were in a non-contingent control group. Generalized estimating equations (GEE) were used to analyze urine test results over 36 timepoints during the 12-week intervention. To assess for a critical period, the first three visits were included in the GEE as a covariate for remaining urine test results.

RESULTS

Participants who provided more negative samples during the critical period were significantly more likely to produce a negative urine sample during the remainder of the trial, though some effects of group remained after controlling for the critical period.

CONCLUSIONS

These results indicate that a critical period exists for CM trials, and it can explain a substantial amount of future performance. Early contact with an abstinence-contingent high magnitude alternative reinforcer may explain additional performance beyond the critical period, further justifying the use of high magnitude alternative reinforcers.

Psychosocial and pharmacologic interventions for problematic methamphetamine use: Findings from a scoping review of the literature

RATIONALE

Methamphetamine use and related harms have risen at alarming rates. While several psychosocial and pharmacologic interventions have been described in the literature, there is uncertainty regarding the best approach for the management of methamphetamine use disorder (MUD) and problematic methamphetamine use (PMU). We conducted a scoping review of recent systematic reviews (SR), clinical practice guidelines (CPG), and primary controlled studies of psychosocial and pharmacologic treatments for MUD/PMU.

METHODS

Guided by an a priori protocol, electronic database search updates (e.g., MEDLINE, Embase) were performed in February 2022. Screening was performed following a two-stage process, leveraging artificial intelligence to increase efficiency of title and abstract screening. Studies involving individuals who use methamphetamine, including key subgroups (e.g. those with mental health comorbidities; adolescents/youths; gay, bisexual, and other men who have sex with men) were sought. We examined evidence related to methamphetamine use, relapse, use of other substances, risk behaviors, mental health, harms, and retention. Figures, tables and descriptive synthesis were used to present findings from the identified literature.

RESULTS

We identified 2 SRs, one CPG, and 54 primary studies reported in 69 publications that met our eligibility criteria. Amongst SRs, one concluded that psychostimulants had no effect on methamphetamine abstinence or treatment retention while the other reported no effect of topiramate on cravings. The CPG strongly recommended psychosocial interventions as well as self-help and family support groups for post-acute management of methamphetamine-related disorders. Amongst primary studies, many interventions were assessed by only single studies; contingency management was the therapy most commonly associated with evidence of potential effectiveness, while bupropion and modafinil were analogously the most common pharmacologic interventions. Nearly all interventions showed signs of potential benefit on at least one methamphetamine-related outcome measure.

DISCUSSION

This scoping review provides an overview of available interventions for the treatment of MUD/PMU. As most interventions were reported by a single study, the effectiveness of available interventions remains uncertain. Primary studies with longer durations of treatment and follow-up, larger sample sizes, and of special populations are required for conclusive recommendations of best approaches for the treatment of MUD/PMU.

Implementing an evidence-based prize contingency management protocol for stimulant use

INTRODUCTION

Contingency management (CM) is an efficacious treatment for stimulant use disorders. Support materials for the clinical delivery of prize-based CM are widely accessible, but few resources are available to support design and preparation for CM implementation. This guide aims to fill that gap.

METHOD/RESULTS

The article outlines a suggested prize CM protocol and discusses the best practices most aligned with the evidence base and acceptable-if-necessary modifications. This guide also highlights modifications that are not evidence-based and not recommended. In addition, I discuss practical and clinical aspects of preparing for CM implementation.

CONCLUSIONS

Deviations from evidence-based practices are common, and poorly designed CM is unlikely to impact patient outcomes. This article provides planning stage guidance to support programs' adoption of evidence-based prize CM for the treatment of stimulant use disorders.

Loss-Framed Adaptive Microcontingency Management for Preventing Prolonged Sedentariness: Development and Feasibility Study

BACKGROUND

A growing body of evidence shows that financial incentives can effectively reinforce individuals' positive behavior change and improve compliance with health intervention programs. A critical factor in the design of incentive-based interventions is to set a proper incentive magnitude. However, it is highly challenging to determine such magnitudes as the effects of incentive magnitude depend on personal attitudes and contexts.

OBJECTIVE

This study aimed to illustrate loss-framed adaptive microcontingency management (L-AMCM) and the lessons learned from a feasibility study. L-AMCM discourages an individual's adverse health behaviors by deducting particular expenses from a regularly assigned budget, where expenses are adaptively estimated based on the individual's previous responses to varying expenses and contexts.

METHODS

We developed a mobile health intervention app for preventing prolonged sedentary lifestyles. This app delivered a behavioral mission (ie, suggesting taking an active break for a while) with an incentive bid when 50 minutes of uninterrupted sedentary behavior happened. Participants were assigned to either the fixed (ie, deducting the monotonous expense for each mission failure) or adaptive (ie, deducting varying expenses estimated by the L-AMCM for each mission failure) incentive group. The intervention lasted 3 weeks.

RESULTS

We recruited 41 participants (n=15, 37% women; fixed incentive group: n=20, 49% of participants; adaptive incentive group: n=21, 51% of participants) whose mean age was 24.0 (SD 3.8; range 19-34) years. Mission success rates did not show statistically significant differences by group (P=.54; fixed incentive group mean 0.66, SD 0.24; adaptive incentive group mean 0.61, SD 0.22). The follow-up analysis of the adaptive incentive group revealed that the influence of incentive magnitudes on mission success was not statistically significant (P=.18; odds ratio 0.98, 95% CI 0.95-1.01). On the basis of the qualitative interviews, such results were possibly because the participants had sufficient intrinsic motivation and less sensitivity to incentive magnitudes.

CONCLUSIONS

Although our L-AMCM did not significantly affect users' mission success rate, this study configures a pioneering work toward adaptively estimating incentives by considering user behaviors and contexts through leveraging mobile sensing and machine learning. We hope that this study inspires researchers to develop incentive-based interventions.

Escalating schedules of incentives increase physical activity with no differences between deposit and no-deposit groups: A systematic replication

Physical inactivity has increasingly affected public health in the United States during the COVID-19 pandemic as it is associated with chronic diseases such as arthritis, cancer, and heart disease. Contingency management has been shown to increase physical activity. Therefore, the present study sought to evaluate the effects of an escalating schedule of monetary reinforcement with a reset contingency on physical activity, as compared between 2 counterbalanced groups in which a monetary deposit of $25 was either required (deposit group) or not (no-deposit group). Twenty-five adults wore Fitbit accelerometers to monitor step counts. An ABA reversal design was used; in the 2 baseline phases, no programmed contingencies were in place for step counts. During intervention, step goals were set using a modified 70th percentile schedule with a 7-day window: Reaching the first goal would result in $0.25, and incentives increased by $0.25 for each subsequent day in which the goal was met. Failure to reach a goal resulted in a reset of the monetary incentive value to $0.25. Ten out of 12 participants from the deposit group were determined to be responders to intervention, whereas 8 out of 13 participants from the no-deposit group were determined to be responders to intervention. Overall, there were no significant differences between the groups' step counts. However, the deposit group's intervention was cheaper to implement, which suggests that deposit contracts are a viable modification for physical activity interventions.

A Systematic Review of Treatment Maintenance Strategies in Token Economies: Implications for Contingency Management

Contingency management (CM) interventions are based on operant principles and are effective in promoting health behaviors. Despite their success, a common criticism of CM is that its effects to not persist after the intervention is withdrawn. Many CM studies evaluate posttreatment effects, but few investigate procedures for promoting maintenance. Token economy interventions and CM interventions are procedurally and conceptually similar. The token economy literature includes many studies in which procedures for promoting postintervention maintenance are evaluated. A systematic literature review was conducted to synthesize the literature on treatment maintenance in token economies. Search procedures yielded 697 articles, and application of inclusion/exclusion criteria resulted in 37 articles for review. The most successful strategy is to combine procedures. In most cases, thinning or fading was combined with programmed transfer of control via social reinforcement or self-management. Social reinforcement and self-monitoring procedures appear to be especially important, and were included in 70% of studies involving combined approaches. Thus, our primary recommendation is to incorporate multiple maintenance strategies, at least one of which should facilitate transfer of control of the target behavior to other reinforcers. In addition, graded removal of the intervention, which has also been evaluated to a limited extent in CM, is a reasonable candidate for further development and evaluation. Direct comparisons of maintenance procedures are lacking, and should be considered a research priority in both domains. Researchers and clinicians interested in either type of intervention will likely benefit from ongoing attention to developments in both areas.

A preliminary investigation of schedule parameters on cocaine abstinence in contingency management

Contingency management (CM) interventions are the most effective psychosocial interventions for substance use disorders. However, further investigation is needed to create the most robust intervention possible. This study investigated the effects of 1) reinforcer magnitude; and 2) fixed and escalating and resetting incentives on cocaine abstinence in an outpatient trial. In this analysis, 34 treatment-seeking individuals with Cocaine Use Disorder received either high or low value incentives for providing a benzoylecgonine-negative urine sample or were in a control condition and received incentives for providing a urine sample regardless of the results. Participants received either escalating and resetting incentives, wherein the value of each incentive increased with consecutive negative samples and reset to the initial level upon a positive sample (Experiment 1), or fixed incentives, wherein they received the same value incentive for each negative urine sample they provided (Experiment 2). Large incentives produced more abstinence, although escalating and resetting reinforcer values did not have a differential effect. Large, fixed incentives promoted abstinence faster than other reinforcers, whereas smaller incentives resulted in poor abstinence and took many visits to achieve initial abstinence. Future research comparing different schedules on cocaine abstinence in a randomized control trial with a larger sample size is required.

Alcohol Use Disorder in the Age of Technology: A Review of Wearable Biosensors in Alcohol Use Disorder Treatment

Biosensors enable observation and understanding of latent physiological occurrences otherwise unknown or invasively detected. Wearable biosensors monitoring physiological constructs across a wide variety of mental and physical health conditions have become an important trend in innovative research methodologies. Within substance use research, explorations of biosensor technology commonly focus on identifying physiological indicators of intoxication to increase understanding of addiction etiology and to inform treatment recommendations. In this review, we examine the state of research in this area as it pertains to treatment of alcohol use disorders specifically highlighting the gaps in our current knowledge with recommendations for future research. Annually, alcohol use disorders affect approximately 15 million individuals. A primary focus of existing wearable technology-based research among people with alcohol use disorders is identifying alcohol intoxication. A large benefit of wearable biosensors for this purpose is they provide continuous readings in a passive manner compared with the gold standard measure of blood alcohol content (BAC) traditionally measured intermittently by breathalyzer or blood draw. There are two primary means of measuring intoxication with biosensors: gait and sweat. Gait changes have been measured via smart sensors placed on the wrist, in the shoe, and mobile device sensors in smart phones. Sweat measured by transdermal biosensors detects the presence of alcohol in the blood stream correlating to BAC. Transdermal biosensors have been designed in tattoos/skin patches, shirts, and most commonly, devices worn on the ankle or wrist. Transdermal devices were initially developed to help monitor court-ordered sobriety among offenders with alcohol use disorder. These devices now prove most useful in continuously tracking consumption throughout clinical trials for behavioral treatment modalities. More recent research has started exploring the uses for physical activity trackers and physiological arousal sensors to guide behavioral interventions for relapse prevention. While research has begun to demonstrate wearable devices' utility in reducing alcohol consumption among individuals aiming to cutdown on their drinking, monitoring sustained abstinence in studies exploring contingency management for alcohol use disorders, and facilitating engagement in activity-based treatment interventions, their full potential to further aid in understanding of, and treatment for, alcohol use disorders has yet to be explored.

Contingency management for the treatment of methamphetamine use disorder: A systematic review

Methamphetamine use continues to be an important public health problem. Contingency management is among the most effective interventions for reducing methamphetamine use. It has been more than ten years since the last systematic review of contingency management for methamphetamine use disorder. Since then, an additional ten randomized controlled trials and a variety of other studies have been completed. The present systematic review includes 27 studies. Several factors, most notably problem severity, appear to predict treatment outcome. However, the effectiveness of CM has been demonstrated in studies restricted to MSM, studies restricted to implementation in community programs, and in studies of the general population of methamphetamine users conducted in research treatment programs. There appear to be broad benefits of contingency management intervention, including greater drug abstinence, higher utilization of other treatments and medical services, and reductions in risky sexual behavior. Twenty of the twenty-one studies that reported abstinence outcomes showed an effect of contingency management on abstinence, and seven of the nine studies that reported sexual risk behavior outcomes showed an effect of contingency management in reducing risky sexual behavior. Taken together, recent evidence suggests strongly that outpatient programs that offer treatment for methamphetamine use disorder should prioritize adoption and implementation of contingency management intervention.

Adaptation of contingency management for stimulant use disorder during the COVID-19 pandemic

The current coronavirus disease (COVID-19) pandemic has rapidly spread across the world. Individuals with stimulant use disorder are a vulnerable population, who are particularly at risk of negative outcomes during this pandemic due to several risk factors, including mental and physical comorbidities, weakened immune responses, high-risk behaviors, and barriers to healthcare access. Engaging patients with stimulant use disorder in regular treatment has become even more difficult during this pandemic, which has resulted in many cuts to addiction treatment programs. The most effective treatment options for stimulant use disorder are psychosocial interventions, which rely heavily on in-person interactions, posing an added challenge during physical distancing. In particular, contingency management (CM) is a behavioral therapy that utilizes tangible reinforcements to incentivize targeted behavior changes, and is an effective treatment intervention used for stimulant use disorder. This paper highlights the treatment challenges for individuals with stimulant use disorder and the importance of adapting CM programs during COVID-19. We present strategies for how CM can be adapted and its role expanded in a safe way during the COVID-19 pandemic to help prevent infection spread, stimulant use relapse, and worsened psychosocial consequences.

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Stimulant users face increased risk of relapse and infection during a pandemic.

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Contingency management is an effective treatment for stimulant use disorder.

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Contingency management can be adapted to mitigate negative outcomes of COVID-19.

Non-pharmacological interventions for methamphetamine use disorder: a systematic review

BACKGROUND

Methamphetamine (METH) use is on the rise globally, with the number of treatment seekers increasing exponentially across the globe. Evidence-based therapies are needed to meet rising treatment needs. This systematic review intends to appraise the existing evidence to identify effective non-pharmaceutical approaches for the treatment of METH use disorder.

METHODS

Five electronic bibliographic databases-Ovid (Medline), Embase, Cumulative Index of Nursing and Allied Health Literature (CINAHL), Web of Science and PsycINFO- were searched to identify relevant studies that were published between January 1995 to February 2020. Studies were selected and assessed by two independent reviewers. A systematic review of data from both randomised control trials (RCT) and non-RCTs was conducted to appraise the evidence.

RESULTS

A total of 44 studies were included in the review. Behavioural interventions, i.e. cognitive behavioural therapy (CBT), contingency management (CM), exercise, residential rehabilitation based therapies, repetitive transcranial magnetic stimulation (rTMS), and matrix model demonstrated treatment efficacy in promoting abstinence, reducing methamphetamine use or craving in the participants. While CM interventions showed the strongest evidence favouring the outcomes assessed, tailored CBT alone or with CM was also effective in the target population.

CONCLUSIONS

Behavioural interventions should be considered as the first line of treatment for methamphetamine use disorder. Future studies should address the longevity of the effects, and limitations due to smaller sample sizes and high dropout rates to enable better assessment of evidence.

Considerations for Implementing Contingency Management in Substance Abuse Treatment Clinics: The Veterans Affairs Initiative as a Model

Contingency management (CM) is an efficacious intervention for the treatment of substance use disorders that is widely applicable across a range of client populations and characteristics. Despite its strong evidence base, CM remains underutilized in real world practice. This article introduces CM for clinicians interested in adopting CM and briefly reviews this research evidence. In addition, CM protocols are described, with emphasis on the specific design considerations important to CM's efficacy. The recent Department of Veterans Affairs (VA) initiative, which represents the first successful large-scale implementation effort, is presented. It provides a model for the training and supervision components that may be critical to implementation with fidelity. Continued research in this area, as well as further demonstrations of successful dissemination and implementation, will be critical for improving the adoption of this intervention in clinical, nonresearch settings.

Health-related quality of life among people who use methamphetamine

INTRODUCTION AND AIMS

We assessed health-related quality of life amongst people who use methamphetamine, examined how this related to different patterns of methamphetamine use and what other factors were associated with decrements in quality of life in this sample.

DESIGN AND METHODS

A cross-sectional survey of 169 at least monthly methamphetamine users. Health utility scores were derived using the Assessment of Quality of Life - 4D for the past month (0 reflects death and 1 represents full health; the population mean Assessment of Quality of Life score in Australia is 0.81). Dependence on methamphetamine was a score of 4+ on the Severity of Dependence Scale. Other measures included days of methamphetamine use and other substance use in the past month, injecting methamphetamine, demographics, psychiatric symptoms (score of 4+ on the Brief Psychiatric Rating Scale items) and a lifetime DSM-IV diagnosis of schizophrenia.

RESULTS

The mean utility score was 0.52 (95% confidence interval 0.48-0.56). Methamphetamine dependence was associated with lower utility (-0.10, P = 0.003) after adjustment for other univariate correlates of utility. Other factors independently associated with lower utility were being a woman (-0.14, P < 0.001), depression (-0.10, P = 0.008), self-neglect (-0.08, P = 0.035), schizophrenia (-0.17, P = 0.003) and fewer years of schooling (0.02 per year, P = 0.037).

DISCUSSION AND CONCLUSIONS

We found poor quality of life in this sample of methamphetamine users relative to the general population, this being associated with both dependence on methamphetamine and other factors, particularly poor mental health. We also found poorer health amongst women.

A Randomized Trial of Adjunct mHealth Abstinence Reinforcement With Transdermal Nicotine and Counseling for Smoking Cessation

INTRODUCTION

Abstinence reinforcement is efficacious for improving smoking treatment outcomes, but practical constraints related to the need for multiple in-person carbon monoxide (CO) breath tests daily to verify smoking abstinence have limited its use. This study tested an mHealth procedure to remotely monitor and reinforce smoking abstinence in individuals' natural environment.

METHODS

Eligible treatment-seeking smokers (N = 90) were randomized to (1) usual care and ecological monitoring with abstinence reinforcement (mHealth reinforcement) or (2) without reinforcement (mHealth monitoring). Usual care was 8 weeks of transdermal nicotine and twice-weekly telephone counseling. Following training, an interactive voice response system prompted participants to conduct CO tests 1-3 daily at pseudorandom times (7 am to 10 pm) for 4 weeks. When prompted, participants used a study cell phone and CO monitor to complete a CO self-test, video record the process, and submit videos using multimedia messaging. mHealth reinforcement participants could earn prizes for smoking-negative on-time CO tests. The interactive voice response generated preliminary earnings immediately. Earnings were finalized by comparing video records against participants' self-reports.

RESULTS

mHealth reinforcement was associated with a greater proportion of smoking-negative CO tests, longest duration of prolonged abstinence, and point-prevalence abstinence during the monitoring/reinforcement phase compared to mHealth monitoring (p < .01, d = 0.8-1.3). Follow-up (weeks 4-24) analyses indicated main effects of reinforcement on point-prevalence abstinence and proportion of days smoked (p ≤ .05); values were comparable by week 24.

CONCLUSIONS

mHealth reinforcement has short-term efficacy. Research on methods to enhance and sustain benefits is needed.

IMPLICATIONS

This study suggests that mHealth abstinence reinforcement is efficacious and may present temporal and spatial opportunities to research, engage, and support smokers trying to quit that do not exist with conventional (not technology-based) reinforcement interventions.

A Randomized Trial of the Effectiveness of Using Incentives to Reinforce Parolee Attendance in Community Addiction Treatment

This study was a randomized effectiveness trial of the use of incentives to improve treatment retention and post-treatment outcomes among parolees in community treatment. Parolees entering community treatment were randomized to incentives ( N = 104) or brief education ( N = 98). It was hypothesized that the use of incentives to increase treatment retention would result in improved post-treatment outcomes (i.e., arrest, employment, and drug use), but at 18 months post-intake, there were no group differences for any outcome. In secondary analyses, rearrest by 18 months post-intake was predicted by substance use, greater number or severity of psychological symptoms, treatment non-completion, unemployment, and younger age. Contrary to expectations, results indicated that participants who received incentives for attendance had arrest, employment, and drug use outcomes similar to those who received a brief education session. Our findings, in concert with those of several other researchers, suggest that there may be certain populations or settings where incentives may not be effective.

Comparing fixed-amount and progressive-amount DRO Schedules for tic suppression in youth with chronic tic disorders

Chronic tic disorders (CTDs) involve motor and/or vocal tics that often cause substantial distress and impairment. Differential reinforcement of other behavior (DRO) schedules of reinforcement produce robust, but incomplete, reductions in tic frequency in youth with CTDs; however, a more robust reduction may be needed to affect durable clinical change. Standard, fixed-amount DRO schedules have not commonly yielded such reductions, so we evaluated a novel, progressive-amount DRO schedule, based on its ability to facilitate sustained abstinence from functionally similar behaviors. Five youth with CTDs were exposed to periods of baseline, fixed-amount DRO (DRO-F), and progressive-amount DRO (DRO-P). Both DRO schedules produced decreases in tic rate and increases in intertic interval duration, but no systematic differences were seen between the two schedules on any dimension of tic occurrence. The DRO-F schedule was generally preferred to the DRO-P schedule. Possible procedural improvements and other future directions are discussed.

Effectiveness of Using Incentives to Improve Parolee Admission and Attendance in Community Addiction Treatment

This study is a randomized effectiveness trial of the use of incentives to improve treatment utilization among parolees in community treatment. In prison, Admission phase parolees were randomized to Admission Incentive (N=31) or Education (N=29). Attendance phase parolees entering community treatment were randomized to Attendance Incentive (N=104) or Education (N=98). There was no main effect for incentives in either study phase. Neither admission to community treatment (Incentive 60%, Education 64%; p =.74), nor intervention completion (Incentive 22%; Education 27%; p =.46) appeared to be impacted. Time-in-treatment was predicted by age, first arrest age, and type of parole status (Cox regression p<.05), but not by treatment group. Providing incentives did not increase the likelihood that parolees enrolled in or stayed in community treatment. In light of this finding, criminal justice practitioners who are considering incentives to increase admission or retention should be aware that they may not produce the desired outcomes.

The effects of fixed versus escalating reinforcement schedules on smoking abstinence

Studies indicate that when abstinence is initiated, escalating reinforcement schedules maintain continuous abstinence longer than fixed reinforcement schedules. However, these studies were conducted for shorter durations than most clinical trials and also resulted in larger reinforcer value for escalating participants during the 1st week of the experiment. We tested whether escalating reinforcement schedules maintained abstinence longer than fixed reinforcement schedules in a 12-week clinical trial. Smokers (146) were randomized to an escalating reinforcement schedule, a fixed reinforcement schedule, or a control condition. Escalating reinforcement participants received $5.00 for their first breath carbon monoxide (CO) sample <3 ppm, with a $0.50 increase for each consecutive sample. Fixed reinforcement participants received $19.75 for each breath CO sample <3 ppm. Control participants received payments only for delivering a breath CO sample. Similar proportions of escalating and fixed reinforcement participants met the breath CO criterion at least once. Escalating reinforcement participants maintained criterion breath CO levels longer than fixed reinforcement and control participants. Similar to previous short-term studies, escalating reinforcement schedules maintained longer durations of abstinence than fixed reinforcement schedules during a clinical trial.

Small financial incentives increase smoking cessation in homeless smokers: a pilot study

Although over 70% of homeless individuals smoke, few studies have examined the effectiveness of smoking cessation interventions in this vulnerable population. The purpose of this pilot study was to compare the effectiveness of shelter-based smoking cessation clinic usual care (UC) to an adjunctive contingency management (CM) treatment that offered UC plus small financial incentives for smoking abstinence. Sixty-eight homeless individuals in Dallas, Texas (recruited in 2012) were assigned to UC (n=58) or UC plus financial incentives (CM; n=10) groups and were followed for 5 consecutive weeks (1 week pre-quit through 4 weeks post-quit). A generalized linear mixed model regression analysis was conducted to compare biochemically-verified abstinence rates between groups. An additional model examined the interaction between time and treatment group. The participants were primarily male (61.8%) and African American (58.8%), and were 49 years of age on average. There was a significant effect of treatment group on abstinence overall, and effects varied over time. Follow-up logistic regression analyses indicated that CM participants were significantly more likely than UC participants to be abstinent on the quit date (50% vs. 19% abstinent) and at 4 weeks post-quit (30% vs. 1.7% abstinent). Offering small financial incentives for smoking abstinence may be an effective way to facilitate smoking cessation in homeless individuals.

Reducing appointment no-shows: going from theory to practice

Addiction appointment no-shows adversely impact clinical outcomes and healthcare productivity. During 2007-2010, 67 treatment organizations in the Strengthening Treatment Access and Retention program were asked to reduce their no-show rates by using practices taken from no-show research and theory. These treatment organizations reduced outpatient no-show rates from 37.4% to 19.9% (p = .000), demonstrated which practices they preferred to implement, and which practices were most effective in reducing no-show rates. This study provides an applied synthesis of addiction treatment no-show research and suggests future directions for no-show research and practice.

Antisocial personality disorder predicts methamphetamine treatment outcomes in homeless, substance-dependent men who have sex with men

One-hundred-thirty-one homeless, substance-dependent MSM were enrolled in a randomized controlled trial to assess the efficacy of a contingency management (CM) intervention for reducing substance use and increasing healthy behavior. Participants were randomized into conditions that either provided additional rewards for substance abstinence and/or health-promoting/prosocial behaviors ("CM-full"; n=64) or for study compliance and attendance only ("CM-lite"; n=67). The purpose of this secondary analysis was to determine the affect of ASPD status on two primary study outcomes: methamphetamine abstinence, and engagement in prosocial/health-promoting behavior. Analyses revealed that individuals with ASPD provided more methamphetamine-negative urine samples (37.5%) than participants without ASPD (30.6%). When controlling for participant sociodemographics and condition assignment, the magnitude of this predicted difference increases to 10% and reached statistical significance (p<.05). On average, participants with ASPD earned fewer vouchers for health-promoting/prosocial behaviors than participants without ASPD ($10.21 [SD=$7.02] versus $18.38 [SD=$13.60]; p<.01). Participants with ASPD displayed superior methamphetamine abstinence outcomes regardless of CM schedule; even with potentially unlimited positive reinforcement, individuals with ASPD displayed suboptimal outcomes in achieving health-promoting/prosocial behaviors.

Alternative reinforcer response cost impacts methamphetamine choice in humans

Methamphetamine use disorders are a persistent public health concern. Behavioral treatments have demonstrated that providing access to non-drug alternative reinforcers reduces methamphetamine use. The purpose of this human laboratory experiment was to determine how changes in response cost for non-drug alternative reinforcers influenced methamphetamine choice. Seven subjects with past year histories of recreational stimulant use completed a placebo-controlled, crossover, double-blind protocol in which they first sampled doses of oral methamphetamine (0, 8 or 16 mg) and completed a battery of subject-rated and physiological measures. During subsequent sessions, subjects then made eight discrete choices between 1/8th of the sampled dose and an alternative reinforcer ($0.25). The response cost to earn a methamphetamine dose was always 500 responses (FR500). The response cost for the alternative reinforcer varied across sessions (FR500, FR1000, FR2000, FR3000). Methamphetamine functioned as a positive reinforcer and produced prototypical stimulant-like effects (e.g., elevated blood pressure, increased ratings of Stimulated). Choice for doses over money was sensitive to changes in response cost for alternative reinforcers in that more doses were taken at higher FR values than at lower FR values. Placebo choices changed as a function of alternative reinforcer response cost to a greater degree than active methamphetamine choices. These findings suggest that manipulating the effort necessary to earn alternative reinforcers could impact methamphetamine use.

Lifetime substance use and HIV sexual risk behaviors predict treatment response to contingency management among homeless, substance-dependent MSM

Homeless, substance-dependent men who have sex with men (MSM) continue to suffer health disparities, including high rates of HIV. One-hundred and thirty one homeless, substance-dependent MSM were randomized into a contingency management (CM) intervention to increase substance abstinence and health-promoting behaviors. Participants were recruited from a community-based, health education/risk reduction HIV prevention program and the research activities were also conducted at the community site. Secondary analyses were conducted to identify and characterize treatment responders (defined as participants in a contingency management intervention who scored at or above the median on three primary outcomes). Treatment responders were more likely to be Caucasian/White (p < .05), report fewer years of lifetime methamphetamine, cocaine, and polysubstance use (p < or = .05), and report more recent sexual partners and high-risk sexual behaviors than nonresponders (p < .05). The application of evidence-based interventions continues to be a public health priority, especially in the effort to implement effective interventions for use in community settings. The identification of both treatment responders and nonresponders is important for intervention development tailored to specific populations, both in service programs and research studies, to optimize outcomes among highly impacted populations.

Lessons learned from a randomized trial of fixed and escalating contingency management schedules in opioid-dependent pregnant women

BACKGROUND

Contingency management (CM) has shown promise for treating substance use disorders in pregnant women.

METHODS

A randomized clinical trial compared the relative efficacy of three conditions on the measures of opioid and cocaine abstinence and days retained in treatment. A total of 133 pregnant patients attending treatment for substance use disorders were randomized either to an escalating reinforcement condition, a fixed reinforcement condition, or an attendance control condition. Conditions were compared on drug abstinence rates and days retained in treatment.

RESULTS

As expected, the pooled escalating + fixed conditions received a greater total amount of voucher money than the control condition mean [M = 392.40 (SE = 40.47) vs. 219.74 (SE = 39.78)], respectively; p < .001. However, the escalating and fixed conditions did not differ on the outcome variables of drug abstinence and treatment retention.

CONCLUSIONS

The CM conditions examined in the current study did not emerge as superior to the control condition. The lack of significant differences among study conditions may be attributed, in part, to study sample size. Additionally, methodological issues related to the CM intervention may also have compromised outcomes, including delay in reinforcement following the target behavior and limited contact with the reinforcer.

SCIENTIFIC SIGNIFICANCE

This study highlights the importance of key CM implementation features, including immediate reinforcement, and adequate access to the reinforcer. It may also be that the reset feature for missing samples in CM interventions is an essential contingency for promoting behavior change.

Monetary-based consequences for drug abstinence: methods of implementation and some considerations about the allocation of finances in substance abusers

Conceptualizing drug abuse within the framework of behavioral theories of choice highlights the relevance of environmental variables in shifting behavior away from drug-related purchases. Choosing to use drugs results in immediate and certain consequences (e.g., drug high and relief from withdrawal), whereas choosing abstinence typically results in delayed, and often uncertain, consequences (e.g., improved health, interpersonal relationships, money).

METHODS

This is a selective review of the literature on Contingency management (CM).

RESULTS

We highlight a variety of methods to deliver CM in practical, effective, and sustainable ways. We consider a number of parameters that are critical to the success of monetary-based CM, and the role of the context in influencing CM's effects. To illustrate the broad range of applications of CM, we also review different methods for arranging contingencies to promote abstinence and other relevant behavior. Finally, we discuss some considerations about how drug-dependent individuals allocate their finances in the context of CM interventions.

CONCLUSIONS

Contingency management (CM) increases choice for drug abstinence via the availability of immediate, financial-based gains, contingent on objective evidence of abstinence.

The methamphetamine problem in the United States

Significant public health problems associated with methamphetamine (MA) production and use in the United States have emerged over the past 25 years; however, there has been considerable controversy about the size of the problem. Epidemiological indicators have provided a mixed picture. National surveys of the adult U.S. population and school-based populations have consistently been used to support the position that MA use is a relatively minor concern. However, many other data sources, including law-enforcement groups, welfare agencies, substance abuse treatment program admissions, criminal justice agencies, and state/county executives indicate that MA is a very significant public health problem for many communities throughout much of the country. In this article, we describe (a) the historical underpinnings of the MA problem, (b) epidemiological trends in MA use, (c) key subgroups at risk for MA problems, (d) the health and social factors associated with MA use, (e) interventions available for addressing the MA problem, and (f) lessons learned from past efforts addressing the MA problem.

Delay of smoking gratification as a laboratory model of relapse: effects of incentives for not smoking, and relationship with measures of executive function

Nineteen nicotine-deprived cigarette smokers received monetary rewards for each minute they chose not to initiate smoking in 2-h laboratory sessions followed by a 30-min period of enforced abstinence from smoking. Reinforcer amounts were delivered according to one of three schedules: increasing, decreasing, and constant. Relapse time (time until first cigarette) was shortest in the decreasing condition, longest in the increasing condition, and intermediate in the constant condition. All differences were significant except in the constant-decreasing comparison. The relationships between a battery of baseline assessments and relapse times were examined. Relapse times were predicted by delay-discounting coefficients (k) for $10 and $1000 in money and for $1000 of cigarettes. Relapse times were also predicted by the number of cigarettes smoked daily and a Wisconsin Card Sorting Test score. Performance on the Stroop Task and the Fagerström Test for Nicotine Dependence differentiated participants dichotomized into those who relapsed 'earlier' in sessions versus those who first smoked 'later'. The variability in some scores from smoking-urges and affect questionnaires administered after smoking-room sessions was explained by measures related to in-session nicotine intake. Results are discussed as they relate to contingency-management procedures, predictors of relapse, and the competing neurobehavioral decision systems theory of addiction.

Drug court treatment for methamphetamine dependence: Treatment response and posttreatment outcomes

Relatively little is known about the impact of drug court treatment programs for methamphetamine (MA) dependence. This article examines treatment performance among a subsample of 287 MA-dependent adults who participated in the Methamphetamine Treatment Project from 1999 to 2001. To gain a preliminary indication of MA users' response to drug court intervention, we compared a group of 57 MA-dependent participants treated in outpatient treatment within the context of a drug court to a group of comparable MA-dependent individuals treated in outpatient treatment but not supervised by a drug court (n = 230). Analyses reveal that drug court participation was associated with better rates of engagement, retention, completion, and abstinence, compared to outpatient treatment without drug court supervision. Six- and 12-month outcome analyses indicated that participants who were enrolled in drug court intervention used MA significantly less frequently. These findings suggest that drug court supervision coupled with treatment may improve the outcomes of MA-dependent offenders beyond that seen from treatment alone.

Contingency management: an evidence-based component of methamphetamine use disorder treatments

AIMS

To review briefly some of the available evidence regarding the utility of contingency management in treating methamphetamine use disorders.

DESIGN

A literature review was conducted to locate relevant studies for the review.

FINDINGS

The review suggests that contingency management is likely to be a useful component of treatment strategies designed to address methamphetamine use disorders. Results suggest that contingency management can increase the likelihood of providing methamphetamine-free urine samples during treatment.

CONCLUSIONS

Evidence suggests that contingency management is a good candidate for inclusion in treatment strategies for methamphetamine addiction.

Regardless of psychiatric severity the addition of contingency management to standard treatment improves retention and drug use outcomes

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

Delay discounting predicts cigarette smoking in a laboratory model of abstinence reinforcement

RATIONALE

Higher rates of delay discounting, or impulsive choice, may be related to relapse during abstinence reinforcement interventions for cigarette smoking, and a transdermal nicotine patch may attenuate delay discounting.

OBJECTIVE

The objectives of this study are to assess the relation between delay discounting and smoking after nicotine deprivation in a laboratory model of abstinence reinforcement and the effects of a transdermal nicotine patch on discounting and smoking.

MATERIALS AND METHODS

Smokers with no self-reported intention to quit were randomly assigned to an active (14 mg) or placebo patch group (n = 15 per group). In each of three sessions, after a 3-h deprivation period, participants completed a delay discounting task, mood, and craving measures and finally engaged in a laboratory model of abstinence reinforcement. Three abstinence reinforcement conditions were presented in counterbalanced order across the three sessions. During the control session, monetary consequences were delivered every 30 s regardless of smoking. During the low (5.00 dollars available) and high (20.00 dollars available) sessions, participants could earn a progressively increasing amount of money for each 30 s period of abstinence.

RESULTS

The low and high conditions significantly increased the latency to smoke relative to control and significantly decreased the amount of smoking. The nicotine patch decreased negative affect, but it did not significantly affect delay discounting or smoking. Individuals who smoked during the low and high conditions showed higher rates of discounting.

CONCLUSION

The patch did not attenuate delay discounting or smoking after a period of deprivation, but contingencies for abstinence significantly decreased smoking. Higher rates of delay discounting were related to smoking in a model of abstinence reinforcement treatment.