The Utility of Operant Conditioning to Address Poverty and Drug Addiction

A systematic review of enhanced resurgence paradigms

Following successful treatment in which problem behavior is reduced, it may reemerge as a function of changes in contextual stimuli or the worsening of reinforcement conditions for an alternative response. Although understudied, preliminary research suggests that simultaneous changes in contextual stimuli and reinforcement conditions may represent particularly exigent treatment challenges that create the condition for additive or superadditive relapse. The purpose of the present review was to systematically examine the relapse literature involving simultaneous changes in contextual stimuli and reinforcement conditions in relapse tests and experimental preparations arranged to evaluate their effect on response recovery. We identified 16 empirical articles spanning 27 experiments. Although all experiments included at least one condition that experienced a change in contextual stimuli and worsening of alternative reinforcement conditions, only two experiments included the comparison conditions needed to precisely evaluate additive and superadditive relapse. Our findings establish the preclinical generality of relapse effects associated with simultaneous changes to reinforcement conditions and contextual stimuli across a range of subjects, schedule arrangements, response topographies, reinforcers, and types of contextual changes. We make several recommendations for future research based on our findings from this nascent and clinically relevant subdomain of the relapse literature.

How We Lost 90% of Participants on a Bad Bet: Results from a Pilot Randomized Controlled Trial on Cognitive Bias Modification in Problem Gamblers

Whilst opportunities to participate in gambling have increased, access to support for problem gamblers is lacking behind. This lack of balance calls for improved and accessible intervention methods. The present double-blind randomized controlled trial (RCT) explored the effectiveness of two interventions targeting automatic cognitive processes, known as Attentional Bias Modification (AtBM) and Approach Bias Modification (ApBM). It was hypothesized these interventions would reduce gambling behavior and reduce or reverse targeted biases. Participants (N = 331) were community-recruited Flemish (35%) and Dutch (65%) adult problem gamblers motivated to reduce or stop their gambling who received either six sessions of active training (AtBM or ApBM) or of the corresponding sham-training (sham-AtBM or sham-ApBM). Due to high attrition rates (90.1% up to the intervention phase) the study was terminated before completion, since it would greatly limit the validity of any results. A post hoc qualitative study was performed on a subset of participants to gain insight into contributing factors for the high attrition rate. Issues negatively impacting participants' motivation to complete the program were identified, as well as elements of the program that received approval. The results from this study provide a first insight into the potential of the use of online cognitive bias modification (CBM) interventions in problem gambling (PG). Suggestions and directions for future studies are discussed.

Behavior change, health, and health disparities 2023: Contingency management for treating substance use disorders and promoting health in vulnerable populations

This Special Issue (SI) of Preventive Medicine is the 10th in a series on behavior change, health, and health disparities. This issue focuses on Contingency Management (CM), a highly efficacious behavior-change intervention for substance use disorders (SUDs) and other behavioral health conditions wherein patients receive material incentives (e.g., vouchers exchangeable for retail items) contingent on objectively verified behavior change. Despite substantial support for its efficacy, CM remains largely unavailable in U.S. community SUD treatment facilities and other healthcare settings. This is especially concerning regarding stimulant use disorder for which CM is the only reliably efficacious intervention in controlled studies and yet is unavailable to the vast majority of those in need. This SI details recent promising developments in efforts to surmount longstanding implementation obstacles while also detailing other promising advances from meta-analyses and controlled trials examining CM's efficacy in treating other difficult-to-treat problems including smoking among pregnant women and mothers of young children as well among those as those experiencing homelessness and alcohol use disorder, the promise of digital CM, and a potential new application in promoting adherence with SUD medications.

Abstinence-contingent wage supplements for adults experiencing homelessness and alcohol use disorder: A randomized clinical trial

This study evaluated the effectiveness of abstinence-contingent wage supplements in promoting alcohol abstinence and employment in adults experiencing homelessness and alcohol use disorder. A randomized clinical trial was conducted from 2019 to 2022. After a 1-month Induction period, 119 participants were randomly assigned to a Usual Care Control group (n = 57) or an Abstinence-Contingent Wage Supplement group (n = 62). Usual Care participants were offered counseling and referrals to employment and treatment programs. Abstinence-Contingent Wage Supplement participants could earn stipends for working with an employment specialist and wage supplements for working in a community job but had to maintain abstinence from alcohol as determined by transdermal alcohol concentration monitoring devices to maximize pay. Abstinence-Contingent Wage Supplement participants reported significantly higher rates of alcohol abstinence than Usual Care participants during the 6-month intervention (82.8% vs. 60.2% of months, OR = 3.4, 95% CI 1.8 to 6.3, p < .001). Abstinence-Contingent Wage Supplement participants were also significantly more likely to obtain employment (51.3% vs. 31.6% of months, OR = 2.6, 95% CI 1.5 to 4.4, p < .001) and live out of poverty (38.2% vs. 16.7% of months, OR = 3.7, 95% CI 2.0 to 7.1, p < .001) than Usual Care participants. These findings suggest that Abstinence-Contingent Wage Supplements can promote alcohol abstinence and employment in adults experiencing homelessness and alcohol use disorder. ClinicalTrials.gov Identifier: NCT03519009.

Effects of economic context and reward amount on delay and probability discounting

Steep delay and shallow probability discounting are associated with myriad problem behaviors; thus, it is important to understand factors that influence the degree of discounting. The present study evaluated the effects of economic context and reward amount on delay and probability discounting. Two hundred thirteen undergraduate psychology students completed four delay- or probability-discounting tasks. Participants were exposed to hypothetical narratives involving four bank amounts ($750, $12,000, $125,000, and $2,000,000). The delayed/probabilistic amount was $3,000 for the two smaller bank amounts and $500,000 for the two larger bank amounts. The discounting tasks included five delays to, or probabilities of, receipt of the larger amount. The area under the empirical discounting function was calculated for each participant. Participants discounted delayed and uncertain outcomes more when the bank amount was smaller than the outcome (i.e., the economic context was low). Participants discounted the delayed larger amounts less than delayed smaller amounts, even when the relative economic context was the same. In contrast, probability discounting did not differ across magnitudes, which suggests that economic context may attenuate the magnitude effect in probability discounting. The results further highlight the importance of considering the economic context in delay and probability discounting.

Cost and cost-effectiveness of abstinence contingent wage supplements

BACKGROUND

Substance use disorders are correlated with unemployment and poverty. However, few interventions aim to improve substance use, unemployment, and, distally, poverty. The Abstinence-Contingent Wage Supplement (ACWS) randomized controlled trial combined a therapeutic workplace with abstinence-contingent wage supplements to address substance use and unemployment. The ACWS study found that abstinence-contingent wage supplements increased the percentage of participants who had negative drug tests, who were employed, and who were above the poverty line during the intervention period. This study presents the cost of ACWS and calculates the cost-effectiveness of ACWS compared with usual care.

METHODS

To calculate the cost and cost-effectiveness of ACWS, we used activity-based costing methods to cost the intervention and calculated the costs from the provider and healthcare sector perspective. We calculated incremental cost-effectiveness ratios and cost-effectiveness acceptability curves for negative drug tests and employment.

RESULTS

ACWS cost $11,310 per participant over the 12-month intervention period. Total intervention and healthcare costs per participant over the intervention period were $20,625 for usual care and $30,686 for ACWS. At the end of the intervention period an additional participant with a negative drug test cost $1437 while an additional participant employed cost $915.

CONCLUSIONS

ACWS increases drug abstinence and employment and may be cost-effective at the end of the 12-month intervention period if decision makers are willing to pay the incremental cost associated with the intervention.

Rethinking the Place of Qualitative Methods in Behavior Analysis

Single-case design research is pervasive and dominant in the field of behavior analysis (BA). It allows for effective application of behavior change technologies in a wide variety of real-world settings. However, as the field has grown, behavioral scholars have suggested incorporating other methods into the investigator’s toolbox to supplement single-case design. To date, the call to expand beyond using only variations of single-case design as the standard for behavior analytic research has gone largely unheard. Given the need for behavior analytic work to be more closely aligned with consumer and stakeholder needs and priorities, along with a proliferation of practitioners and researchers in the field, now is the time to consider the benefits of qualitative research methods for behavior analysts. In particular, in areas of social validity and in exploring diverse applied topics, qualitative methods may help the field of behavior analysis to achieve greater success with documenting the outcomes from behavior change interventions. The present article explores areas where behavior analysis may benefit from utilizing qualitative methods, namely social validity and breadth of topics for study, and provides examples of the value of qualitative research from other fields. A brief outline of qualitative research is provided alongside consideration of the seven dimensions of applied behavior analysis. In situations where single-case design does not offer behavior analysts sufficient methodological opportunity, qualitative research methods could form a powerful addition to the field of behavior analysis.

Behavioral Interventions Contributing to Reducing Poverty and Inequities

Behavioral science has a long history of engaging in efforts to understand and address socially important issues. Poverty and inequities in health and development are among the most important and complex social issues facing the world today. With its Sustainable Development Goals (SDGs), the United Nations (2015) has focused attention and guidance on addressing key global challenges, including to "end poverty" (SDG 1), "ensure good health and well-being for all" (SDG3), and "reduce inequality within and among countries" (SDG 10). In this paper, we provide a framework and illustrative examples of contributions of behavioral science to these issues. We feature illustrative behavioral interventions at the individual, relationship, community, and societal levels. We highlight the diversity of issues, intervention methods, and settings reflected in applications of behavioral science. By joining methods from behavioral science, public health, and other disciplines-and the experiential knowledge of those most affected by inequities-behavioral methods can make significant contributions to collaborative efforts to assure health and well-being for all.

Relapse after incentivized choice treatment in humans: A laboratory model for studying behavior change

Behavior change interventions that incentivize desired behavior are highly effective for improving personal health, but difficult to maintain long term. Relapse is common and examining the mechanisms that contribute to relapse in experimental settings can identify processes relevant to substance abuse treatment. We developed a laboratory task that parallels a recent operant model of relapse after incentivized choice reported in the rodent laboratory. In two experiments, undergraduate participants first learned to make an operant response (keyboard button; R1) to earn a reinforcer consisting of an image of a preferred snack food (O1). In a second phase (Phase 2), R1 was still reinforced, but a new response (R2) was introduced and reinforced with a different reinforcer (a coin; O2). In a test phase, contingent incentives for R2 were removed (extinction) and relapse of R1 was assessed. Experiment 1 found that the O2 contingency suppressed R1 during Phase 2, and R1 relapsed rapidly in the test. Neither effect was consistently related to O2 value. Experiment 2 examined whether noncontingent presentations of O1 or O2 during the test could weaken relapse. Here, we found that noncontingent reinforcers did little to reduce or slow the increase in R1 responding. The present experiments highlight a laboratory approach to studying variables that may influence relapse after incentivized treatment. We identify and discuss areas for development to address differences between the present results and prior observations from animal and clinical studies. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

A Case for Translation From the Clinic to the Laboratory

Laboratory procedures have been used for decades as analogues for clinical processes with the goal of improving our understanding of psychological treatments for emotional disorders and identifying strategies to make treatments more effective. This research has often focused on translation from the laboratory to the clinic. Although this approach has notable successes, it has not been seamless. There are many examples of strategies that work in the laboratory that fail to lead to improved outcomes when applied clinically. One possible reason for this gap between experimental and clinical research is a failure to focus on translation from the clinic to the laboratory. Here, we discuss potential benefits of translation from the clinic to the laboratory and provide examples of how this might be implemented. We first consider two well-established laboratory analogues (extinction and cognitive reappraisal), identify critical aspects of the related clinical procedures (exposure and cognitive restructuring) that are missing from these analogues, and propose variations to better capture the clinical process. Second, we discuss two clinical procedures that have more recently been brought into the laboratory (eye-movement desensitization and reprocessing and imagery rescripting). We conclude by highlighting potential implications of this proposed shift in focus for translational research.

Abstinence-contingent wage supplements to promote drug abstinence and employment: Post-intervention outcomes

BACKGROUND

Substance use disorder, unemployment, and poverty are interrelated problems that have not been addressed adequately by existing interventions. This study evaluated post-intervention effects of abstinence-contingent wage supplements on drug abstinence and employment.

METHODS

Unemployed adults enrolled in opioid agonist treatment were randomly assigned to an abstinence-contingent wage supplement group (n = 44) or a usual care control group (n = 47). All participants could work with an employment specialist throughout a 12-month intervention period. Those in the abstinence-contingent wage supplement group earned stipends for working with the employment specialist and, after gaining employment, abstinence-contingent wage supplements for working in their community job but had to provide opiate- and cocaine-negative urine samples to maximize pay. To assess post-intervention effects of abstinence-contingent wage supplements and compare those effects to during-intervention effects, we analyzed urine samples and self-reports every 3 months during the 12-month intervention and the 12-month post-intervention period.

RESULTS

During the intervention, abstinence-contingent wage supplement participants provided significantly more opiate- and cocaine-negative urine samples than usual care control participants; abstinence-contingent wage supplement participants were also significantly more likely to become employed and live out of poverty than usual care participants during intervention. During the post-intervention period, the abstinence-contingent wage supplement and usual care control groups had similar rates of drug abstinence, similar levels of employment, and similar proportions living out of poverty.

CONCLUSIONS

Long-term delivery of abstinence-contingent wage supplements can promote drug abstinence and employment, but many patients relapse to drug use and cease employment when wage supplements are discontinued.

Environmental influence on the preclinical evaluation of substance use disorder therapeutics

Substance use disorders (SUD) develop as a result of complex interactions between the environment, the subject, and the drug of abuse. Preclinical basic research investigating each of these tripartite components of SUD individually has resulted in advancements in our fundamental knowledge regarding the progression from drug abuse to SUD and severe drug addiction and the underlying behavioral and neurobiological mechanisms. How these complex interactions between the environment, the subject, and the drug of abuse impact the effectiveness of candidate or clinically used medications for SUD has not been as extensively investigated. The focus of this chapter will address the current state of our knowledge how these environmental, subject, and pharmacological variables have been shown to impact candidate or clinical SUD medication evaluation in preclinical research using drug self-administration procedures as the primary dependent measure. The results discussed in this chapter highlight the importance of considering environmental variables such as the schedule of reinforcement, concurrent availability of alternative nondrug reinforcers, and experimental housing conditions in the context of SUD therapeutic evaluation. The thesis of this chapter is that improved understanding of environmental variables in the context of SUD research will facilitate the utility of preclinical drug self-administration studies in the evaluation and development of candidate SUD therapeutics.

Remotely administered incentive-based treatment for alcohol use disorder with participant-funded incentives is effective but less accessible to low-income participants

The delivery of monetary incentives contingent on verified abstinence is an effective treatment for alcohol use disorder. However, incentive cost has often been cited as a barrier to delivering this type of treatment. In the present randomized parallel groups trial, we systematically replicated a previous trial we conducted that employed remote alcohol monitoring and incentive delivery to promote abstinence from alcohol, but with the additional requirement for participants to partially self-fund their abstinence incentives. Treatment-seeking participants with alcohol use disorder (n = 92) who met inclusion criteria (n = 36) were randomized to either a Contingent or Noncontingent group (n = 18 each). Those not meeting inclusion criteria included 15 participants who agreed to the deposit requirement but failed to make the deposit payment. The Contingent group received nearly immediate monetary incentives each day they remotely provided negative breathalyzer samples. The Noncontingent group received matched incentives each day they successfully provided samples independent of alcohol content. Days abstinent in the Contingent group were 86%, which was significantly higher than the 44% recorded in the Noncontingent group, corresponding to an odds ratio of 8.2. Exploratory analyses revealed that the deposit requirement prevented participation in those with lower incomes and those with greater alcohol use. These results support the efficacy of this remotely deliverable alcohol abstinence reinforcement incentive intervention with a deposit requirement. However, the requirement to provide a monetary deposit to self-fund abstinence incentives may prevent those with greater alcohol use and/or those experiencing extreme poverty from participating in the intervention. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Factors associated with obtaining employment among opioid use disorder patients enrolled in a therapeutic workplace intervention

BACKGROUND

Unemployment is a common problem among adults who have substance use disorder that often persists during treatment and recovery. We identified patient characteristics that were associated with obtaining employment among unemployed adults in opioid use disorder treatment.

METHODS

This analysis used data from participants (N = 91) who were enrolled in a randomized controlled trial evaluating the effectiveness of a therapeutic workplace in promoting drug abstinence and employment. After a 3-month training period (Phase 1), participants were randomly assigned to a study group and could work for 12 months with an employment specialist who assisted participants in obtaining employment (Phase 2). A logistic regression model was used to identify patient characteristics that were associated with obtaining employment.

RESULTS

Of the 91 participants, 39 (42.9 %) obtained employment. Compared to participants who did not obtain employment, participants who obtained employment worked more days in the therapeutic workplace during the training period (Phase 1) [OR (95 % CI) = 1.072 (1.015-1.132), p = .014], provided more opiate- and cocaine-negative urine samples while seeking employment [OR (95 % CI) = 1.015 (1.002-1.027), p = .025], and reported not usually being unemployed at study intake [OR (95 % CI) = 0.229 (0.080-0.652), p = .007].

CONCLUSIONS

Our analyses suggest that among unemployed adults in opioid use disorder treatment, those with the lowest rates of therapeutic workplace attendance, lowest rates of drug abstinence while seeking employment, and relatively long histories of unemployment are the least likely to obtain employment. These relations are potentially addressable at a practical level, and future research could build on these findings to improve the effectiveness of employment-based interventions.

Remotely delivered incentives to promote buprenorphine treatment engagement in out-of-treatment adults with opioid use disorder

BACKGROUND

Opioid overdose remains a leading cause of death. Office-based buprenorphine could expand access to treatment to the many opioid users who are not in treatment and who are at risk for opioid overdose. However, many people in need of buprenorphine treatment do not enroll in treatment. This randomized pilot trial evaluated efficacy of a remotely delivered incentive intervention in promoting engagement in buprenorphine treatment in out-of-treatment adults with opioid use disorder.

METHODS

Participants (N = 41) were offered referrals to buprenorphine treatment and randomly assigned to Control or Incentive groups for 6 months. Incentive participants were offered incentives for enrolling in buprenorphine treatment, verified by providing documentation showing that they received a buprenorphine prescription, and providing videos taking daily buprenorphine doses. Participants used a smartphone application to record and submit a video of their buprenorphine prescription and daily buprenorphine administration. Incentive earnings were added remotely to reloadable credit cards.

RESULTS

Incentive participants were significantly more likely to enroll in treatment compared to control participants (71.4 % versus 30.0 % of participants; OR [95 % CI]: 6.24 [1.46-26.72], p = .014). Few participants in either group adhered to buprenorphine treatment, and the two groups continued to use opioids, including fentanyl at high and comparable rates. The two groups did not differ in the percentage of urine samples that were positive for buprenorphine, opiates, fentanyl, or methadone at monthly assessments conducted during the 6-month intervention.

CONCLUSIONS

Remotely delivered incentives can connect out-of-treatment adults with opioid use disorder to treatment, but additional supports are needed to promote buprenorphine adherence.

Employment outcomes of substance use disorder patients enrolled in a therapeutic workplace intervention for drug abstinence and employment

Poverty is common among people who have substance use disorder. The therapeutic workplace addresses some of the interrelated and chronic problems of poverty, such as unemployment, lack of education and job skills, and drug use. A prior controlled trial showed that the therapeutic workplace was effective in promoting drug abstinence and self-reported community employment in unemployed adults in medication-assisted treatment for opioid use disorder. The current study extends this research by providing a detailed and objective analysis of employment outcomes using objective data abstracted from participants' pay stubs. Secondary analyses examined the types and patterns of employment that participants (N = 44) obtained during the trial, and the extent to which participants gained and maintained financially sufficient employment. Although most participants had relatively long histories of unemployment and underemployment, many participants (n = 26; 59%) obtained employment at some point during the intervention. Most participants worked part time and were employed in low-wage jobs, however. The mean number of hours worked per week was 20.6 h (range 5.5 to 41.3 h per week) and the mean hourly pay was $11.00 per hour (range $9.00 to $15.50 per hour). The most common type of employment was in food preparation and serving-related occupations (e.g., waiters and waitresses, restaurant cooks, and fast food counter workers). Many participants (n = 17; 65%) maintained employment in these jobs over several weeks, while others (n = 9; 35%) were employed sporadically for short durations. Additional supports may be needed for some chronically unemployed adults with substance use disorder to promote consistent employment in well-paying jobs.

Financial incentives promote engagement in employment services for unemployed adults in treatment for opioid use disorder

BACKGROUND

Promoting employment among unemployed adults with substance use disorder is a difficult challenge for which existing interventions have had limited effects. This study examined whether financial incentives could increase engagement in employment services for unemployed adults in treatment for opioid use disorder.

METHODS

The study was conducted from 2014 to 2019 in Baltimore, MD. After a 3-month abstinence initiation and training period, participants (N = 91) were randomly assigned to a Control group or an Incentive group and were invited to work with an employment specialist to seek employment in a community job for 12 months. Participants assigned to the Control group (n = 47) did not receive incentives for working with the employment specialist. Participants assigned to the Incentive group (n = 44) could earn financial incentives for working with the employment specialist, but had to provide opiate- and cocaine-negative urine samples to maximize pay.

RESULTS

Incentive participants attended the employment services and worked with the employment specialist on significantly more days than Control participants (41.8 % versus 1.1 % of days; OR = 40.42, 95 % CI = 32.46-48.38, p < .001), and for significantly more hours than Control participants (3.58 versus 1.25 h, on average; OR=2.34, 95 % CI=1.83-2.85, p < .001). Incentive participants were more likely to be retained than Control participants when analyses were based solely on attendance (HR=0.12, 95 % CI=0.06-0.25, p < .001) and attendance and employment combined (HR=0.15, 95 % CI=0.07-0.31, p < .001).

CONCLUSIONS

Financial incentives were effective in promoting engagement in employment services for individuals who often do not utilize employment services.

Effects of time-based administration of abstinence reinforcement targeting opiate and cocaine use

Polydrug use is a common problem among patients in opioid-substitution treatment. Polydrug use has been reduced by administering abstinence-reinforcement contingencies in a sequence, such that a single drug is targeted until abstinence is achieved, and then an additional drug is targeted. The present study examined effects of administering abstinence-reinforcement contingencies sequentially based on time rather than on achieved abstinence. Participants accessed paid work (about $10/hr maximum) in the Therapeutic Workplace by providing urine samples 3 times per week. The urine samples were tested for opiates and cocaine. During an induction period, participants earned maximum pay independent of drug abstinence. Then, maximum pay depended upon urine samples that were negative for opiates. Two weeks later, maximum pay depended upon urine samples that were negative for both opiates and cocaine. Opiate and cocaine abstinence increased following administration of the respective contingencies. The time-based administration of abstinence reinforcement increased opiate and cocaine abstinence.

Abstinence-contingent wage supplements to promote drug abstinence and employment: a randomised controlled trial

BACKGROUND

Poverty, unemployment and substance abuse are inter-related problems. This study evaluated the effectiveness of abstinence-contingent wage supplements in promoting drug abstinence and employment in unemployed adults in outpatient treatment for opioid use disorder.

METHODS

A randomised controlled trial was conducted in Baltimore, MD, from 2014 to 2019. After a 3-month abstinence initiation and training period, participants (n=91) were randomly assigned to a usual care control group that received employment services or to an abstinence-contingent wage supplement group that received employment services plus abstinence-contingent wage supplements. All participants were invited to work with an employment specialist to seek employment in a community job for 12 months. Abstinence-contingent wage supplement participants could earn training stipends for working with the employment specialist and wage supplements for working in a community job, but had to provide opiate and cocaine-negative urine samples to maximise pay.

RESULTS

Abstinence-contingent wage supplement participants provided significantly more opiate and cocaine-negative urine samples than usual care control participants (65% vs 45%; OR=2.29, 95% CI 1.22 to 4.30, p=0.01) during the 12-month intervention. Abstinence-contingent wage supplement participants were significantly more likely to have obtained employment (59% vs 28%; OR=3.88, 95% CI 1.60 to 9.41, p=0.004) and lived out of poverty (61% vs 30%; OR=3.77, 95% CI 1.57 to 9.04, p=0.004) by the end of the 12-month intervention than usual care control participants.

CONCLUSION

Abstinence-contingent wage supplements can promote drug abstinence and employment.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov NCT02487745.