Interaction effects of age and contingency management treatments in cocaine-dependent outpatients.

As the American population ages, older adults are accounting for a larger percentage of the drug-abusing population, but little attention has been given to this age group especially in regards to evaluating responsivity to different treatment modalities. Contingency management (CM) is a highly effective behavioral treatment that provides positive tangible reinforcers for objective evidence of behavior change. The purpose of this study was to examine main and interactive effects of age on outcomes in cocaine-dependent patients receiving CM with standard care (SC) or SC alone. Patients (N = 393) participating in 1 of 3 randomized trials of CM for cocaine dependence were divided into young, middle, and older age cohorts. Baseline characteristics and outcomes were compared across the age groups. The oldest age group had more medical problems than the youngest and middle age groups but had fewer legal difficulties and psychiatric symptoms. The oldest age group remained in treatment significantly longer than the other age groups, regardless of the type of treatment received. Although all age groups benefited from CM in terms of retention and longest duration of abstinence achieved, a significant age by treatment interaction effect emerged, with the older cohort improving relatively less from CM than the younger age groups. These findings demonstrate that age may play a role in moderating intervention outcomes, and tailoring CM to the needs of older and middle-aged substance abusers may be important for improving outcomes in this growing population. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Low-cost contingency management in community clinics: Delivering incentives partially in group therapy.

This study examined the feasibility and effectiveness of prize-based contingency management (CM) when incentives for attendance were administered in group therapy and incentives for abstinence were administered in individual meetings. Three community substance abuse treatment programs participated in this two-phase, crossover design study. Outpatients (N = 103) entering treatment who met diagnostic criteria for cocaine, opiate, and alcohol abuse or dependence were recruited. During the standard condition, participants received standard treatment and submitted breath and urine samples that were tested for alcohol, cocaine, and opiates twice weekly during Weeks 1-6 and once weekly during Weeks 7-12. During the CM condition, participants received the same standard treatment and sample and attendance monitoring, plus the opportunity to win prizes for negative samples and treatment attendance. Demographic information and substance abuse history were evaluated at intake, and posttreatment substance use (toxicology results and self-report) was evaluated at Month 6 and Month 9 follow-up interviews. Primary outcomes were weeks retained in treatment and longest duration of sustained abstinence (LDA). LDA was significantly greater in CM-condition participants, but weeks retained did not differ between groups. Rates of substance use were lower in CM participants at Month 9 but not at Month 6. This study suggests that it is feasible to deliver incentives for attendance in group therapy, but that further research is needed to understand the modest effects on attendance. Strengths and limitations of this study are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A randomized trial of contingency management delivered in the context of group counseling.

Objective: Contingency management (CM) is efficacious in reducing drug use. Typically, reinforcers are provided on an individual basis to patients for submitting drug-negative samples. However, most treatment is provided in a group context, and poor attendance is a substantial concern. This study evaluated whether adding CM to group-based outpatient treatment would increase attendance and drug abstinence relative to standard care. Method: Substance abusing patients (N = 239) initiating outpatient treatment at 2 community-based clinics were randomized to standard care with frequent urine sample monitoring for 12 weeks (SC) or that same treatment with CM delivered in the context of group counseling sessions. In the CM condition, patients earned opportunities to put their names in a hat based on attendance and submission of drug-negative samples. At group counseling sessions, therapists selected names randomly from the hat, and individuals whose names were drawn won prizes ranging from $1 to $100. Results: Patients assigned to CM earned a median of $160 in prizes, and they attended significantly more days of treatment (d = 0.25), remained in treatment for more continuous weeks (d = 0.40), and achieved longer durations of drug abstinence (d = 0.26) than patients randomized to SC. Group adherence and therapeutic alliance also improved with CM. In addition, HIV risk behaviors were significantly lower in CM relative to SC patients during early phases of treatment and at the 12-month follow-up. Conclusions: These data demonstrate that CM delivered in the context of outpatient group counseling can increase attendance and improve drug abstinence. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Ethnic matching and treatment outcome with Hispanic and Anglo substance-abusing adolescents in family therapy.

This study examined treatment outcomes of 86 highly acculturated Hispanic and Anglo substance-abusing adolescents in functional family therapy, testing the hypothesis that ethnic matching of therapist and client is related to better treatment outcomes for clients. Adolescents reported on their substance use pre- and posttreatment on a timeline follow-back interview. Ethnically matched Hispanic adolescents demonstrated greater decreases in their substance use compared with Hispanic adolescents with Anglo therapists. Ethnic match status was not related to treatment outcome for Anglo clients. Thus, the matching hypothesis was supported for Hispanic clients only. The results underscore the importance of greater ethnic diversity among therapists and better cultural competency training for Anglo therapists. More research is needed on individual differences in the effects of ethnic matching. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Cocaine abusers with and without alcohol dependence respond equally well to contingency management treatments.

Contingency management (CM) treatments are efficacious in treating cocaine abuse. Despite high prevalence rates of alcohol dependence (AD) among individuals with cocaine use disorders, relatively little data are available regarding whether comorbid AD is associated with poorer treatment outcomes in general, or in response to CM in particular. Using data from 3 randomized trials of CM for cocaine abuse, we compared cocaine abusers (N = 393) with and without AD in terms of abstinence and psychosocial problems during treatment and follow-up. Alcohol dependent participants had more lifetime years of cocaine and alcohol use and greater severity of alcohol and psychiatric problems. CM was positively and significantly associated with longer durations of abstinence, regardless of AD status. Although not significantly associated with abstinence, the presence of AD was related to improvement in medical and alcohol-related problems during treatment, and these gains were maintained posttreatment. The results suggest that cocaine abusers benefit equally well from CM treatments, regardless of AD status. Further, alcohol dependent participants are able to offset greater baseline severity in psychosocial functioning and maintain these improvements with CM. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Contingency management improves abstinence and quality of life in cocaine abusers.

Contingency management (CM) treatments enhance drug abstinence. This study evaluated whether CM also improves quality of life and if these effects are mediated by abstinence. Across 3 independent trials, cocaine abusers in intensive outpatient treatment (n = 387) were randomly assigned to 12 weeks of standard treatment as usual or standard treatment with CM. The Quality Of Life Inventory (QOLI) was administered at baseline and at Months 1, 3, 6, and 9. Changes in QOLI scores over time differed significantly by treatment, with QOLI scores rising over time in CM participants and remaining stable in standard treatment participants. CM participants also achieved greater durations of abstinence, and duration of abstinence was correlated with posttreatment QOLI scores. During-treatment abstinence mediated the relationship between treatment condition and QOLI scores over time. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Contingency management treatments: Reinforcing abstinence versus adherence with goal-related activities.

Contingency management (CM) interventions usually reinforce submission of drug-negative specimens, but they can also reinforce adherence with goal-related activities. This study compared the efficacy of the 2 approaches. Substance-abusing outpatients (N = 131) were randomly assigned to 1 of 3 12-week treatments: standard treatment (ST), ST with CM for submitting negative urine toxicology screens, or ST with CM for completing goal-related activities. CM patients remained in treatment longer and achieved more abstinence than ST patients, but the CM condition that reinforced submission of negative samples resulted in better outcomes than the CM condition that reinforced goal-related activities. Abstinence at 6- and 9-month follow-ups did not differ by group, but longest duration of abstinence achieved during treatment was associated with abstinence posttreatment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Low-cost contingency management for treating cocaine- and opioid-abusing methadone patients.

This study evaluated the efficacy of a low-cost contingency management (CM) procedure in reducing concurrent cocaine and opioid use among methadone patients. Forty-two patients were randomly assigned to 12 wks of standard treatment or standard treatment plus CM. CM patients earned the opportunity to draw from a bowl and win prizes ranging from $1 to $100 in value for submitting samples negative for cocaine and opioids. Patients in the CM condition achieved longer durations of continuous abstinence than patients in the standard treatment condition, and these effects were maintained throughout a 6-mo follow-up period. On average, patients in the CM condition earned $137 of prizes. These data suggest that this prize reinforcement procedure may be suitable for community-based settings. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Cognitive-behavioral therapy plus contingency management for cocaine use: Findings during treatment and across 12-month follow-up.

Contingency management (CM) rapidly reduces cocaine use, but its effects subside after treatment. Cognitive-behavioral therapy (CBT) produces reductions months after treatment. Combined, the 2 might be complementary. One hundred ninety-three cocaine-using methadone-maintained outpatients were randomly assigned to 12 weeks of group therapy (CBT or a control condition) and voucher availability (CM contingent on cocaine-negative urine or noncontingent). Follow-ups occurred 3, 6, and 12 months posttreatment. Primary outcome was cocaine-negative urine (urinalysis 3 times/week during treatment and once at each follow-up). During treatment, initial effects of CM were dampened by CBT. Posttreatment, there were signs of additive benefits, significant in 3- versus 12-month contrasts. Former CBT participants were also more likely to acknowledge cocaine use and its effects and to report employment. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Contingency management is efficacious for cocaine abusers with prior treatment attempts.

Efforts are underway to detect subgroups who may be more or less responsive to contingency management (CM) substance abuse treatments. This study examined the impact of prior treatment attempts on primary and posttreatment outcomes in a combined sample of cocaine abusers randomized to standard care substance abuse outpatient treatment (SC) or SC plus CM. Participants (N = 393) were categorized according to self-reported prior treatment attempts (0-1, ≥2). Participants with multiple prior treatment attempts were older, had more severe alcohol and cocaine use disorders, and had greater employment-related problems. Participants with 0?1 prior treatment attempts had comparable treatment retention, regardless of treatment condition; however, among participants with multiple prior treatment attempts, retention was greater for CM than SC. A similar, but nonsignificant (p = .08) pattern was evident for longest duration of abstinence (LDA). LDA was a significant predictor of negative (for cocaine, alcohol, and opiates) specimen results at Month 9. The results provide support for CM as an advantageous option for individuals with multiple prior treatment attempts, as well as for substance abuse treatment patients in general. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Day treatment with contingency management for cocaine abuse in homeless persons: 12-month follow-up.

Abstinence, employment, and homelessness treatment outcomes at 12-month follow-up are presented from a study comparing behavioral day treatment plus abstinence-contingent housing and work therapy with behavioral day treatment only among homeless persons who abuse crack cocaine. Within-group improvements were revealed, but group differences for drug abstinence found in J. B. Milby et al. (2000) failed to persist at 12 months. Drug use measurement and treatment termination explanations are discussed. Within- but not between-group differences were found for employment and homelessness outcomes at long-term follow-up. Research extending abstinence contingencies and continuous drug use monitoring is recommended. Questions about effectiveness of contingency management alone, role of coexisting psychiatric disorders on treatment outcome, and individualized treatment dosing are offered. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Abstinence-contingent reinforcement and engagement in non-drug-related activities among illicit drug abusers.

Methadone-maintained cocaine abusers (N = 78) were randomly assigned to 1 of the following 52-week interventions: (a) usual care only (UC), (b) take-home methadone doses contingent on cocaine- and opiate-negative results (THM), or (c) 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, midtreatment, 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 midtreatment and at the 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-derived 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. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The use of contingency management to reduce cigarette smoking among college students.

The current study tested the feasibility of using contingency management to reduce cigarette smoking among college students. Eighty-eight undergraduate smokers were enrolled in a 3-week ABA study. During the baseline weeks, participants earned noncontingent monetary payments for attending data collection sessions. During the intervention week, participants earned monetary payments contingent on demonstrating recent abstinence. Participants were randomly assigned to either a low- or a high-reinforcer magnitude condition that controlled the amount of money that could be earned during the intervention week. Cigarette smoking was significantly reduced during the intervention week relative to the baseline weeks, and greater reductions were achieved under the high-reinforcer magnitude condition. These results suggest that cigarette smoking among college students is responsive to contingency management procedures. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Diagnostic compared with abstinence outcomes of day treatment and contingency management among cocaine-dependent homeless persons.

Substance use disorder diagnoses were used as a treatment outcome measure in a randomized comparison of day treatment (DT) and day treatment plus contingency management (DT+) among homeless persons with primarily crack/cocaine disorders. Participants (N = 127, DT+ = 69, DT = 58, 73.2% male, 82.7% African American) were assessed at baseline and 6-month treatment completion. Binary positive and negative diagnostic outcomes for cocaine, marijuana, and alcohol were compared by treatment group. DT+ was 2.1 times more likely to have a positive treatment outcome than DT. Concordance between diagnostic change and point and continuous abstinence outcomes were found. The use of diagnostic change can be a practical addition to drug toxicology and self-report treatment outcome measures for research and practice. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Longitudinal association between frequency of substance use and quality of life among adolescents receiving a brief outpatient intervention.

Recognition of the broad consequences of adolescent substance abuse has led to increased emphasis on balancing traditional measures of treatment effectiveness, such as frequency of substance use, with measures of patient functioning and quality of life (QOL). This study evaluated the longitudinal association between frequency of use and QOL among adolescent substance abusers receiving a brief outpatient intervention. Participants were 106 adolescents, aged 13 to 21 years, who met criteria for substance abuse or dependence and completed 4 assessments over a 12 month period. Results of a parallel-process latent growth curve model indicated a moderate longitudinal association, such that reduced frequency of use was associated with QOL improvement. Elaboration of the temporal ordering of this association via a cross-lagged panel model revealed that frequency of substance use predicted subsequent QOL, but that QOL did not predict subsequent frequency of use. Implications pertaining to the assessment of comprehensive outcomes and the setting of treatment expectations are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Juvenile drug court: Enhancing outcomes by integrating evidence-based treatments.

Evaluated the effectiveness of juvenile drug court for 161 juvenile offenders meeting diagnostic criteria for substance abuse or dependence and determined whether the integration of evidence-based practices enhanced the outcomes of juvenile drug court. Over a 1-year period, a four-condition randomized design evaluated outcomes for family court with usual community services, drug court with usual community services, drug court with multisystemic therapy, and drug court with multisystemic therapy enhanced with contingency management for adolescent substance use, criminal behavior, symptomatology, and days in out-of-home placement. In general, findings supported the view that drug court was more effective than family court services in decreasing rates of adolescent substance use and criminal behavior. Possibly due to the greatly increased surveillance of youths in drug court, however, these relative reductions in antisocial behavior did not translate to corresponding decreases in rearrest or incarceration. In addition, findings supported the view that the use of evidence-based treatments within the drug court context improved youth substance-related outcomes. Clinical and policy implications of these findings are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Understanding attitudes toward use of medication in substance abuse treatment: A multilevel approach.

Individual and organizational variables influence attitudes toward use of naltrexone, methadone, and buprenorphine for the treatment of alcohol and drug disorders. Previous research has not considered both sets of influences simultaneously. Hierarchical linear modeling tested the contribution of individual and organizational variables with data from the National Drug Abuse Treatment Clinical Trials Network treatment unit and workforce surveys (n = 2,269 staff nested within 247 treatment units). Individual-level variables consistently had more influence on attitudes, but a unique blend of variables existed for each medication. One predictor, support for psychiatric medications, influenced attitudes across all medications. Staff attitudes toward addiction medications varied significantly between treatment units. Implications for increasing the appropriate use of addiction medications are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Treatment responsivity of cocaine-dependent patients with antisocial personality disorder to cognitive-behavioral and contingency management interventions.

This study compared the efficacy of 2 approaches for the treatment of cocaine dependence among methadone-maintained patients with and without antisocial personality disorder (ASPD). Patients were randomly assigned to 4 study conditions: cognitive-behavioral treatment (CBT), contingency management (CM), CBT with CM, or methadone maintenance. The Structural Clinical Interview for Mental Disorders-IV was administered to 108 patients to assess ASPD. A 2-way analysis of variance showed that patients with ASPD were more likely to abstain from cocaine use during treatment than patients without ASPD. The strong treatment effect for ASPD patients was primarily due to the CM condition. Regression analyses showed that ASPD remained significantly related to CM treatment responsivity while controlling for other factors. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Ethnic background, therapeutic alliance, and treatment retention in functional family therapy with adolescents who abuse substances.

In this study, the authors examined the role of balance between adolescent-therapist and parent-therapist alliances in the retention of functional family therapy clients. Therapeutic alliances of mothers, fathers, and adolescents were assessed from videotapes of the 1st treatment session for 43 Hispanic and 43 Anglo families. Hispanic families who dropped out before completing the requisite number of sessions were found to have greater imbalance in alliance (parent-adolescent) than those who did complete therapy. However, this finding was not replicated with Anglo families. Results are interpreted in terms of previous research on family-level balanced alliance effects. (PsycINFO Database Record (c) 2010 APA, all rights reserved)