August F. Holtyn

The therapeutic workplace to promote treatment engagement and drug abstinence in out-of-treatment injection drug users: A randomized controlled trial

OBJECTIVE Determine if employment-based reinforcement can increase methadone treatment engagement and drug abstinence in out-of-treatment injection drug users. METHOD This study was conducted from 2008 to 2012 in a therapeutic workplace in Baltimore, MD. After a 4-week induction, participants (N=98) could work and earn pay for 26 weeks and were randomly assigned to Work Reinforcement, Methadone & Work Reinforcement, and Abstinence, Methadone & Work Reinforcement conditions. Work Reinforcement participants had to work to earn pay. Methadone & Work Reinforcement and Abstinence, Methadone, & Work Reinforcement participants had to enroll in methadone treatment to work and maximize pay. Abstinence, Methadone, & Work Reinforcement participants had to provide opiate- and cocaine-negative urine samples to maximize pay. RESULTS Most participants (92%) enrolled in methadone treatment during induction. Drug abstinence increased as a graded function of the addition of the methadone and abstinence contingencies. Abstinence, Methadone & Work Reinforcement participants provided significantly more urine samples negative for opiates (75% versus 54%) and cocaine (57% versus 32%) than Work Reinforcement participants. Methadone & Work Reinforcement participants provided significantly more cocaine-negative samples than Work Reinforcement participants (55% versus 32%). CONCLUSION The therapeutic workplace can promote drug abstinence in out-of-treatment injection drug users. Clinical trial registration number: NCT01416584.

Behavioral functions of stimuli signaling transitions across rich and lean schedules of reinforcement.

On multiple fixed-ratio schedules, pausing is extended at the start of a component ending in a small reinforcer (a lean component) but only when this component follows a component ending in a large reinforcer (a rich component). In two experiments, we assessed whether a stimulus correlated with a lean component is aversive and how its function is affected by the preceding component. In Experiment 1, pigeons responded on mixed fixed-ratio schedules ending in large or small reinforcers. Observing responses converted the mixed schedule to a multiple one by producing a stimulus correlated with the current component. Overall, the lean stimulus did not suppress observing, suggesting that it was not sufficiently aversive. In Experiment 2, an escape procedure was used, and pigeons could convert a multiple schedule to a mixed one by pecking a key to remove the discriminative stimuli. Pigeons escaped from the lean-schedule stimulus more than they did from the rich one. For two pigeons, this effect was enhanced when a rich component preceded the lean stimulus. The results indicate that a stimulus correlated with the leaner of two reinforcement schedules can acquire aversive functions, but observing and escape procedures may differ in their abilities to detect this effect.

Employment-based abstinence reinforcement promotes opiate and cocaine abstinence in out-of-treatment injection drug users.

We examined the use of employment-based abstinence reinforcement in out-of-treatment injection drug users, in this secondary analysis of a previously reported trial. Participants (N = 33) could work in the therapeutic workplace, a model employment-based program for drug addiction, for 30 weeks and could earn approximately

Predictors of induction onto extended-release naltrexone among unemployed heroin-dependent adults

10 per hr. During a 4-week induction, participants only had to work to earn pay. After induction, access to the workplace was contingent on enrollment in methadone treatment. After participants met the methadone contingency for 3 weeks, they had to provide opiate-negative urine samples to maintain maximum pay. After participants met those contingencies for 3 weeks, they had to provide opiate- and cocaine-negative urine samples to maintain maximum pay. The percentage of drug-negative urine samples remained stable until the abstinence reinforcement contingency for each drug was applied. The percentage of opiate- and cocaine-negative urine samples increased abruptly and significantly after the opiate- and cocaine-abstinence contingencies, respectively, were applied. These results demonstrate that the sequential administration of employment-based abstinence reinforcement can increase opiate and cocaine abstinence among out-of-treatment injection drug users.

Effects of the benzodiazepine GABAA α1-preferring antagonist 3-isopropoxy-β-carboline hydrochloride (3-ISOPBC) on alcohol seeking and self-administration in baboons

BACKGROUND AND AIM Extended-release naltrexone (XR-NTX) blocks the effects of opioids for 4weeks; however, starting treatment can be challenging because it requires 7 to 10days of abstinence from all opioids. In the present study we identified patient and treatment characteristics that were associated with successful induction onto XR-NTX. METHODS 144 unemployed heroin-dependent adults who had recently undergone opioid detoxification completed self-report measures and behavioral tasks before starting an outpatient XR-NTX induction procedure. Employment-based reinforcement was used to promote opioid abstinence and adherence to oral naltrexone during the induction. Participants were invited to attend a therapeutic workplace where they earned wages for completing jobs skills training. Participants who had used opioids recently were initially invited to attend the workplace for a 7-day washout period. Then those participants were required to provide opioid-negative urine samples and then take scheduled doses of oral naltrexone to work and earn wages. Participants who had not recently used opioids could begin oral naltrexone immediately. After stabilization on oral naltrexone, participants were eligible to receive XR-NTX and were randomized into one of four treatment groups, two of which were offered XR-NTX. Binary and multiple logistic regressions were used to identify characteristics at intake that were associated with successfully completing the XR-NTX induction. RESULTS 58.3% of participants completed the XR-NTX induction. Those who could begin oral naltrexone immediately were more likely to complete the induction than those who could not (79.5% vs. 25.0%). Of 15 characteristics, 2 were independently associated with XR-NTX induction success: legal status and recent opioid detoxification type. Participants who were not on parole or probation (vs. on parole or probation) were more likely to complete the induction (OR [95% CI]=2.5 [1.1-5.7], p=0.034), as were those who had come from a longer-term detoxification program (≥21days) (vs. a shorter-term [<21days]) (OR [95% CI]=7.0 [3.0-16.6], p<0.001). CONCLUSIONS Our analyses suggest that individuals recently leaving longer-term opioid detoxification programs are more likely to complete XR-NTX induction. Individuals on parole or probation are less likely to complete XR-NTX induction and may need additional supports or modifications to induction procedures to be successful.

A potential role of anti-poverty programs in health promotion.

BACKGROUND The major inhibitory neurotransmitter, gamma-aminobutyric acid (GABA), modulates many of the behavioral effects of alcohol, including sedation, tolerance, and withdrawal. The α1 subunit of the benzodiazepine GABAA receptor is the most widely expressed alpha subunit in the brain, and has been implicated in the reinforcing- and abuse-related effects of alcohol. The aim of the present study was to examine whether treatment with a benzodiazepine GABAA α1-preferring ligand, 3-isopropoxy-β-carboline hydrochloride (3-ISOPBC), selectively decreases alcohol seeking and consumption. METHODS Eight baboons self-administered alcohol (4% w/v; n=5; alcohol group) or a non-alcoholic beverage (n=3; control group) in Component 3 of a chained schedule of reinforcement. Responses in Component 2 provided indices of motivation to drink (seeking). Doses of 3-ISOPBC (5.0-30.0mg/kg) and vehicle were administered before drinking sessions under both acute and chronic (5day) conditions. RESULTS Chronic, and not acute, administration of 3-ISOPBC significantly decreased self-administration responses, g/kg alcohol consumed, and the number of drinks in and duration of the first drinking bout in the alcohol group. In the control group, chronic administration of 3-ISOPBC did not significantly decrease any of these measures at any of the doses. CONCLUSIONS The GABAA α1-preferring ligand 3-ISOPBC may have therapeutic potential in the treatment of alcohol use disorder due to its ability to selectively reduce alcohol use.

Baclofen and naltrexone effects on alcohol self-administration: Comparison of treatment initiated during abstinence or ongoing alcohol access in baboons

Poverty is one of the most pervasive risk factors underlying poor health, but is rarely targeted to improve health. Research on the effects of anti-poverty interventions on health has been limited, at least in part because funding for that research has been limited. Anti-poverty programs have been applied on a large scale, frequently by governments, but without systematic development and cumulative programmatic experimental studies. Anti-poverty programs that produce lasting effects on poverty have not been developed. Before evaluating the effect of anti-poverty programs on health, programs must be developed that can reduce poverty consistently. Anti-poverty programs require systematic development and cumulative programmatic scientific evaluation. Research on the therapeutic workplace could provide a model for that research and an adaptation of the therapeutic workplace could serve as a foundation of a comprehensive anti-poverty program. Once effective anti-poverty programs are developed, future research could determine if those programs improve health in addition to increasing income. The potential personal, health and economic benefits of effective anti-poverty programs could be substantial, and could justify the major efforts and expenses that would be required to support systematic research to develop such programs.

Behavior analysts in the war on poverty: A review of the use of financial incentives to promote education and employment

BACKGROUND Baclofen, a GABAB receptor agonist, is under investigation as a pharmacotherapy for alcohol use disorder. Treatment with a pharmacotherapeutic can be initiated during alcohol abstinence or active drinking, which may influence treatment outcomes. This study examined whether baclofen treatment initiated and maintained during alcohol abstinence would reduce alcohol seeking and self-administration upon return to alcohol access, and whether effects differed from treatment initiated and maintained during ongoing alcohol access. Naltrexone was tested under similar conditions for comparison. METHODS Five baboons self-administered alcohol under a three-component chained schedule of reinforcement that modeled periods of anticipation (Component 1), seeking (Component 2), and consumption (Component 3). Alcohol was only available in Component 3. In Experiment 1, baclofen (0.1-1.8mg/kg) or naltrexone (1.0-5.6mg/kg) was administered daily beginning on the first day of a 5-day abstinence period and treatment was continued for 5days of alcohol access. In Experiment 2, selected doses of both drugs were administered during ongoing alcohol access. RESULTS When treatment was initiated during alcohol abstinence, baclofen and naltrexone did not significantly reduce total alcohol intake (g/kg) or alcohol seeking. In comparison, when treatment was initiated during ongoing alcohol access, both baclofen (1.8mg/kg) and naltrexone (3.2 and 5.6mg/kg) significantly reduced total alcohol intake (g/kg). Naltrexone (5.6mg/kg), but not baclofen, significantly reduced alcohol seeking. CONCLUSIONS Initiation of baclofen treatment (or other alcohol use disorder treatments) during abstinence or active drinking may be an important factor in influencing efficacy and appropriate dose selection.

Effects of incentives for naltrexone adherence on opiate abstinence in heroin-dependent adults

Poverty is a pervasive risk factor underlying poor health. Many interventions that have sought to reduce health disparities associated with poverty have focused on improving health-related behaviors of low-income adults. Poverty itself could be targeted to improve health, but this approach would require programs that can consistently move poor individuals out of poverty. Governments and other organizations in the United States have tested a diverse range of antipoverty programs, generally on a large scale and in conjunction with welfare reform initiatives. This paper reviews antipoverty programs that used financial incentives to promote education and employment among welfare recipients and other low-income adults. The incentive-based, antipoverty programs had small or no effects on the target behaviors; they were implemented on large scales from the outset, without systematic development and evaluation of their components; and they did not apply principles of operant conditioning that have been shown to determine the effectiveness of incentive or reinforcement interventions. By applying basic principles of operant conditioning, behavior analysts could help address poverty and improve health through development of effective antipoverty programs. This paper describes a potential framework for a behavior-analytic antipoverty program, with the goal of illustrating that behavior analysts could be uniquely suited to make substantial contributions to the war on poverty.

Effects of pay resets following drug use on attendance and hours worked in a therapeutic workplace

Aim To test whether an incentive‐based intervention that increased adherence to naltrexone also increased opiate abstinence. Design Post‐hoc combined analysis of three earlier randomized controlled trials that showed individually that incentives for adherence to oral and to extended‐release injection naltrexone dosing schedules increased naltrexone adherence, but not opiate abstinence. Setting Out‐patient therapeutic work‐place in Baltimore, MD, USA. Participants One hundred and forty unemployed heroin‐dependent adults participating from 2006 to 2010. Interventions Participants were hired in a model work‐place for 26 weeks and randomized to a contingency (n = 72) or prescription (n = 68) group. Both groups were offered naltrexone. Contingency participants were required to take scheduled doses of naltrexone in order to work and earn wages. Prescription participants could earn wages independent of naltrexone adherence. Measures Thrice‐weekly and monthly urine samples tested for opiates and cocaine and measures of naltrexone adherence (percentage of monthly urine samples positive for naltrexone or percentage of scheduled injections received). All analyses included pre‐randomization attendance, opiate use and cocaine use as covariates. Additional analyses controlled for cocaine use and naltrexone adherence during the intervention. Findings Contingency participants had more opiate abstinence than prescription participants (68.1 versus 52.9% opiate‐negative thrice‐weekly urine samples, respectively; and 71.9 versus 61.7% opiate‐negative monthly urine samples, respectively) based on initial analyses [thrice‐weekly samples, odds ratio (OR) = 3.3, 95% confidence interval (CI) = 1.7–6.5, P < 0.01; monthly samples, OR = 2.6, 95% CI = 1.0–7.1, P = 0.06] and on analyses that controlled for cocaine use (thrice‐weekly samples, OR = 3.9, 95% CI = 3.3–4.5, P < 0.01; monthly samples, OR = 3.4, 95% CI = 1.1–11.1, P = 0.04), which was high and associated with opiate use. The difference in opiate abstinence rates between contingency and prescription participants was reduced when controlling for naltrexone adherence (monthly samples, OR = 1.1, 95% CI = 0.7–1.7, P = 0.84). Conclusions Incentives for naltrexone adherence increase opiate abstinence in heroin‐dependent adults, an effect that appears to be due to increased naltrexone adherence produced by the incentives.