Conrad J. Wong

Contingent reinforcement increases cocaine abstinence during outpatient treatment and 1 year of follow-up

This study assessed whether contingent incentives can be used to reinforce cocaine abstinence in dependent outpatients. Seventy cocaine-dependent outpatients were randomized into 2 conditions. All participants received 24 weeks of treatment and 1 year of follow-up. The treatment provided to all participants combined counseling based on the community reinforcement approach with incentives in the form of vouchers exchangeable for retail items. In 1 condition, incentives were delivered contingent on cocaine-free urinalysis results, whereas in the other condition incentives were delivered independent of urinalysis results. Abstinence-contingent incentives significantly increased cocaine abstinence during treatment and 1 year of follow-up compared with noncontingent incentives.

Increasing opiate abstinence through voucher-based reinforcement therapy

Heroin dependence remains a serious and costly public health problem, even in patients receiving methadone maintenance treatment. This study used a within-subject reversal design to assess the effectiveness of voucher-based abstinence reinforcement in reducing opiate use in patients receiving methadone maintenance treatment in an inner-city program. Throughout the study subjects received standard methadone maintenance treatment involving methadone, counseling, and urine monitoring (three times per week). Thirteen patients who continued to use opiates regularly during a 5-week baseline period were exposed to a 12-week program in which they received a voucher for each opiate-free urine sample provided: the vouchers had monetary values that increased as the number of consecutive opiate-free urines increased. Subjects continued receiving standard methadone maintenance for 8 weeks after discontinuation of the voucher program (return-to-baseline). Tukeys posthoc contrasts showed that the percentage of urine specimens that were positive for opiates decreased significantly when the voucher program was instituted. (P < or = 0.01) and then increased significantly when the voucher program was discontinued during the return-to-baseline condition (P < or = 0.01). Rates of opiate positive urines in the return-to-baseline condition remained significantly below the rates observed in the initial baseline period (P < or = 0.01). Overall, the study shows that voucher-based reinforcement contingencies can decrease opiate use in heroin dependent patients receiving methadone maintenance treatment.

Adults seeking treatment for marijuana dependence: a comparison with cocaine-dependent treatment seekers.

Sixty-two individuals seeking treatment for marijuana dependence completed a comprehensive assessment. Sociodemographics, substance use, psychosocial functioning, psychiatric symptoms, and medical status were compared with similar data collected from 70 treatment-seeking, cocaine-dependent individuals. Substantial psychosocial and psychiatric problems were observed in both groups. In general, the marijuana group reported substance-use histories and a range of impairment comparable with the cocaine group; however, they showed less severe dependence. The marijuana group was more ambivalent and less confident about stopping their marijuana use than the cocaine group was about stopping their cocaine use. These findings indicate that treatment-seeking, marijuana-dependent individuals exhibit substantial problems and that further efforts to develop effective treatments for this population are warranted.

An Internet-based abstinence reinforcement smoking cessation intervention in rural smokers

The implementation of cigarette smoking abstinence reinforcement programs may be hindered by the time intensive burden placed on patients and treatment providers. The use of remote monitoring and reinforcement of smoking abstinence may enhance the accessibility and acceptability of this intervention, particularly in rural areas where transportation can be unreliable and treatment providers distant. This study determined the effectiveness of an Internet-based abstinence reinforcement intervention in initiating and maintaining smoking abstinence in rural smokers. Sixty-eight smokers were enrolled to evaluate the efficacy of an Internet-based smoking cessation program. During the 6-week intervention period, all participants were asked to record 2 videos of breath carbon monoxide (CO) samples daily. Participants also typed the value of their CO readings into web-based software that provided feedback and reinforcement based on their smoking status. Participants (n=35) in the Abstinence Contingent (AC) group received monetary incentives contingent on recent smoking abstinence (i.e., CO of 4 parts per million or below). Participants (n=33) in the Yoked Control (YC) group received monetary incentives independent of smoking status. Participants in the AC group were significantly more likely than the YC group to post negative CO samples on the study website (OR=4.56; 95% CI=2.18-9.52). Participants assigned to AC were also significantly more likely to achieve some level of continuous abstinence over the 6-week intervention compared to those assigned to YC. These results demonstrate the feasibility and short-term efficacy of delivering reinforcement for smoking abstinence over the Internet to rural populations.

Employment-based abstinence reinforcement as a maintenance intervention for the treatment of cocaine dependence: a randomized controlled trial

CONTEXT Due to the chronic nature of cocaine dependence, long-term maintenance treatments may be required to sustain abstinence. Abstinence reinforcement is among the most effective means of initiating cocaine abstinence. Practical and effective means of maintaining abstinence reinforcement programs over time are needed. OBJECTIVE To determine whether employment-based abstinence reinforcement can be an effective long-term maintenance intervention for cocaine dependence. DESIGN Participants (n = 128) were enrolled in a 6-month job skills training and abstinence initiation program. Participants who initiated abstinence, attended regularly and developed needed job skills during the first 6 months were hired as operators in a data entry business and assigned randomly to an employment-only (control, n = 24) or abstinence-contingent employment (n = 27) group. SETTING A non-profit data entry business. Participants Unemployed welfare recipients who used cocaine persistently while enrolled in methadone treatment in Baltimore. INTERVENTION Abstinence-contingent employment participants received 1 year of employment-based contingency management, in which access to employment was contingent upon provision of drug-free urine samples under routine and then random drug testing. If a participant provided drug-positive urine or failed to provide a mandatory sample, then that participant received a temporary reduction in pay and could not work until urinalysis confirmed recent abstinence. MAIN OUTCOME MEASURE Cocaine-negative urine samples at monthly assessments across 1 year of employment. RESULTS During the 1 year of employment, abstinence-contingent employment participants provided significantly more cocaine-negative urine samples than employment-only participants [79.3% and 50.7%, respectively; P = 0.004, odds ratio (OR) = 3.73, 95% confidence interval (CI) = 1.60-8.69]. Conclusions Employment-based abstinence reinforcement that includes random drug testing is effective as a long-term maintenance intervention, and is among the most promising treatments for drug dependence. Work-places could serve as therapeutic agents in the treatment of drug dependence by arranging long-term employment-based contingency management programs.

Examining possible gender differences among cocaine-dependent outpatients.

Potential differences in sociodemographics, drug use, and measures of treatment outcome were examined among 137 male and 51 female cocaine-dependent outpatients. More women than men were unemployed, received public assistance, and were living with their children. Women reported fewer years of regular cocaine use, spending less money per week on cocaine, less prior treatment for cocaine abuse, and were more likely than men to test positive for cocaine at intake. With respect to other drug use, fewer women than men reported using sedatives and tested positive for sedatives at intake. Women reported a lower frequency of alcohol use before intake, and fewer women than men met criteria for cannabis dependence. Men and women experienced comparable improvement during the course of treatment and follow-up.

A Web-based therapeutic workplace for the treatment of drug addiction and chronic unemployment

This article describes a Web-based therapeutic workplace intervention designed to promote heroin and cocaine abstinence and train and employ participants as data entry operators. Patients are paid to participate in training and then to perform data entry jobs in a therapeutic workplace business. Salary is linked to abstinence by requiring patients to provide drug-free urine samples to gain access to the workplace. Prior data show that a prototype of the intervention could promote drug abstinence. Preliminary data on the Web-based intervention suggest that it should be able to teach adults with histories of chronic unemployment and drug addiction to become skilled data entry operators in about 3 to 6 months. Early experience in the business provides preliminary evidence that it might become financially successful. The therapeutic workplace intervention may serve as an effective and practical long-term treatment for chronic unemployment and heroin and cocaine addiction.

Treating Cocaine Abuse: What Does Research Tell Us?

Publisher Summary Despite significant decreases during the past decade in the overall number of cocaine users in the United States, the number of heavy users and the amount of cocaine that they consume has remained stable or increased. As heavy cocaine use and the associated problems persist, treatment demand for cocaine abuse is growing. A primary question that must be addressed in treating cocaine abuse is whether hospitalization is necessary for a positive outcome. The goal is to use the least restrictive setting likely to facilitate a positive outcome. Based on the available evidence, inpatient treatment is difficult to justify as a first-choice intervention for cocaine abuse. Inpatient care is much more expensive than less restrictive settings, and there is no evidence from controlled trials demonstrating that it produces superior outcomes. Prevalence of alcohol dependence among cocaine-dependent individuals is 60% or higher, and as many as 97% of current cocaine users also report current alcohol use. Marijuana use is the most prevalent form of other illicit-drug use among cocaine abusers, with 25-90% of clinical samples of cocaine abusers reporting concurrent use and approximately 30% meeting criteria for marijuana dependence.

Atomoxetine does not alter cocaine use in cocaine dependent individuals: A double blind randomized trial

BACKGROUND Cocaine abuse continues to be a significant public health problem associated with morbidity and mortality. To date, no pharmacotherapeutic approach has proven effective for treating cocaine use disorders. Preclinical and clinical evidence suggests that noradrenergic activity may play a role in mediating some effects of cocaine and may be a rational target for treatment. METHODS This double blind, placebo-controlled randomized, parallel group, 12-week outpatient clinical trial enrolled cocaine dependent individuals seeking treatment to examine the potential efficacy of the selective norepinephrine reuptake inhibitor, atomoxetine (80 mg/day; p.o.; n = 25), compared to placebo (n = 25). Subjects were initially stratified on cocaine use (< 15 days or ≥ 15 days of the last 30), age and race using urn randomization. Attendance, medication adherence and study compliance were reinforced with contingency management, and weekly counseling was offered. An array of measures (vital signs, laboratory chemistries, cognitive and psychomotor tests, cocaine craving and urine samples for drug testing) was collected throughout the study and at follow-up. RESULTS Survival analysis revealed no differences in study retention between the two groups, with approximately 56% of subjects completing the 12-week study (Cox analysis χ(2) = .72; p = .40; Hazard Ratio 1.48 [95% CI 0.62-3.39]). GEE analysis of the proportion of urine samples positive for benzoylecgonine, a cocaine metabolite, revealed no differences between the atomoxetine and placebo groups (χ(2) = 0.2, p = .66; OR = 0.89 [95% CI 0.41-1.74]). Atomoxetine was generally well tolerated in this population. CONCLUSIONS These data provide no support for the utility of atomoxetine in the treatment of cocaine dependence.

Examining Interrelationships Between Abstinence and Coping Self-Efficacy in Cocaine-Dependent Outpatients.

Initial abstinence and self-efficacy predict treatment outcome in cocaine-dependent outpatients. Associations between abstinence and coping self-efficacy were examined among cocaine-dependent outpatients (N=126). Abstinence was verified by urinalysis. Coping self-efficacy was measured using a modified Situational Confidence Questionnaire (SCQ). The modified SCQ had good validity and reliability, and scores increased during treatment. In bivariate analyses, early abstinence and SCQ scores each predicted subsequent abstinence and confidence during treatment and posttreatment follow-up. Based on structural equation modeling, early confidence was a significant predictor of later confidence but not of later abstinence, whereas early abstinence was a significant predictor of later abstinence and confidence. Results suggest a unidirectional relationship wherein prior abstinence predicts subsequent abstinence and confidence.