Kathryn A. Saulsgiver

Randomized Trial of Four Financial-Incentive Programs for Smoking Cessation

BACKGROUND Financial incentives promote many health behaviors, but effective ways to deliver health incentives remain uncertain. METHODS We randomly assigned CVS Caremark employees and their relatives and friends to one of four incentive programs or to usual care for smoking cessation. Two of the incentive programs targeted individuals, and two targeted groups of six participants. One of the individual-oriented programs and one of the group-oriented programs entailed rewards of approximately

A Randomized, Double-blind Evaluation of Buprenorphine Taper Duration in Primary Prescription Opioid Abusers

800 for smoking cessation; the others entailed refundable deposits of

Contingency management for behavior change: applications to promote brief smoking cessation among opioid-maintained patients.

150 plus

Manipulating pre-feed, density of reinforcement, and extinction produces disruption in the Location variation of a temporal discrimination task in pigeons.

650 in reward payments for successful participants. Usual care included informational resources and free smoking-cessation aids. RESULTS Overall, 2538 participants were enrolled. Of those assigned to reward-based programs, 90.0% accepted the assignment, as compared with 13.7% of those assigned to deposit-based programs (P<0.001). In intention-to-treat analyses, rates of sustained abstinence from smoking through 6 months were higher with each of the four incentive programs (range, 9.4 to 16.0%) than with usual care (6.0%) (P<0.05 for all comparisons); the superiority of reward-based programs was sustained through 12 months. Group-oriented and individual-oriented programs were associated with similar 6-month abstinence rates (13.7% and 12.1%, respectively; P=0.29). Reward-based programs were associated with higher abstinence rates than deposit-based programs (15.7% vs. 10.2%, P<0.001). However, in instrumental-variable analyses that accounted for differential acceptance, the rate of abstinence at 6 months was 13.2 percentage points (95% confidence interval, 3.1 to 22.8) higher in the deposit-based programs than in the reward-based programs among the estimated 13.7% of the participants who would accept participation in either type of program. CONCLUSIONS Reward-based programs were much more commonly accepted than deposit-based programs, leading to higher rates of sustained abstinence from smoking. Group-oriented incentive programs were no more effective than individual-oriented programs. (Funded by the National Institutes of Health and CVS Caremark; ClinicalTrials.gov number, NCT01526265.).

Effects of amphetamine on differential reinforcement of low rates of responding.

IMPORTANCE Although abuse of prescription opioids (POs) is a significant public health problem, few experimental studies have investigated the treatment needs of this growing population. OBJECTIVE To evaluate, following brief stabilization with a combination of buprenorphine hydrochloride and naloxone hydrochloride dihydrate, the relative efficacy of 1-, 2-, and 4-week buprenorphine tapering regimens and subsequent naltrexone hydrochloride therapy in PO-dependent outpatients. DESIGN, SETTING, AND PARTICIPANTS A double-blind, 12-week randomized clinical trial was conducted in an outpatient research clinic. Following a brief period of buprenorphine stabilization, 70 PO-dependent adults were randomized to receive 1-, 2-, or 4-week tapers followed by naltrexone therapy. INTERVENTION During phase 1 (weeks 1-5 after randomization), participants visited the clinic daily; during phase 2 (weeks 6-12), visits were reduced to thrice weekly. Participants received behavioral therapy and urine toxicology testing throughout the trial. MAIN OUTCOMES AND MEASURES The percentage of participants negative for illicit opioid use, retention, naltrexone ingestion, and favorable treatment response (ie, retained in treatment, opioid abstinent, and receiving naltrexone at the end of the study). RESULTS Opioid abstinence at the end of phase 1 was greater in the 4-week compared with the 2- and 1-week taper conditions (P = .02), with 63% (n = 14), 29% (n = 7), and 29% (n = 7) of participants abstinent in the 4-, 2-, and 1-week conditions, respectively. Abstinence at the end of phase 2 was also greater in the 4-week compared with the 2- and 1-week conditions (P = .03), with 50% (n = 11), 16% (n = 4), and 20% (n = 5) of participants abstinent in the 4-, 2-, and 1-week conditions, respectively. There were more treatment responders in the 4-week condition (P = .03), with 50% (n = 11), 17% (n = 4), and 21% (n = 5) of participants in the 4-, 2-, and 1-week groups considered responders at the end of treatment, respectively. Retention and naltrexone ingestion also were superior in the 4-week vs briefer tapers (both P = .04). Experimental condition (ie, taper duration) was the strongest predictor of treatment response, followed by buprenorphine stabilization dose. CONCLUSIONS AND RELEVANCE This study represents a rigorous experimental evaluation of outpatient buprenorphine stabilization, brief taper, and naltrexone maintenance for treatment of PO dependence. Results suggest that a meaningful subset of PO-dependent outpatients may respond positively to a 4-week taper plus naltrexone maintenance intervention.

Characterizing and improving HIV and hepatitis knowledge among primary prescription opioid abusers

Cigarette smoking is highly prevalent among patients who are being treated for opioid-dependence, yet there have been limited scientific efforts to promote smoking cessation in this population. Contingency management (CM) is a behavioral treatment that provides monetary incentives contingent upon biochemical evidence of drug abstinence. This paper discusses the results of two studies that utilized CM to promote brief smoking cessation among opioid-maintained patients. Participants in a pilot study were randomly assigned for a 2-week period to a Contingent group that earned monetary vouchers for providing biochemical samples that met criteria for smoking abstinence, or a Noncontingent group that earned monetary vouchers independent of smoking status (Dunn et al., 2008). Results showed Contingent participants provided significantly more smoking-negative samples than Noncontingent participants (55% vs. 5%, respectively). A second randomized trial that utilized the same 2-week intervention and provided access to the smoking cessation pharmacotherapy bupropion replicated the results of the pilot study (55% and 17% abstinence in Contingent and Noncontingent groups, respectively; Dunn et al, 2010). Relapse to illicit drug use was also evaluated prospectively and no association between smoking abstinence and relapse to illicit drug use was observed (Dunn et al., 2009). It will be important for future studies to evaluate participant characteristics that might predict better treatment outcome, to assess the contribution that pharmacotherapies might have alone or in combination with a CM intervention on smoking cessation and to evaluate methods for maintaining the abstinence that is achieved during this brief intervention for longer periods of time.

A Pragmatic Trial of E-Cigarettes, Incentives, and Drugs for Smoking Cessation

When pharmacological and non-pharmacological agents are used to disrupt temporal discrimination, two major findings have emerged in the literature. One result reveals lateral shifts of the psychophysical curve for time due to disruptors, while the other is a decrease in accuracy for classifying short and long intervals and a flattening of the psychophysical curve. These results represent a discrepancy within the timing literature that requires clarification. The current study determined the effects of pre-feed, increased density of reinforcement during session, and extinction on the Location variation of a temporal discrimination procedure. The results showed that extinction and pre-feed (at higher levels), when presented in an acute fashion, led to right-ward shifts in the psychophysical curve. Our results, when compared to similar studies in the literature, suggest that lateral shifts are more likely to be found due to disruptors when the Location variation is being used and when procedures are less complicated.

Preference-adaptive randomization in comparative effectiveness studies

A multiple differential reinforcement of low rate 8 s discrete-trial, differential reinforcement of low rate 8 s free-operant procedure was used to investigate the effects of D-amphetamine on interval timing in pigeons. On the discrete trial differential reinforcement of low rate early responses terminated the trial; on the free-operant differential reinforcement of low rate early responses reset the reinforcement timer but had no other effects. Frequency distributions of log interevent times for responses following reinforcement on both the free-operant and discrete-trial components showed a single-peaked distribution. The interevent time distribution for responses preceded by unreinforced responses on the free-operant differential reinforcement of low rate showed two peaks. The pigeons were administered two doses of D-amphetamine for 20 successive sessions. The means of interevent time distributions did not change under drug for either condition but widths of the distributions increased in both conditions and for both types of interevent times in the free-operant differential reinforcement of low rate. In the free-operant condition the mean interevent time for responses preceded by prior responses declined significantly with drug owing to a reduction in the proportion of responses in the shorter interevent time distribution. In effect, response bouts were shortened by drug administration. The rate-dependent hypothesis well described the effect of amphetamine on responses in the free-operant procedure. These results are discussed in the context of amphetamines effects on the temporal structure of behavior.

D-amphetamine, nicotine, and haloperidol produce similar disruptions in spatial and nonspatial temporal discrimination procedures

BACKGROUND The high rates of HIV and Hepatitis C (HCV) infection among opioid abusers is a serious public health problem, and efforts to enhance knowledge regarding risks for HIV/hepatitis infection in this population are important. Abuse of prescription opioids (POs), in particular, has increased substantially in the past decade and is associated with increasing rates of injection drug use and HCV infection. METHODS This study describes the effects of a brief HIV/HCV educational intervention delivered in the context of a larger randomized, double-blind clinical trial evaluating the relative efficacy of 1-, 2-, and 4-week outpatient buprenorphine tapers and subsequent oral naltrexone maintenance for treating PO dependence. HIV- and HCV-related knowledge and risk behaviors were characterized pre- and post-intervention in 54 primary PO abusers. RESULTS The educational intervention was associated with significant improvements in HIV (p<.001) and HCV (p<.001) knowledge. Significant improvements (p<.001) were observed on all three domains of the HIV questionnaire (i.e., general knowledge, sexual risk behaviors, drug risk behaviors) and on 21 and 11 individual items on the HIV and HCV questionnaires, respectively. Self-reported likelihood of using a condom also increased significantly (p<.05) from pre- to post-intervention. No additional changes in self-reported risk behaviors were observed. CONCLUSION These results suggest that a brief, easy-to-administer intervention is associated with substantial gains in HIV and HCV knowledge among PO abusers and represents the necessary first step toward the dissemination of a structured prevention HIV and HCV intervention for PO abusers.

Effects of acute and chronic d-amphetamine on two variations of a temporal discrimination procedure.

BACKGROUND Whether financial incentives, pharmacologic therapies, and electronic cigarettes (e‐cigarettes) promote smoking cessation among unselected smokers is unknown. METHODS We randomly assigned smokers employed by 54 companies to one of four smoking‐cessation interventions or to usual care. Usual care consisted of access to information regarding the benefits of smoking cessation and to a motivational text‐messaging service. The four interventions consisted of usual care plus one of the following: free cessation aids (nicotine‐replacement therapy or pharmacotherapy, with e‐cigarettes if standard therapies failed); free e‐cigarettes, without a requirement that standard therapies had been tried; free cessation aids plus