Improving contingency management programs for addiction.

Contingency management interventions effectively reduce or eliminate some individuals' problem substance use. Typically, those who do not benefit never experience the reward or planned contingency available through the intervention because they never produce the behavior (often abstinence) on which the reward is contingent. With two analog studies, we examine whether the effectiveness contingency management interventions improves when contingencies are arranged in ways that improve the likelihood of all participants experiencing the available reward. Participants were smokers not planning to quit. In Study 1, smokers were paid 0, 1, 3, 10, or 30 dollars each day for 5 days for delivery of breath carbon monoxide (CO) levels either < or =4 ppm or below half the median of their baseline levels. Higher payment amounts and the easier target criterion resulted in a higher likelihood of participants meeting criterion. Once participants met the 4 ppm criterion, however, they often maintained this behavior even in the absence of payments for reduced breath CO levels. An ineffective contingency management system was made effective based on these results. Study 2 examined the effectiveness of percentile schedules at reducing breath CO levels. Percentile schedules shaped lower breath CO levels. The effectiveness of percentile schedules in shaping abstinence was tested in treatment seekers, and percentile schedules were found to be effective at shaping abstinence.

Multidimensional assessment of perceived treatment-entry pressures among substance abusers.

Motivational assessment instruments typically measure clients' attributions about their readiness to change problem behaviors. They do not indicate why a client may be motivated to change, or provide guidance on how to retain an unmotivated client in treatment. The authors interviewed 415 substance abuse clients about their reasons for entering treatment and scored their responses along the dimensions of (a) negative versus positive treatment-entry pressures, (b) internal versus external sources of those pressures, and (c) the life domain from which the pressures emanated. Exploratory cluster analysis yielded 5 types of clients characterized by different profiles of perceived treatment-entry pressures. Cluster membership was predictive of treatment outcomes, and the clusters differed by demographic variables. These data support the discriminative and predictive utility of performing a multidimensional assessment of pressures to enter treatment.

Technology transfer through performance management: the effects of graphical feedback and positive reinforcement on drug treatment counselors' behavior.

After drug treatment counselors at a community-based methadone treatment clinic were trained in implementing a contingency management (CM) intervention, baseline measures of performance revealed that, on average, counselors were meeting the performance criteria specified by the treatment protocol about 42% of the time. Counselors were exposed to graphical feedback and a drawing for cash prizes in an additive within-subjects design to assess the effectiveness of these interventions in improving protocol adherence. Counselor performance measures increased to 71% during the graphical feedback condition, and to 81% during the drawing. Each counselor's performance improved during the intervention conditions. Additional analyses suggested that counselors did not have skill deficits that hindered implementation. Rather, protocol implementation occurred more frequently when consequences were added, thereby increasing the overall proportion of criteria met. Generalizations, however, may be limited due to a small sample size and possible confounding of time and intervention effects. Nonetheless, present results show promise that feedback and positive reinforcement could be used to improve technology transfer of behavioral interventions into community clinic settings.

Community reinforcement training for family and significant others of drug abusers: a unilateral intervention to increase treatment entry of drug users.

We randomly assigned 32 concerned family members and significant others (FSOs) of drug users (DUs) to a community reinforcement training intervention or a popular 12-step self-help group. We measured problems arising from the DU's behavior, social functioning of the DU and FSO, and mood of the FSO at baseline and 10 weeks later. We also monitored the FSOs' treatment attendance and treatment entry of the DUs. The treatment groups showed equal reductions from baseline to follow-up in problems and improvements in social functioning and mood of the FSO. However the community reinforcement intervention was significantly better at retaining FSOs in treatment and inducing treatment entry of the DUs.

Behavioral and emotional problems among children of cocaine- and opiate-dependent parents.

OBJECTIVE: To test associations between parental drug abuse and children's problems, children of cocaine- and opiate-dependent parents were compared with demographically matched referred and nonreferred children. METHOD: Cocaine- and opiate-dependent parents in treatment completed the Child Behavior Checklist for 410 children (218 boys, 192 girls) from ages 2 through 18 years (mean = 7.9 years). Children of drug abusers (CDAs) were demographically matched to referred (RCs) and nonreferred children (NRCs). RESULTS: RCs scored lower than CDAs and NRCs on most competence scales, and higher than CDAs and NRCs on all problem scales. CDAs scored lower than NRCs on most competence scales, and higher than NRCs on Withdrawn, Thought Problems, Delinquent Behavior, Aggressive Behavior, Internalizing, Externalizing, and Total Problems. Group status also predicted clinical range scores on most competence and all problem scales. CONCLUSIONS: CDAs showed more internalizing and externalizing psychopathology relative to matched NRCs, but they showed significantly less psychopathology than shown by matched RCs. CDAs are an important group to target for preventive interventions.

Schedule of voucher delivery influences initiation of cocaine abstinence.

This study examined whether voucher delivery arrangements affect treatment outcome. First, 90 cocaine-dependent adults were randomly assigned to behavioral counseling or counseling plus vouchers for cocaine-free urine samples. The value of each voucher was low at the beginning but increased as the patient progressed (Voucher Schedule 1). Voucher Schedule 1 produced no improvements relative to counseling only. Next, 23 patients received vouchers on either Voucher Schedule 1 or Voucher Schedule 2. Voucher Schedule 2 began with high voucher values, but requirements for earning vouchers increased as the patient progressed. Average durations of cocaine abstinence were 6.9 weeks on Voucher Schedule 2 versus 2.0 weeks on Voucher Schedule 1 (p = .02). This confirms that vouchers can assist in initiating abstinence and that voucher delivery arrangements are critical.

Congruence of the MCMI-II and MCMI-III in cocaine dependence.

This study compared the MCMI-II and MCMI-III among 40 urban, poor, cocaine abusers in outpatient treatment. The mean group profiles had strikingly similar relative elevations on the Antisocial, Narcissistic, Aggressive-Sadistic, Alcohol Dependence, and Drug Dependence scales. However, the MCMI-III group profile was significantly lower in magnitude compared with the MCMI-II. Interval and rank-order correlations were moderate to low for most scales, and 90% of participants produced discrepant 2-point codetypes between the 2 tests. These results suggest that clinicians working in substance abuse settings should perhaps adjust MCMI-III profile elevations upward on most scales (particularly on the personality disorder scales) when comparing results to extant normative data and should use caution when referencing MCMI/MCMI-II interpretive manuals for descriptive correlates of MCMI-III scales and codetypes.

Counselor prompts to increase condom taking during treatment for cocaine dependence.

This study examined whether active prompting would increase the number of free condoms taken from dispensers placed in counselors' offices in a cocaine abuse treatment clinic. Using a combined multiple baseline and reversal design, two teams of counselors were instructed to actively prompt and encourage condom taking during some conditions and to avoid commenting on or encouraging condom use in other conditions. To monitor accuracy of implementing the intervention, counselors completed a checklist for every subject they saw in their office during the day. Overall, the number of condoms taken per visit during prompting conditions was almost six times greater than during baseline conditions. However, implementation declined during the study, and all counselors complained about the intervention. Implications for dispensing free condoms to reduce HIV risk in drug abuse treatment clinics are discussed.

PIP: HIV infection is increasing among noninjecting as well as iv drug users. Of particular concern, are users of cocaine and crack cocaine, who are likely to trade sex for money or drugs and to have multiple sexual partners. This study investigated whether an active counselor intervention could increase the number of free condoms taken from dispensers placed in counselors' offices in a cocaine abuse treatment program in Philadelphia, Pennsylvania (US). A multiple baseline design across 2 teams of counselors with reversals was utilized. During the initial 5-week baseline period, when condoms were displayed on the counselors' desks but no prompts were given, an average of 0.34 and 0.25 condoms were taken per visit per team. During weeks 6-13, when counseling Team 1 utilized prompting and encouraged condom taking, this average increased to 3.17/visit. When Team 2 implemented the intervention (weeks 13-20), an average of 2.78 condoms/visit were taken. When both teams stopped the intervention, the number of condoms taken fell close to baseline levels. Resumption of the intervention increased use, but not to the previous high level. Over the entire 28-week study period, clients took an average of 0.43 condoms/visit during baseline conditions, and 2.45/visit during counselor prompting conditions. The 6-fold increase in condom uptake associated with active encouragement suggests the feasibility of this strategy for cocaine treatment programs. However, the participating counselors voiced irritation with the mandatory, sometimes intrusive intervention. The availability of free condoms in the clinic waiting area or day room represents an alternative strategy documented to increase the taking of condoms.

Impact of comorbid personality disorders and personality disorder symptoms on outcomes of behavioral treatment for cocaine dependence.

Studies have revealed a significant adverse impact of comorbid personality disorders on treatment tenure and outcome in a variety of psychiatric and substance abuse populations. We investigated whether this negative relationship also exists among 137 urban, poor, cocaine abusers in behaviorally oriented treatment. Axis II diagnoses were generated categorically using the SCID-II as well as dimensionally using numbers of SCID-II symptoms within diagnostic categories. Contrary to expectations, there were no significant differences between subjects with and without various categorical personality disorders on any outcome measures. Categorical Axis II diagnoses were also minimally correlated with drug use severity, depression, and anxiety at intake, indicating that these were not potential coveriates of outcome. However, dimensional analyses of personality symptoms generated from the SCID-II accounted for substantial proportions of variance in treatment outcomes. Implications of these data for Axis II assessment and drug treatment planning are discussed.

Structured interview versus self-report test vantages for the assessment of personality pathology in cocaine dependence.

The study compared structured interview (SCID-II) and self-report test (MCMI-II) vantages for the detection and characterization of personality pathology among 144 urban, poor, cocaine-addicted individuals seeking outpatient treatment. Diagnostic agreement was inadequate for most disorders, and the instruments at best shared only modest common variance. Positive predictive power was poor for all MCMI-II scales, though negative predictive power was good to excellent. This lends support for the use of the MCMI-II as a screening measure to rule out Axis II disorders; however, confirmation of positive diagnoses will require follow-up interview assessment. Future development of self-report personality inventories for substance abusers should focus on controlling for the acute dysphoric effects of drug use and related dysfunction, expanding attention to Cluster B content domains, and incorporating more objective criteria for assessing paranoia and "odd/eccentric" traits.

Assessment of coercive and noncoercive pressures to enter drug abuse treatment.

This paper reports preliminary data derived from a standardized interview scoring procedure for detecting and characterizing coercive and noncoercive pressures to enter substance abuse treatment. Coercive and noncoercive pressures stemming from multiple psychosocial domains are operationalized through recourse to established behavioral principles. Inter-rater reliability for the scoring procedure was exceptional over numerous rater trials. Substantive analyses indicate that, among clients in outpatient cocaine treatment, 'coercion' is operative in multiple psychosocial domains, and that subjects perceive legal pressures as exerting substantially less influence over their decisions to enter treatment than informal psychosocial pressures. Implications for drug treatment planning, legal and ethical issues, and directions for future research are proposed.

Decline in self-reported dysphoria after treatment entry in inner-city cocaine addicts.

This study examined self-reported dysphoria in 82 consecutive admissions to intensive outpatient treatment for cocaine abuse on whom data for the Beck scales for depression, anxiety, and hopelessness were available for intake and 4 subsequent weeks with no more than 1 missing data point. Mean scores on the Beck Depression Inventory (BDI) and the Beck Anxiety Inventory (BAI) decreased significantly between intake and Week 1, with no further significant changes from Weeks 1-4. Similar drops in the rate of clinically significant BDI and BAI scores also were observed. Scores on the Beck Hopelessness Scale (BHS) showed no significant changes. By Week 4, rates of clinically significant depression, anxiety, and hopelessness were similar (17%, 13%, and 16%, respectively). These findings suggest that assessing depression and anxiety using the BDI and BAI in this population should be postponed for at least 1 week after intake and that intake levels of self-reported mood may be inappropriate baseline measures for evaluating treatment effects.

The accelerated intake: a method for increasing initial attendance to outpatient cocaine treatment.

We examined whether offering an accelerated (same-day) versus a standard (1- to 7-day delay) intake appointment increased initial attendance at an outpatient cocaine treatment program. Significantly more of the subjects who were offered an accelerated intake (59%) attended than those who were given a standard intake (33%), chi 2 (2, N = 78) = 4.198, p < .05. The accelerated intake procedure appears to be useful for enhancing enrollment in outpatient addiction treatment.

Situations occasioning cocaine use and cocaine abstinence strategies.

We interviewed 265 cocaine-experienced methadone patients about situations that occasioned their cocaine use and strategies they used to avoid cocaine use. Subjects identified an average of 15 situations that occasioned cocaine use. The three most frequently identified were having the drug present (86% of subjects), being offered the drug (85%) and having money available (83%). Subjects reporting fewer situations also reported longer periods of lifetime abstinence (p < 0.01). A principal components analysis extracted 10 groups of situations that were most frequently identified in combination. Subjects identified a median of seven strategies for avoiding cocaine use; however, there was large inter-subject variability. This variance was not accounted for by demographic variables, employment status or treatment experience. The three strategies identified most frequently were avoiding people and places (81%), thinking about what they could lose (76%) and leaving the situation (66%). The total number and type (reactive vs. proactive) of strategies identified by subjects had no relationship to cocaine abstinence, although four specific strategies (thinking about what could be lost, leaving the situation, moving to a new area and using a different drug) were positively correlated with cocaine abstinence. We discuss implications of these results for clinical practice.

Implications of behavioral pharmacology research for applied behavior analyses: JEAB's special issue celebrating the contributions of Joseph V. Brady (March 1994).

We review four articles from JEAB's March 1994 issue celebrating the contributions of Joseph V. Brady. These articles have implications for studying private events and for studying multiple operants. We suggest that regularly including self-reports about private events in behavioral pharmacological research has resulted in an accumulated knowledge that has facilitated examination of interesting relations among self-reports, environmental factors, and other observable behaviors. Methodological lessons that behavioral pharmacologists have learned regarding the study of multiple operants are also relayed. We provide examples of how these lessons could be useful to applied behavior analysts studying nonpharmacological issues.

Pretreatment dropout as a function of treatment delay and client variables.

Utilizing a retrospective analysis we examined factors correlated with preintake dropout in patients phoning to make intake appointments for cocaine treatment. Inquiries of 235 individuals calling our outpatient cocaine treatment program over a 7-month period were analyzed for relationships between patient age and gender; residence in the city where the program is located; marital status; referral source; reported problems with alcohol, marijuana, and heroin; reported last use of cocaine or other illicit stimulants; assigned counselor gender; person who made the appointment; days to the intake appointment; and attending the scheduled intake session. Only days to appointment was significantly (Wald = 12.4587, df = 1, p < .05 and chi 2 = 17.7, df = 8, p < .05) correlated with attending the scheduled intake session. Appointments scheduled the same day differed significantly (chi 2 = 4.3, n = 235, df = 1, p < .05) from appointments scheduled later. This suggests that client and situational variables are not significantly related to initial attendance and enhances the significance of systemic variables that are under a clinic's control, such as appointment delay. The results indicate that the longer the delay between the initial phone contact and the scheduled appointment, the less likely a client is to attend an appointment. Further, they suggest that the greatest decrease in initial attendance occurs in the first 24 hours following the phone inquiry. Taking a "microscopic" look at the appointment delay variable is valuable in understanding and addressing preintake dropout.

Effect of dispenser location on taking free condoms in an outpatient cocaine abuse treatment clinic.

Crack cocaine use increases risky sexual behavior and HIV exposure; therefore, safe sexual practices should be encouraged during cocaine addiction treatment. Research indicates that placing condom dispensers in private restrooms increases taking free condoms. We investigated two other dispenser locations (a day room vs. counselors' offices) and found that substantially more condoms were taken when dispensers were in the day room. This is an important issue for public health facilities without private restrooms.

Modulation of drug reinforcement by behavioral requirements following drug ingestion.

Eight volunteers with histories of drug abuse participated in two experiments examining the modulation of drug choice by behavioral requirements following drug ingestion. Each morning subjects ingested color-coded capsules containing triazolam (0.25 mg), d-amphetamine (15 mg), or placebo and then engaged in a relaxation or a computer vigilance activity. Experiment 1 involved two phases (i.e. a triazolam and a d-amphetamine phase), presented in counterbalanced order. Within each phase, subjects were first exposed to each of two compounds (placebo and either triazolam or d-amphetamine) once with each activity. Then every other day for 20 days subjects chose which compound they ingested with the vigilance and relaxation activities, with the restriction that they could not choose the same compound with both activities. Seven of eight subjects reliably chose d-amphetamine with the vigilance activity; all subjects always chose triazolam with the relaxation activity. In experiment 2 (5 days' duration), after re-exposure to the color-coded compounds used in experiment 1, subjects chose which compound (placebo, d-amphetamine or triazolam) they ingested with the vigilance activity, and on another occasion (in counterbalanced order), which they ingested with relaxation activity. Seven of eight subjects chose d-amphetamine with the vigilance activity; all subjects chose triazolam with the relaxation activity. The relaxation and vigilance activities modulated triazolam and d-amphetamine reinforcement, thereby demonstrating a new class of environmental variable that can influence drug self-administration.