Adaptive Programming Improves Outcomes in Drug Court: An Experimental Trial.

Prior studies in Drug Courts reported improved outcomes when participants were matched to schedules of judicial status hearings based on their criminological risk level. The current experiment determined whether incremental efficacy could be gained by periodically adjusting the schedule of status hearings and clinical case-management sessions in response to participants' ensuing performance in the program. The adjustments were made pursuant to a priori criteria specified in an adaptive algorithm. Results confirmed that participants in the full adaptive condition (n = 62) were more than twice as likely as those assigned to baseline-matching only (n = 63) to be drug-abstinent during the first 18 weeks of the program; however, graduation rates and the average time to case resolution were not significantly different. The positive effects of the adaptive program appear to have stemmed from holding noncompliant participants more accountable for meeting their attendance obligations in the program. Directions for future research and practice implications are discussed.

Development and preliminary results of the Financial Incentive Coercion Assessment questionnaire.

Financial incentives are often used in research, yet no measure exists to determine whether they lead to perceptions of coercion in subjects. We present a preliminary evaluation of a recently developed Financial Incentive Coercion Assessment (FICA) questionnaire. FICA measures perceived coercion specifically related to payment for participation in a research study. Two hundred sixty-six subjects were recruited from a large randomized controlled trial; 152 returned for a 6-month follow-up and completed the FICA. Approximately 30% of participants reported the major reason for participating was "for the money," but less than 5% felt that the financial incentives were coercive. FICA results are consistent with levels of perceived coercion using an alternative measure. Initial assessment of responses on the FICA suggests that it may provide a novel approach to measuring perceived coercion from financial incentives in research. Future work will refine the FICA and analyze its psychometric properties.

Do Research Intermediaries Reduce Perceived Coercion to Enter Research Trials Among Criminally Involved Substance Abusers?

We examined the efficacy of including a research intermediary (RI) during the consent process in reducing participants' perceptions of coercion to enroll in a research study. Eighty-four drug court clients being recruited into an ongoing study were randomized to receive a standard informed consent process alone (standard condition) or with an RI (intermediary condition). Before obtaining consent, RIs met with clients individually to discuss remaining concerns. Findings provided preliminary evidence that RIs reduced client perceptions that their participation might influence how clinical and judicial staff view them. This suggests that using RIs may improve participant autonomy in clinical studies.

Measuring coercion to participate in research within a doubly vulnerable population: initial development of the coercion assessment scale.

Despite many efforts aimed to ensure that research participation is autonomous and not coerced, there exists no reliable and valid measure of perceived coercion for the doubly vulnerable population of substance-abusing offenders. The current study describes the development and initial validation of an instrument measuring perceived coercion to participate in research among substance-abusing offenders. The results indicated that a substantial number of individuals report feeling coerced to participate in the study. In addition, the instrument has adequate levels of internal consistency, a one-dimensional factor structure, and evidence of discriminative validity. This study provides initial support for the instrument's validity and clinical utility.

Corrected Feedback: A Procedure to Enhance Recall of Informed Consent to Research among Substance Abusing Offenders.

This study examined the efficacy of corrected feedback for improving consent recall throughout the course of an ongoing longitudinal study. Participants (N = 135) were randomly assigned to either a corrected feedback or a no-feedback control condition. Participants completed a consent quiz 2-weeks after consenting to the host study and at months 1, 2, and 3. The corrected feedback group received corrections to erroneous responses and the no-feedback control group did not. The feedback group displayed significantly greater recall overall and in specific content areas (i.e., procedures, protections, risks/benefits). Results support the use of corrected feedback for improving consent recall.

Adaptive interventions may optimize outcomes in drug courts: a pilot study.

Adaptive interventions apply a priori decision rules for adjusting treatment services in response to participants' clinical presentation or performance in treatment. This pilot study (n = 30) experimentally examined an adaptive intervention in a misdemeanor drug court. The participants were primarily charged with possession of marijuana (73%) or possession of drug paraphernalia (23%). Results revealed that participants in the adaptive condition had higher graduation rates and required significantly less time to graduate from the program and achieve a final resolution of the case. It took an average of nearly 4 fewer months for participants in the adaptive intervention to resolve their cases compared with those participating in drug court as usual. Participants in the adaptive condition also reported equivalent satisfaction with the program and therapeutic alliances with their counselors. These data suggest that adaptive interventions may enhance the efficiency and effectiveness of drug courts and justify examining adaptive interventions in large-scale drug court studies.

Monetary incentives improve recall of research consent information: it pays to remember.

Research participants often fail to recall substantial amounts of informed consent information after delays of only a few days. Numerous interventions have proven effective at improving consent recall; however, virtually all have focused on compensating for potential cognitive deficits and have ignored motivational factors. In this pilot study, the authors randomly assigned 31 drug court clients participating in a clinical research trial to a control group that received a standard informed consent procedure or to a group that received the same procedure plus incentives for correctly recalling consent information. The incentive group was told they would receive $5 for each of the 15 consent items they could answer correctly 1 week later. At the follow-up, the incentive group recalled a significantly greater percentage of consent information overall than the control group (65% vs. 42%, p<.01). Findings from this study have important implications for the ethical conduct of human subject research. The incentivized consent procedure may be useful for improving consent recall in research studies, particularly those involving potentially serious side effects. The results also provide an important "proof of concept" regarding the utility of motivational procedures for improving recall of consent information.

Higher magnitude cash payments improve research follow-up rates without increasing drug use or perceived coercion.

In a prior study [Festinger, D.S., Marlowe, D.B., Croft, J.R., Dugosh, K.L., Mastro, N.K., Lee, P.A., DeMatteo, D.S., Patapis, N.S., 2005. Do research payments precipitate drug use or coerce participation? Drug Alcohol Depend. 78 (3) 275-281] we found that neither the mode (cash vs. gift card) nor magnitude ($10, $40, or $70) of research follow-up payments increased rates of new drug use or perceptions of coercion. However, higher payments and payments in cash were associated with better follow-up attendance, reduced tracking efforts, and improved participant satisfaction with the study. The present study extended those findings to higher payment magnitudes. Participants from an urban outpatient substance abuse treatment program were randomly assigned to receive $70, $100, $130, or $160 in either cash or a gift card for completing a follow-up assessment at 6 months post-admission (n congruent with 50 per cell). Apart from the payment incentives, all participants received a standardized, minimal platform of follow-up efforts. Findings revealed that neither the magnitude nor mode of payment had a significant effect on new drug use or perceived coercion. Consistent with our previous findings, higher payments and cash payments resulted in significantly higher follow-up rates and fewer tracking calls. In addition participants receiving cash vs. gift cards were more likely to use their payments for essential, non-luxury purchases. Follow-up rates for participants receiving cash payments of $100, $130, and $160 approached or exceeded the FDA required minimum of 70% for studies to be considered in evaluations of new medications. This suggests that the use of higher magnitude payments and cash payments may be effective strategies for obtaining more representative follow-up samples without increasing new drug use or perceptions of coercion.

Adaptive Interventions in Drug Court: A Pilot Experiment.

This pilot study (N = 30) experimentally examined the effects of an adaptive intervention in an adult misdemeanor drug court. The adaptive algorithm adjusted the frequency of judicial status hearings and clinical case-management sessions according to pre-specified criteria in response to participants' ongoing performance in the program. Results revealed the adaptive algorithm was acceptable to both clients and staff, feasible to implement with greater than 85% fidelity, and showed promise for eliciting clinically meaningful improvements in drug abstinence and graduation rates. Estimated effect sizes ranged from 0.40 to 0.60 across various dependent measures. Compared to drug court as-usual, participants in the adaptive condition were more likely to receive responses from the drug court team for inadequate performance in the program and received those responses after a substantially shorter period of time. This suggests the adaptive algorithm may have more readily focused the drug court team's attention on poorly-performing individuals, thus allowing the team to "nip problems in the bud" before they developed too fully. These preliminary data justify additional research evaluating the effects of the adaptive algorithm in a fully powered experimental trial.

Do research payments precipitate drug use or coerce participation?

Providing high-magnitude cash incentives to substance abuse clients to participate in research is frequently viewed as unethical based on the concerns that this might precipitate new drug use or be perceived as coercive. We randomly assigned consenting drug abuse outpatients to receive payments of 10 US dollars, 40 US dollars, or 70 US dollars in either cash or gift certificate for attending a 6-month research follow-up assessment. At the 6-month follow-up, participants received their randomly determined incentive and were then scheduled for a second follow-up appointment 3 days later to detect new instances of drug use. Findings indicated that neither the magnitude nor mode of the incentives had a significant effect on rates of new drug use or perceptions of coercion. Consistent with the contingency management literature, higher payments and cash payments were associated with increased follow-up rates. Finally, the results suggest that higher magnitude payments may be more cost-effective by reducing the need for more intensive follow-up efforts.

Decreased gray matter concentration in the insular, orbitofrontal, cingulate, and temporal cortices of cocaine patients.

BACKGROUND: Structural deficiencies within limbic and prefrontal regions may contribute to the characteristic drug-seeking and drug-taking behaviors that prevail in persons dependent on cocaine. To date, a focal structural analysis of the brains of cocaine patients has not been undertaken. METHODS: We used voxel based morphometry in conjunction with statistical parametric mapping on the structural magnetic resonance images of cocaine-dependent (n = 13) and cocaine-naive individuals (n = 16) to assess differences between the two groups in gray and white matter concentration. RESULTS: We report a decrease in gray matter concentration in the ventromedial orbitofrontal, anterior cingulate, anteroventral insular, and superior temporal cortices of cocaine patients in comparison to controls (p <.01 corrected for multiple comparisons). The average percentage decrease in gray matter concentration within a region ranged from 5% to 11%. White matter concentration did not differ between groups. CONCLUSIONS: We conclude that the brains of cocaine patients are structurally dissimilar from those of nondrug-using controls. The differences were detected in regions involved in decision-making, behavioral inhibition and assignation of emotional valence to environmental stimuli and, hence, may contribute to some of the behavioral deficits characteristic of chronic cocaine users.