Shaping reduced smoking in smokers without cessation plans.

Most smokers do not plan to quit in the next 6 months. The authors previously demonstrated that percentile schedules shape lower breath carbon monoxide (BCO) levels in smokers trying to quit (R. J. Lamb, A. R. Morral, K. C. Kirby, M. Y. Iguchi, & G. Galbicka, 2004). In that study, the authors set reinforcement criteria based on the 9 most recent samples. In this study, the authors examined whether a more responsive procedure using the 4 most recent samples is more effective in smokers not trying to quit. Following institution of the contingencies in both groups, BCO levels were substantially reduced, and readiness to quit and cessation self-efficacy increased. However, more individuals in the 4-sample window group achieved a BCO level below 4 ppm, indicating recent abstinence. These individuals did so more rapidly and for a greater number of visits.

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.

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.

Hardcore drug users claim to be occasional users: drug use frequency underreporting.

Self-reports of drug use frequency are central to treatment outcome evaluations, estimates of the prevalence of heavy use, estimates of treatment need, and other questions with direct relevance to drug policies. Nevertheless, surprisingly little is known about the validity of these self-reports. This study examines the accuracy of 701 frequency self-reports made by a sample of methadone maintenance clients. Self-report accuracy is evaluated by comparing rates of positive urinalyses found for each case with rates that would be expected had drug use occurred only as often as reported. Expected rates of positive urinalyses are derived from conservative Monte Carlo models of drug use for each case. This procedure reveals extensive heroin and cocaine use frequency underreporting. After adjusting for frequency underreporting, 51% of 279 cases reporting only occasional heroin use (1-10 days in the past 30), and 22% of the 157 cases reporting occasional cocaine use, are found to be using these drugs with frequencies corresponding to what the Office of National Drug Control Policy defines as 'hardcore use' (more than 10 days in the past 30). Drug use frequency underreporting appears substantial, and might constitute an important threat to the validity of some treatment outcome evaluations, needs assessments and other analyses that rely on drug use frequency self-reports.

Identifying methadone maintenance clients at risk for poor treatment response: pretreatment and early progress indicators.

Exhaustive searches have uncovered few demographic or other pretreatment factors that reliably predict performance in substance abuse treatments. In this study we evaluate whether early treatment response offers improved prediction of treatment response 6 and 9 months later. New admissions to methadone maintenance treatment (n = 59) were dichotomized into outcome groups based on treatment retention and ongoing drug use as revealed by urinalysis results 6 and 9 months after admission. Regression analyses revealed two early (week 2) performance measures, counseling attendance and opiate abstinence, could be used to correctly classify, the outcomes of more than 80% of the sample. Strikingly, of the 20 participants who neither submitted an opiate-negative urine sample in week 2 nor attended at least two scheduled counseling sessions by that time, not one achieved a superior 6-month outcome. The odds of having a superior outcome increased considerably for those who submitted two opiate negative urine samples and attended two counseling sessions by week 2. Thus, 6-month outcomes were well predicted by treatment performance in week 2. Similar results are reported for month 9 outcomes.

MMPI profiles of opiate addicts: predicting response to treatment.

Although many studies document the use of the MMPI to classify opiate users, the predictive validity of the resulting subgroups is rarely reported. In this study, we used cluster analysis to identify MMPI profile types that predicted differential response to methadone maintenance treatment. Participants (N = 151) completed MMPIs shortly after entry into treatment. Cluster analysis of MMPI scores produced four distinct subgroups that differed significantly in severity of psychosocial problems measured at admission and on the mean number of drug-free urine specimens submitted during the 24-week study period. Cluster 1 participants evidenced low levels of psychological disturbance, improved their urinalysis results over time, and submitted the most posttest drug-free urine specimens. Cluster 2 was the only other group that improved significantly over time, even though these patients were the most psychologically disturbed. The results suggest the relation between psychological problems and outcome may be more complex than is commonly assumed.

Influence of emotional engagement and habituation on exposure therapy for PTSD.

This study examined 2 process variables, emotional engagement and habituation, and outcome of exposure therapy for posttraumatic stress disorder. Thirty-seven female assault victims received treatment that involved repeated imaginal reliving of their trauma, and rated their distress at 10-min intervals. The average distress levels during each of 6 exposure sessions were submitted to a cluster analysis. Three distinct groups of clients with different patterns of distress were found: high initial engagement and gradual habituation between sessions, high initial engagement without habituation, and moderate initial engagement without habituation. Clients with the 1st distress pattern improved more in treatment than the other clients. The results are discussed within the framework of emotional processing theory, emphasizing the crucial role of emotional engagement and habituation in exposure therapy.

Assessing the helping alliance and its impact in the treatment of opiate dependence.

This study assesses the relationship between the patient-counselor helping alliance (HA) and progress in methadone maintenance treatment. Questionnaire measures of HA were administered to 57 patients 1 and 3 months after admission. Three-month HA measures (especially counselors' ratings) predicted reductions in drug use as measured by weekly urinalysis results and 6-month self-report data. HA was unrelated to treatment retention or improvement in psychiatric symptomatology. Moreover, controlling for urinalysis results in the previous month rendered insignificant the correlations between 3-month HA and subsequent drug use. Thus, this evaluation of the HA's unique contribution to the prediction of outcome suggests that the development of a positive HA may be more a marker of treatment progress than a necessary precursor of positive outcomes in the methadone maintenance treatment setting.

Natural classes of treatment response.

This study examines an approach to identifying patterns of treatment response over time. Treatment response profiles are identified by cluster analyzing a repeated measure of patient performance collected at intervals during treatment. The procedure is demonstrated in Study 1 using monthly urinalysis results of 103 patients entering methadone maintenance treatment. The internal, external, and face validities of derived treatment response profiles are evaluated. A logistic regression model predicting treatment response is then constructed from intake variables found to correspond with the treatment response profiles. Study 2 replicates the procedures on an independent sample. Treatment response profiles facilitate the analysis of treatment response offering advantages over common measures of treatment outcome, such as performance at follow-up, change in performance from treatment entry to follow-up, or performance summed across treatment.

Reinforcing operants other than abstinence in drug abuse treatment: an effective alternative for reducing drug use.

This study examines the effectiveness of using vouchers to reinforce either the provision of urine samples testing negative for illicit drugs (UA group) or the completion of objective, individually defined, treatment-plan-related tasks (TP group). A third group was assigned to the clinic's standard treatment (STD group). Participants were randomly assigned to groups after a 6-week baseline-stabilization period. Urine specimens were collected thrice weekly throughout the study. In the UA condition, participants earned $5 (U.S. dollars) in vouchers for each drug-free urine submitted. In the TP condition, participants earned up to $15 in vouchers per week for demonstrating completion of treatment plan tasks assigned by their counselors. Contingencies were in effect for 12 weeks, after which all participants received the clinic's standard treatment. Urinalysis results indicate that the TP intervention was significantly more effective in reducing illicit drug use than either the UA or STD interventions. These effects were maintained with a trend toward continuing improvement for the TP groups even after contingencies were discontinued.