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Incentives Improve Outcome in Outpatient Behavioral Treatment of Cocaine Dependence

Incentives Improve Outcome in Outpatient Behavioral Treatment of Cocaine Dependence Abstract Objective: To assess whether incentives improved treatment outcome in ambulatory cocaine-dependent patients. Method: Forty cocaine-dependent adults were randomly assigned to behavioral treatment with or without an added incentive program. The behavioral treatment was based on the Community Reinforcement Approach and was provided to both groups. Subjects in the group with incentives received vouchers exchangeable for retail items contingent on submitting cocaine-free urine specimens during weeks 1 through 12 of treatment, while the group without incentives received no vouchers during that period. The two groups were treated the same during weeks 13 through 24. Results: Seventy-five percent of patients in the group with vouchers completed 24 weeks of treatment vs 40% in the group without vouchers (P=.03). Average durations of continuous cocaine abstinence documented via urinalysis during weeks 1 through 24 of treatment were 11.7±2.0 weeks in the group with vouchers vs 6.0±1.5 weeks in the group without vouchers (P=.03). At 24 weeks after treatment entry, the voucher group evidenced significantly greater improvement than the no-voucher group on the Drug scale of the Addiction Severity Index (ASI). and only the voucher group showed significant improvement on the ASI Psychiatric scale. Conclusions: Incentives delivered contingent on submitting cocaine-free urine specimens significantly improve treatment outcome in ambulatory cocainedependent patients. References 1. Chalsson RE, Bacchetti P, Osmond D, Brodie B, Sande MA, Moss AR. Cocaine use and HIV infection in intravenous drug users in San Francisco . JAMA . 1989;261:561-565.Crossref 2. De La Rosa M, Lambert EY, Gropper B, eds. Drugs and Violence: Causes, Correlates, and Consequences. Washington, DC: US Government Printing Office; 1990. National Institute on Drug Abuse research monograph 103. 3. Kain ZN, Kain TS, Scarpelli EM. Cocaine exposure in utero: perinatal development and neonatal manifestations—review . Clin Toxicol . 1992;30:607-636.Crossref 4. National Household Survey on Drug Abuse: Population Estimates 1991. Rockville, Md: National Institute on Drug Abuse; 1991. Dept of Health and Human Services publication ADM 92-1887. 5. Harrison LD. Trends in illicit drug use in the United States: conflicting results from national surveys . Int J Addict . 1992;27:817-847. 6. Gfroerer JC, Brodsky MD. Frequent cocaine users and their use of treatment . Am J Public Health . 1993;83:1149-1154.Crossref 7. Gawin FH, Kleber HD. Cocaine abuse treatment: an open pilot trial with lithium and desipramine . Arch Gen Psychiatry . 1984;41:903-910.Crossref 8. Gawin FH, Kleber HD, Byck R, Rounsaville BJ, Kosten TR, Jatlow PI, Morgan C. Desipramine facilitation of initial cocaine abstinence . Arch Gen Psychiatry . 1989;46:117-121.Crossref 9. Weddington WW, Brown BS, Haertzen CA, Hess JM, Mahaffey JR, Kolar AF, Jaffe JH. Comparison of amantadine and desipramine combined with psychotherapy for treatment of cocaine dependence . Am J Drug Alcohol Abuse . 1991;17:137-152.Crossref 10. Rawson RA, Obert JL, McCann MJ, Castro FG, Ling W. Cocaine abuse treatment: a review of current strategies . J Subst Abuse . 1991;3:457-491.Crossref 11. McLellan AT, Arndt 10, Metzger DS, Woody GE, O'Brien CP. The effects of psychosocial services in substance abuse treatment . JAMA . 1993;269:1953-1959.Crossref 12. Higgins ST, Delaney DD, Budney AJ, Bickel WK, Hughes JR, Foerg F, Fenwick JW. A behavioral approach to achieving initial cocaine abstinence . Am J Psychiatry . 1991;148:1218-1224. 13. Higgins ST, Budney AJ, Bickel WK, Hughes JR, Foerg F, Badger G. Achieving cocaine abstinence with a behavioral approach . Am J Psychiatry . 1993;150:763-769. 14. Bigelow GE, Stitzer ML, Griffiths RR, Liebson IA. Contingency management approaches to drug self-administration and drug abuse: efficacy and limitations . Addict Behav . 1981;6:241-252.Crossref 15. Sisson RW, Azrin NH. The Community Reinforcement Approach . In: Hester RK, Miller WR, eds. Handbook of Alcoholism Treatment Approaches: Effective Alternatives . New York, NY: Pergamon Press Inc; 1989:242-258. 16. Sorensen JL, Costantini MF, Wall TL, Gibson DR. Coupons attract high-risk untreated heroin users into detoxification . Drug Alcohol Depend . 1993;31:247-252.Crossref 17. Higgins ST, Stitzer ML, Bigelow GE, Liebson IA. Contingent methadone delivery: effects on illicit-opiate use . Drug Alcohol Depend . 1986;17:311-322.Crossref 18. Carroll ME, Lac ST, Nygaard SL. A concurrently available nondrug reinforcer prevents the acquisition or decreases the maintenance of cocaine-reinforced behavior . Psychopharmacology . 1989;97:23-29.Crossref 19. Nader NA, Woolverton WL. Effects of increasing the magnitude of an alternative reinforcer on drug choice in a discrete-trials choice procedure . Psychopharmacology . 1991;105:169-174.Crossref 20. Spealman RD. Behavior maintained by termination of a schedule of selfadministered cocaine . Science . 1979;204:1231-1233.Crossref 21. Johanson CE. The effects of electric shock on responding maintained by cocaine injections in a choice procedure in the rhesus monkey . Psychopharmacology . 1977;53:277-282.Crossref 22. Higgins ST, Bickel WK, Hughes JR. Influence of an alternative reinforcer on human cocaine self-administration . Life Sci . In press. 23. Bickel WK, DeGrandpre RJ. Modeling drug abuse policy in the behavioral economics laboratory . In: Green L, Kagel JH, eds. Advances in Behavioral Economics . Norwood, NJ: Ablex Publishing Corp; 3. In press. 24. Anker AA, Crowley TJ. The use of contingency contracts in speciality clinics for cocaine abuse . In: Harris LS, ed. Problems of Drug Dependence 1981 . Rockville, Md: National Institute on Drug Abuse; 1981:452-459. National Institute on Drug Abuse research monograph 41. 25. Stitzer ML, Bickel WK, Bigelow GE, Liebson IA. Effects of methadone dose contingencies on urinalysis test results of poly-abusing methadonemaintenance patients . Drug Alcohol Depend . 1986;18:341-348.Crossref 26. Aickin M. A program for balancing the allocation of subjects in a clinical trial . Comput Biomed Res . 1982;15:519-524.Crossref 27. McLellan AT, Luborsky L, Cacciola J, Griffith J, Evans F, Barr HL, O'Brien CP. New data from the Addiction Severity Index: reliability and validity in three centers . J Nerv Ment Dis . 1985;173:412-423.Crossref 28. McLellan AT, Luborsky L, Woody GE, O'Brien CP, Druley KA. Predicting response to alcohol and drug abuse treatments: role of psychiatric severity . Arch Gen Psychiatry . 1983;40;620-625.Crossref 29. Hudziak J, Helzer JE, Wetzel MW, Kessel KB, McGee B, Janca A, Przybeck P. The use of the DSM-III-R checklist for initial diagnostic assessments . Compr Psychiatry . 1993;34:375-383.Crossref 30. Azrin NH, Naster BJ, Jones R. Reciprocity counseling: a rapid learning-based procedure for marital counseling . Behav Res Ther . 1973;11:364-382.Crossref 31. Azrin NH, Besalel VA. Job Club Counselor's Manual . Baltimore, Md: University Park Press; 1980. 32. Nathan PE, Lansky D. Common methodological problems in research on the addictions . J Consult Clin Psychol . 1978;46:713-726.Crossref 33. SAS Institute Inc. SAS User's Guide: Statistics, Version 5 Edition . Cary, NC: SAS Institute Inc; 1985. 34. Iguchi MY, Stitzer ML. Predictors of opiate drug abuse during a 90-day methadone detoxification . Am J Drug Alcohol Abuse . 1991;17:279-294.Crossref 35. Carroll KM, Rounsaville BJ, Gawin FH. A comparative trial of psychotherapies for ambulatory cocaine abusers . Am J Drug Alcohol Abuse . 1991;17:229-247.Crossref 36. Childress AR, Hole AV, Ehrman RN, Robbins SJ, McLellan AT, O'Brien CP. Cue reactivity and cue reactivity interventions in drug dependence . In: Onken LS, Blaine JD, Boren JJ, eds. Behavioral Treatments for Drug Abuse and Dependence . Rockville, Md: National Institute on Drug Abuse; 1993:73-95. National Institutes of Health publication 93-3684. National Institute on Drug Abuse research monograph 137. 37. Rawson RA. Neurobehavioral treatment for cocaine dependency: a preliminary evaluation . In: Tims FM, Leukefeld CG, eds. Cocaine Treatment: Research and Clinical Perspectives . Rockville, Md: National Institute on Drug Abuse; 1993:92-115. National Institutes of Health publication 93-3639. National Institute on Drug Abuse research monograph 135. 38. Stitzer ML, Iguchi MY, Felch LJ. Contingent take-home incentive . J Consult Clin Psychol . 1992;60:927-934.Crossref 39. Cottler LB, Shillington AM, Compton WM III, Mager D, Spitznagel EL. Subjective reports of withdrawal among cocaine users: recommendations for DSMIV . Drug Alcohol Depend . 1993;33:97-104.Crossref 40. Lewinsohn PM. A behavioral approach to depression . In: Friedman R, Katz M, eds. The Psychology of Depression: Contemporary Theory and Research . Washington, DC: Winston; 1974:157-185. 41. Kang S-Y, Kleinman PH, Woody GE, Millman RB, Todd TC, Kemp J, Lipton DS. Outcomes for cocaine abusers after once-a-week psychosocial therapy . Am J Psychiatry . 1991;148:630-635. 42. Higgins ST, Budney AJ, Bickel WK, Hughes JR, Foerg F. Disulfiram therapy in patients abusing cocaine and alcohol . Am J Psychiatry . 1993;150:676-677. 43. Higgins ST, Budney AJ, Bickel WK, Badger GJ. Participation of significant others in outpatient behavioral treatment predicts greater cocaine abstinence . Am J Drug Alcohol Abuse . 1994;20:47-56.Crossref 44. Holder HD, Blose JO. Typical patterns and cost of alcoholism treatment across a variety of populations and providers . Alcohol Clin Exp Res . 1991;15:190-195.Crossref 45. Drucker E. AIDS and addiction in New York City . Am J Drug Alcohol Abuse . 1986;12:165-181.Crossref 46. Phibbs CS, Batemen DA, Schwartz RM. The neonatal costs of maternal cocaine use . JAMA . 1991;226:1521-1526.Crossref 47. Bigelow G, Strickler D, Liebson I, Griffiths R. Maintaining disulfiram ingestion among outpatient alcoholics . Behav Res Ther . 1976;14:378-381.Crossref 48. Epstein LH, Wing RR. Behavioral contracting: health behaviors . In: Franks C, ed. New Developments in Behavior Therapy: From Research to Clinical Application . New York, NY: The Haworth Press; 1984:409-449. 49. Damico M. Incentives in our schools . Business Incentive Strategies . 1992;51:4-18. 50. Caring for Tomorrow's Children. Columbia, SC: Office of the Governor; 1993. 51. Goldberg SR, Stolerman IP. Behavioral Analysis of Drug Dependence . Orlando, Fla: Academic Press Inc; 1986. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of General Psychiatry American Medical Association

Incentives Improve Outcome in Outpatient Behavioral Treatment of Cocaine Dependence

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Publisher
American Medical Association
Copyright
Copyright © 1994 American Medical Association. All Rights Reserved.
ISSN
0003-990X
eISSN
1598-3636
DOI
10.1001/archpsyc.1994.03950070060011
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Abstract

Abstract Objective: To assess whether incentives improved treatment outcome in ambulatory cocaine-dependent patients. Method: Forty cocaine-dependent adults were randomly assigned to behavioral treatment with or without an added incentive program. The behavioral treatment was based on the Community Reinforcement Approach and was provided to both groups. Subjects in the group with incentives received vouchers exchangeable for retail items contingent on submitting cocaine-free urine specimens during weeks 1 through 12 of treatment, while the group without incentives received no vouchers during that period. The two groups were treated the same during weeks 13 through 24. Results: Seventy-five percent of patients in the group with vouchers completed 24 weeks of treatment vs 40% in the group without vouchers (P=.03). Average durations of continuous cocaine abstinence documented via urinalysis during weeks 1 through 24 of treatment were 11.7±2.0 weeks in the group with vouchers vs 6.0±1.5 weeks in the group without vouchers (P=.03). At 24 weeks after treatment entry, the voucher group evidenced significantly greater improvement than the no-voucher group on the Drug scale of the Addiction Severity Index (ASI). and only the voucher group showed significant improvement on the ASI Psychiatric scale. Conclusions: Incentives delivered contingent on submitting cocaine-free urine specimens significantly improve treatment outcome in ambulatory cocainedependent patients. References 1. Chalsson RE, Bacchetti P, Osmond D, Brodie B, Sande MA, Moss AR. Cocaine use and HIV infection in intravenous drug users in San Francisco . JAMA . 1989;261:561-565.Crossref 2. De La Rosa M, Lambert EY, Gropper B, eds. Drugs and Violence: Causes, Correlates, and Consequences. Washington, DC: US Government Printing Office; 1990. National Institute on Drug Abuse research monograph 103. 3. Kain ZN, Kain TS, Scarpelli EM. Cocaine exposure in utero: perinatal development and neonatal manifestations—review . Clin Toxicol . 1992;30:607-636.Crossref 4. National Household Survey on Drug Abuse: Population Estimates 1991. Rockville, Md: National Institute on Drug Abuse; 1991. Dept of Health and Human Services publication ADM 92-1887. 5. Harrison LD. Trends in illicit drug use in the United States: conflicting results from national surveys . Int J Addict . 1992;27:817-847. 6. Gfroerer JC, Brodsky MD. Frequent cocaine users and their use of treatment . Am J Public Health . 1993;83:1149-1154.Crossref 7. Gawin FH, Kleber HD. Cocaine abuse treatment: an open pilot trial with lithium and desipramine . Arch Gen Psychiatry . 1984;41:903-910.Crossref 8. Gawin FH, Kleber HD, Byck R, Rounsaville BJ, Kosten TR, Jatlow PI, Morgan C. Desipramine facilitation of initial cocaine abstinence . Arch Gen Psychiatry . 1989;46:117-121.Crossref 9. Weddington WW, Brown BS, Haertzen CA, Hess JM, Mahaffey JR, Kolar AF, Jaffe JH. Comparison of amantadine and desipramine combined with psychotherapy for treatment of cocaine dependence . Am J Drug Alcohol Abuse . 1991;17:137-152.Crossref 10. Rawson RA, Obert JL, McCann MJ, Castro FG, Ling W. Cocaine abuse treatment: a review of current strategies . J Subst Abuse . 1991;3:457-491.Crossref 11. McLellan AT, Arndt 10, Metzger DS, Woody GE, O'Brien CP. The effects of psychosocial services in substance abuse treatment . JAMA . 1993;269:1953-1959.Crossref 12. Higgins ST, Delaney DD, Budney AJ, Bickel WK, Hughes JR, Foerg F, Fenwick JW. A behavioral approach to achieving initial cocaine abstinence . Am J Psychiatry . 1991;148:1218-1224. 13. Higgins ST, Budney AJ, Bickel WK, Hughes JR, Foerg F, Badger G. Achieving cocaine abstinence with a behavioral approach . Am J Psychiatry . 1993;150:763-769. 14. Bigelow GE, Stitzer ML, Griffiths RR, Liebson IA. Contingency management approaches to drug self-administration and drug abuse: efficacy and limitations . Addict Behav . 1981;6:241-252.Crossref 15. Sisson RW, Azrin NH. The Community Reinforcement Approach . In: Hester RK, Miller WR, eds. Handbook of Alcoholism Treatment Approaches: Effective Alternatives . New York, NY: Pergamon Press Inc; 1989:242-258. 16. Sorensen JL, Costantini MF, Wall TL, Gibson DR. Coupons attract high-risk untreated heroin users into detoxification . Drug Alcohol Depend . 1993;31:247-252.Crossref 17. Higgins ST, Stitzer ML, Bigelow GE, Liebson IA. Contingent methadone delivery: effects on illicit-opiate use . Drug Alcohol Depend . 1986;17:311-322.Crossref 18. Carroll ME, Lac ST, Nygaard SL. A concurrently available nondrug reinforcer prevents the acquisition or decreases the maintenance of cocaine-reinforced behavior . Psychopharmacology . 1989;97:23-29.Crossref 19. Nader NA, Woolverton WL. Effects of increasing the magnitude of an alternative reinforcer on drug choice in a discrete-trials choice procedure . Psychopharmacology . 1991;105:169-174.Crossref 20. Spealman RD. Behavior maintained by termination of a schedule of selfadministered cocaine . Science . 1979;204:1231-1233.Crossref 21. Johanson CE. The effects of electric shock on responding maintained by cocaine injections in a choice procedure in the rhesus monkey . Psychopharmacology . 1977;53:277-282.Crossref 22. Higgins ST, Bickel WK, Hughes JR. Influence of an alternative reinforcer on human cocaine self-administration . Life Sci . In press. 23. Bickel WK, DeGrandpre RJ. Modeling drug abuse policy in the behavioral economics laboratory . In: Green L, Kagel JH, eds. Advances in Behavioral Economics . Norwood, NJ: Ablex Publishing Corp; 3. In press. 24. Anker AA, Crowley TJ. The use of contingency contracts in speciality clinics for cocaine abuse . In: Harris LS, ed. Problems of Drug Dependence 1981 . Rockville, Md: National Institute on Drug Abuse; 1981:452-459. National Institute on Drug Abuse research monograph 41. 25. Stitzer ML, Bickel WK, Bigelow GE, Liebson IA. Effects of methadone dose contingencies on urinalysis test results of poly-abusing methadonemaintenance patients . Drug Alcohol Depend . 1986;18:341-348.Crossref 26. Aickin M. A program for balancing the allocation of subjects in a clinical trial . Comput Biomed Res . 1982;15:519-524.Crossref 27. McLellan AT, Luborsky L, Cacciola J, Griffith J, Evans F, Barr HL, O'Brien CP. New data from the Addiction Severity Index: reliability and validity in three centers . J Nerv Ment Dis . 1985;173:412-423.Crossref 28. McLellan AT, Luborsky L, Woody GE, O'Brien CP, Druley KA. Predicting response to alcohol and drug abuse treatments: role of psychiatric severity . Arch Gen Psychiatry . 1983;40;620-625.Crossref 29. Hudziak J, Helzer JE, Wetzel MW, Kessel KB, McGee B, Janca A, Przybeck P. The use of the DSM-III-R checklist for initial diagnostic assessments . Compr Psychiatry . 1993;34:375-383.Crossref 30. Azrin NH, Naster BJ, Jones R. Reciprocity counseling: a rapid learning-based procedure for marital counseling . Behav Res Ther . 1973;11:364-382.Crossref 31. Azrin NH, Besalel VA. Job Club Counselor's Manual . Baltimore, Md: University Park Press; 1980. 32. Nathan PE, Lansky D. Common methodological problems in research on the addictions . J Consult Clin Psychol . 1978;46:713-726.Crossref 33. SAS Institute Inc. SAS User's Guide: Statistics, Version 5 Edition . Cary, NC: SAS Institute Inc; 1985. 34. Iguchi MY, Stitzer ML. Predictors of opiate drug abuse during a 90-day methadone detoxification . Am J Drug Alcohol Abuse . 1991;17:279-294.Crossref 35. Carroll KM, Rounsaville BJ, Gawin FH. A comparative trial of psychotherapies for ambulatory cocaine abusers . Am J Drug Alcohol Abuse . 1991;17:229-247.Crossref 36. Childress AR, Hole AV, Ehrman RN, Robbins SJ, McLellan AT, O'Brien CP. Cue reactivity and cue reactivity interventions in drug dependence . In: Onken LS, Blaine JD, Boren JJ, eds. Behavioral Treatments for Drug Abuse and Dependence . Rockville, Md: National Institute on Drug Abuse; 1993:73-95. National Institutes of Health publication 93-3684. National Institute on Drug Abuse research monograph 137. 37. Rawson RA. Neurobehavioral treatment for cocaine dependency: a preliminary evaluation . In: Tims FM, Leukefeld CG, eds. Cocaine Treatment: Research and Clinical Perspectives . Rockville, Md: National Institute on Drug Abuse; 1993:92-115. National Institutes of Health publication 93-3639. National Institute on Drug Abuse research monograph 135. 38. Stitzer ML, Iguchi MY, Felch LJ. Contingent take-home incentive . J Consult Clin Psychol . 1992;60:927-934.Crossref 39. Cottler LB, Shillington AM, Compton WM III, Mager D, Spitznagel EL. Subjective reports of withdrawal among cocaine users: recommendations for DSMIV . Drug Alcohol Depend . 1993;33:97-104.Crossref 40. Lewinsohn PM. A behavioral approach to depression . In: Friedman R, Katz M, eds. The Psychology of Depression: Contemporary Theory and Research . Washington, DC: Winston; 1974:157-185. 41. Kang S-Y, Kleinman PH, Woody GE, Millman RB, Todd TC, Kemp J, Lipton DS. Outcomes for cocaine abusers after once-a-week psychosocial therapy . Am J Psychiatry . 1991;148:630-635. 42. Higgins ST, Budney AJ, Bickel WK, Hughes JR, Foerg F. Disulfiram therapy in patients abusing cocaine and alcohol . Am J Psychiatry . 1993;150:676-677. 43. Higgins ST, Budney AJ, Bickel WK, Badger GJ. Participation of significant others in outpatient behavioral treatment predicts greater cocaine abstinence . Am J Drug Alcohol Abuse . 1994;20:47-56.Crossref 44. Holder HD, Blose JO. Typical patterns and cost of alcoholism treatment across a variety of populations and providers . Alcohol Clin Exp Res . 1991;15:190-195.Crossref 45. Drucker E. AIDS and addiction in New York City . Am J Drug Alcohol Abuse . 1986;12:165-181.Crossref 46. Phibbs CS, Batemen DA, Schwartz RM. The neonatal costs of maternal cocaine use . JAMA . 1991;226:1521-1526.Crossref 47. Bigelow G, Strickler D, Liebson I, Griffiths R. Maintaining disulfiram ingestion among outpatient alcoholics . Behav Res Ther . 1976;14:378-381.Crossref 48. Epstein LH, Wing RR. Behavioral contracting: health behaviors . In: Franks C, ed. New Developments in Behavior Therapy: From Research to Clinical Application . New York, NY: The Haworth Press; 1984:409-449. 49. Damico M. Incentives in our schools . Business Incentive Strategies . 1992;51:4-18. 50. Caring for Tomorrow's Children. Columbia, SC: Office of the Governor; 1993. 51. Goldberg SR, Stolerman IP. Behavioral Analysis of Drug Dependence . Orlando, Fla: Academic Press Inc; 1986.

Journal

Archives of General Psychiatry – American Medical Association

Published: Jul 1, 1994

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