Contingent Vouchers Research Articles

Smoking outcome expectancies predict smoking during voucher-based treatment for smokers with substance use disorders

ObjectiveStrong expectations regarding positive effects of smoking may reduce the likelihood of successfully quitting. The Smoking Effects Questionnaire (SEQ) assesses the importance of seven expected positive and negative effects of smoking. SEQ was used to predict responses to contingent monetary rewards for smoking abstinence among smokers with substance use disorders (SUD). MethodsSmokers (N = 184) in residential (i.e., 24 h/day) treatment for SUD received 19 consecutive days of either contingent vouchers (CV) for smoking abstinence (twice-daily carbon monoxide [CO] readings) or non-contingent vouchers (NV) plus counseling to motivate smoking cessation. Analyses investigated effects of smoking expectancies on days of smoking within-treatment and number of cigarettes/day at 1 month post-treatment. ResultsHigher positive expectancies for reduced negative affect, weight control, stimulation and positive social effects from smoking were related to more days of smoking during treatment only for participants in the CV condition. Post-treatment, expecting positive social and stimulating effects from smoking were related to more smoking only among CV participants. In both conditions, negative expectancies were largely unrelated to smoking outcomes. ConclusionsThe moderation of CV by positive smoking expectancies suggests that those who rate positive expectancies as more important may require a complementary treatment or different incentives to reduce smoking. The SEQ was probably unassociated with smoking in NV due to little reduction in smoking behavior. Helping smokers with SUD develop alternative ways to produce positive effects sought from smoking may be important to improve initial smoking outcomes.

Treating Smokers in Substance Treatment With Contingent Vouchers, Nicotine Replacement and Brief Advice Adapted for Sobriety Settings

Treatment for substance use disorders (SUD) provides an opportunity to use voucher-based treatment for smoking. Nicotine replacement (NRT) could improve outcomes previously observed with vouchers without NRT. MethodsA randomized controlled trial compared contingent vouchers (CV) for smoking abstinence to noncontingent vouchers (NV), when all received counseling and NRT. Smokers who had not sought smoking treatment (n=340) in residential SUD treatment were provided 14days of vouchers for complete smoking abstinence per exhaled carbon monoxide (CO) after a 5-day smoking reduction period, or vouchers only for breath samples, plus brief advice (four sessions) and 8weeks of NRT. ResultsWithin treatment, 20% had complete abstinence with CV, 5% with NV (p<.001), and participants showed 50% of days abstinent in CV compared to 22% in NV (p<.001). Across 1, 3, 6 and 12months after randomization, CV resulted in significantly fewer cigarettes per day (p<.01) and fewer days smoking (p<.01), but with small effects. Point-prevalence abstinence differences across follow-up (e.g., 4% CV, 2% in NV at 6 and 12months) were not significant. No differences in substance use were seen. ConclusionsWithin-treatment effects on abstinence are stronger than in a prior study of the same CV with BA but without NRT, but NRT does not improve abstinence after vouchers end. Implications for voucher-based treatment include investigating effects when combined with stronger smoking medications and using motivational interviewing. Smoking treatment does not harm SUD recovery.

Treating smokers in substance treatment with contingent vouchers, nicotine replacement and brief advice adapted for sobriety settings

Treating smokers in substance treatment with contingent vouchers, nicotine replacement and brief advice adapted for sobriety settings

Predictive Validity of a Cigarette Purchase Task in a Randomized Controlled Trial of Contingent Vouchers for Smoking in Individuals With Substance Use Disorders.

A cigarette purchase task (CPT) is a behavioral economic measure of the reinforcing value of smoking in monetary terms (ie, cigarette demand). This study investigated whether cigarette demand predicted response to contingent monetary rewards for abstinence among individuals with substance use disorders. It also sought to replicate evidence for greater price sensitivity at whole-dollar pack price transitions (ie, left-digit effects). Participants (N = 338) were individuals in residential substance use disorder treatment who participated in a randomized controlled trial that compared contingent vouchers to noncontingent vouchers for smoking abstinence. Baseline demand indices were used to predict number of abstinent days during the 14-day voucher period (after the reduction lead-in) and at 1 and 3 months afterward. Demand indices correlated with measures of smoking and nicotine dependence. As measured by elasticity, intensity and O max, higher demand significantly predicted fewer abstinent exhaled carbon monoxide readings during voucher period for individuals in the noncontingent vouchers condition. Breakpoint exhibited a trend-level association with abstinent exhaled carbon monoxide readings. Demand indices did not predict abstinence in the contingent vouchers group, and did not predict abstinence at 1- and 3-month follow-ups. Left-digit price transitions were associated with significantly greater reductions in consumption. The association of cigarette demand with smoking behavior only in the group for whom abstinence was not incentivized indicates that CPT assesses the value of smoking more than the value of money per se and that vouchers counteract the effects of the intrinsic reinforcing value of cigarettes. Results provide initial short-term evidence of predictive validity for the CPT indices. This study provides the first evidence of the validity of the CPT for predicting early response to brief advice for smoking cessation plus nicotine replacement in smokers with substance dependence. However, demand for cigarettes did not predict voucher-based treatment response, indicating that incentives serve as a powerful motivator not to smoke that acts in opposition to the intrinsic reinforcing value of cigarettes and that the indices reflect the value of smoking more than the value of money per se.

Contingent Vouchers and Motivational Interviewing for Cigarette Smokers in Residential Substance Abuse Treatment

Residential drug treatment provides an opportunity to intervene with smokers with substance use disorders (SUD). A randomized controlled clinical trial compared: (1) contingent vouchers (CV) for smoking abstinence to noncontingent vouchers (NCV), crossed with (2) motivational interviewing (MI) or brief advice (BA), for 184 smokers in SUD treatment. During the voucher period, 36% of carbon monoxide readings indicated smoking abstinence for those receiving CV versus 13% with NCV (p<.001). Post-treatment (3–9 months) point-prevalence abstinence rates were low (3–4% at each follow up), with more abstinence when CV was combined with MI (6.6% on average) than with BA (0% on average). No differential effects on drug use or motivation to quit smoking occurred. Thus, CV had limited effects on long-term smoking abstinence in this population but effects were improved when CV was combined with MI. More effective methods are needed to increase motivation to quit smoking and quit rates in this high-risk population.

A two-phased screening paradigm for evaluating candidate medications for cocaine cessation or relapse prevention: Modafinil, levodopa–carbidopa, naltrexone

BackgroundCocaine pharmacotherapy trials are often confounded by considerable variability in baseline cocaine-use levels, obscuring possible medication efficacy. Testing the feasibility of using a prerandomization, abstinence-induction protocol, we screened three candidate medications to explore treatment response in patients who did, or did not, achieve abstinence during an extended baseline phase. MethodEligible treatment-seeking, cocaine-dependent subjects entered a 4-week baseline period (Phase I) with high-value abstinence contingent vouchers and two motivational interviewing sessions, followed by a 12-week medication trial (Phase II) with random assignment stratified on Phase I abstinence status to (1) modafinil (400mg/d), (2) levodopa/carbidopa (800/200mg/d), (3) naltrexone (50mg/d), or (4) placebo. Treatment consisted of thrice-weekly clinic visits for urine benzoylecgonine testing and weekly cognitive behavioral therapy with contingency management targeting medication compliance. ResultsOf the 118 subjects enrolled, 81 (80%) completed Phase I, with 33 (41%) achieving abstinence, defined a priori as 6 consecutive cocaine-negative urines. Tests of the interaction of each medication (active versus placebo) by baseline status (abstinent versus nonabstinent) permitted moderator effect analysis. Overall, baseline abstinence predicted better outcome. Cocaine-use outcomes for levodopa and naltrexone treatment differed as a function of Phase I abstinence status, with both medications producing benefit in nonabstinent but not baseline-abstinent subjects. There was no evidence of a moderator effect for modafinil. ConclusionsThe two-phase screening trial demonstrated that subgrouping of patients with respect to baseline abstinence status is feasible and clinically useful for exploring cocaine cessation and relapse-prevention effects of candidate medications.

Comparison of the Cigarette Dependence Scale with four other measures of nicotine involvement: Correlations with smoking history and smoking treatment outcome in smokers with substance use disorders

The Cigarette Dependence Scale (CDS) was developed to assess principal aspects of smoking dependence. In a French longitudinal survey, CDS showed stronger relationships to urge and change in smoking rate than the Fagerström Test for Nicotine Dependence (FTND). Neither measure predicted abstinence at follow-up in that survey but there was no treatment or cessation induction. The present study investigated concurrent and predictive validity of the CDS in a treatment population by comparing the CDS to the FTND and other measures of tobacco involvement as (1) a correlate of smoking and cessation history and (2) a predictor of short-term smoking abstinence among smokers with substance use disorders (SUD) receiving smoking treatment. Methods: Smokers (10+ cigarettes per day) in substance treatment received brief advice and nicotine patch for 8weeks; half also received contingent vouchers for smoking cessation. Assessments were conducted pretreatment and 7, 14 and 30days after treatment initiation, with abstinence verified biochemically. Results: At baseline (n=305), the 12-item and 5-item CDS versions showed excellent and marginal reliability, respectively. FTND shared 43 and 61% of variance with CDS-12 and CDS-5, respectively. FTND and CDS scales correlated positively with cigarettes per day, and negatively with time to first cigarette, motivation to quit and age at first daily smoking. Only CDS correlated with the number of past quit attempts. Neither CDS nor FTND predicted abstinence within treatment, unlike the motivation measure and time to first cigarette. Conclusion: In moderate-heavy smokers with SUD in smoking treatment in the U.S., the CDS is largely equivalent to the FTND as an indicator of tobacco dependence but the CDS-5 is less reliable. Motivation was the most consistent predictor of outcome, and time to first cigarette was the only tobacco dependence measure that predicted smoking abstinence during treatment.

The effect of framing incentives as either losses or gains with contingency management for smoking cessation

Cumulative prospect theory predicts that losses motivate behavior more than equal gains. Contingency management procedures effectively reduce drug use by placing incentives in direct competition with the drug taking behavior. Therefore, framing incentives as losses, rather than gains should decrease drug use to a greater extent, given equivalent incentives. We examined whether contingent vouchers described as either losses or gains differentially affected smoking abstinence rates. Over 5 consecutive days, participants could either gain $75 per day for verified abstinence or lose $75 per day (initial endowment=$375) for continuing to smoke. As a result, loss-framed participants were more likely to achieve at least one day of abstinence. There was a trend towards loss-framed participants reducing the amount smoked more than gain-framed participants. However, participants in the gain-framed group were more likely to maintain abstinence, once initiated. The results partially support cumulative prospect theory and suggest additional ways to initiate behavior change using incentives, outside of using larger magnitude incentives in contingency management procedures.

Effects of voucher‐based incentives on abstinence from cigarette smoking and fetal growth among pregnant women

This study examined whether voucher-based reinforcement therapy (VBRT) contingent upon smoking abstinence during pregnancy is an effective method for decreasing maternal smoking during pregnancy and improving fetal growth. A two-condition, parallel-groups, randomized controlled trial was conducted in a university-based research clinic. A total of 82 smokers entering prenatal care participated in the trial. Participants were assigned randomly to either contingent or non-contingent voucher conditions. Vouchers exchangeable for retail items were available during pregnancy and for 12 weeks postpartum. In the contingent condition, vouchers were earned for biochemically verified smoking abstinence; in the non-contingent condition, vouchers were earned independent of smoking status. Smoking outcomes were evaluated using urine-toxicology testing and self-report. Fetal growth outcomes were evaluated using serial ultrasound examinations performed during the third trimester. Contingent vouchers significantly increased point-prevalence abstinence at the end-of-pregnancy (41% versus 10%) and at the 12-week postpartum assessment (24% versus 3%). Serial ultrasound examinations indicated significantly greater growth in terms of estimated fetal weight, femur length and abdominal circumference in the contingent compared to the non-contingent conditions. These results provide further evidence that VBRT has a substantive contribution to make to efforts to decrease maternal smoking during pregnancy and provide new evidence of positive effects on fetal health.

Randomized trial of contingent prizes versus vouchers in cocaine-using methadone patients.

Contingency management (CM) interventions frequently utilize vouchers as reinforcers, but a prize-based system is also efficacious. This study compared these approaches. Seventy-four cocaine-dependent methadone outpatients were randomly assigned to standard treatment (ST), ST plus a maximum of $585 in contingent vouchers, or ST plus an expected average maximum of $300 in contingent prizes for 12 weeks. CM participants achieved longer durations of abstinence (LDA) than ST participants, and CM conditions did not differ significantly in outcomes or amount of reinforcement earned. Although long-term abstinence did not differ by group, LDA during treatment was the best predictor of abstinence at 9 months. Thus, reinforcement with prizes was similar to voucher CM in promoting LDA, which is associated with posttreatment benefits.

EFFECTS OF INTERNET‐BASED VOUCHER REINFORCEMENT AND A TRANSDERMAL NICOTINE PATCH ON CIGARETTE SMOKING

Nicotine replacement products are commonly used to promote smoking cessation, but alternative and complementary methods may increase cessation rates. The current experiment compared the short-term effects of a transdermal nicotine patch to voucher-based reinforcement of smoking abstinence on cigarette smoking. Fourteen heavy smokers (7 men and 7 women) completed the four 5-day phases of the study: baseline, patch treatment, voucher treatment, and return to baseline. The order of the two treatment phases was counterbalanced across participants. In the patch treatment condition, participants wore a 14-mg transdermal nicotine patch every day. In the voucher treatment condition, participants received vouchers contingent on abstinence from smoking, defined as producing carbon monoxide (CO) readings of < or =4 parts per million. Participants e-mailed two video clips per day showing them breathing into a CO monitor and the resulting CO reading to clinic staff. In the voucher treatment, 24% of samples were negative, and 5% of samples were negative in the patch treatment. Results suggest that contingent vouchers were more effective than transdermal nicotine patches in promoting abstinence.

A pilot study on voucher‐based incentives to promote abstinence from cigarette smoking during pregnancy and postpartum

We report results from a pilot study examining the use of vouchers redeemable for retail items as incentives for smoking cessation during pregnancy and postpartum. Of 100 study-eligible women who were still smoking upon entering prenatal care, 58 were recruited from university-based and community obstetric practices to participate in a smoking cessation study. Participants were assigned to either contingent or noncontingent voucher conditions. Vouchers were available during pregnancy and for 12 weeks postpartum. In the contingent condition, vouchers were earned for biochemically verified smoking abstinence. In the noncontingent condition, vouchers were earned independent of smoking status. Abstinence monitoring and associated voucher delivery was conducted daily during the initial 5 days of the cessation effort, gradually decreased to every other week antepartum, increased to once weekly during the initial 4 weeks postpartum, and then decreased again to every other week for the remaining 8 weeks of the postpartum intervention period. Contingent vouchers increased 7-day point-prevalence abstinence at the end-of-pregnancy (37% vs. 9%) and 12-week postpartum (33% vs. 0%) assessments. That effect was sustained through the 24-week postpartum assessment (27% vs. 0%), which was 12 weeks after discontinuation of the voucher program. Total mean voucher earnings across antepartum and postpartum were 397 US dollars (SD=414 US dollars) and 313 US dollars (SD=142 dollars) in the contingent and noncontingent conditions, respectively. The magnitude of these treatment effects exceed levels typically observed with pregnant and recently postpartum smokers, and the maintenance of effects through 24 weeks postpartum extends the duration beyond those reported previously.

Safety and Efficacy of L‐tryptophan and Behavioral Incentives for Treatment of Cocaine Dependence: A Randomized Clinical Trial

L-tryptophan(ie, tryptophan)has shown promise as a pharmacotherapy in cocaine addiction treatment. Abstinent contingent voucher incentives have shown efficacy in abstinence initiation and maintenance for treatment of cocaine dependence. The present study evaluated these two approaches singly and in combination in a relapse prevention+treatment design. A double-blind, parallel-group, placebo-controlled design was used. Cocaine-dependent patients(N=199) were stratified and randomized to one of four groups: tryptophan+contingent vouchers, tryptophan+non-contingent vouchers, placebo+contingent vouchers, and placebo+non-contingent vouchers. The study included residential stabilization (4-9 days), where patients achieved initial cocaine abstinence; outpatient treatment evaluation(16 weeks), where patients received medication, vouchers, and urine testing thrice weekly; and disposition. Main outcomes were retention in treatment, urinalysis, self-reported drug use, and self-reported side effects. Tryptophan did not significantly prevent relapse to cocaine use or attenuate cocaine use after relapse. Contingent vouchers significantly increased the time to cocaine relapse and produced less cocaine use relative to non-contingent vouchers. Results demonstrate the sensitivity of this methodology for detecting decreases in cocaine use, as evidenced by significant changes of the contingent voucher conditions; this suggests that tryptophan's lack of efficacy was not due to model insensitivity for detecting significant differences in cocaine use. This study also showed that contingent vouchers were effective in the novel experimental model of relapse prevention.

Differential effects of methadone dose/contingency management combinations on abstinence from heroin and cocaine

Continued illicit drug use remains a significant problem among patients in methadone maintenance. This study examined the interaction between a pharmacological and a behavioral intervention in patients using illicit heroin and cocaine while in methadone maintenance therapy. The behavioral intervention (contingency management) reinforced abstinence from heroin and cocaine. The pharmacological intervention was a 30-mg methadone dose increase. Methadone-maintained outpatients (N=XXX) were randomly assigned to 4 groups: dose increase & contingent vouchers (given separately for heroin- and cocaine-negative urine screens); dose increase & noncontingent vouchers (independent of urine screen results); no dose increase & contingent vouchers; no dose increase & noncontingent vouchers. The intervention lasted 12 weeks. Analysis of thrice-weekly urine screen results showed that an increase in methadone dose (from 70 to 100 mg/d) significantly reduced heroin use, but not cocaine use, while contingent vouchers significantly reduced both heroin and cocaine use. The effects on heroin use were enhanced by combining the contingency and dose increase interventions, an effect not found in a previous study with lower methadone doses (50 and 70 mg/d; Preston et al., Arch Gen Psychiatry 57, 395–404, 2000), nor found for cocaine in this study. Thus, the interaction between methadone and the behavioral treatment was pharmacologically specific and sensitive to dose. Clinical Pharmacology & Therapeutics (2004) 75, P21–P21; doi: 10.1016/j.clpt.2003.11.079

Contingent reinforcement for compliance with goal-related activities in HIV-positive substance abusers.

This paper describes the use of a contingency management intervention for increasing compliance with goal-related activities in HIV-positive substance abusers. In an HIV drop-in center, substance abuse treatment groups were held throughout a 35-week period. A reversal design was used, in which non-reinforcement and reinforcement conditions were alternated. In the reinforcement condition, the reinforcer was a chance to draw from a bowl and have the possibility of winning a prize. Reinforcers were provided for attending group and for completing steps related to treatment goals. Overall, the procedure increased attendance at groups, with an average of less than one client (range 0-4) per session in the initial baseline condition to an average of 7 clients (range 2-12) per session during the reinforcement conditions. The percentage of goal-related activities completed also rose from 25% during the initial baseline condition to over 70% during the reinforcement condition. It decreased back down to 50% during the return to baseline condition. These data suggest the feasibility of a contingency management intervention that offers reinforcers for compliance with goal-related activities. The process of activity selection and verification is outlined, and the specific activities in which clients engaged are described. ********** Contingency management interventions have data supporting their efficacy in treating substance abusers (see Petry, 2000, for a detailed review of the principles and procedures involved in contingency management programs). These treatments are based on general behavioral principles. In the basic procedure the target behavior is frequently monitored, and tangible reinforcers are provided when the target behavior occurs. When the target behavior does not occur, the reinforcer is witheld or removed. Most contingency management treatments for substance abusers have reinforced drug abstinence. Urine samples are collected two to three times per week. Each sample that is negative for the target drug results in a reinforcer, such as a take-home dose of methadone or a voucher, that is exchangeable for retail goods and services. In a series of clinical trials with cocaine-dependent patients, Higgins et al. (1991, 1993, 1994, 2000) demonstrated the efficacy of these procedures. For example, 75% of cocaine-dependent outpatients who received contingent vouchers remained in treatment for a 3-month period, and 55% of them were able to attain at least 2 months of continuous cocaine abstinence. In contrast, 40% of clients who received the same therapy but who were not provided the vouchers remained in treatment, and only 15% achieved 2 or more months of cocaine abstinence (Higgins et al., 1994). These procedures have also been effective in treating opioid (Bickel et al., 1997; Preston et al., 2000), marijuana (Budney et al., 2001), benzodiazepine (Stitzer et al., 1992), and alcohol (Miller, 1975; Petry et al., 2000) dependence, as well as polydrug abusing methadone clients (Silverman et al., 1996). Thus, contingency management may be widely useful in reducing substance use (see Petry, 2000), but substance abusers also experience an array of psychosocial difficulties. These include unemployment, legal problems, psychiatric distress, and medical illnesses. Reinforcing drug abstinence alone rarely engenders improvements along these other domains, but contingency management approaches can be adapted to reinforce behavioral changes in these dimensions as well. In three studies (Bickel et al., 1997; Iguchi et al., 1997; Petry et al., 2000), clients decided upon discrete activities each week that were related to their long-term treatment goals. These may have included attending a medical appointment if the goal was to improve health, going to the library with their child if the goal was to improve parenting, or filling out a job application if the goal was to obtain employment. If clients accomplished these activities and provided objective verification of their completion via receipts, they received reinforcers. …