Contingency management with community reinforcement for substance abuse treatment

Contingency Management

ALCOHOL & MARIJUANA STUDIES

The purposes of this review are to gain an understanding of the controlled studies using contingency management (CM) in the substance abuse field, and where applicable emphasize those studies that incorporate CM with community reinforcement approach (CRA). This paper should offer a critical review of the literature with an eye toward identifying important and unresolved theoretical and research questions. Logan (1972) holds that there is much evidence that animals also respond to operant contingencies with psychoactive substances.

The New York Times reports in the work entitled: "Toward a Behavioral Economic Understanding of Drug Dependence: Delay Discounting Processes" (2006) states that many times those who are addicted to alcohol or drugs do not stay clean because they either "won't go to or won't stay in treatment." The work of "Scott Kellogg, Ph.D., and Mary Jeanne Kreek, M.D., at the Rockefeller University, and colleagues at the New York City Health and Hospitals Corporation (HHC) and at Johns Hopkins University, show that a treatment approach called contingency management improves patients' motivation to stay in treatment and increases their therapeutic progress." (New York Times, 2006) According to the report "Contingency management is designed to reinforce small steps, especially at the beginning, like celebrating each attendance at a group meeting or each drug-free test result. Later, patients can move on to larger achievements like stable housing. Easy-to-earn material goods, such as movie passes and food vouchers, help to both initiate and maintain positive changes. The program is not thought of as a substitute for counseling or pharmacotherapy, but something that adds to the therapy." (New York Times, 2006) According to Kellogg: "We did have some opposition at first from the staff, people who come from different therapeutic traditions...in general we tend to punish people for doing things that are wrong, so it's not necessarily intuitive to reinforce positive behavior when it does occur in our patients. But once the patients began to respond to the reinforcements, it changed the counselors. The counselors want the patients to get better, and when they saw the patients get better, it was really persuasive." (New York Times, 29006)

Key Terms

1. Contingency Management: "Contingency Management rewards abstinence or punishes drug taking (e.g. By notification of courts, employers or family members) as measured by random, supervised urine, saliva, or hair-follicle monitoring. Is inclusive of cue exposure and relaxation techniques to expose a patient to cues that induce craving while preventing actual substance abuse in order to facilitate extinction of classically conditioned craving. (Treating Substance Use Disorders, 2006; paraphrased)

2.. Vouchers: Awards given to participants that can be used for purchasing all types of merchandise.

3. CRs - Conditioned response.

4. ARCs - Alcohol related cues.

5. SDs - Discriminative Stimuli

Literature Review

The most commonly used "illicit drug in the United States (Anthony et al., 1994) is Marijuana according to the work of McRae, Budney & Brady (2002). Further reported is a "trend toward greater use, especially among adolescents (Monitoring the Future, 1999) Estimates have been given stating that: "10% of individuals who ever use marijuana become daily users (Johnson, O'Malley, & Bachman, 1995)." (McRae, Budney & Brady, 2002) it is stated that: "Anthony et al. (1994) report that marijuana has substantial rates of conditional dependence (9%)" as compared to others as follows: alcohol (15%) cocaine (17%), heroin (23%) tobacco (32%)

Budney, et al. (2006) in the work entitled: "Clinical Trial of Abstinence-Based Vouchers and Cognitive-Behavioral Therapy for Cannabis Dependence" state that the demand increased "twofold during the 1990s" for treatment related to marijuana (cannabis) problems in the United States. (Substance Abuse and Mental Health Services Administration, 2001) This work states that."..only five randomized, clinical trails examining the efficacy of treatment for adult cannabis dependence have been reported, these studies suggest that treatment efficacy appears comparable to that observed with other substances of abuse (Marijuana Treatment Project Research Group, 2004; McRae, Budney & Brady, 2003)." (Budney, et al., 2006) it is interesting to note that: "Cognitive-behavioral treatments such as relapse prevention, behavioral coping skills therapy, and motivational enhancement therapy appear efficacious." (Budney et al., 2006) the problem is that in relation to "abstinence and relapse rates observed across these studies suggest that the majority of participants do not have positive outcomes [in other words this is shown to be complete ineffective] indicating that continued development and testing of more potent and cost-effective treatments remain a priority" (Budney, et al., 2006) One study reported by Budney, et al. which added an "abstinence-based voucher incentive program to a standard cognitive-behavioral therapy significantly improved marijuana abstinence rates during a 14-week treatment episode (Budney, Higgins, Radanovich, & Novy, 2000). Documented analysis of urine testing marijuana clear resulted in the participants receiving vouchers which they could exchange for retail items. Budney, et al. states that: "These findings were concordant with a growing literature showing that incentive-based intervention developed from principles of positive reinforcement can enhance outcomes when combined with other effective psychological and pharmacological interventions for substance dependence (Higgins, Heil, & Lusier, 2004)." (Ibid) However, there is still the only one report "on the efficacy of abstinence-based vouchers for cannabis dependence, and that study was limited by use of a relatively small sample size and did not include posstreatment follow-up assessments." (Ibid) Budney et al. (2006) also relates that in three recent studies relating to treatment of cocaine dependent the examination of whether "combining abstinence-based vouchers with other behavioral therapies improves outcomes." The report states that the "Community Reinforcement Approach therapy, an intensive, outreach-oriented behavioral therapy, plus vouchers enhanced psychosocial and substance use outcomes compared with vouchers alone in a 24-week intervention for primary cocaine dependence (Higgins et al. 2003)" (Budney et al. 2006) However two studies that were with participants relating to methadone maintenance in connection to opiate dependence with the combination of cognitive/behavioral therapy did not improve outcomes with vouchers only. (Epstein, Hawkins, Covi, Umbicht, & Preston, 2003; Rawson et al., 2002)

According to the work of Petry et al. (2000) entitled "Contingency Management Interventions: From Research to Practice": "Behavioral Interventions have enjoyed widespread use in the treatment of variety of psychiatric conditions, including autism (1) conduct disorder (2) developmental disorders (3) eating disorders and (4) even schizophrenia. These techniques are based upon rearranging the environment to reinforce appropriate behavioral patterns while providing negative reinforcement for inappropriate behaviors. Similar procedures have been applied to substance-abusing populations, and these interventions have been termed contingency management." (2001) additionally stated is that: "In treatment of substance use disorders, contingency management techniques have demonstrated efficacy in retaining substance-abusing clients in treatment, promoting drug abstinence, and encouraging appropriate behaviors. These treatments are based on three general behavioral principles: (1) frequent monitoring of the target behavior; (2) Provision of tangible, positive reinforces when the target behavior occurs; and (3) removal of the reinforcer when the target behavior does not occur." (Petry, et al., 2000)

Nancy M. Petry in the work entitled: "A Clinician's Guide for Implementing Contingency Management Programs: A Guideline Developed for the Behavioral Health Recovery Management Project" states that: "Contingency management (CM) interventions, also sometimes called motivational incentives, are based upon principles of behavioral modification. These procedures stem from token economy approaches that were developed over 40 years ago and are still in place today. The behavioral principles are centered around three basic tenets. First, you arrange the environment such that target behaviors (e.g., drug abstinence) are readily detected; this aspect includes frequent monitoring, such as conducting thrice weekly urinalysis testing. Second, you provide tangible reinforcers whenever the target behavior is demonstrated." (n.d.) the first step to take in the design of a contingency management procedure is to identify the behavior that is in need of change. The contingency management procedure "can be designed for an individual client, they can be developed for use with specific populations, or they can be implemented clinic wide. For example, an individualized CM approach can be designed for a client who is having specific problems with drug use, or a client who is failing to take the necessary steps to resolve his or her employment issues. CM procedures can also be applied with specific subpopulations within in a clinic. So, for example, cocaine-dependent methadone patients may be designated to receive the CM procedures. If a problem is clinic wide, such as lack of on-time attendance at group therapy, a procedure can be designed to address this issue among all clients." (Petry, n.d.) Petry states that there are four instances where contingency management may be successfully used. These four are: (1) Engagement and retention; (2) Drug Use; (3) Goal-related behaviors; and (4) Within Clinic behaviors. Of Engagement and Retention, Petry states: "CM procedures that provide positive rewards retain clients in treatment for longer periods than does counseling alone. For example, some studies have shown that provision of a small restaurant gift certificate can enhance therapy attendance in dual diagnosis clients. Other studies in methadone clinics find that take-home doses can be used to reinforce attendance at therapy sessions. Still other studies have found that providing a "dollar a day" encouraged attendance in group therapy for teenage mothers. Contingency Management as related to drug use states Petry should be designed with the goal being the detection of all instances of the use of the target drug. "Thus, CM studies typically monitor drug use 2-3 times per week, because most urine testing systems can detect drug use over this period. When clients submit specimens negative for the targeted drug, they receive the reinforcer (a voucher or take-home dose of methadone). Submission of positive samples results in no reinforcer and sometimes a punisher (reset of voucher to a low value or loss of take-homes)." (n.d.) According to Petry: "CM procedures are effective in reducing use of a variety of different drugs. For example, in one study with cocaine dependent outpatients (Higgins et al., 1994), 55% of clients who received behavior therapy plus vouchers for submitting urine samples negative for cocaine achieved at least 2 months of continuous cocaine abstinence. Only 15% of clients who received the same behavior therapy, but who did not get the vouchers, maintained this period of abstinence. Other studies have demonstrated beneficial effects of vouchers and other reinforcers in reducing use of opioids, marijuana, benzodiazepines, nicotine, and alcohol (see Petry, 2000 for review)." (n.d.) the limitations of the contingency management procedure for reinforcing drug abstinence while "seemingly is a straightforward procedure that can be introduced into clinics" may actually be hindered because "urine samples are sent to outside laboratories or hospitals for screening..." [and]..." The results are not obtained until several days later." (n.d.) Petry states that: "To best reinforce submission of negative samples, you want to provide the reward immediately upon demonstration of the behavior. Just like in the previous example of reinforcing therapy attendance, you don't want to wait 2-3 days before you give the client the token." (n.d.)

The work of Kamon, Budney & Stanger (2005) entitled "Contingency Management Intervention for Adolescent Marijuana Abuse and Conduct Problems" reports a study conducted with a state objective being "To describe an innovative treatment for adolescent marijuana abuse and provide initial information about its feasibility, acceptability, and potential efficacy" and with a stated method of providing "an intervention composed of (1) a clinic-administered, abstinence-based incentive program; (2) parent-directed contingency management targeting substance use and conduct problems; (3) a clinic-administered incentive program for parent participation; and (4) individual cognitive-behavioral therapy for adolescents. Data are presented for 19 adolescents, age 15-18 years. Measures of substance use, psychopathology, and parenting were collected before and after the 14-week treatment. Substance use measures were also collected 1 month post-treatment. Substance use was monitored by twice-weekly urine and breath testing. An intent-to-treat model was used." (Ibid) the study results state that: "Adolescents and parents attended an average of 10.3 and 10.6 of 14 sessions, respectively. Substance use, externalizing behaviors, and negative parenting behaviors decreased by treatment end. Urine testing indicated that abstinence increased from 37% at intake to 74% at treatment end (z value = 2.28, p =.02) and that 53% of adolescents were abstinent 30 days post-treatment." (Ibid) Conclusions of the study state that: "preliminary data provide support for the feasibility and acceptability of a family-based, contingency management model to treat adolescent substance use and conduct problems. Controlled efficacy studies with larger samples are needed." (Ibid)

The work of Bickel and Marsch (2001) entitled: "Toward a Behavioral Economic Understanding of Drug Dependence: Delay Discounting Processes" states that: "Behavioral economics is 'the study of the allocation of behavior within a system of constraint (Bickel, Green & Vuchinich, 1995, p. 258) and examines conditions that influence the consumption of commodities, including drug of dependence." This work examines "the discounting of delayed reinforcers in order to understand the impulsivity and loss of control exhibited by the drug dependent." (Bickel and Marsch, 2001) One shortcoming found in this method is stated to be "the use of hypothetical rewards" (Ibid) in a recent review it has been suggested that "differences between actual and hypothetical rewards may be one of degree rather than form the discounting function (Kirby, 1997) Stated to be 'Potential future directions for the study of discounting of delayed reinforcers include exploring (1) two interesting phenomena closely related to discounting; (2) the relationship of discounting to both the behavioral economic measure of elasticity as well as to outcomes observed in clinical setting; and (3) the relation between impulsivity and other psychological disorders." (Ibid) the research reviewed in this work "suggests that drug-dependent individuals show substantial discounting relative to matched and control non-drug users. The research also suggests that other measure of impulsivity appear to be concordant with the discounting measure. One value of examining impulsivity as discounting is that it enables the study of the behavioral process that has broad generality and permits experimental analyses of its determinants." (Ibid) the authors state that remaining are important questions that must be addressed.

Iguchi, Martin Y. et al. (1997) Reinforcing Operants Other Than Abstinence in Drug Abuse Treatment: An Effective Alternative for Reducing Drug Use. Journal of Consulting and Clinical Psychology, 1997, Vol. 65. No. 3 421-428. American Psychological Association 1997.

Reinforcement of abstinence from drugs through use of incentives such as "take-home methadone doses, changes in methadone dose, or cash, reduces drug use among patients in methadone treatment states Iguchi et al. (1997) citing the work of Hall, Bass, Hargreaves & Loeb (1979); Havassy & Hargreaves (1979); Higgins, Stitzer & Bigelow, 1986; Iguchi, Stitzer, Bigelow & Liebson (1988); Milby, Garrett, English, Fritschi, & Clarke (1978); Stizer, Bigelow, Liebson & Hawthorne (1982) Even so there are still problems relating to contingency management procedures that target abstinence from drugs in that "Such interventions typically achieve only partial success, with a substantial proportion of patients often failing to discontinue illicit drug use long enough to earn a single reinforcer. Such patients either lack the skills necessary to achieve abstinence or the environmental consequences are insufficient to promote change. Contingency management interventions also generally fail to integrate or capitalize on substance abuse counseling, which is available at most clinics and which is at least potentially effective in reducing drug use (McLellan, Woody, Luborsky, & Goehl, 1988)." (Ibid) Iguchi et al. (1997) states that in their study the "evaluated a DRA intervention using vouchers redeemable for goods and services to shape behaviors consistent with long-term treatment plan goals. The intervention diverges significantly from those tested previously, in that we reinforced performance of weekly treatment plan-related tasks that were individually tailored to each participant's goals, rather than a single, specified therapeutic activity. Moreover, if a participant failed to complete a task in a given week, a less difficult task was assigned for the following week, increasing the likelihood that participants' performance would be reinforced. The present study thus assesses the effectiveness of this task-oriented shaping intervention compared with a standard treatment control and a more traditional contingency management intervention reinforcing the provision of drug-free urine samples." (Iguchi et al., 1997) Findings state that: "Unauthorized use of substance was detected in 85.1% of urine samples collected during the 6-week baseline evaluation phase with 68.9% of all urine samples testing positive for illicit opiates, 40.6% testing positive for cocaine, and 23.7% testing positive for benzodiazepines during that period." (Iguchi et al., 1997)

The work of Preston, Umbricht, and Epstein (2002) entitled: "Abstinence Reinforcement Maintenance Contingency and One-Year Follow-Up" states that: "Relapse to drug use is often seen when contingencies designed to reduce drug use are discontinued. This paper reports on a step-down maintenance contingency and 1-year follow-up in 110 patients who were maintained on methadone (50 or 70 mg/day) and who had completed a contingency management trial targeted to decreasing their opiate use. In the prior study participants received vouchers for each opiate-negative urine screen or noncontingently" (Preston, Umbricht, & Epstein (2002). Results of the study state that: "Patients who received the maintenance contingency following an 8-week induction contingency had better outcomes than those who received noncontingent incentives in either the maintenance or induction phases of the trial." (Ibid) the conclusions of the study state that the findings: "support the therapeutic value of extending the duration of contingency management and long-term methadone maintenance." (Ibid)

According to the work of Roffman and Stephens (2006) in the work entitled: "Cannabis Dependence: Its Nature, Consequences and Treatment": "Cannabis dependence is controversial. At the time of the volume's completion in 2005, important advances had been made in understanding the etiology and epidemiology of cannabis dependence, describing its neuropharamacology and the physiology of the endocannabiniod system, identifying associated consequences that impact health and behavior and in evaluating the relative effectiveness of a variety of counseling interventions for adults and adolescents with the cannabis abuse disorders. Our understanding of the existence and nature of cannabis dependence has long been shaped by social and political forces that have polarized opinions and policies. The explosion of scientific research on the phenomena in recent years is starting to build a consensus that a small but significant subset of cannabis users develops a dependence syndrome, many of whom need treatment. Standard nomenclatures and classification systems, such as ICD and DSM, provide reliable and valid operational criteria for cannabis dependence. With these tools it has become possible to characterize participants in clinical research and to obtain population estimates of cannabis use disorders. The elucidation of the structure of delta-9-tetrahydrocannabinol, the discovery of anandamide and cannabinoid receptors, and the synthesis of cannabinoid agonists and antagonists support the existence of an endocannabinoid system in the central nervous system that is believed to modulate cannabis dependence. There is considerable evidence from animal and human models that physical dependence on cannabis, as identified by tolerance and withdrawal phenomena, can be induced via prolonged exposure. Current research is focused on which regions of the brain mediate physical dependence and the nature of the underlying cellular mechanisms of action. Research focusing on the CB1 receptor and the action of antagonists such as SR141716A in precipitating withdrawal has potential relevance to the eventual development of pharmacotherapies for the treatment of cannabis dependence. In the U.S.A., within the first 24 months of cannabis use initiation, 2-4% of users (or 50-80 people each day) progress to cannabis dependence. Annually, that amounts to 20,000-30,000 individuals. Cannabis dependence occurs in 1 in 9 to 11 individuals who have ever used the drug, and 11-16% (1.6-2.3 million individuals) of the 14 million current users." (Roffman & Stephens, 2006) Risk factors that are stated for cannabis dependence are those as follows: (1) mood disorders (2) residing in neighborhoods with greater magnitudes of daily users; and (3) having a history of alcohol use disorder." (Roffman and Stephens, 2006) Health consequences of cannabis dependence stated to be "based on studies with heavy users rather than with the more specific population of those who are cannabis dependent." (Ibid) Some of the health risks mentioned are the increased risk of "chronic bronchitis and histopathological changes in the respiratory system that may precede malignancy....risk for infection diseases such as pneumonia." (Ibid) There is existing research that "supports the existence of cognitive impairment (attention; memory; and impaired verbal learning, retention and retrieval) in long-term cannabis users." (Ibid) Use of cannabis at an early age has been shown to be associated with "earlier withdrawal from school, earlier sexual activity, pregnancy during adolescence, unemployment, and leaving the family home early." (Ibid) Furthermore studies have shown that adolescents "who smoke cannabis heavily appear to be at increased risk of using 'harder drugs'. (Ibid) Roffman and Stephens state that "Subgroups of cannabis-dependent persons at increased health risk include: (1) adults with cardiovascular disease who may precipitate myocardial infarctions by smoking cannabis; (2) adolescents whose school performance and psychosocial development may be adversely affected and who may be at increased risk of using other illicit drugs; (3) persons with schizophrenia and other psychoses whose illnesses may be exacerbated by continued use of cannabis; and (4) persons with a family history of psychoses in whom regular cannabis use may precipitate the onset of a psychosis." (Roffman & Stephens, 2006) Motivational enhancement therapy (MET) and cognitive-behavioral therapy (CBT) have received the most attention from research and "have often been combined with MET strategies used in early sessions and CBT strategies in later sessions." (Ibid) According to Roffman & Stephens (2006) little evidence exists "that either MET or CBT is superior to the other..." (Ibid) in fact, both of these treatment formats are "effective in either group or individual formats." (Ibid) While contingency management (CM) "involving the delivery of monetary incentives for urine-verified abstinence, showed promise in increasing rates of continuous abstinence during treatment" (Ibid) in the "longer-term outcomes after the incentives are discontinued" the outcomes are not know as of yet. It is reported in the work of Roffman & Stephens (2006) that the two sessions MET intervention" resulted in a greater reduction in the frequency of cannabis use during the follow-up period compared to control conditions." (Ibid)

The work of Drummond, Cooper, Glautier (199) reports that "Wikler (1965) proposed a model of relapse of drug use in abstinent opiate addicts which has inspired an era of research into the effects of environmental stimuli (or cues) on drug taking behavior. He suggested that environmental cues associated with drug withdrawal come to elicit conditioned withdrawal-like responses which precipitate further drug use in the abstinent addict. He also suggested that these conditioned responses (CR) remain unaltered by conventional addiction treatment."

In the work of Ludwig, Wikler & Start (1974) the exploration of the "effects of exposure to alcohol related cues in Alcoholics" was explored and it was concluded that: "Obviously any therapeutic approach, whether it be insight, behaviorally or pharmacologically oriented, that does not recognize the powerful, evocative effects of interceptive and exteroceptive stimuli, and that neglects to provide techniques for modifying the strength of these effects will likely be destined for failure." (p.547) (Drummond, Cooper & Glautier, 1990)

Drummond, Cooper & Glautier (1990) further relate that Wikler (1965) asserted "the importance of conditioned responses to environmental stimuli in the process of relapse..." This was "based on the observation that heroin addicts tended to return to drug use even after months of abstinence when exposed to an environment in which drug use had previously taken place. This appeared to be due to the re-emergence of withdrawal symptoms which could not be attributed to elimination of the drug from the body. He suggested that formerly neutral environmental stimuli become associated with the unconditioned stimulus (UCS) of a declining drug plasma level which leads to the unconditioned response of withdrawal symptoms (UCR the environmental stimuli become conditioned stimuli which, when presented in the absence of the UCS invoke a conditioned withdrawal response (CR). According to this model, the connection between a conditioned withdrawal response and relapse is that drug is motivated by the relief or avoidance of withdrawal symptoms which are aversive in nature. In effect, aversive CRs to ARCs act discriminative stimuli (SCs) for operant drinking behavior." (Drummond, Cooper, & Glautier, 1990) the theory of Baker, Morse & Sherman (1987) states that "two distinct, mutually inhibitory neural networks which are responsible for the motivation of drug taking behavior and hence relapse which are agnostic and antagonistic responses to drug cues" resulting in relapse. (Ibid)

The work of Kamon, Budney and Stanger entitled: "A Contingency Management Intervention for Adolescent Marijuana Abuse and Conduct Problems" states that: "Marijuana remains the most prevalent illicit substance used by adolescents (Substance Abuse Mental Health Services Administration, 2000) Adolescents who use marijuana regularly are also at risk of experiencing delinquency, school failure, physical and psychological problems and selling illegal drugs (Dennis et al., 1999) the number of adolescents receiving treatment at publicly funded treatment centers for marijuana abuse or dependence doubled from 1992 to 2000, and the majority of all adolescent substance abuse admission report marijuana as their primary substance (Substance Abuse Mental Health Services Administration 2000)." (2005) the objective of the work of Kamon, Budney and Stanger is "to describe an innovative treatment for adolescent marijuana abuse and provide initial information about its feasibility, acceptability, and potential efficacy." (2005) the method utilized was an intervention which was comprised of: "(1) a clinic-administered, abstinence-based incentive program; (2) parent-directed contingency management targeting substance use and conduct problems; (3) a clinic-administered incentive program for parent participation; and (4) individual cognitive-behavioral therapy for adolescents." (Ibid) the data were presented for those aged 15-18 totaling 19 adolescents. The method of substance use, psychopathology, and parenting are stated to have been collected both prior to and following the treatment period lasting 14 weeks. Kamon, Budney and Stanger state that the "presence of childhood conduct problems" is stated by Brook et al. (1995) to be a "major risk factor for adolescent substance abuse." (2005) Additionally stated is that even though there is a need that is only growing to treatment of adolescent substance abuse "little consensus exists on how to best treat this clinical population."..however there is a growing amount of literature that has been reviewed that gives indication that "adolescents in treatment have better outcomes than adolescents not in treatment and suggest that family-based interventions hold much promise (Waldron, 1997; Williams et al., 2000)" (Kamon Budney, and Stanger, 2005) Stated is that Contingency Management interventions have been used in only two prior studies in connection with adolescent substance users (Azrin et al., 1994; Corby et al., 2000) in both studies, a significantly higher percentage of adolescents were abstinent during CM implementation compared with control conditions." (Kamon, Budney and Stanger, 2005) Kamon, Budney and Stanger (2005) state that their."..multicomponent model expands on these initial CM efficacy demonstrations." (2005) Three factors were considered in order to "create a developmentally appropriate CM intervention." Stated is: "First, adolescents rarely seek treatment on their own but instead are brought to treatment by their parents. Oftentimes, adolescents do not perceive their substance use as problematic and therefore are rarely motivated to quit use or remain abstinent (Dennis et al., 2000). Second, parents are likely to consider their adolescent's marijuana use as problematic and are usually motivated to take action. However, they may not have the skills to effectively change their adolescent's behavior. Third, conduct problems often predate and co-occur with adolescent substance abuse (Lynskey and Fergusson, 1995), suggesting that targeting conduct problems might enhance outcomes in treatment for substance abuse. Our model integrates four empirically based interventions designed to address these issues. First, an abstinence-based reinforcement intervention (voucher program) is used to enhance motivation to engage in treatment and engender marijuana and other drug abstinence.

Monetary-based incentives are provided by the clinic for abstinence documented by urine and breath testing (Budney and Higgins, 1998). Second, a parent-directed CM program is employed to further motivate initiation and maintenance of drug abstinence and to better manage other related behavior problems. The family management (FM) curriculum from the Adolescent Transitions Program teaches parents basic principles and skills to decrease problem behaviors and increase pro-social behaviors (Dishion and Kavanagh, 2003). Because parent compliance with FM treatment has a positive impact on treatment outcome (Nye et al., 1995), the third component of this model uses CM to motivate parent participation. Here, parents earn chances to win prizes for actively participating in each treatment component (Fishbowl procedure: Petry et al., 2000). Last, adolescents receive individual therapy to enhance motivation and provide coping skills training focused on achieving and maintaining abstinence (motivational enhancement therapy and cognitive behavioral therapy (MET/CBT12) (Sample and Kadden, 2001; Webb et al., 2001). In summary, the combination of the individual therapy, voucher program, FM curriculum, and incentives for parent participation is designed to increase adolescents' motivation to achieve and maintain abstinence, parents' abilities to use effective parenting to decrease substance use and other behavior problems, and adolescents' coping skills to help them adapt to a substance-free lifestyle." (Kamon, Budney & Stanger, 2005) According to the article which was published in the June 2005 journal of American Academy of Child Adolescent Psychiatry there is an ongoing "randomized clinical trail..." which examines the "efficacy of this treatment." (Ibid) the following chart labeled Figure 1 shows the participant demographics in the study of Kamon, Budney and Stanger (2005)

Participant Demographics in Adolescent Study

Source: Kamon, Budney & Stanger (2005)

Kamon, Budney & Stanger (2005) report that: "Approximately three fourths of adolescents were abstinent from marijuana by treatment end compared with one third who provided a marijuana-negative specimen at intake. Similarly three fourths of youths reported no alcohol use during the last month of treatment compared with one half who reported no use during the month before intake. The majority of adolescents were still abstinent 30 days post-treatment. Although no control group was available for comparison, such findings suggest that this CM model offers promise to enhance treatment outcomes." Concordant with previous reports (Dennis et al., 2004; Liddle et al., 2001; Waldron et al., 2001), the majority of adolescents displayed significant externalizing problems, suggesting that interventions that specifically target conduct problems appear warranted. Parent reports on the CBCL indicated decreases in externalizing problems over the course of treatment, providing preliminary support for the use of FM treatment in adolescent substance abuse treatment. In addition, parent reports on the Alabama Parenting Questionnaire indicated significant improvement in their ability to monitor their adolescent's activities and use consistent forms of discipline. Previous family-based clinical trials targeting adolescent substance use have reported mixed results in reducing conduct problems (Liddle et al., 2001; Waldron et al., 2001). In two studies of multidimensional family therapy, parenting practices were found to significantly improve (Liddle et al., 2001; Schmidt et al., 1996). Also concordant with previous research, a significant number of adolescents experienced internalizing problems according to parent reports (Dennis et al., 2004; Waldron et al., 2001). Therapists provided case management (i.e., provided professional referrals) to help address problems not directly targeted in treatment including depression and anxiety. Although the MET/CBT12 curriculum contains content designed to address cognitions and behaviors associated with internalizing symptoms, this CM model did not attempt to specifically address internalizing symptoms. Including a component that specifically targets depression and anxiety might further enhance outcomes. This seems especially important in light of a recent review indicating that regular marijuana use is related to subsequent internalizing problems (Rey et al., 2004). A pilot study of a family-based CBT program designed to target substance use and depression demonstrated success in reducing rates of both problems (Curry et al., 2003). Stated limitations include the small number of cases without a control condition for comparison participation required a pretreatment acknowledgement that a parent would participate each week. Hence, results generalize only to adolescents who meet such treatment conditions participating adolescents were primarily white, had two-parent participation, had parents with relatively high levels of education, lived in small metropolitan or rural communities, and reported marijuana as their primary drug of use therapists provided case management, referring families to community providers for problems not directly addressed in this treatment model. Consequently, it may be that changes in adolescent substance use and other psychopathology were due in part to successful treatment of co-morbid disorders." (Kamon, Budney & Stanger, 2005)

In the work entitled: "A Clinician's Guide for Implementing Contingency Management Programs" Nancy M. Petry at the Department of Psychiatry at the University of Connecticut School of Medicine provides the needed steps in implementation of a CM Program. The first step is the design of the CM procedure is to "decide upon a behavior that can be quantified objectively. In other words, if you want to reinforce drug abstinence, you need to use drug screening procedures and not clients' CM procedures can be designed for an individual client, they can be developed for use with specific populations, or they can be implemented clinic wide. For example, an individualized CM approach can be designed for a client who is having specific problems with drug use, or a client who is failing to take the necessary steps to resolve his or her employment issues. CM procedures can also be applied with specific subpopulations within in a clinic. So, for example, cocaine-dependent methadone patients may be designated to receive the CM procedures. If a problem is clinic wide, such as lack of on-time attendance at group therapy, a procedure can be designed to address this issue among all clients." (n.d.) Engagement and retention is the second area of focus listed by Petry in the CM procedure design and implementation. Petry states: "CM procedures that provide positive rewards retain clients in treatment for longer periods than does counseling alone. For example, some studies have shown that provision of a small restaurant gift certificate can enhance therapy attendance in dual diagnosis clients. Other studies in methadone clinics find that take-home doses can be used to reinforce attendance at therapy sessions. Still other studies have found that providing a "dollar a day" encouraged attendance in group therapy for teenage mothers. CM procedures can also be used to enhance initial engagement in treatment. In a demonstration project at an HIV drop-in center in which group therapy sessions were poorly attended, we provided the opportunity to win prizes (ranging from $1 items such as bus token and toiletries to $100 items such as televisions and VCRs) contingent upon coming to groups. Average attendance at group sessions rose from less than one client prior to the introduction of the prizes to over 7 clients per session during the prize phases. If you provide tangible positive incentives for attendance, you are likely to enhance retention in your programs. Many community-based programs that work with voluntary clients have significant problems with treatment retention, and attrition rates, especially in the early phases of treatment, are very high. Some programs already have procedures in place for management of early attrition, and you are probably already familiar with use of some incentives for therapy engagement. For example, in 12-Step meetings and at many community-based programs, clients are provided with free coffee and donuts when they come. Social support and praise from therapists and other group members may also reinforce attendance at sessions. By systematically applying CM principles, you may be able to better garner beneficial effects of these rewards to positively impact your clients." (n.d.) Next listed by Petry in the CM procedure design and implementation is 'Drug Use'. Petry states that: "CM procedures are effective in reducing use of a variety of different drugs. For example, in one study with cocaine dependent outpatients (Higgins et al., 1994), 55% of clients who received behavior therapy plus vouchers for submitting urine samples negative for cocaine achieved at least 2 months of continuous cocaine abstinence. Only 15% of clients who received the same behavior therapy, but who did not get the vouchers, maintained this period of abstinence. Other studies have demonstrated beneficial effects of vouchers and other reinforcers in reducing use of opioids, marijuana, benzodiazepines, nicotine, and alcohol (see Petry, 2000 for review). Reinforcing drug abstinence is a seemingly straightforward procedure that can be introduced into clinics. Most clinics screen urine specimens as part of standard treatment, so you are probably already somewhat familiar with this process. However, urine samples often are sent to outside laboratories or hospitals for screening. This practice can hinder application of CM procedures because the results are often not obtained until several days later. To best reinforce submission of negative samples, you want to provide the reward immediately upon demonstration of the behavior. Just like in the previous example of reinforcing therapy attendance, you don't want to wait 2-3 days before you give the client the token." (Petry, n.d.) the reinforcement of urine specimens according to Petry, "presents some practical difficulties" in that "Onsite testing systems cost about $2 per testing reagent, and using multiple screens (opioids, cocaine and marijuana) increases cost. Submission of urine specimens must be observed by a staff member to ensure validity, but even when submission is observed directly, clients may still try to leave bogus samples. Checking temperature, dilution, and pH can assist in ensuring validity of samples. Some validity test sticks are also available, at a cost of about $1 each." (n.d) Other problems are technical problems such as "many different types of benzodiazepines exist, complicating the detection of all forms of sedative use. Some drugs, such as methadone and benzodiazepines, are frequently prescribed as well as taken illicitly, and differentiating licit from illicit use is difficult. Liver disease may result in increased lag time between abstinence and negative readings. For clients with chronic marijuana use, up to four weeks of abstinence must be achieved prior to urine specimens reading negative. Thus, marijuana abusing clients cannot be reinforced for their efforts at abstinence until a substantial drug-free period has been attained." (n.d.) Petry further relates that the detection of alcohol and nicotine use "suffers from the opposite problem. Breath alcohol readings can assess alcohol use only over short intervals (e.g., 1-12 hours). Thus, breathalyzer readings should be taken several times a day to detect any use of alcohol, and clearly such a testing schedule is impractical in outpatient settings. Although urine and blood alcohol tests are available, they do not measure back much further than breath tests. Carbon monoxide readings must also be taken several times daily to detect smoking. When designing CM interventions, the manufactures' specifications regarding the test's sensitivity should be reviewed with the goal that you want to be able to detect all instances of drug use and to reinforce days of drug abstinence." (n.d.) There is also a the potentiality of a problem of a philosophical nature according to Petry who states that: "Most clinical programs strongly endorse abstinence from all drugs of abuse, and clinicians' initial instincts are to reward patients only when they demonstrate complete abstinence. A review of CM studies (Griffiths et al., 2000), however, finds that beneficial effects of the interventions are less likely to be achieved when clients are required to be abstinent from multiple substances to earn rewards. Clients may not be motivated or able to achieve complete abstinence early in treatment. Targeting just a single drug at a time is a better strategy because clients may achieve initial success, which in turn may promote further motivation to abstain from the primary as well as secondary drug(s). Most CM studies that target abstinence from just a single drug find reductions in other drug use as well." (n.d.) Summarizing, Petry states that in the design of a CM procedure that will reward abstinence from drugs that "first you should pick a single drug on which the rewards will be contingent. Drug use or abstinence should be monitored in such a manner to detect all instances of use, and all days of abstinence. For most illicit drugs, this will require a minimum of twice weekly urine monitoring, and in the initial stages of treatment thrice weekly testing is recommended. For each negative sample submitted, the client should be provided immediately with the designated reward. When a missed sample or a positive sample is provided, the reward should be withdrawn. If escalating systems are in place (see section 3F), the next sample that is submitted would result in a reset to the original amount of reward ($2 voucher, 1 token etc.). A full description of escalating reinforcement systems can be found in a publication by Budney and Higgins (1998). If you follow these guidelines, it is likely that you may be able to enhance abstinence rates among your clients." (n.d.) Next listed by Petry in the design and implementation of the CM procedure is the category of 'Goal-related behaviors'. Petry states that: In addition to their substance use, substance abusing clients have other troubles, including psychiatric disorders, interpersonal difficulties, and legal and employment problems. Growing evidence suggests CM procedures may be adapted to address these other problems as well. In some studies, therapists reinforced compliance with steps toward treatment goals. For example, clients decide upon three discrete activities each week that are related to their treatment goals. These can include attending a medical appointment if the goal is to improve health, going to the library with their child if the goal is to improve parenting, or filling out a job application if the goal is to obtain employment. If clients successfully accomplish these activities and provide objective verification of their completion via receipts, they receive the identified reinforcers. Activities are individually tailored to clients' level of psychosocial functioning. Thus, relatively simple activities can be assigned, thereby increasing the likelihood of successful completion and reinforcement. Reinforcing activity completion may be a procedure well-suited to standard clinical practice. Most therapy sessions focus on long-term treatment goals and steps toward those goals. Reinforcing activity completion may improve the therapeutic alliance, as therapists work collaboratively with clients to decide upon tasks that can be accomplished. Activity assignments also are relatively inexpensive. The only cost is therapist time, which runs about 15 minutes per week for activity verification and setting once the client learns the procedure. Activity reinforcement may improve psychosocial functioning as well." (n.d.) First a needs assessment will be conducted with the client's status currently as related to "housing, transportation, employment, family and social relationships, legal problems, medical and psychiatric issues and recreational activities." (n.d.) Petry relates that the client must choose between two and three major goals which they will focus upon. Next listed in the category of 'Within Clinic Behaviors" which will be modified through use of the CM procedure. Petry states: "Clinics generally have methods for handling such behaviors, but the procedures often are punitive in nature, consisting of disciplinary meetings or discharge. Another approach is to positively reinforce appropriate clinic behaviors. Providing clients with a sticker and a chance of winning $25 for engaging in appropriate behaviors (saying hello, waiting patiently) improved verbal behaviors in one study. In an inpatient setting for dual diagnosis patients, another program found that increased freedoms (phone calls, smoking breaks, outside passes) could be used to reinforce therapy attendance, homework compliance, and clinic behavior. Such techniques may improve staff ability to positively manage clients and create a more pleasant atmosphere for recovery. If you wish to develop such techniques, first you need to decide upon the exact clinic behaviors you want to alter. These may include arriving at group on time, saying hello, thank you etc., conversations that do not involve swearing and discussion of drugs, or not loitering in the parking lots. Monitoring schedules then need to be developed to "catch" clients doing what you want them to be doing. So, you should check parking lots or the waiting rooms frequently (every 15 minutes), and provide reinforcement whenever the appropriate behaviors are occurring. When inappropriate behaviors are noted, simply no rewards are provided. Thus, CM procedures can be applied to reinforce many behaviors, ranging from attendance to drug abstinence, compliance with goal related activities and within clinic behaviors. Once you have decided upon the behavior you wish to alter, you need to select a reinforcer to use. A variety of reinforcers can be used in CM approaches, some of which are commonly used in, or readily adaptable to, standard clinic settings. You can select reinforcers based on availability and practicality at your own site." (n.d.) Petry states that vouchers or cash may be used however that one advantage of vouchers is that "it allows for individual preference and clients can spend their vouchers on virtually any item." (n.d) Limitations include that the voucher programs are "expensive to employ and mange." (n.d) Petry relates that "providing cash may be less expensive than vouchers because staff time is not needed to purchase items." (n.d.)

McRae, Budney, and Brady (2003) in the work entitled; "Treatment of Marijuana Dependence: A Review of the Literature": state that: "Marijuana dependence continues to be a significant problem. Cognitive behavioral, motivational enhancement and contingency management therapies have each been demonstrated to be efficacious for reducing marijuana use in the limited number of studies conducted to date. Several studies have failed to demonstrate differences in outcome between brief interventions and more intensive CBT interventions; however the most recent and largest controlled trial, the Marijuana Treatment Project, found an extended CBT intervention to be more effective than brief motivational therapy." (2003) the study relating to contingency management treatments is stated to "suggest that such approaches are likely to be effective when used in combination with more traditional psychotherapies and may enhance outcomes when combined with other approaches." (McRae, Budney, & Brady, 2003) Further stated in this work is that: "Important methodological differences across the studies leave many questions regarding comparative efficacy unanswered. Studies differed in diagnostic criteria used, length of treatment and follow-up, ethnic diversity of the study population, mode of treatment delivery, and the use of urine drug screens to verify marijuana abstinence." (2003) McRae, Budney and Brady (2002) point out that "Clinical research on pharmacotherapies for marijuana dependence is just in its infancy. Potential appears to exist for antidepressant and anxiolytic medications to be useful in the treatment of marijuana dependence.However, controlled studies are necessary before any conclusions to be useful in the treatment of marijuana dependence. However, controlled studies are necessary before any conclusions or recommendations can be made. Agents targeting the cannabinoid receptors may also prove useful, but again have not been explored." (2003) Finally stated is: "Although the marijuana treatment literature is young and few studies have been published, the trends across this literature suggest that the types of treatments effective with other substances of abuse are likely to be effective with marijuana dependence. The magnitude of the treatment response might also be similar to that observed with other drug dependence treatments. Unfortunately, this means that there are many individuals who do not do well with these therapies. As marijuana abuse and dependence becomes better recognized as a significant public health concern, hopefully more research will be focused on the development of effective treatments for this disorder." (McRae, Budney, and Brady, 2003)

The work of Sinha et al. (2003) entitled: "Engaging Young Probation-Referred Marijuana-Abusing Individual in Treatment; a Pilot Trial" states that: "Young marijuana abusers rarely seek treatment themselves and are difficult to engage in treatment when referred by social agencies. To evaluate treatment engagement strategies in this population, 65 young probation-referred marijuana abusers were randomly assigned to either three-session motivational enhancement therapy (MET alone) or three-session MET plus contingency management (MET/CM), with vouchers for treatment attendance. A significantly higher number of participants in the MET/CM condition completed the three-session intervention as compared with MET alone. Participants in both conditions reported significant reductions in marijuana use and improvement in legal problems. These findings suggest that young marijuana abusers benefit from scientifically validated treatments."

The work of Jones et al. (2000) entitled: "Improving Treatment Outcomes for Pregnant Drug-Dependent Women Using Low-Magnitude Voucher Incentives" published in the Journal of Addictive Behavior states that the objective of the study was the examination of the "effectiveness of low-magnitude behavioral incentives in improving attendance for abstinence-treated patients and sustaining illicit drug abstinence" in patients. Stated is that "one method for improving treatment outcomes involves the use of contingency management. Behavioral incentives in the form of vouchers have successfully promoted drug abstinence and treatment attendance (e.g., Silverman, Chutape, Bigelow, & Stitzer, 1996) in male and nonpregnant populations, however their effectiveness in pregnant women is less established." (Jones et al. 2000) the study results state that "low-magnitude voucher incentives enhanced treatment attendance by methadone treated subjects. Although modest monetary incentives had some utility in improving attendance in methadone-treated patients, more potent interventions are needed to improve attendance and maintain abstinence in this high-risk population. (Jones et al. 2000)

UPDA-NIDA News reports that the values of vouchers may not be as important as the timing of these vouchers stating that "During contingency management (CM) treatment, drug abusers are given vouchers for goods and services when they refrain from using drugs for a given amount of time. With sustained abstinence, the value of the vouchers is increased. With sustain abstinence, the value of the vouchers is increased. Earlier research showed that this escalation in voucher values helped maintain abstinence, but when only fixed-value vouchers were given for abstinence, sustained, continuous abstinence appeared to decrease. In some CM programs, the length of time abusers are required to abstain from drug use to receive a voucher also may increase at certain intervals. NIDA-funded researchers have found that although CM remained effective when vouchers values became fixed, effectiveness was reduced when abusers were required to abstain from drug use for longer period before receiving a voucher." (Zhang, 2003) Yale University school of Medicine's Dr. Thomas Kosten and colleagues recruited 75 participants who abused cocaine and heroin at the same time for a 24-week study. Findings from the study "suggest that to sustain the effects of CM, treatment programs need to focus on both broader psychosocial changes and reduction in drug use. Vouchers alone are not enough to maintain abstinence during treatment. " (Zhang, 2003) the NIDA-funded research states further findings that "treatment for up to 18 months in residential settings, or almost 14 months in outpatient nonmethadone treatment, yielded the greatest reduction in illicit drug use. Both overall and primary drug use declined after 18 months in long-term residential programs, at which point peak use measured about one-tenth the pretreatment level. After 18 months in this setting, the amount of improvement began to wane." (Zhang, 2003) the NIDA report also relates that 2,005 patients were treated for cocaine, heroin, and marijuana addiction in 62 participating drug treatment units in the United States. Evaluation was conducted at admission, discharge and one year after the therapy came to an end during the years of 1993 to 1995. Findings state that "no significant relationship between duration and overall drug use improvement for individuals in methadone maintenance and short-term residential programs." (Zhang, 2003) the report states that what this means is: "Remaining in treatment for an extended time has beneficial outcomes for people in residential or outpatient drug treatment programs. Insurers may consider changing their policies to include a longer length of stay so people can be more effectively treated for their addictions." (Zhang, 2003)

The work of Wong and Svikis entitled: "Effects of Reinforcer Magnitude on Data-Entry Productivity in Chronically Unemployed Drug Abusers Participating in Therapeutic Workplace. states that "Chronic unemployment is a common problem among individuals with long histories of drug abuse. Unemployment rates among methadone maintenance patients have been estimated to be 50% to 80% (French, Dennis, McDougal, Karuntzos & Hubbard, 1992) it is not surprising that unemployment among drug abusers has been shown to be associated with continued drug use, poor treatment outcome, and criminal activity (Platt, 1995)" (2003) Further stated is that "A limited number of studies have evaluated employment interventions for chronic drug users." (2003) Wong and Svikis relate that the quick entry programs have shown only limited success in treating drug abusers. The work of Hall, Loeb, Coyne, & Cooper (1981) along with Hall Loeb, Levois & Cooper 1981; and Kidorf, Hollanders, King & Brooner, 1998; and Zanis, Coviello, Alterman, & Appling (2001) all emphasize that search for employment and initiatives for job placement should match the participants current level of skill. The quick entry programs generally only show that between 52% and 86% of those participating actually secure work. Although there has not been evaluation of the long-term employment outcomes those studies which have been conducted "suggest that work is not often sustained after an intervention has been discontinued." (Wong and Svikis, 2003) the work reports that a voucher and vacation payment system was analyzed in which "participants earned the majority of their voucher earnings in base pay vouchers that were contingent on abstinence and workplace attendance. Participants received a base pay voucher each day that they completed a work shift (i.e. If they arrived within 15 minutes of the start of work and remained in the workplace for 130 minutes as determined by the time clock) " (Ibid) the base pay vouchers were earned by the participants "according to a schedule of escalating reinforcement for sustained behavior. " (Ibid) There were increases provided for the vouchers and setbacks in the form of reductions if the participant "either provided a drug-positive urine sample, or failed to work a complete work shift on a scheduled workday.' (Ibid) Results of the study state that all participants except for two "maintained continuous abstinence throughout the study." (Ibid) Wong and Svikis states that: "Results from this study demonstrate the effectiveness of a voucher-based reinforcement system in increasing productivity by chronically unemployed substance abuse patients..." (Wong & Svikis, 2003)

Offer a short review of any and all CRA studies that incorporate CM in an attempt to modify social behaviors in an attempt to modify alcohol and/or marijuana use.

Discuss how these findings can further inform the field of addictions research.