Contingency management in alcohol and marijuana studies

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

Background of the Study

The work entitled "Pathways of Addiction: Opportunities in Drug Abuse Research" (1996) published by the Institute of Medicine (IOM) states that "A major contribution of behavioral research has been an understanding of the ways in which basic principles of learning and conditioning can be used to modify drug-taking behavior. These principles have been precisely defined so that they can be studied and replicated across conditions and species. For example, research on drug effect expectancies suggests that learned beliefs and attitudes may serve as risk factors for the initiation and use of drugs (Brown, 1993). Further, epidemiological research has pointed to the importance of social modeling and attitudes as having strong impacts on drug use and abuse. Research on learning and conditioning has led to successful treatment models for drug abusers, including relapse prevention, community reinforcement, and focused techniques such as extinction training, relaxation training, contingency management, and job skills training. Two well-studied behavioral interventions are discussed below: contingency management and relapse prevention." (1996) it is additionally stated that: "Contingency management research is based on the fact that, although drugs are potent reinforcers, there are non-drug reinforcers that can compete with drug use (see discussion of behavioral economics, below). Manipulation of the environment can shift the focus toward or away from drug reinforcers (e.g., Azrin et al., 1966; Barrett and Witkin, 1986). In the laboratory, monkeys will choose saccharine over phencyclidine if they are required to work substantially harder for the drug (Carroll and Rodefer, 1993)" (IOM, 1996)

Stitzer and Petry (2006) in the work entitled: "Contingency Management for Treatment of Substance Abuse" published in the Annual Review of Psychology state that: "Clinical research trials demonstrate the efficacy of contingency management procedures in treating substance use disorders. Usually, reinforcement, in the form of vouchers exchangeable for retail goods and services, is provided for drug abstinence in patients treated in psychosocial or methadone maintenance clinics. Recently, the types of reinforcers have been adapted to include lower cost alternatives, and reinforcement is being expanded to alter other target behaviors such as attendance at treatment, adherence to treatment goals, and compliance with medication."

The work of Kirby and Bickel (1995) entitled: "Implications of Behavioral Pharmacology Research for Applied Behavior Analyses: Jeab's Special Issue Celebrating the Contributions of Joseph V. Brady" states that: "Kelly et al. And other studies assessing the reinforcing effects of drugs (e.g., Chait & Zacny, 1992; Foltin & Fischman, 1992) have indicated that multiple dependent measures are necessary for a more complete understanding of a drug's function. The importance of this methodological consideration is underscored by understanding that assessment of a drug's reinforcing effects predicts its abuse liability, and this, in turn, can influence regulation and availability of new medication agents. If Kelly et al.'s data represented the results of an abuse liability assessment of a new medication, and number of self- administrations taken was the only dependent measure examined, one might conclude that the medication was unlikely to be abused. However, if drug choice and ratings of drug liking had been the only dependent measures collected, one could conclude that the medication had a high abuse potential. Abuse liability assessment research has only recently begun to appreciate the complex relations among different operant and to investigate their implications. Although assessment of abuse liability is a socially relevant application of multiple operant methodology, there are many nonpharmacological applications of equal social relevance." (1995) Additionally stated by Kirby and Bickel is: "DeGrandpre et al. studied the effects of different response requirements on two operants: self-administration of cigarette puffs and self-administration of money. The response requirement for these operants was also manipulated by systematically varying the fixed- ratio (FR) schedule for one operant (FR 100, FR 1,000, and FR 2,500) while keeping the schedule for the other operant stable (FR 100). Increasing the FR size for either operant decreased its consumption, with a greater decrease occurring for money. The effects of FR size also differed across the two operants. Although greater responding occurred for money at the lowest ratio employed, increases in FR size decreased responding for money and increased responding for cigarette puffs such that at the higher ratios examined, greater responding occurred for cigarette puffs. Finally, increasing the FR size for one reinforcer had little effect on the consumption of the other concurrently available reinforcer. This study has two important implications for applied research. First, it demonstrates the need to examine responding maintained in multiple contexts. If the two reinforcers employed in this study were examined only at the lowest ratio, one might conclude that money was a more potent reinforcer than cigarette puffs. However, the opposite conclusion would be reached if they were examined only at the higher ratio. As a concrete applied example, imagine that during the early spring, a manager determines that the employees on the loading dock maintain higher work rates when offered financial bonuses contingent on work rate than when offered time off. The manager implements bonuses as a standard procedure for reinforcing high work rates. This procedure works well until summer arrives and the temperature and humidity on the loading dock climb. Now the response cost of the work has increased and the financial bonuses do not seem to be working as well. In this new context, time off may serve as the more effective reinforcer for maintaining higher work rates. Besides evaluating the relative efficacy of reinforcers in different contexts, the procedure used by DeGrandpre et al. provides a useful context for evaluating interactions between concurrently available reinforcers. Such analysis may, for example, have some utility for studying treatments of drug dependence that engage patients in alternative activities to drug use (e.g., Higgins et al., 1993)." (1995) Kirby and Bickel (1995) state that "During discrimination training, subjects were administered 30 mg of d-amphetamine or placebo and told that they could earn extra money by pressing the green lever if they received Drug a (d-amphetamine) or by pressing the red lever if they did not receive Drug a. In addition to this nonverbal operant, subject report measures were collected before and after drug administration. These measures were computer administered and involved a well-established questionnaire (Addiction Research Center Inventory, ARCI) asking the subjects whether or not they were experiencing specific drug effects that have been found to be associated with different drug classes; having subject rate effects such as drug liking, good drug effects, bad drug effects, and drug strength on analogue rating scales; asking subject to identify the drug received as most like one of 14 different drugs, and having them indicate which of 14 drug effects they were experiencing." (1995)

The authors state: "The amphetamines occasioned dose-related increases in d- amphetamine-appropriate responding, whereas hydromorphone did not. Amphetamines also occasioned dose-related increases in reports of the drug being most like "speed," whereas hydromorphone did not. However, both amphetamines and hydromorphone occasioned dose-related increases in reports of drug liking and in three scales of the ARCI. Thus, some self-report measures were well correlated with responding on the drug-appropriate lever and some were not. Lamb and Henningfield (1994) suggest that self-reports are complexly controlled by both the private event and the subject's history of experience with the drug. Some of the self-reports they observed (e.g., feels like speed) are probably occasioned by a relatively narrow range of stimuli because in the subject's experience with drug administration, these reports have been more selectively reinforced by the verbal community relative to other reports (e.g., drug liking). They also suggest that these results imply that private events do not necessarily mediate drug-produced reinforcement, because some reports of private events (e.g., feels like speed) correlate better with the nonverbal operant studied than do those that are assumed to mediate reinforcement (e.g., drug liking). Although this is an interesting speculation, their subjects provided these self-reports in the context of a discrimination task rather than under conditions of a self-administration study that would allow examination of reinforcing functions of the drugs. However, whether stimulant identification mediates discriminative responding or whether both the identification and discriminative responding occur independently as a result of drug discrimination remains to be determined. Nonetheless, Lamb and Henningfield's inclusion of self-report measures and examination of their relation to nonverbal operants provide excellent examples of ways to examine and conceptualize relations among private events, verbal responding, and nonverbal responding." (Ibid)

The work of Drummond, Cooper & Glautier entitled: "Conditioned Learning in Alcohol Dependence: Implications for Cue Exposure Treatment" is a "review of the literature pertinent to cue exposure treatment in alcohol dependence." (1990) This work further evaluates the models of relapse, based on conditioning and social learning theories. He also suggested that these conditioned responses (CRs) remain unaltered by conventional addiction treatment. A later study by Ludwig, Wikler & Stark (1974) which explored the effects of exposure to alcohol related cues (ARCs) in alcoholics, went further by concluding: "Obviously any therapeutic approach, whether it be insight, behaviorally or pharmacologically orientated, that does not recognize the powerful, evocative effects of interoceptive 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) According to Drummond, Cooper & Glautier (1990) While there have been those who have questioned CRs important in treatment and specifically in the relapse of individuals in treatment, "The technique of cue exposure, originally described in relation to the treatment of cat phobia (Freeman & Kendrick, 1960), has gained considerable popularity in the treatment of both phobic and obsessive-compulsive neurosis (Marks, Hodgson & Rachman, 1975), Drummond, Cooper & Glautier (1990) do state however, that "In comparison to the neuroses, however, we argue that no study has so far demonstrated that cue exposure has any influence on the clinical outcome in either alcohol or drug dependence." (Ibid) More recently cue exposure has been applied to the treatment of alcohol and drug dependence (Blakey & Baker, 1980; Rankin, Hodgson & Stockwell, 1983; Laberg & Euertsen, 1987; McLellan et al., 1986) and owes much to this and Wikler's early pioneering work." (1990) According to Wikler's model "the connection between a conditioned withdrawal response and relapse is that the drug is motivated by the relief or avoidance of withdrawal symptoms which are aversive in nature. In effect aversive CRs to ARCs act as discriminative stimuli (SDs) for operant drinking behavior." (Drummond, Cooper, & Glautier, 1990) Related as well is the Siegel (1988) proposed "an alternative explanation of the observed phenomenon of CRs to drug cues..." In which he states the argument that "environmental stimuli which precede drug administration, rather than follow drug withdrawal, come to elicit drug compensatory (or antagonistic) CRs which oppose the unconditional effects of the drug and thus account for the development of tolerance." (Ibid) According to this work what distinguishes the models of Siegel and Wikler "lies in the temporal relationship between the cues and the unconditioned effects of the drug." (Ibid) the authors state however that in actuality it is quite difficult to distinguish the difference "in that drug cues are often present both during withdrawal and for some time after the onset of drug agonist effects when an individual take s a drug whilst experiencing withdrawal." (Ibid)

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.)