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Introduction Understanding how soldiers die after separation from military service, particularly those who die shortly after separating from service, may help to identify opportunities to ease transitions to civilian life. Materials and Methods Mortality data were analyzed for male U.S. Army soldiers who died within 18 months of their separation from service (from 1999 to 2011). Descriptive statistics were calculated for natural, accidental, suicidal, homicidal, undetermined, and legal/operation of war deaths and were stratified by age, component, time in service, and type of discharge. Crude and age-adjusted mortality rates, standardized for all years using the 2004 Regular Army population, were also calculated. The Public Health Review Board of the U.S. Army Public Health Center approved this study as Public Health Practice. Results Of the 1,884,653 male soldiers who separated from service during the study period, 3,819 died within 18 months of separation. A majority of all separations were Reserve or National Guard (58%), and 62% of decedents were in the Reserve or National Guard. Deaths from natural causes (38%) were the most common, followed by accident deaths (34%), suicides (20%), homicides (6%), undetermined deaths (2%), and legal/operation of war deaths ( Conclusions The time period immediately following separation from the Army presents a unique challenge for many soldiers. Developing more effective pre-separation prevention programs that target specific risks requires knowing the causes of death for natural deaths, suicides, and accidents. Over half of all deaths occurring shortly after separation from service are preventable. Continued surveillance of specific causes of preventable deaths following separation can improve pre-separation prevention programs and transitions to post-service care.

The objective of the present study was to determine whether there is an association between pornography use and reported intimate partner violence (IPV) perpetration among a sample of soldiers in the US Army. The study was a secondary analysis of cross-sectional data collected from soldiers at a military installation in 2018 (n = 9,052). IPV was defined as any self-reported perpetration of physical, sexual, or psychological abuse of an intimate partner. Multivariable negative binomial regressions were used to assess the association between pornography use and any lifetime perpetration of IPV, controlling for gender, age group, race/ethnicity, relationship status, educational status, military rank, hazardous drinking, depression, stimulant use, depressant use, and post-traumatic stress disorder. Of the population analyzed, 41% of soldiers reported any pornography use per week, and 9.6% reported perpetrating any form of IPV. Soldiers who reported pornography use had between a 1.72- and 3.56-fold greater likelihood of reporting any lifetime perpetration of IPV, controlling for covariates. Given the prevalence and detrimental effects of IPV, longitudinal studies should be designed to further understand predictors of IPV in military populations.

BackgroundPoverty, unemployment and substance abuse are inter-related problems. This study evaluated the effectiveness of abstinence-contingent wage supplements in promoting drug abstinence and employment in unemployed adults in outpatient treatment for opioid use disorder.MethodsA randomised controlled trial was conducted in Baltimore, MD, from 2014 to 2019. After a 3-month abstinence initiation and training period, participants (n=91) were randomly assigned to a usual care control group that received employment services or to an abstinence-contingent wage supplement group that received employment services plus abstinence-contingent wage supplements. All participants were invited to work with an employment specialist to seek employment in a community job for 12 months. Abstinence-contingent wage supplement participants could earn training stipends for working with the employment specialist and wage supplements for working in a community job, but had to provide opiate and cocaine-negative urine samples to maximise pay.ResultsAbstinence-contingent wage supplement participants provided significantly more opiate and cocaine-negative urine samples than usual care control participants (65% vs 45%; OR=2.29, 95% CI 1.22 to 4.30, p=0.01) during the 12-month intervention. Abstinence-contingent wage supplement participants were significantly more likely to have obtained employment (59% vs 28%; OR=3.88, 95% CI 1.60 to 9.41, p=0.004) and lived out of poverty (61% vs 30%; OR=3.77, 95% CI 1.57 to 9.04, p=0.004) by the end of the 12-month intervention than usual care control participants.ConclusionAbstinence-contingent wage supplements can promote drug abstinence and employment.Trial registration numberClinicalTrials.gov NCT02487745.

The HIV/AIDS epidemic can be eliminated if 73% of people living with HIV take antiretroviral medications and achieve undetectable viral loads. This study assessed the effects of financial incentives in suppressing viral load. People living with HIV with detectable viral loads (N = 102) were randomly assigned to Usual Care or Incentive groups. Incentive participants earned up to $10 per day for 2 years for providing blood samples that showed either reduced or undetectable viral loads. This report presents data on the 1st year after random assignment. Incentive participants provided more (adjusted OR = 15.6, CI 4.2–58.8, p

Aims To review systematically the published literature on extended-release naltrexone (XR-NTX, Vivitrol® ), marketed as a once-per-month injection product to treat opioid use disorder. We addressed the following questions: (1) how successful is induction on XR-NTX; (2) what are adherence rates to XR-NTX; and (3) does XR-NTX decrease opioid use? Factors associated with these outcomes as well as overdose rates were examined. Methods We searched PubMed and used Google Scholar for forward citation searches of peer-reviewed papers from January 2006 to June 2017. Studies that included individuals seeking treatment for opioid use disorder who were offered XR-NTX were included. Results We identified and included 34 studies. Pooled estimates showed that XR-NTX induction success was lower in studies that included individuals that required opioid detoxification [62.6%, 95% confidence interval (CI) = 54.5-70.0%] compared with studies that included individuals already detoxified from opioids (85.0%, 95% CI = 78.0-90.1%); 44.2% (95% CI = 33.1-55.9%) of individuals took all scheduled injections of XR-NTX, which were usually six or fewer. Adherence was higher in prospective investigational studies (i.e. studies conducted in a research context according to a study protocol) compared to retrospective studies of medical records taken from routine care (6-month rates: 46.7%, 95% CI = 34.5-59.2% versus 10.5%, 95% CI = 4.6-22.4%, respectively). Compared with referral to treatment, XR-NTX reduced opioid use in adults under criminal justice supervision and when administered to inmates before release. XR-NTX reduced opioid use compared with placebo in Russian adults, but this effect was confounded by differential retention between study groups. XR-NTX showed similar efficacy to buprenorphine when randomization occurred after detoxification, but was inferior to buprenorphine when randomization occurred prior to detoxification. Conclusions Many individuals intending to start extended-release naltrexone (XR-NTX) do not and most who do start XR-NTX discontinue treatment prematurely, two factors that limit its clinical utility significantly. XR-NTX appears to decrease opioid use but there are few experimental demonstrations of this effect.

Background and aim Extended-release naltrexone (XR-NTX) blocks the effects of opioids for 4weeks; however, starting treatment can be challenging because it requires 7 to 10days of abstinence from all opioids. In the present study we identified patient and treatment characteristics that were associated with successful induction onto XR-NTX. Methods 144 unemployed heroin-dependent adults who had recently undergone opioid detoxification completed self-report measures and behavioral tasks before starting an outpatient XR-NTX induction procedure. Employment-based reinforcement was used to promote opioid abstinence and adherence to oral naltrexone during the induction. Participants were invited to attend a therapeutic workplace where they earned wages for completing jobs skills training. Participants who had used opioids recently were initially invited to attend the workplace for a 7-day washout period. Then those participants were required to provide opioid-negative urine samples and then take scheduled doses of oral naltrexone to work and earn wages. Participants who had not recently used opioids could begin oral naltrexone immediately. After stabilization on oral naltrexone, participants were eligible to receive XR-NTX and were randomized into one of four treatment groups, two of which were offered XR-NTX. Binary and multiple logistic regressions were used to identify characteristics at intake that were associated with successfully completing the XR-NTX induction. Results 58.3% of participants completed the XR-NTX induction. Those who could begin oral naltrexone immediately were more likely to complete the induction than those who could not (79.5% vs. 25.0%). Of 15 characteristics, 2 were independently associated with XR-NTX induction success: legal status and recent opioid detoxification type. Participants who were not on parole or probation (vs. on parole or probation) were more likely to complete the induction (OR [95% CI]=2.5 [1.1–5.7], p =0.034), as were those who had come from a longer-term detoxification program (≥21days) (vs. a shorter-term [ p Conclusions Our analyses suggest that individuals recently leaving longer-term opioid detoxification programs are more likely to complete XR-NTX induction. Individuals on parole or probation are less likely to complete XR-NTX induction and may need additional supports or modifications to induction procedures to be successful.

Background and aim Extended-release naltrexone (XR-NTX) blocks the effects of opioids for 4weeks, yet many patients continue to use them. To learn more about why this occurs, we collected self-reports on subjective effects and drug use factors from participants' most recent heroin/opiate use while under XR-NTX blockade. Methods Participants ( n =38) were unemployed, heroin-dependent adults enrolled in a randomized controlled trial evaluating employment-based incentives to promote adherence to XR-NTX. A subset of participants ( n =18) were asked to complete a survey about their most recent use of heroin/opiates when they provided an opiate-positive urine sample while under XR-NTX blockade. Surveys were administered weekly, and participants could complete multiple surveys throughout the trial. Participants reported how high they were (11-point scale; 0=not at all, 10=extremely), how much heroin/opiates they took (less, more, or about the same as usual before starting naltrexone), whether they used cocaine at the same time, and the routes of administration for heroin/opiates and cocaine (if used). All analyses were descriptive. Results Of the 107 surveys, 75.7% indicated being "not at all" high the last time heroin/opiates were used. 75.5% of surveys reported opiate amounts that were less than usual, and only 7.5% reported amounts larger than usual. Cocaine was used at the same time as heroin for 57.9% of surveys but typically through a different route (74.2%). Discussion Using heroin/opiates while under XR-NTX blockade is not strongly associated with self-reports of high, taking larger than normal amounts of opiates, or taking opiates and cocaine simultaneously via the same route. Future research should incorporate measures of naltrexone concentration and more comprehensive and frequent assessments using ecological momentary assessment.

Drug addiction is a chronic, relapsing health problem that is associated with the degree to which individuals choose small, immediate monetary outcomes over larger, delayed outcomes. This study was a secondary analysis exploring the relation between financial choices and drug use in opioid-dependent adults in a therapeutic workplace intervention. Sixty-seven participants were randomly assigned to a condition in which access to paid job training was contingent upon naltrexone adherence (N = 35) or independent of naltrexone adherence (N = 32). Participants could earn approximately $10 per hour for 4 hours every weekday and could exchange earnings for gift cards or bill payments each weekday. Urine was collected and tested for opiates and cocaine thrice weekly. Participants' earning, spending, and drug use were not related to measures of delay discounting obtained prior to the intervention. When financial choices were categorized based on drug use during the intervention, however, those with less frequent drug use or frequent use of one drug spent a smaller proportion of their daily earnings and maintained a higher daily balance than those who frequently tested positive for both drugs (i.e., opiates and cocaine). Several patterns described the relation between cumulative earning and spending including no saving, periods of saving, and sustained saving. One destructive effect of drug use may be that it creates a perpetual zero-balance situation in the lives of users, which in turn prevents them from gaining materials that could help to break the cycle of addiction.

Deposit contracting may reduce costs and increase efficacy in contingency management interventions. We evaluated two Internet-based deposit contract arrangements for smoking. In Experiment 1, nine participants deposited self-selected amounts that could be earned back for meeting goals. During treatment, participants were reimbursed for breath samples with less than or equal to 6 parts per million carbon monoxide and met the criterion for 47% of samples compared to 1% during baseline. In Experiment 2, 10 participants' deposits were matched up to $50. No samples met the criterion during baseline but 41.5% met it during treatment. The average deposit was $82 in Experiment 1 and $49 in Experiment 2. Participants rated the intervention favorably and sample submission rates were high. These experiments suggest that Internet-based self-tailored deposits are acceptable, feasible, and can promote brief reduction and abstinence in some smokers. Future research should investigate individual and intervention factors that affect long-term cessation and uptake of deposit contracts.

Aim To test whether an incentive-based intervention that increased adherence to naltrexone also increased opiate abstinence. Design Post-hoc combined analysis of three earlier randomized controlled trials that showed individually that incentives for adherence to oral and to extended-release injection naltrexone dosing schedules increased naltrexone adherence, but not opiate abstinence. Setting Out-patient therapeutic work-place in Baltimore, MD, USA. Participants One hundred and forty unemployed heroin-dependent adults participating from 2006 to 2010. Interventions Participants were hired in a model work-place for 26 weeks and randomized to a contingency (n = 72) or prescription (n = 68) group. Both groups were offered naltrexone. Contingency participants were required to take scheduled doses of naltrexone in order to work and earn wages. Prescription participants could earn wages independent of naltrexone adherence. Measures Thrice-weekly and monthly urine samples tested for opiates and cocaine and measures of naltrexone adherence (percentage of monthly urine samples positive for naltrexone or percentage of scheduled injections received). All analyses included pre-randomization attendance, opiate use and cocaine use as covariates. Additional analyses controlled for cocaine use and naltrexone adherence during the intervention. Findings Contingency participants had more opiate abstinence than prescription participants (68.1 versus 52.9% opiate-negative thrice-weekly urine samples, respectively; and 71.9 versus 61.7% opiate-negative monthly urine samples, respectively) based on initial analyses [thrice-weekly samples, odds ratio (OR) = 3.3, 95% confidence interval (CI) = 1.7–6.5, P

Poverty is a pervasive risk factor underlying poor health. Many interventions that have sought to reduce health disparities associated with poverty have focused on improving health-related behaviors of low-income adults. Poverty itself could be targeted to improve health, but this approach would require programs that can consistently move poor individuals out of poverty. Governments and other organizations in the United States have tested a diverse range of antipoverty programs, generally on a large scale and in conjunction with welfare reform initiatives. This paper reviews antipoverty programs that used financial incentives to promote education and employment among welfare recipients and other low-income adults. The incentive-based, antipoverty programs had small or no effects on the target behaviors; they were implemented on large scales from the outset, without systematic development and evaluation of their components; and they did not apply principles of operant conditioning that have been shown to determine the effectiveness of incentive or reinforcement interventions. By applying basic principles of operant conditioning, behavior analysts could help address poverty and improve health through development of effective antipoverty programs. This paper describes a potential framework for a behavior-analytic antipoverty program, with the goal of illustrating that behavior analysts could be uniquely suited to make substantial contributions to the war on poverty.

IntroductionIn the United States (U.S.), approximately 35% of adults sleep less than 7 hours per night. The relationship between social media use and insufficient sleep has not thoroughly been examined among adults. The purpose of this study was to determine if social media use is associated with insufficient sleep among a sample of U.S. Army Soldiers.MethodsThis study surveyed 9,052 U.S. Soldiers in 2018 via a self-administered online questionnaire. Using multivariable logistic regression, we examined the association between social media use (ResultsOverall, 54.9% of Soldiers reported insufficient sleep. There was no significant relationship between excessive social media use and insufficient sleep in the multivariable logistic regression (OR: 1.03; CI: 0.87–1.23). The covariates of sex, race/ethnicity, rank, hazardous alcohol consumption, anxiety, and depression were significantly associated with insufficient sleep. Soldiers who reported symptoms of anxiety were more than twice as likely (OR: 2.11; CI: 1.65–2.70) to report insufficient sleep than Soldiers without signs of anxiety. Additionally, Soldiers who reported depressive symptoms were 85% (OR: 1.85; CI: 1.44–2.37) more likely to experience insufficient sleep than Soldiers without signs of depression.ConclusionSufficient sleep is essential to ensuring mission readiness and preventing accidental morbidity and mortality among Soldiers. The findings of this analysis do not suggest a link between extended social media use and insufficient sleep. However, though previously uninvestigated, Soldiers reporting symptoms of anxiety and depression were more likely to experience insufficient sleep compared to unafflicted Soldiers. Therefore developing a culture that encourages Soldiers to seek necessary behavioral health screening and care could be a key primary strategy to promote adequate sleep.

The objective of the present study was to determine whether there is an association between pornography use and reported intimate partner violence (IPV) perpetration among a sample of soldiers in the US Army. The study was a secondary analysis of cross-sectional data collected from soldiers at a military installation in 2018 (n = 9,052). IPV was defined as any self-reported perpetration of physical, sexual, or psychological abuse of an intimate partner. Multivariable negative binomial regressions were used to assess the association between pornography use and any lifetime perpetration of IPV, controlling for gender, age group, race/ethnicity, relationship status, educational status, military rank, hazardous drinking, depression, stimulant use, depressant use, and post-traumatic stress disorder. Of the population analyzed, 41% of soldiers reported any pornography use per week, and 9.6% reported perpetrating any form of IPV. Soldiers who reported pornography use had between a 1.72- and 3.56-fold greater likelihood of reporting any lifetime perpetration of IPV, controlling for covariates. Given the prevalence and detrimental effects of IPV, longitudinal studies should be designed to further understand predictors of IPV in military populations.

Key Points Question What are the prevalence, patterns, and correlates of use and polyuse of combustible, edible, and vaporized cannabis products among adolescents? Findings In a 2015 cross-sectional survey study of 3177 adolescents, ever use of edible (21.3%) or vaporized (10.5%) cannabis was appreciable, and most ever users of cannabis (61.7%) used at least 2 products. Current use was higher in boys than girls for vaporized (6.1% vs 3.0%) but not for combustible (13.8% vs 13.1%) or edible (8.4% vs 7.3%) cannabis. Meaning Health professionals should be aware that youth might use a diverse spectrum of combustible and alternative cannabis products., This cross-sectional survey study investigates the prevalence, patterns, and sociodemographic correlates of cannabis product use and polyuse by administration methods (combustible, vaporized, and edible) among a sample of adolescents in 10th grade., Importance Cannabis legalization and commercialization have introduced novel alternative cannabis products, including edible and vaporized cannabis that might appeal to youth and be associated with polyuse (ie, use of ≥2 different products). Objective To investigate the prevalence, patterns, and sociodemographic correlates of cannabis product use across combustible, edible, and vaporized administration methods, including polyuse of cannabis via multiple administration methods. Design, Setting, and Participants This cross-sectional survey study included 10th-grade students from 10 Los Angeles, California, area high schools from January 2 through October 6, 2015. Students were recruited from respondents in the Happiness and Health Study, an ongoing prospective cohort study in the 10 high schools. Students not in school during administration of the pencil-and-paper survey completed abbreviated surveys by telephone, internet, or mail. Data were analyzed from July 17, 2017, through July 12, 2018. Exposures Self-reported sex, race/ethnicity, and socioeconomic status (SES). Students with high SES had parents who attained college or a higher educational level and were ineligible for free or subsidized lunch; those with low SES had parents with lower educational attainment or were eligible for free or subsidized lunch. Main Outcomes and Measures Self-report of ever use (yes or no) and past 30-day use (yes or no) status and frequency of use (days in past 30 days) of combustible, edible, and vaporized cannabis. Results The sample included 3177 tenth-grade students (93.5% of study enrollees); among these students, 1715 (54.0%) were girls and the mean (SD) age was 16.1 (0.4) years. Among those with available demographic data, respondents were diverse in race/ethnicity (537 [17.2%] Asian; 149 [4.8%] black; 1510 [48.3%] Hispanic; 507 [16.2%] white; 207 [6.6%] multiethnic/multiracial; and 216 [6.9%] other) and included 1654 (60.1%) with a low SES. Prevalence of ever use was highest for combustible products (993 [31.3%]), followed by edible (676 [21.3%]) and vaporized (333 [10.5%]) products. A similar pattern was found for past 30-day use (426 [13.4%] for combustible, 249 [7.8%] for edible, and 156 [4.9%] for vaporized cannabis). Among participants who reported using cannabis in the past 30 days, mean frequency of use of combustible cannabis was higher by 2.65 days (95% CI, 1.40-3.91 days, P = .001) than the mean frequency of use for edible cannabis and 1.75 days higher (95% CI, 0.59-2.90 days, P = .003) than frequency of use for vaporized cannabis. Most cannabis users (665 [61.7%]) used multiple administration methods, and 260 (8.2%) used all 3 methods. Boys had higher prevalence of ever use for vaporized (170 [11.6%] vs 163 [9.5%]) but not combustible (459 [31.4%] vs 534 [31.1%]) or edible (303 [20.7%] vs 373 [21.7%]) cannabis. Respondents with low SES had higher prevalence of ever use for combustible (614 [37.1%] vs 242 [22.0%]) and edible (408 [24.7%] vs 166 [15.1%]) but not vaporized (186 [11.2%] vs 93 [8.5%]) cannabis. Conclusions and Relevance Among 10th-grade students in Los Angeles, use of cannabis via alternative administration methods was of appreciable prevalence, predominately reported in conjunction with other cannabis products and unequally distributed across sociodemographic strata. Prevention programs and regulatory restrictions addressing the spectrum of cannabis products might benefit pediatric public health.

Some adults with Type 2 diabetes mellitus have difficulty adhering to their oral medication regimens. The current study used a multiple baseline design with 3 adults with Type 2 diabetes. Medication taking was monitored remotely in real time via an electronic pill bottle. During the intervention, monetary incentives were delivered contingent on evidence of adherence to taking medication at specified times. Text-message reminders were also sent if medication was not taken. Adherence increased for all participants. Future studies should separate the relative contributions of text-message and incentive components of the intervention.

Use of technology (e.g., Internet, cell phones) to allow remote implementation of incentives interventions for health-related behavior change is growing. To our knowledge, there has yet to be a systematic review of this literature reported. The present report provides a systematic review of the controlled studies where technology was used to remotely implement financial incentive interventions targeting substance use and other health behaviors published between 2004 and 2015. For inclusion in the review, studies had to use technology to remotely accomplish one of the following two aims alone or in combination: (a) monitor the target behavior, or (b) deliver incentives for achieving the target goal. Studies also had to examine financial incentives (e.g., cash, vouchers) for health-related behavior change, be published in peer-reviewed journals, and include a research design that allowed evaluation of the efficacy of the incentive intervention relative to another condition (e.g., non-contingent incentives, treatment as usual). Of the 39 reports that met inclusion criteria, 18 targeted substance use, 10 targeted medication adherence or home-based health monitoring, and 11 targeted diet, exercise, or weight loss. All 39 (100%) studies used technology to facilitate remote monitoring of the target behavior, and 26 (66.7%) studies also incorporated technology in the remote delivery of incentives. Statistically significant intervention effects were reported in 71% of studies reviewed. Overall, the results offer substantial support for the efficacy of remotely implemented incentive interventions for health-related behavior change, which have the potential to increase the cost-effectiveness and reach of this treatment approach.

AIM: To determine whether extended-release injectable naltrexone (XR-NTX), incentives for opiate abstinence, and their combination reduce opiate use compared to a usual care control and whether the combination reduces opiate use compared to either treatment alone. DESIGN: Randomized 2×2 single-site controlled trial conducted from November 2012 through May 2016. After a detoxification and oral naltrexone induction, participants were assigned to a Usual Care, Abstinence Incentives, XR-NTX, or XR-NTX plus Abstinence Incentives group for a six-month intervention period. SETTING: A model therapeutic workplace where participants could work on automated computer programs that targeted job-skills training for 4 hours every weekday for 24 weeks and earn about $10 per hour. PARTICIPANTS: 84 heroin-dependent adults who were unemployed and medically approved for naltrexone. Most participants were male (71.4%), African American (80.1%), and cocaine dependent (71.4%). MEASUREMENTS: The primary outcome measure was the percentage of urine samples negative for opiates that were collected at once weekly assessments (24 per participant) that were not part of the intervention and for which participants were paid $10 for completing. INTERVENTION: Participants who attended the workplace provided thrice-weekly urine samples. Abstinence Incentives participants had to provide opiate-free urine samples to maintain maximum pay. XR-NTX participants received one injection every 4 weeks and were required to take injections in order to work and to maintain maximum pay. Usual Care participants were not offered XR-NTX and opiate urinalysis results did not affect pay. FINDINGS: A large percentage (65 of 149; 43.6%) of individuals failed the induction protocol required for randomization and to be eligible to receive XR-NTX. When missing urine samples were considered positive, there was no significant interaction between XR-NTX and Abstinence Incentives. XR-NTX plus Abstinence Incentives participants provided significantly more opiate-negative samples (81.3%, SD 39.0%) than XR-NTX participants (64.5%, SD 47.9%; aOR 10.4, 95% CI 1.3–85.5; P = .030). When urine samples were not replaced, there was a significant interaction between XR-NTX and Abstinence Incentives (aOR 77.0, 95% CI 1.3–4432; P = .036); XR-NTX plus Abstinence Incentives participants provided significantly more opiate-negative samples (99.6%, SD 0.1%) than XR-NTX participants (85.0%, SD 35.7%; aOR 147.6, 95% CI 6.3– 3472; P = .002), Abstinence Incentives participants (91.9%, SD 27.3%; aOR 121.7, 95% CI 4.8–3067; P =.004), and Usual Care participants (78.7%, SD 41.0%; aOR 233.4, 95% CI 9.4–5814; P

INTRODUCTION: The aim of this study was to create an interactive computer-based education program to teach Human Immunodeficiency Virus (HIV) prevention behaviors and raise awareness of Pre-Exposure Prophylaxis (PrEP) among individuals at risk for HIV. METHODS: An interactive education program was created and delivered to individuals who were at risk of contracting HIV. The content was divided into modules. Within each module, educational material and multiple-choice questions were presented to participants. Participants received immediate feedback for responses and financial incentives for correct responses to multiple choice questions. Mastery criteria required participants to continue in training on each module until they achieved a specified level of speed and accuracy. The modules were divided into three parts: Course 1 (HIV), Course 2 (PrEP usage) and Course 3 (HIV risk behaviors). Tests of content from all three courses were delivered before and after participants completed each course RESULTS: Test scores on the content delivered in Courses 1, 2 and 3 improved only after participants completed training on Courses 1, 2 and 3, respectively. Knowledge related to HIV and PrEP was initially low, and increased following the implementation of each part of the education program. CONCLUSIONS: Delivering HIV prevention education through computer-based training may offer an inexpensive, convenient and effective approach to promoting awareness and knowledge of HIV prevention approaches, including the use of PrEP.

The legalization of medical and recreational cannabis use has occurred ahead of science. The current evidence base has poor utility for determining if cannabis products can meet the standards of safety, efficacy, and quality intrinsic to modern medicine, and for informing regulation of cannabis as a legal intoxicant. Individual jurisdictions that pass cannabis reforms may not have adequate resources to support the level of new scientific research needed to inform regulatory actions; this could make it difficult to keep a rapidly growing multi-billion-dollar cannabis industry in check. Further, the present lack of evidence-based regulatory oversight for cannabis parallels the climates that gave rise to the tobacco and prescription opioid epidemics, suggesting that continued omission may result in negative public health consequences. However, translating a methodological framework developed through research on these compounds may promote rapid advances in cannabis science germane to regulatory knowledge gaps. The present review highlights specific advancements in these areas, as well as in alcohol regulation, that are prime for informing policy-relevant cannabis science, and also offers some recommendations for evidence-based regulatory policy. Resulting progress may directly inform both regulation of cannabis in both medical and licit recreational drug frameworks, and new cannabis-related public health initiatives.

Background The link between illicit drug use and impaired employee performance in the workplace has been assumed, but the relation has not been demonstrated clearly in research. This study was an evaluation of the relations between cocaine and opiate use, attendance, and performance in a job skills training program in a population with high rates of drug use. Methods Out-of-treatment injection drug users (N = 42) attended a model therapeutic workplace where they could earn a maximum pay of around $10 per hour, 4 h every weekday, for 30 weeks. At the workplace, participants could complete practice trials on computer-based typing and keypad training programs. Participants were asked to provide urine samples thrice weekly, which were tested for opiates and cocaine. Results Participants worked for more hours on a program that resulted in a flat hourly wage when their urine was negative for opiates and cocaine than when their urine was opiate and cocaine positive. Attendance was positively associated with opiate-negative samples during the study. When participants attended the workplace, however, their performance was not related to drug use. Participants completed the same number of practice trials, performed at the same accuracy, and typed at the same speed when they were positive and negative for cocaine and opiates. Conclusions Contrary to common expectations, this study failed to show that the use of opiates or cocaine affected in-training performance, even though opiate and cocaine use predicted reduced attendance under some circumstances.

During contingency management interventions, reinforcement of cocaine abstinence is arranged by delivering an incentive when a urine sample tests cocaine-negative. The use of qualitative versus quantitative urinalysis testing may have important implications for effects on cocaine abstinence. Qualitative testing (i.e., testing that solely identifies whether a particular substance is present or absent) may not detect short-term cocaine abstinence because a single instance of cocaine use can result in cocaine-positive urine over many days. Quantitative testing (i.e., testing that identifies how much of a substance is present) may be more sensitive to short-term cocaine abstinence; however, the selection of a criterion for distinguishing new use versus carryover from previous use is an important consideration. The present study examined benzoylecgonine concentrations, the primary metabolite of cocaine, in urine samples collected three times per week for 30 weeks from 28 cocaine users who were exposed to a cocaine abstinence contingency. Of the positive urine samples (benzoylecgonine concentration >300 ng/ml), 29%, 21%, 14%, and 5% of the samples decreased in benzoylecgonine concentration by more than 20%, 40%, 60%, and 80% per day, respectively. As the size of the decrease increased, the likelihood of that sample occurring during a period leading to a cocaine-negative urine sample (benzoylecgonine concentration ≤300 ng/ml) also increased. The number of days required to produce a cocaine-negative sample following a positive sample ranged from 1 to 10 days and was significantly correlated with the starting benzoylecgonine level (r = 0.43, p < 0.001). The present analyses may aid in the development of procedures that allow for the precise reinforcement of recent cocaine abstinence during contingency management interventions.

Behavior plays an important role in health promotion. Exercise, smoking cessation, medication adherence, and other healthy behavior can help prevent, or even treat, some diseases. Consequently, interventions that promote healthy behavior have become increasingly common in health care settings. Many of these interventions award incentives contingent upon preventive health-related behavior. Incentive-based interventions vary considerably along several dimensions, including who is targeted in the intervention, which behavior is targeted, and what type of incentive is used. More research on the quantitative and qualitative features of many of these variables is still needed to inform treatment. However, extensive literature on basic and applied behavior analytic research is currently available to help guide the study and practice of incentive-based treatment in health care. In this integrated review, we discuss how behavior analytic research and theory can help treatment providers design and implement incentive-based interventions that promote healthy behavior.

Objective: The effects of contingency management to induce physical activity levels were examined in seven non-obese physically inactive undergraduate students by providing monetary payments using a multiple baseline, changing-criterion procedure. Methods: Participants attended a baseline phase, a subsequent intervention phase consisting of three exercise sessions per week for 4 weeks, and a follow-up session 2 weeks post intervention. A total of $145 was available for attendance and exercise contingency payments. Results: Results indicate that all participants significantly increased exercise during intervention from inactivity at baseline to exercising three 30-minute sessions per week. Participants maintained some gains during follow-up. Limitations: The study employed a small and homogenous sample size and required participants to exercise in a lab setting thus limiting external validity. Conclusions: These findings suggest that incentive-based interventions are an effective and viable means for inducing exercise.

The acceptability of an Internet-based contingency management (CM) intervention for cigarette smoking was evaluated in two experiments. In Experiment 1, 67 participants (46% female) completed an Internet-based CM intervention and then answered questions about the intervention. Experiment 2 assessed the acceptability of the intervention among potential treatment users who had never used the intervention, (smokers, n = 164, 52% female), nonsmokers (n = 166, 73% female), and health-care providers (n = 139, 63% female). Participants in Experiment 2 were randomly assigned to either watch a video describing the standard CM intervention (no-deposit group) or to watch a video about the standard intervention plus a deposit incentive (deposit group). Overall, results of both experiments indicated high acceptability across all dimensions of the intervention. In Experiment 1, 74% (n = 26 of participants in the treatment group) of participants said they would use it if they needed to quit, as well as 92% (n = 150 among smokers) of those in Experiment 2. Of the health-care providers, 81% (n = 113) reported that they would be very likely to recommend the intervention to patients. Participants in both experiments reported that monitoring their progress and earning vouchers were strengths of the intervention. The no-deposit group rated voucher earnings, cash earnings, and cost-effectiveness of the intervention higher than the deposit group. Health-care professionals did not differ in their ratings across video conditions. Overall, the results suggest that Internet-based CM is acceptable as a method to help people quit smoking.

Background Excessive alcohol use among the homeless may contribute to their high rates of emergency department use. Survey-based studies have provided some information on the relation between alcohol and emergency department use among the homeless. Methods This study used an intensive schedule of random breath collections and self-report assessments to examine the relation between emergency department utilization and alcohol use in homeless alcohol-dependent adults. Data were from homeless alcohol-dependent adults (N = 116) who were participating in a therapeutic workplace that provided job-skills training every weekday for 26 weeks. Breath-sample collections and assessments of self-reported alcohol use were scheduled each week, an average of twice per week per participant, at random times between 9:00 A.M. and 5:00 P.M. Participants received $35 for each breath sample collected. Self-reports of emergency department use were assessed throughout the study. Results Thirty-four percent of participants reported attending an emergency department and reported an average of 2.2 emergency department visits (range 1–10 visits). Alcohol intoxication was the most common reason for emergency department use. Participants who used the emergency department had significantly more alcohol-positive breath samples and more self-reported heavy alcohol use than participants who did not use the emergency department. Conclusions This study provided a rare intensive assessment of alcohol and emergency department use in homeless alcohol-dependent adults over an extended period. Emergency department use was high and was significantly related to indices of alcohol use.

Poverty is one of the most pervasive risk factors underlying poor health, but is rarely targeted to improve health. Research on the effects of anti-poverty interventions on health has been limited, at least in part because funding for that research has been limited. Anti-poverty programs have been applied on a large scale, frequently by governments, but without systematic development and cumulative programmatic experimental studies. Anti-poverty programs that produce lasting effects on poverty have not been developed. Before evaluating the effect of anti-poverty programs on health, programs must be developed that can reduce poverty consistently. Anti-poverty programs require systematic development and cumulative programmatic scientific evaluation. Research on the therapeutic workplace could provide a model for that research and an adaptation of the therapeutic workplace could serve as a foundation of a comprehensive anti-poverty program. Once effective anti-poverty programs are developed, future research could determine if those programs improve health in addition to increasing income. The potential personal, health and economic benefits of effective anti-poverty programs could be substantial, and could justify the major efforts and expenses that would be required to support systematic research to develop such programs.

Introduction: Video games may serve as an ideal platform for developing and implementing technology-based contingency management (CM) interventions for smoking cessation as they can be used to address a number of barriers to the utiliza- tion of CM (e.g., replacing monetary rewards with virtual game-based rewards). However, little is known about the relationship between video game playing and cigarette smok- ing. The current study determined the prevalence of video game use, video game practices, and the acceptability of a video game-based CM intervention for smoking cessation among adult smokers and nonsmokers, including health care professionals. Methods: In an online survey, participants (N = 499) answered questions regarding their cigarette smoking and video game playing practices. Participants also reported if they believed a video game-based CM intervention could motivate smokers to quit and if they would recommend such an intervention. Results: Nearly half of the participants surveyed reported smoking cigarettes, and among smokers, 74.5% reported playing video games. Video game playing was more prevalent in smokers than nonsmokers, and smokers reported playing more recently, for longer durations each week, and were more likely to play social games than nonsmokers. Most participants (63.7%), including those who worked as health care professionals, believed that a video game-based CM intervention would motivate smokers to quit and would recommend such an intervention to someone trying to quit (67.9%). Conclusions: Our findings suggest that delivering technology- based smoking cessation interventions via video games has the potential to reach substantial numbers of smokers and that most smokers, nonsmokers, and health care professionals endorsed this approach.

Deposit contracting may reduce costs and increase efficacy in contingency management interventions. We evaluated two Internet-based deposit contract arrangements for smoking. In Experiment 1, nine participants deposited self-selected amounts that could be earned back for meeting goals. During treatment, participants were reimbursed for breath samples with less than or equal to 6 parts per million carbon monoxide and met the criterion for 47% of samples compared to 1% during baseline. In Experiment 2, 10 participants’ deposits were matched up to $50. No samples met the criterion during baseline but 41.5% met it during treatment. The average deposit was $82 in Experiment 1 and $49 in Experiment 2. Participants rated the intervention favorably and sample submission rates were high. These experiments suggest that Internet-based self-tailored deposits are acceptable, feasible, and can promote brief reduction and abstinence in some smokers. Future research should investigate individual and intervention factors that affect long-term cessation and uptake of deposit contracts.

Internet-based group contingencies have been shown to promote brief periods of abstinence from cigarette smoking. Under a group contingency, small teams of smokers must collectively meet abstinence goals to receive monetary consequences. The present study investigated two arrangements, one in which all team members had to meet group treatment goals to receive monetary consequences (Full Group), and one in which team members had to meet some group goals and some individual goals to receive these consequences (Mixed Group). Mōtiv8 Systems, an Internet-based remote monitoring platform, was used to collect video-recorded breath carbon monoxide (CO) samples. All team members could communicate with each other via an online discussion forum. During baseline conditions, only 3.3% of CO samples were negative for smoking, which suggests that self-monitoring and access to the online discussion forum were insufficient to initiate abstinence. When the group contingencies were instituted 41.3% of CO samples were negative. There were no statistically significant differences between the two arrangements in the percentage of negative CO samples or point prevalence at the end of treatment or at the 3-month follow-up. Participants posted an average of 25 comments on the discussion forum, most of which were rated as positive by independent observers. The mean cost of vouchers per participant was lower in the Full Group ($33) relative to the Mixed group ($190). The present results replicate and extend previous findings on group contingencies to promote abstinence and social support.

Technology-based interventions (TBIs) for substance use disorders have been increasing steadily. The mechanisms by which TBIs produce change in substance use outcomes have not been reviewed. This article is the first review of the conceptual and empirical underpinnings of the mechanisms associated with TBIs for substance use disorders.We review the literature on potential mechanisms associated with TBIs targeting tobacco, alcohol, and poly-substance use. We did not identify TBIs targeting other drug classes and that assessed mechanisms.Research suggests that TBIs impact outcomes via similar potential mechanisms as in non-TBIs (e.g., in-person treatment), with the exception of substance use outcomes being associated with changes in the quality of coping skills. The most frequent potential mechanisms detected were self-efficacy for tobacco abstinence and perceived peer drinking for alcohol abstinence.Research on mechanisms associated with TBIs is still in a nascent stage. We provide several recommendations for future work, including broadening the range of mechanisms assessed and increasing the frequency of assessment to detect temporal relations between mechanisms and outcomes. We also discuss unique challenges and opportunities afforded by technology that can advance theory, method, and clinical practice.