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Contingency management treatments of substance abuse typically operate by making positive incentives available contingent upon drug abstinence however like all treatments, contingency management treatments are not effective for all individuals. The results indicates that increasing the proportion of individuals who successfully contact the programmed incentives for drug abstinence could increase the proportion of individuals successfully treated with contingency management.

Behavioral interventions that provide incentives contingent upon abstinence are effective addiction treatments. Nevertheless, these treatments often fail for individuals whose recent behaviors are very different from those reinforced. These hard-to-treat individuals may require shaping to achieve abstinence. We used percentile schedules to shape smokers' delivery of breath samples indicative of recent smoking abstinence (breath carbon monoxide (BCO) <4 ppm). Percentile schedules deliver incentives to current behaviors proximal to the target. Participants (N = 102) were assigned to treatments delivering incentives for breath COs at or below the 10th, 30th, 50th, or 70th percentile of recent breath COs. Each condition effectively ensured contact with available contingencies, and resulted in BCO <4 ppm in >90% of the 30th, 50th and 70th percentile groups versus 63% in the 10th percentile. The 30th, 50th and 70th percentiles were especially effective in a sub-sample of hard-to-treat participants who did not deliver a breath CO <4 ppm during an initial abstinence test or during a nine-visit baseline period, suggesting the value of shaping for this important sub-sample.

After drug treatment counselors at a community-based methadone treatment clinic were trained in implementing a contingency management (CM) intervention, baseline measures of performance revealed that, on average, counselors were meeting the performance criteria specified by the treatment protocol about 42% of the time. Counselors were exposed to graphical feedback and a drawing for cash prizes in an additive within-subjects design to assess the effectiveness of these interventions in improving protocol adherence. Counselor performance measures increased to 71% during the graphical feedback condition, and to 81% during the drawing. Each counselor's performance improved during the intervention conditions. Additional analyses suggested that counselors did not have skill deficits that hindered implementation. Rather, protocol implementation occurred more frequently when consequences were added, thereby increasing the overall proportion of criteria met. Generalizations, however, may be limited due to a small sample size and possible confounding of time and intervention effects. Nonetheless, present results show promise that feedback and positive reinforcement could be used to improve technology transfer of behavioral interventions into community clinic settings.

Self-reports of drug use frequency are central to treatment outcome evaluations, estimates of the prevalence of heavy use, estimates of treatment need, and other questions with direct relevance to drug policies. Nevertheless, surprisingly little is known about the validity of these self-reports. This study examines the accuracy of 701 frequency self-reports made by a sample of methadone maintenance clients. Self-report accuracy is evaluated by comparing rates of positive urinalyses found for each case with rates that would be expected had drug use occurred only as often as reported. Expected rates of positive urinalyses are derived from conservative Monte Carlo models of drug use for each case. This procedure reveals extensive heroin and cocaine use frequency underreporting. After adjusting for frequency underreporting, 51% of 279 cases reporting only occasional heroin use (1-10 days in the past 30), and 22% of the 157 cases reporting occasional cocaine use, are found to be using these drugs with frequencies corresponding to what the Office of National Drug Control Policy defines as 'hardcore use' (more than 10 days in the past 30). Drug use frequency underreporting appears substantial, and might constitute an important threat to the validity of some treatment outcome evaluations, needs assessments and other analyses that rely on drug use frequency self-reports.

Exhaustive searches have uncovered few demographic or other pretreatment factors that reliably predict performance in substance abuse treatments. In this study we evaluate whether early treatment response offers improved prediction of treatment response 6 and 9 months later. New admissions to methadone maintenance treatment (n = 59) were dichotomized into outcome groups based on treatment retention and ongoing drug use as revealed by urinalysis results 6 and 9 months after admission. Regression analyses revealed two early (week 2) performance measures, counseling attendance and opiate abstinence, could be used to correctly classify, the outcomes of more than 80% of the sample. Strikingly, of the 20 participants who neither submitted an opiate-negative urine sample in week 2 nor attended at least two scheduled counseling sessions by that time, not one achieved a superior 6-month outcome. The odds of having a superior outcome increased considerably for those who submitted two opiate negative urine samples and attended two counseling sessions by week 2. Thus, 6-month outcomes were well predicted by treatment performance in week 2. Similar results are reported for month 9 outcomes.

Objective: High risk injection practices are common among injecting drug users (IDUs), even following intervention efforts. Moreover, relapse to risk behaviors has been reported among those who initiate risk reduction. Substance abuse treatment offers the potential to reduce or eliminate injecting risk behaviors through drug cessation. We report on the effectiveness of two intervention strategies in facilitating treatment entry among out-of-treatment IDUs: motivational interviewing (MI), and intervention developed to help individuals resolve their ambivalence about behavior change, and free treatment for 90 days. These conditions were compared with an intervention focusing on a hierarchy of safer injecting practice, referred to here as risk reduction (RR), and no free treatment., Methods: Nearly 200 out-of-treatment IDUs were randomly assigned to one of four experimental conditions: MI/free treatment, MI/no free treatment, RR/free treatment, and RR/no free treatment. Regardless of assignment, we assisted anyone desiring treatment by calling to schedule the appointment, providing transportation, and waiving the intake fee., Results: Overall, 42% of study participants entered treatment. No significant differences were found between MI and RR; however, 52% of those assigned free treatment entered compare with 32% for those who had to pay. Other predictors of treatment entry included prior treatment experiences, perceived chance of contracting acquired immunodeficiency syndrome (AIDS) greater than 50%, "determination" stage of change, greater frequency of heroin injecting, and fewer drug-using friends., Conclusions: These findings support the importance of removing barriers to treatment entry.

Although many studies document the use of the MMPI to classify opiate users, the predictive validity of the resulting subgroups is rarely reported. In this study, we used cluster analysis to identify MMPI profile types that predicted differential response to methadone maintenance treatment. Participants (N = 151) completed MMPIs shortly after entry into treatment. Cluster analysis of MMPI scores produced four distinct subgroups that differed significantly in severity of psychosocial problems measured at admission and on the mean number of drug-free urine specimens submitted during the 24-week study period. Cluster 1 participants evidenced low levels of psychological disturbance, improved their urinalysis results over time, and submitted the most posttest drug-free urine specimens. Cluster 2 was the only other group that improved significantly over time, even though these patients were the most psychologically disturbed. The results suggest the relation between psychological problems and outcome may be more complex than is commonly assumed.

Fifty one individuals (37 male and 14 female) were asked to report on the social and behavioral circumstances related to their opiate drug use prior to and during a 90-day methadone detoxification treatment. Data were collected by means of a weekly structured interview. Questions were asked about each occasion of opiate use in the previous week with respect to time, source, cost, social circumstance, etc. Monitored urine samples were tested x 3/week to verify verbal reports. The study demonstrated beneficial effects of the detoxification treatment by showing dramatic decreases in rates and amounts of opiate drug use during treatment. Of perhaps greater significance, large scale changes were also noted in the frequency of use with others. This decline in use with others was most dramatic with respect to strangers and acquaintances. Implications of these observations for HIV transmission are discussed.

This pilot study used snowball recruitment methods and intensive interviews to assess personal drug-using networks and HIV risk behavior of injection drug users (IDUs). Index subjects were 22 methadone maintenance patients reporting current drug injection who were interviewed about personal drug-using networks both current and prior to treatment entry. The index subjects were then asked to recruit other network members to the study. Ninety-seven network members were identified and 40 interviewed, including 18 not in treatment. Index IDUs reported fewer co-IDUs for the treatment period than the pretreatment period, suggesting a reduction in risk of exposure to HIV. The combination of snowball recruitment and intensive interview procedures constitutes a useful method for studying IDU networks.

This study examines an approach to identifying patterns of treatment response over time. Treatment response profiles are identified by cluster analyzing a repeated measure of patient performance collected at intervals during treatment. The procedure is demonstrated in Study 1 using monthly urinalysis results of 103 patients entering methadone maintenance treatment. The internal, external, and face validities of derived treatment response profiles are evaluated. A logistic regression model predicting treatment response is then constructed from intake variables found to correspond with the treatment response profiles. Study 2 replicates the procedures on an independent sample. Treatment response profiles facilitate the analysis of treatment response offering advantages over common measures of treatment outcome, such as performance at follow-up, change in performance from treatment entry to follow-up, or performance summed across treatment.

This study examines the effectiveness of using vouchers to reinforce either the provision of urine samples testing negative for illicit drugs (UA group) or the completion of objective, individually defined, treatment-plan-related tasks (TP group). A third group was assigned to the clinic's standard treatment (STD group). Participants were randomly assigned to groups after a 6-week baseline-stabilization period. Urine specimens were collected thrice weekly throughout the study. In the UA condition, participants earned $5 (U.S. dollars) in vouchers for each drug-free urine submitted. In the TP condition, participants earned up to $15 in vouchers per week for demonstrating completion of treatment plan tasks assigned by their counselors. Contingencies were in effect for 12 weeks, after which all participants received the clinic's standard treatment. Urinalysis results indicate that the TP intervention was significantly more effective in reducing illicit drug use than either the UA or STD interventions. These effects were maintained with a trend toward continuing improvement for the TP groups even after contingencies were discontinued.

In this study the authors evaluated the predictive validity of stages-of-change and processes-of- change measures among methadone maintenance patients. One month after treatment entry, participants completed questionnaires providing stage and process scale scores regarding readiness to discontinue polydrug use. Participants also completed an algorithm assigning them to a stage category on the basis of their stated intentions regarding quitting. The algorithm predicted urinalysis results during a 12-week posttest period; however, only 1 stage scale (contemplation) and no process scales correlated significantly with outcome. In a hierarchical regression, stage and process scale scores significantly improved prediction of posttest abstinence beyond that afforded by baseline drug-free urine rates, but this effect was attributable to the contemplation scale alone. Despite their widespread use, stage and process scales have yet to demonstrate clearly predictive validity.

Objective: To evaluate the hypothesis that long-term methadone detoxification would produce greater HIV risk reduction among injecting drug users (IDU) than short-term detoxification., Design: Random assignment to 21 or 90 days of free detoxification., Setting: Storefront offices in two cities, with referrals to outpatient methadone detoxification., Participants: Out-of-treatment IDU (n = 1803), recruited through street outreach and word of mouth, between April 1990 and March 1991. Of these, 62.6% were successfully located for 6-month follow-up., Main Outcome Measures: Self-reported drug injection and sexual practices at baseline and follow-up., Results: Substantial reductions in risk behavior were observed at follow-up. Substantial percentages of subjects reported less frequent drug injection (54%), use of shooting galleries (85%), needle-sharing (67%), and number of sex partners (73%), and more frequent use of bleach to disinfect needles (67%) and condom use (31%). There were no significant differences in behavioral change between 21 and 90-day treatment, and subjects who entered treatment did not report significantly greater risk reduction than untreated subjects. Discriminant analyses showed a marginal effect for duration of treatment on risk reduction, although results were inconsistent., Conclusions: Large scale behavioral risk reduction appears to be occurring in this population regardless of treatment condition. In minimal service methadone detoxification, subjects treated under a longer-term detoxification protocol demonstrated no greater risk reduction than those receiving short-term detoxification.

Objective: To determine the prevalence of drug and alcohol use in an inner-city family planning population and to identify variables associated with a positive urine screen., Study Design: We conducted blind urine drug and alcohol screening in 309 women attending an inner-city hospital family planning clinic., Results: The prevalence of a positive urine drug and/or alcohol screen was 15.5% (48/309). Specific substance positivity rates were: marijuana 9.4%, cocaine 4.9%, alcohol 1.3%, benzodiazepines 1.0%, opiates 1.0% and amphetamines 0.3%. After controlling for other independent variables, increased age was the only predictor of having a positive drug and/or alcohol screen, while increased age and a history of a sexually transmitted disease predicted the use of drugs other than marijuana or alcohol alone., Conclusions: Our findings support the concept that substance use histories and urine drug screening should be considered in patients seeking family planning services. This strategy can lead to counseling and treatment for a population seeking preventive care that might otherwise not be identified.

This study examined self-reported dysphoria in 82 consecutive admissions to intensive outpatient treatment for cocaine abuse on whom data for the Beck scales for depression, anxiety, and hopelessness were available for intake and 4 subsequent weeks with no more than 1 missing data point. Mean scores on the Beck Depression Inventory (BDI) and the Beck Anxiety Inventory (BAI) decreased significantly between intake and Week 1, with no further significant changes from Weeks 1-4. Similar drops in the rate of clinically significant BDI and BAI scores also were observed. Scores on the Beck Hopelessness Scale (BHS) showed no significant changes. By Week 4, rates of clinically significant depression, anxiety, and hopelessness were similar (17%, 13%, and 16%, respectively). These findings suggest that assessing depression and anxiety using the BDI and BAI in this population should be postponed for at least 1 week after intake and that intake levels of self-reported mood may be inappropriate baseline measures for evaluating treatment effects.

We interviewed 265 cocaine-experienced methadone patients about situations that occasioned their cocaine use and strategies they used to avoid cocaine use. Subjects identified an average of 15 situations that occasioned cocaine use. The three most frequently identified were having the drug present (86% of subjects), being offered the drug (85%) and having money available (83%). Subjects reporting fewer situations also reported longer periods of lifetime abstinence (p < 0.01). A principal components analysis extracted 10 groups of situations that were most frequently identified in combination. Subjects identified a median of seven strategies for avoiding cocaine use; however, there was large inter-subject variability. This variance was not accounted for by demographic variables, employment status or treatment experience. The three strategies identified most frequently were avoiding people and places (81%), thinking about what they could lose (76%) and leaving the situation (66%). The total number and type (reactive vs. proactive) of strategies identified by subjects had no relationship to cocaine abstinence, although four specific strategies (thinking about what could be lost, leaving the situation, moving to a new area and using a different drug) were positively correlated with cocaine abstinence. We discuss implications of these results for clinical practice.

Methadone client volunteers completed the Minnesota Multiphasic Personality Inventory (MMPI; Hathaway & McKinley, 1967) and MMPI-2 (Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989) on consecutive days. MMPI-2 T-scores were lower by a mean of 4.7 on the clinical scales; when 5 points were added to MMPI-2 T-scores the mean difference was 2.3. Rank order of subjects on scale T-scores was not significantly different between the two instruments. High-point similarity for clinically elevated profile pairs ranged from 61% to 92%, depending upon definition of similarity.

A total of 4,375 subjects were recruited through continuous street outreach over 31 months for interviews on HIV-related risk behavior and HIV-antibody testing. Changes over time among sampled subjects with respect to HIV infection and HIV-risk behavior have been examined retrospectively, and significant and consistent trends noted across successive cohorts. Although overall 42% of the sample tested HIV antibody-positive, HIV infection exhibited a consistent downward trend from 60% in the first quarter year of interviewing to 22% in the final quarter year. Scores on a multivariate index of HIV risk also declined significantly. Mean age, proportion of Black subjects, mean length of drug injection career, frequency of drug injection, and the use of shooting galleries all declined significantly across quarters as well. We argue that these observed differences result from a systematic sampling bias inherent in our outreach-driven sampling procedures, which initially favored recruitment of IDUs with greater behavioral and demographic risk for HIV.

Objective: The purpose of the study was to identify characteristics of injection-drug users that predicted whether subjects would redeem a coupon for free methadone detoxification and to determine whether they were more likely to participate in a 90-day detoxification program than in a 21-day program., Methods: A total of 4,390 current heroin users recruited through street-based outreach programs in Newark and Jersey City, New Jersey, accepted coupons for either 21 or 90 days (randomly determined) of methadone detoxification after they were interviewed about drug use and sexual behavior. Subjects also gave blood samples for HIV testing. Multiple regression analysis was used to determine variables associated with coupon redemption., Results: Of 4,390 coupons distributed, 58.5 percent were redeemed; the 90-day coupons were redeemed at a significantly higher rate (59.9 percent) than the 21-day coupons (56.9 percent). Among coupon redeemers, 43.6 percent had never received formal drug treatment, and 44.9 percent were HIV seropositive. Frequent heroin use, previous drug detoxification, frequent drug injection, cleaning needles with bleach, nonblack race, Hispanic ethnicity, and Newark residence each significantly predicted coupon redemption., Conclusions: Outreach-based coupon distribution may be used to recruit large numbers of never-treated and HIV-infected drug users into treatment. The 90-day coupon was more effective in facilitating treatment entry.

This study examined contingent methadone take-home privileges for effectiveness in reducing on-going supplemental drug use of methadone maintenance patients. Fifty-three new intakes were randomly assigned to begin receiving take-home privileges after 2 consecutive weeks of drug-free urines or to a noncontingent procedure in which take-homes were delivered independently of urine test results. The contingent procedure produced more individuals with at least 4 consecutive weeks of abstinence (32% vs. 8%); 28% of noncontingent subjects also achieved abstinence after shifting to the contingent procedure. Lower baseline rate of drug-free urines was strongly associated with successful outcome, whereas the type of drug abused (cocaine vs. benzodiazepines) did not influence outcomes. Findings support a recommendation for using contingent take-home incentives to motivate abstinence during methadone maintenance treatment.

The behavioral circumstances related to opiate drug use were examined during a 90-day out-patient methadone detoxification. Seventy-one subjects (55 male and 16 female) were followed from the day of intake to treatment termination. Data were collected by means of a weekly structured interview. Questions were asked about each occasion of opiate use in the previous week with respect to time, source, cost, social circumstance, etc. Monitored urine samples were tested x 3/week to verify verbal reports. The study demonstrated beneficial effects of the detoxification treatment by showing dramatic decreases in rates and amounts of opiate drug use during treatment. The study also identified race (p less than .0008; t = -3.522; beta = -0.366), gender (p less than .0243; t = 2.305; beta = 0.222), and the number of opiate use episodes/week at baseline (p less than .0013; t = -3.364; beta = -0.338) as significant and independent predictors of treatment outcome. Current duration of regular and continuous opiate use was also found to be marginally significant. The overall regression was highly significant (p less than .0001; F = 9.176; df = 4,66). A second regression analysis with race, age, and gender excluded as independent variables was conducted in order to derive indices which were related to behavioral and environmental characteristics versus global physical/cultural identification. With race and gender removed, the overall regression was still highly significant, although less than a fifth of the variance was accounted for. The number of opiate use episodes/week at baseline and the total number of drug-related stimulus cue exposures at baseline were found to be independently significant variables in the analysis. Knowledge of the impact of such behavioral factors on the treatment process may enable us to better understand the role of environmental contributors to opiate use. Such information may also help us to direct our limited resources and to better focus our treatment interventions.

Treatment outcomes were compared for an intervention emphasizing reinforcement for abstinence from illicit drug use and an alternative intervention which combined the same reinforcement contingencies with aversive consequences for unauthorized drug use. Sixteen polydrug abusing methadone maintenance patients were randomly assigned to one of two treatment groups. Both groups received the opportunity to take methadone doses away from the clinic (take-home dose) as reinforcement for submitting urines testing negative for illicit substances. A regular weekly take-home dose of methadone could be earned for every 2 weeks of verified abstinence from unauthorized drugs, up to a maximum of three take-home doses per week. The combined intervention group had an additional contingency which involved a reduction in methadone dose as an aversive consequence for submitting urine samples testing positive for illicit substances. Specifically, 10% of the patient's daily methadone dose was lost for each week in which two of three urines tested positive for illicit drugs. An examination of the urinalysis results indicated no between group differences. Overall, 8% of the 12-week baseline urinalysis results tested negative for illicit substances while 42% tested negative for unauthorized substances during the 20 weeks of treatment intervention. At the end of the intervention period, nine subjects remained in treatment with three patients in each group receiving at least once weekly take-home privileges. Of the seven subjects no longer in treatment, five were in the combined intervention group.(ABSTRACT TRUNCATED AT 250 WORDS)