The Application of Operant Conditioning to Address Poverty and Drug Addiction

Transcription

1 The Application of Operant Conditioning to Address Poverty and Drug Addiction Kenneth Silverman No financial or non- financial relationships to disclose. Supported by NIH grants: R1 DA9426, R1 DA1317, R1 DA19497, R1 DA23864, R1 DA37314, R1 AI11765 and T32 DA729.

2 The Therapeutic Workplace An intervention to address the interrelated problems of drug addiction and poverty.

3 Collaborators JHU Faculty Maxine L. Stitzer George E. Bigelow Eric C. Strain Dace Svikis Michael Fingerhood Conrad J. Wong Annie Umbricht Sigurdur Sigurdsson Anthony DeFulio August F. Holtyn Software Developers Michael Grabinski Leonard Onyiah Postdoctoral Fellows Elias Robles-Sotelo Jesse Dallery Darlene Crone-Todd Todd W. Knealing Wendy D. Donlin Anthony DeFulio Jeffrey J. Everly Will M. Aklin Kelly E. Dunn Mikhail N. Koffarnus August F. Holtyn Brantley Jarvis Shrinidhi Subramaniam

4 Poverty is Associated with Poor Health Obesity: Drewnowski et al. (24). Am J Clin Nutr. 79, 6-16 Smoking: Hiscock et al. (212). Ann. N. Y. Acad Sci, 1248, HIV: Oldenburg et al. (214). AIDS, 28, Heart Failure: Hawkins et al. (212). Eur J Heart Fail, 14, Stroke: Addo et al. (212). Stroke, 43, Cancer: Ward et al. (24). CA Cancer J Clin, 54, Injection Drug Use: Armstrong (27). Arch Int Med, 167, Death: Muennig, et al. (21). Am J Public Health, 1, Silverman, Holtyn and Jarvis (216). Preventive Medicine, 92,

5 Poverty is Associated with Shortened Lifespan Chetty et al. (216). JAMA, 315,

6 Poverty is Associated with Shortened Lifespan 1 yrs 15 yrs Chetty et al. (216). JAMA, 315,

7 Poverty is Associated with Shortened Lifespan 1 yrs equivalent to decrement in longevity from lifetime smoking 15 yrs Chetty et al. (216). JAMA, 315,

8 Relative HIV Rates in Drug Users in High Poverty Areas in US Adapted from Denning, et al. (21).

9 HIV Diagnoses by Poverty in 11 US States (N=11,252) CDC (215). HIV Surveillance Supplemental Report, 2 (No. 5): [pages]. Silverman, Holtyn and Jarvis (under review). Preventive Medicine.

10 HIV Diagnoses by Poverty, Education, Unemployment CDC (215). HIV Surveillance Supplemental Report, 2 (No. 5): [pages]. Silverman, Holtyn and Jarvis (under review). Preventive Medicine.

11 Injection Drug Use by SES (NHSDA) * * * * P.5 Armstrong (27). Archives of Internal Medicine, 167,

12 Promoting Health In People Who Live in Poverty Develop interventions that promote health behaviors in people who live in poverty Develop interventions to reduce poverty Silverman, Holtyn and Jarvis (216). Preventive Medicine, 92,

13 Drug Addiction In People Who Live in Poverty Develop interventions that promote drug abstinence in people who live in poverty Develop interventions to reduce poverty in low-income adults who have long histories of drug addiction Silverman, Holtyn and Jarvis (216). Preventive Medicine, 92,

14 Develop Interventions that Promote Drug Abstinence in People Who Live in Poverty Silverman, Holtyn and Jarvis (216). Preventive Medicine, 92,

15 Abstinence Reinforcement Interventions Target Drug- Free Urine Consequence Money or Privilege Bigelow et al. (1981). Addictive Behaviors, 6,

16 Voucher-Based Reinforcement-Higgins et al Drug-Free Urine $ Voucher $ $ $ Goods & Services (e.g., shoes) Higgins et al. (1991). The American Journal of Psychiatry, 148,

17 Abstinence Reinforcement is an Effective Approach Meta-Analysis of Psychosocial Treatments Dutra et al. (28). Am J Psychiatry, 165, Review of Cocaine Addiction Treatments Knapp et al. (27). Cochrane Rev Jul 18;(3): CD323 National Institute on Health and Clinical Excellence (NICE) Review of Psychosocial Interventions Pilling et al. (27). British Medical Journal, 335, Review of Interventions for Pregnant Smokers Lumley et al. (29). Cochrane Rev. Jul 8;(3):CD155

18 Parameters Key to Effectiveness Reinforcement magnitude Nader and Woolverton (1991). Psychopharmacology, 15, Stitzer and Bigelow (1983). Behavior Therapy, 14, Stitzer and Bigelow (1984). J Applied Behavior Anal, 17, Silverman et al. (1999). Psychopharmacology, 146, Dallery et al. (21), Exp Clin Psychopharmacology, 9, Petry et al. (24). Addiction, 99, Higgins et al. (27). Addiction,12,

19 Relapse is Common After Reinforcement Ends Alcohol and Benzodiazpines Miller et al. (1974). Behaviour Research and Therapy, 12, Stitzer et al. (1982). Journal of Applied Behavior Analysis, 15, Cigarettes Shoptaw et al. (22). Addiction, 97, Heil et al. (28). Addiction, 13, Cocaine Silverman et al. (1996). Archives of Gen Psychiatry, 53, Silverman et al., (1998). Journal Consul &Clinical Psychology, 66, Silverman et al. (1999). Psychopharmacology, 146, Heroin Stitzer et al. (198). Addictive Behaviors, 5, Silverman et al. (1996). Drug and Alcohol Dependence, 41, Preston et al. (22). Drug and Alcohol Dependence, 67,

20 A Laboratory Model of a Therapeutic Workplace Employment-Based Abstinence Reinforcement Drug-Free Urine Work Wages

21 Phases of Therapeutic Workplace Treatment PHASE 1: Training and Abstinence Initiation PHASE 2: Therapeutic Workplace Business JOB: Training JOB: Work PAY: Vouchers PAY: Paycheck DURATION: Limited DURATION: Unlimited

22 Phase 2 Phase 1 Models for Maintaining Abstinence Adult Program Reinforcement Therapeutic Workplace Adult Education & Job Skills Training Learning & Health Incentives* Social Business* Cooperative Employer IPS & Wage Supplement Abstinence- Contingent Employment* Abstinence- Contingent Employment Abstinence- Contingent Wage Supplements Silverman et al., (216). Trans Issues In Psychological Science, 2,

23 A Therapeutic Workplace Social Business Silverman et al. (25). Behavior Modification, 29,

24 Promoting Cocaine Abstinence in Methadone Patients Cocaine use is widespread in methadone patients Hser et al. (1998). J of Substance Abuse Treatment, 15, Injection and crack cocaine use associated with increase risk of HIV infection - Chaisson et al. (1989). JAMA, 261, Grella et al. (1997). Drug and Alcohol Dependence, 37, 15-21

25 Initial Clinical Trial: Evaluation of Prototype Random Assignment Phase 1 Phase 2 Therapeutic Workplace (n=2) Center for Addiction & Pregnancy Usual Care Control (n=2) Years Silverman et al. (21, 22). Experimental and Clinical Psychopharmacology. Aklin et al. (214). Journal of Substance Abuse Treatment, 47,

26 Attendance in the Therapeutic Workplace Over 4 Yrs Participants Weekdays Silverman et al. (21, 22). Experimental and Clinical Psychopharmacology. Aklin et al. (214). 25 Journal 5 of 75 Substance 1 Abuse 125 Treatment, ,

27 Maintenance of Cocaine Abstinence Silverman et al. (21, 22). Experimental and Clinical Psychopharmacology. Aklin et al. (214). Journal of Substance Abuse Treatment, 47,

28 Cocaine Abstinence Aklin et al. (214). Journal of Substance Abuse Treatment, 47,

29 Cocaine Abstinence Aklin et al. (214). Journal of Substance Abuse Treatment, 47,

30 Employment Outcomes Aklin et al. (214). Journal of Substance Abuse Treatment, 47,

31 Employment Outcomes Aklin et al. (214). Journal of Substance Abuse Treatment, 47,

32 Therapeutic Workplace Business to Maintain Abstinence 75 Enrolled (N = 128) 5 Random Assignment Abstinence-Contingent Employment (n =27) Abstinence & Employment 25 Abstinence Contingent Work (N = 51) Employment Only (n = 24) Phase 1 Consecutive Weeks Phase 2 Consecutive Months DeFulio et al. (29). Addiction, 14,

33 Monday, Wednesday, Friday Urinalysis - Cocaine Positive - Cocaine Negative DeFulio et al. (29). Addiction, 14,

34 Monday, Wednesday, Friday Urinalysis - Cocaine Positive - Cocaine Negative DeFulio et al. (29). Addiction, 14,

35 Cocaine Abstinence in Year of Phase 2 Employment Percentage Cocaine Negative Employment Only Abstinence & Employment Group Mean Individual Subject OR = 3.88 ( ) P =.1 DeFulio et al. (29). Addiction, 14,

36 Attendance in Year of Phase 2 Employment Hours Worked Hours Worked Abstinence-Contingent Employment Abstinence-Contingent Employment Employment Only Abstinence-Contingent Employment Employment Only Employment Only DeFulio et al. (29). Addiction, 14,

37 Post-Treatment Cocaine Abstinence P = NS OR = 4.57 ( ) P=.1 DeFulio et al. (211). Addiction, 16,

38 Post-Treatment Cocaine Abstinence P = NS OR = 4.57 ( ) P=.1 DeFulio et al. (211). Addiction, 16,

39 Post-Treatment Cocaine Abstinence P = NS OR = 4.57 ( ) P=.1 DeFulio et al. (211). Addiction, 16,

40 Summary of Main Studies Silverman (24) Behavior Analyst, 27, Silverman et al. (212). Preventive Medicine, 55, S46 S53.

41 Developing Interventions to Reduce Poverty

42 Anti-Poverty Programs in the United States Large-scale implementation Limited effectiveness Little evaluation of elements Bitler and Karoly (215). J.Policy Anal.Manage. 34,

43 Conditional Cash Transfer for Low-Income Families Riccio et al. (213).

44 Incentives in Anti-Poverty Programs Program Location N Population Training Stipends Opening Doors Louisiana 1,19 Parents X Wage Supplements Performance Scholarship Ohio 2,285 Parents X Performance Scholarship New York 1,52 Adults X New Hope Wisconsin 1,362 Welfare X Jobs First Conneticut 4,83 Welfare X ERAP Texas 5,331 Welfare X Opportunity NYC New York, NY 4,8 Families X X Opportunity NYC 2. New York, NY 2,4 Families X X Holtyn et al. (217). Journal of the Experimental Analysis of Behavior.

45 Wage Supplements for Low Income Adults * = P<.5 Holtyn et al. (217). Journal of the Experimental Analysis of Behavior.

46 Features That May Limit Effectiveness Delay to incentive payment Incentives delivered infrequently Large response requirements Small incentive magnitudes Lack of prerequisite skills Incentive system not clearly described Holtyn et al. (217). Journal of the Experimental Analysis of Behavior.

47 Therapeutic Workplace Anti-Poverty Program Education and job skills training Silverman et al. (27). Subst. Use & Misuse, 42, IPS supported employment Bond et al. (212). World Psychiatry. 11, Abstinence-contingent wage supplements Berlin et al. (27),The Future of Children 17, Michalopoulos et al.( 25). on

48 Poverty Rates by Educational Level in US (212) U.S. Census Bureau, Current Population Survey, 213 Annual Social and Economic Supplement.

49 Participants with High School Education Across Studies Total N = 569 Holtyn et al. (215). Journal of Vocational Rehabilitation. 42,

50 Academic Levels of Therapeutic Workplace Participants Holtyn et al. (215). Journal of Vocational Rehabilitation. 42,

51 Incentives to Promote Education and Training Attendance in training Silverman et al. (1996). Drug and Alcohol Dependence, 41, Koffarnus et al. (211). Alcohol and Alcoholism, 46, Punctuality and complete work shifts Wong et al. (24). Exp and Clinical Psychopharmacology, 12, Wong et al. (24). Drug and Alcohol Dependence, 74, Productivity on training programs Wong et al. (23). Exp and Clinical Psychopharmacology, 11, Koffarnus et al. (213). J of Applied Behavior Analysis, 46, Koffarnus et al. (213). J of Applied Behavior Analysis, 46, DeFulio et al. (29). J of Applied Behavior Analysis, 42, Subramaniam et al. (217). Behavior Analysis: Research and Practice.

52 Effect of Monetary Incentives on Performance Typing Program Keypad Program Koffarnus et al. (213). Journal of Applied Behavior Analysis, 46,

53 Effect of Monetary Incentives on Performance Population: Out-of-treatment injection drug users Study Groups: Group A Typing program: Keypad program: Group B Typing program: Keypad program: Performance Pay Hourly Pay Hourly Pay Performance Pay Koffarnus et al. (213). Journal of Applied Behavior Analysis, 46,

54 One-Minute Timings Per Hour Effects of Performance Pay on Work Output Productivity Pay Hourly Pay Study Week Koffarnus et al. (213). Journal of Applied Behavior Analysis, 46,

55 One-Minute Timings Per Hour Effects of Performance Pay on Work Output Study Week Study week Productivity pay Hourly pay Typing Keypad Koffarnus et al. (213). Journal of Applied Behavior Analysis, 46,

56 Effects of Performance Pay on Work Output *** *** One-min Timings per Hour in Workplace Productivity Pay Hourly Pay Typing Keypad Keypad Typing Group A Group B Koffarnus et al. (213). Journal of Applied Behavior Analysis, 46,

57 Liking Ratings of Performance Pay and Hourly Pay * ** Loved It: 1 Typing and Keypad VAS Ratings Productivity Pay Hourly Pay Hated It: Typing Group A Keypad Keypad Group B Typing Koffarnus et al. (213). Journal of Applied Behavior Analysis, 46,

58 ATTAIN: Stipend-Supported Computer-Based Training Authoring and course presentation system Can create courses on wide range of topics Easy creation of courses without programming Teach skills to high levels of accuracy and speed Integrates stipends for training performance Kenneth Silverman Johns Hopkins University SOM Michael Grabinski Red 5 Group, LLC

59 Percentage Retained in Workpla Percentage Retained in Workpla Abstinence-Contingent Wage Supplements Enrolled Random Assignment Abstinence Contingent Work IPS & Abstinence-Contingent Wage Supplements Abstinence Abstinence & & & Employment Employment Individual Placement & Support (IPS) Phase 1Phase 1Consecutive 1 Weeks Phase 2Phase 2 2 Consecutive Consecutive Months Months R1 DA37314, In Progress

60 American Substance Abuse Professionals &

61 Abstinence-Contingent Wage Supplements (ACWS) R1 DA37314, In Progress

62 A Model of a Comprehensive Anti-Poverty Program Adult Program Therapeutic Workplace Adult Education & Job Skills Training Learning & Health Incentives* Infant, Child & Adolesent Program Early Intervention Learning Center to 5 Years Learning & Health Incentives Social Business* Abstinence- Contingent Employment* Cooperative Employer Abstinence- Contingent Employment IPS & Wage Supplement Abstinence- Contingent Wage Supplements After School and Summer Learning Center 6 to 18 Years Learning & Health Incentives Silverman, Holtyn and Jarvis (216). Preventive Medicine, 92,

63 Drug Addiction In People Who Live in Poverty The Therapeutic Workplace can promote and maintain drug abstinence in people who live in poverty The Therapeutic Workplace may be useful in reducing poverty in low-income adults who have long histories of drug addiction, but more research is needed Silverman, Holtyn and Jarvis (216). Preventive Medicine, 92,