CHAPTER 27: BEHAVIOR ANALYSIS AND TREATMENT OF DRUG ADDICTION

CHAPTER 27: BEHAVIOR ANALYSIS AND TREATMENT OF DRUG ADDICTION Fisher ch.27 Drug addiction is a very prevalent issue in the current United States society. The substance abuse treatments that are available are not effective in treating all patients and not all substance users are in treatment. There is extensive evidence suggesting that drug addiction can be viewed as operant behavior and can effectively be treated with operant conditioning. Operant principles were first applied to drug addiction in the 1960s. Some of the research points to the fact that the behavioral aspects of drug addiction are correlated with the environmental variables that have to do with how much a drug is self-administered. 1

DRUG REINFORCEMENT AND DRUG SELF-ADMINISTRATION The drugs that are self administered most often in humans and nonhumans are: cocaine, opiates, alcohol, benzodiazepines, nicotine, and marijuana. A study in 1976 showed that monkeys who were given free access to stimulants would self-administer those drugs persistently over days to the point of death. The same drugs abused by nonhumans also seem to be abused by humans. ENVIRONMENTAL MODULATION OF DRUG SELF-ADMINISTRATION A great deal of research has revealed that drug self-administration is very flexible. The same environmental variables that affect other operant behaviors can regulate drug self-administration. Drug self administration can be balanced: ü By manipulating the schedule of reinforcement ü By scheduling conditioned reinforcers ü By reinforcing alternative incompatible responses ü By altering the magnitude and immediacy of reinforcement 2

DRUG AND NONDRUG REINFORCERS A concurrent schedule, where one response produces drug reinforcement and another produces nondrug reinforcement, would provide a functioning laboratory model of human drug use. In humans, alternative reinforcers (nondrug) are typically money, tokens, or vouchers and they have been shown to decrease consumption of various drugs. ABSTINENCE REINFORCEMENT These procedures provide pretty direct reinforcement of drug abstinence. Patients provide biological samples (e.g., urine) and are rewarded when the testing confirms their drug abstinence. These operant procedures can be highly effective. 3

ABSTINENCE REINFORCEMENT IN SKID ROW ALCOHOLICS Conducted in the 1970s, these studies showed that human drug addiction could be affected by changing the consequences that went along with drug self-administration. Subjects could consume alcohol under certain controlled conditions, but they were rewarded for abstaining. Abstinence increased as time passed ABSTINENCE REINFORCEMENT IN ADULTS ENROLLED IN METHADONE TREATMENT Methadone is a chemical used in the treatment of heroin addiction and it can decrease use. Seven adult males were studied involving abstinence from opiates who were part of a methadone maintenance program. Five of the seven participants had less opiate presence in their urine samples after some time. 4

CONTINGENCY CONTRACTING WITH HEALTH PROFESSIONALS This was a case of classic contingency management utilized in the 1980s. Health professionals who had traces of drugs in their urine or who failed to provide a sample would have to surrender their medical license. You can imagine that this would decrease the temptation to use the drugs that were at their disposal. SMOKING CESSATION STUDIES Smokers participating in this study were required to leave a certain amount of money with the experimenters when beginning. They would then get small amounts back depending on their ability to abstain from smoking. All monitoring of smoking levels was self-reported. In the end, relapse was common once the program ended. The addition of a biochemical verification of whether or not the participant had actually avoided smoking produced better results in later studies. 5

QUIT AND WIN STUDIES These experiments consist of involving entire communities in the process of quitting smoking. Individuals who were proven smokers that abstained from smoking for certain periods of time were entered into a drawing of all sorts of prizes. There is limited evidence as to whether or not they are effective. VOUCHER-BASED ABSTINENCE REINFORCEMENT Up until 1991, there were no treatments that had been proven to be effective in addressing cocaine dependencies Higgins and colleagues developed a behavioral treatment approach where cocaine dependent participants could earn points for providing negative urine samples 3 X per week for 12 weeks Points printed on vouchers each point worth $.15 4 consecutive clean samples=$10 voucher earned (12 weeks continuous abstinence could = $1000 in vouchers) *contingency management Vouchers could be exchanged for goods and services that were consistent with individual treatment goals (reinforce sustained abstinence differentially) Points earned for each negative urine sample started low (10 pts) and increased by a small amount (5 pts) for each clean sample No voucher received= reset to lowest value and start over 6

COCAINE ABSTINENCE Voucher intervention proves to produce substantial increases in treatment retention and cocaine abstinence Money proves to have a higher reinforcement value then substances Higgins, Wong, Badger, Ogden, & Dantona (2000) study: ü 70 cocaine dependent participants ü contingent group & noncontingent group ü contingent group receives vouchers contingent upon negative samples ü Noncontingent group receives independent vouchers Voucher-based reinforcement for cocaine abstinence continued. Contingent Group Noncontingent Group With cocaine-negative urine samples, participants earned vouchers for 12 weeks and $1 Vermont lottery tickets 2X per week for 12 more weeks (quite the incentive!) SIGNIFICANTLY higher rates of cocaine abstinence while the intervention was in effect and 6 months after abstinence reinforcement intervention ended cocaine abstinence continued 7

Silverman, Stitzer, & Bigelow (1998) study: ü Series of studies in Baltimore City investigated effectiveness of promoting cocaine abstinence in poor, inner-city, injection drug users who persisted in using high rates of cocaine ü Patients attempting to achieve sobriety often exposed to counseling and methadone treatment ü Participants who continued cocaine use during methadone treatment during the first 4 weeks were randomly assigned to either an abstinence reinforcement group or a noncontingent yoked control group ü Abst. Reinf. Group were exposed to voucher-based abstinence reinforcement intervention in which they could earn up to $1,155 in vouchers for negative urine samples over 12 weeks ü control group receives independent vouchers ü SIGNIFICANT differences between group outcomes Roughly HALF (9 out of 19) of abstinence reinforcement participants sustained cocaine abstinence between 7 & 12 weeks Only ONE (1 out of 18) control participants achieved over 2 weeks of sustained abstinence A Cochrane Library review of randomized psychosocial treatment for cocaine addiction concludes that voucher-based reinforcement may be the most effective treatment available for cocaine addiction. pg. 457 OPIATE ABSTINENCE Methadone has proven to be effective in reducing heroin use, but this doesn t mean patients are not continuing heroin use during methadone treatment. Studies show that voucher-based abstinence reinforcement can be effective in attempting to increase opiate abstinence in methadone patients. Preston, Umbricht, & Epstein (2000) study: ü patients who continue heroin use during methadone treatment either receive an increased dose of methadone (n=31; did not affect results), voucher reinforcement of opiate abstinence (n=29; significant effect on results), both interventions (n=32), or neither (n=28). ü Voucher reinforcement participants could earn $554 in vouchers over 8 weeks opiate abstinence graph see figure 27.3 in text 8

SMOKING ABSTINENCE Voucher reinforcement shown to be effective in promoting smoking cessation in methadone patients, pregnant smokers, adolescents, and adults with schizophrenia. Higgins, Heil, Solomon, and colleagues (2004) study: ü compared outcomes of 2 groups of pregnant smokers (contingent [n=31] or noncontingent [n=27] vouchers) ü 1 st week contingent group provided biological evidence of abstinence using negative breath samples daily ü after the 1 st week, contingent group provided negative urinary cotinine results * test measures the amount of cotinine (a byproduct of nicotine) in urine* at varying frequencies depending on time in treatment (from 2X per week to every other week) until 12 weeks postpartum Voucher-based abstinence reinforcement for smoking abstinence continued Higgins 2004 study on smoking cessation showed that voucher-based reinforcement of smoking cessation in pregnant women can produce increases in fetal growth (weight, femur length, abdominal circumference) Dallery, Glenn, & Raiff (2007) study: ü Internet-based approach to promoting smoking cessation ü participant provide breath sample in front of a video camera connected to the internet which contains a meter verifying CO (carbon monoxide) levels on their breath ü reinforcement delivered if CO level displayed meets criterion for abstinence reinforcement ü Easy observations in homes, comfortable, and accessible 9

MARIJUANA ABSTINENCE Budney, Higgins, Radonovish, and Novy (2000) study: ü randomized control trial comparing effectiveness of three interventions in adults; motivational enhancement therapy, motivational enhancement therapy + cognitive-behavioral coping skills therapy, and the two treatments + voucher-based abstinence reinforcement. ü under voucher reinforcement urine samples collected 3X per week and potential $570 in vouchers depending on marijuana-negative samples over 12 weeks ü Coping skills therapy addition provided no effect ü Voucher based addition significantly increased percentage of abstinence at the end of treatment (35%) compared to other two groups (5 & 10%) PRIZE REINFORCEMENT Petry, Martin, Cooney, and Kranzler (2000) study: ü developed a modification of the voucher intervention breath or urine samples ü participants draw prize vouchers from a fishbowl contingent on providing drug-free ü vouchers = slips of papers (500) exchangeable for prizes of varying values : half containing words good job other half read small prize, large prize, or jumbo prize / worth of slips were $1, $20, & $100 ü most slips were for small prizes; only one slip was for a jumbo prize ü number of allowed draws increased upon consecutive drug-free breath or urine samples ü derivative of this study concluded that abstinence incentive participants provided significantly more stimulant-negative urine samples than did the usual care control participants (54% vs 38%) 10

IMPROVING ABSTINENCE OUTCOMES Reviews show effectiveness in abstinence reinforcement contingencies, especially in resilient patients but there are still 2 improvements to be made Not all individuals maintain abstinence Many individuals resume drug use after treatment Therefor the magnitude and durability of abstinence reinforcement can be increased IMPROVING EFFECTIVENESS Study results suggest a variety of approaches to improve abstinence outcomes Effectiveness is greater when; ü High vs low reinforcement magnitude ü Immediate vs delayed reinforcement ü Abstinence from single vs multiple drugs required ü Frequent vs less frequent drug testing Abstinence reinforcement as function of operant conditioning 3 main findings in improving effectiveness: 1. Abstinence outcomes increase as magnitude of reinforcement increases 2. Increasing reinforcement magnitude can increase abstinence in treatment-resistant patients. 3. Decreasing magnitude of reinforcers can eliminate effectiveness of intervention 11

PROMOTING LONG TERM ABSTINENCE Chronic Relapsing Disorder: Drug addiction in where patients resume drug use after exposure to all types of treatments. Though relapse is common for a portion of patients in abstinence reinforcement, not many studies have been done on promoting longterm abstinence. COMBINING ABSTINENCE REINFORCEMENT WITH RELAPSE PREVENTION COUNSELLING Abstinence reinforcement treatment (voucher reinforcement) + counselling intervention designed to prevent relapse (cognitive behavioral relapse prevention therapy) Cocaine use Cigarette smoking Methamphetamine use Voucher-based produced higher rates of abstinence than cognitivebehavioral therapy respectively Combined didn t produce higher rates than voucher-based alone 12

RELATIONSHIP BETWEEN DURING- TREATMENT AND POSTTREATMENT ABSTINENCE Duration of abstinence during treatment related to duration of abstinence after treatment Study of 125 cocaine-dependent participants exposed to behavioral counselling with voucher-based reinforcement of abstinence ABSTINENCE REINFORCEMENT AS MAINTENANCE INTERVENTION McLellan and colleagues suggest treatments for drug addictions adopt long-term health care plans, similar to treatment of chronic illnesses Extended period of abstinence reinforcement to prevent relapse Contract that simply never terminates Winett Study of abstinence reinforcement as maintenance intervention in methadone treatment facility for cocaine-users let participants in control group receive vouchers for entire year that could total to $5,800 Participants typically sustained abstinence throughout treatment with portions of participants sustaining abstinence after that point. Other participants not in control group barely achieved sustained abstinence 13

DISSEMINATION (THE ACT OF SPREADING INFORMATION) Research findings on treatments for drug addiction have not been incorporated reliably into routine clinical practice. Even data-based recommendation as simple as the appropriate methadone dose has been slowly and inconsistently adopted in community methadone programs. Abstinence reinforcement interventions have not been employed widely in community treatment programs. APPLICATION IN DRUG ABUSE TREATMENT CLINICS Researchers have focused primarily on designing abstinence reinforcement interventions for use in standard drug abuse treatment clinics. Because they have limited resources, drug abuse treatment clinics may have difficulty even supporting the frequent drug testing required to implement abstinence reinforcement contingencies. Researchers have tried to use reinforcers that are available in clinics, to devise ways to pay for reinforcers, and to use low-cost reinforcers. Take-home methadone, deposit contracting, donations from the community, and the use of available funds to purchase reinforcers for voucher-based reinforcement contingencies. Applications continued 14

Lower-magnitude reinforcement can have important beneficial effects, but as reinforcement magnitude is reduced, the magnitude of the abstinence effects are likely reduced, and possibly eliminated. Large-scale applications for cigarette smokers in worksites showed this by employing very low-magnitude reinforcement and unfortunately failing to show effects of rates of smoking cessation. Despite the need for relatively highmagnitude reinforcement, it has been suggested that some treatment systems incorporate higher-magnitude voucherbased abstinence reinforcement into routine clinical care. Based on a review done by the National Institute for Health and Clinical Excellence (NICE) that stated that voucher-based reinforcement interventions are among the most effective available psychosocial treatments for drug addiction, the National Health Service now lists voucher-based reinforcement as one of its main interventions in the treatment of drug addiction. HARNESSING EXISTING REINFORCERS BEYOND THE CLINIC Abstinence reinforcement contingencies have been integrated outside of the drug abuse treatment clinic and in contexts where high-magnitude reinforcers are sometimes available and might be harnessed for therapeutic purposes. Early applications of this were used for homeless and unemployed adults. Local agencies used goods and services (food, clothing, and other essentials), housing, and employment as reinforcers for participants. The reinforcement was contingent upon the participants abstinence. Abstinence-contingent access to employment has spread to the workplace as well. Abstinence is monitored through drug-testing programs. Substance abuse treatment services through employee assisted programs. Employees must remain abstinent in order to work and to earn wages. 15

RESEARCH FOR ABSTINENCE- CONTINGENT EMPLOYMENT The therapeutic workplace Participants were hired and paid to work, but were required to provide drug-free urine samples on a routine basis in order to gain and maintain daily access to the workplace. If a participant provided a drug-positive urine sample, they simply were not allowed to work that day (so they weren t able to get paid). However, participants were always encouraged to return the next day to try again. Participants were initially hired as trainees and earned voucher pay under a schedule of escalating pay for sustained abstinence and attendance. Eventually, participants could be hired as employees with standard paychecks. In a study where there was a therapeutic workplace group and a usual care control group, the therapeutic workplace group provided approximately twice the rate of opiate- and cocaine-negative urine samples during the first 6 months of the study, and those effects were maintained over 3 years after intake. CONCLUSION Research has shown that drugs can serve as reinforcers under a wide range of conditions and has also identified environmental conditions that modulate drug reinforcement. This provided a stable foundation for the development of effective operant treatments for drug addiction. (Mainly abstinence reinforcement) Abstinence reinforcement has proven to be effective using a range of reinforcers and contingencies as well as in many contexts (treatment clinics to the workplace). Continuous work is being done to develop procedures that ensure long-term abstinence and to ensure the spread of these procedures in society. 16