Abstinence reinforcement maintenance contingency and one-year follow-up

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Abstract

Background: Relapse to drug use is often seen when contingencies designed to reduce drug use are discontinued. This paper reports on a stepdown maintenance contingency and 1-year follow-up in 110 patients who were maintained on methadone (50 or 70 mg/day) and who had completed a contingency management trial targeted to decreasing their opiate use. In the prior study (induction phase, 8 weeks) participants received vouchers for each opiate-negative urine screen or noncontingently. Methods: In this study (maintenance phase, 12 weeks), participants were rerandomized to receive vouchers and take-home methadone doses contingent on providing opiate-negative urine specimens (N=55) or noncontingently (N=55). Since participants had been rerandomized from induction-phase contingencies, most study data were analyzed as if from a 2×2 (induction×maintenance) design. Follow-up interviews were conducted at 3, 6, and 12 months after study participation. Results: Patients who received the maintenance contingency following an 8-week induction contingency had better outcomes than those who received noncontingent incentives in either the maintenance or induction phases of the trial. Good outcome at follow-up was predicted by enrollment in methadone maintenance after the study. Significantly more participants in the maintenance contingency group transferred directly to another methadone program. Conclusion: These findings support the therapeutic value of extending the duration of contingency management and long-term methadone maintenance.

Introduction

Heroin abuse and dependence is a serious problem that is associated with high levels of morbidity, mortality, and social disruption (Hser et al., 2001, Mark et al., 2001, Goldstein and Herrera, 1995). Methadone is an effective treatment of heroin dependence when given as a maintenance medication. While it has some therapeutic effect when given alone, methadone's effects are greatly enhanced when daily medication administration is combined with counseling and other psychosocial services. Benefits of methadone maintenance plus psychosocial treatment include reductions in illicit drug use, crime, HIV risk, and death, and improvement in employment and social adjustment (Gossop et al., 2001, Zanis and Woody, 1998, Zaric et al., 2001, Goldstein and Herrera, 1995, Bell et al., 1997, McLellan et al., 1993).

One psychosocial adjuvant treatment with demonstrated efficacy is contingency management. Contingency management is based on operant principles whose effectiveness has been demonstrated both preclinically and clinically (Bigelow and Silverman, 1999). Contingent reinforcement of target behaviors, such as drug abstinence and participation in treatment activities, can be a powerful tool in establishing positive behavioral changes in drug abusers (Higgins et al., 1986 Kidorf and Stitzer, 1996 McCaul et al., 1984 Stitzer et al., 1992). One of the most effective applications of the procedure has used a monetary-based escalating reinforcement schedule in which an incentive given for drug-negative urine specimens increases in value with each consecutive incentive earned; drug-positive and missed specimen collections result in loss of the incentive and a return of the next earned incentive to the original value (Higgins et al., 1991, Higgins et al., 1993). This procedure has been used successfully to decrease illicit drug use in non-opioid abusers as well as in patients in methadone clinics (Higgins et al., 1994, Higgins et al., 2000a, Higgins et al., 2000b, Silverman et al., 1996a, Silverman et al., 1998, Kirby et al., 1998).

Even when treatment succeeds and drug use is reduced, patients and their treatment providers continue to face the formidable challenge of relapse prevention (Tims and Leukefeld, 1986). Concerns about relapse following contingency management treatment have been raised because the duration of treatment and availability of external incentives are usually time limited. Relatively rapid relapse to drug use in a portion of patients has been seen in the few studies that closely monitored patients for a period of time after discontinuation of contingent reinforcement of abstinence (Silverman et al., 1996a, Silverman et al., 1996b, Silverman et al., 1998, Preston et al., 2001). There is evidence that the benefits of contingency management are long lasting and can still be seen 12 months after it is discontinued (Higgins et al., 2000b), but it would nonetheless be useful to have the option of a maintenance contingency. To be sustainable over long periods, such a contingency would probably have to rely on fixed-value rather than escalating-value reinforcers. The transition from an escalating-voucher schedule to a fixed-amount schedule would represent a subjective step ‘down’ for the patient, and thus might backfire by inducing negative contrast (Flaherty, 1982). However, we have obtained encouraging data from a stepdown contingency in patients for whom the targeted drug was cocaine (Preston et al., 2001); these data suggested that a stepdown contingency can maintain reductions in cocaine use.

The present study was run concurrently with the cocaine study (Preston et al., 2001), targeting opiates rather than cocaine. Patients who completed a study of the interaction between a methadone dose increase and a contingency management intervention (in which the value of contingent incentives increased with consecutive opiate-negative urine specimens) were switched to a nonescalating reinforcement schedule (with fixed-amount vouchers and take-home doses given as incentives for negative urine specimens). This was tested against a control procedure in which the same fixed-amount vouchers and take-home doses were given noncontingently. Since participants were rerandomized from two contingency groups in the prior study, most data were analyzed as if from a 2×2 design. Follow-up data were collected for 1 year after the end of the maintenance contingency. We hypothesized that the group with the longest exposure to contingent reinforcement would have greater opiate abstinence in the maintenance phase and better long-term outcomes than the other three groups, despite the ‘stepping down’ of the reinforcement schedule.

Section snippets

Participants

The participants in this study had recently completed a clinical trial evaluating the interaction between a behavioral therapy and a modest pharmacotherapy at the treatment research program of the National Institute on Drug Abuse (NIDA) Intramural Research Program in Baltimore, MD (Preston et al., 2000). Males and females were eligible for the treatment research protocol if they were between the ages of 18 and 65, if they qualified for methadone maintenance according to the Food and Drug

Participant characteristics

A total of 110 participants who completed the initial trial (out of 120) were randomized to one of the groups in the present study. Demographic information for the maintenance Contingent and Noncontingent Groups is shown in Table 1. Approximately half in each group were receiving 70 mg/day and half 50 mg/day of methadone. Among the 43 variables compared across the two groups, differences with P values ≤0.10 across groups were found for four: days of sedative or tranquilizer use in the last 30

Discussion

The present study evaluated a maintenance contingency that extended the duration of contingency-management treatment and was nonescalating and comparatively modest. The maintenance contingency's effects appeared accordingly modest themselves. In fact, when assessed on its own, the maintenance contingency did not have a significant effect on opiate use (except by self-report) or on any other outcome variables during the maintenance phase or across the follow-up period. Nevertheless, the best

Acknowledgements

This study was supported by the Intramural Research Program of the National Institute on Drug Abuse (NIDA). We are grateful to the Archway treatment staff and technicians and to Robert Brooner who monitored the methadone maintenance treatment.

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