By John Grabowski, Howard Rhoades, Ronith Elk, Joy Schmitz, and Daniel Creson
INTRODUCTION
Behavioral Approaches Behavioral interventions for treatment of drug dependence have been developed over the last three decades. They involve systematic manipulation of a broad range of treatment conditions and are important for both understanding and treating features of these disorders.
Their utility resides in the focus on drug-seeking and drugtaking, collection of specific data on individual patterns of drug dependence and abuse, and adapting the elements of treatment to the patients’ needs.
Behavioral approaches also emphasize strategies that actively extend to the patients’ everyday life, thereby assuring that behavioral change will endure after treatment ends.
This is best represented by the work of Higgins and Budney (1993). The terms “behavioral intervention,” “behavior modification,” “behavior therapy,” and “behavioral treatment” often are used interchangeably and describe a variety of therapeutic elements. Each originally emphasized some concepts over others.
While cognitive therapies presume that changing speech and “thinking” changes behavior, behavioral approaches focus on more tangible representations of behavior. All derive from the underlying framework that assumes that altering relationships between behavior and its environmental determinants is critical to change.
Thus, for example, Childress and colleagues (1993) focus on behavior following a model originally proposed for application to drug abuse by Wikler (1948) and O’Brien (1977, 1991).
Changes in responses are presumed to contribute to change in other behaviors such as drug-seeking and drug-taking. Hunt and Azrin (1973), Stitzer et al. (1985), Bigelow et al. (1984), Higgins and coworkers (1992), Higgins and Budney (1993), and others focused on operant, or instrumental, behavior based on a model explicated by Skinner (1953).
Modification of the behaviors of drug-seeking and drug-taking is presumed to alter physiological and cognitive correlates. Each approach emphasizes specific techniques and is derived from observations and assumptions about determinants of drug abuse.
The unifying strategy is detailed analyses of specific events surrounding drug abuse and application through regimens designed to alter measurable behavior. Within this framework, drugs of abuse are considered to serve as reinforcers, and in that regard they share many of the same characteristics of other events sustaining behavior.
Drug-taking is considered to be an orderly behavior that results from the interaction of fundamental biologic and behavioral processes.
These perspectives have fostered innovative treatment interventions that focus on the interplay of environmental, behavioral, and pharmacological factors and have been the focus of other National Institute on Drug Abuse (NIDA) reviews (e.g., Krasnegor 1979; Thompson and Johanson 1981; Grabowski et al. 1984; Ray 1988). A critical feature of these efforts is the focus on the relationship between drug-taking and its consequences and, in turn, on establishing a similarly persistent relationship between treatment-oriented behavior and its consequences and ensuring that behavioral change endures.
Explicit application of behavioral approaches has made only limited inroads in traditional treatment environments (e.g., Thompson et al. 1984; Schuster and Silverman 1993), despite extensive research and positive findings indicating unique contributions. Unfortunately, to the extent that behavioral interventions have been acknowledged, they often are linked to the elimination of “problem behaviors,” while other therapeutic strategies are proposed to form the basis for developing positive behaviors.
For example, Woody and colleagues (1984) described behavioral interventions in terms of loitering, gun toting, and drug dealing, while psychotherapy was viewed as the intervention of choice for achieving positive goals, The work of Crowley (1984) and, more recently, of Higgins and Budney (1993) points to use of a spectrum of combined therapeutic elements to develop adaptive behaviors.
All Clinics Have Contingencies
Many clinicians do not refer to their techniques as behavioral interventions, while others simply ignore or eschew behavioral approaches.
However, the very character and framing of therapy dictates that the principles are used, labeled or not. Behavior therapists often refer to “contingencies for reinforcement.”
These specify the relationship between behavior and consequences. Thus, in every clinic, certain behaviors have consequences even if that reaction is punishment or inaction. Typically, contingencies are not recognized or manipulated in a systematic fashion directed at enhancing treatment.
The authors’ thesis is that these often-unspecified contingencies should be made explicit and consistent with treatment goals, then systematically applied. The point of application may range from a single behavior of an individual to an entire treatment system (Thompson et al. 1984).
This chapter illustrates first that common elements of standard treatment settings can be addressed readily from a behavioral perspective rather than being ignored or considered annoyances of clinical systems. The behavioral-environmental features of studies described here were designed, in part, to explicate interventions in the context of standard clinic procedures.
The chapter also describes successive levels of increasingly specific and individualized applications of behavioral approaches. Studies will be summarized with reference to data on clinic function, take-home doses of medications, group contingencies, and, finally, individualized interventions for specific behavioral problems.
A major goal of this chapter is to describe strategies that permit standard drug abuse treatment clinics to operate more effectively (also see Elk et al., in press-a).
GOALS AND IMPLEMENTATION
The goal of implementing clinicwide contingencies is to provide a systemic and systematic foundation for maintenance of treatmentoriented behavior while reducing problems considered endemic and integral to clinics, drug abuse treatment, and the patient population.
Global fixed contingencies for reinforcement and punishment of a variety of behaviors, both adaptive and maladaptive, can be implemented. Thus, for example, many clinics have provisions for gun toting, loitering, and drug dealing, but they should not be the foremost considerations of treatment. In fact, they can be framed as clinicwide contingencies sustaining adaptive behaviors.
These treatment-oriented behaviors include arriving on time, remaining only for necessary activities, complying with the regimen(s), completing necessary paperwork, providing blood and urine samples when required, and generally using the clinic as a treatment site.
This goal is dependent on the clarity of the contingencies and the consistency of their application and requires no more effort than implementation of traditional systems.
Implementation of manipulated contingencies common to a group of patients similarly requires little more effort than other commonly used formulae. An example is the use of take-home doses of methadone provided contingent on opiate- or cocaine-free urine samples to modify behavior.
A patient who does not use other opiates in one week may receive a specified number of take-home doses in the next week. Conversely, use of opiates during a week when take-home doses of methadone are available produces a requirement for daily visits (no take-home doses) in the subsequent week.
This contingency for all patients receiving methadone can be expected to produce behavioral change in some members of the larger group when systematically applied. Lack of change in behavior of other patients dictates the need for additional or alternative strategies similarly implemented for a subset of patients.
The advantage of this dynamic approach resides in systematic collection of information that then determines modifications of the treatment contingent on specific patient behaviors.
Surprisingly, these techniques are commonly thought to be the unique province of research-oriented clinics. Yet they can be readily applied, and their absence in standard treatment clinics may reduce treatment efficacy. The next level of individualized contingencies in treatment has two stages that may be viewed as fixed contingencies applied to the behavior of individuals or as more refined variable-shaping procedures that are adjusted repeatedly based on one or more individual behavioral patterns.
These may be more labor-intensive interventions, but they are no different from the development of detailed individualized treatment plans. Based on intake data, individualized elements of treatment can be prescribed.
This orientation provides for sequential implementation of the elements of treatment. For example, elimination of cocaine use in a pregnant, drug-abusing female may be achieved by providing reinforcers for each successive day for which quantitative or semiquantitative urine screens indicate reduced cocaine use.
Compliance with a rigorous medication regimen for a tuberculosis- (TB-) positive male and concurrent reduction in cocaine use may be similarly tailored on an individual basis. The procedures can be implemented sequentially or concurrently. Patients first may be exposed to the general requirements and successively to the specific approaches. Alternatively, all levels may be introduced within days of intake.
IMPLEMENTATION OF CLINICWIDE CONDITIONS OF TREATMENT
Basic “Rules”
In the authors’ clinic, which primarily treats cocaine and opiate dependent patients, the basic contingencies are defined clearly as an integral part of treatment and treatment research (see table 1). Details described in this table permit improved strategies for providing treatment as well as conducting research.
Potential subject-patients participate in an initial telephone screening interview. All procedures are implemented as they might be at any high-quality health care facility, and patients are treated accordingly. Meeting the basic criteria leads to an immediately specified appointment for intake procedures.
The intake process is carefully scheduled and links elements important to inclusion or exclusion. This assures that less-costly elements are carried out first so that false positives are screened out early. This saves patient and staff time as well as money. An initial interview is followed by a general medical evaluation.
The intake process leads to group assignment and medication dispensing for opiate or cocaine dependence at the earliest time, often the same day but always within 24 hours.
------
TABLE 1 [see source article].
--------
This table lists issues and behaviors that emerge in most drug dependence treatment clinics, although which problems are most frequent is population dependent. Focus on these issues often interferes with service delivery. Generic provisions can be added or eliminated as needed. Positive (“+”) and negative (“-”) consequences must be clearly stated and systematically applied. The goal is specification of positive consequences for which the absence of that consequence is itself unpleasant.
Failure to comply with items 9 and 10 has the consequences of warnings and potential discharge. Some issues, such as discussion of accuracy of laboratory drug screen results, have neither positive nor negative consequences; they are not open for discussion, just as blood pressure readings are medical test results generally accepted and not points for contention.
Examples of Fixed Clinicwide Contingencies for Patients and the Nature of Consequences 1. Regular attendance for continued treatment+/- 2. Maintain appointment time for counseling+/- 3. Maintain appointment time for medication+/- 4. Complete data and information update forms+/- 5. Return of medication bottles+/- 6. Provide urine samples for drug screens as scheduled+/- 7. Arrive and depart in reasonable time (“no loitering”)- 8.
Maintain clean air (“no smoking”)- 9. Contribute to a physically healthy clinic (“no weapons”)- 10. Support the clinic as the sole vendor (“no drug dealing”)- 11. Responsiveness to chemistry laboratory findings (“no arguing”)o Patients are provided with medication time options from three 1-hour periods scheduled daily–early morning, midday, or early evening. Similarly, a fixed counseling time is determined in consultation with the patient.
All data and information collection activities are scheduled to reduce inconvenience for the patient. The basic requirements are described in both the intake and consent procedures and in the first counseling session. Urine screens, routinely collected under observation, are described to the patient as essential medical evaluations for treatment and research.
The difficulties of this process have been eased by using a video recording system with tapes reviewed daily by nurses rather than using a live micturition monitor. Finally, there is an inclusive and clearly stated contingency surrounding treatment; it is that 75 percent of all specified data collection points and visits must be met for the patient to be considered to be “in treatment.”
This provides the patient some leeway, assures that there is contact with the provisions of treatment, provides certainty with respect to sufficient data, and assures a clear criterion for dropout. The result of clearly specified contingencies for basic clinic- and treatment-oriented behavior is that only 5 (of over 700) patients have been discharged in the last 4 years of operation due to the serious problems more common in other clinics.
The relatively high rate of compliance independent of individualized treatment contingencies, in part, may be related to a decent and positive environment in which treatment is provided. In brief, clearly labeled, systematically applied contingencies for participation in treatment appear to have a palliative effect in provision of treatment, even in what is construed to be a difficult population.
Large-N Studies With Fixed Group Conditions
The goal of the authors’ primary studies has been to examine specific components of real treatment. The focus of the research is the joint action of behavioral and pharmacological elements.
In a series of studies, the first step was to examine fixed treatment requirements involving visit frequency. The question was whether being required to visit the clinic more frequently (5 days per week) or less frequently (2 days per week) affected outcome. These requirements meet the criterion of contingencies for reinforcement to the extent that a patient’s behavior determines whether or not he or she will be maintained in treatment.
They are characteristic of standard treatments that typically require a fixed number of visits per week to preclude discharge. Identifying optimal visit frequency is an important issue for cost and effectiveness. Two large studies have addressed the role of take-home dose frequency or visit frequency as a condition of treatment in relation to medication doses (Grabowski et al. 1992a, 19926; Rhoades et al. 1992a).
The importance of medication dose is clear, and medication dose can be expected to interact with other features of treatment. The impetus for examination of take-home dose or visit frequency derives from two sources.
In part, it emanates from findings in behaviorally based studies indicating that contingent take-home doses can be an effective reinforcer (e.g., Bigelow et al. 1984). Beyond potential reinforcing value, this variable was of considerable interest for two pragmatic reasons.
First, it may affect retention, and ultimately success, in treatment independent of manipulating its frequency in a contingent manner. Second, and obviously important, the number of visits per unit time determines the number of patients who can be served by a clinic within available resources. In one ongoing study of primary opiate dependent patients (Rhoades et al. 1992a, two doses of methadone (50 and 80 mg) were examined in relation to two take-home conditions.
Patients received either 2 or 5 take-home doses of methadone each week. Conversely, they were required to visit the clinic either 5 or 2 days per week. Special dispensation was obtained from the Food and Drug Administration and Drug Enforcement Agency to conduct these studies in which takehome requirements other than those provided for by regulation could be implemented; thus, patients were permitted to have take-home doses from the beginning of treatment (Rhoades et al. 1992a).
In a second parallel study with primary cocaine-dependent patients (Grabowski et al. 1992a, submitted), three medication conditions–two fluoxetine doses (20 mg and 40 mg) and placebo–also were examined in relation to two visit conditions–two or five per week. While there was no manipulation of conditions during treatment, the underlying contingencies for reinforcement prevailed as they do in any clinic.
These studies emulate the conditions of traditional clinics, in which failure to comply with the requirements could produce discharge or dropout status. Conditions were specified clearly and consistently implemented. The major independent variables were medication dose and take-home frequency, while the major dependent measures were retention and illicit drug use. The preliminary interim results for retention with primary opiate dependent patients are presented in figure 1.
Methadone take-home frequency (and hence clinic visit frequency) was clearly a determinant of retention. Patients receiving more take-home doses remained in treatment for longer periods. Opiate-positive urine results did not differ as a function of frequency within groups at the same methadone dose, but they did differ across the two dosage levels.
Opiate-positive urine screens were less frequent, occurring at a rate of about 10 percent, in patients receiving the higher methadone medication dose; the higher dose had the expected effect of greater reductions in illicit opiate use. One of the main results of this study addresses the question raised by
Childress and coworkers (1991) regarding minimum required conditions in methadone maintenance. In this case, within identical counseling, drug screen, and other treatment elements, takehome frequency and dose determined retention.
Minimum required conditions are driven, in part, by patient characteristics and goals, but it is clear that visit frequency can have pronounced effects. The retention results for the study with primary cocaine dependent patients are presented in figure 2 and also indicate the importance of general visit requirements. Clinic visit frequency was a determinant of retention.
Cocaine-positive urine screens did not differ significantly across groups regardless of fluoxetine dose or visit frequency (Grabowski et al., submitted). Framed as either clinic visits or take-home frequency, this variable is a major and important feature of treatment.
It was codified in methadone regulations and also is typically an issue of discussion with respect to cocaine-dependent patients. However, it must be noted with respect to methadone regulations that the requirements are imprecise, are not optimal, and were not substantially data based. Specifically, the low (50 mg) and high (80 mg) doses of methadone combined with high-frequency take-home dose produced the best results with respect to retention. High-frequency take-home doses and, thus, fewer clinic visits also had no untoward or differential effects in cocaine-dependent patients in terms of retention.
Subject Retention by Dose and Take-Home Frequency
FIGURE 1. Patients received low- (2/wk) or high- (5/wk) frequency take-home doses of methadone and visited the clinic either 5 or 2 days/week. Patients in these groups received either 50 mg or 80 mg of methadone. Retention data are presented as a function of these four conditions. KEY: HF=high frequency; LF=low frequency; B=baseline Subject Retention by Dose and Take-Home Frequency
FIGURE 2. Patients received low- (2/wk) or high- (5/wk) frequency take-home doses of methadone and visited the clinic either 5 or 2 days/week. Patients in these groups received either 20 mg or 40 mg of fluoxetine or placebo. Retention data are presented as a function of these six conditions. KEY: HF=high frequency; LF=low frequency; PBO=placebo
There are complexities to the data relevant to treatment. A clinically important collateral finding emerged with the higher dose of methadone. While opiate-positive urine screens were less frequent, cocaine-positive urine screens were more frequent, and this difference was statistically significant.
This does not argue against the use of higher doses of methadone, which contributes to reduced human immunodeficiency virus (HIV) transmission risk, but it does indicate the need for explicit manipulation of contingencies surrounding cocaine use or, at least, careful adjustment of methadone dosing to reach an optimal balance (Grabowski et al. 1993). Placebo was more effective than either dose of fluoxetine within the take-home condition (Grabowski et al., submitted).
An important, but not surprising, collateral finding (Grabowski et al. 1992a) was that benzylecgonine-free urine samples at intake were correlated positively with less drug use during treatment, and, conversely, metabolitecontaining urines at intake were correlated with more drug use during treatment as a function of take-home condition.
Specifically, cocainedependent patients with positive drug screens at intake did less well (i.e., had more cocaine-positive drug screens) than patients who had negative drug screens at intake when required to visit less frequently. This suggests that required level of intervention can be predicted at intake, and this addresses a patient matching issue.
A behavioral perspective stipulates that consideration be given to fine-tuning and individualizing the provisions of treatment, with some patients requiring more visits to the clinic and others fewer. In combination, it is evident that take-home dose frequency is an important factor in retention independent of refined systematic manipulation.
Thus, clinicwide contingencies requiring frequent clinic visits (e.g., 5 or 7 days per week) are arguably less efficacious in terms of generating long-term treatment-oriented behavior.
MANIPULATION OF CONTINGENCIES FOR GROUPS OF PATIENTS
The clinicwide provisions for contingencies governing consequences provide a broad-brush approach to increasing the probability of positive, treatment-oriented behavior. As addressed by the work of Iguchi and coworkers (1988), contingencies with positive consequences for drug-free urine screens may have advantages over aversive consequences in terms of retention.
Further, the work described above and implementation of effective clinic procedures described by Elk and colleagues (in press-b) suggest that a generally favorable or positive clinic environment contributes to treatment-oriented behavior. Stitzer and Kirby (1991) reviewed behavioral approaches for reducing illicit drug use among methadone patients.
This augments an extensive literature that points to the ease of inclusion of behavioral interventions in any clinic. Beyond global conditions or contingencies in treatment, manipulation of contingencies and individualized approaches can be implemented.
Progressing through the levels of intervention, the authors have implemented other studies in a manner emulating standard clinic conditions. For example, the effect of contingent take-home doses of methadone was examined (Rhoades et al. 19923).
This A-B-A design study examined the effects of (A) two different baseline conditions (high- and low-frequency take-home) alone for 8 weeks, (B) then contingent consequences dependent on drug screen results for 12 weeks, and (A) return to the baseline condition for 4 weeks.
With the exception of the return to baseline, this was not unlike the circumstances that might prevail in a standard clinic attempting to implement behavioral procedures. That is, patients enter treatment, are stabilized during the first 8 weeks, and then are placed under an active behavior-dependent contingency.
Thirty patients were assigned randomly to one of two groups and received 70 mg of methadone as a maintenance dose. Patients in one group initially received five take-home doses per week, while the other group of patients received two take-home doses per week.
After 8 weeks, patients were reminded that take-home doses would be dependent on results of the twice-weekly drug screens in weeks 9-20. Drug-free urine screens led to high-frequency take-home doses for the following week. Patients were compliant with the basic requirements of treatment during the first weeks of treatment.
They provided data, attended counseling sessions, and attended the clinic according to the requirements of their take-home dose regimen. The contingent arrangement between urine screen results and take-home dose opportunities was, in this case, ineffective in reducing the number of drug- (typically cocaine) positive urine screens.
This is reflected by the fact that, for any given week, approximately 80 to 90 percent of the patients in each of the groups failed to meet the drug-free criterion and were required to attend the clinic 5 days per week (figure 3). However, it is equally clear that this study supports the previously described fixed-condition methadone study in that an early regimen of frequent take-homes was effective.
Extensive analyses indicated that demographics and intake variables were not related to presence or absence of responsiveness to this contingency. Modifications of this procedure likely would have produced a better result.
However, it is clear that the imposition of this basic contingency for a subgroup of patients did not have a substantial effect on collateral drug use. This strongly supports the need for further research to examine factors diminishing or enhancing effects of such contingencies and explain these results in light of the extensive manipulations with positive outcomes.
While this particular study does not affirm the previous reports, it does support the view that contingencies can be implemented readily for large numbers of patients in the context of other ongoing treatments. This is important, since a common argument against the use of behavioral procedures is that they are unduly costly and time consuming.
Another important feature of behaviorally based perspectives is that subsequent procedures are modified based on current results to identify the most effective combination of contingencies. The authors are conducting further work to elucidate determinants of effectiveness of behavioral interventions in implementing clinicwide procedures.
One consideration is that much of the earlier work involved methadone patients dependent on benzodiazepines for whom the simple consequence of drug-screen-dependent take-home doses reduced collateral drug use.
Many of the patients in the present study were cocaine-dependent, and this disorder may require modification of the original contingency management take-home strategy.
Subjects Receiving High-Frequency Take-Homes FIGURE 3. In an A-B-A study, one group received low- (2/wk) or high- (5/wk) frequency take-home doses of methadone for 8 weeks. For 12 weeks, both were placed under a contingency for which negative urine screens produced the high-frequency take-home (HFTH) conditions in the next week, while positive urine screens produced the low-frequency take-home (LFTH) condition in the next week.
During the last 4 weeks, the baseline condition was reinstated. Overall, approximately 10-15 percent of the patients in the baseline LFTH and HFTH conditions met the drug-free criterion during the contingency period.
IMPLEMENTATION OF INDIVIDUALIZED CONTINGENCIES
Clinicwide conditions and manipulated contingencies for specific behaviors of groups of patients am initial applications that are implemented readily. The next step towards precision in treatment includes application of individualized contingencies, both fixed and adjustable (e.g., Bigelow et al. 1984; Pickens and Thompson 1984; Boudin 1972).
Like mutating micro-organisms that require variants on an antibiotic theme, drug dependence is not a unitary invariant problem. Changes have emerged in drug abuse, collateral disorders, and special populations that must be treated; these in turn require adjustments in intervention strategies.
Over the past decade, multiple drug use has emerged describable as concurrent primary drug dependences (e.g., opiate and cocaine). Stitzer and Kirby (1991) have alluded to this in the context of behavioral interventions, and Dunteman and coworkers (1992) have described predictors of outcome in methadone-maintained patients who also use cocaine.
Homeless patients have become more common in this population, providing a major challenge in the development of treatment. Infectious diseases have become intimately intertwined with drug abuse. HIV has vectors directly and indirectly related to drug abuse, including infection through dirty needles on one hand and transmission from drug-abusing partners to non-drug users on the other hand.
TB has reemerged as a major problem, particularly among drug-using populations. Another major concern that has emerged is that of drug-abusing pregnant women whose general repertoire of health behaviors, if not their specific drug of dependence, may have unalterable detrimental effects on the fetus or their children.
It can be expected that behavioral intervention strategies are well suited to application to specific problems of patients and that combined elements may be used to resolve coexisting problems (e.g., Higgins et al. 1992) in special populations. Reinforcer Menus Development of individualized contingencies requires assessment of a wide range of consequences that may serve to reinforce behavior as well as aversive consequences that may eliminate a specific behavior. Schmitz and Grabowski (1992) have used procedures previously described by Stitzer and Bigelow (1978) in identification of potential reinforcers.
This permits individualization of treatments at best or at a minimum provides an indication of the relative strength of those reinforcers that one can apply readily. Using the reinforcer menu approach, the authors have found that some of the readily available presumed reinforcers may, in fact, be of limited utility (figure 4).
FIGURE 4. Patients were provided with a list of 15 methadone treatment clinic privileges as potential reinforcers. Patient preferences were established using this paired comparisons method. Counselors were given the same list and asked to complete it with a view to patient preferences. The solid bar indicates patient preferences, and the lined bar indicates counselors’ ratings of patient preferences.
The plausible potential reinforcers were used in clinic programs. SOURCE: Schmitz et al. 1991
Other opportunities or tangibles have been identified that might be useful but are difficult to provide, In fact, one survey in which both counselors and patients were queried clearly suggests some discrepancies between treatment professionals’ views and those of patients in terms of potential importance of reinforcers (Schmitz and Grabowski 1992). The reinforcer menu approach has the obvious benefit of determining for whom and under what conditions the elements of treatment should be implemented.
A simple determination of patient preferences readily could be achieved during the course of standard intake procedures at any clinic. This, in turn, could provide information to the staff guiding treatment. At the same time, it must be recognized that there may be disparities between tangibles and opportunities that are stated to be important and those that alter behavior when inserted into the tripartite statement of behavior-contingency-consequence.
That is, as previously discussed, take-home doses of methadone may be powerful modulators of drug-taking under some but not all circumstances, although patients may report in an initial survey that they are important. Therefore, the therapist must approach the problems with a view to revision as needed based on patient goals, preferences, and observed results when procedures have been implemented.
The identification of a reinforcer is ultimately determined empirically in its application to a particular problem or the establishment of a new behavior. Two examples are found in work with patients entering treatment for drug abuse: those who are positive for TB and female patients who are pregnant. TB-Positive Patient Study Noncompliance often is viewed as a sine qua non of drug-dependent patients despite the pervasiveness of the problem across therapeutic disciplines.
This is particularly true in the face of unpleasant or timeconsuming treatment requirements. Ironically, strategies for enhancing compliance are an integral element of behavioral treatment for any disorder but are rarely labeled as such in research reports. It can be said that practitioners of behavioral approaches in drug abuse and other areas of behavior therapy and behavioral medicine have developed a specialty in treatment compliance as an integral part of their efforts.
The absence of explicit reference to this matter results in failure of the broader clinical community to appreciate this unique contribution. TB has increased in prevalence both worldwide and in the United States, and it is specifically more prevalent in the drug-abusing population than the general population. This can be attributed to a variety of ancillary factors rather than drug abuse per se. Nevertheless, the disease presents special problems in the drug abuse treatment setting.
In the authors’ clinic, approximately 8 percent of the patients tested with the Mantoux procedure have been positive. In addition, four staff members have become TB positive over the last 3 years. A positive response requires subsequent chest x-rays and evaluation. In the absence of active TB, one of several medications must be administered for 6 months.
All of these agents are potentially hepatotoxic and may have unpleasant side effects such as nausea and vomiting. A solution in some clinics is refusal at intake or discharge of patients found to be TB positive. Working with the Houston Department of Health and Centers for Disease Control and using NIDA funding for drug abuse treatment, the authors examined techniques for assuring compliance with the ioniazide (INH) regimen.
In the first of a series of studies, a fixed-contingency procedure was used to increase TB treatment compliance in opiate-dependent methadone patients (Elk et al., in press-a). TB treatment was provided within the drug abuse treatment clinic. The approach was extremely conservative and attempted to balance patient needs, staff concerns, hepatotoxicity, and drug interactions.
Additional consent procedures were presented explicitly addressing the problems of interaction of INH with alcohol and other drugs. Patients were stabilized on 70 mg of methadone for 2 weeks, and baseline data of drug use were obtained. Methadone was dispensed contingent on INH ingestion throughout. A contingency also was imposed for which drug-positive urine screens resulted in 5 mg decreases in methadone dose, while urine screens indicating no concurrent drug use permitted the patient to request dosing increases or decreases.
The results indicated that the contingent provision of methadone was appropriate and effective in enhancing INH-taking behavior, and with one exception, all patients participated in this treatment regimen (figure 5). The unexpected high rate of concurrent drug (cocaine) use was FIGURE 5. Opiate-dependent patients with positive Mantoux tests were enrolled in a study where methadone dosing was contingent upon INH ingestion.
Positive urine screens resulted in 5 mg methadone dose reductions, while negative urine screens produced the option of patientcontrolled dose adjustment. The conservative contingency was used due to concerns of hepatotoxicity. The contingency produced INH ingestion, but the contingency did not sustain reductions in drug use or long-term treatment-oriented behavior.
Data for 6 patients are presented; only one (top left panel) remained for the entire 6-month course of INH treatment. The others were discharged from this contingency due to collateral cocaine use. KEY: B=baseline; C=contingency. Solid line is methadone dose, dotted line is opiate use, and dashed line is cocaine use. SOURCE: Modified from Elk et al. 1992 unaffected by the contingency. In effect, patients unable to comply established a self-imposed detoxification regimen through successive weeks of positive screens.
On this occasion, the defined intervention produced equivocal results. However, the careful attention to outcome and details of treatment inherent in behavioral approaches resulted in changing the basic contingency. The authors subsequently have intervened with a shaping procedure directed at systematically decreasing cocaine use by reinforcing sequential reductions as measured by quantitative benzyleconine-positive screens (figure 6).
This has proven more successful in reducing risks of hepatotoxicity of INH by reducing illicit drug use. Pregnancy Study Another complex and difficult area is treatment of drug-dependent pregnant women. Much attention has focused on presumed drugeffect- related mechanisms of problems in fetuses and in newborns delivered by these women (e.g., Finnegan and Kandall 1992).
Delineating mechanisms is ultimately of both scientific and clinical importance. However, the absence of clear data on the cause of problems need not deter implementation of behavioral interventions to reduce drug use and enhance healthful behaviors in this population.
Again, necessity was the mother of intervention. The University of Texas Health Science Center Department of Obstetrics requited assistance with cases of pregnant women who had been using drugs. Elk and colleagues (1993) developed strategies based in the behavioral framework.
An interim report by Kirby and colleagues (1992) indicated that while some behavioral change resulted from simple contingency management procedures, behavior at times changed independent of contingencies and at other times was refractory to change (figure 7). The goals and needs of intervention were multiple, as they were with TB-positive patients. Patients required prenatal care and information as well as treatment of drug dependence. The interesting finding indicated above was that some patients were compliant throughout when the treatment began, while others struggled with drug use,
FIGURE 6. SOURCE: Patients with positive Mantoux tests were enrolled. In these cases, sucessive reductions in cocaine use were shaped using a monetary reinforcer while sustaining the INH regimen. This graph shows data for one patient.
These individualized contingencies emphasizing positive reinforcers were effective in sustaining treatment-oriented behavior and reducing drug use as reflected by the benzyleconine level. Elk et al., unpublished data
FIGURE 7. SOURCE: Panels A and B represent two patterns of behavior of pregnent female patients in attendance of the obstetrics and drug clinic and urine screens. The top series (left to right) indicates compliance when contact was made. The bottom panel indicates good but deteriorating attendance for drug counseling and prenatal care sessions but continued attendance for urine screens indicating no drug use; patients received money for urine screens.
Some patients quickly complied with all requirements, others were irregular, and others (not presented here) were dropped out quickly. Patients were enrolled at different times in gestation, and pregnancy periods differ, thus total weeks differ. A shaping procedure has since been implemented.
Modified from Kirby et al. 1992 attendance at clinics, and other aspects of prenatal care. For some, pregnancy itself had a therapeutic effect in a manner similar to that described by Baile et al. (1982) in smoking cessation efforts with recent heart attack patients. The behavior of other patients was less influenced by early efforts with contingencies and presumed substantial reinforcers.
Elk and colleagues (in press-a) are currently examining specific interventions for these patients that might effectively override the behavioral control exerted by circumstances surrounding drug use. Shaping procedures to reduce cocaine use and enhance attendance in all elements of obstetric and drug abuse treatment are being implemented, and development of innovative procedures continues.
The cases of TB patients and pregnant women provide extreme examples at the individual level of detailed behavioral analysis, precision in intervention, and mixed results. They also provide examples of factors controlling behavior that are not accessed readily by behavioral or other psychotherapeutic approaches. Thus, for example, the state of pregnancy may alter the behavior of some women who use drugs and overwhelm the behavioral and pharmacological determinants inherent in drug use as controlling factors.
Thus, they may simply stop using drugs as the result of complex experiential and social factors. However, pregnancy is no more a cure for drug abuse than heart attacks are cures for tobacco smoking. These changes are not magical reversals, and behavior is explicable. Like the cigarette smoking case, pregnant women may cease drug use during pregnancy only to resume postdelivery.
Not uncommonly, a woman may stop using drugs but be generally noncompliant with other requirements of treatment such as prenatal care, with equally or more detrimental consequences. Overall, treatment failures can be as instructive as successes for identifying specific treatment components leading to eventual successful intervention and prevention of drug abuse, as has been the case in the examples of individualized drug abuse treatments for pregnant women and patients who are TB positive.
CONCLUSIONS AND DIRECTIONS
A rationale has been presented for explicit inclusion of behavioral intervention components in drug abuse treatment. The first goal of drug dependence treatment is to diminish and ultimately eliminate behavior sustained by the pharmacological agent and associated social environmental factors. Achieving initial behavioral change requires establishing the conditions for positive treatment-oriented behaviors.
Thereafter, the process can be implemented at several levels of increasingly refined and specific interventions. Enduring change requires that circumstances be established that sustain behavior not only beyond the reach of the clinic but beyond the duration of active therapeutic intervention.
It can be argued that a variety of other factors described, if not explained, by myriad theories and observations modulate drug-taking, and thus, necessarily, a range of factors determines the probability of success of any particular treatment regimen. Nevertheless, achieving behavioral change optimally requires systematic analysis of behavioral and environmental factors controlling drug-taking, precise implementation of therapeutic techniques based on these observations, and perpetuation of these effects.
In the concluding paragraphs, consideration is given to concerns regarding practical implementation of behaviorally based contingency management approaches in both research and nonresearch treatments. The studies that the authors are conducting were not intended to provide guidelines for clinic management, but they have done so (Elk et al., in press-b), and the main variables provide important data for major elements of treatment. Thus, the results will be briefly considered from these perspectives.
As a pragmatic matter, there is a need for encouraging the view that clearly stated clinicwide contingencies be prescribed for staff members and patients. While these are assumed to exist (but may not) by mutual agreement in many traditional treatment environments, the history and current circumstances of drug abuse treatment appear to call for precision in specification of these contingencies, which typically are framed as clinic rules.
The nature of the consequences must be specified with an emphasis on the positive consequence, although a combination of positive and negative consequences may be inherent in any procedure. Certainly, the common standard clinic provision, in which the first-line consequence is exclusion from treatment, is a self-defeating exercise akin to suspension of children from school who are in need of education.
In one case, education cannot proceed, and in the other, the implications are lack of treatment, spread of HIV, and continuing societal and personal costs. Contriving positive consequences can be difficult, but it should be the goal. It necessarily begins with the view of positive behavioral goals rather than a list of “thou shall nots.”
Clinicwide provisions must be institutionalized with little deviation. Deviations that do occur should be well documented and justified by both the patient and provider. Failure to meet an appointment time is rarely accommodated in other treatment or nontreatment settings, but it is much more commonly accepted in drug abuse treatment, not because of humanistic concerns, but rather because of the crisis-oriented provision of service and, perhaps, simple disorganization.
If promptness by patients is not expected, it is not achieved, and patients who are prompt may be punished because of chaos elsewhere in the clinic. Where it exists, the lack of adherence to treatment requirements by patients may be defined in part by the lack of attention by staff members; the interaction is clear and reciprocal. Failure to implement the requirements of the clinic serves only to increase the lack of adherence by the patients.
Related to the preceding points is the requirement that the contingencies should be viewed as facilitating treatment compliance and success rather than as arbitrary rules to suppress unwanted problematic behaviors. The goal is not to regiment these patients unduly, nor is the treatment based on a belief that they require these steps while others do not; rather it is to provide a framework for treatment that is responsive and perhaps an advance over what most patients receive in health care settings.
Further, it simply provides treatment in accord with other settings and indirectly provides valuable training to those patients who do not have basic skills such as promptness that they will need when applying for jobs, attending school, and engaging in social relationships. Adherence to a schedule is, for some patients, a notable achievement and should be reinforced and reciprocated.
A structure of hierarchical levels of interventions has been described. The rationale is twofold. First, it is a logical progression applicable to any such setting, and successive refinement in the intervention presumably can produce better results more frequently. Further, while all patients should expect a generally structured clinic operation, not all patients require the most refined steps in application.
The second issue is pragmatic: the merit and success evidenced by the data from intensive behavioral interventions with procedures such as those used by Higgins and Budney (1993) cannot be argued. Similarly, Thompson and coworkers (1984) provided a systematic plan for case management with patients having multiple disorders and deficiencies. Not all sites will be able to achieve these levels of intervention immediately due to the paucity of available resources.
Arguments that there is long-term saving are logically meritorious but practically irrelevant if the immediate resources are not available. However, the argument of limited resources is insufficient to excuse failure to implement the most general level of contingencies. Thus, a hierarchical arrangement of interventions is a realistic initial strategy from which to begin.
Furthermore, some procedures can be adjusted that would save money or permit redistribution of funds to more effective ends both within clinics and at the level of Federal regulations. There is no question that the treatment system can be enhanced through modifications in delivery based on the best available data, and methadone regulations provide an excellent example.
For instance, patients are not provided with take-home doses for 90 days. Data from the authors’ large fixed-condition study and the first phase of the contingent take-home study suggest that the prevailing regulations are counterproductive. These same seemingly conservative regulations require only eight urine samples per year; this is an obviously inadequate monitoring procedure.
The need for appropriate alternatives in the form of more frequent screens with systematic contingencies is clear, and these ends can be achieved by enhancing the standard of care rather than adding regulation. Whenever possible, clinics should strive for the successive levels of implementation, with counseling sessions serving as the basis for behavioral data collection to the end of developing optimal interventions through as many levels as the clinic’s resources permit.
With respect to the results of the authors’ projects, a few noteworthy features will be mentioned. The data suggest that the context of clinicwide contingencies must be considered.
For example, the effort to expand on those contingencies described in the literature over the years suggest that refinement of provisions such as contingencies based on take-home doses may be necessary, and several sources for these problems have been mentioned.
The data presented in this paper add information to respond to questions raised by Childress and colleagues (1991) regarding conditions of methadone treatment and those pointed to by McLellan and Alterman (1991) concerning patient matching and levels of treatment.
In two studies, one with primary opiate-dependent patients and the other with primary cocaine-dependent patients, differences in retention in treatment were clearly evident as a function of visit frequency and as a function of intake urine screen results.
The consequence of visit frequency itself appears to be “dose dependent”–that is, dependent on the dose of visits required or takehome opportunities permitted. Attention to the diverse problems of patients and the encompassing treatments such as those described by Higgins et al. (1992) and Higgins and Budney (1993) is important.
However, researchers must not lose sight of other factors more closely related to drug-taking and medications. This is exemplified by the finding that other drug-taking (e.g., cocaine use) must be closely monitored, since a valuable and important therapeutic remedy such as higher methadone dose may have untoward consequences in increased use of another drug.
This requires attention to balancing interventions, as is true in all composite therapeutic regimens. This further strengthens the argument that creative and effective contingency management regimens must be developed. The last of these points addresses the issue-perhaps the caution-that the strength of behavioral interventions resides in their continuing requirement of evaluation and reevaluation of treatment conditions and expected behavioral change. Thus, excessive claims about procedures can be damaging.
For example, in the area of evaluation, reinforcer menus provide a patient’s statement about preferences; patients in treatment for substance abuse disorders are likely to be no worse than other patients in their self-report, but they certainly are no better.
Thus, care must be used in application of self-report data. Further, improvement in data analysis capabilities is needed to determine the valid interpretations of such measures (e.g., Rhoades et al., in press). Caveats must accompany claims of utility, and variation in requirements may emanate from patient characteristics and treatment setting. Similarly, contingent take-home doses generally have been considered to be extremely effective reinforcers, but the authors’ data suggest they are helpful but variable.
That is, they are likely to be variable across time, setting, and form of implementation, while fixed conditions can have substantial effect but do not have the flexibility required to adapt to the needs of specific patients.
Thus, the principles and procedures of behavioral interventions should be encouraged rather than an invariant set of prescriptions. A final thought concerns divergence in the area of substance abuse disorders, which is perhaps no more or less than that in other areas of psychology and psychiatry.
Behavior appears, after all, to be everyone’s domain, and the number of theories and strategies for changing behavior often seems to approximate the number of practitioners. This makes communication difficult.
The goal of standardizing the language and orientation of interventions is not predicated on presumed common etiology or sanctity of terms. Rather it is based in the assumption that progress in the development of efficacious treatment of substance abuse disorders is very much dependent on communication and replication.
McLellan and Alterman (1991) have argued the need for prospective studies with common rules if the goal of identification of predictors is to lead to successful matching of patients to treatment. Similarly, the structure and processes of treatment should be described in common terms to permit ready comparison across interventions.
The behavioral framework seems well suited to meeting this need. The need for research and application is clear. The constellation of drug-seeking and drug-taking provides an example of a disorder characterized by interactions of physiological, behavioral and environmental elements.
It thus seems appropriate that interventions rely heavily on systematic application of a behavioral framework that has been demonstrated to be efficacious in a spectrum of biobehavioral disorders.
REFERENCES
Baile, W.F.; Bigelow, G.; Gottlieb, S.H.; Stitzer, M.; and Sacktor, J.D. Rapid resumption of cigarette smoking following myocardial infarction: Inverse relation to MI severity. Addict Behav 7:373-380, 1982.
Bigelow, G.; Stitzer, M.; and Liebson, I. The role of behavioral contingency management in drug abuse treatment. In: Grabowski, J.; Stitzer, M.; and Henningfield, J., eds. Behavioral Interventions in Drug Abuse Treatment. National Institute on Drug Abuse Research Monograph 46. DHHS. Pub. No. (ADM)84-1282. Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1984. pp. 36-52.
Boudin, N. Contingency contracting as a therapeutic tool in deceleration of amphetamine use. Behav Ther 3:604-608, 1972.
Childress, A.R.; Hole, A.V.; Ehrman, R.N.; Robbins, S.J.; McClellan, A.T.; and O’Brien, C.P. Cue reactivity and cue reactivity interventions in drug dependence. In: Onken, L.S.; Blaine, J.D.; and Boren, J.J., eds. Behavioral Treatments for Drug Abuse and Dependence. National Institute on Drug Abuse Research Monograph 137. NIH Pub. No. 93-3684. Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1993. pp. 73-95.
Childress, A.R.; McLellan, A.T.; Woody, G.E.; and O’Brien, C.P. Are there minimum conditions for methadone maintenance to reduce intravenous drug use and AIDS risk behaviors. In: Pickens, R.; Leukefeld, G.; and Schuster, C.R., eds. Improving Drug Abuse Treatment. National Institute on Drug Abuse Research Monograph 106. DHHS Pub. No. (ADM)91-1754. Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1991. pp. 167-177.
Crowley, T. Contingency contracting treatment in doctors, nurses, and dentists. In: Grabowski, J.; Stitzer, M.; and Henningfield, J., eds. Behavioral Interventions in Drug Abuse Treatment. National Institute on Drug Abuse Research Monograph 46. DHHS Pub. No. (ADM)84-1282. Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1984. pp. 68-83.
Dunteman, G.; Condelli, W.; and Fairbank, J. Predicting cocaine use among methadone patients: Analysis of findings from a national study. Hosp Community Psychiatry 43(6):608-611, 1992.
Elk, R.; Grabowski, J.; Rhoades, H.; and McLellan, A.T. A substance abuse research-treatment clinic: Effective procedures and systems. J Subst Abuse Treat, in press-a.
Elk, R.; Grabowski, J.; Rhoades, H.; Schmitz, J.; and Spiga, R. “Shaping by Successive Approximation: An Innovative Treatment of Cocaine Abuse.” Paper presented at the 55th Annual Meeting of the College on Problems of Drug Dependence, Toronto, Canada, 1993.
Elk, R.; Grabowski, J.; Rhoades, H.; Spiga, R.; Schmitz, J.; and Jennings, W. Compliance with tuberculosis treatment in methadone maintained patients: Behavioral interventions. J Subst Abuse Treat, in press-b.
Finnegan, L.P., and Kandall, S.R. Maternal and neonatal effects of alcohol and drugs. In: Lowinson, J.H.; Ruiz, P.; Millman, R.B.; and Langrod, J.G., eds. Substance Abuse: A Comprehensive Textbook. 2d ed. Baltimore: Williams and Wilkins, 1992. pp. 628-656.
Grabowski, J.; Elk, R.; Kirby, K.; Cowan, K.; and Rhoades, H. Fluoxetine and behavioral factors in treatment of cocaine dependence. In: Harris, L., ed. Problems of Drug Dependence 1991. Proceedings of the 53rd Annual Scientific Meeting, The Committee on Problems of Drug Dependence, Inc. National Institute on Drug Abuse Monograph 119. DHHS Pub. No. (ADM)92-1888. Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1992b. p. 362.
Grabowski, J.; Elk, R.; Rhoades, H.; Cowan, K.; Schmitz, J.; and Kirby, K. “Fluoxetine Dose, Visit Frequency, and Severity in Cocaine Dependence Treatment.” Paper presented at the Annual Meeting of the American Psychological Association, Washington, DC, 1992a.
Grabowski, J.; Rhoades, H.; Elk, R.; Schmitz, J.; and Creson, D. Fluoxetine in treatment of a heterogeneous population of cocaine dependent patients. Am J Psychiatry, submitted.
Grabowski, J.; Rhoades, H.; Schmitz, J.; Elk, R.; and Creson, D. Methadone dose, cocaine and opiate abuse. Am J Psychiatry 150:674, 1993.
Grabowski, J.; Stitzer, M.; and Henningfield, J., eds. Behavioral Interventions in Drug Abuse Treatment. National Institute on Drug Abuse Research Monograph 46. DHHS Pub. No. (ADM)84-1282. Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1984.
Higgins, S.T., and Budney, A.J. Treatment of cocaine dependence through the principles of behavior analysis and behavioral pharmacology. In: Onken, L.S.; Blaine, J.D.; and Boren, J.J., eds. Behavioral Treatments for Drug Abuse and Dependence. National Institute on Drug Abuse Research Monograph 137. NIH Pub. No. 93-3684. Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1993. pp. 97-121.
Higgins, S.; Delany, D.; Budney, A.; Bickel, W.; Hughes, J.; Foerg, F.; and Fenwick, J. A behavioral approach to achieving initial cocaine abstinence. Am J Psychiatry 148(9):1218-1224, 1992.
Hunt, G., and Azrin, N. A community reinforcement approach to alcoholism. Behav Res Ther 11:91-104, 1973.
Iguchi, J.; Stitzer, M.; Bigelow, G.; and Liebson, I. Contingency management in methadone maintenance: Effects of reinforcing and aversive consequences on illicit polydrug use. Drug Alcohol Depend 22:1-7, 1988.
Kirby, K.; Andres, R.; Bhatt, P.; Davis, M.; Spiga, R.; Elk, R.; and Grabowski, J. Behavioral treatments of drug abuse during pregnancy. In: Technical Report From Addictive Behaviors Clinic of the Substance Abuse Research Center. (Houston: University of Texas Health Science Center at Houston, Department of Psychiatry and Behavioral Sciences) no. 3:1-10, 1992.
Krasnegor, N.A., ed. Behavioral Analysis and Treatment of Substance Abuse. National Institute on Drug Abuse Research Monograph 25. DHHS Pub. No. (ADM)79-839. Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1979.
McLellan, A.T., and Alterman, A. Patient treatment matching: A conceptual and methodological review with suggestions for future research. In: Pickens, R.; Leukefeld, G.; and Schuster, C.R., eds. Improving Drug Abuse Treatment. National Institute on Drug Abuse Research Monograph 106. DHHS Pub. No. (ADM)91-1754. Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1991. pp. 114-135.
O’Brien, C.P.; Childress, A.R.; and McLellan, A.T. Conditioning factors may help to understand and prevent relapse in patients who are recovering from drug dependence. In: Pickens, R.; Leukefeld, G.; and Schuster, C.R., eds. Improving Drug Abuse Treatment. National Institute on Drug Abuse Research Monograph 106. DHHS Pub. No. (ADM)91-1754. Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1991. pp. 293-312.
O’Brien, C.P.; Testa, T.; O’Brien, T.J.; Brady, J.P.; and Wells, B. Conditioned narcotic withdrawal in humans. Science 195:1000- 1002, 1977.
Pickens, R., and Thompson, T. Behavioral treatment of drug dependence. In: Grabowski, J.; Stitzer, M.; and Henningfield, J., eds. Behavioral Intervention Techniques in Drug Abuse Treatment. National Institute on Drug Abuse Research Monograph 46. DHHS Pub. No. (ADM)84-1282. Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1984. pp. 53-67.
Ray, B., ed. Learning Factors in Substance Abuse. National Institute on Drug Abuse Monograph 84. DHHS Pub. No. (ADM)88-1576. Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1988.
Rhoades, H.; Elk, R.; Grabowski, J.; and Cowan, K. “Effect of Changing Clinic Visit Frequency Contingent on Urine Screens: Drug Use Among Methadone Patients.” Paper presented at the 54th Annual Meeting of the College on Problems of Drug Dependence, Keystone, CO, 19923.
Rhoades, H.; Elk, R.; Kirby, K.; Cowan, K.; and Grabowski, J. Joint action of methadone doses and take-home frequency in treatment compliance. In: Harris, L., ed. Problems of Drug Dependence 1991. Proceedings of the 53rd Annual Scientific Meeting, The Committee on Problems of Drug Dependence, Inc. National Institute on Drug Abuse Monograph 119. DHHS Pub. No. (ADM)92-1888. Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1992a. p. 453.
Rhoades, H.M.; Grabowski, J.; Elk, R.; and Cowan, K. Factor stationarity and invariance of the POMS in cocaine patients. Pscyhopharmacol Bull, in press.
Schmitz, J.M., and Grabowski, J. An assessment of the potential reinforcing value of privileges in methadone maintenance program. In: Harris, L., ed. Problems of Drug Dependence 1991. Proceedings of the 53rd Annual Scientific Meeting, The Committee on Problems of Drug Dependence, Inc. National Institute on Drug Abuse Monograph 119. DHHS Pub. No. (ADM)92-1888. Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1992. p. 421.
Schuster, C.R., and Silverman, K. Advancing the application of behavioral treatment approaches for drug dependence. In: Onken, L.S.; Blaine, J.D.; and Boren, J.J., eds. Behavioral Treatments for Drug Abuse and Dependence. National Institute on Drug Abuse Research Monograph 137. NIH Pub. No. 93-3684. Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1993. pp. 5-17. Skinner, B.F. Science and Human Behavior. New York: Macmillan, 1953.
Stitzer, M., and Bigelow, G. Contingency management in a methadone maintenance program: Availability of reinforcers. Int J Addict 13(5):737-746, 1978.
Stitzer, M.; Bigelow, G.; and McCaul, M. Behavior therapy in drug abuse treatment: Review and evaluation. In: Ashery, R., ed. Progress in the Development of Cost-Effective Treatment for Drug Abusers. National Institute on Drug Abuse Research Monograph 58. DHHS Pub. No. (ADM)85-1401. Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1985. pp. 31-50.
Stitzer, M., and Kirby, K. Reducing illicit drug use among methadone patients. In: Pickens, R.; Leukefeld, G.; and Schuster, C.R., eds. Improving Drug Abuse Treatment. National Institute on Drug Abuse Research Monograph 106. DHHS Pub. No. (ADM)91-1754. Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1991. pp. 178-203.
Thompson, T., and Johanson, C.E., eds. Behavioral Pharmacology of Human Drug Dependence. National Institute on Drug Abuse Research Monograph 37. DHHS Pub. No. (ADM)81-1137. Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1981.
Thompson, T.; Koemer, J.; and Grabowski, J. Brokerage model rehabilitation system for opiate dependence: A behavioral analysis. In: Grabowski, J.; Stitzer, M.; and Henningfield, J., eds. Behavioral Interventions in Drug Abuse Treatment. National Institute on Drug Abuse Research Monograph 46. DHHS Pub. No. (ADM)84-1282. Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1984. pp. 131-146.
Wikler, A. Recent progress in research on the neurophysiologic basis of morphine addiction. Am J Psychiatry 105:329-338, 1948.
Woody, G.E.; McLellan, A.T.; and O’Brien, C.P. Treatment of behavioral and psychiatric problems associated with opiate dependence. In: Grabowski, J.; Stitzer, M.; and Henningfield, J., eds. Behavioral Interventions in Drug Abuse Treatment. National Institute on Drug Abuse Research Monograph 46. DHHS Pub. No. (ADM)84-1282. Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1984. pp. 23-25.
ACKNOWLEDGMENTS
The treatment research projects described here were funded by National Institute on Drug Abuse grant DA 6143, a Houston Department of Health/CDC contract for TB interventions to Dr. Grabowski, and a University of Texas Health Science Center “New Projects Initiative” grant to Drs. Grabowski and Schmitz and the Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center at Houston.
AUTHORS
John Grabowski, Ph.D. Professor of Psychiatry and Behavioral Sciences and Director Substance Abuse Research Center Howard
Rhoades, Ph.D. Assistant Professor of Psychiatry and Behavioral Sciences
Ronith Elk, Ph.D. Assistant Professor of Psychiatry and Behavioral Sciences
Joy Schmitz, Ph.D. Assistant Professor of Psychiatry and Behavioral Sciences
Daniel Creson, M.D., Ph.D. Professor of Psychiatry and Behavioral Sciences Substance Abuse Research Center Department of Psychiatry and Behavioral Sciences University of Texas Health Science Center at Houston 1300 Moursund Houston, Texas 77030
--------
From NIDA Research Monograph 137 Behavioral Treatments for Drug Abuse and Dependence [pdf with multiple chapters, diagrams]