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Given serious consequences of maternal smoking, we aimed to develop and test a multicomponent behavioral intervention to enhance smoking cessation during pregnancy. In this nonconcurrent, multiple-baseline intervention pilot study, 48 daily smoking pregnant women (mean 13.7 weeks of gestation) were recruited from Buffalo, NY, USA. Upon completion of the repeated baseline smoking monitoring (up to 3 weeks), 30 continuous smokers received a contingent financial incentive-based intervention with three additional components (education and counseling, monitoring and feedback, and family support). After the quit date, participants met with counselors (~1 hr/visit) daily for 2 weeks and twice a week for another 6 weeks. Twenty-one out of 30 participants quit smoking completely (verified by urine cotinine) after receiving the intervention, and the other nine nonquitters decreased smoking substantially. The estimated smoking cessation rate was 70.0% (21/30) at the second week of the intervention, and 63.3% (19/30) at the conclusion of the 8-week intervention assuming the dropouts as smoking. In interrupted time series analysis, the mean daily number of cigarettes smoked among quitters decreased by 6.52, 5.34, and 4.67 among early, delayed, and late intervention groups, respectively. Quitters' mean urine cotinine level maintained stably high before the intervention but decreased rapidly to the nonsmoking range once the intervention was initiated. Most participants (85.7%) reported meeting or exceeding expectations, and 100% would recommend the program to others. This pilot multicomponent intervention was feasible and acceptable to most participants, resulting in a high smoking cessation rate among pregnant smokers who were unlikely to quit spontaneously., (© Society of Behavioral Medicine 2018. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Unhealthy behaviors and lifestyle choices are contributing to the obesity epidemic and associated morbidities. Among reproductive aged women, obesity adversely affects perinatal outcomes and longer term maternal and child health. Interventions utilizing strategies of behavior change have the potential to improve outcomes, especially during pregnancy. Antenatal interventions to improve adherence to gestational weight gain guidelines are one such example. Although behaviorally-based intervention trials have been associated with modest decreases in gestational weight gain, the effect on short term perinatal outcomes has thus far been minimal. This commentary aims to discuss possible reasons behind the failure to improve perinatal outcomes as well as to encourage future areas of study., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Hepatitis, HIV and tuberculosis are significant and costly public health problems that disproportionately affect individuals with substance use disorders (SUDs). Incentive-based treatment approaches (i.e., contingency management; CM) are highly effective at reducing drug use. The primary aim of this report is to review the extant literature that examines the efficacy of CM interventions for the prevention, diagnosis and treatment of hepatitis, HIV and tuberculosis among individuals with SUDs. A literature search identified 23 controlled studies on this topic. In approximately 85% of the studies, CM produced significantly better adherence to prevention, diagnosis and treatment-related medical services, with adherence rates averaging almost 35% higher among patients receiving incentives vs. control condition participants. Findings from these studies parallel the results of a meta-analysis of CM interventions for the treatment of SUDs. The results also suggest that the principles that underlie the efficacy of CM generalize across infectious disease and substance abuse treatment behaviors. The application of additional principles from the literature on CM for treatment of SUDs to interventions targeting infectious disease control would be beneficial. Further development and dissemination of these interventions has the potential to greatly impact public health., (Copyright © 2016 Elsevier Inc. All rights reserved.)

This study compares the efficacy of the Community Reinforcement Approach (CRA) with and without an incentive program for cocaine-dependent patients in Spain. A total of 58 patients were randomly assigned to the CRA or CRA plus vouchers condition. In the CRA plus vouchers group, mean percentage of cocaine-negative samples was 97.07%, versus 79.76% in the no-voucher group. Those treated in the CRA plus vouchers condition also achieved greater improvements in psychosocial functioning than those treated in the CRA condition. The present results show that treatment outcome is better if incentives are delivered contingent upon the submission of cocaine-free urine specimens. , (© American Academy of Addiction Psychiatry.)

The aims of this study were to assess the effectiveness of the Community Reinforcement Approach (CRA) plus vouchers treatment in a cohort of Spanish cocaine-dependent outpatients, and to examine the maintenance of treatment effects after the voucher intervention was discontinued. Sixty-four adult outpatients were randomly assigned to one of two treatment conditions, CRA plus vouchers or standard care. The vouchers program was implemented from weeks 1 to 24. Among patients assigned to the CRA plus vouchers condition, 65.5% completed 12 months of treatment versus 28.6% of those assigned to the standard care condition (p = .003). At the 12-month assessment, 58.6% of patients assigned to the CRA plus vouchers condition were abstinent, compared with 25.7% in the standard care condition (p = .008); furthermore, 34.5% of patients assigned to the CRA plus vouchers condition achieved twelve months of continuous cocaine abstinence, versus 17.1% in the standard care condition. Those treated in the CRA plus vouchers condition also achieved greater improvements in psychosocial functioning than those treated in the standard care condition. Overall, these results reveal an extension of the effectiveness of the CRA plus vouchers treatment to a community sample of cocaine-dependent outpatients, while also supporting the maintenance of treatment effects for 6 months after completion of the voucher program.

Background: The community reinforcement approach (CRA) with vouchers is a well-established program developed for the treatment of cocaine addiction. It involves an incentive program in which patients earn vouchers that can be exchanged for goods or services contingent upon abstinence from cocaine use., Aim: To examine the contributions of incentives to retention, abstinence, and psychosocial outcomes in the CRA+vouchers program at the 12-month follow-up., Methods: 58 cocaine addicts were randomly assigned to CRA treatment with or without an added incentive program in a community setting for cocaine dependence in Spain., Results: 65.5% of patients in the group with vouchers completed 12 months of treatment, versus 48.3% in the no-voucher group. In the CRA+vouchers group, mean percentage of cocaine-negative samples was 95.76%, versus 79.31% in the group without vouchers. There were significant improvements in psychosocial functioning in both treatments, but when differences were observed, they supported CRA with vouchers over CRA alone., Conclusion: Combining CRA with incentives improves treatment outcomes in cocaine-dependent outpatients. Additive benefits of vouchers remain 6 months after the incentive program ends., (Copyright © 2011 S. Karger AG, Basel.)

Prevalence of cigarette smoking among opioid-maintained patients is more than threefold that of the general population and associated with increased morbidity and mortality. Relatively few studies have evaluated smoking interventions in this population. The purpose of the present study was to examine the efficacy of contingency management for promoting initial smoking abstinence. Forty methadone- or buprenorphine-maintained cigarette smokers were randomly assigned to a contingent (n = 20) or noncontingent (n = 20) experimental group and visited the clinic for 14 consecutive days. Contingent participants received vouchers based on breath carbon monoxide levels during Study Days 1 to 5 and urinary cotinine levels during Days 6 to 14. Voucher earnings began at $9.00 and increased by $1.50 with each subsequent negative sample for maximum possible of $362.50. Noncontingent participants earned vouchers independent of smoking status. Although not a primary focus, participants who were interested and medically eligible could also receive bupropion (Zyban). Contingent participants achieved significantly more initial smoking abstinence, as evidenced by a greater percentage of smoking-negative samples (55% vs. 17%) and longer duration of continuous abstinence (7.7 vs. 2.4 days) during the 2 week quit attempt than noncontingent participants, respectively. Bupropion did not significantly influence abstinence outcomes. Results from this randomized clinical trial support the efficacy of contingency management interventions in promoting initial smoking abstinence in this challenging population., ((PsycINFO Database Record (c) 2010 APA, all rights reserved).)

Extensive evidence from the laboratory and the clinic suggests that drug addiction can be viewed as operant behavior and effectively treated through the application of principles of operant conditioning. Contingency management interventions that arrange for the direct reinforcement of drug abstinence or of other therapeutically important target behaviors (e.g., regular use of drug abuse treatment medications) are among the most studied type of operant treatments. Behavior analysts have contributed to the substantial and rapidly growing literature on operant treatments for drug addiction, but the publications of this work usually appear in medical, clinical psychology, or drug abuse journals. This special issue of the Journal of Applied Behavior Analysis represents an effort to bring this important work to the attention of the behavior-analytic community. The articles in this special issue illustrate both the enormous potential of contingency management interventions to address the serious and seemingly intractable problem of drug addiction as well as the real challenges involved in attempting to develop and disseminate treatments that will produce substantial and lasting changes in the lives of individuals plagued by the chronic problem of drug addiction.

Delay discounting (DD) describes how the value of a reinforcer decreases as delay to its delivery increases. Relationships between DD and various aspects of drug abuse have been demonstrated reliably. A potential barrier to wider adoption of DD techniques is that results are often expressed in terms that may be too abstract or unfamiliar to a broader audience, particularly when describing or comparing hyperbolic DD functions or values of k. In an effort to potentially make DD results more accessible, the current report explores use of an ED50 value in characterizing DD functions, similar to that used in pharmacology research for characterizing dose-effect functions. The ED50 proposed with regard to DD is the delay that is effective in discounting the subjective value of the delayed reinforcer by 50%. Additionally, a convenient method for calculating ED50 values for DD is discussed.

Previous studies by our group have used money given contingent on abstinence to reduce drug use by individuals with schizophrenia. In this study, we examined the sensitivity of marijuana use by individuals with serious mental illness to voucher-based contingent reinforcement, which represents the first study to date investigating the efficacy of voucher incentives with this population. This within-subject reversal design consisted of three conditions: 4-week baseline, 12-week voucher intervention, and 4-week baseline. During baseline periods, subjects received 10 US dollars vouchers per urine specimen, independent of urinalysis results. During voucher intervention, only specimens testing negative for marijuana earned vouchers, with total possible earnings of 930 US dollars. Seven adults with schizophrenia or other serious mental illnesses participated in the study. The percentage of marijuana-negative specimens was significantly greater during voucher intervention than during baseline periods. These results provide evidence that marijuana use among individuals with serious mental illness is sensitive to voucher-based incentives and further support the potential feasibility of using voucher-based contingency management to reduce substance abuse in this challenging population.

Objective: To examine the contributions of community reinforcement therapy to outcome in the community reinforcement approach (CRA) + vouchers outpatient treatment for cocaine dependence., Methods: One hundred cocaine-dependent outpatients were randomly assigned to one of 2 treatment conditions: CRA + vouchers or vouchers only. All patients earned incentives in the form of vouchers exchangeable for retail items contingent on cocaine-free urinalysis results during treatment weeks 1 to 12. Incentives were combined with a 24-week course of CRA therapy designed to promote healthy lifestyle changes in the CRA + vouchers condition, while incentives represented the primary treatment in the vouchers-only condition. Patient drug use and psychosocial functioning were assessed at intake and at least every 3 months for 2 years after treatment entry., Results: Patients treated with CRA + vouchers were retained better in treatment, used cocaine at a lower frequency during treatment but not follow-up, and reported a lower frequency of drinking to intoxication during treatment and follow-up compared with patients treated with vouchers only. Patients treated with CRA + vouchers also reported a higher frequency of days of paid employment during treatment and the initial 6 months of follow-up, decreased depressive symptoms during treatment only, and fewer hospitalizations and legal problems during follow-up., Conclusions: Combining CRA with vouchers had therapeutic effects on substance abuse and psychosocial functioning during treatment and posttreatment follow-up in cocaine-dependent outpatients, although effects on cocaine use appear to be limited to the treatment period.

In this evaluation of baseline drug use as a predictor of treatment outcome, cocaine use during a 5-week baseline was compared in methadone maintenance patients who had < 5 (n = 10) versus > or = 5 (n = 9) weeks of abstinence during an experimental cocaine abstinence reinforcement treatment. Cocaine use was evaluated at the 1st and last visit and the 1st and last week of baseline and as a mean across the 5-week baseline treatment; response was calculated as a mean across 12 weeks of experimental treatment. Those who had successful outcomes (abstainers) used significantly less cocaine in the 5-week baseline than those with less successful outcomes (nonabstainers). Differences in cocaine use were not evident in the 1st baseline visit or week, but the abstainers used significantly less cocaine in the last visit and week of baseline compared with the nonabstainers. Cocaine use during baseline provided critical predictors of response to the experimental treatment.

This trial assessed whether behavioral treatment improves outcome during a 26-week outpatient opioid detoxification. Thirty-nine opioid-dependent adults were assigned randomly to a buprenorphine dose-taper combined with either behavioral or standard treatment. Behavioral treatment included (a) a voucher incentive program for providing opioid-free urine samples and engaging in verifiable therapeutic activities and (b) the community reinforcement approach, a multicomponent behavioral treatment. Standard treatment included lifestyle counseling. Fifty-three percent of the patients receiving behavioral treatment completed treatment, versus 20% receiving standard treatment. The percentage of patients achieving 4, 8, 12, and 16 weeks of continuous opioid abstinence were 68, 47, 26, and 11 for the behavioral group and 55, 15, 5, and 0 for the standard group, respectively. Behavioral treatment improved outcomes during outpatient detoxification.

Background: Chronic cocaine abuse remains a serious and costly public health problem. This study assessed the effectiveness of a voucher-based reinforcement contingency in producing sustained cocaine abstinence., Methods: A randomized controlled trial compared voucher-based reinforcement of cocaine abstinence to noncontingent voucher presentation. Patients were selected from 52 consecutively admitted injecting heroin abusers in a methadone maintenance treatment program. Patients with heavy cocaine use during baseline period (N = 37) participated. Except where otherwise indicated, the term cocaine abuse is used in this article in a generic sense and not according to the DSM-III-R definition. Patients exposed to abstinence reinforcement received a voucher for each cocaine-free urine sample (ie, negative for benzoylecgonine) provided three times per week throughout a 12-week period; the vouchers had monetary values that increased as the number of consecutive cocaine-free urine samples increased. Control patients received noncontingent vouchers that were matched in pattern and amount to the vouchers received by patients in the abstinence reinforcement group., Results: Patients receiving vouchers for cocaine-free urine samples achieved significantly more weeks of cocaine abstinence (P = .007) and significantly longer durations of sustained cocaine abstinence (P = .001) than controls. Nine patients (47%) receiving vouchers for cocaine-free urine samples achieved between 7 and 12 weeks of sustained cocaine abstinence; only one control patient (6%) achieved more than 2 weeks of sustained abstinence. Among patients receiving vouchers for cocaine-free urine samples, those who achieved sustained abstinence ( > or = 5 weeks) had significantly lower concentrations of benzoylecgonine in baseline urine samples than those who did not achieve sustained abstinence (P < or = .01). Patients receiving voucher reinforcement rated the overall treatment quality significantly higher than controls (P = .002)., Conclusion: Voucher-based reinforcement contingencies can produce sustained cocaine abstinence in injecting polydrug abusers.

This study evaluated preferences for various clinic privileges, retail items, and social activities for use in an outpatient opioid dependence treatment program. Fifty-three opioid-dependent patients who received treatment with buprenorphine for at least 30 days rank ordered 11 clinic privileges, 19 retail items, and 8 social activities from the most desirable (a rank of 1) to the least desirable (a rank equal to the number of items in that category). Additional questions determined preference for counseling frequency and dosing levels. The top three mean rankings for clinic privileges were $50 cash for opioid-negative urines (2.8), take-home doses of buprenorphine (3.6), and voucher points for opioid-negative urines (4.7). The top three mean rankings for retail items were restaurant gift certificates (4.1), movie passes (4.9), and videotape movie and player rentals (6.8). The top three mean rankings for social activities were movies (2.4), barbecues (3.8), and hiking trips (4.3). There was no preference reported for increases or decreases in counseling frequency. Seventy-four percent of subjects preferred to increase their buprenorphine dose by an average of 60.84% independent of their present dose. Consistent with previous findings from methadone treatment, cash payments for opioid-negative urines and take-home medication were the highest ranked clinic privileges. These results suggest that various retail items and social activities may also be useful for reinforcing positive treatment outcomes during outpatient opioid treatment.

Objective: To assess whether incentives improved treatment outcome in ambulatory cocaine-dependent patients., Method: Forty cocaine-dependent adults were randomly assigned to behavioral treatment with or without an added incentive program. The behavioral treatment was based on the Community Reinforcement Approach and was provided to both groups. Subjects in the group with incentives received vouchers exchangeable for retail items contingent on submitting cocaine-free urine specimens during weeks 1 through 12 of treatment, while the group without incentives received no vouchers during that period. The two groups were treated the same during weeks 13 through 24., Results: Seventy-five percent of patients in the group with vouchers completed 24 weeks of treatment vs 40% in the group without vouchers (P = .03). Average durations of continuous cocaine abstinence documented via urinalysis during weeks 1 through 24 of treatment were 11.7 +/- 2.0 weeks in the group with vouchers vs 6.0 +/- 1.5 weeks in the group without vouchers (P = .03). At 24 weeks after treatment entry, the voucher group evidenced significantly greater improvement than the no-voucher group on the Drug scale of the Addiction Severity Index (ASI), and only the voucher group showed significant improvement on the ASI Psychiatric scale., Conclusions: Incentives delivered contingent on submitting cocaine-free urine specimens significantly improve treatment outcome in ambulatory cocaine-dependent patients.

The present study was conducted to identify predictors of cocaine abstinence during outpatient behavioral treatment for cocaine dependence. Subjects were 52 cocaine-dependent adults. Stepwise logistic regression was used to identify predictors of abstinence during a 12-week treatment program. Demographic, drug use, and other subject characteristics were examined. The single best predictor of cocaine abstinence was whether a significant other participated in treatment. The odds of achieving a criterion level of cocaine abstinence were approximately 20 times greater for subjects who had a significant other participate in treatment. Importantly, significant others participated in a structured form of relationship counseling and behavioral contracting that is well specified and can be readily tested in a prospective, randomized trial. Considering the pressing need for the development of effective treatments for cocaine dependence, such a trial merits consideration.

Cocaine dependence continues to be a widespread and serious public health problem in the US. Unfortunately, no consensus exists about how to treat cocaine dependence. Various pharmacological and psychological therapies have been investigated with mixed results. In this report we review findings from several studies conducted to assess the efficacy of an outpatient behavioral treatment for cocaine dependence. The treatment is based on the concepts and principles of behavior analysis and behavioral pharmacology. Results obtained to date indicate the treatment is acceptable to patients, retains them in treatment, engenders clinically significant levels of cocaine abstinence and can be adapted to deal with other forms of substance abuse common in this population. Overall, we believe the treatment represents an important step towards the development of empirically based and effective treatments for cocaine dependence.

Objective: The authors compared the efficacy of a multicomponent behavioral treatment and drug abuse counseling for cocaine-dependent individuals., Method: The 38 patients were enrolled in outpatient treatment and were randomly assigned to the two treatments. Counseling in the behavioral treatment was based on the community reinforcement approach, while the drug abuse counseling was based on the disease model of dependence and recovery. Patients in the behavioral, but not the drug counseling, treatment also received incentives contingent on submitting cocaine-free urine specimens., Results: Of the 19 patients who received behavioral treatment, 58% completed 24 weeks of treatment, versus 11% of the patients who received counseling. In the behavioral treatment group 68% and 42% of the patients achieved at least 8 and 16 weeks of documented continuous cocaine abstinence, respectively, versus 11% and 5% in the drug abuse counseling group., Conclusions: This multicomponent behavioral treatment appears to be an effective intervention for retaining outpatients in treatment and establishing cocaine abstinence.

Two males diagnosed with cocaine dependence received a behavioral intervention comprised of contingency management and the community reinforcement approach. During the initial phase of treatment, reinforcement was delivered contingent on submitting cocaine-free urine specimens. The community reinforcement approach involved two behavior therapy sessions each week. Almost complete cocaine abstinence was achieved, but regular marijuana use continued. During a second phase, reinforcement magnitude was reduced, but remained contingent on submitting cocaine-free specimens. Behavior therapy was reduced to once per week. Cocaine abstinence and regular marijuana use continued. Next, reinforcement was delivered contingent on submitting cocaine- and marijuana-free specimens. This modified contingency resulted in an abrupt increase in marijuana abstinence and maintenance of cocaine abstinence. One- and 5-month follow-ups indicated that cocaine abstinence continued, but marijuana smoking resumed. These results indicate that the behavioral intervention was efficacious in achieving abstinence from cocaine and marijuana; maintenance, however, was achieved for cocaine only.

Objective: The aim of this study was to assess the efficacy of a behavioral treatment program for achieving initial cocaine abstinence in individuals enrolled in outpatient treatment for cocaine dependence., Method: Thirteen consecutively admitted outpatients were offered behavioral treatment consisting of contingency management procedures and the community reinforcement approach. Fifteen consecutively admitted outpatients were offered treatment with 12-step counseling. All 13 of the patients who were offered the behavioral treatment accepted it; 12 of the patients offered 12-step counseling accepted it., Results: Eleven of the 13 patients in the behavioral treatment were retained for 12 weeks of treatment, compared with five of the 12 patients given 12-step counseling. Ten of the patients given behavioral therapy achieved 4 weeks of continuous cocaine abstinence, compared with only three of those given 12-step counseling. Six of the patients in the behavioral treatment group achieved 8 weeks, and three achieved 12 weeks; none of the patients in the 12-step counseling program achieved 8 weeks., Conclusions: The behavioral treatment described in this paper offers promise as an effective intervention for achieving initial cocaine abstinence. A randomized trial is underway to assess the generality of these findings.

This clinical case study extends the literature on behavioral treatment of self-injury to an intellectually normal infant with spina bifida and diminished sensitivity to pain. After treatment by attention-play periods plus an aversive tasting substance applied to the injured finger, severe biting of the index finger was eliminated and the finger healed. Follow-up inquiries 2 months, 2 and 3 yr later revealed no biting and no substantial tissue damage.