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HIV disproportionally affects persons who inject drugs (PWID), but engagement with HIV pre-exposure prophylaxis (PrEP) is low. We describe the rationale and study design for a new study, "Contingency Management and Pre-Exposure Prophylaxis (PrEP) Adherence Support Services (CoMPASS)," a hybrid type 1 effectiveness-implementation trial to promote HIV risk reduction among PWID.In four community-based programs in the northeastern United States, PrEP-eligible PWID (target n = 526) are randomized to treatment as usual or Contingency Management (CM) and, as indicated, stepped up to PrEP Adherence Support Services (CoMPASS) over 24 weeks. During CM sessions, participants receive timely tangible rewards for verifiable activities demonstrating 1) PrEP initiation and adherence, and 2) engagement with medications for opioid use disorder (MOUD) and other OUD-related care. Participants who do not have high levels of biomarker-confirmed PrEP adherence at week 12 will be stepped up to receive PrEP Adherence Support Services (PASS) consisting of strengths-based case management over 12 weeks. Interventions are delivered by trained PrEP navigators, staff embedded within the respective sites. The primary outcome is sustained PrEP adherence by dried blood spot testing at 24 weeks. To inform future implementation, we are conducting implementation-focused process evaluations throughout the clinical trial.Results from this protocol are anticipated to yield novel findings regarding the impact and scalability of CoMPASS to promote HIV prevention among PWID in partnership with community-based organizations. http://ClinicalTrials.gov identifier: NCT04738825.

Behavior therapy implementation relies in part on training to foster counselor skills in preparation for delivery with fidelity. Amidst Covid-19, the professional education arena witnessed a rapid shift from in-person to virtual training, yet these modalities' relative utility and expense is unknown. In the context of a cluster-randomized hybrid type 3 trial of contingency management (CM) implementation in opioid treatment programs (OTPs), a multi-cohort design presented rare opportunity to compare cost-effectiveness of virtual vs. in-person training. An initial counselor cohort (

OBJECTIVE: The rate of cigarette smoking among persons experiencing homelessness is five times the national prevalence, and these smokers experience difficulty quitting. Nicotine withdrawal may be a barrier to initiating and sustaining successful smoking cessation, but its time course is poorly characterized in this population. We hypothesize that withdrawal symptoms will be elevated and related to treatment outcomes. METHODS: This secondary data analysis characterized nicotine withdrawal symptoms, as measured by the Minnesota Nicotine Withdrawal Severity Index, during a quit attempt in treatment-seeking smokers experiencing homelessness who enrolled in a randomized smoking cessation trial. Participants (N = 70) reported MNWS symptoms three times prior to the scheduled quit date and twice weekly for 4 weeks post–quit date. We also examined the relation of pre-quit symptoms to treatment outcomes (quit day smoking status, patch adherence, duration of abstinence, and percent negative CO samples submitted). RESULTS: Endorsement of withdrawal symptoms was highest prior to the quit date and decreased over time with increases at weeks 3 to 4; a sizable percentage (20% to 35%) of participants endorsed symptoms throughout the 4 week post–quit period. Severity for most symptoms was at its lowest 2–3 weeks post–quit date, then increased in weeks 3 and 4. Anticipatory withdrawal was inversely related to nicotine patch adherence (p = .01), but not the abstinence-based treatment outcomes (ps > .05). CONCLUSIONS: Continued withdrawal symptom endorsement throughout treatment and increases in severity noted 3 to 4 weeks post–quit date suggest possible targets for intervention as part of smoking cessation counseling for smokers experiencing homelessness. Anticipatory withdrawal symptoms (prior to the quit date) were common and predictive of poor adherence to cessation aids.

Exercise holds potential to reduce substance use, but engaging patients in exercise regimens is challenging. Contingency management (CM) interventions can directly address adherence by targeting initiation and maintenance of exercise behavior. This study evaluated the efficacy of a CM-reinforced exercise intervention as an adjunct to standard outpatient substance use disorder treatment. Participants were 120 patients with substance use disorders who were randomly assigned to standard care with CM for completing exercise goals or CM for completing general nonexercise goals weekly for a 4-month treatment period. Urine samples were tested for evidence of illicit substance use up to twice a week during treatment and at follow-ups through month 12. Results found that the CM-exercise condition demonstrated during-treatment improvements on several physical activity and relevant psychosocial functioning indices (e.g., self-efficacy for exercise). The CM-exercise condition had no advantage relative to the CM-general condition in decreasing substance use. Overall, this study adds to a small body of well-powered trials assessing effects of exercise interventions as adjunct treatment for substance use disorders and finds no benefit over an alternate CM approach in terms of drug abstinence. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Very little is known about how reward programs are implemented in real-world substance use treatment settings and whether training in contingency management (CM), an empirically supported rewards-based intervention, impacts their design quality. Providers (N = 214) completed surveys assessing CM beliefs, training, and practices related to use of tangible rewards in treatment. For providers reporting they had not used rewards in treatment previously (54%, n = 116), we assessed beliefs about and interest in adopting a reward-based program. For those endorsing prior reward experience (46%, n = 98), we assessed the features and delivery of rewards and the relation of reward-based intervention training to 4 parameters related to CM efficacy: reinforcement magnitude, immediacy, frequency, and escalation. Among providers without reward experience, endorsement of supportive statements about CM predicted interest in adopting a rewards-based program. Providers with reward experience most often targeted treatment attendance and engaged in behaviors likely to decrease the effectiveness of the intervention, including use of low magnitudes (≤ $25/client), delayed reinforcement, failure to escalate reward values, and offering reward opportunities less than weekly. Providers with longer durations of training were more likely to engage in behaviors consistent with effective CM, including larger magnitude rewards and immediate delivery of rewards. Results indicate that real-world treatment clinics are using reward-based programs but not in ways consistent with research protocols. Longer training exposure is associated with greater adherence to some aspects of CM protocol design. Other evidence-based design features are not being implemented as recommended, even with training. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

INTRODUCTION: Cigarette purchasing behavior may reflect quitting intentions. Little is known about how income could modify the association between cigarette purchasing behaviors and quit attempts among smokers experiencing homelessness. METHODS: Homeless, current smokers completed a questionnaire on the amount spent weekly on cigarettes (≤ $20/week versus > $20/week), source of cigarettes (store versus other source), quantity of cigarettes purchased (< pack versus ≥ pack), and past-year quit attempts. The association of participant income and these cigarette purchasing behaviors were examined. The relationship between cigarette purchasing behaviors and quit attempts was also examined and monthly income (none versus any) was explored as a potential moderator of this relationship. RESULTS: Of the 472 currently smoking individuals, 55% reported spending > $20/week on cigarettes, 83% reported purchasing cigarettes from a store, and 86% reported purchasing ≥ pack during their last purchase. Those who reported an income spent a third of their monthly income on cigarettes, and were more likely to spend > $20/week on cigarettes. The amount spent weekly on cigarettes and the source of cigarettes was not associated with quit attempts, nor did income moderate these relationships. Persons without an income who bought a pack or more of cigarettes made fewer quit attempts (β = −0.4, 95% CI −0.7, −0.2), whereas the association between quantity of cigarettes purchased and quit attempts was not significant for those with an income (β = −0.2, 95% CI −0.4, 0.1). CONCLUSIONS: Current smokers experiencing homelessness and who are without an income may find it particularly challenging to engage in attempts to quit smoking. Smoking cessation interventions that highlight relief of financial hardship as a potential benefit of successfully quitting smoking may be useful among this population.

Objective Contingency management (CM) is often criticized for limited long-term impact. This meta-analysis focused on objective indices of drug use (i.e., urine toxicology) to examine the effects of CM on illicit substance use up to 1 year following treatment. Method Analyses included randomized trials (k = 23) of CM for stimulant, opioid, or polysubstance use disorders that reported outcomes up to 1 year after the incentive delivery had ended. Using random effects models, odds ratios (OR) were calculated for the likelihood of abstinence. Metaregressions and subgroup analyses explored how parameters of CM treatment, namely escalation, frequency, immediacy, and magnitude of reinforcers, moderated outcomes. Results The overall likelihood of abstinence at the long-term follow-up among participants who received CM versus a comparison treatment (nearly half of which were community-based comprehensive therapies or protocol-based specific therapies) was OR = 1.22, 95% confidence interval [1.01, 1.44], with low to moderate heterogeneity (I² = 36.68). Among 18 moderators, longer length of active treatment was found to significantly improve long-term abstinence. Conclusions CM showed long-term benefit in reducing objective indices of drug use, above and beyond other active, evidence-based treatments (e.g., cognitive-behavioral therapy, 12-step facilitation) and community-based intensive outpatient treatment. These data suggest that policymakers and insurers should support and cover costs for CM, which is the focus of hundreds of studies demonstrating its short-term efficacy and, now, additional data supporting its long-term efficacy. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Objective Contingency management (CM) interventions that reinforce attendance have rarely been evaluated in terms of reducing drug use. Using a sequential randomized design, this study examined the efficacy of three attendance CM conditions compared to usual care (UC) on drug use outcomes. It evaluated whether the duration (6 vs. 12 weeks) and timing (early vs. later treatment) of CM delivery impact treatment response. Method Upon initiating outpatient treatment, patients with cocaine use disorders (N = 360) were randomized to UC or CM for attending treatment for 6 weeks. At week 6, patients (n = 308) were rerandomized to UC or CM for another 6 weeks, with assignment stratified on current functioning. Samples were screened for illicit drugs twice weekly for 12 weeks. Results Patients randomized to CM at both time-points attended more sessions and achieved more abstinence than those never randomized to CM. Relative to UC, receiving attendance CM in weeks 1-6 only was not efficacious, but those receiving attendance CM in weeks 7-12 only evidenced some benefits compared to those who never received CM. Twelve weeks of attendance CM was more efficacious than 6 weeks. No between-groups differences in drug use were noted at follow-ups, but days attended treatment and proportion negative samples during treatment were associated with long-term cocaine abstinence. Conclusions Attendance-based CM increases treatment participation and reduces drug use, with beneficial effects noted when CM is delivered over longer durations and during later phases of outpatient care. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Smoking-cessation services are an unmet need among the homeless, who smoke at rates more than 4 times the national estimate. Successful interventions have high potential for improving tobacco-related health disparities among homeless smokers. Contingency management (CM) is a behavioral intervention with efficacy in a number of substance-use disorder populations, including smokers. However, no randomized studies have evaluated the effect of CM in homeless smokers. We examined smoking-related outcomes in homeless smokers (N = 70) randomized to standard-care (SC) smoking cessation involving transdermal nicotine-replacement therapy (NRT), standard counseling, and carbon monoxide (CO) monitoring or the same SC plus CM for negative CO sample submissions. Participants randomized to CM achieved significantly longer durations of consecutive abstinence and submitted a significantly higher proportion of CO-negative samples relative to standard-care participants. At 4 weeks postquit day, 22% were abstinent in the CM condition and 9% were abstinent in the SC condition. At the 6-month follow-up, about 10% of smokers in both conditions were abstinent. This study demonstrates that CM is an efficacious option to increase initial quit rates in homeless smokers, but methods to extend effects are needed. (PsycINFO Database Record

Treatment providers have applied contingency management (CM) treatment, an intervention that often rewards individuals for drug abstinence (i.e., ABS CM), to treatment engagement as well. However, we know little about the magnitude of treatment effects when providers target attendance behaviors (i.e., ATT CM).This study conducted a systematic search to identify studies that included ATT CM, either in isolation or in combination with ABS CM. The study used meta-analysis to estimate the effect size of ATT CM and ABS CM + ATT CM on treatment attendance and drug abstinence. We identified a total of 10 studies including 12 CM treatments (6 ATT CM and 6 ABS CM + ATT CM) with 1841 participants.Results indicated a moderate effect (d = 0.47, 95% confidence interval (CI) [0.25, 0.69]) of ATT CM on attendance relative to non-reward active comparison conditions. Frequency of rewards was significantly associated with larger effect sizes. Results also indicated a small effect (d = 0.22, 95% CI [0.12, 0.33]) of ATT CM on abstinence outcomes relative to nonreward comparisons, p 0.001. The study found no significant differences in attendance or abstinence between ATT CM and ABS CM + ATT CM (p's 0.05).Overall, the results supported ATT CM for increasing treatment engagement, with smaller effects on abstinence. Effects on abstinence were smaller than those observed in prior meta-analyses focused on ABS CM. No significant differences existed in attendance or abstinence outcomes between ATT CM and ABS + ATT CM. However, future studies are needed to experimentally compare ABS CM + ATT CM to ABS CM, and ATT CM to determine additive effects. Clinics implementing CM should consider the differential effects between ATT CM and ABS CM when selecting target behavior(s).

AIMS: This study examined associations between tobacco use and diabetes outcomes using the T1D Exchange Registry. METHODS: Adult participants (N=933) completed standardized questionnaires including self-reported outcomes: past year serious hypoglycemic and diabetic ketoacidosis episodes, diabetes self-care, diabetes distress, and self-monitoring of blood glucose. Chart-extracted outcomes included HbA1c, nephrology and neuropathy diagnoses, and BMI. We examined the relation of tobacco use status (never, former, current) and frequency of use (daily versus less than daily) to these outcomes. RESULTS: The majority had never used tobacco (55%, n = 515); 27% (n = 252) were former users and 18% (n = 166) were current users (with 31% using daily). Tobacco status was associated with HbA1c, BMI, self-care, distress, and blood glucose monitoring frequency. Across most outcomes, current users evidenced worse values relative to never users, and former users were largely similar to never users. Daily use was associated with significantly worse outcomes on HbA1c, diabetes self-care, and distress scores relative to less than daily use. CONCLUSIONS: These cross-sectional comparisons suggest that current tobacco use is associated with worse status on important clinical diabetes indicators. Former users did not evidence these deleterious associations. Findings point to potential diabetes-specific motivators that could inform tobacco cessation interventions.

People who inject drugs (PWID) are at increased risk of HIV infection. Although methadone maintenance therapy can help lower this risk, many methadone patients continue to engage in HIV risk behaviors, especially patients who use cocaine and alcohol. The purpose of the current study was to investigate relations between alcohol use disorders and HIV risk behavior in 239 cocaine-dependent methadone patients participating in a randomized controlled trial of a behavioral intervention to promote cocaine abstinence. Past 3-month HIV Risk-taking Behavior Scale (HRBS) scores were compared between cocaine-dependent methadone patients who met DSM-IV-TR diagnostic criteria for alcohol abuse or dependence and those who did not meet these criteria. No significant differences in HRBS drug subscale scores were observed between participants with and without alcohol use disorders, indicating risky drug use was similar between groups. However, alcohol use disorder was significantly associated with HRBS sex subscale scores (t=2.59, p=0.01), indicating participants with alcohol use disorders were more likely to engage in risky sexual behavior. Item-level analyses of the sex-related HRBS questions showed participants with alcohol use disorders were significantly more likely than participants without alcohol use disorders to have unprotected sex, engage in transactional (paid) sex, and have anal sex. Interventions are needed to reduce risky sexual behavior and attenuate the spread of HIV in this high-risk population.

Gambling problems impact 0.2%-4.0% of the population, and research related to treating gambling has burgeoned in the last decades. This article reviews trials for psychosocial treatments of gambling problems. Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses Standards, we identified 21 randomized trials. Eleven studies evaluated interventions delivered via multisession, in-person therapy: cognitive therapies, cognitive-behavioral (CB) therapies, and motivational interventions (MI) alone or with CB therapies. An additional 10 studies used approaches that involved 1 or fewer in-person sessions; these included workbooks with CB exercises alone or in combination with MI and brief feedback or advice interventions. Although most studies found some benefits of CB therapy (alone or combined with MI) and brief feedback or advice relative to the control condition in the short term, only a handful of studies demonstrated any long-term benefits. Nearly half the studies used waitlist controls, precluding an understanding of long-term efficacy, and standardized outcomes measures are also lacking. Populations also differ markedly across studies, from nontreatment-seeking persons who screened positive for gambling problems to those with severe gambling disorder, and these discrepant populations may require different interventions. Although problem gamblers with less pronounced symptoms may benefit from very minimal interventions, therapist contact generally improved outcomes relative to entirely self-directed interventions, and at least some therapist contact may be necessary for patients with more severe gambling pathology to benefit from CB interventions. As treatment services for gambling continue to grow, this review provides timely information on best practices for gambling treatment. (PsycINFO Database Record

Contingency management (CM) interventions consistently improve substance abuse treatment outcomes, yet CM remains a highly controversial intervention and is rarely implemented in practice settings. This article briefly outlines the evidence base of CM and then describes 4 of the most often-cited concerns about it: philosophical, motivational, durability, and economic. Data supporting and refuting each of these issues are reviewed. The article concludes with suggestions to address these matters and other important areas for CM research and implementation, with the aims of improving uptake of this efficacious intervention in practice settings and outcomes of patients with substance use disorders. (PsycINFO Database Record

Contingency management (CM) is an efficacious intervention for the treatment of substance use disorders that is widely applicable across a range of client populations and characteristics. Despite its strong evidence base, CM remains underutilized in real world practice. This article introduces CM for clinicians interested in adopting CM and briefly reviews this research evidence. In addition, CM protocols are described, with emphasis on the specific design considerations important to CM's efficacy. The recent Department of Veterans Affairs (VA) initiative, which represents the first successful large-scale implementation effort, is presented. It provides a model for the training and supervision components that may be critical to implementation with fidelity. Continued research in this area, as well as further demonstrations of successful dissemination and implementation, will be critical for improving the adoption of this intervention in clinical, nonresearch settings.

Lesbian, gay, and bisexual (LGB) individuals have elevated rates of substance use disorders and present to treatment with more severe substance use problems. Despite this health disparity, recent reviews highlight the paucity of studies reporting sexual orientation in substance use research (e.g., Flentje, Bacca, & Cochran, 2015). Using data from 5 clinical trials of contingency management (CM), the current study investigated the impact of sexual orientation on 3 substance use outcomes: treatment retention, longest duration of abstinence, and percent negative samples submitted. Participants (N = 912; mean age = 36.6 years; 51.1% female; 45% African American, 42.2% Caucasian) were randomized to standard care in community-based intensive outpatient treatment (IOP) or the same plus CM. Patients identifying as LGB made up 10.6% of the sample. A significant proportion identified as bisexual (8.2% of the total sample). Regardless of sexual orientation, participants receiving CM achieved better treatment outcomes than those receiving IOP alone. There were no statistically significant differences between LGB and heterosexual participants in their response to IOP in general, and CM specifically, across all 3 treatment outcomes (ps > .05). However, equivalence testing revealed that outcomes were not statistically equivalent for LGB and heterosexual participants, with the exception of percentage of negative samples, which was equivalent within the CM group only. Differences in treatment response to CM and standard community-based IOP do not reach the level of statistical significance; however, in most cases, we cannot conclude that treatment response is equivalent for LGB and heterosexual individuals. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Alcohol consumption has serious potential consequences for persons with type 1 diabetes (T1D). This study examined associations between alcohol consumption status and diabetes outcomes. Participants were N=933 adults at Type 1 Diabetes Exchange Registry clinics who completed an emailed set of standardized self-report instruments that included items on alcohol use; A1c values were extracted from charts and reported by clinics. Participants were on average (SD) age 38 (16) years, 61% female, and 90% non-Hispanic white, and mean (SD) A1c was 7.8% (1.5%). The sample was 61% (n = 567) current non-binge drinkers, 19% (n = 174) current binge drinkers, 11% (n = 103) had never consumed alcohol, and 9% (n = 89) former drinkers. After controlling for relevant covariates, there was a trend toward higher diabetes self-care scores in never drinkers compared to current non-binge drinkers, current binge drinkers, and former drinkers, and a trend towards lower diabetes distress scores relative to current non-binge drinkers and former drinkers. The odds of a history of severe hypoglycemia, and odds of a neuropathy diagnosis, were lower among never drinkers relative to former drinkers (adjusted p < .04). Never drinkers did not differ from other drinking status groups on frequency of self-monitoring blood glucose, A1c, history of diabetic ketoacidosis, or nephropathy diagnosis (adjusted p’s≤.01). BMI was higher among never drinkers compared to former drinkers and non-binge drinkers (adjusted p > .05). These results suggest that experiencing severe hypoglycemia and being diagnosed with neuropathy may motivate some drinkers to stop drinking, and that never drinkers have more salutary self-care and distress, but higher BMI. Strategies to help patients with T1D manage alcohol are warranted. Disclosure S.M. Alessi: None. N.C. Foster: None. C. Rash: None. M.A. Van Name: Research Support; Self; Novo Nordisk Inc. W.V. Tamborlane: Consultant; Self; AstraZeneca, Boehringer Ingelheim International GmbH, Eli Lilly and Company, Medtronic MiniMed, Inc., Novo Nordisk Inc., Sanofi, Takeda Pharmaceutical Company Limited. J. Wagner: None.

Tobacco use confers unique risks to persons with type 1 diabetes (T1D). This study examined associations between tobacco use and diabetes outcomes using the Type 1 Diabetes Exchange Registry. Participants (N=933) were adults who completed an emailed set of standardized self-report instruments that included items on tobacco use. Participants were on average (SD) 38 (16) years of age, 61% female, and 90% non-Hispanic white. The majority had never used tobacco products (55%, n = 515); 18% (n = 166) were current users and 27% (n = 252) were former users. After controlling for relevant covariates, diabetes self-care scores and frequency of self-monitoring of blood glucose were lower among current users vs. never and former users, adjusted ps ≤ .01. Chart-extracted A1c values and participant-reported diabetes distress scores were higher among current users vs. never or former users, adjusted ps ≤ .001. BMI was lower among current smokers relative to never and former users, adjusted p = .04, but the odds of a nephropathy diagnosis or history of severe hypoglycemia or hospitalization for diabetic ketoacidosis did not differ by tobacco status. Among current users and relative to non-daily use, daily use was associated with significantly worse outcomes on diabetes self-care and diabetes distress scores and A1c values. These cross-sectional comparisons suggest that current tobacco use, particularly daily use, is associated with worse status on several clinical indicators outside BMI. Former users do not evidence these negative impacts on diabetes outcomes. Future research should assess whether better functional status on clinical indicators of diabetes management are causally related to successful smoking cessation. In this sample, smoking rates among individuals with T1D were higher than the national average, suggesting a need for evidence-based tobacco cessation strategies directed toward this high risk group. Disclosure C. Rash: None. J. Wagner: None. S.M. Alessi: None. N.C. Foster: None. W.V. Tamborlane: Consultant; Self; AstraZeneca, Boehringer Ingelheim International GmbH, Eli Lilly and Company, Medtronic MiniMed, Inc., Novo Nordisk Inc., Sanofi, Takeda Pharmaceutical Company Limited. M.A. Van Name: Research Support; Self; Novo Nordisk Inc.

Objective This study evaluated the efficacy of brief gambling treatments in patients attending substance abuse treatment clinics. Method Substance abuse treatment patients with gambling problems (N = 217) were randomly assigned to a 10- to 15-min brief psychoeducation gambling intervention; a 10- to 15-min brief advice intervention addressing gambling norms, risk factors, and methods to prevent additional problems; or 4 50-min sessions of motivational enhancement therapy plus cognitive behavior therapy for reducing gambling (MET + CBT). Gambling and related problems were assessed at baseline and throughout 24 months. Results In the sample as a whole, days and dollars wagered and gambling problems decreased markedly from baseline through Month 5; thereafter, reductions in dollars wagered and gambling problems continued to decrease modestly but significantly, and days gambled remained constant. Brief advice significantly reduced days gambled between baseline and Month 5 relative to brief psychoeducation. The MET + CBT condition engendered no benefit beyond brief advice in terms of days gambled but did lead to more precipitous reductions in dollars gambled and problems experienced in the initial 5 months, and greater clinically significant improvements in gambling in both the short and long term. MET + CBT also resulted in initial decreases in self-reported alcohol use and problems but did not differentially impact self-reported illicit drug use or submission of positive samples. Conclusions Gambling problems tend to dissipate over time regardless of the intervention applied, but offering MET + CBT was more efficacious in decreasing gambling than providing a brief single session intervention. (PsycINFO Database Record

Psychological interventions can improve outcomes and reduce symptom severity for individuals with gambling disorder. This chapter provides an overview of current evidence from moderate- to large-scale randomized controlled trials of psychotherapy interventions for the treatment of gambling problems. Interventions include full-length professionally delivered therapies (behavior therapy, cognitive therapy, and cognitive-behavioral therapy), as well as self-directed workbooks and computer-facilitated programs. Motivational interventions, including motivational interviewing, motivational enhancement therapy, and personalized feedback, are also reviewed. This chapter highlights gambling-related treatment outcomes and comparisons between conditions for randomized trials, with an emphasis on treatment dropout. Attrition rates are generally high across all multi-session intervention modalities and formats. Overall, findings suggest that no specific treatment consistently outperforms other active treatments, but cognitive-behavioral therapy does have the most empirical support for the treatment of gambling disorder. In addition, brief motivational interventions are sufficient for some gamblers to change their behavior, particularly those experiencing only a few adverse symptoms from their gambling involvement. Future research efforts will benefit from further refining existing treatments to improve retention, which in turn may enhance effectiveness.

Rates of heavy alcohol use in soup kitchen attendees range from 30% to 38%, but these data are based entirely on self-reported drinking. Little is known about the intensity or frequency of drinking in this population. We assessed alcohol use transdermally every 30 minutes over a 3-week period among heavy drinkers who attended local soup kitchens. In addition to transdermal alcohol monitoring, participants were randomly assigned to daily breath alcohol monitoring with or without reinforcement for alcohol-negative breath samples (BrAC). Analyses assessed feasibility of transdermal monitoring and examined alcohol use based on BrAC, transdermal, and self-report data, as well as effect sizes for these metrics based on group assignment. Nineteen participants completed the 21-day monitoring period in full; three persons removed the anklet 3–16 days early due to hospitalization, impending hospitalization, or incarceration. Participants reported minimal impacts of the monitors and severity ratings of side effects were mild. When using BrAC, transdermal, and self-report data, the percentage of non-drinking days was 93%, 58%, and 57% and the longest duration of consecutive non-drinking days averaged 10.3, 7.2, and 5.7 days, respectively. About half of drinking days involved heavy drinking (5+ drinks). Self-report and transdermal drinking days correlated significantly, p < .001, but neither index was associated with BrAC. Group comparisons indicate small-to-moderate sized effects of reinforcement compared to no reinforcement for increasing the proportion of alcohol negative breath samples and durations of consecutive non-drinking samples during the study when BrAC was the metric. Transdermal data and self-report data indicated a more complex pattern. Reinforcement participants drank more often but at lower quantities than monitoring (control) participants per both transdermal and self-report data. These data suggest that transdermal monitors are well tolerated and documented substantial heavy drinking in this population. Soup kitchens users are in need of alcohol interventions, and soup kitchens may represent a novel opportunistic setting for intervention delivery for an important and growing health disparities population.

Postmenopausal women have substantial concerns about weight gain when quitting smoking, which may contribute smoking relapse. There is a need for smoking cessation and weight gain prevention programs effective in this population.Two formats of a smoking cessation/weight gain prevention follow-up intervention in postmenopausal weight concerned women were compared: a minimally-tailored group format and a highly tailored, multidisciplinary individual format. Effects on sustained abstinence and postcessation weight gain were assessed. Postmenopausal smokers received 6 sessions of behavioral counseling over a 2-week period, 8weeks of the nicotine transdermal patch, and subsequent random assignment to receive follow-up relapse prevention sessions at 1, 3, 8, and 16weeks postcessation in either group or individual format.The sample (N=98) was 67% Caucasian and 33% African-American. Age: m=52.3 (7.8) years, follicle stimulating hormone: m=42.6 (25.7), body mass index (BMI): m=27.4 (6.2), daily smoking rate: m=20.3 (11.5), for m=29.4 (10.7) years, Fagerström Test for Nicotine Dependence (FTND): m=6.4 (2.1), and carbon monoxide: m=23.8 (13.0) ppm. Abstinence rates in the group condition were significantly higher at 8weeks posttreatment. Group format significantly predicted abstinence rates at 8 and 16weeks posttreatment, even while controlling for age, race, BMI, CPD, years smoking, FTND, and weight concern. Weight concern predicted postcessation weight gain at 8 and 16weeks posttreatment.Results indicate that smoking cessation programs for postmenopausal women may best be delivered in a group format and that postcessation weight concerns be dealt with prior to a quit date.

Background Legal difficulties and cocaine use are prevalent in methadone maintenance patients, and they are related to one another, as well as to poor response to methadone treatment. Contingency management (CM) is efficacious for decreasing cocaine use, but the relation of CM treatment to criminal activities has rarely been studied. Methods This study evaluated whether baseline legal problems are related to subsequent substance use and illegal activities for cocaine using methadone maintained patients and whether CM differentially improves outcomes depending on baseline legal problems. Using data from four randomized CM trials (N = 323), we compared methadone maintained patients with legal problems at the start of study participation to those without initial legal problems. Results Overall, the addition of CM to standard methadone care improved substance use outcomes regardless of initial legal problems. Endorsement of legal problems within 30 days of study initiation was associated with reduced proportion of negative samples submitted during the 12-week treatment period. A significant interaction effect of baseline legal problems and treatment condition was present for subsequent self-reports of illegal activities. Those with baseline legal problems who were assigned to CM had reduced self-reports of reengagement in illegal activity throughout a six month follow-up compared to their counterparts randomized to standard care. Conclusions Adding CM to methadone treatment improves substance use outcomes and reduces subsequent illegal activity in cocaine-using methadone patients with legal problems.

Background Contingency management (CM) is an empirically validated intervention but one not often applied in practice settings in the US. Objectives The aim of this article is to describe the veterans administration (VA) nationwide implementation of CM treatment. Methods In 2011, the VA called for integration of CM in its intensive outpatient substance abuse treatment clinics. As part of this initiative, the VA funded trainings and ongoing implementation support, and it provided direct funds for reinforcers and other intervention costs. Results Over 100 clinics received this funding in 2011, and CM has been implemented in over 70 substance abuse treatment clinics since August 2011. Conclusions This training and implementation experience has been highly successful and represents the largest scale training in evidence-based treatments for substance use disorders in the VA health care system to date. Scientific Significance This program may serve as a model for training in evidence-based treatments. (Am J Addict 2014;23:205–210)

Pathological gamblers are at an increased risk for suicide compared to the general population. As suicide usually begins with suicidal ideations (SI), it is important to identify suicidality early to prevent this undesirable outcome. Demographic and clinical variables along with recent SI (i.e., past 7 days) were examined in a sample of 2867 callers to the Problem Gamblers Help Network of West Virginia between 2000 and 2007. Most participants were pathological gamblers (85%) and 11% of the sample endorsed recent SIs. Univariate results indicated that gamblers with recent SIs were more likely to have a comorbid psychopathology, a family history of alcohol problems, and lower educational attainment. Multivariate logistic regression analysis found only education significantly predicted recent SI. These findings could aid in the intervention and prevention of suicide in gamblers by informing providers of the risks associated with SI in this population.

Objectives To examine the effect of proposed the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5) changes to pathological gambling relative to DSM-IV criteria in a large gambling helpline sample (N = 2,750). Changes in prevalence rates, the diagnostic utility of the illegal acts criterion, and severity of alternative diagnostic formulation thresholds were examined. Method Callers to the helpline completed a semistructured interview and DSM-IV criteria were assessed. Results Without lowering the diagnostic threshold, removal of the illegal acts criterion resulted in loss of diagnostic status in less than 2% of helpline callers. The DSM-IV prevalence rate in this sample was 81.2%, and DSM-5 formulations with lowered thresholds of 4, 3, and 2 symptoms increased prevalence rates by 9% to 17%. However, item-level symptom endorsement suggested that subclinical gamblers experience significant adverse consequences. Conclusions Lowered thresholds may lead to earlier provision of treatment to gamblers and prevent escalation of the disorder, while being more consistent with diagnostic thresholds of other addiction disorders.

In the fifth edition of the Diagnostic and Statistical Manual for Mental Disorders (DSM-5), gambling disorder (GD) underwent several changes. This paper reviews recent research related to the revisions, including the elimination of the illegal acts criterion and the newly lowered diagnostic threshold. These studies suggest the removal of the illegal acts criterion has little impact in terms of prevalence or loss of diagnostic status among gamblers, especially when considered in combination with the newly lowered diagnostic threshold. Overall prevalence rates will increase modestly with the lowered threshold in community samples of gamblers. However, increases in GD prevalence rates may be more notable in settings that serve individuals at higher risk for gambling problems (e.g., substance abuse treatment clinics and homeless persons). GD is now aligned more closely with substance use addictions in DSM-5. This re-categorization, along with the lower threshold for diagnosis under DSM-5 diagnostic criteria, may lead to increased recognition of gambling problems, particularly in settings that serve high risk populations. These changes also may necessitate the training of more clinicians in the delivery of efficacious gambling treatments.

HIV is common among individuals with substance use disorders, but relatively few studies have examined the impact of HIV status on response to substance abuse treatment. This secondary analysis compared patients seeking treatment for cocaine use with and without HIV in terms of substance use treatment outcomes. Primary treatment outcomes included treatment retention, longest duration of abstinence, and percent of negative samples; both substance use outcomes reflect abstinence from cocaine, alcohol and opioids concurrently. Participants (N=432) were enrolled in randomized clinical trials comparing contingency management (CM) to standard care, and 32 (7%) reported being positive for HIV. Overall, CM improved both treatment retention (average of 8.2 weeks compared to 6.0 weeks in the standard care condition) and longest duration of abstinence (average of 5.8 weeks compared to 2.8 weeks in the standard care condition), but did not have a significant effect on percent of negative samples. HIV status was not associated with treatment outcomes as a main effect, nor did it have an interaction effect with treatment condition. These results suggest a benefit of CM in substance abuse treatment irrespective of HIV status.

This article introduces the special issue on contingency management (CM), an efficacious intervention for the treatment of substance use disorders with low uptake in clinical settings that is not commensurate with evidence for efficacy. In this special issue of the Journal of Substance Abuse Treatment, we present 16 articles representing the latest research in efficacy, implementation, and technological advances related to CM. Combined, this collection of articles highlights the diverse populations, settings, and applications of CM in the treatment of substance use disorders. We conclude by highlighting directions for future research, particularly those that may increase CM's appeal and uptake in routine clinical care.

Use of homeless and transitional housing (e.g., recovery homes) programs can be associated with success in substance abuse treatment, perhaps because many of these programs encourage or mandate sobriety. In this study, we examined whether contingency management (CM) protocols that use tangible incentives for submission of drug-free specimens or other specific behaviors are effective for treatment-seeking substance abusers whose behavior may also be shaped by housing programs. Of 355 participants in randomized trials of CM, 56 (16%) reported using transitional housing during the 12-week treatment period. Main and interaction effects of housing status and treatment condition were evaluated for the primary substance abuse treatment outcomes: a) longest duration of abstinence from alcohol, cocaine, and opioids, b) percentage of samples submitted that were negative for these substances, and c) treatment retention. After controlling for demographic and clinical characteristics, those who accessed housing programs submitted a higher percentage of negative samples (75%) compared to those who did not access housing programs (67%). Housing status groups did not differ in terms of longest duration of abstinence (accessed housing: M = 3.1 weeks, SE = 0.6; did not access housing: M = 3.9 weeks, SE = 0.3) or retention in substance abuse treatment (accessed housing: M = 6.4 weeks, SE = 0.6; did not access housing: M = 6.6 weeks, SE = 0.3). Regardless of housing status, CM was associated with longer durations of abstinence and treatment retention. No interactive effects of housing and treatment condition were observed (p > .05). Results suggest that those who accessed housing programs during substance abuse treatment benefit from CM to a comparable degree as their peers who did not use such programs. These effects suggest that CM remains appropriate for those accessing housing in community-based programs.

Background Increasingly, financial reinforcement interventions based on behavioral economic principles are being applied in health care settings, and this study examined the use of financial reinforcers for enhancing adherence to medications. Methods Electronic databases and bibliographies of relevant references were searched, and a meta-analysis of identified trials was conducted. The variability in effect size and the impact of potential moderators (study design, duration of intervention, magnitude of reinforcement, and frequency of reinforcement) on effect size were examined. Results Fifteen randomized studies and 6 nonrandomized studies examined the efficacy of financial reinforcement interventions for medication adherence. Financial reinforcers were applied for adherence to medications for tuberculosis, substance abuse, human immunodeficiency virus, hepatitis, schizophrenia, and stroke prevention. Reinforcement interventions significantly improved adherence relative to control conditions with an overall effect size of 0.77 (95% confidence interval, 0.70-0.84; P P Conclusion These results demonstrate the efficacy of medication adherence interventions and underscore principles that should be considered in designing future adherence interventions. Financial reinforcement interventions hold potential for improving medication adherence and may lead to benefits for both patients and society.

Background Contingency management (CM) is a widely recognized empirically-supported addiction treatment; however, dissemination and adoption of CM into routine clinical practice has been slow. Assessment of beliefs about CM may highlight key barriers and facilitators of adoption and inform dissemination efforts. In the present study, we developed a 35-item questionnaire (contingency management beliefs questionnaire; CMBQ) assessing CM beliefs and examined the relation of these beliefs to clinician characteristics and clinical practices. Methods The web-based study was completed by 617 substance abuse treatment providers. We examined the factor structure using exploratory factor analysis (EFA) in a randomly selected half-sample (n = 318) and evaluated the generalizability of the solution using confirmatory factor analysis (CFA) in the second half-sample (n = 299). Results EFA results suggested a 3-factor solution with 32 items retained; factors represented general barriers, training-related barriers, and pro-CM items. CFA results supported the solution, and reliability was good within each half-sample (α = 0.88 and 0.90). Therapeutic approach, years experience in addictions field, perception of CM's research support, prior CM training, and CM adoption interest were significantly associated with the factors. Conclusions Overall, participants viewed CM favorably yet endorsed barriers, indicating a need for more extensive and targeted response to the most common misperceptions in dissemination efforts.

Gambling and alcohol use disorders commonly co-occur. Nationally representative samples suggest that 45% to 73% of pathological gamblers have lifetime alcohol use disorders (Cunningham-Williams, Cottler, Compton, & Spitznagel, 1998; Petry, Stinson, & Grant, 2005). Among treatment-seeking pathological gamblers, comorbidity is also high, with 59% reporting lifetime histories of alcohol use disorders (Kausch, 2003). Despite the high comorbidity rates of these disorders, few studies have examined if drinking changes during gambling treatment. Not only are gambling and substance use disorders frequently comorbid (Kessler et al., 2008), but the behaviors tend to co-occur. Among non-pathological gamblers, up to 80% reported consumption of 4 to10 alcohol drinks during their last gambling episode (Baron & Dickerson, 1999), and those who drank while gambling tended to gamble in more risky ways and experienced more negative consequences of gambling (Cronce & Corbin, 2010; Giacopassi, Stitt, V National Institute of Alcohol Abuse and Alcoholism [NIAAA], 2007). At-risk drinking rates are also high among individuals with gambling problems. Abbott, Williams, and Volberg (2004) reported 40% to 54% of problem and pathological gamblers identified in a community survey engaged in risky drinking, and Smith and colleagues (2010) estimated 31% of treatment-seeking gamblers were risky drinkers. The high rates of drinking among non-pathological gamblers (Baron & Dickerson, 1999) as well as among individuals who have developed gambling-related problems (Abbott et al., 2004; Smith et al., 2010) are concerning given that quantity of alcohol use appears to be related to severity of gambling problems. In a large statewide survey, Blankenship, Starling, Woodall, and May (2007) found that gamblers reporting 3 or more alcohol drinks per occasion were more likely to endorse problem gambling behaviors than those who consumed 1 or 2 drinks per occasion. Using national epidemiological data, French, MacLean, and Ettner (2008) also found an association between severity of gambling problems and alcohol consumption, with the strength of the relationship increasing as alcohol use increased. In addition, Abbott et al. (2004) reported that hazardous alcohol use predicted continued difficulties with gambling over a 7-year period among individuals with problem and pathological gambling. With repeated pairings of the behaviors, gambling situations may become conditioned cues for drinking. In a laboratory study, Stewart and colleagues (2002) found that participants randomized to a condition in which they could gamble were more likely to purchase and consume alcoholic drinks than participants randomized to a non-gambling control activity. Those who drank alcohol during the laboratory gambling situation reported histories of more frequent gambling, more years gambling, and more gambling-related problems compared to those who did not consume any alcohol when randomized to the laboratory gambling situation. A study by Zack and colleagues (2005) examined implicit associations between gambling and alcohol. The results suggested that positive gambling words (i.e., winning) activated alcohol-related semantic networks for gamblers who reported drinking in response to gambling wins, and that this association was stronger for those with more severe alcohol problems. If gambling becomes a conditioned cue for alcohol use as these studies suggest, then the absence of, or a reduction in, gambling during the course of gambling treatment may result in lower drinking as well. Theoretical conceptualizations of behavior change can also be useful in explaining why two behaviors, such as alcohol use and gambling, may decrease in close temporal proximity. The decision to seek treatment for one problem behavior may spur thinking about changes in other domains. Hall and Rossi (2008) found a high degree of similarity in decision-to-change processes across 48 health behaviors. This similarity in decision processes may facilitate the spread of change to other behaviors recognized as unhealthy once primary behavior change begins. Noar and colleagues (2008) frame these changes using a hierarchical model of health behavior attitudes and behaviors. Attitudes toward change of multiple health behaviors are united under a global construct of general health orientation. In this model, change in the higher-order health behavior orientation (e.g., “I need to be more healthy”) may produce multiple individual health behavior attitude changes (e.g., “I need to change smoking, gambling, and alcohol use”) that in turn cascade down to changes in attitudes toward specific behaviors (e.g., “I should stop smoking, only gamble moderately, and stop at two drinks”). These specific attitudes may ultimately produce change in their respective behaviors. Although treatment-seeking gamblers may present to treatment for gambling, they may also be open to changes in multiple health behavior attitude domains, as driven by the higher-order health orientation construct. A contrasting perspective is that of symptom substitution. A concern during the treatment of addictions (Kadden, Litt, Kabela-Cormier, & Petry, 2009), symptom substitution involves switching one substance for another during treatment. Given the strong associations between alcohol and gambling highlighted above, and behavioral and biological similarities across addictive disorders (Petry, 2006, 2007a; Potenza, 2006; Shaffer et al., 2004), symptom substitution (increased alcohol use while attempting to decrease gambling) is a viable hypothesis. Two studies (Toneatto, Skinner, & Dragonetti, 2002; Stinchfield, Kushner, & Winters, 2005) examined the percent of pathological gamblers who drank before and after gambling treatment. Toneatto et al. (2002) found similar rates of self-reported past-month alcohol use (yes/no) at study intake (55.4%) and at a 1 year follow-up (50.6%). Stinchfield and colleagues (2005) categorized treatment-seeking pathological gamblers as never, less than monthly, monthly, weekly, and daily drinkers at baseline and at a 6-month follow-up. Participants evidenced lower drinking levels between baseline and post-treatment follow-up, with the greatest reduction occurring in the initially highest frequency drinkers (e.g., 54% moved from weekly or daily drinking to monthly or less drinking). These results (Toneatto et al., 2002; Stinchfield et al., 2005) do not support symptom substitution, but neither study examined alcohol use during the treatment period. The lack of during treatment assessment of alcohol use limits our ability to understand drinking behavior during gambling treatment, as alcohol use can fluctuate greatly between pre- and post-treatment periods. Additionally, although the Stinchfield et al. (2005) study noted drinking frequency reductions following gambling treatment, neither study examined quantity of alcohol use. Given that many gamblers drink at binge levels (Abbott et al., 2004; Baron & Dickerson, 1999; Smith et al., 2010) and that two large-scale studies identified associations between problem gambling and quantity of alcohol consumed (Blankenship et al., 2007; French et al., 2008), studies that examine drinking quantity may provide a more detailed picture of changes in alcohol use among individuals seeking gambling treatment. The present study used longitudinal data of drinking behavior over 36 weeks to understand more fully the drinking patterns among treatment-seeking pathological gamblers. We assessed drinking behavior prior to treatment (12 weeks), during treatment (12 weeks), and following gambling treatment (12 weeks). Using weekly estimates of drinking quantity (in standard drinks per week), this study provides a more dynamic and thorough view of drinking behavior in relation to gambling treatment relative to prior studies. Given initial results from the Toneatto et al. (2002) and Stinchfield et al (2005) studies, we hypothesized that drinking behavior for the overall sample would remain the same or decrease during gambling treatment.

Background:Efficacious smoking cessation interventions exist, yet few smokers utilise available resources such as psychosocial treatment programs and pharmacotherapy. The goals of the present study were to (1) identify perceived barriers to entering smoking cessation treatment programs among socioeconomically disadvantaged smokers, who are presently underrepresented in smoking cessation interventions; (2) determine what variables are most important in predicting the barriers identified (i.e., age, gender, ethnicity, income, nicotine dependence level, smoking rate, years smoking, stage of change, presence of smoking-related illness and medical insurance status).Methods:Responses from socioeconomically disadvantaged smokers (N= 343) were collected in 2004–2005 and analysed to develop the Treatment Barriers Questionnaire, a 40-item measure of reasons for not entering smoking cessation programs. Study methods were approved by the Institutional Review Board of Louisiana State University; informed consent procedures were employed.Results:Principal components analysis yielded seven scales named for their theme: (1) Preparedness to Quit Smoking; (2) Work and Time Constraints; (3) Smokers Can or Should Quit on Own; (4) Opinions about Professional Assistance; (5) Mobility Limitations; (6) Insurance Limitations and (7) Misinformation about Professional Assistance. Gender, ethnicity, daily smoking rate, nicotine dependence and stage of change were significant predictors in regression analyses for scales 1,F(10, 201) = 7.83,p< .001,R2= .29, 2F(10, 201) = 2.30,p< .05,R2= .11, and 3,F(10, 201) = 3.58,p< .001,R2= .16. Conclusions: Results can inform efforts to facilitate entry and retention of smokers in cessation programs.

Objectives The purpose of this pilot demonstration study was to evaluate the feasibility and effectiveness of adding a contingency management (CM) component to the standard cognitive-behavioral smoking cessation treatment offered to veterans in a residential substance-abuse treatment program. Specifically, we assessed the impact of CM on (1) engagement in smoking cessation treatment, (2) retention in smoking cessation treatment, and (3) abstinence from smoking. Methods Participants were 65 male veterans in inpatient treatment for a primary substance use disorder who expressed interest in quitting smoking. Participants were enrolled in either the standard or CM smoking cessation treatment program. All participants were offered 4 sessions of cognitive-behavioral group counseling; participants in the CM program also had the opportunity to earn cash vouchers for session attendance and abstinence from smoking. Results The CM treatment program showed superior treatment engagement and retention rates. Survival analysis showed that 58% of participants receiving the CM treatment were smoke-free on quit day, versus only 17% of participants in standard care. In addition, the end of treatment continuous abstinence rate was significantly higher in the CM condition compared with standard care (21% vs. 0%). Conclusions These preliminary results suggest that contingency management approaches may be useful for maximizing participation in smoking cessation treatment and improving treatment outcomes among recovering substance users.

Contingency management (CM) is an efficacious intervention for cocaine abusing methadone patients, but typically only about half of patients respond. By investigating time to onset of cocaine abstinence and factors associated with abstinence, we may be able to more efficiently direct CM approaches to patients most likely to benefit. Onset of cocaine abstinence was evaluated in cocaine abusing methadone maintenance patients (N = 193) enrolled in one of three randomized clinical trials of CM. Participants received standard treatment with frequent urine toxicology monitoring or standard treatment plus CM during the trials. Slightly more than half the sample obtained at least one week of cocaine abstinence, and approximately a third of the sample obtained at least four weeks of cocaine abstinence. Discrete-time survival and hazard analyses found Weeks 1 and 2 of the intervention period had the greatest probability for the initiation of abstinence, and few participants initiated any period of abstinence after Week 4. Patients randomized to CM, those with more years of cocaine use, and those with less recent cocaine use were more likely to achieve abstinence. Overall, these results indicate onset of cocaine abstinence is likely to occur early in treatment and in individuals with less severe cocaine use. Practical implications of these results for designing and implementing CM interventions in methadone maintenance clinics are discussed.

Carla J Rash1, Nancy M Petry21Department of Psychiatry, 2Calhoun Cardiology Center, University of Connecticut Health Center, Farmington, CT, USAAbstract: Injection drug users engage in behaviors that increase the spread of human immunodeficiency virus (HIV) and other infectious diseases. Although methadone maintenance (MM) is highly effective in decreasing heroin use and the spread of HIV, polydrug use, especially the combined use of cocaine and alcohol, is common in MM patients. Alcohol use is independently associated with HIV risk behaviors, and the effects of alcohol use on risk behaviors may vary by gender. This study evaluated the effects of recent heavy alcohol use and gender with respect to HIV risk behaviors in 118 cocaine-abusing methadone patients. Both lifetime and past month injection and sexual risk behaviors were examined. Recent heavy drinkers (n = 46) were more likely to be male than nonheavy drinkers (n = 72). Recent heavy drinkers reported more risky sexual behaviors over their lifetimes than nonheavy drinkers. Gender effects were also present for lifetime risk behaviors, with females demonstrating more sexual and injection risk behaviors than men. In terms of recent injection risk behaviors, there was a significant alcohol use by gender effect. Heavy drinking females reported significantly more drug-sharing behaviors and less frequent needle cleaning than nonheavy drinking females. Recent sexual behaviors did not differ based on alcohol use status or gender. These findings may inform HIV prevention strategies in cocaine-abusing MM patients, and they suggest that cocaine-abusing women who drink heavily are a particularly high risk group who should be counseled about risky injection drug use practices.Keywords: HIV risk behaviors scale, gender, alcohol use, methadone maintenance, opioid dependence, cocaine use

The present study examined a commonly held belief that contingency management (CM) may be less effective for substance abusers with relatively more economic resources compared to those with relatively few resources. Using a combined sample of 393 treatment-seeking cocaine abusers from three clinical trials involving randomization to standard care or standard care plus CM conditions, we assessed the impact of past year income, alone and in combination with treatment condition, as well as income type (i.e., earned, illegal, unstable) on the longest duration of continuous verified abstinence (LDA) achieved during treatment. Results suggested that income had no effect on LDA in either condition, and that CM's effectiveness did not deteriorate among those with better economic resources in the present sample. This finding may be of value to clinicians and administrators who are considering the addition of CM to standard care treatments in community outpatient substance abuse clinics and have concerns about the generalizability of CM across clients with various economic resources.