Advertisement

The Behavior Analyst

, Volume 27, Issue 2, pp 209–230 | Cite as

Exploring the limits and utility of operant conditioning in the treatment of drug addiction

  • Kenneth Silverman
Article

Abstract

This article describes a research program to develop an operant treatment for cocaine addiction in low-income, treatment-resistant methadone patients. The treatment’s central feature is an abstinence reinforcement contingency in which patients earn monetary reinforcement for providing cocainefree urine samples. Success and failure of this contingency appear to be an orderly function of familiar parameters of operant conditioning. Increasing reinforcement magnitude and duration can increase effectiveness, and sustaining the contingency can prevent relapse. Initial development of a potentially practical application of this technology suggests that it may be possible to integrate abstinence reinforcement into employment settings using salary for work to reinforce drug abstinence. This research illustrates the potential utility and current limitations of an operant approach to the treatment of drug addiction. Similar research programs are needed to explore the limits of the operant approach and to develop practical applications that can be used widely in society for the treatment of drug addiction.

Key words

operant conditioning reinforcement contingency management drug addiction drug abuse treatment 

Preview

Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References

  1. Aigner, T. G., & Balster, R. L. (1978). Choice behavior in rhesus monkeys: Cocaine versus food. Science, 201, 534–535.CrossRefPubMedGoogle Scholar
  2. Baer, D. M., Wolf, M. M., & Risley, T. R. (1987). Some still-current dimensions of applied behavior analysis. Journal of Applied Behavior Analysis, 20, 313–327.CrossRefPubMedPubMedCentralGoogle Scholar
  3. Bigelow, G. E., Stitzer, M. L., Griffiths, R. R., & Liebson, I. A. (1981). Contingency management approaches to drug self-administration and drug abuse: Efficacy and limitations. Addictive Behaviors, 6, 241–252.CrossRefPubMedGoogle Scholar
  4. Brewington, V., Arella, L., Deren, S., & Randell, J. (1987). Obstacles to the utilization of vocational services: An analysis of the literature. International Journal of Addictions, 22, 1091–1118.CrossRefGoogle Scholar
  5. Budney, A. J., & Higgins, S. T. (1998). Therapy manuals for drug addiction, Manual 2: A community reinforcement approach: Treating cocaine addiction (No. 98–4309). Rockville, MD: National Institute on Drug Abuse.Google Scholar
  6. Centers for Disease Control and Prevention. (2002). HIV/AIDS Surveillance Report 2002, 14, 1–48. Atlanta: Author.Google Scholar
  7. Crowley, T. J. (1984). Contingency contracting treatment for drug-abusing physicians, dentists and nurses. In J. Grabowski, M. L. Stitzer, & J. E. Henningfield (Eds.), Behavioral intervention techniques in drug abuse treatment (NIDA Research Monograph 46, 68–83). Rockville, MD: National Institutes of Health.Google Scholar
  8. Dallery, J., Silverman, K., Chutuape, M. A., Bigelow, G. E., & Stitzer, M. L. (2001). Voucher-based reinforcement of opiate plus cocaine abstinence in treatment-resistant methadone patients: Effects of reinforcer magnitude. Experimental and Clinical Psychopharmacology, 9, 317–325.CrossRefPubMedGoogle Scholar
  9. Dillon,E. M., Wong, C. J., Sylvest, C. E., Crone-Todd, D. E., & Silverman, K. (in press). Computer-based typing and keypad skills training outcomes of unemployed injection drug users in a therapeutic workplace. Substance Use & Misuse.Google Scholar
  10. Epstein, D. H., Hawkins, W E., Covi, L., Umbricht, A., & Preston, K. L. (2003). Cognitive-behavioral therapy plus contingency management for cocaine use: Findings, during treatment and across 12-month follow-up. Psychology of Addictive Behaviors, 17, 73–82.CrossRefPubMedPubMedCentralGoogle Scholar
  11. Galai, N., Safaeian, M., Vlahov, D., Bolotin, A., & Celentano, D. D. (2003). Longitudinal patterns of drug injection behavior in the ALIVE Study Cohort, 1988–2000: Description and determinants. American Journal of Epidemiology, 158, 695–704.CrossRefGoogle Scholar
  12. Griffiths, R. R., Bigelow, G. E., & Henningfield, J. E. (1980). Similarities in animal and human drug taking. In N. K. Mello (Ed.), Advances in substance abuse (Vol. 1, pp. 1–90). Greenwich, CT: JAI Press.Google Scholar
  13. Grund, J. C, Friedman, S. R., Stern, L. S., Jose, B., Neaigus, A., Curtis, R., et al. (1996). Syringe-mediated drug sharing among injecting drug users: Patterns, social context and implications for transmission of blood-borne pathogens. Social Science and Medicine, 42, 691–703.CrossRefPubMedGoogle Scholar
  14. Hartwell, T. D., Steele, P., French, M. T., Potter, F. J., Rodman, N. F, & Zarkin, G. A. (1996). Aiding troubled employees: The prevalence, cost, and characteristics of employee assistance programs in the United States. American Journal of Public Health, 86, 804–808.CrossRefPubMedPubMedCentralGoogle Scholar
  15. Higgins, S. T., Bickel, W. K., & Hughes, J. R. (1994). Influence of an alternative reinforcer on human cocaine self-administration. Life Sciences, 55, 179–187.CrossRefPubMedGoogle Scholar
  16. Higgins, S. T., Budney, A. J., Bickel, W K., Foerg, F, Donham, R., & Badger, M. S. (1994). Incentives improve outcome in outpatient behavioral treatment of cocaine dependence. Archives of General Psychiatry, 51, 568–576.CrossRefPubMedGoogle Scholar
  17. Higgins, S. T., Budney, A. J., Bickel, W. K., Hughes, J. R., Foerg, F, & Badger, M. S. (1993). Achieving cocaine abstinence with a behavioral approach. American Journal of Psychiatry, 150, 763–769.CrossRefPubMedGoogle Scholar
  18. Higgins, S. T., Delaney, D., Budney, A. J., Bickel, W. K., Hughes, J. R., Foerg, F, & Fenwick, J. W. (1991). A behavioral approach to achieving initial cocaine abstinence. American Journal of Psychiatry, 148, 1218–1224.CrossRefPubMedGoogle Scholar
  19. Higgins, S. T., Heil, S. H., & Lussier, J. P. (2004). Clinical implications of reinforcement as a determinant of substance abuse disorders. Annual Review of Psychology, 55, 431–461.CrossRefPubMedGoogle Scholar
  20. Higgins, S. T., & Silverman, K. (Eds.). (1999). Motivating behavior change among illicitdrug abusers: Research on contingency management interventions. Washington, DC: American Psychological Association.Google Scholar
  21. Hser, Y. I., Anglin, M. D., & Fletcher, B. (1998). Comparative treatment effectiveness: Effects of program modality and client drug dependence history on drug use reduction. Journal of Substance Abuse Treatment, 15, 513–523.CrossRefPubMedGoogle Scholar
  22. Hser, Y. I., Hoffman, V., Grella, C. E., & Anglin, D. M. (2001). A 33-year follow-up of narcotic addicts. Archives of General Psychiatry, 58, 503–508.CrossRefPubMedGoogle Scholar
  23. Johanson, C. E., Balster, R. L., & Bonese, K. (1976). Self-administration of psychomotor stimulant drugs: The effects of unlimited access. Pharmacology Biochemistry & Behavior, 4, 45–51.CrossRefGoogle Scholar
  24. Johanson, C. E., & Schuster, C. R. (1981). Animal models of drug self-administration. In N. K. Mello (Ed.), Advances in substance abuse: Behavioral and biological research (Vol. 2, pp. 219–297). Greenwich, CT: JAI Press.Google Scholar
  25. Katz, E. C, Robles-Sotelo, E., Correia, C. J., Silverman, K., Stitzer, M. L., & Bigelow, G. (2002). The brief abstinence test: Effects of continued incentive availability on cocaine abstinence. Experimental and Clinical Psychopharmacology, 10, 10–17.CrossRefPubMedGoogle Scholar
  26. Maryland AIDS Administration. (2003). The Maryland 2003 HIV/AIDS annual report. Baltimore: Maryland Department of Health and Mental Hygiene.Google Scholar
  27. Maryland Alcohol and Drug Abuse Administration. (2003). Outlooks and outcomes in Maryland substance abuse treatment, 2002. Catonsville, MD: Author.Google Scholar
  28. McLellan, A. T (2001). Moving toward a “third generation” of contingency management studies in the drug abuse treatment field: Comment on Silverman et al. (2001). Experimental and Clinical Psychopharmacology, 9, 29–32.CrossRefPubMedGoogle Scholar
  29. McLellan, A. T, Carise, D., & Kleber, H. D. (2003). Can the national addiction treatment infrastructure support the public’s demand for quality care? Journal of Substance Abuse Treatment, 25, 117–121.CrossRefPubMedGoogle Scholar
  30. McLellan, A. T, Lewis, D. C, O’Brien, C. P., & Kleber, H. D. (2000). Drug dependence, a chronic medical illness: Implications for treatment, insurance, and outcome evaluation. Journal of the American Medical Association, 284, 1689–1695.CrossRefPubMedGoogle Scholar
  31. Milby, J. B., Schumacher, J. E., Raczynski, J. M., Caldwell, E., Engle, M., Michael, M., et al. (1996). Sufficient conditions for effective treatment of substance abusing homeless persons. Drug and Alcohol Dependence, 43, 39–47.CrossRefPubMedGoogle Scholar
  32. Nader M. A. & Woolverton W L. 1991. Effects of increasing the magnitude of an alternative reinforcer on drug choice in a discretetrials choice procedure. Psychopharmacology, 105, 169–174.CrossRefPubMedGoogle Scholar
  33. National Consensus Development Panel on Effective Medical Treatment of Opiate Addiction. (1998). Effective medical treatment of opiate addiction. Journal of the American Medical Association, 280, 1936–1943.CrossRefGoogle Scholar
  34. Office of Applied Studies. (2002). The NHSDA report: Awareness of workplace substance use policies and programs. Rockville, MD: Substance Abuse and Mental Health Services Administration.Google Scholar
  35. Office of Applied Studies. (2003a). Emergency department trends from the drug abuse warning network, final estimates 1995–2002, DAWN series: D-24 (DHHS Publication No. SMA 03-3780). Rockville, MD: Substance Abuse and Mental Health Services Administration.Google Scholar
  36. Office of Applied Studies. (2003b). The NHSDA report: Injection drug use. Rockville, MD: Substance Abuse and Mental Health Services Administration.Google Scholar
  37. Petry, N. M. (2001). Challenges in the transfer of contingency management techniques: Com ment on Silverman et al. (2001). Experimental and Clinical Psychopharmacology, 9, 24–26.CrossRefPubMedGoogle Scholar
  38. Pickens, R., & Thompson, T. (1968). Cocainereinforced behavior in rats: Effects of reinforcement magnitude and fixed-ratio size. Journal of Pharmacology and Experimental Therapeutics, 161, 122–129.PubMedGoogle Scholar
  39. Preston, K. L., Epstein, D. H., Cone, E. J., Wtsadik, A. T, Huestis, M. A., & Moolchan, E. T (2002). Urinary elimination of cocaine metabolites in chronic cocaine users during cessation. Journal of Analytical Toxicology, 26, 393–400.CrossRefPubMedGoogle Scholar
  40. Preston, K. L., Silverman, K., Higgins, S. T, Brooner, R. K., Montoya, I., Schuster, C. R., et al. (1998). Cocaine use early in treatment predicts outcome in a behavioral treatment program. Journal of Consulting and Clinical Psychology, 66, 691–696.CrossRefPubMedGoogle Scholar
  41. Preston, K. L., Silverman, K., Schuster, C. R., & Cone, E. J. (1997). Assessment of cocaine use with quantitative urinalysis and estimation of new uses. Addiction, 92, 717–727CrossRefPubMedGoogle Scholar
  42. Preston, K. L., Umbricht, A., Wong, C. J., & Epstein, D. H. (2001). Shaping cocaine abstinence by successive approximation. Journal of Consulting and Clinical Psychology, 69, 643–654.CrossRefPubMedGoogle Scholar
  43. Rawson, R. A., Huber, A., McCann, M., Shoptaw, S., Farabee, D., Reiber, C, et al. (2002). A comparison of contingency management and cognitive-behavioral approaches during methadone maintenance treatment for cocaine dependence. Archives of General Psychiatry, 59, 817–824.CrossRefPubMedGoogle Scholar
  44. Rawson, R. A., McCann, M. J., Hasson, A. J., & Ling, W. (1994). Cocaine abuse among methadone patients: Are there effective treatment strategies? Journal of Psychoactive Drugs, 26, 129–136.CrossRefPubMedGoogle Scholar
  45. Ries, R. K., & Comtois, K. A. (1997). Managing disability benefits as part of treatment for persons with severe mental illness and comorbid drug/alcohol disorders. The American Journal on Addictions, 6, 330–338.PubMedGoogle Scholar
  46. Robles, E., Silverman, K., Preston, K. L., Cone, E. J., Katz, E., Bigelow, G. E., et al. (2000). The brief abstinence test: Voucher-based reinforcement of cocaine abstinence. Drug and Alcohol Dependence, 58, 205–212.CrossRefPubMedGoogle Scholar
  47. Silverman, K., Bigelow, G. E., & Stitzer, M. L. (1998). Treatment of cocaine abuse in methadone patients. In S. T Higgins & J. L. Katz (Eds.), Cocaine abuse: Behavior, pharmacology, and clinical applications (pp. 363–388). San Diego, CA: Academic Press.CrossRefGoogle Scholar
  48. Silverman, K., Chutuape, M. D., Bigelow, G. E., & Stitzer, M. L. (1996). Voucher-based reinforcement of attendance by unemployed methadone patients in a job skills training program. Drug and Alcohol Dependence, 41, 197–207.CrossRefPubMedGoogle Scholar
  49. Silverman, K., Chutuape, M. D., Bigelow, G. E., & Stitzer, M. L. (1999). Voucher-based reinforcement of cocaine abstinence in treatment-resistant methadone patients: Effects of reinforcement magnitude. Psychopharmacology, 146, 128–138.CrossRefPubMedGoogle Scholar
  50. Silverman, K., Chutuape, M. D., Svikis, D. S., Bigelow, G. E., & Stitzer, M. L. (1995). Incongruity between occupational interests and academic skills in drug abusing women. Drug and Alcohol Dependence, 40, 115–123.CrossRefPubMedGoogle Scholar
  51. Silverman, K., Higgins, S. T, Brooner, R. K., Montoya, I. D., Cone, E. J., Schuster, C. R., et al. (1996). Sustained cocaine abstinence in methadone maintenance patients through voucher-based reinforcement therapy. Archives of General Psychiatry, 53, 409–415.CrossRefPubMedGoogle Scholar
  52. Silverman, K., Robles, E., Mudric, T, Bigelow, G. E., & Stitzer, M. L. (in press). A randomized trial of long-term reinforcement of cocaine abstinence in methadone maintained injection drug users. Journal of Consulting and Clinical Psychology.Google Scholar
  53. Silverman, K., Svikis, D., Robles, E., Stitzer, M. L., & Bigelow, G. E. (2001a). A reinforcement-based therapeutic workplace for the treatment of drug abuse: Six-month abstinence outcomes. Experimental and Clinical Psychopharmacology, 9, 14–23.CrossRefPubMedGoogle Scholar
  54. Silverman, K., Svikis, D., Robles, E., Stitzer, M. L., & Bigelow, G. E. (2001b). Towards application of the therapeutic workplace: Reply to Higgins (2001), Marlatt (2001), McLellan (2001), and Petry (2001). Experimental and Clinical Psychopharmacology, 9, 35–39.CrossRefGoogle Scholar
  55. Silverman, K., Svikis, D., Wong, C. J., Hampton, J., Stitzer, M. L., & Bigelow, G. E. (2002). A reinforcement-based therapeutic workplace for the treatment of drug abuse: Three-year abstinence outcomes. Experimental and Clinical Psychopharmacology, 10, 228–240.CrossRefPubMedGoogle Scholar
  56. Silverman, K., Wong, C. J., Grabinski, M. J., Hampton, J., Sylvest, C. E., Dillon, E. M., et al. (in press). A Web-based therapeutic workplace training program and business for the treatment of drug addiction and chronic unemployment. Behavior Modification.Google Scholar
  57. Silverman, K., Wong, C. J., Umbricht-Schneiter, A., Montoya, I. D., Schuster, C. R., & Preston, K. L. (1998). Broad beneficial effects of reinforcement for cocaine abstinence among methadone patients. Journal of Consulting and Clinical Psychology, 66, 811–824.CrossRefPubMedGoogle Scholar
  58. Silverman, K., Wong, C. J., Wentland, R. D., Svikis, D., Stitzer, M. L., & Bigelow, G. E. (2002). The therapeutic workplace business: A long-term treatment for drug addiction and chronic unemployment. Drug and Alcohol Dependence, 66, S165.Google Scholar
  59. Simpson, D. D., Joe, G. W, Fletcher, B. W, Hubbard, R. L., & Anglin, M. D. (1999). A national evaluation of treatment outcomes for cocaine dependence. Archives of General Psychiatry, 56, 507–514.CrossRefPubMedGoogle Scholar
  60. Sisson, R. W, & Azrin, N. H. (1989). The community reinforcement approach. In R. K. Hester & W R. Miller (Eds.), Handbook of alcoholism treatment approaches: Effective alternatives (pp. 242–258). New York: Pergamon Press.Google Scholar
  61. Spealman, R. D., & Goldberg, S. R. (1978). Drug self-administration by laboratory animals: Control by schedules of reinforcement. Annual Review of Pharmacology and Toxicology, 18, 313–339.CrossRefPubMedGoogle Scholar
  62. Stitzer, M. L., Iguchi, M. Y., & Felch, L. J. (1992). Contingent take-home incentive: Effects on drug use of methadone maintenance patients. Journal of Consulting and Clinical Psychology, 60, 927–934.CrossRefPubMedGoogle Scholar
  63. Stitzer, M. L., Iguchi, M. Y, Kidorf, M., & Bigelow, G. I. (1993). Contingency management in methadone treatment: The case for positive incentives. In L. S. Onken, J. D. Blaine, & J. J. Boren (Eds.), Behavior treatment for drug abuse and dependence (NIDA Research Monograph 137, pp. 19–36). Rockville, MD: National Institutes of Health.Google Scholar
  64. Thompson, T, & Schuster, C. R. (1964). Morphine self-administration, food-reinforced, and avoidance behaviors in rhesus monkeys. Pscyhopharmacologia, 71, 87–94.CrossRefGoogle Scholar
  65. Vaillant, G. E. (1973). A 20-year follow-up of New York narcotic addicts. Archives of General Psychiatry, 29, 237–241.CrossRefPubMedGoogle Scholar
  66. Wong, C. J., Dillon, E. M., Sylvest, C. E., & Silverman, K. (2004a). Contingency management of reliable attendance of chronically unemployed substance abusers in a therapeutic workplace. Experimental and Clinical Psychopharmacology, 12, 39–46.CrossRefPubMedGoogle Scholar
  67. Wong, C. J., Dillon, E. M., Sylvest, C, & Silverman, K. (2004b). Evaluation of a modified contingency management intervention for consistent attendance in therapeutic workplace participants. Drug and Alcohol Dependence, 74, 319–323.CrossRefPubMedGoogle Scholar
  68. Wong, C. J., Sheppard, J. M., Dallery, J., Bedient, G., Robles, E., Svikis, D., et al. (2003). Effects of reinforcer magnitude on data entry productivity in chronically unemployed drug abusers participating in a therapeutic workplace. Experimental and Clinical Psychopharmacology, 11, 46–55.CrossRefPubMedGoogle Scholar

Copyright information

© Association for Behavior Analysis International 2004

Authors and Affiliations

  1. 1.Center for Learning and Health, Department of Psychiatry and Behavioral SciencesJohns Hopkins University School of MedicineBaltimoreUSA

Personalised recommendations