Abstract
Poverty is associated with poor health. This article reviews research on proximal and distal operant interventions to address drug addiction and poverty. Proximal interventions promote health behaviors directly. Abstinence reinforcement, a common proximal intervention for the treatment of drug addiction, can be effective. Manipulating familiar parameters of operant conditioning can improve the effectiveness of abstinence reinforcement. Increasing reinforcement magnitude can increase the proportion of individuals that respond to abstinence reinforcement, arranging long-term exposure to abstinence reinforcement can prevent relapse, and arranging abstinence reinforcement sequentially across drugs can promote abstinence from multiple drugs. Distal interventions reduce risk factors that underlie poor health and may have an indirect beneficial effect on health. In the case of poverty, distal interventions seek to move people out of poverty. The therapeutic workplace includes both proximal and distal interventions to treat drug addiction and poverty. In the therapeutic workplace, participants earn stipends or wages to work. The therapeutic workplace uses employment-based reinforcement in which participants are required to provide drug-free urine samples or take scheduled doses of addiction medications to work and/or maintain maximum pay. The therapeutic workplace has two phases, a training and an employment phase. Special contingencies appear required to promote skill development during the training phase, employment-based reinforcement can promote abstinence from heroin and cocaine and adherence to naltrexone, and the therapeutic workplace can increase employment. Behavior analysts are well-suited to address both poverty and drug addiction using operant interventions like the therapeutic workplace.
Similar content being viewed by others
References
Addo, J., Ayerbe, L., Mohan, K. M., Crichton, S., Sheldenkar, A., Chen, R., et al. (2012). Socioeconomic status and stroke: An updated review. Stroke; a Journal of Cerebral Circulation, 43(4), 1186–1191. https://doi.org/10.1161/STROKEAHA.111.639732.
Aklin, W. M., Wong, C. J., Hampton, J., Svikis, D. S., Stitzer, M. L., Bigelow, G. E., & Silverman, K. (2014). A therapeutic workplace for the long-term treatment of drug addiction and unemployment: Eight-year outcomes of a social business intervention. Journal of Substance Abuse Treatment, 47(5), 329–338. https://doi.org/10.1016/j.jsat.2014.06.013.
Armstrong, G. L. (2007). Injection drug users in the United States, 1979-2002: An aging population. Archives of Internal Medicine, 167(2), 166–173. https://doi.org/10.1001/archinte.167.2.166.
Benishek, L. A., Dugosh, K. L., Kirby, K. C., Matejkowski, J., Clements, N. T., Seymour, B. L., & Festinger, D. S. (2014). Prize-based contingency management for the treatment of substance abusers: A meta-analysis. Addiction (Abingdon, England), 109(9), 1426–1436. https://doi.org/10.1111/add.12589.
Berlin, G. L. (2007). Rewarding the work of individuals: A counterintuitive approach to reducing poverty and strengthening families. The Future of Children, 17, 17–42.
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(3), 241–252.
Bitler, M. P., & Karoly, L. A. (2015). Intended and unintended effects of the war on poverty: What research tells us and implications for policy. Journal of Policy Analysis and Management: [The Journal of the Association for Public Policy Analysis and Management], 34(3), 639–696.
Bond, G. R., Drake, R. E., & Becker, D. R. (2012). Generalizability of the individual placement and support (IPS) model of supported employment outside the US. World Psychiatry: Official Journal of the World Psychiatric Association (WPA), 11(1), 32–39.
Castells, X., Kosten, T. R., Capella, D., Vidal, X., Colom, J., & Casas, M. (2009). Efficacy of opiate maintenance therapy and adjunctive interventions for opioid dependence with comorbid cocaine use disorders: A systematic review and meta-analysis of controlled clinical trials. The American Journal of Drug and Alcohol Abuse, 35(5), 339–349. https://doi.org/10.1080/00952990903108215.
Center for Behavioral Health Statistics and Quality. (2018). 2017 National Survey on Drug Use and Health: Detailed Tables. Substance Abuse and Mental Health Services Administration, Rockville, MD. https://www.samhsa.gov/data/nsduh/reports-detailed-tables-2017-NSDUH. Accessed on February 13, 2019.
Chetty, R., Stepner, M., Abraham, S., Lin, S., Scuderi, B., Turner, N., et al. (2016). The association between income and life expectancy in the United States, 2001-2014. The Journal of the American Medical Association. https://doi.org/10.1001/jama.2016.4226.
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(3), 317–325.
Davis, D. R., Kurti, A. N., Skelly, J. M., Redner, R., White, T. J., & Higgins, S. T. (2016). A review of the literature on contingency management in the treatment of substance use disorders, 2009-2014. Preventive Medicine.
DeFulio, A., Donlin, W. D., Wong, C. J., & Silverman, K. (2009). Employment-based abstinence reinforcement as a maintenance intervention for the treatment of cocaine dependence: A randomized controlled trial. Addiction (Abingdon, England), 104(9), 1530–1538. https://doi.org/10.1111/j.1360-0443.2009.02657.x.
Defulio, A., Everly, J. J., Leoutsakos, J. M., Umbricht, A., Fingerhood, M., Bigelow, G. E., & Silverman, K. (2012). Employment-based reinforcement of adherence to an FDA approved extended release formulation of naltrexone in opioid-dependent adults: A randomized controlled trial. Drug and Alcohol Dependence, 120(1-3), 48–54. https://doi.org/10.1016/j.drugalcdep.2011.06.023.
DeFulio, A., & Silverman, K. (2011). Employment-based abstinence reinforcement as a maintenance intervention for the treatment of cocaine dependence: Post-intervention outcomes. Addiction (Abingdon, England), 106(5), 960–967. https://doi.org/10.1111/j.1360-0443.2011.03364.x;10.1111/j.1360-0443.2011.03364.x.
Donlin, W. D., Knealing, T. W., Needham, M., Wong, C. J., & Silverman, K. (2008). Attendance rates in a workplace predict subsequent outcome of employment-based reinforcement of cocaine abstinence in methadone patients. Journal of Applied Behavior Analysis, 41(4), 499–516.
Drewnowski, A., & Specter, S. E. (2004). Poverty and obesity: The role of energy density and energy costs. The American Journal of Clinical Nutrition, 79(1), 6–16.
Dunn, K. E., Defulio, A., Everly, J. J., Donlin, W. D., Aklin, W. M., Nuzzo, P. A., et al. (2013). Employment-based reinforcement of adherence to oral naltrexone treatment in unemployed injection drug users. Experimental and Clinical Psychopharmacology, 21(1), 74–83. https://doi.org/10.1037/a0030743.
Dutra, L., Stathopoulou, G., Basden, S. L., Leyro, T. M., Powers, M. B., & Otto, M. W. (2008). A meta-analytic review of psychosocial interventions for substance use disorders. The American Journal of Psychiatry, 165(2), 179–187. https://doi.org/10.1176/appi.ajp.2007.06111851.
Everly, J. J., DeFulio, A., Koffarnus, M. N., Leoutsakos, J. M., Donlin, W. D., Aklin, W. M., et al. (2011). Employment-based reinforcement of adherence to depot naltrexone in unemployed opioid-dependent adults: A randomized controlled trial. Addiction (Abingdon, England), 106(7), 1309–1318. https://doi.org/10.1111/j.1360-0443.2011.03400.x;10.1111/j.1360-0443.2011.03400.x.
Getty, C. A., Subramaniam, S., Holtyn, A. F., Jarvis, B. P., Rodewald, A., & Silverman, K. (2018). Evaluation of a computer-based training program to teach adults at risk for HIV about pre-exposure prophylaxis. AIDS Education and Prevention: Official Publication of the International Society for AIDS Education, 30(4), 287–300. https://doi.org/10.1521/aeap.2018.30.4.287.
Hawkins, N. M., Jhund, P. S., McMurray, J. J., & Capewell, S. (2012). Heart failure and socioeconomic status: Accumulating evidence of inequality. European Journal of Heart Failure, 14(2), 138–146. https://doi.org/10.1093/eurjhf/hfr168.
Heil, S. H., Higgins, S. T., Bernstein, I. M., Solomon, L. J., Rogers, R. E., Thomas, C. S., et al. (2008). Effects of voucher-based incentives on abstinence from cigarette smoking and fetal growth among pregnant women. Addiction (Abingdon, England), 103(6), 1009–1018. https://doi.org/10.1111/j.1360-0443.2008.02237.x.
Henkel, D. (2011). Unemployment and substance use: A review of the literature (1990-2010). Current Drug Abuse Reviews, 4(1), 4–27.
Higgins, S. T., Delaney, D. D., Budney, A. J., Bickel, W. K., Hughes, J. R., Foerg, F., & Fenwick, J. W. (1991). A behavioral approach to achieving initial cocaine abstinence. The American Journal of Psychiatry, 148(9), 1218–1224.
Higgins, S. T., Heil, S. H., Dantona, R., Donham, R., Matthews, M., & Badger, G. J. (2007). Effects of varying the monetary value of voucher-based incentives on abstinence achieved during and following treatment among cocaine-dependent outpatients. Addiction (Abingdon, England), 102(2), 271–281. https://doi.org/10.1111/j.1360-0443.2006.01664.x.
Hiscock, R., Bauld, L., Amos, A., Fidler, J. A., & Munafo, M. (2012). Socioeconomic status and smoking: A review. Annals of the New York Academy of Sciences, 1248, 107–123. https://doi.org/10.1111/j.1749-6632.2011.06202.x.
Holtyn, A. F., DeFulio, A., & Silverman, K. (2015). Academic skills of chronically unemployed drug-addicted adults. Journal of Vocational Rehabilitation, 42(1), 67–74. https://doi.org/10.3233/JVR-140724.
Holtyn, A. F., Jarvis, B. P., & Silverman, K. (2017). Behavior analysts in the war on poverty: A review of the use of financial incentives to promote education and employment. Journal of the Experimental Analysis of Behavior, 107(1), 9–20. https://doi.org/10.1002/jeab.233.
Holtyn, A. F., Koffarnus, M. N., DeFulio, A., Sigurdsson, S. O., Strain, E. C., Schwartz, R. P., et al. (2014a). The therapeutic workplace to promote treatment engagement and drug abstinence in out-of-treatment injection drug users: A randomized controlled trial. Preventive Medicine, 68, 62–70. https://doi.org/10.1016/j.ypmed.2014.02.021.
Holtyn, A. F., Koffarnus, M. N., DeFulio, A., Sigurdsson, S. O., Strain, E. C., Schwartz, R. P., & Silverman, K. (2014b). Employment-based abstinence reinforcement promotes opiate and cocaine abstinence in out-of-treatment injection drug users. Journal of Applied Behavior Analysis, 47(4), 681–693. https://doi.org/10.1002/jaba.158.
Jarvis, B. P., Holtyn, A. F., DeFulio, A., Koffarnus, M. N., Leoutsakos, J. S., Umbricht, A., et al. (2019). The effects of extended-release injectable naltrexone and incentives for opiate abstinence in heroin-dependent adults in a model therapeutic workplace: A randomized trial. Drug and Alcohol Dependence, 197, 220–227.
Kirby, K. C., Carpenedo, C. M., Dugosh, K. L., Rosenwasser, B. J., Benishek, L. A., Janik, A., et al. (2013). Randomized clinical trial examining duration of voucher-based reinforcement therapy for cocaine abstinence. Drug and Alcohol Dependence, 132(3), 639–645. https://doi.org/10.1016/j.drugalcdep.2013.04.015.
Koffarnus, M. N., DeFulio, A., Sigurdsson, S. O., & Silverman, K. (2013a). Performance pay improves engagement, progress, and satisfaction in computer-based job skills training of low-income adults. Journal of Applied Behavior Analysis, 46(2), 395–406. https://doi.org/10.1002/jaba.51.
Koffarnus, M. N., Wong, C. J., Diemer, K., Needham, M., Hampton, J., Fingerhood, M., et al. (2011). A randomized clinical trial of a therapeutic workplace for chronically unemployed, homeless, alcohol-dependent adults. Alcohol and Alcoholism (Oxford, Oxfordshire), 46(5), 561–569. https://doi.org/10.1093/alcalc/agr057.
Koffarnus, M. N., Wong, C. J., Fingerhood, M., Svikis, D. S., Bigelow, G. E., & Silverman, K. (2013b). Monetary incentives to reinforce engagement and achievement in a job-skills training program for homeless, unemployed adults. Journal of Applied Behavior Analysis, 46(3), 582–591. https://doi.org/10.1002/jaba.60.
Lussier, J. P., Heil, S. H., Mongeon, J. A., Badger, G. J., & Higgins, S. T. (2006). A meta-analysis of voucher-based reinforcement therapy for substance use disorders. Addiction, 101(2), 192–203. https://doi.org/10.1111/j.1360-0443.2006.01311.x.
Magura, S., Staines, G. L., Blankertz, L., & Madison, E. M. (2004). The effectiveness of vocational services for substance users in treatment. Substance use & Misuse, 39(13-14), 2165–2213.
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 outcomes evaluation. The Journal of the American Medical Association, 284(13), 1689–1695.
Miller, P. M., Hersen, M., Eisler, R. M., & Watts, J. G. (1974). Contingent reinforcement of lowered blood-alcohol levels in an outpatient chronic alcoholic. Behaviour Research and Therapy, 12(3), 261–263.
Muennig, P., Fiscella, K., Tancredi, D., & Franks, P. (2010). The relative health burden of selected social and behavioral risk factors in the united states: Implications for policy. American Journal of Public Health, 100(9), 1758–1764. https://doi.org/10.2105/AJPH.2009.165019.
Oldenburg, C. E., Perez-Brumer, A. G., & Reisner, S. L. (2014). Poverty matters: Contextualizing the syndemic condition of psychological factors and newly diagnosed HIV infection in the United States. AIDS (London, England), 28(18), 2763–2769. https://doi.org/10.1097/QAD.0000000000000491.
Pilling, S., Strang, J., Gerada, C., & NICE. (2007). Psychosocial interventions and opioid detoxification for drug misuse: Summary of NICE guidance. BMJ, 335(7612), 203–205. https://doi.org/10.1136/bmj.39265.639641.AD.
Riccio, J., Dechausay, N., Miller, C., Nuñez, S., Verma, N., & Yang, E. (2013). Conditional cash transfers in New York City: The continuing story of the Opportunity NYC-Family Rewards demonstration. New York: https://www.mdrc.org/sites/default/files/Conditional_Cash_Transfers_FR%202-18-16.pdf. Accessed on April 5, 2019.
Robles, E., Stitzer, M. L., Strain, E. C., Bigelow, G. E., & Silverman, K. (2002). Voucher-based reinforcement of opiate abstinence during methadone detoxification. Drug and Alcohol Dependence, 65(2), 179–189.
Robles, E., Silverman, K., Preston, K. L., Cone, E. J., Katz, E., Bigelow, G. E., & Stitzer, M. L. (2000). The brief abstinence test: Voucher-based reinforcement of cocaine abstinence. Drug and Alcohol Dependence, 58(1-2), 205–212.
Rosenthal, A., Bol, K. & Gabello, B. (2016). Examining opioid and heroin-related drug overdose in Colorado. Health Watch. https://www.cohealthdata.dphe.state.co.us/chd/Resources/pubs/Colorado-Opioid-and-Heroin-Overdose.pdf. Accessed on February 13, 2019.
Sees, K. L., Delucchi, K. L., Masson, C., Rosen, A., Clark, H. W., Robillard, H., et al. (2000). Methadone maintenance vs 180-day psychosocially enriched detoxification for treatment of opioid dependence: A randomized controlled trial. The Journal of the American Medical Association, 283(10), 1303–1310.
Semega, J. L., Fontenot, K. R., & Kollar, M. A. (2017). Income and poverty in the United States: 2016. (U.S. Census Bureau, Current Population Reports No. P60-259. Washington, DC: U.S. Government Printing Office. https://www.census.gov/content/dam/Census/library/publications/2017/demo/P60-259.pdf. Accessed on February 13, 2019.
Shoptaw, S., Rotheram-Fuller, E., Yang, X., Frosch, D., Nahom, D., Jarvik, M. E., et al. (2002). Smoking cessation in methadone maintenance. Addiction, 97(10), 28 discussion 1325.
Sigurdsson, S. O., Ring, B. M., O'Reilly, K., & Silverman, K. (2012). Barriers to employment among unemployed drug users: Age predicts severity. The American Journal of Drug and Alcohol Abuse, 38(6), 580–587. https://doi.org/10.3109/00952990.2011.643976.
Silverman, K. (2004). Exploring the limits and utility of operant conditioning in the treatment of drug addiction. The Behavior Analyst, 27(2), 209.
Silverman, K., Chutuape, M. A., Bigelow, G. E., & Stitzer, M. L. (1996a). Voucher-based reinforcement of attendance by unemployed methadone patients in a job skills training program. Drug and Alcohol Dependence, 41(3), 197–207.
Silverman, K., Chutuape, M. A., Bigelow, G. E., & Stitzer, M. L. (1999). Voucher-based reinforcement of cocaine abstinence in treatment-resistant methadone patients: Effects of reinforcement magnitude. Psychopharmacology, 146(2), 128–138 doi:91460128.213 [pii].
Silverman, K., DeFulio, A., & Everly, J. J. (2011a). Behavioral aspects. In P. Ruiz & E. C. Strain (Eds.), Lowinson and Ruiz's substance abuse: A comprehensive textbook (Fifth ed., pp. 88–106). Philadelphia: Wolters Kluwer, Lippincott Williams & Wilkins.
Silverman, K., DeFulio, A., & Sigurdsson, S. O. (2012). Maintenance of reinforcement to address the chronic nature of drug addiction. Preventive Medicine, 55(Suppl), 46. https://doi.org/10.1016/j.ypmed.2012.03.013.
Silverman, K., Higgins, S. T., Brooner, R. K., Montoya, I. D., Cone, E. J., Schuster, C. R., & Preston, K. L. (1996b). Sustained cocaine abstinence in methadone maintenance patients through voucher-based reinforcement therapy. Archives of General Psychiatry, 53(5), 409–415.
Silverman, K., Holtyn, A. F., & Jarvis, B. (2016a). A potential role of anti-poverty programs in health promotion. Preventive Medicine. 92, 58–61.
Silverman, K., Holtyn, A. F., & Morrison, R. (2016b). The therapeutic utility of employment in treating drug addiction: Science to application. Translational Issues in Psychological Science, 2(2), 203–212. https://doi.org/10.1037/tps0000061.
Silverman, K., Holtyn, A. F., & Subramaniam, S. (2018). Behavior analysts in the war on poverty: Developing an operant antipoverty program. Experimental and Clinical Psychopharmacology, 26(6), 515–524. https://doi.org/10.1037/pha0000230.
Silverman, K., Kaminski, B. J., Higgins, S. T., & Brady, J. V. (2011b). Behavior analysis and treatment of drug addiction. In W. W. Fisher, C. C. Piazza, & H. S. Roane (Eds.), Handbook of applied behavior analysis (pp. 451–471). New York: Guilford Press.
Silverman, K., Robles, E., Mudric, T., Bigelow, G. E., & Stitzer, M. L. (2004). A randomized trial of long-term reinforcement of cocaine abstinence in methadone-maintained patients who inject drugs. Journal of Consulting and Clinical Psychology, 72(5), 839–854. https://doi.org/10.1037/0022-006X.72.5.839.
Silverman, K., Svikis, D., Robles, E., Stitzer, M. L., & Bigelow, G. E. (2001). A reinforcement-based therapeutic workplace for the treatment of drug abuse: Six-month abstinence outcomes. Experimental and Clinical Psychopharmacology, 9(1), 14–23.
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(3), 228–240.
Silverman, K., Wong, C. J., Higgins, S. T., Brooner, R. K., Montoya, I. D., Contoreggi, C., et al. (1996c). Increasing opiate abstinence through voucher-based reinforcement therapy. Drug and Alcohol Dependence, 41(2), 157–165.
Silverman, K., Wong, C. J., Needham, M., Diemer, K. N., Knealing, T., Crone-Todd, D., et al. (2007). A randomized trial of employment-based reinforcement of cocaine abstinence in injection drug users. Journal of Applied Behavior Analysis, 40(3), 387–410.
Silverman, K., Wong, C. J., Umbricht-Schneiter, A., Montoya, I. D., Schuster, C. R., & Preston, K. L. (1998). Broad beneficial effects of cocaine abstinence reinforcement among methadone patients. Journal of Consulting and Clinical Psychology, 66(5), 811–824.
Stitzer, M. L., & Bigelow, G. E. (1982). Contingent reinforcement for reduced carbon monoxide levels in cigarette smokers. Addictive Behaviors, 7(4), 403–412.
Stitzer, M. L., & Bigelow, G. E. (1984). Contingent reinforcement for carbon monoxide reduction: Within-subject effects of pay amount. Journal of Applied Behavior Analysis, 17(4), 477–483.
Subramaniam, S., Everly, J. J., & Silverman, K. (2017). Reinforcing productivity in a job-skills training program for unemployed substance-abusing adults. Behavior Analysis: Research and Practice. (Washington D.C.), 17(2), 114–128. https://doi.org/10.1037/bar0000077.
Subramaniam, S., Getty, C. A., Holtyn, A. F., Rodewald, A., Katz, B., Jarvis, B. P., et al. (2019). Evaluation of a computer-based HIV education program for adults living with HIV. AIDS and Behavior. https://doi.org/10.1007/s10461-019-02474-z.
Svikis, D. S., Keyser-Marcus, L., Stitzer, M., Rieckmann, T., Safford, L., Loeb, P., et al. (2012). Randomized multi-site trial of the job seekers' workshop in patients with substance use disorders. Drug and Alcohol Dependence, 120(1-3), 55–64. https://doi.org/10.1016/j.drugalcdep.2011.06.024.
Ward, E., Jemal, A., Cokkinides, V., Singh, G. K., Cardinez, C., Ghafoor, A., & Thun, M. (2004). Cancer disparities by race/ethnicity and socioeconomic status. CA: A Cancer Journal for Clinicians, 54(2), 78–93.
Williams, C. T., & Latkin, C. A. (2007). Neighborhood socioeconomic status, personal network attributes, and use of heroin and cocaine. American Journal of Preventive Medicine, 32(6 Suppl), 203.
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(1), 39–46. https://doi.org/10.1037/1064-1297.12.1.39.
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(3), 319–323. https://doi.org/10.1016/j.drugalcdep.2003.12.013.
Funding
The preparation of this manuscript was supported by the National Institute of Allergy and Infectious Diseases, the National Institute on Drug Abuse, the National Institute on Alcohol Abuse and Alcoholism of the National Institutes of Health under grants R01AI117065, R01DA037314, R01AA024101, and T32DA07209. The content is solely the responsibility of the authors and does not represent the official views of the National Institutes of Health.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of Interest
The authors declare that they have no conflicts of interest related to the material in this manuscript.
Additional information
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
About this article
Cite this article
Silverman, K., Holtyn, A.F. & Toegel, F. The Utility of Operant Conditioning to Address Poverty and Drug Addiction. Perspect Behav Sci 42, 525–546 (2019). https://doi.org/10.1007/s40614-019-00203-4
Published:
Issue Date:
DOI: https://doi.org/10.1007/s40614-019-00203-4