Silverman  - many studies cited that I haven’t cited here – quite a fast talker

•    Operant procedures have been used in the treatment of additions over the years in many populations

•    Probably the most effective psychosocial treatment of drug adaptation

•    Challenges

o    Improve effectiveness of interventions

o    Prevent relapse – long term, lifelong outcomes

o    Facilitate dissemination – effective treatments into widespread use

•    Studding cocaine use in methadone patients

o    Baltimore – high heroin and cocaine use

o    Methadone – good for heroin addiction

o    No effects on cocaine

o    Associated with HIV infection

•    Injection equipment

•    Crack users trading sex for money

o    Application

•    Poor/unemployed

•    Heroin/cocaine

•    All r/c daily methadone

•    Weekly counseling

•    Drug tests 3x/week

o    Drug free urine – money vouchers across study

•    Promotes abstinence

•    Replicated to include individuals using cocaine in Baltimore City

•    Usually take people who continue to use cocaine despite counseling and traditional tx

o    Compared individuals – contingent vouchers v. ncr vouchers

o    Baseline low

•    More clean samples in individuals with contingent vouchers

•    Some relapse in follow-up

•    About half was nonresponsive to intervention

•    Sr magnitude in treatment-resistant

o    Methadone patients who continue to use cocaine

o    Given standard vouchers – those who failed to achieve abstinence

o    Exposed to counterbalanced high, low, and non magnitude vouchers – confident of relapse during 4-week washout period

•    High magnitude vouchers most effective  over 12 weeks

•    Very high risk clients – at risk for HIV

•    What about maintenance?

o    Abstinence Sr might be the most effective for maintenance

o    Three groups

•    Control – standard methadone

•    Take home methadone

•    Take home + vouchers

o    Maintained the contingencies for an entire year

•    Take home + voucher highest over time

o    Those who initiated abstinence tended to maintain abstinence

•    How can high magnitude and long duration abstinence be financed?

•    Workplaces as a context for abstinence Sr

o    Control powerful Sr

o    Regular contact

o    Maintained over extended periods of time

o    Drug testing is accepted and used

o    Workplaces are everywhere

•    There have been descriptive studies but no systematic evaluation

o    Drug free urine -> work -> pay/vouchers

•    Phase I – job skill training, vouchers, limited duration

•    Phase 2: Hired in a therapeutic workplace

•    Paid in paycheck

•    Unlimited duration

o    What type of workplace?

•    Focus on data entry business

o    Urine collected 3x/week

o    Work schedule – 4 hr/day

o    Voucher pay - $8/hr

o    Phase II – minimum wage w/ productivity bonus

o    + cocaine – not allowed to work – temporary reduction in play

•    Initial clinical trial – center for addiction and pregnancy

o    Random assignment to usual care or therapeutic workplace

o    All P not responsive to traditional treatment

•    Results – 45% engaged in the workplace -> 45% hired into the data entry

o    Large increase in – samples as opposed to the controls

•    More likely to be employed full time – (40% over 10% or so) – significant difference

o    Were not employed in the community, however, but were offered jobs in the traditional way

•    Was it providing the employment, or was it the abstinence contingencies?

•    Next study – compared work v. abstinence contingent work (6 month study)

o    Baseline – 6% were negative for cocaine in the two groups

o    After intervention – contingent – significantly higher, but only about 30%

•    More likely to be reliable

•    Purpose of current study under review – maintenance of abstinence over extended periods of time

o    Methadone pts using cocaine

•    6 month phase I intervention – abstinence contingent work

•    abstinent and skilled – randomly assigned to:

•    employment only

•    abstinence-contingent employment

•    worked with them for 1 year

o    Results

•    Phase I – negative samples more likely in the contingent condition

•    Phase II Employment only – more likely to be cocaine positive

•    Year II – Abstinence contingent employment 80% versus 50%

•    For some, short exposure will work, but not for the group

•    Attendance during Phase II – about the same – earnings were just about identical

•    Applications of employment-based reinforcement

o    Social business – sustainable businesses that exist to address poverty (Muhammad Yunus, 2006/2007)

o    Employment training  and supported employment – e.g., the VA

o    Community workplaces – places that provide drug testing and supervision

•    Usually used to get people out of the workplace

•    Conclusions

o    Many chronically unemployed drug users will train and work consistently for modest wages

o    Employment alone is not sufficient to initiate or maintain drug abstinence for most individuals

o    Employment-based abstinence is helpful

•    Has not looked systematically at employment outcomes

o    Quick entry v. education focused approaches

•    Quick entry – workforce quickly at low wage

•    Not as useful for SA populations

•    Education focused – enter workforce after delay at a higher wage

•    Not looked at in the substance abuse populations

•    Some correlations between skills and earnings, but many people did not reliably come

•    Could be helpful….

o    Promoting attendance, punctuality, and productivity

•    Does not work with just an invitation

•    Voucher programs – increase attendance in job skills training program

•    Reinforcement of punctuality and complete work shifts

•    Sr magnitude = increased productivity

•    Some people will maximize contingencies without learning – pitfalls in the contingencies

o    If the contingencies are good, then people will be punctual

o    Lots of articles under review on this subject as of today

•    Professional demeanor

•     Voice volume in the workplace

o    Also working on soft skills in the workplace and behavioral safety

o    Studies on the computerized typing skills program

•    New initiative – an education-focused operant learning center

o    Intensive education and job skills training

o    Voucher reinforcement

o    Employment-based Sr

o    Computerized training and data collection

•    Questions – what about nonresponders

o    Predictor – level of cocaine use during baseline

•    Amount of time in attendance during baseline is associated with better outcomes

•    Manipulating the magnitude, increasing attendance in baseline?

o    What about delay to Sr?

•    Probably pretty relevant

•    Most of the Sr is immediate – has a continuously updated home page and are trained using precision teaching procedures

•    Delay to vouchers – vouchers are gift cards

•    Could shorten the delay by using cash