National

46

Behavioral

Intervention

Techniques in

Drug Abuse

Treatment

Institute on

Drug

Abuse

MONOGRAPH SERIES

U. S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service Alcohol, Drug Abuse. and Mental Health Administration
Behavioral Intervention

Techniques in Drug Abuse

Treatment

Editors:

John Grabowski, Ph.D.

Division of Clinical Research

National Institute on Drug Abuse

Maxine L. Stitzer, Ph.D.

Baltimore City Hospitals, and

The Johns Hopkins Unversity School of Medicine

Jack E. Henningfield, Ph.D.

Addiction Research Center

National Institute on Drug Abuse

NIDA Research Monograph 46

1984

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Public Health Service

Alcohol, Drug Abuse, and Mental Health Administration

National Institute on Drug Abuse

5600 Fishers Lane

Rockville, Maryland 20657

For sale by the Superintendent of Documents, U.S. Government Printing: Office

Washington, D.C. 20402
NIDA Research Monographs are prepared by the research divisions of the

National Institute on Drug Abuse and published by its Office of Science. The

primary objective of the series is to provide critical reviews of research

problem areas and techniques. the content of state-of-the-art conferences, integrative research reviews and significant original research. Its

dual publication emphasis is rapid and targeted dissemination to the

scientific and professional community

Editorial Advisory Board

Avram Goldstein, M.D.

Addiction Research Foundation

Palo Alto, California

Jerome Jaffe, M.D.

University of Connecticut School of Medicine

Farmington, Connecticut

Reese T. Jones, M.D.

Langley Porter Neuropsychiatric Institute

University of California

San Francisco, California

Jack Mendelson, M.D.

Alcohol and Drug Abuse Research Center

Harvard Medical School

McLean Hospital

Belmont, Massachusetts

Helen Nowlis, Ph.D.

Rochester, New York

Lee Robins, Ph.D.

Washington University School of Medicine

St. Louis, Missouri

NIDA Research Monograph Series

William Pollin, M.D.

DIRECTOR, NIDA

Jack Dwell, M.D.

ASSOCIATE DIRECTOR, OFFICE OF SCIENCE, NIDA

EDITOR-IN-CHIEF

Eleanor W. Waldrop

MANAGING EDITOR

Parklawn Building, 5600 Fishers Lane, Rockville, Maryland 20857
Behavioral Intervention

Techniques in Drug Abuse

Treatment
ACKNOWLEDGMENT

This monograph is based upon papers and discussion from a technical

review, Behavioral Intervention Techniques in Drug Abuse Treatment,

held July 8 and 9, 1982, in Bethesda, Maryland, sponsored by the

Division of Research, National 'Institute on Drug Abuse.

COPYRIGHT STATUS

The National Institute on Drug Abuse has obtained permission from

the copyright holders to reproduce certain previously published'

material as noted in the text. Further reproduction of this

material is prohibited without specific permission of the copyright

holders. All other material in this volume except quoted passages

from copyrighted sources is in the public domain and may be used or

reproduced without permission from the Institute or the authors.

Citation of the source is appreciated.

Opinions expressed in this volume are those of the authors and do

not necessarily reflect the opinions or official policy of the

National Institute on Drug Abuse or any other part of the U.S.

Department of Health and Human Services.

The U.S. Government does not endorse or favor any specific

commercial product or commodity. Trade or proprietary names

appearing in this publication are used only because they are

considered essential in the context of the studies reported herein.

Library of Congress catalog card number 83-600623

DHHS publication number (ADM)84-1282

Printed 1984

NIDA Research Monographs are indexed in the Index Medicus. They

are selectively included in the coverage of American Statistics

Index, Biosciences Information Service, Chemical Abstracts, Current

Contents, Psychological Abstracts, and Psychopharmacology Abstracts.

iv
Foreword

Knowledge of the behavioral, environmental, and pharmacological

correlates of substance use and abuse is central to the interests

of the National Institute on Drug Abuse. Thus, NIDA has

contributed to the expansion and dissemination of such knowledge

by supporting research and sponsoring major reviews to examine the

mechanisms that determine substance abuse and other habitual

behaviors, with particular emphasis on the common explanatory

elements. The publications that resulted from these reviews have

explored what we know about the specific behavioral

pharmacological processes which underlie the observed effects of

drug use and abuse.

Several volumes in the NIDA Research Monograph series have

embodied the perspective of behavioral pharmacology.* With

varying emphasis, each has examined broad theoretical issues,

sought to expand on and contribute to a sound conceptual

framework, and applied its findings to improving the science and

techniques of treatment--in which basic research ultimately comes

to fruition. Behavioral Intervention Techniques in Drug Abuse

Treatment, the ninth of these monographs, focuses directly on

treatment applications as well as broader issues in the treatment

domain.

Behavioral intervention techniques are based on the premise that

behavior is controlled by its positive and negative consequences

and can be modified by making changes in selected aspects of the

environment so as to reinforce desired behaviors. They encompass

numerous related procedures, variously labeled as behavior

modification, behavior therapy, contingency contracting,

contingency management, or token economy. These interventions are

increasingly being used, integratively with other more traditional

forms of therapy, in treating the diverse disorders associated

with drug dependency. They can enhance the effectiveness of

essentially all available treatment components, including

pharmacological adjuncts, psychotherapy, family therapy, and job

training. Through such a spectrum of uses, behavioral

intervention techniques, thoughtfully planned and applied, promise

increasing levels of success in the treatment of drug abusers.

v
The contributors to this monograph all are actively involved in

various aspects of drug abuse research and treatment in which

behavioral techniques are used. Representing a broad range of

areas of expertise, their presentations will be of interest to

those who are engaged in clinical research, treatment, and

analysis of drug abuse treatment systems.

William Pollin. M.D.

Director

National Institute on Drug Abuse

*Behavioral Tolerance: Research and Treatment Implications

(No. 18)

Self-Administration of Abused Substances: Methods for Studv

(No. 20)

Behavioral Analysis and Treatment of Substance Abuse (No. 25)

Behavioral Pharmacology of Human Drug Dependence (No. 37)

Research on Smoking Behavior (No. 17)

Cigarette Smoking as a Dependence Process (No. 23)

The Behavioral Aspects of Smoking (No. 26)

Measurement in the Analysis and Treatment of Smoking Behavior

(No. 48)

vi
Contents

Foreword

William Pollin . . . . . . . . . . . . . . . . . . . . . . . v

Therapeutic Application of Behavioral Techniques: An Overview

John Grabowski, Maxine L. Stitzer, and Jack E. Henningfield. 1

Problems in Methadone Treatment: The Influence of Reference

Groups

Dana E. Hunt, Douglas S. Lipton, Douglas S. Goldsmith,

and David L. Strug . . . . . . . . . . . . . . . . . . . . . 8

Treatment of Behavioral and Psychiatric Problems Associated

With Opiate Dependence

George E. Woody, A. Thomas McLellan, and Charles P. O'Brien. 23

The Role of Behavioral Contingency Management in Drug

Abuse Treatment

George E. Bigelow, Maxine L. Stitzer, and Ira A. Liebson . . 36

Behavioral Treatment of Drug Dependence

Roy W. Pickens and Travis Thompson . . . . . . . . . . . . . 53

Contingency Contracting Treatment of Drug-Abusing Physicians,

Nurses, and Dentists

Thomas J. Crowley . . . . . . . . . . . . . . . . . . . . . 68

Contingency Management of Supplemental Drug Use During

Methadone Maintenance Treatment

Maxine L. Stitzer, George E. Bigelow, Ira A. Liebson,

and Mary E. McCaul . . . . . . . . . . . . . . . . . . . . . 84

A Contingency Analysis of Family Treatment and Drug Abuse

Thomas C. Todd . . . . . . . . . . . . . . . . . . . . . . . 104

vii
The Job Seekers' Workshop: A Skill Training Program for

Drug Treatment Clients

Sharon M. Hall, Peter C. Loeb, and Tim Allen . . . . . . . . . 115

Brokerage Model Rehabilitation System for Opiate Dependence:

A Behavioral Analysis

Travis Thompson, Jon Koerner, and John Grabowski . . . . . . 131

Behavioral Intervention Techniques in Drug Abuse Treatment:

Summary of Discussion

Maxine L. Stitzer, John Grabowski, and Jack E. Henningfield. 147

Contributors . . . . . . . . . . . . . . . . . . . . . . . . 157

List of NIDA Research Monographs . . . . . . . . . . . . . . 158

viii
Therapeutic Application of Behavioral Techniques: An Overview

John Grabowski, Ph.D., Maxine L. Stitzer, Ph.D., and

Jack E. Henningfield, Ph.D.

Observations on the History of Treatment

History is replete with examples and reports of drug abuse despite

the current popular perspective that drug abuse is a relatively

recent behavioral anomaly. References to maladaptive patterns of

drug use are prevalent in the treatment literature of the past

century, and, on even casual examination, the characteristic

efforts to eliminate the problems are not unfamiliar.

The techniques have ranged from essentially entirely pharmacological to completely behavioral-psychological. An early example

of treatment in the realm of pharmacological manipulations was

that of Bentley (1880; see Byck 1974, p. 15), who, among others,

treated heroin use by administering cocaine. Later, some

clinicians, researchers, and observers of the discipline did

recognize or acknowledge the importance of environmental factors.

As was noted by Bernfeld (1953), "Neither cocaine nor any other

chemical, in itself, produces addiction. It is a psychological

[behavioral] phenomenon. In the '80s [188Os] the problem of

addiction was approached, if at all, as one of toxicity

to certain habit-forming drugs" (see Byck 1974, p. 3473.

specific

Nevertheless, despite a century of documented treatment experience, intensive research, and repetition of comments paralleling

those of Bernfeld, continued belief in the singular importance of

the substance is frequent, and failure to acknowledge the

importance of behavioral and environmental factors in the

development, maintenance, and elimination of drug use is not

uncommon. Thus, for example, methadone maintenance, when

introduced 20 years ago, constituted a pharmacological intervention which was commonly administered as a primary therapy

rather than as a pharmacological adjunct to other therapy.

Furthermore, this practice is not altogether unusual today.

Early reports of treatment illustrated the general inadequacy of

approaches not explicitly attending to the interactive nature of

drug use. In the United States, "drug addiction," i.e.,

1
maladaptive drug use, was for many years essentially synonymous

with use of narcotic analgesics. "Treatment" for the stereotypic

user was equated, at one extreme, with inpatient drug withdrawal

and discharge, and, at the other, with long-term incarceration at

the United States Public Health Service hospitals. In this case,

seeming attention to the environmental factors, i.e., through

removal from the drug-taking environment, was in fact founded in a

pharmacological perspective. Later, Wikler (1965) and others

pointed to the difficulties in the model and developed a

theoretical position delineating the role of some environmental

factors in the maintenance of opiate use (e.g., Stitzer et al.

1983; Grabowski and Cherek 1983). As Stitzer et al. (1983) have

noted concerning treatment based on the incarceration strategy,

"the therapeutic success...was not impressive." It was, however,

consistent with a general societal view which dictated that

removal of an individual with behavioral disorders to a separate

environment would contribute to a return to health or provide an

opportunity for rehabilitation. As with the mentally ill and

mentally retarded individuals of an earlier era (e.g., see

Thompson and Grabowski 1977; Deutsch 1949). it has since become

clear that temporary, or even prolonged, removal from the natural

environment in which the behavior occurs does not, in and of

itself, have any particular utility unless it is intended that the

individual will never return to that environment. Overall it

became evident that treatment by simple isolation from drugs is

neither a necessary nor sufficient condition to eliminate drug

use. As is indicated elsewhere in this volume, there still exists

some tendency, if not to remove the users from society, at least

to segregate them from other components of the behavioral health

care system.

Interestingly, the reverse condition, of increased likelihood of

drug use under novel environmental conditions, has also been

described. Robins et al. (1974) observed that individuals whose

first exposure to, and repeated use of, heroin occurred in Vietnam

did not in the main continue use of the drug after returning to

the United States. Thus, it may be argued that availability of

the drug in a different environment devoid of other reinforcers

may greatly increase the likelihood of use. In turn, return to

the original environment where drug use may be less acceptable and

where the drug is less available may result in discontinuation of

use. This further illustrates that-diverse environmental stimuli

serve to control and determine the probability of both use and

nonuse. This phenomenon has been adequately documented in the

behavioral pharmacology laboratory (e.g., Thompson and Ostlund

1965).

It is clear that the treatment issues as well as the drugs of

current concern (e.g., heroin, cocaine) are the same as those

about which much has been written in the last century. And yet

there now exists a substantial data base focusing attention on the

importance of nonpharmacological, in addition to pharmacological,

factors in treatment. Numerous reviews delineate the potential or

demonstrated importance of the interactions between behavioral and

environmental factors (e.g., Grabowski and Cherek 1983; Stitzer

2
et al. 1983; Griffiths et al,. 1980). Nevertheless, only slowly is

acceptance emerging at a more general level of the importance of

drug-behavior-environment interactions and the need to attend to

the problems principally from this perspective,

Treatment Strategies and Brief Overview

Both pharmacological and environmental factors must be considered

in treating the specific problems of drug abuse and the plethora

of correlated disorders. However, in fact there are several basic

strategies to "treatment" of drug use and in the main they "treat"

rather different phenomena (e. g, see Grabowski and O'Brien

1981). Approaches include: (1 pharmacological treatment of 4

cessation (i.e., withdrawal and rebound symptoms); (2) pharmacological maintenance treatment; (3) rehabilitation and treatment of

collateral problems; and (4) behavioral intervention techniques.

It is clear that the first strategy, drug withdrawal, is unlikely

to have any long-term utility. The second strategy,

administration of opiate partial agonists (e.g., methadone),

antagonists (e.g., naltrexone), or drugs intended for treatment of

extant psychopathology such as depression (e.g., tricyclic

antidepressants) or anxiety (e.g., benzodiazepines) has potential

benefits. It must be recalled, however, that these drugs are

rarely of utility alone and should, indeed, be viewed as adjuncts

to other treatment. The third strategy, which involves major

efforts to treat psychological problems and to develop social

skills and educational or vocational opportunities is important

but should not take precedence over all other foci of

intervention. Further, this strategy is often applied in an

unintegrated and unsystematic fashion. The fourth strategy is

integrative; it takes in essence a longitudinal perspective

encompassing and using the other techniques as adjuncts and

components. A behavioral analysis is undertaken for the

individual. Current behaviors are examined, goals are developed,

and techniques for achieving these goals are delineated.

Depending on the needs of the individual, the resultant

individualized program may be narrow or broad and rather, all

inclusive, dealing with diverse aspects of the individual's

behavioral repertoire. The program is best implemented in the

context of a clinical milieu based on behavioral management

techniques. It should be evident in this regard that this does

not refer to those systems of punitive consequences which on

occasion are purported to be the foundation of a clinic-wide

behaviorally. based program.

It is important to note that "behavioral intervention techniques"

has been used here as a generic phrase that encompasses the

numerous related specific procedures which are discussed under the

rubrics of behavior modification, behavior therapy, contingency

contracting, contingency management, token economy, and other

labels. In addition it is intended that the phrase indicate the

use of specific behavioral principles in the application or

introduction of other more traditional therapy forms. Thus, for

example, behavioral analysis and procedures can well be used to

enhance the effectiveness of pharmacological adjuncts, therapy

3
involving families, job training, and essentially all other

components of treatment. While pharmacotherapy, family therapy,

and other elements are components focusing on specific loci of

intervention, behavioral intervention constitutes and refers to a

scientific analysis and treatment superstructure.

When a procedure of potential clinical utility is identified, it

should, ideally, proceed through a series of investigations and

evaluations through which its usefulness and limitations are

defined. It should be understood, however, that the development

of more precise techniques does not imply that their application

has always progressed smoothly. Early reports tended to describe

the application of fairly circumscribed techniques to equally

limited problems. These are often thought to have followed

preliminary laboratory efforts in a logical and systematic

fashion, but as Tharp and Wetzel (1969) noted, this logical

progression from laboratory to clinical setting, from simple to

more complex, is not as much in evidence as the historian of a

discipline might wish.

Nevertheless a systematic approach to analysis has developed.

Most important is the recognition that behavioral research and

clinical application are conducted with emphasis on "operationism

and observable anchors" (Craighead et al. 1976). This is

essential to, and indicative of, precise and effective implementation of behavioral techniques. The requirement for use of

measureable intermediate goals and endpoints does not, as some

suggest, limit one to simple interventions, and this is reflected

throughout the present volume. Rather it simply requires and

assures that any therapeutic procedure has been demonstrated with

some rigor to be efficacious.

In the present volume diverse applications of behavioral

interventions are discussed, ranging from the pharmacological,

through the broad rehabilitative efforts involved in socialization

and training, to possible alternative treatment systems based on

integration into the community at large. In addition, background

is provided in the form of a behaviorally based "ethological"

classification system delineating some of the behavioral repertoires in the natural environment of opiate users' who are not in

treatment and treatment clients who are not using opiates.

Hunt et al. have provided an interesting first step in identification of behavioral patterns characterizing methadone clients

in their natural environment and provide insight into both

adaptive and maladaptive patterns of behavior which emerge not

only in the clinic but away from it. Perhaps most important from

the perspective of behavioral analysis is that Hunt and her

coworkers used a procedure explicitly involving in vivo

observation rather than simply relying on the self-reports of the

patients, who are necessarily compromised in their ability to

report objectively on some aspects of their own behavior or the

behavior of others in treatment. These data assist in understanding the problems and issues raised by Woody et al. Woody's

paper describes the structure and the functioning of a clinic

4
which is representative, although it is perhaps more elaborate and

sophisticated in its resources than many, since it is invested in

extensive research activities. This suggests that some of the

problems which emerge reside in basic aspects of the system of

treatment rather than the presence or absence of extensive

resources. Further it is clear that some of the prototypic

problems inherent in the extant treatment system are represented

in the problems described by both Hunt et al. and Woody et al.

Bigelow et al., Pickens and Thompson, Stitzer et al., and Crowley

provide detailed analyses of various aspects of application of

behavioral intervention techniques in a variety of settings with

widely differing populations. Paramount in appreciating this

series of papers is the diversity in the populations and

specificity of the procedures considered. In addition it should

be noted that Bigelow's overview provides a substantive review and

background for considering approaches to behaviorally based

treatment of drug abuse and the development of interventions in

numerous facets of the patient's life. Stitzer et al; attend in

detail to a common problem in the treatment of drug-using

patients: that is, control of ongoing opiate use as well as use

of other drugs, an issue that must be addressed if treatment is

ultimately to be successful.

Those unfamiliar with the scope and utility of the philosophy of

behavioral intervention techniques as well as their explicit

application often assume that behavioral strategies may work well

with the stereotypic opiate user but have little relevance to

other groups. In fact, Pickens and Thompson, as well as Crowley,

amply demonstrate the broad utility of the techniques with respect

not only to populations but also to the drugs in question--in one

case, barbiturates and benzodiazepines, and in the other,

cocaine. A critical issue in this area is that the scope of

application is increasing rapidly and techniques are undergoing

development, refinement, and redefinition. Early efforts by

Crowley in dealing with the particularly pernicious problems

related to abuse of cocaine, an especially effective positive

reinforcer, in patients who have numerous alternative reinforcers

emphasized the control and utilization of punitive consequences in

therapy. Although procedures based on avoidance are clearly

effective, alternative techniques based on positive reinforcements

are being explored which may also be effective and have more

desirable characteristics in terms of both patient and community

acceptance. The efforts of Crowley, as well as those of Pickens

and Thompson, are especially important today since they represent

treatment of forms of drug misuse only recently acknowledged as

prevalent in the mainstream of the population.

The clinical research efforts of Todd in delivering family

therapy, as well as those of Hall et al. in job seekers' training,

illustrate extensions into areas not often thought to be amenable

to intervention through behavioral techniques. In this regard it

should be recalled that the conceptual framework and philosophical

underpinnings of behavioral techniques can readily be applied to a

diversity of behavioral-psychological problems. These authors

5
indicate that the collateral behavioral problems and rehabilitation needs in treatment of drug abuse are amenable to analysis

and resolution using behaviorally based techniques.

As becomes evident throughout the volume, the generality of

behavioral intervention strategies is limited only by the

ingenuity and precision of implementation. Specific behaviors

such as supplemental drug use may be addressed on one hand while

the more global aspects of family interactions may be attended to

on the other. Given the scope of the problems and resources

requisite in many cases of drug use, Thompson et al. address the

more general issues inherent in a "behavioral analysis" of extant

treatment systems for drug abuse problems. The questions are

difficult and answers are not readily achieved. However, it is

apparent that some of the problems related to drug abuse treatment

will not be resolved by patchwork modifications. Given the

increasing diversity and magnitude of drug abuse problems, the

suggestion of Thompson et al. that alternative strategies be

pursued may be especially timely.

Concluding Comments

In considering the techniques described in the present volume a

"word of caution" should perhaps be provided. As has been noted,

there exists an extensive experimental and clinical literature on

the application of behaviorally based intervention techniques to a

wide range of behavioral problems in diverse settings. with equally

diverse populations. Application of therapeutic techniques,

conceptual models, or technological advances to a new problem

outside the mainstream of use may result in disregard of past use

and of experience gained elsewhere. The applications often emerge

de novo in the setting, and as a result the benefits, as well as

errors, of past experience are likely to be overlooked. Thus it

is suggested that attention both to development of specialized

knowledge of behavioral techniques and to experience in

psychopharmacology and behavioral pharmacology will be important

in pursuing the development of new approaches and implementing the

approaches which are currently available. It is hoped that the

present volume will contribute to the wider application of

behavioral techniques in drug abuse treatment by indicating the

scope of applicability of these techniques and that the papers

which follow will serve as a stimulus to the reader to seek

further information from appropriate sources.

REFERENCES

Bentley, W.H. Erythoxylon coca in the opium and alcohol habits.

(In: Brodie, W., and Jungk, C., eds. Detroit Therapeutic

Gazette, IV(g), September 1880.)

Cocaine Papers, by Sigmund Freud. New York: Stonehill

Reprintedin: Byck, R.

Publishing Co., 1974. pp. 15-19.

Bernfeld, S. Freud's studies on cocaine. J Am Psychoanal ASSOC,

1(4), 1953. Reprinted in: Byck, R. Cocaine Papers, by Sigmund

Freud. New York: Stonehill Publishing Co., 1974. pp. 321-352.

6
Craighead, W.E.; Kazdin, A.E.; and Mahoney, M.J. Behavior

Modification: Principles, Issues, and Applications. Boston:

Houghton M f

Deutsch, A. The Mentally Ill in America. 2nd ed. New York:

Columbia University Press, 1949.

Grabowski, J., and Cherek, D. Conditioning factors in opiate

dependence. In: Smith, J., and Lane, J., eds. The

Neurobiology of Opiate Reward Processes. Amsterdam: Elsevier

Biomedical Press, 1983.

Grabowski; J., and O'Brien, C.P. Conditioning factors in drug

dependence: An Overview. In: Mello, N., ed. Advances in

Substance Abuse: Behavioral and Biological Research. Vol. 2.

Greenwich, CT: JAI Press, 1981. pp. 69-121.

Griffiths, R.R.; Bigelow, G.E.; and Henningfield, J.E.

Similarities in animal and human drug-taking behavior. In:

Mello, N., ed. Advances in Substance Abuse: Behavioral and

pp. 1-90.

Biological Research. Vol. 1. Greenwich: JAI Press, 1980.

Robins, L.N.; Davis, D.H.; and Goodwin, D.W. Drug use by U.S.

Army enlisted men in Vietnam: A followup on their return home.

Am J Epidemiol, 99:235-249, 1974.

Stitzer, M.L.; Bigelow, G.E., and McCaul, M.E. Behavioral

Approaches to Drug Abuse. Progress in Behavior Modification,

Vol. 14. New York: Academic Press, 1983. pp. 49-124.

Tharp, R.G., and Wetzel, J.J. Behavior Modification in the

Natural Environment. New York: Academic Press, 1969.

Thompson, T., and Grabowski, J., eds. Behavior Modification of

the Mentally Retarded. New York: Oxford University Press, 1977.

Thompson, T., and Ostlund, W. Susceptibility to readdiction as a

function of the addiction and withdrawal environments. J

Comp Physiol Psychol, 60:388-392. 1965.

Wikler, A. Conditioning factors in opiate addiction and relapse.

In: Wilner, D.J., and Kassenbaum, G.G., eds. Narcotics. New

York: McGraw Hill, 1965. pp. 85-100.
Problems in Methadone Treatment: The Influence of Reference

Groups

Dana E. Hunt, Ph.D., Douglas S. Lipton, Ph.D.,

Douglas S. Goldsmith, M.A., and David L. Strug, Ph.D.

Since its introduction in the late 196Os, methadone treatment has

been evaluated, researched, and reviewed by the scientific

community in innumerable studies focusing on different types of

treatment and treatment strategies: methadone maintenance versus

therapeutic communities, detoxification versus maintenance

(Lowenson et al. 1981; Gearing 1970; Cushman 1972). Others have

described problems in drug treatment such as alcohol abuse among

patients, patterns of criminal activity, or methods for

modification of undesirable patient behavior. Few studies,

however, have left the confines of the treatment facility to

describe the total milieu of methadone treatment.

The Tri-State Ethnographic Project (TRISEP) was a cooperative

effort of researchers and program administrators in New York, New

Jersey, and Connecticut to examine multifaceted aspects of

methadone treatment. By gathering information from patients,

staff, and addicts not in treatment, the project sought to focus

attention on the processes of methadone treatment and the

characteristics of patients which affect those treatment

processes. The purpose was to determine whether informal social

networks among persons in and around a methadone clinic influence

attitudes and opinions about methadone and, consequently, affect

patients' cooperation and compliance. The TRISEP research also

examined problems common to most methadone programs--diversion,

loitering, and polydrug abuse --to gather information which might

be helpful for developing strategies to alleviate these problems.

This paper describes four distinguishable groups identified in and

around the methadone treatment clinic which act as referents for

the behavior of their membership. These groups have important

influences on addicts' decisions regarding whether or not to enter

into and/or to cooperate with methadone treatment. The problems

common to treatment programs can also be better understood in

terms of the social organization of these groups. Therefore, this

paper concentrates on the importance of reference groups and the

normative behavior which characterizes each of them.

8
TRISEP METHODS AND SAMPLE

Interviews and extensive field research were conducted at four

methadone maintenance clinics in three States: New York, New

Jersey, and Connecticut. The four programs were comparable in

terms of demographic makeup of the patient population and the

presence of common clinic behavior problems among clients. The

total patient population of all four sites was approximately 2,000

persons. The study sample consisted of 510 people, 368 patients

randomly selected, from the clinic rolls and 142 narcotics users

not currently in treatment. The individuals not in treatment were

identified through both snowball sampling and the use of

indigenous field workers, trained methadone clients working for

TRISEP. Participation was voluntary; subjects were paid for

participation. 'The interviewing and field observations were

conducted in a four- to six-block radius of each clinic. This

territory included the drug-dealing areas and the social areas

commonly used by both patients and current street addicts who

interact with the clinic population.

RESULTS AND DISCUSSION

The methadone patient population is varied in a number of ways,

including drug histories, previous treatment experiences, and

motivations for treatment. These differences influence the

patients' receptivity to treatment. Methadone patients are also

different in terms of their reference groups in the treatment

setting. The reference groups share common values and beliefs,

have established forms of social interaction, definition of

membership, and recognition of membership by nonmembers (Merton

1968). Four clearly delineated groups have been identified

through ethnographic field observation and through cluster

analysis of respondent behaviors and attitudes:

1) street addict group: active narcotics users not

currently in treatment

2) methadone treatment group: a compliant patient group

with a positive attitude toward treatment

3) methadone street group: a noncompliant patient group who

are involved in alcohol and polydrug use

4) self-prescribing group: composed of (a) persons not in

treatment using illegal methadone to avoid withdrawal and

(b) persons in treatment who are systematically adjusting

their own dose to detoxify without the knowledge of the

program

Characteristics of these four groups will be described, followed

by a discussion of their differential contribution to the problem

areas commonly identified with methadone treatment: premature

treatment dropout, polydrug abuse, loitering, and methadone

diversion. Demographic characteristics of each subcultural group

are summarized in table 1.

9
TABLE 1. DEMOGRAPHIC INFORMATION ON GROUPS

Age

Mean Age

Race

White

Black

Hispanic

Sex

Male

Female

Employment

Employed

Unemployed

Education

Mean years

N*=

Street Methadone Methadone

Addict Treatment Street

Group Group Group

29 32 31 30

38% 45% 48%

54% 38% 42%

8% 18% 10%

46%

54%

0%

69%

31%

70% 51%

30% 49%

73%

27%

28%

72%

41% 14%

59% 86%

10.2

117

11.5 ll.O

185 177

41%

59%

11.3

22**

SelfPrescribing

Group

*Nine persons originally interviewed in the study are not included

in this classification system.

**The Self-Prescribing Group size is disproportionately small for

several reasons. First, this group was not anticipated in the

research design and no questions directly related to

self-detoxification were included in the interview. Secondly,

those persons buying methadone in the clinic area, but not wishing

to become patients, are very difficult to gain access to. The

size of this group in our sample should not be taken as reflective

of the size of this group in the larger population.

10
Street Addict Group (N=117)

The "street addict" lifestyle has been described by many

researchers (Preble and Casey 1969; Agar 1973; Stephens and

McBride 1976). Members of this group are described as heroin

addicts still "ripping and running," involved in daily or near

daily use of heroin often financed through illegal activities.

When heroin is difficult to obtain, the addict may substitute

other drugs such as morphine, codeine, hydromorphone (Dilaudid),

meperidine (Demerol), methadone, or paregoric (Gould et al. 1974),

but heroin is considered the drug of first preference and highest

status.

Results of the present study support previous findings about the

"street addict." Johnson (1981), in a recent study of the

economic behavior of "street addicts" in East Harlem, found that

drug use in the natural environment has been greatly influenced by

the influx of methadone as an available opiate. Methadone is now

the most attractive substitute for heroin, and the street addict

is rarely a user of heroin alone. However, among the "street

addict" community, methadone is seen as a drug of lower status

than heroin. The "street addict" group member can reel off a list

of side effects of methadone which are part of the basis for its

inferior reputation compared to heroin. Its use is justified by

this group in terms of perceived medical necessity rather than as

a desirable euphoriant.

The "street addict" population is, as would be expected, more

heavily involved in criminal activity than the treatment

population in general. They can be found around methadone

programs as merchants of stolen goods and as dealers of pills and

cocaine, using methadone patients as customers.

A strong antitreatment attitude markedly differentiates the

"street addict" from other groups. Over 50% of this group rated

methadone treatment as "not good with some qualification" to "not

good at all." They express contempt for the idea of treatment,

regard treatment as unnecessary, and are suspicious of treatment

staff. This group of subjects argues that methadone has

deleterious side-effects and that it is simply an inexpensive

alternative to more desirable drugs. They also tend to believe

that treatment is unnecessary and that, if they chose to, they

could readily terminate opiate use without treatment.

Methadone Treatment Group (N=l85)

This group is composed of individuals formally in treatment,

generally acting in compliance with program rules concerning

loitering, polydrug use, and methadone diversion. In addition,

commonly accepted treatment goals such as working for a living,

staying clear of serious criminal activity, and maintaining a

stable family situtation are adhered to by the methadone treatment

Their values and behavior are thus congruent with those of

the treatment staff and of the middle class culture in general.

11
The methadone treatment group is somewhat less integrated and less

visible than other groups, primarily because many of its members

work and do not gather for long periods of time at or near the

clinic. They typically come for medication early in the morning

or late in the evening, i.e., before or after work, and remain

only briefly. Because of their. cooperative behavior, they also

contribute disproportionately to the list of patients receiving

"take home" doses of methadone and thus do not show up at the

clinic every day. Members of this group generally know each

other, call greetings, and ask about each others' families. Their

network of friends includes other members of the treatment group

and drug-free people. They make a clear distinction between

themselves and members of the methadone street group, with whom

they choose not to interact.

Although the methadone treatment group members are generally

oriented toward cooperation with the positive goals of methadone

treatment, they nevertheless occasionally engage in

antitherapeutic activities. Although most work at legitimate

jobs, 32% reported income from criminal activities in the week

prior to the interview. Further, some of the jobs cited as

regular employment involve illegal activities, such as policy

writing and bookmaking.

Methadone treatment group members have many complaints about

program policies and even about methadone itself as a treatment

for drug abuse. However, the overall attitude is one of

cooperation with treatment. In contrast with other groups, this

one expresses affirmative and socially valued reasons for entering

treatment, such as avoidance of social, legal, and health hazards

associated with heroin use.

Methadone Street Group (N=177)

There are two clusters within this broad category. The first is

composed of individuals in treatment, taking their methadone dose

as well as any extra doses they are able to purchase, who are

involved in low-level dealing or criminal activity,. abusing other

substances such as tranquilizers, drinking to excess, and

unemployed. These are considered to be the lowest status

individuals in the clinic community, referred to by the street

addicts and the compliant patient group as "pillheads" and

"lowlife." They are also the patients who are most disruptive to

methadone programs. The second cluster is in treatment but using

the methadone dose only as an adjunct to continued active heroin

use. Members of this second group routinely sell their medication

to obtain money for heroin or cocaine purchase.

Methadone is viewed as a drug of pleasure as well as a medication

by the methadone street group. At times, it is used as an

inexpensive euphoriant in combination with other drugs, including

alcohol. When a euphoriant drug effect is sought with methadone,

these patients will ingest extra quantities. For example, if they

have take-home dose, they will commonly "double dose," taking

twice the usual daily dose.

12
Criminal activity in this group is confined to small-scale

operations such as shoplifting, dealing in stolen merchandise or

dealing drugs, primarily pills such as diazepam or amitriptyline.

Stolen merchandise is sold openly among members of this group.

They deal in pills on a small scale, rarely having more than $15

or $20 in operating capital.

Of all the groups, the methadone street group reports the highest

level of ambivalence about methadone as a treatment. Side effects

such as lethargy, muscle and bone aches, and edema are widely

discussed and home remedies exchanged. However, even as they

complain about the methadone and its effects, returning to the

street to shoot heroin or to kick the habit without methadone is

not viewed as a desirable alternative. Methadone is a source of

problems but it is also a source of stability, because of its

relative safety in comparison with the less reliable street heroin.

Self-Prescribing Group (N=22)

The sample size of self-prescribers in the present study is

considerably smaller than that for any of the other groups. This

is primarily due to the difficulty of reaching persons not in

treatment rather than to their scarcity in the population.

Reports of clinic patients and trained patient field workers

indicate that these individuals are an integral part of the clinic

setting. The self-prescriber group also consists of two

subgroups, one existing in the clinic population and one outside

the clinic population. The behavior common to both is the

self-manipulation of methadone dosage, usually in the direction of

detoxification. Both subgroups view methadone as a therapeutic

medication rather than a euphoriant.

Self-prescribers who are not clinic patients are people either

attempting to maintain themselves on methadone as if they were

regular maintenance patients or attempting to detoxify themselves

from heroin, but who do not wish or are unable to become clinic

patients. These individuals regularly buy street methadone

(usually from only a limited number of sellers) and titrate their

dosage to maintain a steady state and preclude withdrawal. These

people appear to self-administer illicit methadone as if they were

compliant patients. They are similar to the methadone treatment

group in terms of stability and appear to be "good patients" who

are simply not enrolled in a program.In some cases they are on

waiting lists, while in others they are avoiding program

regulations and schedules, and in still others they are avoiding

the perceived possibility of disclosing their drug use to friends

or employers.

The other half of this group consists of patients who engage in

self-regulated dose reduction and withdrawal without the knowledge

or permission of program staff. Unused methadone is sold or given

away. Thus, this portion of the self-prescribing group operates

symbiotically with the other self-meditators. The reasons given

for self-regulated dose reduction fall into two broad categories:

13
dissatisfaction with the physician-prescribed rate of dose

reduction and concern over either acute or long-term side-effects

of methadone.

The self-prescribing group is the most difficult to characterize

empirically. Many of the behaviors and characteristics of its

members overlap with the methadone treatment group in terms of

attitudes toward methadone, criminal involvement, and extra drug

use. Further research is needed on this difficult to contact but

important element in the treatment milieu.

PROBLEMS IN TREATMENT AND THE INFLUENCE OF REFERENCE GROUPS

A variety of problems is generally acknowledged to exist in

methadone maintenance programs. Three problem areas have been

selected for discussion in the present paper: (1) early exit from

treatment, (2) the somewhat related problems of loitering and

methadone diversion, and (3) polydrug use. These will be

considered in relation to the attitudes and behaviors of the

reference groups which have been described in the first part of

the paper.

1. Early Exit From Treatment

Recent data indicate that there is a trend towards shorter periods

of enrollment in methadone maintenance treatment. Senay et al.

(1977) found a 27% dropout rate within the first 8 weeks of

methadone treatment, while Brown et al. (1975) reported an 18%

termination rate from three different New York clinics during 44

clinic-months of treatment delivery. Other researchers report

premature exit rates from 7% - 64% (DuPont 1971; Gearing 1971;

Perkins and Richman 1972). Drug-free programs fare even more

poorly, with dropout rates as high as 82% (Kaufman 1972).

The problem of early exit is a serious one, since data indicate

that individuals leaving treatment suffer a higher incidence of

problems than those remaining. Des Jarlais et al. (1978) reported

that 72% of patients who left methadone maintenance treatment

returned either to daily narcotic use or to methadone treatment

programs. The type of discharge was important in predicting

return to narcotics. Those who had completed a full course of

treatment were less likely to return either to treatment or to

narcotics use.

In addition to renewed narcotics use, methadone patients who leave

treatment early appear to have high mortality rates. A recent

report by Des Jarlais (in press) indicates that the death rate of

persons leaving methadone treatment was more than double the rate

of those still in treatment. These deaths were most often related

to drugs, alcohol, accidents, or violence. Compared to the

general population, there are more deaths in both the methadone

treatment and post-treatment populations. Among persons 25 - 44

years of age, those in treatment have death rates five times

higher than the general population, while persons no longer in

treatment have death rates twelve times higher than the comparable

group in the general population. Methadone patients who leave

14
treatment appear to be more susceptible to overdose or other

drug-related calamities. Keeping patients in treatment until they

have a reasonable chance of remaining drug free appears to be not

only an important measure of success, but a life-preserving action.

One goal of the TRISEP study was to examine patient views

concerning treatment termination. Sixty-two percent of the

patients reported that they had given serious consideration to

leaving the program without the sanction of the staff. Reasons

given included the desire to be drug free, fear of the long-term

side effects of methadone, and anger at program rules, schedules,

or policies. Most patients who considered leaving, however, did

not follow through. When asked why they stayed if dissatisfied,

patients cited a sense of uncertainty about the future, fear of a

return to the street, or the monetary advantages of methadone

compared to street hustling.

It is interesting that although the safety of long-term methadone

administration has been demonstrated, many of the self-reported

reasons for leaving early or considering doing so are related to

fears about methadone's side effects. The perception that

methadone produces many serious side effects compared to heroin is

an important belief extant among both street addicts and current

methadone patients. The list of side effects reported is long and

often contradictory. Misinformation or lack of staff attention to

the perceived seriousness of these complaints appear to be factors

in early exit from methadone treatment, especially among the

compliant methadone treatment group.

Members of the methadone street group are more likely to leave

treatment due to disciplinary action by the program than

self-selection. These individuals may commit repeated infractions

of program rules concerning loitering, diversion of methadone, and

polydrug use and thus may have histories of disciplinary actions.

They may also leave programs due to incarceration for recent,

criminal activities. When disciplinary dismissals occurred, the

methadone street group members became agitated, and discussion

increased among the group about the program abuses and unfairness

of program policies. Such behavior within the group may

contribute to perpetuating the chronic lack of treatment

cooperation evidenced by this group. Released from treatment into

the community, methadone street patients are likely to escalate

polydrug use while adding street methadone and/or heroin to their

list of abused drugs.

The self-prescribing group members who are in treatment commonly

depart prematurely. These individuals report that the

physician-prescribed rate of dose reduction is not sufficiently

rapid and that they must therefore establish a self-determined

dose reduction regimen. In some cases patients may have saved or

hoarded methadone to continue their detoxification after the

planned departure. Because the self-prescribers have a rational

reason for leaving treatment, they are likely to be amenable to.

retention through thoughtful distribution of information and

policy changes such as self-regulated detoxification

opportunities.

15
Members of each reference group may leave treatment early for

different reasons. Consequently, intervention in premature exits

should be approached differently for each group. However, the

serious consequences of return to heroin use and increased risk of

death exist for all groups.

2. Loitering and Diversion

Loitering is often mentioned by program administrators as an

annoying clinic problem. Though often seen as synonymous with the

diversion problem, loitering is not necessarily related to drug

In the present study, loitering was found to be

predominantly a social activity, with only a small group of

elements routinely using the loitering site as a place to sell

their medication.

Methadone street group members are most involved in loitering in

the clinic area. These people congregate in areas close to the

programs, often in a snack bar or other eating establishment.

Members of the methadone street group will typically go into the

program about midmorning for medication, then go to the loitering

area and remain there for one to several hours afterward.

Individuals who loiter in the clinic area before and after

receiving medication are usually unemployed and often female.

This daily meeting is often the chief social contact for the

methadone street group members. They stay to socialize, to sell

methadone and other drugs. This group is a highly visible crowd

in the clinic vicinity and frequently the target of community

concern.

Some of the people in the loitering group are not patients in the

nearby clinic. Sociometric analyses of the loitering areas

indicated that a number of people in the loitering group are

ex-methadone patients and "street addicts" using the clinic

population as buyers of stolen merchandise or drugs and as sellers

of methadone. The core of the group, however, tends to be current

patients meeting daily who consider each other to be friends.

Related to the loitering problem is diversion of methadone by

clinic patients (Martin et al. 1973; Stephens and Weppner 1973)

often in the immediate vicinity of the clinic. "Street addicts:'

appear to be the most frequent customers for diverted methadone.

This was reported to be the case by the majority of patients

interviewed in the present study. Further, 50% of the street

addicts interviewed reported using illegally obtained methadone in

the week prior to the interview. Other sales are made to

self-prescribers and methadone street group members who are double

dosing.

A large percentage of patients in the TRISEP sample reported

selling medication while in their current treatment program,

although only a small portion appeared to be regular sellers. The

reasons for selling, however, vary with the group to which the

seller belongs. A methadone street group member may use money

from the sale of methadone to purchase other drugs of abuse

16
(including extra methadone). A few methadone street group members

reported selling all their methadone to support heroin habits or

as a regular income source. It was also members of this group

with limited take-home privileges who sold "spitback" doses, i.e.,

doses held in the mouth at the medication dispensary and spit back

into a cup for resale.

In the compliant methadone treatment group, selling a portion of

one's take-home medication was considered legitimate under some

circumstances. These patients will sell or share their medication

with persons not in treatment if the buyer is using medication

either to avoid withdrawal sickness or to maintain a

self-regulated withdrawal regimen. The buyer may be a friend or a

relative and will almost invariably be known to the seller, while

the seller may be the only source of methadone for that particular

buyer. Interestingly, an occasional sale for financial gain is

also defined by this group as legitimate when the money is to be

used for family-related needs rather than for drug purchases.

In summary, the function and the circumstances of sales are quite

different in different reference groups. The methadone treatment

group may sell to regular customers, often to friends or relatives

not in treatment. The self-prescribing group members manipulating

their dosage on the program may also sell to self-prescribers not

in treatment or to the street addict buying methadone to alleviate

withdrawal rather than to get high. Overall, ethics prevail, and

it appears that sales of methadone are neither random nor

indiscriminate.

3. Polydrug Use

Earlier reports have suggested that methadone maintenance patients

exhibit substantial levels of polydrug use (Stephens and Weppner

1973; Cohen and Stimmel, 1978). Benzodiazepines and cocaine have

been identified as popular drugs of abuse in this population,

while alcohol abuse has long been reported in the treatment

literature (Carroll et al. 1977). The present study was designed

both to investigate the prevalence of polydrug use and to

delineate attitudes toward drug use among the reference groups.

Table 2 indicates the drug use of each group in the week prior to

interview. Use of heroin is generally limited to the "street

addict" group; over half of the street addict subjects reported

heroin use in the previous week. Although some patients in

treatment may also use heroin, in general, patients agreed that it

is neither safe nor cost effective to try to override methadone's

blocking properties by injecting high doses of heroin. Use of

cocaine, marijuana, and methadone is also frequently reported by

members of the "street addict" group. Occasionally, members of

this group report using other drugs such as diazepam or

amitriptyline. This usage is justified as medicinal, e.g., as a

sleeping aid. In general, these drugs are disdained as drugs of

pleasure.

17
TABLE 2. ILLICIT DRUG USE IN WEEK PRIOR TO INTERVIEW

Heroin, Cocaine Metha- Barbitu- Ampheta- Benzodiadone rates mines zepines*

Methadone Street Group (N=l77)

none 71%

once 16%

2-6 Xs 2%

7 Xs 4%

or daily

47% 83% 91%

23% 12% 4%

22% 2% 2%

7% 1% 2%

Methadone Treatment Group (N=185)

none 94% 81% 95%

once 5% 14% 5%

2-6 Xs ** 5% 0

7 Xs 0 ** 0

or daily

Street Addict Group (N=ll7)

none 48% 34% 50%

once 19% 28% 28%

2-6 Xs 22% 27% 19%

7 Xs 11% 9% 2%

or daily

Self-Prescribing Group (N=22)

none 77%

once 23%

2-6 Xs 0

7 Xs 0

or daily

73% 46%

9% 27%

13% 18%

5% 9%

96%

3%

**

**

90%

4%

4%

2%

91%

9%

0

0

95%

2 %

2%

0

98%

1%

**

**

99%

1%

0

0

90%

0

5%

5%

52%

16%

23%

9%

83%

7%

11%

3%

75%

9%

12%

3%

73%

14%

5%

9%

Cannabis

45%

9%

14%

32%

41%

11%

28%

20%

45%

4%

21%

28%

27%

9%

28%

36%

* This category also includes reports of the use of amitriptyline

(Elavil), a drug popular in the New York area.

** less than 1%

18
The methadone treatment group is characterized by the absence of

reported drug use except for marijuana and some cocaine. Both

marijuana and cocaine may be used recreationally and support of

this drug use does not usually require substantial criminal

activity. About 20% reported recent use of cocaine. Cocaine is

viewed as a highly desirable drug whose use connotes high status

and upward mobility of the user. Concurrently, this group views

methadone only as a medication rather than a euphoriant and

disdains the use of pills.

Members of the methadone street group typically use tranquilizers

and other pills as euphoriants. This can be seen in table 2 in

the high rates of reported recent benzodiazepine use. These pills

are readily available in the illicit drug market and relatively

inexpensive. Heroin may also be used as a supplemental drug of

abuse. Their use of drugs and attitude toward methadone as a drug

of pleasure clearly distinguish this group from the others and

are, in part, the basis for their negative status among the

groups. Benzodiazepines and alcohol may be used in combination

with methadone; patients report that such combinations can enhance

the effects of the methadone. On the other hand, prevailing lore

also indicates that heavy alcohol use increases the rate of

metabolism of methadone and thereby exacerbates withdrawal signs

prior to the next daily dose. Discomfort after heavy drinking may

also be due to alcohol hangover effects. The sheer quantity of

alcohol, sedatives, and tranquilizers which may be consumed by

this group explains much of the sedated appearance they often

display on the street.

SUMMARY AND CONCLUSIONS

Methadone patients can be distinguished into unique but

overlapping groups both quantitatively and through qualitative,

ethnographic data analysis. These groups operate in the setting

of treatment and dramatically affect patient behavior and

consequently, treatment outcome. Members are known to each other,

distinct norms govern interaction within and between groups, and

the behavior of group members is affected in the degree to which

the individual identifies with the group.

All groups are in contact with each other and the effect of that

contact appears to be mediated through commmon values and

behaviors and complementary needs. The street addict group serves

the methadone street group as dealers of illegal goods and in turn

uses them for income to support heroin habits. The

self-prescribing group members who are patients and the nonpatient

self-prescribing group members operate symbiotically: the

nonclinic member requires accurate, reliable supplies of methadone

which are best obtained from the methadone treatment or

self-prescribing group seller. The buyer and the seller often

share the same definition of drug use in those transactions in

viewing methadone as a therapeutic agent, thus perhaps diffusing a

sense of deviance in making sales. This is in contrast to the

street addict who often sells to the methadone street buyer and

views drugs as a way either of getting high or of making money, a

view the methadone street group member shares.

19
Common goals and behavior such as these are important keys to

recruitment into or passages between each of the groups. Groups

which share the same definitions of drugs and similar use patterns

have important common ground, and it is the areas where values and

behaviors overlap which seem the most sensitive to membership

recruitment. The self-prescribing group member not in treatment

shares all of the characteristics of the methadone treatment

group, except participation in treatment program. Program

policies which can identify and reach the self-prescriber can

bring into treatment a potentially compliant patient. The

methadone street group member may begin to divorce himself or

herself from that group through an assumption of some of the

methadone treatment groups' behaviors and attitudes and perhaps

gain membership in the latter group. Potential members of each

group take on the characteristics and behaviors of the group in

anticipation of membership. Once a person becomes a member of the

group, the group norms and values become powerful referents for

behavior. In addition, the group members themselves become

powerful reinforcers of individual members' behavior.

While a fascinating study in reference group behavior, this study

has far more significant ramifications. The problems facing

methadone treatment programs are inextricably linked to these

groups and their interactions. The problem of loitering will not

be adequately dealt with by simply prohibiting loitering in the

clinic area because of the important social function loitering

serves for the methadone street group. The loiterers will

continue their behavior in a different place. The problem of

diversion may be alleviated somewhat by a 7-day pickup of

medication schedule for all patients. Unfortunately, however, the

methadone treatment group member and the self-prescribing group

member, the very patients clinics are most eager to keep, may

leave treatment prematurely because of such a policy. Similarly,

program activities or policies which put the methadone treatment

patients and the methadone street patients together may fail

because of the status antagonisms of these groups; participants

remaining in such activities will undoubtedly be the more idle

methadone street group members.

In short, problems in the setting of methadone treatment can not

be adequately addressed without a recognition of the impact of the

unique reference groups on individual behavior. Each group is

both an adaptation to methadone and to each of the other groups.

The delicate interfaces between groups, while affected by program

policy, are also maintained in a complex pattern of their own.

Intervention in the form of individual treatment contracting or

group intervention must consider the social organization of the

methadone setting in the development of successful contingency

planning.

20
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Brown, E.M.; Benante, J.; Greenberg, M.; and MacArthur, M. Study

of methadone terminations. Brit J Addict, 70:83-88, 1975.

Carroll, J.; Malloy T.; and Kendrich, R. Alcohol abuse by drug

dependent persons: A literature review. Am J Drug Alc Abuse,

4(81:293-315, 1977.

Cohen; M.J., and Stimmel, B. Amitriptyline (Elavill abuse in

persons on chronic methadone maintenance. In: Lowinson J., ed.

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Dekker, 1978. pp. 403-404.

Cushman. P. Arrests before and during methadone maintenance. In:

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Des Jarlais, 0.; Dole, V.; Joseph, H.; and Smeidler, J.

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Des Jarlais, D. Research Design, Drug Use and Death: A CrossStudy Comparison. In press.

DuPont, R.L. Profile of a heroin addiction epidemic. New Eng J

Med, 285:320-324, 1971.

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Gearing, F.R. Evaluation of methadone maintenance treatment

programs. In: Einstein S., ed. Methadone, Maintenance.

New York: Marcel Dekker, 1971.

Gould, L.D.; Walker, A.L.; Crane, L.E.; and Ledz, C.W.

Connections: Notes from the Heroin World. New Haven: Yale

University, 1974

Johnson, B.D. "The Criminal Behavior of Street Heroin and Cocaine

Users." Presentations at International Institute on the

Prevention and Treatment of Drug Dependence, Austria, June, 1981.

Kaufman, E.A. A psychiatrist's views on addict self help

programs. Am J Psychiatry, 128:846-851, 1972.

Lowenson, J.; Ruiz, P.; Langrod, J.; and Martinez, M. Consumer

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Martin,.R.; Jasinski, D.R.; Haertzin, C.A.; Kay, D.C.; Jones,

B.E.; Mansky, P.A.; and Carpenter, R.W. Methadone: A

re-evaluation. Arch Gen Psychiatry, 28:286-295, 1973.

Merton, R. Social Theory and Social Structures. New York: Free

Press, 1968.

Perkins, M.E., and Richman, A. Prevalence of participation in

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Preble, E., and Casey, J.H. Taking care of business--The heroin

user's life in the street. Int J Addict, 4:1-24, 1969.

21
Senay, E.C.; Dorus, W.; Goldberg, F.; and Thornton, W. Withdrawal

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Arch Gen Psychiatry, 34 (March):361-367, 1977.

Stephens, R.C., and McBride, D. Becoming a street addict.

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ACKNOWLEDGMENT

This research was supported by a grant from the National Institute

on Drug Abuse (1 H8l DA 02300-01) to Narcotics and Drug Research,

Inc., New York, and by the New York State Division of Substance

Abuse Services.

22
Treatment of Behavioral and

Psychiatric Problems Associated

With Opiate Dependence

George E. Woody, M.D., A. Thomas McLellan, Ph.D., and

Charles P. O’Brien, M.D., Ph.D.

INTRODUCTION

Diverse problems and challenges confront the staff members of

programs/clinics intended to treat individuals with histories of

opiate use and associated problems. The clinic sponsored and

staffed by the Philadelphia Veterans Administration Medical Center

and University of Pennsylvania provides numerous examples of the

merits and problems of such treatment programs. The clinic's

patient population over the past decade has varied from two to

four hundred patients. A range of services is provided along with

pharmacological interventions including opiate-specific treatments

such as methadone, LAAM, naltrexone, and a variety of psychotherapeutic agents administered in treatment of diverse presenting

disorders. It should be noted that the clinic differs in some

respects from "standard" clinics insofar as it includes numerous

associated ongoing basic and applied research projects. There may

therefore be more options and staff available from time to time

but there may also be considerable variability uncharacteristic of

other clinics. In any case the clinic appears to have many of the

problems reported to prevail in other nonresearch clinics. It can

therefore be used as a reference in the sorts of issues which do

arise.

Patients entering standard treatment programs for opiate use often

display serious behavioral and psychiatric problems both within

and outside treatment programs. The successful management of

these problems is of great importance for both the patient and the

community. Failure on the part of a treatment program

successfully to control behavioral problems of its patients has

sometimes resulted in community pressure to close the program, and

in some cases this pressure has achieved its intended result.

Inadequate treatment of the psychological disorders of the opiate

user/patient has contributed to poor treatment response and

sometimes to premature termination from therapy.

23
BEHAVIORAL AND PSYCHIATRIC PROBLEMS

Many of the behavioral problems demonstrated by these patients

originate from drug-seeking behavior which is, of course, a normal

part of the drug-using cycle. Patients may fabricate elaborate

stories to obtain prescriptions for a variety of controlled

substances, buy or sell illicit drugs, attempt to falsify urine

samples to avoid loss of take-home methadone doses, or attempt to

divert methadone at the pharmacy window.

A common problem viewed as serious by most program staff members

is loitering. Its origins and rewards are diverse. The most

common motive for loitering appears to be social contact (see Hunt

et al., this volume), but a considerable amount of drug dealing

also takes place when patients loiter. Persistent loitering can

serve as a nidus for the development of other behavioral problems

such as arguments or fights. The loitering and associated

behaviors can also be frightening to people who happen to be in

the vicinity and who are not familiar with the personalities and

lifestyles of the opiate-using patient population. Threats and

disruptive behavior including fighting may occur, and when clients

carry weapons, special problems are encountered.

These patients also bring with them to the clinic the full range

of social and family problems. Many are unemployed, have few

skills, and could likely benefit from training programs, although

questions as to how best to achieve the training are numerous

(e.g., see Hall et al. and Thompson et al., present volume). In

addition, problems with both family of origin and current family

may exist (e.g., see Todd, this volume). All of these problems

may or may not be related to the addiction or to other factors

such as personality disorders, psychiatric problems, or

socio-environmental circumstances.

As might be expected, the range of psychiatric disorders reported

in the general population has been observed in opiate-using

patients. Table 1 summarizes the Research Diagnostic Criteria

(RDC) diagnoses reported in a sample of 533 opiate users who were

given a thorough and careful psychiatric evaluation as part of a

study recently completed by Rounsaville et al. (1982). Depression

was the most common diagnosis, with about 60% of the sample having

had some form of depression at least once. The next most common,

problem was alcoholism, followed by antisocial personality and

anxiety disorders. Occurring with a much lower frequency were

schizophrenia, other types of personality disorders, mania, and

hypomania. Not included in this table but also seen regularly are

acute situational reactions which involve intense but transient

feelings of anger, anxiety, or depression; psychiatric disorders

complicated by medical conditions such as hepatitis; and illnesses

or injuries which produce chronic pain, such as pancreatitis,

sickle cell anemia, or trauma resulting in nerve root irritation.

The diverse medical, behavioral, and psychiatric problems observed

may be closely related to one another and interact to produce

constellations of complex disorders. For example, either

24
Table 1

Lifetime Rates of Psychiatric Diagnoses

per 100 for Opiate Addicts*

Type of Disorder (n=4O3)

AFFECTIVE DISORDERS

Major depression

Minor depression

Intermittent depression

Cyclothymic personality

Labile personality

Manic disorders

Hypomanic disorder

Bipolar 1 or 2

Any Affective Disorder

SCHIZOPHRENIC DISORDERS

48.9

9.4

18.1

2.5

17.1

0:5

5.5

3.7

70.7

Schizophrenia

Schizoaffective, depressed

Schizoaffective, manic

0.7

2.2

0.5

ANXIETY DISORDERS

Panic 0.5

Obsessive-Compulsive 1.7

Generalized anxiety 4.7

Phobic 8.2

Any anxiety disorder 13.2

ALCOHOLISM

PERSONALITY DISORDERS

Antisocial personality

Briouet's syndrome

Schizotypal feaures

Other psychiatric disorders

37.0

29.5

0.0

8.7

5.7

SEX

(n=130)

69.2

5.4

20.8

6.9

14.6

0.8

10.0

10.8

85.4

0.8

0.0

0.0

3.9

2.3

7.7

13.9

25.4

26.9

16.9

0.7

7.7

10.0

*From: Rounsaville, B.J., et al. Heterogeneity of Psychiatric

Diagnosis in Treated Opiate Addicts. Arch. Gen. Psych.

(39):161-166, 1982. Copyright 1982, American Medical

Association. Reprinted with permission.

25
antisocial personality disorder or addiction itself can lead a

patient to fabricate stories about psychiatric or other medical

problems in attempts to obtain prescriptions for controlled

substances; depression can result in chronic anger and hostile

behavior; and paranoia secondary to schizophrenia or amphetamine

psychosis can lead the patient to carry a weapon for "protection."

In other cases the behavioral and psychiatric problems appear to

be unrelated. Examples include anxiety attacks or schizophrenic

hallucinations which result in psychiatrically correlated

behavioral problems which are not characteristic of the typical

opiate user.

As seen from this brief overview, many combinations of behavioral

and psychiatric problems can occur in a methadone treatment

program. Comments throughout the remainder of the paper review

some thoughts on management and treatment of these problems. They

derive from the perspective of persons who are responsible for

directing a clinic very much invested in methadone maintenance but

with the adjuncts previously mentioned. In any case the comments

have a strong practical orientation,

GENERAL APPROACHES

The staff members of the treatment clinic have spent many hours

deliberating about and experimenting with various general and

specific approaches to management and treatment of patients'

behavioral and psychiatric problems. The strategy that has

emerged is one which uses external environmental controls combined

with procedures designed to change internal processes and

affective states. The external measures are primarily

behavioral-psychological, while the internal ones are mainly

pharmacological. The external interventions aim primarily to

punish certain behaviors and to reinforce others. These in turn

affect attitudes, or reduce the intensity of the affects and

impulses which are part of the problematic behaviors and

psychiatric disturbances demonstrated by the patients.

Clinic patients are similar in many ways, but dissimilar in

others. In this combined approach it is essential to diagnose the

problem correctly in order to make the appropriate response. For

example, a primary focus on behavioral controls and limit-setting

can be destructive for patients who are primarily depressed, but

it can be constructive for patients who are displaying only

sociopathic behavior. Thus the needed strategies and arrangements

to maximize reinforcement must be individualized as well as being

established for the clinic as a whole.

The first treatment priority is often control of the behavioral

problems because they can be detrimental to the entire program,

including staff. The techniques used focus on three potentially

problematic target behaviors: (1) loitering, (2) drug dealing or

other forms of drug-seeking behavior, and (3) disruptive or

aggressive behavior. Many drug treatment programs implement

specific techniques that are aimed to modify these behaviors, and

26
the techniques are usually implemented from specific behavioral

guidelines presented in the form of general program rules.

Treatment occurs within the program milieu, and it is necessary to

consider certain aspects of it that contribute importantly to the

success or failure of the specific techniques used. The milieu

includes the physical location, appearance, and design of the

program facilities, as well as the attitudes, hierarchies, and

power structures that exist within the staff.

The physical layout of programs can vary tremendously and may

include storefront clinics, medical offices in separate buildings,

and offices in both general and psychiatric hospitals. Drug

treatment programs can be located in urban or rural areas and

their level of maintenance can vary from exceptionally clean to

extremely insanitary. The formal and informal power structures

within the staff, and the way patients and staff interact, form

another important part of the milieu. In combination, these

factors determine the success of treatment.

A VIEW OF CLINIC ADMINISTRATION

From the onset, the administrative structure that will be used to

run the program must be clearly established and made known.

This step may sound trivial, but it is extremely important. Drug

abuse programs typically have both professional and

paraprofessional staff who work together to solve many complicated

problems, and competition or role diffusion often occurs.

Similarly, the contributions to general policies and to program

rules that can appropriately be made by patients and staff members

are sometimes unclear, especially concerning issues of the degree

of authority and administrative latitude accorded to the group.

The administrative structure that has been found to be effective

in the Philadelphia VA Medical Center clinic is fairly standard.

It is a hierarchical organization which involves differing levels

of power and responsibility for various categories of people

within the program. Examples of these levels are a service chief,

senior program staff member, nurse, counselor, and patient.

Patients should have input into the formation of rules and

policies, but the program staff must retain the authority to-make

final decisions. The hierarchy of responsibility and authority

should begin with one person who is clearly identified as being in

charge and given the authority to act accordingly and is also the

one held responsible if problems occur. Job descriptions and

delegations of authority must be clearly specified. Regular staff

meetings must be held in which management and clinical issues are

discussed and comment from all staff members can be used in making

decisions and in setting policies. These meetings serve to unify

and coordinate program activities.

Patients often request a democracy, or accuse the administration

of being dictatorial when administrative decisions are made

unilaterally. However, a "democracy" can pose very difficult

problems in a methadone program. One of these is that the

27
drug-seeking behaviors among the patients are often so intense

that there is a strong tendency to attempt to use "democracy" to

manipulate the system in order to obtain extra supplies of drugs

or whatever other tangible rewards are be available in a manner

that subverts the prevailing rules or contingencies. Other

serious problems can occur in situations where rules must be

enforced and patients disciplined. Attempts to implement

democratic forms of government within this population have been

numerous. For example, a committee (the "Judicial Committee") was

established that consisted of patients and staff members whose

purpose was to hear the comments of all interested parties in

situations where program rules had allegedly been violated. It

was never clear that the committee was very effective. Rarely did

the committee agree on whether rule infractions had occurred. The

deliberations often took hours and required large amounts of staff

time, and meaninful punishment (such as suspension from the

program) almost never occurred. After trying very hard to make

this committee work for almost 2 years, it was disbanded and a

much more authoritarian approach to problems was taken. It

resulted in more penalties and more success in controlling

behavioral problems.

There must be written program rules which consist of explicit

guidelines for conduct with specific penalties for violations.

The rules should be carefully formulated by the combined efforts

of staff with comment from patients. Penalties should, of course,

be graduated according to the severity of the offense. The rules

are helpful to both patients and staff, because they provide a

consistency and uniformity of consequences for behavioral

problems. The rules should be explained to all patients when they

are admitted to the program, and patients should sign a copy which

is then placed in their chart. The rules should also be conspicuously posted in the clinic. Program rules can be modified if

necessary, but only after a similar throughtful and deliberate

process.

Many of the specific rules used by programs will vary depending on

the local situation. For example, the program discussed herein is

in a separate building remote from the main hospital. One of the

results of reducing loitering in the clinic and in the immediate

vicinity was that patients spent considerable time and caused some

difficulty in the cafeteria of the main hospital. Therefore

specific rules were developed governing appropriate and inappropriate use of the cafeteria. Many programs such as those located

in storefront clinics rather than general medical centers have no

need for such rules.

As noted earlier there must be a clear line of authority that is

consistent and readily understandable to both patients and staff

if the established rules and policies of the clinic are to be

meaningful. It must be expected that patients will "test the

limits" of the system and this will result in "going to the top,"

especially when serious problems develop, including cases

involving suspension. Good communication among staff members and

clear policies for review of patient requests to speak with people

at higher levels of authority are necessary in these situations.

28
As in any treatment setting, all aspects of activity including

infractions of rules that occur must be documented clearly. In

publicly funded facilities, legislative or congressional inquiries

about response to specific incidents may occur and accurate

documentation is essential. In addition some patients in drug

treatment programs are expert "jailhouse lawyers," experienced at

casting a reasonable doubt upon any evidence of illicit behavior

on their part. In some cases they may have been through similar

procedures on repeated occasions during appearances in court.

Thus, it is not uncommon for patients frankly and adamantly to

deny engaging in a problematic behavior that has been witnessed by

reliable staff people. On the other hand, many patients have been

subjected to arbitrary, discriminatory, and unfair treatment by

people in authority, and it is essential that this pattern not be

repeated by the program. Thus, all alleged infractions of program

rules must be examined thoroughly so that a fair and appropriate

decision concerning consequences may be made.

The chief administrator and the administrative system must, of

course, maintain staff morale. Actions that successfully deal

with problematic patient behaviors build and maintain morale,

while lack of control of behavioral problems has the opposite

effect. Morale is strengthened by providing staff regular

opportunities to contribute to decisions, by encouraging

discussion at the regular staff meetings where clinic policies,

rules, and management problems are reviewed.

Inservice training sessions can make an important contribution to

morale by providing the staff members with opportunities to

develop professionally. This can be done in a variety of ways,

the most direct one being a weekly presentation of topics related

to the problems that are treated by the program. These can

include sessions about family therapy, high- vs. low-dose

methadone treatment, jobs programs, how to use psychotropic

medicines, current issues in the criminal justice system, and many

other topics.

It is essential that the administrators spend time working on the

procedures that are necessary for program operations, such as

scheduling hours, secretarial coverage, treatment manuals, and

directives that the staff use in their daily work. These measures

can be very helpful to staff morale via their organizing and

supporting effects.

Finally, it is helpful to develop a clinic manual that defines and

describes counseling duties. This manual should include

guidelines for making treatment plans, making clinical notes,

procedures for using ancillary medicines and for implementing

clinic take-home policies. These written guidelines provide a

framework that the counseling staff can use in formulating a

unified approach to patient management.

Ideally the physical setting should be one that permits reliable

provision of treatment and makes it easy to enforce rules. For

example, it is sometimes difficult to have a methadone treatment

29
program located in the main traffic area of a general hospital.

This may, depending on the characteristics of the drug patient

population, lead to difficult interactions between addicts and

other patients or hospital staff. Some feel that the ideal

location for a drug treatment program is in a separate building

which patients can enter without having to pass through other

office or clinic areas. If this situation does exist, the

building should have a waiting area that is comfortable yet highly

visible. Patient access to treatment areas should be easily

controlled by a clinic secretary or other staff via locks with

buzzers or other appropriate traffic control devices. This type

of physical design will facilitate control of patient traffic

within the building, and this decreases the chances for behavioral

problems within the clinic. On the other hand, it must be

recognized that while a separate facility may have fewer Obvious

problems, it may simply be the case that the problems such as

loitering are being displaced to other locations. It is most

helpful to have a staffing pattern which includes people trained

to manage the different behavioral and psychiatric problems that

may occur. This includes counselors, medical personnel,

secretaries, and depending again on the nature of the facility and

patients, police. In general the important issue is that the

clinic have well trained personnel for all the services it

provides. If, for example, the clinic does not have professional

job counselors, it should refer clients elsewhere for this

service. Excellence in available services rather then diversity

of services is probably important in reassuring patients

concerning treatment.

Finally, it may at times be necessary to use legal sanctions, in

addition to the program rules, for the more serious problems such

as threats, weapons offenses, thefts, or fights. Since methadone

programs are under Federal control, it can be valuable to work out

an informal liaison with the Federal criminal justice system so

that formal charges can be filed in situations where serious

behavioral problems have occurred. Thus, in addition to

suspension from the program, patients can be fined or may actually

go to jail for certain offenses. When patients know that this

process exists and that it will be used, problems occur less often.

Implementation of these clear guidelines has decreased problems in

the vicinity of the clinic, although success in eliminating some

problems is not as clear. In some instances, the behaviors are

suppressed in the clinic area but transferred to another

location. For example, some of the patients stopped loitering

around the hospital but moved to a fast food restaurant located

nearby. This shift of problems from one locale to another may

limit their occurrence, but it indicates that these measures are

far short of being curative. Nevertheless, they can have the

positive effect of maintaining a therapeutic milieu within the

immediate vicinity of the treatment program, and in developing

positive regard for the program in the community.

30
APPLYING BEHAVIORAL CONTROLS TO SPECIFIC INDIVIDUALS

Careful thought should be given to application of behavioral

control techniques, especially when dealing with "problem

behaviors" as opposed to development of adaptive behaviors leading

to positive consequences. Patients who are often angry must be

approached in ways that will maximize the chances of their

benefitting from the sanctions to be applied, and minimize the

chances for destructive acting out of their anger. Some of the

patients are truly dangerous, and their potential for aggressive

acting out should always be kept in mind. HOW the patient is

approached is an extremely important factor for the safe and

effective management of these situations. Several therapeutic

guidelines may be helpful in these cases.

First, it is important to be open and nonjudgmental when

discussing the specific infraction with the patient/violator.

This should be done in a matter-of-fact, nonhostile manner, and he

should be given the opportunity to express his point of view about

the situation. This approach will minimize the chances for

aggressive acting out by the patient. The patient may complain,

but the complaints should not cause serious problems when things

are consistent, open, and direct, and when he feels that sincere

and honest efforts have been made to assess the situation

accurately and to treat him fairly and in accordance with the

program rules. .

Thus one communicates a sense of firm and consistent limits,

combined with the feeling of underlying support and some degree of

flexibility about the exact timing of his expulsion from the

program. The message that seems important to communicate when

problem behaviors arise is, "We are very concerned with you and

your treatment, but you must understand that certain behaviors are

unacceptable and cannot be tolerated." Support is very important

for this population. Many people have written about the necessity

to provide support for drug-dependent individuals, and this

clinic's experience is consistent with these observations.

Many details have been omitted in the above discussion, such, as

comments about collecting urine specimens, pharmacy dispensing

procedures, and specific techniques for control of patient traffic

flow in the clinic area. Guidelines for these aspects of program

management are also important, and many of them are specified in

FDA or DEA regulations or are found in clinic treatment manuals or

regulations used by the hospital police force.

TREATMENT OF PSYCHIATRIC PROBLEMS

The psychiatric problems experienced by addicts are important

contributors to overall treatment outcome; thus psychiatric

treatments can make important contributions to a program's

effectiveness. Some psychiatric problems appear closely related

to drug dependence, and in these cases one problem cannot be

brought under good control without effective treatment of the

other (McLellan et al. 1979). In general, the psychiatric

31
problems of drug-dependent patients are treated in the same way

similar problems are treated in non-drug-using psychiatric

patients. This view and approach are empirical and do not derive

from experimental evidence but do seem reasonable. Commonly

observed psychiatric conditions are considered below.

Anxiety is one problem commonly observed, particularly in patients

who have recently undergone withdrawal. The condition may have a

different physiological basis from that observed in other patients

with an anxiety disorder. However, post-detoxification anxiety is

usually treated with a combination of supportive counseling or

psychotherapy and psychotropic medications, much as it is treated

in general psychiatric patients. Anxiety may also occur during

the course of maintenance treatment and can be treated with

psychotherapy, counseling, family therapy, biofeedback or relaxation exercises, or with anti-anxiety medications. These

treatments can be used separately or in combination. Anti-anxiety

medications are usually monitored very closely with these patients

because there is a much higher risk of improper use or abuse than

is seen among general psychiatric patients. The anti-anxiety

medications that appear to be most effective are the

benzodiazepines. Diazepam (Valium), however, appears to have high

abuse potential in this population, and thus it is used under very

specific conditions or not used at all. Examples might be

patients being maintained on very low doses of methadone who are

in regular contact with their counselors and who have consistently

drug-free urines; or patients who are detoxified and keeping

regular clinic appointments; or patients who are being treated

with a narcotic antagonist such as naltrexone. Oxazepam (Serax)

is a frequently used benzodiazepine which appears to be effective

and which does not seem to be abused or misused to any significant

degree.

Depression in its various forms appears to be even more common

than anxiety disorder in drug-dependent and post-drug-dependent

patients. These include major, minor, and intermittent depressive

disorders. Depressive illnesses seen in drug-dependent patients

are often precipitated by disruptive life events, and they

commonly have a significant anxiety component. Depression in

these patients is usually not as severe as that seen on general

psychiatric inpatient units, and it appears to respond to

counseling, psychotherapy, or antidepressant medications.

Favorable results have been obtained with administration of

doxepin, a sedative type antidepressant, when used in combination

with counseling and psychotherapy (Woody, 1982). Doxepin appears

to help control the symptoms of anxiety and depression that are so

often found in these patients, and it also appears not to have any

significant abuse potential. It is unclear whether the apparent

positive effect of doxepin with this population is due primarily

to its anti-anxiety or to its antidepressant effects; however, it

seems to be a useful drug.

Sociopathic behavior is another common and serious problem, and

our best treatment for it is to control and structure the milieu

via clear and consistent rules. Treatment contracts emphasizing

aversive control are sometimes used for patients demonstrating

32
sociopathic behavior or for selected patients without sociopathy

who appear to be doing poorly in spite of our best efforts to help

them through traditional psychotherapeutic strategies. These

contracts call for the patient to engage in certain behaviors

within a specific time period or face suspension. Patients who

fail to comply with the conditions of the negative reinforcementbased treatment contracts have the option of detoxification or

transfer to another program. About 50% of patients given a

treatment contract fulfill its conditions.

Alcoholism is another common problem in this population, and it is

one which we have not been able to treat very effectively.

Counseling combined with regular verification of nondrinking,

using breath testing and sometimes disulfiram (Antabuse) is

typically used with these patients. Treatment contracts are also

used with alcoholics, and those patients who fail their contracts

are usually advised to enter an inpatient alcohol treatment

facility. These patients are also encouraged to attend meetings

of Alcoholics Anonymous or engage in other therapeutic activities.

Schizophrenia is observed only infrequently in this population but

it can be quite disruptive not only for the patient but for other

patients and staff members' efforts to maintain the clinic as a

therapeutic environment for others. Almost every case of

schizophrenia we have seen has been of the paranoid type.

Patients with this disorder are usually treated with

phenothiazines, often in the liquid form which can be mixed with .

the daily dose of methadone. It is important to mention that

methadone itself has some antipsychotic effects; it appears to

have a sufficiently positive psychotropic effect in some

schizophrenic patients to make other medications unnecessary.

Patients with manic depressive illness (Bipolar I or II) are seen

infrequently. They are usually treated with lithium or with

combinations of phenothiazines and antidepressants, as are

nonaddicted manic-depressives (Kleber et al. 1983). Special

attention must be given to monitoring compliance if the patient is

treated with lithium because of the narrow margin between the

therapeutic and toxic dose. Patients taking it must thoroughly

understand its dangers and how important it is to take it exactly

as prescribed. Compliance with the regimen is probably encouraged

if patients know that lithium cannot produce euphoria and that

extra doses will only lead to severe adverse reactions.

Drug dependence generated by administration of analgesics for

medical problems involving pain is seen occasionally. Patients

with chronic pain often have significant depression and can be

treated with an antidepressant plus psychotherapy and relaxation.

Amitriptyline HCl (Elavil) may be especially helpful for these

patients, since it appears to have a mild analgesic effect;

however, it has some degree of abuse potential, and compliance

should be monitored carefully.

One serious problem seen occasionally is persistent opiate drug

use in patients who appear to be maintained on doses of methadone

that are more than sufficient to suppress withdrawal symptoms and

33
which also provide some degree of narcotic blockade. In these

cases we will often raise the dose to the highest allowable levels

(80-100 mg/day). Sometimes this process is also combined with a

treatment contract.

RESEARCH IN CLINICAL SETTINGS

An important situation that is worthy of comment is the interface

between research and clinical work when both are performed in the

same setting. The coordination of research projects with the

clinical work is extremely important in these situations.

Competition between clinical and research staff can occur if this

interface is not monitored and cultivated. Lack of coordination

between research and clinical programs can cause treatment or

research staff to feel resentful, and both programs can suffer. A

problem from the therapeutic perspective is that clinicians may

have trouble dealing with the unknowns, e.g., placebos, that are

part of many research projects. Clinical staff feel most

comfortable doing something that will provide known, direct and

tangible benefits. They may also feel uncomfortable with the

basic supposition of research, which is that the most effective

treatment is not known, that several therapeutic approaches will

be examined and that these results will then be evaluated to

delineate an improved treatment. These problems can usually be

managed by explaining to clinical staff placebo effects, the

purposes of research, how there is always a degree of experimentation in medical practice, what the purposes of the specific

study in question are, and especially how it may improve

treatment. Conversely, research staff may have trouble understanding or appreciating the interpersonal and unpredictable

aspects of clinical practice which in fact arise from the same

source; that is that diverse aspects of traditional therapeutic

strategies are poorly understood. Regular meetings of the

research and the clinical staffs will usually resolve problems

that arise in this clinical/research interface. The benefits that

may result from integrating research into a busy clinical program

are considerable, and careful attention to these potential

problems is well worth the effort.

SUMMARY

Many difficult and complex behavioral and psychiatric problems can

occur in a methadone treatment program. Some behavioral problems

are very serious, and it is essential that the program place a

high priority on controlling them. This is best done by

structuring the treatment milieu via program rules. Careful

attention must be paid to consistent, fair, and accurate

enforcement of these rules. A proper staffing pattern is

essential; this should include counselors along with medical,

administrative, and pharmacy personnel, and police. Written

policies explaining clinic procedures such as treatment plans, use

of ancillary medications, and take-home policies are most

helpful. They provide structure for the staff and increase the

chances that work will be done in an organized and consistent

manner. The physical facility may have features which either

34
enhance or interfere with treatment and must be taken into account

when planning. Attention should be paid to accurate diagnosis and

treatment of the patients' psychiatric, behavioral, and social

problems, and staff morale must be maintained. The best general

ingredients for good patient management appear to be a combination

of structure and support, applied in a systematic and coordinated

way by a well-trained staff.

clinical efforts may present

benefit in most programs.

Finally, integration of research and

unique problems but has considerable

REFERENCES

Kleber, H.; Weissman, M.; Rounsaville, B.; Wilber, C.; and

Prusoff, B. Imipramine as treatment for depression in methadone

treated opiate addicts. Arch Gen Psych, 40(6):649-653, 1983.

McLellan, A.T.; Woody, G.E.; and O'Brien, C.P. Development of

psychiatric disorders in drug abusers. New Eng J Med,

301:1310-1314, 1979.

Rounsaville, B.J.; Weissman, M.M.; Kleber, H.; and Wilber, C.

Heterogeneity of psychiatric diagnosis in treated opiate

addicts. Arch Gen Psych, (39):161-166, 1982.

Woody, G.E.; O'Brien, C.P.; McLellan, A.T.; Marcovici, M.; and

Evans, B. Use of tricyclic antidepressants in methadonemaintained addicts. Annals of the New York Academy of Science,

120-127, 1982.

35
The Role of Behavioral. Contingency Management in Drug

Abuse Treatment

George E. Bigelow, Ph.D., Maxine L. Stitzer, Ph.D., and

Ira A. Liebson, M.D.

The purpose of the present paper is to provide an overview of the

role of behavioral contingency management procedures in drug abuse

treatment contexts. The paper is organized so as to provide

initially a discussion of the nature of a behavioral conceptualization of drug abuse, then to provide a brief review of some applications of contingent behavioral procedures to drug abuse problems, and finally to provide a discussion of some of the practical problems faced in implementing these procedures and of some

of the potential future directions for work in this area.

AN OPERANT BEHAVIORAL CONCEPTUALIZATION OF DRUG ABUSE

The value of any conceptualization of drug abuse lies in its

ability to guide us to a valid scientific understanding of the

determinants and controlling variables of the disorder and thereby to enable us to intervene effectively in either preventive or

treatment modalities. The operant behavioral conceptualization

of drug abuse is of value both in a definitional sense of specifying what drug abuse is -- i.e., what is the appropriate target

of drug abuse treatment -- and also in the functional sense of

specifying a range or domain of controlling variables which can

be expected to influence this target. As will be described more

fully below and elsewhere in this volume, this focusing upon objectively specified target behaviors and upon functionally defined

classes of controlling variables has made the operant behavioral

approach to drug abuse a productive one, both in terms of advances

in scientific understanding and in terms of practical therapeutic

applications.

Operant behavior is behavior which is controlled by its consequences. when drug abuse is viewed as operant behavior we are

forced to specify precisely what behavior constitutes drug abuse

and we are forced to look for maintaining consequences of that

behavior. Examination of the range of substance abuse disorders,

of both the experimental and the clinical data concerning these

disorders and, in particular, of the commonalities within and

between substance abuse disorders (cf. Griffiths et al. 1980)

36
leads us to conclude that: (1) drug abuse can be productively

viewed as consisting of the behavior of drug self-administration;

(2) this behavior is maintained by the pharmacological effects of

the drug; and (3) this behavior is influenced in predictable ways

by manipulations of behavioral contingencies in the same fashion

as other classes of operant behavior.

What is the scientific basis for this conceptualization? And,

what are the practical implications for prevention and treatment?

Scientific Basis

The primary scientific basis for this behavioral conceptualization

of drug abuse comes from the experimental! animal drug self-administration laboratory and from comparisons of these basic laboratory data with data concerning human drug self-administration and

drug abuse. These comparative data have been reviewed extensively

elsewhere (Griffiths et al. 1980), and only the conclusions will

be briefly summarized here:

1. The same drugs which are abused by humans tend to be selfadministered by animals in experimental studies . Thus, opioids ,

sedatives, and CNS stimulants all have been shown to sustain

self-administration in a variety of species and have been found

to be abused by humans. Conversely, a variety of compounds (e.g.,

opioid antagonists, certain anorectics) which have molecular

similarities to abused drugs, but which are not self-administered

by experimental animals, are not significantly abused by humans.

This finding of cross-species generality in drug self-administration suggests that it is the pharmacological characteristics of

the compounds (and not the personal characteristics of the individual organisms) which determine the reinforcing efficacy of

drugs.

2. The temporal patterns of drug self-administration tend to be

similar in animals and in humans. While different pharmacological

classes of drugs are characterized by distinctively different

patterns of intake over time there exists a remarkable acrossspecies generality in the temporal patterns of self-administration. For example, ethanol self-administration in both animals

and humans is characterized by spontaneous wide fluctuations in

intake, with several-day periods of voluntary abstinence (even

in the presence of objective withdrawal signs) alternating on a

somewhat irregular basis with several-day periods of heavy consumption. On the other hand, opioid self-administration in both

animals and humans is characterized by a relatively steady level

of intake, with a gradual increasing trend presumably due to

tolerance development, but without periods of spontaneous abstinence. These dual findings of between-drug differences but

across-species similarities in the temporal patterns of drug

self-administration serve to emphasize the importance of the

specific pharmacological characteristics of a compound as a

potent determinant of drug self-administration and drug abuse.

37
3. The controlling variables of animal drug self-administration

and of human drug abuse are similar. For example, manipulations

of such variables as the drug dose, the response requirement (i.e.,

effort) required to obtain doses, and the scheduled consequences

of drug use versus drug abstinence behaviors all tend to have

similar effects in animal experimental settings, in human experimental settings, and in clinical drug abuse settings. This

across-species generality to humans of relationships observed in

the basic animal operant behavior laboratory argues in favor of

the applicability of this operant behavioral conceptualization to

human drug abuse problems.

4. The influences of many controlling variables upon drug selfadministration are similar-across the different pharmacological

varieties of drug abuse. That is, self-administration of pharmacologically dissimilar classes of compounds is often altered in

a similar fashion by a given experimental variable. For example,

variations in the drug dose, the response requirement to obtain

doses, or the scheduled consequences of drug use versus drug abstinence behaviors may exert similar effects upon self-administration of opioids, sedatives, stimulants, etc. This across-drug

similarity in the nature of the controlling variables has served

as a basis for arguing for a general construct of substance abuse.

These data can also be used to argue that drug abuse can best be

understood and influenced by viewing it as an instance of an even

more general construct -- that of operantly reinforced behavior

in which the drug functions as the reinforcer, the maintaining

consequence which sustains the behavior. The utility of this

conceptualization is that it ties drug abuse to an extensive

reservoir of scientific knowledge concerning factors which influence behavior, and it provides guidance to the researcher or

the practitioner concerning the classes of variables to which one

might profitably attend in an effort to modify drug abuse behavior.

Implications

This behavioral conceptualization has implications both for our

specification of therapeutic target behaviors which we wish to

change and for our search for a domain of controlling variables

which we can work with or influence in order to produce these

desired changes.

It is important to recognize that the central and common objective

defining element of all the substance abuse disorders is the behavior of substance self-administration. Thus, the central goal

of drug abuse treatment should be the reduction of drug selfadministration. To the extent that the therapeutic focus is upon

the many other collateral problems which are commonly observed in

drug abuse clients, one is not treating drug abuse, but rather

those other problems. It is quite possible that therapeutic efforts which impact upon these other areas will result inchanges

in drug use also. The point being made here is that if one wishes

to evaluate the efficacy of drug abuse treatment, one must assess

drug use outcomes and not rely upon assessment of hypothesized

intermediary processes.

38
In essence this behavioral conceptualization holds that drugs of

abuse exert actions which are intrinsically biologically reinforcing to organisms. According to this view drug self-administration

behavior is a biologically normal and orderly process similar (in

a scientific sense) to many ‘other varieties of operant behavior.

To the extent that pharmacological reinforcement by drug actions

is a potent explanatory mechanism for understanding the development and maintenance of drug self-administration behavior, then

one need not hypothesize the existence of unique individual or

environmental circumstances as necessary for inducing and maintaining drug abuse. Once the behavior of drug self-administration

is established, the drug itself can function as an adequate reinforcer to sustain continued self-administration. If one views

drug self-administration as being reinforced and sustained by

normal behavioral/biological processes, then it may be appropriate

to ask what characteristics of the non-drug-abuser’s history/environment have protected against the development of abuse rather

than to search for factors which have produced it in the abuser.

In terms of what this behavioral conceptualization tells us about

the classes of variables which we might expect to be effective in

modifying drug self-administration, several possibilities are

suggested. First, treatment might focus upon modifying the antecedent circumstances -- i.e., the conditions of drug availability.

In general, this domain of influence is more characteristic of

the law enforcement/legal regulation approach to drug abuse control. Certainly, ease of access to drugs of abuse would appear

to be one very important element influencing the prevalence of

drug abuse problems. Typically, this is not a set of variables

over which a therapist is likely to exert significant control.

However, residential treatment programs which remove the patient

from environmental circumstances of drug availability are utilizing this approach, and the observation that drug abuse is reduced

by changing the location of a drug abuser’s residence in the

community (Maddux and Desmond 1982) is certainly supportive of

the importance of this class of variables.

Second, treatment could attempt to alter the pharmacological reinforcing consequences of drugs of abuse. This is the approach

attempted when one uses pharmacological interventions to block

or alter the drug effect (e.g., narcotic antagonist treatment of

opioid abuse, or disulfiram treatment of alcohol abuse). This

general approach is also attempted, though with much less success,

when one uses behavioral conditioning procedures to establish

conditioned responses to drug administration which reduce the

drug’s reinforcing efficacy.

Third, treatment might focus upon the nonpharmacological consequences of drug self-administration or drug abstinence in an

effort to influence the future probability of those behaviors.

This is an approach which shows considerable efficacy in research

studies and considerable promise for therapeutic application.

39
Finally, since the behavioral conceptualization of drug abuse

views drug self-administration as just one element in an individual’s overall behavioral repertoire which is occurring excessively,

it may be useful to examine the total behavior of the individual

and to attempt to reduce this undesirable behavior in a competitive fashion by intervening to promote or develop other more

desirable behaviors. This is the approach which is taken when

drug abuse treatment attempts to promote education, employment,

social functioning, etc., or otherwise to correct skill deficits

or increase desirable prosocial behaviors.

TREATMENT GOALS

There are two points to be made concerning the goals of applying

this operant behavioral approach to problems of drug abuse -- one

has to do with the selection of specific target behaviors for

modification, and the second has to do with the procedural element of positive reinforcement which is characteristic of this

approach.

Target Behaviors

The above discussion, which emphasizes the view that drug abuse

is a problem consisting objectively of excessive and/or inappropriate drug self-administration behavior, would certainly suggest

that the goal of drug abuse treatment is to modify that behavior.

This is certainly the case; but therapeutic goals are often not

limited only to this domain. In clinical drug abuse treatment

settings one encounters problems considerably in excess of drug

self-administration. Drug abuse is a disorder with which a very

wide variety of collateral behavioral problems are commonly

associated -- such problems as poor education/employment skills,

impaired social/marital behavior, criminal activity, psychiatric

disturbance , etc. In emphasizing the importance of drug-taking

behavior as the critical aspect of drug abuse we do not wish to

minimize the importance of addressing these collateral problems

when treating drug abuse patients.

We do, however, wish to make a very clear distinction between

treatment of drug abuse and treatment of the drug abuser. We

would argue that in the treatment of drug abuse the critical outcome variable is drug self-administration behavior. Both on a

diagnostic and on an outcome assessment basis we feel it is

crucially important to gain some measure of this behavior (usually

indirectly via biological sample analysis -- e.g., urinalysis).

On the other hand, drug abuser patients may present with a variety

of collateral problems other than drug abuse itself which are

themselves warranting of treatment. We would emphasize, however,

that treatment of these other problems, while desirable, does not

in itself constitute treatment of the drug abuse problem unless

drug-taking behavior itself is changed. Still, one’s goal in

drug abuse clinics is to treat the drug abusing individual, not

only to treat the drug abuse disorder itself. Thus, depending

upon the characteristics of individual patients, it may be

40
appropriate to focus therapeutic attention upon any among a diverse

array of target behaviors -- of which drug abuse itself is just

one.

It should be noted that the functional basis for the relationship

between drug abuse and collateral disorders is not understood at

this time. There is, of course, considerable speculation that

there is a contributing or even causal relationship between these

different problems. However, interestingly, there is not agreement upon the direction of this influence. Some individuals argue

that it is fruitless to attempt to treat the drug abuse problem

without first (or concurrently) correcting collateral disruptive

lifestyle problems -- thus implying that the drug abuse is at

least in part caused by these collateral problems, At other times

it is argued that it is fruitless to attempt to treat the collatera1 disruptive lifestyle problems of drug abusers without first

achieving drug abstinence -- thus implying that the collateral

problems are at least in part caused by the drug abuse. Of

course, there may be truth to both positions. At the present

time, however, we are simply able to note the correlation between

drug abuse and other problems and to suggest that treatment programs must be prepared to address a range of therapeutic problems

among drug abuse patients, including but not limited to drug abuse

itself. Ultimately the therapeutic goals of drug abuse treatment

will be to produce improvements in as many problem areas as

possible for individual patients.

One advantage of the operant view of drug abuse is that this

places the disorder within a broader behavior analytic and therapeutic framework which has generality beyond drug abuse per se,

and which is applicable to understanding and treating the diverse

array of disorders with which patients may present. That is,

operant behavioral approaches can provide treatment programs with

both a conceptual basis for understanding and a practical procedural basis for influencing a wide range of target behaviors

which are of concern in the drug abuse clinic and among drug

abusing patients. Thus, this is an approach which is fully compatible with the practical clinical necessity of individualizing

the selection of specific treatment goals to be pursued with

individual patients.

Positive Reinforcement

Positive reinforcement, in its technical definition, is the presentation of some consequence to a behavior which increases the

probability of recurrence of that behavior; in informal, nontechnical language it is a reward procedure. An emphasis upon positive reinforcement procedures is characteristic of operant behavioral approaches: This is an emphasis which, in general,

distinguishes the operant behavioral approach from other therapeutic modalities. It is one of the therapeutic goals of the

operant approach to develop and implement positively reinforcing

procedures for encouraging and promoting desired behavior change.

41
The implementation of positive reinforcement procedures can have

a desirable effect upon the therapeutic and social atmosphere of

a treatment program. It is unfortunately often the case that in

drug abuse clinics the nature of the relationship between patients

and the clinic can be a rather coercive and aversive one. Clinics

often establish rules regarding standards of behavior and therapeutic progress which are difficult for patients to satisfy, and

a pattern can develop in which some patients become characterized

as chronic “failures” who are repeatedly berated, threatened with

treatment discharge, and perhaps ultimately ejected from treatment

for noncooperation or obstreperousness. On the other hand, the

clinic (especially, for example, a methadone clinic) controls and

dispenses a commodity (i.e. , methadone) which is of considerable

importance and desirability to patients; consequently, a pattern

can develop in which some patients engage in various forms of

manipulativeness and deception in order to alter their methadone

dose or schedule or to preserve their treatment program enrollment.

The use of positive reinforcement techniques can reduce the

threats and manipulativeness which can occur between staff and

patients, and can provide a context within which patients can

succeed in achieving goals and be positively reinforced for that

achievement rather than facing threats and punishments for failure

to make the desired therapeutic progress. Explicit description

of the behavioral contingencies can be a positive contribution to

clinic operation; it can serve to reduce much of the manipulativeness , emotionality, and apparent arbitrariness which are so often

involved in clinic management. At the same time that staff are

freed from these distracting concerns, the contingency management

procedure itself can be exerting a direct therapeutic effect in

promoting the desired behavioral changes.

One important practical element involved in the design of contingency management procedures utilizing positive reinforcement

procedures is the task of identifying and gaining control over

appropriate positive reinforcers. An ideal procedure is one in

which the therapist is able to gain control over some effective

reinforcer which already exists within the patient’s lifestyle

and to arrange for that existing reinforcer to be made available

on a contingent basis. In essence, this procedure of taking advantage of preexisting (i.e., so-called “natural”) reinforcers

allows one to implement positive reinforcement procedures without

the costly requirement of having to produce additional resources

to support the reinforcement procedure. Much of the discussion

which follows will involve application of this cost-effective

positive reinforcement procedure.

INTERVENTION SETTINGS

In this section we will discuss two drug abuse treatment intervention settings which we feel are especially appropriate for implementation of behavioral contingency management procedures.

These are: (1) residential treatment facilities, and (2) methadone treatment programs. In both cases we feel that these are

42
appropriate for contingency management applications because they

represent settings in which significant positive reinforcers are

routinely dispensed to patients. Thus, they provide a convenient

opportunity to interpose a contingent relationship to insure that

these resources are dispensed in a way which promotes therapeutically desirable behavior.

Residential Facilities

In residential treatment facilities the treatment program can exert control over a very substantial proportion of the reinforcers

available to individuals within that environment. In such set-’

tings patients are dependent upon the treatment program for much

of their personal support. Such potential reinforcers as social

access, recreational access, quality of the living environment,

dietary quality, extra program activities, therapeutic activities,

personal autonomy, etc., are potentially available for incorporation in therapeutic contingent reinforcement arrangements. Such

settings should provide a fertile ground for the development and

implementation of positively reinforcing contingency management

procedures for promotion of therapeutic improvements.

However, this potential has yet to be realized. Elsewhere we

have recently reviewed the limited work which has been reported

concerning contingency management procedures within residential

treatment facilities (Stitzer et al. 1983). In general, reports

to date have utilized contingency management procedures only to

encourage the simplest forms of program rule compliance and personal hygiene activity among patients. It appears that, from a

behavioral management point of view, the therapeutic possibilities

of residential contexts have been dramatically underutilized.

Ideally, one would like to see designed into such facilities a

graded progression of contingent access to an increasingly large

array of reinforcers consequent upon desired therapeutic progress.

While this apparently has not yet been done by behaviorally

oriented therapists, it should be noted that on a descriptive

level one can suggest that similar procedures are being used in

therapeutic commmities of the Synanon type. Apparently in these

programs patients enter the facility at the lowest functional

‘status, with the lowest level of privileges, and then are permitted progressively to rise in the hierarchy of the program and

in their level of privileges contingent upon their progressive

development of improved social skills and verbal behavior relative

to drug use and their development of occupational skills and performances . From such a behavior analysis perspective it can

appear that such therapeutic communities are designed according

to sound behavioral principles. However, until behavioral

principles are utilized prospectively in the design of a therapeutic residential facility, our belief in the value of these

reinforcement procedures in such settings must remain speculative.

Methadone Treatment Programs

Methadone maintenance treatment programs represent a context in

43
which the utility of behavioral contingency management procedures

has been clearly demonstrated. In fact, methadone treatment programs would appear to be an ideal context within which to conduct

therapeutic contingency management interventions. The clinic

provides a population of volunteer outpatient chronic drug abusers

who, upon enrolling at the treatment clinic, have agreed to report

to the clinic daily to receive under nursing observation a potent

pharmacological reinforcer. This arrangement provides a structured

basis for routine, frequent, convenient contact with drug abusers

who are freely residing in the community (presumably continuing

to be exposed to the high-risk situations of illicit drug availability), and it provides a basis for establishing behavioral

contingencies so as to promote therapeutically desirable behavior

change as a precondition for continued dispensing of reinforcers.

We would argue that treatment programs should take greater therapeutic advantage of the positive reinforcing characteristics of

methadone treatment so as to encourage desirable behavior change

among patients. In the present section we will describe procedural development studies illustrating how this can be done.

Methadone treatment is a reinforcing (-i.e., desirable) treatment

modality. This is documented by the patient acceptability or

popularity of this modality; it is one of the few substance abuse

treatment approaches for which it is possible to maintain a waiting list for patient admission. But there are reinforcers involved other than simple treatment admission. Inherent in the

operation of a methadone clinic there are a variety of reinforcers

available which could be used in therapeutic contingency management interventions. Some of the parameters which might be contingently manipulated so as to vary the reinforcing value of

methadone treatment are listed in table 1.

TABLE 1: Variations in Methadone Treatment

Procedures with Potential for Use

in Contingency Management Treatment

Procedures

Methadone take-home privileges

Daily clinic attendance frequency

Time of day of authorized clinic attendance

Clinic-controlled dose changes

Patient dose self-control

Extent of counseling or other adjunct services

Adjunct prescription medication

Clinic fee requirements

Lottery tickets

Vacation arrangements

The items listed in the table are derived from a casual “armchair”

analysis of the functioning of methadone treatment clinics. Two

studies have conducted questionnaire surveys of methadone patients

in an effort to identify factors which might serve as reinforcers

in contingency management procedures (Yen 1974; Stitzer and

44
FIGURE 1. Methadone maintenance patients (N=53) ranked the desirability of various potential reinforcers (1 = most desirable).

For each item the average rank is shown, as well as the percent

of patients ranking it among the three most desirable alternatives. Reprinted from Stitzer and Bigelow (19781, p. 471, by

courtesy of Marcel Dekker, Inc. © 1978, Marcel Dekker, Inc.

Bigelow 1978); both have indicated that the methadone take-home

privilege is among the most effective of incentives available

within the methadone treatment clinic. Results of the Stitzer and

Bigelow (1978) survey study are presented in figure 1.

The initial experimental demonstration of the actual behavioral

efficacy of methadone take-home privileges to serve as reinforcers

to produce desirable therapeutic changes in the behavior of drug

abuse patients was provided by Stitzer et al. (1977). In that

study attention was focused upon a subgroup of methadone patients

who were chronically failing to attend their weekly counseling

sessions for the scheduled duration. Using a within-subject reversal experimental design the study evaluated the efficacy of

using methadone take-home privileges to reinforce counseling

session attendance. During two contingent reinforcement phases,

each of 2-month duration, a weekend medication take-home privilege

was available contingent upon attending a counseling session of

at least 45-minute duration that week. Results are shown in

figure 2. During the baseline and noncontingent phases the

average counseling duration per patient-week was approximately

45
FIGURE 2. The functional efficacy of methadone take-home

privileges as reinforcers for improving counseling session

attendance was tested in a within-subject reversal design.

During the contingency phases a weekend take-home privilege

was provided contingent upon at least 45 minutes of counseling attendance. The average minutes of counseling attendance

per patient is graphed over successive weeks. Reprinted, with

permission, from Stitzer et al. Addictive Behaviors, Vol. 2(1),

p.11, © 1977, Pergamon Press, Ltd.

in the 15-30 minute range; during the contingent reinforcement

phases the average duration was approximately 40-60 minutes.

Thus, contingent reinforcement with methadone take-home privileges

effectively produced an approximate doubling in the desired target

behavior.

In a subsequent clinical study the applicability of contingency

management procedures within a methadone maintenance program was

extended to include the use of methadone dosage self-control as

the contingent reinforcer and the modification of supplemental

drug use as the target behavior (Stitzer et al. 1979). Participants were methadone patients who had shown consistent urinalysis

evidence of illicit supplemental use of benzodiazepine minor tranquilizers and who, as part of an effort to supplant some of their

illicit drug supplementation, had received a clinic prescription

making available to them up to two 10-mg diazepam tablets at each

daily methadone clinic visit. The contingency management intervention trial focused upon self-administration of this prescribed

supplemental diazepam as the target behavior and compared the

efficacy of methadone take-hone privileges and methadone dosage

self-control as contingent reinforcers. A within-subject reversal

experimental design was used, and the order of exposure to the two

46
contingency conditions was counterbalanced across subjects. During the contingent phases subjects could, by refusing the available diazepam for 3-4 consecutive days, gain the privilege of

either a one-day methadone take-home privilege or a one-day opportunity to alter the methadone dose by as much as 20 mg above

or below the maintenance dose. Results are shown in figure 3.

During’ baseline conditions (i.e., with no contingency) 95.6% of

available diazepam doses were self-administered. When diazepam

refusal was contingently reinforced, this fell to 11.2% when the

reinforcer was a take-home privilege, and to 69.7% when the reinforcer was methadone dose self-control. Thus, both consequences

functioned to reduce supplemental diazepam use, but the methadone

take-home privilege was far more efficacious than was the dose

self-control option.

The studies described here are intended to be illustrative and to

demonstrate the scientific background for devising and implementing contingency management interventions in methadone treatment

clinics. The studies are admittedly experimental demonstrations

rather than therapeutic trials. Our laboratory has, however,

continued this line of investigation in the direction of true

therapeutic trials. Some of those more recent procedures and

data are discussed by Stitzer et al. elsewhere in this volume.

The major point to be made here is that solid data now exist

documenting the feasibility and effectiveness of implementing

behavioral contingency management procedures within methadone

maintenance clinics to promote therapeutic behavior change.

PRACTICAL PROBLEMS

The above discussion has reviewed both the theoretical/conceptual

basis for contingency management approaches to drug abuse and the

practical empirical demonstration of the applicability and utility

of these approaches. We feel that these discussions clearly

document the appropriateness and effectiveness of this behavioral

approach to treatment of the variety of problems associated with

drug abuse. However, it is appropriate to note here that a

variety of practical problems remain which may limit application

of contingency management treatments in drug abuse clinics

(Bigelow et al. 1981).

Patient Diversity

Drug abuse patients are not a homogenous population, and they do

not present for treatment with a homogenous array of treatment

needs. This diversity is illustrated in figure 4 with data showing the treatment-entry characteristics of methadone maintenance

patients enrolling in a behavioral treatment research project reported by Bigelow et al. (1980). Although this was a “narcotics

addiction treatment” program, the intake data indicated that

only 40% of patients could measurably improve on the available

assessment index of narcotics use; This patient diversity argues

for the necessity of individualization of treatment regimens for

different patients. From a behavior management efficiency point

47
SUCCESSIVE WEEKS

FIGURE 3. Contingent methadone take-home privileges and contingent methadone dose self-control opportunities were compared

as potential reinforcers for reducing supplemental drug use. SubJects had available at the clinic two 10-mg diazepam (Valium(R))

tablets daily. During the contingent periods one of the alternative reinforcers was available contingent upon refusal of the

available diazepam. Reprinted, with permission, from Stitzer

et al. Addictive Behaviors,

Pergamon Press, Ltd.

Vol. 4(3), p.249. © 1979,

48
FIGURE 4. Drug abuse patients are a diverse population, who

present for treatment displaying widely varying performance

levels and therapeutic needs. Shown here is the distribution

of clients across levels of illicit drug use (measured- as percent of urine samples positive for various drug classes),

legal employment (categorized as none, part-, or full-time),

and treatment compliance (measured as percent of counseling

sessions attended) at the time of their enrollment in a methadone maintenance treatment program. Numbers at the right

indicate the percent of patients whose initial level was such

that they could possibly improve or worsen on that measure.

Reprinted from Bigelow et al. (1980), p. 434, by courtesy of

Marcel Dekker, Inc. © 1990, Marcel Dekker, Inc.

of view it would be attractive if “packaged” contingency management programs could be developed and implemented on a program-wide

scale within treatment clinics. However, the data on patient diversity argue against the feasibility or desirability of such an

approach. It may, however, prove possible to devise such programmatic approaches for more homogenous subgroups of patients

who share similar needs.

49
Access to Reinforcers

In the present paper we have discussed two primary settings in

which it was felt contingency management approaches might be especially applicable -- residential facilities and methadone

treatment programs. These were felt to be promising settings

specifically because they would appear to permit the behavior

therapist an especially easy opportunity to gain access to and

control over reinforcers which might then be utilized in contingency management procedures. In other settings it may be much

more difficult to gain control over any relevant reinforcers, and

consequently the applicability of these procedures may be limited

in such settings.

Acceptability

At times contingency management approaches can encounter problems

of acceptability in the community. In our applications of positive reinforcement procedures we have encountered no problems with

patient acceptability; however, this could certainly happen if

contingent reinforcement procedures were implemented as a substitute for a preexisting noncontingent free access arrangement.

At the societal level it is sometimes felt that it is inappropriate

to provide reinforcers to problem patients consequent upon improvements if those same reinforcers are not also provided to

patients who never displayed the problem in the first place. A

possible consequence of this view is that it may be suggested by

some that contingency arrangements take the form of aversive or

punishing contingencies for those patients who continue to display

problems; certainly difficulties with patient acceptability would

arise in such an eventuality. We feel it is essential that contingency management applications emphasize positive reinforcement

procedures and that the ability to individualize reinforcer

availability be retained. It would certainly be regrettable if

the opportunity to promote therapeutic behavior change through

positive reinforcement were to be sacrificed to an administrative

requirement that reinforcers be dispensed noncontingently.

Measurement of Drug Abuse

Application of contingency management procedures to the target

behavior of drug-taking itself is made difficult by the practical

difficulties of detecting and measuring the occurrence of drug

use. Clinics must rely upon urinalysis testing as the best

available objective index of drug use. In many clinics this

testing procedure involves the. lapse of a week or more from the

time a sample is collected until the analysis results return from

an outside laboratory. This long delay may seriously impair the

efficacy of contingency procedures which are targeted upon drug

use behavior. In our clinic we utilize an on-site urinalysis

testing procedure to minimize delays and to maximize the immediacy of contingencies. We would recommend this to other clinics

whenever it is possible.

50
Reversibility/Relapse

Contingency management procedures are sometimes perceived as

having only short-term efficacy and of being uniquely susceptible

to the problem of reversibility or relapse. Certainly it is the

case that the data from many contingency management studies

illustrate this problem -- including the data presented in this

paper; when the contingency procedure is discontinued behavior

tends to return to its prior level. We would suggest that this

reversibility is not a problem unique to contingency management

approaches; this is basically the relapse phenomenon, and this is

an endemic problem for all varieties of substance abuse treatment.

It is probably unrealistic to expect brief, short-term treatment

interventions to display long-term behavioral efficacy. It is

possible also that the appearance of uniquely rapid reversibility

with contingency management procedures is an artifact of their

efficacy; procedures which are not efficacious are incapable of

appearing reversible. Further research on the relative reversibility or durability of various treatment interventions is clearly

required. Until there exist clear data to the contrary, the concern about rapid reversibility of contingency procedures will

probably continue to limit their application.

CONCLUSIONS AND FUTURE DIRECTIONS

Drug abuse can be productively viewed as an example of operant

behavior, with drug self-administration being reinforced by the

pharmacological effects of the drug. The operant behavior conceptual framework provides a useful basis for understanding and

therapeutically influencing not only the drug self-administration

aspect of the drug abuse problem, but also many of the collateral

behavioral problems which are commonly observed in drug abuse

patients. The efficacy of contingency management approaches to

problems of drug abuse has been clearly documented in clinical

research, and several drug abuse treatment contexts would appear

to be especially suitable for contingency management interventions

because of the ease with which contingent access to preexisting

reinforcers can be arranged. Despite this promise, considerable

additional work is required to establish the extent to which these

procedures will have widespread application and acceptability.

We would suggest several directions as being desirable for future

work. First would be the task of continuing to improve the

efficacy of the procedures -- and of pursuing the task of establishing long-ten treatment efficacy. Second would be the use of

contingency management procedures as aids for assessing the value

of other treatments; a valuable treatment evaluation technique

might be to assess the extent to which other treatments enhance

patients ability to respond successfully to contingency procedures. A third valuable direction would be the use of contingency management procedures to study the techniques used by

patients to accomplish changes in their drug use behavior -- that

is, to study what other aspects of the drug abuser’s behavioral

51
repertoire change when drug use is discontinued (e.g., Burling

et al. 1982). Fourth, and finally, contingency management procedures would appear to offer strong opportunities for the study

of the relapse process.

REFERENCES

Bigelow, G.E.; Stitzer, M.L.; Griffiths, R.R.; and Liebson, I.A.

Contingency management approaches to drug self-administration

and drug abuse: Efficacy and limitations. Addict Behav, 6:

241-252, 1981.

Bigelow, G.; Stitzer, M.; Lawrence, C.; Krasnegor, N.; D'Lugoff, B.;

and Hawthorne, J. Narcotics addiction treatment: Behavioral

methods concurrent with methadone maintenance. Int J Addict,

15(3): 427-437, 1980.

Burling, T.A.; Stitzer, M.L.; Bigelow, G.E.; and Russ, N.W.

Techniques used by smokers during contingency motivated smoking

reduction. Addict Behav, 7: 397-401.

Griffiths, R.R.; Bigelow, G.E.; and Henningfield, J.E. Similarities in animal and human drug-taking behavior. In: Mello, N.K.,

ed. Advances in Substance Abuse. Greenwich, CT: JAI Press, Inc.,

1980. pp. 1-90.

Maddux, J.F., and Desmond, D.P. Residence relocation inhibits

opioid dependence. Arch Gen Psychiatry, 39: 1313-1317, 1982.

Stitzer, M.; Bigelow, G.; Lawrence, C.; Cohen, J.; D'Lugoff, B.;

and Hawthorne, J. Medication take-home as a reinforcer in a

methadone maintenance program. Addict Behav, 2: 9-14, 1977.

Stitzer, M., and Bigelow, G. Contingency management in a methadone maintenance program: Availability of reinforcers. Int J

Addict, 13(5): 737-746, 1978.

Stitzer, M.L.; Bigelow, G.E.; and Liebson, I. Reducing benzodiazepine self-administration. with contingent reinforcement.

Addict Behav, 4: 245-252, 1979.

Stitzer, M.L., and Bigelow, G.E. Behavioral approaches to drug

abuse. In: Hersen, M., Eisler, R.M., and Miller, P.M., eds.

Progress in Behavior Modification. New York: Academic Press,

1983. pp. 49-124.

Yen, S.

clinic:

Availability of activity reinforcers in a drug abuse

A preliminary report. Psychol Rep, 34: 1021-1022, 1974.

ACKNOWLEDGEMENT

Supported in part by USPHS research grants DA-01022, DA-01472,

DA-01943, and by Research Scientist Development Award DA-00050

from the National Institute on Drug Abuse.

52
Behavioral Treatment of Drug

Dependence

Roy W. Pickens, Ph.D., and Travis Thompson, Ph.D.

There are many different Interpretations of the problem of drug

dependence. Sane believe it is a medical disease, while others

believe it is a behavioral problem. Some consider It to have genetic origins; others consider It to be primarily environmentally

determined. Some examine it within a cultural context, others consider it to be an individual adjustment reaction. Same view it as

a personality disorder, while others view It as a psychosocial

problem. It is probably true that there iS no single correct interpretation of drug dependence. To scine extent all are correct, for,

like the blind men examining the elephant, each reflects how reputable individuals working in various disciplines view different

aspects of the same basic problem.

This is not to say that the interpretation given to the nature of

drug dependence is unimportant. While the treatment of drug

dependence may be unrelated to its causes, a clinician's view of

the problem will affect his or her approach to treating it. The

clinician who views drug dependence as primarily a personality

disorder will probably take a different approach to treatment than

will a clinician who views It as primarily a medical problem. The

validity of an interpretation of drug dependence is also in part

reflected by the effectiveness of treatment approaches suggested by

that interpretation.

The present paper examines treatment of drug dependence from a

behavioral perspective. Behavioral phatmacologists view drug dependence as learned behavior (Thompson and Pickens 1969; Pickens et

al. 1978). According to this interpretation, repetitive and persistent drug-taking behavior is established and maintained by the

consequences of that behavior. The consequences would include the

drug effect on the individual as well as any change the drug produces in the individual’s interaction with the environment. Within

this context, drugs (and events surrounding drug use) are viewed as

53
reinforcers, that is, events that follow behavior and as consequences make the behavior more likely to recur. Behavioral theorists and practitioners typically make no attempt to explain reductionistically why drugs and related events function as reinforcers,

only that they do. Thus, the behavioral approach attempts to

relate drug self-administration to observable events rather than to

hypothetical constructs or other unobservable events (Thompson

1981).

Viewing drugs as reinforcers and drug dependence as a form of

learned behavior has been very useful. It has allowed factors controlling drug use to be studied experimentally In both humans and

animals, and has also led to development of new techniques for

screening new drugs for dependence potential prior to their marketing (cf. Thompson and Unna 1977). Equally Importantly, however,

the approach has sugested new methods for treating drug dependence

(Thompson et al. 1973). The methods are based on behavioral prlnciples and are directed towards reducing drug-taking and increasing

alternative behavior. Clinically they are applied as behavior

therapy or behavior modification treatment approaches.

There is an extensive literature describing behavior therapy technlques to treat individuals with drug dependency problems. These

reports describe highly specific reinforcement and punishment procedures to modify the behavior of Individual clients. Relatively

few treatment programs have been based entirely on behavioral

treatment approaches. For the past several years we have operated

such a program for the treatment of drug dependence on a psychiatry

ward in the University of Minnesota Hospital. The program was

developed in part to support research activities In the area of

human studies of drug dependence (Pickens et al. 1977; Healey and

Pickens 1983).

It is the purpose of this paper to describe the ward's behavior

therapy program in detail and to explain how behavioral principles

are applied In the treatment of drug dependence. The reader is

cautioned that no comparative experimental test of the effectlveness of the program has been made. Except in certain cases, limited resources have prevented followup of the patients treated on

the ward. Thus, the procedures described here should be viewed as

having possible clinical effectiveness, until their actual worth

has been determined by controlled experimental testing.

GENERAL WARD PROGRAM

Our program is patterned after that originally described by Ayllon

and Azrin (1965) for use in treating chronically hospitalized psychiatric patients, but modified by us to treat acute psychiatric

patients (Pickens et al. 1979) and later to treat drug-dependent

patients (Pickens 1979). The program has two parts. One part utilizes a ward-wide point-economy system to encourage desired behavior and to discourage maladaptive behavior, while the second part

is an individualized treatment plan designed to meet the specific

treatment problem of each individual client.

54
In the ward-wide program, points are used as the medium for behavioraI change. Throughout the 24-hr day, points are given to patients contingent on desired behavior and taken away contingent on

maladaptive behavior. Point transactions are administered by all

staff who normaIly work cm the ward, including psychiatric nurses,

occupational therapists, alcoholism and drug abuse counselors, and

psychologists. All point transactions are recorded in a small

booklet that each patient is Issued dally.

Points are given to patients contingent on three classes of desired

behavior : participating in activities considered to be therapeutically helpful to patients, participating In social activities, and

grooming and personal care. Participating in therapeutic activities includes attending various classes that are offered on the

ward several times each week. The classes are designed to help the

patients in rational thinking about themselves, assertiveness, and

problem solving, and to improve interpersonal skills and communication. Not only are points earned for attending such activities,

but extra points may be earned for being on time and for the quality of participation in the activity. The points are given to

patients individually at the end of each activity. At this time a

staff person marks the points earned in the patients’ point booklet

and briefly describes how the quality of participation earned them

extra points, or how they might improve their participation In the

class to earn extra points in the future.

Other therapeutic activities that may earn points an the ward

Include work on the patient’s individualized treatment plan. This

plan Is devised during the patient’s first week of hospitalization.

It includes a detailed description of problem behaviors to be

changed, the desired behavior, the approach to be taken in changing

the behavior, and how the behavioral change is to be “consequated,”

that is, what the prescribed consequences of the behavior will be.

The plan is developed with the patient’s cooperation, and is signed

by both the patient and the primary staff person. It is considered

a document of agreement between the patient and the staff, indicating goals and methods for behavioral. change during the patient’s

stay on the ward.

Points are also given to patients for attendance and for degree of

participation in other ward activities, such as planned outings to

shopping centers, movies, or parks, as well as various work chores

that must be performed on the ward (e.g., watering plants, preparing meals). Personal care activities that earn points include

cleaning room, washing clothes, appropriate dress, and regular

showers.

The availability of activities for earning points and the number of

points to be earned by each activity are clearly defined in the

patient’s point booklet. However, points can also be given spontaneously by staff to a patient contingent on especially important

therapeutic behavior, such as acting responsibly or being particularly helpful. On such occasions, the staff approaches the patient,

tells the patient what they observed and liked about his or her

behavior, and awards the special points.

55
As points are given to patients for healthy behavior, points are

also taken away from patients for maladaptive behavior. Maladaptive behavior is defined as any behavior that is not in the patient’s

long-term best interest, regardless of whether it relates directly

to drug use or not. Examples of maladaptive behavior would include

verbal abuse, assault, theft, or not working on treatment plan. If

a particular behavior has been a major problem for the patient in

the past, that behavior is typically included in the patient’s

treatment plan. Otherwise, It is consequated as it occurs on the

ward. The same procedure s used in point loss as in point gain.

The staff person approaches the patient, tells the patient what was

observed and what was inappropriate about the behavior, and then

removes points for the behavior In the patient’s point booklet.

Points earned by patients are exchangeable on the ward for a variety of goods and services. Points earned during a day are exchangeable for snack food and soft drinks, supplies, cigarettes, or personal care articles. Points not spent on a given day are placed in

a savings account, from which the patient may purchase access to

visitors, overnight passes, or weekend passes. The major use of

points, however, goes towards put-chase of the patient’s daily privilege or responsibility level on the ward. With a low level of

net point earnings, a patient’ may be able to purchase only the

lowest privilege level on the ward-confined to ward. However,

with higher levels of net point earnings, the patient may be able

to purchase higher and higher privilege levels. At the highest

privilege level, patients are able to purchase unlimited and unescorted privileges on the ward. The maximum privilege level obtainable by a patient is set by the staff and typically increases as a

patient progresses through treatment.

Thus, the ward’s point-economy program can be viewed primarily as a

means for getting patients in contact with the therapeutic activities on the ward. Our patients typically attend most classes and

participate actively in other ward activities. Though many of our

patients are Initially very disturbed, there is a low level of IT&-

adaptive behavior. While we tend to stress behavioral and cognitive-behavioral approaches In the therapeutic activities available

to patients on the unit, the ward program could equally well be

used with other treatment approaches.

The program appears to be well liked by both staff and patients.

In a study of nursing staff attitudes toward behavior therapy,

after working on the ward for one year, the nursing staff said that

the behavior therapy approach was less superficial and less mechanistic than did nursing staff working on a more conventional psychiatry unit which emphasized Interpretative Individual and group

psychotherapy (‘Ihompson et al. 1980). While some patients may complain initially about the “mickey mouse" nature of the point program, most eventually report liking the program, especially as it

provides immediate feedback of progress through treatment. The

program seemingly works well with all types of patients. While

many of our drug-dependent patients are alcoholics or polydrug abusers from lower socioeconomic levels, patients have also Included

physicians, psychologists, engineers, and other professionals.

56
Why points are effective as reinforcers in changing the behavior of

drug-dependent individuals is not clear. One reason is obviously

that points can be used on the ward to buy goods and services. However, there may be other factors operating in the system as well.

One factor may be that the awarding of points requires staff to

Interact with patients many times throughout the day. Not only

does this Increase patient-staff interaction, but it makes the

staff more effective as social reinforcers and improves their ability to serve as role models for the patients. Another factor may

be that points are just lnherently reinforcing for many adults.

After a long history of exposure to a wide range of generalized

conditioned reinforcers, giving almost anything to an adult consistently after behavior may be reinforcing. The inherent reinforcing

property of points is suggested by the fact that most patients earn

considerably more points than they can ever spend on the ward, and

leave the program with a large point surplus.

As an example of the type. of treatment plan employed on the ward,

figure 1 shows a representative treatment plan for one patient who

was a chronic alcoholic. In addition to participating in chemical

dependency counseling and attending AA meetings, the patient was

required to spend increasingly longer Intervals of time off the

ward. Upon returning to the ward, however, the patient was given a

breathalyzer test to determine if recent drinking had occurred. If

drinking had not occurred, the patient’s privilege level was extended and the patient was given an even longer pass for the next

day. If drinking had occurred, the patient was to be Incarcerated,

as a condition of a court order. ‘Ihe purpose of this plan was to

give the necessary counseling for alcoholism on the ward and then

to require the patient to practice drug-free living outside the

ward.

A representative treatment plan for a middle-aged housewife with a

sedative abuse problem is presented In figure 2. Since the patient

lived in a small rural town, her drug abuse problem could be easily

controlled by the cooperation of her physician who agreed to no

longer Issue her prescriptions for sedative drugs. The treatment

plan consisted primarily of getting the patient more involved in

activities outside the home and in reducing her dependency upon her

spouse for mediating other reinforcers.

CONTINGENCY CONTRACTING

The contingency contract is a behavioral device used extensively on

the ward. The contract is a formalized agreement between a staff

person and the patient that specifies the manner In which learning

principles are to be applied to the modification of the patient’s

behavior. Usually the agreement is in the form of a written contract that both parties sign. The contract details the specific

behaviors to be changed, how such behaviors are to be monitored,

and the contingencies to be placed on the behaviors. Contingencies

are arranged to reinforce behavior that is to be Increased, or to

punish or extinguish behavior that is to be eliminated. Details on

writing contingency contracts can be found In a number of sources,

57
FIGURE 1. Example of a treatment plan used with a chronic alcoholic

58
FIGURE 2. Example of a treatment plan used with a chronic sedative

drug abuser

59
including DeRisi and Butz (1975), Homme et al. (1966), Williams and

Anandam (1973), and Dardig and Heward (1976).

Contingency contracts have had wide application in psychology, education, and the corrections area. One of the first applications of

contingency contracts in the treatment of drug dependence was by

Boudin (1972). He employed a contingency contract outside of a

residential setting in the treatment of a female amphetamine abuser.

The contract required the client to deposit $500 in the form of ten

signed $50 checks in a joint bank account with a therapist. The

contract specified that upon each occurrence of amphetamine abuse

by the client, the therapist would endorse one of the checks and

send it as a contribution to a political organization especially

disliked by the client. At the end of the contract period, the

money remaining In the bank account was to be returned to the

client. After only one application of the contingency, the procedure was effective in eliminating drug use, which did not recur in

the 2-year followup period.

Bigelow et al. (1976) also used a contingency contract to maintain

disulfiram (Antabuse) ingestion by alcoholics outside of a residential setting. Clients were asked to deposit money or a valued

object with the therapist. If the patient failed to return to the

clinic or to ingest disulfiram as scheduled, then a portion of the

deposit was sent to a charity. The remainder of the deposit was

returned to the client at the end of the contract period. During

the time of the contract, 80% of the clients reported longer periods

of alcohol abstinence than had occurred during the past 3 years,

and 70% of all clients renegotiated for a second contract.

Use of contingency contracts in the treatment of drug dependence

has also been reported by Miller (1972), Polakow and Doctor (1973),

and Hall et al. (1977). Similar contingency contract procedures

have been used in treating drug-dependent clients during the time

they are Inpatients in the residential ward program and also after

hospital discharge when they return to their home environment. In

the residential ward setting, behaviors are easily monitored and

consequated by the staff. In the home environment, however, behavior is more difficult to monitor, and individuals other than the

staff must participate In consequating the patient’s behavior.

In the ward program, the patients’ individualized treatment plans

are actually contingency contracts, as they Identify problem behaviors, specify desired behaviors, establish the approach to be used

in the behavioral change, state the contingencies to be employed,

and are agreed to and signed by both the patient and staff. Treatment plans may be changed repeatedly while a patient is on the

ward, with new problem behaviors being added when found and old

problem behaviors eliminated when they no longer occur. Point loss

or gain offers a relatively easy way for the staff to consequate a

patient’s behavior. A patient who said she required drugs to get

to sleep at night lost points for being In bed at any time during

the day, but gained points for exercise during the day and taking a

warm bath and listening to relaxation tapes before going to bed in

the evening.

60
In using contingency contracts on the ward, events other than point

loss and gain may also be used to consequate patient behavior. A

female patient who was unassertive in relationships with her husband was provided with extra pass time during the coming week contingent on each assertive statement by the patient in family discussions.

An “activity deck” can also be used to consequate behavior on a

contingency contract. The activity deck is a deck of 20-30 cards,

each describing a different activity the patient is expected to

carry out, which is shuffled dally and placed face down on a table

near the central nursing desk. The deck Is typically used with

nonpsychotic patients who occasionally report having disturbing

Ideas. In such cases a contingency contract is developed in which

the patient is Instructed to draw a card from the activity deck

upon each occurrence of the disturbing Idea and to carry out the

activity described. While it would appear that the purpose of the

activity deck is merely to distract the patient from continuing

with the disturbing thought, the activity deck actually serves two

other purposes as well. The procedure teaches patients how to deal

with such ideas in the future. Moreover, since each activity in

the deck is a moderately onerous task, carrying out the activity is

mildly punishing, so a sound behavioral principle is being used to

reduce the frequency of the disturbing; Ideas.

Point loss or point gain can be equally powerful as contingencies

In behavioral contracts, however. Points have been used as a means

for obtaining self-detoxification from sedative drugs in drug-dependent patients. Self-detoxification is markedly different from the

detoxification procedure employed in most drug treatment programs,

where the physician controls all drug administration and determines

not only the starting dally drug dosage but the rate at which the

patient is withdrawn. Patients were initially allowed to selfadminister pentobarbltal until dally Intake stabilized and then

were allowed to contract (see figure 3) to take one less drug capsule each day until detoxification was completed. Points were

earned by patients for reducing drug intake by one capsule per day

and lost if they remained at the same dosage level for more than 2

days or took more capsules than on the previous day or detoxified

at a rate greater than one capsule per day.

Figure 4 shows the effects of contingency contracting on the drug

Intake of all six subjects employed in one study. All were women

with confirmed histories of sedative abuse. The mean level of pentobarbital intake during the self-administration part of the study

is shown along the left side of the graph. The subjects self-administered form 400-1000 mg of pentobarbital per day, which is typically associated with physiological dependence. Abrupt cessation

of drug use at these dally doses is usually associated with moderate to severe withdrawal symptoms. The variability in drug intake

from day to day for each subject was relatively small.

At the start of the detoxification phase, phenobarbital was substituted, and the subjects were allowed to contract for the number of

61
SELF-DETOXIFICATION CONTRACT

I understand the purpose of this procedure Is to allow me control

over my own rate of drug detoxification from my original addicted

state. I have received a schedule to guide me in undergoing detoxification safely and gradually. I will assume all responsibility for

regulating my drug intake, and the credit will be all mine for the

accomplishments I make. Today I agree to take capsules of

medication; The number of capsules I took yesterday was . I

understand that If the number of capsules taken today is one less than

the number taken yesterday, I will receive points at midnight

tonight. If the number of capsules taken today is the same as the

number of capsules taken yesterday, I will receive no points. In no

case, however, can I remain at the same drug level for more than two

successive days without losing points. If I take more drug today than

I did yesterday, or if I take less drug today than is recommended on

the guide sheet, or if I remain at the same drug level for more than

two successive days, I will be required to pay points for each

capsule over or under the recommended number at midnight tonight. In

following the guide sheet, I am also entitled to any bonuses that I

have earned.

Date Patient’s Signature

Staff’s Signature

FIGURE 3. Example of a self-detoxification contingency contract

62
FIGURE 4. Pentobarbital self-detoxification following pentobarbital self-administration

63
capsules of drug to be taken each day. All subjects showed a reduction In the number of capsules taken each day. Five subjects

showed a systematic decrease in capsule intake, eventually reaching

and maintaining at least 5 days of abstinence. The sixth subject

initially showed a decrease in drug intake but was successful In

reducing her intake only to about 40% of self-administration level.

Withdrawal of this subject was then completed under medical. direction. Followup at 6 weeks after hospital discharge showed no drug

use by the patients able to undergo self-detoxification, while drug

use was evident In the patient who was unsuccessful at self-detoxification.

When patients self–detoxify with phenobarbital, two distinct patterns of behavior emerge. The patient may show a gradual decrease

over time in the number of drug capsules taken throughout the day.

The other pattern Involves initial decrease in drug capsules taken

In the morning, with the capsules taken in the evening remaining

relatively unchanged until the final phases of the detoxification

process. Data are currently being examined to determine if these

two patterns of drug withdrawal reflect the presence or absence of

another clinical state, such as depression.

Contingency contracts are also used with patients during the first

several weeks after discharge, when they return to their home environment following their hospital stay. The contracts are designed

to allow for the implementation of behavioral contingencies In the

patient’s home environment to reduce the likelihood of a return to

drug use. The contracts also make possible a gradual transition

between the highly controlled environment of the hospital ward and

the less controlled environment of the outside world.

The outpatient contract is similar to the inpatient contract,

except that events other than point loss and point gain are used in

the contingency. In the case of one patient who was a sedative

drug abuser from a small community, a contingency contract was

devised before she was discharged from the hospital program to aid

her in becoming more Involved in community affairs once she had

returned home. Working with a counselor In the community’s mental

health clinic, the patient was to plan at least one activity outside the home each day at the beginning of each week and to mail

the schedule of weekly activities to a staff person In the ward

program. On the schedule the patient was to include the date and

time of each activity, and a telephone number at the site of each

activity where she could be contacted. The staff person would randomly call the telephone number listed and verify that the patient

was at the activity listed. If the patient attended at least five

of seven scheduled activities for the week, she was mailed a check

for $10. If she attended fewer than five activities, she received

no money. The patient did not fall to receive a check during the 6

weeks of the contract period, and she became regularly active In a

number of community programs as natural reinforcers replaced the

monetary rewards involved in the contract.

Other types of contracts have also been used to Insure that a patient will remain drug free after treatment. A middle-aged married

64
woman with sedative dependence required involvement by her husband

in managing the contingency. This was done to prevent the husband

from sabotaging the patient’s efforts to remain drug-free, as he

had done on other occasions. Each week for 6 weeks the patient

was to return to the ward for have a blood sample analyzed for drug

content. If no drug was found, both the patient and her husband

benefited by the terms of the contract. The patient was allowed to

exercise a personal agreement negotiated with the husband before

her hospital discharge, and the husband was given back a portion of

a monetary deposit left with the staff ‘at the time of the patient’s

discharge. If drug was found in the patient’s blood sample, however, both the patient and her husband lost reinforcers under the

terms of the contract. The patient was not allowed to exercise the

personal agreement, and the husband had that portion of the money

he would have received sent as a contribution to a disliked organization.

While contingency contracts are widely used by the staff in the

ward treatment program and by others in other treatment settings,

most reports of the clinical effectiveness of contingency contracts’

have been in the form of case studies rather than controlled experimental reports. Nevertheless, a small number of scientifically

valid studies have been conducted demonstrating the effectiveness

of contingency contracts in clinical settings (Stuart and Lott

1972; Winett 1973; Eyberg and Johnson 1974). It is clear that more

experimental research should be conducted on the effectiveness of

contingency contracts, particularly on the variables in contingency

contracting that enhance the effectiveness of this potentially useful procedure in the treatment of drug dependence.

Of the drug-dependent patients treated on our unit at the University of Minnesota Hospitals, all typically have employed contingency contracts as an integral component of inpatient treatment.

How the course of their inpatient stay would have progressed had

another form of treatment been used is not known, and in most

instances, only limited follow-up data are available on durability

of the treatment gains. We have learned that approaching treatment

design from a broad behavior analytic framework t-as led to emergence of a viable strategy for treating patients who are psychologically and physiologically dependent on alcohol, sedative hypnotics, and other drugs. Viewing the self-administered drug as the

nexus of interlocking learned and biological variables has been

useful in developing a technology for understanding and arresting

the drug dependence process.

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Bigelow, G.; Strlckler, D.; Liebson, I.; and Griffiths, R.

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Stuart, R.B., and Lott, L.A. Behavioral contracting with delinquents: A cautionary note. J Behav Ther Exp Psychiatry, 3: 161-169,

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Print. Off., 1981.

Thompson, T., and Pickens, R. Drug self-administration and

conditioning. In H. Steinberg, ed. Scientific Basis of Drug Dependence. London: J.A. Churchill, 1969.

Thompson, T., and Unna, K., eds. Predicting Dependence Liability

of Stimulant and Depressant Drugs. Baltimore: University Park

Press, 1977.

Thompson, T.; Griffiths, R.; and Pickens, R. Behavioral variables influencing drug self-administration by animals: Implications

for controlling human drug use. In L. Goldberg and P. Hoffmeister,

eds. Psychic Dependence. Berlin: Springer-Verlag, 1973.

Thompson, T.; Labeck, L.; and Zimmermann, R. Nursm staff

adjustment as a function of psychiatric treatment modality. J

Behav Ther Exp Psychiatry, 11: 200-214, 1980.

Williams, R.L., and Anandam, K.A. Cooperative Classroom

Management. Columbus, Ohio: Mart-Ill, 1973.

Winett, R. Parameters of deposit contracts in modification of

smoking. Psycho1 Rec, 23: 49-60, 1973.

67
Contingency Contracting Treatment of Drug-Abusing Physicians, Nurses, and Dentists

Thomas J. Crowley, M.D.

Substance abuse often is characterized by remissions and

relapses (Armor et al. 1976; Nurco et al. 1978). Relapse

hazards are especially problematic among certain highly

responsible professionals, such as physicians, dentists, and

nurses. Thus, loss of professional privilege or licensure is a

common consequence of drug abuse in these professions.

On the other hand, these drug-abusing professionals know that

they have ingested drugs hundreds or thousands of times before

without loss of license and that they probably could "get away

with just one more" ingestion. Thus, their fear of future

loss of licensure may not very effectively induce abstinence

today. But if the loss of license could be "rescheduled" to

occur with certainty at the very next use of the drug, that

predictable, clear punishment might suppress the drug use

and permit the initiation of other outpatient treatments while

the m-abstinent professional person works and lives at home.

Moreover, since the only choices would be "abstain and work, or

do not abstain and do not work," the patients of that

professional person would be protected, in turn, from the

ministrations of an intoxicated doctor or nurse. This is a

report of an effort to "reschedule" therapeutically the

threatened loss of professional privileges or licensure with a

contingency-contracting procedure among 17 drug-abusing

physician, nurse, and dentist patients treated in our Halsted

Clinic. William Stewart Halsted (1852-1922) was the famous

American "Father of Modern Surgery." The Halsted Clinic

commemorates his ability to make brilliant contributions

despite a severe cocaine dependence (Heuer 1952); the clinic

offers outpatient treatment with contingency contracting for

drug-dependent health-care professionals.

PATIENTS AND PROCEDURES

Seventeen consecutive patients were referred for treatment from

employers, coworkers, or hospital staff committees (6); from

state licensing boards (5); by a friend, family member,or self

(4); or by private psychiatrists (2). Hospital boards or

licensing authorities had restricted or suspended the professional privileges or licenses of 12 of these 17 patients before

their admission to the Halsted Clinic, while three more had

been told that such actions would be forthcoming unless they

68
immediately found effective treatment: for two others licensure

was a serious concern but had not yet been threatened directly.

This all-white group of 13 physicians, 3 nurses, and 1 dentist had a mean age of 39 (range 25-65) years, and included

3 women. The primary drug of abuse at admission was cocaine (5

patients), meperidine (Demerol; 4 patients), other opioids (5),

mixed and multiple drugs (2), and alcohol (1). The route of

administration was intravenous or intramuscular for 9 patients,

intranasal cocaine insufflation for 2, cocaine "free-base"

smoking for 2, and oral for 4. The mean interval from first

clear drug abuse to admission was almost 8 years (95 months;

range 5-300). The current episode of abuse had persisted for a

mean of 15 months (range 0-95: the zero results from 2 patients

who claimed abstinence for several months before admission,

saying they were entering treatment only to forestall relapse

and to reestablish their professional credibility). Prior to

signing contracts, 13 patients reported daily drug use; 2

reported using drugs several times per week, and 2 claimed no

use for several months. Five patients obtained their drugs

from friends or street sources; self-prescription or diversion

of drugs from legal sources supplied 11 patients, and one

alcoholic patient obtained his drug in bars and liquor stores.

Treatment Procedures

Treatment procedures are specified in the sample treatment

contract and also are exemplified in the case history which

follows. To protect identities, ages are rounded to nearest

decade (e.g., 35-44 is given as 40).

Sample Case History

Case 2 (figure 1). A 30-year-old single professional

woman had snorted 0.5-3, gm of cocaine almost daily for

3 months, while also using flurazepam, alcohol, and a

variety of other drugs. After a car wreck, she began

to abstain. Eight days later, fearing the great

attractiveness of cocaine, she entered treatment to

help assure continued abstinence.

Despite her professional work, her friends were

underworld figures. She obtained her cocaine from

them, supporting her habit from savings and by dealing

in drugs. To help reorganize her chaotic social

situation, she requested brief psychiatric hospitalization, but she went to work on pass from the

hospital after the first few days. The patient saw

loss of her professional license and her job as the

probable Outcomes of continued use.

69
Her therapist remended a contingency contract to

use that fear of license loss as a motivator toward

abstinence. She wrote a letter to her State

licensing board confessing her drug abuse and

surrendering her license: the letter was deposited

with her therapist. In a written contract she

directed the therapist to obtain urine samples and to

mail the letter if any sample contained drugs or if

she failed to provide a scheduled sample. This made

the somewhat remote (albeit eventually probable)

consequence of license loss much more immediate and

certain, and the patient signed the contract, aiming

to force herself to remain abstinent until she could

develop a drug-free pattern of life. With the contract as a powerful motivator toward abstinence, the

patient then used therapy sessions to dispose of her

extensive drug paraphernalia, to list her drug-using

contacts and make plans to end those relationships,

to list her non-using friends and make plans to renew

those contacts, to improve her work performance, and

to develop new strategies for problematic relationships with men and with her parents. She remained

free of cocaine and other drugs of abuse (except

for alcohol and marijuana), repeatedly renewing

the initial 3-month contract for a total of 12

months. By that time she felt that the inherent

rewards of her drug-free life outweighed the combined

benefits and costs of resuming drug use; while she

still thought of cocaine, she said, "it just doesn't

seem worth the hassle." She has continued in

psychotherapy for 19 more months without urinalyses.

She has taken no more cocaine, has completed a course

of postgraduate training, and no longer associates

with underworld figures.

Patients often use these contracts to regain professional

privileges from their hospitals or licensing authorities. For

that reason, as well as to sustain their own motivation to

remain abstinent, patients readily see the need for a nearly

fool-proof drug-detection system. Conversely, the oontract

protects patients against mailing of the surrender letter as a

result of laboratory error by requiring duplicate analyses of

urine samples reported to contain drugs.

Physician's Sample Treatment Contract

This is an agreement between (the

patient) and Dr. Thomas crowley the patient

maintain a resolve to remain free of drugs of abuse.

By this agreement the patient directs Dr. Crowley to

establish a schedule for collecting urine specimens

from the patient. The patient initially will provide

urine samples each Monday, Wednesday, and Friday for

one month. For the next one month Dr. Crowley will

70
prepare a random schedule giving a 67% chance that

the patient will be directed to produce a urine

sample on any given Monday, Wednesday, or Friday:

after the beginning of the third month there will be

a 33% chance each Monday, Wednesday and Friday that

the patient will be directed to produce a urine

sample. The patient will call Dr. Crowley's office

or clinic each Monday, Wednesday, and Friday after

the first month to determine whether that is a day

for delivering a sample. Dr. Crowley or one of his

trained employees will observe the urination. Half

of each urine sample will be submitted for analysis

and half will be saved at Dr. Crowley's office.

Samples, identified only by a code number, will be

assayed for a variety of drugs of abuse,

specifically including . If

the first half of any sample is reported to contain

a drug, the second half of that sample will be

submitted for a separate analysis.

71

The patient has supplied Dr. Crowley with a letter

to the State Board of Medical Examiners. This

letter notes that the patient had used drugs

previously, had entered the present rigorous program

of outpatient drug abuse treatment, but that the

patient nevertheless has resumed drug abuse: in the

letter the patient surrenders his medical license.

By this agreement the patient directs Dr. Crowley to

mail the letter at any time that both halves of a

urine sample are positive for drugs of abuse, or at

any time hat the patient fails to produce a

scheduled urine sample. Each separate analysis

requires 1.5 ounces of urine; if the first portion

of a sample is positive for drugs, and if the

patient has supplied a quantity of urine insufficient for a second analysis, Dr. Crowley is to mail

the letter as described above. If the quantity is

insufficient for even one analysis, that shall be

considered a failure of the patient to provide a

scheduled sample, and Dr. Crowley is hereby directed

to mail the letter, as described above.

If the patient travels out of town, he will inform

Dr. Crowley in advance of leaving, and the urine

collection program will be suspended temporarily

during that absence. Dr. Crowley is authorized to

verify such absences with . If the

patient is sick enough at some time to require

hospitalization, Dr. Crowley will arrange to collect

urine in the hospital: if the patient is sick and

does not require hospitalization, the patient will

arrange to produce scheduled urine specimens in the

usual place. On certain major holidays Dr.
Crowley's office and clinic are closed. Dr. Crowley

and the patient mutually will agree to altered urine

schedules on these occasions.

If the patient needs, for appropriate medical

reasons, one of the drugs which sometimes are abused,

he will obtain that drug on a legal prescription from

another physician or dentist who knows of the

patient's drug problems. The patient will supply

Dr. Crowley with copies of that prescription, and

then the appearance of that drug in the urine will

not trigger the mailing of the letter. The patient

hereby directs Dr. Crowley to communicate by mail or

telephone with that prescribing physician or dentist

when Dr. Crowley deems that action to be appropriate.

This agreement shall remain in effect for

months from the date of signing. If for any reason

the patient moves away during the treatment period

agreed upon here, and if the patient does not arrange

for appropriate followup treatment, Dr. Crowley

hereby is directed at his discretion to inform the

State Board of Medical Examiners that the patient was

in treatment with Dr. Crowley for drug abuse but

that the patient prematurely withdrew from that

treatment: in this situation Dr. Crowley is not to

mail the letter which surrenders the patient's

license. During the time of this contract the

patient and Dr. Crowley will meet for counseling

sessions at a frequency which they will determine.

The patient strongly is encouraged to review with

attorneys, family members, or other advisors, this

agreement, which may be modified before it is

signed.

Followup Procedures

For all but one patient, more than 1 year elapsed from

initiation of contingency-contracting treatment to followup

(mean 20 months, range 10.5-38). Eight patients continued to

attend the Halsted Clinic at the end of the follow-up time: for

7 of these the followup data derive from regular clinical contacts and frequent urinalyses: for the eighth (Case 2, figure

l), some data were derived during biweekly therapy sessions

without urinalyses. Of the 9 patients who no longer were in

treatment in the Halsted Clinic, the author, who treated all 17

patients, made followup contacts by telephone with the

patients and/or their spouses. Thus, followup data were

available for all patients. Obviously, there was more opportunity for underreporting of relapse with simple, posttreatment phone contacts than there would have been during

periods of contingency contracting with frequent treatment

sessions and urinalyses.

72
RESULTS

Reduction of Drug Use

During the contract periods, 1004 urine samples were collected

from these patients: 8 samples (obtained from 5 patients) were

drug positive. Most of these patients had been daily or nearly

daily users, and the record of only 0.8 percent positive urines

indicates a profound reduction of drug use while contracts were

in effect.

Figure 1 shows a time-line for patient outcomes during

treatment and followup, while table 1 summarizes outcome

categories. As shown in figure 1, 53 percent of patients

(Cases 2, 3, 4, 6, 8, 11, 14, 15, 17) remained drug free during

the first 12 months after signing a contract, and 7 of these

patients (Cases 2, 4, 8, 11, 14, 15, 17) sustained abstinence

throqhout the followup period.

FIGURE 1

FOLLOW-UP SUMMARY:

17 DRUG-ABUSING M.D., D.D.S., R.N. PATIENTS

Followup summary of 17 drug-abusing physicians, dentists,

and nurses. ARTS is the Halsted Clinic of the Addiction

Research and Treatment Service, University of Colorado

School of Medicine.

Of these seven, six were under a licensure-loss contract for

longer than 6 months while one (Case 4) was under a contract

for only about 3 months.

73
Ten subjects used drugs at least once during the treatment or

followup periods. Five of these patients (Cases 3, 5, 7, 12,

13) used drugs after, and five (Cases 1, 6, 9, 10, 16) used

during, the contract period. In general, relapses appeared to

be briefer and outcomes better (figure 1) for those who used

drugs while under contract than for those who used after contract termination, whether or not the license was surrendered.

Under the terms of their contracts, two of these patients,

Cases 9 and 10, lost their licenses because of drug-positive

urines. It can be seen in figure 1, however, that both of

these patients subsequently returned to treatment and signed

additional contracts. Loss of license need not produce

catastrophic consequences; in Case 9 a therapeutically positive

outcome ensued. This SO-year-old married male had been selfadministering up to 500 mg per day of meperidine intravenously

for about 6 months. His hospital had suspended him, and he

signed a contingency contract to regain those privileges. But

within two weeks his urine again contained meperidine. He

immediately entered a residential treatment program. Refraining from practice, he said, was within the spirit of the contract, and he convinced his therapist not to send the licensesurrendering letter. The contract was renewed when he returned

two months later. But just before restarting his work, he

resumed meperidine use, avoiding detection for a few days with

a rubber bag-and-tube contraption which allowed him to deliver

a false sample even under observation. But then he wrecked his

car while intoxicated and pointedly did not produce a required

sample. The letter was mailed, and he ceased practicing.

With no contract he remained in outpatient treatment (and

Alcoholics Anonymous), apparently abstaining, for 13 months.

He then regained his license, renewed the contract, and has

resumed practice. The facts that the second relapse occurred

just before he resumed practice,

reapplication for his license,

and that he needlessly delayed

suggest that license loss may

not have been an aversive event for this patient.

Three patients (Cases 1, 6, 16) had drug-positive urines while

under contract, but their letters were not mailed because of

technicalities in their contracts. For example, after

producing drug-free urines for 12 months, one patient (Case 6)

gave two successive samples which contained drugs but which

were too small for double analysis. The contract in use then

required double analyses to mail the license-surrendering

letter. The patient then agreed to modify the contract to

close this loophole, and remained drug free for an additional

seven months. Patient 16 verbally reported two brief relapses;

one went undetected in the random urinalysis screens, and the

second relapse involved too-rapid self-dosing with a drug

obtained for legitimate medical reasons on prescription from

another physician. In general, the relapses seen in these

three patients while under contract were brief; they did not

precipitate sustained drug use or interfere with work performance. Thus, although they did not completely remain

74
TABLE 1

OUTCOMES FOR 17 PATIENTS DURING TREATMENT AND FOLLOWUP

Outcome

Totally Abstinent 12 Months

After Contract Signed

Totally Abstinent Throughout

Followup

Drugs Used During Contract

License lost Via Contract

License Retained Through

Contract Technicalities

Drugs Used After Contract

Termination

*Case numbers refer to figure 1.

Percent

53

41

Cases*

2, 3, 4, 6,

8, 11, 14,

15, 17

2, 4, 8,

11, 14, 15,

17

29

12 9, 10

18 1, 6, 16

29 3, 5, 7,

12, 13

abstinent, the five patients who relapsed while under contracts

may be considered relative treatment successes.

Followup showed that three patients had their licenses revoked

or suspended for reasons other than the contract. In me

instance (Case 3), this was due to drug use which occurred

after termination of the contract; in two other instances

(Cases 7 and ll), the revocation was unrelated to drug use.

Abstinence On-Contract vs. Off-Contract

Among these patients contract duration ranged from 1 to 38

months (figure 1). Figure 2 shows that about half of those who

signed remained in a contingency contract 12 months later.

Although the month-by-month decline in percentage of patients

remaining abstinent parallels the decline in those still on

contract (figure 2), it cannot be concluded that ending the

contract necessarily resulted in relapse. Although some

patients relapsed shortly after their contracts ended (e.g.,

Cases 5, 7, 12 in figure l), others reported no relapse after

the contract ended (Case 4, figure 1) and still others

continued with a contract despite a brief relapse (Cases 6, 16,

figure 1). Considering patients still on contract, together

with those now off amtracts, the fifth month after signing was

75
the peak time (figure 2) for relapses to be occurring, but such

relapses actually had a fairly even distribution through the

first 12 months.

FIGURE 2

Abstinence for 17 patients in first year after signing of

contract.

Figure 1 suggests that these patients were more likely to

abstain when contracts were in effect than when they were not.

Patients abused drugs in 9 of the 187 patient-months when

contracts were in effect (4.8 percent), and in 18 of the 147

patient-months when contracts were not in effect (12.2

percent). Moreover, followup calls suggested that relapses

without contracts tended to be longer and more continuous than

those occurring during contract periods.

Figure 3 also may suggest more abstinence when patients were

on contracts. Month-by-month, an average of 96 percent of

patients still on contract appeared to abstain; whereas, of

those no longer on contract an average of 73 percent reported

abstaining each month. Stated differently, in an average month

of the year after contract-signing, abut 4 percent of those

with contracts still in effect used drugs, vs. abut 27 percent of those with contracts no longer in effect. However,

these estimates may be biased in either direction, considering

such factors as a greater motivation to dissimulate during

contract periods, or greater ease of concealing relapses during

76
FIGURE 3

Abstention on- and off-contract. In each panel the dashed

line shows the percent of the 17 patients who did, or did

not, have contracts in effect. The solid line shows the

percent of patients in each condition who abstained each

month.

77
noncontract periods when urine is not examined, or a possible

tendency for more strongly motivated patients to bind

themselves to longer contracts. It might have been argued

further that those patients most prone to drug use quickly

would relapse, losing their licenses, terminating their

contracts, and loading the off-contract group with poor

prognosis patients; however, only two patients lost licenses

through the contract mechanism, and one of them (Case 9)

apparently remained abstinent thereafter.

DISCUSSION

Drug-abusing health care professionals require treatment, and

their patients must be protected from the consequences of the

drug use. Unfortunately, the availability of drugs to these

professionals, and their familiarity with drug administration,

may pose antecedents of high risk for drug abuse. To protect

patients, stern limits have been placed on the practice of

drug-abusing professionals; for example, Green et al. (1978)

advocate lifetime surrender of a physician's narcotics number,

immediate cessation of practice, and a very slow return of

responsibility after lengthy evaluation and therapy.

Such Draconian measures, whatever their merit, are not without

social cost. A medical or dental practice important to a

neighborhood or small community may close abruptly, perhaps

never to reopen. A hospital administrator, already critically

shortstaffed, may feel obligated to discharge a drug-using

nurse. Patients may be under-treated by a n-abstinent

physician or dentist who cannot prescribe controlled drugs.

And the rehabilitation of the drug-abusing professional may be

severely complicated by impaired self-esteem resulting from

unemployment or stringent limits on professional practice.

Indeed, among one reported group of 40 such probationers, 20

percent committed suicide in one recent year (Crenshaw et al.

1980); the therapist of the present 17 patients assessed a high

suicide risk at some point in the treatment of six of them, and

one patient did make a serious suicide attempt.

Drug-abusing professionals often are dispatched to remote

sanatoria for treatment. But if treatment could proceed with

the patients in their own homes, offices, and hospitals, they

and their families might better learn every-day decisions and

actions to promote continued abstinence. An anesthesiologist

who daily must handle fentanyl (Sublimaze), and who was

addicted to that drug, may need specific, repeated, on-the-job

practice in giving the drug to others and not to himself. And

while he does that, his family may need to practice with him

new behaviors to support his abstinence and to deal more effectively with future relapses.

78
Thus, there might be several advantages to treating such

drug-abusing professionals as they work in their own offices

and hospitals and live at home. But, for the protection of

their patients, these professionals must abstain as such

treatment proceeds. It is well established that drug-use

behavior does change when the reinforcing or punishing

contingencies of that behavior change (Cohen et al. 1971a, b;

Boudin 1972; Bigelow et al. 1972; Crowley 1972; Miller et al.

1974; Miller 1975; Hall et al. 1977; Stitzer et al. 1979;

Havassy et al. 1979).

This paper reports an effort to utilize contingency contracting

procedures to secure a period of abstinence among drug-abusing

physicians, dentists, and nurses so that they could participate

in other abstinence-promoting treatments as they lived and

worked at home. Hospital authorities or licensing boards had

restricted or suspended the professional privileges or licenses

of the majority of these patients before their admission to the

Halsted Clinic, and licensure was serious concern to all of

the patients. With such a powerful contingency operating

naturally among drug-abusing professional patients, they would

seem to be excellent candidates for contingency-contracting

treatment, but this appears to be the first report of such

treatment in this group.

These patients knew, unfortunately, that they could continue’

using drugs for some time before final detection, proof, and

administrative action could occur. To encourage abstinence,

these contracts “rescheduled” the preexisting contingency of

license-loss, making it likely to occur very early in a

relapse.

Advantages and Disadvantages of the Treatment

An immediate effect of the contingency contracts was an abrupt

and dramatic reduction in drug use. Additionally, the patients

remained at home and at work. The written contract, with its

clearly stated contingency for drug use, apparently helped to

suppress relapses; drug-free behavior patterns resumed and

became prepotent over an extended time, even as the risk that

drug use would be detected gradually declined. As that risk

fell, the rewards of drug use gradually could be supplanted by

the rewards inherent in an abstinent life. Counseling during

the contract period aimed at assisting the patient to

reestablish behaviors which could regain those reinforcers

usually available to nonintoxicated professionals: the

contract, an abstinence-securing prerequisite to such

counseling, clearly was not by itself the whole treatment.

Spouses or other parties in important relationships with the

patients often were included in the counseling.

79
Additional flexibility was gained by renegotiation of contracts

upon their termination. Several patients requested random

urine testing to support continued abstinence long after

termination of the original contract. With relapses appearing

to be uncommon after 6 months on a contract (figure 3), Halsted

Clinic patients now are encouraged initially to enter 12-month

agreements.

This technique offered practical and theoretical advantages, as

noted above, and produced results more favorable than those in

many recent reports (Johnson and Connally 1981; Dalton and

Duncan 1978; Talbott et al. 1977; Green et al. 1976;

Murray. 1976). But no reported treatment has eliminated

relapse totally. Even with this rigorous treatment a relapsing

patient could, prior to urinalysis detection, engage briefly in

professional practice while abusing drugs.

Privilege to Practice and License LOSS

on first review, these contracts seen only punitive: drug use

is punished by loss of license. But 70 percent of these

patients had lost their licenses or other privileges to

practice before they entered the Halsted Clinic., These

patients used the contracts to regain probationary privileges

which were unavailable to them immediately before they signed

the contract. Thus, for many patients there was an important

appetitive, or positively reinforced, aspect to the treatment.

Clearly, however, there also is a punitive, aversive element in

the threatened license loss. This raises a serious ethical

concern: is the risk of license loss for these patients

enhanced or reduced by signing a contract? Conceivably, the

risk might be greater because detection of relapses would be

more likely with the contract, or the risk might be reduced if

relapses were less common while the contracts were in effect.

This uncontrolled report cannot finally answer that question,

but our preliminary data appear favorable. Twelve patients had

lost hospital privileges, licenses, etc., before signing

contracts. Later, after all 17 were back at work with

contracts, two patients lost licenses through the contract

mechanism, and three others lost licenses for other reasons.

The contracts apparently resulted in a net gain in licensure

and privileges for our patients, while apparently reducing

relapses to drug use.

In an interesting contrast, inner-city heroin addicts with no

job or family encounter few immediate social rewards for

abstinence, and few immediate social punishments for drug use.

Most of the patients in the present report used drugs with

abandon until very powerful reinforcements or punishments were

rigidly scheduled as consequences of, respectively, abstinence

or drug use. Street heroin addicts, with very few immediate

social consequences differentially attached to abstinence or

80
drug use, have a notoriously worse prognosis for abstinence

during treatment than did patients in the present report.

Limitations of this Report

Conclusions from this initial report must be limited due to

lack of a control group, some procedural variations among

patients' programs, and biases which may arise when the

therapist serves as the followup evaluator in a nonblind

study. Nevertheless, these preliminary data do suggest that

contingency contracting benefitted a number of patients.

SUMMARY

Seventeen drug-abusing physicians, dentists, and nurses entered

contingency-contracting treatment. They deposited with their

therapist letters to their respective licensing boards, confessing renewed drug abuse and surrendering their licenses.

Each contract directed the therapist to collect frequent urine

samples and to mail the letter if a scheduled sample was not

provided, or contained drugs. The followup occurred a mean of

20 months after signing the contracts, which were of varied

duration. Drug use dramatically declined for most patients

after a contract was signed. Most patients' personal and Professional lives also improved over the followup time. Twelve

patients had suspended licenses or professional privileges

before signing the contracts. All then worked; two subsequently lost their licenses through the contract mechanism, and

three lost their licenses for other reasons. About half of the

patients completed a full year with no apparent relapse.

Relapses were more common when contracts were not in effect.

than when they were.

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for a Theory of Addiction. New York: Plenum, 1979. 254 pp.

Miller, P.M.; Hersen, M.; Eisler, R.M.; and Watts, J.G.

Contingent reinforcement of lowered blood-alcohol levels in an

outpatient chronic alcoholic. Behav Res Ther, 12: 261-263,

1974.

Miller, P.M. A behavioral intervention program for chronic

public drunkenness offenders. Arch Gen Psychiat, 32: 915-918,

1975.

Murray, R.M. Characteristics and prognosis of alcoholic

doctors. Brit Med J, 2(6051): 1537-1539, 1976.

82
Nurco, D.N.; Cisin, I.H.; and Balter, M.D. Types of addict

careers. In: (no editor) Problems of Dependence: 1978.

Committee on Problems of Drug Dependence, Inc. (no city), 1978.

Stitzer, M.L.; Bigelow, G.E.; and Liebson, I. Reinforcement of

drug abstinence: a behavioral approach to drug abuse

treatment. In: Krasnegor, N.A., ed. Behavioral Analysis and

Treatment of Substance Abuse.

Research monograph 25.

National Institute oh Drug Abuse

DHEW Pub. No. (ADM) 79-839.

Washington, D.C.: Supt. of Documents, U.S. Gov't. Print. Off.,

1979, pp. 68-89.

Talbott, G.D.; Richardson, A.C., and Atkins, E.C. The MAG

disabled doctor's program: A two-year review. J Med Assn

Georgia, 66: 777-781, 1977.

ACKNOWLEDGMENTS

The work was supported in part by Contract C 2972-17 from the

Alcohol and Drug Abuse Division of the Colorado Health

Department and by Grant DA 02386 from the National Institute on

Drug Abuse, USPHS. AM Wislocki and the staff of the Drug

Analysis Laboratory, Colorado Department of Health, carefully

and thoroughly performed the urine tests. Janice Wagner, R.N.,

supervised urine collections and recordings.

83
Contingency Management of

Supplemental Drug Use During

Methadone Maintenance

Treatment

Maxine L. Stitzer, Ph.D., George E. Bigelow, Ph.D.,

Ira A. Liebson, M.D., and Mary E. McCaul, Ph.D.

Methadone maintenance is a specific pharmacological treatment in

which a long-acting orally effective opiate provides a therapeutic

substitute for the shorter-acting illicit opiates upon which

patients have become dependent. The methadone maintenance regimen frees patients from the necessity of acquiring and using

illicit opiate drugs, as has been consistently confirmed by

treatment evaluation studies (Bale et al. 1980; Gearing 1974;

McGlothlin and Anglin 1981; Newman and Whitehill 1979; Simpson

et al. 1979). However,. it is also clear from these and other

treatment evaluation studies that some supplemental use of illicit opiates continues during methadone maintenance treatment.

Furthermore, patients with preexisting histories of illicit use

of sedative and tranquilizer drugs as well as histories of excessive alcohol use may continue using these drugs during methadone maintenance treatment, since methadone produces no specific

pharmacological attenuation of these drugs’ effects. In short,

supplemental drug and alcohol use constitutes residual behavioral

problems which must be addressed during methadone treatment.

Clinic policies are often designed to influence the behavior of

uncooperative patients displaying evidence of continued supplemental drug use. Program privileges such as take-homes are

generally available to patients on methadone maintenance who adhere to clinic rules and guidelines, abstain from conspicuous

supplemental drug use, and are employed or otherwise socially

productive (Baldridge et al. 1974). On the other hand, clinic

policies generally impose an escalating sequence of program

sanctions, based on evidence of continuing drug use, which includes loss of take-home privileges, probationary status, and

ultimately termination from treatment. Such aversive control

methods generally have mixed results; some patients terminate

their supplemental drug use and others terminate their association

with the treatment clinic. Although clinics may differ widely in

their tolerance of supplemental drug use among their patients, it

.is one of the paradoxes of drug abuse treatment that patients are

routinely terminated from treatment for exhibiting the behavior

84
which characterizes the disorder that initially brought them to

treatment.

The present paper describes an alternative treatment approach

based on contingency management principles of positive reinforcement which has been evaluated for its ability to reduce drug and

alcohol use among methadone maintenance patients. The procedures

described differ from approaches ordinarily taken at treatment

clinics in that privileges and rewards, rather than being available only to patients who are functioning well, are offered to

poorly functioning patients contingent upon evidence of improvement. In this way, aversive control methods are minimized as an

approach to elimination of behavioral problems.

There are ample precedents for the use of operant behavioral

approaches and contingent reinforcement procedures in particular

in the treatment of substance abuse disorders. Experimental

demonstrations of reinforcement of abstinence have been successful in treatment of alcoholism (Bigelow et al. 1975; Griffiths

et al. 1978; Miller 1975; Miller et al. 1974), cigarette smoking

(Winett 1973), and drug abuse (Bigelow et al. 1976; Hall et al.

1977; Stitzer et al. 1979a). Furthermore, the outpatient methadone maintenance clinic has characteristics which make it uniquely

suitable for implementing behavioral intervention techniques since

it provides frequent patient contact, objective measures of recent

drug and alcohol use via breath and urinalysis screening, and

many potential reinforcers and punishers which can be utilized in

contingent arrangements to influence drug use.

The first half of this paper describes a series of studies which

focused upon reduction in use of three drugs widely used and

abused by methadone maintenance patients: opiates, benzodiazepines, and alcohol. These studies have demonstrated the generality across populations and drugs of the efficacy of behavioral

interventions based on positive reinforcement techniques. Consideration will then be given in the second half of the paper to

advantages and difficulties associated with the clinical implementation of therapeutic procedures involving contingent reinforcement of reduced supplemental drug use.

REDUCTION OF SUPPLEMENTAL OPIATE USE DURING METHADONE MAINTENANCE

AND METHADONE DETOXIFICATION

Chronic treatment with methadone provides cross tolerance which

functionally reduces the subjective and physiological effects of

supplementally ingested opiate drugs (Jones and Prada 1975;

McCaul et al. 1983). In spite of this partial pharmacological

blockade of the effects of opiate drugs, considerable supplemental

opiate use is detected among methadone maintenance patients during

routine urinalysis screening. Clinic-wide rates of opiate-positive urine reports during a single screening have ranged from

less than 10% (Harford and Kleber 1978; Siassi et al. 1977; Senay

et al. 1977) to rates as high as 38% of tests (Baldridge et al.

85
1974; Goldstein et al. 1977; Havassy and Hargreaves 1981). In

analyses of the incidence of drug use, 20% to 40% of patients are

commonly reported as showing at least an occasional opiate-positive urine test over a period of several months (Goldstein et al.

1977; Bigelow et al. 1980; Newman and Whitehill 1979; Renault

1973; Stitzer et al. 1980), while incidences of 50% to 85% of

clients with at least occasional positive urines are also reported

(Goldstein et al. 1977; Ling et al. 1978; Siassi et al. 1977;

Woody et al. 1975). Persistent opiate drug use (e.g., more than

10% of urine tests positive over several months of urinalysis

screening) has been observed to occur in 20% (Bigelow et al.

1980), 33% (Ling et al. 1978), and 57% (Goldstein et al. 1977) of

clients in various reports where this statistic has been provided.

Although many factors may contribute to wide discrepancies in

estimates of opiate drug use prevalence, it is clear that use of

opiate drugs during methadone maintenance treatment occurs to a

significant extent.

A number of previous studies have utilized urinalysis results

both as an objective measure of use and as a target for contingent

reinforcement interventions. In these studies, drug abuse patients

have been reinforced for remaining abstinent from drugs and providing drug- free urinalysis samples. Use of an on-site urinalysis

testing apparatus allowed for frequent urine testing and immediate

feedback and delivery of contingent reinforcers. Several case

study reports (Bigelow et al. 1976; Hall et al. 1977; Stitzer

et al. 1979a) suggested that such contingent reinforcement procedures could be effective in reducing the rates of supplemental

opiate drug use by methadone maintenance patients. Some of these

case reports are of interest because they dealt with recalcitrant

chronic opiate abusers with whom previous efforts at contingency

management therapy had been unsuccessful. Abstinence from supplemental opiate use was eventually achieved by escalating the cost

of continued drug use (opiate-positive urines) and/or the payoff

for evidence of drug abstinence (opiate-free urines).

Stitzer, Bigelow, and Liebson (1980) conducted a controlled study

of the effects of contingent reinforcement for opiate-free urines.

Subjects were seven black methadone maintenance patients selected

for participation because of persistent positive urinalysis test

results. A within-subject reversal design was employed which involved rapid alternation of experimental conditions. This design

was possible since opiate drugs such as heroin clear from the body

within days of use. Contingent reinforcement for opiate-free

urines was available during randomly selected weeks, while during

other weeks, no programmed consequences were associated with

urinalysis results. If the urine was opiate free during a contingent reinforcement week, the patient could choose one item

from a reinforcer menu which included methadone take-home privileges, cash payments, and methadone dosage self-regulation.

Contingent reinforcement and nonreinforcement weeks were presented

in random order for an extended period of time (3 to 36 weeks) and

were followed by a return to baseline condition.

86
Substantial reductions in opiate-positive urine test results

during contingent reinforcement weeks were evident for five of

seven participants compared to their own prestudy baseline rates

of urine positives .(see fig. 1), while in two subjects the intervention had no apparent effect on drug use. Four of the five for

whom reduced opiate use occurred during contingent reinforcement.

weeks also exhibited substantial reductions in opiate-positive

tests during the randomly occurring noncontingent study weeks

(fig. 2). This appeared to be a generalization of therapeutic

effects to weeks when contingent reinforcement was not available.

However, generalization was not evident after the contingency was

terminated, since drug use returned to baseline levels. Examination of urinalysis results for a variety of drug classes other

than opiates revealed no detectable increase in the use of these

other drugs during portions of the study when opiate use was reduced.

A logical extension of contingent reinforcement procedures for

reduction of opiate drug use would be application to patients enrolled in methadone withdrawal, since this period is one of particularly high risk for supplemental opiate use. Hall et al.

(1979) reported that contingent payment for opiate-free urines

reduced detected rates of opiate use among 41 narcotic addicts

undergoing 16-day outpatient methadone withdrawal. A similar

study was conducted by McCaul et al. (in press) which examined

the effects of contingent reinforcement for opiate-free urines

during a 90-day methadone withdrawal regimen. Twenty eligible

patients were randomly assigned to experimental or control conditions which were in effect during weeks 4 through 13 of the

90-day detox program. Dose reduction from 30 mg to 0 mg/day

methadone occurred over a 6-week period (study weeks 4 through 9)

at a rate of 5 mg/week, and was identical for the experimental

and control conditions. Placebo methadone (cherry syrup vehicle)

‘was dispensed during the final study weeks. No experimental consequences were attached to twice-weekly urinalysis test results

for control subjects. The consequences attached to urine test

results for the experimental group are listed below:

Consequences Attached to Twice-Weekly Urinalysis

Test Results for Experimental Subjects

Opiate-Negative Opiate-Positive

1) Receive $10 cash payment

2) Receive a single methadone

take-home dose

3) No extra data forms

4) No extra counseling

5) No extra urines

1) No cash payment

2) No take-home dose

3) Complete symptom checklist daily

4) Participate in daily

directive counseling

5) Provide daily urine

samples

87
FIGURE 1. Percent morphine-positive urine tests are shown for

pre- and post-intervention baseline periods (BL) and for study

weeks during which contingent reinforcement was available

(CONT RF) or was not available (NO RF) for providing opiate-free

urine specimens. Percent of positive tests for five individual

subjects was averaged to obtain the data shown. Data for two

additional subjects who failed to respond to the intervention

are not included. Error bars are ± 1 SEM.

88
FIGURE 2. Percent opiate-free urine samples is shown during

successive weeks of a 90-day methadone detoxification program.

Subjects selected for this study had high rates of opiate-free

urine tests during the initial three weeks of treatment

enrollment, during which dosage was stabilized at 30 mg/day.

Methadone dosage reduction occurred during study weeks 4 - 9.

Placebo methadone was dispensed for the remainder of the treatmen t program. Data are shown separately for 10 control subjects

(triangles) who received standard clinic treatment and for 10

experimental subjects (circles) who received privileges contingent upon each urine sample which was opiate-free and penalties

contingent upon each sample which was opiate-positive. Missing

samples were treated as being opiate-positive.

McCaul et al., J Appl Behav Anal (in press). © Society for

Reprinted from

the Experimental Analysis of Behavior, Inc.

89
Reinforcers scheduled for delivery as a ‘consequence of opiate-free

urines (1 and 2) were delivered immediately upon receipt of the

clean urine. Penalties scheduled contingent upon receipt of an

opiate-positive urine (3, 4, and 5) were in effect until an opiatefree urine was obtained.

As shown in fig. 2, fewer opiate-positive urines were obtained

from experimental than from control subjects during the 6 weeks

of dose reduction. The between-group differences resulting from

the contingency were particularly apparent during the first 3

weeks of dose reduction (fig. 2), while during the final 3 study

weeks shown, when subjects were receiving 0 mg/day of methadone,

there was no longer any difference in rates of positive urines

between the experimental and control groups. Efficacy of the

contingent reinforcement intervention during the early portion of

the detoxification protocol was also evident in individual subject

data. Half of the experimental subjects remained opiate free

during the entire 6-week dose reduction period while none of the

control subjects did so.

The studies described above suggest that interventions which include contingent reinforcement for opiate-free urines are effective in reducing opiate drug use among methadone patients during

both maintenance and withdrawal treatment. An interaction between

methadone dose and positive reinforcement condition is suggested

in the opiate withdrawal study since incentive procedures were

efficacious while patients continued to receive active doses of

methadone and lost their efficacy when the methadone dose reached

0 mg/day.

REDUCTION OF SUPPLEMENTAL BENZODIAZEPINE USE DURING METHADONE

MAINTENANCE

Benzodiazepine tranquilizers also appear to be frequently used

and abused by methadone maintenance patients. Kleber and Gold

(1978) noted high rates of benzodiazepine use among their patients

while Woody et al. (1975) designated 40% of their methadone

maintenance patients as “diazepam users” on the basis of selfreports of liking for the drug and/or recent use of street-purchased drug. Similarly, Bigelow et al. (1980) noted high rates

of use based on persistent drug-positive urinalysis tests, and

Stitzer et al. (1981) found that 50% to 60% of methadone maintenance patients in two different clinics showed persistent (n-ore

than 50% of tests) benzodiazepine-positive urinalysis tests during

a single month of screening. Furthermore, self-report data indicate that methadone maintenance patients generally use benzodiazepine drugs such as diazepam in dosages and patterns which suggest

abuse rather than therapeutic self-medication (Stitzer et al.

1981). Specifically, patients generally reported ingesting a

single relatively large (median = 40 mg) daily dose of benzodiazepines close to the time of day that they ingested their

methadone.

90
Stitzer et al. (1979b) evaluated the ability of contingent clinic

privileges to influence benzodiazepine self-administration by

methadone maintenance patients who exhibited persistent urinalysis

positives for benzodiazepines. Diazepam (20 mg/day) was prescribed by the clinic in order to permit observation of supplemental drug use; patients could request or refuse diazepam daily

throughout the study. During contingent reinforcement portions

of the study, the patients could receive clinic privileges (either

a single methadone take-home dose or a single opportunity to regulate their own methadone dose by ± 20 mg) twice weekly by refusing

available diazepam on the preceding three or four consecutive

days. During baseline portions of the study, patients requested

99% of available diazepam doses. When take-home privileges could

be obtained by diazepam refusal, only 17.6% of available doses

were requested, while when the dosage self-regulation option

could be obtained, diazepam was requested on 77.4% of occasions.

The results indicate that drug self-administration at the clinic

was influenced by offering clinic privileges and that different

positive consequences differentially affected drug-taking behavior.

In a subsequent study, contingent reinforcement procedures were

applied to the reduction of benzodiazepine drug use in the natural

environment (Stitzer et al. 1982a, 1982b). Ten methadone maintenance patients were selected for participation on the basis of

persistent benzodiazepine-positive urinalysis results. These

subjects reported a typical daily diazepam dose of 72.5 mg diazepam (interquartile range = 25 - 187.5 mg) and reported occasional

experience with much higher doses (median highest daily dose =

225 mg).

During the contingent reinforcement study, urine samples were delivered twice weekly (Monday and Friday) and tested for presence

of benzodiazepine drugs using an on-site EMIT urinalysis system

which provided the opportunity for immediate feedback and consequences . After baseline evaluation, contingent reinforcement for

benzodiazepine-free urines was offered for 3 consecutive months.

During this period, a benzodiazepine-positive urine had no consequence, while a benzodiazepine-free urine resulted in a choice

between methadone take-home privileges, cash payments, and methadone dosage self-regulation. The contingent reinforcement period

was followed by a return to baseline conditions. Composite results for the group of study participants are presented in

Figure 3. While few benzodiazepine-free urines were obtained

during pre- and post-intervention baseline periods, their occurrence increased dramatically during the contingent reinforcement

intervention. Five of the ten subjects became benzodiazepine free

and remained so, while three additional subjects were temporarily

benzodiazepine free but relapsed while the contingent reinforcement intervention was still in effect. No consistent increases

in other drug use were noted during periods of time when benzodiazepine use was eliminated. This study demonstrates that procedures which include contingent reinforcement for clean urines

can effectively reduce or eliminate ongoing supplemental benzodiazepine use among methadone maintenance patients without precipitating substitute use of drugs from some other class.

91
FIGURE 3. Percent benzodiazepine-positive urine tests is shown

for pre- and post-intervention baseline periods (filled bars)

and for study weeks during which contingent reinforcement was

available for providing bensodiazepine-free urine samples

(striped bars). Each study period was generally 12 weeks in

duration. Percent of positive tests for 10 individual subjects

was averaged to obtain the data shown. Error bars are ± 1 SEM.

Reprinted from Stitzer et al., NIDA Research Monograph 41, 1982.

92
REDUCTION OF ALCOHOL ABUSE AMONG METHADONE MAINTENANCE PATIENTS

Prevalence estimates of excessive alcohol use among methadone

maintenance patients have varied from 10% to 40% of patients

(Bihar-i 1974; Maddux and Elliott 1975; Liebson . et al. 1973; Schut

et al. 1973) although as noted by Stimmel et al; (1978)) these

rates depend on the specific population screened, inquisitiveness

of the observer, and the definition of “excessive consumption”

employed. Some have suggested that methadone treatment may be a

causal factor in the development of alcoholism. Stimmel et al.

(1978) question this contention since epidemiological data indicate similar prevalence of heavy drinking patterns among nondrug-abusing populations and methadone maintenance populations

with similar socioeconomic profiles. Irrespective of the causality

issue, it seems clear that excessive alcohol use is commonly observed in a substantial portion of methadone maintenance patients,

that this problem constitutes a barrier to successful rehabilitation and is thus a legitimate and important area for therapeutic

intervention.

The inappropriateness of both opiate detoxification and Alcoholics

Anonymous as effective treatment strategies for the methadone

patient with alcohol problems has been discussed (Stimmel et al.

1978). Methadone detoxification in particular appears to be

inappropriate since this treatment may itself be associated with

an increased incidence of alcohol abuse (Vaillant 1966; Schut et

al. 1973). Prescription of disulfiram can be an effective treatment, but its success depends upon obtaining adequate patient

compliance. An elegant study by Liebson et al. (1973, 1978)

demonstrated that access to the daily dose of methadone can be

utilized as a reinforcer to obtain compliance with disulfiram

ingestion. The 25 methadone patient subjects who participated

had been or were about to be discharged from other treatment programs as a result of excessive drinking and associated disruptive

behavior. After initial alcohol detoxification and 15-day exposure to disulfiram treatment, subjects were randomly assigned to

an experimental or control condition. Control subjects received

weekly supplies of disulfiram and were instructed to ingest a

daily morning dose, while the experimental subjects were required

to ingest a disulfiram dose daily which was mixed in with their

liquid methadone ‘medication. The study design allowed for transfer of poorly performing control subjects into the experimental

treatment condition.

Better treatment retention was achieved during experimental than

during control conditions, as shown in figure 4. Eleven of 13

experimental subjects completed the full 6 months of treatment,

while this occurred for only one of 10 control subjects. Four

control subjects dropped out or were incarcerated, while five

were reassigned to the experimental condition following initiation of a drinking episode. The experimental treatment also

resulted in less drinking. Subjects spent 21% of their total days

93
FIGURE 4. Treatment duration and reasons for early dropout are

shown for two treatment conditions in which patients dually

addicted to opiates and alcohol participated. All patients

received methadone maintenance treatment. Patients assigned to

the prescription control condition (N=lO treatment episodes)

received supplies of disulfiram from the methadone clinic. For

patients assigned to the experimental treatment condition (N=13

treatment episodes), receipt of the daily methadone dose was

contingent upon observed disulfiram ingestion at the methadone

clinic. Subjects who drank excessively during their participation

in the control condition were reassigned to the experimental

treatment condition. Maximum treatment participation was 6 months

in both conditions.

94
in the program drinking during the control condition as compared

with 2% of total days drinking during the experimental condition.

These figures actually understate the difference between the two

groups since they do not take into account the quantity of alcoho1 consumed. Prevention of alcohol use did not result in increased use of illicit drugs. Illicit drug use was reported on

9% of days during the treatment intervention and 13% of days during

the control condition. Lack of “symptom substitution” is consistent with findings from previous studies in which the use of a

specific class of drugs has been reduced by therapeutic interventions without an increase in other drug use.

The foregoing study illustrates that specific effective intervention is available for the treatment of methadone maintenance

patients exhibiting chronic, severe problems with alcohol. The

efficacy of disulfiram treatment depends upon patient compliance

and the advantage of the program described by Liebson and coworkers,

is that it utilizes frequent contact and the inherent drug reinforcer available in methadone maintenance treatment to achieve

this end. The patient group selected for study was eminently

suitable due to manifest antisocial behavioral problems associated

with their alcoholic drinking. Interestingly, the treatment program was well accepted by the patients studied, although they may

have viewed their options as limited since they had recently been

or were about to be discharged from other treatment programs for

drinking-related behavior problems. The utility of this program

for patients with less severe alcohol-related problems remains

to be evaluated.

CONTINGENCY MANAGEMENT OF SUPPLEMENTAL DRUG USE: ADVANTAGES AND

DIFFICULTIES OF CLINICAL APPLICATION

Therapeutic interventions have been described which arrange contingent consequences for evidence of reduced drug and alcohol use

among drug-abusing patients. Reductions of supplemental drug use

were demonstrated in both methadone maintenance and methadone

detoxification patients whose habitual drugs of abuse were opiates

such as heroin and among maintenance patients who chronically

abused either benzodiazepine tranquilizers or alcohol. The interventions described were effective with a substantial portion of

patients exposed to the procedures. It must be remembered that

the patients selected for participation in all but the methadone

detoxification study showed chronic and persistent use of supplemental drugs during treatment. These were patients, therefore,

for whom a potent pharmacological treatment (methadone) combined

with standard clinical techniques of verbal persuasion and program

sanctions were ineffective in influencing supplemental drug use.

It would seem both appropriate and useful to develop effective

therapeutic interventions for these patients, and the data suggest

that contingency management procedures provide a reasonable

approach.

There are both advantages and difficulties associated with implementation of contingent reinforcement procedures designed to

95
promote reduced supplemental drug and alcohol use in methadone

maintenance patients. The following discussion will first explore limitations imposed by the technology currently available

to measure drug ingestion as a target behavior. Secondly, the

discussion will point out limitations in the generality of therapeutic success which can be expected from this implementation.

Then advantages related to the use of contingency contracting

procedures in general and positive reinforcement techniques in

particular will be discussed, followed by consideration of the

therapeutic advantages of reducing supplemental drug and alcohol

use.

Since drug ingestion invariably takes place outside the treatment

clinic, technologies are needed which provide an accurate objective measure of recent drug and alcohol use. Breath tests are

readily available which meet this need by providing a convenient

measure of current blood alcohol levels. On-site urinalysis

testing systems (EMIT) are also available which detect the presence

of many major drugs of abuse. While convenient and reliable,

these urinalysis testing systems have several limitations. First,

they are expensive to purchase, which limits their availability

to treatment clinics. Secondly, they cannot test for all the

drugs that patients might be using. This limits the applicability

of contingent reinforcement procedures in treatment of multiple

drug abusing patients. However, the major supplemental drugs

abused by methadone maintenance patients (i.e., opiates and

benzodiazepines) can be verified with currently available on-site

urine testing equipment. Thirdly, urinalysis testing systems

provide basically a dichotomous measure of drug use versus no use.

For drugs metabolized within a few days of use (e.g., opiates),

therapeutic interventions can focus upon decreasing the frequency

of illicit use but cannot address the amount of drug used during

a given episode. In the case of drugs such as benzodiazepine

tranquilizers, whose metabolites may be detected for several

weeks after a single ingestion, even frequency of use is obscured

in urinalysis results, and reinforcement can be provided only for

prolonged abstinence. It would be desirable to obtain more

quantitative information from urinalysis testing as well as information about a broader range of drugs of abuse.

Studies discussed in this paper have demonstrated the efficacy of

contingent reinforcement procedures for controlling drug and

alcohol use among methadone maintenance and methadone withdrawal

patients. However, the successful application of contingent reinforcement procedures may not generalize to all patients with

whom they are tried or to all circumstances. Few current guidelines exist, for example, as to how these techniques might be

implemented with individual patients simultaneously abusing

multiple drugs and/or alcohol. If excessive alcohol use is involved, it seems clear that this could be treated with the contingent disulfiram procedure previously described, independently

of illicit drug use. As far as multiple drug use is concerned,

the beneficial effects of contingent reinforcement interventions

focused on a single target drug may generalize to other drugs

96
being simultaneously abused by a given patient, but it is likely

that specific techniques will be needed for focusing on multiple

drugs either sequentially or simultaneously in order to achieve

control of multiple use. As previously noted, measurement problems currently hinder such therapeutic efforts.

Even in patients whose supplemental drug use is restricted to

compounds which can be readily detected with on-site equipment,

a favorable response would not be expected with all patients exposed to a single contingency management intervention. A lack

of universal efficacy is perhaps not surprising in view of the

difficult patient population being treated and the relatively

weak reinforcers which can be offered at the treatment clinic as

alternatives to self-administration of potent drug reinforcers.

However, this limitation may be overcome by judicious selection

of reinforcers. Thus, it has been noted in case study reports

that, by escalating the magnitude of reinforcement for drug-free

urines and/or the penalties for drug-positive urines, conditions

could be found under which individual recalcitrant subjects

would respond to contingency management interventions (Bigelow

et al. 1976; Stitzer et al. 1979a).

From an experimental point of view, these individual differences

in response to a single treatment intervention are intriguing

and suggest that individual patient characteristics might be related to treatment response. These characteristics may exist

in recent as well as lifetime levels of drug use, history of

successful abstinence attempts, levels of sociopathic deviancy,

amount and type of social supports available to the individual,

and historical response to aversive versus positive reinforcement

contingencies. It is possible that patients who have a poor response to positive reinforcement interventions might show a

favorable response to aversive control procedures. This notion

could be empirically tested and might provide a rationale for

more reliably matching patients with appropriate treatment interventions (McLellan et al. 1981).

The apparent impermanence of therapeutic effects following withdrawal of interventions is perhaps the most troublesome limitation of contingency management procedures which provide

tangible external reinforcers for behavior change. The observation of a return to drug use during treatment evaluation studies

does not necessarily limit clinical applicability, however. In

experimental demonstrations, interventions are withdrawn abruptly

at an arbitrary point in time and if relapse occurs, this provides strong evidence that the intervention modified behavior

while it was in effect. In clinical practice, on the other hand,

treatment procedures would not be withdrawn abruptly in the absence of other supports for continued drug abstinence. Additional

research is needed to explore possible long-term utility of contingent reinforcement procedures which can be implemented at the

methadone maintenance treatment clinic and to delineate the conditions under which these interventions may be withdrawn without

precipitating relapse to drug or alcohol use.

97
Several important advantages may be realized as a result of implementing contingency management procedures with drug abusers.

Some of these advantages are characteristic of contingency

management procedures in general, which specify in objective

terms the behavioral goals of treatment as well as the consequences of alternative behaviors. This provides the basis for

feedback to patients about their behavior and circumvents disagreements and conflicts between patients and staff members

over therapeutic progress or its lack. Written contracts

further reduce sources of ambiguity about therapeutic goals,

progress, and consequences of behavior. The resultant clarity

and specificity may be especially important in treatment of

drug abuse patients who may attempt to manipulate the therapeutic situation in various ways in order to obscure behavioral

goals and avoid behavioral change.

Other advantages derive from the use of positive reinforcement

as opposed to aversive control to promote therapeutic change.

Implementation of these procedures can have few detrimental outcomes for patients or staff members, since patients are essentially presented with a choice between continued drug use and

other positive reinforcers. If the patient chooses to give up

drug use, the intervention has been effective; if he or she

chooses not to give up drug use, nothing has been lost. If the

intervention works, patients with a long history of therapeutic

failure will experience success and therapists can be supportive

for improvement and avoid punitive consequences for failure.

Finally, several advantages of contingent reinforcement procedures derive from the therapeutic outcome of suppressing drug

use in patients who are chronic drug abusers. In fact, the advantages of this outcome may be considerable. First, a decrease

in disruptive drug-related behaviors may be achieved along with

the decrease in drug ingestion. This outcome was particularly

notable, for example, in the alcoholic patients studied by

Liebson et al. (1978). Secondly, a diminution of drug-seeking

behavior may free patients to focus their attention and personal

resources on improving other areas of their lives such as employment and interpersonal relations. Any improvements in

economic or social stability which can be gained during a drugfree episode would clearly improve long-term prognosis for the

patient. Thirdly, contingent reinforcement procedures which

suppress drug use can provide an opportunity to initiate additional comprehensive therapies during a period when the

patient is exerting some degree of self-control over drug use.

Reduction or elimination of supplemental drug use would appear

to be an essential first step in the treatment of drug abuse.

Once drug use has been brought under control, two specific

approaches should be considered in developing additional therapy

interventions. First, in patients who have become abstinent or

who have substantially reduced their drug use, and agree that a

long-term abstinence goal is desirable, specific relapse pre98
vention training may be useful. It has been reported, for example, in cigarette smokers who had recently quit smoking, that

those who used either behavioral or cognitive coping techniques

were more successful at maintaining abstinence than were smokers

who did not use these techniques (Shiffman 1982).

A second approach which might be useful in the long-term treatment of drug abusers is one which focuses upon developing alternative sources of reinforcement and punishment in the natural environment and then transferring control of drug use to

these new sources. Thus, for example, families, or non-drugusing peers, might be utilized as sources of both behavior

monitoring and contingency management. Family therapy in particular has recently been shown to improve outcome in the drug

using clients (Stanton et al. 1982). Families have numerous

reinforcers and punishers available to them and could be taught

to influence drug use by more effectively applying contingencies

to the drug-related behaviors of the drug-dependent family member.

At the present time, contingent reinforcement interventions

warrant application in clinical settings as a means to promote

temporary control over drug and alcohol use in patients who

chronically abuse these substances. These techniques would appear to have significant advantages over usual clinical practices

which include disciplinary action for patients who exhibit the

behavior problem characterizing their drug abuse disorder. To

the extent that these techniques are successful in reducing

supplemental drug and alcohol use, they will free the patient

from continual drug-seeking activities and intoxication, allow

the patient to focus on other life problems, and facilitate

implementation of other more comprehensive therapies designed to

promote long-term rehabilitation of drug-dependent patients.

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ACKNOWLEDGMENT

This research was supported by National Institute on Drug Abuse

grants 5 R01 DA-01472, 2 K02 DA-0050, and T32 DA-07209.

103
A Contingency Analysis of

Family Treatment and Drug Abuse

Thomas C. Todd, Ph.D.

Historically, there has been relatively little interchange between

family therapists and behavior analysts or therapists, although

there are subareas with greater overlap, including teaching parents

to use operant approaches with their children (Patterson 1971;

Patterson et al. 1973; Mash et al. 1976), and teaching couples

behavioral skills and communication and problem-solving (Jacobson

and Martin 1976; Stuart 1969, 1980; Margolin and Christensen

1981). The aim of this chapter is to demonstrate that there is a

family treatment approach to drug abuse (Stanton and Todd 1979;

Stanton et al. 1982) that is based on sound behavioral principles

and to articulate these principles so that they can be applied to

any treatment program wishing to increase family involvement.

The chapter will deal with three major topics: (1) evidence of the

power. of the family to influence treatment outcome; (2) engagement

of the family in treatment; (3) development of a treatment plan

which includes the family.

Much of the material presented relates to the process of initial

engagement of the family in treatment and the broad contingencies

affecting the degree of family participation. Specific principles

will be presented which can dramatically increase the degree of

family participation in treatment. Less emphasis is placed upon

specific family therapy techniques which have been discussed in

detail by Stanton et al. (1982). This differential emphasis is

based on the rationale that a finegrained analysis of specific

therapeutic techniques is premature until a program develops

effective methods of involving the family in the program initially

and maintaining family involvement.

THE FAMILY AS A DETERMINANT OF CURRENT BEHAVIOR

Even when the drug user is a young adult, it is highly probable

that the family of origin continues to be a powerful determinant of

his current behavior.

imniediately obvious,

The validity of this statement may not be

since many drug clients are in their 3Os, and

104
are often married and have children. Even with married clients,

however, the family of origin rather than the family of procreation

tends to have primary importance. There is an increasing body of

evidence documenting high rates of contact between patients and

their families. Vaillant (1966) found that 90% of patients

surveyed lived with their parents at age 22 and that this

percentage was still 59% at age 30. Similarly, Stanton et al.

(1978) found that 82% of young adult male patients in a Veterans

Administration program had at least weekly contact with their

mothers. Overall, it is clear that efforts to stabilize the

patient's marriage without first involving his parents are likely

to fail (Stanton et al. 1982, p. 121).

Potential Detrimental Effects of the Family on Treatment Outcome

Unless it is influenced by the treatment system, the family is

likely inadvertently to reinforce drug taking and undermine any

treatment program. Virtually any treatment program, regardless of

approach, has an extensive anecdotal "folklore" about ways in which

family members have subverted treatment. Family members often

behave in ways that overtly or covertly encourage drug taking (the

"enabling" role is similar to that described in the alcoholism

literature). Family members also will frequently undercut the

treatment program, especially at a stage when the client is

beginning to show progress (Haley 1980).

These observations are not surprising when one sees that substance

abuse can have powerful adaptive consequences in maintaining the

stability of the family system. The work of Steinglass and Davis

(Steinglass et al. 1977; Davis et al. 1974) has shown this

particularly clearly for alcohol. In their work, each family

member typically experiences a positive change in the pattern of

marital or family interaction at the moment alcohol is introduced

into the system. This may take a variety of forms, such as

decreased conflict and tension, increased intimacy or frequency of

interaction, or increased emotional expression.

For those unfamiliar with the family therapy literature, it is

important to point out that the reactions of family members may

often be viewed as maintaining drug-taking behavior whether or not

they served a predisposing causal role in the initiation of drugtaking behavior. The family is seen as a relatively stable system

which tends to resist change, even those changes which might seem

desirable in the long run. Although some families exhibit this

"resistive" behavior more dramatically than others, some change-'

resistant behavior should be expected in any family in which the

drug abuse has occurred on a chronic basis for several years.

It is also suspected that family factors may play an important role

in the etiology of drug abuse, particularly in determining whether

a young person will move from drug experimentation to a pattern of

chronic abuse and dependence. In particular, the behavior of the

drug abuser may help the family to avoid difficulties in

negotiating transitions in the family life cycle, especially the

stage of "leaving home" (Stanton et al. 1982; Haley 1980).

105
Potential Positive Effects of the Family on Treatment Outcome

Family members can also exert an important positive effect on

treatment outcome, even in the absence of specific efforts to

involve the family in treatment. Evidence for this conclusion

comes from several retrospective surveys. Eldred and Washington

(1976) interviewed 158 heroin clients and asked who had been most

helpful in their efforts to get off of drugs. The rank order of

responses was (1) family of origin, (2) opposite sex partner, (3)

Similarly, MACRO Systems researchers interviewed 462 clients and

found that the family was seen as second only to treatment (70.9%

vs. 79.6%) as an important influence in change (NIDA 1975). Levy

(1972), in a 5-year followup of 50 narcotic clients, found that

those whose treatment is successful typically have family support.

It is worth noting that similar conclusions have been drawn for

alcoholism, although with alcohol it is typically the spouse, not

the parents, who is most important. Regardless of the mode of

treatment used to deal with alcoholism (AA, inpatient treatment,

disulfiram, etc.), family and spouse involvement adds significantly

to the probability of success (Jacobson 1981).

ENGAGING THE FAMILY IN TREATMENT

Perhaps a more appropriate title for this section would be "active

recruiting" of families into treatment because, as will be noted,

considerable effort is required to succeed in involving families in

treatment. Family recruitment became one of the most important

aspects of our project, although we had initially underemphasized

its importance and difficulty. Space does not permit a full elaboration of the principles and techniques of effective engagement;

the interested reader is referred to publications on this topic.

(Van Deusen et al. 1980; Stanton and Todd 1981; Stanton et al.

1982, pp. 39-106).

Use of Contingent Reinforcement to Engage Families in Treatment

Without specific attention to the contingencies affecting the

behavior of both the client and the family, it is extremely

unlikely that the client will give permission to contact family

members or that family members will agree to participate in

treatment. This results from a combination of factors, all of

which need to be specifically addressed.

First, the family therapist initially has few, if any, positive

reinforcers under his control. Certainly the "opportunity" to

participate in family therapy is not seen as a reward. This is

particularly important in the context of a methadone maintenance

program, where the most important reinforcers relate to medication. Several steps may be taken to offset this initial

difficulty. In the program described here, the family therapist

assumed the role of "drug counselor " to increase his salience and

106
thereby become associated with methadone dispensation, which is-a

powerful positive reinforcer for opiate-dependent clients.

Next, efforts were made to increase the primacy of contact with the

family therapist, so that the client contacted the family therapist

early in the chain of treaters and overall treatment process.

Finally, we attempted to have the family therapist placed in charge

of the overall treatment, including all important treatment'

decisions. With respect to this final point, we learned that it

was important not to pretend to have control over contingencies

that would not actually be invoked, such as transferring the client

to another program.

A second major factor is the need for the client to receive

positive reinforcement from the family therapist before the

therapist broaches the subject of family involvement. This usually

means paying considerable attention initially to the client's

physical discomfort and to his requests for methadone or other

medications, since these issues are paramount from his viewpoint.

A third major factor is that the therapist must act to decrease the

client's anticipation of possible negative outcomes of family

involvement. The therapist must convey an attitude about the

family that indicates that no one will be blamed. It is crucial to

resist the temptation to create an alliance with the patient by

implying that his problems may be the fault of the parents. It is

also useful for the therapist to agree to "take the rap" for

involvement of the family and its outcome. Concretely, this means

asking the client for permission to contact the family directly,

removing the addict from the awkward position of having to persuade

the family that their participation in treatment would be helpful.

Neutralizing the Negative Connotation of Treatment

Initial contact with the family must be conducted with the

knowledge that the idea of becoming involved in treatment is likely

to have strong negative connotations. Such an attitude on the part

of family members is not surprising. It is likely that they have

been repeatedly disappointed through a long history of having hopes

aroused only to be shattered. Thus, they have ample justification

for the assumption that they may be blamed. Particular effort must

be made to decrease the atmosphere of blame and to emphasize the

potential helpfulness of the parents and other family members.

(See Stanton et al. 1982, pp. 124-127, on "Noble Ascriptions" and

avoiding blame.) It is also helpful for the therapist to elicit

the goals of the parents in some detail and then to propose a

treatment plan that will address these goals. For example, some

parents will emphasize employment, while others may emphasize

breaking away from undesirable friends and associations. AS in all

behavioral intervention approaches, effective family therapy using

these techniques benefits from individualized determination of

steps, goals, and reinforcers in treatment.

In general it is clear that conducting recruitment efforts

according to these principles can be quite effective. In a sample

107
of 95 adult male heroin clients, 71% of all eligible families were

successfully engaged in treatment. The most frequent barrier was

the client's refusal to allow contact with the family. Of the

families for whom permission was obtained, 88% were successfully

recruited.

EFFICACY OF CONTINGENT PAYMENT FOR ATTENDANCE

A recent study (Stanton et al. 1982) has demonstrated that payment

for attendance improves treatment retention and the attendence of

family members at sessions. The subject families were lower income

and working class families who had a son, the index patient (or

"IP"), enrolled in a VA methadone program. The IP had to be opiate

dependent for at least 2 years and in regular contact with parents

or parent surrogates. The mean age of the IP's was 25.3 and 25%

were married. Each family was randomly assigned to one of three

treatment conditions which were adjuncts to the methadone program.

These included Paid Family Therapy, Paid Family Movies, and Unpaid

Family Therapy. (The family movie group served as a control for

the effects of payment and of family involvement.) Ten sessions

were scheduled, and in the paid groups every family member age 12

or over received $5 at each session attended. In addition, there

were other contingencies, discussed below.

Once families were engaged in treatment, remarkably high rates of

treatment compliance were achieved. In the paid family therapy

group, all families attended a minimum of four sessions. Equally

striking was the finding that 81% attended ten or more sessions as

specified by the initial treatment contract.

Comparable figures for unpaid family therapy showed a clear payment

effect, although attendance was still much better than might have

been expected for such a difficult population. Eight per cent

dropped out before treatment began, and 40% attended only one to

three sessions. Fifty-two per cent completed at least four

sessions, and 40% completed ten or more.

Although payment did influence attendance, it did not significantly

influence treatment outcome, above the contribution of attendance

alone. (See Stanton et al. 1979 for statistical analysis of the

comparative contributions of payment and family therapy.)

Interestingly, many family members went to considerable lengths to

emphasize that the money was not important. These statements do

not necessarily imply that payment did not influence their

behavior. It does appear likely that considerable cognitive

dissonance was created by the possibility that their behavior was

motivated by money, especially since life-and-death issues were

often at stake. Even if payment is not a realistic possibility,

either legal or program pressure may be brought to bear to increase

family involvement, as long as effective treatment can be conducted

when the family does attend. Clearly, whenever possible, an effort

should be made to establish contingencies which rely on positive

reinforcement and minimize the aversiveness of the treatment

setting for the client and family.

1O8
DEVELOPING A COMPREHENSIVE TREATMENT PLAN WHICH INCLUDES THE FAMILY

The focus of the treatment efforts described is, of course, the

interaction between the client and his family. While this would

typically be labelled "family therapy," the designation of "family

therapy" often creates unnecessary resistance, since it implies

that the family has the problem, not the addict. For this reason,

we emphasize the helping role of the family and avoid labelling

this as family therapy.

Whether or not formal family treatment is involved, and regardless

of the other components in the treatment plan, the family can

almost always play a positive role. For example, the family can

help to increase compliance with treatment involving a narcotic

antagonist or can help to insure attendance and treatment compliance in an outpatient methadone program. Conversely, it is almost

invariably a mistake to keep family members in the dark about

treatment or to set up covert competition about who can be most

helpful to the client. Again it should be noted that general

procedural rules are helpful but it is always necessary to

individualize the approach and maximize positive reinforcement.

The beginning stages of treatment should be designed to create an

initial experience of success. In this regard there are many

specific things that the therapist should do. The therapist should

'create an overall favorable climate and maximize the opportunities

for positive reinforcement. The treatment should be time-limited

and goal-directed, especially directed toward goals identified by

the family. In the present program, an attempt was made to develop

explicit goals in three areas, including: drug abuse itself,

employment and other productive use of time, and living/social

situation. Tasks addressing and directed towards achieving these

goals were delineated in small steps, with success a high

probability.

There are also issues and problems that the therapist should

definitely avoid. These include. leaving treatment open-ended and

vague, with only marginal relevance to the drug problem. It is

particularly important to avoid conflict between the parents, and

it is equally important to discourage a "catharsis" of negative

emotions. While many drug-dependent clients have come to expect

unpleasant encounters as part of treatment, such an emphasis makes

therapy extremely aversive for one or more family members, and the

treatment will almost certainly fail.

The parents (often, in these families, the father) should be given

a major advisory and decisionmaking role in all important aspects

of the treatment program. In the family treatment program

described herein, parents have been encouraged to become involved

intimately in the overall treatment program. Naturally, in order

to do this effectively, the parents need education, support, and

guidance from the therapist. Typical areas in which parents are

asked to become involved in discussion and decisionmaking include

take-home privileges, decisions about hospitalization, readiness to

109
decrease dosage or terminate methadone, and the credibility of

urine reports intended to screen for drug use.

There are several important reasons for involving the parents in

spite of the complexities involved. First, explicit involvement of

the parents minimizes the client's opportunities to play the

therapist and parents, or parents themselves, against each other.

For example, without family involvement, the client is likely to

complain to the parents about aspects of the treatment and enlist

their support, while concurrently complaining to the therapist

about the parents. Second, the participation of the parents in

treatment decisions enhances the power of the parents, which

enables them to be more helpful. Finally, such participation has a

major effect on the degree of committment and investment that the.

parents have in the long-range success of the treatment, which

helps to ensure that gains made during the program are maintained

afterwards.

It has been particularly evident that a behaviorally oriented

treatment approach can be useful in keeping treatment focused.

Although the treatment program described here is not primarily

behavioral in orientation, it successfully incorporates several

behavioral elements.

First, in all of the family treatment cases, the therapist provides

systematic feedback about current drug use to the parents, based on

the result of the latest urine tests. This feedback is very

important because it maintains the focus of the treatment on hard

data. It is also extremely important that the therapist be present

to guide the family in evaluating the feedback in the light of the

patient's overall pattern of success and failure and to help shape

the family's response to this feedback. These data permit the

therapist to keep the family focused on what they will actually do,

rather than remaining at the level of vaque generalities. The

therapist may allow the family to accept-the-client's initial

excuses but at the same time point out problems which may arise in

the future concerning falsification of urine test reporting and the

like.

In the research project, the effects of contingent payment for

clean urines in combination with program attendance have been

examined. Using this procedure, both the client and the other

family members have a financial stake in having everyone attend and

having the client maintain abstinence, as reflected by uncontaminated urine samples. (For details of the complex contingencies

involved, see Stanton et al. 1979, pp. 14-15.) As mentioned

earlier, contingent payment has a clear effect on attendance and

encourages the family to be present so that treatment can work.

There is modest evidence that offering contingent payments to the

family as a whole for the success of the client at providing clean

urine samples and hence being "drug free" has a positive effect on

treatment outcome, although payment alone is consistently less

powerful than family therapy.

110
A promising new approach for changing the consequences to the

family of the client's relapse to drug taking has been the

development of a "home detoxification" procedure. The idea of

having the addict detoxify at home grew naturally out of work with

the clients and their families and was also heavily influenced by

Haley (1980). It is clear that admission of an addicted family

member to the hospital for withdrawal is generally a "nonevent" for

most families and produces little emotional involvement in its

success or failure. In fact, for many families, hospitalization is

positively reinforcing, since it relieves stress and reduces

anxiety and guilt. It is a socially acceptable means of demonstrating that the problem is being addressed and that it is out of

the family's hands. Given these contingencies, it is not surprising that the typical result is a cycle of repeated hospitalizations and unsuccessful attempts to terminate administration of

methadone or other opiates.

Home drug withdrawal attempts to keep the family focused on the

therapeutic realities and has aversive components that the family

is not eager to repeat. Several principles should be kept in mind

when implementing a home drug withdrawal effort: (1) The conditions for the eventual home drug withdrawal must be carefully

worked out. (2) It is important to build on the strengths of the

family and upon success experiences earlier in therapy. (3) The

family must not be allowed to escape from the home detoxification

through initial failure. Instead, the possibility of failure must

be anticipated and a backup plan developed. (4) While the conditions for success should be carefully managed, it is nevertheless

important that the home detoxification experience should require a

high level of family involvement. They will therefore experience

success as more meaningful and, as noted, will also not care to

repeat the experience (Stanton et al. 1982).

ENDING THERAPY

One of the major advantages of involving the family in treatment

comes at the end of treatment. If family treatment has been

successful, the formerly drug dependent client is left with an

important natural support system that will continue after treatment is over. This is in marked contrast to other treatment

approaches. For example, a frequent problem with methadone

maintenance and therapeutic community programs is that successful

treatment leads to loss of the reinforcers in the therapeutic

support system. That is, success results in diminished contact

with all phases of treatment ranging from the conversations with

other clients, the dispensing pharmacist, and the drug counsellor

to contacts with various medical and mental health professionals.

Although the problem is diminished in family treatment, loss of

support or decreased availability of reinforcers may still be a

significant issue for the family when therapy ends, since the

family loses the therapist as an important source of support. The

therapist can utilize three techniques to minimize the disruption

of ending therapy. First, throughout therapy, it should be

111
emphasized that credit for success belongs to the family and the

drug-dependent client, not the therapist. This will be most

meaningful if the therapist clearly identifies how the success was

achieved and how the family could handle similar issues in the

future. Second, the therapist should promote a model of episodic

involvement in treatment. That is, the family should not feel that

they have failed if they need to return for a "booster" of a few

additional sessions. Indeed, planned followup sessions are often

helpful. Third, it is especially important to avoid a dichotomous

success-failure perspective that is extremely likely to lead to

relapse. The therapist should assist the family in anticipating

potential problems and should discourage the notion that the future

will be problem free. It is often useful to rehearse strategies

for solving problems that may occur.

EVIDENCE OF EFFECTIVENESS

Despite reported widespread use of family therapy in drug abuse

treatment agencies (Coleman and Davis 1978), unfortunately there

are few controlled outcome studies. Recently evidence has been

obtained from a controlled treatment outcome study that a family

treatment therapy program can have a significant impact on heroin

abuse. In addition to the initial outcome data (Stanton et al.

1979, 1982), which were highly positive, there is accumulating

evidence that the results are well maintained in a 2- to 3-year

followup period. The home drug withdrawal approach is currently

being tested and appears to be relatively successful when it is

implemented, but it is not always readily initiated.

Results have been obtained for several outcome variables and will

only be briefly summarized here. For the best treatment condition

(paid family therapy), 67% of the cases showed a successful outcome

in abstinence from use of illegal opiates. Successful outcome was

defined as free from use of illegal opiates for at least 80% of one

time interval. This contrasts with 33% in the non-family treatment

condition and 39% in the control Condition. Results for legal

opiates (including detoxification from methadone) were similar:

paid family therapy, 62% success; non-family treatment, 27%

success; control, 28% success. The results for unpaid family

therapy were less dramatic, but the differences between paid and

unpaid family therapy were not statistically significant. Finally,

a dramatic finding was related to the difference in death rates

between clients in the family and non-family treatment groups. For

non-family treatment clients, there was a 10% death rate, compared

to 2% for clients whose families were involved in treatment. This

is not only highly significant statistically, but is also of

obvious social significance.

In conclusion, it should be evident that behaviorally based family

treatment requires both skill and effort in implementation. It

should be equally clear that there is no implication that similar

results can be obtained with "garden-variety" family therapy.

Treatment was highly structured and systematic, although it should

be reemphasized that these results were obtained with only 10

112
sessions. There is little doubt that, given ample training and

administrative support, this approach can be implemented in other

settings with positive results.

REFERENCES

Coleman, S.B., and Davis, D.I. Family therapy and drug abuse: A

national survey. Family Process, 17:21-29, 1978.

Davis, D.I.; Berenson, D.; Steinglass, P.; and Davis, S.

adaptive consequences of drinking.

The

Psychiatry, 37:209-215, 1974.

Eldred, C.A., and Washington, M.N. Interpersonal relationships in

heroin use by men and women and their role in treatment

outcome. Int J Addict, 11:117-130, 1976.

Haley, J. Leaving Home: Therapy with Disturbed Young People.

New York, McGraw Hill 1980 .

Jacobson, N.S. A review of the research on the effectiveness of

marital therapy. In Paolino, T.J., and McCrady B.S., eds.,

Marriage and Marital Therapy: Psychoanalytic, Behavioral and

Systems Theory Perspectives. New York, Brunner/Mazel., 1981.

Jacobson, N.S., and Martin, B. Behavioral marriage therapy:

Current status. Psychological Bulletin, 83:540-556, 1976.

Levy, B. Five years after: A follow-up of 50 narcotic addicts.

American Journal of Psychiatry, 7:102-106, 1972.

Margolin, G., and Christensen, A. The treatment of marital

problems. In Bautzman, R., ed. Clinical Behavior Therapy and

Behavior Modification, New York: Garland, 1981.

Mash, E.J.; Handy, L.C.; and Hamerlynck, L.A., eds. Behavior

Modification Approaches to Parenting. New York: Brunner/Mazel,

1976.

National Institute on Drug Abuse. Three-year Follow-up Study of

Clients Enrolled in Treatment Programs in New York City:

Phase III-Final Report. Report submitted to NIDA by MACRO

System, Inc., June 1975.

Patterson, G. Families: Application of Social Learning to Family

Life. Champaign, IL.: Research Press, 1971.

Patterson, G.; Cobb, J.A.; and Ray, R.S. A social-engineering

technology for retraining the families of aggressive boys.

In Adams, H.E., and Unikel, I.P., eds. Issues and Trends in

Behavioral Therapy. Springfield, IL.: CC Thomas, 1973.

Stanton, M.D., and Todd, T.C. Engaging "resistant" families in

treatment: II. Principles and techniques in recruitment.

Family Process, 20:261- 280, 1981.

Stanton, M.D., and Todd, T

addicts.

Structural family therapy with drug

In Kaufman, E., and Kaufmann, P., eds. Family Therapy

of Drug and Alcohol Abuse. New York: Gardner Press, 1979 .

Stanton, M.D., and Todd, T.C., and Associates. The Family Therapy

of Drug Abuse and Addiction. New York: Guilford Press, 1982.

Stanton, M.D., Todd T.C.; Heard, D.B.; Kirschner, S.;

Kleiman; J:I.; Mowatt, D.T.; Riley, P.; Scott, S.M.; and

VanDeusen, J.M. Heroin addiction as a family phenomenon: A new

conceptual model. A J Drug Alc Abuse, 5:125-150, 1978.

113
Stanton, M.D.; Todd, T.C.; Steir, F.; VanDeusen, J.M.;

Marder, L.R.; Rosoff, R.J.; Seaman, S.F.; and Skibinski, E.

Family Characteristics and Family Therapy of Heroin Addicts:

Final Report, 1974-1978. Report to the National Institute on

Drug Abuse (Grant No. RO1 DA 01119), 1979.

Steinglass, P.; Davis, D.I.; and Berenson, D. Observations of

conjointly hospitalized "alcoholic couples" during sobriety

and intoxication: Implications for theory and-therapy.

Family Process, 16:1-16, 1977.

Stuart, R. Helping Couples Change: A Social Learning Approach to

Marital Therapy. New York: Guiltford, 1980.

Stuart, R. Operant-Interpersonal treatment of marital discord,

J Consult Clin Psycho, 33:675-682, 1969.

Vaillant, G.E. A 12-year follow-up of New York narcotic addicts:

III. Some social and psychiatric characteristics. Arch Gen

Psychiatry, 15:599-609, 1966.

Vanbeusen, J.M.; Stanton, M.D.; Scott, S.M.; and Todd, T.C.

Engaging "resistant" families in treatment: I. Getting the drug

addict to recruit his family members. Int J Addict,

15:1069-1089, 1980.

114
The Job Seekers’ Workshop: A

Skill Training Program for Drug

Treatment Clients

Sharon M. Hall, Ph.D., Peter C. Loeb, M.S.W.,

and Tim Allen

The Job Seekers’ Workshop is a behaviorally based skill training program designed to assist exheroin addicts to increase job

interviewing and job finding skills. It is one example of the

way in which behavioral skill training can be used in drug

treatment.

Some of the impetus for the workshop came from data gathered on

the need for specific ancillary services in methadone maintenance, completed in San Francisco by another University of

California, San Francisco faculty member (Hargreaves 1980).

Three methadone programs in the San Francisco area were included. The programs varied in size from 128 to 270 active clients

but were similar in that systematic ancillary services were not

well developed in any of them.

All clients in the three programs were asked to complete a brief

questionnaire. Approximately forty-one percent (269/661) completed a 19-item inventory of interests in ancillary services.

The 19 activities on the questionnaire are shown in rank order

of preference in table 1. Rank preference was computed from a

mean preference score where raw scores ranged from 1 for “Never

want to do that” to 4, “Want to do that very much.” In the

second column is the proportion of responders who indicated a

strong interest in that particular activity (a score of 4). Of

the ‘five top areas of interest, three have to do with

vocational activities, including either job help, educational

services, or job experience. Job experience, job help, legal

problems, and educational services form what Dr. Hargreaves

called an “adult role functioning” factor. The factor structure

of the questionnaire is shown in table 2. The services making

up this factor have not been addressed in the literature in

systematic studies to any great extent, except the supported

work studies of the last decade (Friedman 1978: Bass and

Woodward 1978; Dickenson and Maynard 1981). Despite their

high ranking, they are also services most clinics do not

provide (Hubbard and Harwood 1981).

115
TABLE 1

Expressed Interest in 19 Activities

by Methadone Maintenance Clients

(N=259 respondents out of 661 total clients)

PERCENT EXPRESSING

ACTIVITIES IN RANK ORDER STRONG INTEREST

LEGAL PROBLEMS 56

JOB HELP 54

EDUCATIONAL SERVICES 52

JOB EXPERIENCE 52

CLIENT COUNCIL 48

HOW MY BODY WORKS 41

RELAXATION TECHNIQUES 42

PEOPLE'S GUIDE TO THE CITY 37

INDIVIDUAL COUNSELING 38

"PSYCHOLOGY TODAY" 37

FUN AND GAMES 31

SPORTS PROGRAM 32

COUPLES COUNSELING 29

A LOOK AT THE "STRAIGHT LIFE" 23

GROUP THERAPY 24

PROBLEMS OF PARENTS 25

HOMEMAKING SKILLS 22

FAMILY COUNSELING 20

WEIGHT CONTROL 22

From, Hargreaves, W.A. Interest in ancillary services in

methadone maintenance. © J Psychedelic Drugs, 12:

47-52, 1980.

Reprinted with permission.

116
TABLE 2

Rotated Factor Loadings for 19 Interest Items1

Activity Factor I Factor II Factor III

Job Experience 74 12 2

Job Help 68 10 9

Legal Problems 32 3 6

Educational Services 26 14 8

“Psychology Today” 8 79 7

How My Body Works 21 66 17

A Look at the “Straight Life” 7 33 27

Relaxation Techniques 7 29 17

Individual Counseling 6 17 71

Group Therapy 10 13 44

Family Counseling 7 3 27

Client Council 18 3 27

Couples Counseling

Homemaking Skills

Fun and Games

Weight Control

People’s Guide to the City

Problems of Parents

Sports Program

11

8

6

10

7

6

13

5 20

21 5

15 10

9 14

26 15

15 16

16 9

Mean Interest Rating (x 100)

Mean Percent Expressing

Strong Interest

Mean Estimated Percent

Total Interest

123 83

54 36

21 14

72

33

13

From, Hargreaves, W.A. Interest in ancillary services in

methadone maintenance. © J Psychedelic Drugs, 12:

47-52, 1980.

Reprinted with permission.

1. Factor I is focused on practical help with adult role

functioning; Factor II relates to psychological education;

Factor III relates to personal counseling and psychotherapy

approaches.

117
Dr. Hargreaves' data, combined with our interest in behavioral

skill training techniques, resulted in a series of three

studies, all focused on evaluating the Job Seekers’ Workshop, an

intervention designed to provide drug treatment clients with

the skills necessary to find jobs in both the public and private

sector.

The activities included in the Workshop were based on our

observations of the problem behaviors drug treatment clients

showed in interview situations, as well as in their general jobseeking strategies. These included 1) poor work histories,

especially few jobs or many short-lived jobs, long gaps in work

history, or repeated firings; 2) criminal records; 3) ignorance

of effective behaviors in an interview situation, including

ineffective masochistic honesty or poorly formulated lies, use

of addict slang, distracting mannerisms, or inappropriate dress;

4) ignorance of informal job-seeking resources, Such as telephone books, Friends, and interviewers.

The initial project (Hall et al. 1977) had three specific aims:

1) to determine whether the experimental workshop would be

attractive to drug treatment clients; 2) to test the hypothesis

that experimental subjects would be superior to controls on

ratings of employability or training acceptability, and 3) to

test the hypothesis that experimental subjects would be more

likely than controls to find vocational placement.

The subjects were 49 methadone maintenance clients referred to

the project from four clinics. Only subjects who were psychotic,

illiterate, or who anticipated serving jail time within three

months were ruled out. We accepted subjects from two placement

categories. Fifteen subjects indicated their interest in a

competitive skill training program, and the remaining 34

subjects were seeking jobs. A competitive skill training program was a publicly-supported work or training program that

demanded an application procedure and an admission interview

and only accepted a certain percentage of applicants. The

sample is described in table 3. Most of the subjects were

Caucasian, although almost half were black or of Latin

descent; 34 subjects were male, and 15 were female. The mean

number of months in treatment at the current treatment clinic

was slightly under 11.

Subjects were randomly assigned to experimental or minimal

contact control conditions. Five two-week workshops were held

over a six-month period. Each consisted of three to six individuals. During each week of the workshop subjects met on

two days for approximately five hours and one each for three

hours. Both experimental and control subjects attended an

initial meeting during which the director of Vocational

Rehabilitation services for the four clinics provided all subjects with information about places and training programs and

resources open to them. The assessment interview was explained

to subjects and they were then told of their condition assign118
TABLE 3

Composition of Control and Experimental Job-Seeking and Training-Seeking Groups by Age, Sex,

Level of Education and Job History Variables

MEAN AGE (Yr)

LEVEL OF EDUCATION:

CONTROL EXPERIMENTAL

Job- Training- Job- TrainingSeeking Seeking Seeking Seeking Overall

(N=15) (N=8) (N=12) (N=7) (N=42)

31.50 30.62 29.17 31.14 30.48

High School Graduate

or GED 6 5 6 5 22

High School, GED

not completed

MEAN NUMBER OF JOBS

IN PAST 5 YEARS

MONTHS WORKED IN

PAST 5 YEARS

MEAN SES STATUS1

OF PAST JOBS

9 3 6 2 20

1.54 2.21 2.27 1.86 1.92

21.60 18.13 30.77 15.57 24.14

5.65 5.63 5.80 6.00 5.78

1The scale ranges from 1 to 7, with 1 indicating professional positions, and 7 indicating unskilled labor.
ment. Control subjects were dismissed at that point. They were

scheduled for an assessment interview at the same time as the

experimental subjects. Experimental subjects then reconvened

for an afternoon session where the format of the workshop was

outlined. At this point, the content of the workshop included

a discussion of vocational aspirations followed by a brief relaxation training session. Subjects used active coping relaxation to relax before the interview. Subjects then role-played

short segments of the initial interview and the final component

of the interview. At the end of the second day, difficulties

involving completing job application forms were discussed.

Subjects were given a form to complete before the next session.

They also formulated a “next step” in the placement process

which they were to have completed in the free day that followed.

Following the “free day,” subjects met for a half-day session.

They discussed the difficulties encountered and ways of handling these difficulties.

The remainder of the session was devoted to written application

forms. The rest of the workshop was concerned with the complete

interviews. Subjects had opportunities to role-play interviews

in progressively more difficult situations; that is, the interviewer acted cold, hostile, or distracted. Subjects also took

the interviewer role with other subjects, and proved to be

difficult interviewers, indeed, usually by drawing from their

own experiences.

At the end of the workshop, all subjects participated in a

simulated interview. A single interviewer, blind to experimental condition, rated subjects on a global scale tapping

employability/acceptability as a trainee. Three months after

the end of the assessment interview, subjects were contacted

and asked to indicate whether they had found a job, the date

of the placement, and the number of interviews attended since

the end of the workshop. The place of employment and date of

placement were verified by checking with the subjects’ counselor.

The results from this initial study were promising. Only 17%, or

four of the experimental subjects, dropped out (three of the control subjects “dropped out” also; that is, they did not appear for .

this final interview). Participation in the experimental condition resulted in significant increases in vocational placement.

As figure 1 indicates, at follow-up, 50% of the experimental

subjects had been placed as compared with 14% of the controls.

Experimental subjects were rated also superior to controls on

both interview performance and written applications.

This study led to two companion studies. In both of these

studies, the effect of the Job Seekers’ Workshop on job finding

only was examined. We did not. accept potential subjects

attempting to find placement in a competitive training program

as we had in the original study, mostly because of design

considerations.

120
FIGURE 1

Percent of Subjects in Job Seekers’ Workshop and Control

Conditions Placed by Three-Month Follow-up

In the first of these, a revised version of the Job Seekers’

Workshop with exheroin addicts drawn from the criminal justice

system was evaluated (Hall et al. 198la). In the second, the

Workshop was cross validated in a methadone maintenance sample

(Hall et al. 1981b). The criminal justice sample provides an

interesting contrast with the methadone samples.

In the criminal justice study, subjects were 55 parolees or probationers who had documented histories of heroin abuse who were

referred to the project from either county probation officers

or State parole officers.

Agency personnel were blind to experimental conditions and

assignments. Again, we ruled out only subjects who were psychotic, illiterate, or who anticipated serving jail time within

three months. The characteristics of the sample are shown in

table 4. The majority of the subjects were black. A sizeable

121
TABLE 4

Characteristics of Criminal Justice Sample

AGE MEAN

NUMBER OF MEAN

JOBS, PAST

FIVE YEARS

MONTHS SINCE MEAN

LAST JOB

MONTHS WORKED MEAN

PAST FIVE

YEARS

Experimental Control

(N=30) (N=25)

34.41 33.24

 1.28 1.67

Entire

Sample

(N=55)

33.87

1.46

27.44 30.22 28.65

12.21 15.58 13.74

SEX MALE

FEMALE

EDUCATIONAL

LEVEL; HIGH

SCHOOL

DIPLOMA/GED

YES

NO

24

6

18

12

23

2

10

15

47

8

28

27

CRIMINAL PAROLE 15 18 33

JUSTICE PROBATION 7 5 12

STATUS BOTH 4 5 9

minority were Caucasian. There was a greater proportion of male

subjects than in our previous study. The two samples did not

seem to differ markedly in educational level or job indicators.

However, the job data are not meaningful, since many subjects had

spent significant amounts of time within the last five years in

jail or the penitentiary.

A treatment/no-treatment design was used again. Treatment content was streamlined to three components: 1) job interview

training; 2) instruction in completion of application forms;

3) job search procedures. The components of each are shown

in tables 5. Emphasis placed on job interview training and on

122
TABLE 5

Three Components of the Job Seekers’ Workshop

1. JOB INTERVIEW TWINING

A. Video desensitization

B. Desirable entrance and exit behaviors

C. Eliminate distracting behaviors

D. Positive presentation of self

E. Video and verbal feedback

F. Gradually increasing “difficulty” of interview

2. COMPLETION OF APPLICATION FORMS

A. Know crucial personal information

B. Handling difficult items, especially drug histories

and arrests

C. Emphasizing positive aspects of job history

3. JOB SEARCH PROCEDURES

A. Sharing job leads

B. Using friends and relatives as resources

C. Unexpected resources--job interviewer, the telephone

and telephone books and the newspaper

123
completion of application forms was increased. The job search

procedures were largely modeled after the work of Azrin and

his colleagues (Azrin et al. 1975’; Azrin and Philips 1979). They

included sharing of job leads and learning how to obtain them

from friends, relatives, job interviewers, newspapers, and

telephone books. Subjects also practiced making telephone calls

with coaching and suggestions by the leaders.

In this study, as in the subsequent one, the “free day” activity

and relaxation training were omitted. The “free day” activity

was omitted because subjects in the initial study failed to

follow through with these activities, viewing them as unimportant, ‘make work” tasks. Relaxation training was omitted

because anxiety wasn’t a problem for many subjects. Also,

for those for whom it was a problem, knowledge of interviewing

skills seemed to be more potent in reducing anxiety than relaxation training. A more sophisticated assessment device, a

factor-based instrument called the Interview Rating Survey

was used. It included two scales, the items of which are

shown in table 6. The first might best be characterized as a

general, primarily verbal, competency factor. The second consists mostly of specific nonverbal behaviors.

At a mock assessment interview, subjects were rated on this

scale by two interviewers who were blind to treatment conditions, and blind to the content of the experimental intervention.

Following treatment, subjects were contacted once a month for

three months and information about the day of their hiring

and the amount earned obtained. Again, we verified employment whenever possible. Results of this study are shown in

figure 2. These data represent a Life Table Analysis (Fleiss

et al. 1976; Cutler and Ederer 1958). At the end of three

months, this analysis indicates approximately 86% of the experimental subjects had found employment as compared to 54% of the

controls . The differences, between the conditions were apparent

as early as one week posttreatment. The difference at this

point is significant, and remains so throughout the three-month

period.

Resides having higher placement rates, the experimental condition differed significantly from the control condition on the

second IRS scale--the one measuring specific, nonverbal

behaviors.

We were surprised at the high general rate of employment in

both experimental and control conditions in this study. We

had selected this population for replication because we thought

they would provide a more stringent test of the effectiveness

of the intervention since they had both recent prison histories

and a history of heroin abuse. There are several factors that

might explain the reason for the differences between this condition and the methadone sample,’ including prevailing employment

rates, differences in leaders, and differences in subjects’

abilities and degree of addiction. Our hypothesis was that

124
1. Level of information provided about job skills

2. Level of information about past jobs

3. Responses to interviewer questions

4. Possesses relevant job skills

5. Absence of self-disparaging statements

6. Ability to explain problem areas

7. Positive presentation of self

8. Likelihood of hiring, if position available

TABLE 6

Interview Rating Scale

FACTOR 1 FACTOR 2

1. Posture

2. Tension level

3. Absence of distracting mannerisms

4. Appearance

5. Eye contact

6. Courtesy

7. Appropriate exit and entrance

8. Use of an assertive closing

9. Manner of speaking
FIGURE 2

these differences were the results of a potent contingency.

That is, many of these subjects faced a return to prison

if they did not find jobs.

In the final study we returned to methadone maintenance clinics.

Sixty job-seeking methadone maintenance clients were assigned

to either the Job Seekers’ Workshop or to the information-only

condition. The sample for this study is described in table 7.

In this study, the program was presented over four days with

the assessment interview on the final, fifth day. However, the

content was the same as that used with the criminal justice

sample. The outcome, which was again percentage of subjects

employed at each week, is shown ‘in figure 3, which is also based

on a Life Table analysis. A comparison for all experimental

subjects with controls indicated differences which narrowly

failed to reach conventional levels of statistical significance,

although they were in the expected direction. Of the experimental subjects, 52% were employed, as compared with 30% of

the controls. Four experimental subjects left immediately

126
TABLE 7

Characteristics of Second Methadone Maintenance Sample

AGE

NUMBER OF

JOBS, PAST

FIVE YEARS

MONTHS SINCE

LAST JOB

MONTHS WORKED

PAST FIVE

YEARS

MEAN

MEAN

MEAN

MEAN

MALE

FEMALE

Experimental Control

(N=30) (N=30)

30.14 30.83

1.43 .96

Entire

Sample

(N=60)

30.52

1.37

33.12 49.76 36.94

10.71 8.00 9.25

SEX

EDUCATIONAL

LEVEL: HIGH

SCHOOL

DIPLOMA/GED

YES

NO

16 19 35

14 11 25

14 19 33

16 11 27

CRIMINAL PAROLE 5 3 8

JUSTICE PROBATION 9 8 17

STATUS NEITHER 16 19 35

following the information presentation and therefore never

received the experimental treatment. If they are excluded,

along with their matched controls, differences in employment

are significant. In interview behaviors, as rated by blind

interviewers, we found that participation in the workshop

increased scores on the general competency scale of the IRS

but not on the specific behavior scale.

These data indicate that the Job Seekers' Workshop is effective

in helping drug treatment clients find employment. However,

demonstrating effectiveness is one thing. Motivating programs

to implement treatment techniques of demonstrated effectiveness

127
FIGURE 3

may be another. This is the dissemination problem: once an

approach has been shown to be of value, what methods effectively

motivate service providers to adopt it?

To answer this question, a study is currently being conducted

through the Human Interaction Research Institute (HIRI) in Los

Angeles in collaboration with our group. The participating

investigators are Drs. Edward Glaser (Principal Investigator)

and Paul Greenberg of HIRI, Dr. James Sorensen, and the authors

from University of California, San Francisco.

This project has two goals: 1) to disseminate the Job Seekers’

Workshop to drug treatment programs in the western United

States, and 2) to evaluate the effectiveness of three different

strategies for encouraging programs to adopt the approach.

128
One hundred and ninety drug treatment programs will be recruited

over the next year. Participating programs are stratified by

modality (outpatient drug free, methadone maintenance, and

residential) and randomly assigned from within these blocks to

one of four conditions:

Printed Information Only. These 65 programs receive a 20-page

booklet. The booklet describes the Workshop. summarizes the

research, and discusses issues of appropriate clients, staffing,

and equipment. They also receive a 52-page Leaders’ Manual,

which is a step-by-step “cookbook” for conducting the research.

The contents of the Manual include discussions of recruitment

and screening of clients, equipment and materials needed, and

detailed descriptions of Workshop activities, including suggested comments for the leader and anecdotal material about issues

that arise.

Site Visit. The 30 programs in this condition receive the

printed information plus a one-day site visit from a project

staff member. The site visit includes a one-hour videotape of

an actual workshop, brief training in role-play interviews

and videotape feedback, and development of specific plans to

implement a Job Seekers’ Workshop in the program. Programs are

called one week after the site visit to review implementation

plans, and to remind them that project staff are available for

telephone consultation. Programs can receive as much telephone

consultation as they wish.

Training Conference. These 30 programs receive the printed

material, and are invited to attend a two-day training conference in San Francisco. Approximately eight programs participate in any one conference, which includes intensive experience

in role-playing and videotape feedback, discussion of implementation, and interaction with the entire project staff. Followup

consultation is available as in the site visit condition.

Control. The 65 programs in the, control condition receive

printed information after the study period is completed.

All programs are followed at three and nine months after condition assignment. They are assessed by mailed questionnaires and

telephone to determine adoption rates, and other ways in which

the intervention has influenced the provision of vocational

services by the program.

The first wave of recruitment is underway. Recruitment letters

have been sent to a total of 127 programs in two separate

mailings. About 50% of the eligible programs have agreed to

participate. Programs agreeing to participate have indicated

interest and enthusiasm and commented on the relevance of the

Job Seekers’ Workshop to their clients’ needs. Programs declining have most frequently given lack of sufficient staff as their

reason for declining. No additional data are available at this

time. The projected completion date for data collection is

May, 1984.

129
ACKNOWLEDGMENT

Preparation of this manuscript and research described in it

funded in part by Grants Number 5 K02 00065, IH8 DA0l978, and

1 R81 DA03058, from the National Institute on Drug Abuse.

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group-assisted program for obtaining employment. Behav Res Ther,

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handicapped: A comparative outcome study. Rehab Counsel Bull,

23:144-155, 1979.

Bass, U.F., and Woodward, J.A. Skills Training and Employment

for Exaddicts in Washington, D.C.: A Report on Treatment.

National Institute on Drug Abuse Services Research Report,

DHEW Pub. No. (ADM) 76-694 Rockville, MD: The Institute, 1978.

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table method

and Ederer? P. Maximum utilization of the life

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Exaddicts. New York: Manpower Demonstration Research Corpora-Text

tion, 1981.

Fleiss, J.L.; Dunner, D.L. ; Stallone, F. ; and Fieve, R.R.

The life table; A method for analyzing longitudinal studies.

Arch Gen Psychaiatry, 33:107-110, 1976.

Friedman, N. The Wildcat Experiment: An Early Test of Supported

Work in Drug Abuse Rehabilitation. National Institute on Drug 

Abuse Services Research Monograph. DHEW Pub. No. (ADM) 79-782:

Rockville, MD: The Institute, 1978.

Hall, S.M. ; Loeb, P. ; Norton, J.W. ; and Yang, R. Improving

vocational placement in drug treatment clients: A pilot study.

Addict Behav, 15:438-441, 1977.

Hall S.M.; Loeb, P.; Coyne, K.; and Cooper, J.

employment in ex-heroin addicts I:

Increasing

Criminal justice sample.

Behav Ther, 12:443-452, 1981a.

Hall, Loeb, D.; Levois, M.; and Cooper, J. Increasing

employment in ex-heroin addicts II: Methadone maintenance

sample, Behav Ther 12:453-460 1981b.

Hargreaves, Interest in ancillary services in methadone

maintenance. J Psychedelic Drugs, 12:47-52, 1980.

HUbbard, R.L., and Harwood, H.J. Employment Related Services in

Drug Treatment Programs. National Institute on Drug Abuse

Treatment Research Report, DHHS Pub. No. (ADM) 81-144.

Rockville, MD: The Institute, 1981.

130
Brokerage Model Rehabilitation

System for Opiate Dependence: A

Behavioral Analysis

Travis Thompson, Ph.D., Jon Koerner, and

John Grabowski, Ph.D.

INTRODUCTION

Clinicians and policy tacticians have attempted to determine

whether refinements in the existing methadone treatment system

might lead to improvements in treatment. Thus, for example,

specific aspects of methadone administration (e.g., dosage and

duration) have been reviewed (e.g., Cooper et al., 1983) and

overviews of the prevailing system have been provided (Dole and

Nyswander 1983). The suggested resolution to problems depends in

part on the theoretical perspective of the observer. Indeed, Dole

and Nyswander (1983) have observed that "priorities in treatment

have been complicated by ideological arguments, competition for

public funds and deeply felt issues of morality." In a similar

vein, Pickens and Thompson (this volume) have noted that differing

theoretical perspectives have resulted in different interpretations

and approaches to treating drug-dependent patients. Inroads have

been made in developing effective therapeutic strategies, but it is

clear that some of the problems in treatment will not be resolved

through further refinement of the current system. The time may be

appropriate to examine the systems within which drug dependence

treatment services are provided and, if necessary, to make

appropriate modifications. This may be particularly true with

respect to treatment services provided for heroin use.

Discussions of heroin dependence are usually based on two

assumptions: (1) The individuals have an underlying biological or

psychological abnormality, which, if rectified, will make them well

again, and (2) Specific treatments exist, or can be discovered,

which will eradicate the disorder suffered by the heroin user.

Based on these assumptions or variants of them, practitioners

attack the putative illness of the opiate-dependent person.

Treating activities are designed to eliminate, or at least

modulate, the underlying disorder, which it is believed is heroin

dependence. Treating, in this sense, becomes an activity equated

primarily with process rather than effect. Depending on the

practitioner's theoretical orientation, the focus of treatment

could be methadone maintenance, group therapy, individual

counseling, or biofeedback training. Aspects of the client's life

131
not central to the primary "treating" activities of the

practitioner are typically viewed as adjunctive services to which

attention may or may not be directed in a systematic fashion.

Considerable variability exists from facility to facility in terms

of these services.

The line of reasoning on which much treatment is based is flawed in

several respects. The analysis of what it is to be a stereotypic

heroin-dependent individual is inaccurate. First, heroin

dependence is not an illness per se or a thing, akin to a diseased

appendix which can be extirpated to render a sick patient well.

Rather, heroin dependence is a behavioral state, defined by the

nexus of environmental and pharmacological factors which has

impinged on the individual, and interacts with the current

environmental conditions to engender the characteristic pattern of

deviant behavior. Second, although numerous individual procedures

exist which effectively alter one or another of the deviant

behaviors or deficiencies characterizing the lives of heroin users,

they are seldom applied in concert in an organized way.

Combinations of technologies, addressed to the array of variables

characterizing heroin dependence processes, are required for

meaningful rehabilitation. Moreover, no procedures can be

effective if they are irregularly or improperly administered, alone

or in combination. Overall it is apparent that no single treatment

or technology can be applied which will cure or ameliorate the

problems of the heroin-dependent individual. As should be evident

in succeeding pages, an alternative policy and associated

technology may prove more effective than the current dominant forms.

BASIC MECHANISMS INVOLVED IN HEROIN DEPENDENCE

The prevailing scientific opinion until the early 1960s was that

opiate use and dependence were synonymous with physical

dependence. In the early 1960s several studies were conducted with

rats and monkeys suggesting compulsive opiate self-administration

was a special case of operant behavior in which the

dependence-producing drug serves as a rewarding event (Deneau et

al. 1969; Schuster and Thompson 1962; Thompson and Schuster 1964;

Weeks 1962) maintaining drug-seeking behavior. While physical

dependence could serve an important role, as a setting condition

for further self-administration, it was not essential to the drug

dependence process. Growing out of this early work has been an

extensive literature with opiates, alcohol, and other drugs of

abuse corroborating the generality of this model (cf. Schuster and

Thompson 1969; Thompson and Pickens 1969; Meisch 1982; Griffiths et

al. 1980; Spealman and Goldberg 1978; Johanson and Schuster 1981;

Pickens et al. 1978; Thompson and Johanson 1981). This literature

has pointed to the importance of interactions between behavioral,

environmental, and pharmacological variables as determinants of

drug use. Conceptualizing drug dependence in this way has lea to

new treatment technologies which have successfully reduced the

control drugs exercise over the behavior of the user under specific

circumstances. Broader implications of a behavioral analysis of

drug dependence processes have been limited. Behavioral

practitioners attempting to treat heroin-dependent individuals in

132
the natural environment have often believed that while they could

identify major variables requiring attention, they could not gain

the control over Family, vocational, educational, or drug resources

that iS necessary to engender enduring behavioral change. The

solution has typically been to Focus on one or two Factors which

have been accessible, and to deemphasize or ignore the remainder.

This is an understandable practical response to a Frustrating

problem, but, as with other approaches, has diminished the

effectiveness of otherwise very effective procedures. Thus

problems may reemerge to original proportions as treatment is

removed. It should be noted that one consequence of the behavioral

treatment perspective, i.e., its attention to data and

documentation, has resulted in acknowledgment of its Failures as

well as its successes. Nevertheless, an analysis of the behavioral

repertoire and environment of a typical urban heroin user reveals

that such modest efforts with primarily a single focus cannot be

expected to bring about more than modest results.

ANALYSIS OF HEROIN USERS' OPTIONS

Three groups of options may be identified as available to a

prototypic urban heroin user: (1) a licit life style; (2) a

treatment/rehabilitative life style; and (3) an illicit life

style. A method of analysis developed by Findley (1962, 1966) and

pursued by others is helpful in elucidating relevant variables and

understanding complex multioperant behavioral repertoires. Using

this analytic technique, major components of behavior are

identified and systematically examined. Findley proposed a useful

system for schematic presentation Of the elements of a behavioral

system and repertoire, and this has been used here to delineate

major components of the heroin user's behavioral choices, or

options.

As has been discussed in the context Of specific examples by other

authors in this volume, the options can be compared on numerous

dimensions, two of which are (1) positive reinforcement parameters

and (2) punishment parameters. Presented in Figure 1 is an

analysis of what might be termed the behavioral space of an urban

heroin user. While it is clear that the complete array of possible

detailed analyses For all categories of heroin users, or even urban

users, is not represented, one can obtain a sense of the necessary

Form Of analysis by the example presented. In this case the First

sequence of behaviors (or operant 1)1, illicit activity, would

typically involve theft or burglary, leading to selling the stolen

goods (operant 2). The heroin user would then buy drug, most

likely from a dealer (operant 3), which would be self-administered

(operant 4). The likelihood of a given act of theft or burglary

being detected by the police (operant 8) is extremely low; hence

the punishment branch of the multioperant schedule is rarely

experienced. Concurrently, the individual may apply for public

assistance and then wait for money (a generalized conditioned

reinforcer) (operants 12, 13) to be delivered without regard to

events in the other branch Of the schedule (operants 2-7). That

is, the several different layers of the system reinforce deviant

behaviors, and the contingencies of one are counterproductive For

133
FIGURE 1

Overview diagram of options available to a stereotypic opiete using client.

The sequence starting with 1 has the most consistently reliable consequence in the form of drug use with occasional interaction with police.

134
The sequence beginning with 12 is fairly reliable, but benefits are remote

and can occur concurrently with drug use. The sequence beginning with

15 is the most difficult and has the greatest delay of reinforcement.

135
the requirements of another. In this case providing assistance,

even though it is clearly needed, may undercut other aspects of

rehabilitation, not because it is provided but because of the

manner in which it is provided. The schedule of illicit behavior

itself is also under strong stimulus control, with several daily

intravenous heroin reinforcements sustaining the overall

repertoire.

Consider a rehabilitative alternative: a weaker delayed opiate

reinforcer is self-administered once daily (oral methadone) at a

clinic (operant 11). A relatively minor response requirement, that

of appearing at the clinic, is placed on the client. Successful

engagement in such other activities as academic or vocational

training (operants 15-17) is highly improbable. Typical adolescent

or young adult heroin users may have such deficient academic skills

that the reinforcers available in most educational settings have

little possibility of being effective (e.g., approval,

satisfaction, praise, high grades). Those reinforcers which are

available are infrequent, delayed, and not very powerful. However,

punishment for inappropriate academic behavior is immediate and

frequently provided by school personnel (e.g., verbal disapproval

or threats). The result is that most heroin users drop out of

educational programs. The situation for job training is virtually

identical. In both instances they are then further removed from

the licit system of reinforcers which would lead to a more adaptive

lifestyle.

A brief examination of the licit lifestyle reveals that this option

would probably be sustained by only a limited number of typical

young heroin users. Jobs are very difficult to obtain, and only 15

percent of potential employers say they would ever hire an "addict"

or "ex-addict," while only 33 percent of the individuals have ever

held a job (Gildenberg 1972). If they do obtain work, the rate of

pay is typically very low and the delay of reinforcement is long (a

minimum of 1 week and often 2 weeks). Since their experience with

obtaining monetary reinforcement, i.e., time to receiving a

paycheck, is in the main characterized by immediate payoff for

illicit activity, delay in obtaining money, a feature which

characterizes most jobs, is not acceptable. This is a skill which

must be acquired. In addition, these individuals are unlikely to

find social support initially from fellow workers and hence will be

exposed to very few conditioned reinforcers to sustain work-related

performance over the period between paychecks. Absenteeism,

tardiness, or poor work skills, all of which are likely in

unskilled, inexperienced workers, will be punished by supervisors,

thereby tending to weaken overall work-oriented behavior and will

lead to dismissal if repeated. Most of the other skills and

environmental supports for sustaining an abstinent and licit

lifestyle are typically lacking. A further impediment to success

under the normal licit contingencies for an individual with the

history described is that existing neighborhood social and leisure

time stimuli set the occasion for illicit behavior, including drug

taking. An appraisal of the behavioral options makes it clear why

most heroin users alternate between illicit and rehabilitative life

styles, rarely engaging in sustained licit performance. Overall,

136
the prevailing contingencies in combination with the drug user's

experience are such that the reinforcers for maintaining an illicit

life Style are considerably more powerful than those which would be

necessary to produce change in the direction of maintenance of the

diverse behavioral repertoire of a licit lifestyle.

BEHAVIORAL TECHNOLOGICAL SOLUTIONS

The foregoing analysis suggests attention must be directed to a

number of critical loci in the lives of heroin-dependent

individuals if diverse forms of interaction are to be

rehabilitative. Table 1 presents seven loci of client behavior,

the site(s) in which these actions take place, and the objectives

of rehabilitation in each of these sites. An overall

rehabilitative program must attend to all of these variables if it

is to effectively develop and maintain-e necessary behaviors.

While many current treatment programs provide methadone in a

controlled clinical setting and/or group counseling at a clinic,

they have only limited resources or control to alter other

conditions and are often restricted to making referrals and

advising the patient to change his/her behavior.

Numerous agencies and sites must be involved in a heroin dependence

rehabilitation program. In many instances, technologies already

exist which can be applied in such settings (e.g., public schools,

job training, methadone clinics) and in other cases (e.g.,

residential, health care) technologies can be modified from those .

designed for other clinic populations (e.g., juvenile delinquent,

mentally ill, mentally retarded (cf. Phillips 1968; Thompson and

Carey 1980). Thus, it is not necessary to build new behavioral

intervention systems, but, rather, use can be made of extant

approaches. Perhaps the most important issue is that the problems

are not so much in designing individual rehabilitative programs

within a given site (e.g., a school), but rather in engendering

coordinated rehabilitative services and contingencies concurrently

across all sites. Coordination must emanate from overall public

policy and funding mechanisms. It is clear that coordination will

not arise spontaneously and that instead a systematic integrative

effort must be made to organize the various components of the

rehabilitative services. Current policy emphasizes treatment

delivered at specific sites (e.g., a clinic) and provides few

incentives for coordination across facilities. Indeed, funding

mechanisms may hinder cooperative effort. Thus, for example,

funding is generally contingent on the number of client slots

filled, i.e., the number of people being provided service rather

than number of cases treated successfully. This constitutes a

disincentive for graduating, or discharging, clients. It should be

apparent that no treatment group is attempting to preclude advances

by patients. Instead, the prevailing system of contingencies is

contrary to the goals that staff members are attempting to

achieve. It is not surprising that some clients remain in

treatment for years without appreciable change of status.

A superficial analysis might lead to the proposal that a

"fee-for-service" model would be a preferable alternative to the

137
TABLE 1

LOCI OF DRUG ABUSE CLIENT BEHAVIORS AND SERVICES

LOCUS of Sites Therapeutic Objective

Residential Public housing Remove discriminative

and reinforcing

stimuli associated

with heroin

Educational Public schools

Vocational Vocational schools;

on-the-job

training

Opiate management Clinics

Health

Relational

Leisure time

Health providers;

HMOs; pharmacies

Individuals;

therapist;

support groups

Support groups;

service organizations; community

organizations

138

Increase basic academic

skills; math and

writing related to job

Skills

Train job skills;

increase tolerance for

delays of reinforcement

Decrease reinforcing

properties of opiates;

reinforce clean urines,

punish dirty urines

Extinguish health

providers as discriminative stimuli for

drug seeking

Increase responsible

social relationships

Increase leisure activities outside drug

culture
current system. Several problems suggest this is an unsuitable

alternative in and of itself. Without coordination,' service might

be duplicated or delivered unnecessarily and reimbursement of the

redundant providers would be required. Moreover, other critical

services might never be provided, since administratively these

activities are often funded under auspices of different public

agencies (e.g., vocational or educational versus medical).

Finally, since the current system reinforces "treating" activities

in the main independently of outcome, ineffective treatment will be

reimbursed at the same rate as effective treatment. This is

obviously disfunctional in two respects. It may deprive the client

of effective rehabilitation procedures, and more generally, may

perpetuate ineffective procedures.

The process of modifying the environment within which a service is

provided to shape organizational behavior to meet the needs of

clients is called formative management (Budde 1979). The notion

that management of human service systems should be based on

performance measures of system components is not new. However,

problems have typically arisen in that financial resource

allocations are often made with minimal regard to the degree to

which services meet client needs. This is especially troublesome

in the human service industry, where specification of goals and

success may be difficult. The questions are not whether regulation

of rehabilitative services to heroin-dependent clients is

necessary, but which data are necessary, to whom they should be

provided, and what consequences flow from such performance

evaluation.

Alternatives to extant service delivery and performance evaluation

systems have been employed in other areas of human service and

rehabilitation. An interesting and instructive example derives

from the efforts of a group of families of mentally retarded people

in Victoria, British Columbia, who were faced with the problem of

devising an adequate service-delivery system for their handicapped

family members. This need resulted from the closing of

institutions which had previously provided residential care, a

situation even more difficult than that provided by patients who

already have necessary skills for living in the community. They

formed a nonprofit organization (the Community Living Board) which

established a brokerage system for services to their family

members, ranging from where the people lived to who provided

medical, dental, and other health care services, and which

recreational services were purchased. The Province of British

Columbia provided a per diem for each client to the broker, and it

was the broker's responsibility to purchase the most appropriate

and effective services for each client (Rioux and Crawford 1982).

The brokerage model may have numerous advantages. The broker

selects providers, which in the case of treatment for heroin

dependence represent seven classes of services (see table 1).

Service selection must be based on client needs, cost, and data

concerning effectiveness of services previously provided by a given

vendor. The broker's fees, in turn, are based on objective

measures of client outcome. Centralization of services in

139
specialized centers, as exemplified by "methadone clinics,"

unnecessarily segregates these patient/clients. These facilities

arose because of a need and serve a valuable function. But like

State hospitals serving mentally ill and mentally retarded people,

they are, in many respects, not an optimum service model. The

clinics do serve to monitor urines for illicit drugs and prescribe

and administer methadone. They also provide ongoing monitoring of

general health and referrals to appropriate medical services,

counseling, and referrals for other services. However, as noted in

other chapters in this volume, methadone clinics are likely to

experience problems with loitering, vandalism, muggings, and

related criminal activity in the vicinity. These are precisely the

behaviors one would expect at a site where a major reinforcer is

reliably administered every day to individuals whose repertoires

include these illicit or antisocial behaviors and for whom other

activities (e.g., work, educational opportunities) are not readily

available. Parallel behavior patterns can be demonstrated in

laboratory experiments, clinical settings, and the natural

environment. Notable recent social examples of difficulties which

arise in crowds around dispensers of reinforcers are the

disagreements in gas lines during shortages or similar "scuffles"

in groups waiting to obtain concert tickets or enter a variety of

large entertainment events. The added fact that in this case the

group encouraged to congregate has an extensive repertoire of

illicit or socially difficult behaviors increases the probability

that problems may emerge. The contingencies of the methadone

clinic encourage regular attendance, segregate drug users in one

area, assure daily interactions, and set the occasion and provide

reinforcers for drug-related deviant behavior. In brief, the

clinic inadvertently creates an "addictive institution" within the

community which assures that difficulties are most likely in the

vicinity. It is essential to note that it is not the dispensation

of methadone per se which establishes this "institution" but rather

the contingencies and conditions governing its dispensation and

provision of other services. Overall, it is remarkable that many

clinics have been as effective as they have at minimizing the

problems which emerge.

The need for central clinics has become less evident as a strong

human services system has evolved. In general, all of the services

provided by most specialized drug treatment clinics could be

provided by vendors integrated in the community. Private

physicians or public clinics could prescribe methadone and monitor

urines as well as monitor their patients' health. To the extent

that medical supervision and care were widely distributed among

doctors throughout a community, problems with loitering or other

related deviant behaviors would be minimized. Similarly, housing,

family counselors, and recreational services are available

throughout a community, not only in the poorest neighborhoods with

the highest crime rates. By dispersing these individuals widely

throughout a community, many of the problems with deviant behaviors

which exist in the current clinic system would be diminished.

A single broker would be unable to monitor all seven service

domains for each client (table 1) and maintain an adequate client

140
load. A proposed administrative arrangement might involve a single

broker, 8 case managers, and 96 clients. Case managers would

collect data. and serve as liaison consultants to service

providers. While brokers would be technically knowledgeable, their

primary job would involve performance evaluation. Case managers

could be baccalaureate-level behavioral science technicians trained

to collect data and provide technical expertise to vendors. The

question which arises is what assures that each of the major

participants in this process will, contribute effectively to its

success. Table 2 shows the incentives for the client, the brokers,

and vendors for participating in the program and for performance

evaluation. Each participant has a good reason to cooperate with

program activities and work toward program goals.

Estimates of costs of drug abuse must be viewed with caution. They

may, however, give a general sense of the relative magnitude of the

problem. Such estimates for heroin use in New York City in 1978

provide an example. It was calculated that a heroin user in the

city, untreated, cost society about $25,000 a year in criminal

activity. Imprisonment, at the time, cost about $15,000 per year.

A methadone maintenance treatment slot was considered to cost

approximately $1,800 annually, while a drug treatment slot

including services in excess of methadone was estimated to cost

$2,700 per year. Of the approximately 290,000 narcotics abusers in

New York State, about 77 percent (or 223,000) lived in New York

City (U.S. Congress 1978). Given these figures for the city, if no

treatment services were available, the cost to society in criminal

activity would be $5.575 billion per year. Since some portion of

the individuals were in treatment (about 50,000). the figure might

be reduced to $4.325 billion per year. Exclusion of some portion

of the population of users because they pay for drugs through licit

income would still result in costs of substantial proportions. Any

treatment program that led to better client health and adjustment

and reduced costs would be considered successful. If it were only

'possible to reduce the number of individuals engaged in the illicit

life style by 10%, it would represent a large savings in New York

City alone, and monumental annual savings nationwide.

An obvious question is whether the cost of a brokerage program

would be less than or equivalent to costs for the extant system.

It is likely that the proposed approach, or a similar one, with

clear contingencies for client improvement, would cost no more, and

it is clear that the benefits of such a program would be

considerable.

The system would consist of a token economy, along the lines of

that described by Ayllon and Azrin (1968). A program would be

designed for each client in accord with his or her needs. A

bookkeeping system with specified monetary equivalents would be

maintained to provide a ledger of reinforcement for patient

successes. Acknowledgment of success would be tangible, immediate,

and consistent. Money earned would be credited to the patient and

would be in excess of the subsistence provided for food and

shelter. The token system would not only provide reinforcement for

remaining in treatment but would explicitly provide positive

141
Locus of What's In It

Client Action For the Addict

Residential

Educational

Vocational

Opiate management

Health

Relational

Leisure time

TABLE 2

INCENTIVES FOR PARTICIPATING IN THE BROKERAGE REHABILITATION SYSTEM

Decent place to

live, free rent

for 6 months

Money

Money; prospect of

job

(1) No worry about

withdrawal

(2) Methadone

(3) Money

Free health care

(1) Improved family

relationships

(2) Money-

(1) More enjoyable

(2) Money

Why Provider Should

Cooperate

Rent for 6 months;

guaranteed clientele

Tuition paid to

school

Tuition to school;

free workers

Fee for service

(physician and

pharmacist)

Fee for service

(physician)

Fee for service

(therapist)

Voluntary

Voluntary

Broker's

Responsibility

Monitor living

environment

Provide money

administered by

school staff

Provide money

administered by

staff;

supervise point system

Provide money for

clean urines

Followup

Provide money for

responsible family

life

Provide money for

time in nondrug

culture activities
consequences for successful responses. Specific requirements would

be adjusted as needed for the duration of treatment with the tokens

exchangeable for money throughout. There would, of course, be

continuing examination and updating of goals based on progress. The

proportion of the total of tokens which could be earned each week

would vary across the seven doci of client activity over the period

of involvement with the rehabilitation program. The relative

availability of tokens for each activity would assure systematic

"economic pressures" to emphasize certain activities, and the

values would shift as a function of progress, thereby moving

behavior in the direction required.

The government would serve the important role of determining the

accuracy of brokers' reporting practices and providing financial

support for the system. The performance evaluation would be done

on a random sampling basis to verify brokers' evaluations of client

outcomes. Sampling similar to that done with income tax returns by

the Internal Revenue Service could be used to assess reliablility

of brokers' reports. The brokers themselves would require only

relatively small numbers of data points per client per week to

effectively monitor progress, and for any given broker the data

could be maintained on currently available small business

computers. Summary outcome data (e.g., quarterly change scores)

would be used to determine funding levels to vendors. By providing

vendors with timely information concerning client progress or its

absence it would be possible to assist service providers in making

appropriate changes in their programs. The contingencies for

broker and client alike would, within this system, be directed to

progress and change.

Inevitable questions arise concerning fee structure and client

characteristics. Similarity in fees for all clients would

encourage vendors to serve only those clients with the least

serious problems, as is inherent in the current system, but this

problem could be readily circumvented, since, again, equivalent

models exist for other services. At present, insurance companies

make decisions based on actuarial data concerning risk; for

example, clients with high health risk may pay more for health or

life insurance. Development of a parallel system of adjusted fees

permitting translation of client characteristics into differential

service-delivery costs based on our knowledge of treatment outcome

with similar clients would be an essential component of the

system. This would minimize the incentive for vendors to deal only

with the easiest cases. Numerous problems, some of which could not

be anticipated, would evolve and require resolution but should not

deter the formulation of a workable system.

The disincentives to change which may in some cases be produced by

public assistance must be considered. There are divided views on

the issue of whether any contingencies may ever be attached to

availability of public funds for food, clothing, and housing for

the needy. This is clearly a legitimate and reasonable area of

concern and must be examined with caution.It appears that, in the

case of some heroin users, availability of noncontingent financial

support contributes to sustaining an illicit life style. Since the

143
life style of a heroin user is often characterized by isolation

from the culture at large and the absence of dignity, providing

funds without concern or attention to the consequences of doing so

is irresponsible. Noncontingent funds not only produce food and

shelter, they also maintain an addictive lifestyle, and Society

cannot be absolved of this responsibility. Appropriate contingent

provision of money, housing, and food can generate behavioral

change for the benefit of the client. It may be reasonable,

therefore, to link multiple drug-related legal encounters to

further access to public assistance based on participation in a

meaningful rehabilitative program. Some portion of the public

assistance (e.g., housing and food) might be provided with minimal

requirements, while all funds above and beyond these amounts would

be provided only in the context of rehabilitation.

Overall, the various aspects of the system discussed would provide

a reasonable mix of government and private endeavor. The brokers

and case managers would be employees of licensed nonprofit

organizations that would compete for contracts to deliver services

for which they would be reimbursed. Oversight and sampling of the

accuracy of the brokerage reporting and administration of funding

would entail a neutral government agency. The design of this

system is a reasonable outgrowth of experience in the provision of

diverse health care services with a focus on the desired outcome.

CONCLUSION

The problems in treatment of drug use are numerous and arise from

pharmacological, behavioral, and environmental determinants. In

the case of the typical heroin-dependent individual who enters

methadone treatment, it is clear that multiple social and economic

problems exist concurrently. Skillful scientists and clinicians

have investigated and addressed various aspects of these problems

and in many cases have generated impressive solutions. It is

becoming increasingly clear, however, that specific treatment of

one or another component will not provide resolution to a

multifaceted problem. This is true because heroin dependence does

not involve a predominantly biological illness amenable to

treatment in the conventional sense. In addition, despite efforts

to broaden the scope of treatment, an applied behavioral systems

analysis of the contingencies governing provision of treatment

suggests that even if the component strategies were optimal,

considerable difficulty would emerge in their application.

Models from other human services domains suggest an objective

accountability-oriented system of services coordinated and

administered by skilled brokers may be an excellent alternative.

Such a system assures that decisions concerning financial

incentives to service providers are based on objective measures of

progress. It further assures that from the perspective of the

client the rewards resemble those which are required for

maintaining a licit life style. While some difficult decisions are

demanded of communities, the resultant rehabilitation strategy is

one incorporating all the resources of the community rather than

relying heavily on that portion least able to provide support of a

144
licit behavioral repertoire. Furthermore, inherent in the system

is the fact that clients learn under supervised conditions how to

live in the broader community rather than spending time loitering

or consorting with former peers and heroin-using cohorts.

Conceptually and practically it is clear that a procedure based on

contingencies and reinforcers anchored in progress and emphasizing

outcome rather than process could offer significant advantages for

drug abuse treatment and rehabilitation.

FOOTNOTE

1. "Operant," shorthand for "operant behavior," or behavior which

operates on the environment, denotes a behavioral unit defined at a

level appropriate for purposes of analysis. Self-injection of the

opiate could be the operant of interest, reinforced by drug effect,

in a microanalysis of self-administration behavior. Alternatively,

drug-seeking through drug-taking behavior could be viewed as an

operant of interest in analysis of a more global character. In the

present case, large behavioral chains are being defined as

behavioral units for purposes of exposition.

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Survey of Drug Abuse Treatment Cost. Menlo Park CA: Stanford

Research Institute, 1975

Budde, J.F. Measuring Performance in Human Service Systems.

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Supt. of Docs., U.S. Govt. Print. Off., 1981.

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Science, 138:143,

146
Behavioral Intervention Techniques in Drug Abuse Treatment:

Summary of Discussion

Maxine L. Stitzer, Ph.D., John Grabowski, Ph.D., and

Jack E. Henningfield, Ph.D.

A lengthy discussion concluded the technical review at which the

papers in this monograph were presented. The meeting participants

considered both general and specific advantages that might accrue

to making fundamental changes in the extant treatment delivery

system. Specific suggestions arose from that discussion on how to

improve the delivery of treatment services to drug-dependent

persons. While there was not complete agreement among all

participants, there was striking unanimity on many issues.

The comments that follow are divided into four major categories in

an attempt to reflect the tenor and emphasis of the discussion

without providing a verbatim reconstruction. The discussion points

include consideration of (1) improving treatment for specific drug

abuse problems, (2) improving delivery of ancillary treatment

services to drug abusers, (3) strengthening nondrug reinforcers,

and (4) establishing a long-term prophylactic environment for drug

users. Since some pharmacological treatments such as methadone

maintenance otter unique opportunities for behavioral management

interventions, much of the discussion centered on suggestions

specifically applicable to improving this treatment modality; many

innovations discussed can, however, be more generally applied to

treatments involving other pharmacological adjuncts as Well as to

nanpharmacological treatment approaches.

IMPROVING TREATMENT FOR SPECIFIC DRUG ABUSE PROBLEMS

Reduction of illicit drug use is the first goal of drug abuse

treatment. One model for achieving this goal is exemplified by

chronic methadone administration, which is currently the best

available treatment for accomplishing this goal for opiate drug

dependence. In particular, this treatment modality dramatically

reduces the ongoing use of illicit opiate drugs and is assumed

concomitantly to reduce the criminal activity associated with

obtaining funds to support illicit drug purchases. In terms of

this model it is desirable to attract as many opiate users as

possible, into treatment so as to maximize the beneficial effects of

treatment not only for the clients but also for the community.

147
Although methadone is used primarily as a pharmacological adjunct 

for treatment of chronic opiate use and dependence, an important

property from a behavioral point of view is that it is a reinforcer

which can be used to establish and maintain treatment-oriented

behavior. In the initial stage of treatment, when methadone is

established as a reinforcer for heroin users, improvement in

treatment enrollment and retention might be established by more

effective introduction of the drug to patients.

One specific strategy suggested for improving the introduction of

methadone to opiate users was to begin treatment by pairing

methadone with intravenous administration of an opiate drug. In

this model, clients would initially be given both oral methadone

and intravenous opiate drugs at the clinic in an attempt to enhance

the reinforcing potency of the oral maintenance drug through

repeated pairings. Although it is unlikely that opiate abusers

would ever prefer oral methadone to intravenous opiate drugs, more

opiate users might find oral methadone an acceptable substitute for

street drugs under an improved system of introduction.

Aside from this specific introduction strategy, it is also probable

that higher rather than lower maintenance doses of methadone, as

well as a nonpunitive attitude on the part of the staff, are likely

to bring dependent individuals more effectively into treatment and

to maintain treatment participation. It should be apparent as well

that in those cases where other agents with a degree of reinforcing

effectiveness are used as adjuncts (e.g., benzodiazepines,

methylphenidate), contingencies governing their dispensing can be

established.

Methadone treatment does not eliminate all concurrent drug use, and

a considerable amount of supplementation with both opiate and

nonopiate drugs is observed among maintenance patients. Once oral

methadone is serving as a reinforcer to maintain treatment

participation, its reinforcing properties can be utilized to

influence ongoing supplemental drug use by judicious manipulation

of contingencies for daily methadone dose delivery based on the

results of onsite urine testing. For example, dose delivery hours

might be Utilized. Patients who provide a drug-free specimen in

the morning might receive their daily dose immediately, while those

whose urines indicate recent drug use would be required to return

in the afternoon for their methadone dose.

Additionally, the frequency of required attendance at the drug

clinic can be manipulated. Clinics generally grant take-home

privileges to patients who adhere to rules and consistently deliver

drug-free urines. Take-home privileges can be used explicitly to

produce marked improvement in poor performers when delivered

contingent on drug-free urinalysis results. The privilege of

take-home doses as well as the total number of such doses could be

made contingent on adherence with clinic requirements.

Finally, dosage level can be utilized in contingent arrangements:

dosage could be decreased for patients who provide drug-positive

148
samples, while those delivering drug-free samples receive dosage

increases or have the option of changing dose. In one procedure

based on this approach, patients using illicit opiates are offered

the chance to choose an increased methadone dose each day they

deliver a urine sample that is free of illicit opiates, while they

receive only their regular dose if an opiate-positive sample is

delivered. This is effective because it offers the pharmacological

benefits of an increased methadone dose while utilizing the

reinforcing potential of extra methadone to motivate

discontinuation of illicit drug use. Contingent delivery of other

therapeutic medications, when their prescription is clinically

indicated, should also be considered.

The foregoing examples are based on the concept of a two-stage

treatment process in which methadone is first established as a

reinforcer and then its reinforcing power utilized to effect

behavioral change. The important point is that drugs commonly used

for treatment of behavioral disorders do have reinforcing effects

which can be used in contingent arrangements to influence

concurrent drug use as well as other therapeutically important

behaviors. Clinics often have rules which mimic clear

contingencies for reinforcement of adaptive behavior, but these may

be vaguely and unsystematically formulated and applied. It is

evident that explicit development of precisely defined

contingencies may better serve both the overall program and

individual patients. It is essential that the contingencies

applied to drug delivery not be so aversive or punitive as to

interfere with patient retention 'in treatment and should, in fact,

be couched in the terms of a positive reinforcement approach.

There has been considerable discussion over the years concerning

optimal techniques for dispensing drugs such as methadone. The

present system in which drug abuse patients receive all treatment

services in a segregated treatment system may appear to have

advantages from society's point of view; however, it also has clear

disadvantages' from a treatment or rehabilitation viewpoint.

Segregated treatment tends to isolate patients, to maintain the

social stigma which surrounds them, and to perpetuate friendships,

associations, and activities based on drug use. In addition, the

present methadone distribution system promotes loitering and

related behaviors which are the antithesis of desirable treatment

outcomes. Finally, the use of take-home medication for

well-behaved clients results in some illicit drug diversion. One

method suggested for improving this situation was to disperse

medication delivery more widely in the community, for example by

dispensing prescribed drugs at local pharmacies or mental health

centers.

While several practical problems would be raised with such a

system, it is likely that they could be minimized or circumvented.

For example, some drug abuse patients would attempt to secure

multiple rescriptions at different dispensing sites. This could

be prevented if medication dispensing were coordinated with

telephone or computer verification (Via a computerized prescription

149
file) of patients' status and prescription. Interestingly,

computer-linked pharmacies are being developed for economic

advantage and the prescription "tracking" is one consequence. The

resistance of physicians and pharmacists in the community

concerning illicit activity would have to be overcome through

effective information programs, and satisfactory measures to meet

their objections would be essential. With community dispensing, it

would also be necessary to rely more consistently on reinforcers

other than methadone itself, since it might be difficult to arrange

contingencies between dose delivery and behavior or to arrange

convenient contact between patients and counselors offering

ancillary treatment services. Many of the problems could be

overcome or be precluded if appropriate preliminary efforts were

made in development of the "new" distribution system.

Agreement exists that community dispensing could at minimum replace

take-home privileges for a subgroup of well-adjusted patients who

do not need continual drug abuse surveillance and ancillary

treatment services, and this would have a positive impact on drug

diversion. For the pharmacists' purposes it would, of course, be

critical that drug dosage decisions be made elsewhere than at the

dispensing site, as is typically the case with all other

prescription drugs.

Drug clinic and community dispensing might profitably be combined

in a sequential approach. Thus, treatment could begin at a central

drug abuse clinic where intravenous as well as oral methadone was

available. Patients who continued to show illicit drug

supplementation, would be retained at this clinic and put under a

contingency management program based on methadone availability.

Other patients who showed little or no illicit drug use could be

recommended as candidates for convenient community dispensary

sites, a privilege which would depend upon continuing to provide

drug-free urine specimens. It would also be important to give

clinics credit for successfully graduating their patients into

community dispensary programs, since prevailing funding policies

tend to promote long-term retention of well-adjusted patients in

treatment at the drug abuse clinic. All patients would, of course,

be referred to other agencies for appropriate services.

IMPROVING DELIVERY OF ANCILLARY TREATMENT SERVICES

While the initial goal of drug abuse treatment is the reduction or

elimination of illicit drug use, it is also generally agreed that a

specific focus on drug use is Often not sufficient, since many drug

abuse patients exhibit a variety of psychiatric, behavioral, and

psychosocial deficits in addition to drug abuse. Although there is

disagreement as to the relationship between drug use and the other

behavioral disorders that drug abusers may exhibit, the most

reasonable approach is to advocate treatment interventions in all

appropriate areas based on assessment of individual needs. Several

suggestions were discussed for improving delivery of ancillary

treatment services to drug-using patients and for utilizing

behavioral principles to improve treatment outcome in areas other

than drug use.

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The ancillary problems presented by patients often are not

adequately addressed at the drug abuse clinic. In part the fact

that services are limited occurs because the skills and resources

of the paraprofessional counselors are limited when it comes to

providing treatment for ancillary problems and correlated

disorders. Yet there exist in the community expert providers of

services such as vocational training and psychological counseling,

from which many drug-dependent patients could greatly benefit. It

was suggested that treatment of patients' ancillary problems could

be addressed more effectively by reintegrating the treatment of

drug abuse patients into the existing network of mental health and

vocational training services, utilizing either drug abuse

counselors or a group of independent treatment brokers to arrange

for provision of services by appropriate professionals.

Numerous objections to this strategy may exist, but clear

advantages could emerge. Some may argue that since the population

in need of treatment is concentrated in urban settings, it may

overwhelm existing resources. However, redirection of drug

treatment resources would benefit all users of the communities'

resources and eliminate multiple administrative systems. It may be

feasible for some patients to move their residence to other

localities where more services are available. Indeed this step

could be encouraged by offering benefits or subsidies, thereby

further diminishing the problems which evolve from the

concentrations of patients at sites such as methadone clinics.

Alternatively, if available treatment services are inadequate to

deal with the demand, then money should be spent to develop more

services by well-trained professionals in specific areas of need

rather than simply providing a subsistence level of treatment

services by paraprofessional counselors who have not been trained

in these ancillary problem areas.

In addition to ensuring that adequate treatment resources exist, a

better system is needed for encouraging utilization of appropriate

ancillary treatment services by drug abusers. In theory, drug

abuse patients have all existing community resources at their

disposal, but, in fact, these resources are virtually never

utilized since these patients may be referred by these agencies to

special "drug abuse treatment clinics." This can be attributed in

part to the lack of appropriate contingencies Within the existing

treatment system. To take better advantage of existing services

and to improve delivery of ancillary treatment services, providers

must be motivated to deliver treatment to drug abuse patients, who

must in turn have incentives to take advantage of treatment

services from which they could benefit.

A brokerage system proposed at this meeting [see Thompson et al.,

this volume) would incorporate motivational features for both the

drug user and service providers. Each patient would be monitored

by a broker who would act as an intermediary or liaison between the

patient and community service providers. Brokers would use

monetary incentives to encourage appropriate behavior both on the

part of the drug user and on the part of treatment providers. For

151
example, the drug treatment broker might establish a contract with

the county vocational training institute to accept a specified

number of urban drug abuse patients per year, pay the institute for

training the patients, and pay the patients for attendance and

success. Brokers might receive the money they need to perform

their service directly from drug abuse clinic treatment funds.

Alternatively, they might work by contract with employers of

persons with drug dependency problems, or with social welfare

agencies or medical insurance companies that are interested in

securing an effective range of treatment services for

drug-dependent clients. Quality control is also built into this

system, since experienced brokers would become selective in their

utilization of referral sources based on the-effectiveness of those

treatment facilities. Thus, a job training program that did not

consistently produce employable clients would find its enrollment

falling off as brokers took their business elsewhere.

Money is a universal reinforcer which can be used in contingent

arrangements to promote utilization of ancillary treatment services

within the context of the existing system as well as any improved

system that may be developed. As discussed in connection with the

brokerage system, patients can be paid explicitly for attending job

training workshops or psychological counseling sessions. Another

approach, which could be coordinated by either a broker or drug

abuse counselor, is to offer access to preferred activities as a

contingent reinforcer for engaging in some specified therapeutic

activity. A survey can be used to determine the kinds of

activities that individual patients would find desirable. These

may be, for example, specific educational opportunities such as

child care classes, recreational or social activities, access to

legal services, or altered levels of participation in the existing

treatment program. Social reinforcers available at the treatment

clinic can also be utilized as contingent reinforcers. For

example, the job-seeking client can be granted an interview with

the counselor only when he or she provides specific evidence of

job-seeking activities. Care must be taken, however, to preclude

the clinic's becoming the primary source of reinforcers for

patients.

Whether or not benefits would derive from any proposed new system

is an empirical question. Both short- and long-term cost-benefit

analysis would be essential for evaluating procedures which attempt

to better utilize community services for drug abusers. Possible

secondary benefits, such as improvement in services for persons

other than drug abusers, would have to be factored into the

analysis, as would any potential risks. Small-scale efforts in a

single geographic area or city would provide an opportunity to

further evaluate the brokerage system. An alternative approach to

improving delivery of ancillary services might be to bring

additional expertise to the drug abuse clinic and focus on

motivating patients to take advantage of services offered, although

this perpetuates the problem of segregation of one category of

behavioral disorder, i.e., drug use. In addition, this sort of

"patch up" approach leaves intact all of the difficulties inherent

152
in the current system. It appears that due to current fiscal and

social issues this may be a propitious time to modify the treatment

system.

STRENGTHENING NONDRUG REINFORCERS

The dominant positive reinforcers for the chronic user of

illicit-illegal drugs are typically closely linked to acquisition

of drugs, interaction with dealers and others engaged in peripheral

illegal activities, and, of course, interaction with other drug

users. In some cases, drug-using patients have jobs and families

which can provide a source of external motivation for initial

behavioral change and continued good performance. Drug-using

health professionals, for example, may be motivated to seek and

continue treatment by the threat of losing their jobs or

professional licensure. Frequently, however, these external

motivators are absent or weak in drug abuse patients of lower

socioeconomic status. Since work and social relations are perhaps

the two most important sources of nondrug reinforcement available,

it is important to take steps which build these sources of

reinforcement into patients' lives whenever possible. Professional

job training and psychological services may be needed to accomplish

these goals.

In addition to establishing employment and social relationships as

potential sources of reinforcement for drug abuse patients, it

might be desirable also to establish more complex nondrug

activities such as sports, hobbies, or cultural events as .

reinforcers. In contrast to drugs and money, which can serve as

powerful reinforcers in the absence of complex learned behavioral

repertoires, these other nondrug activites generally can function

as reinforcers only after prolonged exposure and after some

competence has been developed in performing the activity. Some

drug abuse patients have never been particularly competent in

socially acceptable areas of activity unrelated to obtaining drugs,

and may, therefore, have few alternative reinforcers available to

them. In this situation, a technique called reinforcer priming can

be utilized which consists of exposing people to new activities and

continuing exposure for a sufficient time for them to gain interest

and some competence.

New activities might profitably be introduced at the methadone

clinic to take advantage of pairing with an existing reinforcer.

Alternatively, methadone delivery might be made specifically

contingent upon engaging in new activities. For example, it may be

considered therapeutically beneficial to help patients to routinize

a daily schedule of activities which are more socially adaptive

than those in which they normally engage. Divided ingestion of the

methadone dose at intervals throughout the day following the

completion of specified activities might be arranged. A similar

system could be set up using token reinforcers rather than

methadone dose, if dosage fractionation proved impractical.

Alternatively, patients might be required to engage in one new

activity per week from a list provided in order to continue

153
treatment participation with full privileges. Presumably, if

patients continue to sample new activities, some will be

established as reinforcers and will continue independently of

contingencies at the clinic related to drug dispensing.

Overall it should be recognized that the approach of strengthening

nondrug reinforcers is one component (albeit an important one) of a

more thorough behavioral intervention program. It clearly serves

as an important feature in the more general approach of structuring

or restructuring environmental conditions which will maintain

adaptive behavior.

ESTABLISHING A PROPHYLACTIC ENVIRONMENT

The success of behavior therapy depends greatly on the number and

effectiveness of reinforcers which the therapist can control for

use in contingent arrangements to promote behavior change. In the

previous section, consideration was given to development of new

nondrug reinforcers for drug-dependent patients. Once a repertoire

of reinforcing activities and social relationships has been

established, the next step in therapy would be to transfer

behavioral control from the treatment clinic to the nonclinic

environment. The optimal administrative system would permit the

broker or therapist to build a prophylactic environment for the

patient which would contain appropriate contingencies to discourage

reinitiation of drug use. In addition, the optimal program, unlike

a traditional "drug clinic," would provide an environment and

structuring of contingencies which would preclude evolution of a

new maladaptive repertoire.

A recurrent theme in the discussion was that drug 'abuse treatment

is necessarily a long-term rather than a short-term undertaking

although this is clearly related to the experience of the

individual patient and pattern of use. For some patients, return

to drug use may occur months or even years after an apparently

successful treatment episode. Because return to use may be a

critical feature of substance abuse, the time frame for drug abuse

treatment should be reevaluated to assure the continuing dominance

of nondrug reinforcers. Instead of short-term interventions,

attention-should be devoted to treatment commitments lasting for

several years, during which a prophylactic environment is built for

the dependent patient. Urine monitoring on at least an occasional

basis should continue to be a part of treatment for an extended

period of time, since this provides an objective source of

information about drug use as well as a target for prophylactic

contingencies.

Family, employers, and agents of the legal system should be

considered to be the best sources of natural environment control

for former drug abuse patients.

(1966), while studying the long-term outcomes of drug abusers

A number of years ago Vaillant

incarcerated at the Public Health Service Hospital in Lexington,

Kentucky, noted that enforced abstinence during incarceration was

insufficient. Rather, it was observed that long-term legal

154
supervision in the community was associated with the best outcome

for narcotic-dependent individuals. It is particularly important

to emphasize that incarceration itself has no apparent value as a

treatment mode; rather, it is the continued natural environment

intervention which increases probability of success. Contingencies

which require active participation in drug abuse and ancillary

treatment services can be built into legal supervision systems when

appropriate. Effective contingency programs can be utilized with

drug abuse probationers, and specific contingencies can also be

based on evidence of good performance in a drug treatment program.

For example, specified periods of probation time (e.g., 1 week)

may be subtracted for each treatment week in which drug-free urines

are provided.

Employers can also be an excellent source of longer-term

prophylactic supervision, although this issue of exposing an

individual's problem to public view must be approached cautiously

for obvious ethical reasons. Many employers are becoming

increasingly aware of the financial benefits to be gained from

reducing drug and alcohol use among their employees. It might be

particularly useful if contingencies, such as loss of wages and

mandatory reenrollment in treatment, were attached to any detected

drug use episodes of former drug abusers and bonuses were

associated with drug-free periods. At the same time caution to

assure protection of civil rights and the individual's integrity is

essential. Although it is unlikely that the existing welfare

system will be dramatically changed, creative contingencies could

be attached to the receipt of welfare payments to promote improved

functioning among indigent drug abuse patients.

Finally, the family should be considered as an important source of

natural environment contingencies. Families have control over many

reinforcers, both social and material, which they routinely

dispense to the drug-using family member. The family would be an

important source of behavioral control, especially if they could be

taught to dispense these reinforcers more effectively contingent

upon desirable rather than disruptive behaviors. Surrogate

families could serve a comparable function for drug abusers who

lack contact with their own families. Given the recent reports of

success with family therapy treatment of drug addicts, referral to

an experienced family therapist should be considered as an

important step in drug abuse treatment for some patients.

Hunt and Azrin (1973), working with chronic alcoholics in a rural

Illinois community, showed that it is possible to improve outcomes

for chronic alcoholics dramatically by establishing a prophylactic

environment in which access to jobs, social relations, and social

activities is contingent upon sobriety. Jobs were found for the

alcoholics, but they would lose wages if they came to work drunk.

Marital therapy was offered and spouses were taught special

techniques and skills for dealing with both specific behavioral

events and long-term behavioral goals. In addition, a nonalcoholic

social club was established, admission to which depended on

sobriety. These efforts, along with others, demonstrated the

155
effectiveness of behavioral intervention techniques. There can be

little doubt that contingencies appropriately arranged in the

environment can have a large impact on substance abuse behavior. A

cost-benefit analysis would be needed to determine whether

individualized behavioral interventions with drug abuse patients

would have a sufficient payoff in improved outcomes to warrant

investment in such an approach.

CONCLUSION

Consideration has been given to four general areas where the

existing treatment of drug abuse patients might benefit from

changes based on behavioral analysis and behavioral management

approaches: (1) improving treatment for specific drug abuse

problems, (2) improving delivery of ancillary treatment services to

drug users, (3) strengthening nondrug reinforcers, and (4)

establishing a long-term prophylactic environment for drug users.

Major changes and specific approaches that might be desirable in

each of these areas were discussed. The overall point to be made,

however, is that a behavioral approach may offer advantages both

for assessing problems within the existing treatment delivery

system and for suggesting changes which might lead to more

effective treatment delivery systems for drug abusers. One of the

main advantages of behaviorally oriented treatment approaches is

that they specify objective therapeutic goals and evaluate the

outcome of treatment empirically. Further, behavioral techniques

are compatible with many other approaches such as family therapy or

worksite interventions.

Actual implementation of any changes in existing treatment services

would best be achieved by a gradual rather than a dramatic shift

and should be subject to cost-benefit analysis on a small scale

before large scale implementation is considered. It is hoped that

this monograph and discussion will encourage treatment planners and

evaluators to adopt a flexible approach in considering the

application of behavioral technology to the treatment of drug abuse

patients.

REFERENCES

Hunt, G.M., and Azrin, N.H. A community-reinforcement approach to

alcoholism. Behavior Research and Theory, 11:91-104, 1973.

Vaillant, G.E. A 12 year follow-up of New York narcotic addicts:

The relation of treatment to outcome. Am J Psychiatry,

122:727-737, 1966.

156
CONTRIBUTORS

Behavioral Intervention Techniques in Drug Abuse Treatment

George E. Bigelow, Ph.D. Roy W. Pickens, Ph.D.

Ira A. Liebson, M.D.

Mary E. McCaul, Ph.D.

Department of Psychiatry

Maxine L. Stitzer, Ph.D.

Research Unit, Box 392 Mayo

University of Minnesota

Department of Psychiatry D5W Minneapolis, Minnesota 55414

Baltimore City Hospitals

4900 Eastern Avenue Travis Thompson, Ph.D.

Baltimore, Maryland 21224 Jon Koerner

Thomas J. Crowley, M.D.

Department of Psychology

75 East River Road

Univ. of Colorado Med. Center University of Minnesota

4200 East Ninth Avenue Minneapolis, Minnesota 55414

Denver, Colorado 80262

Thomas C. Todd, Ph.D.

John Grabowski, Ph.D. Harlem Valley Psychiatric

Division of Clinical Research Center

National Institute on Drug Abuse P. 0. 330, Station A

5600 Fishers Lane Wingdale, New York 12594

Rockville, Maryland 20857

George E. Woody, M.D.

Sharon M. Hall, Ph.D. A. Thomas McLellan, Ph.D.

Peter C. Loeb, M.S.W. Charles P. O'Brien, M.D., Ph.D.

Tim Allen Philadelphia VA Medical Center

1490 Fifth Avenue University and Woodland Avenue

University of California Philadelphia, Pennsylvania 19104

San Francisco, California 94143

Jack E. Henningfield, Ph.D.

NIDA Addiction Research Center

Baltimore City Hospitals

4900 Eastern Avenue

Baltimore, Maryland 21224

Dana E. Hunt, Ph.D.

766 West Solana Avenue

Solana Beach, California 92075

Douglas S. Lipton, Ph.D.

Douglas S. Goldsmith, M.A.

David L. Strug, Ph.D.

State of New York, Division of

Substance Abuse Services

2 World Trade Center

New York, New York 10047

157
National

Institute on

monograph series

While limited supplies last, single copies of the monographs may

be obtained free of charge From the National Clearinghouse for

Drug Abuse Information (NCDAI). Please contact NCDAI also For

information about availability of coming issues and other

publications of the National Institute on Drug Abuse relevant to

drug abuse research.

Additional copies may be purchased from the U.S. Government

Printing Office (GPO) and/or the National Technical Information

Service (NTIS) as indicated. NTIS prices are for paper copy.

Microfiche copies, at 94.50, are also available from NTIS.

Prices from either source are subject to change.

Addresses are:

NCDAI

National Clearinghouse for Drug Abuse Information

Room lOA-43

5600 Fishers Lane

Rockville, Maryland 20857

GPO NTIS

Superintendent of Documents National Technical Information

U.S. Government Printing Office Service

Washington, D.C. 20402 U.S. Department of Commerce

Springfield, Virginia 22161

1 FINDINGS OF DRUG ABUSE RESEARCH. Not available from NCDAI.

Vol. 1: GPO out of stock NTIS PB 1272 867/AS $32.50

Vol. 2: GPO out of stock NTIS PB #272 868/AS $29.50

2 OPERATIONAL DEFINITIONS IN SOCIO-BEHAVIORAL DRUG USE RESEARCH

1975. Jack Elinson, Ph.D., and David Nurco, Ph.D., eds. Not

available from NCDAI.

GPO out of stock NTIS P8 #246 338/AS 316

3 AMINERGIC HYPOTHESES OF BEHAVIOR: REALITY OR CLICHE? Bruce J.

Bernard, Ph.D., ed.

GPO Stock #017-024-00486-3 $6.50 NTIS PB #246 687/AS $16

158
4 NARCOTIC ANTAGONISTS: THE SEARCH FOR LONG-ACTING PREPARATIONS.

Robert Willette, Ph.D., ed.

GPO out of stock NTIS PB #247 096/AS $8.50

5 YOUNG MEN AND DRUGS: A NATIONWIDE SURVEY. John A. O'Donnell,

Ph.D., et al.

GPO Stock #017-024-00511-8 $6.50 NTIS PB #247 446/AS $16

6 EFFECTS OF LABELING THE "DRUG ABUSER": AN INQUIRY. Jay R.

Williams, Ph.D.

GPO Stock #017-024-00512-6 $4.75 NTIS PB #249 092/AS $8.50

7 CANNABINOID ASSAYS IN HUMANS. Robert Willette, Ph.D., ed.

GPO Stock #017-024-00510-O $6.00 NTIS PB #251 905/AS $14.50

8 Rx: 3x/WEEK LAAM - ALTERNATIVE TO METHADONE. Jack Elaine, M.D.,

and Pierre Renault, M.D., eds.

Not available from GPO NTIS PB #253 763/AS $14.50

9 NARCOTIC ANTAGONISTS: NALTREXONE PROGRESS REPORT. Demetrios

Julius, M.D., and Pierre Renault, M.D., eds.

GPO Stock #017-024-00521-5 $7.00 NTIS PB #255 833/AS $17.50

10 EPIDEMIOLOGY OF DRUG ABUSE: CURRENT ISSUES. Louise G. Richards,

Ph.D., and Louise B. Blevens, eds.

GPO Stock #017-024-00571-l $6.50 NTIS PB #266 691/AS $22

11 DRUGS AND DRIVING. Robert Willette, Ph.D., ed. Reviews

'research on effects of drugs on psychomotor performance, focusing

on measures of impairment by different drugs at various levels.

GPO Stock #017-024-00576-2 $5.50 NTIS PB #269 602/AS $16

12 PSYCHODYNAMICS OF DRUG DEPENDENCE. Jack D. Blaine, M.D., and

Demetrios A. Julius, M.D., eds. Theoretical and clinical papers

concerned with the intrapsychic determinants of drug addiction.

GPO Stock #017-024-00642-4 $5.50 NTIS PB #276 084/AS 317.50

13 COCAINE: 1977. Robert C. Petersen, Ph.D., and Richard C.

Stillman, M.D., eds. Reports the extent and limits of current

knowledge about cocaine, its use and misuse.

GPO Stock #017-024-00592-4 $6.00 NTIS PB #269 175/AS $19

14 MARIJUANA RESEARCH FINDINGS: 1976. Robert C. Petersen, Ph.D.,

ed. Technical papers on which the 6th Marijuana and Health report

to Congress was based.

GPO out of stock NTIS PB #271 279/AS-$22

15 REVIEW OF INHALANTS: EUPHORIA TO DYSFUNCTION. Charles Wm.

Sharp, Ph.D., and Mary Lee Brehm, Ph.D., eds. Review of inhalant

abuse, including an extensive bibliography.

GPO Stock #017-024-00650-5 97.50 NTIS PB #275 798/AS $28

159
16 THE EPIDEMIOLOGY OF HEROIN AND OTHER NARCOTICS. Joan Dunne

Rittenhouse, Ph.D., ed. Task Force report on research

technologies and implications for studying heroin-narcotic use.

GPO Stock #017-024-00690-4 $6.50 NTIS PB #276 357/AS 120.50

17 RESEARCH ON SMOKING BEHAVIOR. Murray E. Jarvik, M.D., Ph.D.,

et al., eds. Includes epidemiology, etiology, consequences of

use, and approaches to behavioral change. From a NIDA-supported

UCLA conference.

GPO Stock #017-024-00694-j $7.50 NTIS PB #276 353/AS $29.50

18 BEHAVIORAL TOLERANCE: RESEARCH AND TREATMENT IMPLICATIONS.

Norman A. Krasnegor, Ph.D., ed. Theoretical and empirical studies

of nonpharmacologic factors in development of drug tolerance.

GPO Stock #D17-024-00699-8 $5.50 NTIS PB #276 337/AS $16

19 THE INTERNATIONAL CHALLENGE OF DRUG ABUSE. Robert C. Petersen,

Ph.D., ed. Papers from the VI World Congress Of Psychiatry .

GPO Stock #017-024-00822-2 $7.50 NTIS PB #293 807/AS $28

20 SELF-ADMINISTRATION OF ABUSED SUBSTANCES: METHODS FUR STUDY.

Norman A. Krasnegor, Ph.D., ed. Techniques used to study basic

processes underlying abuse of drugs, ethanol, food, and tobacco.

GPO Stock #017-024-00794-3 $6.50 NTIS PB #288 471/AS $22

21 PHENCYCLIDINE (PCP) ABUSE: AN APPRAISAL. Robert C. Petersen,

Ph.D., and Richard C. Stillman, M.D., eds. For clinicians and

researchers, assessing the problem of PCP abuse.

GPO Stock #017-024-00785-4 $7.00 NTIS PB #288 472/AS $25

22 QUASAR: QUANTITATIVE STRUCTURE ACTIVITY RELATIONSHIPS OF

ANALGESICS, NARCOTIC ANTAGONISTS, AND HALLUCINOGENS. Gene

Barnett, Ph.D.; Milan Trsic, Ph.D.; and Robert Willette, Ph.D.;

eds. Reports from an interdisciplinary conference on molecular

drug-receptor interactions.

GPO Stock #017-024-00786-2 $8.00 NTIS PB #292 265/AS 935.50

23 CIGARETTE SMOKING AS A DEPENDENCE PROCESS. Norman A.

Krasnegor, Ph.D., ed. Discusses factors involved in the onset,

maintenance, and cessation of the cigarette smoking habit.

Includes an agenda for future research.

GPO Stock #017-024-00895-8 $6.00 NTIS PB #297 721/AS $19

24 SYNTHETIC ESTIMATES FOR SMALL AREAS: STATISTICAL WORKSHOP

PAPERS AND DISCUSSION. Jos. Steinberg, ed. Papers from a workshop on statistical approaches that yield needed estimates of

data for States and local areas. Not available from NCDAI.

GPO Stock #017-024-00911-3 $8.00 NTIS P8 #299 009/AS $23.50

25 BEHAVIORAL ANALYSIS AND TREATMENT OF SUBSTANCE ABUSE. Norman

A. Krasnegor, Ph.D., ed. Papers on commonalities and

implications for treatment of dependency on drugs, ethanol, Food,

and tobacco.

GPO Stock #017-024-00939-3 35.00 NTIS PB #80-112428 $22

160
26 THE BEHAVIORAL ASPECTS OF SMOKING. Norman A. Krasnegor, Ph.D.,

ed. Reprint of the behavioral section of the 1979 Report of the

Surgeon General on Smoking and Health; introduction by editor.

GPO out of stock NTIS PB #80-118755 $17.50

27 PROBLEMS OF DRUG DEPENDENCE, 1979: PROCEEDINGS OF THE 41ST

ANNUAL SCIENTIFIC MEETING, THE COMMITTEE ON PROBLEMS OF DRUG DEPENDENCE, INC. L.S. Harris, Ph.D., ed. Not available from NCDAI.

GPO Stock #017-024-00981-4 $9.00 NTIS PB #80-175482 337

28 NARCOTIC ANTAGONISTS: NALTREXONE PHARMACOCHEMISTRY AND

SUSTAINED-RELEASE PREPARATIONS. Robert Willette, Ph.D., and

Gene Barnett, Ph.D., eds. Papers report research on sustainedrelease and long-acting devices for use with the narcotic antagonist naltrexone.

GPO Stock #017-024-01081-2 37.00 NTIS PB 881-238875 $23.50

29 DRUG ABUSE DEATHS IN NINE CITIES: A SURVEY REPORT. Louis A.

Gottschalk, M.D., et al. Epioemiologic study providing data on

drug-involved deaths and procedures for their investigations.

Not available from NCDAI.

GPO Stock #D17-024-00982-2 $6.50 NTIS PB #80-178882 $17.50

30 THEORIES ON DRUG ABUSE: SELECTED CONTEMPORARY PERSPECTIVES.

Dan J. Lettieri, Ph.D.; Mollie Sayers; and Helen Wallenstein

Pearson, eds. Volume presents summaries of the major contemporary theories of drug abuse by each of 43 leading theorists.

GPO Stock #017-024-00997-l $10.00 Not available from NTIS

31 MARIJUANA RESEARCH FINDINGS: 1980. Robert C. Petersen, Ph.D.,

ed. The text of the 8th Marijuana and Health report to Congress

and the background scientific papers on which it was based.

GPO out of stock NTIS PB #80-215171 $20.50

32 GC/MS ASSAYS FOR ABUSED DRUGS IN BODY FLUIDS. Rodger L. Foltz,

Ph.D.; Allison F. Fentiman, Jr., Ph.D.; and Ruth B. Foltz. A

collection of methods For quantitative analysis Of several

important drugs of abuse by gas chromatography- mass spectrometry.

GPO Stock #017-024-01015-4 $6.00 NTIS PB #81-133746 $19

33 BENZODIAZEPINES: A REVIEW OF RESEARCH RESULTS, 1980. Stephen

I. Szara, M.D., D.Sc., and Jacqueline P. Ludfora, M.S., eds.

A RAUS (Research Analysis and Utilization System) Review Report

on the abuse liability of the benzodiazepine "tranquilizers."

GPO Stock #017-024-01108-8 $5.00 NTIS PB #82-139106 $13

34 PROBLEMS OF DRUG DEPENDENCE, 1980: PROCEEDINGS OF THE 42ND

ANNUAL SCIENTIFIC MEETING, THE COMMITTEE ON PROBLEMS OF DRUG

DEPENDENCE, INC. Louis S. Harris, Ph.D., ed.

GPO Stock #017-024-01061-8 $8.00 NTIS PB #81-194847 $34

161
35 DEMOGRAPHIC TRENDS AND DRUG ABUSE, 1980-1995. Louise G.

Richards, Ph.D., ed. Estimates of probable extent and nature Of

nonmedical drug use, 1980-1995, based on age structure and other

characteristics of U.S. population.

GPO Stock #017-024-01087-l $4.50. NTIS PB 182-103417 $13

36 NEW APPROACHES TO TREATMENT OF CHRONIC PAIN: A REVIEW OF MULTIDISCIPLINARY PAIN CLINICS AND PAIN CENTERS. Lorenz K.Y. Ng, M.D.,

ed. A sharing of ideas among active practitioners in the treatment Of pain.

GPO Stock #017-024-01082-l $5.50. NTIS Pa #81 -240913 $19

37 BEHAVIORAL PHARMACOLOGY OF HUMAN DRUG DEPENDENCE. Travis

Thompson, Ph.D., and Chris E. Johanson, Ph.D., eds. Presents a

growing body of data, systematically derived, on the behavioral

mechanisms involved in use and abuse of drugs.

GPO Stock #017-024-01109-6 $6.50 NTIS PB #82-136961 $25

38 DRUG ABUSE AND THE AMERICAN ADOLESCENT. Dan J. Lettieri,

Ph.D., and Jacqueline ?. Ludford, M.S., eds. A RAUS Review

'Report, emphasizing use of marijuana: epidemiology, sociodemographic and personality factors, family and peer influence,

delinquency, and biomedical consequences.

GPO Stock #017-024-01107-O $4.50 NTIS PB #82-148198 $14.50

39 YOUNG MEN AND DRUGS IN MANHATTAN: A CAUSAL ANALYSIS.

Richard R. Clayton, Ph.D., and Harwin L. Voss, Ph.D. Examines

the etiology and natural history of drug use, with special focus

on heroin. Includes a Lifetime Drug Use Index.

GPO Stock #017-024-01097-9 $5.50 NTIS PB #82-147372 $19

40 ADOLESCENT MARIJUANA ABUSERS AND THEIR FAMILIES. Herbert

Hendin, M.D., Ann Pollinger, Ph.D., Richard Ulman, Ph.D., and

Arthur Carr, Ph.D. A psychodynamic study of adolescents

involved in heavy marijuana use, to determine what interaction between family and adolescent gives rise to drug abuse.

GPO Stock #017-024-01098-7 $4.50 NTIS P8 #82-133117 $13

41 PROBLEMS OF DRUG DEPENDENCE, 1981: PROCEEDINGS OF THE 43RD

ANNUAL SCIENTIFIC MEETING, THE COMMITTEE ON PROBLEMS OF DRUG

DEPENDENCE, INC. Louis S. Harris, Ph.D., ed. A broad review Of

current research. Includes treatment issues; chemistry and

pharmacology of abused drugs; efficacy and dependence liability

of new compounds.

Not available from GPO NTIS PB #82-190760 941.50

42 THE ANALYSIS OF CANNABINOIDS IN BIOLOGICAL FLUIDS. Richard L.

Hawks, Ph.D., ed. Presents varied approaches to sensitive,

reliable, and accessible quantitative assays for the chemical

constituents of marijuana, For basic researchers in biomedical

and forensic science.

GPO Stock # 017-024-01151-7 35 NTIS PB #83-136044 $16

162
43 PROBLEMS OF DRUG DEPENDENCE, 1982: PROCEEDINGS OF THE 44TH

ANNUAL SCIENTIFIC MEETING, THE COMMITTEE ON PROBLEMS OF DRUG

DEPENDENCE, INC. Louis S. Harris, Ph.D., ed. A collection of

papers which together record a year's advances in drug abuse

research; also includes reports on tests of new compounds for

efficacy and dependence liability.

GPO Stock #017-024-01162-2 $8.50 NTIS PB 83-252-692 $40

47 PREVENTING ADOLESCENT DRUG ABUSE: INTERVENTION STRATEGIES.

Thomas J. Glynn, Ph.D.; Carl G. Leukefeld, D.S.W..; and

Jacqueline P. Ludford, M.S., eds. A RAUS Review Report on a

variety of approaches to prevention of adolescent drug abuse, how

they can be applied, their chances for success, and needed Future

research.

Not available from GPO NTIS PB to be assigned

48 MEASUREMENT IN THE ANALYSIS AND TREATMENT OF SMOKING

BEHAVIOR. John Grabowski, Ph.D., and Catherine S. Bell, M.S.,

eds. Based upon a meeting cosponsored by NIDA and the National

Cancer Institute to delineate necessary and sufficient measures

for analysis of smoking behavior in research and treatment

settings.

GPO Stock #017-024-01181-9 $4.50 NTIS PB to be assigned

IN PREPARATION

44 MARIJUANA EFFECTS ON THE ENDOCRINE AND REPRODUCTIVE SYSTEMS.

Monique C. Braude, Ph.D., and Jacqueline P. Ludford, M.S., eds.

A RAUS Review Report of animal studies and preclinical and

clinical studies of effects of cannabinoids on human endocrine

and reproductive functions.

45 CONTEMPORARY RESEARCH IN PAIN AND ANALGESIA, 1983. Roger M.

Brown, Ph.D.; Theodore M. Pinkert, M.D., J.D.; and Jacqueline P.

Ludford, M.S., eds. A RAUS Review Report on the anatomy,

physiology, and neurochemistry of pain and its management.

163
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