A randomized trial of contingency management delivered in the context of group counseling.

Contingency management interventions provide tangible reinforcers for objective evidence of behavior change. Typically, researchers provide vouchers exchangeable for retail goods or services (Higgins et al., 1994) or the chance to win prizes of varying magnitudes (Petry, Martin, Cooney, & Kranzler, 2000) when patients submit urine samples that indicate drug abstinence. A recent meta-analysis (Dutra et al., 2008) of psychosocial treatments for substance use disorders found that CM is the intervention with the greatest effect size. Meta-analyses of CM studies (Lussier, Heil, Mongeon, Badger, & Higgins, 2006; Prendergast, Podus, Finney, Greenwell, & Roll, 2006) likewise reveal efficacy of CM in treating substance use disorders. However, the vast majority of studies evaluated CM when delivered entirely on an individual basis, yet most treatment is provided in a group context. An empirically established method for delivering CM in group settings would enhance the dissemination of CM. Given providers’ concerns about the practicality of individually administered CM (Kellogg et al., 2005; Kirby, Benishek, Dugosh, & Kerwin, 2006), a handful of studies have begun examining CM when delivered in a group context (Alessi, Hanson, Tardif, & Petry, 2007; Kirby, Kerwin, Carpendo, Rosenwasser, & Gardner, 2008; Ledgerwood, Alessi, Hanson, Godley, & Petry, 2008; Petry, Martin, & Finocche, 2001; Sigmon & Stitzer, 2005). With the exception of the Alessi et al. (2007) and Kirby et al. (2008) studies, the researchers chose attendance alone, rather than drug abstinence, as the behavioral target of their intervention, primarily because of concerns about confidentiality related to urine testing; these studies did not monitor substance use, so effects of the group-based CM interventions on substance use outcomes could not be determined. Although these studies found benefits of CM on attendance, more research on group-based CM approaches is needed to evaluate its effects on substance use. If efficacious, a CM intervention delivered in a group context could have benefits for patients, providers, and society at large. Patients may remain in treatment longer and reduce drug use (Higgins et al., 1994; Higgins, Wong, Badger, Ogden, & Dantona, 2000; Petry, Alessi, Marx, Austin, & Tardif, 2005; Petry, Peirce et al., 2005). Providers could benefit because CM can increase attendance at treatment (Higgins et al., 1994; Higgins, Wong et al., 2000; Ledgerwood et al., 2008; Petry, Alessi et al., 2005; Petry et al., 2001; Petry, Peirce et al., 2005) so that groups should be fuller, and unexcused absences and attrition reduced. Job satisfaction may increase when therapists provide CM (Kellogg et al., 2005), which in turn may reduce therapist turnover rates. Potentially, CM could also enhance the therapeutic alliance and improve group cohesion, resulting in more satisfying groups for both patients and providers. Greater attendance can increase provider reimbursement rates in non-capitated reimbursement systems (Lott & Jencius, 2009). Society may also benefit from the introduction of CM clinically. Reductions in drug use that occur with CM may reduce drug-related criminal activity and medical consequences associated with substance abuse. In particular, recent analyses (DeFulio, Donlin, Wong, & Silverman, 2009; Ghitza, Epstein, & Preston, 2008; Hanson, Alessi, & Petry, 2008) find that CM reduces HIV risk behaviors in methadone-maintained patients, and it is associated with a reduction in viral loads when administered to HIV-positive substance abusers (Petry, Weinstock, Alessi, Lewis, & Dieckhaus, 2010). CM can be very beneficial, but a practical group-based CM approach for use in community settings must be applicable to all patients attending a group, as groups in community settings are usually heterogeneous with respect to substance use problems. To date, however, most CM studies have limited enrollment to individuals with a particular substance use disorder, and most reinforcement has been contingent on abstinence from just the primary substance of abuse (Higgins et al., 1994; Lussier et al., 2006). Meta-analyses reveal that effect sizes for CM are higher when abstinence from a single substance is reinforced versus when abstinence from multiple substances is reinforced (Griffith, Rowan-Szal, Roark, & Simpson, 2000; Lussier et al., 2006), but the vast majority of patients entering treatment programs have polysubstance use problems (Substance Abuse and Mental Health Services Administration Office of Applied Studies, 2009). The purpose of the present study was to evaluate the efficacy of CM when delivered in a group format and applicable to patients with a range of substance use disorders. The reinforcement procedure was a novel adaptation from previous group-based CM interventions (Alessi et al., 2007; Ledgerwood et al., 2008; Petry et al., 2001). Each day CM patients attended group counseling sessions, they earned at least one chance to have their name drawn from a hat, and chances increased with sustained attendance and abstinence from four substances (cocaine, methamphetamine, opioids and alcohol) as assessed by twice-weekly testing. Whenever their names were drawn from the hat, patients won a prize ranging from $1 to $100 in value. We evaluated the efficacy of this CM treatment delivered in a group format compared to standard care. Patients with a variety of substance use disorders were included to enhance generalization to those typically treated in outpatient treatment programs, and the study was conducted at two community clinics that had never participated in CM projects. We also assessed effects of CM on the therapeutic process and HIV risk behaviors. We expected patients assigned to the CM condition would evidence greater attendance, more abstinence, stronger group cohesion and therapeutic alliances, and reduced HIV risk behaviors than patients assigned to standard care.