Journal of Consulting and Clinical Psychology 2001, Vol. 69, No.

4, 643-654

In the public domain DOI: 10.I037//0022-006X.69.4.643

Shaping Cocaine Abstinence by Successive Approximation

Kenzie L. Preston, Annie Umbricht, Conrad J. Wong, and David H. Epstein
National Institute on Drug Abuse
Cocaine-using methadone-maintenance patients were randomized to standard contingency management (abstinence group, n = 49) or to a contingency designed to increase contact with reinforcers (shaping group, n = 46). For 8 weeks, both groups earned escalating-value vouchers based on thrice-weekly urinalyses: The abstinence group earned vouchers for cocaine-negative urines only; the shaping group earned vouchers for each urine specimen with a 25% or more decrease in cocaine metabolite (first 3 weeks) and then for negative urines only (last 5 weeks). Cocaine use was lower in the shaping group, but only in the last 5 weeks, when the response requirement was identical. Thus, the shaping contingency appeared to better prepare patients for abstinence. A 2nd phase of the study showed that abstinence induced by escalating-value vouchers can be maintained by a nonescalating schedule, suggesting that contingency management can be practical as a maintenance treatment.

In the substantial effort expended to find effective therapies for cocaine abuse, contingency management has been among the most successful treatments to date. Contingency management was developed using operant principles whose effectiveness had been demonstrated preclinically (Bigelow & Silverman, 1999). Contingent reinforcement of target behaviors, such as drug abstinence and participation in treatment activities, can be a powerful tool in establishing positive behavioral changes in drug abusers (Higgins, Stitzer, Bigelow, & Liebson, 1986; Kidorf & Stitzer, 1996; McCaul, Stitzer, Bigelow, & Liebson, 1984; Stitzer, Iguchi, & Felch, 1992). One of the most effective applications of the procedure has used a monetary-based escalating-reinforcement schedule in which the value of the incentive increases with each consecutive drugnegative urine specimen, whereas lapses (positive urine specimens) and missed specimen collections result in loss of the incentive and a return of the next earned incentive to the original value (Higgins et al., 1991, 1993, 1994). This procedure has been used successfully in a number of clinics, including our own (Kirby, Marlowe, Festinger, Lamb, & Platt, 1998; Silverman et al., 1996, 1998). Most studies using contingency management have made the delivery of incentives contingent on drug-negative urine specimens (i.e., reinforcement of abstinence). Although this technique

Kenzie L. Preston, Annie Umbricht, Conrad J. Wong, and David H. Epstein, Intramural Research Program, National Institute on Drug Abuse, Baltimore, Maryland. Conrad J. Wong is now at the Department of Psychiatry and Behavioral Biology, Johns Hopkins University School of Medicine. This study was supported by the Intramural Research Program of the National Institute on Drug Abuse. We are grateful to the Archway treatment staff and technicians; to Kenneth Silverman and Charles R. Schuster who helped design the clinical trial; to Robert Brooner who monitored the methadone-maintenance treatment; and to Anna DeJesus who assisted in the conduct of this study. Correspondence concerning this article should be addressed to Kenzie L. Preston, Intramural Research Program, National Institute on Drug Abuse, 5500 Nathan Shock Drive, Baltimore, Maryland 21224. Electronic mail may be sent to kpreston@intra.nida.nih.gov.
643

has been effective for many patients, experience in our clinic has shown that some participants who reduce their cocaine use will not immediately produce negative urine specimens. Cocaine urine screens are typically considered positive above a cutoff of 300 ng/ml in benzoylecgonine equivalents (BZE); benzoylecgonine, the major metabolite of cocaine, has a urinary excretion half-life of 6 to 8 hr (Ambre, 1985) and can usually be detected for 48 hr (Saxon, Calsyn, Haver, & Delaney, 1988). In some cases, patients may cease or reduce their cocaine use, yet go unreinforced because not enough time has elapsed before sample collection, especially if initial BZE levels were high. For example, in patients who had appeared unresponsive to a voucher contingency in one of our earlier studies (Silverman et al., 1996), quantitative urinalyses showed significant decreases in BZE levels (from a mean of approximately 60,000 ng/ml during baseline to approximately 30,000 ng/ml during the voucher contingency). These patients had presumably reduced their cocaine use, yet they received few or no vouchers because their BZE concentrations remained above the standard cutoff. Upon not receiving a voucher, such patients may have become discouraged and relapsed to drug use before achieving abstinence of adequate duration to have a negative urine screen. In this study we tested a variation of contingency management in which incentives were initially given for decreases in BZE concentrations and subsequently were given only for samples testing negative for BZE at the standard cutoff. Reinforcement of successive approximations of a desired behavior (in this case, cocaine abstinence) is known in the operant conditioning literature as shaping (Catania, 1973). Shaping has an extensive history for training desirable behaviors in nonhumans and has been used successfully to modify behavior in clinical populations as well (e.g., see Catania, 1973; Meyer & Chesser, 1970). We hypothesized that patients would be more likely to reach the ultimate goal of cocaine abstinence if incremental decreases in BZE concentrations were reinforced early in treatment. This shaping of abstinence was compared with a more typical contingency procedure in which incentives were given only for samples testing negative for BZE at the standard cutoff.

644

PRESTON, UMBRICHT, WONG, AND EPSTEIN (Syva, Palo Alto, CA) system that gave qualitative results for cocaine (BZE), opiates (morphine), benzodiazepines (oxazepam), phencyclidine, barbiturates, and marijuana. Cutoff concentrations for positive specimens were 300 ng/ml for cocaine, opiates, and benzodiazepines; 25 ng/ml for PCP; and 50 ng/ml for marijuana. BZE concentrations were measured by fluorescence polarization immunoassay (FPIA) using TDx Cocaine Metabolite Assay reagents (TDx; Abbott Laboratories, Abbott Park, IL) on a TDx instrument. Cross-reactivity was 100% for BZE and less than 1% for cocaine, ecgonine methyl ester, and ecgonine. The assay provides accurate quantitation for concentrations between 30 and 5,000 ng/ml; specimens with concentrations higher than 5,000 ng/ml were diluted to concentrations within the 30 to 5,000 ng/ml range and reanalyzed. Breath alcohol levels were determined with an Alco-Sensor III (Intoximeters, St. Louis, MO).

A secondary goal of the study was to evaluate the use of a maintenance contingency as a follow-up to the escalatingreinforcement procedure. Patients who completed the main intervention phase of the present study were switched to a nonescalating reinforcement schedule (with fixed-amount vouchers and takehome doses given as incentives for negative urine specimens). This was tested against a control procedure in which the same fixed-amount vouchers and take-home doses were given noncontingently. Method Participants
Participants were selected from 285 patients consecutively admitted for methadone maintenance at Archway Clinic, the treatment research program of the National Institute on Drug Abuse Intramural Research Program in Baltimore, MD. Applicants were first screened by telephone and then in two on-site visits that included medical, psychiatric, and drug-use histories, a physical examination, urine and blood screens, and a battery of assessment instruments: Addiction Severity Index (McLellan et al., 1985); National Institute on Mental Health Diagnostic Interview Schedule (Helzer, Croughan, Robins, & Ratcliff, 1981); Beck Depression Inventory (BDI; Beck & Steer, 1987); Symptom Check List90Revised (SCL-90-R; Derogatis, 1977); and the Shipley Institute of Living Scale (Zachary, 1986). Persons were eligible for the study if they were between 18 and 65 years of age, if they qualified for methadone maintenance according to Food and Drug Administration guidelines, and if they reported histories of intravenous opiate use. Two studies were conducted concurrently, this study focusing on cocaine use and the other focusing on opiate use (Preston, Umbricht, & Epstein, 2000). Patients were eligible for the opiate or cocaine study if at least 3 of 15 urine specimens collected during a 5-week baseline treatment phase tested positive for morphine (heroin metabolite) or BZE, respectively. Patients who met the criteria for cocaine but not for opiates were assigned to the present cocaine study. Patients who met the criteria for both drugs were randomly assigned to one of the studies. Persons with current major psychiatric illness or unstable serious medical illness were excluded. The local institutional review board for human research approved this study, and all participants gave informed written consent prior to participation.

Self-Report

Questionnaires

We collected participants' self-reports of drug use immediately after each urine collection. Participants were asked whether they had used, the amount and number of times used, and the dollars spent on alcohol, opiates, cocaine, benzodiazepines, phencyclidine, or marijuana on each day since their last clinic visit. On Wednesdays, participants completed a craving questionnaire and the Lifestyle Changes Questionnaire (Silverman et al., 1998). On the craving questionnaire, participants rated how much they had wanted cocaine and heroin during the past week on a scale from 0 (not at all) to 4 (extremely). On the Lifestyle Changes Questionnaire, participants indicated whether they had engaged in any of nine activities to stop, reduce, or avoid cocaine/heroin use during the past week (analyzed as total number of items endorsed) and whether they had engaged in any criminal activity.

Study Timeline and Groups

The study was conducted in three consecutive phases: a 5-week baseline treatment phase, an 8-week intervention, and a 12-week maintenance phase. Baseline began on study enrollment and continued until the participant had provided 15 urine specimens, typically at the end of 5 weeks. At the end of baseline, participants were randomized to one of two intervention groups, an experimental group reinforced for decreases in drug use and a control group reinforced for cocaine-negative urine specimens only. At the end of the intervention, participants remaining in treatment were offered 12 weeks of additional methadone maintenance; half of the participants in each group were randomly assigned to continue on a maintenance contingency or to switch to a noncontingent condition. (This "rerandomization" aspect of the study design is similar to that used in the Pittsburgh study of maintenance treatments for depression; Kupfer et al., 1992.) Treatment and data collection otherwise remained the same throughout the study.

Standard Treatment
All participants received, without charge, standard methadone maintenance that consisted of daily methadone and weekly individual counseling throughout the 25-week study. Methadone HO (Mallinckrodt, St. Louis, MO) was administered orally in a constant volume (35 ml) of a cherryflavored solution. Methadone dose was stabilized at 50 mg within the first week of treatment and held constant through the 25-week study. Counseling sessions were problem focused and included both supportive and motivational techniques. Counselors completed a semistructured psychosocial assessment and master treatment plan for each participant that guided the focus of all counseling sessions. Reduction of substance use was the primary goal. Counselors helped participants develop a functional analysis of their substance use, identify and avoid high-risk substance use situations, avoid friends and acquaintances who used drugs, cope with urges to use drugs, and examine acute and long-term consequences of drug use.

Intervention
During the intervention, all participants could earn vouchers on the basis of urine specimens collected every Monday, Wednesday, and Friday. The abstinence group (n = 49) earned vouchers for each urine specimen that tested cocaine negative on the qualitative urine screen at the 300 ng/ml BZE cutoff. This criterion for earning vouchers was in place throughout the 8 weeks of intervention. Patients in this group received the following instruction at the beginning of the intervention: "For the next 8 weeks, you can earn vouchers for providing urine samples which indicate that you have not used cocaine." The shaping group (n = 46) earned vouchers for each urine specimen whose BZE concentration was 25% or less than that of the specimen collected 48 hr to 72 hr earlier during the previous clinic visit or less than 300 ng/ml. This shaping contingency was in effect for 3 weeks, followed by 5 weeks of an abstinence contingency (identical to the one

Urine and Breath Toxicology

Each Monday, Wednesday, and Friday urine specimens were collected under the observation of trained laboratory technicians. We conducted qualitative testing with an enzyme multiplied immunoassay technique

SHAPING COCAINE ABSTINENCE used for the abstinence group). Patients in this group received the following instructions: For the next 8 weeks, you can earn vouchers for providing urine samples which indicate that you have decreased your use or not used cocaine. During the first 3 weeks we will measure the amount of cocaine in your urine. If the amount of cocaine in your urine is decreased by at least one quarter (25%) compared to your previous urine sample, you will earn a voucher. You will also receive a voucher if your urine sample is cocaine-free during Weeks 1 to 3. During Weeks 5 to 8, you will earn vouchers only if your urine sample is cocaine-free. The 25% criterion was chosen to reflect what we thought would be clinically significant decreases in use and was based on earlier work in our clinic showing that a 50% decrease in BZE concentration generally indicates abstinence (Preston, Silverman, Schuster, & Cone, 1997). The voucher incentive program was based on that developed by Higgins and colleagues (Higgins et al., 1991, 1993, 1994). The values of the vouchers were the same for both groups. Values began at $2.50 and increased in value by $1.50 for each consecutive voucher earned. In addition, for every three consecutive vouchers earned, participants received an additional voucher worth $10. A participant who met the criteria for earning a voucher for 8 consecutive weeks could earn a total of $554 (average $9.89 per day). If the participant did not meet the criteria for earning a voucher, the participant did not receive a voucher, and the value of the next earned voucher was reset to $2.50. Earned vouchers were given to participants the day after urine collections (Tuesday, Thursday, and Saturday). The vouchers were exchangeable for goods and services (e.g., passes to the movies, exercise equipment, driver's license, or gift certificate) that would support a drug-free lifestyle. When the participant accumulated enough vouchers to purchase a desired item, a staff member reviewed the request to determine whether the desired item was consistent with that participant's treatment goals. Items were purchased by staff members and given to participants in the clinic; no money was given directly to participants.

645

Maintenance Contingency
At the end of the intervention phase, participants were rerandomized to one of two maintenance conditions: contingent or noncontingent. Participants in the contingent group received a $10 voucher for each cocainenegative specimen submitted for the thrice-weekly urine tests. In addition, if participants had two out of three cocaine-negative urine specimens during the week, they received a dose of methadone on Saturday to take at home on Sunday. Participants assigned to the noncontingent group received vouchers and take-home doses independent of their urine results. Each noncontingent group participant was randomly yoked to a participant in the contingent group, independent of intervention group assignment. For each clinic visit numbered from 1 to 36 (3 per week for 12 weeks) that the contingent participant earned a voucher or take-home dose for testing cocaine-negative, the noncontingent participant received an identical voucher or take home dose for providing urine. If the noncontingent participant did not provide a urine specimen or did not attend clinic, the incentive was forfeited; participants were not told when this occurred. Rules for using vouchers remained as in the intervention phase; unused voucher money accumulated across the entire study and could be used for up to 1 year after study participation ended.

To ensure comparability between groups, we analyzed intake measures by analysis of variance (ANOVA; for continuous variables), Pearson chi square (for categorical variables), or Fisher's exact test (for categorical variables with expected cell sizes less than 5). Retention rates were compared between groups with survival analysis, by using a log-rank test of time until the provision of the final urine sample; participants who left before the final week of the experimental phase (intervention or maintenance) were coded as dropouts. Participants with three or more sporadically missing urine tests (i.e., not because of dropout) during the experimental phase were coded as poor attenders; this was compared between groups with Fisher's exact test. Voucher earnings were compared by ANOVA; percentages of participants never earning a voucher were compared by Pearson chi-square test. The time course of cocaine use during intervention was analyzed with generalized linear mixed models fit with the SAS macro GLIMMIX (Littel, Milliken, Stroup, & Wolfinger, 1996). GLIMMIX analyzes dichotomous repeated measures with missing datapoints by invoking the SAS procedure MIXED with a logit link (SAS, 1997) and gives adjusted proportions. A first-order autoregressive error structure was used. Continuous measures taken at repeated timepoints during intervention (such as BZE levels, craving, self-reported use, and lifestyle changes) were analyzed with mixed regressions (SAS MIXED procedure). Each model contained one withinsubject factor (Time) and four between-subjects factors: contingency, baseline percentage negative (or mean), poor attendance, and dropout (Hedeker & Gibbons, 1997). Analyses of maintenance-phase data controlled for prior contingency as an additional between-subjects factor; some maintenance-phase analyses also controlled for intervention percentage negative. In the intervention phase, eight intake measures differed between groups at p s .10; in the maintenance phase, five intake measures differed between groups at p & .10. To control for potential confounding, we considered each intake measure for inclusion in the GLIMMIX and mixedregression models if it had a main effect on the outcome measure at p s .05 and if that effect remained significant when it was entered into a model with the factors listed in the previous paragraph. In no case did that occur. Because the BZE data were heavily right-skewed, all nonzero values were log-transformed (Delucchi, Jones, & Batki, 1997) to reduce the influence of extremely high values before the data were entered into a mixed-regression model. Longest duration of cocaine abstinence was calculated for each participant as the longest run of consecutive cocaine-negative urine specimens during intervention and maintenance phases; groups were compared by an ANOVA. All analyses were two-tailed; a was set at .05, with trends noted at .10.

Results Participant Characteristics

Of the 285 participants who enrolled in the study, 253 completed the 5-week baseline. Of these 253, 22 participants met the criteria for cocaine use only, 29 met the criteria for opiate use only, and 190 participants met the criteria for both opiate and cocaine use. Twelve patients did not meet criteria for either drug; they received standard treatment for the duration of the study. A total of 95 participants were randomized to one of two groups in the present study; the two groups did not differ in terms of drug criteria met, x*(l, N = 95) = 0.38, p = .54. Their demographic information is shown in Table 1. Among the 43 demographic variables compared, eight differed across intervention groups at p < .10: The shaping group had more illegal income, more years of sedative use, more recent days of cocaine use, more recent days of heroin use, higher BDI scores, and more psychiatric symptom-

Data Analysis
Because participants were rerandomized into new groups between the intervention and maintenance phases, data from the two phases were analyzed separately (but similarly). The analyses described here apply to both phases, with exceptions as noted.

646
Table 1 Demographic Characteristics of Patients

PRESTON, UMBRICHT, WONG, AND EPSTEIN

Intervention phase Variable Age (in years; M SD) Male (%) African American (%) Marital status (%) Married Divorced/widowed Never married Separated Employment (%) Full time Part time Unemployed Income past 30 days (U.S. $; M SD) Legal Illegal Education (in years; M SD) Self-reported life years of drug use (M SD) Heroin Cocaine Alcohol Sedatives/tranquilizers Marijuana Drug use in past 30 days
(M SD)

Maintenance phase

Abstinence ( = 49)
38.2 6.1 51 52
14 18 41 27 27

Shaping (n = 46)
37.9 5.3 59 59
22 20 46 13

Analysis" F(l,93) ^(1) = ^(D = ^(3) = = 0.06 0.56 0.47 3.04

P
.81 .45 .49

Contingent Noncontingent (n = 41) (n = 39)

38.5 5.6 54 54
15 20 42 24

Analysis'"
F(l, 78) = 0.04 A^d) = 0.19 X*W = 0.05 ?(3) = 0.80

P
.84 .67 .68 .85

38.7 5.6 46 52
21 21 41 18

.39

X*(2) = 0.05

.98
29

^(2) = 1.37

.50

16
57 642 478 70 76

28 15 57 715 526 868 1,919

20 51
F(l, 93) = 0.52 F(l, 93) = 8.39
.47 <.01 570 396 363 843

31 10

59
776 571 181 390

F(l, 78) = 3.53 F(l,78) = 1.51 F(l, 78) = 0.66 F(l, 78) = F(l, 78) = F(l,78) = F(l, 78) = F(l, 78) = F(l, 78) = F(l, 78) = F(l,78) = F(l, 78) = F(l, 78) = 1.00 0.24 7.41 0.11 5.3 0.09 0.00 1.31 0.11 4.04

<.07 .22
.42 .32 .63 <.01 .74 .024 .76 .99 .26 .74 <.05

11.5 1.8 15.2 6.0 3.6 0.02 3.6 22.3 9.9 4.1 0.2 0.8 7.6 7.5 6.2 0.1 6.2
11.4 10.0 7.3 0.6 1.9

11.6 1.9 12.3 8.3 6.6 6.0 4.4 8.0 0.7 2 . 1 4.0 6.7 25.9 15.8 3.7 0.9 1.0
8.3 10.5 7.0 3.0 2.8

F(l,93) = 0.18 F(l,93) F(l, 93) F(l,93) F(l, 93) F(l,93)

F(l, F(l, F(l, F(l, F(l,
93) 93) 93) 93) 93)

.68 .08
.67 .60 .04 .74 .08 <.01 .74 .12 .64

11.4 2.0

11.7 1.9 13.4 7.7 6.1 7.0

= = = = =
= = = = =

3.18 0.18 0.28 4.43 0.11

3.13 7.84 0.11 2.46 0.22

15.2 6.9 5.4 0.6 5.5

8.7 6.7 8.2 2.5 7.7

1.6 3.4 0.5 2.1

2.1 4.7

Heroin Cocaine Alcohol Sedatives/tranquilizers Marijuana Current DSM-III-R diagnosis (% of Ss; from DIS) Phobia PTSD Antisocial personality Nicotine dependence Heroin dependence Cocaine dependence Alcohol dependence Sedative dependence BDI (M SD) SCL-90-R Global Severity Index
(M SDf

23.4 10.7 12.8 10.4 4.8 8.2 0.6 2.5 1.4 3.1

24.1 12.8 2.9 0.5 0.4

10.2 11.1 6.3 2.1 0.9

6 2 18 53 96 53 10 4 17.5 10.5

13 2 7 52 98 59 7 4 21.6 10.3

^(1) = 3.02 ^(1) = 0.01 ^(1) = 0.31 F(l, 93) = 3.62

,31d 1.00d .08 .93 1.00d .58 .72d 1.00d

.06
<.001

11 5 11 37 95 74 11 5 18.9 9.9

22 0 0 67 100 61 6 6 18.7 10.7

1.00d
|

,41d

/(I) = 3.29
/(D = 0.67

F(l, 78) = 0.0 F(l, 77) = 1.10 F(l, 78) = 0.42 F(l, 78) = 1.83 ^(1) = .0003

.49d .07 1.00d .41 1.00d 1.00d .95"

.30 .52 .18

60.4 8.8 39.7 9.9 47.9 9.0

67.7 10.4 39.9 10.8 48.4 9.7

F(l,92) = 13.53
F(l, 93) = 0.01 F(l, 93) = 0.06

64.8 10.4 39.3 10.1 47.7 8.5

54 46

62.4 10.0 40.7 8.9 50.3 9.0

54 46

Shipley Institute of Living Scale (M SD) Vocabulary Abstract thinking Prior contingency Abstinence (%) Shaping (%)

.92 .81

.99

Note. DSM-IH-R = Diagnostic and Statistical Manual of Mental Disorders (3rd ed., rev., American Psychiatric Association, 1987); Ss = participants; DIS = National Institute on Mental Health Diagnostic Interview Schedule; PTSD = posttraumatic stress disorder; BDI = Beck Depression Inventory; SCL-90-R = Symptom Check List-90Revised. " N for chi-square tests is 95. b N for chi-square tests is 89. c SCL-90-R data were missing for one participant in the abstinence group. d Fisher's exact.

SHAPING COCAINE ABSTINENCE atology on the SCL-90-R but had fewer years of heroin use and a lower prevalence of Antisocial Personality Disorder. After completing the intervention, 80 participants were rerandomized to one of the maintenance groups. The demographic characteristics of the rerandomized maintenance groups are also shown in Table 1. The groups did not differ in terms of prior group during intervention. Five demographic variables differed across groups at p < .10: The contingent group had less legal income, more years of alcohol and marijuana use, more recent days of cocaine use, more recent days of marijuana use, and lower prevalence of nicotine dependence.

647

Intervention Phase (Shaping vs. Abstinence Contingencies)

Retention, missing urine specimens, and voucher earnings. Overall, 80 (84%) of 95 participants completed all 8 weeks of intervention. Survival analysis showed no significant betweengroups difference in retention rates. Groups also did not differ in numbers of missed urine specimens (Table 2). Total voucher earnings did not differ between groups, but the number of vouchers earned in the first 3 weeks was significantly higher in the shaping group (Table 2). Participants in the abstinence group were significantly more likely to fail to contact the reinforcer (i.e., to earn at least one voucher), even during the

final 5 weeks of intervention, when the response requirement for the two groups was identical (Table 2). Cocaine useurine screens. Overall, approximately 15% of all urine specimens were cocaine negative during the 5-week baseline, with participants in the shaping group having a slightly, though not significantly, higher proportion of negative urines (Table 3; Figure 1). The trend during baseline was for the rate of negative urine specimens to decreasethat is, for use to increase. This trend was reversed in both groups with the onset of the contingent-voucher invention, resulting in a significant effect of phase (baseline vs. intervention, see Table 3). During the first 3 weeks of intervention, the percentage of cocainenegative urine specimens increased similarly in both groups (Figure 1). At the end of the third intervention week, when the shaping group was switched to the more stringent requirement of earning vouchers for cocaine-negative urine specimens, the percentage of cocaine-negative urine specimens in that group increased further. No corresponding increase occurred in the abstinence group. Data from the intervention phase were entered into a generalized linear mixed model, controlling for dropout, poor attendance, and each participant's percentage of cocaine-negative urine specimens during baseline. There was no main effect of group, but there was a significant Group X Day interaction, F(23, 1842) = 2.13, p < .002), reflecting the

Table 2 Retention, Missing Urine Specimens, and Voucher Earnings During Intervention and Maintenance Variable Abstinence Intervention phase Reached Week 8 of intervention, n Completed Week 8 of intervention, n Total weeks in treatment, including baseline (M SD) Sporadically missing urines during intervention M SD % poor attendersa Voucher earnings (U.S. $; M SD) Number of vouchers earned in first 3 weeks (M SD) Number of vouchers earned in final 5 weeks (M SD) Participants earning no vouchers First 3 weeks, n Final 5 weeks, n Throughout intervention phase, n
43 (88%) 43 (88%) 40 (87%) 37 (80%)

Shaping

Analysis

Log-rank /(I) = 0.83

F(l, 93) = 0.06 F(\, 93) = 0.61 ^(1) = 1.25 F(l,93) = 0.15

.36 .80 .44 .26 .70

12.34 1.93

12.23 2.04

1.12 1.94 16 $101 185 2.69 3.31 3.71 5.76

23 (47%) 27 (55%) 19 (39%)

0.87 1.05 9 $115 170 5.09 2.52 5.17 5.51

2 (4%) 14 (30%) 2 (4%)

F(l, 93) = 15.60 F(l, 93) = 1.60

^(1) = 22.20 ^(D = 5.88 /(I) = 16.33

<.001
.21

<.0001 .015 <.0001

Maintenance phase Number enrolled Reached Week 12 of maintenance, n Completed Week 12 of maintenance, n Total weeks in treatment, including baseline (M SD) Sporadically missing urines during maintenance M SD % Poor attenders" Voucher earnings (U.S. $; M SD) Number of take-home doses of methadone (M SD)
a

41 36 (88%) 34 (83%)

39 35 (90%) 34 (87%)

Log-rank ^(1) = 0.25

F(l, 78) = 0.23 F ( l , 78) = 1.91 /(I) = 4.47 F ( l , 78) = 0.30 F(l, 78) = 0.46

.62 .63 .17 <.04 .58 .50

24.5 1.7
1.2 1.5 9.8 $135 132 4.4 7.7

24.7 1.1
1.6 1.7 28.2 $119 126
3.7 4.6

Poor attenders are patients missing three or more urine specimens.

648
Table 3

PRESTON, UMBRICHT, WONG, AND EPSTEIN

Urine Test Results During Intervention: Mean Percentage of Drug-Negative Specimens and Standard Deviation
Group Abstinence Variable Cocaine-negative Baseline Intervention Opiate negative15 Baseline Intervention Benzodiazepine negative15 Baseline Intervention Cannabis negative6 Baseline Intervention Alcohol-negative0 Baseline Intervention
b

ANOVA Shaping Phase

F"
P

Phase X Group
F-

M
12 27 58 58 93 89 84 86 98 94

SD

M
17 33 61 57 95 92 90 87 98

SD 20 34

131.43

< .001
.73 < .02 .44 .21

2.01 0.39 0.05 0.73 3.80

.16 .54 .82 .40 < .06

18
37 29 38 16 24 29 27

0.12
23 30

5.48
14 17

0.61
24 27

1.61
5 21 99
5 4

Note. ANOVA = analysis of variance. 8 dfs = 1,93. b Urine specimens. c Breath specimens.

superior performance of the shaping group during the latter part of the intervention. Other measures of cocaine use also appeared to favor the shaping intervention, though not to a statistically significant degree. Mean BZE levels were 48,389 (SEM = 8,644) ng/ml in the shaping group and 56,340 (SEM = 8,626) in the abstinence group, mixed regression, F(l, 90) = 1.70, p = .20. The longest duration of abstinence, inferred from consecutive negative specimens, averaged 5.5 (SEM = 1.1) in the shaping group and 5.1 (SEM = 1.2) in the abstinence group, ANOVA, F(l, 93) = 0.04, p = .83; the difference remained nonsignificant in an analysis of covariance controlling for each participant's baseline percentage negative. Use of other drugs. There were only minor changes in other drug use from baseline to intervention, with rates of use similar across the two intervention groups (Table 3). There was a significant effect of phase (baseline vs. intervention) on percentage of benzodiazepine-negative urine specimens, with both groups having slightly fewer negative specimens during the intervention. The near-significant (p = .054) Phase X Group interaction for alcohol reflects the slightly greater tendency for the abstinence group to test positive for alcohol during the intervention. In both cases, however, the rates of positives for benzodiazepines and alcohol were relatively low and of doubtful clinical significance. Self-reported cocaine use, heroin use, cocaine craving, positive lifestyle changes, and criminal activity. Self-reported frequency of cocaine use tended to be higher during baseline in the shaping group than in the abstinence group; thus, when intervention data were analyzed in a mixed regression controlling for baseline, there was a trend toward a main effect of group, favoring the shaping intervention (Table 4). There were no significant group differences in other self-reported indices of cocaine or heroin use, drug craving, lifestyle changes, or criminal activities (Table 4). However, significant improvements occurred from baseline to intervention

(in both groups) in frequency, amount, and cost of heroin use, in craving for cocaine and heroin, and in criminal activities (repeatedmeasures ANOVAs on whole-phase means; data not shown).

Maintenance Phase (Abstinence Contingency vs. Noncontingent Vouchers)

Retention, missing urine specimens, and voucher earnings. Eighty participants completed the intervention and were rerandomized, with approximately half of each intervention group assigned to each of the contingent and noncontingent maintenance groups. Sixty-eight (85%) of the 80 participants completed all 12 weeks of maintenance. Survival analysis showed no significant betweengroups difference in retention rates during either phase. Groups also did not differ in numbers of missed urine specimens, in total voucher earnings, or in number of take-home doses of methadone (Table 2). However, there were significantly more poor attenders (participants missing three or more urine specimens) in the noncontingent group; this was controlled for in mixed models. Cocaine useurine screens. For the contingent group, the percentage of cocaine-negative urine specimens fluctuated around 40%; for the noncontingent group, it fluctuated around 20% (Figure 2). There was substantial day-to-day variability in each group, but no clear upward or downward trend in either. Before testing between-groups differences, we noted that the contingent group overrepresented participants who had already achieved high degrees of abstinence during intervention. Therefore, each participant's percentage of cocaine-negative urine specimens during intervention was included as a covariate in a generalized linear mixed model; the other covariates were dropout, poor attendance, prior contingency, and maintenance group (contingent vs. noncontingent). The main effect of maintenance group was significant, F(l, 73) = 6.58, p < .02. Adjusted percentages of cocaine-

SHAPING COCAINE ABSTINENCE

601

649

0 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 48 51 54 57 60 63 66 69 72 75 Baseline Intervention Maintenance Number of consecutive urine specimens

Figure 1. Percentage of participants cocaine abstinent on 75 successive urine test days in the baseline phase (15 specimens), intervention phase (24 specimens), and maintenance phase (36 specimens) in the two treatment groups: abstinence group (vouchers for cocaine-negative urine specimens only), shaping group (vouchers for decreased cocaine metabolite concentration for 3 weeks followed vouchers for cocaine-negative urine specimens only). Data shown here are raw percentage values; missing specimens (including those due to dropout) are treated as positive. For the abstinence group, n = 49 in the baseline and intervention phases and 43 in the maintenance phase; for the shaping group, n = 45 in the baseline and intervention phase and 37 in the maintenance phase. Note that the shaded area represents the only portion of the study during which the two groups were treated differently (see interpretation in Discussion). During the maintenance phase, participants within each group were rerandomized to new contingencies (see Figure 2); data in this figure are collapsed across those contingencies.

negative urine specimens were 7% in the noncontingent group and 22% in the contingent group. (These percentages appear low because they are adjusted for all effects in the model, including each participant's earlier percentage of negative urine specimens. We present them here for intergroup comparisons rather than as absolute indicators of performance.) The effect of prior contingency is discussed below. The longest duration of abstinence, inferred from consecutive negative specimens, showed a trend toward being significantly greater in the contingent group (M = 8.2, SEM = 1.7) than in the noncontingent group (M = 4.3, SEM =1.0), F(l, 78) = 3.92, p = .051. Use of other drugs. There were no significant between-group differences in use of other drugs during maintenance as determined in urine or breath screens (Table 5). Self-reported cocaine use, heroin use, cocaine craving, positive lifestyle changes, and criminal activity. There were few differences between the maintenance groups on self-reported measures (Table 6). Trends (p < .10) toward significant Group X Week interactions occurred only in mean dollars spent on cocaine per day and mean amount of heroin used per day.

Effect of prior contingency. One of the mixed models (described above in the section Cocaine useurine screens) enabled us to evaluate the effect of prior contingency (shaping vs. abstinence) while controlling for current contingency and other variables. The effect of prior contingency was not significant, F(l, 73) = 1.21,/j = .27, but participants formerly in the shaping group did tend to maintain higher rates of cocaine-negative urine than did participants formerly in the abstinence group, regardless of rerandomization (Figure 1). Adjusted percentages of cocaine-negative urine specimens were 26% (former shaping) versus 19% (former abstinence) in the abstinence groups and 10% (former shaping) versus 4% (former abstinence) in the noncontingent groups. As before, we present these adjusted percentages for intergroup comparisons rather than as absolute indicators of performance. Discussion The results show that contingency management for cocaine abuse can be more effective when introduced in a stepwise fashion. Reinforcement of decreases in urine BZE concentrations prior to initiation of abstinence reinforcement (shaping

650

PRESTON, UMBRICHT, WONG, AND EPSTEIN

Table 4 Self-Reported Cocaine and Heroin Use, Craving, Lifestyle Changes, and Criminal Activity Intervention
Group Abstinence Variable
8

Mixed regression Shaping Group Week Group X Week

SD

SD

Self-reported cocaine use Mean frequency per day Baseline 0.32 0.26 Intervention 0.31 0.35 Intervention (adj)b 0.54 0.49 Mean amount per day (mg) 30.4 Baseline 30.3 Intervention 29.8 40.7 Intervention (adj)b 81.6 186.2 Mean dollars spent per day Baseline 2.18 3.05 Intervention 1.94 3.15 Intervention (adj)b 3.53 4.83 Self-reported heroin usea Mean frequency per day Baseline 0.15 0.15 Intervention 0.11 0.18 Intervention (adj)b 0.21 0.15 Mean amount per day (mg) Baseline 0.19 0.18 Intervention 0.12 0.19 Intervention (adj)b 0.25 0.49 Mean dollars spent per day Baseline 1.21 1.48 Intervention 0.78 1.41 Intervention (adj)b 1.89 1.16 Weekly self-report questionnaire Cocaine cravingc 0.77 Baseline 1.56 Intervention 0.94 1.51 Intervention (adj)b 1.57 1.12 0 Heroin craving Baseline 1.43 1.03 Intervention 1.16 1.21 1.47 Intervention (adj)b 0.97 1 Lifestyle changes' Baseline 3.74 2.21 Intervention 4.02 2.64 Intervention (adj)b 3.88 2.87 1 Criminal activities' Baseline 0.07 0.19 Intervention 0.02 0.14 0.001 0.03 Intervention (adj)b

0.46

0.41

0.30
0.47 44.2 55.4 84.4

0.32
0.47 49.7 206.1 181.8 2.98
< .09

1.20

.23

0.76

.79

0.09

.77

0.90

.60

0.75

.80

2.69
2.02 3.08 0.18 0.11 0.13 0.29 0.22

3.03
3.10 4.75 0.49 0.16 0.12 0.20 0.55 0.59 0.73
.49

1.04

.41

0.85

.67

.46

1.23

.21

0.45

.99

0.23
1.39

0.47
1.83

0.12

.73

1.00

.47

1.01

.44

0.64 0.90
.52 .27 .35 .39 .20
1.03 4.22 4.05 3.53 0.17 0.05 0.04

1.03 1.83 1.23 0.84 0.96 1.09 2.52 1.06 1.08

1.36 0.13

.27

0.96

.52

0.98

.50

.12

1.73

.10

0.58

.77

.72

1.13

.34

0.38

.91

1.73 2.13 2.78 0.90 0.53 0.16 0.03

.35

1.21

.29

0.88

.53

1.76

.19

1.07

.38

1.35

.22

Note. Adj = adjusted. a Data were available for 95 participants. Degrees of freedom are (1, 90) for group and (23, 1927) for time and Group X Time. b Adjusted means control for baseline, dropout, and poor attendance; they are presented here as intergroup comparisons rather than as absolute indicators of performance. c Data were available for 93 participants. Degrees of freedom are (1, 88) for group and (7, 534) for time and Group X Time. Craving was rated on a scale of 0 - 4. d Data were available for 93 participants. Degrees of freedom are (1, 88) for group and (7, 534) for time and Group X Time. Lifestyle changes are reported as the mean sum of the items reported per week. Criminal activities are the mean of the total reported per week.

group) resulted in lower cocaine use (as indicated by more cocaine-negative urine specimens) than did a contingency that reinforced only cocaine-negative urine specimens (abstinence group). Although both groups had similar rates of cocainenegative urine specimens during the first 3 weeks of the intervention, the shaping group showed an increase in negative

specimens on escalation of the contingency requirement. This added treatment effect was evident during the latter 5 weeks of the intervention and tended to be maintained across a 12-week maintenance treatment. As we had hypothesized, participants in the shaping group contacted the reinforcer more frequently than did those in the abstinence group.

SHAPING COCAINE ABSTINENCE

601

651

50"

40-

30

20

10

contingent noncontingent

42 45 48 51 54 57 60 63 66 69 72 75
Number of consecutive urine specimens

Figure 2. Percentage of participants cocaine abstinent on 36 successive urine test days in the maintenance phase in the two treatment groups: contingent group (vouchers and take-home methadone doses for cocainenegative urine specimens; n = 41), noncontingent group (vouchers and take-home methadone doses independent of urine test results; n = 39). Approximately half of the patients had participated in the abstinence group and half had participated in the shaping group just prior to the maintenance phase. Data shown here are raw percentage values; missing specimens (including those due to dropout) are treated as positive.

The present findings extend the body of work on shaping (reinforcement of successive approximations of a final target behavior) as a method of substance-abuse treatment. Shaping has been used to increase substance-abuse patients' completion of treatment-plan tasks (Iguchi, Belding, Morral, Lamb, & Husband, 1997). Patients received contingent vouchers for counselorassigned behaviors directed at meeting treatment goals, such as gaining employment. If the patient did not complete an assigned task, a less difficult task was substituted; if the task was completed, a more difficult task was assigned. Contingencies were thus tailored to each patient's needs. The shaping procedure was apparently successful, as patients had significant increases in drugfree urine specimens compared with patients receiving voucher reinforcement of drug-negative urine specimens and with patients in a standard-care group. Prior studies have also involved reinforcement of decreases in biological indicators of drug use; this has been attempted most frequently with tobacco, using exhaled carbon monoxide (CO) as the indicator of use. Early studies did not involve shaping in the strictest sense because the response requirements never changed; monetary rewards were given each time participants reached a fixed target of 50% of baseline CO (Stitzer & Bigelow, 1982; Schmitz, Rhoades, & Grabowski, 1995) or a fixed target of 16 or 8 ppm (Stitzer & Bigelow, 1985). In the latter study, it was noted that the use of a difficult target (8 ppm) led to failures to contact the reinforcer, leading the authors to suggest that such a target should not be introduced abruptly. The development of a slidingscale procedure, in which the magnitude of each reward was inversely related to the amount of CO detected (Stitzer & Bigelow, 1984), led to a study similar to the current one, in which a sliding-scale phase was followed by an abstinence-contingency phase (Stitzer, Rand, Bigelow, & Mead, 1986). In that study,

Table 5 Urine Test Results: Percentage of Drug-Negative Specimens in Maintenance

ANOVAa Group Variable Cocaine negative M (SEM) Adj for baseline urine Adj for intervention urine Opiate negative0 M (SEM) Adj for baseline urine Benzodiazepine negative0 M (SEM) Cannabis negative0 M (SEM) Alcohol negative*1 M (SEM)
0

GLIMMIX" Group Day p F p Group X Day

Group F p F

Contingent

Noncontingent
21 (4.5) 3 7

37(6)

5.06

.027 4.71 6.58

< .04 < .02 .50

37 22
61(5)

1.76 1.63 1.19

< .01 < .02 .21

1.29 1.11
0.97

.12 .30
.52

66
93(2) 75(6) 97(1)

58(5) 60 87(4) 86(4)

98 (1)

0.31
.

.578 0.47 .182 .107 .566

1.81 2.66 0.33

Note. Generalized linear mixed model (GLIMMIX) is an SAS macro that analyzes dichotomous repeated measures with missing datapoints by invoking the SAS procedure MIXED with a logit link. ANOVA = analysis of variance, adj = adjusted. * ANOVA degrees of freedom are 1 and 78; missing urine samples were considered positive for cocaine and opiates for ANOVAs. b GLIMMIX degrees of freedom for group are 1 and 73 and for day and Group x Day, 35 and 2,410. Adjusted (Adj) percentages are from GLIMMIX models; they appear low because they control for intervention-phase contingency, dropout, poor attendance, and either baseline urine sample tests or intervention urine tests; they are presented here for intergroup comparisons rather than as absolute indicators of performance. GLIMMIX models were not fitted for benzodiazepines, cannabis, or alcohol because low rates of use led to underdispersion (lack of variation) in the data. c Urine specimens. d Breath specimens.

652

PRESTON, UMBRICHT, WONG, AND EPSTEIN Table 6 Self-Reported Cocaine and Heroine Use, Craving, Lifestyle Changes, and Criminal Activity Maintenance Mixed regression Group Variable Self-reported cocaine use" Mean frequency per day:
M (SEM) Adj M (SEM)

Group F p

Week F p

Group X Week

Contingent

Noncontingent

0.27(0.06) 0.42(0.09) 28.5(7.3) 42.0(14.4) 1.86(0.60) 4.82(1.80) 0.08(0.02) 0.11(0.03) 0.11(0.03) 0.16(0.04) 0.52(0.14) 0.75(0.26) 1.21(0.15) 1.43(0.18) 1.25(0.18) 1.57(0.20) 4.14(0.42) 3.90 (0.46) 0.03 (0.02) 0.05(0.02)

0.41(0.07) 0.54(0.09) 41.9(14.7) 35.7(13.9) 1.59(0.30) 3.91(1.71) 0.12(0.03) 0.15(0.03) 0.13(0.04) 0.19(0.03) 0.76(0.26) 1.07(0.24) 1.22(0.15) 1.39(0.17) 1.13(0.15) 1.38(0.20) 4.23(0.43) 3.62(0.43) 0.02 (0.02) 0.04(0.02)

1.66 0.20 0.22

.20 .66 .64

0.92 0.97 1.09

.61 .52 .33

1.06 0.92 1.32

.38
.61 < .10

Mean amount per day (mg)

M (SEM) Adj M (SEM)

Mean dollars spent per day

M (SEM)

Adj M (SEM)

Self-reported heroin use Mean frequency per day

M (SEM) Adj M (SEM)

1.29 1.05 1.66

.26 .31 .20

0.88 1.04 0.75

.67 .41 .86

0.95 1.40 1.25

.55 .06 .15

Mean amount per day (mg)

M (SEM) Adj M (SEM)

Mean dollars spent per day

M (SEM) Adj M (SEM)

Weekly self-report questionnaire Cocaine cravingb

M (SEM) Adj M (SEM)

Heroin craving

0.05 0.85 0.36 0.11

.82 .36 .55 .74

1.21 0.90 0.90 0.80

.27 .54 .54 .64

0.69 1.31 0.35 1.06

.75 .22 .97 .39

M (SEM) Adj M (SEM)

Lifestyle changes
M (SEM) Adj M (SEM)

Criminal activities'
M (SEM) Adj M (SEM)

Note. Adjusted (Adj) means control for baseline, intervention-phase contingency, dropout, and poor attendance. a Data were available for 80 participants. Degrees of freedom are 1 and 73 for group and 35 and 2,410 for time and Group X Time. b Data were available for 78 participants. Degrees of freedom are 1 and 71 for group and 11 and 684 for time and Group X Time. Craving was rated on a scale of 0-4. c Data were available for 78 participants. Degrees of freedom are 1 and 71 for group and 11 and 684 for time and Group X Time. Lifestyle changes are reported as the mean sum of the items reported per week. Criminal activities are the mean of the total.

participants' reductions in smoking during the sliding-scale phase predicted their subsequent ability to abstain. However, all participants in that study were exposed to the sliding scale; there was no abstinence-only group for comparison. We know of only two published studies (prior to this one) involving reinforcement of decreases in biological indicators of cocaine use. In one of them, the reinforcement was used only as a means to induce abstinence so that withdrawal symptoms could be studied; thus, there was no baseline condition and no control group (Evans, Levin, Fischman, & Foltin, 1998). Nonetheless, there was some suggestion of efficacy. Nine non-treatment-seeking cocaine smokers earned vouchers for each urine specimen that had a decreased concentration of BZE (compared with the previously collected specimen). Of 81 specimens collected, 68% had concentrations lower than the previous specimen, 56% had decreases of 50% or greater (suggesting no new use since the prior specimen

collection), and 23% of all specimens were negative for BZE. Another study used a sliding scale (monetary reinforcers of $10 or $12 for each successive decrease in the level of BZE and $12 or $15 for each cocaine-negative specimen) in 12 cocaine-dependent methadone-maintenance patients (Elk et al., 1995). The procedure was effective; BZE levels significantly decreased and cocainenegative specimens increased compared with a period of baseline treatment. Again, there was no abstinence-contingency control group, nor was there a subsequent attempt to introduce an abstinence-only requirement. In our study, those two elementsan abstinence-contingency control group and an elevation of the response requirement enabled the most striking of our findings: The shaping group's rate of cocaine use differed from that of the abstinence group only when the response requirement ceased to differ. During the first 3 weeks of intervention (the only time when the shaping contingency

SHAPING COCAINE ABSTINENCE

653

was in effect), participants in both groups sharply reduced their rates of use relative to baseline (Figure 1). On the basis of every available drug-use measure, the two groups were behaving almost identically. The difference lay in the consequences: For participants in the shaping group, reductions in cocaine use were reinforced more frequently (Table 2). In the subsequent 5 weeks of intervention, when the response requirement for both groups was abstinence, the former shaping participants maintained a higher rate of abstinence than did those for whom the response requirement had been abstinence all along. Even in the ensuing maintenance phase, this trend continued (though not to a degree that reached statistical significance) within each of the new reinforcement schedules to which participants were rerandomized. These results are reminiscent of findings from the applied behavior analysis literature on compliance, where it has been shown that reinforcement of a high-probability behavior (i.e., a behavior that participants will readily engage in) increases subsequent compliance with a requirement to perform a low-probability behavior (i.e., a behavior that participants will not readily engage in; Mace, Mauro, Boyajian, & Eckert, 1997). This "high-p procedure" describes our shaping intervention, which reinforced a behavior (reduction of drug-use frequency) that occurs in nearly all participants at the start of a voucher intervention, even if vouchers are given noncontingently (Preston et al., 2000). The effectiveness of the high-/? procedure has been interpreted as an example of behavioral momentum, defined by Nevin as the product of response rate and resistance to change (Nevin, 1992; Nevin, Mandell, & Atak, 1983). According to this theory, greater density of reinforcement of a behavior leads to greater resistance for the behavior to change, even when the reinforcement schedule changes (Plaud & Gaither, 1996; Plaud, Gaither, & Lawrence, 1997). The aptness of the "momentum" metaphor has been questioned (Houlihan & Brandon, 1996), but our results at least add to the body of data to which it seems applicable. The maintenance-phase results are encouraging. Contingency management is intended for use in real-world clinical settings, and one of its most effective variants is the escalating-reinforcement procedure used in the intervention phase (and in many of our other studies)but this variant has the inherent limitation of escalating cost. Our maintenance-phase results show that even in patients who have been exposed to escalating reinforcement, abstinence can be at least partly sustained by a more modest schedule of nonescalating reinforcement (i.e., fixed-amount vouchers and takehome doses). Comparable findings have been reported by Higgins et al. (1994), who successfully followed an escalating schedule with one in which each negative urine specimen was reinforced with a state lottery ticket. Nonescalating schedules could have practical applications for patients who return to frequent cocaine use when an escalating contingency is discontinued. The present study had a number of limitations. First, there was no nonvoucher or noncontingent-voucher control group with which to compare the shaping and abstinence groups. Nevertheless, patients in both groups clearly improved with the onset of contingency management, and (with due acknowledgement of the limitations of historical controls) their improvements appeared greater than those of noncontingent-voucher groups in our other studies (Silverman et al., 1996, 1998). Second, patients were maintained on relatively low methadone doses; the rates of heroin and cocaine use might have been lower had methadone doses been higher or individualized. Finally, the overall level of improvement

may have been reduced by the delayed delivery of reinforcers and by the short duration of the intervention. Vouchers were given 1 day after urine specimens were collected because of our use of an outside laboratory to obtain quantitative urine test results. Delay of delivery can weaken the strength of a reinforcer. Overall, shaping (by means of reinforcement of decreases in urine-cocaine metabolite concentrations) led to more participants contacting the reinforcer and a greater density of reinforcer delivery per participant. When a more stringent response requirement was introduced, cocaine abstinence was enhanced for participants who had previously been reinforced on the shaping schedule. We conclude that this procedure prepared participants for abstinence. Improvements were sustained in a maintenance treatment providing nonescalating reinforcers that were contingent on abstinence.

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Received May 1, 2000

Revision received September 26, 2000

Accepted October 8, 2000

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