Promoting abstinence from cocaine and heroin with a methadone dose increase and a novel contingency

Abstract

To test whether a combination of contingency management and methadone dose increase would promote abstinence from heroin and cocaine, we conducted a randomized controlled trial using a 2 X 3 (Dose X Contingency) factorial design in which dose assignment was double-blind. Participants were 252 heroin-and cocaine-abusing outpatients on methadone maintenance. They were randomly assigned to methadone dose (70 or 100 mg/day, double blind) and voucher condition (noncontingent, contingent on cocaine-negative urines, or "split"). The "split" contingency was a novel contingency that reinforced abstinence from either drug while doubly reinforcing simultaneous abstinence from both: the total value of incentives was "split" between drugs to contain costs. The main outcome measures were percentages of urine specimens negative for heroin, cocaine, and both simultaneously; these were monitored during a 5-week baseline of standard treatment (to determine study eligibility), a 12-week intervention, and a 10-week maintenance phase (to examine intervention effects in returnto-baseline conditions). DSM-IV criteria for ongoing drug dependence were assessed at study exit. Urine-screen results showed that the methadone dose increase reduced heroin use but not cocaine use. The Split 100mg group was the only group to achieve a longer duration of simultaneous negatives than its same-dose Noncontingent control group. The frequency of DSM-IV opiate and cocaine dependence diagnoses decreased in the active intervention groups. For a split contingency to promote simultaneous abstinence from cocaine and heroin, a relatively high dose of methadone appears necessary but not sufficient; an increase in overall incentive amount may also be required.

Incubation of Methamphetamine but not Heroin Craving After Voluntary Abstinence in Male and Female Rats

“…As argued elsewhere, our rat model of relapse/incubation after choice-based voluntary abstinence is analogous to the human condition of relapse to drug use after termination of contingency management (Caprioli et al, 2015a). Regarding the 'translational' value of our new model, the data on lack of sex differences in both the efficacy of our choice-based procedure in inhibiting drug selfadministration and relapse after cessation of 'contingency management' agree with the lack of gender differences in the efficacy of contingency management or the high relapse rates after treatment cessation in humans (Epstein et al, 2009;Lussier et al, 2006;Roll et al, 2013).…”

Randomized Trial Comparing Two Treatment Strategies Using Prize‐based Reinforcement of Abstinence in Cocaine and Opiate Users

“…Another is that we cannot be certain that the findings are generalizable to CM based on other types of reinforcers, such as vouchers. In fact, in a separate study using vouchers (Epstein, Schmittner, Schroeder, & Preston, 2003), we found that splitting the vouchers between reinforcement of cocaine and opiate abstinence without a bonus element for simultaneous abstinence appeared to enhance opiate abstinence at the expense of cocaine abstinence. Direct comparison in a single randomized trial would be necessary to resolve this seeming discrepancy and determine the role of the bonus contingency.…”

Hepatitis C and human immunodeficiency virus risk behaviors in polydrug users on methadone maintenance

“…This report is based on a retrospective analysis of data from 659 patients consecutively admitted to any of 3 clinical trials evaluating the efficacy of combining contingency management and methadone maintenance for dual cocaine and heroin use (Epstein et al, 2005;Epstein et al, 2003). The trials were conducted at an outpatient treatment research clinic in Baltimore, MD.…”