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INTRODUCTION

Contingency management interventions are based on a well-validated literature supporting a position that drug use appears to be a form of operant behavior [e.g., Refs. (1, 2)]. As such, the probability of using drugs should be influenced by the environmental context in which drug use occurs. This suggests that the availability of alternative nondrug reinforcers should decrease drug use if they are available in sufficient magnitude (3-5). These observations form the conceptual basis for the contingency-management approaches to drug abuse treatment, which have proven generally effective at initiating clinically relevant periods of abstinence (6-10).

A common type of contingency management intervention currently being used to treat substance abuse was popularized by Higgins and colleagues [e.g., Refs. (11-13)]. In this procedure, patients receive "vouchers" for the provision of biological samples (i.e., urine, blood, breath) that indicate no recent drug use. Hence, the procedure is often called Voucher Based Reinforcement Therapy (VBRT). These vouchers are withheld when the biological sample indicates recent drug use. As originally conceived, these vouchers were to be for goods or services that would help the patient initiate or reestablish behavior that resulted in nondrug-based reinforcement. For example, if, prior to becoming dependent on cocaine, a person had spent considerable time with his children but had neglected them since developing his addiction, he might use any vouchers earned during treatment to engage in activities with his children such as going to a circus or a sporting event. Thus, the vouchers could be conceptualized as tools for acquainting or reacquainting individuals in treatment to nondrug sources of reinforcement in their environment, which might then serve to compete with drug use.

VBRT has proven to be successful at initiating periods of abstinence when compared to standard treatment regimens [e.g., Refs. (7, 9)] and has been shown to produce relatively long periods of abstinence (14, 15). Most individuals achieve some period of sobriety with this approach.

Many variables that may contribute to the success of contingency management have been examined, including: type of drug abuse [e.g., Ref. (16)], type of reinforcer ]e.g., Refs. (17-19)], type of response needed to earn reinforcement [e.g., Refs. (20, 21)], type of procedure for distributing reinforcers (22), delay to the delivery of reinforcement (23, 24), magnitude of reinforcement [e.g., Refs. (20, 25-27)], schedule with which reinforcement is delivered (28-30), and population (31-34). This last factor, the population to which the treatment is to be provided, is the topic of the investigation reported on in this article.

Specifically, this brief report outlines an initial investigation into the comparability of voucher exchanges made by criminal justice involved and noninvolved persons. This is potentially important because it speaks to the utility of VBRT for use in criminal justice populations, it may provide information on the specific needs of those involved in the criminal justice system, and it may suggest novel contingency-management based treatment strategies that may be more cost effective than a traditional VBRT program. For example, if individuals in the criminal justice system exchanged a significant portion of their vouchers for legal advice it would suggest that arranging free access to an attorney at a treatment center contingent on drug abstinence might be an effective treatment strategy.

It is important to explore as many aspects of treating the substance use of individuals in the criminal justice system as possible, because there is such a compelling need to provide effective treatment for this population [e.g., Ref. (35)]. The relationship between drug use and crime has been well documented ]e.g., Ref. (36)]. Thus, any knowledge that helps researcher and clinicians achieve their common goal of finding effective treatments for drug abusers in the criminal justice system will have potentially wide-ranging consequences.

PROCEDURE

This article compares the requests for goods or services made by participants in two different contingency management programs being run concurrently at the same research clinic. One program was for participants involved with the criminal justice system, and one was for participants who were not involved in the criminal justice system.

PARTICIPANTS

Participants were all of the randomized individuals from the two ongoing clinical trials of contingency management for the treatment of substance abuse. One of these trials was designed to assess the efficacy of contingency management in the treatment of the substance abuse of individuals who were part of a criminal justice system-based treatment program (criminal justice group). The other trial was a contingency management substance abuse program for individuals who were not explicitly involved in the criminal justice system (noncriminal justice group). Both trials were conducted at the same research clinic at the same time. Counselors for both trials employed the same cognitive behavioral therapy-based treatment strategies with participants in both groups.

The demographics of participants in the two groups were similar, with 66% being male in the criminal justice group and 63% being male in the noncriminal justice group. The ethnic make-up was 67% Caucasian, 24% Hispanic, and 6% African American in the criminal justice group; 61% Caucasian, 30% Hispanic, and 2% African American in the noncriminal justice group. The average age was 32 in the criminal justice group and 31 in the noncriminal justice group. In the criminal justice group, methamphetamine was the drug of choice for 81%, cocaine for 8%, marijuana for 6%, and opiates for 5%. In the noncriminal justice group, the drug of choice was methamphetamine for 100% of the group, as methamphetamine abuse was an inclusion criterion for this group. Data from 83 individuals were available from the criminal justice group and data from 80 individuals were available from the noncriminal justice group.

In both groups participants could earn vouchers that had a monetary value for abstaining from illicit drugs [e.g., Ref. (13)]. In the criminal justice group these vouchers were delivered if the participants were abstinent from all drugs of abuse, and in the noncriminal justice group they were delivered if the participants were abstinent from methamphetamine. Additionally, in the criminal justice group, vouchers could be earned by some participants for engaging in behaviors that supported the development of a drug-free lifestyle. In both groups participants decided with their counselor and research staff what they would like to exchange their vouchers for. Vouchers could only be exchanged for those goods or services that were in line with developing a drug-free lifestyle. Once a request was made, a staff member made the transaction for the participant within approximately one working day. The specific details of the programs are not relevant to the present analysis and will be published when the trials are completed.

DATA ANALYSIS AND RESULTS

We were interested in comparing the goods and services for which the participants in both groups exchanged their vouchers. It is was our intention that this analysis would help us to identify those goods and services available in the community that are valuable to the participants and, therefore, may function as reinforcers. We also were interested in identifying any differences between groups, as such differences may indicate clinically relevant issues that need to be addressed or could be utilized. For example, if participants in the criminal justice group exchanged more vouchers for housing-related costs, it would indicate that this group has greater need in this area. Toward these ends, we categorized goods and services for which vouchers were exchanged and compared the percentages of exchanges for the various goods and services across the two groups.

The results of this initial comparison can be seen by examining the first three columns of Table 1. As can be seen from Table 1, the two groups were quite different, with the majority of the exchanges being made for criminal justice related fines and fees by those in the criminal justice group, with a very small percentage of such requests being made by those in the noncriminal justice group. In order to better understand the differences between the two groups, we conducted another analysis. We removed the exchanges made for fines and fees from the criminal justice group and recalculated the percentages. The results from this analysis can be seen in the fourth column of Table 1. With fines and fees removed, the criminal justice group's exchanges mirror those of the noncriminal justice group.

DISCUSSION

These results suggest that both groups are similar in what they find reinforcing, which supports the use of contingency management programs developed for noncriminal justice populations with criminal justice populations. The results also suggest that for those substance abusers involved in the criminal justice system, assistance in paying fines and fees related to the criminal justice system may be a potentially powerful source of reinforcement. Thus, criminal justice involvement may function as an establishing operation to make the payment of these fines and fees a potentially useful source of negative reinforcement that could be incorporated into contingency management programs designed specifically for this population. For instance, it may be possible to implement fines for drug use or program infractions and then reduce or eliminate them contingent on abstinence or compliance with other program guidelines. This would be a potentially cost effective way to treat members of this population as it would not involve the actual provision of anything with a monetary value to the participants. Similar strategies have been used in which clients, in noncriminal justice populations, have been required to make an upfront payment that was returned to them contingent on the performance of behaviors designed to promote abstinence [e.g., Ref. (37)]. It also has been demonstrated that reductions in clinic fees or rebates [e.g., Ref. (38)] delivered contingent on abstinence can increase abstinence. Taken in whole, these results and those from the current analysis suggest that contingency-management based interventions are likely to be successful with members of the criminal justice population and that novel approaches centered on reducing or forgiving fines may be a useful behavior change strategy.

ACKNOWLEDGMENTS

This research was supported by the National Institute on Drug Abuse (grant # R01 DA13114, RO3 DA13941, P50 DA 12755). The authors would like to thank Collin Ring and Ruthlyn Sodano for their assistance with data collection.

REFERENCES

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(38.) Amass L, Ennis E, Mikulich SK, Kamien JB. Using fee rebates to reinforce abstinence and counseling attendance in cocaine abusers. In: Harris LS, ed. Presented to the College on Problems of Drug Dependence, Inc. (CPDD), Nashville, TN, June 14-19. Problems of Drug Dependence, NIDA Research Monograph No. 178. Washington, DC: U.S. Government Printing Office, 1998:99. NIH Publication No. 432-965/60003.

John M. Roll, Ph.D., (1,2) Michael L. Prendergast, (1) Keeli Sorensen, (1,2) Sharlyn Prakash, (1) and Joy E. Chudzynski, (1,2)

(1) University of California Los Angeles, Integrated Substance Abuse Programs, Los Angeles, California, USA

(2) Friends Research Institute, Los Angeles, California, USA

Address correspondence to John M. Roll, Ph.D., Washington State University-WIMRT, 310 N. Riverpoint Blvd., P.O. Box 1495, Spokane, WA 99210-1495, USA; Fax: (509) 358-7619; E-mail: johnroll@wsu.edu

Table 1. Percentage of voucher exchanges requested by each group

Goods and services               Non CJ            CJ Group
                                group (%)  +Fines/fees  -Fines/fees (%)

Groceries                          27            8               27
Restaurants                         2            1                1
CJ fines and fees                   1           66             -- *
  (e.g., criminal fines,
  court fees, parking
  tickets, etc.)
Gasoline                           30           10               30
Miscellaneous                      10            2                7
  (e.g., lawnmower
  repair, purchase pet, etc.)
Health care                         1            1                1
Automobile home                     6            1                4
  maintenance
Discount/department stores         20           10               29
Entertainment                       3            1                1
  (e.g., movie tickets,
  ice skating, museum
  tickets, etc.)

For the criminal justice (CJ) group, the percentages were calculated
with and without the CJ fines and fees category.

* Removed for this analysis.

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