Positive Reinforcement


Results of Reward System for Abstinence: Implications for "Disease Concept"

From: Andrew J. O'Brien

I have been involved as an informal consultant to a local children's home that feels it is having remarkable success in reducing drug use their adolescent population's drug use. They provide group and individual counseling to these long term residents , in addition to lots of other interventions related to the many other issues these "troubled youth" experience. The counseling is from a loosely harm reduction perspective and a key component is paying dollars for abstinence. The "kids" get $50.00 per month if they have a "clean" urine test. If they fail the test (or opt not to take it) they get NO consequences other than no money (they are quick to point out that failing the urine test does not result in confrontation, just motivational efforts suggesting they can try again next month). The $50.00 is instrumental in attracting kids into the program component, since participation is voluntary. Oh, and you don't have to actually have to have a drug problem to get into the program, it's open to all children placed in the Children's Home, regardless of their primary issues.

Their outcome measures are focused on improving functioning in various aspects of life, attendance at the public school, academic performance, family interactions, and the like. Officials of the agency have described a major "culture change" since the program was begun a year ago. The "cool" thing among kids is NOT to use drugs, whereas a year ago they had much drug use. The vast majority are volunteering for the drug screens and over 85% are "negative" . Attendance at school has dramatically increased , so has academic performance. They claim that upon reviewing a local university study of drugs abuse prevalence in local schools, the frequency of drug use is significantly lower among the "troubled" children's home kids than the other "normal" high school kids . The irony of this is that the agencies that regulate children's homes in New York State have essentially opposed the plan. They have requested that the agency provide research evidence from academic centers that paying for abstinence and the use of urine screening for drugs has any proven effectiveness in "a reductionist approach". They also oppose the voluntary urine screening as a violation of a child's rights and insists that they can only be so screened if sent to a formal licensed treatment program . In years past they sent all their drug abusing kids to an outpatient clinic and the home was frustrated by the kids being kicked out for using. The drug problems at the home remained high until they stopped using the treatment center !

My role is to try help them navigate the govt red-tape by lending association with the formal treatment world. My advise so far has been that they should avoid the formal treatment system like the plague! I did advise them that they have lots of holes in their "plan" in that they leave themselves open to charges that the kids can easily cheat on the urine screen. They do no observed screenings and essentially trust the kids not to "cheat". They point out that trust is a central component of their approach. One kids admitted to successfully cheating last month and they let him keep the $50.00 for being honest. They also point out that even if all kids cheated, the outcomes that reveal significant social and educational improvements are real . They acknowledge that the improved outcomes could be due to unknown aspects of their program. However most of the program components have been in place for years, the only new program is the harm reduction focus on drug use and the elimination of focusing on drug use as an addiction/disease. Any thoughts from the list ? Any research supporting this type of approach would be welcome (and not supporting it too, I guess).



From: Fred Rotgers


     This is a variation on contingency management approaches such as Community Reinforcement. These approaches are among the most successful in maintaining abstinence over time of any approaches currently available. Why? Because they do directly what other approaches only do indirectly--they make it worthwhile for the client to not use! Most other approaches take away the benefits of using without as rapidly replacing them with any significant benefits for abstinence--other than avoiding negative consequences--sort of like saying if you do your work today I won't dock your pay, but if you work hard today, I won't give you anything extra either!

Frederick Rotgers, Psy.D., Director

Program for Addictions Consultation and Treatment of the Rutgers Center of Alcohol Studies
950 Hamilton Street
Somerset, NJ 08873



From: Maia Szalavitz


I know there is stuff in the cocaine literature about paying people not to use-- someone at U Connecticut, perhaps? Joe V. knows I think.
In fact, I think it may be one of the few empirically demonstrated approaches for dealing with cocaine addiction.

But I don't think you will get over the *real* objections that Robin describes because it is seen as morally wrong to pay the "bad guys" not to do what the "good guys" don't do for free.

I have frequently remarked that given the $17 billion we spend on the WOD on the federal level alone (and about another $17 bill on the state level) and the fact that there are only allegedly 3.5 million hardcore drug users, wouldn't it be cheaper to just give each of them a million not to use?

No one would *ever* go for that proposal, though.



From: Frederick Rotgers


Higgins and Budney at the University of Vermont, George Bickel and Maxine Stitzer at Hopkins, and Martin Iguchi (who is now at Rand) have all published randomized clinical trials using this sort of approach with "hard drug" users with great success.

The National Institute for Drug Abuse (NIDA) currently has a treatment manual by Higgins and Budney that details how to run such an incentive system on their website.

This is a well-researched, well-documented approach that should draw no objections from anyone who is truly interested in what helps people stay abstinent and then doing it! It's only the "war on drugs" types who object--primarily because of the "it sends the wrong message" objection. May send the wrong message, but it also gets users abstinent and functioning again!

And, your proposal of spending WOD money on such programs makes infinite common sense. But then when did common sense ever drive what happens with respect to drugs and drug users ;-)?

Frederick Rotgers, Psy.D., Director

Program for Addictions Consultation and Treatment of the Rutgers Center of Alcohol Studies
950 Hamilton Street
Somerset, NJ 08873