In Brief

A preliminary trial that offered escalating reinforcements has doubled abstinence rates in drug abusers who are among the toughest to treat: chronically unemployed women who are or have recently been pregnant.

Johns Hopkins University researchers led by Kenneth Silverman, PhD, developed the program based on years of research on voucher-based contingency management therapy. In the program, they invited 20 women who were patients at a comprehensive drug-treatment program to attend a "Therapeutic Workplace" three hours a day for six months and paid them with vouchers for goods and services. To gain entrance each day, the women had to provide a urine sample negative for cocaine and opiates. Their "work" was learning data-entry job skills including reading, arithmetic and data entry.

After each shift, each woman received vouchers exchangeable for goods and services, and the staff would buy the items. The value of the vouchers started at $7, and increased by 50 cents for each shift completed, up to a maximum of $27. If a patient did not attend the workshop or if she had a positive urine sample, the researchers reset next day's voucher at $7. If the patient had nine days in a row without a slip, her voucher was reset at the highest level she had before.

The women also earned $1 for every 30 minutes of "professional demeanor"--not doing things like cursing, eating, sleeping or arguing on the job. Other incentives were added as well: 25 cents for each learning aim met; $1 for a completing a batch of data with two cents subtracted for each incorrect character.

The precise and continuous rewards seemed to have worked. After six months, Therapeutic Workplace patients had drug-free urine samples 59 percent of the time. That compared to 33 percent for the control group patients, who were in the same treatment program, but not in Therapeutic Workplace, according to the study in Experimental and Clinical Psychopharmacology (Vol. 9, No. 1).

The project has now moved into second phase: The researchers created a business unit to employ the training graduates and continue monitoring them. As of December, eight of the women from the first class are temporary Johns Hopkins employees, doing data entry for customers both inside and outside the university. In this phase they receive regular salaries instead of the vouchers, but still must give a negative urine sample three times a week.

Silverman says the women are fast and accurate, and the unit has been attracting more customers than it can handle. The women are guaranteed a minimum wage, but if they are productive they can make twice that, he says.

The goal is to create a self-sustaining business that will continue to employ these women and pay for their monitoring, says Silverman. "And we have good reason to think that we can make it."

That kind of sustainability would overcome a drawback of contingency management treatments, which are too expensive for the long-term care that many patients need. Silverman and colleagues are continuing randomly controlled studies on both the women in the business unit and new groups of patients in the training.