Contingency Management for Cocaine Dependence: Cash vs Vouchers

描述（由申请人提供）：应急管理（CM）是一种明显有效的药物滥用和依赖干预措施。大量的实证研究支持其在提高治疗出勤率和戒断药物的功效。尽管CM协议采用了多种强化手段，但它们几乎完全依赖于非现金特权（例如，带回家的美沙酮剂量）、奖品或可以交换商品或服务的代金券。尽管中药有强有力的实证支持，但我们的研究表明，对其成本和安全性的担忧（例如，奖励破坏内在动机或被出售以购买药物所造成的潜在伤害）阻碍了其向现实世界实践的转移。非现金管理的独家使用可能源于未经检验的假设，即客户将使用现金奖励购买药物或从事其他高风险行为。这种假设有两个问题。首先，非现金激励的使用增加了CM协议的大量成本和复杂性。其次，使用非现金激励可能会降低CM干预的有效性，因为研究表明，现金可能是比代金券更有效的强化物。本研究将探讨与现金管理程序有关的实际和道德问题。我们建议进行一项三组随机研究，比较(1)基于凭证的CM干预、(2)基于现金的CM干预和(3)非CM干预的疗效、成本效益和伦理。自愿参加社区门诊治疗项目的可卡因依赖者将按相同比例随机分配到每种情况。本研究将测量与(1)疗效相关的结果，包括UDS确认的戒断和咨询出席率；(2)成本效益;(3)伦理，包括对内在动机、吸毒和其他高危行为的影响。这项研究将是第一个检查现金与基于凭证的CM方案在治疗药物依赖方面的疗效、成本效益和伦理差异的研究。这项调查不仅将解决有关将传统医疗干预措施转移到社区治疗方案的实际问题，而且还将开始对许多反对使用现金和传统医疗干预措施的伦理批评提供经验启示。

DESCRIPTION (provided by applicant): Contingency management (CM) is a demonstrably efficacious intervention for substance abuse and dependence. Substantial empirical research supports its efficacy in increasing treatment attendance and drug abstinence. Although CM protocols have employed a variety of reinforcers, they have almost exclusively relied upon non-cash privileges (e.g., take-home methadone doses), prizes, or vouchers that can be exchanged for goods or services. Despite the strong empirical support for CM, our research suggests that concerns relating to its cost and safety (e.g., potential for harm caused by rewards undermining intrinsic motivation or being sold to purchase drugs) have hindered its transfer to real-world practice. The exclusive use of non-cash CM likely stems from the untested assumption that clients will use cash incentives to buy drugs or engage in other high-risk behaviors. This assumption is problematic for two reasons. First, the use of non-cash incentives adds substantial costs and complexity to CM protocols. Second, the use of non-cash incentives may reduce the efficacy of CM interventions, as research suggests that cash may be a more effective reinforcer than vouchers. This study will examine practical and ethical issues relating to cash-based CM procedures. We are proposing to conduct a 3-group randomized study comparing the efficacy, cost-effectiveness, and ethics of a (1) voucher-based CM intervention, (2) cash-based CM intervention, and (3) non-CM intervention. Consenting cocaine-dependent clients attending a community outpatient treatment program will be randomly assigned to each condition in equal proportions. This study will measure outcomes related to (1) efficacy, including UDS confirmed abstinence and counseling attendance; (2) cost-effectiveness; and (3) ethics, including the effects on intrinsic motivation, drug use, and other high-risk behavior. This study will be the first to examine the differential efficacy, cost-effectiveness, and ethics of a cash- versus a voucher-based CM protocol in the treatment of drug dependence. This investigation not only will address practical issues pertaining to the transfer of CM interventions into community-based treatment programs, but also will begin to shed empirical light on many of the ethical criticisms that have been levied against the use of cash and CM interventions.