Contingency Management for Cocaine Dependence: Cash vs Vouchers

描述(由申请人提供)：应急管理(CM)是对药物滥用和依赖的一种明显有效的干预措施。大量的实证研究支持了它在提高就诊率和戒毒率方面的有效性。虽然CM协议使用了各种增强剂，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CM得到了强有力的经验支持，但我们的研究表明，与其成本和安全性相关的担忧(例如，由于奖励破坏内在动机或被出售以购买药物而造成的潜在伤害)阻碍了其向现实世界实践的转移。非现金CM的独家使用可能源于一个未经检验的假设，即客户将使用现金激励来购买药物或从事其他高风险行为。这一假设存在问题，原因有两个。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，非现金激励的使用可能会降低CM干预的有效性，因为研究表明，现金可能比代金券更有效地增强效果。这项研究将审查与现金为基础的CM程序有关的实践和伦理问题。我们建议进行一项三组随机研究，比较(1)基于代金券的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。同意参加社区门诊治疗计划的可卡因依赖患者将被随机分配到每种情况下，比例相等。这项研究将衡量与(1)疗效相关的结果，包括UDS确认的戒酒和咨询出席；(2)成本效益；(3)伦理，包括对内在动机、药物使用和其他高风险行为的影响。这项研究将首次检验现金和代金券CM方案在治疗药物依赖方面的不同疗效、成本效益和伦理。这项调查不仅将解决与将CM干预措施转移到以社区为基础的治疗计划有关的实际问题，而且还将开始实证地阐明许多针对现金和CM干预措施的使用的伦理批评。

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.