Opiate detoxification treatments reach many addicts not seen in methadone maintenance treatment. Unfortunately, detoxification treatments have little success eliminating opiate use. In addition to treating the physical dependence on opiates, successful treatments must extinguish drug-use behaviors while cultivating competing behaviors that facilitate abstinence. Past research suggests that contingency management interventions are effective at promoting such new behaviors among opiate abusers. We have found, for instance, that reinforcing either abstinence or behavioral progress toward treatment plan goals leads to increased abstinence rates among methadone maintenance patients. The proposed study extends this approach to the problem of low detoxification success rates and poor naltrexone maintenance compliance. We examine whether reinforcing both abstinence and progress toward treatment plan goals is more effective than reinforcing either behavior in isolation. This study compares the efficacy of three different contingency management interventions used in an outpatient treatment combining a 20-week methadone detoxification and 12 weeks of naltrexone maintenance treatment- A total of 168 subjects will be randomly assigned to one of four treatment conditions -- three voucher-based contingency management interventions and a control condition with no programmatically delivered reinforcement. Subjects in the experimental conditions will receive vouchers for: 1) submitting drug-free urines, 2) completing treatment plan tasks, or 3) submitting drug-free urines and completing treatment plan tasks. Vouchers will be exchanged for reimbursement of expenses related to achieving treatment plan goals (e.g., paying for health care, day-care, resume development, etc.). Assessments of treatment process and outcome will occur during treatment, and at 12-month follow-up. Measures of treatment efficacy will include number of-drug-free urines submitted during the 32-week intervention, detoxification treatment completion, days of compliance with naltrexone maintenance therapy, and drug use at 12-month follow-up. This study examines a time-limited alternative for those ineligible, unable, or unwilling to participate in methadone maintenance. The development and objective evaluation of such alternatives is particularly important in this era of managed care when shorter, less expensive treatments are likely to be used even in the absence of clear data supporting their efficacy.
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