Drug addiction is a chronic disorder characterized by excessive drug use that persists over years and often until death. We propose to evaluate a novel method for implementing a highly effective and potentially practical intervention for cocaine addiction to maintain long-term drug abstinence. Our application focuses on methadone patients who use injection or crack cocaine because of their increased risk of acquiring or transmitting HIV through injection or drug-related sexual behavior. Methadone is effective for heroin addiction, but many methadone patients continue to use cocaine. High magnitude and long-duration voucher-based abstinence reinforcement is one of the most effective treatments for drug addiction and can maintain cocaine abstinence over extended periods of time, but practical methods of implementing this intervention are needed. Our research on a model Therapeutic Workplace has shown that employment-based abstinence reinforcement, in which participants must provide drug-free urine samples to access the workplace and maintain maximum pay, can maintain cocaine abstinence and reduce drug-related HIV risk behaviors over extended time periods. Our next challenge is to disseminate employment-based reinforcement for the treatment of drug addiction. We propose to develop, manualize, and pilot test a community-friendly Therapeutic Workplace intervention that can be implemented widely throughout the US and elsewhere. To test the Community Therapeutic Workplace intervention, we will conduct a randomized pilot study. Methadone patients who use injection or crack cocaine during methadone treatment will be invited to participate (N = 58) and randomly assigned to one of two groups: Usual Care (control) group or Community Therapeutic Workplace group. As in our prior implementations of the Therapeutic Workplace intervention, Community Therapeutic Workplace participants will enroll in Phase 1 to initiate drug abstinence and acquire job skills. Participants who initiate abstinence and acquire job skills in Phase 1 will be hired into community workplaces with collaborating employers in Phase 2. During Phase 2, employment-based abstinence reinforcement contingencies will be implemented using existing infrastructure and procedures for workplace drug and alcohol testing overseen by the US Department of Transportation. Using this system, a national provider of Drug-Free Workplace Services will arrange random drug testing and employment-based abstinence reinforcement contingencies in which employees will be required to remain drug-free to maintain employment. We will pilot-test the manual and revise in response to feedback from staff, participants, and employers. The study will provide vital information on the acceptability of the intervention to participants and employers, and provide preliminary data on the effectiveness of our procedures to maintain abstinence and promote employment. The data we collect in this study will be crucial to inform future larger-scale studies on the effectiveness of the Community Therapeutic Workplace intervention to maintain long-term drug abstinence and to reduce drug-related HIV risk behaviors.]
Providing vouchers exchangeable for goods and services for being abstinent from drugs and alcohol is very effective in establishing and maintaining abstinence, but is impractical to sustain for long periods of time. We will develop and pilot test an intervention that allows drug abusers to first become abstinent and get job skills, and then secure real jobs with collaborating employers in the community with the stipulation that they must undergo random workplace drug-testing to stay in the jobs. This model of contingent access to employment would address the inherent impracticality of voucher reinforcement of abstinence, and provides a clear pathway for implementing contingency management interventions for the treatment of drug addiction and decrease of HIV/AIDS risk behavior in a scalable fashion throughout the United States.
