Elsevier

Drug and Alcohol Dependence

Volume 61, Issue 3, 1 February 2001, Pages 297-306
Drug and Alcohol Dependence

The effectiveness of incentives in enhancing treatment attendance and drug abstinence in methadone-maintained pregnant women

https://doi.org/10.1016/S0376-8716(00)00152-6Get rights and content

Abstract

This study examined the effectiveness of short-term contingency management for eliminating cocaine use and increasing full day treatment attendance with pregnant methadone-maintained women randomly assigned to either an escalating voucher incentive schedule (n=44) or non-incentive (n=36) conditions. Full day treatment attendance and urine toxicology for cocaine and heroin were assessed and consequated for 14 days. The escalating voucher incentive schedule significantly increased full day treatment attendance and drug abstinence compared to the non-incentive schedule. These results suggest that reinforcing the co-occurrence of two required behaviors (treatment attendance and abstinence from illicit drug use) is effective, and may be an important adjunct to methadone pharmacotherapy for treating pregnant drug dependent women.

Introduction

Drug abuse during pregnancy poses a serious public health problem. Survey results in the US show that 221 000 or 5.5% of women have used an illicit drug at least once during their pregnancy (National Institute on Drug Abuse, 1992).

Most pregnant drug-abusing women do not seek prenatal care early in pregnancy and are therefore more vulnerable to medical and obstetrical complications (Ostrea and Chavez, 1979, Cox et al., 1988, Finnegan, 1991). Although numerous reports suggest that drug use during pregnancy is associated with adverse maternal and infant outcomes (e.g. pre-eclampsia, stillbirths, abruptio placentae, premature labor, fetal distress), the extent to which these complications are a direct result of drug use or to lifestyle differences, lack of prenatal care and/or poor nutrition remains elusive (Robins and Mills, 1993). Regardless of the specific etiology, pregnant women who use drugs are at increased risk for pregnancy complications. The nature or severity of such problems may vary as a function of drug class, quantity and frequency of drug use, rate of drug metabolism and timing of gestational exposure.

For heroin dependent pregnant women, methadone maintenance has been the standard of care and is the only medication currently approved for treatment of opiate dependence in pregnancy (Kaltenbach et al., 1998). However, methadone by itself is not usually adequate for improving maternal and infant outcomes (Finnegan and Wapner, 1988). For it to be effective in improving pregnancy outcome, methadone must be given in the context of comprehensive care which, although more expensive, has significant economic and clinical utility (Svikis et al., 1997b). Both clinicians and researchers have reported the beneficial maternal and fetal effects of methadone maintenance as a part of comprehensive treatment (Wilson et al., 1981, Finnegan, 1991, Chang et al., 1992). Compared to untreated heroin abuse, methadone maintenance treatment during pregnancy has been associated with more prenatal care, increased fetal growth, reduced fetal mortality, decreased risk of HIV infection, decreased cases of pre-eclampsia (Kandall et al., 1977, Finnegan, 1978, Finnegan, 1991), and increased retention in treatment (Svikis et al., 1997a). Increased treatment attendance is especially important since birth outcomes are improved for children of women who remain in treatment through delivery (Svikis et al., 1997b).

Although methadone maintenance during pregnancy is associated with many benefits for mother and baby, there are a number of reasons for which non-pharmacological intervention may be a beneficial addition to pharmacotherapy. For instance, methadone is an opiate agonist that selectively reduces opiate use and may not impact on other drug use (e.g. cocaine use) which may also exert a detrimental effect on the fetus. Further, there may be situations where higher doses of methadone fail to eliminate opiate use or where higher doses are contraindicated due to pregnancy (Jarvis and Schnoll, 1994, Jarvis and Schnoll, 1995). Therefore, identifying effective behavioral methods for reducing or eliminating illicit drug use in pregnant drug dependent women in treatment is imperative.

One promising non-pharmacological drug abuse treatment intervention is contingency management. Under contingency management interventions, patients receive tangible incentives (e.g. money or goods) contingent on providing objective evidence of drug abstinence (e.g. for providing drug-free urine samples). Behavioral incentives have reduced illicit substance use during outpatient treatment in the absence and presence of opioid agonist medication (Stitzer and Higgins, 1995). One system of contingency management is a voucher-based reinforcement of target behavior (Higgins et al., 1991). Under this system, participants receive a voucher exchangeable for appropriate goods and services every time they perform a target behavior such as providing a drug-free urine sample (Silverman et al., 1996a). Although voucher incentive procedures have been effective in promoting drug abstinence (Higgins et al., 1991, Silverman et al., 1996a, Silverman et al., 1996b) or treatment attendance (Higgins et al., 1994) in non-pregnant populations, their effectiveness in pregnant women has received less attention. Previous contingency management studies conducted with cocaine abusing pregnant women demonstrated increased cocaine abstinence rates with monetary (Elk et al., 1995, Elk et al., 1998) and voucher incentives (Seracini et al., 1997). However, these studies used small sample sizes and targeted only cocaine use in a cocaine dependent population. A previous study evaluated four magnitudes of monetary voucher incentives ($0, $1, $5 and $10) on treatment retention and participation in methadone-maintenance and abstinence-treated (non-methadone) opiate and/or cocaine dependent pregnant women during the first 7 days of intensive outpatient treatment following residential care. Results showed that methadone-maintained women were retained in treatment for a longer period of time and attended more full treatment days (i.e. attended at least 4 h of individual or group counseling) (mean 3.3 days) than did abstinence-treated women (mean 2.3 days). However, the increase in full day treatment attendance observed in the methadone-maintained group was unrelated to the type of incentive procedure (Svikis et al., 1997a).

Because procedures that deliver vouchers which escalate in magnitude for consecutive instances of drug abstinence appear efficacious in reducing illicit drug use in outpatient populations (Higgins et al., 1991, Silverman et al., 1996a, Silverman et al., 1996b), one aim of the present study was to examine the effectiveness of this method with pregnant women. A second aim was to examine the effect of simultaneously targeting two desirable behaviors — full day treatment attendance with a built-in participation component and abstinence from illicit drug use (e.g. cocaine use). The first behavior was selected based on previous results that showed that even though methadone-maintained pregnant women exhibit a moderate baseline rate of full day treatment attendance, there is need for improvement in this rate of attendance. In addition, methadone-maintained pregnant women often continue to use illicit substances (Svikis et al., 1997a). Since illicit drug use early in treatment predicts greater drug use later in treatment (Budney et al., 1996), the present study also targeted reducing cocaine use early in treatment.

Section snippets

Participants

A total of 155 pregnant women admitted for the first time to a specialized substance abuse treatment program between October 1, 1996 and August 26, 1997 were considered for possible study participation. Inclusion criteria were 18 years of age and older, meeting DSM-III-R criteria for opiate dependence with cocaine abuse, and meeting eligibility requirements for methadone-maintenance treatment. Women who did not qualify for methadone pharmacotherapy (n=61), delivered prematurely during the study

Effect of voucher incentives on residential treatment retention and participation

The incentive and non-incentive groups did not differ in rates of premature drop-out against medical advice (AMA), with only five of the patients in either group leaving treatment prematurely. Of the five patients who left AMA, three were from the incentive group and two were from the non-incentive group. Since these five participants dropped out of treatment prematurely, their data were omitted from further analysis. During the entire 7-day residential period, participants in the voucher

Discussion

The present study suggests that voucher-based reinforcement for residential and outpatient full day treatment attendance and non-contingent opiate and contingent cocaine abstinence can be an effective adjuvant to methadone in the treatment of pregnant drug dependent women. Although a number of other studies have employed explicit compound operants of treatment attendance and drug abstinence (Milby et al., 1978, Elk et al., 1998) the present study employed the use of a compound behavioral target

Acknowledgements

This research was supported by USPHS Research Grant DA 09258 from the National Institute on Drug Abuse. The authors wish to thank Andrea Balzano, Paula Zackon, and Kelly Sosnow for their assistance in the conduct of the research.

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