The Effect of a Contingency Management Intervention on Substance Use (REAP)

• Urine drug and breath alcohol screens during the 8 week intervention period; attendance at treatment appointments during the 8 week intervention period; days abstinent during the prior 30 days at follow-up interviews. [ Time Frame: 8 weeks, 6 months, 12 months ] [ Designated as safety issue: No ]
  

• Employment, housing, legal, and psychiatric status at two, six, and 12 month follow-up interviews; administrative data on VA service utilization at six and 12 month follow-ups. [ Time Frame: 8 weeks, 6 months, 12 months ] [ Designated as safety issue: No ]
  

Objectives: To compare differences between usual care alone and usual care plus contingency management on: 1) negative urine drug and breath alcohol screens over the 8-week intervention period, 2) rates of attendance at scheduled substance use disorders treatment appointments during the 8-week intervention period, and 3) self-reported percent days abstinent at six and 12 month follow-up interviews.

Design: This will be a randomized, controlled trial. 360 veterans presenting for specialty substance use disorders treatment at the Minneapolis VAMC and the VA Puget Sound Health Care System will be randomly assigned to 8 weeks of Usual Care or Usual Care plus Contingency Management. Minimal exclusion criteria include primary cannabis dependence, primary opioid dependence, screening positive for pathological gambling, serious psychiatric symptoms or suicide risk. Randomization will be stratified by site and primary substance use disorder (alcohol or stimulant). All participants will meet with a research assistant twice per week to submit urine drug and breath alcohol samples. Participants randomized to the contingency management interventions will have the opportunity to draw tokens (with replacement) from a bowl each time they submit negative urine drug and breath alcohol screens. The number of drawings allowed escalates with continuous weeks of negative screens or returns to baseline if screens are positive or missed. Half of the 500 tokens will result in social reinforcement ("Good Job!"). The remainder will earn a VA canteen voucher worth $1 (209 of 500), $20 (40 of 500) or $80 (1 of 500). Follow-up assessments occur 2, 6, and 12 months after enrollment into the study. Primary outcomes measures include number of days with negative urine drug and breath alcohol screens during the intervention phase, days of treatment attendance during the intervention phase, and percent days abstinent on the Timeline Follow-Back interview at follow-up assessments. Secondary outcomes include a brief assessment of employment, housing, legal, and psychiatric status, and administrative data on VA service utilization. A process evaluation and an economic analysis are included.

Significance: This trial will determine the impact on treatment attendance and during and post-treatment abstinence rates of adding a contingency management intervention to standard substance use disorders treatment within the VA. An economic analysis will assess the cost of the contingency management intervention as well any potential savings generated by improved outcomes. In addition to data on extended outcome effects, this trial will provide the research team and participating clinic staff with valuable experience in the process and barriers of establishing contingency management interventions in VA substance use disorders treatment clinics and will inform future implementation and dissemination efforts.