The use of a token economy to reduce illicit drug use among methadone maintenance clients

Addictive Behaviors, Vol. 8, pp. 93-104, Printed in the USA. All rights reserved.

1983 Copyright

THE USE OF A TOKEN ECONOMY TO REDUCE USE AMONG METHADONE MAINTENANCE

0306-4603/83 $3.00 + .OO o 1983 Pergamon Press Ltd

ILLICIT DRUG CLIENTS

DAVID S. GLOSSER Chandler

Street Center,

Worcester,

Massachusetts

Abstract-The effects of a token economy in modifying the illicit polydrug use of 97 methadone maintenance clients was investigated over a period of two and a half years. Subjects’ drug-free urinalysis reports were reinforced with points which could be redeemed to obtain methadone. Each subject’s daily dose level varied with the point balance. A multiple baseline analysis showed that when methadone acquisition was in part made contingent upon drug-free urinalyses, illicit drug use declined rapidly. After six months, the token economy group’s urines were 14% positive for illicit drugs compared to 39% in the traditional treatment group. As time in treatment increased, illicit drug use further declined. These results suggest a more effective and practical strategy for the treatment of polydrug abusing methadone maintenance clients than has previously been available.

Methadone substitution therapy for narcotics addiction, methadone maintenance, has been a mainstay of the addiction treatment system in the United States for the past fifteen years (Meyer, 1977) and has been well described elsewhere (Dole & Nyswander, 1965; 1968). While methadone maintenance has been shown to offer some control of illicit narcotics use, its impact on the total drug use behavior of addict patients is questionable. Estimates of the extent of polydrug abuse among methadone maintenance clients, or the narcotics addicted population in general, vary from report to report depending on the population surveyed, assessment procedures, region, and statistical presentation. However, typical reports of illicit drug use in the early months of M.M. treatment show that from 30% to 50% of all urine samples are positive for supplemental drugs; benzodiazepines and propoxyphene accounting for the bulk of this illicit use (Bigelow, Lawrence, Stitzer & Wells, 1976; Cheney, Restegheni, Potter, & Renner, 1979; Glosser, 1977). Drug positive urines among methadone maintenance clients tend to decline as time in treatment increases but still may remain as high as 30 percent with the preponderance of supplemental drugs remaining non-opiates (Handal & Lander, 1976; Langley, Norris, & Parker, 1973). Such findings are consonant with the opinion of many experts that the percentage of addicts who use only opiates has dropped, while the number of polydrug users has mushroomed (Finney, 1975; Lennard, Epstein, & Rosenthal, 1972). In short, it appears that many methadone maintenance clients are polydrug users, if not addicts, and might be expected to retain the problems associated with drug abuse common among untreated addicts, with the possible exception of reduced need to commit property crimes in order to finance an expensive heroin habit (Bowden, Maddux, & Esquivel, 1978; Kahn, 1980). The.importance of devising means to reduce polydrug abuse among methadone maintenance clients, both as an end in itself and as a part of their overall rehabilitation is compelling. Contingency management strategies for the control of substance abuse have been of two principle types. One has been to reinforce the participation of clients in a variety of treatment activities designed to remediate social, emotional, or behavioral problems Reprint requests should be sent to David S. Glosser, Biobehavioral sity School of Medicine, 85 East Newton Street, Suite 915, Boston, 93

Sciences Department, MA 02118.

Boston Univer-

94

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S. GLOSSER

thought to contribute to substance abuse (Gotestam & Melin, 1973; Stitzer, Bigelow, Lawrence, Cohen, D’Lugoff, & Hawthorne, 1977; Beatty, 1978). The other strategy has been to directly reinforce reduction in, or abstinence from, substance ingestion (Boudin et al., 1977; Liebson & Bigelow, 1972; Liebson, Bigelow, & Flamer, 1973; Miller, 1975). Both strategies are based on the operant behavioral principle that all behavior, including drug use, is maintained by environmental influences and that by altering the consequences of behavior, it can be changed. A frequently cited difficulty in operantly based treatment strategies is the problem of identifying and controlling reinforcers of sufficient potency to compete with the drug reinforcers available in the addict’s natural environment. A variety of reinforcers have been used in an effort to influence the behavior of substance abusers: tokens redeemable for food, clothing, and shelter (Miller, 1975); access to special privileges and facilities (Beatty, 1978; Gotestam & Melin, 1973; individually contracted material and social reinforcers (Boudin et al., 1977); as well as money and methadone take-home privileges (Stitzer et al., 1980). Additionally, Liebson and Bigelow (1972, 1973) made alcoholic methadone clients’ daily dose contingent upon the supervised ingestion of disulfiram. In the case of polydrug abusing methadone maintenance clients, there appears, however, to have been no attempt to systematically use the methadone dose level itself as a reinforcer, despite widespread recognition of the drug’s potency as a reinforcing agent. If, in fact, methadone is a potent reinforcer for narcotics addicts, an apparently optimal use of it would be to reinforce behavior incompatible with drug use and directly reinforce abstinence from other drugs by contingently titrating the daily dose upwards or downwards. This study describes a methadone maintenance clinic, regulated by a token economy, in which the acquisition of a stable daily dose was made contingent upon urinalysis results demonstrating abstinence from illicit drugs and successful completion of contingency contracts. METHODS

Subjects Subjects were enrollees of the Chandler Street Center, a drug treatment facility licensed by the Commonwealth of Massachusetts, serving an urban drug abusing population. All subjects had a documented narcotics addiction history of at least two years with at least two prior detoxification attempts, and a current physiological addiction to narcotics. There were three groups of subjects that together accounted for all clients admitted to the center’s methadone maintenance program from September 30, 1976 to March 25, 1980, n = 117. Each subject was assigned to the treatment condition extant at the time of admission. Group I was composed of all clients (n = 20) admitted to methadone maintenance treatment receiving a stable dose of methadone daily, in a traditional low dose range program. Group I1 (n = 11) was composed of clients who had been inducted into the traditional low dose range clinic, and who elected to remain clients of the clinic when the experimental reinforcement contingency management procedures were instituted (one client elected to transfer). Group I11 (n = 86) was composed of all clients admitted to the methadone maintenance program from the institution of the experimental procedures on June 13, 1977 to March 25, 1980. Table 1 describes the demographic characteristics and addiction histories of the three groups. No significant pre-treatment differences between the groups on any of the measures were found.

95

Methadone maintenance clients

Table 1.

Characteristics of the Three Groups.

Mean Age at Admission Mean Years of Addiction Mean Years of Education Race/Ethnicity Percentage white Percentage black Percentage Puerto Rican Males Females Total N

Group I

Group II

Group III

21 8.9 10.8

28 9.7 10.5

28 9.4 10.5

90 0 10 60 40 20

91 0 9 73 27 11

19 8 13 51 49 86

Design Being essentially an evaluation of an ongoing clinical project, it was not feasible to employ a true experimental design to compare outcomes between groups. Random assignment to distinct treatment programs was not possible from either a political or economic standpoint. Rather, outcomes were evaluated using a quasi-experimental design (Campbell dz Stanley, 1963), in which Group I clients (those admitted to treatment prior to the onset of the experimental treatment and who received only the traditional treatment) serve as a comparison group for the subsequently admitted clients receiving the experimental treatment. The effect of the experimental manipulation was further examined by a multiple baseline across subjects design in which four subjects serving as their own controls were exposed sequentially to the same treatment (Hersen & Barlow, 1976). In this case the baseline was of illicit drug use, and the experimental contingencies were introduced at different times to members of the cohort. The four subjects in the multiple baseline experiment were drawn from members of Group II who had the highest frequency of urines positive for illicit drugs (see Table 2). PROCEDURES: DESCRIPTION PROGRAMS OF THE

OF THE TREATMENT THREE GROUPS

Group I: traditional treatment (dose level not contingent on abstinence) The clients in this group had their initial dose level set according to the program physician’s judgement of the clients’ level of addiction. Subsequent dose changes were negotiated by the client, his/her counselor, and the program physician. Some of the clinic ancillary services were made compulsory for Group I clients, including weekly supportive individual and group counseling sessions with professional and paraprofessional counselors. Referrals were made available for vocational and social services. Family counseling and psychiatric services were available by referral to cooperating inTable 2.

Description of Multiple Baseline Study Participants.

Subject

age

Sex

Race/Ethnicity

JG MF AS FS

31 30 34 24

F F M M

white Puerto Rican white white

Years of Addiction 8 9 10 I

mgs. Met hadone per day 20 25 35 35

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DAVID

S. GLOSSER

stitutions. Medical services were delivered through the clinic physicians or referral to local hospitals. Continued illicit drug use and failure of Group I clients to attend scheduled individual or group counseling sessions were counted as “violations” of their agreement with the clinic. Frequent violations resulted in an attempt by the counselor and client to make a “fresh start” with new goals and a new agreement. Continued failure of new agreements led to a “last chance” contract, which stipulated the number of violations that would lead to detoxification or transfer. On scheduled days (three times per week), supervised urine specimens were collected prior to dosing. Failure to provide a specimen was counted as a “dirty urine.” Two take-home medication privileges per month were available to clients who had been in treatment over 90 days and who had obtained their counselor’s consent. Clients had to be judged to be making good progress, but the criteria were variable. After two years of methadone maintenance treatment, clients were expected to attempt detoxification. The basic philosophy of the clinic was that methadone maintenance was a suitable treatment only for those who had tried and failed other forms of treatment. It was generally believed that narcotics addiction resulted from a variety of social and emotional disturbances and that maintenance allowed a period of relative stability in which the addict would be able to make use of counseling to resolve both immediate problems and the underlying conflicts presumed to contribute to his or her addiction. Counselors had average caseloads of 8-10 clients.

Group II: transition group (multiple baseline group) Group II clients were admitted unde- the same conditions as Group I clients and were subject to the same procedures. However, when the experimental program began, all treatment was continued under the new procedures. The Group II clients had been in treatment for varying periods of time at the time of transition, and it is from this group that the data of the multiple baseline is drawn. All but one client, who moved to another city, elected to participate in the contingency management program.

Group III: the contingency management group (daily dose level contingent upon behavior) Group III clients were admitted under the same criteria as Group I, but their daily dose of methadone was regulated differently. Each client’s initial dose level was set by the physician as before, but following the first week of dosing, the client’s daily dose was regulated by a token economy. Clients were able to receive their individual maximum daily dose only by presenting a token worth four points to the dispensing nurse. Table 3 describes the point acquisition contingencies.

Table 3. Required

Point

Acquisition

Points

Action

I. On time for dose each day 2. Provide urine sample four times per week 3. On time for weekly counseling session 4. “Clean” urine report from laboratory (two analyzed per week) 5. On time for dose seven consecutive days

Contingencies.

1 2 4 4

I

Awarded

Maximum 7 8 4 8

point per day points per sample points points per “clean” report point Total

1 = 28 points

Methadone maintenance clients

97

During the first six weeks of treatment, a total of 28 points per week was available, as well as required, leaving the client no surplus of points to “bank” in the event of future shortages. If the client was short of points, the dose received that day would be reduced from the previous day’s dose level by an amount, in milligrams, equal to the client’s point deficit. Thus, a client with a maximum individual dose of 40 milligrams would receive the 40 mg dose on each day that he had four points. If only 3 points were submitted on a given day, the dose for that day would be 39 mg; 2 points-38 mg; 1 point- 37 mg; 0 points- 36 mg. On successive days in which the client was short of points, the dose level continued to fall, since “today’s” dose was determined by “yesterday’s” dose minus today’s point deficit. Thus clients who were continually deficient of points could lose up to 4 mg per day from their dose and eventually detoxify themselves out of the program. No client was able to lose more than 4 mg per day. Clients could restore their dose to their original maximum level by submitting the required four points. On each day that a client submitted the full four points, the dose would be increased by 4 mg, up to their individual maximum. For example, a client whose maximum was 40 mg and who had reduced his dose level to 20 mg through point deficits could restore his full dose by submitting four points per day for five consecutive days. A client’s dose could fluctuate by no more than 4 mg per day. It was easier to restore one’s dose rapidly than to reduce it rapidly, since decreases could be made in increments of less than 4 mg, and restoration was always made in increments of 4 mg. During the first six weeks, clients were required to engage in an assessment of current drug use problems and other difficulties in the areas of employment, health, legal status, living situation, etc., and with the help of his or her counselor, to compile a list of problems prioritized in the order in which they were to be solved. Satisfactory completion of the assessment task earned 12 points, which could be used to cover point shortfalls or could be saved to buy program privileges such as a reduction in the number of urine samples required per week or eventual take-out privileges, or for that matter, an illicit drug use binge if the client so decided. Following development of a problem list, individual contingency contracts were negotiated to solve the identified problems. Upon the start of individual contracting, point values were roughly divided so that two thirds of the points remained contingent upon providing urine samples and absence of illicit drug use, and one third of the points were assigned as consequences for contracted activities. During this phase it was possible to accumulate 1 to 2 extra points per week. All contingency management clients were required to have obtained full-time productive activity by the end of their fifth month of treatment in order to remain a member of the clinic. Productive activity was defined as (a) full-time employment of 35 hours per week or more, (b) full-time enrollment and passing work in an accredited educational institution, (c) full-time bonafide child care and homemaking, (d) any combination of these activities equaling full-time productive activity. Four take-out medication privileges were available per month to those in treatment over three months, who had clean urines for six weeks prior to the take-out, and had acquired 95 percent of all available points in the four weeks prior to the take-out. Take-outs were available for a maximum of two consecutive days. A “reduced structure” status was granted to clients in treatment for more than three months with three months of consecutive productive activity, two months of clean urine, and a 95% point acquisition rate for two months. Clients retained this status by maintaining productive activity and submitting the required urine samples free of illicit drugs. In exchange, they received a weekly slip entitling them to their maximum daily dose and maximum take-out medication privi-

98

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S. GLOSSER

leges. Additionally, they were required to submit two urine samples per week. Reduced structure status was revoked in the event of failure to submit a requested urine sample or if a urinalysis was positive. Reduced structure clients were free to decline all counseling; however, they all chose to maintain contact with their counselors. Operation of the token economy Point slips were printed on carbonless copy paper in a form resembling an ordinary bank check. Each slip was one of a continuous numbered sequence which facilitated data control and minimized the possibility of fraud. The slips were of two basic types. The first type described the behavior of the client and the number of points earned, for example, four points payable for a drug-free urine sample. The second type was essentially a receipt naming the reinforcer bought by the client and its price, for example, 35 mg of methadone administered for payment of four points. When a slip was issued, the original was given to the client and the carbon copy was given to the clerk for entry in the client’s chart. When the client redeemed a point slip, it was also sent to the clerk for recording. In this way it was possible to visually examine graphs of the clients’ progress and calculate the amount of any point surpluses. The date of issuance and redemption of reinforcers was easily accessed. Summary of essential differences and similarities between the programs In summary, the treatment programs of the three groups were the same with regard to admissions criteria, availability of individual and vocational counseling, medical services, determination of initial dose, frequency of urinalyses, and encouragement to abstain from illicit drugs. The major differences between the traditional treatment and the experimental contingency management programs were: 1. There was no requirement for group counseling in the contingency management program; 2. The daily dose levels of clients in the experimental program were contingent upon their performance of contracted behaviors, including submitting urine samples and abstinence from illicit drugs, while the dose levels of the traditional programs’ clients were largely stable, with occasional changes initiated by clients’ requests. Monitoring illicit drug use Data regarding illicit drug use of each group was collected by examining the results of urine specimens collected from each client three times per week. Two of the collected urines were selected at random for analysis by a toxicological laboratory using thin layer chromatography and gas liquid confirmation of positives. (The laboratory maintained a Center for Disease Control reliability rating of 97% throughout the course of the study.) Urine specimens were all collected under the visual observation of program staff members. Refusal or inability to provide a urine specimen when required was treated as a positive finding. Illicit drug use was defined as a urinalysis positive for any drug not specifically prescribed or approved by physicians. No psychotropic drugs were prescribed or approved. RESULTS

The effects of the experimental contingencies on the subjects of the multiple baseline study can be seen in Figure 1. The number of urinalyses for each client performed each month is shown by the length of the shaded bar. The upper segment of the bar denotes the number of urines per month negative for any illicit drugs. Similarly, the lower segme:rt denotes the number of urines per month positive for any illicit drug(s). None of

Methadone

maintenance

clients

Figure 1. Changes in illicit drug use for multiple baseline subjects as shown by urinalysis results. The dashed line indicates time of transition from traditional to experimental conditions. The bars’ upper segments show the number of negative urinalyses, and the lower segments show the number of urinalyses positive for illicit drugs.

99

100

DAVID

Table 4.

S. GLOSSER

Cumulative Illicit Drug Use Rates of Clients Six Months Treatment Tenure Group

Number of Urinalyses Positive for Drugs Number of Urinalyses Performed Percentage Positive

Group

I

II

with

Group

197

57

596

511 39%

264 22%

4158 14%

III

the subjects’ illicit drug use continued at as high a rate following the onset of the experimental contingencies. In each case the rate of illicit drug use fell substantially after the experimental treatment began. It should be noted that none of the four subjects had experienced a month without drug positive urinalyses prior to contingency management treatment. The effects do not appear to be transient in nature insofar as improvement is sustained for up to a year. The cumulative percentages of illicit drug use of the three groups during the first six months of treatment are presented in Table 4. Group I’s (dose level non-contingent) urinalysis results were 39% positive for illicit drugs; Group II’s (transition group) urinalysis results were 22% positive for illicit drugs, and Group III’s (contingency management group) urinalyses were 14% positive. When the group means were compared through a one way ANOVA, they were found to be significantly different (F = 9.61; df = 2, 15; p < .Ol). These results show that during the early months of treatment the contingency management group obtained fewer than one half as many drug positive urines of all types than did the non-contingent dose group. The mean percent of urinalyses positive for illicit drugs as a function of number of months in treatment is depicted in Table 5. In Group I (non-contingent dose level), it can be seen that there is no tendency for the high rate of illicit drug use to decline as treatment tenure increases. Group II (transition) clients initially showed illicit drug use rates similar to that of Group I but rapidly reduced abuse as treatment tenure increased. The results obtained by Group II (contingency management) show a low initial rate of drug abuse which further declines in a rather steady trend as treatment tenure increased. The illicit drugs used by the three groups, as detected by urinalysis, are depicted in Table 6. The sums of the rows may exceed the totals, since one urine sample may contain traces of several different drugs. The totals represent the total percentage of urine samples positive for any drug of abuse. In all three groups, the benzodiazepines were the most favored drug followed by the opiates. Drugs in the “all others” category were almost entirely propoxyphene. The ratio of opiate to benzodiazepine to “all others” used was quite similar from group to group. Table 5.

Percent

of Urines

Positive

for any Illicit Drug as a Function Number

1

2

3

4

5

6

7

8

of Months

9

10

11

of Time in Treatment

in Treatment

12

13

14

15

Group

I

35

39

35

33

47

67

Group

II

46

21

26

33

17

04

I5

04

13

02

09

07

19

17

28

Group

111

19

15

14

11

15

13

10

11

13

07

04

07

06

05

0

16

17

18

19

Over 19

09

01

04

0000 04

02

0

101

Methadone maintenance clients

Table 6.

Group I Group II Group III

Percentage of Urine Samples Positive for Various Drugs of Abuse Opiates

Benzodiazepines

All Others

Total

17 8 4

26 9 6

5 .30 .40

39 13 10

Attrition

All three groups experienced attrition as some clients moved out of the region, were incarcerated, detoxified, transferred, died, or departed for places unknown. The mean number of months of methadone treatment achieved by Group I was 5.1 months; Group II- 19.5 months; and Group III (as of June 1, 1980)- 10.0 months. It is expected that if recent admissions to Group III resemble the clients admitted during the first year of the experimental procedures, then Group III should eventually achieve treatment tenure similar to that of Group II. Dose levels

The mean daily methadone dose of the three groups was as follows: Group I, 34.9 mg; Group II, 32 mg; Group III, 28.4 mg. DISCUSSION

Contingent reinforcement strategies, as reviewed in the introduction, have been shown to be influential in modifying the behavior of various addict populations, and the present study lends support to both the findings of other researchers and earlier reported preliminary outcome studies of these procedures (Glosser, 1977; 1980). The results of the present study have shown that the regulation of methadone dose, primarily contingent upon urinalysis results, can have a clinically significant impact upon drug supplementing. The use of illicit drugs was reduced both among those who had been introduced to the experimental contingencies after a period of traditional treatment and among those exposed only to the experimental program. Among the multiple baseline subjects, all four had lower rates of drug positive urines following the application of response cost contingencies. Additionally, there appeared to be no substitution of one illicit drug for another, as drug supplementing declined proportionately across the different types of drugs. Further, the average dose levels of those in the experimental program were lower than those receiving traditional treatment. It is difficult to attribute these changes to selective attrition of drug supplementers, insofar as the mean treatment tenures achieved by subjects in the experimental program greatly exceeds that of subjects in the traditional program. However, it is possible that rapid turnover among traditional treatment subjects contributes to that group’s relatively high rate of illicit drug use. However, on the whole, it appears that a substantially beneficial therapeutic effect was achieved. It should be noted that since truly random assignment to the three treatment groups did not occur, it is possible that the differences in illicit drug use between the groups was due to pretreatment differences. Insofar as urine samples were not available before enrollment of the clients, this matter cannot be conclusively resolved. However, the attribution of reduction in drug use to pretreatment differences is weakened by two factors. First are the similarities of the groups in terms of their demographic characteristics and prior addiction treatment histories. Virtually all of the clients were members of the Worcester area drug subculture. Their drug use careers were generally well

102

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S. GLOSSER

known to one another and to the ex-addict staff members of the clinic. Upon intake virtually all self-reported and were known by others to have episodic polydrug use with a preference for opioids. Additionally, the data of the transition group shows that prior to the introduction of contingency management, they had at least as high a rate of drug positive urinalyses as the traditional treatment group. Despite this similarity in initial drug use, their subsequent urinalyses came to resemble that of the experimental group when they were exposed to the experimental contingencies. Finally, it is unlikely that the 86 addicted experimental subjects of the Worcester area enrolled over a 33-month period were consistently less likely to be polydrug users than were the clients of the state’s other methadone maintenance programs enrolled during the same time. An additional challenge may be raised to the meaning of the multiple baseline data. The data presented were of those clients with the most frequent drug positive urinalyses. It might be argued that the observed improvement was the result of regression to the mean of the most extreme scores. However, of the four cases, only subject “A.S.” showed marked improvement before imposition of the experimental treatment. Additionally, even in the case of “J.G.,” who was the first subject introduced to the experimental procedures, there was a baseline consisting of 35 urinalyses over a 4-month period. Finally, from the clinician’s perspective, it is pointless to test a new treatment on persons with only a minor problem. The procedures employed in the present study offer several advantages over other abstinence incentive systems. First, they do not rely upon access to reinforcers not typically available to clinical programs, such as material or monetary incentives. Also, the contingencies were implemented immediately upon induction into treatment, unlike the use of take home medication as an incentive which may be delayed for several weeks or months. Thus, an available relevant consequence, methadone dose level, was made contingent upon clearly identifiable behavioral criteria in a timely manner. While actual dose reductions were usually temporally remote from drug abuse episodes, the granting or withholding of tokens (points) was not, and the tokens clearly discriminated for methadone acquisition and were treated like “cash” by the clients. Episodes of illicit drug use were eventually associated with a reduction of methadone, a somewhat aversive event. Of particular importance is the nature of the aversive event. It is well known that one of the effects of narcotic analgesics is to make aversive events more tolerable to the user. The use of narcotics can be seen as a pain avoidance or escape behavior. It might be predicted that the presentation of an aversive stimulus, such as a token loss contingent upon illicit drug use, would result in accelerated narcotics use as an escape maneuver. However, in this study the aversive stimulus, reduction of methadone, did not appear to have this effect. The effectiveness of small dose reductions and token point losses (discriminative stimulus for an episode of reinforcement reduction) may be credited to the clients’ unwillingness to lose access to the escape/avoidance properties of methadone as well as to its positively reinforcing properties. In other words, methadone functions both as a positive and negative reinforcer for the addict, and the token economy used in the study took good advantage of both functions. However, a problem in the use of dose reduction as an aversive consequence is that a too large reduction of the dose might precipitate opiate withdrawal syndrome and discriminate for an additional drug use episode. This would be especially true if the individual’s drug abuse episodes were under more or less exclusive stimulus control of the abstinence syndrome and if too great a delay were introduced between dose reduction and restoration. Likewise, addicts with different base doses are likely to respond differently to equal, non-proportional dosage changes.

Methadone

maintenance

clients

103

A clinical problem which deserves mention is the dilemma of a new client, or a transfer client, who is simultaneously dependent on opiates as well as other drugs, and who cannot be expected to manage a self-detoxification from illicit non-opiates. For such an individual, inpatient withdrawal from a “drug cocktail” down to a maintenance level of methadone alone, prior to the onset of the experimental contingencies is indicated. This is quite similar to the procedure described by Fordyce (1976) in the treatment of addicted pain patients. An additional advantage of the experimental procedure was that there was no reliance on a system of long-deferred threats of expulsion from treatment, which may or may not be consistently applied among clients. The aversive consequences of a single episode of illicit drug use were not severe but were rapid, as was the positive reinforcement for return to abstinence. Additionally, consistently good performance on the part of the client yielded increased autonomy. In this way it was possible to fade away program structure as the natural consequences of abstinence from illicit drug use came to influence the clients’ behavior. Clients often remarked that the system resembled the real world in which they lived. Disadvantages included those difficulties of accounting and data management common to all token economies. However, the growing availability of powerful minicomputers would substantially ease this burden. Other problems included the expense of frequent urinalyses and the additional nursing time required to adjust dose levels. (However, it should be noted that only the normal clinical budget was required to carry out the project.) While the conclusions of the study are weakened by virtue of its quasi experimental design, its findings suggest a reasonably economic and feasible methodology for the treatment of polydrug abusing methadone maintenance clints that may offer distinct advantages over current practice. This is of importance, because the population now enrolled in methadone maintenance may be substantially different than the population for whom narcotic substitution therapy was initially developed. The polydrug abusing individual who is also addicted to heroin may represent the majority of maintenance clients if the Massachusetts experience is comparable to that of other regions. Finally, the acceptability to clients of any treatment approach is an important consideration, and procedures must be perceived to be basically fair. Injudicious manipulation of dose levels of an addicted person raises serious ethical questions, and the potential for grievous abuses cannot be ignored. A regular program of peer and community review is essential.

REFERENCES Beatty, D. Contingency contracting with heroin addicts. The International Journal of the Addictions. i978, 13, 509-327. Bigelow, G., Lawrence, C., Stitzer, M., Wells, D. Behavioral treatments during outpatient methadone maintenance: A controlled evaluation. Paper presented at the Annual Meeting of the American Psvcholoaical . _ Association, Washington, D.C., 1976. Boudin, H., Valentin, V., Ingraham, R.D., Brantley, .I., Ruiz, M., Smith, G., Catlin, R., & Regan, E. Contingency contracting with drug abusers in the natural environment. International Journal of the Addictions, 1977, 12, I-16. Bowden, C.L., Maddux, J.F., & Esquivel, M. Arrests before and during methadone maintenance. The International Journal of the Addictions, 1978, 13, 921-931. Campbell, D.T., & Stanley, J.C. Exnerimental and Quasi-exoerimental designs 1 ”for research, Chicaeo. L IL: Rand McNally, 1963.. Cheney, T.W., Restighini, S.S., Potter, R.E., & Renner, J.A. Substance abuse indicator assessment for Boston: Summary. Boston: City of Boston Drug Treatment Program, 1979. Dole, V.P., & Nyswander, M.E., A medical treatment for diacetylmorphine (heroin) addiction. Journal of the American Medical Association, 1965, 193, 646-659.

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V.P. & Nyswander, M.E. Methadone maintenance and its implications for theories of narcotic addiction. Research publication. Association for Research of Nervous and Mental Diseases, 1968, 46,

359-366. Finney, G. Drugs: Administering catastrophe. Washington, D.C.: The Drug Abuse Council, Inc., 1975. Fordyce, W. Behavioral methods for chronic pain and illness. St. Louis, MO: C. V. Mosby, 1976. Glosser, D.S. An integrated program of contingency contracting and methadone maintenance: description and preliminary evaluation. Mass. Division of Drug Rehabilitation conference on methadone maintenance, 1977. Glosser, D.S. Reduction of illicit drug use among methadone maintenance clients through reinforcement contingency management. Symposium, World Congress of Behavior Therapy, Jerusalem, Israel, 1980. Gotestam, K.G., & Melin, L. A modified token economy with patients in a methadone maintenance treatment program. Proceedings of the5th National Conference on Methadone Treatment, 1973, New York: NAPAN, 1184-1190. Handal, P.J., & Lander, J.J. Methadone treatment: Program evaluation and dose response relationships. The International Journal of the Addictions, 1976, 11, 363-375. Hersen, M.J., & Barlow, D.H. Single case experimental designs. New York: Pergamon Press, 1976. Kahn, R.B. Study of arrests and convictions in a methadone maintenance program. The International Journal of the Addictions, 1980, 15, 283-286. Langley, M., Morris, B., & Parker, L. Methadone dosage levels, positive urine tests, and length of time in a methadone treatment program. Proceedings of the 5th National Conference on Methadone Treatment, 1973, New York: NAPAN, 963-979. Lennard, H.L., Epstein, L.J., & Rosenthal, M.S. The methadone illusion. Science, 1972, 176, 881-884. Liebson, I., & Bigelow, G. A behavioral-pharmacological treatment of dually addicted patients. Behavioral Research and Therapy, 1972, 10, 403. Liebson, I., Bigelow, G., & Flamer, R. Alcoholism among methadone patients: A specific treatment method.

American Journal of Psychiatry, 1973, 130, 483-485. Meyer,

R.E.

Introduction.

APA

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