A Pilot Study of Youth With Type 1 Diabetes Initiating Use of a Hybrid Closed-Loop System While Receiving a Behavioral Economics Intervention.

OBJECTIVE: Many youth do not use the hybrid closed-loop system for type 1 diabetes effectively. This study evaluated the impact of financial incentives for diabetes-related tasks on use of the 670G hybrid closed-loop system and on glycemia. METHODS: At auto mode initiation and for 16 weeks thereafter, participants received a flat rate for wearing and calibrating the sensor ($1/day), administering at least 3 mealtime insulin boluses per day ($1/day), and uploading ($5/week). Weekly bonuses were given for maintaining at least 70% of the time in auto mode, which were increased for persistent auto mode use from $3/week to a maximum of $13/week. If a participant failed to maintain auto mode for a week, the rewards were reset to baseline. Data from 17 participants aged 15.9 years ± 2.5 years (baseline hemoglobin A1c [HbA1c] 8.6% ± 1.1%) were collected at 6, 12, and 16 weeks. The reinforcers were withdrawn at 16 weeks, with a follow-up assessment at 24 weeks. RESULTS: With reinforcers, the participants administered an average of at least 3 mealtime insulin boluses per day and wore the sensor over 70% of the time. However, auto mode use waned. HbA1c levels decreased by 0.5% after 6 weeks, and this improvement was maintained at 12 and 16 weeks (P < .05). Upon withdrawal of reinforcers, HbA1c levels increased back to baseline at 24 weeks. CONCLUSION: Compensation for diabetes-related tasks was associated with lower HbA1c levels, consistent administration of mealtime insulin boluses, and sustained sensor use. These results support the potential of financial rewards for improving outcomes in youth with type 1 diabetes.

Individualized assessment and treatment program (IATP) for cannabis use disorder: Randomized controlled trial with and without contingency management.

This study tested a new approach to the treatment of cannabis use disorder (CUD). CUD is difficult to treat, and achieving abstinence is particularly difficult. The individualized assessment and treatment program (IATP) was intended to address this problem by providing a highly individualized approach to the training of coping skills most relevant for each individual. To do this, an experience sampling procedure was used prior to treatment to record patients' marijuana use behavior and associated thoughts, feelings, coping behaviors, and situations. This information was used by therapists to plan treatment that would address the specific strengths and weaknesses of each patient in drug-use situations. The present study tested IATP against a conventional combined motivational enhancement cognitive-behavioral treatment (MET-CBT), with or without the addition of contingency management (CM) for abstinence. The patients were 198 men and women randomly assigned to 1 of 4 nine-session treatment conditions: MET-CBT, MET-CBT-CM, IATP, or IATP-CM. Patients were assessed out to 14 months. Planned contrasts indicated that the IATP conditions yielded greater levels of abstinence than did the MET-CBT conditions. The addition of CM did not bolster the performance of IATP but did do so for MET-CBT. As expected, IATP lead to greater use of coping skills than did the MET-CBT conditions. However, coping skills use was not a significant predictor of outcome when other variables were in the same analyses. Self-efficacy was a robust predictor and mediator of outcome. We suggest that the IATP may act by enhancing self-efficacy. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Glucose management for rewards: A randomized trial to improve glucose monitoring and associated self-management behaviors in adolescents with type 1 diabetes.

BACKGROUND: This randomized, controlled trial evaluated a monetary-based reinforcement intervention for increasing self-monitoring of blood glucose (SMBG) among youth with poorly controlled type 1 diabetes. METHODS: After a 2-week baseline, 60 participants were randomized to enhanced usual care (EUC) or Reinforcers. The Reinforcers group earned monetary rewards for SMBG and associated behaviors such as uploading glucose meters. Reinforcers were withdrawn at 24 weeks. A follow-up evaluation occurred at 36 weeks. RESULTS: Participants in the reinforcers group increased the proportion of days they completed ≥4 SMBG from 14.6% at baseline to 64.4%, 47.5%, and 37.8% at 6, 12, and 24 weeks, respectively. In contrast, EUC participants declined from 22.7% at baseline to 17.5%, 10.5%, and 11.1% (Ps < .01 vs EUC at all time points). Group differences were attenuated but remained significant after withdrawal of reinforcers. Effect sizes for SMBG were very large during reinforcement and large after withdrawal of reinforcers. In the reinforcers group, mean A1c dropped from 9.5% ± 1.2% at baseline to 9.0% ± 1.3% at week 6 and 9.0% ± 1.4% at week 12. For EUC, A1c was 9.2% ± 0.2% at baseline and ranged from 9.2% ± 1.5% to 9.6% ± 1.6% throughout the study (P < .05 vs EUC). Group differences in A1c were no longer significant at weeks 24 and 36. Effect sizes for A1c were small during reinforcement and also after withdrawal of reinforcement. CONCLUSIONS: Monetary-based reinforcement of adolescents with type 1 diabetes caused durable increases in SMBG. Modification of the reinforcement structure may be needed to sustain improved metabolic control in this challenging age group.

A cohort study of patients seeking Internet gaming disorder treatment.

BACKGROUND AND AIMS: Although Internet gaming disorder (IGD) is included as a condition in the fifth edition of Diagnostic and Statistical Manual of Mental Disorders, little is known about its nature or treatment response. This study is a follow-up of 755 patients who received professional treatment for IGD over a 5-year period. METHODS: The initial recommended treatment course lasted for 8 weeks, with additional care provided as needed. Treatment completion rates in the complete sample, as well as baseline predictors of treatment completion and long-term recovery among the 367 patients who completed the follow-up, are reported. RESULTS: Nearly two thirds of patients who initiated treatment for IGD completed the 8-week psychotherapy. Of these, about two thirds who had not recovered completely by the end were offered additional care. Independent predictors of extended treatment were higher baseline scores on the Young Internet Addiction Scale, Beck Depression Inventory (BDI), and Korean-Attention Deficit Hyperactivity Disorder-Rating Scale (K-ADHD-RS). Between 1 and 5 years later, 33.5% of the complete sample was considered as recovered from IGD. Significant predictors of recovery from IGD were older age, earlier admission to the clinic, lower baseline scores on the BDI and K-ADHD-RS, and no offer of extended treatment. DISCUSSION AND CONCLUSIONS: The majority of the patients seeking treatment for IGD continued experiencing difficulties and randomized controlled trials of interventions, which are needed to be conducted to improve outcomes. Age, family, social factors, and psychological symptoms should be considered, while designing and evaluating interventions, because they impact initial and sustained response to treatment for IGD.

A randomized trial of contingency management for smoking cessation in the homeless.

Smoking-cessation services are an unmet need among the homeless, who smoke at rates more than 4 times the national estimate. Successful interventions have high potential for improving tobacco-related health disparities among homeless smokers. Contingency management (CM) is a behavioral intervention with efficacy in a number of substance-use disorder populations, including smokers. However, no randomized studies have evaluated the effect of CM in homeless smokers. We examined smoking-related outcomes in homeless smokers (N = 70) randomized to standard-care (SC) smoking cessation involving transdermal nicotine-replacement therapy (NRT), standard counseling, and carbon monoxide (CO) monitoring or the same SC plus CM for negative CO sample submissions. Participants randomized to CM achieved significantly longer durations of consecutive abstinence and submitted a significantly higher proportion of CO-negative samples relative to standard-care participants. At 4 weeks postquit day, 22% were abstinent in the CM condition and 9% were abstinent in the SC condition. At the 6-month follow-up, about 10% of smokers in both conditions were abstinent. This study demonstrates that CM is an efficacious option to increase initial quit rates in homeless smokers, but methods to extend effects are needed. (PsycINFO Database Record

Contingency management treatment for substance use disorders: How far has it come, and where does it need to go?

Contingency management (CM) interventions consistently improve substance abuse treatment outcomes, yet CM remains a highly controversial intervention and is rarely implemented in practice settings. This article briefly outlines the evidence base of CM and then describes 4 of the most often-cited concerns about it: philosophical, motivational, durability, and economic. Data supporting and refuting each of these issues are reviewed. The article concludes with suggestions to address these matters and other important areas for CM research and implementation, with the aims of improving uptake of this efficacious intervention in practice settings and outcomes of patients with substance use disorders. (PsycINFO Database Record

Testing for rewards: a pilot study to improve type 1 diabetes management in adolescents.

OBJECTIVE: To evaluate the effectiveness of monetary reinforcement to increase the frequency of self-monitoring blood glucose (SMBG). RESEARCH DESIGN AND METHODS: Ten adolescents with poorly controlled diabetes enrolled in a 12-week program in which they earned monetary reinforcers based on SMBG frequency ($0.10 per test, with bonuses for ≥4 tests per day, and $251.40 maximum). RESULTS: SMBG increased from 1.8 ± 1.0 to 4.9 ± 1.0 tests per day (P < 0.001) with 90% completing four or more tests per day. Mean A1C fell from 9.3 ± 0.9% to 8.4 ± 1.5% (P = 0.05). Adolescents and parents reported high satisfaction with procedures. CONCLUSIONS: Reinforcing adolescents for SMBG may increase testing and improve A1C.

Patients Undergoing Substance Abuse Treatment and Receiving Financial Assistance for a Physical Disability Respond Well to Contingency Management Treatment.

Physical illness and disability are common in individuals with substance use disorders, but little is known about the impact of physical disability status on substance use treatment outcomes. This study examined the main and interactive effects of physical disability payment status on substance use treatment. Participants (N = 1,013) were enrolled in one of six prior randomized clinical trials comparing contingency management (CM) to standard care; 79 (7.8%) participants reported receiving disability payments, CM improved all three primary substance use outcomes: treatment retention, percent negative samples and longest duration of abstinence. There was no significant main effect of physical disability payment status on treatment outcomes; however, a significant treatment condition by physical disability status interaction effect emerged in terms of retention in treatment and duration of abstinence achieved. Patients who were receiving physical disability payments responded particularly well to CM, and their time in treatment and durations of drug and alcohol abstinence increased even more markedly with CM than did that of their counterparts who were not receiving physical disability assistance. These findings suggest an objectively defined cohort of patients receiving substance use treatment who respond particularly well to CM.

The price elasticity of demand for heroin: Matched longitudinal and experimental evidence.

This paper reports estimates of the price elasticity of demand for heroin based on a newly constructed dataset. The dataset has two matched components concerning the same sample of regular heroin users: longitudinal information about real-world heroin demand (actual price and actual quantity at daily intervals for each heroin user in the sample) and experimental information about laboratory heroin demand (elicited by presenting the same heroin users with scenarios in a laboratory setting). Two empirical strategies are used to estimate the price elasticity of demand for heroin. The first strategy exploits the idiosyncratic variation in the price experienced by a heroin user over time that occurs in markets for illegal drugs. The second strategy exploits the experimentally induced variation in price experienced by a heroin user across experimental scenarios. Both empirical strategies result in the estimate that the conditional price elasticity of demand for heroin is approximately -0.80.

Reinforcing adherence to antihypertensive medications.

This pilot study evaluated a reinforcement intervention to improve adherence to antihypertensive therapy. Twenty-nine participants were randomized to standard care or standard care plus financial reinforcement for 12 weeks. Participants in the reinforcement group received a cell phone to self-record videos of adherence, for which they earned rewards. These participants sent videos demonstrating on-time adherence 97.8% of the time. Pill count adherence differed significantly between the groups during treatment, with 98.8%±1.5% of pills taken during treatment in the reinforcement condition vs 92.6%±9.2% in standard care (P<.002). Benefits persisted throughout a 3-month follow-up, with 93.8%±9.3% vs 78.0%±18.5% of pills taken (P<.001). Pill counts correlated significantly (P<.001) with self-reports of adherence, which also differed between groups over time (P<.01). Systolic blood pressure decreased modestly over time in participants overall (P<.01) but without significant time-by-group effects. These results suggest that reinforcing medication adherence via cellular phone technology and financial reinforcement holds potential to improve adherence.

Prize contingency management for smoking cessation: a randomized trial.

BACKGROUND: Adjunctive behavioral smoking cessation treatments have the potential to improve outcomes beyond standard care. The present study had two aims: (1) compare standard care (SC) for smoking (four weeks of brief counseling and monitoring) to SC plus prize-based contingency management (CM), involving the chance to earn prizes on days with demonstrated smoking abstinence (carbon monoxide (CO) ≤6 ppm); and (2) compare the relative efficacy of two prize reinforcement schedules-one a traditional CM schedule, and the second an early enhanced CM schedule providing greater reinforcement magnitude in the initial week of treatment but equal overall reinforcement. METHODS: Participants (N=81 nicotine-dependent cigarette smokers) were randomly assigned to one of the three conditions. RESULTS: Prize CM resulted in significant reductions in cigarette smoking relative to SC. These reductions were not apparent at follow-up. We found no meaningful differences between the traditional and enhanced CM conditions. CONCLUSIONS: Our findings reveal that prize CM leads to significant reductions in smoking during treatment relative to a control intervention, but the benefits did not extend long-term.

Sex differences in antisocial personality disorder: results from the National Epidemiological Survey on Alcohol and Related Conditions.

Despite the 3:1 prevalence ratio of men versus women with Antisocial Personality Disorder (ASPD), research on sex differences on correlates of ASPD in the general population is scarce. The purpose of this study was to examine sex differences in childhood and adult adverse events, lifetime psychiatric comorbidity, and clinical correlates of DSM-IV ASPD. The sample included 819 men and 407 women with DSM-IV ASPD diagnosis. Data were derived from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) (N = 43,093). Compared to men, women with ASPD reported more frequent childhood emotional neglect (AOR = 2.25; 95% CI: 1.52-3.34) and sexual abuse (AOR = 4.20; 95% CI: 2.78-6.35), any parent-related adverse event during childhood (e.g., parental substance use disorder) (AOR = 2.47; 95% CI: 1.60-3.82), and adverse events during adulthood (AOR = 4.20; 95% CI: 2.78-6.35). Although women with ASPD present less violent antisocial behaviors and higher rates of aggressiveness and irritability (OR = 0.46; 95% CI: 0.31-0.67), they have higher rates of victimization, greater impairment, and lower social support. Our findings suggest increased mental health needs in women with ASPD, meriting development of different treatment programs for women and men.

Antisocial personality disorder is associated with receipt of physical disability benefits in substance abuse treatment patients.

BACKGROUND: Opioid dependence is growing at an alarming rate in the United States, and opioid dependent patients have substantial medical, as well as psychiatric, conditions that impact their ability to work. This study evaluated the association between antisocial personality disorder (ASPD) and receipt of physical disability payments in methadone maintenance patients. METHODS: Using data from 115 drug and alcohol abusing methadone maintained patients participating in two clinical trials, baseline characteristics of individuals receiving (n=22) and those not receiving (n=93) physical disability benefits were compared, and a logistic regression evaluated unique predictors of disability status. RESULTS: Both an ASPD diagnosis and severity of medical problems were significant predictors of disability receipt, ps<.05. After controlling for other variables that differed between groups, patients with ASPD were more than five times likelier to receive physical disability benefits than patients without ASPD (odds ratio=5.66; 95% confidence interval=1.58-20.28). CONCLUSIONS: These results demonstrate a role of ASPD in the receipt of disability benefits in substance abusers and suggest the need for greater understanding of the reasons for high rates of physical disability benefits in this population.

Reliability and validity of the Functional Assessment of Human Immunodeficiency Virus Infection (FAHI) in patients with drug and alcohol use disorders.

Human Immunodeficiency Virus (HIV) and substance use disorders can both significantly impact a patient's quality of life (QOL), and it is, therefore, important to assess QOL throughout treatments for these chronic conditions. This study evaluated the psychometric properties of the Functional Assessment of Human Immunodeficiency Virus Infection (FAHI) in 170 HIV-positive patients who participated in a substance abuse treatment study. Internal consistency of the FAHI was good. Convergent and discriminant validity were generally supported with comparisons to other patient-reported measures. FAHI scores were not significantly associated with viral loads or CD4 counts, and they were similar in patients with and without AIDS. Patients who achieved longer durations of drug and alcohol abstinence during treatment reported better QOL post-treatment. The FAHI appears to be a reliable and valid measure for assessing QOL in HIV-positive patients with concurrent drug and alcohol use disorders.

National gambling experiences in the United States: will history repeat itself?

AIMS: The aim of this paper is to offer an account of the history and current status of gambling research in the United States. METHODS: A review of the literature. RESULTS: Gambling has been a part of society in the United States since its early history. However, it was not until 1980 that the medical profession in the United States first recognized pathological gambling as a psychiatric disorder. Today, it is still rarely diagnosed or treated, and relatively little federal funding is available to support research in this area. With the upcoming fifth revision of the Diagnostic and Statistical Manual of Mental Disorders, pathological gambling is likely to be included alongside substance use disorders as the first non-substance-related addictive disorder. This change may represent an opportunity to expand research on gambling and treatment of pathological gambling. CONCLUSIONS: We provide 10 suggestions for reducing societal and personal harm associated with this disorder.

Financial reinforcers for improving medication adherence: findings from a meta-analysis.

BACKGROUND: Increasingly, financial reinforcement interventions based on behavioral economic principles are being applied in health care settings, and this study examined the use of financial reinforcers for enhancing adherence to medications. METHODS: Electronic databases and bibliographies of relevant references were searched, and a meta-analysis of identified trials was conducted. The variability in effect size and the impact of potential moderators (study design, duration of intervention, magnitude of reinforcement, and frequency of reinforcement) on effect size were examined. RESULTS: Fifteen randomized studies and 6 nonrandomized studies examined the efficacy of financial reinforcement interventions for medication adherence. Financial reinforcers were applied for adherence to medications for tuberculosis, substance abuse, human immunodeficiency virus, hepatitis, schizophrenia, and stroke prevention. Reinforcement interventions significantly improved adherence relative to control conditions with an overall effect size of 0.77 (95% confidence interval, 0.70-0.84; P<.001). Nonrandomized studies had a larger average effect size than randomized studies, but the effect size of randomized studies remained significant at 0.44 (95% confidence interval, 0.35-0.53; P<.001). Interventions that were longer in duration, provided an average reinforcement of $50 or more per week, and reinforced patients at least weekly resulted in larger effect sizes than those that were shorter, provided lower reinforcers, and reinforced patients less frequently. CONCLUSION: These results demonstrate the efficacy of medication adherence interventions and underscore principles that should be considered in designing future adherence interventions. Financial reinforcement interventions hold potential for improving medication adherence and may lead to benefits for both patients and society.

Health-care service utilization in substance abusers receiving contingency management and standard care treatments.

AIM: To determine the impact of standard care and contingency management treatments on the utilization of general health-care services by substance abusers. PARTICIPANTS, DESIGN AND MEASUREMENTS: This secondary analysis pooled 1028 treatment-seeking substance abusers from five randomized clinical trials that compared the effects of standard care (SC, n = 362) to standard care plus contingency management (CM, n = 666). In each trial, subjects in the CM condition showed significantly greater reductions in substance use than their SC counterparts. For each subject, utilization of 15 general health-care services was measured 1 year prior to treatment intake and up to 9 months following treatment intake. Post-intake utilization data were pro-rated to be comparable to the 1-year pre-intake data. Paired t-tests evaluated changes in service utilization pre- and post-intake, and difference-in-differences regression models were used to estimate the impact of CM, compared to SC, on changes in the utilization of each of the 15 health services. SETTING: Out-patient community substance abuse clinics in Connecticut and Massachusetts, USA. FINDINGS: Utilization of several types of out-patient services increased significantly between the pre- and post-intake periods [e.g. dental visits (0.47, P < 0.001), community health center visits (0.50, P < 0.001), visits to a mental health professional office (1.03, P = 0.001)], while in-patient hospital care for mental health problems decreased significantly (-3.50 nights, P < 0.001). A substantial portion of these changes occurred during the treatment period. No significant differences were found between the two treatment conditions. CONCLUSIONS: Initiating out-patient substance abuse treatment is associated with changes in general health-care service utilization, independent of the type of treatment offered.

The impact of contingency management on quality of life among cocaine abusers with and without alcohol dependence.

The use of quality of life (QOL) measures in substance abuse treatment research is important because it may lead to a broader understanding of patients' health status and effects of interventions. Despite the high rates of comorbid cocaine and alcohol use disorders, little is known about the QOL of this population, and even less about the impact of an efficacious behavioral treatment, contingency management (CM), on QOL. In this study, data from three clinical trials were retrospectively analyzed to examine QOL in outpatient cocaine abusers with and without alcohol dependence (AD) and the impact of CM on QOL over time as a function of AD status. Patients were randomized to standard care (n = 115) or standard care plus CM (n = 278) for 12 weeks. QOL was assessed at baseline and Months 1, 3, 6, and 9. At treatment initiation, AD patients had lower QOL total scores and they scored lower on several subscale scores than those without AD. CM treatment was associated with improvement in QOL regardless of AD status. These data suggest that CM produces benefits that go beyond substance abuse outcomes, and they support the use of QOL indexes to capture information related to treatment outcomes.

Is exposure to an effective contingency management intervention associated with more positive provider beliefs?

This study empirically examined opinions of treatment providers regarding contingency management (CM) programs while controlling for experience with a specific efficacious CM program. In addition to empirically describing provider opinions, we examined whether the opinions of providers at the sites that implemented the CM program were more positive than those of matched providers at sites that did not implement it. Participants from 7 CM treatment sites (n = 76) and 7 matched nonparticipating sites (n = 69) within the same nodes of the National Institute of Drug Abuse Clinical Trials Network completed the Provider Survey of Incentives (PSI), which assesses positive and negative beliefs about incentive programs. An intent-to-treat analysis found no differences in the PSI summary scores of providers in CM program versus matched sites, but correcting for experience with tangible incentives showed significant differences, with providers from CM sites reporting more positive opinions than those from matched sites. Some differences were found in opinions regarding costs of incentives, and these generally indicated that participants from CM sites were more likely to see the costs as worthwhile. The results from the study suggest that exposing community treatment providers to incentive programs may itself be an effective strategy in prompting the dissemination of CM interventions.