Aug. 17, 2001 Rewarding drug users with vouchers that they exchange for food, clothing, or, as one did, a robe for singing in a church choir, was effective in keeping patients drug free and on a medication regimen, according to research at Yale University. The principal investigator of the study funded by the National Institute on Drug Abuse, Kathleen Carroll, professor of psychiatry at Yale School of Medicine, said the intent was to evaluate the best way to encourage patients addicted to opioids, among them, codeine, morphine and heroin, to take naltrexone regularly.
Naltrexone is an opioid antagonist that blocks the effect of opioids in the brain. Unlike methadone, it is non-addicting and does not have to be dispensed daily in a clinic setting.
"When patients take methadone, they stop feeling sick," Carroll said. "Naltrexone doesn’t have that kind of immediate reinforcement. It is, though, a very important tool because, if patients use it consistently, it will block the opioid receptors in the brain so that they don’t experience euphoria if they use heroin."
The researchers tested the strategy of using specific behavioral therapies to enhance pharmacotherapies and encourage patients to take naltrexone regularly.
The study included 127 patients who sought treatment for opioid dependence and who completed outpatient detoxification. Each patient received naltrexone three times a week and attended a group therapy session once a week. A second group of patients also received vouchers redeemable for goods and services contingent on targeted behaviors. Yet another group was offered, in addition to the vouchers and naltrexone, family therapy sessions with a non-substance abusing relative or friend.
The study targeted two behaviors: taking the naltrexone and submitting a drug-free urine specimen. The patients were given a voucher equivalent to 80 cents for the first drug-free urine test. The vouchers were increased by 40 cents for each consecutive drug-free test. Vouchers of the same value were given each time the patient took naltrexone. Each time a patient either failed the drug test or missed a visit to take naltrexone, the value of the voucher went back to 80 cents.
Patients who complied perfectly could earn up to $561 worth of items during the 12-week treatment. Most patients on average earned $200. The money was not given directly to the patients; instead they were able to redeem their vouchers for items consistent with a drug-free lifestyle, such as gift certificates for food and clothing.
"One man had pawned his mother’s jewelry, and he used the vouchers to get her jewelry back," Carroll said. "Others had inconsistent involvement in their children’s lives, so they used the vouchers to pay for their child’s birthday party or Christmas presents. There were some very touching ways in which they used this program to help them stop using and move out of drug-using patterns."
The researchers found that use of the vouchers significantly improved treatment retention and naltrexone compliance. Family therapy did not improve retention in the program, but did improve family functioning. One session with a significant other, in addition to vouchers, had an effect on treatment retention, naltrexone compliance and opioid use.
"Many people who are addicted to opioids such as heroin think that all that is available to help them is methadone maintenance, which is very effective, but it’s not for everyone," Carroll said. "New Haven has one of the relatively few established and successful naltrexone programs in the United States."
"Research suggests that the usual level of compliance with any medication is around 50 percent," Carroll added. "It’s possible these types of strategies also could be used with any other medications."
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