Employment-based abstinence reinforcement as a maintenance intervention for the treatment of cocaine dependence: a randomized controlled trial


Anthony DeFulio, Department of Psychiatry and Behavioral Sciences, 5200 Eastern Avenue, Ste. W142, Baltimore, MD 21224, USA. E-mail: adefuli1@jhmi.edu


Context  Due to the chronic nature of cocaine dependence, long-term maintenance treatments may be required to sustain abstinence. Abstinence reinforcement is among the most effective means of initiating cocaine abstinence. Practical and effective means of maintaining abstinence reinforcement programs over time are needed.

Objective  To determine whether employment-based abstinence reinforcement can be an effective long-term maintenance intervention for cocaine dependence.

Design  Participants (n = 128) were enrolled in a 6-month job skills training and abstinence initiation program. Participants who initiated abstinence, attended regularly and developed needed job skills during the first 6 months were hired as operators in a data entry business and assigned randomly to an employment-only (control, n = 24) or abstinence-contingent employment (n = 27) group.

Setting  A non-profit data entry business.

Participants  Unemployed welfare recipients who used cocaine persistently while enrolled in methadone treatment in Baltimore.

Intervention  Abstinence-contingent employment participants received 1 year of employment-based contingency management, in which access to employment was contingent upon provision of drug-free urine samples under routine and then random drug testing. If a participant provided drug-positive urine or failed to provide a mandatory sample, then that participant received a temporary reduction in pay and could not work until urinalysis confirmed recent abstinence.

Main outcome measure  Cocaine-negative urine samples at monthly assessments across 1 year of employment.

Results  During the 1 year of employment, abstinence-contingent employment participants provided significantly more cocaine-negative urine samples than employment-only participants [79.3% and 50.7%, respectively; P = 0.004, odds ratio (OR) = 3.73, 95% confidence interval (CI) = 1.60–8.69].

Conclusions  Employment-based abstinence reinforcement that includes random drug testing is effective as a long-term maintenance intervention, and is among the most promising treatments for drug dependence. Work-places could serve as therapeutic agents in the treatment of drug dependence by arranging long-term employment-based contingency management programs.