Monitoring Cocaine Use and Abstinence among Cocaine Users for Contingency Management Interventions

By Holtyn, August F.; Knealing, Todd W. et al. | The Psychological Record, June 2017 | Go to article overview

Monitoring Cocaine Use and Abstinence among Cocaine Users for Contingency Management Interventions


Holtyn, August F., Knealing, Todd W., Jarvis, Brantley P., Subramaniam, Shrindhi, Silverman, Kenneth, The Psychological Record


Cocaine use is a disorder of choice that has serious negative health and social consequences for both the individual user and society. Currently, there are no FDA-approved medications for treatment of cocaine dependence (Shorter, Domingo, & Kosten, 2015), making psychosocial approaches central to treating cocaine-using patients. Contingency management interventions are evidence-based psychosocial treatments that have been highly effective in reducing use of a wide range of substances, including cocaine (Knapp, Soares, Farrell, & Silva de Lima, 2007; Lussier, Heil, Mongeon, Badger, & Higgins, 2006; Minozzi, Saulle, De Crescenzo, & Amato, 2015). Under these types of interventions, abstinence reinforcement is arranged by routinely collecting biological measures of drug use and then delivering incentives (e.g., money or vouchers) when the measure indicates drug abstinence, and withholding incentives when the measure indicates drug use. One of the most effective applications of the procedure uses an escalating schedule of reinforcement with a reset contingency, in which the value of the incentive increases with each consecutive drug-negative urine sample. A drug-positive or missed urine sample results in loss of the incentive and a reset in the value of the next available incentive to the initial value (Higgins et al., 1991).

Detection of benzoylecgonine, the primary metabolite of cocaine, is a common method for monitoring cocaine use during contingency management interventions. Qualitative urinalysis testing (i.e., testing that solely identifies whether a particular substance is present or absent) is often used, with results expressed as positive or negative if the benzoylecgonine concentration is above or below, respectively, a certain cutoff value (typically 300 ng/ml). Urine samples are often collected two or three times per week (every 48 to 72 hours) because it has been reported that benzoylecgonine can be detected in urine for approximately 48 hours after cocaine use (for a review, see Verstraete, 2004). However, the duration of the window of detection may vary based on several factors, such as the amount of cocaine used, route of administration, the amount of water consumed, and individual differences in drug metabolism and excretion (for a review, see Cone & Dickerson, 1993). Because of this variability in the window of detection, it is possible that a single instance of cocaine use may result in multiple cocaine-positive urine samples if subsequent samples are collected before all of the metabolite has been excreted (Preston, Silverman, Schuster, & Cone, 1997; Preston, Goldberger, & Cone, 1998; Preston, Epstein, Cone, Wtsadik, Huestis, & Moolchan, 2002). This carryover effect could be problematic for contingency management interventions: in some cases, participants may stop using cocaine, yet will not receive an incentive because not enough time has elapsed before urine sample collection. Simply testing less frequently so as to reduce the likelihood of carryover effects may be problematic because it could allow new instances of cocaine use and abstinence to go undetected (for a discussion, see Cone & Dickerson, 1993).

Preston and colleagues (1997) developed procedures to identify whether a urine sample is cocaine-positive due to carryover from earlier use or due to recent cocaine use. Development of these "New Use" criteria was based on pharmacokinetic parameters of cocaine and benzoylecgonine, and used quantitative urinalysis testing (i.e., testing that identifies how much of a substance is present). According to these criteria, when the current and prior urine samples have been collected at least 48 hours apart and have benzoylecgonine concentrations that are greater than 300 ng/ml, the current sample may be considered positive due to carryover if the benzoylecgonine concentration of the current sample has decreased by 50% or more from the prior sample. These criteria for detecting new use versus carryover from previous drug use were validated using data from a laboratory-based cocaine dosing study and a clinical trial evaluating a treatment for cocaine use (Preston et al. …

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