Intervention Summary

Reinforcement-Based Therapeutic Workplace

The reinforcement-based therapeutic workplace (RBTW) is a practical application of contingency management theory. Contingency management is historically based on a construct central to behavioral psychology known as operant conditioning, or the use of consequences to modify the occurrence and form of behavior. In voucher-based abstinence reinforcement therapy for cocaine abuse, cocaine-abusing outpatients in ongoing methadone maintenance treatment programs receive escalating monetary vouchers for successive cocaine-free urine samples. These vouchers can be exchanged for goods and services purchased by staff on behalf of the patients. When this voucher-based reinforcement is applied to a therapeutic workplace, patients are hired, trained, and paid to work in a supportive environment. They can continue working and earn escalating base-pay vouchers while they remain abstinent from cocaine (and sometimes opiates) as verified by negative urine samples. Employment-based abstinence reinforcement has been proposed as a long-term treatment goal primarily for two reasons: (1) workplaces serve as a controller for reinforcers and enable regular, long-term monitoring of patients; and (2) the use of drug testing, which is part of RBTW, is consistent with existing workplace practices. Participants are eligible for participation in the therapeutic workplace if they provide evidence of enrollment in a community methadone treatment program.

Descriptive Information

Areas of Interest	Substance use disorder treatment
Outcomes	1: Cocaine and Opiate Use 2: Drug-related HIV Risk Behaviors 1: Cocaine use 2: Opiate use 3: Cocaine and opiate use 4: Cocaine craving 5: Workplace attendance
Outcome Categories	Drugs Employment Treatment/recovery
Ages	18-25 (Young adult) 26-55 (Adult) 55+ (Older adult)
Genders	Male Female
Races/Ethnicities	Black or African American White Race/ethnicity unspecified
Settings	Outpatient Workplace
Geographic Locations	Urban
Implementation History	Voucher-based abstinence reinforcement therapy for substance use disorders has been in use, primarily in university/research settings and, to a limited extent, community-based treatment settings. The therapeutic workplace, a specific adaptation of voucher-based reinforcement, was developed at the Johns Hopkins University and has developed over time. Although external funding continues to supplement its operation at Johns Hopkins, the goal for this specialized workplace intervention is to become economically self-sustaining.
NIH Funding/CER Studies	Partially/fully funded by National Institutes of Health: Yes Evaluated in comparative effectiveness research studies: Yes
Adaptations	The applicant identified no population- or culture-specific adaptations.
Adverse Effects	The applicant identified no adverse effects, concerns, or unintended consequences.
IOM Prevention Categories	IOM prevention categories are not applicable.

Quality of Research

Documents Reviewed

The documents below were reviewed for Quality of Research. The research point of contact can provide information regarding the studies reviewed and the availability of additional materials, including those from more recent studies that may have been conducted.

Study 1

DeFulio, A., Donlin, W., Wong, C., & Silverman, K. Employment-based abstinence reinforcement as a maintenance intervention for the treatment of cocaine dependence: A randomized controlled trial. Society for the Study of Addiction, 104, 1530-1538.

Outcomes

Outcome 1: Cocaine and Opiate Use
Description of Measures	Main outcomes were cocaine and opiate use measured through urinalysis based on samples collected at monthly assessments throughout the second phase of the study.
Key Findings	Overall, the randomized controlled trial showed that employment-based abstinence reinforcement is an effective long-term maintenance intervention for the treatment of cocaine dependence. When compared with the employment-only control group (for which positive cocaine or opiate urine samples resulted in no consequences), the abstinence-contingent employment group provided significantly higher rates of cocaine-negative urine samples. Forty-six percent of employment-only participants relapsed to regular cocaine use early in the study compared with 18.5% among the abstinence-contingent group.
Studies Measuring Outcome	Study 1
Study Designs	Experimental
Quality of Research Rating	3.6 (0.0-4.0 scale)

Outcome 2: Drug-related HIV Risk Behaviors
Description of Measures	Drug-related HIV risk behaviors were assessed at the 6- and 12-month time-points using the Risk Assessment Battery (RAB). The RAB is a self-administered questionnaire with 29 questions. For our analyses, we determined if each participant did or did not (1 or 0) engage in each of the behaviors listed in Table 1 of the published manuscript (i.e., reported sharing injection equipment, reported going to shooting gallery or crack house and reported trading drugs for money). Responses to two or more questions were used to determine if the person engaged in each of the behaviors.
Key Findings	The study showed that lower percentages of participants in both the employment-only and employment-based abstinence reinforcement groups engaged in HIV risk behaviors from intake through phase 1 of the study. However, during phase 2, significantly more employment-only participants reported trading sex for drugs or money than their abstinent-contingent counterparts (16.7% vs 0% respectively; p=0.046).
Studies Measuring Outcome	Study 1
Study Designs	Experimental
Quality of Research Rating	3.4 (0.0-4.0 scale)

Study Populations

The following populations were identified in the studies reviewed for Quality of Research.

Study	Age	Gender	Race/Ethnicity
Study 1	26-55 (Adult) 55+ (Older adult)	77% Female 23% Male	88% Black or African American

Quality of Research Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the Quality of Research for an intervention's reported results using six criteria:

Reliability of measures
Validity of measures
Intervention fidelity
Missing data and attrition
Potential confounding variables
Appropriateness of analysis

For more information about these criteria and the meaning of the ratings, see Quality of Research.

Outcome	Reliability of Measures	Validity of Measures	Fidelity	Missing Data/Attrition	Confounding Variables	Data Analysis	Overall Rating
1: Cocaine and Opiate Use	3.3	3.3	3.5	3.8	3.8	3.8	3.6
2: Drug-related HIV Risk Behaviors	3.3	2.8	3.5	3.5	3.8	3.6	3.4

Study Strengths

The researchers used appropriate measures, including urinalysis, in order to objectively measure abstinence from drug use and lowered drug-related HIV risk behaviors. The study used an intent-to-treat approach. The study was blinded. Researchers were able to ensure that both intervention and control groups were similar at baseline through the use of computerized stratification/randomization, and outcome measures were assessed at multiple time points. In addition, the level of attrition was low. Overall, this was a well-designed and theory-driven intervention study.

Study Weaknesses

Reliability was low (for the sex risk portions of the Risk Assessment Battery, Cronbach's alpha = 0.42) to fair (test-retest for methadone and cocaine populations = 0.69 and 0.88, respectively). The authors did not use corrected alphas to consider the possibility that intervention effects were obtained by chance. No fidelity information was provided. The study excluded drug-related HIV risk behavior data for the one participant in the abstinence-contingent group who died, which could have biased results for this outcome, especially given the low rate of reported HIV risk behaviors (i.e., sex for drugs or money). The sample was primarily female (77%), but the influence of gender was not examined, nor was gender included as a statistical control in the analysis. Additional study weaknesses were related to the challenges of data collection with a high-risk community-based population and funding issues rather than the study design. For example, many participants did not qualify for phase 2 of the study because they failed to maintain the required attendance level and acquire necessary job skills during phase 1 of the project. In addition, power analyses were calculated for a three group design, but the usual care group was dropped due to unforeseen high rates of workplace attendance. Hence it is unclear whether the study had adequate power to detect intervention effects.

Documents Reviewed

Study 1

Silverman, K., Higgins, S. T., Brooner, R. K., Montoya, I. D., Cone, E. J., Schuster, C. R., et al. Sustained cocaine abstinence in methadone maintenance patients through voucher-based reinforcement therapy. Archives of General Psychiatry, 53, 409-415.

Study 2

Silverman, K., Wong, C. J., Umbricht-Schneiter, A., Montoya, I. D., Schuster, C. R., & Preston, K. L. Broad beneficial effects of cocaine abstinence reinforcement among methadone patients. Journal of Consulting and Clinical Psychology, 66(5), 811-824.

Study 3

Silverman, K., Chutuape, M. A., Bigelow, G. E., & Stitzer, M. L. Voucher-based reinforcement of cocaine abstinence in treatment-resistant methadone patients: Effects of reinforcement magnitude. Psychopharmacology, 146, 128-138.

Study 4

Silverman, K., Robles, E., Mudric, T., Bigelow, G. E., & Stitzer, M. L.. A randomized trial of long-term reinforcement of cocaine abstinence in methadone-maintained patients who inject drugs. Journal of Consulting and Clinical Psychology, 72(5), 839-854.

Study 5

Silverman, K., Svikis, D., Robles, E., Stitzer, M. L., & Bigelow, G. E. A reinforcement-based Therapeutic Workplace for the treatment of drug abuse: Six-month abstinence outcomes. Experimental and Clinical Psychopharmacology, 9(1), 14-23.

Silverman, K., Svikis, D., Wong, C. J., Hampton, J., Stitzer, M. L., & Bigelow, G. E. A reinforcement-based Therapeutic Workplace for the treatment of drug abuse: Three-year abstinence outcomes. Experimental and Clinical Psychopharmacology, 10(3), 228-240.

Study 6

Silverman, K., Wong, C. J., Needham, M., Diemer, K. N., Knealing, T., Crone-Todd, D., et al. A randomized trial of employment-based reinforcement of cocaine abstinence in injection drug users. Journal of Applied Behavioral Analysis, 40(3), 387-410.

Supplementary Materials

Dillon, E. M., Wong, C. J., Sylvest, C. E., Crone-Todd, D. E., & Silverman, K.. Computer-based typing and keypad skills training outcomes of unemployed injection drug users in a Therapeutic Workplace. Substance Use and Misuse, 39(13-14), 2325-2353.

Knealing, T. W., Roebuck, M. C., Wong, C. J., & Silverman, K. Economic cost of the Therapeutic Workplace intervention added to methadone maintenance. Journal of Substance Abuse Treatment, 34(3), 326-332.

Silverman, K., Wong, C. J., Grabinski, M. J., Hampton, J., Sylvest, C. E., Dillon, E. M., et al. A Web-based Therapeutic Workplace for the treatment of drug addiction and chronic unemployment. Behavior Modification, 29(2), 417-463.

Silverman, K., Wong, C. J., Higgins, S. T., Brooner, R. K., Montoya, I. D., Contoreggi, C., et al. Increasing opiate abstinence through voucher-based reinforcement therapy. Drug and Alcohol Dependence, 41(2), 157-165.

Wong, C. J., Dillon, E. M., Sylvest, C., & Silverman, K.. Evaluation of a modified contingency management intervention for consistent attendance in Therapeutic Workplace participants. Drug and Alcohol Dependence, 74(3), 319-323.

Wong, C. J., Dillon, E. M., Sylvest, C. E., & Silverman, K.. Contingency management of reliable attendance of chronically unemployed substance abusers in a Therapeutic Workplace. Experimental and Clinical Psychopharmacology, 12(1), 39-46.

Wong, C. J., Sheppard, J. M., Dallery, J., Bedient, G., Robles, E., Svikis, D., et al. Effects of reinforcer magnitude on data-entry productivity in chronically unemployed drug abusers participating in a Therapeutic Workplace. Experimental and Clinical Psychopharmacology, 11(1), 46-55.

Outcomes

Outcome 1: Cocaine use
Description of Measures	Cocaine use was measured using urinalysis. Some studies also used the Addiction Severity Index (ASI), an interview instrument that evaluates the severity of psychosocial problems across seven domains: employment, family/social, legal, drug, alcohol, medical, and psychiatric. Composite scores of 0 to 1 are calculated for each domain, with higher scores reflecting greater problem severity.
Key Findings	Three clinical randomized controlled trials (RCTs) and one within-subject crossover study of cocaine-abusing outpatients in methadone treatment programs showed that voucher reinforcement for either cocaine abstinence alone or for both cocaine and opiate abstinence was more effective than comparison conditions in sustaining abstinence from cocaine. When different magnitudes of vouchers were compared, more sustained abstinence was seen for vouchers of higher magnitude than for those of lower magnitude. Urinalysis was conducted during a baseline period of 4, 5, or 6 weeks to select patients with verified, severe cocaine use. One 12-week study compared escalating voucher reinforcement for cocaine-negative urine samples with a "yoked" control condition. Each control outpatient was paired with a patient in the voucher reinforcement group and received vouchers based on whether his or her experimental counterpart submitted a cocaine-negative urine sample. These yoked control patients were told that they would receive vouchers according to an unpredictable schedule. Patients in the voucher reinforcement group achieved more weeks of cocaine abstinence (p = .007) and longer durations of sustained cocaine abstinence (p = .001) relative to patients in the control group. Forty-seven percent (9) of the patients in the voucher reinforcement group achieved 7 to 12 weeks of sustained cocaine abstinence, while only 6% (1) in the control group achieved more than 2 weeks of abstinence. Among voucher reinforcement participants, those who achieved 5 or more weeks of sustained abstinence had lower levels of the primary cocaine metabolite in their baseline urine samples compared with those who failed to achieve sustained abstinence (p ≤ .01). Although not targeted by the voucher intervention, weekly opiate abstinence averaged 52% across voucher reinforcement participants compared with 33% across control group participants (p ≤ .01). Weekly alcohol abstinence, also not targeted, averaged 78% across voucher reinforcement participants, compared with 60% among control participants (p ≤ .01). In another study, outpatients who were unable to achieve sustained cocaine abstinence in a previous voucher reinforcement program participated in three 9-week conditions, each with a different magnitude (zero, low, and high) of voucher reinforcement for cocaine-negative urine samples. Increasing voucher magnitude significantly increased the longest duration of sustained cocaine abstinence (p < .001) and the percentage of cocaine-free urine samples submitted (p < .001). Forty-five percent (10) of the patients in the high-magnitude condition achieved 4 or more weeks of sustained cocaine abstinence, while only 5% (1) in the low-magnitude condition and no patients in the zero-magnitude condition achieved cocaine abstinence for more than 2 weeks. As the magnitude of the voucher increased, the total number of reported cocaine injections decreased (p = .024). The high-magnitude voucher condition eliminated reports of cocaine injections by outpatients who achieved 4 or more weeks of sustained abstinence. A study of pregnant and recently postpartum women compared usual care (methadone maintenance and specialized drug abuse treatment) with usual care plus a Therapeutic Workplace program. For the intervention group, workplace admittance, job training, and base-pay vouchers were contingent on the daily submission of cocaine- and opiate-free urine samples. Analyses were based on data collected from 18 to 36 months after intake. Eighty percent (16) of the Therapeutic Workplace participants provided cocaine-negative urine samples for 2 or more months, compared with 40% (8) of participants in the usual care condition. Thirty percent (6) of the Therapeutic Workplace participants submitted all cocaine-negative urine samples across months 18 through 36. On the basis of monthly urinalysis and self-report (ASI), Therapeutic Workplace participants achieved longer abstinence relative to those receiving usual care (p = .04). A 26-week study involving 11 urban methadone treatment programs compared workplace access, training, and base pay independent of urinalysis results (work-control condition) with the same benefits contingent on cocaine-negative urine samples (abstinence-dependent work condition). Participants in the abstinence-dependent work condition provided a higher percentage of cocaine-negative urine samples (28.7%) than participants in the work-control condition (10.2%) (p = .004). This difference represents a large effect size (odds ratio = 5.80). Across the 26 weeks, self-reports of cocaine use (ASI) were consistent with urinalysis data; participants in the abstinence-dependent work condition reported more cocaine abstinence relative to participants in the work-control condition (p = .03).
Studies Measuring Outcome	Study 1, Study 3, Study 5, Study 6
Study Designs	Experimental
Quality of Research Rating	3.2 (0.0-4.0 scale)

Outcome 2: Opiate use
Description of Measures	Opiate use was measured using urinalysis and the ASI, an interview instrument that evaluates the severity of psychosocial problems across seven life domains. Composite scores of 0 to 1 are calculated for each domain, with higher scores reflecting greater problem severity.
Key Findings	A clinical RCT involving cocaine- and heroin-abusing pregnant and recently postpartum women compared usual care (methadone maintenance and specialized drug abuse treatment) with usual care plus a Therapeutic Workplace program. For the intervention group, workplace admittance, job training, and base-pay vouchers were contingent on the daily submission of cocaine- and opiate-free urine samples. Urinalysis was conducted during a baseline period of 6 weeks to select patients with verified, severe cocaine use. Analyses were based on data collected from 18 to 36 months after intake. On average, Therapeutic Workplace participants submitted a higher percentage of opiate-negative urine samples over the 18 months compared with usual care participants (60% vs. 37%, p = .05). Self-reports of opiate use (ASI) were almost identical to these urinalysis data. Thirty percent (six) of the Therapeutic Workplace participants submitted opiate-negative urine samples across all 18 months relative to 5% (one) of the usual care participants (p = .04). Self-reports of opiate use (ASI) were similar to these urinalysis data.
Studies Measuring Outcome	Study 5
Study Designs	Experimental
Quality of Research Rating	3.0 (0.0-4.0 scale)

Outcome 3: Cocaine and opiate use
Description of Measures	Use of cocaine and opiates was measured using urinalysis.
Key Findings	Three clinical RCTs involved cocaine-abusing outpatients in methadone treatment programs. One showed that voucher reinforcement for cocaine abstinence alone generalized to opiates so that participants achieved higher rates of abstinence for both cocaine and opiates relative to comparison conditions. Two other studies showed that voucher reinforcement for both cocaine and opiate abstinence had greater effects than comparison conditions in sustaining abstinence from these two drugs. Urinalysis was conducted during a baseline period of 5, 6, or 10 weeks to select patients with verified, severe cocaine use. One study compared three 12-week conditions: escalating voucher reinforcement for cocaine-negative urine samples plus a start-up bonus, escalating voucher reinforcement for cocaine-negative urine samples only, and a yoked control condition. Each control outpatient was paired with a patient in the reinforcement plus start-up bonus condition and received vouchers based on whether his or her experimental counterpart submitted a cocaine-negative urine sample. Participants in both voucher reinforcement groups submitted more opiate-free urine samples (p < .01), achieved the highest rate of cocaine abstinence (voucher reinforcement only condition, p ≤ .01), and maintained significantly higher rates of cocaine abstinence during the 8-week postintervention period (p ≤ .01) compared with control group participants. Participants in both voucher reinforcement groups had higher rates of opiate abstinence relative to control group participants (voucher reinforcement plus a start-up bonus: p ≤ .01; voucher reinforcement only: p ≤ .05). These comparatively higher rates of opiate abstinence persisted across the 8-week postintervention period. Another study compared three 52-week conditions: usual care (daily methadone and weekly individual and group counseling), take-home methadone doses contingent upon opiate- and cocaine-negative urine samples, and the same contingent take-home methadone doses plus escalating monetary vouchers for the urine testing negative for cocaine. Participants receiving take-home methadone plus vouchers achieved higher rates of cocaine and opiate abstinence compared with usual care participants throughout the 52 weeks (p ≤ .05). The take-home methadone plus voucher group also achieved higher rates of cocaine and opiate abstinence compared with the group receiving take-home methadone only across the final three 13-week blocks of the intervention (p ≤ .05). Effect sizes for these differences ranged from medium to large (Cohen's f = 0.39 to 0.59). Study completers from the take-home methadone plus voucher condition had higher rates of cocaine and opiate abstinence relative to participants receiving take-home methadone only or usual care (p ≤ .05). These comparatively higher abstinence rates were sustained through the 9-week postintervention follow-up. Participants in the take-home methadone plus voucher condition sustained 18.8 weeks of continuous abstinence from cocaine and opiates compared with 6.3 weeks for those receiving take-home methadone only and 2.3 weeks for those receiving usual care (p < .001). This difference was associated with a large effect size (Cohen's f = 0.66). Participants in the take-home methadone plus voucher condition were significantly more likely to be completely free of cocaine and opiates during weeks 14-26 (p = .023), weeks 27-39 (p = .001), and weeks 40-52 (p = .001), compared with participants receiving only take-home methadone or usual care. Abstinence reinforcement groups reported fewer cocaine injections compared with usual care participants during the third 13-week block of the intervention period (group receiving take-home methadone only) and the fourth block (both reinforcement groups) (p ≤ .05). A study of pregnant and recently postpartum women compared usual care (methadone maintenance and specialized drug abuse treatment) with usual care plus a Therapeutic Workplace program. For the intervention group, workplace admittance, job training, and base-pay vouchers were contingent on the submission of cocaine- and opiate-free urine samples each weekday for the first 6 months after intake. Participants in the Therapeutic Workplace submitted almost twice as many cocaine- and opiate-negative urine samples compared with usual care participants (50% vs. 27%, p = .032). Forty percent of Therapeutic Workplace participants submitted urine samples negative for both cocaine and opiates on 75% or more of the testing occasions, compared with only 10% of usual care participants.
Studies Measuring Outcome	Study 2, Study 4, Study 5
Study Designs	Experimental
Quality of Research Rating	3.3 (0.0-4.0 scale)

Outcome 4: Cocaine craving
Description of Measures	Cocaine craving was measured by asking patients a single question: "How much have you wanted cocaine in the past week?" The 5-point rating scale ranged from 0 (not at all) to 4 (extremely).
Key Findings	One clinical RCT of cocaine-abusing outpatients in a methadone treatment program compared three 12-week conditions: escalating voucher reinforcement for cocaine-negative urine samples plus a start-up bonus, escalating voucher reinforcement for cocaine-negative urine samples only, and a yoked control condition. Each control outpatient was paired with a patient in the reinforcement plus start-up bonus condition and received vouchers based on whether his or her experimental counterpart submitted a cocaine-negative urine sample. Urinalysis was conducted during a baseline period of 5 weeks to select patients with verified, severe cocaine use. Patients in the two voucher reinforcement conditions experienced decreased cocaine craving across the 12 weeks relative to control group participants (p ≤ .01). Responders to abstinence reinforcement--patients who achieved 5 or more weeks of sustained cocaine abstinence--experienced decreased cocaine craving across the intervention period relative to nonresponders (p ≤ .01). This finding persisted into the 8-week postintervention period (p < .001).
Studies Measuring Outcome	Study 2
Study Designs	Experimental
Quality of Research Rating	2.3 (0.0-4.0 scale)

Outcome 5: Workplace attendance
Description of Measures	Workplace attendance was measured in several different ways: days and/or weeks of sustained attendance, percentage of participants in daily attendance, and percentage of participants with sustained attendance for 6 months or more.
Key Findings	Two clinical RCTs of cocaine-abusing outpatients in methadone treatment programs assessed the effect of employment-based voucher reinforcement for either cocaine abstinence alone or both cocaine and opiate abstinence on workplace attendance. Intervention and comparison conditions had different effects on attendance. Urinalysis was conducted during a baseline period of 4 or 6 weeks to select patients with verified, severe cocaine use. A study of pregnant and recently postpartum women compared usual care (methadone maintenance and specialized drug abuse treatment) with usual care plus a Therapeutic Workplace program. For the intervention group, workplace admittance, job training, and base-pay vouchers were contingent on the submission of cocaine- and opiate-free urine samples each weekday for 36 months. On average, 45% (9) of the Therapeutic Workplace participants attended the workplace daily, with 40% (8) maintaining high rates of attendance throughout most of the first 6 months and 30% (6) achieving sustained attendance lasting 3 or more consecutive months. Workplace attendance and cocaine/opiate abstinence were highly associated with one another (p < .01). On average, Therapeutic Workplace participants attended the workplace on 43% of weekdays within the 36-month intervention period, with 60% (12) of participants maintaining periods of sustained attendance for 6 months or more. Forty-five percent (9) of the participants attended the workplace consistently across 36 months. Workplace attendance and cocaine/opiate abstinence were highly associated with one another (p < .001). A 26-week study involving 11 urban methadone treatment programs compared workplace access, training, and base pay independent of urinalysis results (work-control condition) with the same benefits contingent on cocaine-negative urine samples (abstinence-dependent work condition). During the baseline period, participants in both conditions achieved high rates of attendance: 85.5% by the abstinence-dependent work participants and 82.1% by the work-control participants. While those in the work-control condition continued to maintain these high rates of attendance across the 26 weeks (71.3% of days), attendance rates dropped among participants in the abstinence-dependent work condition (38.6% of days), a difference that represents a medium effect size (odds ratio = 3.77). Nevertheless, almost all the participants in the abstinence-dependent work condition continued attending the workplace intermittently across the intervention period, with a nearly threefold increase in cocaine abstinence rates relative to abstinence rates for participants in the work-control condition.
Studies Measuring Outcome	Study 5, Study 6
Study Designs	Experimental
Quality of Research Rating	3.5 (0.0-4.0 scale)

Study Populations

The following populations were identified in the studies reviewed for Quality of Research.

Study	Age	Gender	Race/Ethnicity
Study 1	18-25 (Young adult) 26-55 (Adult) 55+ (Older adult)	73% Male 27% Female	54.1% White 45.9% Black or African American
Study 2	18-25 (Young adult) 26-55 (Adult) 55+ (Older adult)	66.1% Male 33.9% Female	62.7% Black or African American 37.3% White
Study 3	26-55 (Adult)	54.5% Male 45.5% Female	54.5% Black or African American 45.5% White
Study 4	18-25 (Young adult) 26-55 (Adult)	55.1% Male 44.9% Female	69.2% Black or African American 29.5% White 1.3% Race/ethnicity unspecified
Study 5	18-25 (Young adult) 26-55 (Adult)	100% Female 0% Male	82.5% Black or African American 17.5% White
Study 6	26-55 (Adult)	62.5% Female 37.5% Male	91.1% Black or African American 7.1% White 1.8% Race/ethnicity unspecified

Quality of Research Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the Quality of Research for an intervention's reported results using six criteria:

Reliability of measures
Validity of measures
Intervention fidelity
Missing data and attrition
Potential confounding variables
Appropriateness of analysis

For more information about these criteria and the meaning of the ratings, see Quality of Research.

Outcome	Reliability of Measures	Validity of Measures	Fidelity	Missing Data/Attrition	Confounding Variables	Data Analysis	Overall Rating
1: Cocaine use	3.7	3.2	3.5	3.3	2.7	3.0	3.2
2: Opiate use	2.8	2.8	4.0	2.8	3.0	3.0	3.0
3: Cocaine and opiate use	3.9	3.4	3.4	3.2	2.9	3.4	3.3
4: Cocaine craving	1.5	1.5	2.5	2.5	3.0	2.5	2.3
5: Workplace attendance	4.0	3.7	4.0	3.4	3.0	2.9	3.5

Study Strengths

The researchers used standard methods/assays for the urine drug screens and were careful to examine and compare outcomes using different approaches to account for missing urine samples. Workplace attendance is an excellent measure given its practicality, with clear reliability and validity. The studies were strong methodologically in nearly every regard, with solid attention to fidelity.

Study Weaknesses

Because the timing of the monthly urine samples in the 3-year workplace study was under the control of the participants, some degree of result manipulation cannot be ruled out. The lack of examination of order effects in the study using a within-subject crossover design introduces the possibility of confounding variables. As noted by the authors, the self-reported craving measure has no established psychometrics.

Readiness for Dissemination

Materials Reviewed

The materials below were reviewed for Readiness for Dissemination. The implementation point of contact can provide information regarding implementation of the intervention and the availability of additional, updated, or new materials.

Needham, M., & Silverman, K. Manual dilutions study manual. Baltimore: Johns Hopkins School of Medicine, Department of Psychiatry and Behavioral Sciences.

Needham, M., & Silverman, K. Sample Therapeutic Workplace training schedule. Baltimore: Johns Hopkins School of Medicine, Department of Psychiatry and Behavioral Sciences.

Needham, M., & Silverman, K. Visitor introduction to the Therapeutic Workplace. Baltimore: Johns Hopkins School of Medicine, Department of Psychiatry and Behavioral Sciences.

Needham, M., & Silverman, K. Visitor training curriculum--Staff version. Baltimore: Johns Hopkins School of Medicine, Department of Psychiatry and Behavioral Sciences.

Silverman, K.. Therapeutic Workplace trainee manual, step 3. Baltimore: Johns Hopkins School of Medicine, Department of Psychiatry and Behavioral Sciences.

Silverman, K. Therapeutic Workplace typing technique evaluation forms. Baltimore: Johns Hopkins School of Medicine, Department of Psychiatry and Behavioral Sciences.

Silverman, K. Voucher review, step 1. Baltimore: Johns Hopkins School of Medicine, Department of Psychiatry and Behavioral Sciences.

Silverman, K. Therapeutic Workplace trainee manual, step 1. Baltimore: Johns Hopkins School of Medicine, Department of Psychiatry and Behavioral Sciences.

Silverman, K. Therapeutic Workplace trainee manual, step 2. Baltimore: Johns Hopkins School of Medicine, Department of Psychiatry and Behavioral Sciences.

Silverman, K. The Therapeutic Workplace treatment manual. Baltimore: Johns Hopkins School of Medicine, Department of Psychiatry and Behavioral Sciences.

Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the intervention's Readiness for Dissemination using three criteria:

Availability of implementation materials
Availability of training and support resources
Availability of quality assurance procedures

For more information about these criteria and the meaning of the ratings, see Readiness for Dissemination.

Implementation Materials	Training and Support Resources	Quality Assurance Procedures	Overall Rating
1.5	0.5	2.3	1.4

Dissemination Strengths

The treatment manual provides detailed information on how this intervention can be implemented successfully in one setting. Implementers can contact the developers for training and technical assistance. Quality assurance guidelines and instruments are provided to track client progress and intervention fidelity.

Dissemination Weaknesses

Implementation materials are specific to the founding program and have not been written for general use. Very little guidance is provided on program initiation and organizational requirements. No formal training and technical support system is available to assist potential implementers. No guidance is provided for using data derived from quality assurance instruments to manage the program.

Costs

The cost information below was provided by the developer. Although this cost information may have been updated by the developer since the time of review, it may not reflect the current costs or availability of items (including newly developed or discontinued items). The implementation point of contact can provide current information and discuss implementation requirements.

Item Description	Cost	Required by Developer
Implementation materials, training, technical support/consultation, and quality assurance materials	Contact the developer	Contact the developer

Additional Information

The estimated combined cost of implementing methadone maintenance and the therapeutic workplace is $362 per client per week. An abstinence-based voucher reinforcement program using escalating vouchers to target cocaine use costs approximately $50 to $100 per client per week for monetary vouchers, $15 per client per week for thrice-weekly urinalysis, and the salary for one full-time staff member to manage the program.

Replications

Selected citations are presented below. An asterisk indicates that the document was reviewed for Quality of Research.

Donlin, W. D., Knealing, T. W., Needham, M., Wong, C. J., & Silverman, K. Predicting employment-based reinforcement. A reinforcer assessment to predict the effectiveness of employment-based reinforcement of cocaine abstinence in methadone patients. Manuscript submitted for publication.

Lussier, J. P., Heil, S. H., Mongeon, J. A., Badger, G. J., & Higgins, S. T. A meta-analysis of voucher-based reinforcement therapy for substance use disorders. Addiction, 101(2), 192-203.