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Working to Stay Clean
Tucked quietly inside Bayview's oldest building is a unique drug treatment program that's breaking the cycle of addiction and poverty.

One Powerful Business

When behavioral scientist Kenneth Silverman first envisioned setting up a non-profit business as a treatment for drug addiction, the concept was hard to sell. "It took me three tries to get the first grant," he says. "You have to have enormous confidence that it can work."

But the six women now employed at Hopkins Data Services are not only proving that Silverman's "therapeutic workplace" can keep them off drugs, they're providing a first-rate service for researchers who need a reliable way to manage their study data. Using software Silverman had designed, two operators enter each cutomer's data. Then a computerized program compares both data files to find discrepancies.

"They operate a wonderful program," says Assistant Professor of Psychiatry Patricia Santora, who's hired Hopkins Data Services to handle the stacks of information she and her colleague Heidi Hutton have generated from their study on the role of religion in recovery from substance abuse. "It's really superior to other data entry we've had. They work closely with you to organize your data, which are double-entered with an exceptional degree of accuracy. And, we wanted our project to 'give back' to teh women in a concrete and measurable way by helping them move toward their goal of responsible employment."

"On of the tragic facts about addiction," adds Hutton, an assistant professor of psychiatry, "is the loss of hope. It's not just about getting clean. It's getting clean to do what? The program is designed so the women can get rewards. They need jobs, too, just like anyone else."

With more than a dozen clients so far, Hopkins Data Services is about to hire more of its trainees (some of whom are now men). And Silverman is far from finished. "If we can make the business self-sustaining," he says, "then this salary-based reinforcement could be maintained at little or no cost to society. One of our next missions is to grow the business to a franchise. As a country, we know a lot about how to grow a business. And that's probably a lot easier than finding another drug addiction treatment thatt works."

To learn more about Hopkins Data Services, call 410-550-5079, e-mail hds@jhmi.edu, or visit the Web site at www.hopkinsmedicine.org/hds.

 

If you want a job at Hopkins Data Services, you can count on one thing. Every Monday, Wednesday and Friday morning, you'll be escorted to the bathroom to give a urine sample under observation. No excuses. No exceptions. Test negative for cocaine use and you can get down to business. Test positive and you're on your way home-until the next day, when you can come back and try again.

What kind of employer expects such inflexible proof of abstinence, then doesn't automatically fire you if you slip?

The answer is the brainchild of School of Medicine behavioral scientist Kenneth Silverman, who launched the data entry business two years ago this April as a way to help people who want to free themselves from the clutches of cocaine. Located in the west wing of the Mason F. Lord Building on the Bayview campus, Hopkins Data Services grew out of the well-documented observation that when it comes to influencing drug behavior, money talks.

A number of researchers, including Silverman, have studied the phenomenon. Methadone programs in particular, says the associate professor of psychiatry, are plagued by cocaine use, and though methadone is very effective in treating heroin addiction, no one has been able to find a pharmacological treatment that's reliable for cocaine. Most psychosocial approaches haven't panned out either, he says.

What does help, Silverman and others have shown, are monetary rewards, usually given as vouchers that can be exchanged for goods and services. Furthermore, the higher the reward, the better the results. In one of Silverman's studies, $1,155 given over 13 weeks induced almost half the people to stop using cocaine for up to three months. When the voucher total in a subsequent study was $3,480 over nine weeks-the equivalent of an $18,000 annual salary-about half the really tough cases who'd previously failed to produce drug-free urine samples were able to abstain from injecting cocaine.

"That's pretty good news in a field that's struggling," says Silverman. "But there are a couple of problems. When you stop the vouchers, people relapse, which is also what happens when you stop other interventions. And, the vouchers get only about half the people to stop using. You do get more to respond by increasing the magnitude of the vouchers, but it's not practical."

Silverman also admits that no matter how effective the treatment might be, society tends to balk at the idea of simply "paying" people not to do drugs. Still, a picture of how such treatment could be made feasible had already formed in his mind.

To test his idea of a "therapeutic workplace," Silverman recruited chronically unemployed women on methadone who were attending Bayview's Center for Addiction and Pregnancy. The patients were continuing to use heroin and cocaine despite the program's best efforts. "We took the people who were not being helped," says Silverman. "Eighty-five percent were in the welfare system, despite pressure in the Baltimore City program to get welfare people to work. We wanted to hire them into a business, but we didn't know what to hire them as, so we surveyed them to find out what jobs interested them."

When business itself emerged as the top choice (followed by cosmetology, which, Silverman deadpans, he "didn't know anything about"), the last piece of the puzzle clicked into place. Because he and his colleagues do data entry for their own research, Silverman realized it was not only something he already understood, but a service that could be offered to other researchers.

First, he had to teach the women how to type and demonstrate that this "paid" training alone could sustain abstinence. Silverman enrolled 40 people in a randomized, controlled study to compare usual care with a step-by-step teaching method he developed that awards monetary vouchers for achieving keyboard speed and accuracy. "They start by learning one character," says Silverman, "then another character, then characters randomly presented, all with black covers over the keys so they can't peek. They earn for correct responses, lose for incorrect ones and get bonuses for mastering the steps. We've even taught people with a second-grade reading level how to type. And they become really skilled data entry operators."

In the first six months, the abstinence rate-confirmed by regular, repeated urinalysis-nearly doubled among women in the training group compared to the control group. Even more encouraging, 45 percent of the women continued to enroll over the next three years. In the usual care group, meanwhile, employment was "extremely rare," says Silverman, "averaging less than one day per month."

Three years may seem a long stretch to offer only training, but along the way to showing that the results he was getting weren't a fluke, Silverman also was fine-tuning his instruction method. By the time Hopkins Data Services opened for business in the spring of 2000, every step was on custom-designed software, including an instant-feedback module that lets trainees and employees alike see exactly how much they've earned at any given moment.

"A lot of people want to be over here, I'll tell you that," says Yvonne Reed, 31, one of Silverman's original study participants who's now earning a paycheck as a Hopkins Data Services employee. "I've been here since Dec. 23, 1996, and I've been clean the whole time. Before that, I was sniffing heroin. I also smoked coke. I had to have it-I was rippin' and runnin'. Thank God I was only on five years. That seems like a lifetime.

"Here, it's like a family. Dr. Silverman becomes concerned about you. They do care. It was exciting, like going to school all over. We had to read, do math. I never typed til I got here. In school, when I had my notebook, I knew I was smart. A lot came from this place really helping me. Here, there's that structure. If I got high, I knew I couldn't come to work, and if you can't work, how are the bills gonna get paid? You can't live off Social Services. When I came here, I don't think I owned but four pairs of pants. Now I can pay my rent, buy my kids clothes, buy myself clothes. This is the only income I have, and I'm doin' all right. It's still a struggle to stay clean because where I live, there are drugs all around-up the street, out the back, everywhere I walk is a drug strip. But I have it in my head that I just don't wanna use. So I don't pick up. I would have too much to lose."

Because Reed consistently passes her urinalyses and is nearly 100 percent accurate in her keyboarding, she's earning more than $10 an hour-not a fortune, but clearly a living wage. And that's what makes a difference, says Silverman. "These are people who have a long history of not succeeding under looser contingencies. Here, they can experience success."

"I tell everybody about this program," says Robin Bost, 36, who started her keyboard training in April. "Who better to know a drug abuser than an ex-drug abuser? I started using heroin when I was 23. I was spending at least $50 a day. I wasn't working. They pay you money and heroin to be a lookout. I'd do it after my kids went off to school. I didn't want them to see me on the corner.

"Once I got on a methadone program, it cut the dope out. Then I started with the cocaine. Drug addiction is a selfish disease. That white powder takes over your life. It tells you when to eat, when to sleep, when to go out. I've seen it all. I've seen doctors, lawyers pull into the slot. It don't discriminate. I was on my way to being kicked off the methadone program because I messed up. When I got accepted here, I put the cocaine down. This is ideal because it's like a paid training. You appreciate it because you work for it. It's not money that they're giving us, it's money that we earn. In the drug game, nobody gets paid but the man. Dealing drugs, you're gonna get locked up. I don't want my kids to go through what I went through. I gotta be a role model. I come here and type like crazy. Those teenagers, they need everything. Now I notice they need new shoes. Before, they had to come and tell me. I'm a 100 percent mother now. It's like a fairy tale, like Cinderella. And I'm living it."

-Mary Ann Ayd

 

 

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