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. Author manuscript; available in PMC: 2017 Jun 1.
Published in final edited form as: Transl Issues Psychol Sci. 2016 Jun;2(2):203–212. doi: 10.1037/tps0000061

The Therapeutic Utility of Employment in Treating Drug Addiction: Science to Application

Kenneth Silverman 1, August F Holtyn 2, Reed Morrison 3
PMCID: PMC5074553  NIHMSID: NIHMS762368  PMID: 27777966

Abstract

Research on a model Therapeutic Workplace has allowed for evaluation of the use of employment in the treatment of drug addiction. Under the Therapeutic Workplace intervention, adults with histories of drug addiction are hired and paid to work. To promote drug abstinence or adherence to addiction medications, participants are required to provide drug-free urine samples or take prescribed addiction medications, respectively, to gain access to the workplace and/or to maintain their maximum rate of pay. Research has shown that the Therapeutic Workplace intervention is effective in promoting and maintaining abstinence from heroin, cocaine and alcohol and in promoting adherence to naltrexone. Three models could be used to implement and maintain employment-based reinforcement in the treatment of drug addiction: A Social Business model, a Cooperative Employer model, and a Wage Supplement model. Under all models, participants initiate abstinence in a training and abstinence initiation phase (Phase 1). Under the Social Business model, Phase 1 graduates are hired as employees in a social business and required to maintain abstinence to maintain employment and/or maximum pay. Under the Cooperative Employer model, cooperating community employers hire graduates of Phase 1 and require them to maintain abstinence to maintain employment and/or maximum pay. Under the Wage Supplement Model, graduates of Phase 1 are offered abstinence-contingent wage supplements if they maintain competitive employment in a community job. Given the severity and persistence of the problem of drug addiction and the lack of treatments that can produce lasting effects, continued development of the Therapeutic Workplace is warranted.

Keywords: abstinence reinforcement, incentives, contingency management, employment, poverty

Addressing chronic drug addiction among unemployed and economically disadvantaged adults is a daunting challenge. Employment is clearly critical in addressing the poverty and economic disadvantage of these individuals; however, controlled research suggests that employment could play a valuable role in treating drug addiction as well (Silverman, DeFulio, & Sigurdsson, 2012). Contrary to common conceptions, employment alone may not have robust effects on drug use (DeFulio, Donlin, Wong, & Silverman, 2009; Silverman et al., 2007). Employment may have greatest effects on drug use when it is used by employers as an incentive to promote drug abstinence (Silverman et al., 2012). This article reviews controlled research on the utilization of employment in the treatment of drug addiction, highlights the key ways in which employment can be used to promote and maintain drug abstinence and adherence to addiction medications, and suggests potential models of applying these findings in society. Importantly, the potential of employment in treatment of drug addiction may not be realized without the direct and concerted actions by employers in community workplaces and governments.

Employment as an Incentive to Motivate Drug Abstinence

A vast body of research suggests that incentives for drug abstinence can be highly effective in both initiating and maintaining abstinence from most commonly abused drugs (Dutra et al., 2008; Lussier, Heil, Mongeon, Badger, & Higgins, 2006; Silverman, Kaminski, Higgins, & Brady, 2011). These interventions are rooted in basic and applied research on operant conditioning and arrange reinforcement for drug abstinence (Bigelow & Silverman, 1999). These abstinence reinforcement interventions, commonly referred to as incentive or contingency management interventions, are relatively simple procedures in which patients receive a tangible benefit for providing objective evidence of drug abstinence. The nature of the benefit can vary as long as it is attractive to the patients and can be applied and withheld. Money or some kind of monetary incentive can be particularly useful because it is attractive to most people; its magnitude and frequency can be varied over a wide range; and because most people will not lose interest in this benefit, even after receiving a fair amount of it.

The parameters of incentive interventions matter (Lussier, Heil, Mongeon, Badger, & Higgins, 2006). The effectiveness of incentive interventions in initiating abstinence is related to the magnitude of the incentive. High magnitude incentives are more effective in promoting drug abstinence and are effective in a larger proportion of patients than smaller incentives (e.g., Silverman, Chutuape, Bigelow, & Stitzer, 1999). Incentives are more effective when delivered immediately or at least soon after abstinence occurs (Lussier et al., 2006). The effects of incentives are more durable if they are maintained over extended periods of time (Silverman, Robles, Mudric, Bigelow, & Stitzer, 2004).

The need to use high magnitude incentives and to maintain those incentives over an extended period of time raises an obvious practical problem: How can we finance high magnitude and long duration incentives for drug abstinence? To address this issue, a line of research has been conducted to determine whether employment can be used as a vehicle for applying and maintaining high magnitude incentives for drug abstinence and other therapeutic behavior change. To investigate this possibility, a model employment intervention was developed that has been referred to as the Therapeutic Workplace. The basic features of this intervention are simple. Adults with long histories of drug addiction, including patients who have failed to respond to conventional treatment approaches, are hired and paid to work in the Therapeutic Workplace. To promote drug abstinence, Therapeutic Workplace participants are required to provide drug-free urine samples to gain access to the workplace and/or to maintain their maximum rate of pay. In this way, participants can work and earn money or maintain their maximum pay rate only as long as they stay abstinent from drugs. A number of randomized controlled clinical evaluations of this intervention have been conducted in poor and chronically unemployed adults with long histories of drug addiction. These studies have shown that the Therapeutic Workplace intervention can initiate and maintain cocaine abstinence in injection drug and crack cocaine users who are enrolled in methadone treatment but continue to use cocaine; initiate abstinence from opiates and cocaine in pregnant and postpartum women who continue to use cocaine during treatment; initiate abstinence from opiates and cocaine in out-of-treatment injection drug users; promote abstinence from alcohol in homeless, alcohol-dependent adults; and, with a change in the nature of the contingency, promote adherence to the opioid antagonist naltrexone in opioid-dependent adults who have completed opioid detoxifications (Silverman, 2004; Silverman, et al., 2012). The rigor of the Therapeutic Workplace research was evaluated and affirmed by SAMSHA's National Registry of Effective Programs and Practices (SAMSHA, 2014) and the intervention has been recognized by the White House Office of National Drug Control Policy (ONDCP) as an important innovation in the treatment of drug addiction (ONDCP, 2014).

Lessons from Research on the Therapeutic Workplace Interventions

The effectiveness of the Therapeutic Workplace intervention is clear. This laboratory model workplace has allowed for careful and controlled clinical trials that might not be possible in most community workplaces. In addition to demonstrating the overall efficacy of this approach, this research has provided clear evidence of how employment can be used in the treatment of drug addiction, and it has provided additional tentative evidence that warrants further investigation. This section outlines both the firm and tentative evidence that this line of research has produced.

Employment-Based Abstinence Reinforcement in Promoting Drug Abstinence

Research has shown that employment alone is not sufficient to promote sustained abstinence in our participants; our participants achieve sustained abstinence primarily when required to provide drug-free urine samples to maintain access to the workplace and to maintain maximum pay. In these studies, persistent drug users were hired to work in our model workplace and then randomly assigned to a condition in which continued drug use had no explicit consequences (as in typical employment) or to a condition in which drug-positive urine samples or missed samples resulted in a temporary workplace suspension and decreased pay. The results of these studies are clear. In the populations studied, employment alone does not appear sufficient to promote sustained abstinence; however, employment-based abstinence reinforcement can both promote initiation (Silverman et al., 2007) and maintenance of sustained abstinence (DeFulio et al., 2009). This research suggests that persistent drug users will likely continue to use drugs when given a job, but they may stay abstinent if required to do so as a condition of employment or if they must remain abstinent to maximize their wages.

Long-Term Maintenance of the Abstinence Requirement to Prevent Relapse

Like other substance abuse treatments, abstinence reinforcement or incentive interventions do not reliably produce lasting effects (Silverman et al., 2011). Employment-based abstinence reinforcement can be used to maintain cocaine abstinence, for example, for as long as a year (DeFulio et al., 2009). However, when the employment-based abstinence reinforcement contingency is discontinued, many individuals relapse to cocaine use and the effects of employment-based abstinence reinforcement are not sustained during the year following employment in the Therapeutic Workplace (DeFulio & Silverman, 2011). One study showed that abstinence from cocaine and opiates and employment could be maintained for four years in a population of chronically unemployed women who were pregnant or postpartum at intake to the study (Aklin et al., 2014), however the effects of the Therapeutic Workplace on drug abstinence and employment were not evident in the years following employment in the Therapeutic Workplace. These studies suggest that for some people it may be necessary to maintain employment-based abstinence reinforcement contingencies for extended periods of time, and possibly indefinitely. It is not yet clear whether employment-based abstinence reinforcement will have lasting effects in some people if it is maintained for some minimal time period.

Phases of Treatment

Most of the people who have participated in the Therapeutic Workplace have been chronically unemployed and unskilled individuals (Holtyn, DeFulio, & Silverman, 2015; Silverman, Chutuape, Svikis, Bigelow, & Stitzer, 1995). For these individuals, an education and job skills training phase prior to employment has been offered. In the education and job skills training phase, each person's “job” is to participate in an intensive education and job skills training program. Participants receive stipends for attendance and performance in the training program, which appears essential to maintain regular attendance and progress on the training programs (Koffarnus et al., 2013; Koffarnus, DeFulio, Sigurdsson, & Silverman, 2013; Silverman, Chutuape, Bigelow, & Stitzer, 1996). Participants are also required to become abstinent from drugs to attend the training program and/or maintain maximum pay. Participants who become abstinent and skilled during this initial phase (Phase 1) progress to the second phase (Phase 2) and become employed in a Therapeutic Workplace business. To evaluate this second phase of the Therapeutic Workplace intervention, a data entry business called Hopkins Data Services was opened, hired Phase 1 graduates to serve as data entry operators in that business, and sold data entry services to paying customers (Aklin et al., 2014; Silverman et al., 2005). The contribution of the abstinence initiation and training phase (Phase 1) to long-term abstinence or employment outcomes has not been experimentally evaluated, but this phase may be useful to initiate sustained abstinence, establish education and job skills that employers may value, and establish core professional behaviors such as punctuality and regular attendance at work. This phase may be unnecessary, particularly for low-skilled jobs or for people who already have valued job skills, but future research will need to determine whether such a training and abstinence-initiation phase is necessary and economically justifiable.

Introduction to the Workplace Through an Induction Period

Participants have frequently been allowed to attend the Therapeutic Workplace at the beginning of Phase 1 without requiring that they provide drug-free urine samples to work or to maintain maximum pay (Donlin et al., 2008; Holtyn et al., 2014; Silverman et al., 2007). During this “induction” period, participants are invited to attend the workplace four hours every weekday, where they can earn money for working. Although participants provide urine samples on Mondays, Wednesdays, and Fridays during this induction period, they do not have to provide drug-free urine samples to gain access to the workplace or to maintain maximum pay. This induction period is intended to engage participants in the workplace by allowing them to experience the workplace and the opportunity to earn and spend money through their participation prior to imposing requirements for drug abstinence. The value of the induction period has not experimentally evaluated, but we suspect that this induction period could increase the attractiveness of the workplace to participants and increase their persistence and success once the abstinence contingencies begin.

Repeated Exposure to the Contingencies to Initiate Abstinence

Many people who are exposed to abstinence reinforcement interventions, including employment-based abstinence reinforcement, do not stop using drugs abruptly (Donlin, Knealing, Needham, Wong, & Silverman, 2008; Silverman et al., 2004; Silverman et al., 2007). Many people ultimately achieve sustained periods of abstinence, but use drugs periodically or even consistently when initially exposed to employment-based abstinence reinforcement contingencies (Donlin et al., 2008; Silverman et al., 2004). We do not know whether harsher contingencies that do not tolerate any drug use and terminate a person after a single instance of drug use would produce more abrupt effects on abstinence, or whether such contingencies would produce higher or lower rates of ultimate success than contingencies that allow repeated exposure to the contingencies.

Sequential Application of Abstinence Contingencies Across Drugs

Requiring that individuals achieve abstinence from all drugs of abuse from the outset of a treatment episode may be appealing, but it may not be the most effective approach. We do not have firm evidence, but we suspect that incentive interventions focused on initiating abstinence will be most effective if the abstinence reinforcement contingencies are applied sequentially across drugs as opposed to simultaneously. Prior reviews (Lussier et al., 2006; Prendergast, Podus, Finney, Greenwell, & Roll, 2006) and one controlled study (Epstein et al., 2009) suggest that reinforcing abstinence from multiple drugs may be more difficult than reinforcing abstinence from one drug. In addressing persistent opiate and cocaine use in Therapeutic Workplace participants who were enrolled in methadone treatment, we have required abstinence from both drugs simultaneously with mixed results. One showed positive results (Silverman, Svikis, Robles, Stitzer, & Bigelow, 2001) and one showed negative results (Knealing, Wong, Diemer, Hampton, & Silverman, 2006). One study (Holtyn, Koffarnus, DeFulio, Sigurdsson, Strain, Schwartz, & Silverman, 2014; Holtyn, Koffarnus, DeFulio, Sigurdsson, Strain, Schwartz, Leoutsakos et al., 2014), designed to promote abstinence from both opiates and cocaine in adults who were out-of-treatment and injected drugs, arranged employment-based reinforcement for participants enrolled in the Therapeutic Workplace first for enrolling in methadone treatment; then for providing urine samples every Monday, Wednesday and Friday that were negative for opiates; and then for providing urine samples that were negative for opiates and cocaine. The study showed that the sequential application of abstinence reinforcement contingencies was effective in promoting abstinence from opiates and cocaine. We do not know if it is necessary or beneficial to apply the contingencies for multiple drugs sequentially as opposed to simultaneously, but we suspect that it is at least beneficial. Future research will have to address this issue more thoroughly.

Decreasing Pay May Be Sufficient

In most studies, participants have been required to provide drug-free urine samples to gain access to the workplace; participants who provide a drug-positive urine sample are sent home and not allowed to return to work until they provide a drug-negative urine sample. This contingency arranges an immediate and substantial consequence for a drug-positive urine sample; however, it may also reduce attendance in the workplace (Silverman et al. 2007). One study recently arranged an employment-based abstinence reinforcement contingency in which participants receive a temporary decrease in their hourly pay when they provide a drug-positive urine sample, but they are allowed to work under the reduced pay rate (Holtyn, Koffarnus, DeFulio, Sigurdsson, Strain, Schwartz, & Silverman, 2014; Holtyn, Koffarnus, DeFulio, Sigurdsson, Strain, Schwartz, Leoutsakos et al., 2014). Importantly, the more lenient employment-based abstinence reinforcement contingency was effective in promoting abstinence from opiates and cocaine and did not appear to reduce workplace attendance. The two types of employment-based abstinence reinforcement contingencies have not been experimentally compared, so we do not know for certain whether either has benefits over the other. However, the recent results (Holtyn, Koffarnus, DeFulio, Sigurdsson, Strain, Schwartz, & Silverman, 2014; Holtyn, Koffarnus, DeFulio, Sigurdsson, Strain, Schwartz, Leoutsakos et al., 2014) suggest that a temporary decrease in pay for drug positive urine samples may be sufficient to promote drug abstinence and can do so without reducing attendance.

Promoting Adherence to an Addiction Medication

Some medications used in the treatment of drug addiction have pharmacological effects that should make them effective treatment agents but are not attractive to patients. Naltrexone is a prime example. Naltrexone is an opioid antagonist that can block the effects of opioids; prevent patients from experiencing the typical physiological and behavioral effects of opioids; and prevent them from becoming physically dependent on opioids, even if they take the opioids regularly. Although naltrexone has features that could make it an ideal treatment agent, its clinical utility has been very limited because few patients will take it regularly. Incentives can promote adherence to naltrexone, and employment-based reinforcement in the Therapeutic Workplace has been effective in promoting adherence both to oral naltrexone (Dunn et al., 2013) and extended-release naltrexone (Defulio et al., 2012; Everly et al., 2011).

Models to Apply Therapeutic Workplace Practices in Society

Despite the proven efficacy of the Therapeutic Workplace intervention, the intervention has not been applied in society as a therapeutic tool. We propose three models to implement and maintain employment-based reinforcement in the treatment of drug addiction: A Social Business model, a Cooperative Employer model, and a Wage Supplement model. Under all models, individuals enroll in the abstinence initiation and training phase of the Therapeutic Workplace (Phase 1) to initiate abstinence and establish skills. The models differ in how employment-based reinforcement would be maintained over time. As noted above, we do not know whether participation in Phase 1 of the Therapeutic Workplace is essential or even helpful in producing beneficial outcomes for Therapeutic Workplace participants. However, our findings to date are based on people who have been exposed to Phase 1. Until we show that Phase 1 participation is not essential or beneficial to the long-term success of participants, we assume that Phase 1 participation is important. It is certainly possible that individuals could initiate abstinence by other methods and progress directly to the employment phase (Phase 2), particularly if they are already skilled, if the Phase 2 job does not require great skill, or if the employer provides the needed on-the-job training.

The Social Business Model

Under the Social Business model, Phase 1 graduates are hired as employees in a social business. A “social business is outside the profit-seeking world. Its goal is to solve a social problem by using business methods, including the creation and sale of products and services” (Yunus & Weber, 2010, p. 1). “Social firms” serve a similar purpose and have been used throughout the world to provide employment opportunities to people with mental illness (Gilbert et al., 2013; Warner & Mandiberg, 2006). Social businesses have been used in low-income countries to address poverty with some success (Weber and Yunus, 2010). Social firms have been used in Italy, Germany, the United Kindom, New Zealand, Japan, Korea, Canada and the United States (Gilbert et al., 2013; Warner and Mandiberg, 2006). Hopkins Data Services was a Therapeutic Workplace social business that existed to serve the needs of a group of low-income women who had long histories of poverty and drug addiction. It hired and employed these women to serve as data entry operators, and sold data entry services to customers. The income from providing data entry services to those customers was used to sustain the business, not to generate profit. As a Therapeutic Workplace social business, Hopkins Data Services used employment-based reinforcement to promote and maintain both employment and drug abstinence (Aklin et al., 2014; Silverman et al., 2005). Experience with Hopkins Data Services suggests that the Therapeutic Workplace Social Business model could be feasible and effective, but it may have limited capacities.

The Cooperative Employer Model

Under the Cooperative Employer model, a community employer hires graduates of Phase 1. The Cooperative Employer requires that employees undergo random drug testing and remain abstinent to maintain employment. This model may provide added employment slots and could hold great promise if socially-conscious employers adopt this approach. Although not experimentally evaluated, a variation of this model has been used for people in safety-sensitive jobs (e.g., trucking) to ensure that they stay drug-free while at work (Cashman, Ruotsalainen, Greiner, Beirne, & Verbeek, 2009). A similar system is used for physicians (DuPont, McLellan, Carr, Gendel, & Skipper, 2009; DuPont, McLellan, White, Merlo, & Gold, 2009; McLellan, Skipper, Campbell, & DuPont, 2008). Under a grant from the National Institute on Drug Abuse (R34 DA032778), a small pilot evaluation will be conducted of the Cooperative Employer model for low-income, unemployed adults with long histories of heroin and cocaine addiction.

The Wage Supplement Model

Under the Wage Supplement Model, graduates of Phase 1 are offered abstinence-contingent wage supplements if they maintain competitive employment in a community job. Governments in Minnesota, Connecticut, Milwaukee, New York, and Canada have used wage supplements to increase employment in welfare recipients (Berlin, 2007; Michalopoulos, 2005; Riccio et al., 2010). This model harnesses the power of wage supplements to promote employment, while simultaneously using the wage supplements to reinforce drug abstinence. We have used abstinence-contingent wage supplements, but only to maintain abstinence in occasional participants who obtain employment while participating in the Therapeutic Workplace (e.g., Silverman et al., 2002). The efficacy of abstinence-contingent wage supplements has not yet been systematically evaluated. A randomized controlled evaluation of the Wage Supplement model will be conducted under a new grant from the National Institute on Drug Abuse (R01 DA037314).

Federal Workplace Drug Testing Infrastructure and Practices

To facilitate ultimate adoption of employment-based abstinence reinforcement through our proposed application models, an enormous infrastructure and rigorous guidelines for workplace drug testing exist that could be co-opted to apply employment-based abstinence reinforcement as a therapeutic intervention. The system is overseen by the U.S. Department of Transportation (U.S. Department of Transportation, DOT, 2015) and has been used to protect the public from the hazards associated with drug-impaired workers. Beyond this protective function, research on employment-based abstinence reinforcement suggests that the Federal drug testing system could have considerable therapeutic benefits, and could be used for a wide range of individuals with drug problems beyond those in safety-sensitive jobs. In fact, the DOT regulated procedures for managing drug and alcohol problems among safety-sensitive employees have been characterized as belonging to the contingency management model (Morrison, 2008). Under the DOT system, participants are sent to an extensive network of Health and Human Services certified collection facilities throughout the United States. All collection sites use procedures that are in compliance with DOT regulations and are designed to ensure safe, secure, valid specimen collection. Each collection facility collects the sample and sends it to a certified laboratory for testing. Under DOT regulations, all positive drug tests must be reviewed by a Medical Review Officer to ensure that all procedures were followed properly. An employee who tests positive on DOT panels must be either suspended from safety-sensitive duties or terminated. Those who wish to either regain employment or become eligible for new regulated employment must submit to evaluations by a qualified substance abuse professional, successfully complete treatment and maintain abstinence throughout a follow-up drug testing period that lasts from 1 to 5 years. Relapses (i.e., subsequent drug-positive tests) require the employee to start the process again. Akin to the operations of the Therapeutic Workplace, the DOT regimen acts as a therapeutic reinforcement schedule that permits the abstinent employee to regain an old job or acquire a new one. Specialized private companies manage workplace drug testing and related services for employers (e.g., American Substance Abuse Professionals, ASAP, 2014). They provide assistance to regulated employers in complying to the DOT system and relieve them of the responsibility of becoming experts in the management of substance use disorders among their safety-sensitive employees.

Discussion

Research on a laboratory model of a Therapeutic Workplace has allowed for systematic and controlled research on the utilization of employment in the treatment of drug addiction and has suggested key ways in which employment can be used to promote and maintain drug abstinence and adherence to addiction medications. The basic features of the Therapeutic Workplace intervention are simple. Adults with long histories of drug addiction are hired and paid to work in the Therapeutic Workplace. To promote drug abstinence or adherence to addiction medications, Therapeutic Workplace participants are required to provide drug-free urine samples or take prescribed addiction medications, respectively, to gain access to the workplace and/or to maintain their maximum rate of pay. In this way, participants can work and earn money and/or maintain their maximum pay rate only as long as they sustain the prescribed therapeutic behaviors (i.e., drug abstinence or adherence to addiction medications). This intervention has been shown effective in promoting and maintaining abstinence from heroin, cocaine and alcohol and promoting adherence to the opioid antagonist naltrexone; however, the potential of this intervention may not be realized without the direct and concerted actions by the business community and support by the government.

We have proposed three models to implement and maintain employment-based reinforcement in the treatment of drug addiction: A Social Business model, a Cooperative Employer model, and a Wage Supplement model. Under all models, individuals enroll in Phase 1 of the Therapeutic Workplace to initiate abstinence and establish skills. The models differ in how employment-based reinforcement would be maintained over time. If participation in Phase 1 proves essential or beneficial, financing that part of the treatment will depend on the same types of funding sources that currently support substance abuse treatment (i.e., government, foundation and health insurance). The three models for maintaining therapeutic employment-based reinforcement over time rely on economically sound businesses or workplaces to provide employment opportunities for Therapeutic Workplace participants. Additional support from public or private sources will probably be required to finance the therapeutic reinforcement contingencies to maintain abstinence or adherence to addiction medications. While this will not be simple, there are limited alternative approaches that have proven effective in maintaining long-term drug abstinence. Given the severity and persistence of the problem of drug addiction and the lack of robust treatments that can produce lasting effects, continued development and evaluation of the Therapeutic Workplace approach to the treatment of drug addiction is clearly warranted. For the poor and chronically unemployed adults who have been the focus of the Therapeutic Workplace research, this intervention offers the potential to address both the seemingly inescapable poverty that pervades the lives of these individuals and the chronic drug addiction that compromises their ability to lead healthy and productive lives. The success of the Therapeutic Workplace approach will depend on creative, bold and compassionate public and private partnerships.

Acknowledgements

The preparation of this publication was supported by the National Institute on Drug Abuse of the National Institutes of Health under Award Numbers R01 DA037314, R01 DA019497, and T32 DA07209. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Footnotes

An abbreviated version of this paper was previously published in the Quarterly Update of the Partnership for a Drug-Free New Jersey. Reed Morrison is the President and CEO of American Substance Abuse Professionals®, which provides substance abuse services to workplaces throughout the United States.

Contributor Information

Kenneth Silverman, Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine.

August F. Holtyn, Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine

Reed Morrison, American Substance Abuse Professionals®..

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