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Novak MD, Toegel F, Holtyn AF, Rodewald AM, Arellano M, Baranski M, Barnett NP, Leoutsakos JM, Fingerhood M, Silverman K. Abstinence-contingent wage supplements for adults experiencing homelessness and alcohol use disorder: A randomized clinical trial. Prev Med 2023; 176:107655. [PMID: 37541600 PMCID: PMC10837308 DOI: 10.1016/j.ypmed.2023.107655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 07/10/2023] [Accepted: 08/01/2023] [Indexed: 08/06/2023]
Abstract
This study evaluated the effectiveness of abstinence-contingent wage supplements in promoting alcohol abstinence and employment in adults experiencing homelessness and alcohol use disorder. A randomized clinical trial was conducted from 2019 to 2022. After a 1-month Induction period, 119 participants were randomly assigned to a Usual Care Control group (n = 57) or an Abstinence-Contingent Wage Supplement group (n = 62). Usual Care participants were offered counseling and referrals to employment and treatment programs. Abstinence-Contingent Wage Supplement participants could earn stipends for working with an employment specialist and wage supplements for working in a community job but had to maintain abstinence from alcohol as determined by transdermal alcohol concentration monitoring devices to maximize pay. Abstinence-Contingent Wage Supplement participants reported significantly higher rates of alcohol abstinence than Usual Care participants during the 6-month intervention (82.8% vs. 60.2% of months, OR = 3.4, 95% CI 1.8 to 6.3, p < .001). Abstinence-Contingent Wage Supplement participants were also significantly more likely to obtain employment (51.3% vs. 31.6% of months, OR = 2.6, 95% CI 1.5 to 4.4, p < .001) and live out of poverty (38.2% vs. 16.7% of months, OR = 3.7, 95% CI 2.0 to 7.1, p < .001) than Usual Care participants. These findings suggest that Abstinence-Contingent Wage Supplements can promote alcohol abstinence and employment in adults experiencing homelessness and alcohol use disorder. ClinicalTrials.gov Identifier: NCT03519009.
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Affiliation(s)
- Matthew D Novak
- Department of Psychiatry and Behavioral Sciences, Center for Learning and Health, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Forrest Toegel
- Department of Psychiatry and Behavioral Sciences, Center for Learning and Health, Johns Hopkins University School of Medicine, Baltimore, MD, United States; Department of Psychological Science, Northern Michigan University, Marquette, MI, United States
| | - August F Holtyn
- Department of Psychiatry and Behavioral Sciences, Center for Learning and Health, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Andrew M Rodewald
- Department of Psychiatry and Behavioral Sciences, Center for Learning and Health, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Meghan Arellano
- Department of Psychiatry and Behavioral Sciences, Center for Learning and Health, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Mackenzie Baranski
- Department of Psychological Science, Northern Michigan University, Marquette, MI, United States
| | - Nancy P Barnett
- Department of Psychiatry and Human Behavior, Brown University, Providence, RI, United States
| | - Jeannie-Marie Leoutsakos
- Department of Psychiatry and Behavioral Sciences, Center for Learning and Health, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Michael Fingerhood
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Kenneth Silverman
- Department of Psychiatry and Behavioral Sciences, Center for Learning and Health, Johns Hopkins University School of Medicine, Baltimore, MD, United States.
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Orme S, Zarkin GA, Luckey J, Dunlap LJ, Novak MD, Holtyn AF, Toegel F, Silverman K. Cost and cost-effectiveness of abstinence contingent wage supplements. Drug Alcohol Depend 2023; 244:109754. [PMID: 36638680 PMCID: PMC10207811 DOI: 10.1016/j.drugalcdep.2022.109754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 12/14/2022] [Accepted: 12/19/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Substance use disorders are correlated with unemployment and poverty. However, few interventions aim to improve substance use, unemployment, and, distally, poverty. The Abstinence-Contingent Wage Supplement (ACWS) randomized controlled trial combined a therapeutic workplace with abstinence-contingent wage supplements to address substance use and unemployment. The ACWS study found that abstinence-contingent wage supplements increased the percentage of participants who had negative drug tests, who were employed, and who were above the poverty line during the intervention period. This study presents the cost of ACWS and calculates the cost-effectiveness of ACWS compared with usual care. METHODS To calculate the cost and cost-effectiveness of ACWS, we used activity-based costing methods to cost the intervention and calculated the costs from the provider and healthcare sector perspective. We calculated incremental cost-effectiveness ratios and cost-effectiveness acceptability curves for negative drug tests and employment. RESULTS ACWS cost $11,310 per participant over the 12-month intervention period. Total intervention and healthcare costs per participant over the intervention period were $20,625 for usual care and $30,686 for ACWS. At the end of the intervention period an additional participant with a negative drug test cost $1437 while an additional participant employed cost $915. CONCLUSIONS ACWS increases drug abstinence and employment and may be cost-effective at the end of the 12-month intervention period if decision makers are willing to pay the incremental cost associated with the intervention.
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Affiliation(s)
- Stephen Orme
- RTI International, Research Triangle Park, NC, United States.
| | - Gary A Zarkin
- RTI International, Research Triangle Park, NC, United States
| | - Jackson Luckey
- RTI International, Research Triangle Park, NC, United States
| | - Laura J Dunlap
- RTI International, Research Triangle Park, NC, United States
| | - Matthew D Novak
- Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - August F Holtyn
- Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Forrest Toegel
- Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Kenneth Silverman
- Johns Hopkins University School of Medicine, Baltimore, MD, United States
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DeFulio A, Cosottile DW, Devoto A, Silverman K. A pilot study of a therapeutic workplace in women arrested for prostitution. BEHAVIORAL INTERVENTIONS 2022. [DOI: 10.1002/bin.1906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Anthony DeFulio
- Department of Psychology Western Michigan University Kalamazoo Michigan USA
| | | | - Amanda Devoto
- National Institute on Drug Abuse Intramural Research Program Rockville Maryland USA
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Hoang BL, Sledge D. The association between medication for opioid use disorder and employment outcomes in the U.S.: The relevance of race and ethnicity. DRUG AND ALCOHOL DEPENDENCE REPORTS 2022; 4:100081. [PMID: 36846575 PMCID: PMC9948818 DOI: 10.1016/j.dadr.2022.100081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 06/24/2022] [Accepted: 06/27/2022] [Indexed: 11/15/2022]
Abstract
•White admissions given MOUD were less likely to become unemployed at discharge.•Blacks and Hispanics given MOUD were more likely to remain unemployed at discharge.•Racial disparities associated with MOUD have notable implications for policy.
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Abstinence-contingent wage supplements to promote drug abstinence and employment: Post-intervention outcomes. Drug Alcohol Depend 2022; 232:109322. [PMID: 35077956 PMCID: PMC8885832 DOI: 10.1016/j.drugalcdep.2022.109322] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 01/17/2022] [Accepted: 01/18/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND Substance use disorder, unemployment, and poverty are interrelated problems that have not been addressed adequately by existing interventions. This study evaluated post-intervention effects of abstinence-contingent wage supplements on drug abstinence and employment. METHODS Unemployed adults enrolled in opioid agonist treatment were randomly assigned to an abstinence-contingent wage supplement group (n = 44) or a usual care control group (n = 47). All participants could work with an employment specialist throughout a 12-month intervention period. Those in the abstinence-contingent wage supplement group earned stipends for working with the employment specialist and, after gaining employment, abstinence-contingent wage supplements for working in their community job but had to provide opiate- and cocaine-negative urine samples to maximize pay. To assess post-intervention effects of abstinence-contingent wage supplements and compare those effects to during-intervention effects, we analyzed urine samples and self-reports every 3 months during the 12-month intervention and the 12-month post-intervention period. RESULTS During the intervention, abstinence-contingent wage supplement participants provided significantly more opiate- and cocaine-negative urine samples than usual care control participants; abstinence-contingent wage supplement participants were also significantly more likely to become employed and live out of poverty than usual care participants during intervention. During the post-intervention period, the abstinence-contingent wage supplement and usual care control groups had similar rates of drug abstinence, similar levels of employment, and similar proportions living out of poverty. CONCLUSIONS Long-term delivery of abstinence-contingent wage supplements can promote drug abstinence and employment, but many patients relapse to drug use and cease employment when wage supplements are discontinued.
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P Hong PY, Kim SH, Marley J, Park JH. Transforming Impossible into Possible (TIP) for SUD recovery: A promising practice innovation to combat the opioid crisis. SOCIAL WORK IN HEALTH CARE 2021; 60:509-528. [PMID: 34414853 DOI: 10.1080/00981389.2021.1958127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Accepted: 07/15/2021] [Indexed: 06/13/2023]
Abstract
The purpose of this study is to examine the psychological self-sufficiency (PSS) process among low-income individuals participating in the Transforming Impossible into Possible (TIP) program and explore the implications of TIP as a SUD recovery intervention. A sample of 622 individuals from 9 local job training programs in a large Midwestern city was used to examine the group differences in substance abuse barrier and employment hope as they relates to economic self-sufficiency (ESS). Individuals in the TIP program (n = 315) had statistically significant path coefficients between substance abuse barriers, employment hope and ESS while the non-TIP counterpart (n = 307) showed a significant path only between employment hope and ESS. Also, the time difference score in substance abuse barrier and ESS was greater for the TIP group compared to the non-TIP comparison group. Results provide implications for social work practice among persons with SUDs. While the traditional employment programs focused only on the interview and job skills, TIP allowed participants to discover their resources to address the inner obstacles that have been holding them back. TIP could serve as a promising model to treat SUDs and support the recovery process.
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Affiliation(s)
| | - Suk-Hee Kim
- School of Social Work, Northern Kentucky University, Highland Heights, KY, USA
| | - James Marley
- School of Social Work, Loyola University Chicago, Chicago, IL, USA
| | - Jang Ho Park
- School of Social Work, Loyola University Chicago, Chicago, IL, USA
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Boloori A, Arnetz BB, Viens F, Maiti T, Arnetz JE. Misalignment of Stakeholder Incentives in the Opioid Crisis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E7535. [PMID: 33081276 PMCID: PMC7589670 DOI: 10.3390/ijerph17207535] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 10/03/2020] [Accepted: 10/04/2020] [Indexed: 12/14/2022]
Abstract
The current opioid epidemic has killed more than 446,000 Americans over the past two decades. Despite the magnitude of the crisis, little is known to what degree the misalignment of incentives among stakeholders due to competing interests has contributed to the current situation. In this study, we explore evidence in the literature for the working hypothesis that misalignment rooted in the cost, quality, or access to care can be a significant contributor to the opioid epidemic. The review identified several problems that can contribute to incentive misalignment by compromising the triple aims (cost, quality, and access) in this epidemic. Some of these issues include the inefficacy of conventional payment mechanisms in providing incentives for providers, practice guidelines in pain management that are not easily implementable across different medical specialties, barriers in adopting multi-modal pain management strategies, low capacity of providers/treatments to address opioid/substance use disorders, the complexity of addressing the co-occurrence of chronic pain and opioid use disorders, and patients' non-adherence to opioid substitution treatments. In discussing these issues, we also shed light on factors that can facilitate the alignment of incentives among stakeholders to effectively address the current crisis.
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Affiliation(s)
- Alireza Boloori
- Department of Statistics and Probability, Michigan State University, East Lansing, MI 48824, USA; (F.V.); (T.M.)
- Department of Family Medicine, Michigan State University, Grand Rapids, MI 49503, USA; (B.B.A.); (J.E.A.)
| | - Bengt B. Arnetz
- Department of Family Medicine, Michigan State University, Grand Rapids, MI 49503, USA; (B.B.A.); (J.E.A.)
| | - Frederi Viens
- Department of Statistics and Probability, Michigan State University, East Lansing, MI 48824, USA; (F.V.); (T.M.)
| | - Taps Maiti
- Department of Statistics and Probability, Michigan State University, East Lansing, MI 48824, USA; (F.V.); (T.M.)
| | - Judith E. Arnetz
- Department of Family Medicine, Michigan State University, Grand Rapids, MI 49503, USA; (B.B.A.); (J.E.A.)
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