Long-Term Effects of Incentives for HIV Viral Suppression: A Randomized Clinical Trial

Achieving viral suppression in people living with HIV improves their quality of life and can help end the HIV/AIDS epidemic. However, few interventions have successfully promoted HIV viral suppression. The purpose of this study was to evaluate the long-term effectiveness of financial incentives for viral suppression in people living with HIV. People living with a detectable HIV viral load (≥ 200 copies/mL) were randomly assigned to Usual Care (n = 50) or Incentive (n = 52) groups. Incentive participants earned up to $10 per day for providing blood samples with an undetectable or reduced viral load. During the 2-year intervention period, the percentage of blood samples with a suppressed viral load was significantly higher among Incentive participants (70%) than Usual Care participants (43%) (OR = 7.1, 95% CI 2.7 to 18.8, p < .001). This effect did not maintain after incentives were discontinued. These findings suggest that frequent delivery of large-magnitude financial incentives for viral suppression can produce large and long-lasting improvements in viral load in people living with HIV. ClinicalTrials.gov Identifier: NCT02363387.

Abstinence-contingent wage supplements for adults experiencing homelessness and alcohol use disorder: A randomized clinical trial

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.

Discounting of employment opportunities with urine drug testing requirements in opioid users enrolled in the Therapeutic Workplace

BACKGROUND

The evidence-based Therapeutic Workplace (TWP) is a promising employment-based treatment where access to work is contingent on objective evidence of abstinence from drugs. TWP is sometimes criticized for requiring individuals who use drugs to voluntarily enroll in a program requiring urine drug testing.

OBJECTIVE

This experiment was conducted to assess whether urine drug testing as a condition of employment decreases the value of employment opportunities and to what degree.

METHODS

Participants were unemployed, DSM-IV opioid-dependent, and enrolled in TWP. Participants completed discounting tasks assessing preference for a hypothetical job paying a constant wage that did not require urine drug testing and a job that paid a variable wage but required drug testing. The primary outcome was 'job value' operationalized as percentage wage difference to accept a job requiring urine drug testing.

RESULTS

Percent wage difference to accept a job that required urine testing was analyzed using GEE. Results revealed a significant main effect of recent drug use (χ2(1) = 10.07, p < .01).

CONCLUSION

Most participants were willing to accept a urine drug-testing job across wages similar non-drug testing jobs. Participants reporting recent cocaine or heroin use were less likely to choose urine drug-testing employment.

Cost and cost-effectiveness of abstinence contingent wage supplements

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.

Being at work improves stress, craving, and mood for people with opioid use disorder: Ecological momentary assessment during a randomized trial of experimental employment in a contingency-management-based therapeutic workplace

Employment problems are common among people with substance use disorders (SUDs), and improving vocational functioning is an important aspect of SUD treatment. More detailed understanding of the psychosocial benefits of employment may help refine vocational interventions for people with SUDs. Here, we used ecological momentary assessment to measure possible affective improvements associated with work. Participants (n = 161) with opioid use disorder were randomized to work (job-skills training) in a contingency-management-based Therapeutic Workplace either immediately or after a waitlist delay. Throughout, participants responded via smartphone to randomly scheduled questionnaires. In linear mixed models comparing responses made at work vs. all other locations, being at work was associated with: less stress, less craving for opioids and cocaine, less negative mood, more positive mood, and more flow-like states. Some of these differences were also observed on workdays vs. non-workdays outside of work hours. These results indicate that benefits associated with work may not be restricted to being actually in the workplace; however, randomization did not reveal clear changes coinciding with the onset of work access. Overall, in contrast to work-associated negative moods measured by experience-sampling in the general population, Therapeutic Workplace participants experienced several types of affective improvements associated with work.

Cost and Cost-Effectiveness of Incentives for Viral Suppression in People Living with HIV

Only 63% of people living with HIV in the United States are achieving viral suppression. Structural and social barriers limit adherence to antiretroviral therapy which furthers the HIV epidemic while increasing health care costs. This study calculated the cost and cost-effectiveness of a contingency management intervention with cash incentives. People with HIV and detectable viral loads were randomized to usual care or an incentive group. Individuals could earn up to $3650 per year if they achieved and maintained an undetectable viral load. The average 1-year intervention cost, including incentives, was $4105 per patient. The average health care costs were $27,189 per patient in usual care and $35,853 per patient in the incentive group. We estimated a cost of $28,888 per quality-adjusted life-year (QALY) gained, which is well below accepted cost-per-QALY thresholds. Contingency management with cash incentives is a cost-effective intervention for significantly increasing viral suppression.

Factors associated with obtaining employment among opioid use disorder patients enrolled in a therapeutic workplace intervention

BACKGROUND

Unemployment is a common problem among adults who have substance use disorder that often persists during treatment and recovery. We identified patient characteristics that were associated with obtaining employment among unemployed adults in opioid use disorder treatment.

METHODS

This analysis used data from participants (N = 91) who were enrolled in a randomized controlled trial evaluating the effectiveness of a therapeutic workplace in promoting drug abstinence and employment. After a 3-month training period (Phase 1), participants were randomly assigned to a study group and could work for 12 months with an employment specialist who assisted participants in obtaining employment (Phase 2). A logistic regression model was used to identify patient characteristics that were associated with obtaining employment.

RESULTS

Of the 91 participants, 39 (42.9 %) obtained employment. Compared to participants who did not obtain employment, participants who obtained employment worked more days in the therapeutic workplace during the training period (Phase 1) [OR (95 % CI) = 1.072 (1.015-1.132), p = .014], provided more opiate- and cocaine-negative urine samples while seeking employment [OR (95 % CI) = 1.015 (1.002-1.027), p = .025], and reported not usually being unemployed at study intake [OR (95 % CI) = 0.229 (0.080-0.652), p = .007].

CONCLUSIONS

Our analyses suggest that among unemployed adults in opioid use disorder treatment, those with the lowest rates of therapeutic workplace attendance, lowest rates of drug abstinence while seeking employment, and relatively long histories of unemployment are the least likely to obtain employment. These relations are potentially addressable at a practical level, and future research could build on these findings to improve the effectiveness of employment-based interventions.

Remotely delivered incentives to promote buprenorphine treatment engagement in out-of-treatment adults with opioid use disorder

BACKGROUND

Opioid overdose remains a leading cause of death. Office-based buprenorphine could expand access to treatment to the many opioid users who are not in treatment and who are at risk for opioid overdose. However, many people in need of buprenorphine treatment do not enroll in treatment. This randomized pilot trial evaluated efficacy of a remotely delivered incentive intervention in promoting engagement in buprenorphine treatment in out-of-treatment adults with opioid use disorder.

METHODS

Participants (N = 41) were offered referrals to buprenorphine treatment and randomly assigned to Control or Incentive groups for 6 months. Incentive participants were offered incentives for enrolling in buprenorphine treatment, verified by providing documentation showing that they received a buprenorphine prescription, and providing videos taking daily buprenorphine doses. Participants used a smartphone application to record and submit a video of their buprenorphine prescription and daily buprenorphine administration. Incentive earnings were added remotely to reloadable credit cards.

RESULTS

Incentive participants were significantly more likely to enroll in treatment compared to control participants (71.4 % versus 30.0 % of participants; OR [95 % CI]: 6.24 [1.46-26.72], p = .014). Few participants in either group adhered to buprenorphine treatment, and the two groups continued to use opioids, including fentanyl at high and comparable rates. The two groups did not differ in the percentage of urine samples that were positive for buprenorphine, opiates, fentanyl, or methadone at monthly assessments conducted during the 6-month intervention.

CONCLUSIONS

Remotely delivered incentives can connect out-of-treatment adults with opioid use disorder to treatment, but additional supports are needed to promote buprenorphine adherence.

Technology-assisted opioid education for out-of-treatment adults with opioid use disorder

OBJECTIVE

To evaluate the feasibility and potential efficacy of a technology-assisted education program in teaching adults at a high risk of opioid overdose about opioids; opioid overdose; and opioid use disorder medications.

METHOD

A within-subject, repeated-measures design was used to evaluate effects of the novel technology-assisted education program. Participants (N = 40) were out-of-treatment adults with opioid use disorder, recruited in Baltimore, Maryland from May 2019 to January 2020. The education program was self-paced and contained three courses. Each course presented information and required answers to multiple-choice questions. The education program was evaluated using a 50-item test, delivered before and after participants completed each course. Tests were divided into three subtests that contained questions from each course. We measured accuracy on each subtest before and after completion of each course and used a mixed-effects model to analyze changes in accuracy across tests.

RESULTS

The technology-assisted education program required a median time of 91 min of activity to complete. Most participants completed the program in a single day. Accuracy on each subtest increased only after completion of the course that corresponded to that subtest, and learning comparisons were significant at the p < .001 level for all subtests. Accuracy on each subtest was unchanged before completion of the relevant course, and increases in accuracy were retained across subsequent tests. Learning occurred similarly independent of participant education, employment, and poverty.

CONCLUSIONS

Technology-assisted education programs can provide at-risk adults with access to effective education on opioids, opioid overdose, and opioid use disorder medications. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Effects of incentives on viral suppression in people living with HIV who use cocaine or opiates

BACKGROUND

Antiretroviral therapy (ART) adherence is essential to maintenance of undetectable viral loads among people living with HIV, which improves health and reduces HIV transmission. Despite these benefits, some people living with HIV do not maintain the level of adherence required to sustain an undetectable viral load. This problem is particularly common among people who use drugs.

OBJECTIVE

To determine effects of incentivizing viral suppression in people living with HIV who used cocaine or opiates.

METHODS

In this secondary analysis of data collected during a randomized controlled trial, participants (N=102) with detectable HIV viral loads (>200 copies/mL) were randomly assigned to a Usual Care or Incentive group. Usual Care participants did not earn incentives for viral suppression. Incentive participants earned incentives ($10/day maximum) for providing blood samples with reduced or undetectable (<200 copies/mL) viral loads. All participants completed assessments every three months. Results collected during the first year were compared based on group assignment and drug use.

RESULTS

Among participants who used cocaine or opiates, Incentive participants (n = 27) provided more (OR:4.0, CI:1.6-10.3, p = .004) blood samples with an undetectable viral load (69 %) than Usual Care participants (n = 25; 41 %). Among participants who did not use cocaine or opiates, Incentive participants (n = 25) provided more (OR:4.1, CI:1.5-10.7, p = .005) blood samples with an undetectable viral load (78 %) than Usual Care participants (n = 25; 36 %). Effects of incentives did not differ by drug use (OR:1.0, CI:0.3-4.0, p = .992).

CONCLUSIONS

Incentivizing viral suppression can promote undetectable viral loads in people living with HIV who use cocaine or opiates.

Financial incentives promote engagement in employment services for unemployed adults in treatment for opioid use disorder

BACKGROUND

Promoting employment among unemployed adults with substance use disorder is a difficult challenge for which existing interventions have had limited effects. This study examined whether financial incentives could increase engagement in employment services for unemployed adults in treatment for opioid use disorder.

METHODS

The study was conducted from 2014 to 2019 in Baltimore, MD. After a 3-month abstinence initiation and training period, participants (N = 91) were randomly assigned to a Control group or an Incentive group and were invited to work with an employment specialist to seek employment in a community job for 12 months. Participants assigned to the Control group (n = 47) did not receive incentives for working with the employment specialist. Participants assigned to the Incentive group (n = 44) could earn financial incentives for working with the employment specialist, but had to provide opiate- and cocaine-negative urine samples to maximize pay.

RESULTS

Incentive participants attended the employment services and worked with the employment specialist on significantly more days than Control participants (41.8 % versus 1.1 % of days; OR = 40.42, 95 % CI = 32.46-48.38, p < .001), and for significantly more hours than Control participants (3.58 versus 1.25 h, on average; OR=2.34, 95 % CI=1.83-2.85, p < .001). Incentive participants were more likely to be retained than Control participants when analyses were based solely on attendance (HR=0.12, 95 % CI=0.06-0.25, p < .001) and attendance and employment combined (HR=0.15, 95 % CI=0.07-0.31, p < .001).

CONCLUSIONS

Financial incentives were effective in promoting engagement in employment services for individuals who often do not utilize employment services.

Effects of time-based administration of abstinence reinforcement targeting opiate and cocaine use

Polydrug use is a common problem among patients in opioid-substitution treatment. Polydrug use has been reduced by administering abstinence-reinforcement contingencies in a sequence, such that a single drug is targeted until abstinence is achieved, and then an additional drug is targeted. The present study examined effects of administering abstinence-reinforcement contingencies sequentially based on time rather than on achieved abstinence. Participants accessed paid work (about $10/hr maximum) in the Therapeutic Workplace by providing urine samples 3 times per week. The urine samples were tested for opiates and cocaine. During an induction period, participants earned maximum pay independent of drug abstinence. Then, maximum pay depended upon urine samples that were negative for opiates. Two weeks later, maximum pay depended upon urine samples that were negative for both opiates and cocaine. Opiate and cocaine abstinence increased following administration of the respective contingencies. The time-based administration of abstinence reinforcement increased opiate and cocaine abstinence.

Randomized controlled trial of d-cycloserine in cocaine dependence: Effects on contingency management and cue-induced cocaine craving in a naturalistic setting

Cocaine dependence constitutes a significant public health concern. This randomized, double-blind, placebo-controlled trial tested a novel approach to reducing cocaine use among cocaine-dependent individuals with d-cycloserine, a drug known to enhance learning and some learning-based therapies. Urine samples and cocaine craving were assessed across three phases: induction (Weeks 1-2), treatment (Weeks 3-5; urinalysis-based contingency management plus exposure therapy), and posttreatment (Weeks 6-7). During the treatment phase, either 50 mg of d-cycloserine or placebo was administered after delivery of urinalysis feedback with potential monetary reward and before exposure therapy sessions in naturalistic contexts individually associated with cocaine use. d-cycloserine significantly improved learning on an operant laboratory task. Contingency management significantly reduced cocaine use and craving. d-cycloserine did not significantly affect cocaine use or craving in the treatment phase. Craving significantly increased for the d-cycloserine group during the post treatment phase. Therefore, although the study showed that d-cycloserine was capable of improving learning, enhancement of learning-based therapy was not observed. Moreover, no differences in behavioral measures of cocaine demand (cocaine purchasing task) or monetary or sexual delay discounting were observed across phases or between groups in any phase. These results are somewhat consistent with previous findings suggesting that d-cycloserine administration increases cocaine craving, although they differ from other findings showing that d-cycloserine administration reduces alcohol or nicotine cravings. Methodological variables (e.g., guided vs. unguided exposure therapy sessions, length of extinction exposure) likely play a role in dissimilar findings observed across studies. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Effects of incentivizing viral suppression in previously incarcerated adults living with HIV

Background: The amount of HIV in a person's blood can be suppressed to an undetectable level through antiretroviral therapy medications (ART). Adhering to an ART regimen can improve a person's health and reduce HIV transmission. Despite these benefits, many people with HIV do not maintain the level of adherence required to achieve an undetectable viral load. This problem is particularly common among people who have been incarcerated.Objective: To determine effects of incentivizing viral suppression in previously incarcerated adults with HIV.Methods: Adults with HIV (N = 102) and detectable viral load (>200 copies/mL) were randomly assigned to a Usual Care or Incentive group. Usual Care participants did not earn incentives for viral suppression. Incentive participants earned incentives ($10/day maximum) for providing blood samples with a reduced or undetectable (<200 copies/mL) viral load. Assessments were conducted every 3 months. Results collected during the first year were aggregated and compared based on group assignment and incarceration history.Results: Previously incarcerated participants in the Incentive group provided more (OR: 2.9; CI: 1.3-6.8; p <.05) blood samples with an undetectable viral load (69%) than those in the Usual Care group (41%). Never-incarcerated participants in the Incentive group provided more (OR: 6.8; CI: 2.2-21.0; p <.01) blood samples with an undetectable viral load (78%) than those in the Usual Care group (36%). Effects of incentives did not differ by incarceration history.Conclusions: Incentivizing viral suppression can increase viral suppression (undetectable viral load) in people who have been incarcerated.

Abstinence-contingent wage supplements to promote drug abstinence and employment: a randomised controlled trial

BACKGROUND

Poverty, unemployment and substance abuse are inter-related problems. This study evaluated the effectiveness of abstinence-contingent wage supplements in promoting drug abstinence and employment in unemployed adults in outpatient treatment for opioid use disorder.

METHODS

A randomised controlled trial was conducted in Baltimore, MD, from 2014 to 2019. After a 3-month abstinence initiation and training period, participants (n=91) were randomly assigned to a usual care control group that received employment services or to an abstinence-contingent wage supplement group that received employment services plus abstinence-contingent wage supplements. All participants were invited to work with an employment specialist to seek employment in a community job for 12 months. Abstinence-contingent wage supplement participants could earn training stipends for working with the employment specialist and wage supplements for working in a community job, but had to provide opiate and cocaine-negative urine samples to maximise pay.

RESULTS

Abstinence-contingent wage supplement participants provided significantly more opiate and cocaine-negative urine samples than usual care control participants (65% vs 45%; OR=2.29, 95% CI 1.22 to 4.30, p=0.01) during the 12-month intervention. Abstinence-contingent wage supplement participants were significantly more likely to have obtained employment (59% vs 28%; OR=3.88, 95% CI 1.60 to 9.41, p=0.004) and lived out of poverty (61% vs 30%; OR=3.77, 95% CI 1.57 to 9.04, p=0.004) by the end of the 12-month intervention than usual care control participants.

CONCLUSION

Abstinence-contingent wage supplements can promote drug abstinence and employment.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov NCT02487745.

The Utility of Operant Conditioning to Address Poverty and Drug Addiction

Poverty is associated with poor health. This article reviews research on proximal and distal operant interventions to address drug addiction and poverty. Proximal interventions promote health behaviors directly. Abstinence reinforcement, a common proximal intervention for the treatment of drug addiction, can be effective. Manipulating familiar parameters of operant conditioning can improve the effectiveness of abstinence reinforcement. Increasing reinforcement magnitude can increase the proportion of individuals that respond to abstinence reinforcement, arranging long-term exposure to abstinence reinforcement can prevent relapse, and arranging abstinence reinforcement sequentially across drugs can promote abstinence from multiple drugs. Distal interventions reduce risk factors that underlie poor health and may have an indirect beneficial effect on health. In the case of poverty, distal interventions seek to move people out of poverty. The therapeutic workplace includes both proximal and distal interventions to treat drug addiction and poverty. In the therapeutic workplace, participants earn stipends or wages to work. The therapeutic workplace uses employment-based reinforcement in which participants are required to provide drug-free urine samples or take scheduled doses of addiction medications to work and/or maintain maximum pay. The therapeutic workplace has two phases, a training and an employment phase. Special contingencies appear required to promote skill development during the training phase, employment-based reinforcement can promote abstinence from heroin and cocaine and adherence to naltrexone, and the therapeutic workplace can increase employment. Behavior analysts are well-suited to address both poverty and drug addiction using operant interventions like the therapeutic workplace.

Incentives for Viral Suppression in People Living with HIV: A Randomized Clinical Trial

The HIV/AIDS epidemic can be eliminated if 73% of people living with HIV take antiretroviral medications and achieve undetectable viral loads. This study assessed the effects of financial incentives in suppressing viral load. People living with HIV with detectable viral loads (N = 102) were randomly assigned to Usual Care or Incentive groups. Incentive participants earned up to $10 per day for 2 years for providing blood samples that showed either reduced or undetectable viral loads. This report presents data on the 1st year after random assignment. Incentive participants provided more (adjusted OR = 15.6, CI 4.2-58.8, p < 0.001) blood samples at 3-month assessments with undetectable viral load (72.1%) than usual care control participants (39.0%). We collected most blood samples. The study showed that incentives can substantially increase undetectable viral loads in people living with HIV. Financial incentives for suppressed viral loads could contribute to the eradication of the HIV/AIDS epidemic.

The effects of extended-release injectable naltrexone and incentives for opiate abstinence in heroin-dependent adults in a model therapeutic workplace: A randomized trial

AIM

To determine whether extended-release injectable naltrexone (XR-NTX), incentives for opiate abstinence, and their combination reduce opiate use compared to a usual care control and whether the combination reduces opiate use compared to either treatment alone.

DESIGN

Randomized 2 × 2 single-site controlled trial conducted from November 2012 through May 2016. After a detoxification and oral naltrexone induction, participants were assigned to a Usual Care, Abstinence Incentives, XR-NTX, or XR-NTX plus Abstinence Incentives group for a six-month intervention period.

SETTING

A model therapeutic workplace where participants could work on automated computer programs that targeted job-skills training for 4 h every weekday for 24 weeks and earn about $10 per hour.

PARTICIPANTS

84 heroin-dependent adults who were unemployed and medically approved for naltrexone. Most participants were male (71.4%), African American (80.1%), and cocaine dependent (71.4%).

MEASUREMENTS

The primary outcome measure was the percentage of urine samples negative for opiates that were collected at once weekly assessments (24 per participant) that were not part of the intervention and for which participants were paid $10 for completing.

INTERVENTION

Participants who attended the workplace provided thrice-weekly urine samples. Abstinence Incentives participants had to provide opiate-free urine samples to maintain maximum pay. XR-NTX participants received one injection every 4 weeks and were required to take injections in order to work and to maintain maximum pay. Usual Care participants were not offered XR-NTX and opiate urinalysis results did not affect pay.

FINDINGS

A large percentage (65 of 149; 43.6%) of individuals failed the induction protocol required for randomization and to be eligible to receive XR-NTX. When missing urine samples were considered positive, there was no significant interaction between XR-NTX and Abstinence Incentives. XR-NTX plus Abstinence Incentives participants provided significantly more opiate-negative samples (81.3%, SD 39.0%) than XR-NTX participants (64.5%, SD 47.9%; aOR 10.4, 95% CI 1.3-85.5; P = .030). When urine samples were not replaced, there was a significant interaction between XR-NTX and Abstinence Incentives (aOR 77.0, 95% CI 1.3-4432;P = 0.036); XR-NTX plus Abstinence Incentives participants provided significantly more opiate-negative samples (99.6%, SD 0.1%) than XR-NTX participants (85.0%, SD 35.7%; aOR 147.6, 95% CI 6.3-3472; P = 0.002), Abstinence Incentives participants (91.9%, SD 27.3%; aOR 121.7, 95% CI 4.8-3067; P =0.004), and Usual Care participants (78.7%, SD 41.0%; aOR 233.4, 95% CI 9.4-5814; P <.001). No other group differences were significant.

CONCLUSION

XR-NTX plus incentives for opiate abstinence increased opiate abstinence, but XR-NTX alone did not. XR-NTX can promote opiate abstinence when it is combined with incentives for opiate abstinence in a model therapeutic workplace.

Behavior analysts in the war on poverty: Developing an operant antipoverty program

Poverty is associated with poor health and affects many United States residents. The therapeutic workplace, an operant intervention designed to treat unemployed adults with histories of drug addiction, could form the basis for an effective antipoverty program. Under the therapeutic workplace, participants receive pay for work. To promote drug abstinence or medication adherence, participants must provide drug-free urine samples or take scheduled doses of medication, respectively, to maintain maximum pay. Therapeutic workplace participants receive job-skills training in Phase 1 and perform income-producing jobs in Phase 2. Many unemployed, drug-addicted adults lack skills they would need to obtain high-skilled and high-paying jobs. Many of these individuals attend therapeutic workplace training reliably, but only when offered stipends for attendance. They also work on training programs reliably, but only when they earn stipends for performance on training programs. A therapeutic workplace social business can promote employment, although special contingencies may be needed to ensure that participants are punctual and work entire work shifts, and social businesses do not reliably promote community employment. Therapeutic workplace participants work with an employment specialist to seek community employment, but primarily when they earn financial incentives. Reducing poverty is more challenging than promoting employment, because it requires promoting employment in higher paying, full-time and steady jobs. Although a daunting challenge, promoting the type of employment needed to reduce poverty is an important goal, both because of the obvious benefit in reducing poverty itself and in the potential secondary benefit of reducing poverty-related health disparities. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Illicit drug use and work in a model therapeutic workplace

BACKGROUND

The link between illicit drug use and impaired employee performance in the workplace has been assumed, but the relation has not been demonstrated clearly in research. This study was an evaluation of the relations between cocaine and opiate use, attendance, and performance in a job skills training program in a population with high rates of drug use.

METHODS

Out-of-treatment injection drug users (N = 42) attended a model therapeutic workplace where they could earn a maximum pay of around $10 per hour, 4 h every weekday, for 30 weeks. At the workplace, participants could complete practice trials on computer-based typing and keypad training programs. Participants were asked to provide urine samples thrice weekly, which were tested for opiates and cocaine.

RESULTS

Participants worked for more hours on a program that resulted in a flat hourly wage when their urine was negative for opiates and cocaine than when their urine was opiate and cocaine positive. Attendance was positively associated with opiate-negative samples during the study. When participants attended the workplace, however, their performance was not related to drug use. Participants completed the same number of practice trials, performed at the same accuracy, and typed at the same speed when they were positive and negative for cocaine and opiates.

CONCLUSIONS

Contrary to common expectations, this study failed to show that the use of opiates or cocaine affected in-training performance, even though opiate and cocaine use predicted reduced attendance under some circumstances.

Evaluation of a Computer-Based Training Program to Teach Adults at Risk for HIV About Pre-Exposure Prophylaxis

This study developed a computer-based program to teach HIV prevention behaviors and raise awareness of pre-exposure prophylaxis (PrEP) among individuals at risk for HIV. The program was divided into modules containing educational material and multiple-choice questions. Participants received immediate feedback for responses and incentives for correct responses to multiple-choice questions. Participants trained on each module until they met speed and accuracy criteria. The modules were divided into: Course 1 (HIV), Course 2 (PrEP), and Course 3 (HIV risk behaviors). Tests of content from all three courses were delivered before and after participants completed each course. Test scores on the content delivered in the courses improved only after participants completed training on each course. HIV and PrEP knowledge was initially low and increased following completion of each part of the program. Computer-based training offers a convenient and effective approach to promoting HIV prevention knowledge, including use of PrEP.

Extended-release injectable naltrexone for opioid use disorder: a systematic review

AIMS

To review systematically the published literature on extended-release naltrexone (XR-NTX, Vivitrol^® ), marketed as a once-per-month injection product to treat opioid use disorder. We addressed the following questions: (1) how successful is induction on XR-NTX; (2) what are adherence rates to XR-NTX; and (3) does XR-NTX decrease opioid use? Factors associated with these outcomes as well as overdose rates were examined.

METHODS

We searched PubMed and used Google Scholar for forward citation searches of peer-reviewed papers from January 2006 to June 2017. Studies that included individuals seeking treatment for opioid use disorder who were offered XR-NTX were included.

RESULTS

We identified and included 34 studies. Pooled estimates showed that XR-NTX induction success was lower in studies that included individuals that required opioid detoxification [62.6%, 95% confidence interval (CI) = 54.5-70.0%] compared with studies that included individuals already detoxified from opioids (85.0%, 95% CI = 78.0-90.1%); 44.2% (95% CI = 33.1-55.9%) of individuals took all scheduled injections of XR-NTX, which were usually six or fewer. Adherence was higher in prospective investigational studies (i.e. studies conducted in a research context according to a study protocol) compared to retrospective studies of medical records taken from routine care (6-month rates: 46.7%, 95% CI = 34.5-59.2% versus 10.5%, 95% CI = 4.6-22.4%, respectively). Compared with referral to treatment, XR-NTX reduced opioid use in adults under criminal justice supervision and when administered to inmates before release. XR-NTX reduced opioid use compared with placebo in Russian adults, but this effect was confounded by differential retention between study groups. XR-NTX showed similar efficacy to buprenorphine when randomization occurred after detoxification, but was inferior to buprenorphine when randomization occurred prior to detoxification.

CONCLUSIONS

Many individuals intending to start extended-release naltrexone (XR-NTX) do not and most who do start XR-NTX discontinue treatment prematurely, two factors that limit its clinical utility significantly. XR-NTX appears to decrease opioid use but there are few experimental demonstrations of this effect.

An intensive assessment of alcohol use and emergency department utilization in homeless alcohol-dependent adults

BACKGROUND

Excessive alcohol use among the homeless may contribute to their high rates of emergency department use. Survey-based studies have provided some information on the relation between alcohol and emergency department use among the homeless.

METHODS

This study used an intensive schedule of random breath collections and self-report assessments to examine the relation between emergency department utilization and alcohol use in homeless alcohol-dependent adults. Data were from homeless alcohol-dependent adults (N=116) who were participating in a therapeutic workplace that provided job-skills training every weekday for 26 weeks. Breath-sample collections and assessments of self-reported alcohol use were scheduled each week, an average of twice per week per participant, at random times between 9:00 A.M. and 5:00 P.M. Participants received $35 for each breath sample collected. Self-reports of emergency department use were assessed throughout the study.

RESULTS

Thirty-four percent of participants reported attending an emergency department and reported an average of 2.2 emergency department visits (range 1-10 visits). Alcohol intoxication was the most common reason for emergency department use. Participants who used the emergency department had significantly more alcohol-positive breath samples and more self-reported heavy alcohol use than participants who did not use the emergency department.

CONCLUSIONS

This study provided a rare intensive assessment of alcohol and emergency department use in homeless alcohol-dependent adults over an extended period. Emergency department use was high and was significantly related to indices of alcohol use.

Effects of incentives for naltrexone adherence on opiate abstinence in heroin-dependent adults

AIM

To test whether an incentive-based intervention that increased adherence to naltrexone also increased opiate abstinence.

DESIGN

Post-hoc combined analysis of three earlier randomized controlled trials that showed individually that incentives for adherence to oral and to extended-release injection naltrexone dosing schedules increased naltrexone adherence, but not opiate abstinence.

SETTING

Out-patient therapeutic work-place in Baltimore, MD, USA.

PARTICIPANTS

One hundred and forty unemployed heroin-dependent adults participating from 2006 to 2010.

INTERVENTIONS

Participants were hired in a model work-place for 26 weeks and randomized to a contingency (n = 72) or prescription (n = 68) group. Both groups were offered naltrexone. Contingency participants were required to take scheduled doses of naltrexone in order to work and earn wages. Prescription participants could earn wages independent of naltrexone adherence.

MEASURES

Thrice-weekly and monthly urine samples tested for opiates and cocaine and measures of naltrexone adherence (percentage of monthly urine samples positive for naltrexone or percentage of scheduled injections received). All analyses included pre-randomization attendance, opiate use and cocaine use as covariates. Additional analyses controlled for cocaine use and naltrexone adherence during the intervention.

FINDINGS

Contingency participants had more opiate abstinence than prescription participants (68.1 versus 52.9% opiate-negative thrice-weekly urine samples, respectively; and 71.9 versus 61.7% opiate-negative monthly urine samples, respectively) based on initial analyses [thrice-weekly samples, odds ratio (OR) = 3.3, 95% confidence interval (CI) = 1.7-6.5, P < 0.01; monthly samples, OR = 2.6, 95% CI = 1.0-7.1, P = 0.06] and on analyses that controlled for cocaine use (thrice-weekly samples, OR = 3.9, 95% CI = 3.3-4.5, P < 0.01; monthly samples, OR = 3.4, 95% CI = 1.1-11.1, P = 0.04), which was high and associated with opiate use. The difference in opiate abstinence rates between contingency and prescription participants was reduced when controlling for naltrexone adherence (monthly samples, OR = 1.1, 95% CI = 0.7-1.7, P = 0.84).

CONCLUSIONS

Incentives for naltrexone adherence increase opiate abstinence in heroin-dependent adults, an effect that appears to be due to increased naltrexone adherence produced by the incentives.

Monitoring cocaine use and abstinence among cocaine users for contingency management interventions

During contingency management interventions, reinforcement of cocaine abstinence is arranged by delivering an incentive when a urine sample tests cocaine-negative. The use of qualitative versus quantitative urinalysis testing may have important implications for effects on cocaine abstinence. Qualitative testing (i.e., testing that solely identifies whether a particular substance is present or absent) may not detect short-term cocaine abstinence because a single instance of cocaine use can result in cocaine-positive urine over many days. Quantitative testing (i.e., testing that identifies how much of a substance is present) may be more sensitive to short-term cocaine abstinence; however, the selection of a criterion for distinguishing new use versus carryover from previous use is an important consideration. The present study examined benzoylecgonine concentrations, the primary metabolite of cocaine, in urine samples collected three times per week for 30 weeks from 28 cocaine users who were exposed to a cocaine abstinence contingency. Of the positive urine samples (benzoylecgonine concentration >300 ng/ml), 29%, 21%, 14%, and 5% of the samples decreased in benzoylecgonine concentration by more than 20%, 40%, 60%, and 80% per day, respectively. As the size of the decrease increased, the likelihood of that sample occurring during a period leading to a cocaine-negative urine sample (benzoylecgonine concentration ≤300 ng/ml) also increased. The number of days required to produce a cocaine-negative sample following a positive sample ranged from 1 to 10 days and was significantly correlated with the starting benzoylecgonine level (r = 0.43, p < 0.001). The present analyses may aid in the development of procedures that allow for the precise reinforcement of recent cocaine abstinence during contingency management interventions.

Predictors of induction onto extended-release naltrexone among unemployed heroin-dependent adults

BACKGROUND AND AIM

Extended-release naltrexone (XR-NTX) blocks the effects of opioids for 4weeks; however, starting treatment can be challenging because it requires 7 to 10days of abstinence from all opioids. In the present study we identified patient and treatment characteristics that were associated with successful induction onto XR-NTX.

METHODS

144 unemployed heroin-dependent adults who had recently undergone opioid detoxification completed self-report measures and behavioral tasks before starting an outpatient XR-NTX induction procedure. Employment-based reinforcement was used to promote opioid abstinence and adherence to oral naltrexone during the induction. Participants were invited to attend a therapeutic workplace where they earned wages for completing jobs skills training. Participants who had used opioids recently were initially invited to attend the workplace for a 7-day washout period. Then those participants were required to provide opioid-negative urine samples and then take scheduled doses of oral naltrexone to work and earn wages. Participants who had not recently used opioids could begin oral naltrexone immediately. After stabilization on oral naltrexone, participants were eligible to receive XR-NTX and were randomized into one of four treatment groups, two of which were offered XR-NTX. Binary and multiple logistic regressions were used to identify characteristics at intake that were associated with successfully completing the XR-NTX induction.

RESULTS

58.3% of participants completed the XR-NTX induction. Those who could begin oral naltrexone immediately were more likely to complete the induction than those who could not (79.5% vs. 25.0%). Of 15 characteristics, 2 were independently associated with XR-NTX induction success: legal status and recent opioid detoxification type. Participants who were not on parole or probation (vs. on parole or probation) were more likely to complete the induction (OR [95% CI]=2.5 [1.1-5.7], p=0.034), as were those who had come from a longer-term detoxification program (≥21days) (vs. a shorter-term [<21days]) (OR [95% CI]=7.0 [3.0-16.6], p<0.001).

CONCLUSIONS

Our analyses suggest that individuals recently leaving longer-term opioid detoxification programs are more likely to complete XR-NTX induction. Individuals on parole or probation are less likely to complete XR-NTX induction and may need additional supports or modifications to induction procedures to be successful.

Reinforcing Productivity in a Job-Skills Training Program for Unemployed Substance-Abusing Adults

Chronically unemployed adults may benefit from intensive job-skills training; however, training programs do not always reliably engage participants in mastering skills. This study examined effects of voucher reinforcement for performance on a job-skills training program in the therapeutic workplace. Participants were four unemployed, substance abusing adults who earned monetary vouchers for working on programs targeting typing skills. Participants were exposed to two payment conditions that differed in whether or not pay was dependent on performance in a within-subject reversal design. In the productivity-pay condition, participants earned $8.00 per hour for attending the workplace plus a bonus for performance. In the base-pay condition, participants were paid an hourly wage that was equivalent to the total hourly earnings from the previous productivity-pay condition. Participants completed less work on the typing programs in the base- than the productivity-pay condition, but the amount of time spent in the workroom and the accuracy and rate of typing were not affected by the pay manipulation. All participants reported preferring base pay over productivity pay. Explicit reinforcement of productivity maintains consistent work in training programs, but more aspects of productivity pay need to be refined for effective, efficient, and socially valid implementation with unemployed, substance-abusing adults.

Behavior analysts in the war on poverty: A review of the use of financial incentives to promote education and employment

Poverty is a pervasive risk factor underlying poor health. Many interventions that have sought to reduce health disparities associated with poverty have focused on improving health-related behaviors of low-income adults. Poverty itself could be targeted to improve health, but this approach would require programs that can consistently move poor individuals out of poverty. Governments and other organizations in the United States have tested a diverse range of antipoverty programs, generally on a large scale and in conjunction with welfare reform initiatives. This paper reviews antipoverty programs that used financial incentives to promote education and employment among welfare recipients and other low-income adults. The incentive-based, antipoverty programs had small or no effects on the target behaviors; they were implemented on large scales from the outset, without systematic development and evaluation of their components; and they did not apply principles of operant conditioning that have been shown to determine the effectiveness of incentive or reinforcement interventions. By applying basic principles of operant conditioning, behavior analysts could help address poverty and improve health through development of effective antipoverty programs. This paper describes a potential framework for a behavior-analytic antipoverty program, with the goal of illustrating that behavior analysts could be uniquely suited to make substantial contributions to the war on poverty.

Factors associated with using opiates while under extended-release naltrexone blockade: A descriptive pilot study

BACKGROUND AND AIM

Extended-release naltrexone (XR-NTX) blocks the effects of opioids for 4weeks, yet many patients continue to use them. To learn more about why this occurs, we collected self-reports on subjective effects and drug use factors from participants' most recent heroin/opiate use while under XR-NTX blockade.

METHODS

Participants (n=38) were unemployed, heroin-dependent adults enrolled in a randomized controlled trial evaluating employment-based incentives to promote adherence to XR-NTX. A subset of participants (n=18) were asked to complete a survey about their most recent use of heroin/opiates when they provided an opiate-positive urine sample while under XR-NTX blockade. Surveys were administered weekly, and participants could complete multiple surveys throughout the trial. Participants reported how high they were (11-point scale; 0=not at all, 10=extremely), how much heroin/opiates they took (less, more, or about the same as usual before starting naltrexone), whether they used cocaine at the same time, and the routes of administration for heroin/opiates and cocaine (if used). All analyses were descriptive.

RESULTS

Of the 107 surveys, 75.7% indicated being "not at all" high the last time heroin/opiates were used. 75.5% of surveys reported opiate amounts that were less than usual, and only 7.5% reported amounts larger than usual. Cocaine was used at the same time as heroin for 57.9% of surveys but typically through a different route (74.2%).

DISCUSSION

Using heroin/opiates while under XR-NTX blockade is not strongly associated with self-reports of high, taking larger than normal amounts of opiates, or taking opiates and cocaine simultaneously via the same route. Future research should incorporate measures of naltrexone concentration and more comprehensive and frequent assessments using ecological momentary assessment.

The effects of the therapeutic workplace and heavy alcohol use on homelessness among homeless alcohol-dependent adults

BACKGROUND

A clinical trial demonstrated that a therapeutic workplace could promote alcohol abstinence in homeless, alcohol-dependent adults. This secondary-data analysis examined rates of homelessness and their relation to the therapeutic workplace intervention and alcohol use during the trial.

METHODS

In the trial, homeless, alcohol-dependent adults could work in a therapeutic workplace for 6 months and were randomly assigned to Unpaid Training, Paid Training, or Contingent Paid Training groups. Unpaid Training participants were not paid for working. Paid Training participants were paid for working. Contingent Paid Training participants were paid for working if they provided alcohol-negative breath samples. Rates of homelessness during the study were calculated for each participant and the three groups were compared. Mixed-effects regression models were conducted to examine the relation between alcohol use (i.e., heavy drinking, drinks per drinking day, and days of alcohol abstinence) and homelessness.

RESULTS

Unpaid Training, Paid Training, and Contingent Paid Training participants did not differ in the percentage of study days spent homeless (31%, 28%, 17%; respectively; F(2,94)=1.732, p=0.183). However, participants with more heavy drinking days (b=0.350, p<0.001), more drinks per drinking day (b=0.267, p<0.001), and fewer days of alcohol abstinence (b=-0.285, p<0.001) spent more time homeless.

CONCLUSIONS

Reducing heavy drinking and alcohol use may help homeless, alcohol-dependent adults transition out of homelessness.

A potential role of anti-poverty programs in health promotion

Poverty is one of the most pervasive risk factors underlying poor health, but is rarely targeted to improve health. Research on the effects of anti-poverty interventions on health has been limited, at least in part because funding for that research has been limited. Anti-poverty programs have been applied on a large scale, frequently by governments, but without systematic development and cumulative programmatic experimental studies. Anti-poverty programs that produce lasting effects on poverty have not been developed. Before evaluating the effect of anti-poverty programs on health, programs must be developed that can reduce poverty consistently. Anti-poverty programs require systematic development and cumulative programmatic scientific evaluation. Research on the therapeutic workplace could provide a model for that research and an adaptation of the therapeutic workplace could serve as a foundation of a comprehensive anti-poverty program. Once effective anti-poverty programs are developed, future research could determine if those programs improve health in addition to increasing income. The potential personal, health and economic benefits of effective anti-poverty programs could be substantial, and could justify the major efforts and expenses that would be required to support systematic research to develop such programs.

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

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.

Behavioral factors predicting response to employment-based reinforcement of cocaine abstinence in methadone patients

We sought to identify behavioral factors associated with response to an employment-based intervention, in which participants had to provide drug-free urine samples to gain access to paid employment. The present secondary analysis included data from a randomized clinical trial. The trial evaluated whether employment-based reinforcement could decrease cocaine use in community methadone patients. Participants (N=56) in the trial worked in a model workplace for 4 hr every weekday and earned about $10 per hr. After a 4-week baseline, participants were randomly assigned to an Abstinence & Work (n = 28) or Work Only (n = 28) condition and could work for an additional 26 weeks. Abstinence & Work participants had to provide cocaine-negative urine samples to work and maintain maximum pay. Work Only participants only had to work to earn pay. For Work Only participants, cocaine abstinence during baseline and the intervention period were significantly (r_s = .72, p <.001) correlated. For Abstinence & Work participants, baseline opiate abstinence was significantly correlated (r_s = .59, p <.001) and workplace attendance was marginally correlated (r_s = .32, p = .098) with cocaine abstinence during the intervention period. Furthermore, participants who provided over 60% cocaine-negative urine samples during the intervention period (i.e., responders) had significantly higher baseline rates of opiate abstinence (p <.0001) and workplace attendance (p = .042) than non-responders. Employment-based reinforcement of cocaine abstinence may be improved by increasing opiate abstinence and workplace attendance prior to initiating the cocaine-abstinence intervention.

Effects of pay resets following drug use on attendance and hours worked in a therapeutic workplace

This secondary data analysis examined effects of an abstinence contingency on participation in a therapeutic workplace. Participants exposed to a pay reset after drug use did not differ in overall attendance from participants who were not exposed to a pay reset after drug use; however, they initially worked less after a pay reset than participants who did not receive a pay reset, and their attendance increased as their pay increased. Overall participation was not influenced by the abstinence contingency, but transient decreases in attendance occurred.

Academic skills of chronically unemployed drug-addicted adults

BACKGROUND

The strong association between unemployment and drug addiction suggests that employment interventions are an important and needed focus of drug-addiction treatment. The increasing necessity of possessing basic academic skills to function in the workplace may require that some individuals receive educational training along with vocational training.

OBJECTIVE

This study investigated the academic skills of drug-addicted and chronically-unemployed adults (N = 559) who were enrolled in one of six studies conducted at the Center for Learning and Health in Baltimore, MD.

METHODS

Upon study enrollment, academic skills in math, spelling, and reading were examined using the Wide Range Achievement Test (WRAT-3 or WRAT-4) and educational history was examined using the Addiction Severity Index-Lite.

RESULTS

Although participants completed an average of 11 years of education, actual academic skill level was at or below the seventh grade level for 81% of participants in math, 61% in spelling, and 43% in reading, and most participants were classified as Low Average or below based on age group norms. Despite the fact that participants in this analysis were studied across several years and were from diverse populations, rates of high school completion and academic skill levels were remarkably similar.

CONCLUSIONS

Programs designed to improve the long-term employment status of drug-addicted individuals may benefit from the inclusion of basic adult education; future research on the topic is needed. Although establishing basic skills does not directly address chronic unemployment, it may help individuals obtain the jobs they desire and function effectively in those jobs.

The therapeutic workplace to promote treatment engagement and drug abstinence in out-of-treatment injection drug users: a randomized controlled trial

OBJECTIVE

Determine if employment-based reinforcement can increase methadone treatment engagement and drug abstinence in out-of-treatment injection drug users.

METHOD

This study was conducted from 2008 to 2012 in a therapeutic workplace in Baltimore, MD. After a 4-week induction, participants (N=98) could work and earn pay for 26 weeks and were randomly assigned to Work Reinforcement, Methadone & Work Reinforcement, and Abstinence, Methadone & Work Reinforcement conditions. Work Reinforcement participants had to work to earn pay. Methadone & Work Reinforcement and Abstinence, Methadone, & Work Reinforcement participants had to enroll in methadone treatment to work and maximize pay. Abstinence, Methadone, & Work Reinforcement participants had to provide opiate- and cocaine-negative urine samples to maximize pay.

RESULTS

Most participants (92%) enrolled in methadone treatment during induction. Drug abstinence increased as a graded function of the addition of the methadone and abstinence contingencies. Abstinence, Methadone & Work Reinforcement participants provided significantly more urine samples negative for opiates (75% versus 54%) and cocaine (57% versus 32%) than Work Reinforcement participants. Methadone & Work Reinforcement participants provided significantly more cocaine-negative samples than Work Reinforcement participants (55% versus 32%).

CONCLUSION

The therapeutic workplace can promote drug abstinence in out-of-treatment injection drug users. Clinical trial registration number: NCT01416584.

A therapeutic workplace for the long-term treatment of drug addiction and unemployment: eight-year outcomes of a social business intervention

This study evaluated the long-term effects of a therapeutic workplace social business on drug abstinence and employment. Pregnant and postpartum women (N = 40) enrolled in methadone treatment were randomly assigned to a therapeutic workplace or usual care control group. Therapeutic workplace participants could work weekdays in training and then as employees of a social business, but were required to provide drug-free urine samples to work and maintain maximum pay. Three-year outcomes were reported previously. This paper reports 4- to 8-year outcomes. During year 4 when the business was open, therapeutic workplace participants provided significantly more cocaine- and opiate-negative urine samples than controls; reported more days employed, higher employment income, and less money spent on drugs. During the 3 years after the business closed, therapeutic workplace participants only reported higher income than controls. A therapeutic workplace social business can maintain long-term abstinence and employment, but additional intervention may be required to sustain effects.

Employment-based abstinence reinforcement promotes opiate and cocaine abstinence in out-of-treatment injection drug users

We examined the use of employment-based abstinence reinforcement in out-of-treatment injection drug users, in this secondary analysis of a previously reported trial. Participants (N = 33) could work in the therapeutic workplace, a model employment-based program for drug addiction, for 30 weeks and could earn approximately $10 per hr. During a 4-week induction, participants only had to work to earn pay. After induction, access to the workplace was contingent on enrollment in methadone treatment. After participants met the methadone contingency for 3 weeks, they had to provide opiate-negative urine samples to maintain maximum pay. After participants met those contingencies for 3 weeks, they had to provide opiate- and cocaine-negative urine samples to maintain maximum pay. The percentage of drug-negative urine samples remained stable until the abstinence reinforcement contingency for each drug was applied. The percentage of opiate- and cocaine-negative urine samples increased abruptly and significantly after the opiate- and cocaine-abstinence contingencies, respectively, were applied. These results demonstrate that the sequential administration of employment-based abstinence reinforcement can increase opiate and cocaine abstinence among out-of-treatment injection drug users.

Reduction of classroom noise levels using group contingencies

The therapeutic workplace is an employment-based abstinence reinforcement intervention for unemployed drug users where trainees receive on-the-job employment skills training in a classroom setting. The study is an extension of prior therapeutic workplace research, which suggested that trainees frequently violated noise standards. Participants received real-time graphed feedback of noise levels and had the opportunity to earn monetary group reinforcement for maintaining a low number of noise violations. Results suggested that feedback and monetary reinforcement reduced the number of noise violations.

Employment-based reinforcement of adherence to oral naltrexone in unemployed injection drug users: 12-month outcomes

Oral naltrexone could be a promising relapse-prevention pharmacotherapy for recently detoxified opioid-dependent patients; however, interventions are often needed to promote adherence with this treatment approach. We recently conducted a study to evaluate a 26-week employment-based reinforcement intervention of oral naltrexone in unemployed injection drug users (Dunn et al., 2013). Participants were randomly assigned into a contingency (n = 35) group required to ingest naltrexone under staff observation to gain entry into a therapeutic workplace or a prescription (n = 32) group given a take-home supply of oral naltrexone and access to the workplace without observed ingestion. Monthly urine samples were collected and analyzed for evidence for naltrexone adherence, opioid use, and cocaine use. As previously reported, contingency participants provided significantly more naltrexone-positive urine samples than prescription participants during the 26-week intervention period. The goal of this current study is to report the 12-month outcomes, which occurred 6 months after the intervention ended. Results at the 12-month visit showed no between-groups differences in naltrexone-positive, opioid-negative, or cocaine-negative urine samples and no participant self-reported using naltrexone at the follow-up visit. These results show that even after a period of successfully reinforced oral naltrexone adherence, longer-term naltrexone use is unlikely to be maintained after reinforcement contingencies are discontinued. (PsycINFO Database Record

Performance pay improves engagement, progress, and satisfaction in computer-based job skills training of low-income adults

Advancing the education of low-income adults could increase employment and income, but adult education programs have not successfully engaged low-income adults. Monetary reinforcement may be effective in promoting progress in adult education. This experiment evaluated the benefits of providing incentives for performance in a job-skills training program for low-income, unemployed adults. Participants worked on typing and keypad programs for 7 months. Participants randomly assigned to Group A (n = 23) earned hourly and productivity pay on the typing program (productivity pay), but earned only equalized hourly pay on the keypad program (hourly pay). Group B (n = 19) participants had the opposite contingencies. Participants worked more on, advanced further on, and preferred their productivity pay program. These results show that monetary incentives can increase performance in a job-skills training program, and indicate that payment in adult education programs should be delivered contingent on performance in the training program instead of simply on attendance.

Employment-based abstinence reinforcement following inpatient detoxification in HIV-positive opioid and/or cocaine-dependent patients

Employment-based reinforcement interventions have been used to promote abstinence from drugs among chronically unemployed injection drug users. The current study used an employment-based reinforcement intervention to promote opioid and cocaine abstinence among opioid and/or cocaine-dependent, HIV-positive participants who had recently completed a brief inpatient detoxification. Participants (n = 46) were randomly assigned to an abstinence and work group that was required to provide negative urine samples in order to enter the workplace and to earn incentives for work (n = 16), a work-only group that was permitted to enter the workplace and to earn incentives independent of drug use (n = 15), and a no-voucher control group that did not receive any incentives for working (n = 15) over a 26-week period. The primary outcome was urinalysis-confirmed opioid, cocaine, and combined opioid/cocaine abstinence. Participants were 78% male and 89% African American. Results showed no significant between-groups differences in urinalysis-verified drug abstinence or HIV risk behaviors during the 6-month intervention. The work-only group had significantly greater workplace attendance, and worked more minutes per day when compared to the no-voucher group. Several features of the study design, including the lack of an induction period, setting the threshold for entering the workplace too high by requiring immediate abstinence from several drugs, and increasing the risk of relapse by providing a brief detoxification that was not supported by any continued pharmacological intervention, likely prevented the workplace from becoming established as a reinforcer that could be used to promote drug abstinence. However, increases in workplace attendance have important implications for adult training programs.

Randomized clinical trial examining duration of voucher-based reinforcement therapy for cocaine abstinence

BACKGROUND

This is the first study to systematically manipulate duration of voucher-based reinforcement therapy (VBRT) to see if extending the duration increases abstinence during and following VBRT.

METHODS

We randomized cocaine-dependent methadone-maintained adults to Standard (12 weeks; n=62) or Extended (36 weeks; n=68) VBRT and provided escalating voucher amounts contingent upon urinalysis verification of cocaine abstinence. Urinalysis was scheduled at least every 2 weeks during the 48-week study and more frequently during VBRT (3/week) and 12 weeks of Aftercare (2/week).

RESULTS

Extended VBRT produced longer durations of continuous cocaine abstinence during weeks 1-24 (5.7 vs 2.7 weeks; p=0.003) and proportionally more abstinence during weeks 24-36 (X(2)=4.57, p=.03, OR=2.18) compared to Standard VBRT. Duration of VBRT did not directly predict after-VBRT abstinence; but longer continuous abstinence during VBRT predicted abstinence during Aftercare (p=0.001) and during the last 12 weeks of the study (p<0.001). Extended VBRT averaged higher monthly voucher costs compared to Standard VBRT ($96 vs $43, p<.001); however, the average cost per week of abstinence attained was higher in the Standard group ($8.06 vs $5.88, p<.001). Participants in the Extended group with voucher costs exceeding $25 monthly averaged 20 weeks of continuous abstinence.

CONCLUSIONS

Greater abstinence occurred during Extended VBRT, but providing a longer duration was not by itself sufficient to maintain abstinence after VBRT. However, if abstinence can be captured and sustained during VBRT, then providing longer durations may help increase the continuous abstinence that predicts better long-term outcomes.

Monetary incentives to reinforce engagement and achievement in a job-skills training program for homeless, unemployed adults

The current study examined whether monetary incentives could increase engagement and achievement in a job-skills training program for unemployed, homeless, alcohol-dependent adults. Participants (n=124) were randomized to a no-reinforcement group (n=39), during which access to the training program was provided but no incentives were given; a training reinforcement group (n=42), during which incentives were contingent on attendance and performance; or an abstinence and training reinforcement group (n=43), during which incentives were contingent on attendance and performance, but access was granted only if participants demonstrated abstinence from alcohol. abstinence and training reinforcement and training reinforcement participants advanced further in training and attended more hours than no-reinforcement participants. Monetary incentives were effective in promoting engagement and achievement in a job-skills training program for individuals who often do not take advantage of training programs.