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.

Psychosocial Interventions to Promote Undetectable HIV Viral Loads: A Systematic Review of Randomized Clinical Trials.

Suppressing HIV viral loads to undetectable levels is essential for ending the HIV/AIDS epidemic. We evaluated randomized controlled trials aimed to increase antiretroviral medication adherence and promote undetectable viral loads among people living with HIV through November 22, 2019. We extracted data from 51 eligible interventions and analyzed the results using random effects models to compare intervention effects between groups within each intervention and across interventions. We also evaluated the relation between publication date and treatment effects. Only five interventions increased undetectable viral loads significantly. As a whole, the analyzed interventions were superior to Standard of Care in promoting undetectable viral loads. Interventions published more recently were not more effective in promoting undetectable viral loads. No treatment category consistently produced significant increases in undetectable viral loads. To end the HIV/AIDS epidemic, we should use interventions that can suppress HIV viral loads to undetectable levels.

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.

Increased Reinforcer Immediacy can Promote Employment-Seeking in Unemployed Homeless Adults with Alcohol Use Disorder.

Unemployment, homelessness, and substance use are interrelated. The present study took place as part of a clinical trial aimed to promote employment and abstinence from alcohol in unemployed, homeless adults with alcohol use disorders. Participants earned abstinence-contingent financial incentives for completing employment-seeking activities and hourly stipends for working with an employment specialist. In the initial condition, participants were paid all earnings on Bi-Monthly intervals. Despite the availability of incentives for completing employment-seeking activities, participants completed activities at low rates. A multiple-baseline across participants was used to evaluate the effect of providing pay every day for completing employment-seeking activities. Daily pay increased rates of completing activities for all three participants. Results suggest that reinforcer immediacy can be an important parameter in the control of employment-seeking activities.

Evaluation of a Computer-Based HIV Education Program for Adults Living with HIV.

This study evaluated a computer-delivered HIV and antiretroviral treatment education program in adults (N = 102) living with detectable HIV viral loads (> 200 copies/mL). The self-paced program provided immediate feedback for responses and financial incentives for responding correctly. The program was divided into three courses and a test of content from all three courses was delivered before and after participants completed each course. Test scores on the content delivered in Courses 1, 2 and 3 improved only after participants completed training on the relevant course. Initial test scores were positively correlated with health literacy and academic achievement; were negatively correlated with viral load; and were lowest for participants living in poverty. Education, academic achievement, and health literacy were related to how much participants learned following each course. Computer-based education is a convenient, effective approach to promoting an understanding of HIV and its treatment.

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.

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.

Earning, Spending, and Drug Use in a Therapeutic Workplace.

Drug addiction is a chronic, relapsing health problem that is associated with the degree to which individuals choose small, immediate monetary outcomes over larger, delayed outcomes. This study was a secondary analysis exploring the relation between financial choices and drug use in opioid-dependent adults in a therapeutic workplace intervention. Sixty-seven participants were randomly assigned to a condition in which access to paid job training was contingent upon naltrexone adherence (N = 35) or independent of naltrexone adherence (N = 32). Participants could earn approximately $10 per hour for 4 hours every weekday and could exchange earnings for gift cards or bill payments each weekday. Urine was collected and tested for opiates and cocaine thrice weekly. Participants' earning, spending, and drug use were not related to measures of delay discounting obtained prior to the intervention. When financial choices were categorized based on drug use during the intervention, however, those with less frequent drug use or frequent use of one drug spent a smaller proportion of their daily earnings and maintained a higher daily balance than those who frequently tested positive for both drugs (i.e., opiates and cocaine). Several patterns described the relation between cumulative earning and spending including no saving, periods of saving, and sustained saving. One destructive effect of drug use may be that it creates a perpetual zero-balance situation in the lives of users, which in turn prevents them from gaining materials that could help to break the cycle of addiction.

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.

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.

Differences in extinction of cue-maintained conditioned responses associated with self-administration: alcohol versus a nonalcoholic reinforcer.

BACKGROUND: Stimuli paired with alcohol may evoke conditioned responses that influence consumption and relapse. Understanding extinction of conditioned responses for both alcohol and nonalcoholic reinforcers, and their relation to subsequent consumption, may be useful in identifying methods to maintain abstinence. METHODS: Nine baboons self-administered alcohol (n = 4) or a nonalcoholic reinforcer (orange-flavored Tang(®) , n = 5) under a 3-component chained schedule of reinforcement (CSR). Each component was associated with distinct stimuli and response requirements, which modeled periods of anticipation (Component 1), seeking (Component 2), and consumption (Component 3). No behavioral contingencies were in effect during Component 1. Responses in Component 2, required to gain access to Component 3, provided indices of seeking behavior. Alcohol or Tang® was available only in Component 3. Initial conditions parametrically manipulated the concentration of alcohol (2 to 6% w/v) or Tang (25 to 100%) that was available for self-administration. The breaking point (BP) of alcohol- and Tang-seeking responses at each of the concentrations was determined by adding a progressive ratio schedule to Component 2. Extinction of responding under stimulus conditions identical to those during baseline, but with no access to alcohol or Tang, was examined using across- and within-session extinction procedures. RESULTS: The BP for 2% w/v alcohol was lower than that for 4 and 6%, which were closely similar. For Tang, BPs increased as the concentration increased. When concentrations of alcohol and Tang were adjusted to produce comparable BPs, self-administration of Tang was higher when compared to alcohol; however, alcohol-related cues maintained higher BPs than Tang-related cues when only water was available for self-administration. Alcohol seeking and self-administration responses were more resistant to extinction than those for Tang. CONCLUSIONS: Stimuli paired with alcohol or nonalcoholic reinforcers will gain different motivational properties. Alcohol-related stimuli produced persistent responding that was highly resistant to change, highlighting the role of environmental stimuli in compulsive drinking and relapse.

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.

Latent factor structure of behavioral economic heroin and cocaine demand curves.

Research has shown that behavioral economic demand curve indices can be characterized by a two-factor latent structure and that these factors can predict dimensions of substance use. No study to date has examined the latent factor structure of heroin and cocaine demand curves. The objective of this study was to use exploratory factor analysis to examine the underlying factor structure of the facets of heroin and cocaine reinforcement derived from heroin and cocaine demand curves. Participants were 143 patients from two samples that met the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5; American Psychiatric Association [APA], 2013) criteria for opioid dependance and were undergoing medication-assisted treatment (methadone or buprenorphine). Heroin and cocaine demand curves were generated via hypothetical purchase tasks (HPT) that assessed consumption at 9 or 17 levels of prices from $0 to $500. Five facets of demand were generated from the tasks (Q0, 1/α, Pmax, Omax, and break point). Principal components analysis was used to examine the latent structure among the variables. The results revealed a two-factor solution for both heroin and cocaine demand. These factors were interpreted as persistence, consisting of 1/α, Pmax, Omax, and break point, and amplitude, consisting of Q0 and Omax, and in one case, 1/α. Heroin factors had some predictive power for future substance use, but cocaine factors did not. These findings suggest that heroin and cocaine demand indices can be reduced to two factors indicating sensitivity and volume of consumption, and that these factors may be able to predict substance use for heroin. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

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.

GABAB Receptors and Alcohol Use Disorders: Preclinical Studies.

Preclinical research over the past several decades has demonstrated a role for the γ-aminobutyric acidB (GABAB) receptor in alcohol use disorder (AUD). This chapter offers an examination of preclinical evidence on the role of the GABAB receptor on alcohol-related behaviors with a particular focus on the GABAB receptor agonist baclofen, for which effects have been most extensively studied, and positive allosteric modulators (PAMs) of the GABAB receptor. Studies employing rodent and non-human primate models have shown that activation of the GABAB receptor can reduce (1) stimulating and rewarding effects of alcohol; (2) signs of alcohol withdrawal in rats made physically dependent on alcohol; (3) acquisition and maintenance of alcohol drinking under a two-bottle alcohol versus water choice procedure; (4) alcohol intake under oral operant self-administration procedures; (5) motivational properties of alcohol measured using extinction and progressive ratio procedures; (6) the increase in alcohol intake after a period of alcohol abstinence (the alcohol deprivation effect or ADE); and (7) the ability of alcohol cues and stress to reinstate alcohol seeking when alcohol is no longer available. Baclofen and GABAB PAMs reduce the abovementioned behaviors across different preclinical models, which provides strong evidence for a significant role of the GABAB receptor in alcohol-related behaviors and supports development of medications targeting GABAB receptors for the treatment of AUD. This chapter highlights the value of examining mechanisms of alcohol-related behaviors across multiple animal models to increase the confidence in identification of new therapeutic targets.

The aversiveness of timeout from response-dependent and response-independent food deliveries as a function of delivery rate.

Seven experiments with rats assessed the aversiveness of timeout using punishment and avoidance procedures. Experiments 1 and 2 considered the contributions of stimulus change, suspending the response-reinforcer contingency, response prevention, the general disruption in the reinforcement schedule during time-in, and overall decreases in reinforcement. Results support the conclusion that response-contingent timeouts punish behavior because they are signaled periods during which an ongoing schedule of positive reinforcement is suspended. Experiments 3, 4, and 5 assessed effects of the reinforcement rate during time-in on the punitive efficacy of timeout and, for comparison, electric shock. Evidence for a direct relation between reinforcement rate and punitive efficacy was equivocal. In Experiments 6 and 7, responding avoided timeout from response-independent food deliveries. Responding was acquired rapidly when it avoided timeouts from free deliveries of pellets or a sucrose solution, but not when it avoided free deliveries of water. At steady-state, avoidance rates and proficiency were directly related to the rate of pellet or sucrose deliveries. The relation between the nature of the time-in environment and the aversiveness of timeout was clear in our avoidance experiments, but not in our punishment experiments. We discuss interpretive problems in evaluating the aversiveness of timeout in the punishment paradigm.

Practical Technology for Expanding and Improving Substance Use Disorder Treatment: Telehealth, Remote Monitoring, and Digital Health Interventions.

The US opioid crisis and the COVID-19 pandemic have sparked innovation in substance use disorder (SUD) treatment such that telehealth, remote monitoring, and digital health interventions are increasingly feasible and effective. These technologies can increase SUD treatment access and acceptability, even for nontreatment seeking, remote, and underserved populations, and can be used to reduce health disparities. Overall, digital tools will likely overcome many barriers to delivery of evidence-based behavioral treatments such as cognitive behavioral therapy and contingency management, that, along with appropriate medications, constitute the foundation of treatment of SUDs.

Abstinence-contingent wage supplements to promote drug abstinence and employment: Post-intervention outcomes.

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.