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.

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.

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.

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.

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.

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.

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) 2022 APA, all rights reserved).

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.

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.

Employment outcomes of substance use disorder patients enrolled in a therapeutic workplace intervention for drug abstinence and employment.

Poverty is common among people who have substance use disorder. The therapeutic workplace addresses some of the interrelated and chronic problems of poverty, such as unemployment, lack of education and job skills, and drug use. A prior controlled trial showed that the therapeutic workplace was effective in promoting drug abstinence and self-reported community employment in unemployed adults in medication-assisted treatment for opioid use disorder. The current study extends this research by providing a detailed and objective analysis of employment outcomes using objective data abstracted from participants' pay stubs. Secondary analyses examined the types and patterns of employment that participants (N = 44) obtained during the trial, and the extent to which participants gained and maintained financially sufficient employment. Although most participants had relatively long histories of unemployment and underemployment, many participants (n = 26; 59%) obtained employment at some point during the intervention. Most participants worked part time and were employed in low-wage jobs, however. The mean number of hours worked per week was 20.6 h (range 5.5 to 41.3 h per week) and the mean hourly pay was $11.00 per hour (range $9.00 to $15.50 per hour). The most common type of employment was in food preparation and serving-related occupations (e.g., waiters and waitresses, restaurant cooks, and fast food counter workers). Many participants (n = 17; 65%) maintained employment in these jobs over several weeks, while others (n = 9; 35%) were employed sporadically for short durations. Additional supports may be needed for some chronically unemployed adults with substance use disorder to promote consistent employment in well-paying jobs.

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 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.

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.

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.

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.