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Shearer J, Metrebian N, Weaver T, Goldsmith K, Strang J, Pilling S, Mitcheson L, Day E, Dunn J, Glasper A, Akhtar S, Bajaria J, Charles V, Desai R, Haque F, Little N, McKechnie H, Mosler F, Mutz J, Poovendran D, Byford S. The Cost-Effectiveness of Financial Incentives to Achieve Heroin Abstinence in Individuals With Heroin Use Disorder Starting New Treatment Episodes: A Cluster Randomized Trial-Based Economic Evaluation. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2023; 26:658-665. [PMID: 36509367 DOI: 10.1016/j.jval.2022.11.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 09/14/2022] [Accepted: 11/17/2022] [Indexed: 05/03/2023]
Abstract
OBJECTIVES Cost-effectiveness analysis of two 12-week contingency management (CM) schedules targeting heroin abstinence or attendance at weekly keyworker appointments for opioid agonist treatment compared with treatment as usual (TAU). METHODS A cost-effectiveness analysis was conducted alongside a cluster randomized trial of 552 patients from 34 clusters (drug treatment clinics) randomly allocated 1:1:1 to opioid agonist treatment plus weekly keyworker appointments with (1) CM targeted at heroin abstinence (CM abstinence), (2) CM targeted at on-time attendance at weekly appointments (CM attendance), or (3) no CM (TAU). The primary cost-effectiveness analysis at 24 weeks after randomization took a societal cost perspective with effects measured in heroin-negative urine samples. RESULTS At 24 weeks, mean differences in weekly heroin-negative urine results compared with TAU were 0.252 (95% confidence interval [CI] -0.397 to 0.901) for CM abstinence and 0.089 (95% CI -0.223 to 0.402) for CM attendance. Mean differences in costs were £2562 (95% CI £32-£5092) for CM abstinence and £317 (95% CI -£882 to £1518) for CM attendance. Incremental cost-effectiveness ratios were £10 167 per additional heroin-free urine for CM abstinence and £3562 for CM attendance with low probabilities of cost-effectiveness of 3.5% and 36%, respectively. Results were sensitive to timing of follow-up for CM attendance, which dominated TAU (better outcomes, lower costs) at 12 weeks, with an 88.4% probability of being cost-effective. Probability of cost-effectiveness remained low for CM abstinence (8.6%). CONCLUSIONS Financial incentives targeted toward heroin abstinence and treatment attendance were not cost-effective over the 24-week follow-up. Nevertheless, CM attendance was cost-effective over the treatment period (12 weeks), when participants were receiving keyworker appointments and incentives.
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Affiliation(s)
- James Shearer
- King's Health Economics, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, England, UK.
| | - Nicola Metrebian
- Addictions Department, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, England, UK
| | - Tim Weaver
- Faculty of Health, Social Care and Education, Middlesex University, London, England, UK
| | - Kimberley Goldsmith
- Department of Biostatistics & Health Informatics, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, England, UK
| | - John Strang
- Addictions Department, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, England, UK
| | | | - Luke Mitcheson
- South London and Maudsley NHS Foundation Trust, London, England, UK
| | - Ed Day
- Institute for Mental Health, University of Birmingham, Birmingham, England, UK
| | - John Dunn
- Camden and Islington NHS Foundation Trust, London, England, UK
| | - Anthony Glasper
- Sussex Partnership NHS Foundation Trust, London, England, UK
| | - Shabana Akhtar
- Birmingham & Solihull Mental Health NHS Foundation Trust, London, England, UK
| | - Jalpa Bajaria
- CRN North West London, Imperial College Healthcare NHS Trust, London, England, UK
| | - Vikki Charles
- Addictions Department, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, England, UK
| | - Roopal Desai
- ADAPT Lab, Research Department of Clinical, Educational and Health Psychology, University College London, London, England, UK
| | - Farjana Haque
- National Addiction Centre, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, England, UK
| | | | | | - Franziska Mosler
- Unit for Social and Community Psychiatry, Queen Mary University of London, London, England, UK
| | - Julian Mutz
- Addictions Department, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, England, UK
| | - Dilkushi Poovendran
- Centre for Mental Health, Division of Brain Sciences, Imperial College London, London, England, UK
| | - Sarah Byford
- King's Health Economics, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, England, UK
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Metrebian N, Weaver T, Goldsmith K, Pilling S, Hellier J, Pickles A, Shearer J, Byford S, Mitcheson L, Bijral P, Bogdan N, Bowden-Jones O, Day E, Dunn J, Glasper A, Finch E, Forshall S, Akhtar S, Bajaria J, Bennett C, Bishop E, Charles V, Davey C, Desai R, Goodfellow C, Haque F, Little N, McKechnie H, Mosler F, Morris J, Mutz J, Pauli R, Poovendran D, Phillips E, Strang J. Using a pragmatically adapted, low-cost contingency management intervention to promote heroin abstinence in individuals undergoing treatment for heroin use disorder in UK drug services (PRAISE): a cluster randomised trial. BMJ Open 2021; 11:e046371. [PMID: 34210725 PMCID: PMC8252884 DOI: 10.1136/bmjopen-2020-046371] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
INTRODUCTION Most individuals treated for heroin use disorder receive opioid agonist treatment (OAT)(methadone or buprenorphine). However, OAT is associated with high attrition and persistent, occasional heroin use. There is some evidence for the effectiveness of contingency management (CM), a behavioural intervention involving modest financial incentives, in encouraging drug abstinence when applied adjunctively with OAT. UK drug services have a minimal track record of applying CM and limited resources to implement it. We assessed a CM intervention pragmatically adapted for ease of implementation in UK drug services to promote heroin abstinence among individuals receiving OAT. DESIGN Cluster randomised controlled trial. SETTING AND PARTICIPANTS 552 adults with heroin use disorder (target 660) enrolled from 34 clusters (drug treatment clinics) in England between November 2012 and October 2015. INTERVENTIONS Clusters were randomly allocated 1:1:1 to OAT plus 12× weekly appointments with: (1) CM targeted at opiate abstinence at appointments (CM Abstinence); (2) CM targeted at on-time attendance at appointments (CM Attendance); or (3) no CM (treatment as usual; TAU). Modifications included monitoring behaviour weekly and fixed incentives schedule. MEASUREMENTS Primary outcome: heroin abstinence measured by heroin-free urines (weeks 9-12). SECONDARY OUTCOMES heroin abstinence 12 weeks after discontinuation of CM (weeks 21-24); attendance; self-reported drug use, physical and mental health. RESULTS CM Attendance was superior to TAU in encouraging heroin abstinence. Odds of a heroin-negative urine in weeks 9-12 was statistically significantly greater in CM Attendance compared with TAU (OR=2.1; 95% CI 1.1 to 3.9; p=0.030). CM Abstinence was not superior to TAU (OR=1.6; 95% CI 0.9 to 3.0; p=0.146) or CM Attendance (OR=1.3; 95% CI 0.7 to 2.4; p=0.438) (not statistically significant differences). Reductions in heroin use were not sustained at 21-24 weeks. No differences between groups in self-reported heroin use. CONCLUSIONS A pragmatically adapted CM intervention for routine use in UK drug services was moderately effective in encouraging heroin abstinence compared with no CM only when targeted at attendance. CM targeted at abstinence was not effective. TRIAL REGISTRATION NUMBER ISRCTN 01591254.
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Affiliation(s)
- Nicola Metrebian
- Addictions, King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Tim Weaver
- Department of Mental Health & Social Work, Middlesex University, London, UK
| | - Kimberley Goldsmith
- Biostatistics and Health Informatics, King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Stephen Pilling
- Centre for Outcomes, Research and Effectiveness, University College London, London, UK
| | - Jennifer Hellier
- Biostatistics and Health Informatics, King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Andrew Pickles
- Biostatistics and Health Informatics, King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - James Shearer
- Health Services and Population Research, King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Sarah Byford
- Health Services and Population Research, King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Luke Mitcheson
- Addictions, South London and Maudsley NHS Foundation Trust, London, UK
| | - Prun Bijral
- Management Offices, Change Grow Live, Manchester, UK
| | - Nadine Bogdan
- Sankey House, Essex Partnership University NHS Foundation Trust, Pitsea,Essex, UK
| | - Owen Bowden-Jones
- Addictions and Substance Misuse, Central and North West London NHS Foundation Trust, London, UK
| | - Edward Day
- Addiction Services, Birmingham and Solihull Mental Health NHS Foundation Trust, Birmingham, UK
| | - John Dunn
- Drugs and Alcohol Services, Camden and Islington NHS Foundation Trust, London, UK
| | - Anthony Glasper
- Substancce Misuse Service, Sussex Partnership NHS Foundation Trust, Worthing, UK
| | - Emily Finch
- Addictions, South London and Maudsley NHS Foundation Trust, London, UK
| | - Sam Forshall
- Drug and Alcohol Services, Avon and Wiltshire Mental Health Partnership NHS Trust, Bath, UK
| | - Shabana Akhtar
- Addiction Services, Birmingham and Solihull Mental Health NHS Foundation Trust, Birmingham, UK
| | - Jalpa Bajaria
- Sankey House, Essex Partnership University NHS Foundation Trust, Pitsea,Essex, UK
| | - Carmel Bennett
- Addiction Services, Birmingham and Solihull Mental Health NHS Foundation Trust, Birmingham, UK
| | - Elizabeth Bishop
- Centre for Outcomes, Research and Effectiveness, University College London, London, UK
| | - Vikki Charles
- Addictions, King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Clare Davey
- Drug and Alcohol Services, Avon and Wiltshire Mental Health Partnership NHS Trust, Bath, UK
| | - Roopal Desai
- Addictions, King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Claire Goodfellow
- Centre for Outcomes, Research and Effectiveness, University College London, London, UK
| | - Farjana Haque
- Addictions, King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Nicholas Little
- Centre for Outcomes, Research and Effectiveness, University College London, London, UK
| | - Hortencia McKechnie
- Addictions, King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
- Centre for Mental Health, Imperial College London, London, UK
| | - Franziska Mosler
- Addictions, King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Jo Morris
- Drug and Alcohol Services, Avon and Wiltshire Mental Health Partnership NHS Trust, Bath, UK
| | - Julian Mutz
- Addictions, King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Ruth Pauli
- Addiction Services, Birmingham and Solihull Mental Health NHS Foundation Trust, Birmingham, UK
| | | | - Elizabeth Phillips
- Sankey House, Essex Partnership University NHS Foundation Trust, Pitsea,Essex, UK
| | - John Strang
- Addictions, King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
- Addictions, South London and Maudsley NHS Foundation Trust, London, UK
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Telephone delivered incentives for encouraging adherence to supervised methadone consumption (TIES): Study protocol for a feasibility study for an RCT of clinical and cost effectiveness. Contemp Clin Trials Commun 2020; 17:100506. [PMID: 31909291 PMCID: PMC6938936 DOI: 10.1016/j.conctc.2019.100506] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 11/18/2019] [Accepted: 12/07/2019] [Indexed: 02/02/2023] Open
Abstract
The majority of people receiving treatment for their heroin addiction, are prescribed methadone; for which there is an extensive evidence base. When treatment starts, people take their daily dose of methadone under supervision at a community pharmacy. Supervision guarantees methadone is taken as directed by the individual for whom it has been prescribed, helps to ensure individuals take their correct dose every day, and safeguards against diversion and overdose. However, individuals often fail to attend the pharmacy to take their methadone. Each missed dose is of concern. If a patient misses their daily dose of methadone, they will start to experience opiate withdrawal and cravings and are more likely to use heroin. If they miss three days dose, there are concerns that they may lose tolerance to the drug and may be at risk of overdose when the next dose is taken. Hence there is an urgent need to develop effective interventions for medication adherence. Research suggests that incentive-based medication adherence interventions may be very effective, but there are few controlled trials and the provision of incentives requires time and organisational systems which can be challenging in pharmacies. The investigators have developed the technology to deliver incentives by mobile telephone. This cluster randomised trial will test the feasibility of conducting a future trial evaluating the clinical and cost effectiveness of using telephone delivered incentives (praise and modest financial rewards via text messaging) to encourage adherence with supervised consumption of methadone in community pharmacies. Three drug services (each with two or three community pharmacies supervising methadone consumption that will enrol 20 individuals, a total of 60 participants) will be recruited and randomly allocated to deliver either i) telephone delivered incentives, ii) telephone delivered reminders or iii) no telephone system. Acceptability, recruitment, follow-up, and suitable measures of clinical and cost effectiveness will be assessed. Findings from this feasibility study will be assessed against stated progression criteria and used to inform a future confirmatory trial of the clinical and cost effectiveness of telephone delivered incentives to encourage medication adherence. Trial registration ISRCTN58958179 (retrospectively registered).
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