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

Risky Sexual Practices, Sexually Transmitted Infections, Motivations, and Mental Health among Heterosexual Women and Men Who Practice Sexualized Drug Use in Spain

Sexualized drug use (SDU) has been poorly studied among heterosexuals. The purpose of the present study was to analyze the prevalence of and gender differences in types of substances, risky sexual practices, sexually transmitted infections (STIs), motivations, and psychological adjustment among heterosexual women and men who engage in SDU. The study sample consisted of 1181 heterosexuals (795 women) between 18 and 78 years old (mean age = 24.4, SD = 7.4). Approximately 12% of the participants had engaged in SDU. No differences were found in the prevalence of SDU between men and women. Alcohol, cannabis, and 3,4-methylenedioxy-methamphetamine (MDMA) were the substances most frequently used for sexual purposes. Men were significantly more likely to use MDMA, ecstasy, cocaine, and erectile dysfunction (ED) drugs, and they tended to have more sexual partners than women. Likewise, SDU was related to have more sexual partners, penetrative sex without a condom, practice a fetish, be diagnosed with syphilis, chlamydia, and others STIs, and present more depression symptoms (but not with more anxiety). In conclusion, SDU was associated with poorer physical and mental health. It is, therefore, necessary to design programs aimed at reducing the incidence of the consequences of SDU on the physical and mental health of both men and women. Moreover, programs that seek to understand why these individuals engage in SDU should be undertaken.

Comparison of Treatments for Cocaine Use Disorder Among Adults: A Systematic Review and Meta-analysis

IMPORTANCE

In the US and the United Kingdom, cocaine use is the second leading cause of illicit drug overdose death. Psychosocial treatments for cocaine use disorder are limited, and no pharmacotherapy is approved for use in the US or Europe.

OBJECTIVE

To compare treatments for active cocaine use among adults.

DATA SOURCES

PubMed and the Cochrane Database of Systematic Reviews were searched for clinical trials published between December 31, 1995, and December 31, 2017.

STUDY SELECTION

This meta-analysis was registered on Covidence.org (study 8731) on December 31, 2015. Clinical trials were included if they (1) had the term cocaine in the article title; (2) were published between December 31, 1995, and December 31, 2017; (3) were written in English; (4) enrolled outpatients 18 years or older with active cocaine use at baseline; and (5) reported treatment group size, treatment duration, retention rates, and urinalysis results for the presence of cocaine metabolites. A study was excluded if (1) more than 25% of participants were not active cocaine users or more than 80% of participants had negative test results for the presence of cocaine metabolites at baseline and (2) it reported only pooled urinalysis results indicating the presence of multiple substances and did not report the specific proportion of positive test results for cocaine metabolites. Multiple reviewers reached criteria consensus. Of 831 records screened, 157 studies (18.9%) met selection criteria and were included in the analysis.

DATA EXTRACTION AND SYNTHESIS

This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guideline. Search results were imported from PubMed XML into Covidence.org then Microsoft Excel. Data extraction was completed in 2 iterations to ensure fidelity. Analyses included a multilevel random-effects model, a multilevel mixed-effects meta-regression model, and sensitivity analyses. Treatments were clustered into 11 categories (psychotherapy, contingency management programs, placebo, opioids, psychostimulants, anticonvulsants, dopamine agonists, antidepressants, antipsychotics, miscellaneous medications, and other therapies). Missing data were imputed using multiple imputation by chained equations. The significance threshold for all analyses was P = .05. Data were analyzed using the metafor and mice packages in R software, version 3.3.2 (R Foundation for Statistical Computing). Data were analyzed from January 1, 2018, to February 28, 2021.

MAIN OUTCOMES AND MEASURES

The primary outcome was the intention-to-treat logarithm of the odds ratio (OR) of having a negative urinalysis result for the presence of cocaine metabolites at the end of each treatment period compared with baseline. The hypothesis, which was formulated after data collection, was that no treatment category would have a significant association with objective reductions in cocaine use.

RESULTS

A total of 157 studies comprising 402 treatment groups and 15 842 participants were included. Excluding other therapies, the largest treatment groups across all studies were psychotherapy (mean [SD] number of participants, 40.04 [36.88]) and contingency management programs (mean [SD] number of participants, 37.51 [25.51]). Only contingency management programs were significantly associated with an increased likelihood of having a negative test result for the presence of cocaine (OR, 2.13; 95% CI, 1.62-2.80), and this association remained significant in all sensitivity analyses.

CONCLUSIONS AND RELEVANCE

In this meta-analysis, contingency management programs were associated with reductions in cocaine use among adults. Research efforts and policies that align with this treatment modality may benefit those who actively use cocaine and attenuate societal burdens.

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.

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.

Review of Individual Placement and Support Employment Intervention for Persons with Substance Use Disorder

Objectives: Work is a critical part of recovery for many people with chronic health conditions, including Substance Use Disorders (SUD). Individual Placement and Support (IPS) is an evidence-based practice designed initially for adults with mental illness. Although the evidence for using IPS with individuals with severe mental illness is well documented, less is known about the efficacy of using IPS with consumers with substance use disorders, and the results have yet to be systematically evaluated and organized. Key components of zero exclusion, rapid competitive job search, and incorporation with treatment services as well as benefits are components that make IPS a strong practice to incorporate into substance abuse treatment. This study aims to evaluate and organize the evidence base of using IPS with adults with substance use disorders. Results: A systematic review was conducted of meta-analyses, reviews, and individual studies from 2000 through 2019, measuring the efficacy of IPS with individuals with SUD or comorbid SUD. Databases searched were Scopus, PubMed, and PsychInfo. Experimental and quasi-experimental studies are reviewed and critiqued for their application to a SUD population. Then, barriers and facilitators of IPS implementation with this population are discussed. Conclusions/Importance: There is a high evidence to support to application of IPS for persons with SUD, both singly and when combined with a mental health disorder. Barriers to IPS implementation including episodic treatment, risk of relapse, and housing or criminal justice instability make the IPS program a useful best practice to consider for this population.

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.

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).

A Randomized Controlled Trial of Ethyl Glucuronide-Based Contingency Management for Outpatients With Co-Occurring Alcohol Use Disorders and Serious Mental Illness

OBJECTIVE

The authors examined whether a contingency management intervention using the ethyl glucuronide (EtG) alcohol biomarker resulted in increased alcohol abstinence in outpatients with co-occurring serious mental illnesses. Secondary objectives were to determine whether contingency management was associated with changes in heavy drinking, treatment attendance, drug use, cigarette smoking, psychiatric symptoms, and HIV-risk behavior.

METHOD

Seventy-nine (37% female, 44% nonwhite) outpatients with serious mental illness and alcohol dependence receiving treatment as usual completed a 4-week observation period and were randomly assigned to 12 weeks of contingency management for EtG-negative urine samples and addiction treatment attendance, or reinforcement only for study participation. Contingency management included the variable magnitude of reinforcement "prize draw" procedure contingent on EtG-negative samples (<150 ng/mL) three times a week and weekly gift cards for outpatient treatment attendance. Urine EtG, drug test, and self-report outcomes were assessed during the 12-week intervention and 3-month follow-up periods.

RESULTS

Contingency management participants were 3.1 times (95% CI=2.2-4.5) more likely to submit an EtG-negative urine test during the 12-week intervention period, attaining nearly 1.5 weeks of additional alcohol abstinence compared with controls. Contingency management participants had significantly lower mean EtG levels, reported less drinking and fewer heavy drinking episodes, and were more likely to submit stimulant-negative urine and smoking-negative breath samples, compared with controls. Differences in self-reported alcohol use were maintained at the 3-month follow-up.

CONCLUSIONS

This is the first randomized trial utilizing an accurate and validated biomarker (EtG) to demonstrate the efficacy of contingency management for alcohol dependence in outpatients with serious mental illness.

A review of the literature on contingency management in the treatment of substance use disorders, 2009-2014

This report describes a systematic literature review of voucher and related monetary-based contingency management (CM) interventions for substance use disorders (SUDs) over 5.2years (November 2009 through December 2014). Reports were identified using the search engine PubMed, expert consultations, and published bibliographies. For inclusion, reports had to (a) involve monetary-based CM; (b) appear in a peer-reviewed journal; (c) include an experimental comparison condition; (d) describe an original study; (e) assess efficacy using inferential statistics; (f) use a research design allowing treatment effects to be attributed to CM. Sixty-nine reports met inclusion criteria and were categorized into 7 research trends: (1) extending CM to special populations, (2) parametric studies, (3) extending CM to community clinics, (4) combining CM with pharmacotherapies, (5) incorporating technology into CM, (6) investigating longer-term outcomes, (7) using CM as a research tool. The vast majority (59/69, 86%) of studies reported significant (p<0.05) during-treatment effects. Twenty-eight (28/59, 47%) of those studies included at least one follow-up visit after CM was discontinued, with eight (8/28, 29%) reporting significant (p<0.05) effects. Average effect size (Cohen's d) during treatment was 0.62 (95% CI: 0.54, 0.70) and post-treatment it was 0.26 (95% CI: 0.11, 0.41). Overall, the literature on voucher-based CM over the past 5years documents sustained growth, high treatment efficacy, moderate to large effect sizes during treatment that weaken but remain evident following treatment termination, and breadth across a diverse set of SUDs, populations, and settings consistent with and extending results from prior reviews.

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 (rs = .72, p <.001) correlated. For Abstinence & Work participants, baseline opiate abstinence was significantly correlated (rs = .59, p <.001) and workplace attendance was marginally correlated (rs = .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.

Novel interventions to prevent HIV and HCV among persons who inject drugs

Persons who inject drugs (PWID) are at high risk for infection with and poor outcomes from HIV and hepatitis C virus (HCV). Well-established interventions for HIV/HCV prevention among PWID include syringe access, opioid agonist maintenance treatment, and supervised injection facilities, yet these interventions remain unavailable or inadequately resourced in much of the world. We review recent literature on biomedical and behavioral interventions to reduce the burden of HIV/HCV among PWID, with an emphasis on randomized controlled trials and quasi-experimental studies. Since 2013, there have been significant advancements in utilizing antiviral therapy and behavioral interventions for prevention among PWID, including approaches that address the unique needs of couples and sex workers. In addition, there have been significant developments in pharmacotherapies for substance use and the implementation of naloxone for opioid overdose prevention. Notwithstanding multiple ongoing structural challenges in delivering HIV/HCV prevention interventions to PWID, these emerging and rigorously evaluated interventions expand possibilities for prevention among PWID.

Behavior change, health, and health disparities: an introduction

This Special Issue of Preventive Medicine (PM) focuses on behavior change, health, and health disparities, topics of fundamental importance to improving population health in the U.S. and other industrialized countries. While the U.S. health care system and those of other industrialized countries were developed to manage infectious disease and acute illnesses, it is chronic health conditions that most need to be understood and managed in the 21st century. The evidence is clear that personal behavior patterns like cigarette smoking and physical inactivity/obesity are critically important proximal causes of chronic disease (cardiovascular disease, site-specific cancers, type-2 diabetes) and as such behavior change will need to be a key component of their management. As the outstanding contributions to this Special Issue illustrate, substantial headway is being made in advancing knowledge including developing effective prevention and treatment strategies, with cigarette smoking being an excellent example that change is possible. That said, cigarette smoking continues to be responsible for approximately 480,000 premature deaths annually in the U.S. alone and 5 million globally. So more needs to be done, especially in economically disadvantaged populations. The same certainly applies to the challenges of the obesity epidemic, which of course is a more recent problem and understandably efforts to curtail it are in earlier stages of development.

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.