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.

BACKGROUND:Alcohol use disorder, unemployment, and risk of homelessness are linked and often co-occurring, but most interventions do not address both alcohol use disorder and unemployment. The Abstinence-Contingent Wage Supplement (ACWS) model of the Therapeutic Workplace offers participants stipends or wage supplements contingent on both their abstaining from alcohol and engaging with an employment specialist or working in a community job. Wearable biosensors continuously tracked alcohol use. METHODS AND DATA:The study randomized participants to Usual Care (UC) (n = 57) and ACWS (n = 62). We used micro-costing methods to identify the resources and costs of the 6-month ACWS intervention. The study team tracked the cost of incentives for wearing biosensors, stipends, and wage supplements. We used 6-month cost and effectiveness data to calculate incremental cost-effectiveness ratios and cost-effectiveness acceptability curves. RESULTS:Over the 6-month study period, average intervention costs per participant were $7282, with contingent stipends and wage supplements accounting for 50 % of intervention costs. We also reported average per participant costs for healthcare (UC: $17,785; ACWS: $26,734), justice system (UC: $131; ACWS: $153), and public welfare (UC: $1107; ACWS: $1275). The incremental cost-effectiveness ratios (ICERs) at 6 months were $80,911 for an additional participant abstinent, $3894 for an additional drinking free day, $22,756 for an additional participant employed, and $1514 for an additional day worked. CONCLUSIONS:The ACWS intervention for adults with an alcohol use disorder and experiencing homelessness increased costs and improved alcohol use and employment outcomes compared with Usual Care. For policymakers seeking a solution to alcohol use and unemployment with populations experiencing homelessness, ACWS may be a cost-effective solution.

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

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.

Abstract Contingency Management (CM) is an effective, evidence-based approach for the treatment of substance use disorder, including opioid use disorder (OUD). CM interventions derive from the operant behavior perspective of psychology and have an extensive theoretical, laboratory, and clinical foundation that laid the foundation for development of CM interventions to treat substance use disorder. Hundreds of studies, including controlled trials, systematic reviews,5,8 and meta-analyses have shown CM interventions to be a highly effective treatment for substance use disorder, particularly when used for OUD. This chapter reviews the underlying foundation for CM and a brief history of its use for the treatment of OUD. We then review the use of CM in opioid agonist treatment for promoting abstinence from opioids, cocaine, cigarettes, and other substances in persons who are using opioids, as well as its use in withdrawal settings and to promote behaviors other than abstinence, such as treatment engagement or retention and vocational training.

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.

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).

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.

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 Sup-plement (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 in-cremental 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.

OBJECTIVE To evaluate the feasibility and potential efficacy of a technology-assisted education program in teaching adults at a high risk of opioid overdose about opioids; opioid overdose; and opioid use disorder medications. METHOD A within-subject, repeated-measures design was used to evaluate effects of the novel technology-assisted education program. Participants (N = 40) were out-of-treatment adults with opioid use disorder, recruited in Baltimore, Maryland from May 2019 to January 2020. The education program was self-paced and contained three courses. Each course presented information and required answers to multiple-choice questions. The education program was evaluated using a 50-item test, delivered before and after participants completed each course. Tests were divided into three subtests that contained questions from each course. We measured accuracy on each subtest before and after completion of each course and used a mixed-effects model to analyze changes in accuracy across tests. RESULTS The technology-assisted education program required a median time of 91 min of activity to complete. Most participants completed the program in a single day. Accuracy on each subtest increased only after completion of the course that corresponded to that subtest, and learning comparisons were significant at the p < .001 level for all subtests. Accuracy on each subtest was unchanged before completion of the relevant course, and increases in accuracy were retained across subsequent tests. Learning occurred similarly independent of participant education, employment, and poverty. CONCLUSIONS Technology-assisted education programs can provide at-risk adults with access to effective education on opioids, opioid overdose, and opioid use disorder medications. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

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.

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.

Poverty presents a profound burden on health. Financial incentives can shape behavior to benefit individuals living in poverty and to benefit society. As current research shows, large-scale wage supplement programs (i.e., those that provide cash assistance for working) can sometimes increase employment, but tend not to address health problems like addiction. As proof of concept, the Therapeutic Workplace intervention treated addiction, increased employment, and reduced poverty in adults with long-term unemployment and opioid use disorder. The Therapeutic Workplace also developed academic skills, encouraged job readiness, enhanced engagement with employment services, and improved mood and quality of life. Granted, in this and similar trials, some participants did not become employed and many relapsed to drug use or were unemployed after the intervention ended. Continued battles in the war on poverty include identifying evidence-based methods to promote steady employment in high-wage jobs and maintaining positive health outcomes long term.

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.