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.

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.