Alcohol use disorder, unemployment, and homelessness are interrelated problems that are concentrated among people living in poverty. A recent clinical trial evaluating an employment-based contingency management intervention called abstinence-contingent wage supplements (ACWS) found that ACWS promoted alcohol abstinence, increased employment, and reduced poverty among unemployed adults experiencing homelessness and alcohol use disorder. This secondary analysis evaluated employment and poverty outcomes during the intervention for the 62 participants randomized into the ACWS group using paystubs and self-reported measures collected during the intervention. Paystub measures correlated positively with self-reported outcomes. Most ACWS participants (n = 41; 66%) obtained employment during the intervention. During the intervention, employed participants became employed in 6.0 weeks, worked at a job or training program for 15 weeks, worked 33.7 hr per week while employed or in training, and earned $1,054.31 per pay period, on average. Most employed participants earned enough income to qualify as living out of poverty for at least one pay period (80%). While employed, participants lived above the poverty level for most pay periods (79%) during the intervention. Understanding the effects of the ACWS intervention on employment and poverty may prove useful in providing targeted support to people at increased risk of poverty-related health problems.

The HIV/AIDS epidemic remains a global health challenge. This secondary analysis evaluated time-course effects of a contingency management intervention designed to improve antiretroviral therapy (ART) adherence and sustained HIV viral suppression. Participants were randomized to a usual care or an incentive group. Incentive participants could earn monetary incentives for submitting blood samples with reduced or undetectable HIV viral loads. A thinning procedure gradually reduced testing and reinforcer delivery frequency for participants who consistently met reinforcement criteria. Over the 2-year intervention period, the incentive group demonstrated significantly shorter times to viral suppression and significantly longer durations of sustained suppression and maintained undetectable viral loads even as testing intervals increased. Engagement in the intervention correlated strongly with treatment success. These findings illustrate the potential of adaptive, reinforcement-based strategies to enhance ART adherence, sustain HIV viral suppression, inform scalable interventions for HIV care, and contribute to ending the HIV/AIDS epidemic.

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.

Contingency management procedures that incentivize drug abstinence have been remarkably effective in promoting drug abstinence; however, as with other chronic health problems, treatment effects dissipate when interventions are removed. Researchers and policymakers should consider using contingency management as a long-term maintenance procedure to retain treatment effects and prevent relapse indefinitely. Contingency management procedures that provide incentives for evidence of recent drug abstinence are remarkably effective in the treatment of stimulant use disorder, but are not used widely in society. Khazanov et al. [1] suggested two types of very reasonable steps to promote more widespread use of these interventions: (a) change contingency management interventions themselves (e.g. change parameters of the reinforcement schedule); and (b) change policies and practices of the treatment system (e.g. offer incentives to providers for using contingency management interventions). The proposed changes could improve society's treatment of stimulant use disorder and reduce the broad and debilitating problems associated with stimulant use. Although the proposals are reasonable, we would like to make one suggestion that could be critical to improving the effectiveness, acceptance, and widespread dissemination of contingency management interventions: the use of contingency management as a maintenance intervention to promote long-term drug abstinence. Substance use disorders are chronic and relapsing problems that, like other chronic illnesses, require long-term treatment [2]. As with other substance use disorder treatments, contingency management procedures that incentivize abstinence do not reliably promote abstinence that persists after abstinence incentives are discontinued [3]. To enhance the long-term outcomes of contingency management interventions, Khazanov et al. [1] suggest that patients be allowed to re-engage in contingency management interventions, that the typical duration of treatment increase from 12 to 24 weeks, and that contingency management intervention be tapered at the end of treatment instead of being terminated abruptly. Although these suggestions are reasonable and potentially effective for some patients, we suggest that long-term maintenance of abstinence incentives may be required for many patients [4]. The treatment of chronic conditions frequently must be maintained to retain treatment effects. The treatment of opioid use disorder by methadone treatment is a good example. Methadone is one of the most effective treatments for opioid use disorder, but it must be maintained to maintain effectiveness [5]. Although few studies have arranged long-term exposure to contingency management interventions, we know that cocaine abstinence can be maintained by maintaining abstinence incentives [6-10]. As with other substance use disorder treatments, many patients relapse when abstinence incentives are discontinued, even after abstinence incentives are maintained for a long time [6, 11, 12]. A study conducted by DeFulio et al. [7, 11] provides a good illustration. After a 6-month abstinence initiation period, participants in this study provided routine urine samples and were invited to work in a model workplace for 1 year where they could earn an hourly wage for working. During that year, participants were randomly assigned to receive incentives that depended on employment alone (employment only) or employment and cocaine abstinence (abstinence-contingent employment). Employment only participants could work and earn hourly wages ($8 per hour) independent of urinalysis results. Abstinence-contingent employment participants had to provide cocaine-negative urine samples to maintain the highest hourly wage ($8 per hour). Abstinence-contingent employment participants provided significantly more cocaine-negative urine samples during the year of that study than employment only participants [7]. That study showed that contingency management procedures that incentivize cocaine abstinence can maintain abstinence over a long period (1 year). To evaluate post-intervention effects, both groups were monitored in a 1-year follow-up period during which neither group earned incentives for cocaine-negative urine samples. During that follow-up year, many abstinence-contingent employment participants relapsed, and the two groups provided similar rates of cocaine-negative urine samples [11]. This study showed that long-term incentives can maintain cocaine abstinence, but many people relapse when the incentives are discontinued. Using abstinence incentives as a long-term maintenance intervention could be an effective way to prevent relapse and sustain long-term abstinence [4]. The long-term maintenance of contingency management interventions has implications for society and for individual patients. For society, long-term maintenance of contingency management interventions is costly, much like the costs of maintaining methadone for opioid use disorder or antiretroviral medication for HIV. However, failing to acknowledge and address the chronic, relapsing nature of drug use disorders (including stimulant use disorders) risks dismissal of contingency management interventions as ineffective, which could lead to the further resistance to their widespread adoption. For individual patients, short-term exposure to abstinence incentives will not have lasting or lifelong effects for many patients. For these people, achieving lasting, lifelong abstinence may require maintenance of abstinence incentives. Forrest Toegel: Conceptualization; writing—original draft; writing—review and editing. Cory Toegel: Conceptualization; writing—original draft; writing—review and editing. Kenneth Silverman: Conceptualization; writing—original draft; writing—review and editing. None. The authors declare no conflicts of interest.

This issue's Survey focuses on the U.S. Securities and Exchange Commission's ("SEC") rulemaking activities and other decisions relating to the Securities Act of 1933, as amended (the "1933 Act"), the Securities Exchange Act of 1934, as amended (the "1934 Act"), and other federal securities laws from October 1, 2022 through December 31, 2022.

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.

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.

People with substance use disorder who have been arrested for prostitution are likely to require intensive interventions to increase drug abstinence and reduce HIV risk behaviors. The Therapeutic Workplace (TW) may be ideal for this population, because it combines contingency management for drug abstinence and paid job training. This study was a preliminary evaluation of the TW intervention in opioid dependent women arrested for prostitution. Participants (N = 37) were randomly assigned to a specialized diversion program, or the diversion program plus the TW for 4 months. Group comparisons showed no difference in drug use. However, analysis of drug use relative to the onset of drug abstinence contingencies in the TW group showed greater abstinence during the implementation period, with a significant difference for opioids (p = 0.046). The pre-post contingency outcomes provide preliminary evidence that the TW could promote drug abstinence in people involved in the criminal justice system who attend paid job training.

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).

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.