title: Employment-based reinforcement of adherence to oral naltrexone treatment in unemployed injection drug users.
abstract: Oral naltrexone has high potential for use as a relapse prevention pharmacotherapy for opiate dependence yet suffers from notoriously poor adherence. This study evaluated whether entry to a therapeutic workplace could reinforce adherence with oral naltrexone. Opiate-dependent and cocaine-using injection drug users were detoxified, inducted onto oral naltrexone, and randomly assigned to a contingency (n = 35) or prescription (n = 32) group for a 26-week period. Contingency participants were required to ingest naltrexone under staff observation to gain access to the therapeutic workplace. Prescription participants received a take-home supply of naltrexone and could access the workplace independent of naltrexone ingestion. Primary outcome measures were percent of urine samples positive for naltrexone at 30-day assessments and negative for opiates and cocaine at 30-day assessments. Contingency participants provided significantly more urine samples that were positive for naltrexone compared with prescription participants (72% vs. 21%, p < .01); however, no effect of experimental group was observed on percent opiate-negative (71% vs. 60%, p = .19.) or cocaine-negative (56% vs. 53%, p = .82) samples in the contingency and prescription groups, respectively. Opiate-positive samples were significantly more likely to occur in conjunction with cocaine (p < .001) and when not protected by naltrexone (p < .02), independent of experimental group. Overall, these results show that contingent access to a therapeutic workplace significantly promoted adherence to oral naltrexone, and that the majority of opiate use occurred in conjunction with cocaine use, suggesting that untreated cocaine use may limit the effectiveness of oral naltrexone in promoting opiate abstinence.
authors.affiliation: Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, 5200 Eastern Avenue, W142, Baltimore, MD 21224, USA.
authors.forename: Kelly E
authors.initials: KE
authors.lastname: Dunn
authors.forename: Anthony
authors.initials: A
authors.lastname: Defulio
authors.forename: Jeffrey J
authors.initials: JJ
authors.lastname: Everly
authors.forename: Wendy D
authors.initials: WD
authors.lastname: Donlin
authors.forename: Will M
authors.initials: WM
authors.lastname: Aklin
authors.forename: Paul A
authors.initials: PA
authors.lastname: Nuzzo
authors.forename: Jeannie-Marie S
authors.initials: JM
authors.lastname: Leoutsakos
authors.forename: Annie
authors.initials: A
authors.lastname: Umbricht
authors.forename: Michael
authors.initials: M
authors.lastname: Fingerhood
authors.forename: George E
authors.initials: GE
authors.lastname: Bigelow
authors.forename: Kenneth
authors.initials: K
authors.lastname: Silverman
mesh_terms: D000284:Administration, Oral; D000293:Adolescent; D000328:Adult; D000368:Aged; D019970:Cocaine-Related Disorders / Q000150:complications / Q000188:drug therapy / Q000523:psychology; D004651:Employment / Q000523:psychology*; D005260:Female; D006801:Humans; D008297:Male; D055118:Medication Adherence / Q000523:psychology*; D008875:Middle Aged; D009271:Naltrexone / Q000008:administration & dosage* / Q000009:adverse effects; D009292:Narcotic Antagonists / Q000008:administration & dosage / Q000009:adverse effects; D009293:Opioid-Related Disorders / Q000150:complications / Q000188:drug therapy / Q000523:psychology; D010352:Patient Dropouts / Q000523:psychology; D012054:Reinforcement, Psychology; D015819:Substance Abuse, Intravenous / Q000150:complications / Q000188:drug therapy / Q000523:psychology*; D019966:Substance-Related Disorders / Q000150:complications / Q000188:drug therapy / Q000523:psychology; D017132:Workplace / Q000523:psychology
chemical_list: D009292:Narcotic Antagonists; D009271:Naltrexone