title: Effects of incentives for naltrexone adherence on opiate abstinence in heroin-dependent adults.
abstract: OBJECTIVE
  To test whether an incentive-based intervention that increased adherence to naltrexone also increased opiate abstinence.
  
  
  METHODS
  Post-hoc combined analysis of three earlier randomized controlled trials that showed individually that incentives for adherence to oral and to extended-release injection naltrexone dosing schedules increased naltrexone adherence, but not opiate abstinence.
  
  
  METHODS
  Out-patient therapeutic work-place in Baltimore, MD, USA.
  
  
  METHODS
  One hundred and forty unemployed heroin-dependent adults participating from 2006 to 2010.
  
  
  METHODS
  Participants were hired in a model work-place for 26 weeks and randomized to a contingency (n = 72) or prescription (n = 68) group. Both groups were offered naltrexone. Contingency participants were required to take scheduled doses of naltrexone in order to work and earn wages. Prescription participants could earn wages independent of naltrexone adherence.
  
  
  METHODS
  Thrice-weekly and monthly urine samples tested for opiates and cocaine and measures of naltrexone adherence (percentage of monthly urine samples positive for naltrexone or percentage of scheduled injections received). All analyses included pre-randomization attendance, opiate use and cocaine use as covariates. Additional analyses controlled for cocaine use and naltrexone adherence during the intervention.
  
  
  RESULTS
  Contingency participants had more opiate abstinence than prescription participants (68.1 versus 52.9% opiate-negative thrice-weekly urine samples, respectively; and 71.9 versus 61.7% opiate-negative monthly urine samples, respectively) based on initial analyses [thrice-weekly samples, odds ratio (OR) = 3.3, 95% confidence interval (CI) = 1.7-6.5, P < 0.01; monthly samples, OR = 2.6, 95% CI = 1.0-7.1, P = 0.06] and on analyses that controlled for cocaine use (thrice-weekly samples, OR = 3.9, 95% CI = 3.3-4.5, P < 0.01; monthly samples, OR = 3.4, 95% CI = 1.1-11.1, P = 0.04), which was high and associated with opiate use. The difference in opiate abstinence rates between contingency and prescription participants was reduced when controlling for naltrexone adherence (monthly samples, OR = 1.1, 95% CI = 0.7-1.7, P = 0.84).
  
  
  CONCLUSIONS
  Incentives for naltrexone adherence increase opiate abstinence in heroin-dependent adults, an effect that appears to be due to increased naltrexone adherence produced by the incentives.
authors.affiliation: Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
authors.forename: Brantley P
authors.initials: BP
authors.lastname: Jarvis
authors.affiliation: Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
authors.forename: August F
authors.initials: AF
authors.lastname: Holtyn
authors.affiliation: Department of Psychology, Western Michigan University, Kalamazoo, MI, USA.
authors.forename: Anthony
authors.initials: A
authors.lastname: DeFulio
authors.affiliation: Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
authors.forename: Kelly E
authors.initials: KE
authors.lastname: Dunn
authors.affiliation: Department of Psychology, University of Pittsburgh at Greensburg, Greensburg, PA, USA.
authors.forename: Jeffrey J
authors.initials: JJ
authors.lastname: Everly
authors.affiliation: Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
authors.forename: Jeannie-Marie S
authors.initials: JS
authors.lastname: Leoutsakos
authors.affiliation: Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
authors.forename: Annie
authors.initials: A
authors.lastname: Umbricht
authors.affiliation: Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
authors.forename: Michael
authors.initials: M
authors.lastname: Fingerhood
authors.affiliation: Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
authors.forename: George E
authors.initials: GE
authors.lastname: Bigelow
authors.affiliation: Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
authors.forename: Kenneth
authors.initials: K
authors.lastname: Silverman
mesh_terms: D000328:Adult; D000553:Ambulatory Care; D016832:Employment, Supported; D005260:Female; D006556:Heroin Dependence / Q000188:drug therapy*; D006801:Humans; D008297:Male; D055118:Medication Adherence / Q000523:psychology*; D008875:Middle Aged; D009042:Motivation; D009271:Naltrexone / Q000627:therapeutic use*; D009292:Narcotic Antagonists / Q000627:therapeutic use*; D016032:Randomized Controlled Trials as Topic
chemical_list: D009292:Narcotic Antagonists; D009271:Naltrexone
keywords: Contingency management; employment; extended-release; heroin; medication adherence; naltrexone; opiates; opioids; therapeutic workplace