Effects of incentives for naltrexone adherence on opiate abstinence in heroin‐dependent adults

Abstract

Aim To test whether an incentive-based intervention that increased adherence to naltrexone also increased opiate abstinence. Design Post-hoc combined analysis of three earlier randomized controlled trials that individually showed that incentives for adherence to oral and to extended-release injection naltrexone dosing schedules increased naltrexone adherence but not opiate abstinence. Setting Outpatient therapeutic workplace in Baltimore, MD, USA. Participants 140 unemployed heroin-dependent adults participating from 2006–2010. Interventions Participants were hired in a model workplace 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. Measures 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 prerandomization attendance, opiate use, and cocaine use as covariates. Additional analyses controlled for cocaine use and naltrexone adherence during the intervention. Findings Contingency participants had more opiate abstinence than Prescription participants (68.1% vs. 52.9% opiate-negative thrice-weekly urine samples, respectively; and 71.9% vs. 61.7% opiate-negative monthly urine samples, respectively) based on initial analyses (thrice-weekly samples, OR = 3.3, 95% CI = 1.7–6.5, p < .01; monthly samples, OR = 2.6, 95% CI = 1.0–7.1, p = .06) and on analyses that controlled for cocaine use (thrice-weekly samples, OR = 3.9, 95% CI = 3.3–4.5, p < .01; monthly samples, OR = 3.4, 95% CI = 1.1–11.1, p =.04), which was high and associated with opiate use. The difference in opiate abstinence rates between Contingency participants and Prescription participants was reduced when controlling for naltrexone adherence (monthly samples, OR = 1.1, 95% CI = 0.7–1.7, p = .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.

Extended‐release injectable naltrexone for opioid use disorder: a systematic review

“…When participants adhere to oral naltrexone at higher rates, such as those produced by contingency management interventions (16), the effects on opioid use are significant (17). However, in the absence of specialized interventions, problems related to adherence reduce the effectiveness of naltrexone.…”

“…The inability to properly evaluate oral naltrexone was due to poor adherence-fewer than one-third of participants who began taking oral naltrexone continued to the end of treatment, which averaged 6 months. When participants adhere to oral naltrexone at higher rates, such as those produced by contingency management interventions [16], the effects on opioid use are significant [17]. However, in the absence of specialized interventions, problems related to adherence reduce the effectiveness of naltrexone.…”

Misalignment of Stakeholder Incentives in the Opioid Crisis

“…Improving treatment adherence and program retention: To improve retention in treatment programs or increase the number of days of opioid/drug abstinence, initiatives have included contingency management and financial incentives for patients [ 99 , 100 , 101 , 102 , 103 , 104 , 105 , 106 , 107 ] (see [ 108 ] for a review). Challenges associated with these initiatives include the use of monetary incentives to buy drugs [ 109 , 110 ] and diversion or misuse of methadone and buprenorphine [ 111 , 112 ].…”

Building a Group-Based Opioid Treatment (GBOT) blueprint: a qualitative study delineating GBOT implementation

“…Clinical trials studying various behavioral approaches in managing OUD concluded that individual counseling does not have a consistent impact above high-quality standardized medication management approaches [131]. Some evidence has demonstrated that, among patients with OUD on MOUD, contingency management approaches significantly improve retention in treatment [132–135] and relapse rates on opioids [134–136] and other substances [117, 136–143]. However, while CM has some proven benefit in preventing opioid use at the individual level, its benefit in preventing opioid use in a group setting has not been demonstrated.…”