Using a pragmatically adapted, low-cost contingency management intervention to promote heroin abstinence in individuals undergoing treatment for heroin use disorder in UK drug services (PRAISE): a cluster randomised trial

Abstract

IntroductionMost individuals treated for heroin use disorder receive opioid agonist treatment (OAT)(methadone or buprenorphine). However, OAT is associated with high attrition and persistent, occasional heroin use. There is some evidence for the effectiveness of contingency management (CM), a behavioural intervention involving modest financial incentives, in encouraging drug abstinence when applied adjunctively with OAT. UK drug services have a minimal track record of applying CM and limited resources to implement it. We assessed a CM intervention pragmatically adapted for ease of implementation in UK drug services to promote heroin abstinence among individuals receiving OAT.DesignCluster randomised controlled trial.Setting and participants552 adults with heroin use disorder (target 660) enrolled from 34 clusters (drug treatment clinics) in England between November 2012 and October 2015.InterventionsClusters were randomly allocated 1:1:1 to OAT plus 12× weekly appointments with: (1) CM targeted at opiate abstinence at appointments (CM Abstinence); (2) CM targeted at on-time attendance at appointments (CM Attendance); or (3) no CM (treatment as usual; TAU). Modifications included monitoring behaviour weekly and fixed incentives schedule.MeasurementsPrimary outcome: heroin abstinence measured by heroin-free urines (weeks 9–12). Secondary outcomes: heroin abstinence 12 weeks after discontinuation of CM (weeks 21–24); attendance; self-reported drug use, physical and mental health.ResultsCM Attendance was superior to TAU in encouraging heroin abstinence. Odds of a heroin-negative urine in weeks 9–12 was statistically significantly greater in CM Attendance compared with TAU (OR=2.1; 95% CI 1.1 to 3.9; p=0.030). CM Abstinence was not superior to TAU (OR=1.6; 95% CI 0.9 to 3.0; p=0.146) or CM Attendance (OR=1.3; 95% CI 0.7 to 2.4; p=0.438) (not statistically significant differences). Reductions in heroin use were not sustained at 21–24 weeks. No differences between groups in self-reported heroin use.ConclusionsA pragmatically adapted CM intervention for routine use in UK drug services was moderately effective in encouraging heroin abstinence compared with no CM only when targeted at attendance. CM targeted at abstinence was not effective.Trial registration numberISRCTN 01591254.

Do financial incentives increase mental health treatment engagement? A meta-analysis.

“…We converted binary outcomes (provided as proportions), t values from between-samples t tests, odds ratios, and Cohen’s d values provided in the text to Hedges’ g s (Lipsey & Wilson, 2001). For studies with cluster randomized designs (Metrebian et al, 2021; Priebe et al, 2013), we adjusted Hedges’ g s using the intraclass correlation coefficients (ICC) provided in the text (Higgins, Eldridge, et al, 2020). For within-subject designs, we calculated Hedges’ g av using pretest and posttest means and SDs (or SEs) for continuous outcomes (Goulet-Pelletier & Cousineau, 2018; Lakens, 2013) and converted binary outcomes (provided as proportions) to Hedges’ g av (Borenstein et al, 2009).…”

The Cost-Effectiveness of Financial Incentives to Achieve Heroin Abstinence in Individuals With Heroin Use Disorder Starting New Treatment Episodes: A Cluster Randomized Trial-Based Economic Evaluation

“…Our clinical report (9) found that CM in addition to TAU (OAT plus 12 weekly specialist drug and alcohol keyworker sessions) only achieved a statistically significant difference in heroin use compared to TAU alone in the CM Attendance group at the 12-week follow-up, which was not sustained at the 24-week follow-up after incentives were withdrawn. CM targeted at attendance and abstinence (CM Abstinence) failed to achieve statistically significant reductions in heroin use compared to TAU at either follow-up.…”

“…Each cluster was randomly assigned to additionally provide either: i) positive reinforcement in the form of a £10 voucher given to participants at each weekly appointment for both on-time attendance and abstinence from opiates using an instant cup test (CM Abstinence group); ii) positive reinforcement in the form of a £10 voucher given at each weekly appointment for on-time attendance only (CM Attendance group); or no CM. The main clinical results (9) and design details (10) are reported elsewhere.…”

Modeling the population‐level impact of opioid agonist treatment on mortality among people accessing treatment between 2001 and 2020 in New South Wales, Australia

“…While buprenorphine and buprenorphine–naloxone prescription have been associated with higher rates of discontinuation versus methadone prescription [ 52 ], others have reported contrasting findings [ 55 ] and large‐scale studies are being implemented to guide clinical practice [ 24 , 56 , 57 ]. Interventions to improve medication regimen choice through better assessment of symptoms have been proposed [ 58 ], and strategies to increase retention through counselling, therapeutic drug monitoring [ 59 ] and contingency management are being tested [ 59 , 60 ] and have shown promise [ 61 ]. Providing stable housing and employment opportunities support the recovery process beyond OAT retention through promoting personal satisfaction and social integration.…”