Study Details | Pathways to Work

101057-Study of Abstinence-

Study quality: High

High

Reason for the rating: This study received a high study quality rating because it is a randomized controlled trial with low attrition, suggesting the findings can be attributed to the program.

Program: Abstinence-Contingent Wage Supplements to Promote Drug Abstinence and Employment

Characteristics of study participants:

Justice involvement, Substance use disorder

Services provided:

Job placement, Job search assistance, Performance- or behavior-based financial incentives, Treatment or recovery services for substance use disorder

Setting: Urban only

Methods and Standards Protocol version used for review: Version 2.0

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Study design

Design:

Randomized controlled trial

Study group formation:

Study participants were unemployed adults in treatment for opioid use recruited from community agencies and via street outreach in Baltimore, Maryland. Prior to the study, all interested participants were offered 90 days of a phased therapeutic workplace program where positive drug tests reset base pay and each negative sample increased pay up to a maximum level. Participants who had attended the therapeutic workplace on 10 of the final 20 days of the 90-day period were invited to participate in the present study. Participants were then randomly assigned to the program or comparison condition. A total of 91 participants were enrolled, with 44 assigned to the program group and 47 assigned to the comparison group.

Time period of study:

The study ran from 2015 to 2020. Study enrollment occurred from November 2015 through April 2018. Study data collection occurred from 2015 through 2020, with follow-up data collected monthly during the 12-month program period and quarterly up to 12 months post-program.

Primary outcome domains examined:

Increase long-term employment

Other outcome domains examined:

Substance use

Study funded by:

The study was funded by the National Institute on Drug Abuse, Grant Numbers R01DA037314 and T32DA07209.

Results

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Outcome domain	Measure	Timing	Study quality by finding	Units	Findings	Sample size
Increase long-term employment	Average employment rate in past 12 months, quarterly	Month 24	High	Odds ratio (impact estimate not shown)		91

Short-term outcomes are those measured 18 months or fewer after participants are first offered services. Long-term outcomes are those measured between 18 months and 5 years after participants are first offered services. Very long-term outcomes are those measured 5 years or more after participants are first offered services.

Means are not displayed when not reported or not aligned with the impact estimates. For example, if the impact estimate is regression-adjusted but only unadjusted means are reported in the study, the unadjusted means are not displayed as they are not aligned with the adjusted impact estimate.

Impact estimates are not shown when the estimate units cannot be converted to natural units.

Findings quality key:

High
Moderate

Study quality terms?

The findings quality describe our confidence that a given study’s finding is because of the program. We do not display findings that rate low.

Findings key:

A moderate-to-large favorable finding that is unlikely to be due to chance
A moderate-to-large favorable finding that might to be due to chance
A small favorable finding that is unlikely to be due to chance
A small favorable finding that might be due to chance
A favorable finding that is unlikely to be due to chance, but we cannot determine the standardized effect size
A favorable finding that might be due to chance, but we cannot determine the standardized effect size
A moderate-to-large unfavorable finding that is unlikely to be due to chance
A moderate-to-large unfavorable finding that might to be due to chance
A small unfavorable finding that is unlikely to be due to chance
A small unfavorable finding that might be due to chance
An unfavorable finding that is unlikely to be due to chance, but we cannot determine the standardized effect size
An unfavorable finding that might be due to chance, but we cannot determine the standardized effect size
A finding that is unlikely to be due to chance, but we cannot determine the standardized effect size or direction
A finding of no effect that might be due to chance

Favorable findings are impacts in a direction that is socially desirable. Statistical significance indicates the likelihood that a study finding is due to the program, rather than due to chance. Findings are described as moderate-to-large if the program produced a sufficiently large change in the outcome. An impact receives this designation if the standardized effect size is equal to or greater than 0.25 or equal to or less than -0.25.

Sample characteristics

Participants were adults who were unemployed, enrolled in or eligible for methadone or buprenorphine maintenance treatment, provided an opioid-positive urine sample, indicated an interest in employment, and lived in or near Baltimore City, Maryland. Most participants were in poverty (98 percent) and had a history of incarceration (81 percent). The majority of participants were African American (56 percent) and male (55 percent).

Age

Mean age

48 years

Sex

Female	45%
Male	55%

Race and ethnicity

Black or African American	56%
White	40%
Another race	4%

The race and ethnicity categories may sum to more than 100 percent if the authors reported race and ethnicity separately; in these cases, we report the category White, rather than White, not Hispanic.

Employment and public benefit status

Were employed	2%
Were unemployed	98%

Education

Had a high school diploma or GED

66%

Specific employment barriers

Had a substance abuse disorder	100%
Were involved with the justice system	81%

Program implementation

Implementing organization:

Johns Hopkins Center for Learning and Health

Program history:

The program was a pilot program.

Program services:

Participants in the program could earn abstinence-contingent stipends for working with an employment specialist for up to 12 months and for engaging in job-seeking behaviors for up to 20 hours per week (up to approximately $10 per hour), in addition to receiving usual care. Stipends were divided into base pay for hours worked and performance pay for job seeking behaviors. When employed, participants could earn additional abstinence-contingent wage supplements for all verified hours worked in community jobs for up to 40 hours per week (for up to $8 per hour). Abstinence was confirmed through a routine drug testing schedule and then a progressively more intermittent random drug testing schedule.

Mandatory services:

None

Comparison services:

Participants in the usual care comparison condition did not receive the abstinent-contingent stipends or wage supplements but could work with an employment specialist for up to one year. The employment specialist implemented a variation of individual placement and support model, which focused on promoting employment in competitive jobs that were selected based on client preferences. Departures from this model included the employment specialists not spending most of their time in the community or establishing relationships with employers, and participants not being referred to jobs identified by the employment specialists through their contacts with employers.

Service receipt duration:

Program services were delivered for 12 months.

Program funding:

The study did not describe the source of program funding.

Study publications

Holtyn, August F., Forrest Toegel, Meghan Arellano, Shrinidhi Subramaniam, and Kenneth Silverman. Employment outcomes of substance use disorder patients enrolled in a therapeutic workplace intervention for drug abstinence and employment, Journal of Substance Abuse Treatment, 120: Article 108160. Available at: https://doi.org/10.1016/j.jsat.2020.108160

Holtyn, August F., Forrest Toegel, Shrinidhi Subramaniam, Brantley P Jarvis, Jeannie-Marie Leoutsakos, Michael Fingerhood, and Kenneth Silverman (2020). Abstinence-contingent wage supplements to promote drug abstinence and employment: A randomized controlled trial, Journal of Epidemological Community Health 74(5): 445-452. Available at: https://doi.org/10.1136/jech-2020-213761

Holtyn, August F., Forrest Toegel, Shrinidhi Subramaniam, Meghan Arellano, Jeannie-Marie Leoutsakos, Michael Fingerhood, and Kenneth Silverman (2020). Financial incentives promote engagement in employment services for unemployed adults in treatment for opioid use disorder, Drug and Alcohol Dependence 212: Article 107982. Available at: https://doi.org/10.1016/j.drugalcdep.2020.107982

Novak, Matthew D., August F. Holtyn, Forrest Toegel, Jeannie-Marie Leoutsakos, and Kenneth Silverman (2022). Abstinence-contingent wage supplements to promote drug abstinence and employment: Post-intervention outcomes, Drug and Alcohol Dependence, 232: Article 109322. Available at: https://doi.org/10.1016/j.drugalcdep.2022.109322

Orme, Stephen, Gary A. Zarkin, Jackson Luckey, Laura J. Dunlap, Matthew D. Novak, August F. Holtyn, Forrest Toegel, and Kenneth Silverman (2022). Cost and cost-effectiveness of abstinence contingent wage supplements, Drug and Alcohol Dependence 244: Article 109754. Available at: https://doi.org/10.1016/j.drugalcdep.2022.109754

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Study of Abstinence-Contingent Wage Supplements to Promote Drug Abstinence and Employment