Long-term treatment of opioid use disorder - poverty and opioid addiction are interrelated and chronic problems which have not been addressed adequately

The therapeutic workplace could treat the many adults with opioid use disorder who are unemployed and live in poverty. The therapeutic workplace pays participants to work. To promote drug abstinence, the therapeutic workplace arranges employment-based abstinence reinforcement in which participants are required to provide drug-free urine samples to maintain maximum wages. Many studies have shown that employment-based abstinence reinforcement in the therapeutic workplace can promote and maintain drug abstinence. Recently, we showed that abstinence-contingent wage supplements in the therapeutic workplace could promote drug abstinence and employment, and reduce poverty. However, we have not demonstrated the real-world impacts of the therapeutic workplace. The therapeutic workplace requires two modifications to produce real world impacts. 1) we must develop a real-world version of the therapeutic workplace that community treatment programs can implement. 2) we must reduce the costs of maintaining employment-based abstinence reinforcement. This application seeks to develop and evaluate a low-cost therapeutic workplace that community treatment programs can implement and that addresses the persistent nature of opioid addiction and poverty. We propose to conduct a stage III study in which a community clinic (reach health services) adapts and implements the therapeutic workplace intervention. To improve the feasibility of this intervention, we will use low-cost abstinence-contingent wage supplements to maintain abstinence. We propose to conduct a randomized controlled study to evaluate the effectiveness of the low-cost abstinence-contingent wage supplements in a community therapeutic workplace to maintain long- term drug abstinence and employment, and to reduce poverty in adults with opioid use disorder. After a 4-week induction period, reach unemployed methadone or buprenorphine patients with opioid use disorder (N=225) will be randomly assigned to a "usual care control," an "initiation only," or an "initiation and maintenance" group. All groups will continue to receive methadone or buprenorphine treatment and will receive an employment specialist for 72 weeks. "initiation only" and "initiation and maintenance" participants will earn high magnitude abstinence-contingent wage supplements ($8/hour) during a 24-week initiation period (weeks 1-24). "initiation and maintenance" participants will also earn low-magnitude abstinence-contingent wage supplements ($1/hour) during a 48-week maintenance period (weeks 25-72). We will base the primary outcome measures on assessments conducted every four weeks of the maintenance period. If low-cost abstinence-contingent wage supplements in the community therapeutic workplace maintain drug abstinence and employment and decrease poverty, community drug abuse treatment clinics could apply this intervention widely as a long-term maintenance treatment for unemployed adults with opioid use disorder.