Long-Term Treatment of Opioid Use Disorder

贫穷和类阿片成瘾是相互关联的长期问题，尚未得到解决 充分。治疗工作场所可以治疗许多患有阿片类药物使用障碍的成年人， 失业，生活贫困。治疗工作场所支付参与者工作。促进药物 禁欲，治疗工作场所安排基于就业的禁欲强化，其中 参加者必须提供不含毒品的尿液样本，以维持最高工资。许多研究 表明，在治疗工作场所以就业为基础的禁欲强化可以促进和 保持戒毒。最近，我们发现，在美国， 治疗性工作场所可以促进戒毒和就业，并减少贫困。但我们 还没有证明治疗工作场所的现实影响。治疗工作场所 需要两次修改才能产生真实的世界影响。1)我们必须开发一个真实世界版本的 社区治疗计划可以实施的治疗工作场所。2)我们必须降低 保持以就业为基础的禁欲强化。本申请旨在开发和评估 低成本的治疗工作场所，社区治疗计划可以实施，并解决 阿片类药物成瘾和贫困的持续性。我们建议进行第三阶段研究， 社区诊所（REACH卫生服务）适应并实施治疗性工作场所干预措施。到 为了提高这一干预措施的可行性，我们将使用低成本的节欲工资补贴， 保持禁欲。我们建议进行一项随机对照研究，以评估 在社区治疗工作场所提供低成本的禁欲工资补贴，以维持长期的 长期戒毒和就业，并减少阿片类药物使用障碍成年人的贫困。4周后 诱导期，患有阿片类药物使用障碍的REACH失业美沙酮或丁丙诺啡患者（N=225） 将被随机分配到“产后护理对照组”、“仅启动组”或“启动和维持组” 组所有组将继续接受美沙酮或丁丙诺啡治疗，并将接受 就业专家72周“入门”及“入门及维持”参加者可获 在24周的启动期（周）内，高幅度的禁欲-视情况而定的工资补贴（8美元/小时 1-24）。“启动和维护”参与者还将获得低幅度的禁欲-视情况而定的工资 在48周的维持期（第25-72周）内提供补充剂（1美元/小时）。我们会把初选 维持期每四周进行一次评估的结局指标。如果低成本 在社区治疗工作场所维持戒毒 和就业和减少贫困，社区药物滥用治疗诊所可以应用这种干预措施， 广泛用作患有阿片类药物使用障碍的失业成年人的长期维持治疗。

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.