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Abstinence-contingent wage supplements to promote drug abstinence and employment: a randomised controlled trial
  1. August F Holtyn1,2,
  2. Forrest Toegel1,2,
  3. Shrinidhi Subramaniam1,2,
  4. Brantley P Jarvis1,2,
  5. Jeannie-Marie Leoutsakos1,2,
  6. Michael Fingerhood2,
  7. Kenneth Silverman1,2
  1. 1 Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
  2. 2 Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
  1. Correspondence to Dr August F Holtyn, Johns Hopkins University, Baltimore, MD 21224, USA; aholtyn1{at}


Background Poverty, unemployment and substance abuse are inter-related problems. This study evaluated the effectiveness of abstinence-contingent wage supplements in promoting drug abstinence and employment in unemployed adults in outpatient treatment for opioid use disorder.

Methods A randomised controlled trial was conducted in Baltimore, MD, from 2014 to 2019. After a 3-month abstinence initiation and training period, participants (n=91) were randomly assigned to a usual care control group that received employment services or to an abstinence-contingent wage supplement group that received employment services plus abstinence-contingent wage supplements. All participants were invited to work with an employment specialist to seek employment in a community job for 12 months. Abstinence-contingent wage supplement participants could earn training stipends for working with the employment specialist and wage supplements for working in a community job, but had to provide opiate and cocaine-negative urine samples to maximise pay.

Results Abstinence-contingent wage supplement participants provided significantly more opiate and cocaine-negative urine samples than usual care control participants (65% vs 45%; OR=2.29, 95% CI 1.22 to 4.30, p=0.01) during the 12-month intervention. Abstinence-contingent wage supplement participants were significantly more likely to have obtained employment (59% vs 28%; OR=3.88, 95% CI 1.60 to 9.41, p=0.004) and lived out of poverty (61% vs 30%; OR=3.77, 95% CI 1.57 to 9.04, p=0.004) by the end of the 12-month intervention than usual care control participants.

Conclusion Abstinence-contingent wage supplements can promote drug abstinence and employment.

Trial registration number NCT02487745.

  • employment
  • unemployment
  • poverty
  • substance abuse

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  • Correction notice This article has been corrected since it first published. The provenance and peer review statement has been corrected and the trial registration number included.

  • Contributors KS and AH accept full responsibility for the work and the conduct of the study, had access to the data and controlled the decision to publish. KS developed the study concept and design. AH, FT, SS, BJ, MF and KS contributed to the acquisition, analysis and interpretation of data. JML performed the statistical analyses. AH and KS drafted the manuscript and all authors provided revisions of the manuscript for important intellectual content. AH attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted. All authors have approved the final article.

  • Funding The study was supported by the National Institute on Drug Abuse of the National Institutes of Health under grants R01 DA037314 and T32 DA07209.

  • Disclaimer The content is solely the responsibility of the authors and does not represent the official views of the National Institutes of Health. The National Institutes of Health had no part in the study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the article for publication. All authors had full access to all of the data (including statistical reports and tables) in the study and can take responsibility for the integrity of the data and the accuracy of the data analysis.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval The Johns Hopkins Medicine Institutional Review Board approved the study (IRB00046990) and all participants provided written informed consent to take part in the study.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon reasonable request. Data may be made available by emailing the corresponding author at