The Effect of Employment-Based Contingency on Treatment Enrollment, Retention, and Long-Term Abstinence among Individuals with Substance use Disorder: A Systematic Review

Background and Objective: Substance use disorders (SUD) remain a major public health concern and represent a significant cause of morbidity and mortality. Our goal in this study is to explore and determine the effect(s) of employment-based contingency (EBC) on enrolling SUD individuals into treatment, the rate of treatment adherence, and the rate of post-treatment abstinence. Methods: PubMed and Google Scholar search was conducted using the search terms ((substance use disorder) AND (unemployment)) OR (therapeutic workplace)), for randomized controlled trials (RCT) published between 2012 and 2022, reporting on participants between ages 18 and 65 years who use opioids, cocaine or alcohol. Results: Seven RCT which met the criteria and addressed the study objectives had a total of 389 participants. Three RCT of the seven with 203 participants found EBC to positively impact the rate of enrollment to treatment with 100%, 92%, and 100% enrollment rates in the respective studies. Three articles with 172 participants found a higher rate of treatment adherence and retention to treatment among EBC participants compared to the control group. There was more naltrexone-positive urine in the EBC group compared to control (72% vs. 21%, with a p-value of .01), and 74% (EBC) vs 26% (control) participants completed treatment. Four articles with 238 participants found that EBC improved the rate of abstinence by over 50%, which is double the rate among the control group without EBC. Conclusion: EBC is effective in improving SUD treatment enrollment, treatment adherence, and post-treatment abstinence, however, the efficacy may be dependent on how much is earned as an incentive.