Addictions, King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
Department of Mental Health & Social Work, Middlesex University, London, UK.
BMJ Open. 2021 Jul 1;11(7):e046371. doi: 10.1136/bmjopen-2020-046371.
Most individuals treated for heroin use disorder receive opioid agonist treatment (OAT)(methadone or buprenorphine). However, OAT is associated with high attrition and persistent, occasional heroin use. There is some evidence for the effectiveness of contingency management (CM), a behavioural intervention involving modest financial incentives, in encouraging drug abstinence when applied adjunctively with OAT. UK drug services have a minimal track record of applying CM and limited resources to implement it. We assessed a CM intervention pragmatically adapted for ease of implementation in UK drug services to promote heroin abstinence among individuals receiving OAT.
Cluster randomised controlled trial.
552 adults with heroin use disorder (target 660) enrolled from 34 clusters (drug treatment clinics) in England between November 2012 and October 2015.
Clusters were randomly allocated 1:1:1 to OAT plus 12× weekly appointments with: (1) CM targeted at opiate abstinence at appointments (CM Abstinence); (2) CM targeted at on-time attendance at appointments (CM Attendance); or (3) no CM (treatment as usual; TAU). Modifications included monitoring behaviour weekly and fixed incentives schedule.
Primary outcome: heroin abstinence measured by heroin-free urines (weeks 9-12).
heroin abstinence 12 weeks after discontinuation of CM (weeks 21-24); attendance; self-reported drug use, physical and mental health.
CM Attendance was superior to TAU in encouraging heroin abstinence. Odds of a heroin-negative urine in weeks 9-12 was statistically significantly greater in CM Attendance compared with TAU (OR=2.1; 95% CI 1.1 to 3.9; p=0.030). CM Abstinence was not superior to TAU (OR=1.6; 95% CI 0.9 to 3.0; p=0.146) or CM Attendance (OR=1.3; 95% CI 0.7 to 2.4; p=0.438) (not statistically significant differences). Reductions in heroin use were not sustained at 21-24 weeks. No differences between groups in self-reported heroin use.
A pragmatically adapted CM intervention for routine use in UK drug services was moderately effective in encouraging heroin abstinence compared with no CM only when targeted at attendance. CM targeted at abstinence was not effective.
ISRCTN 01591254.
大多数接受海洛因使用障碍治疗的患者都接受阿片类激动剂治疗（OAT）（美沙酮或丁丙诺啡）。然而，OAT 与高脱落率和持续、偶尔使用海洛因有关。有一些证据表明，当与 OAT 联合使用时，行为干预措施——附带适度经济激励的附带管理（CM），在鼓励药物戒除方面是有效的。英国毒品服务机构在实施 CM 方面记录不佳，资源有限。我们评估了一种针对英国毒品服务机构易于实施的 CM 干预措施，以促进接受 OAT 治疗的个体戒除海洛因。
集群随机对照试验。
2012 年 11 月至 2015 年 10 月期间，从英格兰的 34 个集群（毒品治疗诊所）中招募了 552 名患有海洛因使用障碍的成年人（目标为 660 名）。
集群被随机分配 1:1:1 接受 OAT 加 12 次每周预约：（1）针对阿片类药物戒除的 CM（CM 戒除）；（2）针对按时就诊的 CM（CM 出席）；或（3）无 CM（常规治疗；TAU）。修改包括每周监测行为和固定奖励计划。
主要结果：用海洛因尿液检测（第 9-12 周）测量海洛因戒除。
CM 停止后 12 周（第 21-24 周）的海洛因戒除；出席；自我报告的药物使用、身体和心理健康。
与 TAU 相比，CM 出席在鼓励海洛因戒除方面表现出优势。与 TAU 相比，CM 出席第 9-12 周海洛因阴性尿液的可能性统计学显著更高（OR=2.1；95%CI 1.1 至 3.9；p=0.030）。CM 戒除与 TAU（OR=1.6；95%CI 0.9 至 3.0；p=0.146）或 CM 出席（OR=1.3；95%CI 0.7 至 2.4；p=0.438）相比没有优势（无统计学显著差异）。在第 21-24 周时，海洛因使用的减少并未持续。各组在自我报告的海洛因使用方面没有差异。
针对英国毒品服务机构常规使用的一种实用的 CM 干预措施与仅无 CM 相比，在鼓励海洛因戒除方面具有中等有效性，尤其是针对出席情况。针对戒除的 CM 没有效果。
ISRCTN 01591254。
