The Therapeutic Workplace is an employment-based incentive program that uses opportunities to earn wages through work to promote and reinforce abstinence from problem substances.
Participants are trained and employed as data entry operators, and opportunities to work, along with rate of pay, depend on participants’ substance use behavior. That is, access to the workplace and hourly rate of pay are based on behaviors such as abstinence, attendance, and medication adherence. Wages are earned in vouchers, and the value grows the longer the desired behaviors are maintained. Relapses result in restricted access to the workplace and a drop in the value of vouchers back to the original starting point.
Contingency management (CM)
Young Adults (18-30)
Addiction treatment clinics
A randomized controlled trial of the Therapeutic Workplace for community methadone patients: A partial failure to engage.
Knealing TW, Wong CJ, Diemer KN, Hampton J, Silverman K. Experimental and Clinical Psychopharmacology. 2006. 14(3):350-360. PMID: 16893278.
Summary: In this randomized controlled trial, participants enrolled in methadone maintenance treatment were assigned to receive either Therapeutic Workplace (n=22) or usual care (n=25). All participants received standard case management and HIV risk counseling, but those in the usual care condition were not able to access the workplace. Contingent on steady attendance and negative urines, those in the Therapeutic Workplace condition were able to access the workplace for 4 hours each weekday for 9 months.
There were no significant differences between the Therapeutic Workplace and usual care participants on cocaine and/or opiate abstinence, or on HIV risk behaviors (e.g., trading sex for drugs).
Take Away: The Therapeutic Workplace was comparable to usual care in supporting consistent abstinence from cocaine and opiates for participants in methadone maintenance treatment.
A randomized trial of employment-based reinforcement of cocaine abstinence in injection drug users.
Silverman K, Wong CJ, Needham M, Diemer KN, Knealing T, Crone-Todd D, Fingerhood M, Nuzzo P, Kolodner K. Journal of Applied Behavior Analysis. 2007. 40(3):387-410. PMID: 17970256.
Summary: This is a randomized controlled trial among 56 adults who were unemployed and continued to use cocaine despite participating in standard methadone maintenance treatment. Participants were randomly assigned to an abstinence-and-work group, in which access to the workplace and rate of pay were dependent on cocaine-free urine samples, or a work-only group, in which access to the workplace was unrestricted. During the 26-week trial, participants regularly provided urine samples and were allowed to work 4 hours each weekday.
Fifty-six adults participated in the trial (28 in each group). In comparison to the work-only group, the abstinence and work group had significantly higher rates of cocaine abstinence (27% vs.14%), self-reported abstinence from cocaine (23% vs. 12%), and self-reported abstinence from both crack and injection drugs (28% vs. 16%). There were no significant differences at 6-month follow-up.
Take Away: The Therapeutic Workplace was effective during the intervention period in promoting abstinence from cocaine use among these adults in methadone maintenance treatment.
Employment-based abstinence reinforcement as a maintenance intervention for the treatment of cocaine dependence: a randomized controlled trial.
DeFulio A, Donlin WD, Wong CJ, Silverman K. Addiction. 2009. 104(9):1530-1538. PMCID: PMC2729763.
Summary: This is a randomized controlled trial involving 128 adults who were unemployed and continued to use cocaine despite participating in standard methadone maintenance treatment. Phase 1 of the study involved a 6-month period in which participants received job skills training and the Therapeutic Workplace intervention aimed at abstinence first from cocaine, then from opiates and other problem substances. Individuals who were abstinent at least 80% of the time, attended the workplace at least 50% of the time, and achieved minimal job skills proficiency were eligible for Phase 2. In this phase, participants were hired as data entry people for one year at a non-profit data entry business and were randomly assigned to an abstinence-contingent employment group or an employment only group. All participants provided random urine samples for drug testing. Those in the employment only group were able to work regardless of their urine test results, while those in the abstinence-contingent employment group were only able to work if their urine tests were negative.
Participants in the abstinence-contingent employment group (n=27) had significantly more drug-free urines (79%) than the employment only group (n=24; 51%). Those in the abstinence-contingent employment group also had significantly higher rates of self-reported cocaine abstinence (79% vs. 61%) and significantly lower rates of self-reported trading sex for drugs (0% vs. 17%).
Take Away: The Therapeutic Workplace intervention, delivered via actual employment, was effective as a means of supporting maintenance of cocaine abstinence among adults attending methadone maintenance treatment.
Attendance rates in a workplace predict subsequent outcome of employment-based reinforcement of cocaine abstinence in methadone patients.
Donlin WD, Knealing TW, Needham M, Wong CJ, Silverman K. Journal of Applied Behavior Analysis. 2008. 41(4):499-516. PMCID: PMC2606606.
Summary: This paper describes analyses conducted with data from the above study to examine whether workplace attendance or percentage of cocaine-negative urine samples during the induction period predicted cocaine abstinence outcomes during the intervention. Both attendance at the workplace and percentage of cocaine-negative urine samples during the induction period were significantly associated with percentage of cocaine-negative urine samples during the intervention period. Participants who worked over 60% of the time during the induction period were more likely to achieve abstinence from cocaine during the intervention, while those who worked less than 40% of the time were much less likely to achieve abstinence from cocaine. It is possible that access to the workplace during the induction period helped facilitate the effectiveness of the intervention by allowing participants to develop work skills or to experience the positive effects of working. It is also possible that using an induction period may help identify people who will not benefit from a reinforcement-based abstinence program.
Take Away: Workplace attendance during an induction period predicted abstinence from cocaine, and may be helpful in identifying individuals who will not respond to a reinforcement-based abstinence intervention.
Employment-based abstinence reinforcement as a maintenance intervention for the treatment of cocaine dependence: post-intervention outcomes.
DeFulio A, Silverman K. Addiction. 2011. 106(5): 960–967. doi: 10.1111/j.1360-0443.2011.03364.x
Summary: This paper describes the extended follow-up of participants from the above study. Participants were assessed at 6 and 12 months post intervention to evaluate long-term abstinence from cocaine. There were no significant differences in cocaine-negative urine samples between the employment-only and abstinence-contingent employment groups at follow-up. There were also no significant differences in self-reported HIV risk behaviors between the groups. The employment-only group had a stable rate of cocaine-negative urines during both the intervention (54.2%) and continuing into the follow-up period (50%). The abstinence-contingent group showed a drop in the rate of negative urines between the intervention period (82.7%) and the follow-up period (44.2%).
Take away: Employment-based abstinence was not maintained when the intervention was discontinued.
Employment-based reinforcement of adherence to depot naltrexone in unemployed opioid-dependent adults: a randomized controlled trial.
Everly JJ, DeFulio A, Koffarnus MN, Leoutsakos JM, Donlin WD, Aklin WM, Umbricht A, Fingerhood M, Bigelow GE, Silverman K. Addiction. 2011. 106(7):1309-1318. PMCID: PMC3107896.
Summary: Thirty-five unemployed adults with opioid dependence were included in this randomized clinical trial. Participants went through a detoxification program, were started on oral naltrexone, and then were randomly assigned to a contingency group (n=18) or a prescription group (n=17). Those in the contingency group were only allowed access to the workplace and maximum rates of pay if they received their naltrexone via depot injections of Depotrex®, while those in the prescription group were allowed unrestricted access to the workplace.
There were no significant differences between the groups in negative urines for cocaine (56% versus 54%) or opiates (74% versus 62%). However, the contingency group received significantly more naltrexone injections than the prescription group (81% versus 42%), and were significantly more likely to receive all of their injections (66% versus 35%).
Take Away: The contingent workplace intervention was effective in promoting higher rates of adherence to Depotrex® injections.
A randomized clinical trial of a therapeutic workplace for chronically unemployed, homeless, alcohol-dependent adults.
Koffarnus MN, Wong CJ, Diemer K, Needham M, Hampton J, Fingerhood M, Svikis DS, Bigelow GE, Silverman K. Alcohol and Alcoholism. 2011. 46(5): 561-569. PMCID: PMC3156886.
Summary: This randomized controlled study examines rates of abstinence from alcohol among homeless adults with alcohol dependence. Participants were recruited from an inpatient detoxification unit and from community agencies serving homeless adults, and were randomly assigned to one of three groups: contingent paid training group (n=43), paid training group (n=42), and the unpaid training group (n=39). Those in the contingent paid training group received vouchers for job training activities in the workplace, but were only given access to the workplace if their breath samples were negative for alcohol. Those in the paid training group and the unpaid training group were given access to the workplace job training regardless of whether they provided clean breath samples, but only those in the paid group were given vouchers for job training activities. Breath samples were taken monthly, as well as randomly.
Participants in the unpaid training group had a significantly lower attendance rate (19%) than either the contingent (39%) or the paid participants (45%). On randomly obtained breath samples, the contingent group had significantly fewer samples that were positive for alcohol than the paid group (24% vs. 42%). Similarly, on monthly breath samples, the contingent group had significantly fewer positive samples than the paid group (17% vs. 40%).
Take Away: Receiving pay for job training improved attendance in the program. The contingent intervention improved rates of abstinence from alcohol without reducing attendance at the workplace.
Employment-based reinforcement of adherence to an FDA approved extended release formulation of naltrexone in opioid-dependent adults: a randomized controlled trial.
DeFulio A, Everly JJ, Leoutsakos JM, Umbricht A, Fingerhood M, Bigelow GE, Silverman K. Drug and Alcohol Dependence. 2012. 120(1-3):48-54. PMCID: PMC3245785.
Summary: This is a randomized clinical trial assessing adherence rates to an FDA-approved extended release naltrexone injection formulation and whether the therapeutic workplace intervention can be effective at improving adherence rates. Participants were 38 unemployed adults who recently completed opioid detoxification and were medically appropriate for naltrexone. They were started on oral naltrexone and then randomly assigned a contingency group (n=19) or prescription group (n=19). Participants in the contingency group were only able to access the workplace and earn vouchers if they received their Vivitrol® naltrexone injections, while the prescription group was able to access the workplace independent of naltrexone adherence or delivery method.
Those in the contingency group received significantly more naltrexone injections than those in the prescription group (87% versus 52%), and were more likely to receive all possible injections (74% versus 26%). There were no significant differences between the groups in negative urines for cocaine (58% versus 54%) or opiates (72% versus 65%).
Take Away: The contingent workplace intervention was effective in promoting higher rates of adherence to Vivitrol® injections.