Combining Stepped-Care Approaches with Behavioral Reinforcement to Motivate Employment in Opioid-Dependent Outpatients

Abstract

Employment is associated with improved treatment outcome for opioid-dependent outpatients receiving methadone (e.g., Platt, ). Opioid-dependent individuals typically enter treatment unemployed and many remain unemployed despite reductions in heroin use. Additional interventions are needed to motivate employment seeking behaviors and outcome. This article reports on a promising approach to reduce the chronic unemployment commonplace in treatment-seeking, opioid-dependent patients—a “stepped care” service delivery intervention that incorporates multiple behavioral reinforcements to motivate patient participation in and adherence to the treatment plan. This therapeutic approach (Motivated Stepped Care—MSC; Brooner and Kidorf () was refined and modified to motivate and support a range of positive treatment behaviors and outcomes in patients with opioid-dependence (Kidorf et al. ), including job-seeking and acquisition. Patients who are unemployed after one year of treatment are systematically advanced to more intensive steps of weekly counseling and remain there until employment is attained. Those who remain unemployed despite exposure to at least 4 weeks of counseling at the highest step of care (Step 3, which is 9 h weekly of counseling) are started on a methadone taper in preparation for discharge, which is reversible upon attaining a job. This article describes the MSC approach and presents rates of employment for patients who were judged capable of working (n = 228). A review of medical and billing records during August–September 2002 revealed that the great majority of these patients were employed (93%), usually in full-time positions. Employment was associated with less frequent advancement to higher intensities of weekly counseling because of drug use. Further, multiple indices of improved employment stability and functioning, including months of work, hours of work, and annualized salary, were associated with better drug use outcomes. These data suggest that the MSC intervention is an effective platform for motivating and supporting both job seeking and employment in patients with chronic and severe substance use disorder.

• Behavioral reinforcement
• Opioid dependent patients
• Stepped-care treatment

Additional information

Notes on contributors

Michael Kidorf

Michael Kidorf, Ph.D., is an Associate Professor at Johns Hopkins University School of Medicine. He received a B.A. at Emory University and a Ph.D. in clinical psychology at Florida State University. He also completed an internship at Brown University and postdoctoral training at the Behavioral Pharmacology Research Unit. He is a licensed psychologist and Associate Director of the Addiction Treatment Services at Hopkins Bayview. His current research interests include the study of motivational interventions to encourage out-of-treatment drug abusers to enroll in substance abuse treatment.

Karin Neufeld

Karin Neufeld M.D., M.P.H., is Assistant Professor at Johns Hopkins University School of Medicine. She received an M.D. degree from University of Manitoba, completed postdoctoral residency training in General Adult Psychiatry at Johns Hopkins University School of Medicine, and an M.P.H. degree from the Johns Hopkins School of Public Health in Baltimore. She is currently an Associate Medical Director of the Addiction Treatment Services at Hopkins Bayview. Her current research interests include the study of adherence to psychiatric treatments among the substance-dependent population of patients with other psychiatric comorbidity, and the study of psychiatric epidemiology of drug use disorders in national and international settings.

Robert K. Brooner

Robert K. Brooner, Ph.D., is a tenured Professor of Psychiatry at the Johns Hopkins University School of Medicine. He received a B.A at the University of California-Santa Cruz, a Ph.D. at the California School of Professional Psychology, and completed an internship in Medical Psychology at the Johns Hopkins University School of Medicine. He is a licensed psychologist and Director of the Addiction Treatment Services at Johns Hopkins Bayview Medical Center. His current research interests include assessment of psychiatric comorbidity, integration of behavioral with verbal and pharmacological therapies to maximize treatment response, and improving patient motivation for and adherence to treatment using new and sometimes novel service delivery treatment approaches.