A Therapeutic Workplace to Address Poverty and Substance Use
Phase: NA
Conditions: Substance Use Disorders
Sponsor: Johns Hopkins University

A Therapeutic Workplace to Address Poverty and Substance Use
NCT03519009
March 7, 2023

 
 
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Date: March 7, 2023_    
Principal Investigator: Kenneth Silverman 
Application Number: IRB00160297 
 
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1. 
Abstract 
Alcohol addiction is a chronic relapsing disorder. High magnitude and long-duration voucher-based 
abstinence reinforcement is one of the most effective treatments for alcohol and drug addiction and can 
maintain abstinence over extended periods of time, but practical methods of implementing these 
interventions are needed. Workplaces could be ideal and practical vehicles for arranging and maintaining 
abstinence reinforcement over long time periods. Our research on a model Therapeutic Workplace has 
shown that employment-based abstinence reinforcement, in which participants must provide alcohol- or 
drug-free urine samples to maintain maximum pay, can maintain alcohol and drug abstinence. Now we 
need to develop effective and economically sound methods to arrange long-term exposure to 
employment-based abstinence reinforcement. We are proposing to evaluate the effectiveness and 
economic benefits of a Wage Supplement Model of arranging long-term exposure to employment-based 
abstinence reinforcement. Under this model, successful Therapeutic Workplace participants are offered 
abstinence-contingent wage supplements if they obtain and maintain competitive employment. 
Governments have used wage supplements effectively to increase employment in welfare recipients. The 
Wage Supplement Model harnesses the power of wage supplements to promote employment, while 
simultaneously using the wage supplements to reinforce alcohol abstinence. The intervention will combine 
3 elements -- the Therapeutic Workplace, Individual Placement and Support (IPS) supported employment, 
and abstinence-contingent wage supplements. IPS is a supported employment intervention that has been 
proven effective in promoting employment in adults with severe mental illness. Under this model, 
participants will be exposed to the Therapeutic Workplace to initiate alcohol abstinence and establish job 
skills. To promote employment and prevent relapse to alcohol use, participants will receive IPS Plus 
Abstinence-Contingent Wage Supplements. A randomized trial will evaluate the effectiveness and 
economic benefits of the Abstinence-Contingent Wage Supplement Model in promoting employment and 
sustaining alcohol abstinence in homeless adults with alcohol use disorder (N=130). Participants will be 
enrolled in the Therapeutic Workplace for 1 month and then randomly assigned to a Usual Care Control 
group or an IPS Plus Abstinence-Contingent Wage Supplement group for 6 months. Usual Care Control 
participants will be offered counseling and referrals to employment and treatment programs. IPS Plus 
Abstinence-Contingent Wage Supplement participants will receive the IPS intervention and abstinence-
contingent wage supplements. Throughout the study, a wearable alcohol biosensor will be used to 
continuously monitor alcohol use. This novel intervention could be an effective and economically sound 
way to promote long-term employment and alcohol abstinence in homeless adults with alcohol use 
disorder, a population at risk for many adverse outcomes because of their poverty, unemployment, 
homelessness and alcohol use. 
 
2. 
Objectives 
The project will have the following Specific Aims: 
Primary Aim 
 
• 
Biologically-Verified Alcohol Abstinence. Assess the effectiveness of IPS Plus Abstinence-
Contingent Wage Supplements in promoting biologically-verified alcohol abstinence during the 
intervention. 

 
 
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Secondary Aims 
• 
Self-Reported Alcohol Use. Assess the effectiveness of IPS Plus Abstinence-Contingent Wage 
Supplements in reducing self-reported alcohol use during the intervention. 
• 
Employment. Assess the effectiveness of IPS Plus Abstinence-Contingent Wage Supplements in 
promoting employment during the intervention. 
• 
Post-Intervention Effects. Assess the effectiveness of IPS Plus Abstinence-Contingent Wage 
Supplements in promoting alcohol abstinence and employment after the intervention ends. 
• 
Economic Analyses. Assess the costs, cost-effectiveness, and cost-benefit of IPS Plus Abstinence-
Contingent Wage Supplements.   
3. 
Background 
 
Alcohol and drug addiction are often chronic problems that persist for many years and sometimes 
throughout a person’s lifetime (Dennis & Scott, 2007; McLellan et al., 2000; Moos & Moos, 2007; Vaillant, 
1996, 2003). Treatments can promote abstinence in some patients, but relapse is common after treatment 
(Etter & Stapleton, 2006; Knapp et al., 2007; Lancaster et al., 2006; Sees et al., 2000; Tonstad et al., 2006; 
Veilleux et al., 2010). Many individuals achieve periods of abstinence that last a year or more, but still 
relapse (Galai et al., 2003; Shah, Galai et al., 2006; Vaillant, 1996, 2003). Developing enduring solutions to 
sustain abstinence over many years is perhaps the greatest challenge facing the alcohol treatment 
research community. This project seeks to develop a long-term treatment to address the chronic relapsing 
nature of alcohol addiction. 
Treating Homeless Adults with Alcohol Use Disorder 
 
This project will focus on homeless adults with alcohol use disorder. Few populations are beset 
with the constellation of problems that afflict homeless individuals (Fischer & Breakey, 1991b). At the heart 
of much of this misfortune are staggering rates of alcoholism (Breakey et al., 1989; Fazel et al., 2008; 
Fischer & Breakey, 1991b; Toro et al., 1995). Estimates show that as much as half of homeless adults 
have current alcohol use disorders (Fazel et al., 2008). Treatment of alcohol use disorder in the homeless 
is complicated by the range of problems they face (Fischer & Breakey, 1991a; Toro et al., 1995) including 
"extreme poverty; underutilization of public entitlements; isolation from family, friends, and other support 
networks; frequent contact with correctional agencies; and poor general health (Fischer & Breakey, 
1991a).” The Institute of Medicine identified the homeless as a group in need of specialized interventions 
that are tailored to their unique characteristics and needs (IOM 1990), including housing, income and 
employment (Zerger, 2002). 
 
Studies have experimentally evaluated interventions for homeless adults who used drugs and/or 
alcohol, but few studies have focused exclusively on homeless adults with alcohol use disorder. Early 
projects supported by NIAAA and NIDA demonstrated both the challenge and potential of treating 
substance abusing homeless individuals.  A few treatments were found to be effective (Lam et al., 1995; 
Milby et al., 1996; Sosin et al., 1995), but most controlled studies failed to show clear effects of 
experimental treatments relative to control conditions  (Lapham et al., 1995; Smith et al., 1995; Stahler, 
1995; Wright & Devine, 1995), and both dropout and relapse to substance use were common (Orwin et al., 
1999; Zerger, 2002). More recent interventions for homeless, substance-dependent adults have had mixed 
effects (Fitzpatrick-Lewis et al., 2011; Hwang et al., 2005; de Vet et al., 2013). One recent and well-
controlled study investigated intensive and long-term Chronic Care Management that combined 
motivational enhancement therapy, relapse prevention counseling, and onsite medical, addiction, and 
psychiatric services. This intensive approach did not affect drug and alcohol use in a general population of 
drug and alcohol users, in the subset of alcohol users, or in a subset of homeless adults (Saitz et al., 
2013). Housing first interventions that provide housing to homeless adults with alcohol use disorder can be 
cost effective, however, their effects are directly related to the duration of the housing provided and the 
effects of housing on alcohol use have not been experimentally demonstrated (Larimer et al., 2009). 
Overall, although some treatments have shown promise, the experimental results have been mixed and it 
is unclear which treatments are effective and best suited to the needs of this population.  
Behavioral Economic Incentives in the Treatment of Homeless Adults with Alcohol Use Disorder 
 
Behavioral economic incentive treatments for drug and alcohol dependence have a strong 
theoretical and empirical foundation and have produced some of the most promising effects in homeless 
adults. 
 
Theoretical and empirical underpinnings. Behavioral economic incentive interventions are rooted in 
research that suggests that alcohol addiction is operant behavior that is maintained and modifiable by its 

 
 
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consequences (Bigelow & Silverman, 1999). Consequences that increase behavior are called reinforcers, 
commonly referred to as incentives. Operant research shows that the value of incentives decreases as the 
delay to the incentive increases (Bickel et al. 2014). Benefits of health behaviors like alcohol abstinence 
are delayed, which may explain why alcohol abstinence does not always maintain without special 
interventions. Behavioral economic incentive interventions are designed to bridge the gap between health 
behaviors and their delayed health benefits. They provide immediate incentives for health behaviors to 
increase their frequency. Seminal studies by Bigelow (Co-investigator) showed that alcohol use in “chronic 
alcoholics” could be reduced by providing incentives contingent on alcohol abstinence (Bigelow et al., 
1975; Bigelow and Liebson, 1972). 
 
Application of behavioral principles to the treatment of homeless adults. Miller offered incentives to 
alcohol-dependent adults contingent on the provision of alcohol-free breath samples (Miller et al., 1974), 
including in a study with “skid row alcoholics” (Miller, 1975). Milby showed that an intervention that 
provided abstinence-contingent housing and work therapy could promote abstinence in homeless, cocaine-
dependent adults (Milby et al., 1996, 2000, 2010). A behavioral treatment that applied the Community 
Reinforcement Approach, incentives for attendance, and housing contingent on alcohol-free breath 
samples was effective in promoting alcohol abstinence in homeless adults (Smith et al., 1998). A study by 
Silverman (Co-PI) and his colleagues showed that access to paid employment in a model “therapeutic 
workplace” contingent on alcohol-free breath samples increased alcohol abstinence relative to a condition 
in which access to paid employment was offered independent of breath-alcohol results (Koffarnus et al., 
2011). These studies show that behavioral treatments can be effective in homeless adults. However, like 
other treatments, behavioral treatments have not reliably produced long-term abstinence, employment or 
housing that persists after the intervention ends.  
A Therapeutic Workplace to Address the Chronic Nature of Drug Addiction 
 
We propose to develop a novel incentive-based treatment for homeless adults with alcohol use 
disorders designed to promote long-term employment and abstinence from alcohol. Interventions in which 
patients receive incentives contingent on providing objective evidence of alcohol or drug abstinence may 
be the most effective psychosocial addiction treatments (Castells et al., 2009; Dutra et al., 2008; Knapp et 
al., 2007; Pilling et al., 2007). One of the most effective incentive interventions is voucher reinforcement in 
which patients receive monetary vouchers for providing drug-free urine samples (Higgins et al., 1991). 
Voucher reinforcement can increase abstinence from alcohol and a wide range of drugs (Lussier et al., 
2006). The Co-PI (Silverman) and others (Castells et al., 2009) have shown that voucher reinforcement 
can increase drug abstinence in injection drug users (Silverman et al., 1996a, 1998); and that high value 
vouchers can initiate abstinence in refractory drug users (Dallery et al., 2001; Silverman et al., 1999). As 
with other treatments, many patients relapse to alcohol or drug use after abstinence incentives are 
discontinued. To address this, Silverman (Co-PI) and colleagues have used abstinence reinforcement as a 
maintenance intervention and showed that sustained voucher reinforcement could maintain drug 
abstinence for a year (Silverman et al., 2004).  
The Therapeutic Workplace. The need for high magnitude and long duration abstinence 
reinforcement raises an obvious practical problem: How can high magnitude and long duration 
reinforcement be financed? Silverman and his colleagues developed the Therapeutic Workplace to 
address this problem. The essential features of the intervention are simple: Participants are hired and paid 
to work, as in typical employment. To promote abstinence, participants must provide objective evidence of 
drug and/or alcohol abstinence to maintain access to the workplace and maximum pay. The approach 
does not require an independent source of funds to address abstinence, but instead harnesses the 
reinforcing effects of wages to reinforce abstinence. Since employment can be sustained for years, this 
approach offers the potential advantage of maintaining high magnitude employment-based abstinence 
reinforcement over long periods of time. 
Phases of treatment. The Therapeutic Workplace was originally designed to treat low-income, 
unemployed drug-dependent women. Since many women lacked job skills (Silverman et al., 1995), we 
designed two phases of treatment. During Phase 1, each patient's "job" was to participate in a stipend-
supported training program designed to establish job skills and initiate abstinence. Once participants 
initiated abstinence and acquired skills, they progressed to Phase 2 and were hired as data entry 
operators (Silverman et al., 2005). Employment-based abstinence reinforcement is maintained throughout 
both phases.  

 
 
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Therapeutic Workplace research. Our initial study showed that the Therapeutic Workplace could 
initiate (Silverman et al., 2001) and maintain drug abstinence for 4 years (Aklin et al., 2014; Silverman et 
al., 2002) in pregnant/postpartum methadone patients. 
Other studies showed that employment-based abstinence 
reinforcement could promote drug abstinence in injection 
drug users (Holtyn et al., 2014; Silverman et al., 2007), 
and could promote adherence to naltrexone in opioid-
dependent adults (DeFulio et al., 2012; Dunn et al., 2013; 
Everly et al., 2011). Particularly relevant to this application, 
the Therapeutic Workplace has been shown effective in 
promoting alcohol abstinence in homeless alcohol-
dependent adults (Koffarnus et al., 2011). The adjacent 
figure shows outcomes from 10 studies evaluating the 
Therapeutic Workplace on drug or alcohol abstinence and 
naltrexone adherence (asterisks). Values above the bars show the amount of increase produced by the 
Therapeutic Workplace; all were significant (See Silverman et al., 2012). 
Scientific Premise: A critical challenge. Most controlled studies conducted with substance 
abusing homeless adults have failed to show clear effects of experimental treatments relative to control 
conditions. Our research shows that a year-long exposure to employment-based abstinence reinforcement 
effectively sustains drug abstinence throughout a year of employment (DeFulio et al., 2009), but many 
participants relapsed in the year after the employment-based abstinence reinforcement ended (DeFulio & 
Silverman, 2011). This suggests that we may need to maintain employment-based abstinence 
reinforcement over an extended time to prevent relapse in some patients. The proposed research seeks to 
develop cost-effective ways of arranging long-term employment-based reinforcement to support recovery. 
Models to Arrange Long-Term Employment-Based Abstinence Reinforcement 
 
We developed three models to maintain employment-based abstinence reinforcement (Silverman, 
Holtyn and Morrison, in press; Appendix). Under all models, individuals enroll in Phase 1 to initiate 
abstinence and establish skills. The models differ in how employment-based reinforcement is maintained. 
 
The Social Business Model. Under the Social Business model, Phase 1 graduates are hired as 
employees in a social business. A social business, a concept that won Muhammad Yunus the Nobel Prize, 
exists to address the needs of low-income people (Weber & Yunus, 2010; Yunus & Weber, 2007). We 
established a Therapeutic Workplace Social Business, Hopkins Data Services, to maintain employment-
based abstinence reinforcement. Our experience suggests that the Therapeutic Workplace Social 
Business can be feasible (Silverman et al., 2005) and effective (Aklin et al., 2014), but it may have limited 
capacity and is difficult to scale up relative to our other models. 
 
The Cooperative Employer Model. Under the Cooperative Employer model, a community employer 
hires Phase 1 graduates and requires that they undergo drug testing and remain abstinent to maintain 
employment. This model is more scalable, but has limited capacity, since it requires cooperating 
employers. 
The Wage Supplement Model. Under the Wage Supplement Model, graduates of Phase 1 are 
offered abstinence-contingent wage supplements if they maintain employment. Governments in 
Minnesota, Connecticut, Milwaukee, New York, and Canada have used wage supplements to increase 
employment in welfare recipients (Berlin, 2007; Michalopoulos, 2005; Riccio et al., 2010). This model 
harnesses the power of wage supplements to promote employment, while simultaneously using the wage 
supplements to reinforce alcohol abstinence. We have used abstinence-contingent wage supplements in 
occasional participants who obtain employment while participating in the Therapeutic Workplace 
(Silverman et al., 2002). 
Development and Evaluation of the Abstinence-Contingent Wage Supplement Model 
 
The Wage Supplement Model could expand employment opportunities and provide a financially 
viable means of arranging employment-based abstinence reinforcement as a long-term intervention. 
However, we must address three challenges of this model: 1) incorporate a method to increase 
employment; 2) evaluate the effectiveness of abstinence-contingent wage supplements in maintaining 
abstinence; and 3) assess the economic costs and benefits of abstinence-contingent wage supplements. 
Several innovative components of the proposed project designed to address these challenges are 
described here. 
 

 
 
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Individual Placement and Support (IPS). Increasing employment is critical to facilitate the success 
of the Therapeutic Workplace’s Abstinence-Contingent Wage Supplement Model. Employment 
interventions for unemployed drug users have been ineffective (Magura et al., 2004; Svikis et al., 2012) 
and behavioral interventions for homeless cocaine-dependent (Kertesz et al., 2007) or alcohol-dependent 
(Smith et al., 1998) adults have failed to affect long-term employment outcomes. Therapeutic Workplace 
participants are employed at significantly higher rates after participation in the Therapeutic Workplace than 
before, but still only about 20% of participants work fulltime after Therapeutic Workplace participation 
(Sigurdsson et al., 2011). To increase employment, we will combine the Therapeutic Workplace with the 
IPS model of supported employment. IPS was designed to promote employment in persons with severe 
mental illness. Under IPS, employment specialists establish relationships with potential employers, and 
work with participants to identify available jobs, prepare applications, apply for positions, and support 
participants during employment. IPS has been shown effective in increasing employment in the U.S. and 
several other countries (Bond et al., 2012). IPS produced significant increases in employment in a subset 
of individuals with severe mental illness and a substance use disorder (Mueser et al., 2011) and in 
homeless adults with psychiatric or substance abuse problems (Rosenheck & Mares, 2007). We will adapt 
IPS to promote employment in participants after they initiate abstinence and acquire job skills in the 
Therapeutic Workplace.  
 
Wage supplements to increase employment. Our research shows that participants, including 
homeless alcohol-dependent adults (Koffarnus et al., 2013), will not attend our training program or work 
consistently without incentives (Koffarnus et al., 2013; Koffarnus, DeFulio et al., 2013; Silverman, 
Chutuape et al., 1996; Wong et al., 2004a; Wong et al., 2004b). To increase motivation of participants to 
engage in IPS and obtain employment, participants will earn wage supplements for maintaining 
employment. Wage supplements can promote employment in welfare recipients (Berlin, 2007; 
Michalopoulos, 2005; Riccio et al., 2010). Given the failure of previous employment interventions for 
unemployed drug and alcohol users, combining IPS and wage supplements is warranted and could 
increase employment in this difficult population. 
 
Abstinence contingency in provision of wage supplements to prevent relapse. Our research shows 
that employment alone is not sufficient to maintain abstinence. In the most relevant study (DeFulio et al., 
2009), after completing Phase 1, participants who initiated cocaine abstinence were hired in our Phase 2 
data entry business for one year and randomly assigned to two groups. Employment Only participants 
could work independent of their urinalysis results. Abstinence-Contingent Employment participants had to 
provide drug-free urine samples to work and maintain maximum pay. During Phase 2, Abstinence-
Contingent Employment participants provided significantly more cocaine-negative samples than 
Employment Only participants (79.3% and 50.7%, respectively). Based on this study, we expect that many 
participants who become employed will relapse to alcohol use when employment-based abstinence 
reinforcement is discontinued. To sustain abstinence, participants who become employed will earn 
abstinence-contingent wage supplements as long as they continue to abstain from alcohol use. If a 
participant obtains employment, the participant will receive wage supplements ($8/hr for a maximum of 40 
hours per week) for verified employment. The maximum amount in wage supplements will be available as 
long as the participant continues to abstain from alcohol use.  
 
Utilization of a wearable alcohol biosensor. To facilitate dissemination of this intervention, we will 
use a wearable alcohol biosensor to monitor alcohol use. Wearable alcohol biosensors are devices that 
can be passively worn by individuals in their daily lives and can provide a continuous measure of alcohol 
use. NIAAA recently announced the winners of the Wearable Alcohol Biosensor Challenge, which was 
issued to stimulate public and private investment in development and refinement of these devices 
(www.challenge.gov/challenge/ a-wearable-alcohol-biosensor/). The proposed research will select the most 
appropriate biosensor from the available options. For example, the Secure Continuous Remote Alcohol 
Monitor (SCRAM) is an ankle bracelet that can be worn continuously, including in the shower, and includes 
features that allow for detection of removal and tampering. It provides an estimate of blood alcohol 
concentration by sampling alcohol vapor just above the skin, and also measures changes in skin 
temperature and skin reflectivity, which are used to detect device removal and tampering. These data are 
stored on the bracelet and transmitted wirelessly via a modem. Transmitted data are encrypted and stored 
in a web-based system called SCRAMNET, which research staff can access to monitor alcohol use. 
BACtrack Skyn is a wrist bracelet that also provides an estimate of blood alcohol concentration by 
sampling alcohol vapor just above the skin. The bracelet can measure changes in skin temperature, which 
can be used to detect removal or tampering. Data are stored on the bracelet and can be transmitted 

 
 
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wirelessly via Bluetooth using a smartphone. Transmitted data are encrypted and stored in a web-based 
system provided by BACtrack, which research staff can access to monitor alcohol use. The proposed 
research will be the first to use a wearable alcohol biosensor to apply employment-based abstinence 
reinforcement as a therapeutic intervention.    
 
The cost-effectiveness and cost-benefit of IPS plus abstinence-contingent wage supplements. We 
expect that costs of IPS plus abstinence-contingent wage supplements will be comparable to 
buprenorphine maintenance (Schackman et al., 2012) and less expensive than extended-release 
naltrexone (Kennedy et al., 2011). We will assess the costs, cost-effectiveness, and cost-benefits of IPS 
Plus Abstinence-Contingent Wage Supplements. Dunlap and Zarkin (Co-Is), experts in economic analyses, 
will conduct these analyses.  
 
4. 
Study Procedures 
a. Study design, including the sequence and timing of study procedures   
Study Participants 
 
Participants will be recruited from the Chemical Dependency Unit (CDU), an inpatient treatment 
program on the Johns Hopkins Bayview Campus that treats ~300 homeless adults with alcohol use 
disorder per year and the Johns Hopkins Bayview Medical Center (JHBMC) that treats ~180 homeless 
adults with alcohol use disorder per year. We may recruit from additional programs that serve homeless 
adults. We may recruit via internet-posted notices and newspaper advertisements using our study flyers 
and/or information sheets, and on social media platforms using our online advertisement scripts. We will 
use recruitment procedures that we used previously to successfully recruit homeless alcohol-dependent 
adults (Koffarnus et al., 2011).  
Therapeutic Workplace and Job-Skills Training 
 
To increase the chance that we engage participants, upon enrollment, participants will be invited to 
participate in a 1-week Therapeutic Workplace induction period. During the induction period, participants 
will be asked to maintain contact with Therapeutic Workplace staff by calling or texting staff every 
weekday. We have used similar induction procedures in our prior studies to successfully engage 
participants. Participants will be able to earn $20 per weekday for maintaining contact with our staff during 
the induction period. Participants who complete the 1-week induction will be given a wearable alcohol 
biosensor, invited to call in to the Therapeutic Workplace every weekday for 3 weeks, and can earn about 
$32/weekday for participating in our job-skills training program. Participants will be taught about the 
Therapeutic Workplace. Some or all of the training may be given through a computer-based training 
program. We may also evaluate the effectiveness of the training program by giving participants tests 
before and after they complete parts or all of the training program. We may re-administer the test at the 
end of the intervention to measure retention.  Each Therapeutic Workplace participant will have a 
participant ID, which will be used to enter participant drug and alcohol testing results into our therapeutic 
workplace software, automatically implement any responses to drug and/or alcohol use based on testing 
results, and to automatically calculate participant daily pay based on compliance with drug and/or alcohol 
contingencies. Participants will be required to wear their wearable alcohol biosensor (SCRAM or BACtrack 
Skyn), which will record transdermal alcohol concentrations. Participants will be given separate care and 
use information about their wearable alcohol biosensor. Participants who wear a SCRAM bracelet will need 
to come to the Therapeutic Workplace (about every 30 days) so that the data stored on their bracelet can 
be transmitted to SCRAMNET and accessed by our research staff. Participants who wear a BACtrack Skyn 
bracelet will need to transmit the data stored on their bracelet via Bluetooth using a smartphone. At the end 
of Phase 1, participants will be randomly assigned to groups. 
Experimental Design 
 
Participants (N = 130) will be randomly assigned to a Usual Care Control or IPS Plus Abstinence-
Contingent Wage Supplements group. Computerized urn randomization (Wei & Lachin, 1988) will balance 
groups on characteristics that may influence outcome: (1) percent of days abstinent from alcohol 
(assessed by transdermal alcohol concentrations prior to random assignment; ≥ rolling median, Y/N); (2) 
evidence of opiate and cocaine use from the assessment prior to random assignment (Y/N); (3) completed 
high school or obtained a GED (Y/N); and (4) gender (male/female). Participants will be stratified by 
alcohol and drug use because they should predict alcohol abstinence during the intervention period. High 
school completion or GED should be associated with employment. Participants will be stratified by gender 
to balance the two groups on a key biological factor that may influence outcome. 

 
 
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Individual Placement and Support (IPS) & Abstinence-Contingent Wage Supplement Group 
 
This group will receive the full intervention being evaluated in this study for 6 months. 
 
Individual Placement and Support (IPS). After Phase 1, participants will be offered the IPS model of 
supported employment for 6 months. IPS involves rapid job search, promotes competitive employment, 
and provides job supports and benefits counseling.  
Abstinence-contingent wage supplements. Participants in this group will receive abstinence-
contingent wage supplements. Before obtaining employment, participants will earn wage supplements for 
participating in IPS sessions and for completing tasks prescribed by IPS (e.g., developing a worker 
profile, applying for jobs, and completing interviews). The incentive system is designed to encourage 
participants to engage in about 4 hours of IPS each weekday and to allow participants to earn about $200 
per week. We may offer bonus incentives to increase some job-seeking behaviors (e.g., completing job 
applications). We may also evaluate the effectiveness of those bonus incentives, for example, by applying 
and withdrawing them to see if those bonus incentives are needed to promote the job seeking behaviors. 
Once a participant becomes employed, participants will be able to earn up to $8 per hour for a maximum 
of 40 hours per week for working in a competitive job. To maintain long-term alcohol abstinence, 
participants will be required to wear their alcohol biosensor and to provide alcohol negative transdermal 
alcohol concentration readings to earn the maximum in wage supplements. $8 per hour was selected 
because that amount was effective in our prior research (Silverman et at., 2005). 
Abstinence monitoring using SCRAM or BACtrack Skyn.  Each participant will be paid for wearing 
a wearable alcohol biosensor (SCRAM or BACtrack Skyn). SCRAM will measure transdermal alcohol 
concentrations every 30 minutes. Infrared signals and temperature also will be recorded to ensure that no 
tampering or device removal occurs. Data recorded by SCRAM will be transferred wirelessly to a modem 
installed in our laboratory, which will transfer the data to a secure central server operated by the 
developers of SCRAM. These data can then be accessed via SCRAMNET, a secure, web-based platform 
where all data are stored, including information on alcohol consumption, monitor obstructions or 
tampering, and the functioning of the battery and equipment. Participants may need to attend the 
Therapeutic Workplace (about every 30 days) so that data stored on their bracelet can be transmitted to 
SCRAMNET and accessed by our research staff. BACtrack Skyn can measure transdermal alcohol 
concentrations every second. Temperature will be recorded to capture potential tampering or device 
removal. Data recorded by BACtrack Skyn will be transferred wirelessly via Bluetooth to a secure portal 
operated by BACtrack. If participants do not have a smartphone that is capable of transmitting the data 
via Bluetooth, we may provide them with one to use during their study participation. Participants will need 
to remove their BACtrack Skyn bracelet to shower or bathe. Participants must receive permission to 
remove their bracelet by sending research staff a photo or video of themselves wearing the bracelet after 
they put it back on. Bracelet removal cannot exceed 60 minutes. To earn the maximum in wage 
supplements, participant’s transdermal alcohol concentrations must not test positive for alcohol at any 
point between the last and the current data transmission.  
Resetting the wage supplement value. If a participant removes their wearable alcohol biosensor 
without permission or provides a transdermal alcohol concentration reading that is positive for alcohol, the 
value of the wage supplement will be reduced to $1 per hour. The value of the wage supplement will be 
increased by $1 per hour for every day that the participants wear their wearable alcohol biosensor and 
provide transdermal alcohol concentration readings that are negative for alcohol. 
Usual Care Control Group 
 
Participants assigned to the Usual Care Control group will be offered counseling and referrals to 
employment and treatment services, and will be paid (see below) for wearing a wearable alcohol biosensor 
(SCRAM or BACtrack Skyn) for 6 months. 
Standard Treatment Services 
 
Participants in this research will have completed an inpatient alcohol detoxification at the Chemical 
Dependency Unit (CDU) or will be referred to treatment at the CDU, if necessary. The CDU is a 20-bed 
inpatient acute detoxification program for drug and/or alcohol addiction.  
 
We will provide appropriate referrals to address patient needs in the areas of housing, and mental 
and medical health.  Most importantly, we will assist patients in finding shelter/housing and encourage 
them to use Therapeutic Workplace earnings to pay for shelter.  We will attempt to guide patients to seek 
available social service benefits, and to utilize Baltimore City's network of emergency shelters, transitional 
shelters, and motel placements, as needed. We may provide participants with transportation via Lyft or 
Uber, and cover transportation costs, when participants are traveling to and from our research unit.   

 
 
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Other Training and Employment Activities 
Academic and computer skills training. Participants may have access to training in typing, keypad, 
general computer use, reading, spelling, math, GED preparation, and the use of Microsoft computer 
applications. We may evaluate the effectiveness of the academic and computer skills training programs by 
giving participants tests, such as the Wide Range Achievement Test, before and after participants 
complete a portion of or the entire training program. 
 
Review and expungement of criminal record. Criminal records are a major barrier to competitive 
employment in homeless adults. To help participants prepare for competitive employment, we may 
collaborate with community partners (e.g., Maryland Legal Aid) who offer free legal assistance to 
participants. This assistance typically consists of determining eligibility for expungement, processing 
petitions for expungement of criminal records, and other free services approved by the legal team. 
Participants are notified by research staff that legal assistance is available, and that participation is 
voluntary. We may collect data to describe and evaluate the expungement process so we may better 
understand legal barriers to employment in homeless adults. The data we would collect are the types of 
offenses participants have on their public records (i.e., records available to potential future employers), the 
number of convictions on record, which records are eligible or ineligible for expungement, whether 
petitions for expungement are filed by the legal team, whether petitions for expungement are granted or 
require a hearing, and how long it takes for participants to have their records expunged. We may publish 
an article to describe the expungement process and de-identified data of our participants.  All data that we 
collect and publish on the criminal histories of our participants will be data that are publicly available. 
Verification of employment. To gain verified and objective records of employment, we may get an 
objective measure of each participant's employment history by getting each participant's earnings history 
using federal Form SSA-7050-F4 (10-2016) UF, REQUEST FOR SOCIAL SECURITY EARNINGS 
INFORMATION. Participants and research staff will complete this form and have the participant's earnings 
history sent to our research unit.  Our research unit will pay for the costs of this service.  We may request 
these documents one or more times. We will take the following steps to protect this sensitive information in 
our study databases: (1) when storing a completed form, we will redact name, date of birth, and social 
security number from the written document and label the document with an ID number; (2) keep paper 
copies in a locked file cabinet in a locked office and never keep documents out while unattended by 
research staff; and (3) only enter relevant information into the database (i.e., information about when 
participants worked, how much they earned, and what type of employment they had). The risks associated 
with collecting this information are explained on the consent form. 
b. Study duration and number of study visits required of research participants. 
 
Participants will be invited to enroll in Phase 1 of the therapeutic workplace for 1 month.  All 
participants that report to be assessed at the end of Phase 1 and are willing to continue to wear a 
wearable alcohol biosensor will be randomly assigned to the study groups and followed for 6 months.  All 
participants will be invited to participate in an intake assessment to determine eligibility and characterize 
the population. Outcome assessments will be conducted immediately prior to random assignment, every 
30 days throughout the 6-month intervention evaluation period after random assignment and then at 6 and 
12 months after the end of the intervention evaluation period. These assessments may be collected using 
REDCap and conducted via phone or web-conferencing.  
 
c. Blinding, including justification for blinding or not blinding the trial, if applicable. 
NA 
d. Justification of why participants will not receive routine care or will have current therapy 
stopped. 
NA 
e. Justification for inclusion of a placebo or non-treatment group. 
NA 
f. Definition of treatment failure or participant removal criteria. 
Participants will be removed from the study if they threaten the safety of CLH staff or other 
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g. Description of what happens to participants receiving therapy when study ends or if a 
participant’s participation in the study ends prematurely. 
Throughout the study, participants will be given referrals to services they might need (e.g., drug 
counseling, housing, medical, or employment services). 
 
5. 
Inclusion/Exclusion Criteria 
Inclusion criteria: a) 18 to 55 years old; b) homeless at the time of intake as defined by the 
McKinney-Vento Homeless Assistance Act (lacked a fixed, regular, and adequate nighttime residence 
including staying in a shelter, on the street, in an abandoned house or building, a car, or a park); c) 
unemployed; d) meet DSM V criteria for alcohol use disorder; and e) interested in obtaining employment. 
Exclusion criteria: a) report current suicidal/homicidal ideation; b) currently have nickel or other metal 
allergies, deep vein thrombosis, or leg ulcers where the SCRAM bracelet should be placed. Individuals 
excluded from the study will be linked with appropriate care as needed.  
 
6. 
Drugs/ Substances/ Devices 
a. The rationale for choosing the drug and dose or for choosing the device to be used. 
NA 
b. Justification and safety information if FDA approved drugs will be administered for non-FDA 
approved indications or if doses or routes of administration or participant populations are 
changed. 
NA 
c. Justification and safety information if non-FDA approved drugs without an IND will be 
administered.  
NA 
 
7. 
Study Statistics 
a. Primary outcome variable. 
 
Biologically-Verified Alcohol Abstinence (primary aim). Assess the effectiveness of IPS Plus 
Abstinence-Contingent Wage Supplements in promoting biologically-verified alcohol abstinence during the 
intervention. We will assess the number of days of alcohol abstinence (based on transdermal alcohol 
concentrations) during the 6 months after random assignment. Primary Hypothesis: Our primary 
hypothesis is that IPS Plus Abstinence-Contingent Wage Supplements will promote alcohol abstinence 
during the intervention after random assignment relative to Usual Care Control.  
 
b. Secondary outcome variables. 
 
Self-Reported Alcohol Use (secondary aim). Assess the effectiveness of IPS Plus Abstinence-
Contingent Wage Supplements in reducing self-reported alcohol use during the intervention. We will use 
three self-report measures of alcohol use (based on TLFB) during the 30 days prior to each of the 6 
monthly assessments during the year after random assignment. We will assess: 1) the percent of days 
abstinent from alcohol; 2) the average number of standard drinks per drinking day ingested; and 3) the 
percent of heavy drinking days (≥5 standard drinks per day for men and ≥4 standard drinks per day for 
women). Hypothesis: We expect that IPS Plus Abstinence-Contingent Wage Supplement participants will 
have less self-reported alcohol use during the intervention after random assignment relative to Usual Care 
Control. 
 
Employment (secondary aim). Assess the effectiveness of IPS Plus Abstinence-Contingent Wage 
Supplements in promoting employment during the intervention. We will assess the number of days 
participants are employed during the 30 days prior to each of the 6 monthly assessments during the 
intervention after random assignment. Hypothesis: We expect that IPS Plus Abstinence-Contingent Wage 
Supplements will increase employment during the intervention after random assignment relative to Usual 
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Post-Intervention Effects (secondary aim). Assess the effectives of IPS Plus Abstinence-
Contingent Wage Supplements in promoting employment and abstinence from alcohol after the 
intervention ends. We will compare the groups on self-reported measures of alcohol use and employment 
at 6- and 12-month follow-up assessment time points after the intervention ends. Hypothesis: We expect 
that IPS Plus Abstinence-Contingent Wage Supplements may need to be maintained to promote long-term 
employment and abstinence from alcohol, and thus alcohol abstinence and employment may not be 
sustained after the intervention ends.  
 
Economic Outcome Measures  
Costs of Treatment (secondary aim). Assess the costs of treatment for Usual Care and IPS Plus 
Abstinence-Contingent Wage Supplements. We will assess the total cost per participant in both study 
groups. Hypothesis: We expect that treatment costs for IPS Plus Abstinence-Contingent Wage 
Supplements will be higher per person relative to Usual Care due to the IPS and wage supplements and 
because we expect that IPS Plus Abstinence-Wage Supplement participants will have greater treatment 
engagement. 
Cost-Effectiveness (secondary aim). Assess the cost-effectiveness of IPS Plus Abstinence-
Contingent Wage Supplements. Separate cost-effectiveness analyses will be conducted for the outcomes 
of alcohol use, employment, and homelessness. We will assess incremental cost-effectiveness ratio 
(ICER) by dividing the difference in costs of two interventions by the difference in the effects of the two 
interventions. The estimated ICER can be interpreted as dollars spent per unit of desired outcomes 
gained. Hypothesis: We expect that IPS Plus Abstinence-Contingent Wage Supplements will yield better 
ICERs for all measures.  
Cost-Benefit (secondary aim). Assess the cost-benefit of IPS Plus Abstinence-Contingent Wage 
Supplements. We will perform a Cost-Benefit Analysis (CBA) to examine the monetized benefits relative to 
costs for the two groups. The economic outcomes are employment, crime, subsidized housing, and health 
care utilization. Hypothesis: We expect that IPS plus Wage Supplement will yield greater economic 
benefits in the 18-month post random assignment time period relative to the costs of Usual Care.  
 
c. Statistical plan including sample size justification and interim data analysis. 
Power Analysis 
The primary outcome measures will be analyzed with a longitudinal binominal regression model 
using generalized estimating equations (GEE; Diggle & Diggle, 2002). We used Liu and Liang (Liu & 
Liang, 1997) to determine the total N required to detect 
differences between groups with 80% power. The 
adjacent figure shows the total number of participants (N) 
that would be required to detect a difference of 15% 
between the Usual Care Control and the IPS Plus 
Abstinent-Contingent Wage Supplement with the monthly 
assessments. The figure shows possible percentages for 
the Usual Care Control group because that value affects 
the sample size required. Fifteen percent is smaller than 
any difference in any Therapeutic Workplace study in 
which we promoted alcohol abstinence in homeless 
adults or cocaine abstinence in methadone patients (see 
figure in “Significance Section”). The horizontal red lines 
show the number of participants planned based on the number of participants randomized to the two 
groups without (top dashed red line) and after adjusting for the anticipated rates of missing data (10% 
missing, bottom solid red line). Based on this analysis, we need to randomize 130 participants (dashed red 
line) to ensure that we have sufficient sample sizes after adjusting for the rates of missing data. After 
adjusting for missing data (10% missing), this would yield a sample size of 117 participants (130 
participants x 0.90 collected assessments = 117 participants). The adjusted sample size of 117 
participants (solid red line) is a little more than the maximum number of required participants.  
Main Statistical Analyses  
Main analysis. All measures assessed repeatedly will be analyzed with a longitudinal binominal 
regression model. Within-person correlated outcomes will be handled using GEE (Zeger et al., 1988). 
Measures assessed once will be analyzed using logistic regression. The magnitude of effect for both 
0
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60
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80
0
20
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60
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Liu and Lang (1997)
Adjusted for
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Unadjusted
Possible Percentages for Usual Care Control
Required Sample Size (N)

 
 
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regression and GEE will be expressed using odds ratios with 95% CI. Analyses will include all 
randomized participants as intent-to-treat, and will be adjusted for pre-specified covariates used for 
stratification (Pocock et al., 2002). Tests will be two-sided and, because we have one primary outcome, 
alpha will be set at 0.05. Based on our previous experience, we expect rates of attrition at monthly visits 
to be low. If rates are higher than expected, we will use mixed effects models rather than GEE estimation, 
as the former has less strict assumptions regarding missing data (MAR, rather than MCAR).  If it appears 
that the missing data are MNAR, then we will fit pattern mixture models as described by Hedeker & 
Gibbons (1997).  
Missing data. We expect to collect >90% of assessments. Our approach to handle missing data 
will be to impute all missing values as the adverse outcome (e.g., alcohol positive). Model parameter 
estimates from this approach will be compared to a method without imputation. If these methods yield 
differing results, conclusions will need to be tentative, but results from both approaches will be reported in 
publications. To investigate sensitivity to missing values, participants with and without missing values will 
be compared by covariates and treatment assignment. If rates of missingness are higher than expected, 
we may use multiple imputation (Rubin, 1996) or pattern mixture models (Hedeker & Gibbons, 1997) to 
obtain unbiased estimates of treatment effects. 
Consideration Of Sex And Other Variables In Moderating The Outcomes 
We will conduct analyses to identify biological and other variables that moderate the outcomes of 
employment and alcohol abstinence. We will examine efficacy differences as a function of four variables 
assessed prior to random assignment by including interaction terms in our regression models: 1) Percent 
of days abstinent from alcohol (based on transdermal alcohol concentrations) prior to random assignment. 
2) Opiate- and cocaine-negative urine samples from the assessment prior to random assignment. 3) 
Completed high school or obtained a GED; and 4) gender (male/female).  Alcohol use and opiate/cocaine 
use prior to random assignment should be associated with higher rates of alcohol use and lower rates of 
employment during the 6 months after random assignment. We expect that high school completion or 
obtaining a GED will be associated with higher rates of employment. Gender is a key biological factor that 
may influence outcome. We also expect that the effect of IPS Plus Abstinence-Contingent Wage 
Supplements will be affected by these variables.  
Balancing of potential moderators of treatment response via urn randomization merely ensures that 
the estimation of the treatment effect is unbiased. Balancing the randomization by these variables allows 
for them to be adjusted for in subsequent analyses. It does not take the place of these adjustments. 
Moderator analysis entails fitting a model with the main effects of treatment and the putative moderating 
variable, and their interaction. Likewise, balancing the variables during randomization does not take the 
place of fitting this interaction. For more discussion, see Pocock et al. (2002).  
We will conduct similar analyses to identify variables that moderate outcomes on employment and 
alcohol use during the follow-up year after the interventions have ended. We will examine differences in 
outcomes during the follow-up year as a function of three variables assessed at the end of the intervention 
period by including interaction terms in our regression models: 1) Percent days abstinent from alcohol 
from the last 3 months under the study interventions; 2) percent of opiate- and cocaine-negative urine 
samples from the last 3 monthly assessments under the study interventions; 3) Highest hourly wage that 
each participant earned during the year after random assignment. We expect that alcohol and 
opiate/cocaine use during the last 3 months under the study interventions will be associated with higher 
rates of alcohol use and lower rates of employment during the follow-up year. We expect that the highest 
wage achieved under the study interventions will be associated with higher rates of employment and lower 
rates of alcohol use during the follow-up year.  
Economic Analyses 
Our economic evaluation will be done from the provider perspective. 
Cost Analysis. We will derive cost estimates of intervention activities following an activity-based 
approach (Drummond et al., 2005; Gold et al., 1996; Zarkin, Dunlap et al., 2004; Zarkin et al., 2005; 
Zarkin, Dunlap, et al., 2008). The total cost per participant of each intervention will be the sum of the cost 
for (1) staff labor, (2) building space, (3) wage supplements, and (4) supplies or materials. The total 
intervention cost for each participant is the cost per activity multiplied by the number of activities or 
services received by the participant. Taking the mean across participants in an intervention yields the 
mean per participant cost of that intervention. Treatment attendance will be captured in the modified 
Economic Form 90 AIR/ED. Standard addiction treatment costs will be drawn from the literature (e.g., 
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Cost-Effectiveness. Our Cost-Effectiveness Analysis (CEA) methodology (e.g., Zarkin et al.,1996, 
1997, 2008; Dunlap et al., 2010) will combine the cost estimates (above) with intervention effectiveness 
measures. Separate cost-effectiveness analyses will be conducted for alcohol use, employment, and 
homelessness. The incremental cost-effectiveness ratio (ICER) is calculated by dividing the difference in 
costs of two alternatives by the difference in effects of the alternatives. The estimated ICER can be 
interpreted as dollars spent per unit of desired outcomes gained (e.g., $300 per day abstinent). To gauge 
ICER sampling uncertainty, we will calculate the CI via nonparametric bootstrap methods (Indurkhya et al., 
2001; Briggs et al., 2006). We will estimate cost-effectiveness acceptability curves (CEAC) using 
nonparametric bootstrap methods (e.g., Dunlap, et al., 2010; Zarkin et al., 2008). The CEACs show the 
probability that a treatment is cost-effective as a function of the policy maker’s intrinsic 
valuation/willingness to pay for the clinical outcome. 
Cost-Benefit. We will perform a Cost-Benefit Analysis to examine the monetized benefits relative to 
costs for the two study conditions. The key economic outcomes are employment, crime, and health care 
utilization assessed through the modified Economic Form 90 AIR/ED. The unit costs of these outcomes 
will be drawn from literature and public data sources (e.g., Zarkin et al, 2010). 
Sensitivity Analysis. We will conduct sensitivity analyses to assess whether the economic results are 
affected by changes in model parameters. We will perform one-way sensitivity analyses in which we 
examine the effect of changing one of the model parameters while holding all other parameters constant. We 
will perform n-way sensitivity analyses in which n parameters of the model are varied jointly, holding other 
parameters constant. 
Northern Michigan University 
Dr. Forrest Toegel and his team are at Northern Michigan University and will see and handle de-
identified data for this protocol. The Northern Michigan University IRB has determined that Dr. Toegel team's 
part in the research (analyzing de-identified data) is exempt. The letter from the Northern Michigan University 
IRB is uploaded below. 
Here is NMU's Scope of Work for this project. Northern Michigan University will assist in preparing 
the data for analyses, and preparing and submitting manuscripts for publication and presentation. Forrest 
Toegel is an Assistant Professor at Northern Michigan University. Under Dr. Toegel's supervision, research 
assistants will work with research staff at Johns Hopkins University School of Medicine to prepare the study 
data for analyses, and summarize and graph data for reports, publication, and presentation. 
d. Early stopping rules. 
The protocol will be stopped if the Data Safety Monitoring Board recommends that the protocol be 
stopped due to unexpected rates of adverse events related to the protocol. 
 
8. Risks 
a. Medical risks, listing all procedures, their major and minor risks and expected frequency. 
There is essentially no risk above those of normal daily living associated with the training or work 
in the Therapeutic Workplace, with participation in the Individual Placement and Support program, with 
obtaining employment in community workplaces, with the incentive program, or with the data collection 
procedures used in these studies. 
Side effects may occur from wearing a SCRAM bracelet. These include sores, open wounds, 
bruising, skin irritation and redness. Individuals who currently have nickel or other metal allergies, deep 
vein thrombosis, or leg ulcers may be more likely to experience side effects of wearing SCRAM. 
Side effects may occur from wearing a BACtrack Skyn bracelet. These include skin irritation and 
redness. 
 
b. Steps taken to minimize the risks. 
We will take several steps to minimize the risks associated with wearing SCRAM. Participants will 
be taught how to clean around and underneath their SCRAM bracelets to minimize the risk of developing 
side effects. Study staff will inspect the area surrounding participants’ bracelets for skin redness, sores, 
bruising, or irritation when participants attend the research site to transmit the data stored on their 
bracelets. The bracelet may be loosened or switched to the other ankle. Participants who experience 
sores, open wounds, or severe bruising, irritation or redness will be seen by the study clinician, who will 
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To protect confidentiality, all research participants are identified by participant identification codes 
(Participant IDs) consisting of their initials and sequentially-assigned participant numbers on most forms 
and data files, and not by their names. Picture ID cards are maintained by staff in a locked container, and 
kept in a locked, secured area when not in use. All research data are stored in locked areas accessible 
only to research staff and are not left unattended. Documents with confidential information are shredded 
before being discarded. Confidential information is never given to anyone outside of the research program 
without the explicit written permission of the research participant. Only selected designated staff members 
are approved to give confidential information out after obtaining explicit written permission from the 
participant. All research staff are trained in these procedures. We collect only general information about 
participant activities, legal and illegal. We do not collect information about specific illegal acts. In addition 
to these procedures, all persons who visit or work at the Center for Learning and Heatlh are required to 
sign a confidentiality agreement, in which they agree not to disclose any confidential information that they 
may become aware of in the course of their time at the center. All participants are also invited to take a 
break and leave the workplace when visitors come to the Center for Learning and Health. To further 
protect confidentiality, we will obtain a confidentiality certificate from NIH to protect data collected in this 
study.  Finally, to protect the confidentiality of participants who become employed in a community job, we 
will not interact with an employer unless the participant gives explicit written permission. 
c. Plan for reporting unanticipated problems or study deviations. 
Unanticipated problems or study deviations will be reported based on the guidelines of the Johns 
Hopkins University School of Medicine IRB. 
 
d. Legal risks such as the risks that would be associated with breach of confidentiality. 
There are risks that the confidential information we collect could be revealed to people not involved 
in the research such as a friend, relative, or an outside organization. This could be embarrassing to the 
participant if the participant wanted to keep participation in the study secret. The legal risks are limited 
because we collect only general information about participant activities, legal and illegal. We do not collect 
information about specific illegal acts. Thus, the risks associated with the assessments are not greater 
than the risks associated with routine psychological examinations or tests. 
 
e. Financial risks to the participants. 
There are no financial risks above those of normal daily living.  Each participant is responsible for 
ensuring that the earning of incentives is reported properly to relevant government or private agencies and 
for determining whether or not the earnings will affect any benefits they might receive from those 
agencies. 
9. 
Benefits 
a. Description of the probable benefits for the participant and for society. 
Benefits for the participant. All participants will have access to training in skills that could be 
useful in obtaining employment. Training will be provided in typing, keypad, general computer use, 
reading, math, GED preparation, and the use of Microsoft computer applications. IPS supported 
employment will be provided to help participants become employed.  Since all participants in this study 
will be unemployed at the start of the study, this experience could help prepare participants for 
employment. 
All participants will receive monetary incentives for participating in the Therapeutic Workplace 
during the first month of the study. Participants in the IPS Plus Abstinence-Contingent Wage 
Supplements group will get abstinence-contingent incentives for engaging in IPS supported employment 
and for obtaining and maintaining competitive employment. These incentives should increase 
participation in the Therapeutic Workplace, development of job skills, employment, and abstinence from 
alcohol. The earnings and payments could also have the benefit of providing a means of purchasing 
things that the individual would not otherwise be able to afford, including housing. 
 
Benefits for society. The study will evaluate the effectiveness, cost-effectiveness, and cost-
benefit of IPS Plus Abstinence-Contingent Wage Supplements in increasing employment and promoting 
long-term alcohol abstinence. This novel intervention could be an effective and economically sound 
means of promoting long-term alcohol abstinence and employment in homeless adults with alcohol use 
disorder, a population at considerable risk for a range of adverse outcomes including HIV because of 

 
 
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their poverty, unemployment and continued alcohol use. If participants complete the job training and use 
IPS supported employment services, they could become employed which could reduce their need for 
government services.  If employed, they could also contribute to the overall tax revenue generated in 
their community.  If the job skills training and employment program increases the employment of 
participants, it could reduce their poverty and reduce transmission of poverty to their children. 
 
10. 
Payment and Remuneration 
a. 
Detail compensation for participants including possible total compensation, proposed bonus, 
and any proposed reductions or penalties for not completing the protocol. 
All incentives in this study will be provided by giving participants reloadable credits and adding 
incentives to the card when earned. Restrictions can be placed on these cards to restrict where they can 
be used to make purchases. We have been using these reloadable credit cards in our ongoing research 
and they have proved attractive to participants and convenient for staff to manage. 
 
Phase 1 Induction and Training Incentives. All participants will be invited to enroll in the 
Therapeutic Workplace induction period for 1 week, where they can earn $20 every weekday or a total of 
$100. Participants who complete the induction period will be invited to enroll in the Therapeutic Workplace 
for about 3 weeks, where they can earn about $32/weekday for participating in our job skills training 
program. In total, participants will be able to earn $580 in Phase 1. 
 
Phase 2 Abstinence-Contingent Wage Supplements. Participants in the Abstinence-Contingent 
Wage Supplement group will be able to earn wage supplements of up to $8 per hour for up to 40 hours 
per week for 24 weeks. In total, participants in the Abstinence-Contingent Wage Supplement group will be 
able to earn up to $7,680 in wage supplements. 
 
Participant payment for wearing alcohol biosensor. Participants can earn daily pay for wearing 
their wearable alcohol biosensor. Participants can earn $0.25 per hour for wearing their alcohol biosensor 
and can earn a $5 bonus for wearing their alcohol biosensor for at least 18 hours per day. However, to 
receive the daily payment participants must receive permission to remove their bracelet by sending 
research staff a photo or video of themselves wearing the bracelet after they put the bracelet back on. In 
total, participants could earn a maximum of $11 per day for wearing their biosensor.  
Participant payment for assessments. Assessments will be conducted for all participants at 
intake to determine eligibility and characterize the population, immediately prior to random assignment, 
every 30 days throughout the 6-month intervention evaluation period after random assignment and then at 
6 and 12 months after the end of the intervention evaluation period. Participants will be paid $30 for the 
intake and monthly assessments during the 1-month training period and the 6-month intervention 
evaluation period, and $50 for the assessments conducted 6 and 12 months after the end of the 
intervention evaluation period. In total, participants will be able to earn up to $340 for completing the 
assessments in this study. 
Participant referral fees.  As in our previous studies, participants will have the optional 
opportunity to earn incentives for referring people who are interested in the study.  If a referral attends the 
initial screening appointment and completes the necessary assessments, the participant who referred the 
person will receive up to $20.  If a referred person enrolls in the main study, the participant who referred 
the person will receive up to $40 for making the referral. 
Device Return. To help ensure that participants return their wearable alcohol biosensor bracelets 
after their study participation ends, participants will be able to earn $100 for returning the bracelet to our 
staff.  
 
11. 
Costs 
a. 
Detail costs of study procedure(s) or drug (s) or substance(s) to participants and identify 
who will pay for them. 
There will be no costs to participants for any services or treatment provided in this study.  All 
procedures in the study will be paid for out of grant funds.