Abstinence-contingent recovery housing and reinforcement-based treatment following opioid detoxification

Pharmacotherapies such as methadone or buprenorphine are effective in the treatment of opioid dependence,1,2 but many patients are not interested in these medications, or simply have no access to them.3,4 For opioid dependent individuals who enter drug-free treatment, the road to recovery typically begins with detoxification. However, detoxification appears to be ineffective as a stand-alone treatment for opioid dependence, with relapse rates that range from 65% to 80% at one month post-discharge.5,7 Outpatient substance abuse treatment that includes housing may be especially attractive to opioid dependent patients who have completed a detoxification program. Individuals recovering from substance use disorders frequently report their need for housing as a top priority.8 Drug users who return to their former housing after leaving a controlled environment, such as inpatient detoxification, may encounter environmental cues that could precipitate relapse to drug use.9 Several recent controlled studies show that housing improves outcomes for substance users,10,11 and that making housing contingent upon drug abstinence produces higher rates of drug abstinence than non-contingent housing.12–15 In Baltimore City, recovery houses are typically operated by individuals in recovery and require that residents pay rent, remain abstinent, and obey house policies. The current study investigated the utility of abstinence-contingent housing for maintaining drug abstinence following medication-assisted detoxification. In previous research with recently detoxified opioid dependent patients, abstinence-contingent housing was provided in the context of Reinforcement-Based Treatment (RBT), a multi-component intensive day-treatment program based in part on the community reinforcement approach16–18. RBT includes cognitive behavioral group therapy,19 abstinence-contingent recreational activities, vocational assistance, and individual counseling in addition to housing support. In a short-term evaluation, RBT participants were more likely to be enrolled in a treatment program at 1 month compared to usual care controls (61% versus 17%, respectively), and more likely to be continuously abstinent from opioids and cocaine (50% versus 21%, respectively) during the first month after detoxification.20 However, abstinence rates of RBT participants declined once abstinence-based incentives were removed. In a similar but larger study (N = 130), RBT participants were significantly more likely than usual care controls to be drug abstinent at 1 and 3-month follow-up, but not at 6 or 12-month follow-up.21 However, RBT participants had higher rates of employment and legal earnings at 6 and 12 month follow-up compared to usual care. Although abstinence-contingent housing is a major component of RBT, the specific contribution of housing to improved outcomes has not been examined. The purpose of this randomized study was to determine whether abstinence-contingent recovery housing (RH) is an effective intervention for sustaining abstinence in opioid-dependent patients exiting residential detoxification and whether outcomes are further improved when abstinence contingent housing is delivered in the context of a day treatment program (RH+RBT). We hypothesized that RH+RBT would have the best overall outcomes, and that RH would have better outcomes than usual care. The specific role of recovery housing as a mediator of primary outcomes also was explored.