Kenneth Silverman - US grants

Incentive therapies designed to reinforce drug abstinence have been effective in enhancing patient motivation and reducing drug use. Recent research suggests particular efficacy for a novel incentive system in which patients earn tokens or vouchers for drug-free urines that are exchanged for retail items or services in the community. We propose a series of four interrelated studies to be conducted in methadone maintenance patients who continue high rates of intravenous cocaine and/or opioid use despite participation in standard methadone treatment. The general objective of these studies is to enhance the effectiveness of voucher-based incentive procedures both for promoting initial abstinence in chronic intravenous polydrug abusers and for preventing relapse. This goal will be accomplished by systematically altering features of the voucher incentive program with attention to behavior analytic principles that suggest how such alternations should influence behavior and by evaluating the result of parametric alteration in controlled clinical research. Study 1 will replicate promising preliminary results showing that voucher incentive programs can have dramatic efficacy in promoting abstinence from supplemental drug use during methadone treatment, and examine the influence of voucher pay amount to determine if treatment effectiveness is improved by increasing the magnitude of the reinforcers employed. Study 2 will determine the influence of voucher scheduling parameters (e.g., "start-up bonus") on rates and patterns of abstinence obtained. Study 3 will determine if relapse can be prevented in previously abstinent patients by using a schedule of intermittent reinforcement that gradually tapers reinforcer delivery over time. Finally, Study 4 will determine if a more intensive intervention program can be effective for impacting drug use of treatment-resistant patients who have failed to become abstinent in a standard voucher incentive program. Results of these interventions will be evaluated on specific primary measures of drug use as well as a broader range of measures of psychosocial functioning and behavioral adjustments needed to achieve abstinence. In all studies, demographic, psychiatric diagnostic and drug use variables will be used to identify characteristics of patients who do and do not respond to voucher incentive therapies. Overall, these studies will provide valuable information concerning the potential of voucher-based incentive therapies to initiate and sustain long-term drug abstinence. Results obtained will improve understanding of the general principles and mechanisms of behavior therapy for intravenous polydrug abusers and should have broad generality for treatment of drug abusers in a variety of settings.

Economic and social conditions are recognized as important determinants of drug abuse, leading some observers to suggest that a primary focus of drug abuse treatment should be to alter those basic living conditions that are at the roots of the problem. Unemployment is one of those conditions that has received considerable attention. Indeed, drug use is associated with unemployment in the general population, it is common among drug abusers in treatment, and it is associated with poor treatment outcomes. Supported work programs represent a promising approach in the treatment of severe employment problems among drug abusers since they provide job training, work experience, and income. But these programs have an extraordinary, yet simple potential use in the treatment of drug abuse that thus far has not been tapped, and herein lies the crux of this proposal: The salaries that supported work participants earn for work can also be used to reinforce drug abstinence. We are proposing to develop and evaluate a model therapeutic workplace for drug abusers that utilizes this untapped potential of supported workplaces. The therapeutic workplace is designed to integrate the therapeutic effects of abstinence reinforcement contingencies of proven efficacy into a model supported work environment. The target population will be new mothers who are patients in a model treatment program for pregnant drug-abusing women, a population sorely in need of effective interventions to control their drug use and associated risk of acquiring HIV infection and AIDS, as well as interventions to improve their employment status. A pilot phase and one controlled study are planned over a three-year period. The pilot phase will be conducted to refine the therapeutic workplace procedures including refinement of the teaching curriculum, training of staff, refining the scheduling and payment parameters, and integrating of research and training activities. The main study will examine the effects of voucher reinforcement on abstinence and workplace attendance using a balanced factorial design in which incentives are targeted on attendance, abstinence, both or neither for different subject groups. The hypothesis is that best overall outcomes (on productivity and drug use) will be obtained when both desired behaviors (abstinence and attendance) are targeted. This study will directly test the therapeutic benefits of the novel idea being proposed here using appropriate control and comparison conditions. Overall, these studies will allow for the development and rigorous evaluation of a novel approach to the treatment of drug abuse, the therapeutic workplace, in a population of drug abusing new mothers who desperately need effective interventions to control their drug use and to improve their employment status.

DESCRIPTION: (provided by applicant) The Therapeutic Workplace is a novel treatment designed to address the chronic and persistent nature of drug addiction and unemployment. Under this intervention, drug abuse patients are hired and paid to work in an income-producing Therapeutic Workplace business. To promote abstinence, participants are required to provide drug-free urine samples to maintain daily access to the workplace. Applicants actively using drugs and lacking job skills participate in an initial training phase to initiate abstinence and establish job skills. If the business is financially successful, this treatment could be maintained over extended periods of time at little cost to society. This application is a competing continuation of a grant in which we developed and pilot tested a computerized Therapeutic Workplace designed to train and employ adults as data entry operators. A randomized trial is planned over 5 years to investigate the Therapeutic Workplace business as a maintenance intervention to sustain long-term abstinence and employment. Welfare recipients in methadone treatment, actively using cocaine, and at risk for contracting or spreading HIV infection will participate in an initial Therapeutic Workplace training phase. Participants (N=156) who become abstinent and skilled will be randomly assigned to a "Usual Care Control," an "Employment Only," or an "Abstinence & Employment" group. "Usual Care Control" participants will be referred to seek a job in the community. "Employment Only" participants will be offered employment for one year in a Therapeutic Workplace business, but these participants will not have to provide drug-free urine samples to work. Participants in the "Abstinence & Employment" group will be employed for one year also, but these participants will have to provide drug-free urine samples to work and earn salary. This study will provide a rigorous evaluation of the efficacy of the Therapeutic Workplace business as a long-term treatment of cocaine addiction and unemployment; determine the benefits of requiring daily evidence of abstinence to work; and provide information on the extent to which a Therapeutic Workplace business can become self-sustaining. This research could provide firm scientific foundation for the dissemination of Therapeutic Workplace businesses in the long-term treatment of cocaine addiction and unemployment.

A THERAPEUTIC WORKPLACE TO PREVENT HIV TRANSMISSION Intravenous drug users who are infected with the human immunodeficiency virus (HIV) are at considerable risk for spreading HIV infection through the sharing of infection equipment. Reducing or eliminating drug use in this critical population may be an unusually efficient and effective means of preventing the spread of HIV infection, and herein lies the crux of this proposal: We propose to evaluate a novel drug-abuse treatment program of proven efficiency, the Therapeutic Workplace, in a population of HIV positive, intravenous drug abusers. The intervention integrates abstinence reinforcement contingencies into a model supported work program. Patients are paid to perform data entry jobs in the Therapeutic Workplace. Those lacking needed skills are given intensive training. To reinforce and promote drug abstinence, patients are required to provide a drug free urine sample to gain entrance to the workplace each day. In this way, patients can work and earn salary only when they abstain from drugs. Patients are paid in vouchers instead of cash to reduce the chance they will use their earning to purchase drugs. A randomized trial is planned over 5 years to evaluate the efficacy of this intervention and to assess the contribution of the abstinence reinforcement component in adult intravenous drug abusers who are HIV positive and who complete an inpatient drug and alcohol detoxification. After the detoxification, 156 participants will be invited to attend the workplace for 6 months and randomly assigned to one or three groups that will differ in the requirements of voucher reinforcement. One group will receive the full therapeutic workplace intervention in which vouchers are contingent on both abstinence and work. A second group will be paid for work, but will not have to provide a drug-free urine sample to gain access to the workplace (vouchers contingent on work only). A third group will receive vouchers on a non-contingent basis. This group will control for the increases in wealth associated with voucher reinforcement. Critical measures of drug use and HIV risk behaviors will be assessed. We expect the most abstinence when both abstinence and work are required to earn vouchers. This study will allow for the rigorous evaluation of a novel approach to the treatment of drug abuse, the Therapeutic Workplace, in HIV positive, intravenous drug abusers; and provide critical information on the potential of this intervention to serve as a targeted strategy to prevent the spread of HIV infection.

Cocaine abuse is a serious public health problem which has been difficult to treat. One of the most effective treatments involves the reinforcement of cocaine abstinence. Abstinence reinforcement procedures derive from an extensive body of laboratory and clinical research in the field of operant conditioning which has shown that drug use can be maintained and modified by manipulating its environmental consequences. We propose to conduct Stage I research to complete development of a novel treatment, a reinforcement-based Therapeutic Workplace, for chronically unemployed, cocaine dependent adults. The Therapeutic Workplace integrates abstinence reinforcement contingencies of proven efficacy into a model supported work program. The critical feature of the intervention is simple: Patients must provide drug free-urine samples to gain entrance to a workplace where they can work and earn salary. This procedure in which two responses are required sequentially (abstinence and then work) to earn salary is called a chained schedule of reinforcement. The chaining is useful because it does not require an independent source of funds to address the abstinence issue, but utilizes work-based salary to reinforce abstinence. The first phase of this treatment (Phase I) is designed to initiate abstinence, teach job skills, and promote professional demeanor. In this critical period, patients earn vouchers instead of cash to reduce the chance that they use earnings to purchase drugs. Phase I has been partially developed and evaluated in a controlled trial which showed that voucher-based salary can reinforce drug abstinence. In Phase II, abstinent and skilled patients will be hired into a business where they will perform real jobs; earn cash salary; and receive random and progressively less frequent drug testing. Phase II will be fully integrated into Baltimore City's welfare-to-work program. We propose to develop Phase II of the intervention, including its integration into Baltimore's welfare-to-work program; to develop a detailed treatment manual for Phases I and II; to computerize most aspects Phases I and II to facilitate their implementation and dissemination to new sites; to conduct a pilot study of a model of the full Therapeutic Workplace intervention; and revise the manual and software based on the results of the pilot study. This research will allow for the development of a novel drug abuse treatment, the Therapeutic Workplace, which could provide a cost-effective means of arranging abstinence reinforcement contingencies of proven efficacy on a wide scale, and could serve as a model program for addressing the often debilitating problem of drug abuse in the nation's welfare-to-work programs.

APPLICANT'S ABSTRACT: Few populations are beset with the constellation of economic, social and health problems that afflict homeless individuals. Alcoholism is one of their most common and serious problems. Given the nature and severity of their problems, the Institute of Medicine has suggested that the homeless need specialized substance abuse interventions. We propose to examine the efficacy of a novel treatment for chronically unemployed substance abusers, the Therapeutic Workplace, in homeless, alcohol-dependent adults. Prior research has shown that this intervention is effective in the treatment of heroin and cocaine dependence. The intervention integrates abstinence reinforcement contingencies of proven efficacy into a model supported work program. Patients are paid to perform data entry jobs in the Therapeutic Workplace. Those lacking needed skills are given intensive training. To reinforce abstinence from alcohol, patients can work and earn salary only when they remain abstinent from alcohol as assessed in weekday morning and random daily breath-alcohol tests. Patients are paid in vouchers instead of cash to reduce the chance they will use their earnings to Purchase alcohol or drugs. A randomized trial is planned over 5 years to evaluate the efficacy of this intervention and to assess the contribution of the abstinence reinforcement component in homeless, alcohol-dependent adults who complete an inpatient alcohol detoxification. After the detoxification, 156 participants will be invited to attend the workplace for 6 months and randomly assigned to one of three groups that will differ in the requirements for voucher reinforcement. One group will receive the full therapeutic workplace intervention in which vouchers are contingent on both abstinence and work. A second group will be paid for work, but will not have to provide an alcohol-free breath sample to gain access to the workplace (vouchers contingent on work only). A third group will receive vouchers on a noncontingent basis. This group will control for the increases in wealth associated with voucher reinforcement. Critical measures of alcohol use, other drug use, HIV risk behaviors, employment and housing will be assessed. We expect the most abstinence when both abstinence and work are required to earn vouchers. This study will allow for the rigorous evaluation of a novel approach to the treatment of alcohol dependence, the Therapeutic Workplace, in a group of homeless, alcohol-dependent individuals who desperately need effective interventions to control their alcohol use, and to improve their chronic conditions of unemployment and homelessness.

DESCRIPTION (provided by applicant): Heroin addiction can have devastating social, medical and economic consequences. Methadone maintenance is an effective treatment for heroin addiction, but only about 20 percent of opiate dependent individuals receive it. Naltrexone is an opiate antagonist that could provide an extraordinarily effective alternative for many individuals. However, its utility has been limited because most individuals refuse it. A randomized study is planned over 5 years to evaluate the effectiveness of the Therapeutic Workplace in promoting naltrexone ingestion and abstinence in unemployed opiate-dependent injection drug users. The Therapeutic Workplace is a novel employment-based intervention that uses salary for work to reinforce clinically important behavior change. Drug abuse patients are hired and paid in this model workplace. To promote clinically important behaviors, salary is arranged contingent both on work and on the emission of those behaviors. Participants will be offered an opioid detoxification and naltrexone induction. Participants who complete the naltrexone induction will be randomly assigned to one of three groups. All groups will be invited to work in the Therapeutic Workplace and prescribed naltrexone for 26 weeks. The groups will differ in the contingencies imposed to work and earn salary. "Work Plus Naltrexone Contingency" participants will be required to ingest naltrexone to work, and will receive a brief pay decrease for missing a dose. "Work Plus Naltrexone and Abstinence Contingency" participants will be required to ingest naltrexone to work, and will receive a brief pay decrease for missing a dose of naltrexone or for providing an opiate or cocaine positive urine sample. "Work Plus Naltrexone Prescription" participants will be prescribed naltrexone, but will not be required to ingest it to work. Critical measures of opiate and cocaine use and HIV risk behaviors will be assessed. This study will provide a rigorous evaluation of a novel employment based intervention, the Therapeutic Workplace, to promote naltrexone ingestion and drug abstinence in a population of injection drug users who are at considerable risk of spreading or contracting HIV infection.

DESCRIPTION (provided by applicant): Injection heroin use is a chronic problem that fuels the transmission of HIV/AIDS through risky injection behaviors. Methadone and buprenorphine can reduce heroin use and risky injection behavior; however, they have abuse potential, produce physical dependence, can produce lethal overdose, are highly regulated, and some patients simply do not want agonist treatment. Opiate detoxifications can serve as an alternative to agonist treatment, but many injection drug users relapse to heroin use and resume risky injection behaviors after detoxification. Vivitrol(R), an extended release formulation of naltrexone, was recently approved by the FDA for the treatment of opioid dependence, but its clinical utility is uncertain given the reluctance of many opioid- dependent adults to maintain its long-term use, and the fact that some patients continue to use opiates while under naltrexone blockade. Our research in the first period of this grant showed that employment-based reinforcement can be highly effective in promoting long-term adherence to Vivitrol(R). Employment-based reinforcement may be ideally suited to address the limitations of extended release naltrexone by capitalizing on its potential to simultaneously reinforce naltrexone adherence and opiate abstinence. This grant will evaluate the effectiveness of employment-based reinforcement to simultaneously promote high rates of Vivitrol(R) adherence and increase opiate abstinence. In this 5-year study, we propose to evaluate the separate and combined effects of the FDA-approved formulation of extended release naltrexone (Vivitrol(R)) and employment- based reinforcement of opiate abstinence in promoting opiate abstinence and reducing risky injection behavior in recently detoxified, opioid-dependent, injection drug users. After an opioid detoxification and induction onto oral naltrexone, participants will be invited to attend the Therapeutic Workplace for 24 weeks (where they can work and earn wages) and will be randomly assigned to one of four groups that will differ in whether they receive Vivitrol(R), employment-based opiate abstinence reinforcement, both or neither. Participants in Vivitrol(R) conditions will be required take scheduled injections to work and earn wages. Participants exposed to opiate abstinence reinforcement will receive a temporary decrease in their workplace pay if they fail to provide an opiate-free urine sample. The study will assess the effects of the interventions on weekly opiate urinalysis results, and on measures of injection drug use and cocaine use. If this study shows that the combined use of Vivitrol(R) and employment-based reinforcement of adherence and opiate abstinence is effective in maintaining long-term opiate abstinence, this model of employment-based addiction pharmacotherapy could be integrated into community workplaces to disseminate the effective use of Vivitrol(R); it could be used to enhance the utility of other new antagonist-like addiction medications; and it could provide an effective means of reducing injection drug use in individuals who persist in injecting heroin and exposing themselves and others to the risk of acquiring or transmitting HIV infection due to their continued injection drug use and risky injection behaviors.

DESCRIPTION (provided by applicant): Injection drug use is a common mode of HIV transmission. Methadone can reduce injection heroin use and injection-related HIV risk behaviors, but most injection heroin users are difficult to engage in treatment. A randomized study is planned over 5 years to evaluate the effectiveness of the Therapeutic Workplace in promoting engagement in methadone treatment and increasing drug abstinence in unemployed, out-of- treatment, injection heroin users. The Therapeutic Workplace is a novel employment-based intervention that uses wages for work to reinforce clinically important behavior change. Workplace participants are paid to work in a supported workplace. To promote clinically important behaviors, wages are arranged contingent both on work and those behaviors. In this study, participants will be invited to attend the workplace and enroll in methadone treatment. During a workplace induction period, participants will be allowed to work and earn wages independent of whether they enroll in methadone treatment and independent of their drug use. After 4 weeks, workplace participants (N = 162) will be randomly assigned to one of three groups. All groups will be invited to attend the workplace for 26 weeks. "Methadone Contingency" participants will be required to take methadone to work, and will receive a brief pay decrease for missing a dose. Because many heroin users also use cocaine, even during methadone treatment, "Methadone and Abstinence Contingency" participants will be required to take methadone to work, and will receive a brief pay decrease for missing a methadone dose or for providing a cocaine-positive urine sample. "Usual Care" participants will be allowed to work independent of their methadone use or urinalysis results. We expect that the "Methadone Contingency" group will increase methadone adherence and decrease heroin use;and that the "Methadone and Abstinence Contingency" group will increase methadone adherence, and decrease heroin and cocaine use. Since methadone is effective at retaining patients in treatment once enrolled, we expect that once the "Methadone Contingency" engages participants in methadone treatment, the methadone will serve to maintain their participation in treatment after exposure to the Therapeutic Workplace ends. The Therapeutic Workplace could serve as a bridge to engage out-of-treatment injection heroin users into methadone treatment, and to reduce their drug use and injection-related HIV risk behaviors.

? DESCRIPTION (provided by applicant): Drug addiction is a chronic relapsing disorder. High magnitude and long-duration voucher-based abstinence reinforcement is one of the most effective treatments for drug addiction and can maintain cocaine 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 drug-free urine samples to maintain maximum pay, can maintain cocaine abstinence. Now we need to develop effective and economically sound methods to arrange long-term exposure to employment-based abstinence reinforcement. We are proposing 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 drug abstinence. The intervention will combine 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 drug abstinence and establish job skills. To promote employment and prevent relapse to drug 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 cocaine abstinence in low-income unemployed injection drug users who continue to use cocaine during opioid agonist treatment (N=120). Participants will be enrolled in the Therapeutic Workplace for 3 months and then randomly assigned to an IPS Only group or an IPS Plus Abstinence-Contingent Wage Supplement group for one year. IPS Only participants will receive the IPS intervention. IPS Plus Abstinence-Contingent Wage Supplement participants will receive the IPS intervention and abstinence-contingent wage supplements. Drug use while participants are employed in community jobs will be monitored by American Substance Abuse Professionals, Inc. (ASAP(r)), a leading provider of workplace substance abuse services in the U.S. This novel intervention could be an effective and economically sound way to promote long-term cocaine abstinence and employment in injection drug users, a population at risk for many adverse outcomes because of their poverty, unemployment and injection drug use.

? DESCRIPTION (provided by applicant): Consistent use of antiretroviral medications by adults living with HIV can suppress plasma HIV-1 RNA (viral load) to undetectable levels and thereby improve survival rates and quality of life, and reduce HIV-related infections, health care costs, and transmission of HIV. Despite the potential benefits of antiretroviral therapy, adults living wih HIV have not been reliably engaged in HIV care or sustained on antiretroviral medications. Few interventions have been shown effective in increasing adherence and suppressing viral loads to undetectable levels, and no treatments have produced long-term effects that sustain after the intervention is discontinued. Interventions that provide incentives to patients when they meet required therapeutic goals have been demonstrated extraordinarily effective in promoting therapeutic behavior change in diverse populations and they have shown promise in promoting adherence to antiretroviral medications and suppression of viral loads. However, only limited evaluations of these interventions have been conducted to promote adherence to antiretroviral medications and suppress viral loads, those evaluations have not employed optimal parameters of incentive interventions, and they have not produced levels of viral load suppression that are needed clinically. We propose to evaluate a novel incentive intervention to promote suppression of viral load in people living with HIV that will employ empirically-based parameters that have been proven critical to the effectiveness of incentive interventions. Participants (N = 200) from two medical clinics that serve adults living with HIV in Baltimore will be randomly assigned to an Incentive or a Usual Care Control group. Incentive group participants will receive incentives for maintaining suppressed and undetectable viral loads. The incentive program will employ high magnitude incentives, provide incentives for decreases in viral load early in treatment before a patient s viral load has reached undetectable levels, arrange frequent incentives early in treatment and reduce the frequency of incentives as participants achieve progressively longer periods of viral load suppression, arrange a schedule of escalating incentives for sustained suppression of viral load, and the intervention will be maintained for two years. Usual Care Control participants will only receive the standard HIV medical care offered in their clinic. Assessments will be conducted every 3 months throughout the two years of treatment and every 6 months throughout the year following treatment. The primary outcome measure will be the percentage of participants that have undetectable viral loads at the 3-month assessments conducted throughout the 2-year intervention period. Secondary measures will include adherence to HIV care and post- treatment outcomes. We will also assess moderators and mediators of the effects of the incentives on the suppression of viral load, and conduct cost-effectiveness and cost-benefit analyses. If the incentive intervention maintains suppressed viral load and is economically sound, it could be used to improve the health of adults living with HIV, reduce health care costs, and reduce HIV transmission in the community.

Alcohol addiction is as 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 3 months and then randomly assigned to a Usual Care Control group or an IPS Plus Abstinence-Contingent Wage Supplement group for one year. 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 alcohol abstinence and employment in homeless adults with alcohol use disorder, a population at risk for many adverse outcomes because of their poverty, unemployment, homelessness and alcohol use.