Effectiveness of incentivised adherence and abstinence monitoring in buprenorphine maintenance: a pragmatic, randomised controlled trial

Hesham Farouk Elarabi*, Mansour Shawky, Nael Mustafa, Doaa Radwan, Abuelgasim Elarasheed, Ahmed Yousif Ali, Mona Osman, Ahmed Kashmar, Helal Al Kathiri, Tarek Gawad, Ayman Kodera, Mohammed Al Jneibi, Abdu Adem, Amanda J. Lee, John Marsden

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

6 Citations (Scopus)
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Background and Aim: Buprenorphine (BUP) maintenance treatment for opioid use disorder (OUD) begins with supervised daily dosing. We estimated the clinical effectiveness of a novel incentivised medication adherence and abstinence monitoring protocol in BUP maintenance to enable contingent access to increasing take-home medication supplies. Design: Two-arm, single-centre, pragmatic, randomised controlled trial of outpatient BUP maintenance, with during-treatment follow-ups at 4 weeks, 8 weeks, 12 weeks and 16 weeks. Setting: Inpatient and outpatient addictions treatment centre in the United Arab Emirates. Participants: Adults with OUD, voluntarily seeking treatment. Interventions: The experimental condition was 16 weeks BUP maintenance with incentivised adherence and abstinence monitoring (I-AAM) giving contingent access to 7-day, then 14-day, then 21-day and 28-day medication supply. The control, treatment-as-usual (TAU) was 16 weeks BUP maintenance, with contingent access to 7-day then 14-day supply. Measurements: The primary outcome was number of negative urine drug screens (UDS) for opioids, with non-attendance or otherwise missed UDS, imputed as positive for opioids. The secondary outcome was retention in treatment (continuous enrolment to the 16-week endpoint). Findings: Of 182 patients screened, 171 were enrolled and 141 were randomly assigned to I-AAM (70 [49.6%]) and to TAU (71 [50.4%]. Follow-up rates at 4 weeks, 8 weeks, 12 weeks and 16 weeks were 91.4%, 85.7%, 71.0%, 60.0% respectively in I-AAM and 84.5%, 83.1%, 69.0%, 56.3% in TAU. By intention-to-treat, the absolute difference in percentage negative UDS for opioids was 76.7% (SD = 25.0%) in I-AAM versus 63.5% (SD = 34.7%) in TAU (mean difference = 13.3%; 95% CI = 3.2%–23.3%; Cohen's d = 0.44; 95% CI = 0.10–0.87). In I-AAM, 40 participants (57.1%) were retained versus 33 (46.4%) in TAU (odds ratio = 1.54; 95% CI = 0.79–2.98). Conclusions: Buprenorphine maintenance with incentivised therapeutic drug monitoring to enable contingent access to increasing take-home medication supplies increased abstinence from opioids compared with buprenorphine maintenance treatment-as-usual, but it did not appear to increase treatment retention.

Original languageEnglish
Pages (from-to)2398-2408
Number of pages11
Issue number9
Early online date6 Jan 2021
Publication statusPublished - Sept 2021

Bibliographical note

The authors wish to thank the patients and staff at the National Rehabilitation Centre for their participation and to the NRC director general, Dr. Hamad Al Ghaferi, for his advice and support. Work on this study was included as part of H.E.'s doctoral studies and supervisor J.M. kindly acknowledge support from the Scholarship Office at the Ministry of Presidential Affairs, United Arab Emirates.


  • abstinence
  • adherence
  • buprenorphine
  • effectiveness
  • opioid use disorder
  • therapeutic drug monitoring


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