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Original Investigation
July 14, 2021

Efficacy and Cost-Benefit of Onsite Contraceptive Services With and Without Incentives Among Women With Opioid Use Disorder at High Risk for Unintended Pregnancy: A Randomized Clinical Trial

Author Affiliations
  • 1Department of Psychiatry, University of Vermont, Burlington
  • 2Department of Psychological Science, University of Vermont, Burlington
  • 3University of Nebraska Medical Center, Omaha
  • 4Department of Medical Biostatistics, University of Vermont, Burlington
  • 5Brandeis University, Waltham, Massachusetts
  • 6Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Vermont, Burlington
JAMA Psychiatry. Published online July 14, 2021. doi:10.1001/jamapsychiatry.2021.1715
Key Points

Question  Do onsite contraceptive services with and without incentives increase verified prescription contraceptive use compared with usual care among women with opioid use disorder at high risk for unintended pregnancy and do so in a cost-beneficial manner?

Findings  In this randomized clinical trial of 138 participants, a significant graded increase in verified prescription contraceptive use was seen in participants assigned to usual care vs contraceptive services vs contraceptive services plus incentives at the 6-month end-of-treatment assessment. Both contraceptive services and contraceptive services plus incentive interventions yielded economic benefits.

Meaning  Results of this study suggest that onsite contraceptive services exceeded usual care, but that the combination of contraceptive services with incentives for attending follow-up visits to assess contraceptive satisfaction was the most efficacious and cost-beneficial intervention.

Abstract

Importance  Rates of in utero opioid exposure continue to increase in the US. Nearly all of these pregnancies are unintended but there has been little intervention research addressing this growing and costly public health problem.

Objective  To test the efficacy and cost-benefit of onsite contraceptive services with and without incentives to increase prescription contraceptive use among women with opioid use disorder (OUD) at high risk for unintended pregnancy compared with usual care.

Design, Setting, and Participants  A randomized clinical trial of 138 women ages 20 to 44 years receiving medication for OUD who were at high risk for an unintended pregnancy at trial enrollment between May 2015 and September 2018. The final assessment was completed in September 2019. Data were analyzed from October 2019 to March 2021. Participants received contraceptive services at a clinic colocated with an opioid treatment program.

Interventions  Participants were randomly assigned to receive 1 of 3 conditions: (1) usual care (ie, information about contraceptive methods and community health care facilities) (n = 48); (2) onsite contraceptive services adapted from the World Health Organization including 6 months of follow-up visits to assess method satisfaction (n = 48); or (3) those same onsite contraceptive services plus financial incentives for attending follow-up visits (n = 42).

Main Outcomes and Measures  Verified prescription contraceptive use at 6 months with a cost-benefit analysis conducted from a societal perspective.

Results  In this randomized clinical trial of 138 women (median age, 31 years [range, 20-44 years]), graded increases in verified prescription contraceptive use were seen in participants assigned to usual care (10.4%; 95% CI, 3.5%-22.7%) vs contraceptive services (29.2%; 95% CI, 17.0%-44.1%) vs contraceptive services plus incentives (54.8%; 95% CI, 38.7%-70.2%) at the 6-month end-of-treatment assessment (P < .001 for all comparisons). Those effects were sustained at the 12-month final assessment (usual care: 6.3%; 95% CI, 1.3%-17.2%; contraceptive services: 25.0%; 95% CI, 13.6%-39.6%; and contraceptive services plus incentives: 42.9%; 95% CI, 27.7%-59.0%; P < .001) and were associated with graded reductions in unintended pregnancy rates across the 12-month trial (usual care: 22.2%; 95% CI, 11.2%-37.1%; contraceptive services: 16.7%; 95% CI, 7.0%-31.4%; contraceptive services plus incentives: 4.9%; 95% CI, 0.6%-15.5%; P = .03). Each dollar invested yielded an estimated $5.59 (95% CI, $2.73-$7.91) in societal cost-benefits for contraceptive services vs usual care, $6.14 (95% CI, $3.57-$7.08) for contraceptive services plus incentives vs usual care and $6.96 (95% CI, $0.62-$10.09) for combining incentives with contraceptive services vs contraceptive services alone.

Conclusions and Relevance  In this randomized clinical trial, outcomes with both onsite contraceptive service interventions exceeded those with usual care, but the most efficacious, cost-beneficial outcomes were achieved by combining contraceptive services with incentives. Colocating contraceptive services with opioid treatment programs offers an innovative, cost-effective strategy for preventing unintended pregnancy.

Trial Registration  ClinicalTrials.gov Identifier: NCT02411357

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