Superiority and cost-effectiveness of Individual Placement and Support for people with alcohol and drug dependence

Individual Placement Support (IPS) is an intensive psychosocial intervention to help people find and maintain employment in the open competitive labour market. There has been no superiority evaluation for people with alcohol and drug dependence.

The Individual Placement and Support – Alcohol and Drug (IPS-AD) was  the first superiority trial to evaluate effectiveness and cost-effectiveness. This was a pragmatic, parallel-group, multi-centre, randomised, controlled, phase 3 trial of standard employment support (treatment-as-usual [TAU]) versus IPS. IPS was offered as a single episode for up to 13 months. The study was done at seven community treatment centres for alcohol and drug dependence in England. Study participants were adults (18-65 years), who had been enrolled for at least 14 days in treatment for alcohol use disorder (AUD), opioid use disorder (OUD), or another drug use disorder (DUD; mostly cannabis and stimulants); were unemployed or economically inactive for at least six months; and wished to attain employment in the open competitive labour market. After random allocation to study interventions, the primary outcome was employment during 18-months of follow-up, analysed by mixed-effects logistic regression, using multiple imputation for the management of missing outcome data. There were two cost-effectiveness outcomes: a health outcome expressed as a quality adjusted life year (QALY) using £30,000 and £70,000 willingness-to-pay [WTP] thresholds; and additional days of employment, with a WTP threshold of £200 per day worked. 

Between 8 May 2018 and 30 September 2019, 2,781 potentially eligible patients were identified. 1,720 participants were randomly allocated to TAU or IPS. The full-analysis was 1,687 participants [70% male; mean age 41years]; TAU, n=844; IPS, n=843 [AUD, n=610; OUD, n=837; DUD, n=240]). Standard employment support was received by 559 [66%] of 844 participants in the TAU group. IPS was received by 804 [95%] of 843 participants in the IPS group. IPS was associated with an increase in attainment of employment compared with TAU (adjusted odds ratio [OR] 1.3; 95% CI 1.0–1.6). IPS was effective for the AUD and DUD groups only (OR 1.5; 95% CI 1.1–1.9; OR 1·45, 95% CI 1·03–2·04, respectively), but not the OUD group. IPS returned an incremental QALY outcome gain of 0·01 (range 0·003–0·02) per participant with no evidence of cost-effectiveness at either WTP threshold – but QALY gains were cost-effective for the AUD and DUD groups at the £70,000 WTP threshold (probability 0·52 and 0·97, respectively). IPS was cost-effective for additional days of employment (probability 0·61), with effectiveness relating to the AUD group only (probability >0·99). It would seem that a more intensive or enhanced IPS approach may be needed to help patients enrolled in OUD attain employment.