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• W1569732023 abstract "Lucke & Hall 1 and Project Prevention are to be commended for raising awareness about the alarmingly high rate of unintended pregnancy among drug-abusing women. This is a serious problem that has been ignored in the field of addiction for too long. Lucke & Hall noted the many serious adverse consequences of unintended pregnancy for the offspring. We believe clear acknowledgement of the consequences for women is an equally important part of an informed discussion of the ethics of any intervention to reduce unintended pregnancy. Indeed, data from the general population underscore myriad adverse consequences, including increased risk of pregnancy complications, depression and poorer psychological wellbeing, domestic violence, school dropout and lost career opportunities 2, 3. The medical costs alone of unintended pregnancy in the United States have been estimated at $5 billion annually 4, and the personal and societal costs are probably incalculable. Regarding the use of incentives to promote contraceptive use among drug-abusing women, while Project Prevention's practices can be justifiably criticized on several grounds, their use of incentives is consistent with a large literature documenting the efficacy of incentives to promote drug abstinence and other healthy behavior change among drug abusers 5, 6. This approach is based on empirical evidence demonstrating that drug abusers place disproportionate weight on more immediate gains and losses at the expense of longer-term outcomes 7, 8 and that therapeutic interventions that leverage this bias by offering relatively immediate financial rewards contingent upon healthy choices (e.g. decreasing cocaine use) can be highly effective at changing otherwise recalcitrant, unhealthy behavior 9. Importantly, this same framework underscores why we believe it is unethical to provide incentives contingent on sterilization. This bias towards more immediate gains could result in women overvaluing the relatively immediate gain (cash for undergoing sterilization) while substantially underestimating the longer-term consequences of that decision (permanent sterility). Returning to the larger literature on incentives to promote healthy behaviors in drug abusers, in addition to studies targeting drug abstinence, a number have used incentives to promote medication adherence, including medications to reduce drug use 10, 11, antiretroviral medications for human immunodeficiency virus (HIV)-positive drug abusers 12, 13 and antibiotic medications for drug abusers with tuberculosis 14, 15. In each case, these medications have tremendous, often life-saving, longer-term benefits for the patient, but because there are shorter-term behavioral costs associated with initiating and sustaining medication use (e.g. obtaining and filling a prescription and tolerating generally minor side effects), they are rarely utilized to their full potential. Incentives are effective at increasing medication adherence in these conditions 16, 17 and to our knowledge have raised few ethical objections. From our analysis, these same factors probably contribute significantly to the underutilization of highly effective contraceptives among drug-abusing women. The long-acting reversible contraceptives (LARCs) incentivized by Project Prevention are the most effective contraceptives, averaging <2% typical use failure rates, but shorter-term behavioral costs include the fact that they require insertion/administration by a health-care provider and cause some side effects, most of which are minor and not medically concerning 18. Given the serious consequences of unintended pregnancy, and assuming that some basic procedures are followed, it seems that the potential benefits of using incentives to promote LARC use among drug-abusing women far outweigh the consequences. Basic procedures that should be followed when using incentives to promote LARC use among drug-abusing women begin with adequate medical screening; like all prescription medications, LARCs have contraindications and women must meet medical eligibility. Sobriety tests should also be conducted to ensure that women are not under the influence when considering LARC use. LARC users also need to be educated about rare, but potentially serious, side effects and instructed when and to whom to report them. Importantly, women at risk of sexually transmitted infections (STIs) must also be informed that LARCs do not protect against STIs, and ‘dual protection’ with condoms is recommended. Finally, the magnitude of the incentives offered should not be so large as to be coercive. More research is needed to determine optimal incentive values, schedules and targets, but the extant literature on incentives for other types of medication adherence is probably a useful starting-point. In summary, while we do not agree with all Project Prevention's practices, we recognize their efforts to address this serious problem. We also believe that, as with other medications that promote the health of drug-abusing individuals, there are many conditions under which it is ethical to use incentives to encourage contraceptive use among drug-abusing women and support research on this important topic. None. This work was supported in part by National Institute on Drug Abuse grant R34DA030534." @default.
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• W1569732023 date "2012-05-04" @default.
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• W1569732023 title "THE SCIENTIFIC AND ETHICAL RATIONALE FOR USING INCENTIVES TO PROMOTE CONTRACEPTIVE USE AMONG DRUG-ABUSING WOMEN" @default.
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• W1569732023 doi "https://doi.org/10.1111/j.1360-0443.2012.03798.x" @default.
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