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Drugs

Contingency Management Programme

Contingency management in addiction treatment

This programme of research consists of 5 linked research studies which aim to develop a UK Evidence Base for Contingency Management in Addiction Treatment and are funded for 5 years by a NIHR Programme Grant.

Background

Effective treatments for drug dependence now exist (eg opiate substitution treatment) but do not produce the full patient or public benefit because of high levels of progressive drop-out. Adjunctive contingency management (CM) interventions have recently been developed to amplify patient benefit by provision of positive reinforcement of desired change in behaviour (e.g. rewarding medication compliance, or abstinence from street drugs). CM is based on principles of operant conditioning. CM has a strong evidence base from US trials and has recently been recommended by NICE for UK implementation. However, the UK has no track record of applying CM in drug treatment settings. Also, it is unclear whether this benefit derives from a direct effect of CM on the selected target behaviour or is a general benefit resulting from CM-stimulated improved retention in treatment. Hence, there is an urgent need to generate evidence about the feasibility, acceptability and clinical and cost-effectiveness of different possible CM interventions applied in NHS drug treatment settings.

Programme Aims

The aims of the studies include - to evaluate the feasibility, acceptability and clinical and cost-effectiveness of contingency management (CM) interventions in NHS drug treatment settings designed to (a) promote improved physical health care (Hep B vaccination) and (b) achieve better retention in treatment and reduced opiate use for opiate dependent clients in treatment. The studies will also describe treatment process and assess the feasibility and acceptability of CM interventions from clinician and service user perspectives and to use evidence thus generated to develop, deliver and evaluate staff training which supports the introduction of CM.

This programme of research will assess whether CM is feasible, acceptable and effective in NHS drug treatment settings. We plan to learn lessons from services already starting to implement CM (Study 1/Module 1) and apply these lessons to test how effective CM is in (a) promoting completion of hepatitis B vaccination (Study 2/Module 2) and (b) promoting abstinence from opiate/heroin use amongst patients receiving OST (Study 3/Module 3). In parallel we will support the implementation of CM by training staff and studying the impact of implementing CM on services, clinicians and patients (Studies 4 & 5/Themes A & B).

The first study in the programme of research will investigate management, clinician and service-user experiences of CM as implemented in English services who participated in the National Treatment Agency for Substance Misuse (NTA) pilots . The study will identify aspects of organisational culture, structure, process and resourcing which facilitate or hinder the implementation of CM and use this evidence to inform intervention strategies and staff training delivered and evaluated in subsequent studies/modules.

The Programme includes two randomised trials of CM within UK addictions treatment services. The first, will examine whether CM (inventives) can help increase the completion of hepatitis B vaccination schedule among opiate users in treatment. The trial will be undertaken at 12 drug services in London. The second will examine whether 12 week supplementary CM interventions can increase (a) retention in treatment and (b) abstinence from heroin/opiates. This trial will be conducted at 33 drug services in England.

Alongside these trials, two cross cutting studies will be undertaken. The first will identify factors present in structure, management, operation and workforce of treatment services which facilitate or hinder the implementation of CM and which influence treatment outcome. It will also identify the CM related training needs of staff. Measuring the knowledge and beliefs of staff and managers re CM before and after CM training and implementation. Using this evidence we will develop bespoke CM training and evaluate its impact on key staff competencies.

The second of these cross cutting studies will establish mechanisms for service user involvement in development of CM protocols. We will describe the treatment process from the service-user perspective and utilise these data in development and evaluation of interventions.

Findings from these studies within this Programme of research will help to introduce CM into NHS addiction treatment settings. This will be achieved by providing generalisable evidence about patient benefit and costs, evidence about organisational and professional factors that affect the implementation of CM in the NHS, and by developing new CM training modules and materials and producing information about good practice that will enhance CM implementation generally across the NHS.

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Research Team

The research programme is led by the South London & Maudsley (SLaM) NHS Foundation Trust but is a collaborative venture by investigators based at three London NHS trusts and universities. These are SLaM and Kings College London, together with Central & North West London MHT (CNWL) and Imperial College London, and Camden & Islington (C&I) Trust and University College London, Birmingham & Solihull Mental Health NHS Trust and the University of Birmingham.

For more information please contact Professor John Strang, Dr Tim Weaver or Dr Nicola Metrebian.

Publications
  • Metrebian N, Weaver T, Pilling S, Hellier J, Byford S, Shearer J, Mitcheson L, Astbury M, Bijral P, Bogdan N, Bowden-Jones O, Day E, Dunn J, Finch E, Forshall S, Glasper A, Morse G, Akhtar S, Bajaria J, Bennett C et al. Positive reinforcement targeting abstinence in substance misuse (PRAISe): Study protocol for a Cluster RCT & process evaluation of contingency management. Contemporary Clinical Trials 2018; 71:124-132
  • Rafia R, Dodd P.J, Brennan A, Meier P. S, Hope V. D, Ncube F, Byford S, Tie H, Metrebian N, Hellier J, Weaver T & Strang J. An economic evaluation of contingency management for completion of hepatitis B vaccination in those on treatment for opiate dependence. Addiction 2016:111(9):1616-1627.
  • Weaver T, Metrebian N, Strang J. Correspondence. Use of contingency management incentives to improve completion of hepatitis B vaccination in people undergoing treatment for heroin dependence: a cluster randomised trial. Lancet 2015; 385:116.
  • McLellan A T. Should at-risk patients be paid to receive interventions? Lancet 2014; 384: 113-114.
  • Metrebian, N. Should we pay drug users to get vital vaccines? New Scientist 9th April 2014.
  • Weaver T, Metrebian N, Hellier J, Pilling S, Charles V, Little N, Poovendran D,  Mitcheson L, Ryan F, Bowden-Jones O, Dunn J, Glasper A, Finch E, Strang J. Use of contingency management incentives to improve completion of hepatitis B vaccination in people undergoing treatment for heroin dependence: a cluster randomised trial. Lancet 2014; 384:153-63.

 

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