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TIES Project

Telephone delivered Incentives for Encouraging adherence to Supervised methadone consumption: development and feasibility study for a RCT of clinical and cost effectiveness 

Funded by NIHR

 

Background

Most people treated for heroin addiction are prescribed methadone which enables them to stop heroin use safely avoiding withdrawal [1,2]. People starting methadone take a daily dose under a pharmacist’s supervision to prevent overdose. If a patient misses their daily methadone they will experience opiate withdrawal and cravings which make them more likely to use heroin. If a patient misses their methadone for three days in a row they will lose their tolerance to the drug and risk overdose. Unfortunately, many patients do miss their doses. Non-adherence with medication is associated with non-attendance at medical and psychosocial appointments [3,4]. There is an urgent need to develop effective interventions for medication adherence [5]. Research shows that contingency management interventions (delivery of small financial incentives) can improve medication adherence [6].

While, contingency management requires time and organisational systems which can be challenging in pharmacies dispensing to high volume of patients, effective methods to improve adherence need to be maintained for as long as the treatment is needed, requiring interventions that can be integrated into the care system in a cost-effective manner. We believe CM delivered by technology can encourage medication adherence among individuals receiving OST and be resource light and cost effective.

Research Aims

Assess the feasibility of conducting a cluster randomised controlled trial (RCT) to evaluate the clinical and cost effectiveness of using telephone delivered incentives (via text) to encourage adherence with supervised consumption of methadone in community pharmacies. 

Methods

We will survey pharmacists to find out about current methadone dispensing practice and develop the telephone incentive scheme to fit routine practice. We will then look at the feasibility of conducting a trial to evaluate whether the intervention increases attendance at pharmacies. Drug services will be recruited and randomly offered one of three approaches (which we plan to compare in a future trial). Some patients will receive telephone delivered incentives for attending the pharmacy and consuming their supervised methadone (via text), others a reminder to attend the pharmacy to receive their supervised methadone (text), while others receive no text messages. We will assess the acceptability of these approaches, how recruitment works and whether we can track patients to measure their outcomes.

This will be achieved through a 3 Phase study:

Phase 1 – Conduct a survey of community pharmacists in England to examine the nature and extent of existing dispensing and supervised methadone consumption schemes. Pharmacists will also be questioned on their acceptability of using telephone delivered incentives (with small financial incentives) and/or reminders to encourage adherence to supervised methadone.

Phase 2 – Develop technology for delivering a) telephone delivered incentives to provide positive reinforcement (praise and modest financial rewards via text messages) to individuals for attending and taking their methadone under supervision at the pharmacy and b) a system for providing routine monitoring of medication compliance and an early warning to prescribers (drug service) when patients have missed their dose.

Phase 3 – To assess the feasibility of a future RCT of the clinical and cost effectiveness of telephone delivered incentives.

Research Team

Dr Nicola Metrebian (Principal Investigator, King’s College London)

Prof Sir John Strang (Kings College London & South London & Maudsley NHS Trust)

Dr Tim Weaver (Middlesex University)

Prof Steve Pilling (University College London)         

Dr Kimberley Goldsmith (Kings College London)

Dr Emily Finch (South London & Maudsley NHS Trust)

Dr Prun Bijral (Change, Grow, Live)

Prof David Taylor (Kings College London & South London & Maudsley NHS Trust)

Dr James Shearer (Kings College London)

Carol-Ann Getty (Research Assistant, King’s College London)

This research is led by the South London & Maudsley (SLaM) NHS Foundation Trust but is a collaborative venture by investigators based at SLaM and Kings College London, Middlesex University, University College London and Change Grow Live (UK charity providing treatment for substance misusers)

For more information please contact Dr Nicola Metrebian or Carol-Ann Getty.

References

[1] National Institute for Clinical Excellence (NICE) 2006 Methadone and buprenorphine for the management of opioid dependence. NICE technology appraisal guidance [TA114] Published date: January 2007

[2] Godfrey C, Stewart D, and Gossop M. Economic analysis of costs and consequences of the treatment of drug misuse: 2-year outcome data from the National Treatment Outcome Research Study (NTORS) Addiction 2004; 99 (6); 697-707.

[3] Ward J, Hall W, Mattick R.P Role of maintenance treatment in opiod dependence. The Lancet 1999; 353:221-226.

[4] Michael Farrell, Jeff Ward, Richard Mattick, Wayne Hall, Gerry V Stimson, Don des Jarlais, Michael Gossop, John Strang Methadone maintenance treatment in opiate dependence: a review BMJ, 1994, 309: 997-1001.

[5] Cutler D.M and Everett W. Thinking outside the Pillbox – medical adherence as a priority for health care reform. New England Journal of Medicine 2010; 362: 1553-1555.

[6] Anthony DeFulio, Kenneth Silverman The use of incentives to reinforce medication adherence. NIH Public access. Preventative Medicine. 2012; November  55(suppl): S86-S94.

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