Facilitating the adoption of contingency management for the treatment of substance use disorders

The reflections of health service providers on implementing contingency management for methamphetamine use disorder in Australia

INTRODUCTION

Contingency management (CM) is the most effective treatment for reducing methamphetamine use. We sought to understand why CM has not been taken up to manage methamphetamine use disorder in Australia.

METHODS

Six focus groups (4-8 participants per group) were conducted with health workers from agencies in Australia that provided drug-related health care to people who use methamphetamine. These agencies had no previous experience delivering CM for substance use. The potential acceptability and feasibility of implementing CM in their services were discussed.

RESULTS

Participants felt that it would be beneficial to have an evidence-based treatment for methamphetamine use disorder. This sentiment was offset by concerns that CM conflicted with a client-centred harm-reduction approach and that it dictated the goal of treatment as abstinence. It was also perceived as potentially coercive and seen to reify the power imbalance in the therapeutic relationship and therefore potentially reinforce stigma. There was also concern about the public's perception and the political acceptability of CM, who would fund CM, and the inequity of providing incentives only to clients with a methamphetamine use disorder. Some concerns could be ameliorated if the goals and structure of CM could be tailored to a client's needs.

DISCUSSION AND CONCLUSIONS

Many healthcare workers were keen to offer CM as an effective treatment option for people with methamphetamine use disorder, but CM would need to be sufficiently flexible to allow it to be tailored to client needs and implemented in a way that did not adversely impact the therapeutic relationship.

Lessons learned from statewide contingency management rollouts addressing stimulant use in the Northwestern United States

Increases in stimulant drug use (such as methamphetamine) and related deaths creates an imperative for community settings to adopt evidence-based practices to help people who use stimulants. Contingency management (CM) is a behavioral intervention with decades of research demonstrating efficacy for the treatment of stimulant use disorder, but real-world adoption has been slow, due to well-known implementation barriers, including difficulty funding reinforcers, and stigma. This paper describes the training and technical assistance (TTA) efforts and lessons learned for two state-wide stimulant-focused CM implementation projects in the Northwestern United States (Montana and Washington). A total of 154 providers from 35 community-based service sites received didactic training in CM beginning in 2021. Seventeen of these sites, ten of eleven in Montana (90.9%) and seven of 24 in Washington (29.2%), went on to implement contingency management programs adherent to their state's established CM protocol and received ongoing TTA in the form of implementation coaching calls. These findings illustrate that site-specific barriers such as logistical fit precluded implementation in more than 50% of the trained sites; however, strategies for site-specific tailoring within the required protocol aided implementation, resulting in successful CM program launch in a diverse cross-section of service sites across the states. The lessons learned add to the body of literature describing CM implementation barriers and solutions.

Perspectives and sentiments on contingency management from people who use methamphetamine

INTRODUCTION

Contingency management (CM) is currently the most efficacious treatment for methamphetamine use, yet it is rarely available in routine care. We examined the viewpoints of people who use methamphetamine on CM as a potential treatment for methamphetamine use disorder.

METHODS

Semi-structured qualitative interviews with 30 Australians aged 18 years or older who had used methamphetamine at least weekly in the past 6 months.

RESULTS

Participants reported overall positive attitudes towards CM as a potential treatment option for methamphetamine use disorder. However, there was need for greater flexibility in meeting participant treatment goals (e.g., reduced use or complete abstinence), with particular concern about the viability of initiating abstinence, both in terms of the sufficiency of the initial financial incentive and managing withdrawal symptoms. There was strong interest in the use of digital technologies to provide remote CM, particularly around the convenience and flexibility this offered. Despite this, participants remained keen to access adjunctive treatment and support services but stressed that engagement with these additional services should not be mandatory. Marketing of CM will need to address preconceptions about drug-testing used in abstinence-based CM being punitive (especially urine testing) and its connotations with criminal justice interventions.

DISCUSSION AND CONCLUSION

Positive attitudes towards CM bode well for potential uptake should CM be made available in routine clinical practice. However, there is a need to adapt CM to ensure it is feasible and attractive to people who are seeking treatment for methamphetamine use disorder.

Feasibility, Engagement, and Usability of a Remote, Smartphone-Based Contingency Management Program as a Treatment Add-On for Patients Who Use Methamphetamine: Single-Arm Pilot Study

BACKGROUND

In the United States, methamphetamine-related overdoses have tripled from 2015 to 2020 and continue to rise. However, efficacious treatments such as contingency management (CM) are often unavailable in health systems.

OBJECTIVE

We conducted a single-arm pilot study to evaluate the feasibility, engagement, and usability of a fully remotely delivered mobile health CM program offered to adult outpatients who used methamphetamine and were receiving health care within a large university health system.

METHODS

Participants were referred by primary care or behavioral health clinicians between September 2021 and July 2022. Eligibility criteria screening was conducted by telephone and included self-reported methamphetamine use on ≥5 out of the past 30 days and a goal of reducing or abstaining from methamphetamine use. Eligible participants who agreed to take part then completed an initial welcome phase that included 2 videoconference calls to register for and learn about the CM program and 2 "practice" saliva-based substance tests prompted by a smartphone app. Participants who completed these welcome phase activities could then receive the remotely delivered CM intervention for 12 consecutive weeks. The intervention included approximately 24 randomly scheduled smartphone alerts requesting a video recording of themselves taking a saliva-based substance test to verify recent methamphetamine abstinence, 12 weekly calls with a CM guide, 35 self-paced cognitive behavioral therapy modules, and multiple surveys. Financial incentives were disbursed via reloadable debit cards. An intervention usability questionnaire was completed at the midpoint.

RESULTS

Overall, 37 patients completed telephone screenings, with 28 (76%) meeting the eligibility criteria and consenting to participate. Most participants who completed a baseline questionnaire (21/24, 88%) self-reported symptoms consistent with severe methamphetamine use disorder, and most had other co-occurring non-methamphetamine substance use disorders (22/28, 79%) and co-occurring mental health disorders (25/28, 89%) according to existing electronic health records. Overall, 54% (15/28) of participants successfully completed the welcome phase and were able to receive the CM intervention. Among these participants, engagement with substance testing, calls with CM guides, and cognitive behavioral therapy modules varied. Rates of verified methamphetamine abstinence in substance testing were generally low but varied considerably across participants. Participants reported positive opinions about the intervention's ease of use and satisfaction with the intervention.

CONCLUSIONS

Fully remote CM can be feasibly delivered within health care settings lacking existing CM programs. Although remote delivery may help reduce barriers to treatment access, many patients who use methamphetamine may struggle to engage with initial onboarding. High rates of co-occurring psychiatric conditions in the patient population may also contribute to uptake and engagement challenges. Future efforts could leverage greater human-to-human connection, more streamlined onboarding procedures, larger incentives, longer durations, and the incentivization of non-abstinence-based recovery goals to increase uptake and engagement with fully remote mobile health-based CM.

Expanding access to treatment for stimulant use disorder in a frontier state: A qualitative study of contingency management and TRUST program implementation in Montana

BACKGROUND

The client population eligible for treatment services supported by State Opioid Response (SOR) grant funding, administered by the Substance Abuse and Mental Health Services Administration (SAMHSA), was expanded to include individuals with a stimulant use disorder (stimUD) in 2020. Due to a significant need to improve services for individuals with stimUD in Montana, the Behavioral Health and Developmental Disabilities Division (BHDD) of the Montana Department of Public Health and Human Services used the grant opportunity to work with experts in the field of stimUD to pilot contingency management (CM) and the Treatment for Individuals who Use Stimulants (TRUST) treatment model. The CM protocol included twice weekly visits for twelve weeks, using an escalating schedule of gift card incentives contingent upon stimulant-negative urine samples. TRUST is a multi-component treatment program, incorporating exercise, group therapy, and individual therapy with content guided by cognitive behavioral therapy (CBT) and clinical research associate (CRA) materials. In addition to SOR dollars, BHDD used additional funding for CM reinforcers provided by state tax dollars to meet research-supported target incentive totals.

METHODS

In this pilot project, TRUST/CM was implemented by four state-approved treatment providers and three Federally Qualified Health Centers (FQHCs), all of which had little prior experience with CM as a component of their treatment programs for stimUD. This article examines the processes of training staff, the experiences among staff with initial implementation of the treatment model, and the client characteristics of initial pilot treatment cohorts. Data for this study include primary qualitative data collected from providers, as well as client characteristics collected on the SAMHSA Government Performance and Results Act (GPRA) data collection form.

RESULTS

Seven sites were trained in TRUST/CM, and these sites enrolled a total of 70 patients in the program. Qualitative data collected through interviews with site staff revealed the following themes: the value of intensive technical assistance being integrated in the program, concerns about staff retention and loss of expertise, adjustments of target client populations, and the importance of creative strategies for the provision of evidence-informed incentive totals.

CONCLUSIONS

TRUST/CM was implemented throughout Montana, including rural and urban communities. Qualitative and quantitative data support that providers viewed the CM component as beneficial for treatment retention and improved outcomes for people with stimUD. These implementation study results provide insight into challenges and solutions for providers who are considering the implementation of CM within either a state-approved substance use treatment clinic or FQHC.

Contingency Management for Stimulant Use Disorder: Progress, Challenges, and Recommendations

The United States is currently in the fourth wave of the overdose crisis wherein stimulants together with fentanyl are the major drivers of overdose deaths. To date, there has been limited effort outside the US Veterans Administration Health System health system to disseminate evidence-based treatment for people with stimulant use disorder. Contingency management, a behavioral intervention in which positive reinforcement is provided for a target behavior indicating treatment progress, has decades of empirical support but limited implementation in real-world, non-US Veterans Administration Health System settings. The purpose of the report is to provide an overview of contingency management, the barriers to adoption, and recommendations for overcoming these barriers.

A systematic review of remotely delivered contingency management treatment for substance use

BACKGROUND

Substance use and related consequences (e.g., impaired driving, injuries, disease transmission) continue to be major public health concerns. Contingency management (CM) is a highly effective treatment for substance use disorders. Yet CM remains vastly underutilized, in large part due to implementation barriers to in-person delivery. If feasible and effective, remote delivery of CM may reduce barriers at both the clinic- and patient-level, thus increasing reach and access to effective care. Here, we summarize data from a systematic review of studies reporting remote delivery of CM for substance use treatment.

METHODS

We conducted a systematic review, reported according to PRISMA guidelines. The study team identified a total of 4358 articles after deduplication. Following title and abstract screening, full-text screening, and reference tracking, 39 studies met the eligibility criteria. We evaluated the methodological quality of the included studies using the Effective Public Health Practice Project Quality tool.

RESULTS

Of 39 articles included in the review, most (n = 26) targeted cigarette smoking, with others focusing on alcohol (n = 9) or other substance use or targeting multiple substances (n = 4). Most remotely delivered CM studies focused on abstinence (n = 29), with others targeting substance use reduction (n = 2), intervention engagement (n = 5), and both abstinence and intervention engagement (n = 3). CM was associated with better outcomes (either abstinence, use reduction, or engagement), with increasingly more remotely delivered CM studies published in more recent years. Studies ranged from moderate to strong quality, with the majority (57.5 %) of studies being strong quality.

CONCLUSIONS

Consistent with in-person CM, remotely delivered CM focusing on abstinence or use reduction from substances or engagement in substance use treatment services improves outcomes at the end of treatment compared to control conditions. Moreover, remotely delivered CM is feasible across a variety of digital delivery platforms (e.g., web, mobile, and wearable), with acceptability and reduced clinic and patient burden as technological advancements streamline monitoring and reinforcer delivery.

Rewarding recovery: the time is now for contingency management for opioid use disorder

Contingency management (i.e. rewarding people, often with money, for achieving their recovery goals) is backed by decades of empirical support yet remains highly underutilized. Rewards are rarely used in real-world clinical practice due to a number of concerns, including most notably, the apparent lack of innovation, as well as moral, philosophical, ethical, and economic concerns, and even federal rules meant to prevent illegal inducements in health care. Still, other opponents argue that some patients will try to "game" the system by simply doing whatever it takes to earn monetary rewards. This paper provides a succinct, up-to-date overview of the current evidence base for contingency management for opioid use disorder. Common barriers and solutions to implementation, as well as implications for future research and clinical practice are discussed. Although important, greater uptake of contingency management interventions is about more than legislation and regulations; it's about recognizing stigma, shaping attitudes, and increasing awareness. Provider involvement in advocacy efforts at all levels and collaboration involving academic-industry partnerships is necessary to advance the burgeoning digital health care space and improve outcomes for people with opioid use disorder. Key MessagesContingency management is highly effective but highly underutilized.Low uptake is largely attributed to a lack of innovation and moral, ethical, and economic concerns, among other barriers.Technology-enabled solutions and academic-industry partnerships are critical to advance opioid use disorder care.

Trends in comorbid opioid and stimulant use disorders among Veterans receiving care from the Veterans Health Administration, 2005-2019

BACKGROUND

Identifying solutions to the continued rise in overdose deaths is a public health priority. However, there is evidence of change in recent substance type associated with morbidity and mortality. To better understand the continued rise in overdose deaths, in particular those attributed to opioid and stimulant use disorders, increased knowledge of patterns of use is needed.

METHODS

Retrospective cohort study of Veterans diagnosed with an opioid or stimulant use disorder between 2005 and 2019. The outcome of interest was diagnosis of substance use disorders, specifically examining combinations of opioid and stimulant use disorders among this population.

RESULTS

A total of 1932,188 Veterans were diagnosed with at least one substance use disorder (SUD) during the study period, 2005 through 2019. While the annual prevalence of opioid use disorder (OUD) diagnoses increased more than 155%, OUD diagnoses absent of any other SUD diagnosis increased by an average of 6.9% (95% CI, 6.4, 7.5) per year between 2005 and 2019. Between 2011 and 2019, diagnoses of co-morbid methamphetamine use disorder (MUD) and OUD increased at a higher rate than other SUD combinations.

CONCLUSIONS

The prevalence of comorbid SUD, in particular co-occurring opioid and methamphetamine use disorder, increased at a higher rate than other combinations between 2005 and 2019. These findings underscore the urgent need to offer patients a combination of evidence-based treatments for each co-morbid SUD, such MOUD and contingency management for persons with comorbid opioid and methamphetamine use disorders.

New Directions for Motivational Incentive Interventions for Smoking Cessation

Background

Motivational incentive interventions are highly effective for smoking cessation. Yet, these interventions are not widely available to people who want to quit smoking, in part, due to barriers such as administrative burden, concern about the use of extrinsic reinforcement (i.e., incentives) to improve cessation outcomes, suboptimal intervention engagement, individual burden, and up-front costs.

Purpose

Technological advancements can mitigate some of these barriers. For example, mobile abstinence monitoring and digital, automated incentive delivery have the potential to lower the clinic burden associated with monitoring abstinence and administering incentives while also reducing the frequency of clinic visits. However, to fully realize the potential of digital technologies to deliver motivational incentives it is critical to develop strategies to mitigate longstanding concerns that reliance on extrinsic monetary reinforcement may hamper internal motivation for cessation, improve individual engagement with the intervention, and address scalability limitations due to the up-front cost of monetary incentives. Herein, we describe the state of digitally-delivered motivational incentives. We then build on existing principles for creating just-in-time adaptive interventions to highlight new directions in leveraging digital technology to improve the effectiveness and scalability of motivational incentive interventions.

Conclusions

Technological advancement in abstinence monitoring coupled with digital delivery of reinforcers has made the use of motivational incentives for smoking cessation increasingly feasible. We propose future directions for a new era of motivational incentive interventions that leverage technology to integrate monetary and non-monetary incentives in a way that addresses the changing needs of individuals as they unfold in real-time.

A Pilot Study for Testing the Effectiveness and Cost-Efficiency of Lottery Incentive in mHealth App that Promotes Walking

This is a pilot study that investigated differences in effectiveness, maintenance of effectiveness, cost-efficiency, satisfaction, and usability of a lottery incentive via mobile devices to promote walking, depending on the chance of winning the lottery, the amount of the prize, and gender. Sixty-six college students (male = 26) were randomly assigned to 3 groups: 10% chance of a big prize (10% + B), 50% chance of a medium prize (50% + M), and 100% chance of a small prize (100% + S). Step counts were collected through mobile devices before and after the intervention, as well as at the 2-month follow-up. The results showed significant increases in the step counts among males after the intervention in the 10% + B and the 50% + M groups, and females in the 100% + S group. Only males in the 50% + M group exhibited maintenance in effectiveness during follow-up. With regard to cost-efficiency, the 10% + B and the 50% + M male groups, which showed significant differences in effectiveness, were compared, and no significant difference was found. With regard to intervention satisfaction, satisfaction of the 10% + B group was lower than that of the 100% + S group. There were no significant interactions or main effects regarding the usability of the intervention. The results suggest that a lottery incentive is effective only for men to promote walking when a medium size prize is given with a 50% of chance of winning the lottery.

Long-term efficacy of contingency management treatment based on objective indicators of abstinence from illicit substance use up to 1 year following treatment: A meta-analysis

OBJECTIVE

Contingency management (CM) is often criticized for limited long-term impact. This meta-analysis focused on objective indices of drug use (i.e., urine toxicology) to examine the effects of CM on illicit substance use up to 1 year following treatment.

METHOD

Analyses included randomized trials (k = 23) of CM for stimulant, opioid, or polysubstance use disorders that reported outcomes up to 1 year after the incentive delivery had ended. Using random effects models, odds ratios (OR) were calculated for the likelihood of abstinence. Metaregressions and subgroup analyses explored how parameters of CM treatment, namely escalation, frequency, immediacy, and magnitude of reinforcers, moderated outcomes.

RESULTS

The overall likelihood of abstinence at the long-term follow-up among participants who received CM versus a comparison treatment (nearly half of which were community-based comprehensive therapies or protocol-based specific therapies) was OR = 1.22, 95% confidence interval [1.01, 1.44], with low to moderate heterogeneity (I² = 36.68). Among 18 moderators, longer length of active treatment was found to significantly improve long-term abstinence.

CONCLUSIONS

CM showed long-term benefit in reducing objective indices of drug use, above and beyond other active, evidence-based treatments (e.g., cognitive-behavioral therapy, 12-step facilitation) and community-based intensive outpatient treatment. These data suggest that policymakers and insurers should support and cover costs for CM, which is the focus of hundreds of studies demonstrating its short-term efficacy and, now, additional data supporting its long-term efficacy. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

User-centered design of contingency management for implementation in opioid treatment programs: a qualitative study

Background

Contingency management (CM) is one of the only behavioral interventions shown to be effective for the treatment of opioid use disorders when delivered alone and in combination with pharmacotherapy. Despite extensive empirical support, uptake of CM in community settings remains abysmally low. The current study applied user-centered design principles to gather qualitative data on familiarity with CM, current clinical practice, and preferences regarding the implementation of CM in community-based opioid treatment programs.

Methods

Participants were 21 leaders and 22 front-line counselors from 11 community-based opioid treatment programs. Semi-structured interviews were about 45 min long. Transcripts from each interview were coded by independent raters and analyzed using a reflexive team approach. Frequencies of responses were tallied, and queries were run in NVivo to identify exemplar quotes for each code.

Results

Results indicated low familiarity with CM, with less than half of the respondents defining CM correctly and over 40% of respondents declining to answer/ did not know. Abstinence was the most commonly recommended CM target, yet over 70% of respondents indicated that urine screens only occurred monthly. Attendance was also a popular recommendation, with respondents suggesting a range of possible indices including counseling, dosing, and/or case management sessions. Regarding the ideal role to administer CM prizes, program directors and supervisors were most commonly recommended, closely followed by front-line counselors. The most commonly suggested strategies to afford CM incentives included soliciting community donations and offering non-financial incentives.

Conclusions

User design principles to understand workflow constraints, target user needs, and simplify the intervention guided this qualitative investigation of CM implementation in opioid treatment programs. Findings highlighted the potential value of flexible, organization-specific definitions of CM attendance and non-financial incentives, as well as active involvement of clinical leaders and supervisors to promote buy in among staff/patients. Respondents were generally optimistic about their ability to fundraise or solicit donations to overcome cost-related barriers of CM. Implications for CM implementation strategies, including the use of targeted leadership coaching focused on sustainability, are explored.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4308-6) contains supplementary material, which is available to authorized users.

The dissemination and implementation of contingency management for substance use disorders: A systematic review

Contingency management is one of the most effective behavioral interventions for substance use. However, the implementation of contingency management has not been as widespread as might be expected given its efficacy. This review summarizes literature that examines the dissemination and implementation of contingency management for substance use in community (e.g., specialized substance use treatment) and clinical (e.g., primary care) settings. A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Databases including Google Scholar, World of Knowledge, PsycINFO, and PubMed were searched. Search results yielded 100 articles and after the screening of titles and abstracts 44 were identified. Full-text articles were examined for eligibility and yielded 24 articles that were included in this review. Of the 24 articles included in the review, the majority (n = 11) focused on implementing contingency management in methadone clinics and opioid treatment programs. Training methods, implementation strategies, fidelity assessments, and attitudes toward the implementation of contingency management are discussed in greater detail. These findings highlight the importance of organizational input and ongoing supervision and consultation, and the need for additional research that is guided by theoretical frameworks and use rigorous study designs. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Contingency Management: New Directions and Remaining Challenges for An Evidence-Based Intervention

This article introduces the special issue on contingency management (CM), an efficacious intervention for the treatment of substance use disorders with low uptake in clinical settings that is not commensurate with evidence for efficacy. In this special issue of the Journal of Substance Abuse Treatment, we present 16 articles representing the latest research in efficacy, implementation, and technological advances related to CM. Combined, this collection of articles highlights the diverse populations, settings, and applications of CM in the treatment of substance use disorders. We conclude by highlighting directions for future research, particularly those that may increase CM's appeal and uptake in routine clinical care.

The Effectiveness of Ultra-Low Magnitude Reinforcers: Findings From a "Real-World" Application of Contingency Management

BACKGROUND

Research has consistently found contingency management (CM) to be an effective tool in increasing desired patient behaviors in substance use disorder (SUD) treatment. Despite the strong evidence for the effectiveness of this intervention, practical issues and the cost of implementing CM in treatment programs have been significant barriers to adoption.

OBJECTIVES

To evaluate the impact of a CM program designed and implemented by university-affiliated methadone clinic staff to increase patient group attendance. The CM program consisted of a weekly raffle for patients attending clinician-led group counseling and/or in-clinic Methadone Anonymous (MA) groups in which slips with patient ID#s were entered and one ID slip was drawn per week with a fee credit for a dose of methadone ($15) as the prize.

METHODS

The CM program continued for 12 months. Group attendance was tracked before, during, and after CM implementation as part of ongoing clinic service utilization monitoring.

RESULTS

Following the implementation of CM, attendance at any clinician-led or MA groups increased significantly from baseline to month 1 (X²=5.78, p<0.05) but this increase was not sustained beyond month 6. Analysis of attendance by type of group revealed that clinician-led group attendance did not increase significantly but there was a significant increase in in-clinic MA group attendance from baseline to month 1 (X²=20.27, p<0.001), which was sustained through the 12-month implementation period (X²=11.21, p<0.001) and through 3 months post-implementation (X²=14.73; p<0.001).

CONCLUSIONS

A low-cost, simple CM intervention implemented by clinic staff was associated with significant increases in the target behavior of increasing group attendance.

Interest and preferences for contingency management design among addiction treatment clientele

BACKGROUND

Despite strong support for its efficacy, debates persist about how dissemination of contingency management is most effectively undertaken. Currently-promoted contingency management methods are empirically-validated, yet their congruence with interests and preferences of addiction treatment clientele is unknown. Such client input is a foundational support for evidence-based clinical practice.

OBJECTIVE

This study documented interest in incentives and preferences for fixed-ratio vs. variable-ratio and immediate vs. distal distribution of earned incentives among clients enrolled at three community programs affiliated with the National Institute on Drug Abuse Clinical Trials Network.

METHODS

This multi-site study included anonymous survey completion by an aggregate sample of 358 treatment enrollees. Analyses first ruled out site differences in survey responses, and then tested age and gender as influences on client interest in financial incentives, and preferences for fixed-ratio vs. variable-ratio reinforcement and immediate vs. distal incentive distribution.

RESULTS

Interest in different types of $50 incentives (i.e. retail vouchers, transportation vouchers, cash) was highly inter-correlated, with a mean sample rating of 3.49 (0.83) on a five-point scale. While consistent across client gender, age was an inverse predictor of client interest in incentives. A majority of clients stated preference for fixed-ratio incentive magnitude and distal incentive distribution (67% and 63%, respectively), with these preferences voiced by a larger proportion of females.

CONCLUSION

Sample preferences contradict currently-promoted contingency management design features. Future efforts to disseminate contingency management may be more successful if flexibly undertaken in a manner that incorporates the interests and preferences of local client populations.

Technology transfer for the implementation of a clinical trials network on drug abuse and mental health treatment in Mexico

Low- and middle-income countries (LMIC) lack the research infrastructure and capacity to conduct rigorous substance abuse and mental health effectiveness clinical trials to guide clinical practice. A partnership between the Florida Node Alliance of the United States National Drug Abuse Treatment Clinical Trials Network and the National Institute of Psychiatry in Mexico was established in 2011 to improve substance abuse practice in Mexico. The purpose of this partnership was to develop a Mexican national clinical trials network of substance abuse researchers and providers capable of implementing effectiveness randomized clinical trials in community-based settings. A technology transfer model was implemented and ran from 2011-2013. The Florida Node Alliance shared the "know how" for the development of the research infrastructure to implement randomized clinical trials in community programs through core and specific training modules, role-specific coaching, pairings, modeling, monitoring, and feedback. The technology transfer process was bi-directional in nature in that it was informed by feedback on feasibility and cultural appropriateness for the context in which practices were implemented. The Institute, in turn, led the effort to create the national network of researchers and practitioners in Mexico and the implementation of the first trial. A collaborative model of technology transfer was useful in creating a Mexican researcher-provider network that is capable of changing national practice in substance abuse research and treatment. Key considerations for transnational technology transfer are presented.

Concurrent alcohol and tobacco treatment: Effect on daily process measures of alcohol relapse risk

OBJECTIVE

The aim of this study was to compare the effects of alcohol treatment along with concurrent smoking treatment or delayed smoking treatment on process measures related to alcohol relapse risk.

METHOD

Alcohol dependent smokers (N = 151) who were enrolled in an intensive outpatient alcohol treatment program and were interested in smoking cessation were randomized to a concurrent smoking cessation (CSC) intervention or to a waiting list for delayed smoking cessation (DSC) intervention scheduled to begin 3 months later. Daily assessments of relapse process measures were obtained using an Interactive Voice Response (IVR) system for 12 weeks after the onset of smoking treatment in the CSC condition, and before beginning smoking treatment in the DSC condition. Smoking outcomes were assessed at 2 and 13 weeks after starting treatment.

RESULTS

Seven-day carbon monoxide (CO) verified smoking abstinence in the CSC condition was 50.5% at 2 weeks and 19.0% at 13 weeks compared with 2.2% abstinence at 2 weeks and 0% abstinence at 13 weeks for those in the DSC condition. Drinking outcomes were not significantly different for CSC versus DSC treatment conditions. On daily IVR assessments, CSC participants had significantly lower positive alcohol outcome expectancies relative to DSC participants. Multilevel modeling (MLM) analyses of within-person effects across the 12 weeks of daily monitoring showed that daily smoking abstinence was significantly associated with same day reports of lower alcohol consumption, lower urge to drink, lower negative affect, lower positive alcohol outcome expectancies, greater alcohol abstinence self-efficacy, greater alcohol abstinence readiness to change, and greater perceived self-control demands.

CONCLUSIONS

Analyses of process measures provide support for recommending smoking intervention concurrent with intensive outpatient alcohol treatment. (PsycINFO Database Record

Acceptability of an Internet-based contingency management intervention for smoking cessation: views of smokers, nonsmokers, and healthcare professionals

The acceptability of an Internet-based contingency management (CM) intervention for cigarette smoking was evaluated in two experiments. In Experiment 1, 67 participants (46% female) completed an Internet-based CM intervention and then answered questions about the intervention. Experiment 2 assessed the acceptability of the intervention among potential treatment users who had never used the intervention, (smokers, n = 164, 52% female), nonsmokers (n = 166, 73% female), and health-care providers (n = 139, 63% female). Participants in Experiment 2 were randomly assigned to either watch a video describing the standard CM intervention (no-deposit group) or to watch a video about the standard intervention plus a deposit incentive (deposit group). Overall, results of both experiments indicated high acceptability across all dimensions of the intervention. In Experiment 1, 74% (n = 26 of participants in the treatment group) of participants said they would use it if they needed to quit, as well as 92% (n = 150 among smokers) of those in Experiment 2. Of the health-care providers, 81% (n = 113) reported that they would be very likely to recommend the intervention to patients. Participants in both experiments reported that monitoring their progress and earning vouchers were strengths of the intervention. The no-deposit group rated voucher earnings, cash earnings, and cost-effectiveness of the intervention higher than the deposit group. Health-care professionals did not differ in their ratings across video conditions. Overall, the results suggest that Internet-based CM is acceptable as a method to help people quit smoking.

Training workshops positively impact beliefs about contingency management in a nationwide dissemination effort

In 2011, the Veterans Administration called for nationwide implementation of contingency management (CM) in its intensive outpatient substance use disorders treatment programs, and this study evaluated the impact of the initial 1 and ½ day training workshops on knowledge and perceptions about CM among 159 clinical leaders from 113 clinics. Workshop attendance significantly increased CM-related knowledge (d=1.88) and changed attendees' perceptions of CM (ds=0.26-0.74). Endorsement of barriers to CM adoption decreased and positive impressions of CM increased. These perceptions about CM emerged as key correlates of post-training preparedness to implement CM. Results suggest that training workshops can be an effective avenue for increasing CM-related knowledge, as well as addressing persistent misperceptions about CM that may impede adoption efforts. Continued efforts to introduce educational materials and offer training and consultation opportunities may increase understanding about this evidence-based intervention among clinicians, thereby leading to improved patient outcomes.

Investigating group contingencies to promote brief abstinence from cigarette smoking

In contingency management (CM), monetary incentives are contingent on evidence of drug abstinence. Typically, incentives (e.g., "vouchers" exchangeable for goods or services) are contingent on individual performance. We programmed vouchers contingent on group performance to investigate whether these contingencies would promote brief abstinence from cigarette smoking. Thirty-two participants were divided into small teams (n = 3 per team). During three 5-day within-subject experimental conditions, participants submitted video recordings of breath carbon monoxide (CO) measures twice daily via Motiv8 Systems, an Internet-based remote monitoring application. During the interdependent contingency condition, participants earned vouchers each time they and their teammates submitted breath CO samples indicative of abstinence (i.e., negative samples). During the independent contingency condition, participants earned vouchers each time they submitted negative samples, regardless of their teammates' performance. During the no vouchers condition, no monetary incentives were contingent on abstinence. In addition, half of the participants (n = 16) could communicate with their teammates through an online peer support forum. Although forum access did not appear to promote smoking abstinence, monetary incentives did promote brief abstinence. Significantly more negative samples were submitted when vouchers were contingent on individual performance (56%) or team performance (53%) relative to when no vouchers were available (35%; F = 6.9, p = .002). The results show that interdependent contingencies can promote brief abstinence from cigarette smoking. Moreover, the results suggest that these contingencies may help lower treatment costs and promote social support.

Community treatment adoption of contingency management: a conceptual profile of U.S. clinics based on innovativeness of executive staff

BACKGROUND

Community adoption of contingency management (CM) varies considerably, and executive innovativeness may help explain variance due to its presumed influence on clinic decision-making.

METHODS

Sixteen U.S. opioid treatment programs (OTPs) were visited, with ethnographic interviewing used in casual contacts with executives to inform their eventual classification by study investigators into one of Rogers' (2003) five adopter categories. Audio-recorded interviews were also conducted individually with the executive and three staff members (N = 64) wherein they reported reactions to clinic CM implementation during the prior year, from which study investigators later identified salient excerpts during interview transcript reviews.

RESULTS

The executive sample was progressive, with 56% classified as innovators or early adopters. Implementation reports and corresponding staff reactions were generally consistent with what might be expected according to diffusion theory. Clinics led by innovators had durably implemented multiple CM applications, for which staff voiced support. Clinics led by early adopters reported CM exposure via research trial participation, with mixed reporting of sustained and discontinued applications and similarly mixed staff views. Clinics led by early majority adopters employed CM selectively for administrative purposes, with staff reticence about its expansion to therapeutic uses. Clinics led by late majority adopters had either deferred or discontinued CM adoption, with typically disenchanted staff views. Clinics led by a laggard executive evidenced no CM exposure and strongly dogmatic staff views against its use.

CONCLUSION

Study findings are consistent with diffusion theory precepts, and illustrate pervasive influences of executive innovativeness on clinic practices and staff impressions of implementation experiences.

Contingency management in substance abuse treatment: a structured review of the evidence for its transportability

AIMS

Extant literature on contingency management (CM) transportability, or its transition from academia to community practice, is reviewed. The Consolidated Framework for Implementation Research (CFIR; Damschroder et al., 2009) guides the examination of this material.

METHODS

PsychInfo and Medline database searches identified 27 publications, with reviewed reference lists garnering 22 others. These 49 sources were examined according to CFIR domains of the intervention, outer setting, inner setting, clinicians, and implementation processes.

RESULTS

Intervention characteristics were focal in 59% of the identified literature, with less frequent focus on clinicians (34%), inner setting (32%), implementation processes (18%), and outer setting (8%). As intervention characteristics, adaptability and trialability most facilitate transportability whereas non-clinical origin, perceived inefficacy or disadvantages, and costs are impediments. Clinicians with a managerial focus and greater clinic tenure and CM experience are candidates to curry organizational readiness for implementation, and combat staff disinterest or philosophical objection. A clinic's technology comfort, staff continuity, and leadership advocacy are inner setting characteristics that prompt effective implementation. Implementation processes in successful demonstration projects include careful fiscal/logistical planning, role-specific staff engagement, practical adaptation in execution, and evaluation via fidelity-monitoring and cost-effectiveness analyses. Outer setting characteristics-like economic policies and inter-agency networking or competition-are salient, often unrecognized influences.

CONCLUSIONS

As most implementation constructs are still moving targets, CM transportability is in its infancy and warrants further scientific attention. More effective dissemination may necessitate that future research weight emphasis on external validity, and utilize models of implementation science.

Identifying provider beliefs related to contingency management adoption using the contingency management beliefs questionnaire

BACKGROUND

Contingency management (CM) is a widely recognized empirically-supported addiction treatment; however, dissemination and adoption of CM into routine clinical practice has been slow. Assessment of beliefs about CM may highlight key barriers and facilitators of adoption and inform dissemination efforts. In the present study, we developed a 35-item questionnaire (contingency management beliefs questionnaire; CMBQ) assessing CM beliefs and examined the relation of these beliefs to clinician characteristics and clinical practices.

METHODS

The web-based study was completed by 617 substance abuse treatment providers. We examined the factor structure using exploratory factor analysis (EFA) in a randomly selected half-sample (n=318) and evaluated the generalizability of the solution using confirmatory factor analysis (CFA) in the second half-sample (n=299).

RESULTS

EFA results suggested a 3-factor solution with 32 items retained; factors represented general barriers, training-related barriers, and pro-CM items. CFA results supported the solution, and reliability was good within each half-sample (α=0.88 and 0.90). Therapeutic approach, years experience in addictions field, perception of CM's research support, prior CM training, and CM adoption interest were significantly associated with the factors.

CONCLUSIONS

Overall, participants viewed CM favorably yet endorsed barriers, indicating a need for more extensive and targeted response to the most common misperceptions in dissemination efforts.

Is exposure to an effective contingency management intervention associated with more positive provider beliefs?

This study empirically examined opinions of treatment providers regarding contingency management (CM) programs while controlling for experience with a specific efficacious CM program. In addition to empirically describing provider opinions, we examined whether the opinions of providers at the sites that implemented the CM program were more positive than those of matched providers at sites that did not implement it. Participants from 7 CM treatment sites (n = 76) and 7 matched nonparticipating sites (n = 69) within the same nodes of the National Institute of Drug Abuse Clinical Trials Network completed the Provider Survey of Incentives (PSI), which assesses positive and negative beliefs about incentive programs. An intent-to-treat analysis found no differences in the PSI summary scores of providers in CM program versus matched sites, but correcting for experience with tangible incentives showed significant differences, with providers from CM sites reporting more positive opinions than those from matched sites. Some differences were found in opinions regarding costs of incentives, and these generally indicated that participants from CM sites were more likely to see the costs as worthwhile. The results from the study suggest that exposing community treatment providers to incentive programs may itself be an effective strategy in prompting the dissemination of CM interventions.

Internet-based group contingency management to promote abstinence from cigarette smoking: a feasibility study

BACKGROUND

In contingency management (CM) interventions, monetary consequences are contingent on evidence of drug abstinence. Typically, these consequences are contingent on individual performance. Consequences contingent on group performance may promote social support (e.g., praise).

METHODS

Thus, to combine social support with the monetary incentives of CM, we integrated independent and interdependent group contingencies of reinforcement into an Internet-based intervention to promote smoking abstinence. Breath carbon monoxide (CO) measures were compared between treatment conditions and a baseline control condition. Thirteen participants were divided into 5 groups or "teams" (n=2-3 per team). Each participant submitted video recordings of CO measurement twice daily via the Internet. Teammates could monitor each other's progress and communicate with one another through an online peer support forum. During a 4-day tapering condition, vouchers exchangeable for goods were contingent on gradual reductions in breath CO. During a 10-day abstinence induction condition, vouchers were contingent on abstinence (CO≤4ppm). In both treatment conditions, concurrent independent and interdependent group contingencies were arranged (i.e., a mixed contingency arrangement).

RESULTS

Less than 1% of CO samples submitted during baseline were≤4ppm, compared to 57% submitted during abstinence induction. Sixty-five percent of participants' comments on the online peer support forum were rated as positive by independent observers. Participants rated the intervention favorably on a treatment acceptability questionnaire.

CONCLUSION

The results suggest that the intervention is feasible and acceptable for promoting abstinence from cigarette smoking.