Application of Contingency Management-Prize Reinforcement to Community Practice With Alcohol and Drug Problems: A Critical Examination

What are the ethical implications of using prize-based contingency management in substance use? A scoping review

BACKGROUND

The area of substance use is notable for its early uptake of incentives and wealth of research on the topic. This is particularly true for prize-based contingency management (PB-CM), a particular type of incentive that uses a fishbowl prize-draw design. Given that PB-CM interventions are gaining momentum to address the dual public health crises of opiate and stimulant use in North America and beyond, it is imperative that we better understand and critically analyze their implications.

PURPOSE

The purpose of this scoping review paper is to identify the characteristics of PB-CM interventions for people who use substances and explore ethical implications documented in the literature as well as emerging ethical implications that merit further consideration.

METHODS

The PRISMA-ScR checklist was used in conjunction with Arksey and O'Malley's methodological framework to guide this scoping review. We completed a two-pronged analysis of 52 research articles retrieved through a comprehensive search across three key scholarly databases. After extracting descriptive data from each article, we used 9 key domains to identify characteristics of the interventions followed by an analysis of ethical implications.

RESULTS

We analyzed the characteristics of PB-CM interventions which were predominantly quantitative studies aimed at studying the efficacy of PB-CM interventions. All of the interventions used a prize-draw format with a classic magnitude of 50%. Most of the interventions combined both negative and positive direction to reward processes, behaviors, and/or outcomes. One ethical implication was identified in the literature: the risk of gambling relapse. We also found three emerging ethical implications by further analyzing participant characteristics, intervention designs, and potential impact on the patient-provider relationship. These implications include the potential deceptive nature of PB-CM, the emphasis placed on the individual behaviors to the detriment of social and structural determinants of health, and failures to address vulnerability and power dynamics.

CONCLUSIONS

This scoping review offers important insights into the ethics on PB-CM and its implications for research ethics, clinical ethics, and public health ethics. Additionally, it raises important questions that can inform future research and dialogues to further tease out the ethical issues associated with PB-CM.

A 12-Week Multi-Domain Lifestyle Modification to Reduce Depressive Symptoms in Older Adults: A Preliminary Report

OBJECTIVE

The objective of this study was to compare the effectiveness of usual care management (UCM) and a newly-developed lifestyle modification with contingency management (LMCM) for geriatric depressive symptoms in the community.

METHODS

A randomized controlled trial was conducted in 93 older adults with major depressive disorder at community mental health centers. A 12 week multi-domain LMCM was developed by providing positive reinforcement using 'gold medal stickers' as a symbolic incentive to motivate their participation and adherence. Participants were allocated to LMCM (n=47) and UCM (n=46) groups. They were then subjected to the 12 week treatment. Effects of the two intervention methods on Geriatric Depression Scale were determined using mixed model analysis.

RESULTS

Participants in the LMCM group had greater decline in GDS score per month than participants in the UCM group after adjusting for age, sex, years of education, living alone, and MMSE scores at baseline examination [coefficient for GDS score (95% CI): -1.08 (-1.51, -0.65), p<0.001, reference: UCM group].

CONCLUSION

LMCM is safe and easy to use with a low cost. LMCM is suitable as psychosocial intervention for older adults with depressive symptoms in the community.

Effects of a multidomain lifestyle modification on cognitive function in older adults: an eighteen-month community-based cluster randomized controlled trial

BACKGROUND

A healthy lifestyle may protect against cognitive decline. We examined outcomes in elderly individuals after 18 months of a five-group intervention program consisting of various modalities to prevent cognitive decline.

METHODS

We conducted a cluster randomized controlled trial assessing 460 community-dwelling individuals aged 60 years and older in a geriatric community mental health center in Suwon, Republic of Korea, between 2008 and 2010. We developed an intervention program based on the principles of contingency management, which could be delivered by ordinary primary health workers. Group A (n = 81) received standard care services. Group B (n = 80) received bimonthly (once every 2 months) telephonic care management. Group C (n = 111) received monthly telephonic care management and educational materials similar to those in group B. Group D (n = 93) received bimonthly health worker-initiated visits and counseling. Group E (n = 94) received bimonthly health worker-initiated visits, counseling, and rewards for adherence to the program.

RESULTS

The primary outcome was the change in Mini-Mental State Examination (MMSE) scores from baseline to the final follow-up visit at 18 months. Group E showed superior cognitive function to group A (adjusted coefficient β = 0.99, p = 0.044), with participation in cognitive activities being the most important determining factor among several health behaviors (adjusted coefficient β = 1.04, p < 0.01).

CONCLUSIONS

Engaging in cognitive activities, in combination with positive health behaviors, may be most beneficial in preserving cognitive abilities in community-dwelling older adults.

Acceptability of financial incentives for encouraging uptake of healthy behaviours: A critical review using systematic methods

OBJECTIVE

Financial incentives are effective in encouraging healthy behaviours, yet concerns about acceptability remain. We conducted a systematic review exploring acceptability of financial incentives for encouraging healthy behaviours.

METHODS

Database, reference, and citation searches were conducted from the earliest available date to October 2014, to identify empirical studies and scholarly writing that: had an English language title, were published in a peer-reviewed journal, and explored acceptability of financial incentives for healthy behaviours in members of the public, potential recipients, potential practitioners or policy makers. Data was analysed using thematic analysis.

RESULTS

Eighty one papers were included: 59 pieces of scholarly writing and 22 empirical studies, primarily exploring acceptability to the public. Five themes were identified: fair exchange, design and delivery, effectiveness and cost-effectiveness, recipients, and impact on individuals and wider society. Although there was consensus that if financial incentives are effective and cost effective they are likely to be considered acceptable, a number of other factors also influenced acceptability.

CONCLUSIONS

Financial incentives tend to be acceptable to the public when they are effective and cost-effective. Programmes that benefit recipients and wider society; are considered fair; and are delivered to individuals deemed appropriate are likely to be considered more acceptable.

Effectiveness of prize-based contingency management in a methadone maintenance program in China

BACKGROUND

Methadone maintenance treatment (MMT) has been successfully scaled up nationally in China. However, the program faces problems of poor attendance and high rates of continued drug use. We assessed whether a contingency management (CM) intervention implemented by MMT clinic staff could improve treatment attendance and drug abstinence.

METHODS

Eight MMT clinics in Guangdong province were randomly selected and divided into two groups. A total of 126 participants (55 in urban clinics and 71 in rural clinics) received CM during a 12-week trial, 120 participants (83 in urban clinics and 37 in rural clinics) received usual treatment (UT). Participants in the CM group had the opportunity to draw for prizes contingent on attending treatment daily and testing negative for morphine. Clinic- and individual-level outcomes were compared between the intervention and control groups.

RESULTS

The retention rate and negative urine testing rate were 14.2% (P=0.010) and 10.7% (P<0.001) higher in the CM group compared to the UT group, respectively. Compared with participants who received UT, CM participants missed on average 7.3 fewer (P=0.008) visits and were 1.91 (95% CI: 1.53-2.39) times more likely to submit a negative urine sample. All clinic- and individual- level effects of the intervention were observed at rural clinics, but the difference in retention rate between urban CM and UT clinics was not significant.

CONCLUSION

Although the frequency of monitoring and value of the incentives in this study was lower than in previous studies, the CM intervention significantly improved attendance and reduced drug use in China.