Publication Guide: Contingency Management

Below are some citations and abstracts from publications from the library’s database :

Aletraris, L., Shelton, J. S., & Roman, P. M. (2015). Counselor attitudes toward contingency management for substance use disorder: Effectiveness, acceptability, and endorsement of incentives for treatment attendance and abstinence. Journal of Substance Abuse Treatment, 57, 41-48.

Despite research demonstrating its effectiveness, use of contingency management (CM) in substance use disorder treatment has been limited. Given the vital role that counselors play as arbiters in the use of therapies, examination of their attitudes can provide insight into how further use of CM might be effectively promoted. In this paper, we examine 731 counselors’ attitudes toward the effectiveness and acceptability of CM in treatment, as well as their specific attitudes toward both unspecified and tangible incentives for treatment attendance and abstinence. Compared to cognitive behavioural therapy, motivational interviewing, and community reinforcement approach, counselors rated CM as the least effective and least acceptable psychosocial intervention. Exposure through the use of CM in a counselor’s employing organization was positively associated with perceptions of acceptability, agreement that incentives have a positive effect on the client–counselor relationship, and endorsement of tangible incentives for abstinence. Endorsement of tangible incentives for treatment attendance was significantly greater among counselors with more years in the treatment field, and counselors who held at least a master’s degree. Counselors’ adaptability or openness to innovations was also positively associated with attitudes toward CM. Further, female counselors and counselors with a greater 12-step philosophy were less likely to endorse the use of incentives. A highlight of our study is that it offers the first specific assessment of the impact of “Promoting Awareness of Motivational Incentives” (PAMI), a Web-based tool based on findings of CM protocols tested within the Clinical Trials Network (CTN), on counselors employed outside the CTN. We found that 10% of counselors had accessed PAMI, and those who had accessed PAMI were more likely to report a higher degree of perceived effectiveness of CM than those who had not. This study lays the groundwork for vital research on the impact of multiple Web-based educational strategies. Given the barriers to CM adoption, identifying predictors of positive attitudes among counselors can help diffuse CM into routine clinical practice.

Barnett, N. P., Celio, M. A., Tidey, J. W., Murphy, J. G., Colby, S. M., & Swift, R. M. (2017). A preliminary randomized controlled trial of contingency management for alcohol use reduction using a transdermal alcohol sensor. Addiction, 112(6), 1025-1035.

We tested the efficacy of daily contingent reinforcement for reducing alcohol use compared with (yoked) noncontingent reinforcement (NR) using a transdermal alcohol sensor to detect alcohol use. Pilot randomized controlled design with 1 baseline week, 3 intervention weeks and 1‐month follow‐up. New England, USA. Heavy drinking adults (46.7% female) not seeking treatment were randomized to (1) an escalating schedule of cash reinforcement (CR; n= 15) for days on which alcohol was neither reported nor detected or (2) yoked NR (n= 15).

Reinforcement for CR participants started at $5 and increased $2 every subsequent day on which alcohol was not detected or reported, to a maximum of $17. Participants received no reinforcement for days on which alcohol use was detected or reported, and the reinforcer value was re‐set to $5 the day after a drinking day. NR participants were yoked to the daily reinforcer value of an individual in the CR condition, in order of enrolment. Paired participants in CR and NR therefore received the same amount of money, but the amount for the NR participant was not behaviour‐related. The primary outcome was percentage of days without sensor‐detected drinking. Secondary outcomes were number of consecutive days with no detected drinking, peak transdermal alcohol concentration (TAC), self‐reported drinks per week and drinking below NIH low‐risk guidelines. Controlling for baseline, CR had a higher percentage of days with no drinking detected (54.3%) than NR (31.2%) during intervention weeks [P= 0.05, Cohen’s d= 0.74; 95% confidence interval (CI) = 0.007–1.47]. The longest period of consecutive days with no drinking detected was 8.0 for CR versus 2.9 for NR (P= 0.03, d= 0.85; 95% CI = 0.08 –1.61). Peak TAC during intervention showed a nonsignificant group difference (P= 0.20; d= 0.48; 95% CI = 0.00–1.18); a similar result was found for drinks per week (P= 0.12; d= 0.59; 95% CI = 0.00–1.30). Four times more participants in CR drank below NIH low‐risk drinking guidelines during intervention than did participants in NR: 31.1 versus 7.1% (P= 0.07; d= 0.71; 95% CI = –0.04 to 1.46). At 1‐month follow‐up, the highest number of consecutive days without drinking (self‐report) did not differ significantly between conditions (P= 0.26), but showed a medium effect size (d= 0.44; 95% CI = −0.32 to 1.18). Cash incentives linked to a transdermal alcohol sensor can reduce heavy alcohol consumption while the incentives are in operation.

Burch, A. E., Rash, C. J., & Petry, N. M. (2017). Cocaine-using substance abuse treatment patients with and without HIV respond well to contingency management treatment. Journal of Substance Abuse Treatment, 77, 21-25.

HIV is common among individuals with substance use disorders, but relatively few studies have examined the impact of HIV status on response to substance abuse treatment. This secondary analysis compared patients seeking treatment for cocaine use with and without HIV in terms of substance use treatment outcomes. Primary treatment outcomes included treatment retention, longest duration of abstinence, and percent of negative samples; both substance use outcomes reflect abstinence from cocaine, alcohol and opioids concurrently. Participants (N=432) were enrolled in randomized clinical trials comparing contingency management (CM) to standard care, and 32 (7%) reported being positive for HIV. Overall, CM improved both treatment retention (average of 8.2weeks compared to 6.0weeks in the standard care condition) and longest duration of abstinence (average of 5.8weeks compared to 2.8weeks in the standard care condition). HIV status was not associated with treatment outcomes as a main effect, nor did it have an interaction effect with treatment condition. These results suggest a benefit of CM in substance abuse treatment irrespective of HIV status.

Cunningham, C., Stitzer, M., Campbell, A. N., Pavlicova, M., Hu, M. C., & Nunes, E. V. (2017). Contingency management abstinence incentives: cost and implications for treatment tailoring. Journal of Substance Abuse Treatment, 72, 134-139.

Objective: To examine prize-earning costs of contingency management (CM) incentives in relation to participants’ pre-study enrolment drug use status (baseline (BL) positive vs. BL negative) and relate these to previously reported patterns of intervention effectiveness.

Methods: Participants were 255 substance users entering outpatient treatment who received the therapeutic educational system (TES), in addition to usual care counselling. TES included a CM component such that participants could earn up to $600 in prizes on average over 12-weeks for providing drug negative urines and completing web-based cognitive behaviour therapy modules. We examined distribution of prize draws and value of prizes earned for subgroups that were abstinent (BL negative; N = 136) or not (BL positive; N = 119) at study entry based on urine toxicology and breath alcohol screen.

Results: Distribution of draws earned (median = 119 vs. 17; p < .0001) and prizes redeemed (median = 54 vs. 9; p < .001) for drug abstinence differed significantly for BL negative compared to BL positive participants. BL negative earned on average twice as much in prizes as BL positive participants ($245 vs. $125). Median value of prizes earned was 5.4 times greater for BL negative compared to BL positive participants ($237 vs. $44; p < .001).

Conclusions: Two-thirds of expenditures in an abstinence incentive program were paid to BL negative participants. These individuals had high rates of drug abstinence during treatment and did not show improved abstinence outcomes with TES versus usual care (Campbell et al., 2014). Effectiveness of the abstinence-focused CM intervention included in TES may be enhanced by tailoring delivery based on patients’ drug use status at treatment entry.

Dallery, J., Raiff, B. R., Kim, S. J., Marsch, L. A., Stitzer, M., & Grabinski, M. J. (2017). Nationwide access to an internet‐based contingency management intervention to promote smoking cessation: a randomized controlled trial. Addiction, 112(5), 875-883.

Contingency management (CM) is one of the most effective behavioural interventions to promote drug abstinence, but availability of this treatment is limited. We evaluated the efficacy and acceptability of internet‐based CM relative to an internet‐based monitoring and goalsetting control group in a nationwide sample of cigarette smokers. Randomized controlled trial with 3‐ and 6‐month follow‐ups. United States. Smokers (n= 94) from 26 states were enrolled (mean age 36, 56% female). Participants were randomized to earn financial incentives (up to $480 over 7 weeks) based on video‐verified abstinence using breath carbon monoxide (CO) output (n= 48; abstinent contingent group, AC), or based on submitting CO samples (n= 46, submission contingent, SC). Both groups also received the same CO‐based goals. A $50 deposit was required in both groups that could be recouped from initial earnings. The primary outcome was point prevalence at week 4. Secondary outcomes were point prevalence at the 3‐ and 6‐month follow‐ups, percentages of negative CO samples, adherence to the CO sampling protocol, and treatment acceptability ratings on a 0–100‐mm visual analogue scale. Abstinence rates differed at 4 weeks between the AC (39.6%) and SC (13.0%) groups [odds ratio (OR) = 4.4, 95% confidence interval (CI) = 1.6 –12.3], but not at the 3‐ (29.2% AC and 19.6% SC, OR = 1.7, 95% CI = 0.6–4.4) or 6‐ (22.9% AC and 13.0%

SC, OR = 2.0, 95% CI = 0.7–5.9) month follow‐ups. During the two main treatment phases, there were significant differences in negative COs (53.9% AC and 24.8% SC, OR = 3.5, 95% CI = 3.1–4.0; 43.4% AC and 24.6% SC, OR = 2.3, 95% CI = 1.6–3.4). Adherence to the CO submission protocol was equivalent (78% AC and 85% SC, difference = 7.0%, 95% CI = −10.3 to 23.8 %, F < 1, P= 0.39). The lowest acceptability ratings were for the items assessing the deposit, whereas the highest ratings concerned the ease of the intervention, the graph of CO results, and earning money. A contingency management/financial incentive program delivered via the internet improved short‐term abstinence rates compared with an internet program without the incentives.

Hartzler, B., Donovan, D. M., Tillotson, C. J., Mongoue-Tchokote, S., Doyle, S. R., & McCarty, D. (2012). A multilevel approach to predicting community addiction treatment attitudes about contingency management. Journal of Substance Abuse Treatment, 42(2), 213-221.

Adoption of contingency management (CM) by the addiction treatment community is limited to date despite much evidence for its efficacy. This study examined systemic and idiographic staff predictors of CM adoption attitudes via archival data collected from treatment organizations affiliated with the National Drug Abuse Treatment Clinical Trials Network. Multilevel modelling analyses evaluated potential predictors from organizational, treatment unit, and workforce surveys. Among these were individual and shared perceptions of staff concerning aspects of their clinic culture and climate. Modelling analyses identified three systemic predictors (clinic provision of opiate agonist services, national accreditation, and lesser shared perception of workplace stress) and five idiographic predictors (staff with a graduate degree, longer service tenure, managerial position, e-communication facility, and openness to change in clinical procedures). Findings are discussed as they relate to extant literature on CM attitudes and established implementation science constructs, and their practical implications are discussed.

Helseth, S. A., Janssen, T., Scott, K., Squires, D. D., & Becker, S. J. (2018). Training community-based treatment providers to implement contingency management for opioid addiction: Time to and frequency of adoption. Journal of Substance Abuse Treatment, 95, 26-34.

Contingency management (CM) is a well-established treatment for opioid use, yet its adoption remains low in community clinics. This manuscript presents a secondary analysis of a study comparing a comprehensive implementation strategy (Science to Service Laboratory;

SSL) to didactic training-as-usual (TAU) as a means of implementing CM across a multi-site opioid use disorder program. Hypotheses predicted that providers who received the SSL implementation strategy would 1) adopt CM faster and 2) deliver CM more frequently than TAU providers. In addition, we examined whether the effect of implementation strategy varied as a function of a set of theory-driven moderators, guided by the Consolidated Framework for Implementation Research: perceived intervention characteristics, perceived organizational climate, and provider characteristics (i.e., race/ethnicity, gender). Sixty providers (39 SSL, 21 TAU) across 15 clinics (7 SSL, 8 TAU) completed a comprehensive set of measures at baseline and reported biweekly on CM use for 52 weeks. All participants received didactic CM training; SSL clinics received 9 months of enhanced training, including access to an external coach, an in-house innovation champion, and a collaborative learning community. Discrete-time survival analysis found that SSL providers more quickly adopted CM; provider characteristics (i.e., race/ethnicity) emerged as the sole moderator of time to adoption. Negative binomial regression revealed that SSL providers also delivered CM more frequently than TAU providers. Frequency of CM adoption was moderated by provider (i.e., gender and

race/ethnicity) and intervention characteristics (i.e., compatibility). Implications for implementation strategies for community-based training are discussed.

McKay, J. R. (2017). Making the hard work of recovery more attractive for those with substance use disorders. Addiction, 112(5), 751-757.

Research has led to improvements in the effectiveness of interventions for substance use disorders (SUD), but for the most part progress has been modest, particularly with regard to longer‐term outcomes. Moreover, most individuals with SUD do not seek out treatment. This paper presents two recommendations on how to improve treatment engagement and long‐term outcomes for those with SUD. First, treatments should go beyond a focus on reducing or eliminating substance use to target greater access to and more time spent in experiences that will be enjoyable or otherwise rewarding to clients. Secondly, there must be sufficient incentives in the environment to justify the effort needed to sustain long‐term abstinence for individuals who often have limited access to such incentives. To increase rates of long‐term recovery from substance misuse, treatments should link clients to reinforcers that will make continued abstinence more appealing. This work needs to extend beyond interventions focused on the individual or family to include the local community and national policy in an effort to incentivise longer‐term recoveries more strongly.

McPherson, S., Brooks, O., Barbosa-Leiker, C., Lederhos, C., Lamp, A., Murphy, S., … & Roll, J. (2016). Examining longitudinal stimulant use and treatment attendance as parallel outcomes in two contingency management randomized clinical trials. Journal of Substance Abuse Treatment, 61, 18-25.

The primary aim of this study was to examine stimulant use and longitudinal treatment attendance in one ‘parallel outcomes’ model in order to determine how these two outcomes are related to one another during treatment, and to quantify how the intervention impacts these two on- and off-target outcomes differently. Data came from two multi-site randomized clinical trials (RCTs) of contingency management (CM) that targeted stimulant use. We used parallel multilevel modelling to examine the impact of multiple pre-specified covariates, including selected Addiction Severity Index (ASI) scores, age and sex, in addition to CM on concurrent attendance and stimulant use in two separate analyses, i.e., one per trial. In one trial, CM was positively associated with attending treatment throughout the trial (β = 0.060, p < 0.05). In the second trial, CM predicted negative urinalysis (UA) over the 12-week treatment period (β = 0.069, p < 0.05). In both trials, there was a significant, positive relationship between attendance and UA submission, but in the first trial a UA at both baseline and over time was related to attendance over time (r = 0.117; r = 0.013, respectively) and in the second trial, a UA submission at baseline was associated with increased attendance over time (r = 0.055).

These findings indicate that stimulant use and treatment attendance over time are related but distinct outcomes that, when analysed simultaneously, portray a more informative picture of their predictors and the separate trajectories of each. This ‘indirect reinforcement’ between two clinically meaningful on-target (directly reinforced behaviour) and off-target (indirectly reinforced behaviour) outcomes is in need of further examination in order to fully exploit the potential clinical benefits that could be realized in substance use disorder treatment trials.

Neale, J., Tompkins, C. N., & Strang, J. (2016). Qualitative evaluation of a novel contingency management‐related intervention for patients receiving supervised injectable opioid treatment. Addiction, 111(4), 665-674.

To evaluate a novel contingency management (CM) ‐related intervention for people experiencing complex drug problems, thereby increasing understanding of CM implementation in real‐world settings. Objectives are to provide new insights into (i) how context influences intervention delivery; (ii) aspects of intervention delivery that influence outcomes; and (iii) intervention outcomes.

Qualitative realist evaluation of a novel CM‐related intervention: conditional budgets (CB). Supervised injectable opioid treatment (IOT) clinic in England (May 2014–March2015). Twenty IOT clinic patients (14 men; six women); 10 IOT clinic staff (seven men; three women). Semi‐structured interviews systematically coded relating to knowledge and views of the intervention, experiences of delivering/receiving the intervention, and effectiveness of the intervention. Personal budgets provided to patients who reduced their supervised IOT while demonstrating ongoing stability. (i) Contextual factors influencing intervention delivery included patient motivation; clarity of intervention information; prior trust in the treatment system; patient and staff involvement in intervention design; stability of the treatment setting. (ii) Aspects of delivery influencing outcomes included transparency of the eligibility criteria, rules and operating processes; rule enforcement; continued verbal information about the intervention; speed of incentive processing and receipt. (iii) Reduced drug use was difficult to attribute to CBs, as patients who did well were those most motivated to change before the intervention started. Unintended outcomes were positive (improved patient psychological wellbeing, staff job satisfaction, staff/patient relationships) and negative (patient relapse, increased staff work‐load, tensions in clinic relationships). A ‘qualitative realist’ evaluation of a contingency management intervention to help address complex substance use disorder problems suggests that the programmes need to have stakeholder input, implement consistent eligibility criteria, rules and processes and be introduced into stable treatment settings where relationships are trusting and patients and staff feel secure.

Rash, C. J., Alessi, S. M., & Petry, N. M. (2017). Substance abuse treatment patients in housing programs respond to contingency management interventions. Journal of Substance Abuse Treatment, 72, 97-102.

Use of homeless and transitional housing (e.g., recovery homes) programs can be associated with success in substance abuse treatment, perhaps because many of these programs encourage or mandate sobriety. In this study, we examined whether contingency management (CM) protocols that use tangible incentives for submission of drug-free specimens or other specific behaviours are effective for treatment-seeking substance abusers whose behaviour may also be shaped by housing programs. Of 355 participants in randomized trials of CM, 56 (16%) reported using transitional housing during the 12-week treatment period. Main and interaction effects of housing status and treatment condition were evaluated for the primary substance abuse treatment outcomes: a) longest duration of abstinence from alcohol, cocaine, and opioids, b) percentage of samples submitted that were negative for these substances, and c) treatment retention. After controlling for demographic and clinical characteristics, those who accessed housing programs submitted a higher percentage of negative samples (75%) compared to those who did not access housing programs (67%). Housing status groups did not differ in terms of longest duration of abstinence (accessed housing: M = 3.1 weeks, SE = 0.6; did not access housing: M = 3.9 weeks, SE = 0.3) or retention in substance abuse treatment (accessed housing: M = 6.4 weeks, SE = 0.6; did not access housing: M = 6.6 weeks, SE = 0.3). Regardless of housing status, CM was associated with longer durations of abstinence and treatment retention. No interactive effects of housing and treatment condition were observed (p > .05). Results suggest that those who accessed housing programs during substance abuse treatment benefit from CM to a comparable degree as their peers who did not use such programs. These effects suggest that CM remains appropriate for those accessing housing in community-based programs.

Shearer, J., Tie, H., & Byford, S. (2015). Economic evaluations of contingency management in illicit drug misuse programmes: a systematic review. Drug and Alcohol Review, 34(3), 289-298.

Issues. UK clinical guidelines published in 2007 recommended contingency management (CM) as an adjunct to opiate substitution therapy. However, CM has not been adopted in the UK despite evidence of clinical effectiveness. Evidence for the cost-effectiveness of CM is less clear and will need to be explored if CM is to be adopted by national health systems in countries such as the UK. Approach. Systematic review and descriptive synthesis of published economic evaluations. Key Findings. The review identified nine published studies that could be classified as economic evaluations. These were all based within US treatment settings, and five were conducted by the same group of authors. All studies found that the addition of CM to usual care increased both costs and effects (commonly drug abstinence or medication adherence). Implications. This review confirms that the existing evidence base for cost-effectiveness has limited generalisability beyond the original research clinical settings and populations.

Conclusion: The data were not sufficiently strong to make any conclusion about the cost-effectiveness of CM. More relevant and comprehensive evidence for cost-effectiveness than currently exists is needed.

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