Mental health and behavioural conditions
Drug misuse in over 16s: opioid detoxification
Clinical guideline [CG52] Published date: July 2007
Key priorities for implementation
1 Guidance
2 Research recommendations
Appendix: Contingency management – key elements in the delivery of a programme
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The introduction of contingency management into drug misuse services in the NHS presents a considerable challenge. This is primarily because contingency management has not been widely used in the NHS; hence staff are not trained in the technique and a major training programme will be required to implement it. Another challenge is address the concerns of staff, service users and the wider public about contingency management, in particular concerns that:
the intervention may 'reward' illicit drug use
the effects will not be maintained in the long term
the system is open to abuse as people may 'cheat' their drug tests
incentive-based systems will not work outside the healthcare system (that of the United States) in which they were developed.
The aim of this appendix, firstly, is to provide a brief introduction to contingency management for those not familiar with this intervention. Secondly, it will address the issues outlined above by setting out a possible strategy for implementation in the NHS, drawing on an evidence base from the United States, Europe and Australia.
Introduction to contingency management
Contingency management refers to a set of techniques that focus on the reinforcement of certain specified behaviours. These may include abstinence from drugs (for example, cocaine), reduction in drug misuse (for example, illicit drug use by people receiving methadone maintenance treatment), and promoting adherence to interventions that can improve physical health outcomes (for example, attending for hepatitis C tests) (Petry 2006). To date, over 25 trials of contingency management have been conducted, involving over 5000 participants, which constitute the largest single body of evidence for the effectiveness of psychosocial interventions in drug misuse. In the formal studies of contingency management, incentives have included vouchers (exchangeable for goods such as food), cash rewards (of low monetary value), prizes (including cash and goods) and clinic privileges (such as non-supervised consumption). All the incentives have been shown to be effective, although it was the view of the guideline development group that vouchers and clinic privileges would generally be more easily implemented in the NHS.
The following principles underlie the effective delivery of contingency management (Petry 2006).
Robust, routine testing for drug misuse should be carried out.
Targets should be agreed in collaboration with the service user.
Incentives should be provided in a timely and consistent manner.
The relationship between the treatment goal and the incentive schedule should be understood by the service user
Incentives should be perceived by the service user to be reinforcing and to support a healthy/drug-free lifestyle.
Implementing contingency management in the NHS
Although contingency management has not yet been implemented in the NHS (but see McQuaid et al. 2007 for a report of a pilot study), there have been a number of major studies looking at its uptake in the United States, Europe and Australia. Crucially, these studies give an account of its implementation in services where initially there was considerable resistance on the part of both staff and people who misuse drugs. They report positive shifts in staff attitudes as the understanding of contingency management increased and its beneficial impact on the lives of people who misuse drugs became apparent (McGovern et al. 2004; Kellogg et al. 2005; Kirby et al.2006; Ritter and Cameron 2007).
Studies have also looked at the organisational development required to support successful implementation. Kellogg et al. (2005) identified, in addition to the principles outlined above, four key aspects of the uptake of contingency management in the public healthcare system in New York:
endorsement of the programme by senior managers and clinicians, and their engagement with the concerns of direct care staff
provision of a comprehensive education and training programme that provided clear direction for staff, many of whom were unfamiliar with the basic principles of contingency management
recognition by staff that contingency management is an intervention aimed at changing specific key behaviours, and does not simply reward people for general good behaviour
a shift in the focus of the service to one that is incentive-orientated, where contingency management plays a central role in promoting a positive relationship between staff and service users.[1]
In a series of interviews and discussions with staff and service users, Kellogg et al. (2005) found that contingency management increased the motivation of service users to undergo treatment, facilitated therapeutic progress, increased staff optimism about treatment outcomes and their morale, and promoted the development of more positive relationships both between service users and staff and among staff members. As a result, there was a shift from viewing contingency management as an intervention that would be difficult to integrate with other interventions to it becoming the main focus of interventions with service users. Other studies (for example, Higgins et al. 2000) also provide important advice on how the effects of interventions can be maintained once incentives are discontinued.
In the NHS, several other factors will need to be considered when developing an implementation programme. These may include:
the integration, where appropriate, of contingency management with the keyworking responsibilities of staff
the identification of those groups of people who misuse drugs who are most likely to benefit from contingency management (for example, it might be expected that about 30% of people receiving methadone maintenance treatment will be considered for contingency management)
the development of near-patient testing
the impact on service-user government benefits.
The implementation process
Where possible, implementation in the NHS should draw on the experience so far (albeit limited) of contingency management in the NHS and on the experience of agencies such as the National Treatment Agency for Substance Misuse (NTA) in the implementation of service developments in drug misuse. The NTA, with its lead role in drug misuse, is best placed to lead an implementation programme, as it has both the national and regional infrastructure and the experience (for example, through its work on the International Treatment Effectiveness Project). Any implementation programme should include the following elements:
the establishment of a series of demonstration sites
dissemination of the findings, including those emerging from demonstration sites, to inform the field
an agreement with local commissioners where change of contracts or service level agreements are required
a review of service readiness to implement contingency management and the involvement of senior management, clinicians and key workers in any required service developments
training programmes for staff to enable them to deliver contingency management
working with service users to raise awareness about contingency management and involve them in local service design
evaluation of the implementation programme.
The provision of training to deliver contingency management may include a requirement for service managers, supervisors and front-line staff to acknowledge the need for institutional change and staff 'buy in'. Training could be designed to provide a foundation covering the theory, practice and research findings of contingency management, including the factors associated with its successful implementation (Kellogg et al. 2005). A major focus of the training programme will be on identifying and developing staff competencies to deliver contingency management in a manner that emphasises the positive, reinforcing aspects of the intervention.
The structure of any evaluation of contingency management could follow that of the implementation programme and may examine the following issues using quantitative and qualitative methods:
service design (the feasibility of establishing contingency management in services, structures associated with effective uptake and barriers to uptake)
the most effective training models associated with sustained uptake
the experiences of staff and service users.
This appendix sets out the background and process by which contingency management may be implemented in drug misuse services in the NHS. Successful implementation of contingency management will have considerable benefits for people who misuse drugs, their families and wider society.
Higgins ST, Badger GJ, Budney, AJ (2000) Initial abstinence and success in achieving longer term cocaine abstinence. Experimental and Clinical Psychopharmacology 8: 377–86.
Kellogg SH, Burns M, Coleman P, et al. (2005) Something of value: the introduction of contingency management interventions into the New York City Health and Hospital Addiction Treatment Service. Journal of Substance Abuse Treatment 28: 57–65.
Kirby KC, Benishek LA, Dugosh KL, et al.(2006) Substance abuse treatment providers' beliefs and objections regarding contingency management: implications for dissemination. Drug and Alcohol Dependence 85:19–27.
McGovern MP, Fox TS, Xie H, et al. (2004) A survey of clinical practices and readiness to adopt evidence-based practices: dissemination research in an addiction treatment system. Journal of Substance Abuse Treatment 26:305–12.
McQuaid F, Bowden-Jones O, Weaver T (2007) Contingency management for substance misuse. British Journal of Psychiatry 190: 272.
Messina N, Farabee D, Rawson R (2003) Treatment responsivity of cocaine-dependent patients with antisocial personality disorder to cognitive-behavioral and contingency management interventions. Journal of Consulting and Clinical Psychology 71: 320–9.
Petry N (2006) Contingency management treatments. British Journal of Psychiatry 189: 97–8.
Ritter A, Cameron J (2007) Australian clinician attitudes towards contingency management: comparing down under with America. Drug and Alcohol Dependence 87: 312–5.
[1] The emphasis on incentives is consistent with current knowledge about the underlying neuropsychology of many people who misuse drugs; specifically that people with antisocial personality disorder (ASPD) (who account for a significant proportion of long-term drug users) are much more likely to respond to positive than to punitive approaches. Messina et al. (2003) found that people with ASPD who received contingency management were more likely to abstain from cocaine use than both participants without ASPD receiving contingency management or cognitive behavioural therapy and participants with ASPD receiving cognitive behavioural therapy.