Examining implementation of contingency management in real-world settings

Harnessing Implementation Science in Clinical Psychology: Past, Present, and Future

Implementation science aspires to equitably accelerate the uptake of clinical research into practice to improve population health. The focus of implementation science includes individual behavior change mechanisms that are similar to those that drive the field of clinical psychology. For this reason, clinical psychologists are well-suited to take up implementation science methods in pursuit of improving the quality of behavioral health care. To do so, clinical psychologists must expand beyond individual behavior change to include a focus on organizations and systems. In this review, we reflect on ways that clinical psychologists can lead in the integration of implementation science principles and approaches into clinical psychology research and practice. We discuss the role clinical psychologists play in closing know-do gaps in behavioral health and describe how clinical psychologists can build implementation science competencies. We end with current controversies and opportunities for innovation to further improve the quality of behavioral health care.

Implementing contingency management in family medicine: A qualitative inquiry on provider and patient preferences for a low magnitude reward program compatible with buprenorphine treatment

Background

Contingency management (CM) is an effective yet underutilized behavioral intervention that uses rewards to improve outcomes in medication for opioid use disorder (MOUD) treatment. Prior implementation attempts have focused on specialized addiction clinics, using intensive daily treatment with methadone and high reward values (e.g. >$200 total). However, many people get MOUD from less specialized, more accessible, family medicine clinics. These clinics could also benefit from CM, yet present unique challenges for CM. Family medicine clinics typically use buprenorphine as their primary medication, which requires less intensive dosing schedules and thus provides fewer CM opportunities. They may also have lower institutional willingness to use high-value rewards. As an initial step in user-centered design of a low value reward (<$75 total) CM program for the family medicine context, we conducted qualitative interviews with patients and staff in the buprenorphine treatment program of a family medicine department. We gathered and analyzed qualitative data on CM knowledge, preferred program parameters, and implementation considerations.

Method

Participants (N = 24) were buprenorphine treatment staff (n = 12) and patients (n = 12). Participants completed 30-50-minute semi-structured interviews, analyzed using rapid matrix analysis.

Results

Participants had little experience with CM, but generally viewed CM as acceptable, appropriate, and feasible. Interviewees coalesced around having staff who were not providers with prescription privileges conduct CM, consistent rather than escalating payments, and physical rewards delivered in-person. Potential challenges included medical record integration, demands on staff time, and confirmation of patients' goal completion.

Conclusions

Patient and staff feedback was well-aligned, especially regarding rewards as an opportunity for staff-patient connection and the need for simplicity. Some consensus suggestions (e.g. non-escalating rewards) conflict with extant CM literature. Implications for implementation of CM in this setting are presented. These findings inform user-centered design and iteration of a CM program for this accessible, non-specialized family medicine setting.

Using the IFASIS (Inventory of Factors Affecting Successful Implementation and Sustainment) to advance context-specific and generalizable knowledge of implementation determinants: case study of a digital contingency management platform

BACKGROUND

Contingency management (CM) is the most effective treatment for stimulant use disorder but is underutilized by opioid treatment programs (OTPs) despite the high prevalence of stimulant use in this setting. As part of a state-wide initiative, we piloted a novel assessment, the Inventory of Factors Affecting Successful Implementation and Sustainment (IFASIS), to examine determinants of implementation of a digital CM platform across a set of OTPs. We describe how the IFASIS was used to elucidate both generalizable and context-specific implementation determinants, and to guide the provision of implementation facilitation.

METHODS

Six OTPs received a multi-level implementation strategy (including facilitation) to promote programmatic uptake of a digital CM platform. Pre-implementation, OTPs completed the IFASIS, a 27-item questionnaire that assesses both the valence (positive/negative) and importance of determinants across 4 domains: outside the organization, within the organization, about the intervention, and about intervention recipients. OTP staff completed the IFASIS as a team, identifying consensus ratings during recorded discussions. Transcripts of IFASIS recordings were analyzed using rapid qualitative analysis. Quantitative IFASIS results were aggregated into medians and ranges within and across organizations. A detailed review of implementation facilitation meeting notes was conducted to examine how the IFASIS was used to guide facilitation.

RESULTS

Quantitative ratings and qualitative feedback revealed common barriers to implementation of the digital CM platform, including a lack of sustainable funding sources, absence of external and organizational policies, insufficient higher-level leadership support, and mixed attitudes among staff members toward CM. Common implementation facilitators included enthusiasm and commitment among organization leadership and the perception that the digital CM platform would reduce the workload and burden on OTP counselors. The IFASIS was used to guide facilitation in several ways, including stimulating discussion about barriers and facilitators, brainstorming strategies to address barriers rated as "very important", and identifying facilitators that could be harnessed as part of implementation efforts.

CONCLUSIONS

The IFASIS identified important determinants of CM implementation in OTPs and was instrumental in shaping facilitation. The IFASIS may be a valuable assessment for the implementation science community to identify and address generalizable and context-specific implementation determinants.

Evolution of the substance use landscape: Implications for contingency management

Contingency management (CM), which involves the delivery of incentives upon meeting behavioral goals, has the potential to improve substance use treatment outcomes. The intervention allows for flexibility through numerous modifiable components including changes to incentive magnitude and schedule, target behavior, and intervention structure. Unfortunately, numerous changes in the substance use landscape have occurred in the past 10 to 15 years: Substances are more potent, overdose risk has increased, new substances and methods of use have been introduced, and substance classes are increasingly being intentionally and unintentionally mixed. These developments potentially undermine CM outcomes. We explored recent substance use changes due to legislative, regulatory, social, and economic factors for four substance classes: stimulants, opioids, tobacco, and cannabis. We discuss potential adjustments to the modifiable components of CM for future research in response to these changes. By continually adapting to the shifting substance use landscape, CM can maintain optimal efficacy.

Examining the impact of low magnitude incentives in contingency management protocols: Non-engagement in Petry et al. 2004

INTRODUCTION/METHOD

Current federal regulations limit the use of incentives in contingency management (CM) interventions to a nominal total value (i.e., up to $75/patient/year in aggregate of federal funds). This limit represents a striking divergence from the magnitudes used in evidence-based CM protocols. In the present report, we re-analyze data from the Petry et al. (2004) study, which was designed to test the efficacy of two different magnitude CM protocols ($80 and $240 in 2004 dollars) relative to usual intensive outpatient services for treatment-seeking patients with cocaine use. Petry et al. (2004) found that the $240 condition [~$405 in 2024 dollars], but not the $80 condition [~$135 in 2024 dollars], improved abstinence outcomes relative to usual care. The lower-cost $80 condition is the closest condition to the current federal $75 limit that permits a head-to-head comparison of magnitudes. A re-analysis offers an opportunity to examine the impact of low magnitude protocols in more detail, specifically in terms of non-engagement with treatment (defined as absence of negative samples and thus not encountering incentives for abstinence).

RESULTS

We found moderate to large effects favoring the $240 condition over both usual care (ds ranging 0.33 to 0.97) and the $80 condition (ds ranging 0.39 to 0.83) across various thresholds of non-engagement with the incentives/reinforcers for abstinence. Importantly, the $80 condition evidenced higher (worse) rates of non-engagement compared to the usual care condition (i.e., small and negative effect sizes ranging -0.30 to 0.14), though not reaching statistical significance.

CONCLUSIONS

These results suggest that CM protocols designed to stay within the federal limitation of $75 should be discouraged, and evidence-based protocols should be recommended along with the regulatory reforms necessary to support their implementation.

Using the IFASIS (Inventory of Factors Affecting Successful Implementation and Sustainment) to Advance Context-Specific and Generalizable Knowledge of Implementation Determinants: Case Study of a Digital Contingency Management Platform

Background

Contingency management (CM) is the most effective treatment for stimulant use disorder but is underutilized by opioid treatment programs (OTPs), despite the high prevalence of stimulant use in this setting. As part of a state-wide initiative, we piloted a novel assessment, the Inventory of Factors Affecting Successful Implementation and Sustainment (IFASIS), to examine determinants of implementation of a digital CM platform across a set of OTPs. We describe how the IFASIS was used to elucidate both generalizable and context-specific implementation determinants, and to guide the provision of implementation facilitation.

Methods

Six OTPs received a multi-level implementation strategy (including facilitation) to promote programmatic uptake of a digital CM platform. Pre-implementation, OTPs completed the IFASIS, a 27-item questionnaire that assesses both the valence (positive/negative) and importance of determinants across 4 domains: outside the organization, within the organization, about the intervention, and about intervention recipients. OTP staff completed the IFASIS as a team, identifying consensus ratings during recorded discussions. Transcripts of IFASIS recordings were analyzed using rapid qualitative analysis. Quantitative IFASIS results were aggregated into medians and ranges within and across organizations. Implementation facilitation meeting notes were analyzed to examine how the IFASIS was used to guide facilitation.

Results

Quantitative ratings and qualitative feedback revealed common barriers to implementation of the digital CM platform, including a lack of sustainable funding sources, absence of external and organizational policies, insufficient higher-level leadership support, and mixed attitudes among staff members toward CM. Common implementation facilitators included enthusiasm and commitment among organization leadership and the perception that the digital CM platform would reduce the workload and burden on OTP counselors. The IFASIS was used to guide facilitation in several ways, including stimulating discussion about barriers and facilitators, brainstorming strategies to address barriers rated as "very important", and identifying facilitators that could be harnessed as part of implementation efforts.

Conclusions

The IFASIS identified important determinants of CM implementation in OTPs and was instrumental in shaping facilitation. The IFASIS may be a valuable assessment for the implementation science community to identify and address generalizable and context-specific implementation determinants.

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.

Contingency Management for Drug Use Disorders: Meta-Analysis and Application of Tolin's Criteria

Several professional organizations and federal agencies recommend contingency management (CM) as an empirically supported treatment for drug use disorder. However, the release of the "Tolin criteria" warrants an updated recommendation. Using this methodology, five meta-analyses (84 studies, 11,000 participants) were reviewed. Two meta-analyses were rated moderate quality, and three were rated low or critically low quality. Comparator conditions included active treatment, placebo, treatment as usual, and no treatment. The primary outcome was abstinence. Considering only the moderate quality meta-analyses, the effect of CM versus control on posttreatment abstinence was d = 0.54 [0.43, 0.64] and follow-up abstinence was d=0.08 [0.00, 0.16]. A "strong" recommendation was provided for CM as an empirically supported treatment for drug use disorder.

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.

Effective, but underused: lessons learned implementing contingency management in real-world practice settings in the United States

Despite being one of the most effective adjunctive behavioral interventions in combination with medication for opioid use disorder, contingency management (CM) is one of the least available interventions in opioid treatment programs. This paradoxical state of affairs is perhaps the greatest example of the research-to-practice gap in the behavioral health field. Implementation science, a discipline that aims to identify replicable methods that can be used across settings and populations to bridge the gap between research and practice, can potentially help. Based on our team's experience implementing CM in opioid treatment programs, we detail five key lessons for researchers, clinicians, policy makers, and others seeking to implement and sustain CM in real-world settings. First, multiple barriers to CM implementation exist at both the counselor- and organization-levels, requiring multi-level solutions. Second, one-shot CM training alone is not sufficient for successful implementation: ongoing support is essential to achieve levels of intervention fidelity that will benefit patients. Third, assessing an organization's capacity for implementation prior to support provision can prevent costly mistakes. Fourth, implementors should plan for high staff turnover rates and expect the unexpected by developing detailed contingency plans. Finally, implementors should remember that the goal is to implement evidence-based CM and not simply incentives. We encourage colleagues to consider these lessons to increase the likelihood that CM can be implemented and sustained in a manner that improves the quality of care in opioid treatment programs.

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.

Implementing an evidence-based prize contingency management protocol for stimulant use

INTRODUCTION

Contingency management (CM) is an efficacious treatment for stimulant use disorders. Support materials for the clinical delivery of prize-based CM are widely accessible, but few resources are available to support design and preparation for CM implementation. This guide aims to fill that gap.

METHOD/RESULTS

The article outlines a suggested prize CM protocol and discusses the best practices most aligned with the evidence base and acceptable-if-necessary modifications. This guide also highlights modifications that are not evidence-based and not recommended. In addition, I discuss practical and clinical aspects of preparing for CM implementation.

CONCLUSIONS

Deviations from evidence-based practices are common, and poorly designed CM is unlikely to impact patient outcomes. This article provides planning stage guidance to support programs' adoption of evidence-based prize CM for the treatment of stimulant use disorders.

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.

Increasing Attendance in Addiction Treatment With Limited Resources: A Narrative Review

Treatment nonattendance frequently compromises client outcomes in psychosocial addiction treatment services. However, there is limited literature on strategies that increase attendance and retention without a significant resource burden on clinician or organization. This review of 13 studies describes strategies that do not financially reward clients for attendance or require more than 1 day of training/supervision to implement. These strategies are as follows: role induction; pretreatment written or verbal contact; short message service and telephone reminders; and contracting, prompting, and reinforcement. There is some evidence that role induction strategies can increase attendance in early treatment, with stronger evidence for a more intensive approach. Short message service and telephone reminders show a consistent positive impact on early attendance, although the relationship may weaken over time and for individuals with more complex needs (ie, high impulsivity). The strategy: contracting, prompting, and reinforcement shows promising findings, particularly in the first 3 months of treatment. There is considerable variability in study designs, interventions, and sample sizes-future research should more precisely identify relationships between outcomes and the "active ingredients" in each strategy. However, preliminary evidence suggests that some low clinician/organization-burden strategies increase treatment attendance and retention. The mechanisms underpinning these strategies may overlap with therapeutic engagement theories (eg, outcome expectations, common-factors model). Although these interventions have small to moderate effect sizes, their relative simplicity and low cost increase the likelihood of being implemented at a broad scale, amplifying their benefits.

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.

Contingency management for treatment attendance: A meta-analysis

BACKGROUND

Treatment providers have applied contingency management (CM) treatment, an intervention that often rewards individuals for drug abstinence (i.e., ABS CM), to treatment engagement as well. However, we know little about the magnitude of treatment effects when providers target attendance behaviors (i.e., ATT CM).

METHODS

This study conducted a systematic search to identify studies that included ATT CM, either in isolation or in combination with ABS CM. The study used meta-analysis to estimate the effect size of ATT CM and ABS CM + ATT CM on treatment attendance and drug abstinence. We identified a total of 10 studies including 12 CM treatments (6 ATT CM and 6 ABS CM + ATT CM) with 1841 participants.

RESULTS

Results indicated a moderate effect (d = 0.47, 95% confidence interval (CI) [0.25, 0.69]) of ATT CM on attendance relative to non-reward active comparison conditions. Frequency of rewards was significantly associated with larger effect sizes. Results also indicated a small effect (d = 0.22, 95% CI [0.12, 0.33]) of ATT CM on abstinence outcomes relative to nonreward comparisons, p < 0.001. The study found no significant differences in attendance or abstinence between ATT CM and ABS CM + ATT CM (p's > 0.05).

CONCLUSION

Overall, the results supported ATT CM for increasing treatment engagement, with smaller effects on abstinence. Effects on abstinence were smaller than those observed in prior meta-analyses focused on ABS CM. No significant differences existed in attendance or abstinence outcomes between ATT CM and ABS + ATT CM. However, future studies are needed to experimentally compare ABS CM + ATT CM to ABS CM, and ATT CM to determine additive effects. Clinics implementing CM should consider the differential effects between ATT CM and ABS CM when selecting target behavior(s).

Beliefs related to health care incentives: Comparison of substance use disorder treatment providers, medical treatment providers, and a public sample

This study surveyed substance use disorder (SUD) treatment providers, medical treatment providers, and a public sample about beliefs regarding health care incentives to explore differences among the groups and across health disorders for which research has demonstrated incentives improve outcomes. Six hundred participants (n = 200/group) completed the Provider Survey of Incentives. The study found between group differences for positive and negative beliefs. The public sample was highest on the positive beliefs subscale (M = 3.81), followed by SUD (M = 3.63) and medical treatment providers (M = 3.48; F(2, 597) = 20.09, p < .001). The medical treatment providers were highest on the negative beliefs subscale (M = 2.91), compared to the public sample (M = 2.77) and SUD treatment providers (M = 2.65; F(2, 597) = 7.521, p < .001). Endorsement of incentives to treat medical disorders was similar across the groups, with obesity the most endorsed disorder. In contrast, endorsement of incentives to treat SUDs differed across groups, except for smoking. The SUD treatment providers were almost twice as likely as the public sample (OR = 1.81, 95% CI = 1.27-2.59) and the public sample almost twice as likely as the medical treatment providers (OR = 1.74, 95% CI = 1.24-2.47) to endorse the use of incentives to treat more SUDs. Medical treatment providers were also the least likely to endorse incentives to treat both legal and illicit substance use. These findings suggest that incentive programs have good acceptability among SUD treatment providers and the public, but medical treatment providers are less accepting of incentive programs. This study provides evidence that incentive-based interventions are acceptable to the public and is the first to document specific objections that individuals disseminating incentive interventions will most likely face when introducing them in medical settings.

Challenges to Conducting Contingency Management Treatment for Substance Use Disorders: Practice Recommendations for Clinicians

A growing empirical literature supports contingency management (CM) as an efficacious treatment for substance use disorders, especially when reinforcers are immediate, frequent, and of sufficient magnitude on escalating schedules. However, in real world-practice, CM is often conducted in ways that are inconsistent with research protocols. One reason for these inconsistencies may be due to pragmatic challenges inherent in conducting CM. In this article, we described an outpatient CM treatment program for drug use disorders and several specific challenges associated with adherence to CM parameters from research protocols. Finally, we propose possible solutions for these challenges and discuss implications for practice.

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).