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

Abstract

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.

Project MIMIC (Maximizing Implementation of Motivational Incentives in Clinics): A cluster-randomized type 3 hybrid effectiveness-implementation trial

“…The Petry model uses prizes of varying magnitude to reinforce patient behavior and has been shown to be effective when targeting abstinence, attendance, and other treatment goals [ 53 ]. Based on qualitative feedback with 11 OTPs using user-centered design principles [ 21 ], this study uses a customizable CM protocol targeting attendance, in which each OTP can develop an organization-specific definition of patients’ weekly attendance goals. The attendance target must include verifiable clinical encounters such as receipt of medication doses, completion of individual counseling sessions, and/or completion of group counseling sessions.…”

“…Guided by the EPIS framework, which conceptualizes implementation as a “process,” [ 41 ] implementation activities in both conditions are divided into four phases. The Exploration phase was completed in recent formative work with OTP counselors and leaders, soliciting their preferences for CM implementation [ 21 , 55 ]. Both strategies consist of both a 5-month Preparation phase and a 9-month Implementation phase.…”

“…First, OTP providers are often unfamiliar with CM. In recent interviews with 43 OTP providers in Rhode Island, the investigative team found that only 42% were able to define CM correctly [ 21 ]. Second, OTP providers often object philosophically to the idea of incentivizing patients with tangible reinforcers for meeting treatment goals [ 22 , 23 ].…”

Implementation support for contingency management: preferences of opioid treatment program leaders and staff

“…At the time of this study (see [ 22 ]), there were 13 OTPs in the state of Rhode Island, all of which were invited to nominate staff for participation. Research staff contacted executive leaders and directors from the OTPs via both phone and email to describe the qualitative study, to describe researcher interest in receiving input from OTPs on the SSL strategy, and to request nominations of eligible staff.…”

“…Interviewers included two postdoctoral fellows (KS and CM), one Bachelor’s level Research Assistant, and one Master’s level Research Assistant. Interviews included questions about a wide range of CM design and training preferences (see Becker et al, 2019 for the interview guide [ 22 ]). All providers were given a working definition of CM at the start of the interview to ensure that all participants had sufficient knowledge of CM principles.…”