(119) Evaluation of a Family Medicine Contingency Management Program for Substance Use Disorder

Background & Introduction: Contingency management (CM) is a behavioral treatment approach involving the delivery of positive reinforcements that are contingent on achieving specific pre-defined program goals. Providing active recognition of individual achievements can serve as a valuable mechanism for fostering a positive self-image and facilitating ongoing treatment support. The use of CM is supported by decades of research demonstrating its efficacy and effectiveness for patients with substance use disorders (SUDs), including retention in treatment and other recovery goals for patients being treated for stimulant use disorder (StUD) or opioid use disorder (OUD). Despite the substantial evidence demonstrating the effectiveness of CM for treating SUD, it remains an underutilized intervention in the real-world clinical setting. This pilot study examined the development and delivery of a CM intervention for patients receiving SUD treatment in a family medicine residency program.

Methods: This retrospective observational pilot study examined family medicine patients enrolled in the CM program between August 2023-June 2024. Patients were considered eligible if they were being treated in the local family medicine residency program; receiving SUD treatment for OUD, StUD, cocaine use disorder, benzodiazepine use disorder, or barbiturate use disorder; and willing to complete a urine drug screen (UDS) at each visit. Participants earned points based on achievement of CM program goals. A maximum of 2-points were awarded per visit with 1-point for awarded for visit attendance and 1-point for awarded if the UDS was negative for the substance being treated. Points were redeemable in real time for a prize during the visit. Prizes were distributed using a 2-tiered fishbowl method with a selection of lower-value prizes in the 1-point fishbowl and higher-value prizes in the 2-point fishbowl. Potential prizes included a positive affirmation note with candy, individual items worth $5 or less (e.g., coffee mugs, socks, etc.), or $5 gift cards to grocery/retail stores. We explored sociodemographic and program characteristics of participants. Outcome measures included CM program retention at 3 and 6 months. Descriptive statistics characterized participants and Fisher’s exact tests examined the relationships between characteristics and outcomes.

Results: Within the study period, 47 patients were enrolled in the CM program. The mean (SD) age at enrollment was 46.7 (13.4) years with ages ranging 25-71 years. Participants primarily identified as male (59.6%, N=28), white (59.6%, N=28), not Hispanic/Latine (97.8%, N=46), and Medicaid recipients (61.7%, N=29). Of the 41 participants with employment reported, 51.2% (N=29) were employed full-time or part-time, 31.7% (N=13) identified as not employed, and 17.1% (N=7) identified as not in the labor force (e.g., retired, on disability, student). Of the 38 participants with housing status reported; 89.5% (N=34) identified as living with family, roommates, etc.; 7.9% (N=3) identified as living alone; and 2.6% (N=1) identified as living in a supervised setting such as a residential institution, group home, etc. In terms of SUD treatment goals, participants were primarily treated for OUD (95.7%, N=45). Participants were enrolled in the program for a median (IQR) number of 9 (5,10) months, ranging 0-11 months. In terms of CM program retention, 93.6% (N=44) and 78.7% (N=37) remained in the program at 3 and 6 months, respectively. Overall, 27.7% (N=13) participants left the CM program with 38.5% (N=5) leaving the CM program before 6 months and 61.5% (N=8) leaving the program after 6 months. A significant difference was observed between participants being treated for OUD versus other SUDs and retention in the CM program for 6 or more months (p=0.04). There were no other signification associations between other participant characteristics and CM program retention. Reasons for ending CM program participation included out-of-pocket visit costs, insurance coverage issues, difficulty traveling to the clinic, declining medication for OUD, moving out of state, transferring SUD care from the family medicine clinic to psychiatry or an opioid treatment program, declining CM but remaining in SUD treatment, and being lost to follow-up. To protect participant privacy, individual frequencies of reasons for leaving the CM program were not reported due to small sample sizes. Participants had a median (IQR) of 5 (3,10) visits ranging 1-17 visits and a median (IQR) of 2 (1,3) ‘no shows’ ranging 0-8 ‘no shows.’ In total, participants earned a median (IQR) number of 8 (5,12) points, ranging from 1-28 points during their time in the program. With participants having the ability to earn a median (IQR) number of 10 (6, 20) possible points ranging 2-34 points, participants were awarded 80% of the median total points possible during their respective time in the program.

Conclusion & Discussion: Utilizing evidence-based strategies, such as CM, have the potential to improve treatment outcomes for people with SUD. Our program illustrates a framework developing and delivering a CM intervention in family medicine residency program setting. This pilot study identified some key lessons learned and potential limitations. In terms of patient engagement, the types of prizes offered are important and patient preferences should be tracked to identify which prizes will have a higher perceived value. Our program was limited in terms of the monetary value of prizes that were offered. The monetary value of CM prizes has been demonstrated to be associated with improved outcomes. As such, program budget planning should account for the cost of prizes and maximize the prize value per patient to the extent possible. Lastly, delivery of CM in a real-world setting can be difficult for busy clinical practices in terms of managing and tracking patient progress. Automated quick texts in the electronic health record can assist with standardizing and expediting the completion of CM patient visit notes. Training personnel in CM to serve as clinical champions and maintain patient documentation can potentially reduce the administrative burden for other providers and staff.

References: Hirchak, K. (2024). Closing the research‐to‐implementation gap for contingency management as an effective intervention for substance use disorders across diverse communities. Addiction, 119(9), 1519–1521. https://doi.org/10.1111/add.16569

Office of the Assistant Secretary for Planning and Evaluation. (2023). Contingency Management for the Treatment of Substance Use Disorders: Enhancing Access, Quality, and Program Integrity for an Evidence-Based Intervention. US Department of Health and Human Services.

Pfund, R. A., Ginley, M. K., Rash, C. J., & Zajac, K. (2022). Contingency management for treatment attendance: A meta-analysis. Journal of Substance Abuse Treatment, 133, 108556. https://doi.org/10.1016/j.jsat.2021.108556

Pfund, R. A., Cook, J. E., McAfee, N. W., Huskinson, S. L., & Parker, J. D. (2021). Challenges to conducting contingency management treatment for substance use disorders: Practice recommendations for clinicians. Professional Psychology: Research and Practice, 52(2), 137–145. https://doi.org/10.1037/pro0000356

Rash, C. J., Stitzer, M., & Weinstock, J. (2017). Contingency Management: New Directions and Remaining Challenges for An Evidence-Based Intervention. Journal of Substance Abuse Treatment, 72, 10–18. https://doi.org/10.1016/j.jsat.2016.09.008