An Introduction to Contingency Management in the UK

An Introduction to Contingency Management in the UK

For people with an interest in evidence-based drug treatment services a page that appeared on the NTA website in early August might have come as a bit of a surprise.  The five line page appeared on the 3rd of August 2007 stating that “following new guidance from NICE the NTA are seeking expressions of interest for demonstration sites to deliver a range of contingency management approaches to expand the UK evidence base.”

One reason why this may pleasantly surprise some is the fact that CM is a treatment modality that has a large body of research supporting its effectiveness, in other words; it seems to work.  However, despite this body of evidence until recently the number of sites implementing CM in the UK were in the low single figures (Weaver et al., 2007). 

So what is this technique that few outside the academic world have heard of and what are the implications for commissioners, service providers and service users for the future?

In essence contingency management refers to a range of interventions in which substance misusers receive positive reinforcement (reward) for objective evidence of behaviour change. For example, patients receive a voucher, exchangeable for goods and services whenever they submit a urine specimen that tests drug negative (Petry, 2006).  This approach is most often used in conjunction with existing psychosocial and other treatment modalities that many will be aware of (CM is rarely used as a standalone).  One variation of CM involves increasing the rewards as people continue to provide clean urine offering added incentive to comply with a treatment programme. 

A review by Prendergast et al., (2006) provides a useful starting point when looking at the research related to CM.  Prendergast’s review examined 47 studies of the effectiveness of CM covering adults and young people in order to determine whether the treatment technique was effective.  The review concluded that “CM is among the more effective approaches to promoting abstinence during the treatment of substance use disorders.  CM improves the ability of the client to remain abstinent, thereby allowing them to take fuller advantage of other clinical treatment components.” Prendergast et al., (2006).

Undoubtedly the NTA have taken a bold step in seeking demonstration sites, many wait with baited breath to see how many volunteers step forward.  Research has shown that staff are often reluctant to implement CM in practice, in addition CM may be viewed by some elements of the press as “rewarding drug addicts” and this too brings its own set of challenges; potential backlash by elements of the press not renowned for their sympathy toward drug users is very real.

With these points in mind commissioners need to be aware of the growing momentum behind CM and its apparent effectiveness.  This is particularly true in a performance orientated climate focused on treatment retention.  CM has demonstrated its effectiveness time and time again, with both young people and adults, for a range of substances and in a mix of settings.  Commissioners are in an advantageous position to work with service providers to develop and deliver innovative evidence-based treatment services that utilise the growing research in this area.

These developments clearly have implications for service providers too; the evidence to support CM is growing but with implementation will come new challenges.  Studies have shown treatment workers are often hesitant about implementing CM with ethical objections often given, however CM is effective and all involved need to explore whether failing to provide service users with effective treatment modalities is in itself ethical.

Finally, service users must also be involved in decisions in this area and be consulted closely as services strive to respond to the needs of clients.  Truly patient-centred care plans may in the future include Contingency Management programmes and all stakeholders will benefit from a greater understanding of CM and its likely impact.

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Matt Hayman is Director of Innovation With Substance a social enterprise providing drug training and substance misuse consultancy services, as well as fully managed projects, to UK public sector organisations whose work addresses drug and alcohol misuse.

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