“Setting people up for success and then failure” – health care and service providers’ experiences of using prize-based contingency management

Abstract

Background Over the last 50 years, there has been a growing interest in and use of contingency management (CM) for people who use substances. Yet, despite showing some level of efficacy (albeit only short-term) and being praised by researchers as beneficial and cost-saving, it continues to be underutilized by health care and service providers. Why that is remains unclear. Methods Recognizing a gap, we conducted a targeted analysis of a larger set of qualitative interviews conducted on the experience of health care and service providers with incentives (including prize-based CM) (n = 25). Results Four themes were identified during the analysis: 1) The specificities of prize-based CM, 2) The role of providers in administering prize-based CM, 3) The positive and negative impact on the relationship, and 4) The ethical concerns arising from prize-based CM. Overall, our findings are consistent with existing literature and suggest that providers are wary of using prize-based CM because they tend to value effort over success, support over reward, honesty over deceit, and certainty over probability and variability. Conclusion Our analysis offers additional insights into the experiences of providers who use prize-based CM and possibly some indications as to why they may not wish to work with this type of incentive. The question raised here is not whether there is enough evidence on the effectiveness of prize-based CM, but rather if this type of incentive is appropriate and ethical when caring for people who use substances.

Meta-Analysis on the Effect of Contingency Management for Patients with Both Psychotic Disorders and Substance Use Disorders

“…Indeed, implementing CM might be specifically important within the management of patients who would otherwise a poorer prognosis in standard care [34]. However, despite the growing evidence of its effectivity, CM is-as of yet-still underutilized in our care systems and many barriers remain [10,39,53]. As to the latter, ethical and political discussions, i.e., whether rewarding patients for abstinence is an appropriate strategy, often over-shadow the evidence on CM's (cost) effectiveness [10,53].…”

“…However, despite the growing evidence of its effectivity, CM is-as of yet-still underutilized in our care systems and many barriers remain [10,39,53]. As to the latter, ethical and political discussions, i.e., whether rewarding patients for abstinence is an appropriate strategy, often over-shadow the evidence on CM's (cost) effectiveness [10,53]. Thus, additional studies in the future, allowing for a larger meta-analytic approach, are needed to confirm the effectivity of this approach within patients with severe psychiatric co-morbidities and provide additional support for larger clinical implementation within services targeting these vulnerable co-morbid patients.…”

Rewarding recovery: the time is now for contingency management for opioid use disorder

“…A number of studies [ 34–36 ] have identified concerns voiced by treatment providers tasked with implementing contingency management (largely prize-based protocols) as well as patients, including the over-reliance on abstinence, fairness, perceived power imbalance, and how incentives will be spent. Opponents to contingency management may object on moral or philosophical grounds.…”

“…What if we rewarded OUD patients with incentives for not only producing negative urinalysis drug screens, which is often the exclusive target behaviour of traditional contingency management protocols, but also engaging in recovery-oriented behaviours such as attending therapy sessions, taking their medication (buprenorphine, methadone), and participating in community-based mutual-help support groups? In fact, this broadened approach to contingency management rewards has been used to good effect in several studies [ 42 , 43 ], and the overemphasis on abstinence is viewed by treatment professionals as a leading barrier to more wide-scale adoption [ 34–36 ]. In light of the tragic death toll associated with the ongoing overdose crisis—and 275 Americans dying of an overdose every day [ 1 ]—I am less concerned with a patient's “why” regarding their motivation for engaging in treatment care and more focussed on keeping them alive so that they can achieve the benefits of recovery.…”

Increasing physical activity in adults using self-tailored deposit contacts.

“…The punitive nature of deposit contracts has also been cited as a limitation (Gagnon et al, 2020; Giles et al, 2015; Kerrigan et al, 2020; Volpp & Galvin, 2014). Kerrigan et al (2020), for example, evaluated the effectiveness and acceptability of deposit contracts with and without daily feedback on physical activity in adults who were overweight or obese.…”