The Hexagon: An Exploration Tool
The Hexagon can be used as a planning tool to guide selection and evaluate potential programs and practice for use.
Usability - Rating: 4
4 - Usable
The intervention has operationalised principles and values, core components that are measurable and observable, tools and resources to measure fidelity, and identified modifiable components
Usability
Core Components
Contingency Management (CM) involves the use of reinforcing procedures to alter substance use behaviours across a range of substances (e.g. opioids [with or without methadone maintenance], cannabis, alcohol, and stimulants), in a variety of populations. This behavioural therapy involves provision of incentives to reward evidence of positive behaviours that promote abstinence from substance use and other substance use treatment outcomes (e.g. monetary based reinforcers for drug free urine sample). CM therefore aims to promote behaviours that are well-suited for a lifestyle that is non-inclusive of substance use. CM also draws on CBT techniques to support behavioural change.
At its core, CM consists of four critical elements; 1) selecting specific, achievable, substance use related target behaviour (e.g. abstinence, confirmed by drug-negative urinalysis); 2) regular monitoring of target behaviour to increase positive reinforcement opportunities and spot reversion to competing behaviours (e.g. breath and urine samples submitted for drug and alcohol testing two to three times weekly on non-consecutive days); 3) providing tangible reward in close proximity to their occurrence to reinforce positive behaviour. Rewards can include clinic privileges (e.g. take-home opioid-replacement medication), vouchers for goods and services that are compatible with treatment goals, low monetary cash rewards, and prizes (ranging in value from £1 to £100). Incentives provided should be of adequate significance to the client to compete with their substance use behaviours; 4) holding back rewards when target behaviour is not detected. CM also includes work around increasing drug refusal skills, leverage and including systemic supports and using CBT techniques to alter cognitions that lead to use.
The positive reinforcement strategy applied in CM can also be used to promote other behaviours that are associated with the attainment of treatment goals. These include reinforcement of medication compliance; reinforcement of treatment adherence/ retention in substance misuse clinics if reinforcement provided is contingent on attendance; and reinforcement of other treatment-related goals, e.g. improving parenting, increasing physical activity, and seeking employment. CM can be delivered alongside other programmes (e.g. methadone maintenance, psychological treatment) to improve treatment outcomes in substance use management.
Fidelity
Practitioner training prior to CM delivery promotes treatment fidelity. Practitioner fidelity to CM can be assessed through a review of recorded CM sessions, using the CM Competence Scale (CMCS) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2875270/pdf/nihms173049.pdf.
Modifiable Components
CM can be delivered in a diverse range of settings including outpatient clinics, community centres, residential setting and the client's own home. It can be delivered as part of other treatment programmes (e.g. methadone maintenance programmes, opioid treatment programs, outpatient psychosocial programmes, and multisystemic therapy) to manage a range of substance use presentations (e.g. alcohol, cannabis, cocaine, nicotine, and opioids). CM can differ in the testing frequency applied, length of CM course, and type of incentives provided. Web-based and phone-based CM processes (e.g. via web camera or video-record function on phones) have facilitated the remote monitoring of breath sampling (e.g. for alcohol and tobacco detection). CM can be delivered to adolescents and adults, including veterans.
Supports - Rating: 2
2 - Minimally Supported
Limited resources are available beyond a curriculum or once-off training
Supports
Implementation Support
Currently in the UK, CM is not routinely delivered as a standalone treatment. It is implemented as part of Multisystemic Therapy (MST) for adolescents. Please refer to the MST intervention description for more information.
Start-up Costs
Costs associated with CM delivery will include costs of urinalysis and breath tests (e.g. intoximeter for alcohol screening, and onsite test-sticks for other substances like cocaine, opioids and marijuana). Other costs include costs of providing reinforcers to patients who demonstrate target behaviours. This can include vouchers, low monetary cash rewards, and prizes. These incentives could introduce budget constraints and barriers to CM adoption. However, a low-cost reinforcer can also be associated with increased patient attendance in methadone maintenance programme. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5154900/. Practitioner training costs should also be considered, however, the exact costs of practitioner training are unclear.
Building Staff Competency
Qualifications Required
CM can be delivered by direct care clinicians, with appropriate qualifications in areas of education, counselling, social work, psychology, psychiatry and other mental health fields. Prior exposure to CM is not required.
Training Requirements
In research, practitioner training sessions to support CM delivery have varied in intensity. They have included two-hour long training sessions, two ½ day training workshops, 1.5-day trainings, and four weekly ½ day sessions. Trainings can cover the basic principles of CM; evidence in support of CM; adaptation of the CM protocol to suit needs in different settings; practical delivery of CM (including sample monitoring process, role playing exercises); fidelity monitoring; and CM implementation challenges.
Supervision Requirements
Supervisors can use CMCS scores and recorded CM sessions to provide feedback on practitioner fidelity to CM and competence in delivery.
When CM is delivered as part of a wider package of psychological therapies, it should involve regular supervision with a practitioner who has expertise in a) the intervention b) the clinical area and c) has completed training in supervision of psychological therapies and interventions (Further information: https://www.nes.scot.nhs.uk/our-work/supervision-of-psychological-therapies-and-intervention/).
Evidence - Rating: 4 - 5
4 - Evidence
The intervention has demonstrated effectiveness with one rigorous, external research study with the focus population and a control group.
5 - High Evidence
The intervention has demonstrated evidence of effectiveness based on at least two rigorous, external research studies with the focus population and control groups, and has demonstrated sustained effects at least one year post treatment.
Evidence
Theory of Change
Based on operant conditioning, a behavioural approach to learning first described by B.F. Skinner. Operant conditioning theorises that behaviours are shaped by their consequences; they will increase over time if followed by a pleasant experience (reward) or decrease if followed by an unpleasant experience (punishment). Addiction is maintained and reinforced by a combination of the rewarding biochemical effects of the substance and environmental influences.
Contingency Management is guided by principles of basic behavioural analysis. It suggests that rewarding positive behaviours in close proximity to their occurrence will reinforce those positive behaviours (e.g. monetary based reinforcers for drug free urine sample). Application of this behavioural principle in substance misuse management is expected to increase the frequency of occurrence of positive behaviours which reinforce substance use abstinence and other substance use disorder treatment outcomes.
Research Design & Number of Studies
The best available evidence for CM in adults includes eight meta-analytic studies that evaluated its effect on multiple substance use outcomes.
Outcomes Achieved
Compared to the control group who did not receive CM, the following outcomes were observed;
- Significantly increased abstinence from tobacco (1,2), and other substances (e.g. cocaine, opiates, stimulants, poly-substances) at post-intervention (1,3). Effect on abstinence reduced but still significant at 3-months follow-up, but not detectable at 6-months follow-up (4).
- Significantly reduced use of substances (tobacco, cannabis, stimulants, poly-substances) at 3-months follow-up (5).
- Significantly longer duration of abstinence and significantly higher percentage of negative samples for non-prescribed drug use during opiate addiction treatment. Effects were observed at post-intervention (6).
- Significantly longer duration of abstinence and significantly higher percentage of negative samples for tobacco and alcohol use among adults not in treatment for substance use disorders (7).
- Significantly increased therapy attendance (1,8) and medication adherence at end-of-treatment. Outcomes were evaluated in patients receiving medication for opioid use disorder (1).
Child Evidence
The best available evidence for CM in children and young people includes three Randomised Controlled Trials (RCTs) conducted in USA. One study included 153 adolescents, aged 12- 18, who met the criteria for cannabis abuse or dependence in New Hampshire, USA (9). Another study included 134 young people, aged 12 to 21 years, who smoked a minimum of 5 cigarettes daily and were interested in smoking cessation (10). The study was conducted in South Carolina, USA. The third study included 337 adolescents, aged 12–18 years, admitted to residential treatment with alcohol and other drug (AOD) use disorders in Illinois, USA (11).
Child Outcomes
Compared to the control group who did not receive CM, the following outcomes were observed:
- Significantly greater longest period of continuous cannabis abstinence during treatment (when delivered with individualized Motivational Enhancement [MET] and Cognitive Behavioural Therapy [CBT]). Abstinence rates were reduced by 3-months follow-up, with similar abstinence rates in all groups at 6, 9 and 12-months follow-up (9).
- Significantly higher smoking abstinence rates during active treatment (when delivered with specific antidepressant medication) (10).
- Significantly higher rates of abstinence for heavy alcohol use, alcohol use, cannabis use, and any alcohol or other drugs (AOD) use in the 12 months after discharge from residential treatment (11).
- Significantly higher remission rate at month 12 (11).
Need
Comparable Population
Contingency Management aims to alter substance use behaviours across a range of substances (e.g. opioids [with or without methadone maintenance], cannabis, alcohol, cigarettes, and benzodiazepines), in a variety of SUD populations (e.g. people not receiving treatments, people accessing methadone maintenance programmes, in residential treatment programmes, or in outpatient psychosocial programs).
Desired Outcome
CM is associated with significant improvements across several outcomes including increased abstinence (from smoking, cocaine, opiates, stimulants, and poly-substances), increased percentage of negative samples (e.g. non-prescribed drugs, tobacco and alcohol), increased therapy attendance, and increased medication adherence.
1 - Does Not Meet Need
The intervention has not demonstrated meeting need for the identified population
2 - Minimally Meets Need
The intervention has demonstrated meeting need for the identified population through practice experience; data has not been analysed for specific subpopulations
3 - Somewhat Meets Need
The intervention has demonstrated meeting need for the identified population through less rigorous research design with a comparable population; data has not been analysed for specific subpopulations
4 - Meets Need
The intervention has demonstrated meeting need for the identified population through rigorous research with a comparable population; data has not been analysed for specific subpopulations
5 - Strongly Meets Need
The intervention has demonstrated meeting the need for the identified population through rigorous research with a comparable population; data demonstrates the intervention meets the need of specific subpopulations
Fit
Values
Contingency Management involves the use of reinforcing procedures to alter substance use behaviours across a range of substances (e.g. opioids, cannabis, alcohol, and benzodiazepines), in a variety of substance use populations (e.g. people not receiving treatments, people accessing methadone maintenance programmes, in residential treatment programmes, or in outpatient psychosocial programs). Contingency Management is guided by principles of basic behavioural analysis.
Priorities
CM aims to promote behaviours that are well-suited for a lifestyle that is non-inclusive of substance use. At its core CM involves; 1) selecting substance use target behaviour; 2) regular monitoring of target behaviour; 3) providing tangible reward to reinforce positive behaviour; 4) holding back rewards when target behaviour is not detected. The positive reinforcement strategy applied is intended to promote substance use abstinence and improve other substance use treatment outcomes, e.g. medication compliance, treatment adherence, and clinic retention.
Existing Initiatives
1 - Does Not Fit
The intervention does not fit with the priorities of the implementing site or local community values
2 - Minimal Fit
The intervention fits with some of the priorities of the implementing site, but it is unclear whether it aligns with local community values and other existing initiatives
3 - Somewhat Fit
The intervention fits with the priorities of the implementing site, but it is unclear whether it aligns with local community values and other existing initiatives
4 - Fit
The intervention fits with the priorities of the implementing site and local community values; however, the values of culturally and linguistically specific population have not been assessed for fit
5 - Strong Fit
The intervention fits with the priorities of the implementing site; local community values, including the values of culturally and linguistically specific populations; and other existing initiatives
Capacity
Workforce
CM can be delivered by direct care clinicians with appropriate qualifications in areas including education, counselling, social work, psychology, psychiatry and other mental health fields. Prior exposure to CM is not required. In research, practitioner training sessions to support CM delivery have varied in intensity. They have included two-hour long training sessions, two ½ day training workshops, 1.5-day trainings, and four weekly ½ day sessions. CM can differ in the testing frequency applied, and length of CM delivery.
Technology Support
Testing kits are required for urinalysis and breath tests (e.g. intoximeter for alcohol screening, and onsite test-sticks for other substances like cocaine, opioids and marijuana). Web-based and phone-based CM processes (e.g. via web camera or video-record function on phones) can facilitate the remote monitoring of sampling. Availability of technology for recording sessions for supervision will be useful.
Administrative Support
CM can be delivered in a diverse range of settings including outpatient clinics, community centres, and residential settings. It can be delivered as part of other treatment programmes (e.g. methadone maintenance programmes, opioid treatment programs, outpatient psychosocial programs, and multisystemic therapy) to manage a range of SUDs. Administrative support will be needed for a number of activities including scheduling appointments, organising sampling and testing, monitoring attendance, and providing incentives. CM can differ in the testing frequency applied, length of CM course, and type of incentives provided.
Financial Support
Costs associated with CM delivery will include costs of urinalysis and breath tests. Other costs include costs of providing reinforcers to patients who demonstrate target behaviours. This can include vouchers, low monetary cash rewards, and prizes. Incentives provided should be of adequate significance to the client to compete with their substance use behaviours.
1 - No Capacity
The implementing site adopting this intervention does not have the capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
2 - Minimal Capacity
The implementing site adopting this intervention has minimal capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
3 - Some Capacity
The implementing site adopting this intervention has some of the capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
4 - Adequate Capacity
The implementing site adopting this intervention has most of the capacity necessary, including a qualified workforce, financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
5 - Strong Capacity
Implementing site adopting this intervention has a qualified workforce and all of the financial supports, technology supports, and administrative supports required to implement and sustain the intervention with integrity
