Implementation of Contingency Management at a Large VA Addiction Treatment Center

This column discusses the local challenges, solutions, and lessons learned during implementation at a U.S. Department of Veterans Affairs (VA) facility of a national VA effort to disseminate contingency management (CM). CM is a behavior modification intervention that establishes a contingency between new, targeted behavior and the opportunity to obtain a desired reward. There are several variants of CM, and more details are available elsewhere (1,2).

CM Implementation at the VA’s Largest ATC

Despite the efficacy of CM, its implementation into community clinical treatment programs remains low (3). Accordingly, VA launched a national effort to integrate CM into intensive outpatient substance use treatment clinics (4). This initiative supported CM implementation through identification of pilot sites and provision of funds to support the program and train staff. Despite the critical assistance provided by this initiative, local implementation encountered additional barriers that had to be addressed for success. This column discusses implementation at the largest Addiction Treatment Center (ATC) within VA.

In fall 2012, VA Puget Sound Health Care System, Seattle Division, joined the VA national CM roll-out and implemented CM among veterans being treated for stimulant use who were participating in the three-week intensive outpatient program (IOP) of the ATC. A subset of IOP patients—those who were eligible and interested—participated in CM, which consisted of two 20-minute sessions each week in addition to the regular IOP program (nine hours of groups per week). Eligible veterans were those who had enrolled in IOP for stimulant use in the past six months. Veterans were ineligible for the following reasons: inability to participate in full course of CM, active legal issues, last stimulant use more than six months ago, and a diagnosis of gambling disorder.

CM sessions were conducted twice weekly, with no more than three days between drug testing. Veterans participated in CM for a total of eight weeks and provided a urine specimen at each CM session. Participants earned draws from a prize bowl (“fishbowl”) for each stimulant-negative specimen provided. Slips ranged from written praise to prizes in the form of vouchers redeemable at the VA store ($1, $20, or $100). Participants earned an increasing number of draws with the provision of consecutive stimulant-negative specimens, up to a maximum of eight draws, which could be maintained to the end of CM with continued abstinence. Draws were reset when the specimen was not negative for stimulants, the participant was unable to provide a valid specimen, or the participant missed a CM session without a legitimate reason (for example, a medical appointment). This CM protocol paralleled the standardized implementation in the national rollout.

Consistent with standard IOP treatment at the ATC, CM participants transferred to continuing care after completing the three-week IOP. They continued to attend CM sessions two days a week for another five weeks after the transfer. Their CM schedule was adjusted to accommodate their new treatment schedule as long as there were no more than three days between testing.

On the day of CM enrollment, CM participants completed a standard measure used in the clinic, the Brief Addiction Monitor (BAM) (5). Those who finished the full eight-week CM program completed the BAM in the final session. Research has found that higher scores for risk factors and lower scores for protective factors predict an increased likelihood of substance use and treatment dropout (5).

As of July 2016, more than 80 veterans had enrolled in CM, and unsolicited feedback has been overwhelmingly positive. Because of eligibility criteria, many veterans did not participate for reasons such as pending residential treatment or active legal issues. Nevertheless, enrollment is the second highest in the nation. The mean±SD number of sessions attended was 8.64±4.78, of 16 sessions in the eight-week course—an attendance of 54%. This is consistent with the national average of 50%. Over 87% of the urine screens were negative for stimulants, which is comparable to the VA CM national average of 92%. Twenty-three participants completed the BAM before and after CM, and responses showed a consistent trend of decreased use and risk factors and increased protective factors. Outcome data for the entire group would be useful, and formal research using intent-to-treat analyses is needed to contribute to the literature on efficacy. In addition, future studies could evaluate the impact of CM on IOP adherence and treatment completion.

Implementation Challenges

Although provision of CM training and funding for prizes addressed common barriers to CM implementation, we encountered additional, unique local challenges as well, which is expected in implementation science.

Staff reception and limited referrals.

A major barrier to CM adoption is treatment providers’ negative beliefs and attitudes about this modality (6), which is often rooted in a limited understanding of CM. Fortunately, when CM is implemented and providers observe positive outcomes, such negative beliefs usually dissipate quickly (6). When CM was first rolled out at this facility, staff expressed concerns about paying patients for abstinence, gambling-like qualities of the slip-draw method, and doubts about CM’s effectiveness. This was not surprising, considering that CM is one of the least understood evidence-based addiction treatments (7). It was helpful to address these attitudes by providing education and research evidence about CM. Furthermore, with positive feedback from veterans who participated, staff’s attitudes became more accepting and even enthusiastic.

Nonetheless, referrals were initially slow, which required ongoing efforts in monitoring patient eligibility and enrollment. A quality improvement (QI) project was developed to increase patient awareness of and participation in CM and to educate staff. The QI project tracked the percentage of CM-eligible patients who enrolled in CM. Tracking and monitoring appeared to heighten staff awareness of CM, which increased enrollment over time. CM enrollment showed an upward trend, starting at 60% enrollment of eligible IOP patients and ending at 100% after five quarters of QI tracking. This rate has remained stable over time.

Instituting an appropriate drug testing method.

Prior to CM rollout, identifying and instituting an appropriate drug testing method for CM was a significant barrier, because it involved collaborating with the facility’s laboratory and pathology services and finding solutions that addressed the needs of both programs. The process unfolded over two years, and once developed, the method provided a good foundation for the new CM program. We ultimately decided on the iCup because it provided instant urinalysis results, which met the need for immediate management of contingencies and also met laboratory requirements.

Staff confidence in iCups.

The iCup was a novel device for most staff. Although it met the laboratory’s stringent criteria for validity, clinic staff expressed doubts about results and concerns about patient disputes of results. At initial CM sessions, some iCups were sent to the lab for confirmation. When staff saw that confirmations were always consistent with iCup results, their confidence increased. Although staff had predicted that patients would distrust and dispute the test results, this was not observed.

Point-of-care testing (POCT) training.

Because the iCup fell under the oversight of the laboratory’s department of ancillary testing, we functioned under the umbrella of the facility’s laboratory licensing and certification. The ancillary testing coordinator also provided training and follow-up competence monitoring to clinical staff conducting CM. This arrangement resulted in a reliance on the laboratory and POCT program to train and certify clinicians before they could deliver CM services, which required dedication of resources and caused two separate delays in CM implementation. The delays were three months during the initial rollout and a year in 2015 as the program expanded. This highlights the importance of ongoing collaboration for sustainment, because training of new staff is required to address staffing changes.

Financial cost of the CM program.

The financial cost associated with the CM voucher-based reward system is a common implementation barrier (6). The cost of our CM implementation included vouchers, testing devices, and CM staff. The cost of vouchers was not a barrier because the program received $5,000 of VA store vouchers from the national VA dissemination effort. Furthermore, as a formal member of VA Central Office’s CM Sustainability Incentive Program, our facility is eligible for ongoing renewal of funding for vouchers to sustain our program. However, this financial commitment may be prohibitive in some contexts and must be taken into consideration. To date, our facility has expended $6,500 in vouchers. The cost of iCups was absorbed by the facility’s laboratory, which provides an ongoing supply to maintain POCT needs. To date, we have used approximately 700 iCups, costing approximately $5,600. In terms of staffing, CM services are provided by existing clinicians who, with approval of their supervisors, voluntarily deliver this intervention in addition to their regular duties. These staff have dedicated approximately 300 hours to the CM program. Staff and supervisors have not reported this to be burdensome to their workflow; rather, staff have noted how CM sessions bring a predictable and structured experience to their work. This highlights the important role of leadership buy-in and internal facilitators for successful implementation.

Local Innovations

A unique feature of our CM program was the addition of alcohol breath testers to CM sessions. Because iCups do not test for alcohol, breath analysis was added to detect alcohol use, which allows for monitoring of use of both alcohol and other substances without increasing patient burden by requiring duplicative urine samples. However, this introduced the problem of whether to reinforce a stimulant-negative urinalysis when breath analysis was positive. It was decided that a slip draw could be earned in this situation but had to be banked until the next session when the participant provided both a stimulant-negative urinalysis and a negative breath analysis.

Lessons Learned

Implementation of CM could have been more expedient if we had initially devoted intentional strategic planning and dedication of staff time in two areas: partnering with the laboratory to develop mutually beneficial processes and conducting a promotional campaign to increase staff awareness of CM. As noted above, much of the delay in both the initiation and the expansion phases of our program was related to the CM program’s reliance on POCT for training and certification. We have since partnered with the laboratory to develop a POCT authorized trainer model, which greatly enhances CM program autonomy and efficiency. Closer collaboration with the laboratory at an earlier implementation stage to identify shared objectives may have led to such solutions sooner. Similarly, we could have begun the process of CM promotional campaigning and staff education at an earlier stage. This may have increased staff knowledge of and interest in CM, provided the program with more staff to draw upon, and increased initial referrals.

CM Program Expansion

In 2012, CM was launched at VA Puget Sound Health Care System, Seattle Division. Today, our CM program is one of the largest and longest-running CM programs in the nation. Because of the increased popularity of CM and demand for this intervention, the CM program that began in the IOP has gone through multiple expansion phases. In 2014, CM expanded beyond the IOP to include all veterans in the Seattle ATC. In February 2015, we implemented attendance CM for smoking cessation and in May 2015, abstinence CM was expanded to the ATC at the American Lake Division. In September 2016, the CM program coordinated with the VA Puget Sound Health Care System’s surgery, anesthesiology, and mental health service lines to initiate a national pilot of applying CM to perioperative care to improve veteran safety and promote more rapid recovery from serious surgery. With the continued success of the CM program, we hope to see designated CM funding at the local level and expect to see further expansion and ever more innovative applications of this approach.