Using a pragmatically adapted, low-cost, contingency management intervention to promote heroin abstinence in individuals undergoing treatment for heroin use disorder in UK drug services (PRAISE): a cluster randomised trial

Nicola Metrebian; Timothy Weaver; Kimberley Goldsmith; Stephen  Pilling; Jennifer Hellier; Andrew Pickles; James Shearer; Sarah Byford; Luke Mitcheson; Prun Bijral; Nadine A. Bogdan; Owen Bowden-Jones; Ed Day; John Dunn; Anthony Glasper; Emily Finch; Sam Forshall; Shabana  Akhtar; Jalpa Bajaria; Carmel  Bennett; Elizabeth Bishop; Vikki Charles; Clare Davey; Roopal Desai; Claire  Goodfellow; Farjana Haque; Nicholas  Little; Hortencia McKechnie; Franziska Mosler; Jo Morris; Julian Mutz; Ruth  Pauli; Dilkushi Poovendran; Elizabeth Philips; John Strang

doi:10.1136/bmjopen-2020-046371

Using a pragmatically adapted, low-cost, contingency management intervention to promote heroin abstinence in individuals undergoing treatment for heroin use disorder in UK drug services (PRAISE): a cluster randomised trial

Nicola Metrebian^*, Timothy Weaver, Kimberley Goldsmith, Stephen Pilling, Jennifer Hellier, Andrew Pickles, James Shearer, Sarah Byford, Luke Mitcheson, Prun Bijral, Nadine A. Bogdan, Owen Bowden-Jones, Ed Day, John Dunn, Anthony Glasper, Emily Finch, Sam Forshall, Shabana Akhtar, Jalpa Bajaria, Carmel BennettElizabeth Bishop, Vikki Charles, Clare Davey, Roopal Desai, Claire Goodfellow, Farjana Haque, Nicholas Little, Hortencia McKechnie, Franziska Mosler, Jo Morris, Julian Mutz, Ruth Pauli, Dilkushi Poovendran, Elizabeth Philips, John Strang

^*Corresponding author for this work

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Abstract

INTRODUCTION: Most individuals treated for heroin use disorder receive opioid agonist treatment (OAT)(methadone or buprenorphine). However, OAT is associated with high attrition and persistent, occasional heroin use. There is some evidence for the effectiveness of contingency management (CM), a behavioural intervention involving modest financial incentives, in encouraging drug abstinence when applied adjunctively with OAT. UK drug services have a minimal track record of applying CM and limited resources to implement it. We assessed a CM intervention pragmatically adapted for ease of implementation in UK drug services to promote heroin abstinence among individuals receiving OAT. DESIGN: Cluster randomised controlled trial. SETTING AND PARTICIPANTS: 552 adults with heroin use disorder (target 660) enrolled from 34 clusters (drug treatment clinics) in England between November 2012 and October 2015. INTERVENTIONS: Clusters were randomly allocated 1:1:1 to OAT plus 12× weekly appointments with: (1) CM targeted at opiate abstinence at appointments (CM Abstinence); (2) CM targeted at on-time attendance at appointments (CM Attendance); or (3) no CM (treatment as usual; TAU). Modifications included monitoring behaviour weekly and fixed incentives schedule. MEASUREMENTS: Primary outcome: heroin abstinence measured by heroin-free urines (weeks 9-12). SECONDARY OUTCOMES: heroin abstinence 12 weeks after discontinuation of CM (weeks 21-24); attendance; self-reported drug use, physical and mental health. RESULTS: CM Attendance was superior to TAU in encouraging heroin abstinence. Odds of a heroin-negative urine in weeks 9-12 was statistically significantly greater in CM Attendance compared with TAU (OR=2.1; 95% CI 1.1 to 3.9; p=0.030). CM Abstinence was not superior to TAU (OR=1.6; 95% CI 0.9 to 3.0; p=0.146) or CM Attendance (OR=1.3; 95% CI 0.7 to 2.4; p=0.438) (not statistically significant differences). Reductions in heroin use were not sustained at 21-24 weeks. No differences between groups in self-reported heroin use. CONCLUSIONS: A pragmatically adapted CM intervention for routine use in UK drug services was moderately effective in encouraging heroin abstinence compared with no CM only when targeted at attendance. CM targeted at abstinence was not effective. TRIAL REGISTRATION NUMBER: ISRCTN 01591254.

Original language	English
Article number	e046371
Pages (from-to)	e046371
Number of pages	15
Journal	BMJ Open
Volume	11
Issue number	7
DOIs	https://doi.org/10.1136/bmjopen-2020-046371
Publication status	Published - 1 Jul 2021

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Metrebian, N., Weaver, T., Goldsmith, K., Pilling, S., Hellier, J., Pickles, A., Shearer, J., Byford, S., Mitcheson, L., Bijral, P., Bogdan, N. A., Bowden-Jones, O., Day, E., Dunn, J., Glasper, A., Finch, E., Forshall, S., Akhtar, S., Bajaria, J., ... Strang, J. (2021). Using a pragmatically adapted, low-cost, contingency management intervention to promote heroin abstinence in individuals undergoing treatment for heroin use disorder in UK drug services (PRAISE): a cluster randomised trial. BMJ Open, 11(7), e046371. [e046371]. https://doi.org/10.1136/bmjopen-2020-046371

@article{c8ae08d5e515492db30a3c2922c1aed3,

title = "Using a pragmatically adapted, low-cost, contingency management intervention to promote heroin abstinence in individuals undergoing treatment for heroin use disorder in UK drug services (PRAISE): a cluster randomised trial",

abstract = "INTRODUCTION: Most individuals treated for heroin use disorder receive opioid agonist treatment (OAT)(methadone or buprenorphine). However, OAT is associated with high attrition and persistent, occasional heroin use. There is some evidence for the effectiveness of contingency management (CM), a behavioural intervention involving modest financial incentives, in encouraging drug abstinence when applied adjunctively with OAT. UK drug services have a minimal track record of applying CM and limited resources to implement it. We assessed a CM intervention pragmatically adapted for ease of implementation in UK drug services to promote heroin abstinence among individuals receiving OAT. DESIGN: Cluster randomised controlled trial. SETTING AND PARTICIPANTS: 552 adults with heroin use disorder (target 660) enrolled from 34 clusters (drug treatment clinics) in England between November 2012 and October 2015. INTERVENTIONS: Clusters were randomly allocated 1:1:1 to OAT plus 12× weekly appointments with: (1) CM targeted at opiate abstinence at appointments (CM Abstinence); (2) CM targeted at on-time attendance at appointments (CM Attendance); or (3) no CM (treatment as usual; TAU). Modifications included monitoring behaviour weekly and fixed incentives schedule. MEASUREMENTS: Primary outcome: heroin abstinence measured by heroin-free urines (weeks 9-12). SECONDARY OUTCOMES: heroin abstinence 12 weeks after discontinuation of CM (weeks 21-24); attendance; self-reported drug use, physical and mental health. RESULTS: CM Attendance was superior to TAU in encouraging heroin abstinence. Odds of a heroin-negative urine in weeks 9-12 was statistically significantly greater in CM Attendance compared with TAU (OR=2.1; 95% CI 1.1 to 3.9; p=0.030). CM Abstinence was not superior to TAU (OR=1.6; 95% CI 0.9 to 3.0; p=0.146) or CM Attendance (OR=1.3; 95% CI 0.7 to 2.4; p=0.438) (not statistically significant differences). Reductions in heroin use were not sustained at 21-24 weeks. No differences between groups in self-reported heroin use. CONCLUSIONS: A pragmatically adapted CM intervention for routine use in UK drug services was moderately effective in encouraging heroin abstinence compared with no CM only when targeted at attendance. CM targeted at abstinence was not effective. TRIAL REGISTRATION NUMBER: ISRCTN 01591254.",

author = "Nicola Metrebian and Timothy Weaver and Kimberley Goldsmith and Stephen Pilling and Jennifer Hellier and Andrew Pickles and James Shearer and Sarah Byford and Luke Mitcheson and Prun Bijral and Bogdan, {Nadine A.} and Owen Bowden-Jones and Ed Day and John Dunn and Anthony Glasper and Emily Finch and Sam Forshall and Shabana Akhtar and Jalpa Bajaria and Carmel Bennett and Elizabeth Bishop and Vikki Charles and Clare Davey and Roopal Desai and Claire Goodfellow and Farjana Haque and Nicholas Little and Hortencia McKechnie and Franziska Mosler and Jo Morris and Julian Mutz and Ruth Pauli and Dilkushi Poovendran and Elizabeth Philips and John Strang",

note = "Funding Information: Competing interests JS, SP and LM have contributed to UK guidelines on the potential role of contingency management in the management of opioid addiction (NICE, 2007; convened by SP, chaired by JS). SP receives funding from NICE for the production of clinical guidelines. JS has chaired the broader scope pan-UK working group preparing the 2017 and 2007 Orange Guidelines for the UK Departments of Health and Social Care, providing guidance on management and treatment of drug dependence and misuse, including guidance on possible inclusion of contingency management. LM and ED contributed to these guidelines. JS is a researcher and clinician who, through his university, has worked with various pharmaceutical companies to identify new or improved treatments and his employer (King{\textquoteright}s College London) has received grants, travel costs and/or consultancy payments from companies including, past 3 years, Indivior, Mundipharma, Camurus, Molteni Farma and Accord. JS has also worked with various drug policy organisations and advisory bodies including the Society for the Study of Addiction (SSA) and the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA). JS and KG are supported by the National Institute for Health Research (NIHR) Biomedical Research Centre for Mental Health at South London and Maudsley NHS Foundation Trust and King's College London. JS is an NIHR senior investigator. For a fuller account, see JS{\textquoteright}s web page at http://www.kcl.ac.uk/ioppn/depts/addictions/people/hod.aspx. NM is involved in research project funded by pharmaceutical company Mundipharma. LM has been in receipt of an untied educational grant from Indivior for the ARC study which incorporated the use of CM in the intervention arm. LM is currently involved in pharmaceutical company (Indivior) funded study–the EXPO trial which will incorporate the use of CM as part of the psychosocial intervention. LM has a paid secondment to PHE to advise on best practice psychological interventions in drug and alcohol treatment. ED has recently been appointed as the government{\textquoteright}s Drug Recovery Champion. Funding Information: Funding This paper presents independent research funded by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research Programme (grant reference number RP-PG-0707-10149). The research was also part funded by the NIHR Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King{\textquoteright}s College London. Publisher Copyright: {\textcopyright} 2021 BMJ Publishing Group. All rights reserved. Copyright: Copyright 2021 Elsevier B.V., All rights reserved.",

year = "2021",

month = jul,

day = "1",

doi = "10.1136/bmjopen-2020-046371",

language = "English",

volume = "11",

pages = "e046371",

journal = "BMJ Open",

issn = "2044-6055",

publisher = "BMJ Publishing Group",

number = "7",

}

Metrebian, N, Weaver, T, Goldsmith, K, Pilling, S, Hellier, J , Pickles, A , Shearer, J , Byford, S , Mitcheson, L, Bijral, P, Bogdan, NA, Bowden-Jones, O, Day, E, Dunn, J, Glasper, A, Finch, E, Forshall, S, Akhtar, S, Bajaria, J, Bennett, C, Bishop, E, Charles, V, Davey, C, Desai, R, Goodfellow, C, Haque, F, Little, N, McKechnie, H , Mosler, F, Morris, J, Mutz, J, Pauli, R, Poovendran, D, Philips, E & Strang, J 2021, 'Using a pragmatically adapted, low-cost, contingency management intervention to promote heroin abstinence in individuals undergoing treatment for heroin use disorder in UK drug services (PRAISE): a cluster randomised trial', BMJ Open, vol. 11, no. 7, e046371, pp. e046371. https://doi.org/10.1136/bmjopen-2020-046371

Using a pragmatically adapted, low-cost, contingency management intervention to promote heroin abstinence in individuals undergoing treatment for heroin use disorder in UK drug services (PRAISE): a cluster randomised trial. / Metrebian, Nicola; Weaver, Timothy; Goldsmith, Kimberley et al.

In: BMJ Open, Vol. 11, No. 7, e046371, 01.07.2021, p. e046371.

Research output: Contribution to journal › Article › peer-review

TY - JOUR

T1 - Using a pragmatically adapted, low-cost, contingency management intervention to promote heroin abstinence in individuals undergoing treatment for heroin use disorder in UK drug services (PRAISE): a cluster randomised trial

AU - Metrebian, Nicola

AU - Weaver, Timothy

AU - Goldsmith, Kimberley

AU - Pilling, Stephen

AU - Hellier, Jennifer

AU - Pickles, Andrew

AU - Shearer, James

AU - Byford, Sarah

AU - Mitcheson, Luke

AU - Bijral, Prun

AU - Bogdan, Nadine A.

AU - Bowden-Jones, Owen

AU - Day, Ed

AU - Dunn, John

AU - Glasper, Anthony

AU - Finch, Emily

AU - Forshall, Sam

AU - Akhtar, Shabana

AU - Bajaria, Jalpa

AU - Bennett, Carmel

AU - Bishop, Elizabeth

AU - Charles, Vikki

AU - Davey, Clare

AU - Desai, Roopal

AU - Goodfellow, Claire

AU - Haque, Farjana

AU - Little, Nicholas

AU - McKechnie, Hortencia

AU - Mosler, Franziska

AU - Morris, Jo

AU - Mutz, Julian

AU - Pauli, Ruth

AU - Poovendran, Dilkushi

AU - Philips, Elizabeth

AU - Strang, John

N1 - Funding Information: Competing interests JS, SP and LM have contributed to UK guidelines on the potential role of contingency management in the management of opioid addiction (NICE, 2007; convened by SP, chaired by JS). SP receives funding from NICE for the production of clinical guidelines. JS has chaired the broader scope pan-UK working group preparing the 2017 and 2007 Orange Guidelines for the UK Departments of Health and Social Care, providing guidance on management and treatment of drug dependence and misuse, including guidance on possible inclusion of contingency management. LM and ED contributed to these guidelines. JS is a researcher and clinician who, through his university, has worked with various pharmaceutical companies to identify new or improved treatments and his employer (King’s College London) has received grants, travel costs and/or consultancy payments from companies including, past 3 years, Indivior, Mundipharma, Camurus, Molteni Farma and Accord. JS has also worked with various drug policy organisations and advisory bodies including the Society for the Study of Addiction (SSA) and the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA). JS and KG are supported by the National Institute for Health Research (NIHR) Biomedical Research Centre for Mental Health at South London and Maudsley NHS Foundation Trust and King's College London. JS is an NIHR senior investigator. For a fuller account, see JS’s web page at http://www.kcl.ac.uk/ioppn/depts/addictions/people/hod.aspx. NM is involved in research project funded by pharmaceutical company Mundipharma. LM has been in receipt of an untied educational grant from Indivior for the ARC study which incorporated the use of CM in the intervention arm. LM is currently involved in pharmaceutical company (Indivior) funded study–the EXPO trial which will incorporate the use of CM as part of the psychosocial intervention. LM has a paid secondment to PHE to advise on best practice psychological interventions in drug and alcohol treatment. ED has recently been appointed as the government’s Drug Recovery Champion. Funding Information: Funding This paper presents independent research funded by the National Institute for Health Research (NIHR) under its Programme Grants for Applied Research Programme (grant reference number RP-PG-0707-10149). The research was also part funded by the NIHR Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King’s College London. Publisher Copyright: © 2021 BMJ Publishing Group. All rights reserved. Copyright: Copyright 2021 Elsevier B.V., All rights reserved.

PY - 2021/7/1

Y1 - 2021/7/1

N2 - INTRODUCTION: Most individuals treated for heroin use disorder receive opioid agonist treatment (OAT)(methadone or buprenorphine). However, OAT is associated with high attrition and persistent, occasional heroin use. There is some evidence for the effectiveness of contingency management (CM), a behavioural intervention involving modest financial incentives, in encouraging drug abstinence when applied adjunctively with OAT. UK drug services have a minimal track record of applying CM and limited resources to implement it. We assessed a CM intervention pragmatically adapted for ease of implementation in UK drug services to promote heroin abstinence among individuals receiving OAT. DESIGN: Cluster randomised controlled trial. SETTING AND PARTICIPANTS: 552 adults with heroin use disorder (target 660) enrolled from 34 clusters (drug treatment clinics) in England between November 2012 and October 2015. INTERVENTIONS: Clusters were randomly allocated 1:1:1 to OAT plus 12× weekly appointments with: (1) CM targeted at opiate abstinence at appointments (CM Abstinence); (2) CM targeted at on-time attendance at appointments (CM Attendance); or (3) no CM (treatment as usual; TAU). Modifications included monitoring behaviour weekly and fixed incentives schedule. MEASUREMENTS: Primary outcome: heroin abstinence measured by heroin-free urines (weeks 9-12). SECONDARY OUTCOMES: heroin abstinence 12 weeks after discontinuation of CM (weeks 21-24); attendance; self-reported drug use, physical and mental health. RESULTS: CM Attendance was superior to TAU in encouraging heroin abstinence. Odds of a heroin-negative urine in weeks 9-12 was statistically significantly greater in CM Attendance compared with TAU (OR=2.1; 95% CI 1.1 to 3.9; p=0.030). CM Abstinence was not superior to TAU (OR=1.6; 95% CI 0.9 to 3.0; p=0.146) or CM Attendance (OR=1.3; 95% CI 0.7 to 2.4; p=0.438) (not statistically significant differences). Reductions in heroin use were not sustained at 21-24 weeks. No differences between groups in self-reported heroin use. CONCLUSIONS: A pragmatically adapted CM intervention for routine use in UK drug services was moderately effective in encouraging heroin abstinence compared with no CM only when targeted at attendance. CM targeted at abstinence was not effective. TRIAL REGISTRATION NUMBER: ISRCTN 01591254.

AB - INTRODUCTION: Most individuals treated for heroin use disorder receive opioid agonist treatment (OAT)(methadone or buprenorphine). However, OAT is associated with high attrition and persistent, occasional heroin use. There is some evidence for the effectiveness of contingency management (CM), a behavioural intervention involving modest financial incentives, in encouraging drug abstinence when applied adjunctively with OAT. UK drug services have a minimal track record of applying CM and limited resources to implement it. We assessed a CM intervention pragmatically adapted for ease of implementation in UK drug services to promote heroin abstinence among individuals receiving OAT. DESIGN: Cluster randomised controlled trial. SETTING AND PARTICIPANTS: 552 adults with heroin use disorder (target 660) enrolled from 34 clusters (drug treatment clinics) in England between November 2012 and October 2015. INTERVENTIONS: Clusters were randomly allocated 1:1:1 to OAT plus 12× weekly appointments with: (1) CM targeted at opiate abstinence at appointments (CM Abstinence); (2) CM targeted at on-time attendance at appointments (CM Attendance); or (3) no CM (treatment as usual; TAU). Modifications included monitoring behaviour weekly and fixed incentives schedule. MEASUREMENTS: Primary outcome: heroin abstinence measured by heroin-free urines (weeks 9-12). SECONDARY OUTCOMES: heroin abstinence 12 weeks after discontinuation of CM (weeks 21-24); attendance; self-reported drug use, physical and mental health. RESULTS: CM Attendance was superior to TAU in encouraging heroin abstinence. Odds of a heroin-negative urine in weeks 9-12 was statistically significantly greater in CM Attendance compared with TAU (OR=2.1; 95% CI 1.1 to 3.9; p=0.030). CM Abstinence was not superior to TAU (OR=1.6; 95% CI 0.9 to 3.0; p=0.146) or CM Attendance (OR=1.3; 95% CI 0.7 to 2.4; p=0.438) (not statistically significant differences). Reductions in heroin use were not sustained at 21-24 weeks. No differences between groups in self-reported heroin use. CONCLUSIONS: A pragmatically adapted CM intervention for routine use in UK drug services was moderately effective in encouraging heroin abstinence compared with no CM only when targeted at attendance. CM targeted at abstinence was not effective. TRIAL REGISTRATION NUMBER: ISRCTN 01591254.

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U2 - 10.1136/bmjopen-2020-046371

DO - 10.1136/bmjopen-2020-046371

M3 - Article

SN - 2044-6055

VL - 11

SP - e046371

JO - BMJ Open

JF - BMJ Open

IS - 7

M1 - e046371

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Metrebian N, Weaver T, Goldsmith K, Pilling S, Hellier J , Pickles A et al. Using a pragmatically adapted, low-cost, contingency management intervention to promote heroin abstinence in individuals undergoing treatment for heroin use disorder in UK drug services (PRAISE): a cluster randomised trial. BMJ Open. 2021 Jul 1;11(7):e046371. e046371. doi: 10.1136/bmjopen-2020-046371

Using a pragmatically adapted, low-cost, contingency management intervention to promote heroin abstinence in individuals undergoing treatment for heroin use disorder in UK drug services (PRAISE): a cluster randomised trial

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