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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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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 & 15 more 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

Original languageEnglish
Article numberbmjopen-2020-046371.R1
Pages (from-to)1-15
Number of pages15
JournalBMJ Open
Accepted/In press26 May 2021
Published1 Jul 2021

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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 12x weekly appointments with: i)CM targeted at opiate-abstinence at appointments (CM Abstinence); ii)CM targeted at on-time attendance at appointments (CM Attendance); or, iii)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 to 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.
The trial is prospectively registered, number ISRCTN 01591254.
Funding: NIHR (RP-PG-0707-10149)

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