Abstract
Prevalence of tobacco smoking amongst those in treatment for opiate dependence is almost five times greater than that of the general population. Despite this, very few of those undergoing treatment for opiate addiction receive help to stop smoking. Contingency management (CM) is a behavioural intervention, based on the principles of operant conditioning, where desired behaviours are positively reinforced with some form of reward. CM may represent a potentially useful addition to standard stop smoking treatments for those in opiate addiction treatment, but has never been tested in this context in the UK. This thesis describes the development and piloting of an intervention, investigating the addition of a contingency management intervention for tobacco smoking, to standard stop smoking services treatment, in individuals undergoing treatment for opiate addiction.A meta-analysis was first conducted, investigating the use of CM as an intervention for the use of non-prescribed drug use during opiate addiction treatment. CM was found to be to be more effective than control in engendering abstinence from a wide range of drugs. Moderator analysis showed CM to be more effective than control in preventing use of cocaine, cocaine and opiates, tobacco, and poly-substance use, but not of opiates.
Whilst carrying out the meta-analysis, it was discovered that no tool currently existed for assessing the quality of CM studies. This was addressed by the design and testing of a new tool, the CMQAT (Contingency Management Quality Assessment Tool). The tool underwent three stages of reliability and validity testing. Inter-rater reliability increased from slight at stage one, to fair at stage two, and was better than that of an established quality assessment tool (EPHPP) that achieved only slight agreement. Predictive validity could not be established at any stage.
The results of the meta-analysis and CMQAT development were used to design a feasibility and pilot study, testing the addition of a CM intervention, to standard stop smoking services treatment. Forty opiate addiction patients were recruited into the study, and 37 were randomised to either an experimental (CM for smoking abstinence) or control (CM for attendance at the clinic) condition. The rate of recruitment was greater than that of other similar studies, yet only ten participants completed the intervention, two from the experimental condition and eight from the control, with none of the participants attending follow-up. The most widely reported reason for dropping out of the study was that the smoking clinic was not run at convenient times.
Overall, I believe this thesis constitutes a significant contribution to the CM literature. The findings of the meta-analysis offer further support for the efficacy of CM as an intervention for non-prescribed drug use during opiate addiction treatment. The CMQAT forms the foundation for future work to improve both the accuracy of quality assessments of CM trials, and the reporting of methods and data in published reports of CM trials. The feasibility/pilot study represented the first time in the UK that CM had been used as an intervention for tobacco smoking during opiate addiction treatment. The primary observation from this study was that with the CM protocol used, retention in treatment was poor, with only 25% of participants completing the five-week intervention. Taken together, the findings have a number of implications for research, practice and policy. Perhaps the most important of these though, is that implementing CM in a clinical setting alongside standard stop smoking services treatment, introduces a number of new challenges not encountered in a laboratory setting. Further feasibility and pilot work is required before a full scale randomised controlled trial can be carried out.
| Date of Award | 2018 |
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| Original language | English |
| Awarding Institution |
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| Supervisor | Ann McNeill (Supervisor), John Strang (Supervisor) & Leonie Brose (Supervisor) |