[Note: this information was archived by the NTA in 2017]

Contingency management (CM) is an evidence-based treatment intervention recommended by the National Institute for Health and Clinical Excellence (NICE). It is based on principles of behaviour modification and aims to incentivise and then reinforce changes in behaviour with the aid of vouchers, privileges, prizes or modest financial incentives that are of value to the client.

Providing incentives is supported by government as a way to “nudge” people to change their behaviour in a positive direction across a wide range of health and social policy domains.

Used properly and implemented carefully (see next section), CM can be a useful intervention within a balanced treatment system. Alongside other interventions, it can be used to encourage and support:
•abstinence from drugs of dependence, usually alongside substitute medication and relapse prevention
•engagement in recovery related activities
•engagement in treatment by incentivising attendance
•Improved compliance with health promotion, such as preventing BBVs, an example of which is hepatitis B vaccination.

NICE recommended:
“Drug services should introduce contingency management programmes… to reduce illicit drug use and/or promote engagement with services for people receiving methadone maintenance treatment. … Where possible, implementation in the NHS should draw on the experience so far (albeit limited) of contingency management in the NHS and on the experience of agencies such as the National Treatment Agency for Substance Misuse (NTA) in the implementation of service developments in drug misuse.”

In 2009 the NTA conducted a demonstration programme that looked at the implementation of CM in selected drug treatment services. Since the programme concluded, CM for drug use has been included as an intervention in the NDTMS modality codes. Meanwhile, the expertise of the pilot sites has been placed at the disposal of the ConMan programme of five linked research studies that started in 2009 and runs to 2014.

The aim of the study is to develop a UK evidence base for contingency management in addiction treatment. The programme, which is funded by a National Institute for Health Research (NIHR) Programme Grant, is being led by the South London & Maudsley (SLaM) NHS Foundation Trust, but is a collaborative venture by investigators based at three London NHS trusts and universities.

Implementation of contingency management:
To maximise the use of resources, local partnerships need to consider where CM would genuinely add value beyond the standard treatment offer. This will depend on local population need and what health gains and recovery orientated outcomes are considered priorities.

CM programmes should have the following characteristics:
•Focus on a discrete behaviour under voluntary control
•Have quantifiable targets e.g. good behaviour from a child
•Have identified reinforcement (incentives, rewards) e.g. praise, vouchers, prizes, privileges, cash
•Have a clear contingent relationship between behaviour and reinforcement (schedules of reinforcement which are consistent and immediate – at least initially)

Any treatment service wishing to set up a CM programme should think carefully about the behaviours they are seeking to change and how the programme will fit into the service they deliver. A number of implementation tips were provided by services that took part in the NTA’s CM demonstration programme, in 2009. These included:
•Make sure you have the resources to run a CM programme – in terms of funding and staff ◦Services often underestimated these costs and how much staff time the programme would take up.
•Think about the logistical and practical aspects of running a CM programme ◦Services that assessed the impact CM would have on their other activities were more successful at implementing CM.
•Make sure staff are provided with the right level of training and supervision ◦Staff training not only provides them with the knowledge they need to deliver a CM. programme, but can also be useful for persuading sceptical staff of CM’s benefits.
◦Supervision is a central tool for monitoring staff performance and also provides a means of support and professional guidance.
•Keep it simple – don’t overcomplicate the process ◦Services that tried to run more than one model of CM often struggled to deliver them simultaneously.
•Make sure you use appropriate incentives e.g. clinical privileges or vouchers
◦And make sure they are meaningful and available at the point the behaviour is achieved.
•Consider the implications of partnership working ◦Some CM programmes (such as BBV CM programmes) can operate across wide areas, such as a whole local treatment system.
•Have a CM champion/someone who takes ownership of the programme ◦Having a dedicated CM champion was a common feature of services that delivered CM successfully.