Implementing contingency management in family medicine: A qualitative inquiry on provider and patient preferences for a low magnitude reward program compatible with buprenorphine treatment.

BACKGROUND

Contingency management (CM) is an effective yet underutilized behavioral intervention that uses rewards to improve outcomes in medication for opioid use disorder (MOUD) treatment. Prior implementation attempts have focused on specialized addiction clinics, using intensive daily treatment with methadone and high reward values (e.g. >$200 total). However, many people get MOUD from less specialized, more accessible, family medicine clinics. These clinics could also benefit from CM, yet present unique challenges for CM. Family medicine clinics typically use buprenorphine as their primary medication, which requires less intensive dosing schedules and thus provides fewer CM opportunities. They may also have lower institutional willingness to use high-value rewards. As an initial step in user-centered design of a low value reward (<$75 total) CM program for the family medicine context, we conducted qualitative interviews with patients and staff in the buprenorphine treatment program of a family medicine department. We gathered and analyzed qualitative data on CM knowledge, preferred program parameters, and implementation considerations.

METHOD

Participants ( = 24) were buprenorphine treatment staff ( = 12) and patients ( = 12). Participants completed 30-50-minute semi-structured interviews, analyzed using rapid matrix analysis.

RESULTS

Participants had little experience with CM, but generally viewed CM as acceptable, appropriate, and feasible. Interviewees coalesced around having staff who were not providers with prescription privileges conduct CM, consistent rather than escalating payments, and physical rewards delivered in-person. Potential challenges included medical record integration, demands on staff time, and confirmation of patients' goal completion.

CONCLUSIONS

Patient and staff feedback was well-aligned, especially regarding rewards as an opportunity for staff-patient connection and the need for simplicity. Some consensus suggestions (e.g. non-escalating rewards) conflict with extant CM literature. Implications for implementation of CM in this setting are presented. These findings inform user-centered design and iteration of a CM program for this accessible, non-specialized family medicine setting.