Implementation of Contingency Management at a Large VA Addiction Treatment Center

A major barrier to CM adoption is treatment providers’ negative beliefs and attitudes about this modality (6), which is often rooted in a limited understanding of CM. Fortunately, when CM is implemented and providers observe positive outcomes, such negative beliefs usually dissipate quickly (6). When CM was first rolled out at this facility, staff expressed concerns about paying patients for abstinence, gambling-like qualities of the slip-draw method, and doubts about CM’s effectiveness. This was not surprising, considering that CM is one of the least understood evidence-based addiction treatments (7). It was helpful to address these attitudes by providing education and research evidence about CM. Furthermore, with positive feedback from veterans who participated, staff’s attitudes became more accepting and even enthusiastic.

Nonetheless, referrals were initially slow, which required ongoing efforts in monitoring patient eligibility and enrollment. A quality improvement (QI) project was developed to increase patient awareness of and participation in CM and to educate staff. The QI project tracked the percentage of CM-eligible patients who enrolled in CM. Tracking and monitoring appeared to heighten staff awareness of CM, which increased enrollment over time. CM enrollment showed an upward trend, starting at 60% enrollment of eligible IOP patients and ending at 100% after five quarters of QI tracking. This rate has remained stable over time.

Prior to CM rollout, identifying and instituting an appropriate drug testing method for CM was a significant barrier, because it involved collaborating with the facility’s laboratory and pathology services and finding solutions that addressed the needs of both programs. The process unfolded over two years, and once developed, the method provided a good foundation for the new CM program. We ultimately decided on the iCup because it provided instant urinalysis results, which met the need for immediate management of contingencies and also met laboratory requirements.

The iCup was a novel device for most staff. Although it met the laboratory’s stringent criteria for validity, clinic staff expressed doubts about results and concerns about patient disputes of results. At initial CM sessions, some iCups were sent to the lab for confirmation. When staff saw that confirmations were always consistent with iCup results, their confidence increased. Although staff had predicted that patients would distrust and dispute the test results, this was not observed.

Because the iCup fell under the oversight of the laboratory’s department of ancillary testing, we functioned under the umbrella of the facility’s laboratory licensing and certification. The ancillary testing coordinator also provided training and follow-up competence monitoring to clinical staff conducting CM. This arrangement resulted in a reliance on the laboratory and POCT program to train and certify clinicians before they could deliver CM services, which required dedication of resources and caused two separate delays in CM implementation. The delays were three months during the initial rollout and a year in 2015 as the program expanded. This highlights the importance of ongoing collaboration for sustainment, because training of new staff is required to address staffing changes.

The financial cost associated with the CM voucher-based reward system is a common implementation barrier (6). The cost of our CM implementation included vouchers, testing devices, and CM staff. The cost of vouchers was not a barrier because the program received $5,000 of VA store vouchers from the national VA dissemination effort. Furthermore, as a formal member of VA Central Office’s CM Sustainability Incentive Program, our facility is eligible for ongoing renewal of funding for vouchers to sustain our program. However, this financial commitment may be prohibitive in some contexts and must be taken into consideration. To date, our facility has expended $6,500 in vouchers. The cost of iCups was absorbed by the facility’s laboratory, which provides an ongoing supply to maintain POCT needs. To date, we have used approximately 700 iCups, costing approximately $5,600. In terms of staffing, CM services are provided by existing clinicians who, with approval of their supervisors, voluntarily deliver this intervention in addition to their regular duties. These staff have dedicated approximately 300 hours to the CM program. Staff and supervisors have not reported this to be burdensome to their workflow; rather, staff have noted how CM sessions bring a predictable and structured experience to their work. This highlights the important role of leadership buy-in and internal facilitators for successful implementation.