The versatility of counselling psychology in the field of substance misuse
The present study was part of a nationwide multisite trial of contingency management (CM) implemented by the National Treatment Agency for Substance Misuse (NTA). The research programme aimed to target drug using, health and attendance related behaviours to gain an understanding of the acceptability and feasibility of contingency management to the UK substance misuse population. The use of CM to incentivise abstinence from an illicit substance was recommended in the guidelines of the National Institute for Health and Clinical Excellence (NICE, 2007). This study examined whether CM reduced concurrent crack cocaine misuse among opiate maintenance clients at a community drug and alcohol service (NHS). The study employed a quasi experimental design in which twenty-one (n = 21) opiate maintenance clients voluntarily chose to participate in the CM group. The incentive consisted of monetary based vouchers in the CM group, contingent upon the submission of cocaine free urine samples. A natural unplanned comparison group (n = 21) developed from participants that initially agreed to participate in the CM intervention but did not attend any of the scheduled reinforcement sessions. These clients continued to receive standard treatment (ST), including opiate maintenance treatment and key working. The data analysis consisted of two parts of data analysis; the first part employed a between-group analysis to compare the frequency of self-reported crack cocaine misuse for the CM and ST groups at baseline, 1 week after the 12-week CM intervention concluded and at 6 months follow-up. The analysis showed that there was a significant difference in crack use at followup and that there was a decrease in crack use over time in the CM group but not in the ST group. The second part utilised a within-group analysis, investigating study results for evidence of clinically meaningful changes on an individual participant level in the CM group. Accordingly, 5 participants (24%) demonstrated statistical and clinical improvement. Additionally, a survival analysis revealed that the estimated median time to study dropout was 14 days. These results seemed to indicate onset of crack abstinence is likely to occur early in treatment or not at all. The results of the study provide a tentative overview of the feasibility and generalisability of a voucher based contingency management programme reducing crack use among clients in opiate maintenance treatment in the UK. The 29 implications of the study will be discussed in relation to clinical practice and future research. Finally, a brief discussion of the moral and ethical concerns about using incentives in health care will be provided. This information will be useful in expanding this evidence-based approach into community settings.
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