Implementing incentives in family medicine for opioid use disorder treatment: a qualitative inquiry on provider and patient preferences for a low magnitude reward program compatible with buprenorphine treatment
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Background
Incentive programs are an effective yet underutilized behavioral intervention that can improve outcomes in medication for opioid use disorder (MOUD) treatment. Contingency Management (CM) is a rigorous incentive program run per seven evidence-based principles (e.g. objectively verifiable target behaviors, frequent opportunities for incentives). Prior implementation attempts have focused on implementing CM in specialized addiction clinics with methadone as the primary medication treatment. However, many people get MOUD from less specialized, more accessible family medicine clinics. These clinics might also benefit from the use of incentive programs, yet present unique challenges for implementation. For example, family medicine clinics typically use buprenorphine as their primary medication, which requires less intensive dosing schedules than methadone and thus provides fewer incentive opportunities. As an initial step in user-centered design of a CM-informed incentive 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 ( N = 24) were buprenorphine treatment staff ( n = 12) and patients ( n = 12). Participants completed 30–50-minute semi-structured interviews, analyzed using rapid matrix analysis.
Results
Participants had little experience with formal incentive programs, but generally viewed incentives as acceptable, appropriate, and feasible. Interviewees coalesced around having staff who were not MOUD prescribers run the program, 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. Comparing end-user suggestions with the literature, some consensus suggestions (e.g. non-escalating rewards) highlighted feasible places to compromise on ideal effectiveness to gain implementability. However, others (e.g. use of self-report to verify goals) conflicted directly with CM principles and indicate where more intensive education, support, and monitoring will be needed for implementation fidelity. These findings inform user-centered design and iteration of an incentive program for this accessible, non-specialized family medicine setting.
