Adherence to buprenorphine-XR through hybrid telehealth contingency management procedures: a case series

Abstract

Background and objectives:

Contingency management (CM) for substance use disorders (SUD) is effective in strengthening recovery behaviors, however can be quite burdensome. When health facilities experience staff shortages, adapting current CM protocols to be less staff and time intensive may be one way to address this challenge.

Methods:

Case series (N = 3).

Results:

Three veterans with opioid use disorder (OUD) received CM for treatment adherence through a Veteran Health Administration Outpatient Substance Disorder program. Due to the COVID-19 pandemic, traditional CM procedures resulted in limited accessibility and staff, delayed appointments, and decreased patient satisfaction. In response, the hybrid telehealth contingency management (HTCM) procedure was developed and implemented. Flexibility offered by HTCM allowed for consecutive completion of appointments and maintained adherence to BUP-XR treatment.

Conclusions:

This is a novel method of CM implementation. HTCM streamlined the process and was successful in increasing accessibility, reducing time-burden on patients and staff, while preserving fidelity to key components of the model. Considerations for future implementation and implications of HTCM are discussed.

Introduction

Opioid use disorders (OUD) account for many societal costs associated with substance use, including financial and loss of life (Luo et al., 2021). Extended-release buprenorphine (BUP-XR), which allows patients to receive one buprenorphine injection each month, is an effective (Compton & Volkow, 2021) and FDA-approved treatment for OUD. Individuals receiving buprenorphine experience several benefits, including increased quality of life and likelihood of employment (Ling et al., 2020), as well as reduced likelihood of mortality (Larochelle et al., 2018). However, the efficacy of treatment is dependent upon consistent adherence. Although retention rates for BUP-XR are superior to sublingual buprenorphine (Lee et al., 2021), real-world rates remain a major obstacle to both treatment effectiveness and curbing the opioid overdose epidemic (Farrell et al., 2022). Through application of behavioral principles such as positive and negative reinforcement, contingency management (CM) can strengthen recovery behaviors, including abstinence and medication adherence (Khazanov et al., 2022).

Prize CM, which includes the opportunity to win prizes through chance drawings has been shown to be as efficacious and more cost-effective than voucher CM, which a patient receives a standard amount for the desired behavior (Olmstead & Petry, 2009; Petry et al., 2005). Key features of CM include 1) patient understanding of the CM procedure and primed expectations of what they can earn (Petry, 2000); 2) immediate delivery of the CM prize as optimal learning occurs when a target behavior is reinforced without delay (Davis et al., 2016; Lussier et al., 2006); and 3) understanding rules and expectations of CM (Petry, 2000).

Over the past 30 years, a large body of evidence has supported the efficacy of CM in the treatment of substance use disorders (SUD), including for increasing abstinence, treatment attendance, and medication adherence (Khazanov et al., 2022). However, CM requires monitoring for the delivery of immediate reinforcement, which can be time-intensive for healthcare staff. Shortages in medical professionals across the U.S. and the world (Bagwell, et al., 2023), create a scarcity in the time they must administer treatment. Adapting current interventions to be less time-intensive, while maintaining key components of administration, may be one way to meet the needs of both patients and healthcare providers. Additionally, increasing elements of treatments that can be completed remotely, improves treatment access and decreases burden on providers and patients (Dallery et al., 2023).

Ideally, both the medication and CM prize are administered during the same encounter because the reinforcement can be provided with the greatest immediacy possible with no need for the patient to see another provider to receive reinforcement. However, not all providers who administer the injectable medication have been receptive to administering the CM, and among those willing to do so, adding CM to their injection administration clinics can lead to a time-burden on these providers. An alternative approach involves having a separate CM provider immediately following medication administration, which requires coordinated scheduling efforts. This option introduces sources of delay that could compromise the effectiveness of the CM intervention (e.g., the veteran is late, or the provider is occupied by unforeseen demands). Preserving key components of CM, while decreasing administration time, is crucial to maintaining and expanding treatment; particularly in CM, where time-burden has been a critique (Buresh et al., 2021; Petry, 2010).

The COVID-19 pandemic introduced additional constraints in delivering treatments like CM in-person. In response to staffing limitations from the COVID-19 pandemic, increasing health and safety needs, and patient preference for more remote care options, and CM procedures were adapted to continue to provide CM care in an intensive outpatient mental health and SUD treatment clinic. A key adaptation is the use of a hybrid remote/in-person protocol, which included the CM procedure being completed before the injection and the reward not provided until after the injection. While adaptations to CM interventions for smoking cessation and alcohol abstinence have been conducted remotely and shown to be both acceptable and feasible there are few studies on CM for medication adherence that have been delivered using remote or hybrid remote/in-person procedures (Coughlin et al., 2023; Holtyn et al., 2021). The development of this novel Hybrid Telehealth Contingency Management (HTCM) procedure is demonstrated through a case series of three veterans enrolled in a VA outpatient mental health and SUD treatment program from 2020 through 2021. Injections were administered in brief, consecutively scheduled appointments, so adding traditional CM procedures to each encounter would delay other patients’ subsequent medication administration appointments, decrease their customer experience, and limit the number of veterans served. Solutions to addressing the problem of delayed reinforcement and limited nursing staff were explored as the HTCM procedure was developed.

Materials and methods

In 2018, U.S. Department of Veteran Affairs healthcare facilities (VA) began using CM to reinforce adherence to BUP-XR. As of 2023, 26 VA facilities participate in CM for adherence. Veterans accepting CM receive reinforcement when their medication is administered. This earns them draws from a prize bowl containing 500 prize slips, ranging in value from $0 to $100, immediately following medication administration (Petry, 2013). Veterans receive four draws for the first injection administered and increase by four to a maximum of 16 with consecutive injections administered (i.e., 4, 8, 12, 16). Veterans received a minimum of $10 for receiving their first injection (i.e., if the four draws yielded less than $10 in earnings, the veterans received $10). If administered, on time, for all 12 months, veterans can earn a maximum of 168 draws with average earnings of $372.86 if all injections are received as scheduled.

The authors developed, implemented, and examined the delivery of HTCM. Due to pandemic-related concerns, all veterans in the program during the evaluation period were offered HTCM rather than traditional CM, and verbally consented to receive treatment. The current project was reviewed by the local Institutional Review Board and received exempt status. The primary and secondary coauthors (a licensed psychologist, and a supervised doctoral psychology trainee) administered the protocol to veterans in their care. Of the 42 individuals utilizing HTCM in this time-period, authors included three cases to include, similarity across diagnoses (e.g., OUD), but different ages and circumstances to illustrate the HTCM procedure. All three veterans (identifying details changed) received BUP-XR to aid their recovery. Each case presented (Table 1), outlines the participants’ backgrounds, psychosocial circumstances, real world implementation challenges and successes, as well as describes a 6-month follow-up.

Table 1.

Hybrid telehealth contingency management case summaries.

Case	Veteran A	Veteran B	Veteran C
Age	Late 40’s	Late 60’s	Early 30’s
Gender Identity	Male	Male	Male
Race	White	White	White
Ethnicity	Not Hispanic or Latino	Not Hispanic or Latino	Not Hispanic or Latino
Mental Health Diagnoses	OUD, Major Depressive Disorder, Other co-occurring diagnoses	OUD, PTSD, Other co-occurring diagnoses	OUD, Major Depressive Disorder, Other co-occurring diagnoses
Level of Care	IOP and Outpatient	Inpatient, IOP, Outpatient	Outpatient
HTCM Sessions	12	12	8

Procedure

Veterans were referred to the program by healthcare providers and discussed treatment options with their psychiatrist. Veterans engaged in shared decision-making processes with their psychiatrist and HTCM prior to deciding to choose BUP-XR. To further inform Veterans about HTCM, they were contacted prior to their first injection or educated in-person upon arriving for their first injection. Veterans were approached in-person to facilitate rapport between the veteran and CM provider. During their appointment, the HTCM provider explained procedures (Appendix A), which included an education form with HTCM processes and expectations (e.g., duration, draw accrual) for adherence to BUP-XR. This also included information regarding the prize system (i.e., on-site Veteran Canteen Store (VCS) vouchers), and consent.

Following or just before the administration of the first injection, HTCM providers demonstrated the virtual fishbowl. The virtual fishbowl is a spreadsheet containing numbers from 1–500 on the y-axis, each number corresponding to a prize, which can be easily shuffled (i.e., press F9) after each number is selected. Veterans were asked to select four numbers between 1 and 500 to complete draws. For the first session, a minimum amount of $10 in VCS vouchers is guaranteed. In the first session, the total prize amount earned was then immediately awarded to the veteran by the HTCM provider, along with a prize reminder slip informing the veteran how many draws would be earned (i.e., eight) for receiving their injection at their next scheduled session. A refused or missed appointment reset draws for the next appointment to four with no guaranteed minimum of $10 in earnings, with escalation resuming as before (i.e., by four for each injection until 16 draws are earned) for sustained adherence.

Subsequent HTCM sessions (2–12) were delivered via telephone, typically 1–12 hours before the appointment, however if there were foreseeable staff shortages or veteran scheduling challenges (e.g., a veteran could not take the call due to work or other life circumstances), the phone call could be completed up to 24 hours prior to their scheduled appointment. Typically, HTCM consisted of a 5–15-minute call, where the provider conducted a brief recovery check-in (e.g., urges and cravings, useful coping skills) followed by gathering the veteran’s fishbowl number selections and what they intended to purchase with their earnings. After number selection, veterans remained masked to the value of the incentive earned to mitigate potentially diminished motivation to have their injection administered if the prize value was low. They were informed that their prize would be available for pick-up at the time of injection administration. The HTCM provider would then wrap a reminder slip around the earnings and place them in an envelope to ensure the veteran would view the reminder slip when receiving the incentive. The envelope was given to the staff member performing the injection (e.g., nurse) to be immediately awarded to the veteran after BUP-XR administration. HTCM providers also encouraged recovery efforts and explained how many draw opportunities would be received during their next appointment. During each HTCM session, the provider queried the Veterans about their desired purchases made with earned vouchers, commented on how close the veteran was to earning an item they were saving for, and briefly discussed other treatment-related goals (e.g., attending Narcotics Anonymous, abstinence-related goals, social well-being activities). Upon injection, the administering nurse would praise efforts toward adherence and provide the prepackaged envelope to the veteran (Figure 1).

Figure 1.

Hybrid telehealth contingency management procedure. *Recommended.

Results

Veteran A

Veteran A is a White male in his late forties, who served in a non-combat role during the Persian Gulf War. He is married with adult children and works full-time. He has a history of childhood physical abuse, legal involvement pursuant to drug-related charges, and among several diagnoses (Table 1), he primarily reported challenges with OUD. The current episode of care was for the treatment of OUD, as well as symptoms such as rumination, hopelessness, fatigue, and passive suicidal ideation. His current treatment plan included a coordinated effort between his case counselor, psychologist, and psychiatrist. He commenced treatment with BUP-XR (300 mg/.5 solution) administered once-monthly and enrolled in HTCM.

Throughout treatment, he regularly stated that HTCM was “great” and helped to “keep [him] on track.” He was regularly joined by his wife for sessions. Each week, they planned the numbers they would choose from the fishbowl. He earned a total of $348, saving his winnings to purchase a gift for his grandchild. Veteran A reported it was helpful to have his spouse involved. He maintained adherence to BUP-XR treatment, consecutively completed all HTCM sessions, regularly met with his case manager and psychiatrist, and noted a reduction in his cravings and mental health symptoms. He continued to attend his BUP-XR injections (100 mg/.5 solution) after completion of HTCM and remained abstinent per Urine Drug Screen (UDS) results from all other substances (6 months post-engagement).

Veteran B

Veteran B is a White male veteran in his late sixties, who served in a non-combat role during the Vietnam War. He is divorced with one adult child and is unemployed. He has a history of incarceration for drug-related offenses. Among several diagnoses (Table 1), he primarily reported challenges with post-traumatic stress disorder and OUD and experiences additional symptoms related to chronic pain. His treatment plan included case management, psychiatry, and housing support. He received monthly BUP-XR injections (300 mg/.5 solution) for the first two months of treatment and reported no longer wanting to take BUP-XR and “do it by myself.” Rather than stop BUP-XR immediately, he was tapered to 100 mg/.5 solution at his third injection to decrease the likelihood of experiencing cravings. However, following the taper, he resumed opioid use and was admitted to acute inpatient care before reengaging with intensive outpatient treatment. He maintained treatment adherence to BUP-XR throughout his transition to and from inpatient care. He noted that the chance to earn incentives motivated him to continue treatment, even after a brief resumption of use, stating “I like the money.” After being discharged from his inpatient care he re-commenced BUP-XR at the original dose (300 mg/.5 solution). He attended 12 consecutive sessions including one while inpatient. He “banked” draws while inpatient, meaning he received an injection, but no incentive at the time of the injection and received double the draws (i.e., 32) at the next HTCM session. He used his earnings for food and similar items. He attended weekly AA meetings and remained abstinent after HTCM, six months post-engagement per UDS results.

Veteran C

Veteran C is a White male in his early thirties, who served in a combat role in Iraq. He is divorced with no children and works as a tradesman. He reported a challenging childhood marked by physical and sexual abuse. Following his military service, Veteran C reported legal involvement on drug-related charges. He has a history of engagement in multiple treatment programs, as well as multiple suicide attempts via overdose. His most recent attempt occurred five years before presenting to the HTCM program. Among several diagnoses (Table 1), he primarily reported challenges with major depressive disorder and OUD. He commenced BUP-XR (300 mg/.5 solution) on a monthly schedule and enrolled in HTCM.

Veteran C’s engagement in HTCM came because of his struggle to navigate recovery and obtain treatment due to a demanding work schedule. He reported appreciating the flexibility of the program, as he was able to complete HTCM procedures on his lunch break and receive his injection in the evening. He used his earnings to purchase a variety of items including household products and food. He completed eight consecutive injections and had one absence because he “forgot” but was able to receive his injection without HTCM incentives the following day. At his eighth injection, he chose to stop medication and explained “I’m doing amazing, I want to push it back and wean off of it.” He began missing HTCM appointments and sporadically attended weekly individual therapy with a psychologist to support his recovery and address symptoms of anger/irritability, relationship distress, and trauma. Several weeks after his eighth HTCM session he began using alcohol (less than 4 drinks per episode) and marijuana weekly. After five months he reported the resumption of opioid use and then re-initiated BUP-XR (300 mg/.5 solution) (without HTCM) to manage cravings. Veteran C had attended eight HTCM sessions but missed the four remaining sessions; 12 months being the limit of HTCM is offered in the program, and as result, he was not offered HTCM upon BUP-XR re-engagement.

Discussion

This case series describes the early development of HTCM, a novel method to implement CM to BUP-XR medication adherence through a hybrid telehealth format. The global COVID-19 pandemic created the opportunity for rapid adoption and increased use of telemedicine to support recovery from substance use (Wang et al., 2021). Moreover, with studies demonstrating trends toward increased rates of substance use during the pandemic (Wainwright et al., 2020), providing evidence-based treatment that is accessible (Wang et al., 2021) became even more essential. To our knowledge, this is the first study examining the integration of CM for treatment adherence through a telehealth format. Overall, this case series demonstrated how CM, an evidence-based intervention, can be implemented in a resource-limited setting, without compromising the fidelity of critical behavioral principles of reinforcement and components of the CM model.

The procedural adjustments made to maintain CM services to adapt it to a telehealth format potentially enhanced elements of CM, while also introducing some factors that potentially compromise CM. Most importantly, this process ensured veterans and providers safety during COVID restrictions through minimizing in-person contact, while providing treatment. Separating the prize drawing and injection also resulted in a time-reduction in implementation. A dedicated non-nurse HTCM provider focused on the administrative aspects of CM increased efficiency and streamlined the process, which resulted in several benefits including (a) increased flexibility and convenience, (b) decreasing burden on staff providing the injections, and (c) having the capacity to enroll a higher volume of veterans in HTCM.

One unique element observed during HTCM was that some veterans chose to involve a family member in their treatment during prize selection. Specifically, couples frequently engaged in collaborative discussions selecting numbers and choosing how to spend winnings. The non-veteran partner was observed to provide secondary reinforcement for the veteran’s adherence to the protocol through giving praise, even leading to instrumental aspects of supporting recovery (e.g., driving the veteran to the appointment). This observation presents an opportunity to engage a family member or partner into treatment through CM to play a supportive role. Partner support is also shown to enhance recovery and improve relationship functioning (Ariss & Fairbairn, 2020). Including supportive significant others in CM treatment could potentially bolster CM effects and recovery as it does in other SUD treatment interventions (Ariss & Fairbairn, 2020; Klostermann & O’Farrell, 2013; Powers et al., 2008), however further research is required.

Despite the promising processes developed through HTCM, there are several limitations that should be noted. While some adjustments preserved essential components of CM, it is unknown how the ritual of reaching into the fishbowl to draw their prize could affect outcomes. Other limitations include the nature of a case series and lack of cases with diverse gender, ethnic and demographic backgrounds. Despite these limitations, the efficiency of the HTCM may provide a valuable contribution to treatment programs trying to provide this service with limited resources.

Lessons learned in implementation

When deciding to implement this protocol, a major decision-point for the program was the need for efficiency. The clinic often stacked injection appointments to specific days and times of the week, and a decrease in nursing staff availability created an increase in wait times, so HTCM was implemented to decrease frequency and duration of in-person contact during the COVID-19 restrictions, and maintain CM treatment, trust in services, and proper customer service. For staff, training non-nurse CM providers who took ownership of the procedure from conception, preparation, and execution appeared to be widely accepted within the program. Moreover, pairing the same HTCM provider with a specific veteran each month was regarded as a means of building rapport. Another key implementation factor may have been repetitive communication about the purpose and process of HTCM to both staff and veterans in care. Priming psychiatrists, nursing staff and other healthcare staff to discuss HTCM with veterans in care when introducing OUD treatment may have increased the likelihood of participation. It is plausible that HTCM procedures could be utilized for other forms of CM (e.g., abstinence and attendance), but more evidence is needed to determine the feasibility of HTCM.