Title: Telephone delivered Incentives for Encouraging adherence to Supervised methadone consumption: development and feasibility study for a RCT of clinical and cost effectiveness (TIES)
Funder: Department of Health and Social Care

Abstract: Background to the research: The majority of people in treatment for their addiction to heroin are prescribed methadone for which there is an extensive evidence base. When treatment starts, people take their daily dose of methadone at a community pharmacist under supervision. Supervision guarantees methadone is taken as directed by the individual for whom it has been prescribed; and helps to ensure individuals take their correct dose every day to ensure they experience little or no withdrawal or craving. Moreover, supervision safeguards against diversion and overdose. Supervision may be relaxed after a few months if abstinence is demonstrated. There is a network of community pharmacists in England who dispense methadone and supervise its consumption. However, individuals often fail to attend the pharmacy to take their methadone. Each missed dose is of concern. If a patient has missed their daily pick-up of methadone they will start to experience opiate withdrawal and cravings and are more likely to use heroin. If they miss their dose for three days, they may have lost their tolerance to the drug and may be at risk of overdose when the next dose is taken. The success of any pharmacotherapy depends heavily on medication adherence. Non adherence with medication is associated with non-attendance at medical and psychosocial appointments. There is an urgent need to develop effective interventions for medication adherence. Research suggests that incentive-based medication adherence interventions may be very effective, but there are few controlled trials and the provision of incentives requires time and organisational systems which can be challenging in pharmacies. The authors have developed the technology to deliver incentives by telephone. We propose to develop and test the feasibility of using telephone delivered incentives (praise and modest financial rewards via text messaging) to encourage adherence to supervised consumption of methadone at community pharmacies. Each time a patient attends their pharmacy for supervised consumption of their medication they will earn a financial reward. Aims of the work: To develop and test the feasibility of conducting a future trial evaluating the clinical and cost effectiveness of using telephone delivered incentives to encourage adherence with supervised consumption of methadone in community pharmacies. Plan of Investigation: The research will be undertaken in 3 phases. Phase 1: National postal survey of community pharmacists to determine the nature and extent of current practice of dispensing and supervising methadone; Phase 2: development of a telephone delivered incentive scheme that fits with routine dispensing practice; and Phase 3: testing the feasibility of conducting a future trial to evaluate the clinical and cost effectiveness of telephone delivered incentives (praise and modest financial rewards via text) to encourage adherence to medication. Three drug services (each with two community pharmacies supervising methadone consumption to 20 individuals) will be recruited and allocated to i. telephone delivered incentives, ii. Telephone delivered reminders or iii. no telephone system. Acceptability, recruitment, follow-up, and suitable measures of clinical and cost effectiveness will be assessed. Potential benefits to patients and the NHS: A new innovative scheme using telephone delivered incentives to encourage medication adherence will be developed which can be used by the NHS for addiction treatment but also has wider application. This study will inform the feasibility of and design for a future trial to evaluate telephone delivered incentives to encourage adherence to supervised methadone consumption. If found to be effective, telephone delivered incentives would encourage individuals to adhere to their methadone treatment which in turn would increase their chances of completing their opiate substitution treatment and achieving abstinence from street heroin and reduce the changes of diversion and overdose.

Lay abstract: Research Aim: Assess the feasibility of a trial to test whether attendance with supervised methadone consumption in pharmacies can be improved by using incentives delivered by mobile phone. Background: Most people treated for heroin addiction are prescribed methadone which enables them to stop heroin use safely avoiding withdrawal. People starting methadone take a daily dose under a pharmacist s supervision. Supervision prevents overdose. If a patient misses their daily methadone they will experience opiate withdrawal and cravings which make them more likely to use heroin. If they miss methadone for three days, people lose their tolerance to the drug and risk overdose. Unfortunately many patients do miss their doses. Research shows that small financial incentives can improve medication adherence. We have developed the technology to deliver such incentives using mobile phones but need to test the feasibility of this approach before conducting a full trial. Methods: We will survey pharmacists to find out about current methadone dispensing practice and develop the telephone incentive scheme to fit routine practice. We will then look at the feasibility of conducting a trial to evaluate whether the intervention increases attendance at pharmacies. Three drug services (each with pharmacies supervising 20 patients) will be recruited and randomly offered one of three approaches - which we plan to compare in the future trial. Some patients will receive telephone delivered incentives (via text), others an appointment reminder (text), while others receive no texts. We will assess the acceptability of these approaches, how recruitment works and whether we can track patients to measure their outcomes. Patient & public involvement: An existing service user advisory group will meet three times to advise on delivery of telephone delivered incentive scheme, patient information and dissemination. Dissemination: Results will be published in scientific papers and made available to participants, pharmacists and drug services.

Research activity codes: 7.1 INDIVIDUAL CARE NEEDS
Health categories: MENTAL HEALTH