Contingency Management to increase naloxone carriage: development and testing of a new behavioural intervention (‘Contingency Management for Carry-on-you Naloxone’; CM4COYN)

Research question To develop and test a new intervention providing incentives by mobile telephone (mobile contingency management) to encourage individuals using heroin to carry on them the antidote to heroin overdose Background Opioid overdose deaths, approach 150,000 globally per annum, doubling over the last decade and still rising sharply. Across England and Wales, there were 4,859 substance use deaths in 2021, continuing the marked upward trend of recent years. Half of these deaths involve opiates. Reducing opioid-related deaths is a major clinical and public health policy challenge. Naloxone (injection or nasal spray) reverses life-threatening respiratory depression. Most heroin overdoses occur in the presence of others. Take-Home Naloxone (THN) schemes prevent deaths by providing naloxone and training to individuals at risk and their families, so that they can administer naloxone in these emergency situations whilst awaiting arrival of emergency medical care. Most local authorities in England now commission THN schemes. However, recent evidence finds consistently low naloxone carriage rates: at 10-20% in UK. Improved naloxone carriage is vital. Mobile Contingency Management (mCM) can encourage behaviour change among individuals with substance use disorders. However, no CM intervention has been developed for naloxone carriage. We will collaborate with US-based CM-expert application-developer (Q2i) to adapt CM behavioural methods to incentivise naloxone carriage. CM is acceptable among service users/commissioners. Aims and Objectives Working with Q2i, and stakeholders (individuals in treatment/harm reduction and service providers/commissioners), we will a) develop a mCM intervention to increase carriage of THN among individuals with substance use disorder, b) test the acceptability, usability, and reliability of the mCM intervention. Methods Stage 1:improve understanding of the target behaviour of THN carriage & guiding foundations for intervention. Working with the PPIE group, we will undertake a literature review and conduct focus groups with stakeholders in London, Derby and nationally (service users and commissioners). Following the COM-B model, focus groups will identify the components relevant to naloxone carriage to guide design of our intervention. Findings will inform a logic model including a contextualized theory of behaviour change showing how mCM operates adjunctively with THN. Stage 2: adapt and develop Q2i's existing OARS+CM application, to a new target behaviour (naloxone carriage), and a new population (SUD patients pre-supplied with THN). Operational aspects such as reinforcement schedule, incentives value and delivery methods will be refined. The intervention will be tested by the research team in collaboration with Q2i . A PPIE workshop will review and refine the mCM intervention. Stage 3: testing adherence, acceptability and usability of the mCM intervention through an iterative process. Participant sample (n=30) recruited from naloxone services in London and Derby (two iterations anticipated), including participants likely to witness high numbers of opioid overdoses, those receiving injectable and nasal forms of naloxone and those who are 'digitally-excluded', 'digitally-cautious' and 'digitally-experienced . We will collect data on compliance, acceptability and usability over a 3-month study period. Anticipated Impact and Dissemination This project will develop a digital mCM Intervention designed specifically to increase naloxone carriage, to a stage ready for feasibility and effectiveness testing.