Implementing contingency management for hepatitis B vaccination among

people in treatment for heroin dependence: a Foucauldian discourse analysis

Transfer to PhD Middlesex University

Candidate: Anthea Martin Supervisors: Betsy Thom & Michael Traynor

Overview Background to the PhD

Statement of the research

Background to the research

Two ways of positioning contingency management:

As evidence-based

Within a Foucauldian framework

Foucauldian discourse analysis:

Methodology & method

Preliminary findings & future analysis

Original contribution to knowledge

Completing the thesis

Background to the PhD

Middlesex University studentship started in September 2009

‘Problem drug users’ as welfare claimants: a discourse analytic study

Unexpected change of focus in summer 2010

Data made available by National Addiction Centre, Institute of Psychiatry, King’s College London

New focus on use of contingency management to promote hepatitis B vaccination among people in treatment for heroin dependence

Statement of the researchMy thesis focuses on the use of contingency management (CM) to promote hepatitis B vaccination among people in treatment for heroin dependence. It is underpinned theoretically by ideas introduced by Michel Foucault. The thesis is in two inter-related parts. First, a ‘macro’ analysis of the rationalities of government within which the use of CM to promote hepatitis B vaccination among heroin users is embedded. Second, a ‘micro’ analysis of technologies of power and technologies of the self apparent in drug service consultations in which CM is used to promote hepatitis B vaccination among heroin users.

Background to the research

Illicit heroin use a leading health problem

Much of physical damage associated with injecting and sharing injecting equipment

Blood borne viruses from sharing equipment

IDUs largest group at risk of HBV infection in England and Wales (Hahne et al. 2004)

Hepatitis B (HBV) a preventable disease

DH recommends all IDUs vaccinated against HBV infection (DH 2007)

UK drug policy, drug treatment and harm reduction

Current UK drug strategy Reducing demand, restricting supply, building recovery: supporting people to live a drug free life (HM Government 2010)

Pharmacological treatments for illicit heroin use effective but potential individual and public health benefit not produced because of high levels of attrition

Physical health interventions for drug treatment populations fail to deliver full benefit due to poor completion of those interventions

UK drug policy and contingency management

Recommended that while pharmacological approaches are the primary treatment option for illicit opiate use psychosocial interventions should comprise ‘an important element of the overall treatment package’ (NICE 2007)

Recommended that drug services should introduce contingency management programmes to reduce illicit drug use and promote engagement with services for people receiving methadone maintenance treatment (DH 2007; NICE 2007)

Introducing contingency management

Use of incentives

Reinforcement theory

Reward plus positive verbal reinforcement

Adjunct to drug treatment and harm reduction interventions

US evidence for effectiveness of CM

Recommendations for use in the UK

Two approaches to positioning contingency management

Positioning contingency management: 1. as evidence-based

Mainstream approach

Evaluating the effectiveness of CM as an adjunct to drug treatment or harm reduction

Evidence-based policy

Systematic review

Randomised controlled trial: gold standard

Used methodology and methods of systematic review to demonstrate how CM interventions:

Are evaluated in contemporary drug policy research

Acquire the label ‘evidence-based’

Positioning contingency management: 2. within a Foucauldian framework

Alternative approach

‘Macro’ analysis of rationalities of government within which use of CM to promote heroin users’ engagement with hepatitis B vaccination is embedded

Key concepts: problematisations; rationalities of government

Problematising drug use: from addiction to harm

The problem of addiction

Prioritising public health: the question of harm

Rationalities of government: from welfarism to neo-liberalism

Neo-liberalism and harm reduction

Contingency management, ‘nudge’ and soft paternalism

Foucauldian discourse analysis (FDA) methodology

‘Micro’ analysis of discursive activity in consultations in which CM is used to promote heroin users’ engagement with hepatitis B vaccination

Discourse, power and knowledge

The subject and research

Technologies of power; technologies of the self

Health care consultation

FDA method: ConMan Programme

Developing a UK Evidence Base for Contingency Management in Addiction Treatment: Incentive-based interventions to improve treatments to reduce drug use and associated harms

Broad aim: To evaluate the feasibility, acceptability and clinical and cost-effectiveness of CM interventions in NHS drug treatment settings

FDA method: ConMan Module 2

Cluster randomised controlled trial of contingency management targeting increased completion of hepatitis B vaccination amongst people in treatment for heroin dependence

Aim: To measure the effectiveness of two voucher-based CM schedules in increasing the proportion of service users who initiate and complete a super-accelerated HBV vaccination schedule when compared against a control intervention (same schedule; no incentive)

FDA method: empirical data Audio recordings of consultations between drug

service users and nurses in which CM is used to promote the uptake of hepatitis B vaccinations

Approx. 192 service users

12 sites across 4 NHS foundation trusts; 3 trial arms / clusters (CM-fixed; CM-escalating; control)

1-4 blood borne virus / key worker nurses per site

0-3 consultations (vaccinations) per service user

(Potentially) dataset of nearly 600 consultations

Primary outcome data, demographic and service information

FDA preliminary analysis: research question

Broad research question:

How does power / knowledge function within the context of consultations in which CM is used to promote the uptake of hepatitis B vaccinations among people in treatment for heroin dependence?

FDA preliminary analysis: aims

More specific aims:

To identify the technologies of governmentality -technologies of power and technologies of the self - at work in these consultations

To describe (a) the components of these different technologies / how these different practices are achieved, and (b) the interplay between the different technologies of governmentality

FDA preliminary analysis: method

N=18 service users / cases

N total = 28 (18 service users + 10 nurses)

36 recordings

Sampled to capture the full range of interventions (3 trial arms), primary outcomes (1-3 consultations), gender differences

Recordings transcribed verbatim professionally where possible (within resource constraints); features of consultations summarised and extracts of special interest transcribed verbatim for remaining recordings

Coding and analysis

Focused listening / reading: framed and guided by theoretical and methodological underpinnings of the empirical analysis and the thesis more broadly

On second listening-reading: notes about interesting features of the interaction (first cycle coding)

Second cycle coding: more specific attention to the research aims; that is, to identifying and describing technologies of governmentality and their relationships to one another

Analysis proper: coding in NVivo 8

Preliminary findings: identifying technologies of governmentality

Technologies of power within consultations include:

Administering the HBV vaccination

Delivering the CM intervention

Supplying harm reduction advice

Making referrals

Key working

Performing administrative tasks

Making ‘small talk’ (facilitates information-gathering, promotes familiarity and trust)

Preliminary findings: describing technologies of governmentality

Features of technologies of power include:

Nurses’ use of positive reinforcement throughout the consultation (not just in relation to the vaccination)

Nurses’ positioning of service users as ‘harm reducers’ (capacity for self-government)

Nurses’ positioning of service users in relation to control of and responsibility for heroin use is ambivalent

Nurses production of a non-judgmental self

Future analysis

1. Develop the preliminary method for sampling, coding and analysing consultations to perform analysis proper with the full dataset

2. Perform a dispositif (apparatus) analysis:

Foucault’s work prescribes both a ‘macro’ and a ‘micro’ approach

Dispositif analysis describes the connections or relationships between elements at these two levels

Original contribution to knowledge generated by thesis

1. Soft paternalism and its operationalisation within current UK health and social policy as ‘nudge theory’ has to date received little academic attention in relation to the topic of illicit drug use. I plan to develop further my Foucauldian account of the evolution of the relationship between UK drug policies and ‘nudge theory’. This development will make a significant contribution to work focusing on substantive examples of the application of ‘nudge theory’.

Original contribution to knowledge generated by thesis

2. I plan to develop a mode of FDA grounded firmly in the concepts of: 1. technologies of governmentality (technologies of power and technologies of the self); and 2. the dispositif. This development will make a significant contribution in the area of poststructuralist methodologies.

Completing the thesis: progress to date

Completed:

Introduction and literature review

Methodology and method chapter

In progress:

Data coding and analysis

Outstanding:

Empirical chapters (3 expected)

Discussion and conclusions chapter

Completing the thesis: timetable

Coding and analysis:

Ongoing - July 2012 (inclusive)

3 empirical chapters:

June – September 2012

Discussion and conclusions:

September – December 2012

Consolidate and prepare thesis:

December 2012 – February 2013

Submit thesis

February 2013

References

Department of Health (England) and the devolved administrations (2007) Drug Misuse and Dependence: UK guidelines on clinical management. London: Department of Health (England), the Scottish Government, Welsh Assembly Government and Northern Ireland Executive.

Hahne, S., Ramsay, M., Balogun, K., Edmunds, W. & Mortimer, P. (2004) Incidence and routes of transmission of hepatitis B virus in England and Wales, 1995-2000: implications for immunisation policy. Journal of Clinical Virology, 29(4): 211-220.

HM Government (2010) Drug Strategy 2010. Reducing demand, restricting supply, building recovery: supporting people to live a drug-free life. London: The Stationery Office.

National Institute for Health and Clinical Excellence (NICE) (2007) Drug Misuse: Psychosocial interventions. NICE clinical guideline 51. London: NICE.