Finding harmony so the music plays on: pragmatic trial design considerations to promote organizational sustainment of an empirically-supported behavior therapy
Let staff co-design, opt in, and lead a 90-day pilot if you want your reward program to last.
01Research in Context
What this study did
Hartzler et al. (2016) worked with one opioid-treatment clinic to keep a prize-based reward program alive. Staff and leaders co-wrote the plan, chose to join, and ran the program for 90 days. Two on-site champions tracked data and coached peers.
The team asked: can we train people and still use the reward system after outside researchers leave?
What they found
The clinic kept the reward system going after the trial ended. Staff liked the 90-day test run and felt they owned the plan. Local leaders kept data checks and coaching in place.
How this fits with other research
Woodman et al. (2025) and DeFulio et al. (2023) move the same reward idea onto phones. They kept the money for clean drug tests but let patients earn it through an app instead of clinic visits. These studies extend Hartzler’s work by removing the need for daily site trips.
Davidson et al. (2025) tried paying prescribers, not patients, to look at reward-program data. The extra money was liked but did not bring more patients into the program. This mixed result warns that staff-only cash may not be enough; Hartzler’s focus on staff choice and shared planning looks safer.
Matson et al. (2008) ran an earlier clinic trial with prize rewards. They saw small gains only when rewards targeted both opioids and cocaine. Hartzler did not test drug levels as the main goal; the new study shifts focus from patient abstinence to staff upkeep, filling a gap L et al. left open.
Why it matters
You can copy this low-cost road map in any clinic. Invite staff to help write the plan, let them opt in, pick two champions, and run a short pilot with data checks. The program survived without outside cash, showing that ownership beats top-down orders. Use this when you need an evidence-based practice to stick after the grant ends.
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02At a glance
03Original abstract
Pragmatic trials of empirically-supported behavior therapies may inform clinical and policy decisions concerning therapy sustainment. This retrospective trial design paper describes and discusses pragmatic features of a hybrid type III implementation/effectiveness trial of a contingency management (CM) intervention at an opioid treatment program. Prior reporting (Hartzler et al., J Subst Abuse Treat 46:429–438, 2014; Hartzler, Subst Abuse Treat Prev Policy 10:30, 2015) notes success in recruiting program staff for voluntary participation, durable impacts of CM training on staff-level outcomes, provisional setting implementation of the intervention, documentation of clinical effectiveness, and post-trial sustainment of CM. Six pragmatic design features, and both scientific and practical bases for their inclusion in the trial, are presented: (1) a collaborative intervention design process, (2) voluntary recruitment of program staff for therapy training and implementation, (3) serial training outcome assessments, with quasi-experimental staff randomization to either single or multiple baseline assessment conditions, (4) designation of a 90-day period immediately after training in which the setting implemented the intervention on a provisional basis, (5) inclusive patient eligibility for receipt of the CM intervention, and (6) designation of two staff as local implementation leaders to oversee clinical/administrative issues in provisional implementation. Each pragmatic trial design feature is argued to have contributed to sustainment of CM. Contributions implicate the building of setting proprietorship for the CM intervention, culling of internal staff expertise in its delivery, iterative use of assessment methods that limited setting burden, documentation of setting-specific clinical effectiveness, expanded penetration of CM among staff during provisional implementation, and promotion of setting self-reliance in the oversight of sustainable implementation procedures. It is hoped this discussion offers ideas for how to impact local clinical and policy decisions via effective behavior therapy dissemination.
Addiction Science & Clinical Practice, 2016 · doi:10.1186/s13722-016-0049-6