Contingency Management: Everything You Need to Know for Treatment

Contingency management (CM) is a type of cognitive-behavioral therapy based on the principle of operant conditioning. An extensive body of research supports CM’s efficacy in treating various behavioral disorders, 12 step programs for addiction recovery including AOD abuse (Higgins and Silverman 1999; Higgins et al. 1998). This article briefly reviews the conceptual background and empirical research demonstrating the efficacy of CM in AOD abuse treatment.

Refer a Patient

Those receiving CM were also significantly more likely to achieve ≥8 weeks (53% vs. 30%) and ≥10 weeks of continuous abstinence (50% vs. 19%). However, there was no significant between-condition difference in abstinence 9 months post treatment. There was an increase in cannabis use from discharge to the 9-month follow up, that, while not returning to intake levels, was of significant concern. a dmt trip ‘feels like dying’ and scientists now agree bbc three In the second study,21 youth receiving CM were more likely to achieve 4 weeks of continuous cannabis abstinence during treatment (48%) than were those not receiving CM (30%). In addition, among youth with at least one negative urine drug test during treatment, those who received CM had significantly more weeks of continuous abstinence from cannabis than those who did not receive CM.

Extensions to other health behaviors

For example, a specific reinforcer (e.g., pizza or movie theatre passes) that serves as an effective incentive for one youth may not be reinforcing for another. Use of a range of incentives or allowing youth to choose their incentive can increase the probability that the incentive will be effective and facilitate the desired target behavior. Gift cards or reloadable credit cards are often used as they serve as a flexible reward, allowing the youth to select personalized rewards that vary over time. Not only do patients stand to gain by the introduction of contingencymanagement but so do providers.

How Does Contingency Management Work in Reinforcing Drug Abstinence?

These policy changes represent a pivotal modification that may provide a path for nationwide dissemination and implementation of one of the most effective, yet underutilized, interventions for SUDs. First, the clinician arranges for regular testing to ensure that the patient’s use of the targeted substance is readily detected. Second, the clinician provides agreed-upon tangible reinforcers when abstinence is demonstrated.

1 Background and Efficacy

This can be described as how much of the reward should be provided to achieve the target behavior. Contingency management is clearly efficacious for promoting abstinence and, therefore, merits consideration for adoption. Implementation efforts should consider common concerns about CM, as well as important understudied aspects related to this intervention. In addition, implementation science should be consulted because adoption of even non-controversial evidence-based practices can be slow (e.g., Lash, Timko, Curran, McKay, & Burden 2011; Sorensen & Kosten, 2011). Contingency Management (CM) may be used to increase engagement with other types of interventions, such as psychosocial treatment or medications.

However, continued studies of implementation strategies are vital to the progress of CM as a clinical tool and could speed such efforts. Two studies (Hartzler, Beadnell, & Donovan, 2017; Kropp, Lewis, & Winhusen, 2017) in this issue provide additional perspective on real-world implementation efforts. Kropp et al. (2017) described the impact of an ultra-low cost CM program targeting patient attendance to clinician-led therapy sessions and patient-led precipitated withdrawal: definition symptoms traits causes Methadone Anonymous groups within a methadone clinic. The CM program was a clinical effort, without research support, and due to clinic budget constraints, the cost of the incentive program was limited to about $15 per week. Results suggested a significant positive impact on attendance to the patient-led Methadone Anonymous groups, that was sustained throughout the 12-month intervention phase and was still evident 1- and 3-months post-intervention.

Finally, better understanding of the mechanisms of action underlying CM’s efficacy may help us improve and tailor CM programs to further increase benefits. Continued research efforts in these directions is likely to further build the powerful evidence base supporting CM’s application to the treatment of SUD. Alternative versions or optimizations of CM have been used to adequately address population-specific or tailored interventions for individuals that may need different rates, magnitudes, or schedules of reinforcement to improve SUD-treatment outcomes significantly.

Similarly, CM improves outcomes compared to usual care among patients with issues like criminal justice system involvement, medical comorbidities, previous treatment attempts, unemployment, and homelessness (Petry, Rash, & Easton 2011; Rash, Alessi, & Petry 2008; Schumacher et al., 2007; Silverman, DeFulio, & Sigurdsson 2012; Walter & Petry 2015). We are aware of no studies demonstrating adverse outcomes of CM relative to standard care in any population. The Contingency Management (CM) approach, sometimes also referred to as “motivational incentives,” is based on the principle of operant conditioning – that behavior is shaped by its consequences. It is comprised of a broad group of behavioral interventions that provide or withhold rewards and negative consequences quickly in response to at least one measurable behavior (e.g., substance use as measured by a drug test, also called a toxicology screen). Such research demonstrates, for instance, that animals exhibit consumption patterns indicative of dependence and that researchers can modify animals’ AOD intake by using reinforcing and punishing consequences.

1. Different associations may also relate to whether reinforcers are provided for attempting a task, finishing it, or reaching some threshold of performance (Cameron et al., 2001).
2. Within the CM framework, AOD use is considered a form of operant behavior—that is, behavior that is maintained in part by the reinforcing biochemical effects of the abused substance and by reinforcing environmental influences (e.g., social reinforcement from peers).
3. CM is one of the most effective behavioral interventions for initiating and maintaining abstinence from most types of commonly used drugs and alcohol.
4. Several teams have developed extensive training materials that provide best-practice guidance on CM implementation, including didactic trainings, ongoing coaching, and technical support.
5. The third group will not receive either training or employment but will receive vouchers regardless of alcohol use.

Fitzsimons et al. (2015) and Lott and Jenicus (2009) provide an example of clinic-based implementation resulting in increased program revenues that offset the costs of the CM intervention. Fitzsimons and colleagues (2015) estimated an additional $24,000 in reimbursement possible for the CM group relative to the comparison condition, attributed to increased attendance among patients receiving CM. Notably, the CM intervention was in effect for only 1 week and low cost ($25 maximum per patient), yet effects on attendance persisted well after the end of the CM program. Another paper in this special issue by Brolin et al. (2017) describes a study conducted in Massachusetts that had a similar intent – in this case to improve outcomes for SUD patients with multiple prior detoxification admissions.

Not only can abstinence be reinforced using these CM techniques, but variations of these procedures are effective in modifying other behavior patterns of substance abusers. Reinforcement can be provided for attendance at therapy sessions (Carey and Carey, 1990), for prosocial behaviors within the clinic (Petry et al., 1998) or for compliance with goal-related activities (Bickel et al., 1997; Iguchi et al., 1997; Petry et al., 2000). In terms of this latter category, clients may decide upon three discrete activities each week that are related to their treatment goals.

Contingency management refers to a type of behavioural therapy in whichindividuals are ‘reinforced’, or rewarded, for evidence ofpositive behavioural change. These interventions have been widely tested andevaluated in the context of substance misuse treatment, and they most ofteninvolve provision of monetary-based reinforcers for submission ofdrug-negative urine specimens. In many CM interventions involving illicit drug abusers, clients submit urine specimens several times weekly to be screened for evidence of drug use. When the specimens are negative for drug use, clients receive reinforcers, such as take-home doses of methadone, increases in clinic privileges, money, and vouchers exchangeable for retail goods. In many of the CM studies that use vouchers as reinforcers, the value of the earned vouchers escalates as the patient demonstrates consecutively longer periods of abstinence. Submission of samples showing drug use results in no reinforcer and sometimes a punishment (i.e., the voucher amount decreased to a lower value or loss of take-home privileges).

It takes into account different variables, such as the target behavior, resources, the amount of clinical contact a provider has with their patients, and whether a behavior will be reinforced every time or only some of the time a behavior occurs. Such mechanisms include ways to identify and tap the beneficiaries of CM to contribute their share of the treatment costs, government subsidies, or some combination thereof. Screening and brief interventions for alcohol use have been reimbursed by commercial insurance, Medicare, and Medicaid for years (Neighbors, Barnett, Rohsenow, Colby, & Monti 2010; Bray et al., 2014; SAMHSA, 2016). These services are reimbursed by private and public payers, begging the question as to why they are not for CM. As with other substance abuse treatment approaches, CM therapy has advantages and disadvantages. Research during the 1960s, 1970s, and 1980s examined the role of CM in alcoholism treatment as a strategy for reinforcing abstinence as well as accomplishing other treatment goals, including medication compliance and treatment attendance.