Author: John Carter

Contingency Management Is a Powerful Clinical Tool for Treating Substance Use Research Evidence and New Practice Guidelines for Use

contingency management interventions

In weeks 19–24, the magnitude of the reinforcement was decreased, such that each client earned just one draw from the prize bowl for attendance on Thursdays only. One person’s name was drawn from that second urn at the end of the session, and that individual received 10 draws from the prize bowl described earlier. In this way, the number of total draws per week (by all clients) was decreased from an average of 50 in weeks 7–18 to an average of 21 in weeks 19–24.

The use of contingent disbursement of disability payments is a novel, no-cost reinforcement approach (25–27). Reinforcement is provided in traditional substance abuse treatment programs as well. Examples include social recognition and sponsor status in 12-step treatments and take-home privileges, early dosing windows, or dose adjustments in methadone programs. Future research may assess whether utilization of behavioral principles when administering these and other reinforcers improves efficacy in altering problematic behaviors.

  1. Contingency Management (CM) may be used to increase engagement with other types of interventions, such as psychosocial treatment or medications.
  2. Examples include social recognition and sponsor status in 12-step treatments and take-home privileges, early dosing windows, or dose adjustments in methadone programs.
  3. Historically, funding for CM programs has relied on grants, donations, and funding from federal sources.

A retrospective analysis of predictors of long-term abstinence in cocaine-dependent patients receiving both contingency management and noncontingency management treatments finds that duration of continuous abstinence is the best indicator of long-term outcome (18). Some clients are able to achieve long periods of abstinence through 12-step and standard treatment approaches. These patients may not benefit substantially from the addition of contingency management. A significant proportion of substance abusers, however, never come in for treatment, and among those who do enter treatment, attrition rates are very high (19–21). A primary benefit of positive-incentive contingency management approaches is that they increase the percent of patients who respond favorably to treatment. These cases are illustrations of individuals who did not engage in or significantly benefit from standard therapy.

She reported two incarcerations, one related to prostitution and the other for burglary. Ms. A was a 45-year-old Caucasian woman diagnosed with heroin and cocaine dependence, bipolar disorder, antisocial personality disorder, and cocaine-induced psychotic episodes. She had contracted HIV 5 years ago and was awarded a psychiatric disability at that time. Contingency Management (CM) may be used to increase engagement with other types of interventions, such as psychosocial treatment or medications. It really doesn’t matter if the prize is just a fun-size candy bar—clients are excited to have the chance to be recognized while having a little bit of fun. Mr. B worked as a carpenter but lost several jobs because of his “attitude.” In the past 5 years, he had not been able to hold down a part-time job for more than a month or two at a time.

The structure and content of the incentive and nonincentive groups were identical, with the exception that in the incentive groups, clients earned draws from a prize bowl for the number of consecutive weeks that they attended group. If objective verification (e.g., receipts) of completion of an activity was brought to group (see reference 15 for description of activities and verifications), clients earned one additional drawing. If they successfully completed and verified both of their activities in a given week, they earned bonus draws that escalated with the number of weeks that they completed both activities.

Nevertheless, the subject’s drug-related problems remain considerably lower than in pre-contingency-management periods. 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.

Advantages to healthcare providers

Lott &Jencius14 foundthat reimbursement rates substantially increased when contingency managementwas introduced to adolescents who misused substances. For 4 months from the initiation of the contingency management plan, Mr. C gave drug-free urine samples, made scheduled visits to his therapist, complied with medications, and remained housed at the motel. With time, his overall grooming and hygiene improved, followed by a marked improvement in mood and cognition. Mr. C demonstrated several instances of good judgment as he resisted temptations to use drugs.

contingency management interventions

While motivational incentives can help individuals achieve their treatment goals, this method should be used in conjunction with another approach, such as cognitive behavioral therapy (CBT). CBT can help a person address their thoughts and feelings, eventually phasing out unhealthy thought patterns. Finally, clinic administrators, policy makers, and payers express concern about the economics (i.e., cost, benefit, and reimbursement) of CM.

Contingency Management Interventions: From Research to Practice

On a Quality of Life Inventory (12), Ms. A’s scores increased from –2.2 at intake to the contingency management study to –0.83 and –0.45 during treatment; they rose to 1.46 posttreatment. At the time of this report, she had missed only 1 day of methadone treatment in over 6 months and was being considered for take-home privileges. She reported using three bags of heroin and half of a dime bag of cocaine, and her urine sample was positive for both drugs. Although she admitted to no further drug use, she remained opioid positive for over a week. During this week, she submitted cocaine-free specimens and therefore earned one draw each time. She was remorseful about the relapse and was encouraged to regain abstinence from both opioids and cocaine to reestablish her bonus draws.

California received a Medicaid demonstration waiver for the state’s CM pilot, planned to cost more than $50 million, that will include as many as 200 sites. Importantly, these implementations of CM include models that are based on research evidence with funding for reinforcers varying from $325 to $599. 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. Although more than 30 years of research evidence collected throughout the world supports the effectiveness of CM, widescale implementation of CM in clinical care has been limited, particularly due to funding and regulatory issues.

contingency management interventions

Several empirical questions linger, however, about how long CM needs to be delivered before the abstinence-related benefits it offers will carry on without the rewards (or negative consequences) in place. Also, despite its place as one of the most effective approaches to address substance use disorder, few programs implement standalone CM given its mismatch with the fee-for-service model used in many managed health care settings (e.g., they can’t obtain the funds to implement it). Empirical evidence is mixed about whether external rewards impact intrinsic motivation. In non-clinical contexts, providing external rewards to complete tasks such as puzzles or games may undermine intrinsic motivation and subsequent participation in them (Deci et al., 1999).

Addiction and Mental Health Resources

Although urine sample testing was not conducted at this clinic, Mr. B did not once appear at the clinic intoxicated since attending groups. He admitted to regular use of alcohol and marijuana but reported no cocaine use in the past 4 months. The first 6 weeks served as a baseline period, during which attendance at groups and compliance with activities were recorded, but no reinforcers were provided. In weeks 7–18, the reinforcers were instituted, first in Tuesday groups (weeks 7–12) and then in Thursday groups (weeks 13–18).

Careers – Join Our Team

Researchers and public research funds have invested decades into designing and evaluating CM interventions, and CM clearly is beneficial for improving substance use treatment outcomes when it is administered appropriately. It is now up to policy makers to ensure that substance use treatment patients receive this efficacious intervention and that the intervention is delivered in a manner similar to which it is known to be efficacious. In no other medical field would a clinic, hospital, or provider be expected to cover costs of additional testing and treatment without reimbursement. Extensive adoption and implementation of CM by substance abuse treatment clinics will require that reimbursement procedures and policies are consistent with other medical and psychiatric specialties. It may also necessitate development of methods to ensure that, when CM is administered, it is done according to methods known to be efficacious, including appropriate magnitudes and frequencies of reinforcement.

Although CM can be integrated alongside virtually any other therapy and almost always demonstrates benefits compared to standard care or other platform therapies, it does not always yield synergistic effects with other treatments (Carroll et al., 2012; Godley et al., 2014). Despite its established efficacy, contingency management is the empiricallyvalidated treatment with which clinicians are least familiar. As more and more clinicians and researchers apply contingency management procedures to treat substance abusing patients, new developments and refinement in the techniques may emerge.

Patient Care Network

Despite the positive impact of CM and its generalization to a wide range of populations and settings, clinicians and the public sometimes hold negative views of this treatment and express concerns that it does not lead to long-term benefits. This paper initially summarizes the empirical evidence for CM and then describes the primary concerns about this treatment. This contingency management plan had long-term efficacy for encouraging therapy attendance, enhancing compliance with antipsychotics, and reducing crisis-related psychiatric emergency room visits.