Contingency Management: Effectiveness, Tips, and Risks

In addition to funding, the prohibition against the use of reinforcers with Medicaid and Medicare patients through antikickback regulations, has produced a regulatory roadblock. Until recently, it was unclear if CM violated these prohibitions; however, in 2019, the Office of the Inspector General published a document providing guidance on how CM can be used within specific parameters. This has led to increased interest in CM, with state-level implementation underway in Montana, Washington, and California. California received a Medicaid addiction recovery art demonstration waiver for the state’s CM pilot, planned to cost more than $50 million, that will include as many as 200 sites.

It has been noted (Carroll and Onken, 2005) that contingency management is limited by a number of factors, including the weakening of its effects following the end of the treatment. Coupled to the high costs of providing the incentives that underlie this treatment, a long-term maintenance on contingency maintenance therapy would be difficult. This type of therapy is also unpopular with the general public, as reflected by the responses to the introduction of contingency management as a therapy for drug addiction in the UK National Health Service (McCrae, 2007). Finally, clinic administrators, policy makers, and payers express concern about the economics (i.e., cost, benefit, and reimbursement) of CM. Providing tangible reinforcers increases costs of treatment, especially because CM is typically an add-on to usual care.

Are there Certain Skills Required When Delivering this Approach?

1. This paper initially summarizes the empirical evidence for CM and then describes the primary concerns about this treatment.
2. Despite promising results, this literature remains relatively small, in part because of technological limitations on detecting smoking via breath or urine tests in the context of contingency management (see Contingency Management for a more detailed discussion).
3. In clinics that adopt CM, training and supervision are paramount to ensure core aspects of CM are retained.

A large body of research demonstrates that substance use can be modified by changing environmental consequences of use like the availability of alternative (nondrug) reinforcers, thus supporting the use of contingency management to treat substance abuse. Contingency management is a widely used behavioral therapy for treating substance use disorders and is regarded as effective in clinical application (Ainscough et al., 2017; Petry, 2011). Contingency management involves operant conditioning through the systematic delivery of alternative reinforcers that are contingent upon the performance of a target response/behavioral change (Higgins et al., 1994; Higgins and Silverman, 1999; Petry et al., 2018). The alternative reward is intended to act as a positive reinforcer that directly competes with the reinforcing effects of a drug, thus increasing the likelihood of abstinence being initiated and maintained (Bigelow et al., 1981).

The persistence of maladaptive memory: Addiction, drug memories and anti-relapse treatments

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. According to the National Institutes of Health, “In a number of studies, individuals who earlier received contingency management continue to benefit even after tangible reinforcement is no longer available. The longest duration of abstinence achieved during treatment is a robust and consistent predictor of long-term abstinence.” Any behavior changes made by patients that can improve their chances of successful recovery outcomes are not “artificial.” Even if individuals are showing up only for the chance to win, they are still choosing to be there.

This refers to the specific person or people in a treatment program who will receive the specific reinforcement. Not everyone in a treatment program will be working on the same goals at the same time. 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.

Psychiatric treatments suffer from highrates of attrition, which in turn relates to increased morbidity andmortality. Substance misuse treatment clinics typically experience attritionrates of 80% or higher, and attrition is high in most other out-patient mentalhealth treatment as well. By providing reinforcement contingent on attendance,attendance rates across a range of treatment settings can be substantiallyimproved,1-3thereby increasing exposure to effective care. An equally important question is the extent to which preclinical choice models can be used to develop behavioral innovations that improve contingency management efficacy. To this end, the incentivized choice model developed by Bouton and Thraikill holds promise.

Journal of Substance Abuse Treatment

Contingency management was included as a recommended treatment in guidelines published by the National Institute for Health and Clinical Excellence in the United Kingdom. Investigations of contingency management dissemination are currently underway, including studies designed to better understand systemic and clinical variables that impede and facilitate contingency management implementation. Novel approaches have been developed to assist in funding contingency management liberty bells mushrooms interventions, such as providing greater control of disability benefits and providing opportunities for employment contingent on drug abstinence.

It is important to recognize that these contingencies may overlap and compete within the individual. There is less research in the context of CM for treating alcohol use disorders, primarily because of limited ability to quantify alcohol use objectively (Higgins & Petry, 1999). Nevertheless, recent technology to assess alcohol use over longer durations of time and in the natural environment is expanding the application of CM to this population as well (Alessi & Petry, 2013; Barnett, Tidey, Murphy, Swift, & Colby 2011; Dougherty et al., 2015a,b; McDonell et al., 2012). Despite the efficacy of CM in enhancing drug abstinence and improving other psychosocial problems, some logistical concerns have hindered its dissemination, the primary of which is cost. The voucher amounts escalate as the number of consecutive negative urine samples increases, such that the first negative sample earns $2.50, the second $3.75, the third $5 and so on. Typically, successful voucher programs (Higgins et al., 2000; 1994; 1993; Silverman et al., 1996) have allowed for earnings exceeding $1,000 during a 12-week treatment period, and average earnings are about $600 per patient.

Clinical Course

In these models, the drug remains readily available in the environment but is forgone in favor of non-addictive alternative rewards (Caprioli et al., 2015; Carroll et al., 1989; Carroll and Lac, 1993; Epstein and Preston, 2003; Lenoir et al., 2007; Lenoir et al., 2013; Marlatt, 1996). Recently, Caprioli and colleagues published a nuanced rodent model of craving and relapse following a contingency management-like intervention, based on the principle of choice-based suppression of drug intake (Caprioli et al., 2015; Venniro et al., 2020). In this model, rats were trained to difference between na and aa self-administer palatable food pellets, then subsequently trained to self-administer a drug via a different lever (Caprioli et al., 2015; Lenoir et al., 2013).