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. 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 demonstration waiver for the state’s CM pilot, planned to cost more than $50 million, that will include as many as 200 sites.

Examples of Contingency Management Therapy

One schedule that has demonstrated efficacy across multiple substance abuse treatment studies is a fixed schedule with escalating rewards and a reset contingency (typically referred to as abstinence-based vouchers or incentives3). This schedule provides monetary rewards for each negative sample that can be “held” in a clinic account or loaded onto a reloadable credit card, with a small (usually financial) reward for the first negative sample, and rewards increase in value with each subsequent negative sample. Positive samples reset the reward value to the starting point, but a period of abstinence can reset the value back to the prior maximum. In addition, rewards can be provided according to an intermittent schedule using the fishbowl method,4 in which negative samples earn the opportunity to complete “draws” that have a possibility of winning a reward, with rewards of varying values available. Contingency management refers to a type of behavioural therapy in whichindividuals are ‘reinforced’, or rewarded, for evidence ofpositive behavioural change.

Research on CM with Youth

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). Budney, Bickel, and Hughes (1991) have developed a protocol called voucher-based reinforcement therapy (VBRT), in which clients earn vouchers for biological meth addiction: symptoms getting help detox treatment and more samples (urine or breath) that are tested negative for drugs. The vouchers typically represent a monetary amount but do not provide actual money, thereby enabling the client to acquire goods or facilitate activities conducive to a drug-free lifestyle with the long-term goal of continuous abstinence (Budney et al., 1991; Petry & Simcic, 2002). A review of the VBRT literature suggests that not only is VBRT efficacious in the treatment of SUDs, but that VBRT may also yield improvements across other therapeutic behaviors (e.g., clinic attendance, medication compliance; Lussier, Heil, Mongeon, Badger, & Higgins, 2006).

Refer a Patient

1. Petry NM, Martin B (in press), Lower cost contingency management for treatment cocaine and opioid abusing methadone patients.
2. Effective monitoring of the targeted behavior is essential to a CM program, because consequences (reinforcement or punishment) must be applied systematically in order to be effective.
3. However, there is a ‘substantial proportion’ of addicts who do not respond to contingency management as a form of therapy (Carroll and Onken, 2005).
4. Despite its established efficacy, contingency management is the empirically validated treatment with which clinicians are least familiar.

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. When the behavior they’re working to change is attendance, their choice to be there on time proves the incentive is working. As with other substance abuse treatment approaches, CM therapy has advantages and disadvantages.

Indeed, the neural mechanisms underlying relapse following contingency management remain largely unknown, with no preclinical model recapitulating aspects of contingency management until the last decade (Ahmed et al., 2013; Venniro et al., 2016). According to a National Library of Medicine study, some experts describe tangible reinforcement as “bribery” that doesn’t encourage the client to stay sober after they leave treatment. Some also believe rehab centers shouldn’t reward residents for doing what they signed up to do.

Many of these optimization strategies have not been examined in depth through additional Phase II or Phase III clinical trials across substances or different populations; however, such studies could help enormously to personalize treatment for SUDs better. Not only can abstinence be reinforced using these CM techniques, but variations of these procedures drug-induced tremor 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).

Researchers began studying Contingency Management (CM) as an intervention for alcohol use disorder in the 1960s. Also during this time, other more involved treatment approaches capitalized on these operant conditioning principles present in CM, while also incorporating ways to enhance coping skills and sober social activities, such as the Community Reinforcement Approach (CRA). After a comprehensive functional analysis of environmental contingencies, the therapist plans a program of intervention to modify contingencies to change the rate of the target behavior. Contingency management involves a thorough functional analysis of controlling contingencies, the rearranging of the functional analysis of controlling contingencies, the rearranging of the functional environment, and a careful monitoring of outcome. Third, formal mechanisms are needed by which clinics are adequately reimbursed to provide CM.

Our core objective is to review, describe, and discuss three critical advancements of CM currently happening (ie, adapting CM for underserved populations, CM with experimental technologies, and optimizing CM for personalized interventions). We close by speculating on possible future directions and methods of maximizing the impact of CM, an area we view as largely underdeveloped. Petry NM, Martin B (in press), Lower cost contingency management for treatment cocaine and opioid abusing methadone patients. We asked clinicians at the Hazelden Betty Ford Foundation to explain this approach and its relationship to substance abuse disorders and treatment. Contingency management (CM) is the application of the three-term contingency (or operant conditioning), which uses stimulus control and consequences to change behavior. CM originally derived from the science of applied behavior analysis (ABA), but it is sometimes implemented from a cognitive-behavior therapy (CBT) framework as well (such as in dialectical behavior therapy, or DBT).

With this procedure, a target behavior is identified, like abstinence, and defined objectively (e.g. drug-negative urinalysis). It is monitored often to maximize chances for reinforcement and minimize failing to detect competing behaviors (e.g. drug use). When the target behavior occurs, tangible incentives or rewards (e.g. voucher) are provided, and incentives are not provided when the target behavior does not occur. 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. A vast amount of empirical evidence indicates the efficacy of contingency management for treating substance use disorders.

Historically, funding for CM programs has relied on grants, donations, and funding from federal sources. Currently, the Substance Use and Mental Health Services Administration (SAMHSA) allows grantees to spend up to $75 per patient for CM incentives, although there is limited evidence for the efficacy of this amount. An equally important question is the extent to which preclinical choice models can be used alcoholism: definition symptoms traits causes treatment to develop behavioral innovations that improve contingency management efficacy. It differs from the procedures described above because it obtains voluntary abstinence without requiring mutually exclusive choice. The difference in reward magnitude is sufficient to incentivize choice of R2 over R1, effectively suppressing R1 in both rats (Bouton et al., 2017) and humans (Thrailkill and Alcala, 2021).

We identified five studies of contingency management (Table 8), four with experimental designs and one quasi-experimental. Although contingency management studies typically involve a short-term intervention with a narrow focus on reducing substance use, these interventions were provided for 4–6 months, and the studies examined additional outcomes. The exception (Helmus, Saules, Schoener, & Roll, 2003) was a study in which group attendance rather than abstinence was reinforced, and this study did show increased group attendance. Thus, contingency management appears to be a highly promising intervention for addressing substance use disorder in this population.

Convincing policy makers of why this should be more broadly integrated into drug- and alcohol-use-disorder treatment has proven difficult. One area in which contingency management has widespread potential benefitsis individual retention in treatment. 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.

Many see contingency management as an additional safety net to help this vulnerable population keep on track with recovery. In sum, contingency management interventions have substantive evidence of efficacy in positively modifying a variety of patient behaviours, and adaptations of these techniques to a variety of problem behaviours may further increase their relevance and widespread use. Eventually, greater understanding and awareness of contingency management may assist in bringing this empirically based intervention into a variety of psychiatric settings and specialty areas. 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).