Contingency Management for Substance Abuse & Addiction

What is Contingency Management Therapy?

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Contingency management (CM) refers to a specific form of cognitive-behavioral therapy. CM principles are mainly based on giving patients tangible rewards to reinforce positive behaviors, such as sobriety or drug abstinence. 

Several studies have shown that incentive-based interventions, such as CM, are highly effective treatments that reduce drug abuse through behavior modification.

Behaviors targeted by CM typically include:

  • Abstinence
  • Treatment Engagement
  • Lifestyle Improvements

Contingency Management Intervention: How The Program Works

Contingency management is the application of the three-term contingency (operant conditioning). There are two primary components of CM intervention therapy, including voucher-based reinforcement and prize incentives.

1. Voucher-Based Reinforcement (VBR)

This strategy provides positive reinforcement to adults who stop drug use. These drugs include alcohol, opioids, stimulants, methamphetamine, or cocaine, among others.

With VBR, patients receive vouchers, with varying monetary value, for every drug-free urine sample that they provide. These vouchers can be exchanged for goods or services in line with a drug-free lifestyle, such as grocery items, gift certificates, or show passes. 

The value of these vouchers is initially low but increases with consecutive drug-free urine samples that each patient provides. Positive samples result in resetting the value of the vouchers back to their original low values.

Studies have shown that VBR is a useful behavior therapy in helping patients abstain from opioids and stimulants during detoxification.

2. Prize Incentives CM (PICM)

Prize Incentive Contingency Management therapy also uses a rewards-based system, but there are more possibilities for types of prizes. 

Unlike with VBR, PICM utilizes cash prizes instead of vouchers to reward patients for abstinence. 

Over the course of a three-month PICM program, participants that provide weekly drug-negative urine or breath tests or complete goal-related activities draw for the chance to win small cash prizes. 

The number of draws per session increases with consecutive negative drug tests or goals achieved. However, the session resets if any positive drug test or failed goal occurs.

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The Seven Principles of CM Programs

There are seven principles that all CM programs follow:

1. Target behavior — this seeks out negative behavior to be reduced or a positive behavior to be increased. Negative behaviors are associated with substance use (such as buying or using). The positive behaviors are associated with measurable improvements (such as compliance with sessions and establishing better relationships).

2. Choice of the target population — some patients will not want to participate because they have enough motivation to progress in treatment. New patients or those with prior poor success rates are more ideally suited for this treatment program.

3. Choice of reinforcer — this is a central aspect of CM therapy. If a reward is offered to a person with no interest in that type of reward, the goal will not be reached. Since people are different, money can be a good motivator, but it can also trigger cravings and lead to relapses.

4. Incentive magnitude — with unlimited resources, CM programs could offer rewards of unlimited value. However, programs must work to find rewards that fit their budget while offering enough incentive; some people need the possibility of larger rewards to remain engaged.

5. Frequency of incentive distribution — some programs reinforce the desired behavior change each time it occurs; others use a specified or variable rate

6. Timing of incentive — timing is as important as the frequency. When rewards are given immediately after the desired behavior is completed, it builds a strong association between the wanted behavior and the reward.

7. Duration of intervention — since the treatment goal is long-term sobriety, CM therapy will take longer for some people than others. Ending treatment needs to be paired with relapse prevention strategies to reduce the risk of relapsing.

Examples of Contingency Management

Contingency management is based on a simple behavioral principle: if a behavior is rewarded, it is more likely to happen again in the future.

This principle is commonly used in every day life by parents, employers, teachers, and others. For example, parents will give their children an allowance for doing their chores. Employers use promotions and bonuses as motivation.

Examples of Contingency Management in Substance Use Treatment

There are many ways CM can be used to reinforce positive behavior during addiction treatment.

  • Every urine sample that is negative for drugs is rewarded with a voucher or cash prize
  • If patients complete three goal-related activities (attend a medical appointment, fill out a job application, attend group therapy etc.) they receive a reward
  • If a patient exhibits prosocial behavior (voluntary actions that are intended to help another person or group) they receive a reward
  • If a patient is undergoing medication-assisted treatment, taking their medicine every day for a week can earn them a reward
  • Certain programs will reward continued drug abstinence with vocational training or housing

Advantages vs. Disadvantages of Contingency Management

As with other substance abuse treatment approaches, there are both advantages and disadvantages to CM therapy:

Advantages of Contingency Management Treatment
  • The rewards-based system offers incentives to stay on track
  • Incremental reward increase further incentivizes compliance
  • Good success rate
  • Can be used in combination with other treatment options
Disadvantages of Contingency Management Treatment
  • Resources are not always available to give adequate rewards
  • When reinforcement stops, there is a high chance of relapse
  • Some are concerned that PICM could promote gambling—as it contains an element of chance when receiving money—which could lead to relapse

Contingency Management in Addiction Treatment 

There are several different types of addictions treated with CM, though the most common are opioid and stimulant addictions. All types of addictions treated with CM therapy fall under two broad categories: substance use disorders (SUD) and alcohol use disorders (AUD)

Treating Substance Use Disorders (SUD)

CM treatment has been shown to be consistently effective for many types of substance use disorders, in large part because it is based firmly on sound principles of behavioral treatment. It also is effective in treating people with co-occurring disorders, which is when someone is diagnosed with a SUD and mental health disorder simultaneously.

The efficacy of CM therapy incentives, such as vouchers and cash payments, has been proven successful. They are particularly helpful in helping individuals with cocaine dependence achieve cocaine abstinence. CM has also been effective in treating freebase cocaine and heroin users as well as in methadone patients.

Treating Alcohol Use Disorder (AUD)

In an early study of CM in treating alcoholism, researchers found evidence for reducing alcohol dependence after studying CM therapy effects on a contingent group and a noncontingent group:

  1. Contingent Group —  participants in this group were given shelter, employment, food, and clothing only if they remained sober
  2. Noncontingent Group — participants in this group received the above social services whether or not they altered their drinking behavior

In this study, the contingent group’s arrest rate for public intoxication decreased significantly while at the same time, the average number of employment hours rose across the board. This effect was not found in the other group, with zero statistical change in both the arrest rate and employment hours. 

Opioid and stimulant addiction can be difficult to break, even with traditional treatment plans. If you are concerned about your recovery progress, talk with a health care professional about finding a treatment provider that offers contingency management.

Contingency Management and Co-Occurring Disorders

If someone has a substance use disorder and a mental health disorder simultaneously, they have a co-occurring disorder. These cases need specialized treatment due to the complexity of the conditions. Contingency management is an effective tool for these cases.

One study performed by the Department of Psychiatry, University of Pittsburgh School of Medicine and Western Psychiatric Institute and Clinic, analyzed patients with co-occurring disorders enrolled in a partial hospitalization program.

The patients that attended contingency management during their treatment sessions attended nearly twice as many treatment days compared to those who were not exposed to CM.

"Contingency management is a valuable adjunct for increasing retention in treatment among patients with dual disorders in partial hospitalization treatment. Exposure to contingency management increases retention in treatment, which in turn contributes to increased drug-free days."

Contingency Management for Patients with Dual Disorders in Intensive Outpatient Treatment for Addiction

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Resources +

National Institute on Drug Abuse. “Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition) - Contingency Management Interventions/Motivational Incentives (Alcohol, Stimulants, Opioids, Marijuana, Nicotine) NIDA, https://www.drugabuse.gov/publications/principles-drug-addiction-treatment-research-based-guide-third-edition.

Petry, N & Stitzer, M. “Contingency Management: Using Motivational Incentives to Improve Drug Abuse Treatment.” NIDA, Yale University Psychotherapy Development Center Training Series No. 6, http://lib.adai.washington.edu/ctnlib/PDF/CMmanual.pdf

Petry, N. “Contingency management: what it is and why psychiatrists should want to use it” Psychiatrist. 2011 May; 35(5): 161–163. doi: 10.1192/pb.bp.110.031831, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3083448/

Higgins ST, Petry NM. “Contingency management.” Incentives for sobriety. Alcohol Res Health. 1999;23:122–12. https://pubs.niaaa.nih.gov/publications/arh23-2/122-127.pdf

Kelly, Thomas M et al. “Contingency management for patients with dual disorders in intensive outpatient treatment for addiction.” Journal of dual diagnosis vol. 10,3 (2014): 108-17. doi:10.1080/15504263.2014.924772, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4292935/

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