Contingency Management
Contingency management is a reward-based program used to complement existing addiction treatments. It provides incentives for sobriety to replace unhealthy reward-seeking behavior of substance abuse. Despite some drawbacks, it is considered a practical treatment option for addiction, especially for individuals struggling with stimulant and opioid addiction.
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What Is Contingency Management?
Contingency Management (CM) is an evidence-based behavioral approach designed to supplement the treatment of substance use disorders.
The therapy is built on the principles of cognitive behavioral therapy (CBT) and can serve as a powerful supplement to existing addiction therapy treatments.
CM can supplement either inpatient or outpatient addiction treatment. CM treatment works by incentivizing addicts to avoid abusing substances in exchange for tokens of no monetary value or vouchers that represent items of monetary value or usefulness.
Contingency management interventions have largely found success in methadone treatment programs for opioid use disorder and treating cocaine dependence and addiction.
CM is similar to the Community Reinforcement Approach (CRA), a behavioral treatment program used to treat alcohol use disorder and other drug disorders by providing or withholding rewards and negative consequences depending on behavior during treatment.
Core Principles of Contingency Management
CM uses operant conditioning, which theorizes that behaviors are shaped by their consequences.
Operant conditioning proposes that behaviors increase when rewarded by a pleasant experience or decrease over time when punished by an unpleasant experience.
Patterns of addiction are maintained and reinforced by the release of neurotransmitters related to pleasure and reward each time they abuse a substance. CM looks to replace that mechanism by rewarding addicts with positive experiences for sticking to their treatment goals.
How Does Contingency Management Work?
CM works by providing incentives with monetary value or usefulness in exchange for desired behaviors like abstinence from drug abuse and compliance with treatment plans.
The focus of CM is to encourage positive behavior change rather than negative incentives or threats involving law enforcement.
First, a therapist identifies the target behaviors the patient or loved ones wish to address, usually related to substance abuse. Depending on the CM program, these rewards may be tokens, Voucher-Based Reinforcement (VBR), or prize incentives.
Then, patients earn these tokens or motivational incentives by providing negative urine samples or drug tests, cooperating during therapy sessions, and abstinence from drug use.
Tokens
Tokens are not uncommon in the addiction treatment world; support groups like Alcoholics Anonymous use small tokens or coins earned for remaining sober at certain milestones.
In the case of CM, these tokens have no monetary value but may represent certain privileges or prestige for staying committed to their sobriety. While these tokens do not carry any material value, they can provide positive reinforcement and a sense of accomplishment for the patient.
Voucher-Based Reinforcement (VBR)
One popular method of CM is Voucher-Based Reinforcement (VBR), which is often used for the treatment of stimulant use disorder and opioid use disorder due to its high effectiveness.
VBR works by awarding a voucher to patients who demonstrate drug-free urine tests at periodic check-ins.
Patients can use their vouchers to exchange for food, non-alcoholic drinks, movie or show tickets, or other items with no monetary value. At the start, vouchers have low monetary values but increase as clean drug test samples are consistently provided.
If a patient’s drug test is positive for the substance, the voucher value resets at the starting value. While this may seem like a punishment, the healthcare provider reframes it as an opportunity to try building back to their previous value through continued abstinence.
Prize Incentives Contingency Management
Like Voucher-Based Reinforcement, Prize Incentives Contingency Management uses cash prizes rather than the voucher system to reward clean drug test results. Patients who have drug-free urine samples are allowed to draw once from a pot to win prizes between $1 and $100 in value.
The number of drawings increases with each consecutive clean drug test. However, like with the voucher system, a positive drug test resets the drawings to one per clean drug test.
Patients can also earn additional chances to draw from the pot by meeting certain goals in their treatment plan or attending therapy sessions. Prize incentives appear to be especially effective for maintaining opioid, methamphetamine, and cocaine abstinence.
Contingency Management and Addiction Treatment
CM was initially developed to treat addiction, although it gets its roots from other behavioral therapies like cognitive behavioral therapy and dialectical behavioral therapy.
Over the years, many studies have concluded that CM can be a highly effective supplemental behavioral treatment for addiction, especially stimulant use disorder and opioid use disorder.
According to a study from the University of Connecticut School of Medicine, CM significantly enhanced retention rates in addiction treatment, with 49% of the contingency management group completing their 12 weeks of treatment and only 35% in the standard care group completing the same treatment.
Unfortunately, few treatment centers use CM for several reasons. The biggest reason is that some clinicians don’t know about it or lack access to education on administering CM. For others, the cost of providing the monetary incentives is too high.
Benefits of Contingency Management
CM effectively gets patients more involved and engaged with their treatment. For some patients, CM adds a competitive or game-like element to staying abstinent. Overall, CM also increases abstinence rates across the board.
Other benefits of CM include:
- Increases treatment motivation
- Deepens commitment to recovery
- Strengthens and supplements existing addiction therapy
Potential Drawbacks of Contingency Management
Unlike other behavioral therapies, CM does not help address the root causes of addictive behaviors. CM is most effective when patients are attending other talk therapies that reinforce the positive incentives offered by CM.
Another drawback to CM is that it is considered unlawful in certain states to provide monetary incentives to patients enrolled in health plans funded by the federal government or state, like Medicaid. These incentives could be considered kickbacks under certain federal laws.
CM can also be expensive for the treatment centers that employ them. A study from the National Institute on Drug Abuse (NIDA) reports that incentives for CM programs average $400–$500 per patient or more throughout treatment.
Aside from these reasons, there is also some ideological disagreement on the ethics of CM. Some mental health providers argue CM is the same as bribery or that patients will revert to abusing substances once they exit CM programs.
Get Contingency Management Treatment for Your Addiction
Contingency management treatment can be a powerful tool in substance abuse treatment. If you or a loved one think CM may help, talk to your healthcare provider about treatment options that include CM incentives.
If you’re just getting started and unsure what treatment options are available in your area, check out SAMHSA’s online treatment locator. You can also call the helpline to learn what treatment centers are in your area.
Contingency Management FAQs
How effective is contingency management in addiction treatment?
CM can be an effective treatment in completing treatment and maintaining abstinence. A study from the University of Connecticut School of Medicine showed that CM significantly enhanced retention rates in addiction treatment.
The study revealed that 49% of patients in the contingency management group completed 12 weeks of treatment, while only 35% in the standard care group completed the same treatment.
What types of rewards are common with contingency management therapy?
Rewards in CM therapy can range from tokens representing sobriety milestones to vouchers that recipients can exchange for items with monetary value, such as food or movie tickets, and prize drawings.
Patients receive these rewards when they provide a clean drug test or complete specific treatment goals.
How is contingency management different from other types of therapy?
CM typically does not provide talk therapy like other therapies. Instead, CM serves as a valuable supplement to talk therapies like CBT or psychosocial treatments that focus on skill-building and social and vocational training.
How long does contingency management therapy last?
CM therapy is typically held in 12-week sessions. Patients can do as many sessions as they like or as their healthcare provider or treatment plan recommends.
Is contingency management common in addiction treatment programs?
Somewhat. Contingency management is often underutilized due to providers being unaware of its existence, cost difficulties, or limitations for patients on government-funded healthcare plans.
When CM is used, it is most often found in programs focusing on stimulant use disorder and opioid use disorders.
