All the data indicate that providing CM either results in no significant change or reductions in drug use relative to treatments without CM at long term follow-ups. Thus, decades of research clearly indicate excellent short term benefits of CM, and no or possibly some long term improvements with this treatment. There are no known published data to suggest that CM adversely impacts participation in 12-step meetings or 12-step oriented care. Therefore, even though CM may not address deep-seated beliefs about causes of addiction, it still improves substance abuse treatment outcomes. In spite of its effectiveness, one barrier to be overcome for CM has been the common necessity of participants to attend visits for biochemical monitoring of recent substance use and delivery of immediate behavioral consequences (ie, obtain reinforcers).
Advantages to healthcare providers
A resident who passes a drug test or has a therapeutic breakthrough receives a gift card that triggers their brain’s reward system, encouraging them to progress further so they receive more gifts. The concept of rewarding positive teen drug abuse behavior with positive reinforcement or some type of tangible reward is not a new one. It operates according to the simple premise that an individual, when rewarded for positive behavior, is likely to continue that behavior.
Behavioral Treatments for Smoking
Such mechanisms include ways to identify and tap the beneficiaries of CM to contribute their share of the treatment costs, government subsidies, or some combination thereof. 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. In clinics that adopt CM, training and supervision are paramount to ensure core aspects of CM are retained.
- We identified five studies of contingency management (Table 8), four with experimental designs and one quasi-experimental.
- Lott & JenciusReference Lott and Jencius14 found that reimbursement rates substantially increased when contingency management was introduced to adolescents who misused substances.
- Contingency management might also be helpful for individuals with co-occurring substance use disorders, who are at elevated risk of smoking-related morbidity and mortality.
- There has been limited research focused on determining if CM interventions are differentially effective for racial, ethnic, and other groups for whom CM could benefit from adaptation (eg, patients with co-occurring SMI, rurally dwelling patients, and patients with co-occurring SUDs) to maximize its effectiveness in treating SUDs.
Cognitive-Behavioral Approaches (CBT)
Reasons for the lack of use range from little formal training or coursework in behaviour analysis generally or contingency management specifically, ideological concerns, disconnect between research and practice, and costs. Each of these barriers can be overcome, and introduction of contingency management techniques into substance misuse treatment and psychiatric practice more broadly can have a positive impact on patients, providers, amphetamine addiction and perhaps even society at large. Despite its established efficacy, contingency management is the empiricallyvalidated treatment with which clinicians are least familiar. Medication take-home privileges is another form of contingency management frequently used in methadone maintenance treatment. Patients are permitted to « earn » take-home doses of their methadone in exchange for increasing, decreasing, or ceasing certain behaviors.
Applications in Diverse Populations
This may be because contingency management does not work on those that already show increased time spent in pursuit of drug in comparison to other natural and social reinforcers, as is part of the criteria for substance dependence according to DSM-IV and ICD-10 (Table 1). In these users there may be a short term effect of novelty of the shopping voucher reinforcer, but this will ultimately become degraded in comparison to the reward of the addictive drug, as did other aspects of the individual’s life as the addiction developed. As with other addiction therapies, contingency management does not treat the underlying cause of the addiction, and in a number of addicts is not effective at all (Carroll and Onken, 2005). FHE Health is a behavioral health and addiction treatment center with a strong focus on evidence-based therapies and a step-down continuum of care. As clients grow stable and more confident in their ability to manage their addiction, they transition to less structured treatment programs. We’re able to provide treatment no matter where individuals happen to be in their recovery journey.
This paper initially summarizes the empirical evidence for CM and then describes the primary concerns about this treatment. Obtaining initial training and ongoing technical support from CM experts is key to successful implementation and compliance with Office of Inspector General regulations. Several teams have developed extensive training materials that provide best-practice guidance on CM implementation, including didactic trainings, ongoing coaching, and technical support.
In the largest clinical trial for alcohol-use disorders among AI/AN adults, three tribal communities partnered with university researchers to adapt and implement CM for alcohol-use disorders. As described by McDonell et al,7 using components of community-based participatory research and community engagement, 400 AI/AN adults will be randomized in the ongoing trial. Studies have shown improved outcomes when CM techniques are applied to clients dependent on marijuana (Budney et al., 2000), cigarettes (Roll et al., 1996), alcohol (Petry et al., 2000), opioids (Bickel et al., 1997), benzodiazepines (Stitzer et al., 1992) and multiple drugs (Petry and Martin, in press; Piotrowski et al., 1999).
CM is also effective in treating people with co-occurring disorders.2 This is when someone is diagnosed with a SUD and a mental health disorder. Many of these prize reinforcement Contingency Management (CM) strategies have built-in bonuses, such that with the accumulation of negative toxicology screens over time, the patient can earn greater and greater rewards for each subsequent negative screen that is completed. Habits, compulsions, patterns of behavior— read any type of overview about alcohol or drug addiction and you’re likely to come across these terms referring to key aspects of addiction development and progression. Consequently, medical practitioners must address these aspects of addiction when determining the best course of treatment for an individual, whether that person is addicted to street drugs like heroin, prescription painkillers, or alcohol. Another concern is that CM, with its emphasis on external reinforcement, may impede intrinsic motivation to change. Intrinsic motivation refers to one’s desire to do something because it is self-fulfilling, while extrinsic motivation relates to doing something to obtain an item of value or to avoid punishment.
Contingency management is a highly effective treatment for substance use and related disorders. However, few psychiatrists are familiar with this intervention or its application to a range of patient behaviours. This paper describes contingency management and evidence of its efficacy for reducing drug use.
By providing reinforcement contingent on attendance,attendance rates across a range of treatment settings can be substantiallyimproved,1-3thereby increasing exposure to effective care. 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.
When there’s motivation to change behavior, there’s an increased likelihood that patients will stay active in their treatment programs. 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 10 fetal alcohol syndrome celebrities you’ll be surprised who! predictor of long-term abstinence. » Contingency management is an effective behavior change technique commonly used to treat substance use disorders. Based on applied behavior analysis (ABA), contingency management includes techniques such as choice and preference assessments, shaping, making contracts between the therapist and patient, community reinforcement approach and family training, and token economy.
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. When abstinence is the target behavior, this typically involves some form of biochemical verification, usually via urinalysis testing. Such testing requires careful planning so that the schedule of testing (frequency) allows optimal detection of substance use and abstinence. For example, detection windows range from hours (for alcohol use) to many days (cannabis), and depend on the type of testing employed (e.g., breath, urine, saliva).
The prizes available ranged from $1 prizes (choice of a bus token or fast-food coupon), $20 prizes (choice of a personal tape player, watch or phone card) and $100 prizes (choice of television or stereo). Chances of winning were inversely related to prize costs, such that chances of winning a $1 prize were approximately 1 in 2, while chances of winning a $100 prize were 1 in 250. This intermittent schedule of reinforcement may be an inexpensive expansion of vouchers, as average cost per client was under $200. The beneficial effects of this technique were replicated in cocaine-abusing methadone patients (Petry and Martin, in press). When people are rewarded for positive behavior, they’re likely to repeat that behavior in the future. This is referred to as operant conditioning—a type of learning where behavior can be modified when reinforced in a positive and supportive manner.
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. Most commonly, contingency management has been successfully used in smoking reduction programs for pregnant women who are receiving treatment for drug abuse and for pregnant women who are in treatment for alcohol or cocaine dependence. Contingency management for women can effectively utilize personal hygiene, household, or children’s items as “prizes” for attaining or sustaining abstinence, based on urine test results. Contingency management interventions have also been combined with brief motivational interventions within the context of case management services for pregnant women. Contingency management refers to the systematic provision of incentives and/or disincentives for specific behaviors for the purpose of modifying those behaviors (Petry, 2000).
The efficacy of contingency management has been demonstrated in community clinic settings in large randomized clinical trials. 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.
If you are struggling with an addiction to alcohol or drugs, contact us to learn more about our enrollment process. Not only do patients stand to gain by the introduction of contingency management but so do providers. A positive report comes from the introduction of contingency management into standard practice in substance misuse treatment programmes in New York.Reference Kellogg, Burns, Coleman, Stitzer, Wale and Kreek13 As individuals were reinforced for attending groups, group sizes and participant morale increased, along with provider morale. Lott & JenciusReference Lott and Jencius14 found that reimbursement rates substantially increased when contingency management was introduced to adolescents who misused substances. Contingency management is effective regardless of patients’ background characteristics, pre-existing conditions, or presenting problems.
Contingency management is based on a robust basic science literature supporting a position that drug use is, in part, a form of operant behavior. The availability of alternative nondrug reinforcers (i.e. vouchers, prizes) should decrease drug use if they are available in sufficient magnitude and according to a schedule that is incompatible with substance use. Contingency management is a powerful technique that has been used effectively to promote abstinence from alcohol, benzodiazepines, cocaine, nicotine, opiates, marijuana, and methamphetamine.
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). However, for behaviors that rarely occur on their own or that are challenging in nature, external rewards may enhance engagement in them (Cameron, Banko, & Pierce 2001). Different associations may also relate to whether reinforcers are provided for attempting a task, finishing it, or reaching some threshold of performance (Cameron et al., 2001).