These techniques can also be used to encourage adherence to medication in substance abusers. Preston et al. (1999) found that providing vouchers significantly enhanced adherence to naltrexone (ReVia) in recently detoxified heroin-dependent patients, and Rigsby et al. (2000) reported similar beneficial effects of CM techniques with adherence to anti-retrovirals among HIV-positive patients.
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.
A way to reduce the costs of CM is to provide only a proportion of the behaviors with a tangible reinforcer. In one outpatient treatment program, alcohol-dependent patients earned the chance to draw from a bowl and win prizes of varying magnitudes for submitting negative breath-alcohol samples and completing steps toward their treatment goals (Petry et al., 2000). 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).
The time or money associated with obtaining prizes, however, may still exceed the resources available to many treatment providers. To further reduce costs, clinics may consider having both monetary and non-monetary prizes available (e.g., lunches and special parking spots for a week or take-home doses or rapid dosing lines in methadone clinics). Clinics may solicit donations of some prizes or write for small grants ($5,000) that may cover the costs of prizes for a year. Nevertheless, if the magnitude of the rewards becomes too low, or if the prizes available are not desired by the patients, the procedure is unlikely to produce its desired effects (Petry, 2000).
Contingency management procedures that provide any form of monetary-based incentives are clearly going to be more costly than standard treatment. However, the costs of the CM approach, which can be accompanied by dramatic reductions in substance use, may be small in contrast to those associated with continued drug use, including emergency department visits, inpatient stays or medical care for an individual who contracts HIV (Holder and Blose, 1991). Thus, CM interventions may ultimately save money through reduced hospitalizations, medical care, criminal justice system costs and public assistance payments and through increased productivity. These treatments may also have direct beneficial effects to the treatment programs, i.e., if clients are retained in treatment longer, the reimbursements provided to the clinic may increase. The potential cost-savings effects of CM from both programmatic as well as societal perspectives have yet to be studied. If found to be cost-effective, General Assistance programs and managed care companies may find the upfront costs of CM programs to be modest with respect to their long-term cost offsets. Creative adaptation of these techniques by community providers may assist in disseminating CM techniques for improving the treatment of substance abusers.
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