Contingency Management Is a Powerful Clinical Tool for Treating Substance Use Research Evidence and New Practice Guidelines for Use

Contingency management (CM) is an effective behavior change technique commonly used to treat substance use disorders (SUDs). CM is one of the most effective behavioral interventions for initiating and maintaining abstinence from most types of commonly used drugs and alcohol.

Background and Rationale

CM-based treatments for SUD originate in basic behavioral science, namely the operant conditioning literature. Operant conditioning is a type of learning in which behavior is modified or maintained through the consequences it produces. In the context of SUD treatment, CM typically modifies substance use by delivering tangible, positive reinforcers (eg, prizes, vouchers, or monetary reinforcement) in exchange for evidence of the performance of the targeted behavior, such as the submission of a drug-negative urine sample.¹

Several meta-analyses have found CM to be among the most effective interventions for SUDs, in addition to being effective at promoting treatment retention and medication adherence.^2-5 Moreover, clinical trials have consistently shown that CM is also a cost-effective technique.^6-8 Indeed, studies conducted over the past 30 years have found that CM can be used to promote abstinence from substances including cocaine,⁹ methamphetamine,¹⁰ tobacco,¹¹ alcohol,¹² opioids,¹³ cannabis,¹⁴ and benzodiazepines.¹⁵ Further, the aforementioned meta-analyses have also found CM to be effective among highly diverse populations, including pregnant women, adolescents, veterans of war, individuals with serious mental illness, unhoused individuals, those from racial and ethnic minority backgrounds, LGBTQ+ community members, and individuals with HIV and hepatitis. Notably, CM’s consistent effects during treatment across diverse trials may be indicative of CM’s ability to improve long-term treatment outcomes, in light of evidence indicating that longer abstinence during treatment is associated with better long-term treatment outcomes.^16,17

Optimizing Therapeutic Effects

Research results suggest that CM must have 3 key ingredients to optimize utility (Table). The first is the frequency with which the reinforcer is delivered. Studies suggest that reinforcers should be provided at least twice weekly to enhance the efficacy of CM for SUD management.¹⁸ The second ingredient is the immediacy of the reinforcer, or the exchange delay (ie, the shorter the period between the performance of the targeted behavior and delivery of the reinforcer, the greater likelihood of behavioral change).¹⁹ The third ingredient is the magnitude of the reinforcer. Although higher-magnitude reinforcers increase the chances of behavior change, they also increase the cost of the CM intervention.²⁰ In at least 1 study, however, it is notable that the average reinforcer actually costs around 40% of the maximum amount.²¹

Implementation Challenges

Funding

Although more than 30 years of research evidence collected throughout the world supports the effectiveness of CM, widescale implementation of CM in clinical care has been limited, particularly due to funding and regulatory issues. While reinforcers are commonly used in health care to increase a targeted behavior (eg, gift cards for completing a health assessment), the recommended frequency (twice weekly) and magnitude of CM reinforcers is unique. 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.

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. Importantly, these implementations of CM include models that are based on research evidence with funding for reinforcers varying from $325 to $599. These policy changes represent a pivotal modification that may provide a path for nationwide dissemination and implementation of one of the most effective, yet underutilized, interventions for SUDs.

Philosophical and Moral Concerns

One important challenge for CM implementation includes philosophical and/or moral concerns about “paying substance users” to stop using drugs; another is the belief that the effect may not persist after CM is concluded.²² Implementation research has shown that provider resistance can be allayed with education and training and, more importantly, from observing increased patient engagement and other positive treatment outcomes.²³ In fact, after being exposed to CM in the workplace, previously skeptical clinicians noticed that CM had not only improved response to treatment, but also helped improve therapeutic alliances with patients and increased practitioners’ job satisfaction.²⁴ In other words, training and exposing practitioners to CM in the workplace is effective in overturning philosophical and moral concerns.

Tips for Successful Integration

A burgeoning science is focused on CM implementation, and lessons learned from the Veterans Administration CM program and other state-level implementations can provide guidance to clinicians hoping to implement CM.²⁵ Clinicians must secure funding for an adequate dose (eg, reinforcer monetary value) of CM. Programs must identify the clinical staff members who will implement the program. We have found that nurses, care managers, substance use disorder counselors, and peer support specialists are well positioned to conduct CM, depending on the clinical setting required to effectively deliver CM.^23,24 CM can be integrated into other treatment modalities or delivered separately by nonlicensed staff, as long as the CM provider has been adequately trained in the use of CM, with emphasis on administering urine tests, tracking reinforcer distribution, and maintaining a positive, nonjudgmental tone with patients. Coaching sessions and fidelity monitoring are also important elements to ensure the success of a CM program.^22-24

Although evidence indicates that CM is associated with increased attendance, use of reinforcers to increase revenue from billable encounters is prohibited and should be avoided.

Another tip includes using an electronic CM platform system to calculate and monitor reinforcer magnitude and distribution. CM often incorporates a reinforcement schedule that includes escalating reinforcement magnitude as increased durations of abstinence are achieved, as well as loss and recovery of the escalation bonus if and when a return to use and a return to sustained abstinence occur (known as “reset” and “recovery”).²⁶ Although adding these features to a CM program increases the complexity, the therapeutic benefit is well documented and can be executed consistently by using an electronic CM platform. Notably, in various stages of development are a number of phone apps (with accompanying web-based management portals) that could help clinicians, staff, and patients deliver and receive reinforcers more readily; such a system would reduce staff burden for tracking and calculating reinforcer values.¹⁸

Lastly, CM can represent a paradigm shift for many systems and clinicians who have been required to deliver punitive consequences when substance use occurs. When objective evidence of use is recorded, clinicians focus on strength-based feedback, such as praise for attendance, and encouragement that the next opportunity for reinforcement will occur again in just a few days. They can further engage the patient by discussing what reinforcer they are excited to work toward, orienting the patient toward the reinforcement inherent in CM.

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. Driven by the escalating prevalence of methamphetamine use and recent changes in federal policy, the rapid dissemination of CM can bring this feasible, strength-based approach to millions of people affected by stimulant use disorders throughout the United States—if the unique challenges that the method presents can be overcome.

Concluding Thoughts

One of the biggest barriers to effectively utilizing CM in real-world treatment situations has been the lack of adequate public policies to finance CM interventions. Convincing policy makers why CM should be more broadly integrated into drug and alcohol use disorder treatment has proven difficult. Nonetheless, CM interventions are being applied in a variety of clinical practices throughout the United States and the United Kingdom.²⁷ For example, CM is being increasingly used as the SUD treatment of choice within the Veterans Administration system in the United States.²⁸ Since 2011, the Veterans Administration has successfully integrated CM into 70 of its intensive outpatient substance abuse treatment clinics for veterans.²⁸ At the same time, the National Health Service in the United Kingdom has also implemented CM into its SUD treatment guidelines, and CM is currently being offered at several treatment facilities.²⁷

Investigations of CM dissemination are currently underway, including studies designed to better understand systemic and clinician variables that impede or facilitate CM implementation.^23,24 One of the most important pieces of evidence that has emerged in the CM literature, especially in light of the political challenges, is that CM is a cost-effective treatment option.^6,7 This should lead to greater adoption across the US health care system, which is in desperate search of economically viable alternatives in the face of scarce and diminishing resources.

A final crucial aspect of CM that makes it amenable to several different adaptations and optimizations is that CM produces virtually no adverse events and can be combined with virtually any other form of treatment.²⁹ This makes CM both effective and amenable to ongoing experimentation and optimization efforts across a diverse array of settings and populations that will only be leveraged further by ongoing technological, psychosocial, and pharmacological developments.

Dr McPherson is director of the Program of Excellence in Addictions Research; assistant dean, research; and a professor at the Washington State University (WSU) Elson S. Floyd College of Medicine. He is also associate director of research for analytics and discovery at the Providence Medical Research Center and head and principal investigator of the Analytics and Psychopharmacology Laboratory. Dr Parent is a scientific assistant at WSU. Dr Miguel is an assistant research professor at WSU Elson S. Floyd College of Medicine. Dr McDonell is a professor in the Department of Community and Behavioral Health at WSU Elson S. Floyd College of Medicine. Dr Roll is a professor and vice dean for research at WSU Elson S. Floyd College of Medicine.

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