Highlights
- Contingency Management (CM) is an effective, person-centered, and cost-beneficial intervention to engage patients in substance use disorder treatment and improve health outcomes.
- The body of research around CM presents significant evidence for the intervention’s efficacy across many different types of substance use disorders, population sub-groups, and cultural settings.
- CM has demonstrated efficacy as an intervention delivered in-person or via a web-based application.
- CM programs demonstrate stronger results with higher-value incentives.
- Cost savings from avoiding emergency visits and improving health outcomes can significantly offset the cost of a CM program.
The scale of the opioid epidemic continues to outpace the resources available to both providers and individuals seeking treatment for substance use disorder (SUD). Despite increasing attention and calls for change, the United States continues to suffer from a plague of substance-related deaths. The COVID-19 pandemic only made things more difficult as isolation and uncertainty around housing, employment, and health led to more substance use and, consequently, more deaths. The impacts of these national trends are clear in Colorado. We have witnessed a staggering 38% increase in overdose deaths between 2019 and 2020 – the largest increase in fatal overdoses in two decades. The trend may be shifting westward as 68% of synthetic opioid (eg, fentanyl) overdoses in 2018 were primarily seen in the Western US.
At the same time, substance use and overdoses of psychostimulants like methamphetamine and cocaine continue to impact the state. In 2018, 318 Coloradans died from methamphetamine overdoses representing a 40% increase in methamphetamine-related deaths from 2017. For the second year in a row, methamphetamine overdose deaths exceeded those from heroin in Colorado. Compounding this trend is the increased prevalence of synthetic opioids, like fentanyl, being cut into other common street drugs, including methamphetamine and counterfeit pills sold as alprazolam (XanaxⓇ) or oxycodone.
Treating SUD presents its own set of obstacles. Many patients with SUD reside in lower socioeconomic neighborhoods, including rural communities, with higher levels of poverty. The geographic distance to reach a provider may significantly interfere with hourly shift work, child care, and fuel prices. These patients need to feel confident that they are benefiting from the time and money they are investing in their health. An intervention that addresses engagement as part of the therapy, contingency management (CM) provides concrete incentives and support for individuals to show up for their care. Evidence for the effectiveness of CM as a treatment for SUD continues to build.
According to the National Institute of Health, CM is a type of evidence-based behavioral therapy that uses incentives or non-drug rewards, such as cash stipends, prizes, or vouchers for various goods or services, to encourage behavior change among participants. Research on the effectiveness of contingency management dates back over 30 years, and this intervention has shown promise across genders, ages, races, ethnicities, in both individual and group settings, and for special populations, such as pregnant people and men who have sex with men.
While CM can be implemented using positive and/or negative reinforcement, most iterations of CM tend to use positive reinforcement. CM programs follow a multi-week schedule, most often ranging 12 to 24 weeks, and include frequent drug screenings in combination with other therapies. While many iterations of CM exist, the fishbowl and voucher-based reinforcement therapy (VBRT) methods are the most common.
The Fishbowl Method
In the fishbowl method, clients draw a prize from a “fishbowl” after earning an incentive for a chance to win something of varying value. This strategy was tested by Petry, et al in a 2010 randomized control trial of 170 HIV-positive patients who were randomized into weekly CM or 12-step groups for 24 weeks of treatment. In the CM group, individuals who completed health activities and submitted clean urine samples were eligible to pull a card from the fishbowl, with prize values varying from $0 (a card that read, “Good Job”) to $100 (a higher-value item, such as a stereo or television). The results of this study demonstrated that the CM group submitted significantly more consecutive clean urine samples than the control (12-step) group. The CM group also demonstrated a greater reduction in HIV viral loads and risky behaviors than the control group. However, there were no significant differences between the two groups in either proportion of the group submitting a clean sample or the long-term impact of the intervention on viral load and high risk behaviors during the follow-up period.
Voucher-Based Reinforcement Therapy
In the VBRT model for CM, patients earn vouchers for completion of desired behaviors. The level of vouchers increases as reinforcing behaviors escalate. VBRT can also be combined with the fishbowl method. A 2009 study implemented a voucher-based CM program for veterans in continuing care for SUD with the goal of increasing attendance. The intervention retrospectively analyzed the attendance records of 135 veterans in three different CM programs. Each group provided either a small, medium, or high value incentive while 55 veterans serving as a control group received standard of care. The results indicated a significantly higher appointment attendance and clinic retention in the two higher-value CM programs suggesting that higher magnitude incentives are associated with more desirable outcomes. Additionally, National Institute on Drug Abuse (NIDA) studies have demonstrated that incentives of $400-$500 per patient optimize outcomes. Smaller rewards are associated with less benefit, and rewards under $100 are not associated with statistically significant changes in behavior.
CM and Specific SUDs
Stimulants
In the treatment of stimulant use disorders, CM has consistently demonstrated improvements in treatment attendance, retention, and rate of stimulant-negative urine samples. In a 2006 randomized controlled trial, stimulant-dependent patients were randomized into three different 16-week treatment groups: CM only; CM and cognitive behavioral therapy (CBT); and CBT only. Both CM groups showed significantly better outcomes than the CBT only group (higher retention and lower rates of stimulant use). While CM demonstrated robust impact during the intervention period, CBT demonstrated equivalent long-term impacts on appointment attendance and stimulant use as CM. Another 2006 study on CM as treatment for methamphetamine use disorder suggested that the fishbowl method yielded significantly more negative biosamples and produced longer periods of abstinence compared to the standard of care group despite the same treatment duration.
Opioids
CM’s effectiveness as an intervention in the context of opioid use disorder treatment continues to accrue evidence. A systematic review and meta-analysis from 2017 found that CM performed significantly better than the standard of care.
Alcohol
CM has shown promise in alcohol use disorder leading to increases in appointment attendance, treatment retention, and sustained abstinence. A randomized, controlled trial in 2000 implemented the fishbowl method whereby participants were eligible to win prizes upon completion of treatment goals or submission of a negative breathalyzer test. The CM group demonstrated a fourfold higher treatment retention metric than the standard care group at the end of the eight-week study period (84% vs 22%) as well as a higher rate of abstinence from alcohol at the end of the treatment period (69% vs 61%). Participants earned an average of $200 worth of prizes over the course of the study period.
Another study of cash-based VBRT for negative test results from a transdermal alcohol sensor suggested that CM led to a sustained abstinence of 8.0 days during the intervention versus the control group (2.9 days). This study also found that CM can improve moderation behaviors in alcohol-dependent individuals. The CM group had a higher proportion of days with no drinking during the study period (54% vs 31%) and less risky drinking behavior (31% vs 7%). Similarly, a 2017 study using a transdermal alcohol sensor examined whether CM could reduce risky drinking behaviors. After an initial ‘drinking as usual’ 4-week observation period, participants then enter the ‘contingency’ period whereby they received $50 per week for sensor readings of more than .03 g/dL in addition to $105 each week they visited the clinic and wore the monitor. Compared to the observation phase, the contingency period saw episodes of heavy drinking days decrease and days of no or low-to-moderate drinking increased.
Cannabis
A 2015 study of CM for cannabis dependence suggested both improved outcomes with CM and opportunities for cost savings. Seventy-five adults seeking care for a cannabis use disorder were randomized into one of three treatment groups: (1) motivational enhancement therapy delivered by a therapist; (2) CM, motivational enhancement therapy, and CBT provided by a therapist; and (3) CM, motivational enhancement therapy, and CBT delivered by a computer. The groups with CM had significantly longer periods of sustained abstinence during treatment than the motivational-enhancement-only group, and these results did not differ by treatment delivery method (therapist vs computer). The CM groups also demonstrated higher sustained abstinence rates and a greater reduction in days of use at the end of the nine-month follow-up period. A cost analysis also revealed $130 in savings per case compared to the therapist arm offsetting almost the entire cost of the CM program. Another study found that increasingly valuable cash VBRT incentives for continued abstinence and appointment attendance over the 30-day intervention improved moderation management. With a maximum reward of $585 for perfect attendance, 90% maintained 30-day abstinence; however, 94% had resumed use within two weeks of the program’s conclusion.
Nicotine
A 2006 study of adolescent nicotine users compared CM in combination with CBT versus CBT alone. The program was designed as a 30-day, school-based smoking cessation program. Twenty-eight participants were randomized to the CM group who then received an increasing VBRT incentive. The CM + CBT group showed better outcomes than the CBT-only group at both one week (77% vs 7% abstinence) and at the end of the one-month intervention period (56% versus 0% abstinence).
CM and Special Populations
CM is a generalizable intervention in a community setting. Overall outcomes do not differ by income status, neither during the intervention nor the follow-up period; however, the relationship between the incentive and the intervention remains significant. Among low-income populations, evidence suggests that higher value incentives yield a greater likelihood of abstinence. For example, a 2018 study by Baker et al. compared the effectiveness of higher- and lower-value VBRT incentive models for contingency management in smoking cessation programs among low-income, pregnant women enrolled in a perinatal birth program. The average total payout for the higher-incentive group was $212, whereas the lower-incentive group received a maximum of $80. Results demonstrated that the higher-value VBRT group reported a significantly higher 6-month abstinence rate than the lower-value group (15% and 9%, respectively), as well as a greater likelihood of accepting postpartum home visit counseling calls.
CM as an intervention tool in low-income populations is cost-effective. A 2019 study found that moderate VBRT incentives improved seven-day abstinence as compared to a non-incentivized control group in Medicaid-enrolled individuals seeking smoking cessation treatment via the Wisconsin Tobacco Quit Line. Cost-effectiveness analysis found that the piloted CM program saved $300 per additional person who quit compared to a standard course of varenicline and telephone counseling.
Black, Indigenous, and People of Color
Use of CM as an intervention in Black, Indigenous, and People of Color (BIPOC) communities has yielded positive outcomes due to its unique flexibility in different communal and cultural settings. A 2020 study examined CM as part of alcohol use disorder and other SUD treatments among Native American adults living in a Northern Plains reservation. This study compared four distinct intervention groups of substance-dependent adults seeking treatment: (1) CM for alcohol; (2) CM for other substances; (3) CM for both alcohol and other substances; (4) no CM for either substance. Researchers found that the three CM groups were significantly more likely to submit negative urine samples than the control group. CM has also demonstrated potential applications for HIV treatment in transgender women of color (Reback et al., 2021). Using CM may also be an important strategy for addressing obstacles that occur at disproportionately higher rates in BIPOC communities (i.e., housing instability, mental illness, substance use, and unemployment).
Challenges for CM
Many of the studies mentioned pointed to a lack of significant long-term impacts on individual treatment outcomes. Future studies will need to focus on longitudinal outcomes given that CM produces longer periods of abstinence during treatment, and that the best indicator of future abstinence is abstinence during treatment.
Conclusion
Contingency management is appropriate for a variety of healthcare settings, including primary care, community outpatient programs, and inpatient settings. CM models have even been adapted to web-based platforms allowing access to people in geographically diverse, isolated, and/or rural areas. Researchers in 2018 found that the use of CM via mobile technology has a sustained positive impact on the communities most affected by substance use disorders. These programs automate contingency management and rely on new technologies such as smartphones to minimize the risk of incentive abuse among participants.
Moreover, CM is associated with a broad range of productive outcomes. In addition to those listed above, data show that the use of contingency management for people with stimulant use disorders reduces the number of days using stimulants, stimulant cravings, new stimulant use, and behaviors leading to high risk of HIV.
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