Contingency management treatment for substance use disorders: How far has it come, and where does it need to go? PMC

Thus, if you give a child a small toy or sticker each time he makes his bed, the child will start making his bed more often. Behavioural principles of positive reinforcement are widely applied in everyday settings (childrearing, employment, pet training), as well as molly withdrawal symptoms clinical settings (autism, conduct disorder in adolescents, intellectual disability). Perhaps most importantly, there are no data to suggest that patients who earlier received CM have poorer long term substance use outcomes than patients who never received CM.

  1. Use of a range of incentives or allowing youth to choose their incentive can increase the probability that the incentive will be effective and facilitate the desired target behavior.
  2. In addition, implementation science should be consulted because adoption of even non-controversial evidence-based practices can be slow (e.g., Lash, Timko, Curran, McKay, & Burden 2011; Sorensen & Kosten, 2011).
  3. Lott &Jencius14 foundthat reimbursement rates substantially increased when contingency managementwas introduced to adolescents who misused substances.
  4. There are two major principles of contingency management interventions, which are voucher-based reinforcement and prize incentives.
  5. In terms of CM for substance use disorders specifically, only a handful of trials have investigated internal motivation, and only one known study found results consistent with the hypothesis that CM may decrease internal motivation.
  6. Only about half of clinics providing CM arranged for in-house or off-site training (Olmstead, Abraham, Martino, & Roman 2012).

Patient-facing mobile apps, combined with provider-facing dashboards, can facilitate tracking progress towards recovery goals and overall program-level management of the selected rewards system. Full automation is any solution not requiring action or verification by treatment staff before rewards can be delivered, whereas partial automation involves rapid delivery of rewards for certain recovery-oriented behaviours with other behaviours requiring verification by individual providers. Depending on the identified target behaviours, validation can be achieved via multiple easy and convenient methods. Supplementing patient or collateral self-report, smartphone video and GPS location capabilities, as well as external testing hardware have all been used to good effect to monitor and confirm medication adherence, abstinence, and appointment attendance [28,51–54].

Contingency management refers to a type of behavioural therapy in which individuals are ‘reinforced’, or rewarded, for evidence of positive behavioural change. These interventions have been widely tested and evaluated in the context of substance misuse treatment, and they most often involve provision of monetary-based reinforcers for submission of drug-negative urine specimens. The reinforcers typically consist of vouchers exchangeable for retail goods and services or the opportunity to win prizes. Contingency management refers to a type of behavioural therapy in whichindividuals are ‘reinforced’, or rewarded, for evidence ofpositive behavioural change.

Family and Children’s Programs

Education and training may be indicated to improve uptake of contingency management by addressing perceived skill deficits and competence needs of clinical staff [26,56], who often receive limited formal training in contingency management as part of their graduate coursework or licensure/certification requirements [57]. Traditional, largely didactic training approaches to scaling adoption of evidence-based interventions may be effective for enhancing staff knowledge, but are insufficient for sustained change in staff competence and skill, as well as patient outcomes [58]. Instead, preferred training strategies for contingency management scale-up in community treatment settings, as identified by opioid treatment program staff themselves, include the provision of a brief (half-day to 2 days) didactic training workshop supplemented with case examples and research data, along with experiential learning strategies such as role-paying [59].

How Does Contingency Management Intervention Work?

8 years of nursing experience in wide variety of behavioral and addition settings that include adult inpatient and outpatient mental health services with substance use disorders, and geriatric long-term care and hospice care. He has a particular interest in psychopharmacology, nutritional psychiatry, and alternative treatment options involving particular vitamins, dietary supplements, and administering auricular acupuncture. The Biden-Harris administration has been transparent in its support for expanding access to evidence-based treatment, including contingency management [50]. The Office of National Drug Control Policy’s stated priorities include addressing policy barriers related to contingency management interventions, and exploring reimbursement for motivational incentives and digital treatment for addiction. The U.S. Surgeon General and several federal agencies and institutes, including the National Institute on Drug Abuse (NIDA), Substance Abuse and Mental Health Services Administration (SAMHSA), U.S.

Frequency of Rewards

Several empirical questions linger, however, about how long CM needs to be delivered before the abstinence-related benefits it offers will carry on without the rewards (or negative consequences) in place. Also, despite its place as one of the most effective approaches to address substance use disorder, few programs implement standalone CM given its mismatch with the fee-for-service model used in many managed health care settings (e.g., they can’t obtain the funds to implement it). One area in which contingency management has widespread potential benefitsis individual retention in treatment. Psychiatric treatments suffer from highrates of attrition, which in turn relates to increased morbidity andmortality.

This is consistent with prior work [36,37] demonstrating that one of the most commonly identified concerns about contingency management is the use to which any monetary incentives are put (i.e. “giving people ‘extra’ money at a vulnerable point in their treatment pathway may do more harm than good”). For those sharing these sentiments, I ask, do people with OUD not need money for basic human necessities such as groceries, rent, childcare, electricity, and other expenses? I also find it important to highlight that the amount of monetary incentives that patients can expect to pocket by participating in a contingency management intervention is relatively minimal. Total earnings rarely exceed $100, on average, per month in most studied contingency management programs [39–41]. So why then is the opportunity for patients—many of whom may be unemployed when they begin treatment—to earn a few bucks each week for achieving their goals so controversial?

A behaviour that is reinforced in close temporalproximity to its occurrence will increase in frequency. Thus, if you give achild a small toy or sticker each time he makes his bed, the child will startmaking his bed more often. Behavioural principles of positive reinforcementare widely applied in everyday settings (childrearing, employment, pettraining), as well as clinical settings (autism, conduct disorder inadolescents, intellectual disability). 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. 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).

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