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Contingency Management Remains Underutilized Amid Addiction Crisis
Often associated with treatment for addiction to stimulants such as methamphetamine and cocaine, contingency management programs are an underutilized tool when it comes to treating patients with other substance use disorders, says Steven Proctor, PhD, senior program director for health outcomes at Thriving Mind South Florida in Miami Beach, Florida.
Earlier this month at the East Coast Symposium on Addictive Disorders, Dr Proctor presented a session on the untapped potential of contingency management in substance use disorder treatment. Recently, he spoke with Addiction Professional about recent research findings on the efficacy of contingency management, behaviors in recovery that it can be used to reinforce, and other best practices for what he tells practitioners is “the most effective, evidence-based treatment you’ve never used.”
Editor’s note: This interview has been lightly edited for clarity.
Addiction Professional: What has recent research shown us with regards to the efficacy of contingency management?
Steven Proctor: Decades of rigorous studies going back to the early clinical trials in the 1990s provide strong evidence supporting contingency management and have since been replicated nationally and internationally. We now have hundreds of studies, including many recent meta-analyses, systematic reviews, and clinical trials, all linking contingency management to longer periods of abstinence, longer treatment engagement, and greater improvements in quality of life and social functioning. When it comes to substances like methamphetamine and cocaine, no other treatment—psychosocial or pharmacological—has as strong an evidence base as contingency management, which is why it is considered the standard of care for stimulant addiction.
AP: What are some of the biggest reasons that the use of contingency management isn’t more common? While contingency management is frequently associated with treatment for stimulant use disorder because of a lack of FDA-approved medications, do you feel there are missed opportunities to incorporate it more frequently into treatment for opioid use disorder (OUD), for which medications do exist?
SP: When I talk with front-line clinicians and treatment systems, I like to tell people that contingency management is the most effective, evidence-based treatment you’ve never used. Despite a large body of research pointing to the value of contingency management and linking it to a variety of positive outcomes, it is rarely used due to several barriers—some of which I acknowledge are very real, while others are unfounded. Some providers may even rationalize the withholding of evidence-based care on ethical grounds and concerns about how monetary rewards will be spent. Although ethics and the belief by some opponents that giving people “extra” money at such a vulnerable point in their recovery could do more harm than good—along with moral, philosophical, and legal concerns among the many reasons cited as well—I’ve found that cost, stigma, and limited knowledge/familiarity with contingency management are often the drivers of the low uptake we see in real-world treatment settings.
In light of the escalating overdose crisis claiming the lives of 306 Americans each day, I believe there is a huge opportunity to incorporate contingency management into medication-assisted treatment (MAT) for OUD. While medications such as methadone and buprenorphine remain the gold standard for opioid use disorder, many people taking these medications drop out of treatment early and the overwhelming majority simply do not take their medication long enough to experience robust benefits. That is where contingency management—when delivered as an “add-on” to medication treatment—can reliably improve outcomes above-and-beyond medication alone. A recent meta-analysis of 74 randomized clinical trials with a combined sample size of over 10,000 adults on medication for opioid use disorder showed improved treatment retention, attendance at appointments, and adherence to their medication when also receiving contingency management. Another well-designed study found that adding contingency management to medication for opioid addiction resulted in additional cost savings compared to medication alone.
AP: What behaviors are most commonly reinforced through contingency management?
SP: By far, the most common target behavior in research studies and real-world practice is negative urine drugs screens, but a number of studies support reinforcing additional behaviors, namely attendance at appointments. Research shows that rewarding appointment attendance is equally effective to rewarding abstinence (via drug tests) in terms of treatment engagement. This can take the form of not only individual therapy sessions, but any type of appointment or meeting, such as community-based mutual-help groups (AA, NA, SMART Recovery) or even clinic, case management, peer, or medical appointments, when applicable. I believe there is a strong argument to be made for rewarding any recovery-oriented behavior consistent with an individual’s personalized treatment plan beyond abstinence alone.
AP: What are the differences between prize-based and voucher-based contingency management programs, and what are the reasons for using each?
SP: Both voucher-based (popularized by Dr Stephen Higgins) and prize-based (popularized by Dr Nancy Petry) reinforcement models are supported by a large body of literature demonstrating their effectiveness. While either protocol can involve cash or other monetary rewards, clients receive guaranteed reinforcement in a fixed amount upon achieving the identified target behavior every time in a voucher-based program, whereas in a prize-based program, clients earn draws from a prize bowl upon meeting target behaviors with only a chance to earn prizes ranging in value ($0 to $100) with usually only about half earning tangible rewards.
AP: Is there anything else you’d like to mention that we have not yet covered?
SP: In real-world treatment settings, research shows that very few programs use contingency management, and of those programs that actually do, most use no-cost or low-cost rewards, often totaling less than $25 throughout the duration of the program. However, in research trials and all those hundreds of rigorous, well-designed studies showing that contingency management works, the average reward values are typically much higher. If treatment programs want to give their clients the best possible chance at achieving those same positive outcomes from the published research literature, contingency management must be delivered with fidelity to the underlying model and reward values must be at that same level.
I’d also like to point out that not all rewards are created equal. A reinforcer must be of sufficient salience and value to each individual client so that they find it incentivizing and meaningful to them. Otherwise, recovery may remain elusive.
References
Proctor S. Contingency management for substance use disorders: Rewarding recovery. Presented at: East Coast Symposium on Addictive Disorders. November 3-5, 2023; Ponte Vedra, Florida.
