Contingency management in substance use treatment

Contingency management, or CM, is a behavioral therapy that gives a person tangible rewards for evidence of change. A 2017 review by Petry and colleagues in Psychology of Addictive Behaviors describes it as based on operant conditioning principles and, for substance use, most often involving monetary-based rewards for drug-negative urine samples. NIDA describes the rewards as small incentives such as prizes or gift cards.

How it works

The idea is simple. A goal is set that can be objectively checked, the check happens regularly, and meeting the goal brings a reward. NIDA's overview adds that rewards or privileges can also be linked to attending and taking part in counseling sessions, or to taking treatment medications as prescribed, as well as to staying drug free.

NIDA says CM aims to replace drugs with healthy, non-drug rewards, helping people stop using and restoring their ability to enjoy and engage with other activities. See what happens when you ask for help for how treatment is arranged.

What the evidence says, starting with stimulants

NIDA states that CM has been shown to be especially effective in treating addiction to stimulants like cocaine and methamphetamine. This matters because, as NIDA also notes, no medications are currently available to treat stimulant addiction, so behavioral therapies carry the load.

Petry and colleagues report that patients receiving CM achieved an average of 4.4 weeks of objectively verified continuous stimulant abstinence, compared with 2.6 weeks for patients receiving standard care alone. In another analysis they cite, the odds ratio for stimulant-negative samples was 1.9, which they describe as CM nearly doubling the likelihood of stimulant-negative samples. They also report that CM had the largest effect size (Cohen's d of 0.58) among the psychosocial treatments compared, against 0.32 for the next largest, relapse prevention interventions.

The review says CM has been tested for stimulant, opioid, marijuana, nicotine and polydrug use disorders, and that it has emerging applications for alcohol use disorders.

What happens when the rewards stop

A frequent criticism is that benefits fade once rewards end. A 2021 meta-analysis by Ginley and colleagues in the Journal of Consulting and Clinical Psychology pooled 23 studies with 3,320 participants, and looked at follow-up after incentives were discontinued (median 24 weeks). It reported a weighted odds ratio of 1.22, meaning that participants who received CM were 1.22 times more likely to be abstinent by urinalysis at follow-up than those given comparison treatments. That is a modest but statistically significant difference.

Petry and colleagues acknowledge that meta-analyzes find CM effects are not sustained at long-term follow-ups, though they report that 29 percent of the studies evaluating long-term effects found significant benefits retained after rewards stopped. They also say there are no data suggesting that people who earlier received CM have poorer long-term outcomes than those who never did.

Practical and ethical debates

Petry and colleagues describe CM as highly controversial and rarely used in practice settings, and they set out the main objections:

• Cost. Providing rewards increases the cost of treatment. The review points to direct reward costs for each person over a 12-week course, plus administrative costs and frequent urine testing.
• Philosophy. Some clinicians object that CM does not address the underlying cause of addiction, or that external rewards may impede intrinsic motivation to change. The review notes that clinicians with a 12-step orientation perceived more problems with implementing CM than counselors with other orientations.
• Funding. The review says clinics generally receive no reimbursement for the extra testing or rewards, so they have no economic incentive to use it.

Whether paying people for abstinence is fair or respectful is a values question that research does not settle. The evidence above bears on whether it works, and each person and program may weigh the rest differently.

Limits

• CM rewards what a test can verify. Ginley and colleagues note that urine toxicology provides an objective index of use but is not without limitations.
• Their meta-analysis had a median follow-up of only about 6 months after treatment ended and may be affected by publication bias, so longer-term effects remain uncertain.
• CM is one tool. NIDA says treatment should address the whole person, and NIDA lists cognitive behavioral therapy and motivational interviewing beside CM among its behavioral therapies. Medicines are covered in medications used in treatment.

Questions to ask a clinician

• Does this program offer contingency management, and what behavior is rewarded?
• How are goals checked, and what happens if a test is positive?
• What are the rewards, and who pays for them?
• How would it fit alongside counseling or medication in my plan?
• What support continues after the rewards end?