Contingency management for substance use disorders: Efficacy, implementation, and training
- Maxine Stitzer, PhD
Maxine Stitzer, PhD
- Professor of Psychiatry and Behavioral Sciences
- Johns Hopkins Bayview Medical Center
- Colin S Cunningham, PhD
Colin S Cunningham, PhD
- Postdoctoral Fellow, Department of Psychiatry and Behavioral Sciences
- Johns Hopkins School of Medicine
Contingency management and other psychosocial interventions have a substantial role in the treatment of patients with substance use disorders (SUDs), particularly those for which pharmacotherapy is unavailable or only partially effective. Contingency management is typically delivered as an augmentation to psychosocial treatment such as SUD counseling or psychotherapy.
Contingency management uses incentives to encourage treatment attendance and/or abstinence from alcohol/drug use. Contingency management interventions can be customized to some extent to address patient preferences or program needs, such as the resources available for the intervention.
This topic describes the efficacy, implementation, and training for contingency management. The theoretical foundation, indications, assessment, and components of contingency management for SUD are discussed separately. Other SUD treatments, including those for specific substances, are also discussed separately. (See "Contingency management for substance use disorders: Theoretical foundation, principles, assessment, and components" and "Pharmacotherapy for alcohol use disorder" and "Psychosocial treatment of alcohol use disorder" and "Cannabis use disorder: Treatment, prognosis, and long-term medical effects" and "Psychosocial interventions for stimulant use disorder in adults" and "Pharmacotherapy for smoking cessation in adults" and "Behavioral approaches to smoking cessation" and "Continuing care for addiction: Indications, features, and efficacy" and "Continuing care for addiction: Implementation".)
Clinical trials generally support the efficacy of contingency management for enhancing treatment attendance and increasing abstinence outcomes in treatment of substance use disorders (SUDs).
Treatment attendance — A review of 16 clinical trials of contingency management targeting attendance concluded that findings were mixed but generally supportive of efficacy .
- Milward J, Lynskey M, Strang J. Solving the problem of non-attendance in substance abuse services. Drug Alcohol Rev 2014; 33:625.
- Corrigan JD, Bogner J, Lamb-Hart G, et al. Increasing substance abuse treatment compliance for persons with traumatic brain injury. Psychol Addict Behav 2005; 19:131.
- Petry NM, Martin B, Finocche C. Contingency management in group treatment: a demonstration project in an HIV drop-in center. J Subst Abuse Treat 2001; 21:89.
- Kidorf M, Brooner RK, Gandotra N, et al. Reinforcing integrated psychiatric service attendance in an opioid-agonist program: a randomized and controlled trial. Drug Alcohol Depend 2013; 133:30.
- Sigmon SC, Stitzer ML. Use of a low-cost incentive intervention to improve counseling attendance among methadone-maintained patients. J Subst Abuse Treat 2005; 29:253.
- Petry NM, Martin B, Simcic F Jr. Prize reinforcement contingency management for cocaine dependence: integration with group therapy in a methadone clinic. J Consult Clin Psychol 2005; 73:354.
- Petry NM, Alessi SM, Ledgerwood DM. Contingency management delivered by community therapists in outpatient settings. Drug Alcohol Depend 2012; 122:86.
- Ledgerwood DM, Alessi SM, Hanson T, et al. Contingency management for attendance to group substance abuse treatment administered by clinicians in community clinics. J Appl Behav Anal 2008; 41:517.
- Walker R, Rosvall T, Field CA, et al. Disseminating contingency management to increase attendance in two community substance abuse treatment centers: lessons learned. J Subst Abuse Treat 2010; 39:202.
- Branson CE, Barbuti AM, Clemmey P, et al. A pilot study of low-cost contingency management to increase attendance in an adolescent substance abuse program. Am J Addict 2012; 21:126.
- Businelle MS, Rash CJ, Burke RS, Parker JD. Using vouchers to increase continuing care participation in veterans: does magnitude matter? Am J Addict 2009; 18:122.
- Crèvecoeur-MacPhail D, Ransom L, Myers AC, et al. Inside the black box: measuring addiction treatment services and their relation to outcomes. J Psychoactive Drugs 2010; Suppl 6:269.
- Vandrey R, Stitzer ML, Acquavita SP, Quinn-Stabile P. Pay-for-performance in a community substance abuse clinic. J Subst Abuse Treat 2011; 41:193.
- Lussier JP, Heil SH, Mongeon JA, et al. A meta-analysis of voucher-based reinforcement therapy for substance use disorders. Addiction 2006; 101:192.
- Benishek LA, Dugosh KL, Kirby KC, et al. Prize-based contingency management for the treatment of substance abusers: a meta-analysis. Addiction 2014; 109:1426.
- Cochran G, Stitzer M, Campbell AN, et al. Web-based treatment for substance use disorders: differential effects by primary substance. Addict Behav 2015; 45:191.
- Petry NM, Carroll KM. Contingency management is efficacious in opioid-dependent outpatients not maintained on agonist pharmacotherapy. Psychol Addict Behav 2013; 27:1036.
- Higgins ST, Budney AJ, Bickel WK, et al. Incentives improve outcome in outpatient behavioral treatment of cocaine dependence. Arch Gen Psychiatry 1994; 51:568.
- Higgins ST, Wong CJ, Badger GJ, et al. Contingent reinforcement increases cocaine abstinence during outpatient treatment and 1 year of follow-up. J Consult Clin Psychol 2000; 68:64.
- Silverman K, Higgins ST, Brooner RK, et al. Sustained cocaine abstinence in methadone maintenance patients through voucher-based reinforcement therapy. Arch Gen Psychiatry 1996; 53:409.
- Silverman K, Wong CJ, Umbricht-Schneiter A, et al. Broad beneficial effects of cocaine abstinence reinforcement among methadone patients. J Consult Clin Psychol 1998; 66:811.
- Silverman K, Robles E, Mudric T, et al. A randomized trial of long-term reinforcement of cocaine abstinence in methadone-maintained patients who inject drugs. J Consult Clin Psychol 2004; 72:839.
- Petry NM, Tedford J, Austin M, et al. Prize reinforcement contingency management for treating cocaine users: how low can we go, and with whom? Addiction 2004; 99:349.
- Petry NM, Peirce JM, Stitzer ML, et al. Effect of prize-based incentives on outcomes in stimulant abusers in outpatient psychosocial treatment programs: a national drug abuse treatment clinical trials network study. Arch Gen Psychiatry 2005; 62:1148.
- Petry NM, Martin B. Low-cost contingency management for treating cocaine- and opioid-abusing methadone patients. J Consult Clin Psychol 2002; 70:398.
- Peirce JM, Petry NM, Stitzer ML, et al. Effects of lower-cost incentives on stimulant abstinence in methadone maintenance treatment: a National Drug Abuse Treatment Clinical Trials Network study. Arch Gen Psychiatry 2006; 63:201.
- Budney AJ, Higgins ST, Radonovich KJ, Novy PL. Adding voucher-based incentives to coping skills and motivational enhancement improves outcomes during treatment for marijuana dependence. J Consult Clin Psychol 2000; 68:1051.
- Budney AJ, Moore BA, Rocha HL, Higgins ST. Clinical trial of abstinence-based vouchers and cognitive-behavioral therapy for cannabis dependence. J Consult Clin Psychol 2006; 74:307.
- Carroll KM, Easton CJ, Nich C, et al. The use of contingency management and motivational/skills-building therapy to treat young adults with marijuana dependence. J Consult Clin Psychol 2006; 74:955.
- Stanger C, Budney AJ, Kamon JL, Thostensen J. A randomized trial of contingency management for adolescent marijuana abuse and dependence. Drug Alcohol Depend 2009; 105:240.
- Petry NM, Martin B, Cooney JL, Kranzler HR. Give them prizes, and they will come: contingency management for treatment of alcohol dependence. J Consult Clin Psychol 2000; 68:250.
- Volpp KG, Gurmankin Levy A, Asch DA, et al. A randomized controlled trial of financial incentives for smoking cessation. Cancer Epidemiol Biomarkers Prev 2006; 15:12.
- Volpp KG, Troxel AB, Pauly MV, et al. A randomized, controlled trial of financial incentives for smoking cessation. N Engl J Med 2009; 360:699.
- Halpern SD, French B, Small DS, et al. Randomized trial of four financial-incentive programs for smoking cessation. N Engl J Med 2015; 372:2108.
- Cleary M, Hunt GE, Matheson S, Walter G. Psychosocial treatments for people with co-occurring severe mental illness and substance misuse: systematic review. J Adv Nurs 2009; 65:238.
- Drake RE, O'Neal EL, Wallach MA. A systematic review of psychosocial research on psychosocial interventions for people with co-occurring severe mental and substance use disorders. J Subst Abuse Treat 2008; 34:123.
- McDonell MG, Srebnik D, Angelo F, et al. Randomized controlled trial of contingency management for stimulant use in community mental health patients with serious mental illness. Am J Psychiatry 2013; 170:94.
- Azar MM, Springer SA, Meyer JP, Altice FL. A systematic review of the impact of alcohol use disorders on HIV treatment outcomes, adherence to antiretroviral therapy and health care utilization. Drug Alcohol Depend 2010; 112:178.
- Altice FL, Bruce RD, Lucas GM, et al. HIV treatment outcomes among HIV-infected, opioid-dependent patients receiving buprenorphine/naloxone treatment within HIV clinical care settings: results from a multisite study. J Acquir Immune Defic Syndr 2011; 56 Suppl 1:S22.
- Petry NM, Weinstock J, Alessi SM, et al. Group-based randomized trial of contingencies for health and abstinence in HIV patients. J Consult Clin Psychol 2010; 78:89.
- Ghitza UE, Epstein DH, Preston KL. Contingency management reduces injection-related HIV risk behaviors in heroin and cocaine using outpatients. Addict Behav 2008; 33:593.
- DeFulio A, Silverman K. The use of incentives to reinforce medication adherence. Prev Med 2012; 55 Suppl:S86.
- Petry NM, Rash CJ, Byrne S, et al. Financial reinforcers for improving medication adherence: findings from a meta-analysis. Am J Med 2012; 125:888.
- Haug NA, Sorensen JL, Gruber VA, et al. HAART adherence strategies for methadone clients who are HIV-positive: a treatment manual for implementing contingency management and medication coaching. Behav Modif 2006; 30:752.
- Higgins ST, Bernstein IM, Washio Y, et al. Effects of smoking cessation with voucher-based contingency management on birth outcomes. Addiction 2010; 105:2023.
- Higgins ST, Washio Y, Heil SH, et al. Financial incentives for smoking cessation among pregnant and newly postpartum women. Prev Med 2012; 55 Suppl:S33.
- Tappin D, Bauld L, Purves D, et al. Financial incentives for smoking cessation in pregnancy: randomised controlled trial. BMJ 2015; 350:h134.
- Prendergast M, Podus D, Finney J, et al. Contingency management for treatment of substance use disorders: a meta-analysis. Addiction 2006; 101:1546.
- Petry NM, Alessi SM, Marx J, et al. Vouchers versus prizes: contingency management treatment of substance abusers in community settings. J Consult Clin Psychol 2005; 73:1005.
- Petry NM, Alessi SM, Hanson T, Sierra S. Randomized trial of contingent prizes versus vouchers in cocaine-using methadone patients. J Consult Clin Psychol 2007; 75:983.
- Petry NM, Alessi SM, Barry D, Carroll KM. Standard magnitude prize reinforcers can be as efficacious as larger magnitude reinforcers in cocaine-dependent methadone patients. J Consult Clin Psychol 2015; 83:464.
- Olmstead TA, Petry NM. The cost-effectiveness of prize-based and voucher-based contingency management in a population of cocaine- or opioid-dependent outpatients. Drug Alcohol Depend 2009; 102:108.
- Roll JM, Higgins ST, Badger GJ. An experimental comparison of three different schedules of reinforcement of drug abstinence using cigarette smoking as an exemplar. J Appl Behav Anal 1996; 29:495.
- Roll JM, Higgins ST. A within-subject comparison of three different schedules of reinforcement of drug abstinence using cigarette smoking as an exemplar. Drug Alcohol Depend 2000; 58:103.
- Higgins ST, Badger GJ, Budney AJ. Initial abstinence and success in achieving longer term cocaine abstinence. Exp Clin Psychopharmacol 2000; 8:377.
- Higgins ST, Heil SH, Dantona R, et al. Effects of varying the monetary value of voucher-based incentives on abstinence achieved during and following treatment among cocaine-dependent outpatients. Addiction 2007; 102:271.
- Farronato NS, Dürsteler-Macfarland KM, Wiesbeck GA, Petitjean SA. A systematic review comparing cognitive-behavioral therapy and contingency management for cocaine dependence. J Addict Dis 2013; 32:274.
- Carroll KM, Nich C, Lapaglia DM, et al. Combining cognitive behavioral therapy and contingency management to enhance their effects in treating cannabis dependence: less can be more, more or less. Addiction 2012; 107:1650.
- Higgins ST, Sigmon SC, Wong CJ, et al. Community reinforcement therapy for cocaine-dependent outpatients. Arch Gen Psychiatry 2003; 60:1043.
- Petry NM, Alessi SM, Carroll KM, et al. Contingency management treatments: Reinforcing abstinence versus adherence with goal-related activities. J Consult Clin Psychol 2006; 74:592.
- Cunningham CS, Stitzer MS, Campbell AN, et al. Contingency management abstinence incentives: Cost and implications for treatment tailoring. J Subst Abuse Treat 2015.
- Campbell AN, Nunes EV, Matthews AG, et al. Internet-delivered treatment for substance abuse: a multisite randomized controlled trial. Am J Psychiatry 2014; 171:683.
- Stitzer ML, Petry N, Peirce J, et al. Effectiveness of abstinence-based incentives: interaction with intake stimulant test results. J Consult Clin Psychol 2007; 75:805.
- Petry NM, Barry D, Alessi SM, et al. A randomized trial adapting contingency management targets based on initial abstinence status of cocaine-dependent patients. J Consult Clin Psychol 2012; 80:276.
- Dennis ML, Foss MA, Scott CK. An eight-year perspective on the relationship between the duration of abstinence and other aspects of recovery. Eval Rev 2007; 31:585.
- Hser YI, Hoffman V, Grella CE, Anglin MD. A 33-year follow-up of narcotics addicts. Arch Gen Psychiatry 2001; 58:503.
- Petry NM. Contingency Management for Substance Abuse Treatment: A Guide to Implementing This Evidence-Based Practice, Taylor & Francis, New York, NY 2012.
- Petry NM, Alessi SM, Ledgerwood DM. A randomized trial of contingency management delivered by community therapists. J Consult Clin Psychol 2012; 80:286.
- Treatment attendance
- Drug abstinence
- - Stimulants
- - Cannabis
- - Alcohol
- - Tobacco smoking
- SUBGROUP CONSIDERATIONS
- Dual diagnosis
- Pregnant smokers
- Voucher versus intermittent prize reinforcement
- Escalating versus fixed schedules
- Behavioral therapy platform
- Treatment tailoring
- - Remitted versus active drug users
- Multple drugs
- Treatment duration
- SUMMARY AND RECOMMENDATIONS