UpToDate
Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate®

Contingency management for substance use disorders: Theoretical foundation, principles, assessment, and components

Authors
Maxine Stitzer, PhD
Colin S Cunningham, PhD
Mary M Sweeney, PhD
Section Editor
Andrew J Saxon, MD
Deputy Editor
Richard Hermann, MD

INTRODUCTION

Contingency management is a powerful tool in the treatment of patients with substance use disorders (SUD), particularly those for which pharmacotherapy is unavailable or only partially effective. Contingency management is typically delivered as an augmentation to psychosocial treatment such as group addiction counseling cognitive-behavioral therapy delivered in the context of an addiction treatment program.

Contingency management provides incentives to SUD patients contingent upon treatment attendance and/or verified drug abstinence in order to increase the likelihood of these behaviors, which are essential components and outcomes of effective treatment. Contingency management interventions can be customized to address patient preferences or program needs, such as the resources available for the intervention.

This topic describes the theory, principles, assessment, and components of contingency management for use in SUD treatment. Efficacy, implementation, and training for contingency management are discussed separately. Other SUD treatments, including for specific substances and continuing care models, are discussed separately. (See "Contingency management for substance use disorders: Efficacy, implementation, and training" and "Pharmacotherapy for alcohol use disorder" and "Psychosocial treatment of alcohol use disorder" and "Treatment of cannabis use disorder" and "Pharmacotherapy for stimulant use disorders in adults" 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".)

THEORETICAL FOUNDATION

Contingency management is based on the principles of operant conditioning, a type of learning in which positive consequences (also called reinforcers) sustain and increase frequency of the behavior that produces them. From this perspective, drug use is conceptualized as operant behavior motivated and maintained by the biological reinforcing effects of drugs, which include their euphoric subjective effects or relief from withdrawal symptoms. In this conceptual model, contingency management works by enhancing the positive consequences of drug abstinence through alternative sources of reinforcement that compete with continued substance use.

In the natural environment, positive consequences of drug abstinence may be remote and uncertain (eg, better health, repaired relationships, social productivity) relative to the immediate psychological and physiological effects of using drugs. Contingency management interventions motivate and maintain drug abstinence by providing the drug user with earlier, more salient, and more predictable positive consequences for abstaining from drugs. As examples, monetary-based reinforcers such as tangible prizes or vouchers exchangeable for retail goods have been offered to patients with substance use disorders (SUDs) based on their achievement of objectively measured, agreed-upon goals, particularly drug abstinence as demonstrated by drug-negative urine tests.

                 

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Jun 2017. | This topic last updated: Jul 13, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
References
Top
  1. 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.
  2. 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.
  3. Barnett NP, Tidey J, Murphy JG, et al. Contingency management for alcohol use reduction: a pilot study using a transdermal alcohol sensor. Drug Alcohol Depend 2011; 118:391.
  4. Dougherty DM, Lake SL, Hill-Kapturczak N, et al. Using contingency management procedures to reduce at-risk drinking in heavy drinkers. Alcohol Clin Exp Res 2015; 39:743.
  5. Barnett NP, Celio MA, Tidey JW, et al. A preliminary randomized controlled trial of contingency management for alcohol use reduction using a transdermal alcohol sensor. Addiction 2017; 112:1025.
  6. McDonell MG, Howell DN, McPherson S, et al. Voucher-based reinforcement for alcohol abstinence using the ethyl-glucuronide alcohol biomarker. J Appl Behav Anal 2012; 45:161.
  7. McDonell MG, Leickly E, McPherson S, et al. A Randomized Controlled Trial of Ethyl Glucuronide-Based Contingency Management for Outpatients With Co-Occurring Alcohol Use Disorders and Serious Mental Illness. Am J Psychiatry 2017; 174:370.
  8. Alessi SM, Petry NM. A randomized study of cellphone technology to reinforce alcohol abstinence in the natural environment. Addiction 2013; 108:900.
  9. Alessi SM, Rash CJ, Petry NM. A Randomized Trial of Adjunct mHealth Abstinence Reinforcement With Transdermal Nicotine and Counseling for Smoking Cessation. Nicotine Tob Res 2017; 19:290.
  10. Stoops WW, Dallery J, Fields NM, et al. An internet-based abstinence reinforcement smoking cessation intervention in rural smokers. Drug Alcohol Depend 2009; 105:56.
  11. Dallery J, Raiff BR, Kim SJ, et al. Nationwide access to an internet-based contingency management intervention to promote smoking cessation: a randomized controlled trial. Addiction 2017; 112:875.
  12. Dempsey JP, Back SE, Waldrop AE, et al. The influence of monetary compensation on relapse among addicted participants: empirical vs. anecdotal evidence. Am J Addict 2008; 17:488.
  13. Festinger DS, Marlowe DB, Dugosh KL, et al. Higher magnitude cash payments improve research follow-up rates without increasing drug use or perceived coercion. Drug Alcohol Depend 2008; 96:128.
  14. 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.
  15. Lussier JP, Heil SH, Mongeon JA, et al. A meta-analysis of voucher-based reinforcement therapy for substance use disorders. Addiction 2006; 101:192.
  16. 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.
  17. 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.
  18. Higgins ST, Budney AJ, Bickel WK, et al. Incentives improve outcome in outpatient behavioral treatment of cocaine dependence. Arch Gen Psychiatry 1994; 51:568.
  19. Petry NM, Martin B. Low-cost contingency management for treating cocaine- and opioid-abusing methadone patients. J Consult Clin Psychol 2002; 70:398.
  20. 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.
  21. 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.
  22. 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.
  23. Hayes SC, Barlow DH, Nelson-Gray RO. The Scientist Practitioner: Research and Accountability in the Age of Managed Care, 2nd, Allyn & Bacon, Boston, MA 1999.
  24. Tuten ML, Jones HE, Schaeffer CM, Stitzer ML. Reinforcement-Based Treatment for Substance Use Disorders, American Psychological Association Press, Washington, DC 2012.
  25. Motivational Incentives: A proven approach to treatment. National Institute of Drug Abuse. http://www.bettertxoutcomes.org (Accessed on April 28, 2015).