Contingency management for substance use disorders: Theoretical foundation, principles, assessment, and components
- Maxine Stitzer, PhD
Maxine Stitzer, PhD
- Professor of Psychiatry and Behavioral Sciences
- Johns Hopkins University School of Medicine; Bayview Medical Center
- Colin S Cunningham, PhD
Colin S Cunningham, PhD
- Baltimore, MD
- Mary M Sweeney, PhD
Mary M Sweeney, PhD
- Instructor of Psychiatry and Behavioral Sciences
- Johns Hopkins University School of Medicine; Bayview Medical Center
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".)
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.
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- THEORETICAL FOUNDATION
- Target behaviors
- - Treatment session attendance
- - Drug abstinence
- Drug testing
- - Stimulants, opiates, marijuana
- - Alcohol
- - Tobacco smoking
- Reinforcement methods
- - Voucher reinforcement
- - Intermittent prize-based reinforcement
- Base treatment