Training efforts should directly address concerns about CM, including issues related to motivation to change and its durability. They should emphasize that long-term change is not possible without first achieving abstinence and no psychosocial intervention does as well as CM in promoting abstinence during treatment. Furthermore, aligning reinforcement principles with 12-step and standard care procedures is key, as well as emphasizing its effects in virtually all patient populations (see Petry, 2012). Kropp, Lewis, and Winhusen (2017) provide an example of an implementation effort to integrate CM with 12-step treatment, and voices from non-research perspectives may be more convincing to clinicians than technical research reports. Other examples of implementation efforts provide valuable information on how CM can be tailored to unique needs of a clinic and population (Fitzsimons, Tuten, Borsuk, Lookatch, & Hanks 2015; Hartzler 2015; Kellogg et al., 2005; Lott & Jencius 2009; Petry et al., 2014; Sigmon & Stitzer 2005; Squires et al., 2008; Walker et al., 2010).
It will enhance the individual’s desire for longer stretches of abstinence while still providing the subconscious benefits of the conditioning. Importantly, this CM benefit may be provided over and above the empirically supported combination of Motivational Enhancement Therapy and Cognitive Behavioral Therapy (MET/CBT). Unique to adolescent CM approaches is that parents are typically trained in the rationale and delivery of CM interventions. Parents efforts to reinforce abstinence can be in addition to rewards received for negative https://sober-home.org/ toxicology screens by the treatment program. Some programs object to implementing CM on the grounds that it could be classified as “a game of chance.” In some CM interventions, for example, participants pick tickets out of a fishbowl after a negative toxicology screen, but only some of the tickets have prizes, and these prizes range in value. In Contingency Management (CM) interventions, patients receive a reward for meeting a treatment goal or, in some cases, a negative consequence if the individual is unable to meet this goal.
- Despite decades of rigorous clinical trials and robust meta-analyses showing considerable benefits for contingency management interventions, a number of barriers precluding widespread adoption persist.
- He has a particular interest in psychopharmacology, nutritional psychiatry, and alternative treatment options involving particular vitamins, dietary supplements, and administering auricular acupuncture.
- In these cases, rather than sending the person to jail for a length of time, the individual is allowed to live at home but is required to remain abstinent from alcohol.
- Please also list any non-financial associations or interests (personal, professional, political, institutional, religious or other) that a reasonable reader would want to know about in relation to the submitted work.
- A recent meta-analysis of studies where treatment providers targeted attendance behaviours, either in isolation or in combination with targeting abstinence, found that only one study was conducted outside of the U.S. [42].
- Contingency management is just one approach used in treatment and recovery from alcohol or other drug addictions.
Cognitive evaluation theory proposes that external reinforcers, that shift causality from internal factors to those outside the person, reduce feelings of autonomy and competence necessary for behavior change (Deci & Ryan 1985; Ryan & Deci 2000). Accordingly, this theory predicts behavior should return to its initial state once reinforcers are removed (Deci, Koestner, & Ryan 1999). Petry NM, Martin B (in press), Lower cost contingency management for treatment cocaine and opioid abusing methadone patients.
Variations of Contingency Management Programs
Gift cards or reloadable credit cards are often used as they serve as a flexible reward, allowing the youth to select personalized rewards that vary over time. Effective monitoring of the targeted behavior is essential to a CM program, because consequences (reinforcement or punishment) must be applied systematically in order to be effective. When abstinence is the target behavior, this typically involves some form of biochemical verification, usually via urinalysis testing.
A vast amount of empirical evidence indicates the efficacy of contingency management for treating substance use disorders. In the contingency management group, individuals earned at least one draw with a chance of winning a prize ranging from US$1 to 100 in value for each stimulant-negative sample submitted, and number of draws earned increased with weeks of consecutive abstinence. About half of the sample were recruited from psychosocial (non-methadone) and half from methadone clinics. In the psychosocial clinics,Reference Petry, Peirce, Stitzer, Blaine, Roll and Cohen3 contingency management significantly enhanced retention in treatment, with 49% of the contingency management group completing 12 weeks of treatment v. only 35% the of standard care group. The mean number of weeks of consecutive abstinence from stimulants was 4.4 for those assigned to contingency management v. 2.6 for those assigned to standard care. The percentage of individuals who sustained stimulant abstinence throughout the full 12 weeks was nearly 4 times greater for the contingency management condition (18.7% v. 4.9%).
The duration of reinforcement(s)
Adoption of technology-enabled contingency management solutions, that reward more than simply negative drug screens to include additional recovery-oriented behaviours [42,43], is a requisite if enhanced rates of adherence and engagement, as well as quality of life improvements are to be achieved. Acceptance and uptake of reward-based interventions empirically shown to improve adherence to life-saving medications and retention in OUD treatment have the potential to curb the devastation currently felt by the ongoing opioid overdose crisis and ultimately save lives. Academic researchers and industry professionals have unique, often complementary skillsets and resources that, when pooled together, have a real shot at turning the tide on the overdose crisis. Such collaboration will inevitably have a considerably greater impact at-scale on individuals and families affected by OUD than ever thought possible in their own siloed efforts. As America’s tragic overdose death toll continues to rise, we have also seen a number of technological advancements emerge in recent years, suggesting the time is now to rapidly accelerate the development and testing of innovative contingency management solutions. Despite decades of research supporting the effectiveness of contingency management and generally positive beliefs held by front-line addiction treatment providers and patients alike [23,24], its application in real-world clinical settings is limited for a variety of reasons; many of which, as this paper will demonstrate, can be overcome.
In implementation science more generally, Damschroder and Hagedorn (2011) likewise note the need to adapt evidence-based practices to the broader context, distinguishing the core from the adaptable components. It is also critical that contingency management researchers continue to expand on existing work to explore the feasibility and effectiveness of rewarding additional recovery-oriented behaviours beyond negative urinalysis drug screens. Finally, despite positive preliminary findings from several recent studies testing innovative technology-enabled solutions leveraging contingency management for OUD, additional rigorous, large-scale trials are needed, particularly with more racially and culturally diverse, underserved populations. Although there has been a proliferation of mobile apps for OUD in recent years [63,64], only a select few reward-based solutions have empirical evidence of preliminary effectiveness published in peer-reviewed journals [20,28], underscoring the need for greater collaboration between academic researchers and technology startups involved in the OUD treatment space. Barriers to widespread adoption of contingency management in routine clinical practice, although pervasive, can be overcome. A number of innovative technologies, as described below, now allow for many aspects of contingency management to be fully or partially automated, thereby addressing common logistical barriers to implementation.
A 2013 study on patients with dependence on marijuana showed improvement in all patients for a duration extending to 14 months. In the management of psychological conditions such as addiction, various therapies and techniques can be used to break the hold that the condition has on the individual. Clinical treatment settings have not widely embraced CM for reasons ranging from philosophical to theoretical and practical. One of the most important skills in delivering CM is being able to effectively communicate behavior expectations and work with patients to make sure they clearly understand those expectations.
Contingency Management: The Pros, Cons, and Details
Focusing on behaviors that can derive reinforcement from the natural environment, such as is apparent with housing and employment, may result in persistence of the behavior pattern even after participation in the research study is completed. The schedule of reinforcement or punishment refers to the temporal relation between the target behavior and the delivery of the consequence. Generally, efficacy is likely to improve as the temporal delay between the occurrence of the target behavior and delivery of the consequence decreases. For example, all else being equal, providing positive reinforcement for drug abstinence on the same day on which a youth submits a negative urine specimen would likely be more effective than waiting a week before reinforcement is delivered.
Recognizing the value of academic-industry collaboration, NIDA’s Small Business Technology Transfer (STTR) Program offers grant funding ranging from $150 K for Phase I up to $3 M for Phase II to foster technology transfer through cooperative R&D between academic researchers from non-profit universities and for-profit small business startups. A true bi-directional approach has the potential to shape and inform scientific research questions with an eye towards real-world challenges to implementation, ultimately improving contingency management solutions. The U.S. digital health market is in the midst of considerable growth with total venture capital invested through mid-2021 at nearly $15 billion [65], surpassing last year’s record total funding in only six months. As funding continues to pour in for digital sober house boston health startups, partnerships between the tech industry and academia are as important as ever to establish high-quality evidence of effectiveness from rigorous yet feasible pilot studies and publish findings in reputable peer-reviewed journals. Clinical researchers—and their distinctive skillset and depth of training in such areas as research design, methodology, statistical analysis, clinical interviews, focus groups, grant writing, and publishing—are uniquely positioned to bring a lot of added value to digital health companies in a scientific advisor/consultant role or by serving on boards. This is of paramount importance given that the overwhelming majority of digital health “unicorns” (i.e. companies valued at over $1 billion) lack any peer-reviewed papers supporting their products [66].