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Contingency Management

    Contingency Management

    Contingency management, also known as motivational incentives, is a form of addiction treatment that offers rewards for positive behaviour such as providing drug-free urine samples, attending medical appointments and taking various other steps towards recovery. [1]

    These incentives can include cash prizes, supermarket vouchers and movie passes.

    This form of treatment is based on the idea that human behaviour can be modified if rewards are awarded for certain actions. If we know we will receive the desired item on completion of an unappealing task, we are much more likely to successfully complete that task. [2]

    Substances such as heroin and cocaine can provide an immediate reward in the form of euphoric and pleasurable feelings while entering addiction recovery can appear unappealing as patients will likely experience withdrawal symptoms and potentially be required to cut contact with certain friends or family members.

    To combat this, contingency management provides an incentive for patients to commit to a treatment programme and begin the recovery process.

    As it does not treat the root cause of the addiction, it is recommended that contingency management should be used in conjunction with other forms of treatment such as cognitive behavioural therapy to increase the chances of long-term abstinence.

    Types of contingency management programmes

    Contingency management typically falls into two main methods of treatment: voucher-based reinforcement and prize incentives.

    1. Voucher-based reinforcement

    During voucher-based reinforcement, also known as VBR, patients will receive one voucher each time they successfully present a sample of drug-free urine or attend a mandated activity. These vouchers may be in the form of movie passes, supermarket tokens and other useful activities with an initially low value that increases each time the patient produces a successful sample.

    If the patient relapses or fails to attend an activity, the voucher value will be reset to the original amount.

    2. Prize incentives

    Similar to the above treatment method, patients have the chance to win cash prizes (usually with a value of between $1 and $100) each time they present a sample of drug-free urine or attend a mandated activity.

    This is often seen in the form of a prize draw with the patient choosing a number at random. Initially, they will be given one chance per successful sample, but over the course of the treatment, they will receive a greater number of chances.

    As above, this number will be reset to one if the patient fails to attend an activity or provides a positive sample.

    Which addictions can contingency management help to treat?

    While this form of treatment has yet to gain traction in the United Kingdom, it has found some success in the US particularly when combined with other therapy methods such as cognitive behavioural therapy.

    Contingency management has proven to be effective at treating a range of addictions including:

    • Alcohol
    • Cannabis
    • Cocaine
    • Nicotine
    • Opioids

    It can also be helpful in reinforcing positive behaviours that can lead to addiction recovery such as attending therapy sessions and other appointments as well as receiving necessary medical treatment.

    What are the main principles of contingency management?

    There are seven key principles of contingency management, all of which contribute to a successful treatment programme that can be personalised for each individual.

    Below is a short explanation of each of the seven main principles of contingency management:

    1. Behaviour identification

    Identifying the specific behaviour/s that require reducing or increasing is the first step toward establishing a successful treatment programme. Examples of behaviours to be reduced include the purchase and use of substances, while behaviours to be increased include therapy attendance and relationship management.

    2. Client choice

    Contingency management may not be required in some cases, as the patient has sufficient levels of motivation without the help of a tangible incentive. It is important to identify the patients who will most benefit from this treatment, such as those who have struggled to maintain abstinence in the past.

    3. Reward selection

    The chosen reward must be of an equal or greater incentive than the short-term pleasure gained by ingesting substances. If the patient does not desire the reward, they will have little motivation to change their behaviour.

    4. Economical consideration

    There is a limit as to the potential value of the incentive, as it would not be practical to offer expensive prizes such as cars and electronics. There is a fine balance between practical and desirable, and this may vary between patients depending on their level of addiction and personal motivation.

    5. Frequency of reward

    Some individuals may respond well to frequent and regular rewards, while others may benefit from more unpredictable incentives. Some experimentation may be required in order to arrive at the most optimal frequency.

    6. Timing of reward

    It is thought that patients respond best to treatment when the reward is given immediately on completion of the contingent behaviour. Therefore, it is important to ensure that the rewards are available in a timely manner and in advance of each treatment session.

    7. Length of treatment

    The aim of this method of treatment is to eventually raise the patient’s motivation levels to a point in which they no longer require a reward in order to continue the positive behaviour change. Each patient will have individual motivation levels, so care must be taken to ensure the length of treatment is sufficient in each case.

    Is contingency management effective in treating addiction?

    Contingency management is relatively unexplored when compared to many other forms of addiction treatment, but initial studies have shown this form of treatment to be effective at treating a range of substance abuse disorders.

    It is widely believed that many individuals struggling with addiction prefer short-term rewards as opposed to delayed gratification. The immediate effects of substances such as heroin and cocaine are therefore more appealing than the uncomfortable and difficult road to recovery despite the knowledge that abstinence would be far preferable in the long term.

    In these cases, contingency management is effective as it provides small, immediate rewards while still working towards the long-term reward of abstinence. Studies have shown that individuals were more likely to avoid relapse and continue with treatment when contingency management methods were used, with participants twice as likely to complete treatment and three times more likely to produce drug-free urine even two months later. [2]

    What are the most common criticisms of contingency management?

    Despite the proven effectiveness of the contingency management programme, concerns have been raised surrounding the potential ethical and economical consequences of this method of treatment.

    1. Undermines motivation

    As contingency management provides tangible rewards and incentives to refrain from substance use, there is a concern that patients may relapse back into substance abuse once the treatment has ended – particularly if their sole motivation to recover was based on receiving vouchers and cash prizes.

    However, there is no evidence to suggest that patients receiving contingency management treatment are more likely to relapse once the programme has ended, particularly when the treatment has been combined with another form of therapy.

    Instead, this should be taken as yet more evidence towards the overarching obstacle of relapse that is present in every form of addiction treatment.

    2. Expensive

    The incentive-based aspect of contingency management has proven to be expensive to maintain, with one estimate placing the overall value of the prizes at $600 per patient over the duration of the treatment programme in order to be effective. [2]

    These costs may be unappealing or unsustainable for government assistance programmes and insurers, with further studies needed to determine whether the value of the incentives could be lowered without undermining the effectiveness of this form of treatment.

    3. Promotes gambling

    Concerns have been raised regarding the gambling-based aspects of this form of treatment, particularly the method in which patients receive chances to win cash prizes. There is the potential for the development of detrimental gambling behaviours if this method is used on individuals who may be predisposed to this condition.

    However, some studies refute this suggestion with gambling behaviours observed in individuals who participated in contingency management and conclude that no increase was reported. [3]

    4. Potentially unethical

    Contingency management could be viewed as a form of bribery, with critics likening it to the act of paying criminals not to commit crimes. The ethical implications of providing incentives and cash prizes to people with substance use disorders evoke feelings of discomfort in many people.

    However, positive reinforcement and reward incentives are acceptable methods in various other situations including employment, child-rearing and autism management. This reveals that the levels of discomfort around contingency management may be rooted in emotions as opposed to the treatment’s effectiveness within the addiction recovery model.

    While this form of treatment has yet to gain a foothold in the United Kingdom, contingency management has proven to be an effective method of addiction treatment for various substance use disorders including cocaine, alcohol and cannabis abuse.

    It is most effective when combined with other forms of therapy and has had success with patients who are in the early stages of addiction recovery. Contingency management looks to be a promising option for those struggling with substance use disorder and should not be easily dismissed, despite the relatively few studies conducted in the UK.

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