Chapter 27. Contingency Management

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Chapter 27. Contingency Management

CONTINGENCY MANAGEMENT: INTRODUCTION

Contingency management (CM) treatments for substance use disorders (SUDs) have been in the published literature since

the 1960s but have achieved a higher profile within the past two decades (see Higgins et al. 2008). CM treatments can

vary in many respects, but the central feature common to all of them is the systematic application of reinforcing or

punishing consequences in order to achieve therapeutic goals. With regard to treatment of SUDs, CM most commonly

involves the systematic application of positive reinforcement to increase abstinence from drug use, an approach referred

to as abstinence reinforcement therapy, but also to facilitate other therapeutic changes, including retention in treatment,

attendance at therapy sessions, and compliance with medication regimens. Typically, CM is used as part of a more

comprehensive treatment intervention. Below we outline the scientific rationale underlying this treatment approach,

discuss the basic elements of CM, and discuss its treatment efficacy and effectiveness.

Preparation of this manuscript was supported by research grants DA09378, DA14028, and DA08076 (Higgins); and DA13107, DA19386,

and DA19497 (Silverman) from the National Institute on Drug Abuse.

SCIENTIFIC RATIONALE

CM is a generic behavioral intervention based on the principles of operant conditioning, namely reinforcement and

punishment. The idea of using behavioral interventions to treat SUDs is quite rational considering the extensive empirical

evidence demonstrating that operant conditioning plays an important role in the genesis and maintenance of repeated

drug use and dependence (e.g., Higgins et al. 2004a). There is an extensive basic science literature going back to the

1940s showing that abused drugs will function as unconditioned positive reinforcers for laboratory animals in the same

way that food, water, and sex do. Laboratory animals readily learn arbitrary operant responses, such as pressing a lever

or pulling a chain, when the only consequence for doing so is the receipt of an injection of a prototypical drug of abuse

such as amphetamines, barbiturates, cocaine, or morphine. Laboratory animals not only will voluntarily ingest abused

drugs but, when given unconstrained access to cocaine and related drugs, they will consume them to the exclusion of

basic sustenance and to the point of overdose and death. There is a growing understanding of the neurobiology of these

drug-produced reinforcing effects, which appear to depend critically on effects in the mesolimbic dopamine system.

This basic research has also revealed that, while drug-produced reinforcement is powerful, it is also malleable and

sensitive to environmental context (Higgins et al. 2004a). For example, alterations in the schedule of drug availability,

increases in how much the subject has to work in order to obtain the drug, and increases in the availability of alternatives

to drug use can all produce orderly reductions in drug consumption. That is true with laboratory animals and with

drug-dependent human research subjects as well. In fact, a highly regarded series of studies conducted in the 1970s

demonstrated this point with individuals with severe alcoholism (e.g., Bigelow et al. 1975). In these studies, alcoholic

subjects resided on a hospital unit where they were permitted to purchase and consume alcohol under medically

supervised conditions. Abstinence from voluntary drinking increased when 1) access to an alternative reinforcer (i.e., an

enriched ward environment) was made available contingent on doing so, 2) monetary reinforcement was provided

contingent on abstinence from alcohol consumption, 3) the cost of drinking in the form of the amount of work required to

purchase the alcohol was increased, and 4) brief periods of social isolation were imposed contingent on drinking. Each of

these outcomes followed from predictions based on alcohol use being a form of operant responding, which by definition is

sensitive to environmental consequences. More recent studies conducted with cocaine and opioid abusers, marijuana

abusers, and cigarette smokers have similarly conformed to predictions based on operant conditioning and demonstrated

sensitivity of these different forms of drug use to systematically arranged environmental consequences (Higgins et al.

2004a).

An obvious question is, if drug use is so sensitive to environmental consequences, why is it that individuals continue

abusing drugs despite the many horrific adverse consequences that they experience? There are many answers to that

question, but here are three important ones to consider. First, many individuals do respond to adverse consequences; that

is, the majority of those who experiment with drug use, including the use of highly addictive drugs like cocaine, do not go

on to become dependent, and many of those who do become dependent resolve their problem without professional

treatment. Also, those drug-dependent individuals who seek treatment often do so following some untoward health or

social consequences related to their drug abuse. A safe assumption is that naturalistic reinforcement and punishment

contingencies are operative in these scenarios. Second, the reinforcing effects of drugs are relatively immediate and

reliable, while associated adverse consequences are typically more delayed and intermittent. Temporal delays and

inconsistent delivery weaken the effect of behavioral consequences. These features would favor a greater influence by the

reinforcing effects of abused drugs than by their adverse effects. Third, recent research has revealed potentially important

individual differences with regard to sensitivity to temporal delays that may be involved in vulnerability to drug

dependence (see Bickel and Marsch 2001). A normal aspect of our biological makeup is a preference for more immediate

over delayed reinforcement, all else being equal. Such a bias would have had obvious survival advantage in our

evolutionary history. However, as with most everything biological, there is variability in this characteristic, and

accumulating evidence indicates that individuals with SUDs discount the value of delayed consequences to a significantlyPrint: Chapter 27. Contingency Management http://www.psychiatryonline.com/popup.aspx?aID=353782&print=yes…

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greater extent than do nonabuser matched controls (Bickel and Marsch 2001). That is, individuals with SUDs, more so

than those without, are more biased toward immediate reinforcement than delayed reinforcement, even when the more

immediate option is of lesser value. Note that such a bias can be expected to work against recovery from SUDs, as the

benefits of quitting drug use in terms of improved health, marriage, or vocation are going to be delayed in time relative to

the immediate reinforcing effects that will follow in short order from a return to drug abuse. Indeed, in one of the first

studies to look into this matter, greater discounting of delayed monetary reinforcement assessed upon treatment entry

predicted postpartum relapse to smoking among women who quit smoking during pregnancy (Yoon et al. 2007). This

relationship held even though the antepartum baseline assessment of delayed discounting was conducted almost 1 year

prior to the 6-month postpartum assessment, when most relapse to smoking was noted.

Overall, when considered together, the extensive literature supporting an important role of operant conditioning in drug

use, the sensitivity of drug use to systematically delivered environmental consequences, and a possible bias of

drug-dependent individuals toward immediate rather than delayed reinforcement all suggest that CM should be quite

useful in the treatment of SUDs. In order to drive recovery, CM interventions use the same reinforcement process that

drives repeated drug use. As is discussed in the following section, CM programs are designed to produce frequent,

relatively immediate positive reinforcement for abstaining from drug use, rather than relying exclusively on more delayed

naturalistic reinforcing consequences of recovery. This can be thought of as tailoring treatment to the known

characteristics of the patient population. As is outlined below, the extant evidence on the efficacy of CM interventions for

improving treatment outcomes across a wide range of different types of SUDs, populations, and settings suggests that the

reinforcement process has as important a role to play in recovery from drug abuse as it does in its genesis and

maintenance (Lussier et al. 2006).

BASIC ELEMENTS OF CM

Before we turn to the literature on the efficacy of CM interventions for SUDs, some discussion of the basic elements of

these interventions is warranted. A brief discussion is sufficient since these basic elements have been outlined elsewhere

(e.g., Higgins et al. 2008). Briefly, CM interventions promote behavioral change through the use of one of the following

generic types of contingencies administered alone or in combination.

Positive reinforcement. The delivery of a reinforcing consequence (e.g., a monetary voucher) contingent on meeting a

therapeutic goal (e.g., abstinence from recent drug use).

Negative reinforcement. The removal or a reduction in the intensity of an aversive event (e.g., job suspension) contingent on

meeting a therapeutic goal (e.g., successful completion of treatment).

Positive punishment. The delivery of an aversive event (e.g., social reprimand) contingent on evidence of the occurrence of a

therapeutically undesirable response (e.g., failure to attend therapy sessions).

Negative punishment. The removal of a positive condition (e.g., forfeiture of clinic privileges) contingent on the occurrence of an

undesirable response (e.g., resumption of drug use).

Reinforcement and punishment interventions are effective with SUDs, but the latter are disliked by patients and staff and

can inadvertently increase treatment dropout. The evidence suggests that CM interventions that are composed largely of

high rates of positive reinforcement along with judicious use of occasional negative punishment can be very effective at

retaining patients in treatment, reducing drug use, and improving other therapeutic outcomes (Lussier et al. 2006).

To be effective, CM interventions need to be carefully designed and implemented—with CM, the details matter. Below are

10 points to consider when designing an effective CM intervention.

1. Use a written contract. A written contract is recommended.

Operationally define the therapeutic target. For example, when using a CM intervention to reinforce cocaine abstinence, the target

would be abstinence from recent cocaine use as defined by a cocaine-negative urine toxicology result.

2.  

Stipulate the schedule on which progress will be monitored. The schedule for monitoring progress should be well specified.

Staying with the example of a CM intervention for cocaine abstinence, the schedule might be a three-times-a-week (Monday,

Wednesday, Friday) assessment of recent cocaine use.

3.  

Schedule frequent opportunities for patients to experience the programmed consequences. CM interventions are designed to

promote new behavior while decreasing the frequency of well-learned behavior. As in any learning experience, repetition is

important. The thrice-weekly schedule mentioned above has been effective in reinforcing abstinence from cocaine and opioid

abuse. When designing the frequency of monitoring, one should consider practical issues, such as the half-life of the drug in

question.

4.  

Objectively verify that the target response occurred. The methods for verifying that the target response occurred must be

specified and should be objective; reliance on patient self-reports would not be adequate for these purposes. Furthermore,

because many individuals with SUDs have lost the confidence of family, friends, and employers in their veracity by the time they

enter treatment, objective monitoring of abstinence has the added benefit of providing an effective means to reduce suspicion

about their progress in treatment and to rebuild respect among their significant others. For CM interventions to be effective they

must be precise, and that is only possible when there is precision in determining whether the target response occurred. In

applications with SUDs, objective and precise verification typically entails some form of testing for biological markers of recent

drug use—for example, urine toxicology testing with specimen collection observed by a same-sex staff member would be

conducted at the thrice-weekly assessments.

5.  

When feasible, target single rather than multiple responses. CM interventions that focus on a single target (e.g., cocaine

abstinence) produce larger treatment effects on average than those that have multiple targets (e.g., abstinence from multiple

substances; Lussier et al. 2006). This appears to be simply a matter of trying to have a reasonable balance between the

behavioral change that is being targeted and the magnitude of the consequence being delivered.

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Specify what consequences will follow when the target response occurs and when it does not occur. The consequences that will

follow success and failure to emit the target behavior need to be made clear. For example, cocaine-negative urine toxicology

results would earn a voucher with a specified monetary value that can be used to purchase retail items in the community.

Cocaine-positive urine toxicology results would result in no voucher and a recommendation to meet with one’s counselor as soon

as possible. The exact schedule of voucher earnings over the course of the intervention would be specified.

7.  
8. Specify the duration of the contract. For example, the voucher program would be operative from weeks 1 through 12 of treatment.

Minimize delays in delivering consequences following verification. Delays weaken behavioral consequences. Delivering the

consequence on the same day that occurrence of the target response is verified produces larger treatment effects than delivering

the consequence on the next day or later (Lussier et al. 2006). Treatment outcome studies have not shown whether differences in

response occur as a function of still further delays. Human laboratory studies suggest that the size of the treatment effect would

progressively decrease as the length of the delay increased, until a delay was reached beyond which efficacy would disappear (see

Higgins et al. 2004a).

9.  

Use a consequence of sufficient magnitude or intensity to function as an effective reinforcer or punisher. On average, larger-value

incentives produce larger treatment effects (Lussier et al. 2006).

10.  

With respect to the last point in the list above, it is important to note that the magnitude of reinforcement or punishment

necessary to change behavior will depend on the nature of the behavioral change involved and the patient population,

among other things. We know empirically that larger-value reinforcement on average results in larger treatment effects,

with effect size varying in a graded manner across daily incentive values of less than $5, $5–$10.99, $11–$16, and greater

than $16 (Lussier et al. 2006). Direction in choosing appropriate incentive magnitudes for the various populations and

types of therapeutic targets with which one may be working is best obtained by consulting previously published studies

involving those populations and therapeutic targets (or at least close approximations of them). The CM literature is

sufficiently large at this time that there should not be situations where one cannot find a relevant study or two that

provides at least some initial guidance in selecting appropriate parameters. Thereafter, some initial pilot testing of the

new intervention with the targeted clinical population is essential to working out unforeseen problems and fine-tuning the

parameters. The effects on treatment of SUDs of varying the intensity of punishment have not been assessed in any

systematic manner in the CM literature, because of the sparse use of all but minimal punishment interventions. Based on

the basic operant literature, effect size can be expected to vary as a function of the intensity of the punishment, and if the

research calls for a higher-intensity punishment, it is best to implement it early in the intervention rather than gradually

escalating intensity, which fosters habituation.

THE EVOLUTION OF A TREATMENT APPROACH: TREATMENT OUTCOME STUDIES ON

CONTINGENCY MANAGEMENT AND SUDS

Early CM Applications

As is typical of treatment development, early reports on the use of CM to treat SUDs first appeared in the form of

uncontrolled case studies in which, for example, smokers earned back portions of a monetary deposit contingent on

remaining abstinent from smoking, amphetamine abusers earned retail items donated by community businesses

contingent on drug abstinence, or individuals with chronic alcoholic dependence earned coupon booklets contingent on

submitting alcohol-negative breath specimens. A particularly impressive seminal controlled study in this area was

reported by Miller (1975). In this study, 20 homeless men with severe alcohol dependence were randomly assigned to a

control condition or CM intervention. Those in the control condition received the usual social services in the form of food,

clothing, and housing, while those in the CM condition received those same services as long as they sustained abstinence,

verified through breath alcohol testing and observation of signs of gross intoxication. Evidence of drinking resulted in a

5-day suspension from such services. Arrests for public drunkenness decreased and days of employment increased among

those in the contingent condition compared with the control condition.

These impressive findings were not followed up in the published literature in any systematic manner, but CM began to be

pursued as a treatment for other types of SUDs. Several controlled studies reported that abstinence levels increased when

cigarette smokers had to submit monetary deposits that they earned back in portions contingent on remaining abstinent

(e.g., Bowers et al. 1987). Other investigators reported controlled studies demonstrating that contingent cash payments

increased abstinence from cigarette smoking (e.g., Stitzer and Bigelow 1982). Large-scale workplace and community

incentive-based interventions for smoking cessation also appeared in the 1980s; however, results from those

interventions were not encouraging, most likely because of a failure by investigators to adhere to the points listed in the

numbered list earlier in this chapter, especially the points regarding reinforcement magnitude and frequency in the

monitoring of abstinence. For a more detailed examination of CM and smoking, see a review by Sigmon et al. (2008).

A particularly influential and programmatic series of controlled experimental studies was conducted with patients enrolled

in methadone treatment for opiate dependence (see Stitzer et al. 1984). These studies firmly established the efficacy of

using contingent positive reinforcement, such as access to clinic privileges (e.g., methadone take-home privileges), cash

payments, and adjustments in methadone dose, for increasing abstinence from illicit drug use. For example, 10 patients

receiving methadone maintenance treatment and with consistently positive urine toxicology results for benzodiazepine

use participated in a study using a within-subject reversal design (Stitzer et al. 1982). During a 12-week intervention

period, patients earned 2 days of medication take-home privileges, a cash payment ($15.00), or a 20-mg methadone dose

adjustment contingent on submitting benzodiazepine-negative urine toxicology results. Reinforcers were not available

during the baseline periods that preceded and followed the intervention period. During the intervention period, 43% of

specimens were benzodiazepine-negative compared with only 3.6% and 7.9% in the initial and final baseline periods.

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the development of CM as a formal treatment for SUDs. Other uncontrolled studies conducted with health care workers

during this same period suggested that CM may be efficacious in treating cocaine dependence (e.g., Crowley 1985–1986),

which was an important observation, considering that cocaine dependence was emerging as a major public health concern

in the United States at the time that the studies were conducted. The cocaine epidemic caught drug abuse experts

unprepared and created a strong need for effective treatments, and many of the treatments examined, both behavioral

and pharmacological, were ineffective. An exception was a CM intervention that has come to be known as voucher-based

reinforcement therapy (VBRT).

Voucher-Based Reinforcement Therapy

Cocaine and opiate abuse

With VBRT, patients earn vouchers that are exchangeable for retail items, which is contingent on biochemically verified

abstinence from recent drug use or meeting some other therapeutic target. The initial trials with VBRT integrated it with

an intensive behavioral therapy known as the community reinforcement approach (CRA) and thus did not allow for

inferences regarding what contributions VBRT was making to the positive outcomes obtained with the CRA-plus-vouchers

intervention (Higgins et al. 1991). Nevertheless, the positive outcomes obtained with the CRA-plus-VBRT intervention

were in such contrast with the many negative outcomes that were being reported in efforts to treat cocaine dependence

that it garnered a large amount of attention.

Inferences about the contributions of VBRT to research outcomes were made possible through a series of experiments in

which 40 cocaine-dependent outpatients were randomly assigned to 24 weeks of CRA treatment, with half of the patients

receiving VBRT during weeks 1–12 (Higgins et al. 1994). Seventy-five percent of patients assigned to the VBRT condition

were retained in treatment for the recommended 24 weeks, compared with only 40% in the condition without VBRT.

Those who received VBRT achieved an average of 11.5 + 2.0 weeks of continuous cocaine abstinence, compared with only

6.0 + 1.5 weeks of abstinence by those not receiving VBRT. This trial demonstrated that VBRT increased treatment

retention and cocaine abstinence among cocaine-dependent outpatients, a group for whom there were no reliably

efficacious treatments. Subsequent randomized clinical trials conducted in this same clinic demonstrated the reliability of

the treatment effects and showed that the positive effects of VBRT on cocaine abstinence remained discernible throughout

the 2 years following treatment entry (e.g., Higgins et al. 2007).

Because the basic voucher schedule arrangement used in those original studies by Higgins et al. (1994) with

cocaine-dependent outpatients became the prototype on which most subsequent VBRT interventions were based, we

describe it in detail here. Urine specimens were collected during treatment weeks 1–12 and tested for benzoylecgonine, a

cocaine metabolite. Specimens that tested negative for cocaine earned points that were recorded on vouchers and given

to subjects. Each point was worth the equivalent of $0.25. The first specimen to test negative for cocaine per subject

earned 10 points, or $2.50. The value of each subsequent consecutive cocaine-negative specimen increased by 5 points.

The equivalent of a $10 bonus was provided for each three consecutive cocaine-negative specimens. The intent of the

escalating magnitude of reinforcement and bonuses was to reinforce continuous cocaine abstinence. Cocaine-positive

specimens or failure to submit a scheduled specimen reset the value of vouchers back to the initial $2.50 value. This

feature was designed to punish relapse back to cocaine use following a period of sustained abstinence, with the intensity

of the punishment tied directly to the length of sustained abstinence that would be broken. In order to provide patients

with a reason to continue abstaining from use following a reset, submission of five consecutive cocaine-negative

specimens following a cocaine-positive specimen returned the value of points to where they were prior to the reset. Points

could not be lost once earned. Use of vouchers had to be approved by staff who recommended patients to use them to

support the healthy lifestyle changes that were being encouraged as part of the CRA therapy they received. Of course, all

purchases had to be legal and not involve alcohol, cigarettes, or firearms. Testing positive for drug use other than cocaine

did not affect the voucher program or have any other programmed consequence.

Key to the successful development of VBRT was demonstrating that it was efficacious when used by other investigators

and, even more importantly, demonstrating that it had efficacy with an inner-city population of cocaine abusers. The VBRT

studies by Higgins and colleagues were conducted in Burlington, Vermont, a small metropolitan area in a largely rural

state with an almost exclusively white population (Higgins et al. 1991, 1994). That patient population included a large

proportion of intranasal cocaine users (such users generally have a better prognosis). The seminal study extending VBRT

to the large, inner-city setting was a randomized, controlled trial conducted with 37 intravenous cocaine abusers enrolled

in methadone maintenance treatment for opiate dependence (Silverman et al. 1996). The schedule arrangement in the

experimental condition was largely the same as in the studies by Higgins et al. (1991, 1994), with patients assigned to 12

weeks of VBRT in which earning vouchers was contingent on cocaine abstinence. Those assigned to a noncontingent

control condition earned vouchers in an amount and pattern that was yoked to the experimental condition but delivered

independent of cocaine use. Those assigned to the abstinence-contingent voucher condition achieved significantly greater

cocaine abstinence compared with those assigned to the control condition—for example, 47% of patients assigned to

abstinence-contingent vouchers achieved between 7 and 12 weeks of continuous abstinence, compared with 0% in the

noncontingent voucher control condition. Only one patient (6%) assigned to the noncontingent control condition achieved

greater than 2 weeks of continuous cocaine abstinence. The results of this study provide compelling evidence supporting

the generality of earlier findings about VBRT to inner-city populations and methadone patients. Other VBRT trials

investigated the efficacy of VBRT in promoting abstinence from illicit opioid abuse (Silverman et al. 1996), demonstrated

that the use of opioids sometimes decreased along with cocaine use when CM explicitly targeted only cocaine abstinence

(Silverman et al. 1998), and supported the efficacy of increasing the magnitude of VBRT in order to promote a treatmentPrint: Chapter 27. Contingency Management http://www.psychiatryonline.com/popup.aspx?aID=353782&print=yes…

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response in recalcitrant cocaine abusers (e.g., Silverman et al. 1999).

Interest in and research on VBRT as a treatment for SUDs grew considerably after the first publication on that form of CM,

extending use of the intervention to a wide range of different substances, populations, and settings. A meta-analysis by

Lussier et al. (2006) on VBRT identified more than 60 reports of controlled studies published in peer-reviewed journals

examining VBRT as a treatment for SUDs, with robust evidence supporting its efficacy. Figure 27–1 shows average effect

sizes for VBRT across different drugs targeted by the intervention as well as potential moderator variables. No significant

differences were noted between the different types of drug abuse targeted, although a clear trend toward smaller effect

sizes when targeting multiple substances is discernible. The only drug for which the 95% confidence intervals overlapped

with zero (suggesting no significant treatment effect) was alcohol, on which there was only a single study and thus larger

variance. Analyses of potential moderator variables indicated that greater monetary value of potential daily earnings and

immediate (same-day) versus delayed delivery of the voucher were associated with larger treatment effects.

FIGURE 27–1. Estimated effect size (r) and 95% confidence intervals.

Weighted average effect sizes and 95% confidence intervals for subsets of studies as a function of the moderator variables: target,

control condition, duration, daily earnings, voucher-based reinforcement therapy (VBRT) delivery immediacy, setting, and study

quality. All studies target abstinence (N = 30). Weighted average effect sizes are represented by closed diamonds and 95% confidence

intervals by solid lines. Where confidence intervals do not overlap, differences between subsets of studies are significantly different at

the 0.05 level.

Source. Reprinted from Lussier JP, Heil SH, Mongeon JA, et al: “A Meta-Analysis of Voucher-Based Reinforcement Therapy for

Substance Use Disorders.” Addiction 101:192–203, 2006. Used with permission.Print: Chapter 27. Contingency Management http://www.psychiatryonline.com/popup.aspx?aID=353782&print=yes…

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Building upon the success of VBRT in reducing cocaine abuse among cocaine-dependent methadone patients, other studies

were conducted demonstrating efficacy in reducing illicit opiate abuse in this population. In one such study, 120

methadone patients who continued to abuse heroin were randomly assigned to receive a methadone dose increase,

abstinence-contingent vouchers (maximum earnings of $554 in 8 weeks), a combination of the methadone dose increase

with abstinence-contingent vouchers, or continued treatment with a standard intervention technique. Contingent vouchers

increased opiate abstinence significantly above the standard intervention, whereas the methadone dose increase did not.

The combination treatment was equal to the vouchers-only condition, suggesting that it was the vouchers that produced

the increases in abstinence (Preston et al. 2000).

Other drugs of abuse

As illustrated in Figure 27–1, VBRT has been extended to a broad range of different SUDs. For illustration purposes, we

discuss here the extension to marijuana use disorders. Some thought CM would not be feasible in treating marijuana

abuse because of the long half-life of tetrahydrocannabinol, which might be expected to result in too long a delay in being

able to deliver contingent reinforcement for abstinence. Such concerns notwithstanding, VBRT has been successfully

extended to outpatient treatment of marijuana dependence. For example, a study examining the addition of VBRT to a

treatment of motivational enhancement and coping skills therapy increased end-of-treatment abstinence more than

threefold compared with the motivational enhancement therapy alone or motivational therapy plus coping skills (Budney

et al. 2000).

Fishbowl Procedure

Petry et al. (2000) developed a variation of VBRT designed to lower cost without losing efficacy. In this procedure, rather

than having each occurrence of the target response reinforced, patients earned the opportunity to draw from a fishbowl

that contained vouchers of varying value, including many that were of zero value but offered verbal praise, some that

were of relatively low monetary value (e.g., $1), still fewer of moderate value ($20), and a very few worth high monetary

value ($100). Instead of exchanging these vouchers for the opportunity to make retail purchases in the community,

patients chose among prize items already available at the clinic. Importantly, this modified arrangement has been

demonstrated to be efficacious for increasing cocaine and opioid abstinence in drug-free and methadone community

clinics; however, there is no evidence that this more complex schedule arrangement results in better outcomes than the

more conventional voucher program that uses vouchers of lower value. In the only direct comparison of the fishbowl and

conventional voucher programs offered at comparable values, both methods improved outcomes above a control condition

and there was no significant difference between the fishbowl and conventional voucher programs (Petry et al. 2005a).

Thus the important contributions of this development are that it is less costly than the original VBRT intervention and it is

efficacious, giving it a better likelihood than more expensive arrangements of being adopted by community clinics where

cost concerns are an important priority. The likelihood of its increased use seems certain given the results obtained in two

multisite trials conducted in community clinics as part of the National Institute on Drug Abuse Clinical Trials Network, in

which the procedure was shown to improve outcomes of stimulant abusers enrolled in drug-free and methadone clinics

(Peirce et al. 2006; Petry et al. 2005b). There is no evidence that lowering costs with this fishbowl arrangement gets

around the relationship between treatment effect size and reinforcement magnitude in VBRT interventions. Indeed, as

expected, effect sizes obtained with the fishbowl intervention appear to be smaller than those achieved with more

expensive VBRT interventions in comparable populations (Lussier et al. 2006).

Treating Special Populations

Identifying effective treatments for special populations of individuals with SUDs is an important challenge, and another

important development of VBRT is its extension to the treatment of such populations (for a review, see Higgins et al.

2008). The application of VBRT in treating pregnant smokers provides an excellent example of this extension of VBRT.

Maternal cigarette smoking is a leading preventable cause of poor pregnancy outcome and pediatric morbidity. Effective

interventions for promoting smoking cessation among pregnant women are available, but only about 15% of women who

receive them actually quit smoking. Controlled trials indicated that VBRT could increase quit rates to more than 30%. In

one of these trials, VBRT was studied with 58 women who were still smoking upon entering prenatal care and were

assigned to either contingent or noncontingent voucher conditions (Higgins et al. 2004b). In the contingent condition,

vouchers were earned for biochemically verified smoking abstinence; in the noncontingent condition, vouchers were

earned independent of smoking status. Contingent vouchers significantly increased abstinence at the end of pregnancy

(37% vs. 9%) and at 12-week postpartum (33% vs. 0%) assessments. The effect of contingent vouchers remained

significant at the 24-week postpartum assessment (27% vs. 0%), which was 12 weeks after discontinuation of the

voucher program. The magnitude of these treatment effects exceeds levels typically observed with pregnant and

postpartum smokers, and the maintenance of effects through 24 weeks postpartum exceeds previously reported

durations.

Another example of this important direction is a study by Krishnan-Sarin et al. (2008) using VBRT to promote smoking

cessation among adolescents. Twenty-eight adolescent smokers participated in a 1-month, school-based smoking

cessation program in which they were randomly assigned to receive either cognitive-behavioral therapy (CBT) alone or CM

combined with weekly CBT. In the CM plus CBT group, biochemical verification of abstinence was obtained twice daily

during the first 2 weeks, followed by daily appointments during the third week and appointments once every other day

during the fourth week. Participants earned monetary reinforcement contingent on abstinence. At the end of weeks 1 and

4 , abstinence verified using quantitative urine cotinine levels was higher in participants in the CM plus CBT group (week

1: 76.7%; week 4: 53.0%) compared to CBT alone (week 1: 7.2%; week 4: 0%).Print: Chapter 27. Contingency Management http://www.psychiatryonline.com/popup.aspx?aID=353782&print=yes…

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IMPROVING CM INTERVENTIONS: INITIAL TREATMENT RESPONSE AND LONGER-TERM

OUTCOMES

While the treatment effects obtained with CM are impressive, often 50% of patients treated or more do not have positive

outcomes. The 10-point list earlier in this chapter (in the section titled “Basic Elements of CM”) represents what is known

about how to increase treatment response. Using a higher magnitude of reinforcement, minimizing delay in reinforcement

delivery, targeting one response rather than multiple responses, and monitoring abstinence more frequently are all

associated with larger treatment effects (Lussier et al. 2006). The parameter for which there is the greatest amount of

evidence, including experimental evidence and results from meta-analyses, is reinforcement magnitude (e.g., Higgins et

1. 2007; Silverman et al. 1999).

Regarding longer-term outcomes, several studies have shown that VBRT effects on abstinence sometimes last for as long

as 21 months following discontinuation of the intervention (e.g., Higgins et al. 2007). However, many patients exposed to

VBRT or other CM interventions resume drug use following discontinuation of the intervention. Identifying ways to sustain

treatment effects over time is a priority with CM just as it is with virtually all treatments for SUDs. A number of trials have

investigated combining VBRT with relapse prevention therapy, but there is no evidence that this combination extends

treatment effects beyond those obtained with VBRT alone (Rawson et al. 2002).

Another avenue that is being pursued is to use VBRT to increase the proportion of patients who achieve a sustained period

of abstinence during treatment. This approach grew out of observations in studies where VBRT effects were sustained

during posttreatment follow-up as compared with control treatments. In those studies the probability of posttreatment

abstinence during follow-up increased as a function of the duration of continuous abstinence achieved during treatment to

a comparable extent in the VBRT and control treatments (e.g., Higgins et al. 2007).

Knowing that greater reinforcement magnitude produces larger effects during the treatment period, Higgins et al. (2007)

conducted a randomized clinical trial to see if posttreatment outcomes could be increased as well by increasing

reinforcement magnitude. In this study, 100 cocaine-dependent adults were randomly assigned to receive treatment

based on CRA plus VBRT set at a relatively high monetary value (maximal value = $1,995/12 weeks) or CRA with VBRT set

at a relatively low monetary value (maximal value = $499/12 weeks). The high-value vouchers were used to test the

concept and not with the idea that they would have direct practical application. Earning vouchers was contingent on

cocaine-negative urinalysis results during the initial 12 weeks of the 24-week outpatient treatment. It was found that

increasing voucher value significantly increased the duration of continuous cocaine abstinence achieved during treatment

and, as hypothesized, point-prevalence cocaine abstinence assessed every 3 months throughout an 18-month

posttreatment follow-up period was greater in the high-value than in the low-value voucher condition (Figure 27–2). As in

prior studies, the duration of abstinence achieved during treatment predicted posttreatment abstinence, although that

relationship weakened over time. Overall, increasing the value of abstinence-contingent incentives during the initial 12

weeks of treatment represented an effective method for increasing during-treatment and longer-term cocaine abstinence,

although the positive association of during-treatment abstinence with longer-term outcome dissipated over time. This is a

research avenue that will continue to be evaluated.

FIGURE 27–2. Periodic abstinence assessments.Print: Chapter 27. Contingency Management http://www.psychiatryonline.com/popup.aspx?aID=353782&print=yes…

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Percentages of participants abstinent at each of the periodic assessments conducted with subjects retained in treatment as well as

dropouts. Data points represent point-prevalence abstinence at the respective assessments. Abstinence was defined as a self-report of

no cocaine use in the past 30 days and cocaine-negative urinalysis results. In categorical modeling, abstinence levels were

significantly higher in the high-value than low-value voucher conditions based on assessments during treatment (1.5 and 3.0 months,

P = 0.02) and follow-up (6- through 24-month assessments, P = 0.04).

Source. Reprinted from 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 102:271–281, 2007. Used

with permission.

Silverman et al. (2004) conducted a seminal study examining the use of VBRT as a maintenance intervention. This study

examined whether long-term abstinence reinforcement could maintain cocaine abstinence throughout a 1-year period.

Patients who injected drugs and used cocaine during methadone treatment (N = 78) were randomly assigned to one of

two abstinence-reinforcement groups or to a usual-care control group. Participants in the two abstinence-reinforcement

groups could earn take-home methadone doses for providing opiate- and cocaine-free urine samples; participants in one

of those groups also could earn $5,800 in vouchers for providing cocaine-free urine samples over 52 weeks. Both

abstinence-reinforcement interventions increased cocaine abstinence, but the addition of the voucher intervention

resulted in the largest and most sustained abstinence (Figure 27–3). Indeed, patients in the condition with take-homes

and VBRT who achieved a period of continuous cocaine abstinence often sustained it through the duration of the voucher

program and beyond. Patients in the other treatment conditions rarely achieved comparable levels of sustained

abstinence. The study provided proof of concept that VBRT could be a highly effective maintenance intervention for

cocaine abstinence in methadone patients.

FIGURE 27–3. Cocaine urinalysis results across consecutive urine samples for individual participants in each of the three

experimental conditions.Print: Chapter 27. Contingency Management http://www.psychiatryonline.com/popup.aspx?aID=353782&print=yes…

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Top, middle, and bottom panels represent data for the take-home plus voucher, take-home only, and usual-care control conditions.

The vertical dashed lines divide each panel into three periods, the baseline (left), the intervention (center), and the postintervention

(right) periods. Within each panel, horizontal lines represent the cocaine urinalysis results for individual participants across the

consecutive scheduled urine collections of the study. The heavy portion of each line represents cocaine-negative urinalysis results, the

thin portions of each line represent cocaine-positive urinalysis results, and the blank portions represent missing urine samples. Within

each panel, participants are arranged from those showing the least abstinence (fewest cocaine-negative urines) on the bottom of thePrint: Chapter 27. Contingency Management http://www.psychiatryonline.com/popup.aspx?aID=353782&print=yes…

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panel to participants with the most abstinence on the top. The numerals on the ordinates represent participant identification numbers.

Source. Reprinted from 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.” Journal of Consulting and Clinical Psychology 72:839–854, 2004. Used with

permission.

DISSEMINATION: COMMUNITY DRUG ABUSE TREATMENT PROGRAMS

Cost is an important obstacle when considering dissemination of CM into community substance abuse treatment clinics

and there have been encouraging developments in this area. The positive outcomes obtained in the multisite trials using

the fishbowl procedure are quite promising and are likely to facilitate successful dissemination (Peirce et al. 2006; Petry

et al. 2005b). The New York City Health and Hospitals Corporation, the largest provider of public treatment for substance

abuse in New York City, launched low-cost CM programs in five of its community substance abuse treatment clinics that

were supported through public funds (Kellogg et al. 2005). In an initiative that received broad media coverage (e.g.,

Ornstein 2005), the San Francisco Department of Public Health established a VBRT program for gay and bisexual

methamphetamine abusers.

Another strategy is to integrate existing community services into CM arrangements. Two programs offer exciting

examples of how this can be done effectively. One is a program for patients with SUDs and serious mental illness where

the CM program is built around patients’ Social Security disability benefits (Ries et al. 2004). The clinic serves as the

designated payee and patients gain progressively greater control over the use of those benefits contingent on verified

abstinence from drug use.

Another exciting program is being conducted as part of the U.S. Department of Veterans Affairs Compensated Work

Therapy program, which provides veterans with chronic employment problems access to paid training and supported paid

employment. Perhaps not surprisingly, SUDs are an important problem in these programs. Drebing et al. (2005) have

demonstrated how VBRT can be used to increase abstinence and job-seeking and job placement activities in that setting.

Workplaces offer important opportunities to arrange abstinence reinforcement opportunities because of the resources that

they control in the form of wages and benefits. Silverman et al. (2002) developed a model referred to as the therapeutic

workplace that is designed to treat chronically unemployed adults. This program has been evaluated with pregnant and

recently postpartum women who were continuing to abuse cocaine and heroin despite being enrolled in methadone

treatment. Forty women were randomly assigned either to the therapeutic workplace or to usual care. For those assigned

to the therapeutic workplace, daily entry into the work setting was contingent on verified abstinence from cocaine and

opiate use and once in the program they earned vouchers contingent on job performance. The intervention was in place

for several years, with significantly more women in the workplace abstinent from cocaine and opiates than in usual care

(30% vs. 5%) during year 3 (Silverman et al. 2002).

The emergence of the U.S. drug court system holds tremendous promise for the successful dissemination of CM into

mainstream rehabilitation for SUDs (see Marlowe and Wong 2008). Drug courts are themselves an explicit CM program

wherein reinforcers and punishers, termed incentives and sanctions within the drug court literature, are used to

systematically leverage nonviolent criminals with SUDs to obtain the treatment that they need. It is difficult to imagine a

better setting in which to successfully disseminate CM practices.

CONCLUSION

CM treatments have developed in many exciting directions during the past two decades and represent an important part of

evidence-based treatments for SUDs. The varied CM applications outlined in this chapter demonstrate the relevance of

basic principles of behavioral science to the treatment of SUDs, the striking effectiveness and versatility of CM

interventions, and the feasibility of disseminating these interventions in society, both through community treatment

clinics and through other settings, such as workplaces, the Veterans Affairs hospital system, and drug courts. Despite the

promise of CM interventions suggested in this extensive body of research, the research reviewed in this chapter also

shows that more work is needed in order to find ways to increase the effectiveness of the interventions so that they will

succeed with even more patients, to develop methods that will ensure longer-term maintenance of beneficial effects over

time, and to continue to develop and refine practical applications that will be used widely in society. Thus, this chapter

outlines the impressive effectiveness and promise of CM interventions as well as the areas where additional research and

more development are needed.

As is amply shown in the research reviewed in this chapter, CM interventions are not a bag of arbitrary tricks but an

orderly set of procedures that are based on fundamental principles of behavioral science. As such, the further

improvement and development of these procedures can be guided by the basic scientific principles on which the

interventions are based. The broad success the field has achieved to date in applying these basic principles to treat SUDs

across populations, drugs, and settings should give great confidence that we can continue to develop and improve CM

interventions to address the costly and devastating consequences of SUDs.

KEY POINTS

Contingency management (CM) is based on an extensive basic science literature that demonstrates an important role for operant

conditioning in the genesis and maintenance of drug use.

CM is an efficacious intervention for a wide range of different types of substance abuse disorders and populations.

CM has some basic features outlined in the section “Basic Elements of CM” that are important to effective implementation.Print: Chapter 27. Contingency Management http://www.psychiatryonline.com/popup.aspx?aID=353782&print=yes…

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SUGGESTED READING

Higgins ST, Silverman K, Heil SH (eds): Contingency Management in the Treatment of Substance Use Disorders. New York, Guilford,

2008

Copyright © 2008 American Psychiatric Publishing, Inc. All Rights Reserved.