What even is contingency management in addiction treatment?
Contingency management is a behavioral therapy technique that every substance use disorder (SUD) counselor is familiar with. As a common kind of operant conditioning, the basics are familiar even to people outside of addiction counseling circles – any parent will tell you that some version of the reward vs. punishment conversation comes into play almost daily.
While incentives have often been a common kind of shaping technique used in substance abuse counseling, they have typically been offered in mostly symbolic form: the bronze chip you can get in Alcoholics Anonymous after a year of sobriety has enormous personal meaning, but it doesn’t have any particular monetary value.
But some states and some treatment programs are asking what would happen if those contingency awards did come in a more liquid form. And the answers they are finding may change addiction therapy entirely.
Dating Back to the ‘60s, Contingency Management Is Already Common in Other Types of Behavioral Counseling
Contingency management is a behavioral therapy technique with mountains of strong evidence behind it.
Contingency management is one of the most direct kinds of positive reinforcement used in operant conditioning, with applications in everything from childhood education to economics.
Fleshed out in the early 1960s, the theory was first applied in education and psychological therapy settings. It’s heavily taught in special education and is incorporated into many criminal justice and carceral management settings across the country.
Various forms of CM as a reinforcement technique quickly found their way into treatment protocols for alcohol use disorders and nicotine addiction, too. Now, researchers and counselors are exploring uses to tamp down addiction to the deadliest substances today, the ones carving up far too many lives and American communities.
We Know Contingency Management Works To Fight Substance Abuse Already
Since behaviorists have a long history with contingency management (CM) as a method to modify human actions, why hasn’t it caught on more widely in substance abuse treatment?
In principle, offering straightforward financial incentives should be just as, or even more, effective when used in substance abuse treatment. A few privately funded experiments have found that either cash or voucher payments for clean drug tests results in people being likely to stay clean.
In fact, for stimulant use disorders, with no FDA-approved medications, contingency management has been found to offer superior outcomes to other psychosocial treatments counselors typically use. It’s about twice as effective as motivational interviewing or CBT (Cognitive Behavioral Therapy) according to the Department of Health and Human Services.
Administrative and Political Obstacles Stand in the Way of Widespread Use of Contingency Management in Substance Abuse Therapy
But the funding mechanisms that are behind most addiction therapy have long put a stop to such ideas.
The Centers for Medicare and Medicaid Services (CMS) have long limited the total amount of incentive payments to a value of no more than $75. Private insurers have typically followed their lead, not covering programs that use CM with cash incentives.
In part, this can be attributed to typical cost-saving measures. Any program that isn’t already funded is going to be viewed skeptically by the folks who cut the checks.
But there’s also a significant moral and political component to the restriction. In short, public officials, and politicians in particular, are frightened of approving any sort of program that appears to hand public funds over to people experiencing addiction. Long-standing American attitudes around poverty, addiction, and finance make it a risky proposition for elected officials to get behind something like CM, even if, in the long run, it may be more cost-effective than the status quo.
In 2021, however, California became the first state to obtain a waiver from CMS to use contingency management for stimulant addiction treatment. Washington state followed in 2023, and Delaware, Hawaii, and Montana were waived in short order.
Addiction Counselors Looking for Evidence-Based Treatments May Have To Wait for Results
It’s too soon to see the results from either program, but researchers at schools like Washington State University are working hard to both make CM more available and to track the outcomes as more therapists adopt the tool.
California, dealing with a long-term stimulant use disorder issue for more than 30 years, quickly rolled out a pilot project stretching from LA to Marin county to take advantage of the waiver. Participants there will become part of a structured outpatient program that runs for 24 weeks, followed by an additional six months of recovery support.
They are eligible to receive a maximum of $599 in low-denomination gift cards, contingent on testing negative for stimulants in their system during the initial 24 week period. During the pilot, other types of illicit drug use won’t disqualify them. But the results will be carefully tracked to determine the impact of the therapy.
As of 2024, around 3,200 people had participated in the trial. An abstinence rate of 86 percent was measured across all participating sites, with around $280,000 in total incentives disbursed.
Why Higher Education Will Be Vital in Implementing and Assessing Pay-For-Abstinence Drug Treatment Programs
Some of the slow roll-out may be due to the administration and monitoring of CM therapies.
While it’s an accepted and proven behavioral therapy technique, it’s not one that is emphasized in today’s basic substance use disorder education programs. Required coursework for certification or licensure may mention CM briefly or not at all.
It’s going to fall to substance use disorder counselors with more advanced degrees, often master’s degrees in addiction studies, to bring the expertise needed to manage these programs.
With more in-depth training in the essential behavioral psychology behind CM, including the very early foundational research by legends like Watson and Skinner, master’s-qualified SUD counselors have a better grasp on the details that go into making these programs effective.
Not Everyone Is Thrilled To Add Financial Payments To Addiction Therapy Toolboxes
The CMS objections to contingency management for drug abuse therapy was never rooted in questions about efficacy, however. Instead, there are moral, ethical, and practical questions that are harder to answer.
One of the most common is simply the cost. With a surge of SUD patients in the country, the dollar amount required to pay them to abstain would be considerable.
But that question doesn’t really make sense unless you compare it to the cost of business as usual. According to Georgetown University’s Health Policy Institute, the societal costs of tobacco, alcohol, and illicit drug use are almost 6 percent of GDP, or more than $532 billion annually. Even just looking at treatment costs for conventional SUD counseling, the federal budget for drug control for 2020 was $35 billion.
Simply paying patients to abstain may be cheaper in the long run than putting them in expensive in-patient or intensive outpatient counseling services.
Of course, this is the rub for substance abuse counselors—widespread adoption of CM in the field could upend the economics of offering direct clinical counseling.
There are other concerns that contingency management amounts to bribery, or that it’s immoral to reward people for their own recovery. But laying aside the philosophical issues, there’s really only one major consideration that concerns substance abuse counselors about cash contingency management treatments.
Studies Into Contingency Management Methods in Substance Abuse Still Face Steep Obstacles
The major concern with the cash contingency management approach to treating substance use disorders is that it could inadvertently drag more people into addiction. In some vulnerable populations, any way of making money is on the table. There’s a risk that, for some people, putting a financial incentive into therapy would give them a reason to need therapy they otherwise wouldn’t.
There’s also concerns that financial CM rewards would simply turn into a self-fueling addiction cycle: a cash reward for a period of abstinence might suddenly turn into an instant relapse as the patient uses the funds to buy drugs again. The same cycle could continue the next time they got clean.
Finally, consistency becomes a real concern as federal funding and agency approvals enter a new and highly politicized era. With a lack of stability at CMS, both counselors and researchers in various states may be hesitant to start or continue programs based on approval that could disappear in an instant.
But promising techniques combined with devastating problems usually forces some forward progress regardless of political obstacles. If the results from the handful of states practicing contingency management techniques in SUD treatment offer a path to recovery that costs less than traditional methods, cash-strapped federal and state agencies are sure to sit up and take notice.