“Honey works Better than Vinegar”: Contingency Management Programs in Recovery

If you’ve never heard of a contingency management program in out or in-patient treatment centers, it’s because it’s under utilized.  It’s a behavior modification system in which rewards are contingent on staying abstinent.  It’s also called “carrot-and-stick” method where you are rewarded for positive behavior – much like motivating a child to clean up his room by giving him a toy or ice-cream.

It is rooted in the basis of operant conditioning that’s been around since early 1900’s and is can be used with other treatment styles such as cognitive behavioral therapy, medication management, medication maintenance programs (MAT), and motivational interviewing.  It is shown to be effective for a range of issues including defiance, impulsive behaviors and substance abuse.

Here’s How It Works:

“Patients” are rewarded for evidence of positive behavioral changes such as having urine samples free of illicit drugs or showing up at meetings on time. According to the Hazelden Betty Ford clinic, one of the most commonly targeted behaviors in addiction treatment is attendance, with a high attrition rate at 80%.

For example, to motivate one with a substance abuse disorder, if a patients is on time for the first group of the day and workshops after lunch, his name is entered into a drawing the following day to win a carnival prize such as candy, chips or a gift certificate, for example, to McDonald’s.  He needs to be on time the next day.  If he is absent or late, he doesn’t win.

The rewards are contingent on staying abstinent. According to the National Institute on Drug Abuse, “positive studies conducted in both methadone programs and psychosocial counseling treatment programs demonstrate that incentive-based interventions are highly effective in increasing treatment retention and promoting abstinence from drugs.” In fact, according to a study published in Journal of Dual Diagnosis, “patients involved in contingency management-based care attended scheduled treatment sessions more than 50% more often than the patients not involved in contingency management-based care.”

Drawbacks So It Seems…

The practice of contingency management has raised some ethical, ideological and practical concerns from clinicians and the public.  Some look askance at the practicality.  Will the intrinsic motivation dissipate once the CM intervention is over?  Others think rewarding drug users for not taking drugs defeats the purpose.  They should be doing abstinence any way.

It’s possible that the patients could exchange monetary rewards for drugs. It obviously cost more than standard treatment without the bonus of monetary-based incentives. According to studies funded by the National Institute on Drug Abuse, the incentives used average $400 -500 per patient or more over the course of treatment. Medicaid doesn’t cover this treatment.

According to a New York Times.com, no public or private insurer will pay for contingency management except in a few pilot programs so it’s a major challenge to expand it.

The biggest obstacle is that offering motivational rewards to patients violates the federal anti-kickback statute.  Congress recently told states that they could start spending federal “opioid response” grans on treatment for stimulant addiction, but the agency that distributes the grants allows only $75 /patient/yr. to be spent on contingency management.

The punitive approach to drug addiction still reigns.