When I signed up for an addiction medicine elective in an OB/GYN clinic, I didn’t know what I didn’t know. I had heard before about a biopsychosocial model of substance use treatment, but I didn’t realize the extent of services and comprehensive care underlying our society’s efforts to save lives and help people dealing with substance use disorders.. An introduction to this area of medicine requires learning how to think about the disease and how to identify the right therapies for each individual patient. One category of therapy with a strong foundation of evidence has a curious name: Contingency Management (CM). The name comes from operant conditioning, which is the psychological model CM is based on. The concept of contingency is a little tricky. It centers around the idea that changes in repeated behaviors corresponding to repeated changes in the environment may result in reinforcement of the behavior (i.e. Y is contingent on X).
CM is useful because a reward can be a stronger motivator for behavioral change than punishment. Rather than a punitive model of intervention, i.e. incarceration or removal of access to therapeutic modalities, CM adds something positive to the patient’s life. What this looks like in practice is enrolling patients in a multi-week therapeutic program where adherence to treatment goals and substance abstinence is rewarded with prizes or gift cards. The overarching concept is simple but must be executed with a focus on using the most effective and evidence-based methodology. For example, the likelihood of success and magnitude of benefit are greatest when the intervention lasts at least 12 weeks and provides a minimum of $385 total.1 This makes sense if we think about the treatment like a medication, which must be taken for a certain amount of time at a certain dosage to see an effect. Additionally, the reinforcer or prize must be given to the patient immediately after the desired behavior has been met, i.e. the point-of-care urine drug test screens negative.1 CM, in combination with an Intensive Outpatient Program, is actually the first line treatment modality for stimulant use disorder, which has no FDA approved medications.2 It is also used for alcohol use disorder and has even been shown to increase smoking cessation rates.3
From my perspective, it’s important to think about why CM works. It is effective because we are not broken machines that can be programmed to adhere perfectly to treatment regimens. Someone with fatty liver disease may know that they would benefit from exercise, but still find it difficult to motivate themselves to go walking despite the looming possibility of progression to cirrhosis. Substance use treatment is similar but has further challenges layering on top of baseline motivation difficulties. It requires a high degree of participation on the part of patients who often already have significant life stressors making it difficult for them to adhere to treatment, such as legal issues, family strain, or socioeconomic challenges. Contingency Management can work for these patients because it relies on the power of repetitive positive reinforcement. It represents an opportunity to make a lasting impact on the lives of patients with complex needs. I also believe that ethically CM represents an approach to treatment of patients living with substance use that does not reinforce negative stigmas. It lifts them up, congratulates them, and encourages them in a world that usually does the opposite.
References
1. Rash CJ. Implementing an evidence-based prize contingency management protocol for stimulant use. J Subst Use Addict Treat. 2023 Aug;151:209079. doi: 10.1016/j.josat.2023.209079. Epub 2023 May 24. PMID: 37230390; PMCID: PMC10330855.
2. Brown HD, DeFulio A. Contingency management for the treatment of methamphetamine use disorder: A systematic review. Drug Alcohol Depend. 2020 Nov 1;216:108307. doi: 10.1016/j.drugalcdep.2020.108307. Epub 2020 Sep 21. PMID: 33007699.
3. Rash CJ. Implementing an evidence-based prize contingency management protocol for stimulant use. J Subst Use Addict Treat. 2023 Aug;151:209079. doi: 10.1016/j.josat.2023.209079. Epub 2023 May 24. PMID: 37230390; PMCID: PMC10330855.
Sarah Brady is a member of The University of Arizona College of Medicine – Phoenix, Class of 2026. She was born in Georgia, raised in Florida, and currently lives in Arizona. She graduated from Arizona State University with consecutive degrees in English Literature and Biomedical Engineering. She loves to garden and particularly enjoys attempting to grow plants that are entirely unsuited to the Arizona climate.
Image © Ashley Lorraine Baker