Contingency management

Usability

Core Components

Contingency Management (CM) involves the use of reinforcing procedures to alter substance use behaviours across a range of substances (e.g. opioids [with or without methadone maintenance], cannabis, alcohol, and stimulants), in a variety of populations. This behavioural therapy involves provision of incentives to reward evidence of positive behaviours that promote abstinence from substance use and other substance use treatment outcomes (e.g. monetary based reinforcers for drug free urine sample). CM therefore aims to promote behaviours that are well-suited for a lifestyle that is non-inclusive of substance use. CM also draws on CBT techniques to support behavioural change.

At its core, CM consists of four critical elements; 1) selecting specific, achievable, substance use related target behaviour (e.g. abstinence, confirmed by drug-negative urinalysis); 2) regular monitoring of target behaviour to increase positive reinforcement opportunities and spot reversion to competing behaviours (e.g. breath and urine samples submitted for drug and alcohol testing two to three times weekly on non-consecutive days); 3) providing tangible reward in close proximity to their occurrence to reinforce positive behaviour. Rewards can include clinic privileges (e.g. take-home opioid-replacement medication), vouchers for goods and services that are compatible with treatment goals, low monetary cash rewards, and prizes (ranging in value from £1 to £100). Incentives provided should be of adequate significance to the client to compete with their substance use behaviours; 4) holding back rewards when target behaviour is not detected.  CM also includes work around increasing drug refusal skills, leverage and including systemic supports and using CBT techniques to alter cognitions that lead to use.

The positive reinforcement strategy applied in CM can also be used to promote other behaviours that are associated with the attainment of treatment goals. These include reinforcement of medication compliance; reinforcement of treatment adherence/ retention in substance misuse clinics if reinforcement provided is contingent on attendance; and reinforcement of other treatment-related goals, e.g. improving parenting, increasing physical activity, and seeking employment. CM can be delivered alongside other programmes (e.g. methadone maintenance, psychological treatment) to improve treatment outcomes in substance use management.

Fidelity

Practitioner training prior to CM delivery promotes treatment fidelity. Practitioner fidelity to CM can be assessed through a review of recorded CM sessions, using the CM Competence Scale (CMCS) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2875270/pdf/nihms173049.pdf.

Modifiable Components

CM can be delivered in a diverse range of settings including outpatient clinics, community centres, residential setting and the client's own home. It can be delivered as part of other treatment programmes (e.g. methadone maintenance programmes, opioid treatment programs, outpatient psychosocial programmes, and multisystemic therapy) to manage a range of substance use presentations (e.g. alcohol, cannabis, cocaine, nicotine, and opioids). CM can differ in the testing frequency applied, length of CM course, and type of incentives provided. Web-based and phone-based CM processes (e.g. via web camera or video-record function on phones) have facilitated the remote monitoring of breath sampling (e.g. for alcohol and tobacco detection). CM can be delivered to adolescents and adults, including veterans.

Supports

Implementation Support

Currently in the UK, CM is not routinely delivered as a standalone treatment. It is implemented as part of Multisystemic Therapy (MST) for adolescents. Please refer to the MST intervention description for more information.

Start-up Costs

Costs associated with CM delivery will include costs of urinalysis and breath tests (e.g. intoximeter for alcohol screening, and onsite test-sticks for other substances like cocaine, opioids and marijuana). Other costs include costs of providing reinforcers to patients who demonstrate target behaviours. This can include vouchers, low monetary cash rewards, and prizes. These incentives could introduce budget constraints and barriers to CM adoption. However, a low-cost reinforcer can also be associated with increased patient attendance in methadone maintenance programme. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5154900/. Practitioner training costs should also be considered, however, the exact costs of practitioner training are unclear.

Building Staff Competency

Qualifications Required

CM can be delivered by direct care clinicians, with appropriate qualifications in areas of education, counselling, social work, psychology, psychiatry and other mental health fields. Prior exposure to CM is not required.

Training Requirements

In research, practitioner training sessions to support CM delivery have varied in intensity. They have included two-hour long training sessions, two ½ day training workshops, 1.5-day trainings, and four weekly ½ day sessions. Trainings can cover the basic principles of CM; evidence in support of CM; adaptation of the CM protocol to suit needs in different settings; practical delivery of CM (including sample monitoring process, role playing exercises); fidelity monitoring; and CM implementation challenges.  

Supervision Requirements

Supervisors can use CMCS scores and recorded CM sessions to provide feedback on practitioner fidelity to CM and competence in delivery. 

When CM is delivered as part of a wider package of psychological therapies, it should involve regular supervision with a practitioner who has expertise in a) the intervention b) the clinical area and c) has completed training in supervision of psychological therapies and interventions (Further information: https://www.nes.scot.nhs.uk/our-work/supervision-of-psychological-therapies-and-intervention/). 

Evidence

Theory of Change

Based on operant conditioning, a behavioural approach to learning first described by B.F. Skinner. Operant conditioning theorises that behaviours are shaped by their consequences; they will increase over time if followed by a pleasant experience (reward) or decrease if followed by an unpleasant experience (punishment). Addiction is maintained and reinforced by a combination of the rewarding biochemical effects of the substance and environmental influences.

Contingency Management is guided by principles of basic behavioural analysis. It suggests that rewarding positive behaviours in close proximity to their occurrence will reinforce those positive behaviours (e.g. monetary based reinforcers for drug free urine sample). Application of this behavioural principle in substance misuse management is expected to increase the frequency of occurrence of positive behaviours which reinforce substance use abstinence and other substance use disorder treatment outcomes.     

Research Design & Number of Studies

The best available evidence for CM in adults includes eight meta-analytic studies that evaluated its effect on multiple substance use outcomes.

Outcomes Achieved

Compared to the control group who did not receive CM, the following outcomes were observed;

• Significantly increased abstinence from tobacco (1,2), and other substances (e.g. cocaine, opiates, stimulants, poly-substances) at post-intervention (1,3). Effect on abstinence reduced but still significant at 3-months follow-up, but not detectable at 6-months follow-up (4).
• Significantly reduced use of substances (tobacco, cannabis, stimulants, poly-substances) at 3-months follow-up (5).
• Significantly longer duration of abstinence and significantly higher percentage of negative samples for non-prescribed drug use during opiate addiction treatment. Effects were observed at post-intervention (6).
• Significantly longer duration of abstinence and significantly higher percentage of negative samples for tobacco and alcohol use among adults not in treatment for substance use disorders (7).
• Significantly increased therapy attendance (1,8) and medication adherence at end-of-treatment. Outcomes were evaluated in patients receiving medication for opioid use disorder (1).

Child Evidence

The best available evidence for CM in children and young people includes three Randomised Controlled Trials (RCTs) conducted in USA. One study included 153 adolescents, aged 12- 18, who met the criteria for cannabis abuse or dependence in New Hampshire, USA (9). Another study included 134 young people, aged 12 to 21 years, who smoked a minimum of 5 cigarettes daily and were interested in smoking cessation (10). The study was conducted in South Carolina, USA. The third study included 337 adolescents, aged 12–18 years, admitted to residential treatment with alcohol and other drug (AOD) use disorders in Illinois, USA (11).

Child Outcomes

Compared to the control group who did not receive CM, the following outcomes were observed:

• Significantly greater longest period of continuous cannabis abstinence during treatment (when delivered with individualized Motivational Enhancement [MET] and Cognitive Behavioural Therapy [CBT]). Abstinence rates were reduced by 3-months follow-up, with similar abstinence rates in all groups at 6, 9 and 12-months follow-up (9).
• Significantly higher smoking abstinence rates during active treatment (when delivered with specific antidepressant medication) (10).
• Significantly higher rates of abstinence for heavy alcohol use, alcohol use, cannabis use, and any alcohol or other drugs (AOD) use in the 12 months after discharge from residential treatment (11).
• Significantly higher remission rate at month 12 (11).

Values

Contingency Management involves the use of reinforcing procedures to alter substance use behaviours across a range of substances (e.g. opioids, cannabis, alcohol, and benzodiazepines), in a variety of substance use populations (e.g. people not receiving treatments, people accessing methadone maintenance programmes, in residential treatment programmes, or in outpatient psychosocial programs). Contingency Management is guided by principles of basic behavioural analysis.

• Do the guiding principles, intended populations, and substance use focus of the intervention align with the requirements of your organisation?

Priorities

CM aims to promote behaviours that are well-suited for a lifestyle that is non-inclusive of substance use. At its core CM involves; 1) selecting substance use target behaviour; 2) regular monitoring of target behaviour; 3) providing tangible reward to reinforce positive behaviour; 4) holding back rewards when target behaviour is not detected. The positive reinforcement strategy applied is intended to promote substance use abstinence and improve other substance use treatment outcomes, e.g. medication compliance, treatment adherence, and clinic retention.

• Is your organisation looking to deliver an intervention that focuses on substance use problems?
• What substance use treatment outcomes will your CM programme target?
• Does the positive reinforcement approach of CM align with your organisation’s priorities?

Existing Initiatives

• Does your service currently deliver interventions that address substance use disorders?
• Are existing initiatives practicable and effective?
• Do existing initiatives fit current and anticipated requirements?

Workforce

CM can be delivered by direct care clinicians with appropriate qualifications in areas including education, counselling, social work, psychology, psychiatry and other mental health fields. Prior exposure to CM is not required. In research, practitioner training sessions to support CM delivery have varied in intensity. They have included two-hour long training sessions, two ½ day training workshops, 1.5-day trainings, and four weekly ½ day sessions. CM can differ in the testing frequency applied, and length of CM delivery.

• Does your service have practitioners who are available and interested in learning and delivering CM?
• Has a practitioner CM training programme been identified?
• Can your service support the time commitment required for practitioner training?
• Does your service have staffing capacity to deliver the core elements of CM, including testing and rewarding?

Technology Support

Testing kits are required for urinalysis and breath tests (e.g. intoximeter for alcohol screening, and onsite test-sticks for other substances like cocaine, opioids and marijuana). Web-based and phone-based CM processes (e.g. via web camera or video-record function on phones) can facilitate the remote monitoring of sampling. Availability of technology for recording sessions for supervision will be useful.

• Will your service adopt a remote sample monitoring approach?
• Does your service have the technology to adopt this approach?
• Can your service provide test kits to monitor target behaviours like abstinence?
• Can your practitioners access technology to record sessions for supervision?

Administrative Support

CM can be delivered in a diverse range of settings including outpatient clinics, community centres, and residential settings. It can be delivered as part of other treatment programmes (e.g. methadone maintenance programmes, opioid treatment programs, outpatient psychosocial programs, and multisystemic therapy) to manage a range of SUDs. Administrative support will be needed for a number of activities including scheduling appointments, organising sampling and testing, monitoring attendance, and providing incentives. CM can differ in the testing frequency applied, length of CM course, and type of incentives provided.

• In what setting will CM be delivered?
• Does your service have a venue in this setting to deliver CM?
• Will it be delivered alone or as part of other treatment programmes?
• Can your service provide administrative support to deliver (CM alone or as a part of other treatment programmes)?
• What testing frequency will be adopted? Can administrative support to achieve this be provided?

Financial Support

Costs associated with CM delivery will include costs of urinalysis and breath tests. Other costs include costs of providing reinforcers to patients who demonstrate target behaviours. This can include vouchers, low monetary cash rewards, and prizes. Incentives provided should be of adequate significance to the client to compete with their substance use behaviours.

• Has your service identified relevant, financially-feasible reinforcers that can effectively compete with drug reinforcers?
• Can the costs associated with delivering CM (including testing, positive reinforcers) be supported?

Comparable Population

Contingency Management aims to alter substance use behaviours across a range of substances (e.g. opioids [with or without methadone maintenance], cannabis, alcohol, cigarettes, and benzodiazepines), in a variety of SUD populations (e.g. people not receiving treatments, people accessing methadone maintenance programmes, in residential treatment programmes, or in outpatient psychosocial programs).

• In what population would your service like to deliver CM?

Desired Outcome

CM is associated with significant improvements across several outcomes including increased abstinence (from smoking, cocaine, opiates, stimulants, and poly-substances), increased percentage of negative samples (e.g. non-prescribed drugs, tobacco and alcohol), increased therapy attendance, and increased medication adherence.

• Is delivering CM for the treatment of substance use problems a priority for your organisation?
• Does your organisation have other initiatives in place that effectively and efficiency achieve the above outcomes?