Contingency Management

Lately I’ve been thinking about contingency management.

I listened to some sessions about contingency management (CM) during several of the national Addiction Medicine conferences this year. That reminded me our opioid treatment program had been talking about using contingency management to improve attendance at our intensive outpatient group just before COVID hit. But after COVID…*POOF* …no more groups.

Now that COVID is on the decline, it’s time to consider re-establishing our intensive outpatient group.

For those who don’t know what contingency management is, or who are a little foggy about what it means, I can tell you I had to look it up again too. I know what it is…but putting it into words is difficult.

In short, CM is a type of behavioral therapy which rewards progress towards a set goal. Patients are rewarded in some way for positive behaviors.

CM can take all kinds of shapes. For example, during one of the sessions at the American Society of Addiction Medicine conference, presenters described how they rewarded patients with small gifts as they met treatment goals. All patients got a pen and a blank journal upon admission. As patients produced negative urine drug screens, they were rewarded with draws from a fishbowl for vouchers for various prizes. The prizes ranged from positive affirmations (“You did a good job”) to polished stones with affirmations on them to gift cards for up to $25.

This program saw impressive results with these small rewards. Their patients had better attendance and more negative drug screens.

Scientific literature shows that contingency management is effective, if it is used in ways that adhere to several basic concepts. The targeted behavior should be an observable and treatment-adherent behavior. In other words, CM should target a patient behavior that is in harmony with substance use treatment goals. Then CM program should give an immediate and tangible reinforcer to the patient when the desired behavior is exhibited. If the desired behavior is not exhibited, the reinforcer is withheld.

CM is not new; at least two-hundred studies of CM techniques have shown that it works to produce desired behaviors in substance use disorder treatments. CM usually shows at least a medium effect size. This means isn’t the next great thing to fix everyone with substance use disorders, but it does provide reliable improvements for patients.

CM has been used in diverse patient populations and appears to be effective for all different socioeconomic groups.

Strangely, despite producing reliably positive results, CM hasn’t been used as much as one would think.

Some people object to the idea of contingency management. For example, an obstacle to implementing CM in substance abuse treatment cropped up last summer. The Trump administration set a cap of $75 per year per patient on CM programs. That is, whether prizes or rewards are donated by local businesses or bought by the treatment program, these programs can’t reward patients with any more than $75 per year, for fear that money would entice patients to come to one treatment program over another. The U.S. Office of the Inspector General (OIG) said such methods of paying patients to participate in treatment might violate the Anti-Kickback Statute. In other words, it’s illegal to pay patients to come to your treatment program. This could be a type of fraud, particularly if the treatment program bills Medicaid/Medicare for treatment.

Last year, the American Society of Addiction Medicine (ASAM) sent a letter to Alex Azar, the then-Secretary of Health and Human Services, asking that contingency management treatment techniques to be exempt from the Anti-Kickback Statute. The ASAM president, Dr.William Haning, pointed out in the letter that safeguards could be applied to prevent fraud, waste, or abuse when using CM techniques in counseling people with substance use disorders.

Some people feel it’s unethical to pay patients for doing what they “ought” to be doing anyway. Other people say it’s manipulative to induce patients to behave in ways decided upon by authority figures. This may be true, but patients still have the choice of participating or not participating in reward programs.

For example, let’s say a patient comes for treatment of her opioid use disorder at an opioid treatment program. That program gives CM rewards for negative urine drugs screens. Perhaps the patient wants to quit using opioids, but she doesn’t see any need to quit using cocaine. She can continue to use cocaine, and have positive drug screens, meaning she won’t get the small rewards of the CM program. She’s not out anything by her decision, and still gets treatment for opioid use disorder.

Salespeople have been using CM for decades. Many advertisers use CM to shape consumer behavior. For example, look at the BOGO sales. The sales staff want to sell more product, so they advertise “BOGO” in large letters. This means if the consumer buys one, the second one – of whatever it is – is free. The consumer is being tempted to a certain behavior – buying something – by an offer from the seller.

By the way, there’s nothing more irritating than seeing a “BOGO” sale advertised, only to read the fine print that the deal is buy one and get some percentage off the second one. That’s not a real BOGO. That’s what I call a faux BOGO. Don’t even bother me with a faux BOGO.

But I digress.

Other contingency management sales techniques might be the reward of a free sub sandwich after you buy five regularly priced subs.

The point is, we participate in CM deals all the time, but usually the behavior desired of us is buying products or services. For treatment of substance use disorders, the desired behaviors might be attending counseling sessions or ceasing drug use to produce negative drug screens. Progress towards those goals are rewarded in some way with CM.

I’d like to start our groups again, and for every three-hour session attended, each person gets a draw from a fishbowl. The fishbowl might contain any number of rewards: gas card for $10, coupon for a sandwich at a local restaurant, a card with positive affirmations, or something similar. The possibilities are endless. Perhaps local businesses could donate goods or services in exchange for some free advertising, or just to do something nice for people who are trying to achieve recovery from substance use disorders.

Twelve-step meetings have been using a type of CM for decades: group members get chips or key tags for achieving days in recovery: they have these for one day, thirty days, sixty days, ninety days, six months, nine months, and one year and multiple of years. The chips or tags themselves are worth very little, but the value of being recognized for achievement in recovery can be important, especially when the recognition is given by people who understand how difficult recovery is.

Some of our patients don’t get the recognition they should for their achievements in recovery from friends or family. Maybe CM is a great way to acknowledge that achieving little goals is a big deal.

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