Also of interest are legal concerns and whether the use of monetary incentives violates federal and state law because it could be considered unlawful to give patients money who are enrolled in federally- or state-funded health plans or programs. The federal anti-kickback statute provides for criminal penalties for providers who knowingly and wilfully offer, pay, solicit, or receive remuneration to induce or reward, among other things, the referral of business reimbursable under any of the federal health care programs (Medicare and Medicaid). When incentives exceed nominal monetary values, they can be considered kickbacks or inducements per federal and state laws intended to prevent fraud, waste, and abuse.
Treating Alcohol Use Disorder (AUD)
We culled the initial list extensively for relevance before deciding which articles to include in our review. In addition to the specified search criteria, we included meta-analyses and a couple of noted classic CM works prior to the year 2000. This was done because there were some CM-optimization strategies tested before 2000, but that work has not been picked up to any degree of finality since then.
Cost/legal constraints
He likewise refused to receive any treatment offsite, with the exception of occasional medical visits for HIV. He was noncompliant with HIV medication at the onset of the contingency management demonstration project. Behavioral interventions have enjoyed widespread use in the treatment of a variety of psychiatric conditions, including autism (1), conduct disorder (2), developmental disorders (3), eating disorders (4), and even schizophrenia (5). These techniques are based upon the principles of rearranging the environment to reinforce appropriate behavioral patterns while providing negative reinforcement for inappropriate behaviors. Similar procedures have been applied to substance-abusing populations, and these interventions have been termed contingency management.
Cognitive-Behavioral Approaches (CBT)
However, exercise itself is plagued by poor adherence, a problem that can be remediated by applying a CM intervention (Mitchell et al., 2013). Another example of an adjunctive intervention that may improve SUD treatment outcomes is in the paper by Kiluk and colleagues (2017) that describes the use of CM to increase engagement in a cognitive remediation intervention among SUD patients. Their results suggest that either attendance-based or performance-based incentives may be adequate for motivating engagement in cognitive remediation tasks among individuals in SUD treatment. Additional work that includes a non-incentive control group will be needed to determine the additive effects of incentives versus practice effects or exposure alone. There are two main types of contingency management interventions for substance abuse treatment. Both types are often used in inpatient and outpatient behavioral treatment programs for people with cocaine dependence, alcohol dependence, or substance addiction.
Rewarding recovery: the time is now for contingency management for opioid use disorder
Consequently, medical practitioners must address these aspects of addiction when determining the best course of treatment for an individual, whether that person is addicted to street drugs like heroin, prescription painkillers, or alcohol. If you are looking for information on treatment options in the Sunshine State, you have come to the right place. The type of reinforcement, alcohol misconceptions frequency of reinforcement, and amount of reinforcement will all be factors that need to be considered. The analysis is rooted in the observation that repeated behavioral patterns tend to occur more frequently. Its aim is to facilitate changes in behavior perceived as negative while also assisting patients in cultivating better-coping mechanisms to replace such behaviors.
Predictors of CM Efficacy
We then spend most of this review discussing innovative developments within the SUD-treatment literature and how CM can play a unique and increasingly significant role in SUD treatment if political and implementation barriers can be overcome. Our core objective is to review, describe, and discuss three critical advancements of CM currently happening (ie, adapting CM for underserved populations, CM with experimental technologies, and optimizing CM for personalized interventions). We close by speculating on possible future directions and methods of maximizing the impact of CM, an area we view as largely underdeveloped. Historically, smoking cessation for smokers engaged in SUD treatment has gone unaddressed, in part because of fears that attempts to quit smoking may undermine alcohol and illicit drug recovery efforts (Richter, 2006) and because of staff ambivalence (Richter, Hunt, Cupertino, Garrett, & Friedmann, 2012). Within the last two decades, efforts to engage these smokers have increased, and data suggest that concurrent treatment is both efficacious and does not undermine primary recovery efforts (Reid et al., 2008; Thurgood, McNeill, Clark-Carter, & Brose, 2016). Many people suffering from drug or alcohol addiction refuse to seek treatment because they find it difficult to accept their condition, and they fear the idea of going into rehab.
Gender-Specific Treatments for Substance Use Disorders
Contingency management in psychology uses the principles of operant conditioning to influence behavior. To save resources, choosing which persons or groups of people receive incentives is essential. On this occasion, he was intoxicated, carrying razor blades, complaining of auditory hallucinations, and threatening to kill himself if not provided shelter. A plan was developed to address his worsening problems and chronic misuse of the psychiatric emergency room. Alcohol abuse was present in both her parents’ families, and she reported physical and sexual abuse since the age of 3. She has had little contact with her 28- and 13-year-old sons, who are being raised by their fathers.
For example, when first exposed to alcohol, rats bred for high alcohol intake will voluntarily consume larger amounts of alcohol than non-selectively bred rats. However, even initially low-alcohol-consuming rats will voluntarily consume large quantities of alcohol under certain conditions. For example, stress, social isolation, and reduced access to food, liquid, or opportunities for exercise all promote AOD use in laboratory animals. Therefore, susceptibility to the reinforcing effects of AODs appears to be a product of normal neurobiological systems common to many species that can be heightened by certain individual and environmental factors. The use of reinforcing and punishing consequences to alter the form and frequency of voluntary behavior is known as operant conditioning, a method that provides the conceptual framework for CM. Within the CM framework, AOD use is considered a form of operant behavior—that is, behavior that is maintained in part by the reinforcing biochemical effects of the abused substance and by reinforcing environmental influences (e.g., social reinforcement from peers).
As part of this plan, the conservator paid Mr. C’s rent directly to a local motel and provided Mr. C with $30 per day for food and clothing. He had never received substance abuse treatment, and he reported no periods of abstinence except during brief incarcerations. This type of CM intervention involves setting up a contract between the therapist and the patient.
As part of participation in this study, Ms. A agreed to submit staff-observed urine samples on 2–3 randomly selected days each week for 12 weeks. She was told that she had a 50% chance of receiving standard methadone treatment plus frequent urine sample testing or standard treatment along with a contingency management intervention. She provided written informed consent, as approved by the university’s institutional review board. Despite their efficacy in specialized research programs, contingency management approaches have been criticized for their cost and putative lack of applicability in community-based settings. In the studies conducted by Higgins and colleagues, for example, clients earned vouchers that were exchangeable for retail goods and services in excess of $1,000. Non-research-based clinics are unlikely to have the funds to support voucher programs, and less expensive contingency management approaches may be necessary for adaptation in community-based settings.
- American Indian (AI)/Alaska Native (AN) adults have some of the highest alcohol-abstinence rates compared to the general US population.68,69 However, many AI/AN communities continue to suffer from alcohol-related health inequities.
- Still, studies suggest that clients respond well to contingency management, leading rehab centers to continue offering the therapy.
- These services are reimbursed by private and public payers, begging the question as to why they are not for CM.
- The overwhelmingly majority of contingency management research studies conducted to date come from the U.S., and even fewer studies have examined contingency management for OUD specifically outside of the U.S. [42,67].
- Such research demonstrates, for instance, that animals exhibit consumption patterns indicative of dependence and that researchers can modify animals’ AOD intake by using reinforcing and punishing consequences.
- If a goal was to improve health, the client might agree to attend a medical appointment or to record the dates and times of medication consumed.
It is now up to policy makers to ensure that substance use treatment patients receive this efficacious intervention and that the intervention is delivered in a manner similar to which it is known to be efficacious. In no other medical field would a clinic, hospital, or provider be expected to cover costs of additional testing and treatment without reimbursement. Extensive adoption and implementation of CM by substance abuse treatment clinics will require that reimbursement procedures and policies are consistent with other medical and psychiatric how does increased alcohol tolerance affect a person specialties. It may also necessitate development of methods to ensure that, when CM is administered, it is done according to methods known to be efficacious, including appropriate magnitudes and frequencies of reinforcement. Perhaps what CM needs most is a well-placed champion to break down barriers to reimbursement at the federal level before implementation efforts can be expected to be widespread. Silverman and colleagues (1996) further investigated the use of a voucher-based incentive program among inner-city intravenous cocaine abusers.
However, few psychiatrists are familiar with this intervention or its application to a range of patient behaviours. This paper describes contingency management and evidence of its efficacy for reducing drug use. Greater awareness and use of contingency management in practice may improve outcomes across a range of mental health and related conditions. Schedules with frequent opportunities for reinforcement (e.g., at least weekly) are more likely to engender and strengthen abstinence. Once a behavior is established, less frequent schedules are typically considered for maintenance of behavior change.
This paperdescribes contingency management and evidence of its efficacy for reducingdrug use. In order to further advance the extant knowledge base on contingency management in general and technology-enabled solutions in particular, there are a number of muscle relaxers and alcohol areas warranting further work. The overwhelmingly majority of contingency management research studies conducted to date come from the U.S., and even fewer studies have examined contingency management for OUD specifically outside of the U.S. [42,67].
Had this clinic agreed to conduct urine testing, this subject may have benefited further from contingent reinforcement for drug abstinence. Although his self-reports of cocaine abstinence may have been suspect, he did not appear at the clinic intoxicated since he had become involved in the contingency management project. One of the biggest barriers to utilizing CM in real-world treatment situations effectively is not a scientific one, but a political one.
