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Contingency Management for Stimulant Use Disorders

What is Contingency Management?

According to the scholarly journal The Psychiatrist, contingency management is “a type of behavioral therapy in which individuals are ‘reinforced’, or rewarded, for evidence of positive behavioral change.” Having positive reinforcement encourages people to continue it. This method of change has been “widely tested and evaluated in the context of substance misuse treatment.” The article also states that contingency management in these settings “most often involve[s] provision of monetary-based reinforcers for submission of drug-negative urine specimens.” While it may seem ridiculous to award someone for behavior they should already display day in and day out, “contingency management has a great deal of evidence supporting its efficacy, and the UK National Institute for Health and Clinical Excellence guidelines recommend its use.”

Contingency Management is a rare form of treatment, and many psychiatrists and mental health professionals are not as familiar with this method. Subsequently, they do not implement contingency management in their treatment plan for substance use disorders. The method is typically used for weight loss, fitness goals, and parenting because it applies positive reinforcement that focuses on rewarding good behavior, rather than punishing bad behavior. It makes sense why an individual in recovery would be receptive to this form of treatment, as it focuses on the positive rather than their maladaptive behaviors.

Contingency Management For Substance Abuse

There has been “evidence of efficacy for reducing drug use” and reports of positive outcomes from contingency management treatment. The Psychiatry Journal outlines how “contingency management interventions can be applied in the context of psychiatric treatments more generally, including increasing abstinence in individuals with dual diagnoses.” Contingency management is useful for reducing drug use and beneficial for individuals struggling with addiction because it encourages attendance in group therapy sessions, mental health treatment, and adherence to psychiatric medication. The article concludes that “greater awareness and use of contingency management in practice may improve outcomes across a range of mental health and related conditions.”

Money can be used as contingency management in substance use disorder therapy because it can be offered in exchange for abstinence. Drug recovery programs run by the San Francisco AIDS Foundation have used contingency management as their treatment protocol. Their facility’s specific program “incentivizes drug users with money or gift cards to stay off drugs.” A past patient in this program, Billy Lemon, benefited greatly from this method of recovery. After 12 weeks in treatment, Lemon established a strong foundation for his recovery and reentry into society, and “after all of his drug tests came back negative for meth, Lemon received $330.”

Benefits of Contingency Management in Recovery

While everyone appreciates extra money, it is especially useful for someone in the early stages of recovery. The money symbolizes recognition and reward while teaching the person in recovery an important lesson. Those in recovery who receive contingency management treatment feel acknowledged and know that they are on the right track. Unfortunately, this may be the first time in these people’s lives that they have been told that they are doing anything right and that they are doing a good job.

This type of therapy rewards sobriety right away and rewires the brain’s reward system. Receiving recognition and monetary rewards gives the individual a surge of the feel-good hormone dopamine, without having to use drugs. This drug-free dopamine experience demonstrates to the user that they can feel good without the use of substances.

Lemon reflects on his treatment, saying that it was more about the support than the money, saying, “it was the first opportunity where I was like, I have self-worth…this person sees it and is willing to give me seven dollars, just to take care of myself. That was very motivating.” Inspirationally, Lemon was in his forties when he stopped using meth and, he “kicked his meth habit over 9 years ago after taking part in ‘contingency management’ program for meth and cocaine users at the San Francisco AIDS Foundation.” This type of treatment prepared him for a life in active recovery by teaching him to save money and invest it in something he cares about rather than drugs. A small investment allowed Lemon to eventually run the Castro Country Club, a recovery center in San Francisco.

While Lemon’s experience is just one case study, comprehensive research shows that “contingency management is the most effective treatment for meth or cocaine addiction, especially when combined with behavioral therapy.” It is important to understand that these facilities are not just handing out money; they are also offering hands-on and effective behavioral therapy. Lemon was not the only person in recovery who was successful at the San Francisco AIDS Foundation, as “63% of people who participated in the program in 2019 stopped using meth entirely, and another 19% reduced their rate.” Other facilities have utilized contingency management and are proud of the results. Dominick DePhilipphis, a clinical psychologist at the Philadelphia Center for Substance Addiction Treatment & Education launched the VA’s contingency management program and shared that “the Department of Veterans Affairs has relied on the therapy to treat 5,600 vets over the last 10 years. Of the 73,000 urine samples collected in the VA program, 92% tested negative for drugs.”

Controversy Surrounding Contingency Management

Even though contingency management treatment for substance use disorders is statistically successful, this method of treatment is often unsupported and even deemed controversial. Those opposed to contingency management in recovery argue that it is unethical to bribe and pay drug users to not use drugs. Another issue treatment centers run into while implementing contingency management is finding funding, as most insurers and state Medicaid programs do not cover this form of care. In fact, “the feds generally forbid them from offering financial incentives to patients, as a protection against fraud and waste, and state officials have interpreted the role as prohibiting reimbursement for contingency management.”

There is also a concern that the progress of contingency management will dwindle once official treatment stops and those in recovery are no longer awarded for staying sober. This also relates to the concern that the success of contingency management will wane as the individual in treatment becomes accustomed to the rewards and recognition. To prevent this slowdown in progress, physicians who specialize in addiction recovery recommend that this type of incentive treatment be administered continuously. This suggestion for delivering contingency management is “in the same way that medication therapies for opioid use disorders are sometimes prescribed indefinitely.” While there is pushback for this method of treatment, current research shows that the benefits of contingency management in substance use disorder recovery may last longer than previously thought. A study conducted at the University of Connecticut found that in a review of 23 previously published trials, “people who participated in contingency management were 22% more likely to be abstinent 6 months after treatment ended than people who received other treatments.”

The Need For New Forms of Addiction Treatment

As “meth use surges, first responders struggle to help those in crisis” and are encouraging health care providers to try new methods of treatment. Individuals seeking sobriety have a difficult time finding a treatment for their specific drug of choice, making it challenging for those in the healthcare profession to inspire hope in ending stimulant drug use. A sense of hopelessness has emerged among stimulant drug users seeking treatment because of the lack of accessible and effective treatment methods.

For opioid addiction today, there are three FDA-approved medication therapy options (methadone, buprenorphine, and naltrexone). There are no effective recovery medications for stimulant drugs such as meth and cocaine. With this lack of treatment options, it makes it difficult for stimulant users to seek help. With more treatment centers willing to make contingency management treatment more accessible, more stimulant users can get the treatment that works for them and learn invaluable lessons to help them recover. At Boardwalk Recovery Center, we determine which treatment methods are most effective for our clients and consider each person’s unique recovery and drug challenges.

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alcoholic talking to a doctorman drinking alcohol and using cocaine