Author: Gary Jackson

Contingency management: what it is and why psychiatrists should want touse it PMC

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.

• The first 6 weeks served as a baseline period, during which attendance at groups and compliance with activities were recorded, but no reinforcers were provided.
• Probability is introduced via an intermittent reinforcement schedule in which some draws are winning (“small prize”) and others have no prize value (“good job”).
• California received a Medicaid demonstration waiver for the state’s CM pilot, planned to cost more than $50 million, that will include as many as 200 sites.
• Both intensive intervention formats were efficacious in terms of marijuana abstinence, but the computer-delivered format saved $175 on average per participant.
• In this way, the number of total draws per week (by all clients) was decreased from an average of 50 in weeks 7–18 to an average of 21 in weeks 19–24.

He maintains enthusiasm for the contingency management plan, even though he is not earning all his money. As yet, he has not appeared unexpectedly at the psychiatric emergency room or engaged in violent behavior toward staff. The contingency management intervention was instituted on the day of Mr. C’s discharge from the inpatient unit. If this is what I got to do to get my money, I’ll do it.” In the first week, Mr. C honored his first appointment and under supervision produced a clean urine sample. This was a landmark event, since it was the first drug-free urine specimen Mr. C had produced in years outside of a controlled environment.

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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. Following discharge from the psychiatric unit, Ms. A was offered participation in our NIDA-funded study evaluating lower-cost contingency management treatment (e.g., reference 11) for cocaine-abusing methadone patients.

• His longest period of sobriety occurred while incarcerated or hospitalized on a psychiatric ward.
• When the behavior they’re working to change is attendance, their choice to be there on time proves the incentive is working.
• Because drug abuse is a chronic relapsing condition, complete abstinence may be an unrealistic goal, especially in difficult dual-diagnoses cases.
• This introduction to the CM special issue in the Journal of Substance Abuse Treatment briefly summarizes the breadth of this intervention’s efficacy, articles included in this special issue, and highlights directions for future research.
• This can be described as how much of the reward should be provided to achieve the target behavior.
• This refers to how long a person should receive the reinforcement in order to motivate the desired behavior.

Participants could earn a total of $1160 over 6 months for meeting 8 health care compliance and substance abuse abatement targets with bonuses for achieving HIV viral suppression. The paper describes in detail the structure and content of the incentive program and considerations that went into its design. Backed by data from the main outcome paper (Metsch et al., 2016) that shows short-term efficacy of the PN + CM intervention on some key outcome measures, the paper provides an example of the types of interventions that may be useful in the future for addressing complex health care issues of at-risk populations. Overall, CM is an efficacious SUD intervention that is generalizable to a variety of SUD populations with few exceptions.

The magnitude or amount of reinforcement

The prize approach used in cases 1 and 2 was developed to decrease the cost of reinforcement relative to the voucher system (11). The use of contingent disbursement of disability payments is a novel, no-cost reinforcement approach (25–27). Examples include social recognition and sponsor status in 12-step treatments and take-home privileges, early dosing windows, or dose adjustments in methadone programs. Future research may assess whether utilization of behavioral principles when administering these and other reinforcers improves efficacy in altering problematic behaviors.

” Ms. A maintained cocaine and opioid abstinence for 4.5 consecutive weeks, earning bonus drawings weekly. Since her mid 20s, Ms. A had used heroin and cocaine intravenously at the rate of 15 bags of heroin and three to four dime bags of cocaine daily. Her drug use resulted in several emergency room visits for drug overdoses, multiple detoxifications, and three previous methadone treatments, as well as numerous psychiatric hospitalizations for suicidality and cocaine-induced psychotic episodes.

0 Real-world clinical implementation

Also, despite its place as one of the most effective approaches to address substance use disorder, few programs implement standalone CM given its mismatch with the fee-for-service model used in many managed health care settings (e.g., they can’t obtain the funds to implement it). In this issue, Herrmann et al. (2017) conducted a systematized review of studies using incentives in the control of infectious diseases among SUD populations. Individuals who use alcohol and drugs are at especially high risk for non-adherence (e.g., Golin et al., 2002; Hicks et al., 2007; Lucas, Gebo, Chaisson, & Moore, 2002) and are in need of efficacious interventions for infectious disease control.

While these three cases do not provide evidence of the long-term efficacy of contingency management, they do suggest some potentially enduring effects and methods by which some behaviors may be reinforced long-term. Researchers and public research funds have invested decades into designing and evaluating CM interventions, and CM clearly is beneficial for improving substance use treatment outcomes when it is administered appropriately. 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 specialties.

3 Substance use severity

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. Another paper in this special issue by Brolin et al. (2017) describes a study conducted in Massachusetts that had a similar intent – in this case to improve outcomes for SUD patients with multiple prior detoxification admissions. The paper examines cost and behavior outcomes for participants assigned to receive a care support intervention with and without incentives. In this real world setting, however, implementation of the incentive program encountered organizational and attitudinal barriers that may have reduced its effectiveness.