Chapter 27. Contingency Management

Stephen T. Higgins, Ph.D.; Kenneth Silverman, Ph.D.
DOI: 10.1176/appi.books.9781585623440.353776



Contingency management (CM) treatments for substance use disorders (SUDs) have been in the published literature since the 1960s but have achieved a higher profile within the past two decades (see Higgins et al. 2008). CM treatments can vary in many respects, but the central feature common to all of them is the systematic application of reinforcing or punishing consequences in order to achieve therapeutic goals. With regard to treatment of SUDs, CM most commonly involves the systematic application of positive reinforcement to increase abstinence from drug use, an approach referred to as abstinence reinforcement therapy, but also to facilitate other therapeutic changes, including retention in treatment, attendance at therapy sessions, and compliance with medication regimens. Typically, CM is used as part of a more comprehensive treatment intervention. Below we outline the scientific rationale underlying this treatment approach, discuss the basic elements of CM, and discuss its treatment efficacy and effectiveness.

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FIGURE 27–1. Estimated effect size (r) and 95% confidence intervals.Weighted average effect sizes and 95% confidence intervals for subsets of studies as a function of the moderator variables: target, control condition, duration, daily earnings, voucher-based reinforcement therapy (VBRT) delivery immediacy, setting, and study quality. All studies target abstinence (N = 30). Weighted average effect sizes are represented by closed diamonds and 95% confidence intervals by solid lines. Where confidence intervals do not overlap, differences between subsets of studies are significantly different at the 0.05 level.Source. Reprinted from Lussier JP, Heil SH, Mongeon JA, et al: "A Meta-Analysis of Voucher-Based Reinforcement Therapy for Substance Use Disorders." Addiction 101:192–203, 2006. Used with permission.

FIGURE 27–2. Periodic abstinence assessments.Percentages of participants abstinent at each of the periodic assessments conducted with subjects retained in treatment as well as dropouts. Data points represent point-prevalence abstinence at the respective assessments. Abstinence was defined as a self-report of no cocaine use in the past 30 days and cocaine-negative urinalysis results. In categorical modeling, abstinence levels were significantly higher in the high-value than low-value voucher conditions based on assessments during treatment (1.5 and 3.0 months, P = 0.02) and follow-up (6- through 24-month assessments, P = 0.04).Source. Reprinted from Higgins ST, Heil SH, Dantona R, et al: "Effects of Varying the Monetary Value of Voucher-Based Incentives on Abstinence Achieved During and Following Treatment Among Cocaine-Dependent Outpatients." Addiction 102:271–281, 2007. Used with permission.

FIGURE 27–3. Cocaine urinalysis results across consecutive urine samples for individual participants in each of the three experimental conditions.Top, middle, and bottom panels represent data for the take-home plus voucher, take-home only, and usual-care control conditions. The vertical dashed lines divide each panel into three periods, the baseline (left), the intervention (center), and the postintervention (right) periods. Within each panel, horizontal lines represent the cocaine urinalysis results for individual participants across the consecutive scheduled urine collections of the study. The heavy portion of each line represents cocaine-negative urinalysis results, the thin portions of each line represent cocaine-positive urinalysis results, and the blank portions represent missing urine samples. Within each panel, participants are arranged from those showing the least abstinence (fewest cocaine-negative urines) on the bottom of the panel to participants with the most abstinence on the top. The numerals on the ordinates represent participant identification numbers.Source. Reprinted from Silverman K, Robles E, Mudric T, et al: "A Randomized Trial of Long-Term Reinforcement of Cocaine Abstinence in Methadone-Maintained Patients Who Inject Drugs." Journal of Consulting and Clinical Psychology 72:839–854, 2004. Used with permission.
Table Reference Number

Contingency management (CM) is based on an extensive basic science literature that demonstrates an important role for operant conditioning in the genesis and maintenance of drug use.

CM is an efficacious intervention for a wide range of different types of substance abuse disorders and populations.

CM has some basic features outlined in the section "Basic Elements of CM" that are important to effective implementation.


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In the studies by Bigelow et al. (1975) on contingency management in alcoholism treatment, all of the following were demonstrated except
"The removal or a reduction in the intensity of an aversive event contingent on meeting a therapeutic goal" defines. . .
All of the following are desirable components of a contingency management (CM) contract for substance abuse treatment except
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