External rewards promote initial but not longer term drug recovery

Researchers at the University of Connecticut Health Center found that, for regular (dependent) users of marijuana, long-term abstinence was more likely to occur for patients who actively used recovery coping skills. Abstaining patients developed more confidence in the effectiveness of the coping skills and their ability to use these skills. Rewarding abstinence by paying the patients (an approach called “contingency management”) was successful in the early days and weeks of drug recovery. However, unless the patients also developed new insights and actively changed recovery-related behaviors (including actively taking steps to prevent relapse), the initial benefits of rewards wore off over time.

This study offers valuable insights for addiction treatment and drug rehab programs. Rewards of various kinds may be useful initially. However, individuals seeking addiction recovery also need to make internal changes. Simply stopping drug use, without other supporting changes, is unlikely to lead to stable drug recovery.

This study was significant scientifically because it is among the first to study the effects of combining three drug treatments which are already known to be effective. These treatments are motivational enhancement therapy (MET), cognitive-behavioral therapy (CBT) and contingency management (CM).

The participants in the study, 240 adult dependent marijuana users, were assigned to one of four 9-week treatment conditions: CM, MET plus CBT, all three approaches combined, and supportive case management as a control group. CM rewards abstinence with vouchers for retail goods and services. MET helps the patient increase awareness of reasons to change. CBT focuses on developing addiction and life coping skills.

Patients were followed for 12 months post-treatment. Abstinence was verified by urine screens. Contingency management patients had the highest rates of abstinence during treatment. However, these patients had the lowest rates of abstinence during the second six months of follow-up. Regardless of the treatment, abstinence rates were similar during the first six months following treatment, and abstinence during this six-month follow-up period was best predicted by abstinence during treatment. Long-term abstinence, on the other hand, was most clearly predicted by use of coping skills and self-efficacy for abstinence.

The most successful approach with the highest rates of abstinence 12 months post-treatment combined MET, CBT, and CM. While a reward system alone has a weak effect on long-term abstinence, CM appears to strengthen MET and CBT when all three therapies are used simultaneously. These results fit clinical observations about addiction recovery. Initially the task of recovery may seem impossibly large. Small and immediate rewards can keep the patient focused on recovery in the earliest phase. In time, however, these rewards may lose their effectiveness. Only by making internal changes can the patient move to achieving stable abstinence.

This study focused on outpatient addiction treatment. For patients admitted to a drug rehab the value of external rewards may be much smaller. For outpatients, the rewards may support initial abstinence, allowing the patient to focus on learning recovery skills. If admitted to a drug rehab, however, abstinence is assured simply by being in the facility and removed from the patient’s drug using environment. However, upon discharge from drug rehab external rewards might again be useful briefly, as the patient re-adjusts to life outside the facility. Although this study examined recovery from marijuana use, the results also seem applicable to recovery from other substances.

External rewards work well during the initial months of addiction treatment and recovery. Long-term recovery will not likely be achieved, however, unless the initial period of abstinence is used to build a repertoire of recovery skills.

References

Litt M.D., Kadden R.M., Kabela-Cormier E., Petry N.M. Coping skills training and contingency management treatments for marijuana dependence: exploring mechanisms of behavior change. Addiction 2008, 103(4), 638-648.