What is contingency management in drug treatment?

In scientific research, potentially fuzzy concepts are “operationalized” to make them measurable. For example, the fuzzy concept of “length” must be defined in terms of the measurement operations used to obtain length.

The term “contingency management” may have different meanings, depending on how this approach to drug treatment is operationalized in a particular study. The aim of this article is to help the reader understand what subjects in a contingency management drug treatment program might experience. The reader may then have a better sense of whether contingency management would be useful in his or her own addiction treatment or drug rehab program. Although scientists will be interested in the operational differences between different approaches to contingency management, here we will consider the range of contingency management procedures that have typically been used in drug treatment studies, and how these procedures compare with the contingency management that parents might apply to their children in drug treatment.

What is it like to receive contingency management? As a subject you return to the study site up to several times per week, in order to provide a urine sample. The number of times you need to test will depend on the substances being studied. If your study is focused on marijuana, coming to be tested once per week is sufficient, because evidence of marijuana stays in the body longer than it does for other drugs. If the study involves alcohol, stimulants (such as cocaine or amphetamine), or opiates (such as heroin or morphine) then two drug tests per week will not allow much time to use and not get caught. Three times a week testing would be sufficient to catch any slip that occurred.

If your urine test is negative (meaning that no drug is found), then you receive the reward. The reward is a voucher, a piece of paper that authorizes you to “purchase” something, either a product or a service, from the merchants that have agreed to participate, or perhaps from the study “store” itself. In order to make the vouchers valuable, the researchers might interview the subjects to find out what appeals to them. For instance, if your voucher were only good to purchase foods you do not enjoy eating, the voucher would not be valuable to you. Vouchers that are not valuable are not motivating.

Sometimes the rewards increase as you continue to abstain. For instance, if you get one voucher for your first clean test, you might get two at your second or later test. If the rewards keep getting bigger, they can become very motivating. This aspect of contingency management is similar to life, where after working hard at something for a long time, you have more invested, and more to lose.  Scientists can be particularly interested in this aspect of contingency management. How big a reward is needed for it to be motivating? How much does a reward need to increase, and how fast, for success to be maintained? Might the rewards ever be too big and too fast, such that the subject perhaps thinks: “I’ll use for awhile, then I’ll be back to big rewards in no time!”

A significant aspect of contingency management studies is that they often involve subjects for whom the vouchers are significant. If you are a resident in a private drug treatment program, a voucher to purchase something you can easily purchase with your own money will probably not be very motivating. If you do not have much of your own money, the vouchers can be motivating, at least in the short term.

Ironically, however, many of the individuals in drug treatment, even expensive private programs, are on a contingency management program, but of a very different type than one that involves vouchers. Because many individuals in drug treatment are paid for by their parents, it is easy to imagine that the parents have “contingencies” in mind. These contingencies (rewards and also punishments) are often much bigger than vouchers, and operate over longer time frames. Because of the size of the rewards, the presence of punishments also, and the extended time frames (vs. getting a reward one or more times per week), the way parents use contingency management is very different than the contingency management in scientific studies. For now “parental contingency management” is not well studied. It has been largely guided by the clinical judgment of the professionals advising the parents, or by the parents themselves.