How do you explain contingency management to ineligible patients?

This is a pilot program we are testing with only a handful of patients. If it is effective with them, we plan to ask for more funds to extend it to more patients in the future. We have limited resources to test it initially.

Won’t external reinforcers decrease internal motivation to change?

External reinforcers foster behavior change. After being paired with prizes or vouchers, abstinence from drugs and attendance at groups may become reinforcing in their own right.

Many contingency management patients state they initially stop using/attend treatment only for the prizes. Once they cease using drugs and begin attending treatment regularly, these behaviors become reinforcing and meaningful, and the prizes are no longer as salient.

We have measured internal motivation to change in response to standard care and standard care plus contingency management. Contingency management had no adverse impact on motivation to change (Ledgerwood and Petry, 2006. Does contingency management affect motivation to change substance use? Drug and Alcohol Dependence, 83, 65-72).

What happens when contingency management ends?

Many clinicians express concern that when contingency management ends, patients will drop out of treatment or relapse. This is not typically what happens. Most patients prepare for the ending of contingency management, and a strong predictor of long-term abstinence is the longest duration of abstinence achieved during treatment (Higgins et al., 2000; Petry et al., 2005,2007).

In open group formats reinforcing attendance, many former contingency management patients continue attending contingency management groups, even when they are no longer eligible for prizes. They act as mentors to new contingency management patients. If you are comfortable with this option and groups will not become too large, you can encourage former contingency management patients to attend contingency management groups and watch others draw.

In all contingency management programs, remind patients of the time duration two weeks prior to their end dates, and openly discuss reactions. Providing certificates of completion on the last day of contingency management is a nice way to celebrate successful participation in a contingency management program.

Will non-reinforced drug use increase?

No contingency management studies have reported increases in other drug use when abstinence from any one drug is reinforced. If use of the most problematic drug decreases, other drug use is likely to decrease or remain constant.

If your contingency management program reinforces attendance, then attendance should increase. Although drug use could persist when patients are earning prizes for attendance, this rarely happens. Most patients’ drug use will decrease when they are engaging in positive behaviors like attending groups.

Usual clinic practices should apply to all contingency management patients. If a patient arrives intoxicated, standard clinic procedures should be in place, such as calling police or emergency services and not allowing access to clinic services (including contingency management).

Isn’t prize contingency management like gambling?

Although prize contingency management contains an element of chance, it is not gambling.

By definition, gambling entails risking something of value. With prize contingency management, patients risk nothing.

No evidence indicates gambling problems develop with prize contingency management.

We have followed thousands of patients in contingency management projects and assessed gambling before, during and after participating in contingency management. There have been no cases of pathological gambling developing in any contingency management-treated patients (Petry et al. 2006. Prize-based contingency management does not increase gambling: Results of the NIDA Clinical Trials Network multi-site study. Drug and Alcohol Dependence, 83, 269-273).

Although no data suggest that prize contingency management is harmful, patients in recovery from pathological gambling should NOT be included in prize contingency management programs.