Author: James Anderson

Rewarding recovery: the time is now for contingency management for opioid use disorder PMC

American Indian (AI)/Alaska Native (AN) adults have some of the highest alcohol-abstinence rates compared to the general US population.68,69 However, many AI/AN communities continue to suffer from alcohol-related health inequities. In the largest clinical trial for alcohol-use disorders among AI/AN adults, three tribal communities partnered with university researchers to adapt and implement CM for alcohol-use disorders. As described by McDonell et al,7 using components of community-based participatory research and community engagement, 400 AI/AN adults will be randomized in the ongoing trial.

1. Whether it be linking patients to supported employment or vocational rehabilitation training programs, assistance with resume/cover letter writing and interview prep, facilitating job fairs, or providing other resources for those interested in or able to work, earning an income and money management are often addressed in the context of treatment and obtaining employment is viewed as a positive outcome [38].
2. Entire systems – rather than specific treatment programs – may also use CM to help individuals reduce or quit substance use.
3. The federal anti-kickback statute provides for criminal penalties for providers who knowingly and wilfully offer, pay, solicit, or receive remuneration to induce or reward, among other things, the referral of business reimbursable under any of the federal health care programs (Medicare and Medicaid).
4. The same premise informs approaches to parenting that reward children for behaving well (as opposed to punishing their bad behavior).
5. The concept of rewarding positive behavior with positive reinforcement or some type of tangible reward is not a new one.

Surveys of mental health providers practicing in other countries reveal that, similar to the U.S., few are aware of contingency management and even fewer use the intervention in their routine practice [57]. Further research is therefore warranted to determine whether the positive findings observed for contingency management for OUD from U.S. samples generalize to other cultures. Involvement in local, state, and federal advocacy efforts to make contingency management more mainstream is required to lessen treatment providers’ perceived exposure to risk in providing payments to patients as part of contingency management interventions. At the federal level, this involves continuing to push for a safe harbour provision protecting the use of motivational incentives for patients enrolled in federally-funded health plans or programs, and participating in public comment periods. A newly created safe harbour specifically covering contingency management would ensure that despite potentially implicating the federal anti-kickback statute, contingency management would not be treated as an offence under the statute. Addiction treatment professionals, including executives, clinical directors, and front-line clinicians, are encouraged to familiarize themselves with their local and state elected officials, as well as their own state’s statutes regulating contingency management and the use of motivational incentives for state-funded programs as a logical first step, and then taking action, if necessary.

The concept of rewarding positive behavior with positive reinforcement or some type of tangible reward is not a new one. It operates according to the simple premise that an individual, when rewarded for positive behavior, is likely to continue that behavior. The same premise informs approaches to parenting that reward children for behaving well (as opposed to punishing their bad behavior).

Another recent example of CM-related experimental technology was a computer-assisted behavioral therapy that incorporated CM for cannabis-use disorder. This trial compared motivational enhancement therapy (MET) to a combination of MET therapy, CBT, and CM that was delivered either by a therapist or by a computer. MET-CBT-CM was superior to MET alone and was just as efficacious in abstinence rates and reduction in days of use over time when delivered by computer as it was when delivered by a therapist.81 In addition, the computer-based intervention cost an average of $130 per participant, which was significantly less than the cost of administration by a therapist.

Do we proceed “business-as-usual,” continuing to promote the same tired approaches, or do we instead follow the science by allocating resources to expand access to proven, life-saving treatments that work? Surging overdose deaths, coupled with consistently abysmal rates of medication adherence and treatment retention, make it clear that the time is now for contingency management for opioid use disorder (OUD). Contingency management (CM) is an effective behavior change technique commonly used to treat substance use disorders (SUDs).

Adapting CM for underserved populations

Parents of teenagers with substance use disorder or related problems might tie rewards (e.g., use the family car on Friday night) with a negative toxicology screen or other healthy measurable behaviors. Entire systems – rather than specific treatment programs – may also use CM to help individuals reduce or quit substance use. In sum, contingency management interventions have substantive evidence ofefficacy in positively modifying a variety of patient behaviours, andadaptations of these techniques to a variety of problem behaviours may furtherincrease their relevance and widespread use. Eventually, greater understandingand awareness of contingency management may assist in bringing thisempirically based intervention into a variety of psychiatric settings andspecialty areas. The National Institute on Drug Abuse reports that 40% to 60% of people with substance abuse disorders relapse after they leave rehab. Like a depression patient can adjust their medication, a substance use client can try a different treatment, such as contingency management therapy.

A recent survey of 619 opioid-related apps [64] identified 59 apps meeting criteria for quality assessment, but only a single app met basic quality standards, suggesting further work is warranted to fill this gap in technological solutions for OUD recovery management. There has been rapid progress on the innovation front in recent years with respect to emerging technologies leveraging contingency management in the treatment of OUD [20,28,29]. However, such advancements raise questions regarding potential disparities in access to technology-enabled, reward-based smartphone apps for some OUD populations, particularly individuals from low-income and racial/ethnic minority backgrounds. Although disadvantaged and underserved communities have traditionally been shown to have limited access to mobile health technologies and lower digital literacy, this gap is quickly narrowing [30].

Funding Statement

Accumulating evidence suggests smartphone ownership, although certainly not universal, is no longer the barrier it once was. In light of the increasing penetration of smartphones users, and the fact that many patients already leverage technology in all facets of their lives, reward-based apps have the potential to bring contingency management into the hands of more people receiving treatment for OUD. Contingency management refers to a type of behavioural therapy in whichindividuals are ‘reinforced’, or rewarded, for evidence ofpositive behavioural change. These interventions have been widely tested andevaluated in the context of substance misuse treatment, and they most ofteninvolve provision of monetary-based reinforcers for submission ofdrug-negative urine specimens.

One of the biggest barriers to utilizing CM in real-world treatment situations effectively is not a scientific one, but a political one. Convincing policy makers of why this should be more broadly integrated into drug- and alcohol-use-disorder treatment has proven difficult. Alternative versions or optimizations of CM have been used to adequately address population-specific or tailored interventions for individuals that may need different rates, magnitudes, or schedules of reinforcement to improve SUD-treatment outcomes significantly. Also of interest are legal concerns and whether the use of monetary incentives violates federal and state law because it could be considered unlawful to give patients money who are enrolled in federally- or state-funded health plans or programs.

In fact, Petry et al96 examined 260 serious adverse events across two large105 national multisite CM trials (along with two other psychosocial intervention investigations) and found that none was judged by the Data Safety and Monitoring Board to be related to the CM intervention. This makes CM both effective and amenable to ongoing experimentation and optimization efforts across a diverse array of settings and populations that will only be leveraged further by ongoing technological developments. We culled the initial list extensively for relevance before deciding which articles to include in our review. In addition to the specified search criteria, we included meta-analyses and a couple of noted classic CM works prior to the year 2000. This was done because there were some CM-optimization strategies tested before 2000, but that work has not been picked up to any degree of finality since then. We include those works here in an effort to help shape the review and discussion of how best to optimize CM, especially in light of emerging technology and reaching underserved populations (our other two themes of this review).

When Is Contingency Management Most Beneficial?

In many applications of CM, staff must be on hand to meet participants frequently, which can be time-intensive and costly, and participants must travel to the site to supply specimens, which can be difficult in rural areas and for participants who do not have access to transport. However, mobile phones are increasingly becoming a part of everyday life,77 paving the way for new technologies to bridge this gap and allowing for progressively easier remote monitoring and incentive delivery through the Internet. While most technology-based CM is in the feasibility stage, significant progress has been made in remote monitoring of participants, intervention delivery, and incentive delivery through a variety of technologies. The Office of Inspector General (OIG) published a final rule in December 2020 amending safe harbours to the federal anti-kickback statute [49].

Some programs object to implementing CM on the grounds that it could be classified as “a game of chance.” In some CM interventions, for example, participants pick tickets out of a fishbowl after a negative toxicology screen, but only some of the tickets have prizes, and these prizes range in value. For example, there is evidence that this type of treatment may not provide a demonstrable benefit for individuals with a dual diagnosis in association with relapse; however, there has been evidence that dual diagnosis clients show up to therapy 50 percent more often when participating in a contingency management plan. Residents can undergo any type of therapy, including contingency management, and still relapse after they leave rehab. Still, clinics that adopt this program may increase their clients’ chances of staying sober and treat residents who don’t respond to other types of care. Individual therapy helps patients take a closer look at their habits and patterns of behavior and how these may have paved the way to addiction, a chronic condition that is governed by a compulsion to use an addictive substance despite its negative effects.

Depending on the identified target behaviours, validation can be achieved via multiple easy and convenient methods. Supplementing patient or collateral self-report, smartphone video and GPS location capabilities, as well as external testing hardware have all been used to good effect to monitor and confirm medication adherence, abstinence, and appointment attendance [28,51–54]. Rewards contingent on abstinence can be delivered immediately using smartphone-linked remote breathalyzer/saliva drug testing or after verification by the provider following a negative urinalysis drug screen at routine in-person clinic visits.

Also during this time, other more involved treatment approaches capitalized on these operant conditioning principles present in CM, while also incorporating ways to enhance coping skills and sober social activities, such as the Community Reinforcement Approach (CRA). In Contingency Management (CM) interventions, patients receive a reward for meeting a treatment goal or, in some cases, a negative consequence if the individual is unable to meet this goal. In the most common type of CM, patients receive cash, a voucher, or another prize in response to a negative urine toxicology screen (i.e., a good outcome). Finally, one last important aspect of CM that makes it amenable to several different adaptations and optimizations using the aforementioned emerging utilities is that CM produces virtually no adverse events.