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Interest grows in reward-based treatment for addiction

A doctor talks to a patient.
Someone enrolled in a contingency management program might show up at a clinic twice a week and supply a urine sample; if it's drug-negative, they receive immediate, positive reinforcement via a reward. If not, they’re encouraged in a helpful, nonjudgmental way to keep trying.

People who want to quit smoking or stop using other drugs and alcohol need a powerful tool.

Contingency management is the technical name of one such tool that rewards people for not engaging in the behaviors they’re trying to quit, through prizes, vouchers, or gift cards.

Though it’s not new – there are decades of studies showing its effectiveness – there’s growing interest in using contingency management to address addiction. Because faculty at the Washington State University Elson S. Floyd College of Medicine are experienced in researching and implementing contingency management programs, they’re consulting with and training providers around the country. 

“The idea is that when people use drugs it will hijack that reward pathway in our brain,” explained WSU College of Medicine Professor Michael McDonell. “With the incentives in contingency management, you’re trying to get that reward pathway back in balance.” 

Added John Roll, WSU professor and vice dean for research at the WSU College of Medicine, “It relies on principles that have been shown to be active from simple organisms to rodents to animals to humans. All organisms have evolved to be exquisitely sensitive to consequences of their behavior.” 

For example, someone enrolled in a contingency management program would show up at a clinic twice a week and supply a urine sample. If the sample is drug-negative, they receive immediate, tangible positive reinforcement via the prize or gift card. If not, they’re encouraged in a helpful, nonjudgmental way to keep trying.

The typical treatment is 12 to 16 weeks, with an optimal total payout of about $500 in merchandise or gift cards. Studies show that participants are able to maintain long-term abstinence after the treatment period ends.

Compared with other treatments, contingency management represents a big cost savings. Moreover, it promotes abstinence from cocaine, methamphetamine, tobacco, alcohol, opioids, cannabis and benzodiazepines, and is effective for a wide range of people, including pregnant women, adolescents, veterans, people with mental illness, and the homeless. 

In short, contingency management is “among the most effective interventions for substance use disorders,” according to an article published in the Psychiatric Times this fall, whose lead author is Sterling McPherson, WSU College of Medicine professor and assistant dean for research, and co-authors include Roll and McDonell.

So why aren’t more people using it? 

In the past there’s been a stigma attached to paying people to be sober. There’s been a belief that their motivation should be internal, rather than external. Also, until 2019, it wasn’t clear whether the use of incentives violated anti-kickback regulations for Medicare and Medicaid patients. But the federal Office of the Inspector General has clarified how contingency management could be used under certain conditions. 

Combined with overwhelming evidence of its success, interest in contingency management has soared. 

Faculty at the WSU College of Medicine are working with eight tribal communities, California, Wisconsin and Washington to educate providers on setting up contingency management programs. They are also part of research studies in Brazil and Uganda. 

Roll said WSU faculty are one of the biggest centers of knowledge in contingency management in the country right now. 

Additional research under way at the WSU College of Medicine is using contingency management with technology. 

For example, McPherson said, WSU faculty are co-developing an app that would combine biochemical verification, such as a breath sample, with app-based delivery of vouchers, gift cards or other incentives.

“Roughly 10% of patients in the U.S. who have a substance use disorder ever receive treatment,” he said. “That means an alarming 90% do not receive treatment.” Being able to treat a person via a cellphone could expand the reach of contingency management to people in rural areas, those who don’t have transportation, or in places where it’s not otherwise available. 

McDonell said the WSU team is talking with more state-level and healthcare system administrators who are interested in contingency management for addiction treatment.  

“People are getting on board that this is a crisis and we’ve got to do something about it,” he said. “This is the one effective tool we have.” 

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