contingency management

Meth and crack may be as addictive as opioids, but they have a far different impact on the brain and the body. So it only makes sense to treat them differently. A relatively new method called contingency management might just be different enough to work.

That's what more and more addiction experts are insisting anyway. And more and more studies are backing their insistence. Then again, would they be insisting upon anything without actual evidence?

Of course not.

But not all addiction experts are on board with contingency management. Yet with meth overdoses continuing to rise there's mounting pressure for them all to find an effective addiction treatment protocol. In fact, coming up with a solution is literally a matter of life or death.

Contingency Management is a Thing

If contingency management works, then why is it so underused?

That's the question posed by the New York Times' Abby Goodnough. And that's the question even the learned and thorough Ms. Goodnough couldn't quite answer. Oh, she found answers alright. Some of them even made sense. But the sense of it all depended largely upon a person's perspective. And that's pretty much unanswerable.

Nevertheless contingency management is a thing. And armed with the facts we can decide for ourselves whether or not it's a worthy thing. So let's have a look.

Just What is Contingency Management?

"Contingency management," writes Goodnough, "rewards drug users with money and prizes for staying abstinent." A reward may be something as simple as an encouraging message. It could also be a privilege, perhaps aligned with the client's facility. Or it could be a voucher of some sort set up to purchase food or other necessities. Whatever the reward, it's completely contingent upon the user staying absolutely abstinent. Hence the name.

As for method, well, contingency management therapy uses stimulus control. Without getting too technical, this is the term behavioral psychologists use to describe and define differing ways a particular person behaves in the presence or absence of given stimuli. For instance, if you always eat while watching television, then your eating behavior is controlled by the stimulus of watching TV.

It's really rather simple. It also seems to contain an inherent logic. Especially if you linguistically consider the phenomenon. After all, wouldn't something called stimulus control seem to be an effective way to control the use of stimulants?

Just saying.

Anyway, contingency management is nothing more or less than incentive-based therapy. You get something good when you do something good. Period.

How Does it Work?

The best way to gauge the effectiveness of contingency management is to observe the practice in action. Turns out there are scores of clinical trials attesting to its efficacy. So let's have a look at those cited by The Times.

Take Steven Kelty, of Winfield, Pennsylvania. Kelty, writes Goodnough, "had been addicted to crack cocaine for 32 years when he tried" contingency management. He'd "come to a clinic twice a week to provide a urine sample. If the sample was free of drugs, he'd get to draw a slip of paper out of a fishbowl. Half of those slips of paper contained encouraging messages — typically, "Good job!" — but the other half were vouchers for prizes worth between $1 and $100."

“I’ve been to a lot of rehabs," said Kelty, "and there were no incentives except for the idea of being clean after you finished. Some of us need something to motivate us — even if it’s a small thing — to live a better life."

Toledo, Ohio's Jodi Waxler-Malloy was another recent convert to contingency management treatment. The 47-year-old has been battling cocaine, heroin and meth addiction for over two decades. During that time she's been in and out of "more than a dozen treatment programs."

BrightView Health took a different approach to Waxler-Molloy's cross-addictions. The clinic first "restarted" buprenorphine treatment to address her heroin addiction. Then "they set her up with the DynamiCare app and debit card as an incentive to stay off meth. DynamiCare would add between $1 and $25 to her debit card whenever she went to BrightView for a doctor appointment or therapy, though she never knew the amount ahead of time."

Like Kelty, Waxler-Molloy was initially skeptical about the therapy protocol.

"Nothing’s for free," she told Goodnough, "so at first I said, 'Yeah, yeah,' But the next day, I looked at the app on my phone and they’d given me $25 for detoxing. Wow, really? I went back the next day and I got $5 more."

"Ms. Waxler-Malloy said the monetary rewards particularly helped her get through the first month of sobriety," writes Goodnough. "A period when her housing was precarious, her cravings were intense and she needed to save whatever money she earned waitressing for rent at a sober living house that she was waiting to move into."

"It was enough to buy cigarettes or grab something to eat," Waxler-Molloy said. "Maybe I was going to the appointments and meetings for the wrong reason at that time, but it helped me in the long run — helped me meet people, have a support group."

Can anyone argue with that?

The Experts Weigh In

Experts say the surge of meth addiction is largely responsible for the increased interest in contingency management. One of those experts is Dominick DePhilippis. DePhilippis is the clinical psychologist who oversees the program at the Department of Veterans Affairs, where its been implemented since 2011. In fact, the Department is employing contingency management at 110 clinics and hospitals. It is by far the largest such program in the country.

Dr. DePhilippis "published a paper in 2018 that found that, on average, patients in the department’s contingency management program attended more than half of their scheduled sessions," reports Goodnough. Furthermore, "the average percent of urine samples that tested negative for the target drug was 91.1." That's an astonishing high percentage rate in the recovery arena.

"It’s not a panacea — not all patients respond to contingency management," the doctor told Goodnough. "But I think of it as a scaffolding. We can’t provide this reinforcement indefinitely, but for a sufficient amount of time that the patient will begin to experience the naturally occurring benefits of recovery."

Dr. Shawn Ryan, the chief medical officer and president of Ohio's BrightView Health, is another one of those experts who's found positive results after employing contingency management therapy.

"I was hesitant to try it — like, hey, is this legal?" Dr. Ryan told Goodnough. "But the results have been striking. I’m talking about significant improvements in attendance to therapy sessions [and] significant reductions in drug and alcohol use."

Objections! Objections!

Nevertheless, there are objections. Despite successes to the contrary. And those objections tend to be moral.

Indeed, writes Goodnough, "researchers say that one of the biggest obstacles to contingency management is a moral objection to the idea of rewarding someone for staying off drugs. That is one reason publicly funded programs like Medicaid, which provides health coverage for the poor, do not cover the treatment."

Furthermore, "some treatment providers are also wary of giving prizes that they say patients could sell or trade for drugs." That's the belief Pastor Greg Delaney anyway. Delaney, who's also the outreach coordinator for an Ohio residential treatment center, added even more. "Until you’re at the point where you can say, 'I can make a good decision with this $50,' it’s counterproductive."

Some people equate the objections to contingency management with those that have been raised around Medicine-Assisted Treatment (MAT). But the parallels between abstinence incentives and applied medications seem only to be in their reported efficacy. Abundant research shows MAT substantially reduces the risk of death and helps people stay in treatment. In fact, the federal government has started aggressively promoting such opioid addiction treatment. The research in contingency management is showing similar results.

Meth and Crack and Contingency Management

It should be emphasized that we currently have no medicines that effectively "suppress the intense cravings that come with addiction to meth and cocaine." None whatsoever. Instead, treatment providers have applied "a raft of behavioral interventions." And thus far few have shown even a modicum of effectiveness.

"The most common treatment is to do whatever the hell you feel like," said Washington State University's Michael McDonell. The associate professor has conducted a number of contingency management studies, so he's more than informed. "We had two statewide meetings about meth recently, and at one, a colleague said, 'Why aren’t we just doing contingency management? Why would we spend all this money on interventions that won’t work?'"

Indeed. That's the proverbial $64,000 question. The feds say "they want to expand access to contingency management, but that finding an effective medication for stimulant addiction would be better."

"If we were paying for [contingency management to fight meth addiction], that would help," says Dr. Nora Volkow. "But we badly need medications to help strengthen the response to behavioral interventions. This is a highly, highly addictive drug."

Agreed. On that last part anyway. Meth is a highly addictive drug. It's also lethal. And more and more people are learning both the hard way. Would a magic pill for meth addiction be a wonderful thing? Certainly. But right now we don't have a magic pill. And calling for something we don't have instead of advocating for something we do have seems really counterproductive. Especially coming from the director of the National Institute on Drug Abuse.

Can Contingency Management Work?

Let's sum it up. "Rewarding people for changing a behavior or adopting a new habit is a familiar concept. It's used by everyone from parents who are trying to get their children to do chores to companies that are trying to get their employees to stop smoking." Furthermore, writes Goodnough, "it also helps people who are addicted to opioids. But for opioid addicts, there are other treatments that are equally or more effective. For meth and cocaine addiction, however, contingency management has the best outcomes. Especially when combined with therapy that helps people find healthier ways to meet their social and emotional needs."

To amplify her findings, Goodnough cites a 2018 meta-analysis of 50 clinical studies of cocaine and amphetamine addiction interventions. The results found "contingency management combined with community reinforcement was the most effective" treatment.

So there.

What Next?

What happens after people complete contingency management treatment? Glad you asked. Because that's another problem. And a rather significant one at that. People do seem to have less success staying abstinent after the treatment ends. Consequently, meth addiction experts like the University of Vermont's Richard Rawson believe it should be used indefinitely. Just like opioids and MAT.

"Unfortunately, addiction is a chronic brain disease and treatments need to be designed to accommodate this reality," said Rawson.

That unfortunate analysis played out with Ms. Waxler-Malloy. Things got hard after her four months of contingency management ended, despite her therapy sessions and 12-step meetings. Then she lost her waitressing job because of the pandemic and things got even harder. She relapsed. And started using meth and heroin again "full force." This lasted three weeks before she managed to get more help from Brightview.

Still, Goodnough reports that the eight months Waxler-Molloy went without using drugs was her longest stretch of abstinence in more than two decades. Hear that? She experienced her longest bout of sobriety in over twenty years. All because of contingency management. Furthermore, she fully believes there may not have been a relapse if contingency management had still been part of her treatment regimen.

"That kept me real accountable," said Waxler-Molloy. "Even just to stop at McDonald’s when you have that little bit of extra money, to get a hamburger and a fries when you’re hungry. That was really big to me."

That kind of thing is a really big deal to a lot of people in recovery. Why? Because it makes them feel normal again. Just another person doing what other people do.

Recovery Boot Camp Wants to Know

Recovery Boot Camp is all about recovery. It's in our very name. Consequently we most definitely want to know what works. That's why we continue to investigate various treatment protocols. It's also why we report such investigations. Armed with the facts. That's not just our motto. It's also our mantra. We believe everyone should be armed with the facts. Because only then will we be able to make the right decision regarding our recovery. And only then will we be able to achieve real sobriety.

So, what are your thoughts? Is contingency management something you'd try? Does incentive-based therapy sound like AA's chips-system on steroids? Is it something you could get behind? We'd like to know. After all, you've seen what addiction does to people. You've seen the toll it takes on family and friend. And you know how it reverberates throughout a community. Your community. In other words, you know the stakes. Do you believe people should be rewarded simply for staying clean? Head on over to our Facebook page and tell us what you think.

(Image courtesy Picpedia via Creative Commons. With gratitude.)

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