“Contingency management” is a practice that rewards people with vouchers or gift cards for not engaging in behaviors they’re trying to quit. The idea is to realign reward pathways in the brain using positive reinforcement. The practice is gaining traction as a way to help combat substance use disorder — Washington and Montana are both working to incorporate contingency management into state treatment programs, and California is set to launch a pilot program that covers it as a Medicaid benefit.
Joining us to talk about the pros and cons of contingency management is Sara Parent, an assistant professor in the department of community and behavioral health at Washington State College of Medicine.
Note: This transcript was computer generated and edited by a volunteer.
Geoff Norcross: From the Gert Boyle Studio at OPB, this is Think Out Loud. I’m Geoff Norcross. This year, the state of California is going to try something new to help people break their addictions to drugs or alcohol. It’s going to allow state Medicaid dollars to be used on programs that reward people for not using those substances. It’ll be the first state to allow this practice to be used as a Medicaid benefit. Here to talk more about the concept and how it’s applied as Sara Parent, assistant professor in the department of community and behavioral health at Washington State University College of Medicine. Sara, welcome to Think Out Loud.
Sara Parent: Thanks for having me.
Norcross: This concept has a name–contingency management–which you know we’re going to have to get over our problem with the dryness and the density of that term, but can you talk more about how it works?
Parent: Sure. So contingency management is kind of a clunky term for basically using a structured approach to positive reinforcement in order to encourage behavior change. And most specifically it’s used in substance use disorder, so that behavior change is most focused on helping people cut down or stop using the target substance.
Norcross: And I understand it uses a system of rewards. Can you be specific about that?
Parent: Rewards are kind of used broadly. We should focus on what we mean by rewards. A lot in the research world, we like the word ‘reinforcer.’ That doesn’t mean as much to the broader audience. But the reason why we focus on translating this to reinforcement is because it really is about harnessing the power of positive reinforcement to encourage change. And so reinforcement is basically anything that will get a behavior to continue, to increase or to be maintained. Something that feels good is what positive reinforcement is. So a reward, whether it’s a gift card or an experience or a bonus at work or even a smile or a thumbs up emoji, all of these things make us feel good and when we feel good, we’re more likely to repeat that behavior.
Norcross: Yeah, it just sounds basic human nature, more carrot less stick.
Parent: Exactly. Yeah.
Norcross: So what’s new or surprising here?
Parent: Nothing new. In fact, contingency management is essentially making that a structured therapeutic approach. It’s very intuitive, like you just mentioned, to use positive reinforcement. People with kids, with dogs, people go to work and get bonuses. People use social media, we all respond to positive reinforcement all the time.
Contingency management takes it one step further in making this structured approach where we’re going to repeat the experience of positive reinforcement, sort of methodically, over time in order to kind of embed this behavior and change this ability to avoid the substance use and instead sort of point a reward pathway responses toward other rewards. So we use this structured response.
It makes intuitive sense, it works with everything we know about behavior change principles and, but that all sounds great on paper. [What] would also be good to know [is] does it actually work? And turns out it’s been researched for decades and decades. So nothing about this is new.
What is new is being able to do it out in the real world. And it really is because contingency management often uses things like gift cards as reinforcement. It ends up getting caught up in the federal anti-kickback regulations and real concern around using federal funds to provide these types of incentives. So out in the real world, there’s been some difficulty in figuring out a way to do this that doesn’t get people in trouble with federal regulations.
Norcross: Is there an addiction patient for whom contingency management just doesn’t work?
Parent: Any response, whether it’s addiction, whether it’s a medical condition, mental health, we all are individuals, so of course nothing works for everybody. It’s one of those medications that don’t always work the same for everybody, but right now we have such a body of research evidence that says more likely than not somebody is going to respond to contingency management. Is it a magic bullet? Of course not. And could it be used with other things so that we could find a way to meet everybody where they are in their recovery journey? Of course, and this is really an important tool in that toolbox.
Norcross: Can you unroll a scenario for me where a patient is going through a contingency management plan and what benchmarks are they hitting? And how are these reinforcements distributed?
Parent: Yeah. So one of the most common ways to structure a contingency management program is really focused on urine test results. That’s the best objective measure to whether substance use has occurred or not. So really simply put, people come in a couple of times a week, they submit urine test results and if that urine test is negative for the target substance or substances, then they receive that reward. If it isn’t, then they don’t receive the reward, but they do receive encouragement to come back in three days and try again. So that positive approach where people don’t feel ashamed for the fact that the recovery journey wasn’t a total straight line and that they’re encouraged to just feel supported and then return and continue to try is often I think one of the most satisfying parts about doing contingency management.
I’ve done nearly 1000 contingency management visits myself so I’m not just a researcher, I’ve actually done the visits and people really respond to that positive approach. The people are already beating themselves up if they slip up and then return to use and they really appreciate that you keep them thinking forward, thinking ahead and knowing that in three days you get to try again.
Norcross: Yeah, something to look forward to, I get that. What kinds of reinforcements work best?
Parent: That’s a great question because yeah, something’s not reinforcing if you don’t want it, if it’s not desirable or encouraging. Gift cards are kind of a real simple approach to finding something that works for everyone. I’ve also stocked what we call a prize cabinet where you kind of make a little shop in your office and people can trade vouchers for anything from a variety of items, you have small ticket items from the dollar store and then you have bigger ticket items like bluetooth headphones and that sort of thing.
The reason why gift cards are more universally, what we call reinforcing, is that people can do with them what they want or need. Again, it has to feel good to receive it to be a reinforcement. And so if you do just assume that everybody wants the same thing then people could get bored or not feel inspired to continue to earn more. One person might buy groceries with it. I had one contingency management patient who really wanted to buy things like cologne. He was unhoused and he bought a really nice jacket and some cologne and it helped him really feel good about himself. I can’t say that this is exactly why, but he was housed by the end of our contingency management time together and being able to present himself well in places where he was looking for housing could have been part of that and that’s how he chose to spend his gift card.
Norcross: You touched on this earlier, but one of the big hurdles could be the law. Some have interpreted contingency management as a kind of taxpayer-funded kickback that runs afoul of federal law, especially if Medicare or Medicaid dollars are used. How do you get around that problem?
Parent: We’re all really working on interpreting the rule and also advocating to the powers that be for them to understand that contingency management is a methodical therapeutic approach and not a kickback. But they wrote the rules with these broad strokes and broadly speaking, you’re not allowed to induce somebody into receiving services and get business basically by paying them. And so a clinic or a service provider can’t appear to make money based on enrolling people in contingency management. That’s one kind of broad way of why those rules are there to begin with.
One of the ways is to focus on the fact that people aren’t paid to attend your billable services. They receive their gift cards for reaching a treatment goal and objectively speaking, this is often a negative urine test. So you can really document that the negative urine tests led to the distribution of this particular gift card on this day and the day that they had a positive urine tester that they didn’t come in, they didn’t earn that incentive that day. And when you have that good record keeping and you show that it is linked to a therapeutic meaningful behavior, then that is a way to show that your program isn’t doing what the original intention of the anti-kickback regulations were.
Norcross: Another thing that you might run into is the range of feelings that people might have about “paying people not to use drugs or alcohol.” Can you talk about that?
Parent: It’s really interesting [to see] people’s perception of contingency management and their skepticism, which I think is healthy. I think if we’re trying to help people, we should feel good about the ways that we’re doing that. So I’ve seen skepticism anywhere from, well, ‘you can’t give money to people who use drugs because they’re going to spend it on drugs.’ So we really respond to this with the idea that, well, first of all, those rewards are earned by objectively demonstrating that there wasn’t substance use at the time that they were received. And if there is, then they don’t earn them that day. And so there’s a built-in fail safe that way.
But it’s very interesting how narratives change. More recently, I’ve heard from folks that are really focused on harm reduction asking why we are only looking at substance abstinence with this approach. What about harm reduction? There are a lot of people who aren’t ready to stop. How do we help them? I think a lot of times it might be more than we have time to talk about on the show.
The two things we do that help providers most when we do training and technical assistance for contingency management, in terms of buy-in and understanding of contingency management, are to educate them to hear about the mechanism of how it works and also to experience it in action, either to get firsthand accounts from other providers who have done contingency management or to get a chance to experience it yourself. And I would say before I learned contingency management, I was maybe a little bit more on the skeptical side and it wasn’t immediately intuitive to me. Then once I started doing it and seeing, again, how appreciative people were at how we just stood alongside them and cheered them along in the recovery journey, I’ve really just seen it be so powerful. And great relationships are therapeutic kinds of alliances when you can be that patient and positive with folks.
Norcross: Sara, thank you so much for this.
Parent: Thanks for having me.
Norcross: Sara Parent is an assistant professor in the department of community and behavioral health at Washington State University’s College of Medicine.
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