Contingency Management: What It Is and How It Can Help You

Recovering from addiction is hard work. It can take conscious effort to resist cravings. However, some treatment centers use contingency management to reward you for continuing abstinence from drugs or alcohol. And those rewards help you focus on healing, even during stressful times.

What Is Contingency Management?

Contingency management (CM) is a behavioral treatment option ((Petry NM. Contingency management: what it is and why psychiatrists should want to use it. Psychiatrist. 2011 May;35(5):161-163. doi: 10.1192/pb.bp.110.031831. PMID: 22558006; PMCID: PMC3083448.)) for people recovering from substance use disorder. This therapy revolves around positive reinforcement. In other words, patients get rewards for certain activities, encouraging them to keep it up. When you’re in addiction recovery, you might get rewards for sobriety or just for staying in treatment.

Contingency management theory is based on the idea that changing your environment can change your behavior. In an environment that rewards sobriety, you’re more likely to commit to addiction treatment. Treatment rewards include tangible prizes, like vouchers or even cash.

For example, if you submit a drug-negative urine sample or attend your scheduled therapy session, then your therapist might give you a voucher. And the longer you sustain this positive behavior, the larger the rewards get. So after one day of drug-free urine samples, you could receive $1. After a year of proven, sustained abstinence, you could receive up to $100. But if you relapse, your rewards will reset back to the beginning.

How Does Contingency Management Work?

The first step in many contingency management therapy programs is writing a contract between the provider and the patient. ((Higgins ST, Petry NM. Contingency management. Incentives for sobriety. Alcohol Res Health. 1999;23(2):122-7. PMID: 10890806; PMCID: PMC6760431.)) In this contract, you’ll agree to:

• Perform a specific type of desired behavior (like abstinence from drugs and alcohol or attending other therapy sessions)
• Stay in treatment for a certain amount of time
• Submit drug tests on a set schedule

In turn, your provider will commit to giving you specific, predictable rewards based on your behavior. If you keep the commitments in this contract, you’ll know exactly which rewards to expect.

Most people are in contingency management programs for a year ((Washington State Institute for Public Policy. https://www.wsipp.wa.gov/BenefitCost/Program/294. Accessed 19 Apr. 2023.)) or less. Depending on your program, you may have to submit urine tests daily ((Higgins ST, Petry NM. Contingency management. Incentives for sobriety. Alcohol Res Health. 1999;23(2):122-7. PMID: 10890806; PMCID: PMC6760431.)) or 2-3 times a week. You may test in your therapist’s office before attending a counseling session, or you might have to submit tests through a third-party testing center.

The rewards you earn also depend on your program. One popular reward option is a voucher that you exchange for goods, which increase in value the longer you stay sober. Other programs give you money, gift cards, or the opportunity to win prizes like movie passes. Some states limit the total amount ((Adam Creveling, MSW & Paul Brasler, LCSW. “Virginia Medicaid Contingency Management.” The Centers for Medicare and Medicaid Services: SUPPORT Act Section 1003 Grant Department of Medical Assistance Services. December 14 & 16, 2021. https://www.dmas.virginia.gov/media/4188/34-contingency-management.pdf)) that patients can earn. For example, in Virginia, patients can only earn up to $75 annually.

CM can be helpful in every phase of recovery. For example, many patients use this approach during detox from substances like opioids, in combination with other treatments. It may also be a good aftercare option for people leaving residential rehab.

How Contingency Management Works in a Larger Treatment Plan

Contingency management is a supplementary therapy, so it likely won’t be the only addiction treatment you use. Most providers combine this treatment with medication, talk therapy, or other types of care.

Contingency Management and Pharmacotherapy

If your treatment plan includes medication-assisted treatment for substance use, like methadone, your CM program may reward you for taking your medication. You might also get rewards for safely taking methadone doses at home, ((Iguchi MY, Stitzer ML, Bigelow GE, Liebson IA. Contingency management in methadone maintenance: effects of reinforcing and aversive consequences on illicit polydrug use. Drug Alcohol Depend. 1988 Oct;22(1-2):1-7. doi: 10.1016/0376-8716(88)90030-0. PMID: 2906863.)) or reaching other recovery milestones.

CM is very effective for patients using methadone maintenance therapy ((Schottenfeld RS, Chawarski MC, Pakes JR, Pantalon MV, Carroll KM, Kosten TR. Methadone versus buprenorphine with contingency management or performance feedback for cocaine and opioid dependence. Am J Psychiatry. 2005 Feb;162(2):340-9. doi: 10.1176/appi.ajp.162.2.340. PMID: 15677600.)) and other addiction medications. Participating in contingency management therapy actually improves the outcomes of these treatments.

Because drug tests are a regular part of most contingency management programs, make sure your entire team knows about any medications you’re taking. Most providers will include that information in your initial CM contract. This helps patients stay accountable throughout treatment.

Contingency Management With Other Psychosocial Therapies

Combining contingency management with other types of therapy can maximize the benefits of treatment. Rehabs like Renaissance Recovery in California integrate contingency management into their programs for this very reason. Patients attend both behavioral and psychotherapy sessions to learn new relapse prevention techniques. For example, you might combine CM with cognitive behavioral therapy (CBT).

Some studies suggest that contingency management helps most in the short term, ((Sayegh CS, Huey SJ, Zara EJ, Jhaveri K. Follow-up treatment effects of contingency management and motivational interviewing on substance use: A meta-analysis. Psychol Addict Behav. 2017 Jun;31(4):403-414. doi: 10.1037/adb0000277. Epub 2017 Apr 24. PMID: 28437121.)) while other methods like motivational interviewing can help you commit to long-term sobriety. However, other studies show that patients who have undergone contingency management therapy in the past continue to abstain from drugs ((Petry NM. Contingency management treatments: controversies and challenges. Addiction. 2010 Sep;105(9):1507-9. doi: 10.1111/j.1360-0443.2009.02879.x. PMID: 20707772; PMCID: PMC3049167.)) or alcohol even after they stop getting rewards.