Veterans, especially recent veterans, have been hard hit by the opioid epidemic and the rise in other substance use disorders (SUD). Problems of chronic pain and post-traumatic stress disorder (PTSD) make substance use and abuse more likely.
Since 2011, the U.S. Department of Veteran Affairs (VA) has treated SUD with contingency management (CM), a technique that promotes abstinence from drugs and alcohol. The technique is simple, costs little, and boasts a high success rate. More than 4,000 veterans have participated in a 12-week contingency management program at more than 100 VA medical centers.
The CM method has not been widely used by private addiction rehabilitation facilities or accepted by many insurers. For example, Medicaid, which in 2014 paid for 21% of all SUD treatment in the United States, does not cover contingency management.
Contingency management (CM) is a reward or reinforcement technique to bolster abstinence from drug or alcohol use. It relates to behavioral psychologist B. F. Skinner’s theories about operant conditioning, a learning process that uses rewards to reinforce particular behaviors.
A webinar and workshop by the Florida Alcohol and Drug Abuse Association called contingency management “the greatest unused treatment” for opioid use disorder. The organization noted the technique’s effectiveness for treating addictions to stimulants such as cocaine or methamphetamine (meth). It added that the technique may also produce benefits when combined with medication-assisted treatment (MAT) medications such as methadone or buprenorphine.
The National Institute on Drug Abuse (NIDA), a federal scientific research institute, offers similar assessments. It said that contingency management “augments other community-based treatments for adults who primarily abuse opioids (especially heroin) or stimulants (especially cocaine) or both.”
Since the 1990s, contingency management has been studied for use in the treatment of SUDs. While it is not a stand-alone treatment for SUDs, contingency management may be combined with other evidence-based treatments – such as cognitive-behavioral therapy (CBT) or MAT – for better results than either alone.
If clients participate in SUD treatment programs that use contingency management protocols, they may undergo daily or weekly urine tests. If they test negative for drugs or alcohol, they receive a reward, which may come in the form of voucher-based reinforcement or a prize. They may also use breathalyzers to undergo alcohol compliance tests up to several times a day. The clients’ rewards may be cash, vouchers, privileges, prizes, or the opportunity to win prizes.
Sometimes, clients receive automatic prizes based on negative test results. Or, they may win the opportunity to draw prize slips from a fishbowl. The slips may indicate a cash amount, a prize, or a positive affirmation.
In some programs, the more sober days people have, the more slips of paper they may draw, which increases their chances to win. If they test positive for drugs, the program will remove such prizes. Such accountability seems to be as important as the value of the reward.
Privileges may include trust. MAT clients who use methadone often have to report daily to doctors or clinics for their doses of the maintenance drug. This accountability allows them to function in their daily lives, hold down a job, or go to school with lower risks of diversion. If people who use methadone have several drug-free tests, they may be allowed to take some pills home to avoid such frequent medical visits.
After the Seattle VA expanded its contingency management program, 87% of all urine screens came back negative for all targeted substances, including meth and cocaine. More than half of the clients completed their 12-week contingency management programs.
Substance use disorder is difficult to overcome because it rewires the brain. Abusing substances enhances the prefontal cortex and reduces impulse control. That is why people with SUD often cannot stop using substances on their own. By giving them rewards, contingency management helps enable abstinence from alcohol and drugs.
Another problem is that SUDs involve habits. Once established, people may find it very difficult to end them. People may find it easier to change their habits instead of ending them completely. A 12-week contingency management program in conjunction with other therapies may create new, healthier habits.
A related concept is Charles Duhigg’s habit loop that consists of cues, routines, and rewards. Something (a cue) triggers a behavior (a routine) that causes you to seek a reward such as alcohol or drugs. If you can change the reward to something healthier, it may help you remain abstinent.
The VA mainly uses voucher-based contingency management. According to a Yale University manual on contingency management in drug abuse treatment, Dr. Stephen Higgins helped develop this approach. He conducted early trials on voucher reinforcement systems in a Vermont cocaine treatment clinic.
In Higgins’ initial program, half the participants could earn voucher incentives for remaining abstinent (up to $1,000 if they stayed abstinent for the whole period), and half could not. Compliance was monitored with twice-weekly urine testing.
Both groups of participants also received community reinforcement approach (CRA) behavior therapy to reconnect them with positive role models and influences, including Narcotics Anonymous (NA), friends and family, and healthy recreational options.
According to a 1994 study of the trials, 75% of participants in the voucher group remained in treatment for six months, and 60% were drug-free for at least eight weeks. In the non-voucher group, only 40% remained with the program for six months, and only 25% stayed drug-free for at least eight weeks.
Medication-assisted treatment (MAT) is another option to treat SUD. In this type of treatment, opioid drugs such as methadone or buprenorphine are used for maintenance to help clients avoid withdrawal symptoms but not experience euphoria (get high).
One problem with MAT is that people with opioid use disorder sometimes also abuse non-opioid drugs for which there are no MAT options. Contingency management may improve treatment results.
In 1996, Dr. Kenneth Silverman used another voucher-based contingency management regimen for methadone users who abused cocaine. For this study, half earned up to $1,000 in vouchers by remaining drug-free while the other half received them regardless of their urine test results.
While retention rates were similar between the two groups (they had to be; only by remaining in the facility could the participants receive methadone), the abstinence rates were very different. Around 40% of the group who earned vouchers remained drug-free for eight weeks, while none of the group who did not earn the vouchers remained sober during this time.
Vouchers or other incentives have also helped people stop using other drugs and substances, including:
The Veterans Canteen Service (VCS) contributes $100,000 in voucher coupons annually to support VA’s contingency management programs. According to the Center of Excellence in Substance Addiction Treatment and Education (CESATE), it couldn’t run the program across the VA without that support.
Decades of studies have shown that contingency management may work. In the United States, the Department of Veterans Affairs has adopted the technique, while the National Health Service has used it in the United Kingdom. Why is the approach not widely used even more?
Many policymakers, politicians, and addiction physicians do not believe in the approach or trust it. Some ignore the evidence and rely on faulty information, prejudices, or claims:
People with one SUD or mental health issue may have another addiction or addictive behavior, such as gambling. The addiction treatment community sometimes worries that awarding prizes could be a form of gambling or might enable gambling.
No studies of contingency management have validated this fear. In one 2010 study, clients with SUD who gambled prior to contingency management treatment gambled less afterward. The approach is not recommended for people with gambling addictions, however.
It may sound simple or childish to think that veterans or other people with SUD will avoid drugs because they may win a small prize or amount of cash. But even if it seems counterintuitive, the approach does work.
One reason may be because the people in these programs want to stay sober. They have sought assistance and entered rehab programs. They are motivated already.
Contingency management is not used in a vacuum. It is usually not the sole treatment people receive. It is an added inducement. It reinforces veterans’ resolve to stop using and is a psychological tool.
After such programs end, some people may start using again, but that is true of every addiction treatment and every chronic illness. Clients who participate in contingency management programs are more than 100% more likely to achieve abstinence. Contingency management has a higher retention rate than all but one other method: MAT, which is also disliked and distrusted by many critics.
It is a well-known fact that SUDs affect people’s behaviors. People with SUD sometimes steal cash and sell belongings, theirs and other people’s, to finance their habits.
People in treatment and contingency management do not have a greater likelihood of engaging in such behaviors. In a 2014 randomized trial, there was no difference in rates of drug use, cravings, or high-risk behaviors among trial participants who received cash, vouchers, or neither.
Spending one thousand dollars per client for cash and prizes for a contingency management (CM) program is a large expense. It may be difficult to acquire government funding for this amount.
This amount does not even include the costs of conducting urine drug tests twice a week. Governments and private donors may resist contributing to CM programs because they may consider them bribes for people to remain sober.
But $1,000 per client was just the amount used in early trials for the technique. Subsequent trials and programs have been less expensive but have proved as effective.
Since June 2016, Shreveport, Louisiana’s Overton Brooks VA Medical Center Substance Use Disorder clinic mostly offers prizes such as pieces of paper that say, “Good job!”, and vouchers for small dollar amounts, exchangeable for food or merchandise from the Veteran Canteen Service (VCS). There is a single top prize of $100. The cost over twelve weeks works is about $200 per client, a number that may be far more palatable and cost-effective than earlier, more costly programs.
Other programs may use similar incentives. If a particular VA center does not have a canteen, a selection of merchandise offered by the canteens may be kept in prize cabinets.
Prizes in such programs may be small token prizes. One Washington pilot program gives out toiletries such as shampoo and toothbrushes as well as prizes such as coffeemakers and the occasional DVD player. This program keeps costs to about $100 per client.
Aside from the cost of prizes, there are often few expenses for contingency management programs. People must administer urine or breathalyzer tests, but those people do not need to be licensed clinical staff members.
Given the costs of SUD to society (more than $520 billion, and that is not counting an additional $300 billion for tobacco), cognitive management is a bargain.
With substance use disorder rising among recent veterans, and few effective treatments for non-opioid use disorders such as methamphetamine (meth) and cocaine abuse, we need to use and encourage all tools at our disposal.
Fortunately for veterans in the VA, contingency management is one of those tools. Medicaid and private insurers must follow the VA’s example. Contingency management works, saves money, and is the right thing to do.
While the overall SUD rate among veterans is lower than the SUD rate of the general population (6.6% vs. 8.6%), the rate rises significantly based on when the veterans served. For people who have served since September 2001, the rate is almost double, 12.7%. In general, substance use decreases with age, though different kinds of conflict after 9/11 may also be factors that impact SUD rates.
There are stigmas among some veterans and military personnel about treatment for mental health disorders and substance abuse. They think that military service requires mental toughness and that seeking help is a sign of weakness. Despite such stigmas, veterans are more likely to receive treatment for SUD than nonveterans.
Many veterans’ SUDs relate to cigarette smoking and heavy drinking (consuming more than five drinks at a sitting more than five times in a month), but prescription drug and illicit drug use have also skyrocketed. From 2010 to 2016, the rate of opioid-related overdose deaths for veterans increased by 65%.This increase occurred despite a decrease in the number of opioid prescriptions, which suggests that veterans may be abusing illicit opioids such as heroin and black-market fentanyl.
Stimulants such as cocaine and methamphetamine also are a growing problem and have fewer effective treatment techniques than opioids. Contingency management is a treatment that may work.