Contingency Management: Promises, Gaps, and Philosophical Limitations

Am J Accountable Care. 2023;11(2):28-29. https://doi.org/10.37765/ajac.2023.89382

Pregnancy is an opportune time to build relationships between health care providers and patients with substance use disorder (SUD). Many pregnant people can stop or reduce substance use after becoming pregnant, but pregnant people with SUD often require treatment to cease or reduce use. There are 2 main treatment modalities for SUD: medication and behavioral. Although there are FDA-approved medications for the treatment of alcohol, nicotine, and opioid use disorders, there are none for either stimulant or cannabis use disorders. There is extensive literature on behavioral interventions in pregnancy and across SUDs; however, only contingency management (CM) has been shown to have a measurable and positive effect on drug treatment outcomes.¹

In this issue, Major et al describe the integration and outcomes of CM in an outpatient clinic that cares for pregnant people with SUD.² CM during prenatal and postpartum care can increase visit attendance and decrease stimulant use through behavior reinforcement using small vouchers or rewards and can be the beginning of building a provider-patient relationship. This is critical because few treatment options exist for pregnant people with stimulant use disorder. The authors of this study demonstrated an increase in appointment attendance following implementation of CM, despite the challenges of the COVID-19 pandemic and an overall increase in stimulant use and use disorder in this time frame.

CM attempts to make the difficult work of recovery rewarding.³ Health care providers cannot have a meaningful relationship with patients who aren’t there. Reinforcing attendance at scheduled visits, as the authors did, can bring patients over the threshold, and we applaud their work in reinforcing outcomes other than reducing substance use. Reinforcing relational connection rather than abstinence is likely more rewarding and appealing to both patients and providers and resonates more greatly with a holistic appreciation of recovery. It is likely that the rewards that the patient focus group identified were more fulfilling than their monetary value, because they brought further connection to their identity as a parent and their ability to care for their infant.

As mentioned in the article’s conclusion, both difficulties in getting reimbursement and regulations that limit incentive amounts have greatly hampered the integration of CM into addiction treatment. These are despite the fact that studies have found that CM is cost-effective over a treatment course, especially for individuals with stimulant use disorder, and that higher rewards are more cost-effective than lower rewards.⁴ In other words, the greater the amount of money given to participants, the greater the cost savings to the clinic. Despite this evidence, CMS views CM incentives as kickbacks and is hesitant to allow Medicaid funds to be used for CM out of concern for potential fraud. To date, there is no evidence of fraud in the CM literature, although there is ample evidence of fraud in other CMS-supported medical services.⁵

Another criticism of CM has been that its success is limited to the short term only, as acknowledged in this article. However, this same critique could be leveled against medications, as the effect of medication is limited to the duration of time that a person receives it. It is not uncommon for hypertension to return following medication discontinuation, for example, but we don’t conceptualize that as an inherent weakness of medication. In addition, pregnancy is itself a short-term state, and even temporary changes in behavior can positively affect birth outcomes.

Addiction, however, is a chronic condition, often requiring some form of management over years or longer. Most behavioral interventions including CM are of limited time duration, as is the treatment episode itself. Hence there is a fundamental clinical mismatch: the provision of acute services for a chronic condition, which is a mismatch that likely contributes to the recurring remitting nature of the disease. Phrased differently, is addiction truly a chronic recurring remitting condition, or does the nature of the condition rather reflect the reality that we only provide episodic care?

There is no question that CM is an effective intervention that can reduce substance use, increase clinic visit attendance, and overall keep patients engaged in care. In its emphasis on rewards for positive behaviors, it provides a stark alternative to punitive structures of care that remain unfortunately common in addiction treatment. But CM is not, in and of itself, person-centered care, and there is also something fundamentally troubling about operant conditioning, especially from the perspective of recovery. At its theoretical core, CM reflects a specific philosophy of economics, one that assumes choices are both rational and individual,⁶ and thereby conflates human behavior in general with the limited scope of action possible within a capitalist economy. This might explain why the effectiveness of CM lessens when the social context becomes more complex and multifocal, such as during the postpartum period.

Postpartum visits are less well attended in general, and far less attended in populations with SUD. In the article, postpartum visit attendance in fact decreased as the CM intervention continued at the clinic. This points to the possibility that more than just CM is involved in the observed increase in prenatal clinic visits. CM is most likely accentuating the tendency to seek care during pregnancy but withdraw once the infant is born.

Moving forward, qualitative research will be key in identifying what pregnant and parenting people who use drugs actually need. Centering the clinical care on those served may expand the vocabulary of incentive rewards and reflect the relational priorities identified by the clinic patients, in contrast to the crass reductive exchange of a monetary voucher for a negative urine drug test.

Author Affiliations: Friends Research Institute (KA, MT), Baltimore, MD.

Source of Funding: None.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (KA, MT); drafting of the manuscript (KA, MT); and critical revision of the manuscript for important intellectual content (KA, MT).

Send Correspondence to: Mishka Terplan, MD, MPH, Friends Research Institute, 1040 Park Ave, Ste 103, Baltimore, MD 21201. Email: mterplan@friendsresearch.org.

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