Contingency Management Incentives for Sobriety Stephen T. Higgins, Ph.D., and Nancy M. Petry, Ph.D. Contingency management (CM), the systematic reinforcement of desired behaviors and the withholding of reinforcement or punishment of undesired behaviors, is an effective strategy in the treatment of alcohol and other drug (AOD) use disorders. Animal research provides the conceptual basis for using CM in AOD abuse treatment, and human studies have demonstrated the effectiveness of CM interventions in reducing AOD use; improving treatment attendance; and reinforcing other treatment goals, such as complying with a medication regimen or obtaining employment. KEY WORDS: addiction care; treatment method; intervention; reinforcement; treatment outcome; AOD (alcohol and other drug) abstinence; problematic AOD use; multiple drug use; AOD dependence; treatment goals; treatment research; patient compliance; employment; animal model; literature review ontingency management (CM)1 through written contracts that detail CM. Within the CM framework, AOD is a strategy used in alcohol and the desired behavior change, duration use is considered a form of operant Cother drug (AOD) abuse treat- of intervention, frequency of monitoring, behavior—that is, behavior that is main- ment to encourage positive behavior and potential consequences of the patient’s tained in part by the reinforcing biochem- change (e.g., abstinence) in patients by success or failure in making the agreed- ical effects of the abused substance and providing reinforcing consequences when upon behavior changes. by reinforcing environmental influences patients meet treatment goals and by An extensive body of research sup- (e.g., social reinforcement from peers). withholding those consequences or pro- ports CM’s efficacy in treating various viding punitive measures when patients behavioral disorders, including AOD engage in the undesired behavior (e.g., abuse (Higgins and Silverman 1999; STEPHEN T. H IGGINS, PH.D., is a profes- drinking). For example, positive conse- Higgins et al. 1998). This article briefly sor in the Departments of Psychiatry and quences for abstinence may include reviews the conceptual background and Psychology at the University of Vermont, receipt of vouchers that are exchange- empirical research demonstrating the Burlington, Vermont. able for retail goods, whereas negative efficacy of CM in AOD abuse treatment. consequences for drinking may include NANCY M. PETRY, PH.D., is an assistant withholding of vouchers or an unfavor- professor in the Department of Psychiatry able report to a parole officer. The rein- Conceptual and Basic at the University of Connecticut School of forcing or punishing consequences may Science Foundations Medicine, Farmington, Connecticut. be contingent on objective evidence of recent AOD use or on another behavior The use of reinforcing and punishing Preparation of this article was supported important in the treatment process, such consequences to alter the form and fre- in part by Federal grants RO1–DA09378 as compliance with a medication regimen quency of voluntary behavior is known (S.T.H.), RO1–DA0-8076 (S.T.H.), or regular clinic attendance. Often, as operant conditioning, a method that R29–DA12056 (N.M.P.), and P50–AA0- clinicians implement CM procedures provides the conceptual framework for 3510 (N.M.P.). 122 Alcohol Research & Health Contingency Management: Incentives for Sobriety Findings from animal research support exposed to alcohol, rats bred for high substances, an increase in the availability the use of CM in the treatment of AOD alcohol intake will voluntarily consume of alternative reinforcers will decrease use disorders. Such research demonstrates, larger amounts of alcohol than non- AOD consumption. Furthermore, for instance, that animals exhibit con- selectively bred rats. However, even ini- increasing the demands required to obtain sumption patterns indicative of depen- tially low-alcohol-consuming rats will the desired substance (e.g., increasing dence and that researchers can modify voluntarily consume large quantities of the number of times an animal must animals’ AOD intake by using reinforcing alcohol under certain conditions. For press a lever to obtain the alcohol) or and punishing consequences. Generally, directly associating substance use with laboratory animals voluntarily ingest the loss of other desired goods (e.g., the same substances that humans abuse withholding vouchers as a consequence (Griffiths et al. 1980). Rats and monkeys, CM interventions of alcohol use) reduces AOD use as for example, will voluntarily consume well (Higgins 1996). large quantities of cocaine, opioids, and are based on the CM interventions are based on the alcohol. Neither a prior history of drug view that AOD use view that AOD use is a behavior that exposure nor physical dependence is is influenced by neurobiological and necessary to support ongoing and stable is a behavior that environmental factors and that such patterns of AOD use in laboratory ani- behavior can be changed by applying mals. Moreover, studies of voluntary is influenced by consistent environmental consequences AOD consumption by laboratory animals neurobiological and to reinforce the targeted behavior change. show that once a pattern of heavy con- The following sections of this article sumption has been established, animals environmental factors. describe research on the application of will complete cumbersome tasks (e.g., CM in the treatment of alcoholism and press a lever numerous times) to obtain problem drinking as well as of other and consume the desired substance. example, stress, social isolation, and drug use disorders. Additionally, laboratory animals will reduced access to food, liquid, or oppor- forgo other reinforcers, including sweet tunities for exercise all promote AOD liquids, high-calorie solutions, and in use in laboratory animals. Therefore, Early Research and some cases even basic sustenance, to susceptibility to the reinforcing effects Application of CM engage in AOD use (Petry and Heyman of AODs appears to be a product of in the Treatment of 1995). These behavioral patterns are normal neurobiological systems common Problem Drinking analogous to those exhibited by AOD- to many species that can be heightened dependent humans, who often spend by certain individual and environmen- Research during the 1960s, 1970s, and significant amounts of time and money tal factors. 1980s examined the role of CM in abusing alcohol and recovering from Findings from animal studies may alcoholism treatment as a strategy for AOD use, and who often give up recre- have implications for human AOD reinforcing abstinence as well as accom- ation, employment, and family activities abuse treatment in that the environmen- plishing other treatment goals, including to do so. tal conditions which promote AOD medication compliance and treatment These findings—that laboratory ani- use in laboratory animals seem similar attendance. mals voluntarily consume many of the to those associated with excessive AOD same substances that humans abuse and use in humans (Griffiths et al. 1980). Reinforcement of Abstinence exhibit consumption patterns indicative Animal studies also demonstrate that of dependence—suggest that the neces- conditions can be altered to reduce AOD In an early study of CM in alcoholism sary neurobiological systems to experi- use even after high levels of use have treatment, Miller (1975) found that by ence AOD-induced reinforcement and been established. Such studies suggest providing tangible reinforcers to public to engage in compulsive AOD use are that an increase in both the availability inebriates, contingent on negative widely represented across different species. of alternative, nondrug sources of rein- breath-alcohol tests, researchers could However, laboratory studies also indi- forcement and the direct and indirect effectively reduce public inebriation. cate that individual and environmental losses associated with AOD use are In the study, 20 public inebriates were factors clearly influence susceptibility to related to decreased AOD use (Higgins randomly assigned to one of two groups: AOD use and abuse (Wolffgramm and 1996). For example, providing food, a contingent group or a noncontingent Heyne 1995). For example, when first liquids, or novel environmental alterna- group. A person in the contingent group tives reduces AOD use in animals, just received shelter, employment, food, and as providing entertainment or financial clothing from local social services agencies 1Editor’s Note: Community-reinforcement alternatives reduces AOD use in humans. only when he or she remained sober. approach (CRA), a treatment methodology that Although, as previously noted, animals Members of the noncontingent group uses strategies similar to those used in CM, is discussed in a separate article in this issue by Miller and humans will work hard or forgo received social services regardless of et al., pp. 116–121. other reinforcers to consume addictive their drinking behavior. The researchers Vol. 23, No. 2, 1999 123 assessed sobriety by conducting random During the 6-month treatment treatment sessions. Gallant and col- breath-alcohol tests and through staff period, patients in the contingent group leagues (1968b) found beneficial effects observation. When the researchers de- drank, on average, on only 2 percent in making treatment attendance a con- tected alcohol use in a contingent group of the total number of days, compared dition of parole among alcoholics recently