Prize Incentives Contingency Management for Substance Abuse
Prize Incentives Contingency Management for Substance Abuse is a variation of contingency management, or reinforcement, that awards prizes for abstinence and treatment compliance, such as group attendance and healthy behaviors. It is based on a construct central to behavioral psychology known as operant conditioning, or the use of consequences to modify the occurrence and form of behavior. The program augments existing, usual care services in community-based treatment settings for adults who primarily abuse stimulants (especially cocaine) or opioids (especially heroin) or who have multiple substance use problems. Over a period of 3 months, urine and breath samples are collected two or three times a week for at least the first 6 weeks and once or twice weekly thereafter. For each sample that tests negative for the target drug, clients can draw slips of paper or plastic chips from a bowl for the chance of winning a prize valued from $1 to $100. Clients may also receive draws from the prize bowl for attending counseling/group therapy sessions and completing weekly activities designed to meet goals related to health (e.g., scheduling or attending a medical or nutritionist appointment, obtaining medications, recording daily medication or food consumption, exercising at a gym), sobriety (e.g., attending 12-step meetings), employment (e.g., creating a resume), and other areas. The number of draws from the prize bowl increases from 1 to as many as 15 with consecutive negative test results and/or attendance at consecutive sessions. A drug-positive sample or an unexcused absence resets the number of draws to one. Bonus draws may be awarded to clients on a predetermined schedule. Although the original trials of Prize Incentives were conducted over 3 months, the intervention can be used with urine and breath samples collected one to three times weekly for longer durations.
One of the studies reviewed for this summary involved patients with HIV and focused on both drug use and health behaviors. In addition to the goal of improving drug use outcomes, the treatment aimed to reduce HIV viral loads and HIV-related risk behaviors.
Descriptive Information
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Areas of Interest
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Substance use disorder treatment
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Outcomes
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1: Duration of abstinence from substance use
2: Cocaine and alcohol use
3: HIV-related risk behaviors
4: HIV viral load
5: Treatment attendance
1: Drug use during treatment
2: Drug use after treatment
3: Drug problem severity during and after treatment
4: Quality of life
5: Treatment retention
6: Group/counseling attendance
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Outcome Categories
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Alcohol
Drugs
Quality of life
Treatment/recovery
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Ages
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26-55 (Adult)
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Genders
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Male
Female
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Races/Ethnicities
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Black or African American
Hispanic or Latino
White
Race/ethnicity unspecified
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Settings
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Outpatient
Other community settings
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Geographic Locations
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Urban
Suburban
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Implementation History
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The intervention has been used with over 60,000 clients at 200 sites in all 50 States, China, Spain, and the United Kingdom.
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NIH Funding/CER Studies
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Partially/fully funded by National Institutes of Health: Yes
Evaluated in comparative effectiveness research studies: Yes
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Adaptations
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No population- or culture-specific adaptations of the intervention were identified by the developer.
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Adverse Effects
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No adverse effects, concerns, or unintended consequences were identified by the developer.
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IOM Prevention Categories
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IOM prevention categories are not applicable.
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Quality of Research
Documents Reviewed
The documents below were reviewed for Quality of Research. The research point of
contact can provide information regarding the studies reviewed and the availability
of additional materials, including those from more recent studies that may have been conducted.
Study 1Petry, N. M., Weinstock, J., Alessi, S. M., Lewis, M. W., & Dieckhaus, K. Group-based randomized trial of contingencies for health and abstinence in HIV patients. Journal of Consulting and Clinical Psychology, 78(1), 89-97. Study 2Petry, N. M., Weinstock, J., & Alessi, S. M. A randomized trial of contingency management delivered in the context of group counseling. Journal of Consulting and Clinical Psychology, 79(5), 686-696. Study 3Petry, N. M., Alessi, S. M., & Ledgerwood, D. M. A randomized trial of contingency management delivered by community therapists. Journal of Consulting and Clinical Psychology, 80(2), 286-298.
Supplementary Materials Darke, S., Hall, W., Heather, N., Ward, J., & Wodak, A. The reliability and validity of a scale to measure HIV risk-taking behavior among intravenous drug users. AIDS, 5(2), 181-185.
Ledgerwood, D. M., & Petry, N. M. Rating contingency management sessions that reinforce abstinence using the Contingency Management Competence Scale. Farmington, CT: University of Connecticut Health Center.
Petry, N. M., Alessi, S. M., Ledgerwood, D. M., & Sierra, S. Psychometric properties of the Contingency Management Competency Scale. Drug and Alcohol Dependence, 109(1-3), 167-174.
Outcomes
| Outcome 1: Duration of abstinence from substance use |
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Description of Measures
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Duration of abstinence from substance use (i.e., cocaine, opioids, methamphetamine, marijuana, and/or alcohol) was assessed using urine toxicology screens and breath analysis. Participants submitted urine samples that were screened for substances (except alcohol) using OnTrak TesTstiks and breath samples that were screened for alcohol using an Alcosensor IV Alcometer.
Weeks of abstinence were counted on the basis of consecutively scheduled samples that tested negative for the target substances. If a participant refused to provide a sample or failed to provide one due to an unexcused absence, the string of abstinence was coded as broken. Excused missed sessions did not break a string of abstinence if they were preceded and followed by negative samples.
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Key Findings
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In one study, HIV-positive patients with cocaine or opioid abuse or dependence who were attending an HIV drop-in center were randomized to participate in a group receiving the intervention or a group receiving a standardized 12-step-oriented therapy, each of which met weekly for 24 weeks. Urine and breath samples were collected once weekly for 24 weeks. During the 24-week treatment period, the duration of concurrent abstinence from all substances screened for this study (i.e., cocaine, opioids, alcohol) was longer for the intervention group than comparison group (5.2 vs. 3.7 weeks; p < .002). The duration of abstinence from cocaine was significantly longer for the intervention group than comparison group (5.9 vs. 4.2 weeks; p < .05). The duration of abstinence from opioids and alcohol was also longer for the intervention group than the comparison group, but the differences were not statistically significant.
In another study, patients with cocaine, opioid, or alcohol abuse or dependence who were initiating outpatient treatment at community-based clinics were randomized to a group receiving standard outpatient treatment plus the intervention or a group receiving only the standard outpatient treatment. Standard outpatient treatment consisted of group counseling sessions that included life skills training, relapse prevention, and 12-step-oriented treatment. Patients were offered intensive treatment (up to 4 hours per day, 5 days per week) for up to 6 weeks, with reductions in intensity thereafter. Aftercare, one group counseling session per week, was available for up to 12 months. Urine and breath samples were collected twice weekly for 12 weeks. From baseline through 12 weeks, the duration of concurrent abstinence from all substances screened for this study (i.e., cocaine, methamphetamine, opioids, alcohol, marijuana) was longer for the intervention group than comparison group (5.3 vs. 4.1 weeks; p = .02), a result with a small effect size (Cohen's d = 0.31). The intervention group also achieved a longer duration of abstinence than the comparison group for each of the five substances: cocaine (5.8 vs. 4.3 weeks; p = .01), methamphetamine (6.4 vs. 5.1 weeks; p = .02), opioids (6.2 vs. 4.8 weeks; p = .01), alcohol (6.4 vs. 4.8 weeks; p = .01), and marijuana (6.1 vs. 4.9 weeks; p = .03). These findings had small effect sizes (Cohen's d = 0.37 for cocaine, Cohen's d = 0.34 for methamphetamine, Cohen's d = 0.39 for opioids, Cohen's d = 0.42 for alcohol, and Cohen's d = 0.30 for marijuana).
In a third study, methadone-maintained patients with cocaine abuse or dependence were randomized to a group receiving 12 weeks of standard care plus the intervention or a group receiving only standard care. Standard care consisted of daily methadone doses and a minimum of weekly group sessions and monthly individual sessions). Urine and breath samples were collected twice weekly for 12 weeks. During the 12-week treatment period, the duration of concurrent abstinence from all substances screened for this study (i.e., cocaine, alcohol) was longer for the intervention group than comparison group (4.7 vs. 1.7 weeks; p < .001), a finding with a medium effect size (Cohen's d = 0.78). Duration of abstinence was not assessed separately for each drug.
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Studies Measuring Outcome
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Study 1, Study 2, Study 3
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Study Designs
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Experimental
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Quality of Research Rating
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3.6
(0.0-4.0 scale)
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| Outcome 2: Cocaine and alcohol use |
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Description of Measures
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Cocaine and alcohol use was assessed using urine toxicology screens and breath analysis. Participants submitted urine samples that were screened for cocaine using OnTrak TesTstiks and breath samples that were screened for alcohol using an Alcosensor IV Alcometer. Cocaine and alcohol use were measured as the proportion of submitted samples testing negative. Compared with the duration of abstinence measure, which assumed missed samples were positive, this measure was less affected by treatment dropout and missed samples because it was calculated on the basis of submitted samples.
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Key Findings
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Methadone-maintained patients with cocaine abuse or dependence were randomized to a group receiving 12 weeks of standard care plus the intervention or a group receiving only standard care. Standard care consisted of daily methadone doses and a minimum of weekly group sessions and monthly individual sessions). Urine and breath samples were collected twice weekly for 12 weeks and again at month 9. From baseline through month 9, intervention group participants submitted a greater proportion of samples testing negative for both cocaine and alcohol than comparison group participants (57.7% vs. 29.4%; p < .001), a finding with a medium effect size (Cohen's d = 0.77).
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Studies Measuring Outcome
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Study 3
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Study Designs
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Experimental
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Quality of Research Rating
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3.6
(0.0-4.0 scale)
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| Outcome 3: HIV-related risk behaviors |
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Description of Measures
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HIV-related risk behaviors were assessed using the HIV Risk Behavior Scale (HRBS). The 11-item instrument contains 6 questions about injection drug use behaviors (e.g., injecting drugs, using needles used by someone else, cleaning used needles) and 5 questions about sexual behaviors (e.g., using condoms with regular partner[s], casual partners, and when being paid for sex). Responses are coded on a 6-point scale, with higher values indicating riskier behavior. A drug use subscale score and sexual risk behavior subscale score were computed by adding the scores of the relevant items, and an overall summary score was computed by adding the scores of all items. Two versions of the HRBS were used, one assessing behaviors over the past 1 month and the other assessing behaviors over the past 3 months.
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Key Findings
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In one study, HIV-positive patients with cocaine or opioid abuse or dependence who were attending an HIV drop-in center were randomized to participate in a group receiving the intervention or a group receiving a standardized 12-step-oriented therapy, each of which met weekly for 24 weeks. The version of the HRBS assessing the past 3 months was administered at baseline and at months 3, 6, 9, and 12. Results included the following:
- From baseline to month 6, intervention group participants had a greater reduction in HIV-related risk behaviors than comparison group participants (p < .05).
- Assessment of subscale scores indicated that, from baseline to month 6, sexual risk behaviors decreased among intervention group participants relative to comparison group participants (p < .04), while changes in drug use behaviors did not differ significantly between groups.
- From baseline to month 12, intervention group participants had a greater reduction in HIV-related risk behaviors than comparison group participants (p < .05).
- Assessment of subscale scores indicated that, from baseline to month 12, the decrease in sexual risk behaviors was greater for the intervention group than the comparison group, but the difference was not statistically significant. Meanwhile, changes in drug use behaviors were similar between groups.
In another study, patients with cocaine, opioid, or alcohol abuse or dependence who were initiating outpatient treatment at community-based clinics were randomized to a group receiving standard outpatient treatment plus the intervention or a group receiving only the standard outpatient treatment. Standard outpatient treatment consisted of group counseling sessions that included life skills training, relapse prevention, and 12-step-oriented treatment. Patients were offered intensive treatment (up to 4 hours per day, 5 days per week) for up to 6 weeks, with reductions in intensity thereafter. Aftercare, one group counseling session per week, was available for up to 12 months. The version of the HRBS assessing the past 3 months was used at baseline and at 3 and 12 months, and the past-month version was used at 1 month. Results included the following:
- From baseline to month 1, intervention group participants had a greater reduction in HIV-related risk behaviors than comparison group participants (p < .02), a finding with a small effect size (Cohen's d = 0.29).
- Assessment of subscale scores indicated that, from baseline to month 1, sexual risk behaviors decreased among intervention group participants relative to comparison group participants (p < .04), a finding with a small effect size (Cohen's d = 0.29), while changes in drug use behaviors did not differ significantly between groups.
- From baseline to month 3, changes in overall risk behaviors, sexual risk behaviors, and drug use behaviors did not differ significantly between groups.
- From baseline to month 12, intervention group participants had a reduction in HIV-related risk behaviors relative to comparison group participants (p < .02), a finding with a small effect size (Cohen's d = 0.33).
- Assessment of subscale scores indicated that, from baseline to month 12, sexual risk behaviors decreased among intervention group participants relative to comparison group participants (p < .01), a finding with a small effect size (Cohen's d = 0.36), while changes in drug use behaviors did not differ significantly between groups.
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Studies Measuring Outcome
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Study 1, Study 2
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Study Designs
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Experimental
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Quality of Research Rating
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3.4
(0.0-4.0 scale)
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| Outcome 4: HIV viral load |
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Description of Measures
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HIV viral load, a measure of severity of HIV-related viral infection, was assessed as the amount of virus in an involved body fluid (e.g., blood). Viral load was considered a proxy for overall health. For participants with a regular physician, data on viral loads were collected from physician records. For those with no regular physician, viral load testing was arranged.
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Key Findings
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HIV-positive patients with cocaine or opioid abuse or dependence who were attending an HIV drop-in center were randomized to participate in a group receiving the intervention or a group receiving a standardized 12-step-oriented therapy, each of which met weekly for 24 weeks. Viral load test results were obtained at baseline and at months 3, 6, 9, and 12. From baseline through month 6, HIV viral load decreased in the intervention group and increased in the comparison group (p < .01). An analysis of viral load data throughout the 12-month period showed that viral loads generally decreased over time for the intervention and comparison group, with no significant difference between the groups.
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Studies Measuring Outcome
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Study 1
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Study Designs
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Experimental
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Quality of Research Rating
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3.6
(0.0-4.0 scale)
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| Outcome 5: Treatment attendance |
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Description of Measures
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Treatment attendance at group counseling sessions was measured by the number of days in attendance, the number of consecutive weeks in attendance, and the percentage of group sessions attended. A week of consecutive attendance was defined as a 7-day period in which all scheduled groups were attended. If a patient did not attend a scheduled group counseling session because of an unexcused absence, the string of attendance was coded as broken. Excused missed sessions did not break a string of attendance.
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Key Findings
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Patients with cocaine, opioid, or alcohol abuse or dependence who were initiating outpatient treatment at community-based clinics were randomized to a group receiving standard outpatient treatment plus the intervention or a group receiving only the standard outpatient treatment. Standard outpatient treatment consisted of group counseling sessions that included life skills training, relapse prevention, and 12-step-oriented treatment. Patients were offered intensive treatment (up to 4 hours per day, 5 days per week) for up to 6 weeks, with reductions in intensity thereafter. Aftercare, one group counseling session per week, was available for up to 12 months. From baseline through 12 weeks, the number of days in attendance (17.0 vs. 14.7 days; p = .05), number of continuous weeks of attendance (5.7 vs. 4.1 weeks; p = .002), and percentage of group sessions attended (83.8% vs. 77.2%; p = .05) was greater in the intervention group than comparison group. These findings had small effect sizes (Cohen's d = 0.25 for days in attendance, Cohen's d = 0.40 for continuous weeks of attendance, and Cohen's d = 0.26 for percentage of group sessions attended). Intervention group participants also remained in treatment longer than comparison group participants (p = .05).
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Studies Measuring Outcome
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Study 2
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Study Designs
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Experimental
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Quality of Research Rating
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3.5
(0.0-4.0 scale)
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Study Populations
The following populations were identified in the studies reviewed for Quality of
Research.
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Study
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Age
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Gender
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Race/Ethnicity
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Study 1
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26-55 (Adult)
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61% Male
39% Female
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44% Black or African American
32% Hispanic or Latino
15% White
9% Race/ethnicity unspecified
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Study 2
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26-55 (Adult)
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57% Male
43% Female
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56% White
30% Black or African American
9% Hispanic or Latino
5% Race/ethnicity unspecified
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Study 3
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26-55 (Adult)
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53% Male
47% Female
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72% White
18% Hispanic or Latino
8% Black or African American
2% Race/ethnicity unspecified
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Quality of Research Ratings by Criteria (0.0-4.0 scale)
External reviewers independently evaluate the Quality of Research for an intervention's
reported results using six criteria:
For more information about these criteria and the meaning of the ratings, see Quality of Research.
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Outcome
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Reliability
of Measures
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Validity
of Measures
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Fidelity
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Missing
Data/Attrition
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Confounding
Variables
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Data
Analysis
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Overall
Rating
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1: Duration of abstinence from substance use
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3.8
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3.6
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3.5
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3.3
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3.4
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3.8
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3.6
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2: Cocaine and alcohol use
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3.9
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3.8
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4.0
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4.0
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2.3
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3.8
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3.6
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3: HIV-related risk behaviors
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3.3
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3.3
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3.2
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3.3
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3.6
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3.7
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3.4
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4: HIV viral load
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3.9
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3.9
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3.4
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3.8
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2.9
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3.9
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3.6
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5: Treatment attendance
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3.5
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3.5
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3.0
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3.5
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3.7
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3.8
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3.5
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Study Strengths The studies used data collection instruments and measures with established psychometric properties. In all three studies, fidelity was maximized through use of a protocol that included scheduled monitoring by the project manager and a competence adherence scale with good psychometric properties. Although implementation varied slightly across studies, data resulting from the use of the adherence scale indicated high fidelity to the model. Attrition in all three studies was minimal, and intent-to-treat analyses were employed. The analyses also accounted for missing data. Random assignment resulted in demographic equivalence between groups. All three studies employed analyses appropriate for the outcomes.
Study Weaknesses Some confounding variables were not addressed in some of the studies. In one study, baseline comparisons on outcome variables were not conducted to establish equivalence between groups, and research staff were not blinded to study condition. In another study, no efforts were made to examine intervention effects by therapist or by clinic setting.
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Documents Reviewed
The documents below were reviewed for Quality of Research. The research point of
contact can provide information regarding the studies reviewed and the availability
of additional materials, including those from more recent studies that may have been conducted.
Study 1Petry, N. M., Tedford, J., Austin, M., Nich, C., Carroll, K. M., & Rounsaville, B. J.. Prize reinforcement contingency management for treating cocaine users: How low can we go, and with whom? Addiction, 99(3), 349-360. Study 2Petry, N. M., Martin, B., & Simcic, F., Jr. Prize reinforcement contingency management for cocaine dependence: Integration with group therapy in a methadone clinic. Journal of Consulting and Clinical Psychology, 73(2), 354-359. Study 3Petry, N. M., Alessi, S. M., Marx, J., Austin, M., & Tardif, M. Vouchers versus prizes: Contingency management treatment of substance abusers in community settings. Journal of Consulting and Clinical Psychology, 73(6), 1005-1014. Study 4Petry, N. M., Alessi, S. M., & Hanson, T. Contingency management improves abstinence and quality of life in cocaine abusers. Journal of Consulting and Clinical Psychology, 75(2), 307-315. Study 5Petry, N. M., Peirce, J. M., Stitzer, M. L., Blaine, J., Roll, J. M., Cohen, A., et al. Effect of prize-based incentives on outcomes in stimulant abusers in outpatient psychosocial treatment programs. A National Drug Abuse Treatment Clinical Trials Network study. Archives of General Psychiatry, 62(10), 1148-1156. Study 6Peirce, J. M., Petry, N. M., Stitzer, M. L., Blaine, J., Kellogg, S., Satterfield, S., et al. Effects of lower-cost incentives on stimulant abstinence in methadone maintenance treatment. A National Drug Abuse Treatment Clinical Trials Network study. Archives of General Psychiatry, 63(2), 201-208.
Supplementary Materials Hanson, T., Alessi, S. M., & Petry, N. M. Contingency management reduces HIV risk behaviors in cocaine-abusing methadone patients. Unpublished manuscript.
Killeen, T., Carter, R., Copersino, M., Petry, N., & Stitzer, M. Effectiveness of motivational incentives in stimulant abusing outpatients with different treatment histories. American Journal of Drug and Alcohol Abuse, 33(1), 129-137.
Ledgerwood, D. M., & Petry, N. M. Does contingency management affect motivation to change substance use? Drug and Alcohol Dependence, 83(1), 65-72.
Olmstead, T. A., Sindelar, J. L., & Petry, N. M. Cost-effectiveness of prize-based incentives for stimulant abusers in outpatient psychosocial treatment programs. Drug and Alcohol Dependence, 87(2-3), 175-182.
McQuaid, F., & Bowden-Jones, O., & Weaver, T. Contingency management for substance misuse [Correspondence]. British Journal of Psychiatry, 190, 272.
Petry, N. M. Contingency management treatments [Editorial]. British Journal of Psychiatry, 189, 97-98.
Petry, N. M. Contingency management for substance misuse [Author's reply]. British Journal of Psychiatry, 190, 272.
Petry, N. M. Serious adverse events in psychosocial treatment studies: Safety or arbitrary edicts? Unpublished manuscript.
Petry, N. M., Alessi, S. M., Carroll, K. M., Hanson, T., MacKinnon, S., Rounsaville, B., et al. Contingency management treatments: Reinforcing abstinence versus adherence with goal-related activities. Journal of Consulting and Clinical Psychology, 74(3), 592-601.
Petry, N. M., Kolodner, K. B., Li, R., Peirce, J. M., Roll, J. M., Stitzer, M. L., et al. Prize-based contingency management does not increase gambling. Drug and Alcohol Dependence, 83(3), 269-273.
Petry, N. M., & Martin, B. Low-cost contingency management for treating cocaine- and opioid-abusing methadone patients. Journal of Consulting and Clinical Psychology, 70(2), 398-405.
Petry, N. M., Martin, B., Cooney, J. L., & Kranzler, H. R. Give them prizes, and they will come: Contingency management for treatment of alcohol dependence. Journal of Consulting and Clinical Psychology, 68(2), 250-257.
Roll, J. M., Petry, N. M., Stitzer, M. L., Brecht, M. L., Peirce, J. M., McCann, M. J., et al. Contingency management for the treatment of methamphetamine use disorders. American Journal of Psychiatry, 163(11)
Sindelar, J., Elbel, B., & Petry, N. M. What do we get for our money? Cost-effectiveness of adding contingency management. Addiction, 102(2), 309-316.
Stitzer, M. L., Peirce, J., Petry, N. M., Kirby, K., Roll, J., Krasnansky, J., et al. Abstinence-based incentives in methadone maintenance: Interaction with intake stimulant test results. Experimental and Clinical Psychopharmacology, 15(4), 344-350.
Stitzer, M. L., Petry, N. M., Peirce, J., Kirby, K., Killeen, T., Roll, J., et al. Effectiveness of abstinence-based incentives: Interaction with intake stimulant test results. Journal of Consulting and Clinical Psychology, 75(5), 805-811.
Tracy, K., Babuscio, T., Nich, C., Kiluk, B., Carroll, K. M., Petry, N. M., et al. Contingency management to reduce substance use in individuals who are homeless with co-occurring psychiatric disorders. American Journal of Drug and Alcohol Abuse, 33(2), 253-258.
Outcomes
| Outcome 1: Drug use during treatment |
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Description of Measures
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Drug use during treatment was measured using urinalysis (OnTrak TesTstik or OnTrak TesTcup 5) with or without accompanying breath analysis for blood alcohol concentration (Alcosensor IV Alcometer). Across a 3-month treatment period, collected urine/breath samples were tested for the presence of cocaine, opioids, and alcohol; cocaine and opioids; or stimulants (cocaine, methamphetamine, amphetamine) and alcohol.
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Key Findings
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Across five randomized controlled trials (RCTs) conducted in clinical and community-based settings, prize incentives were more effective than usual care conditions in improving abstinence from drug use during treatment. When different prize levels were compared, greater results were seen for higher-valued prize incentives over lesser-valued prize incentives.
In two community-based treatment centers serving cocaine-abusing outpatients:
- Usual care (weekly counseling) was compared with usual care plus prize incentives. Two levels of prize incentives were evaluated: an $80 and $240 maximum.
- Patients receiving $240 in prize incentives abstained from cocaine, opioids, and alcohol for longer periods compared with patients receiving usual care (p < .05).
- Patients receiving $240 in prize incentives had a higher percentage of drug-free samples (84.2%) than patients in usual care (62.3%, p < .01) and those receiving the $80 prize incentives (66.4%, p < .05).
- When the $80 prize incentive condition was compared with usual care, no significant differences were seen in the longest duration of abstinence or in average percentage of drug-free samples.
In a community clinic serving cocaine-dependent methadone patients:
- Usual care (methadone and weekly group therapy) was compared with usual care plus escalating prize incentives (up to 15 prize draws per consecutive urine sample testing negative for cocaine and opioids).
- Prize incentive participants were continuously abstinent for 2.9 weeks on average compared with only 0.8 weeks for usual care participants (p < .05).
- Prize incentive participants had a higher percentage of cocaine-negative urine samples compared with patients receiving usual care (34.6% vs. 16.8%, p < .01).
- Opioid-negative urine samples did not differ between the prize incentive and usual care groups.
In three community-based treatment centers serving cocaine- or heroin-dependent outpatients:
- Usual care (intensive individual and group therapy) was compared with usual care plus prize or voucher incentives.
- Participants receiving prize incentives achieved an average of 7.8 weeks of abstinence from cocaine, heroin, and alcohol, compared with 7.0 weeks for participants receiving voucher incentives and only 4.6 weeks for usual care participants.
- The longest duration of drug abstinence achieved by the usual care group was significantly shorter compared with that achieved by the prize (p < .01) or the voucher (p < .01) incentive groups; the duration did not differ between the two incentive conditions. This difference between the prize incentive and usual care conditions was associated with a small effect size (Cohen's d = 0.42), as was the difference between the voucher incentive and usual care conditions (Cohen's d = 0.29).
- Forty-five percent of prize incentive patients were abstinent for the entire 3 months, compared with 28% in the voucher incentive group (p < .01) and only 8% in the usual care group. The 8% rate of drug abstinence in the usual care condition was significantly lower than the rates for patients in either the prize (p < .01) or the voucher (p = .02) incentive conditions.
In eight nationwide community-based outpatient psychosocial treatment programs serving cocaine or methamphetamine users:
- Usual care (primarily group therapy with some individual and family counseling) was compared with usual care plus escalating prize incentives (up to 12 draws per negative consecutive urine/breath sample).
- On average, prize incentive participants achieved 4.4 weeks of abstinence from stimulants (cocaine, methamphetamines, amphetamines) and alcohol, compared with 2.6 weeks for usual care participants (p < .001).
- Nearly twice as many prize incentive participants (39.7%) achieved sustained drug abstinence for at least 1 month compared with those receiving usual care (21.0%), a difference representing a small effect size (odds ratio = 2.48).
- Another 26.3% of prize incentive participants achieved drug abstinence for at least 2 months compared with 11.7% of the usual care group, a difference that also represents a small effect size (odds ratio = 2.69).
- A medium effect size (odds ratio = 4.48) was found when examining 3 months of sustained abstinence, achieved by 18.7% of the prize incentive group but only 4.9% of the usual care group.
- Prize incentive participants were more likely to submit 19-24 consecutive negative samples compared with usual care patients (p < .001).
In six nationwide community-based methadone maintenance clinics serving stimulant-abusing patients:
- Usual care (methadone with group and some individual counseling) was compared with usual care plus escalating prize incentives (up to 12 draws per negative consecutive urine/breath sample).
- Prize incentive participants, who had an average of 3 weeks of continuous abstinence, were twice as likely to submit stimulant- and alcohol-negative samples as usual care participants, who had an average of 1 week of continuous abstinence (p < .001).
- Prize incentive participants were 3 times more likely than usual care participants to achieve abstinence for 1 or more months, 9 times more likely to achieve abstinence for 2 or more months, and 11 times more likely to achieve abstinence for 3 full months (odds ratio = 3.1, 9.3, and 11.1, respectively). The effect sizes associated with these differences were medium (1 month) or large (2 and 3 months).
- Prize incentive participants were more likely to submit 19-24 consecutive negative samples (21.2%) than usual care participants (8.0%) (p < .001).
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Studies Measuring Outcome
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Study 1, Study 2, Study 3, Study 5, Study 6
|
|
Study Designs
|
Experimental
|
|
Quality of Research Rating
|
3.8
(0.0-4.0 scale)
|
| Outcome 2: Drug use after treatment |
|
Description of Measures
|
In one study, cocaine use after treatment was measured using urinalysis (OnTrak TesTstik) at two time points: at study end (3 months after intake) and 3 months later (6 months after intake). The second study used urinalysis (OnTrak TesTstik) and breath analysis (Alcosensor IV Alcometer) at 3 (study end), 6, and 9 months after intake to test for cocaine, opioids, and alcohol. This study additionally matched the combined urinalysis and breath analysis results with self-reported drug use measured by the Addiction Severity Index (ASI). The ASI is an interview instrument that evaluates the severity of psychosocial problems across employment, family/social, legal, drug, alcohol, medical, and psychiatric domains. Composite scores of 0 to 1 are generated for each domain, with higher scores reflecting greater problem severity.
Drug use (indicated by positive urinalysis) at intake was used to predict abstinence from cocaine at the 6-month follow-up (first study) and abstinence from cocaine, opioids, and alcohol at the 6- and 9-month follow-ups (second study).
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Key Findings
|
In one of two RCTs conducted in clinical and community-based settings, prize incentives were more effective than usual care conditions in improving abstinence from drug use after treatment.
In a community clinic serving cocaine-dependent methadone patients:
- Usual care (methadone and weekly group therapy) was compared with usual care plus escalating prize incentives (up to 15 prize draws per consecutive urine sample testing negative for cocaine and opioids).
- Prize incentive participants submitted a higher percentage of cocaine-negative samples at the 3- and 6-month follow-ups than patients receiving usual care (29.7% vs. 11.1%, p < .02).
- Six months after study initiation, 35.5% of the prize incentive participants submitted cocaine-negative samples compared with only 13.5% of the usual care participants (p < .05), with a high association between the negative clinic-requested samples and the negative study-requested samples across follow-up (p < .001).
- Longest duration of abstinence from cocaine during treatment correctly predicted 79.4% of the patients who would provide a cocaine-negative sample at 6 months (p < .01), but the effect size was very small (odds ratio = 1.26).
In three community-based treatment centers serving cocaine- or heroin-dependent outpatients:
- Usual care (intensive individual and group therapy) was compared with usual care plus prize or voucher incentives.
- Self-reported use of cocaine, opioids, and alcohol and results from urinalysis and breath analysis were highly consistent, with less than 7% of patients denying use that was confirmed by positive samples. There were no differences in self-reported drug use between the prize incentive, voucher incentive, and usual care groups at the 6-month follow-up.
- Weeks of confirmed drug abstinence (based on both self-report and the analysis of samples) correctly predicted 72.6% of drug-abstinent patients at the 6-month (p < .001) and 9-month (p < .001) follow-ups, but the effect size was very small (odds ratio = 0.80 at 6 months, odds ratio = 0.76 at 9 months).
|
|
Studies Measuring Outcome
|
Study 2, Study 3
|
|
Study Designs
|
Experimental
|
|
Quality of Research Rating
|
3.8
(0.0-4.0 scale)
|
| Outcome 3: Drug problem severity during and after treatment |
|
Description of Measures
|
Drug problem severity during and after treatment was measured using composite scores from the drug, cocaine, and medical subscales of the ASI. Two studies administered the ASI at intake and at 3 (study end) and 6 months after intake; the second study also collected data at 9 months after intake. The ASI is an interview instrument that evaluates the severity of psychosocial problems across seven life domains. Composite scores of 0 to 1 are calculated for each domain subscale, with higher scores reflecting greater problem severity.
|
|
Key Findings
|
In one of two RCTs conducted in clinical and community-based settings, prize incentives were more effective than usual care conditions in minimizing drug problem severity during and after treatment.
In a community clinic serving cocaine-dependent methadone patients:
- Usual care (methadone and weekly group therapy) was compared with usual care plus escalating prize incentives (up to 15 prize draws per consecutive urine sample testing negative for cocaine and opioids).
- Prize incentive participants showed a decrease in the drug (p < .05), cocaine (p < .05), and medical (p < .01) composite scores of the ASI from intake to 3 months and intake to 6 months. This decrease over time was absent in the patients receiving usual care only.
In three community-based treatment centers serving cocaine- or heroin-dependent outpatients:
- Usual care (intensive individual and group therapy) was compared with usual care plus prize or voucher incentives.
- Patients in all three study groups--prize incentive, voucher incentive, and usual care--experienced decreases in ASI scores for drug, employment, legal, and psychiatric problems from intake to 3 months and intake to 9 months (p < .01).
- The only improvement that was greater for participants in the prize incentive condition relative to those in the voucher condition was the drug subscale score from intake to 3 months (p < .05).
|
|
Studies Measuring Outcome
|
Study 2, Study 3
|
|
Study Designs
|
Experimental
|
|
Quality of Research Rating
|
3.7
(0.0-4.0 scale)
|
| Outcome 4: Quality of life |
|
Description of Measures
|
Quality of life was evaluated using the Quality of Life Inventory (QOLI), a brief, self-administered instrument that assesses the importance of and satisfaction within 17 life area domains. A subscale score is derived for each domain, with a total scale score obtained by averaging all subscale scores for domains rated either "important" or "extremely important" by the individual. The QOLI was administered at intake and at 1, 3 (study end), 6, and 9 months after intake.
The QOLI scores were compared with the longest duration of abstinence from cocaine, opioids, and alcohol achieved during the study period, as measured by urinalysis and breath analysis.
|
|
Key Findings
|
In three clinical RCTs involving cocaine abusers:
- Usual care (intensive outpatient group and individual therapy sessions) was compared with usual care plus prize or voucher incentives.
- Participants in the incentive (prize or voucher) conditions showed significant increases in posttreatment QOLI scores over time (p = .01), but participants receiving usual care did not. QOLI score improvements in the incentive conditions were highest for participants who also achieved the longest durations (2-3 months) of drug abstinence (p < .05).
- The association between QOLI scores and longest duration of abstinence at 3 months (p < .001), 6 months (p < .05), and 9 months (p < .01) posttreatment was significant across the entire patient sample, even after controlling for baseline score differences. Longest duration of abstinence was a significant predictor (p = .03) of the rate of change (improvement or decline) in QOLI scores over time across the entire patient sample.
|
|
Studies Measuring Outcome
|
Study 4
|
|
Study Designs
|
Experimental
|
|
Quality of Research Rating
|
3.6
(0.0-4.0 scale)
|
| Outcome 5: Treatment retention |
|
Description of Measures
|
One study defined treatment retention as the number of weeks that patients were retained in treatment. Two other studies measured the number of days that elapsed between the first and last submitted urine samples across the 3-month study period. Study compliance, evaluated as part of the treatment retention outcome, was defined by the percentage of participants who submitted at least one sample per week during the study.
|
|
Key Findings
|
In two of three RCTs conducted in clinical and community-based settings, prize incentives were more effective than usual care conditions in retaining patients in treatment.
In three community-based treatment centers serving cocaine- or heroin-dependent outpatients:
- Usual care (intensive individual and group therapy) was compared with usual care plus prize or voucher incentives.
- On average, prize incentive participants were retained for 9.3 weeks; voucher incentive participants, 8.2 weeks; and usual care participants, 5.5 weeks. The difference in retention between the usual care condition and each of the two incentive conditions was significant (p < .01 for both comparisons), but retention did not differ significantly between the two incentive conditions.
- Treatment retention across the three clinics showed similar trends, but only two of the three clinics had significant outcomes (p < .05). The overall effect size for the difference in treatment retention between the usual care and prize incentive conditions was medium (Cohen's d = 0.52) and reflected effect sizes that ranged from small (Cohen's d = 0.44) to medium (Cohen's d = 0.57) across the three clinics. The overall effect size for the difference in treatment retention between the usual care and the voucher incentive conditions was small (Cohen's d = 0.38) and reflected effect sizes that ranged from very small (Cohen's d = 0.17) to medium (Cohen's d = 0.56).
- Only the incentive conditions were significantly related to retention (p = .03).
In eight nationwide community-based outpatient psychosocial treatment programs serving cocaine or methamphetamine users:
- Usual care (primarily group with some individual and family counseling) was compared with usual care plus escalating prize incentives (up to 12 draws per negative consecutive urine/breath sample).
- Prize incentive and usual care participants initially showed a 10% decline in treatment retention; this decline resulted from some patients not returning after the first study visit.
- Prize incentive participants were more likely to be retained in treatment (49%) than usual care participants (35%) at the end of the 3-month study.
- Prize incentive participants were more likely to submit urine/breath samples than usual care participants (an average of 12.9 vs. 9.9 samples, respectively, p < .001), but this difference was associated with a small effect size (odds ratio = 1.56).
- Average weeks retained in treatment showed a similar trend as individual samples submitted but only reached statistical significance at two of the eight treatment sites.
In six nationwide community-based methadone maintenance clinics serving stimulant-abusing patients:
- Usual care (methadone with group and some individual counseling) was compared with usual care plus escalating prize incentives (up to 12 draws per negative consecutive urine/breath sample).
- Prize incentive participants were about as likely as usual care participants to be retained in treatment for the full 3 months (67% vs. 65%).
- During the 3 months of study, prize incentive participants submitted an average of 15.5 samples compared with 14.1 samples submitted by usual care participants, a difference that reflects a very small effect size (odds ratio = 1.2).
|
|
Studies Measuring Outcome
|
Study 3, Study 5, Study 6
|
|
Study Designs
|
Experimental
|
|
Quality of Research Rating
|
3.9
(0.0-4.0 scale)
|
| Outcome 6: Group/counseling attendance |
|
Description of Measures
|
Group/counseling attendance was evaluated using both the number of therapy sessions attended and the percentage of patients attending therapy groups over the 3-month study period.
|
|
Key Findings
|
Across two RCTs conducted in clinical and community-based settings, prize incentives were more effective than usual care conditions in facilitating group/counseling attendance.
In a community clinic serving cocaine-dependent methadone patients:
- Usual care (methadone and weekly group therapy) was compared with usual care plus prize incentives. Patients in both groups received a single prize draw for attending group sessions, but prize incentive participants additionally received escalating prizes for attending consecutive sessions.
- Both weekly group therapy attendance and percentage of patients attending groups were higher for the prize incentive condition compared with the usual care condition (p < .001).
- Prize incentive participants attended group therapy sessions for an average of 6.6 weeks compared with 3.0 weeks for usual care participants.
- For prize incentive participants, the number of groups attended was associated with weeks of continuous cocaine abstinence (p < .001). There was no relationship between therapy group attendance and abstinence among usual care participants.
In eight nationwide community-based outpatient psychosocial treatment programs serving cocaine or methamphetamine users:
- Usual care (primarily group therapy with some individual and family counseling) was compared with usual care plus escalating prize incentives.
- Over the 3-month study period, prize incentive participants attended more group/counseling sessions than usual care participants (19.2 vs. 15.7, p < .02). Adjustment for individual sites did not affect these results.
|
|
Studies Measuring Outcome
|
Study 2, Study 5
|
|
Study Designs
|
Experimental
|
|
Quality of Research Rating
|
3.9
(0.0-4.0 scale)
|
Study Populations
The following populations were identified in the studies reviewed for Quality of
Research.
|
Study
|
Age
|
Gender
|
Race/Ethnicity
|
|
Study 1
|
26-55 (Adult)
|
55.8% Female
44.2% Male
|
64.2% Black or African American
23.3% White
10% Hispanic or Latino
2.5% Race/ethnicity unspecified
|
|
Study 2
|
26-55 (Adult)
|
72.7% Female
27.3% Male
|
45.5% Hispanic or Latino
35.1% Black or African American
19.5% White
|
|
Study 3
|
26-55 (Adult)
|
54.2% Female
45.8% Male
|
59.2% Black or African American
26.8% White
12.7% Hispanic or Latino
1.4% Race/ethnicity unspecified
|
|
Study 4
|
26-55 (Adult)
|
50.1% Male
49.9% Female
|
52.4% Black or African American
34.6% White
11.2% Hispanic or Latino
1.8% Race/ethnicity unspecified
|
|
Study 5
|
26-55 (Adult)
|
55.4% Female
44.6% Male
|
42.2% White
35.9% Black or African American
12.5% Hispanic or Latino
9.4% Race/ethnicity unspecified
|
|
Study 6
|
26-55 (Adult)
|
55.9% Male
44.1% Female
|
50.5% Black or African American
26% White
16.5% Hispanic or Latino
7% Race/ethnicity unspecified
|
Quality of Research Ratings by Criteria (0.0-4.0 scale)
External reviewers independently evaluate the Quality of Research for an intervention's
reported results using six criteria:
For more information about these criteria and the meaning of the ratings, see Quality of Research.
|
Outcome
|
Reliability
of Measures
|
Validity
of Measures
|
Fidelity
|
Missing
Data/Attrition
|
Confounding
Variables
|
Data
Analysis
|
Overall
Rating
|
|
1: Drug use during treatment
|
4.0
|
3.5
|
3.5
|
4.0
|
4.0
|
4.0
|
3.8
|
|
2: Drug use after treatment
|
4.0
|
3.5
|
3.5
|
3.8
|
4.0
|
4.0
|
3.8
|
|
3: Drug problem severity during and after treatment
|
3.5
|
3.5
|
3.5
|
3.8
|
4.0
|
4.0
|
3.7
|
|
4: Quality of life
|
3.0
|
3.0
|
3.5
|
4.0
|
4.0
|
4.0
|
3.6
|
|
5: Treatment retention
|
4.0
|
3.9
|
3.5
|
3.9
|
4.0
|
4.0
|
3.9
|
|
6: Group/counseling attendance
|
4.0
|
4.0
|
3.5
|
4.0
|
4.0
|
4.0
|
3.9
|
Study Strengths The drug use measures used across the studies are highly reliable and widely used in the substance abuse treatment outcomes field. The self-report measures are well regarded in the field and are widely used. Treatment retention is a very commonly used metric of treatment engagement and has strong psychometric properties as a measure. The studies were consistent in maintaining fidelity to the protocol and in the sound application of psychometrics and instrumentation to target drug use and contingency management. State-of-the-science methods were used to handle missing data and subject attrition, and potential confounding factors were addressed with appropriate random assignment. The data were analyzed using a strong modeling approach and state-of-the-science methods.
Study Weaknesses There are some limitations of self-reported drug use, despite its being standard practice in the field. For some of the outcomes, there is no mention in the articles of how treatment fidelity was measured or if such measures had any relationship to treatment response and treatment outcome.
|
|
Readiness for Dissemination
|
Materials Reviewed
The materials below were reviewed for Readiness for Dissemination. The implementation
point of contact can provide information regarding implementation of the intervention
and the availability of additional, updated, or new materials.
Ledgerwood, D. M., & Petry, N. M. Rating contingency management sessions that reinforce abstinence using the Contingency Management Competence Scale. Farmington, CT: University of Connecticut Health Center.
Petry, N. M. Contingency Management for Substance Abuse Treatment: A guide to implementing this evidence-based practice [with CD-ROM]. New York, NY: Routledge.
Petry, N. M. Contingency management: Designing an intervention to improve patient outcomes in your clinical setting [PowerPoint slides]. Farmington, CT: University of Connecticut Health Center.
Petry, N. M., Alessi, S. M., & Ledgerwood, D. M. A randomized trial of contingency management delivered by community therapists. Journal of Consulting and Clinical Psychology, 80(2), 286-298.
Petry, N. M., & Ledgerwood, D. M. The Contingency Management Competence Scale for Reinforcing Attendance. Farmington, CT: University of Connecticut Health Center.
Sample agenda for 1.5-day training
Training vignettes video [CD-ROM]
Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)
External reviewers independently evaluate the intervention's Readiness for Dissemination
using three criteria:
- Availability of implementation materials
- Availability of training and support resources
- Availability of quality assurance procedures
For more information about these criteria and the meaning of the ratings, see Readiness for Dissemination.
Implementation
Materials
|
Training and Support
Resources
|
Quality Assurance
Procedures
|
Overall
Rating
|
|
4.0
|
4.0
|
4.0
|
4.0
|
Dissemination Strengths The implementation guide provides a rationale for the program as well as detailed chapters on specific intervention components. The guide suggests solutions to difficult problems that may arise when working with clients. The program Web site is easy to use and includes information on training and helpful resources. The training provides implementers with opportunities to practice new skills, and a training video is available that demonstrates the use of these skills in vignettes. The developer is available for phone and email consultation. The competence scales measure behaviors that are observable and provide data to support quality assurance. An entire chapter in the implementation manual discusses quality assurance. The implementation guide contains a CD-ROM that includes several forms with instructions that can be used to support quality assurance.
Dissemination Weaknesses No weaknesses were identified by reviewers.
|
|
Materials Reviewed
The materials below were reviewed for Readiness for Dissemination. The implementation
point of contact can provide information regarding implementation of the intervention
and the availability of additional, updated, or new materials.
Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)
External reviewers independently evaluate the intervention's Readiness for Dissemination
using three criteria:
- Availability of implementation materials
- Availability of training and support resources
- Availability of quality assurance procedures
For more information about these criteria and the meaning of the ratings, see Readiness for Dissemination.
Implementation
Materials
|
Training and Support
Resources
|
Quality Assurance
Procedures
|
Overall
Rating
|
|
3.5
|
2.8
|
2.5
|
2.9
|
Dissemination Strengths The implementation materials present a clear rationale for the use of this program. The manual is easy to follow and includes tips for clinicians on managing difficult situations. Some Web-based, self-directed materials are provided that could support the training of clinicians. A knowledge test and a clinician adherence scale are available to support quality assurance.
Dissemination Weaknesses Some program materials are redundant. The manual refers to clinician training that includes a didactic seminar and role-plays, but it is unclear who directs this training. While clinician supervision is strongly recommended to enhance quality assurance, no supervisor training or support is provided. There are no clear suggestions for how one might evaluate program impact in a clinical rather than research setting.
|
|
Costs
The cost information below was provided by the developer. Although this cost information
may have been updated by the developer since the time of review, it may not reflect
the current costs or availability of items (including newly developed or discontinued
items). The implementation point of contact can provide current information and
discuss implementation requirements.
|
Item Description
|
Cost
|
Required by Developer
|
|
Contingency Management for Substance Abuse Treatment: A Guide to Implementing This Evidence-Based Practice (includes CD-ROM)
|
$50 each
|
Yes
|
|
Training vignettes video (CD-ROM)
|
$59 each
|
No
|
|
Rating Contingency Management Sessions That Reinforce Abstinence Using the Contingency Management Competence Scale (scale and manual)
|
Free
|
Yes
|
|
The Contingency Management Competence Scale for Reinforcing Attendance (scale and manual)
|
Free
|
Yes
|
|
1- to 2-day, off-site training
|
$50-$200 per participant for 10-200 participants
|
No
|
|
On-site consultation
|
Contact the developer
|
No
|
|
Phone and email support
|
$100-$200 per hour
|
No
|
|