ADC 630 Module 6 Medications and Contingency Management Example

Pills and Prizes: Medications and Contingency Management in Outpatient Treatment

Student Name

Psychology and Addiction Studies Program, Aspen University

ADC 630: Diagnosis and Treatment of Substance Abuse Disorders

Instructor Name

Month Day, Year

Pills and Prizes: Medications and Contingency Management in Outpatient Treatment

Seven weeks into treatment, Sam had stopped drinking, though evening cravings were strong, and had used cocaine once, at a friend's birthday party. He was discouraged. His counselor, Brooke, considered what else might help. Two well-supported options were open to them; the clinic and both people are fictional.

Medication for Drinking

Jonas et al. (2014) pooled the randomized trials of drinking medications given to adults outside hospitals. Acamprosate and naltrexone, taken by mouth daily, both reduced return to drinking compared with placebo. For acamprosate, roughly twelve patients had to take it for one extra person to stay entirely off alcohol. For naltrexone at fifty milligrams daily, about twenty needed treatment to prevent a return to any drinking and about twelve to prevent a return to heavy drinking. Where the two drugs were tested against each other, neither clearly won. Injectable naltrexone also showed benefits for heavy drinking days. The authors noted that these medications were greatly underused.

Contingency Management

Contingency management applies principles of reinforcement: behaviors followed by immediate rewards become more frequent. In substance use treatment, clients earn tangible rewards, such as vouchers exchangeable for goods or chances to draw prizes, for verified behaviors, usually drug-negative urine samples. Rewards often escalate with consecutive negative samples and reset after a positive one, encouraging sustained abstinence.

Prendergast et al. (2006) conducted a meta-analysis of contingency management studies. Contingency management produced significant reductions in substance use, with a moderate average effect, larger than many other behavioral treatments. Effects were particularly strong for opioids and cocaine and stronger when rewards were delivered immediately after the behavior. Effects tended to decline after the incentives ended, though not always to baseline.

Prize-Based Incentives in Community Clinics

Voucher programs can be costly. Petry et al. (2005) tried a cheaper version, built around prize draws, with stimulant users in ordinary community programs. Clients who submitted stimulant-free samples earned draws from a bowl in which about half the slips said "good job" and the rest offered prizes of varying value, most small. Compared with usual care alone, clients receiving prize-based incentives stayed in treatment longer and submitted more stimulant-free samples, and were more likely to achieve extended periods of abstinence. The trial showed that ordinary clinics could deliver incentives effectively at modest cost.

Why Rewards Must Be Immediate

Prendergast and colleagues' finding that immediate rewards produced stronger effects reflects a basic principle of learning. A reward delivered right after a negative test strengthens the link between abstinence and something good; a reward delivered weeks later competes poorly with the immediate pull of a drug. Programs therefore test frequently and give prizes on the spot, which also makes the program feel concrete and engaging to clients.

Answering the Objection

When Brooke described prize-based incentives, Sam laughed: "So you'd pay me to stay clean?" Some staff and funders raise the same objection. The answer lies in how reinforcement works. Cocaine provides an immediate, powerful reward; the benefits of abstinence, such as better health and relationships, come slowly. Incentives provide an immediate reward for abstinence while those longer-term benefits build. The costs are small compared with the costs of continued use.

Medication and Counseling Together

Medications for alcohol use disorder are not meant to stand alone. In trials, they were usually given alongside some form of counseling or medical management. Naltrexone may reduce the rewarding effect of drinking and ease craving, which can make counseling goals easier to reach, while counseling helps clients take medication consistently and build the skills and supports that medication cannot provide. For Sam, whose evening cravings were the main threat to his abstinence, medication addressed exactly the moment where his plans most often strained.

Testing and Trust

Contingency management depends on reliable testing, which can feel intrusive. Brooke explained that tests in the program were for earning rewards, not for punishment, and that a positive test would reset his prize draws but not lead to discharge or a report to his probation officer beyond what his court agreement already required. Framing testing as a path to rewards rather than surveillance supports trust.

Which Medication?

Naltrexone and acamprosate have different practical profiles. Naltrexone is taken once daily and may reduce the pleasure of drinking and the urge to continue after a first drink, which suits clients whose main difficulty is evening craving and heavy drinking once they start. Acamprosate is taken three times a day and is thought to ease the discomfort of early abstinence. Sam's craving in the evenings and his history of heavy drinking once he began made naltrexone the more natural choice for the prescriber to consider.

The Plan

With Sam's agreement, Brooke arranged a consultation with the clinic's nurse practitioner, who prescribed naltrexone after checking that Sam was not taking opioid medications and reviewing his liver function. Brooke herself does not recommend specific medications; her role was to explain the options and connect Sam with the prescriber. For cocaine, the clinic enrolled Sam in its twelve-week prize-based program, with urine tests twice weekly. Counseling continued, including relapse prevention for situations like the birthday party. Toward the end of the incentive period, Brooke and Sam planned other sources of reward to replace the prizes, such as the softball league and saving the money he no longer spent on cocaine.

Conclusion

Jonas and colleagues showed that acamprosate and naltrexone modestly reduce drinking, Prendergast and colleagues found contingency management among the more effective behavioral treatments and Petry and colleagues showed that prize-based incentives work in community clinics. For Sam, medication for alcohol craving and incentives for cocaine abstinence, combined with counseling, offered more support than counseling alone.

References

Jonas, D. E., Amick, H. R., Feltner, C., Bobashev, G., Thomas, K., Wines, R., Kim, M. M., Shanahan, E., Gass, C. E., Rowe, C. J., & Garbutt, J. C. (2014). Pharmacotherapy for adults with alcohol use disorders in outpatient settings: A systematic review and meta-analysis. JAMA, 311(18), 1889-1900. https://doi.org/10.1001/jama.2014.3628

Petry, N. M., Peirce, J. M., Stitzer, M. L., Blaine, J., Roll, J. M., Cohen, A., Obert, J., Killeen, T., Saladin, M. E., Cowell, M., Kirby, K. C., Sterling, R., Royer-Malvestuto, C., Hamilton, J., Booth, R. E., Macdonald, M., Liebert, M., Rader, L., Burns, R., ... Li, R. (2005). 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. https://doi.org/10.1001/archpsyc.62.10.1148

Prendergast, M., Podus, D., Finney, J., Greenwell, L., & Roll, J. (2006). Contingency management for treatment of substance use disorders: A meta-analysis. Addiction, 101(11), 1546-1560. https://doi.org/10.1111/j.1360-0443.2006.01581.x