Getting Clean Pays: Rewarding Recovering Addicts

Who doesn’t like to receive an affirmation for something well done? It could be a thumbs up, praise, formal recognition, a prize. It’s an age-old concept, popular as ever. You’re familiar with it. Grade school students may get a gold star for an assignment well done. At a more advanced level, college students who earn exceptional grades during a semester or term may have their name added to the Dean’s List. An honor of this nature, no matter small or large, produces warm feelings. It also tends to help maintain or increase motivation. That’s the thinking behind this convention. It pertains to many situations and types of rewards. And it applies to a technique used at times in the recovery process. In clinical circles, it goes by the name of Contingency Management (CM).

What is Contingency Management?

Does CM bestow benefits on those struggling with substance abuse? “Highly effective” is how the National Institutes of Health (NIH) views this principle. The agency describes it as “giving patients tangible rewards to reinforce positive behaviors such as abstinence.” Many others agree. CM, in practical terms, is not complicated or quite costly. Yet it produces desired results. It enhances participation in treatment as well as in staying off substances.

CM is not a new tool in the recovery arsenal. A study on “Contingency Management for Treatment of Substance Abuse” references its use going back to 2000. It notes “Clinical research trials demonstrate the efficacy of contingency management procedures in treating substance use disorders. Usually, reinforcement, in the form of vouchers exchangeable for retail goods and services, is provided for drug abstinence in patients treated in psychosocial or methadone maintenance clinics.”

Based on its efficacy, CM is used more liberally in some programs. In these cases, it targets a range of desirable behaviors clients display during the treatment process. Those include maintaining good attendance, achieving goals as well as complying with medication.

More on the Role of CM 

What is CM in the recovery scheme of things? Is it considered a therapy? A post on “Contingency Management” from the Hazelden Betty Ford Foundation lays it out. “It’s not a therapy unto itself but rather an evidence-based behavior modification intervention.” However, this piece notes that CM is not a standalone. It explains: “While motivational incentives can help individuals achieve their treatment goals, this method should be used in conjunction with another approach, such as cognitive behavioral therapy (CBT).”

This clarification aside, the article points out the value of CM. It “can be a powerful tool for teaching people that they are able to change their behavior when they’re sufficiently motivated.” CM serves as a catalyst as well as a building block. The author says: “Success in a task like showing up on time can lead to success in more complex tasks. Motivational incentives can also help participants build confidence over time, counteracting feelings of shame or low self-esteem.”

What’s more, CM helps in treating people with co-occurring disorders. An entry in the Journal of Dual Diagnosis reported on the use of CM in a clinical setting. The study team concluded that CM is “a valuable adjunct.” It “increases retention in treatment, which in turn contributes to increased drug-free days.”

Why Not More CM?

With all of these testimonials, CM should be a go-to tool in recovery, wouldn’t you think? A recent story in the New York Times addresses this issue in “This Addiction Treatment Works. Why Is It So Underused?” The answer to the question posed is that some in the recovery and healthcare community oppose this technique. “Researchers say that one of the biggest obstacles to contingency management is a moral objection to the idea of rewarding someone for staying off drugs.” This sentiment contributes to why public and private insurers do not fund CM. For these reasons, “few programs offer it.”

There are other factors for the low level of use. Two fall into the broad categories of judgment and red tape. Some clinicians question whether recovering addicts can make sounds decisions about how to use the money they may receive through CM. There’s also a problem in the legal realm. It may violate the federal anti-kickback statute. Activities to waive this provision as it applies to CM have failed; however, requests may be made on an individual basis and judged case-by-case.

Rewarding Recovering Addicts

On that note, the story of one long-time substance abuser recently exposed to CM is compelling. Over the years, this person had attended 12 recovery programs. All attempts ultimately ended unsuccessfully. Thanks to CM that has changed. A new program, as part of its treatment regimen, equipped her with an app and debit card. By staying off substances and going to doctor appointments and therapy sessions, she receives cash deposits on that card. At first, she was hesitant about this “free” money. Then the power of this technique kicked in. She said: “I looked at the app on my phone and they’d given me $25 for detoxing. Wow, really? I went back the next day and I got $5 more.”