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Contingency management (lower cost) for substance use disorders

Substance Use Disorders: Treatment for Adults
Benefit-cost methods last updated December 2019.  Literature review updated May 2014.
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Contingency management is a supplement to counseling treatment that rewards participants for attending treatment and/or abstaining from substance use. The intervention reviewed here focused on those with drug and/or alcohol use disorder (excluding those with a primary diagnosis of marijuana use disorder) where contingencies were provided for remaining abstinent. Two methods of contingency management were reviewed: (1) A voucher system where abstinence earned vouchers that were exchangeable for goods provided by the clinic or counseling center, and (2) a prize or raffle system where clients who remained abstinent could earn the opportunity to draw from a prize bowl. Higher-cost contingency management was determined by maximum voucher or maximum expected value of prizes possible. Based on a statistical analysis of contingency management studies, we determined that programs with a maximum value of vouchers or prizes less than or equal to $500 (in 2012 dollars) represent lower-cost contingency management. Treatment in the included studies lasted between 1 and 12 months with a weighted average of 3.5 months of contingency management and reward opportunities occurring two to three times per week, on average.
The estimates shown are present value, life cycle benefits and costs. All dollars are expressed in the base year chosen for this analysis (2018). The chance the benefits exceed the costs are derived from a Monte Carlo risk analysis. The details on this, as well as the economic discount rates and other relevant parameters are described in our Technical Documentation.
Benefit-Cost Summary Statistics Per Participant
Benefits to:
Taxpayers $488 Benefits minus costs $2,732
Participants $643 Benefit to cost ratio $11.53
Others $237 Chance the program will produce
Indirect $1,624 benefits greater than the costs 60 %
Total benefits $2,992
Net program cost ($260)
Benefits minus cost $2,732
1In addition to the outcomes measured in the meta-analysis table, WSIPP measures benefits and costs estimated from other outcomes associated with those reported in the evaluation literature. For example, empirical research demonstrates that high school graduation leads to reduced crime. These associated measures provide a more complete picture of the detailed costs and benefits of the program.

2“Others” includes benefits to people other than taxpayers and participants. Depending on the program, it could include reductions in crime victimization, the economic benefits from a more educated workforce, and the benefits from employer-paid health insurance.

3“Indirect benefits” includes estimates of the net changes in the value of a statistical life and net changes in the deadweight costs of taxation.
Detailed Monetary Benefit Estimates Per Participant
Benefits from changes to:1 Benefits to:
Taxpayers Participants Others2 Indirect3 Total
Crime $0 $0 $1 $0 $1
Property loss associated with alcohol abuse or dependence $0 $0 $1 $0 $1
Labor market earnings associated with illicit drug abuse or dependence $187 $440 $0 $0 $627
Health care associated with illicit drug abuse or dependence $230 $36 $236 $115 $616
Mortality associated with illicit drugs $71 $167 $0 $1,639 $1,876
Adjustment for deadweight cost of program $0 $0 $0 ($130) ($130)
Totals $488 $643 $237 $1,624 $2,992
Detailed Annual Cost Estimates Per Participant
Annual cost Year dollars Summary
Program costs $240 2012 Present value of net program costs (in 2018 dollars) ($260)
Comparison costs $0 2012 Cost range (+ or -) 40 %
Contingency management is typically provided for a year or less. We calculated the weighted average of the per-participant treatment and comparison group variable costs across studies estimating the cost-effectiveness of an incentive program with an average cost of less than $500 in 2012 (Sindelar, Olmstead, & Peirce, 2007; Sindelar, Elbel, & Petry, 2006; Hartz et al., 1999). Costs of administering the incentive program include staff costs to inventory, shop for, and restock prizes; material cost of items; counseling session costs; and toxicology screens. All staff costs include salary, benefits, and overhead. All costs are calculated from the clinic perspective. Note that because treatment group participants have higher retention rates than the control group, costs also reflect the increased number of counseling sessions attended and urinalysis tests performed for the treated group. Hartz, D.T., Meek, P., Piotrowski, N.A., Tusel, D.J., Henke, C.J., Delucchi, K., Sees, K., Hall, S.M. (1999). A cost-effectiveness and cost-benefit analysis of contingency contracting-enhanced methadone detoxification treatment. The American Journal of Drug and Alcohol Abuse, 25(2), 207-218. Sindelar, J., Elbel, B., & Petry, N.M. (2007). What do we get for our money? Cost-effectiveness of adding contingency management. Addiction, 102(2), 309-316.Sindelar, J.L., Olmstead, T.A., & Peirce, J.M. (2007). Cost effectiveness of prize-based contingency management in methadone maintenance treatment programs. Addiction, 102(9), 1463-1471.
The figures shown are estimates of the costs to implement programs in Washington. The comparison group costs reflect either no treatment or treatment as usual, depending on how effect sizes were calculated in the meta-analysis. The cost range reported above reflects potential variation or uncertainty in the cost estimate; more detail can be found in our Technical Documentation.
Estimated Cumulative Net Benefits Over Time (Non-Discounted Dollars)
The graph above illustrates the estimated cumulative net benefits per-participant for the first fifty years beyond the initial investment in the program. We present these cash flows in non-discounted dollars to simplify the “break-even” point from a budgeting perspective. If the dollars are negative (bars below $0 line), the cumulative benefits do not outweigh the cost of the program up to that point in time. The program breaks even when the dollars reach $0. At this point, the total benefits to participants, taxpayers, and others, are equal to the cost of the program. If the dollars are above $0, the benefits of the program exceed the initial investment.

^WSIPP’s benefit-cost model does not monetize this outcome.

Meta-analysis is a statistical method to combine the results from separate studies on a program, policy, or topic in order to estimate its effect on an outcome. WSIPP systematically evaluates all credible evaluations we can locate on each topic. The outcomes measured are the types of program impacts that were measured in the research literature (for example, crime or educational attainment). Treatment N represents the total number of individuals or units in the treatment group across the included studies.

An effect size (ES) is a standard metric that summarizes the degree to which a program or policy affects a measured outcome. If the effect size is positive, the outcome increases. If the effect size is negative, the outcome decreases.

Adjusted effect sizes are used to calculate the benefits from our benefit cost model. WSIPP may adjust effect sizes based on methodological characteristics of the study. For example, we may adjust effect sizes when a study has a weak research design or when the program developer is involved in the research. The magnitude of these adjustments varies depending on the topic area.

WSIPP may also adjust the second ES measurement. Research shows the magnitude of some effect sizes decrease over time. For those effect sizes, we estimate outcome-based adjustments which we apply between the first time ES is estimated and the second time ES is estimated. We also report the unadjusted effect size to show the effect sizes before any adjustments have been made. More details about these adjustments can be found in our Technical Documentation.

Meta-Analysis of Program Effects
Outcomes measured Treatment age No. of effect sizes Treatment N Adjusted effect sizes(ES) and standard errors(SE) used in the benefit - cost analysis Unadjusted effect size (random effects model)
First time ES is estimated Second time ES is estimated
ES SE Age ES SE Age ES p-value
Alcohol use disorder 37 7 800 -0.196 0.116 37 0.000 0.075 38 -0.290 0.092
Cannabis use^ 37 3 319 -0.049 0.118 37 n/a n/a n/a -0.049 0.676
Illicit drug use disorder 37 29 1595 -0.278 0.049 37 0.000 0.075 38 -0.278 0.001

Citations Used in the Meta-Analysis

Chen, W., Hong, Y., Zou, X., McLaughlin, M.M., Xia, Y., & Ling, L. (2013). Effectiveness of prize-based contingency management in a methadone maintenance program in China. Drug and Alcohol Dependence, 133(1), 270-274.

Groß, A., Marsch, L.A., Badger, G.J., & Bickel, W.K. (2006). A comparison between low-magnitude voucher and buprenorphine medication contingencies in promoting abstinence from opioids and cocaine. Experimental and Clinical Psychopharmacology, 14(2), 148-156.

Hagedorn, H.J., Noorbaloochi, S., Simon, A.B., Bangerter, A., Stitzer, M.L., Stetler, C.B., & Kivlahan, D. (2013). Rewarding early abstinence in Veterans Health Administration addiction clinics. Journal of Substance Abuse Treatment, 45(1), 109-117.

Hall, E.A., Prendergast, M.L., Warda, U., & Roll, J.M. (2009). Reinforcing abstinence and treatment participation among offenders in a drug diversion program: Are Vouchers Effective?. Criminal Justice and Behavior, 36(9), 935-953.

Hser, Y.I., Li, J., Jiang, H., Zhang, R., Du, J., Zhang, C., Zhang, B., ... Zhao, M. (2011). Effects of a randomized contingency management intervention on opiate abstinence and retention in methadone maintenance treatment in China. Addiction, 106(10), 1801-1809.

Iguchi, M.Y., Belding, M.A., Morral, A.R., Lamb, R.J., & Husband, S.D. (J1997). Reinforcing operants other than abstinence in drug abuse treatment: an effective alternative for reducing drug use. Journal of Consulting and Clinical Psychology, 65(3), 421-8.

Jones, H.E., Haug, N.A., Stitzer, M.L., & Svikis, D.S. (2000). Improving treatment outcomes for pregnant drug-dependent women using low-magnitude voucher incentives. Addictive Behaviors, 25(2), 263-267.

McCaul, M.E., Stitzer, M.L., Bigelow, G.E., & Liebson, I A. (1984). Contingency management interventions: effects on treatment outcome during methadone detoxification. Journal of Applied Behavior Analysis, 17(1), 35-43.

McDonell, M.G., Srebnik, D., Angelo, F., McPherson, S., Lowe, J.M., Sugar, A., Short, R.A., ... Ries, R.K. (2013). Randomized controlled trial of contingency management for stimulant use in community mental health patients with serious mental illness. The American Journal of Psychiatry, 170(1), 94-101.

Menza, T.W., Jameson, D.R., Hughes, J.P., Colfax, G.N., Shoptaw, S., & Golden, M.R. (2010). Contingency management to reduce methamphetamine use and sexual risk among men who have sex with men: a randomized controlled trial. Bmc Public Health, 10(1), 774.

Peirce, J.M., Petry, N.M., Stitzer, M.L., Blaine, J., Kellogg, S., Satterfield, F., Schwartz, M., ... Li, R. (2006). 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.

Petry, N.M., Martin, B., Cooney, J.L., & Kranzler, H.R. (2000). Give them prizes, and they will come: Contingency Management for treatment of alcohol dependence. Journal of Consulting and Clinical Psychology, 68(2), 250-257.

Petry, N. M., Tedford, J., Austin, M., Nich, C., Carroll, K. M., & Rounsaville, B. J. (2004). Prize reinforcement contingency management for treating cocaine users: how low can we go, and with whom?. Addiction, 99(3), 349-360.

Petry, N.M., Peirce, J.M., Stitzer, M.L., Blaine, J., Roll, J.M., Cohen, A., Obert, J., ... 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.

Petry, N.M., Alessi, S.M., Marx, J., Austing, M., Tardif, M. 2005. Vouchers versus prizes: Contingency management treatment of substance abusers in community settings. Journal of Consulting and Clinical Psychology, 73(6), 1005-1014

Petry, N.M., Weinstock, J., Alessi, S.M., Lewis, M.W., & Dieckhaus, K. (2010). Group-based randomized trial of contingencies for health and abstinence in HIV patients. Journal of Consulting and Clinical Psychology, 78(1), 89-97.

Petry, N.M., Weinstock, J., & Alessi, S.M. (2011). A randomized trial of contingency management delivered in the context of group counseling. Journal of Consulting and Clinical Psychology, 79(5), 686-96.

Petry, N.M., Alessi, S.M., & Ledgerwood, D.M. (2012). Contingency management delivered by community therapists in outpatient settings. Drug and alcohol dependence, 122(1), 86-92.

Petry, N.M., Alessi, S.M., & Rash, C.J. (2013). A randomized study of contingency management in cocaine-dependent patients with severe and persistent mental health disorders. Drug and alcohol dependence, 130(1), 234-237.

Preston, K.L., Umbricht, A., & Epstein, D.H. (2002). Abstinence reinforcement maintenance contingency and one-year follow-up. Drug and Alcohol Dependence, 67(2), 125-137.

Roll, J.M., Chudzynski, J., Cameron, J.M., Howell, D.N., & McPherson, S. (2013). Duration effects in contingency management treatment of methamphetamine disorders. Addictive Behaviors, 38(9), 2455-2462.

Rowan-Szal, G.A.P.D., Joe, G.W.E.D., Hiller, M. L.P.D., & Simpson, D.D.P.D. (1997). Increasing Early Engagement in Methadone Treatment. Journal of Maintenance in the Addictions, 1(1), 49-61.

Rowan-Szal, G.A., Bartholomew, N.G., Chatham, L.R., & Simpson, D.D. (2005). A combined cognitive and behavioral intervention for cocaine-using methadone clients. Journal of Psychoactive Drugs, 37(1), 75-84.

Tracy, K., Babuscio, T., Nich, C., Kiluk, B., Carroll, K.M., Petry, N.M., & Rounsaville, B.J. (2007). Contingency Management to Reduce Substance Use in Individuals Who are Homeless with Co-Occurring Psychiatric Disorders. The American Journal of Drug and Alcohol Abuse, 33(2), 253-258.