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Contingency management (higher cost) for substance use disorders

Substance Use Disorders: Treatment for Adults
Benefit-cost methods last updated December 2023.  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 substance use disorder (excluding 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 greater than $500 (in 2012 dollars) represent higher-cost contingency management. Treatment lasted two to three months and reward opportunities occurred two to three times per week.
 
ALL
BENEFIT-COST
META-ANALYSIS
CITATIONS
For an overview of WSIPP's Benefit-Cost Model, please see this guide. The estimates shown are present value, life cycle benefits and costs. All dollars are expressed in the base year chosen for this analysis (2022). 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 $3,797 Benefits minus costs $26,081
Participants $5,424 Benefit to cost ratio $39.74
Others $1,646 Chance the program will produce
Indirect $15,888 benefits greater than the costs 78%
Total benefits $26,754
Net program cost ($673)
Benefits minus cost $26,081

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

^^WSIPP does not include this outcome when conducting benefit-cost analysis for this program.

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. See Estimating Program Effects Using Effect Sizes for additional information.

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^^
Clinical diagnosis of alcohol use disorder or symptoms measured on a validated scale.  
 39 1 19 -0.096 0.310 39 n/a n/a n/a -0.096 0.758
Illicit drug use disorder
Clinical diagnosis of illicit drug use disorder or symptoms measured on a validated scale. When possible, we exclude cannabis/marijuana use disorder from this outcome.
 39 37 1323 -0.519 0.060 39 -0.154 0.238 40 -0.519 0.001
Cannabis use^
Adult use of cannabis that does not rise to the level of “disordered.”
39 1 19 -0.301 0.312 39 n/a n/a n/a -0.301 0.334
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
Affected outcome: Resulting benefits:1 Benefits accrue to:
Taxpayers Participants Others2 Indirect3 Total
Illicit drug use disorder Criminal justice system $2 $0 $4 $1 $7
Labor market earnings associated with illicit drug abuse or dependence $1,612 $3,797 $0 $0 $5,409
Health care associated with illicit drug abuse or dependence $1,598 $247 $1,642 $799 $4,286
Mortality associated with illicit drugs $585 $1,379 $0 $15,424 $17,389
Program cost Adjustment for deadweight cost of program $0 $0 $0 ($337) ($337)
Totals $3,797 $5,424 $1,646 $15,888 $26,754
Click here to see populations selected
Detailed Annual Cost Estimates Per Participant
Annual cost Year dollars Summary
Program costs $548 2012 Present value of net program costs (in 2022 dollars) ($673)
Comparison costs $0 2012 Cost range (+ or -) 20%
Contingency management is typically provided for less than a year. We calculated the weighted average of the variable per-participant treatment and comparison group costs across studies estimating the cost-effectiveness of an incentive program with an average cost of greater than $500 in 2012 (Olmstead & Petry, 2009; Olmstead, Sindelar, & Petry, 2007; Olmstead et al., 2007). Costs of administering the incentive program include staff costs to inventory, shop, 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. Olmstead, T.A., & Petry, N.M. (2009). The cost-effectiveness of prize-based and voucher-based contingency management in a population of cocaine- or opioid-dependent outpatients. Drug and Alcohol Dependence, 102(1), 108-115. Olmstead, T.A., Sindelar, J.L., & Petry, N.M. (2007). Cost-effectiveness of prize-based incentives for stimulant abusers in outpatient psychosocial treatment programs. Drug and Alcohol Dependence, 87(2), 175-182. Olmstead, T.A., Sindelar, J.L., Easton, C.J., & Carroll, K.M. (2007). The cost-effectiveness of four treatments for marijuana dependence. Addiction, 102(9), 1443-1453.
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.
Benefits Minus Costs
Benefits by Perspective
Taxpayer Benefits by Source of Value
Benefits Minus Costs Over Time (Cumulative 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 discounted dollars. 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.

Citations Used in the Meta-Analysis

Alessi, S.M., Hanson, T., Wieners, M., & Petry, N.M. (2007). Low-cost contingency management in community clinics: delivering incentives partially in group therapy. Experimental and Clinical Psychopharmacology, 15(3), 293-300.

Brooner, R.K., Kidorf, M.S., King, V.L., Stoller, K.B., Neufeld, K.J., & Kolodner, K. (2007). Comparing adaptive stepped care and monetary-based voucher interventions for opioid dependence. Drug and Alcohol Dependence, 88, S14-S23.

Carroll, K.M., Ball, S.A., Nich, C., O'Connor, P.G., Eagan, D.A., Frankforter, T.L., Triffleman, E.G., Shi, J., & Rounsaville, B.J. (2001). Targeting behavioral therapies to enhance naltrexone treatment of opioid dependence: efficacy of contingency management and significant other involvement. Archives of General Psychiatry, 58(8), 755-761.

Carroll, K.M., Sinha, R., Nich, C., Babuscio, T., & Rounsaville, B.J. (2002). Contingency management to enhance naltrexone treatment of opioid dependence: a randomized clinical trial of reinforcement magnitude. Experimental and Clinical Psychopharmacology, 10(1), 54-63.

Chutuape, M.A., Silverman, K., & Stitzer, M. (1999). Contingent reinforcement sustains post-detoxification abstinence from multiple drugs: A preliminary study with methadone patients. Drug and Alcohol Dependence, 54(1), 69-81.

Downey, K.K., Helmus, T.C., & Schuster, C.R. (2000). Treatment of heroin-dependent poly-drug abusers with contingency management and buprenorphine maintenance. Experimental and Clinical Psychopharmacology, 8(2), 176-184.

Elk, R., Mangus, L., Rhoades, H., Andres, R., & Grabowski, J. (1998). Cessation of cocaine use during pregnancy: effects of contingency management interventions on maintaining abstinence and complying with prenatal care. Addictive Behaviors, 23(1), 57-64.

Epstein, D.H., Hawkins, W.E., Covi, L., Umbricht, A., & Preston, K.L. (2003). Cognitive-behavioral therapy plus contingency management for cocaine use: Findings during treatment and across 12-month follow-up. Psychology of Addictive Behaviors, 17(1), 73-82.

Epstein, D.H., Schmittner, J., Umbricht, A., Schroeder, J.R., Moolchan, E.T., & Preston, K.L. (2009). Promoting abstinence from cocaine and heroin with a methadone dose increase and a novel contingency. Drug and Alcohol Dependence, 101(1), 92-100.

Garcia-Fernandez, G., Secades-Villa, R., Garcia-Rodriguez, O., Sanchez-Hervas, E., Fernandez-Hermida, J.R., & Higgins, S.T. (2011). Adding voucher-based incentives to community reinforcement approach improves outcomes during treatment for cocaine dependence. The American Journal on Addictions, 20(5), 456-461.

Hall, S.M., Bass, A., Hargreaves, W.A., & Loeb, P. (1979). Contingency management and information feedback in outpatient heroin detoxification. Behavior Therapy, 10(4), 443-451.

Higgins, S.T., Budney, A.J., Bickel, W.K., Foerg, F.E., Donham, R., & Badger, G.J. (1994). Incentives Improve Outcome in Outpatient Behavioral Treatment of Cocaine Dependence. Archives of General Psychiatry 51(7), 568-576.

Higgins, S.T., Wong, C.J., Badger, G.J., Odgen, D.E.H., Dantona, R.L. (2000). Contingent Reinforcement increases cocaine abstinence during outpatient treatment and 1 year of follow-up. Journal of Consulting and Clinical Psychology, 68(1), 64-72.

Jones, H.E., Haug, N., Silverman, K., Stitzer, M., & Svikis, D. (2001). The effectiveness of incentives in enhancing treatment attendance and drug abstinence in methadone-maintained pregnant women. Drug and Alcohol Dependence, 61(3), 297-306.

Kennedy, A.P., Phillips, K.A., Epstein, D.H., Reamer, D.A., Schmittner, J., & Preston, K.L. (2013). A randomized investigation of methadone doses at or over 100mg/day, combined with contingency management. Drug and Alcohol Dependence, 130(1), 77-84.

Kirby, K.C., Marlowe, D.B., Festinger, D.S., Lamb, R.J., & Platt, J.J. (1998). Schedule of voucher delivery influences initiation of cocaine abstinence. Journal of Consulting and Clinical Psychology, 66(5), 761-7.

Kosten, T., Oliveto, A., Feingold, A., Poling, J., Sevarino, K., McCance-Katz, E., Stine, S., ... Gonsai, K. (2003). Desipramine and contingency management for cocaine and opiate dependence in buprenorphine maintained patients. Drug and Alcohol Dependence, 70(3), 315-325.

Oliveto, A., Poling, J., Sevarino, K.A., Gonsai, K.R., McCance-Katz, E.F., Stine, S.M., & Kosten, T.R. (2005). Efficacy of dose and contingency management procedures in LAAM-maintained cocaine-dependent patients. Drug and Alcohol Dependence, 79(2), 157-165.

Petry, N.M. and B. Martin. (2002). 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., & Simcic, F. (2005). 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.

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., Alessi, S.M., Carroll, K.M., Hanson, T., MacKinnon, S., Rounsaville, B., & Sierra, S. (2006). Contingency Management Treatments: Reinforcing Abstinence Versus Adherence with Goal-Related Activities. Journal of Consulting and Clinical Psychology, 74(3), 592-601.

Piotrowski, N.A., Tusel, D.J., Sees, K.L., Reilly, P.M., Banys, P., Meek, P., et al. (1999). Contingency contracting with monetary reinforcers for abstinence from multiple drugs in a methadone program. Experimental and Clinical Psychopharmacology, 7(4), 399-411.

Preston, K.L., Umbricht, A., & Epstein, D.H. (2000). Methadone dose increase and abstinence reinforcement for treatment of continued heroin use during methadone maintenance. Archives of General Psychiatry, 57(4), 395-404.

Rawson, R.A., Huber, A., McCann, M., Shoptaw, S., Farabee, D., Reiber, C., & Ling, W. (2002). A comparison of contingency management and cognitive-behavioral approaches during methadone maintenance treatment for cocaine dependence. Archives of General Psychiatry, 59(9), 817-824.

Shoptaw, S., Reback, C.J., Peck, J.A., Yang, X., Rotheram-Fuller, E., Larkins, S., Veniegas, R.C., ... Hucks-Ortiz, C. (2005). Behavioral treatment approaches for methamphetamine dependence and HIV-related sexual risk behaviors among urban gay and bisexual men. Drug and Alcohol Dependence, 78(2), 125-134.

Shoptaw, S., Huber, A., Peck, J., Yang, X., Liu, J., Jeff, D., Roll, J., ... Ling, W. (2006). Randomized, placebo-controlled trial of sertraline and contingency management for the treatment of methamphetamine dependence. Drug and Alcohol Dependence, 85(1), 12-18.

Silverman, K., Higgins, S.T., Brooner, R.K., Montoya, I.D., Cone, E.J. & Schuster, C.R. (1996). Sustained Cocaine Abstinence in Methadone Maintenance Patients Through Voucher-Based Reinforcement Therapy. Archives of General Psychiatry, 53(5), 409-415.

Silverman, K., Wong, C.J., Umbricht-Schneiter, A., Montoya, I.D., Schuster, C.R. & Preston, K.L. (1998). Broad Beneficial Effects of Cocaine Abstinence Reinforcement Among Methadone Patients. Journal of Consulting and Clinical Psychology, 66(5), 811-824.

Silverman, K., Robles, E., Mudric, T., Bigelow, G.E., & Stitzer, M.L. (2004). A Randomized Trial of Long-Term Reinforcement of Cocaine Abstinence in Methadone-Maintained Patients Who Inject Drugs. Journal of Consulting and Clinical Psychology, 72(5), 839-854.