Contingency management (CM) is a behavioral therapy that utilizes tangible reinforcements to incentivize targeted behavior changes (McPherson et al., 2018b; Petry, Alessi, Olmstead, Rash, & Zajac, 2017). It is based on the principle of operant conditioning, in which behavior modification is attempted through providing rewards and/or consequences for certain behaviors. CM has a long history of efficacy in substance use disorder (SUD) treatment, specifically for stimulant, opioid, alcohol, and nicotine use disorders. It has also been used in other broader applications such as medication adherence and HIV prevention (McPherson et al., 2018b; Petry et al., 2017; Rash, Stitzer, & Weinstock, 2017). When used in the treatment of SUDs, reinforcements are usually monetary and target drug abstinence as documented through negative urine drug screens (UDS).
Two main reinforcement models are commonly used—prize-based CM and voucher-based CM—with no difference in outcome noted between them (Petry, Alessi, Marx, Austin, & Tardif, 2005; Petry, Alessi, Hanson, & Sierra, 2007; Rash et al., 2017). Voucher-based CM uses a fixed reinforcement amount that is awarded when patients meet the target behavior (e.g., drug abstinence as defined by negative UDS) and is often accompanied by increasing reinforcements with continued abstinence. Vouchers can then be redeemed for goods, services, and gift cards. Prize-based CM, also known as the “fishbowl model,” is a less costly approach wherein patients who achieve the target behavior earn draws from a fishbowl that contains prizes of varied magnitude, usually ranging from $0 to $100, which can then be exchanged for prizes or gift cards.
SUDs pose significant individual and societal challenges, of which amphetamine and cocaine use are most common (De Crescenzo et al., 2018). Given the lack of effective pharmacological treatments available for stimulant use disorders, many studies have focused their efforts on the use of CM in treating SUDs. Unfortunately, as a result of the coronavirus (COVID-19) pandemic, continuing patient engagement in treatment programs such as CM is a significant challenge that could have major consequences on this already vulnerable population.
Current clinical guideline recommendations suggest psychosocial interventions are first-line treatments for cocaine and/or amphetamine use disorder, with pharmacological interventions being largely ineffective in treating stimulant use disorder (De Crescenzo et al., 2018). There is strong evidence demonstrating that CM is an effective intervention for stimulant use disorder, with many clinical trials and several meta-analyses (Carrico et al., 2018; De Crescenzo et al., 2018; McPherson et al., 2018b; Rawson et al., 2006; Shoptaw et al., 2005; Shoptaw, Landovitz, & Reback, 2017; Vocci & Montoya, 2009) demonstrating its efficacy in a diversity of populations.
The individual and societal challenges of SUDs become further exacerbated during a global crisis. People who use substances are a vulnerable and marginalized population, often with unstable or crowded housing, high-risk behaviors, and other health comorbidities (Ahern, Stuber, & Galea, 2007). The COVID-19 pandemic is likely to precipitate an increase in drug relapse, in part exacerbated by cuts to many drug treatment services. Cuts or limitations have already been seen to what are deemed as nonessential services or health care services that cannot maintain physical distancing. These have included group meetings like CM programs, and peer-support programs such as SMART Recovery and Twelve Step programs (Hoffman, 2020). Psychosocial treatments rely heavily on in-person interactions and the reduction in their availability during this pandemic has been especially detrimental for individuals who use stimulants, as the most effective treatment options are psychosocial interventions, rather than pharmacological (De Crescenzo et al., 2018). Consequently, an increase in overdose deaths has already been noted (City of Vancouver, 2020). Utilizing and adapting CM to treat SUDs can help mitigate the negative effects on this already disadvantaged population (Marsden et al., 2020).
Further, individuals who use substances often have additional risk factors—the presence of health comorbidities, weaker immune responses, engagement in high-risk behaviors like sharing drug-using paraphernalia, and decreased access to health care services (Carrico et al., 2020; Farhoudian et al., 2020; Volkow, 2020)—that put them at higher risk of contracting COVID-19 and developing complications. Individuals who use stimulants such as methamphetamines and crack/cocaine may have weaker immune systems due to a long history of substance use, malnutrition, and homelessness (Farhoudian et al., 2020). Additionally, they may have increased inflammation and damage to lung tissue (Restrepo et al., 2007) as well as greater cardiovascular disease risk (Schwartz, Rezkalla, & Kloner, 2010), both of which contribute to higher mortality and COVID-19 complications (Marsden et al., 2020).
This article highlights the importance of adapting and expanding CM in the treatment of SUDs during the COVID-19 pandemic in order to help prevent stimulant use relapse as well as decrease COVID-19 infection spread. We present practical adaptations to CM groups at our concurrent disorders facilities to help treat this vulnerable population. We hope this article will serve as a preliminary guide to help adapt and expand CM programs during this pandemic, and highlight the importance and utility of CM in the treatment of SUDs in the aftermath of the COVID-19 pandemic.
Many CM programs function as part of a group setting and benefit from the interactive and collegial group environment. A group setting helps build support and maintain reasonable program costs. With physical distancing restrictions, CM programs are facing new challenges in how to adapt to provide treatment in a safe way. Many CM programs include group meetings where a prize draw or voucher system involves participants picking vouchers or prizes out of a bowl, as well as redeeming them at voucher stores. Many of these components of CM are challenging to continue during physical distancing and are areas of possible COVID-19 transmission between patients and health care staff.
CM programs often face several challenges with implementation and maintenance, even during pre-COVID times, including cost barriers and initial hesitation by staff due to lack of awareness of such programs. These issues become more amplified during the COVID-19 pandemic, as resources are even more limited and staff may already be overwhelmed with safety concerns and adapting to the many changes occurring in health care. Typically, many of the issues related to staff hesitation can be addressed through local education and awareness. A study by Henggeler et al. (2008) found that when therapists were provided modest training and access to resources, the majority attempted to implement CM with their patients. The same approach used to educate staff locally about the effectiveness of CM prior to the COVID-19 pandemic needs to be reemphasized now, during a time when staff may have concerns with how to continue CM programs safely. Informing and involving staff in decisions related to adapting CM programs during physical distancing is critical in order to continue CM in an effective and safe way throughout this time. Regular updates and communication with staff about adaptations to how programs are run, as well as emphasis on safety measures including proper personal protective equipment (PPE) for staff are essential. As discussed by Farhoudian et al. (2020), health care providers working during a pandemic, including those who work with individuals who use substances, are at high risk of burnout and distress. This emphasizes the importance of increasing available supports for staff and ensuring proper hygiene protocols and PPE are in place during this time.
Furthermore, there may be concerns about using money in a substance use population during a time where mental health, drug relapse, and overdose rates are increasing as a result of the global pandemic (City of Vancouver, 2020; Lima et al., 2020). Most CM programs already address this through the use of vouchers or prizes rather than money. Interestingly, Rothfleisch, Elk, Rhoades, and Schmitz (1999) surveyed how CM program participants used their money and found that it was used for purposes unrelated to substances 98 percent of the time. The majority of CM programs utilize a prize- or voucher-based model, but as suggested by Kellogg, Stitzer, Petry, and Kreek (2007), rather than fully eliminating the use of money as a reinforcement in CM programs, it should be approached cautiously and with clinical sensitivity, depending on patient population and treatment response. This is especially relevant during the COVID-19 pandemic, where flexibility and individualization of CM programs based on the patient scenario is important.
Firstly, an essential component to adapting CM programs for SUDs successfully during the COVID-19 pandemic is increasing communication and support for staff. Clear and regular communication with staff, outlining the changes being implemented to how CM programs are run during COVID-19 in order to increase safety for providers and patients, is essential so staff feel supported and adequately trained. As recommended by Farhoudian et al. (2020), staff working with individuals who use drugs during this time should perform frequent hand hygiene, wear proper PPE, and keep their distance from affected individuals.
Additionally, clear communication with patients about changes being made to CM programs is important so patients understand the reasoning behind these adaptations to support physical distancing. Flexibility in CM programs during the pandemic is important, but clinicians should also be cautious not to just give out vouchers without some consistency. Participants should be clearly informed that this is an extraordinary time that has resulted in some temporary adjustments to program protocols and expectations as a result of necessary infection-control protocols, but that as the pandemic improves, CM programs will continue to adapt with a hope to return to previous practices.
Secondly, CM programs would benefit from increased protocol flexibility during this pandemic. The ability to run group programs such as CM will vary based on location and how affected a particular region is by COVID-19. However, some physical distancing restrictions are likely to be in place for longer periods even after the peak of COVID-19 has passed in order to prevent a resurgence in cases (Prem et al., 2020). A phased approach to CM program adaptation is useful as the COVID-19 pandemic continues to evolve. These suggestions may be adapted to both outpatient and inpatient CM programs depending on the phase of COVID-19 planning hospitals and clinics are in.
Unlike other support group meetings that primarily rely on verbal communication, CM often includes additional components of direct physical exchange, including drawing vouchers from a shared bowl, redeeming vouchers, group reward activities, and UDS. These introduce possible infection transmission points for patients and staff, which should be eliminated or minimized during COVID-19. In our inpatient CM program, participant fishbowl draws have been eliminated in order to decrease infection risk; instead, only one staff member draws from the bowl for each patient and reads out the prize to the group. Patients must sanitize their hands before and after receiving prizes or vouchers. Additionally, group sizes have been cut in half and session times decreased from one hour to thirty minutes in duration. This allows for increased physical distancing while still maintaining the benefits of CM. Further, voucher stores that are often used in CM programs for participants to redeem their vouchers for prizes (e.g., food and store gift cards) create an issue with physical distancing due to crowding and line-ups. One alternative to this is temporarily eliminating voucher stores and replacing them with delivery of prizes to the patients’ hospital units. In our CM program, after patients win their vouchers they fill out an order form for the item they would like delivered from the store to their hospital unit. This helps minimize physical interaction between patients as well as staff. Additionally, we have implemented creative approaches such as utilizing independent studies like cognitive behavioral therapy (CBT) worksheets in exchange for vouchers, which can be used as substitution for in-person meetings, if appropriate.
Thirdly, telemedicine and virtual approaches for CM should be considered. Various technological interventions have been used to help support medication adherence in patients with mental health and SUDs (Steinkamp et al., 2019). Internet- or phone-based CM has also shown benefits in treatment of other SUDs such as nicotine and alcohol use (Dallery, Raiff, & Grabinski, 2013; Dallery et al., 2017; Dallery, Raiff, Grabinski, & Marsch, 2019; Getty, Morande, Lynskey, Weaver, & Metrebian, 2019). Importantly, telemedicine has already successfully been adapted during the pandemic in many other areas of medicine, including teletherapy for mental health services, which has allowed for expanded access and improved attendance (Sequeira et al., 2020). We suggest that CM for SUDs would similarly benefit from virtual adaptations to preserve this important intervention with a harm-reduction approach during the pandemic.
A possible challenge with virtual CM options in SUD treatment is that many CM programs (Roll et al., 2006) use an abstinence-based delivery model where a negative UDS is used as the target behavior, which is challenging to implement virtually. Petry, Alessi, Rash, Barry, and Carroll (2018) found that another model—attendance-based CM—also improved patient engagement in treatment and decreased stimulant drug use, especially when applied over longer periods of time and in later phases of outpatient care. Although in comparison, they found that abstinence-based CM resulted in larger and more consistent effects. However, during the COVID-19 pandemic, consideration should be given to temporarily adjusting the delivery model to a virtual, attendance-based approach in order to balance drug relapse prevention with physical distancing safety precautions. This could be supplemented by providing UDS at a lab while attending CM sessions virtually to maintain physical distancing. Additionally, immediate prize delivery has been shown to be important in CM success (Lussier, Heil, Mongeon, Badger, & Higgins, 2006). To facilitate this, patients can receive prize incentives through text message reinforcements as well as prepaid debit cards, which can be electronically loaded upon completion of the target behavior (Getty et al., 2019).
In addition to its effectiveness in SUD treatment, CM has also been found to have ancillary effects: increasing medication adherence in a variety of medical disorders like schizophrenia, SUDs, HIV, hepatitis, and hypertension as well as adherence to health-promoting activities like exercise (Rash et al., 2017). Further, reduction in methamphetamine use due to CM programs resulted in a decrease in high-risk behaviors such unprotected sexual behavior in HIV-positive and -negative individuals (Landovitz, Fletcher, Shoptaw, & Reback, 2015; Shoptaw et al., 2017). Given the broad applicability of CM, we suggest expanding the use of CM during the COVID-19 pandemic in hospitals or clinics that already have running CM programs. This can be done in two major ways.
First, due to the COVID-19 pandemic we suggest a role for CM to incentivize hand hygiene and infection-control protocols in order to decrease the spread of the virus. In February 2020, it was reported that at least fifty inpatients and thirty staff became infected with COVID-19 at a psychiatric hospital in Wuhan, China (Xiang et al., 2020). The cause of the inpatient outbreak is multifactorial, and likely the information available about viral transmission, social distancing, and awareness of the importance of PPE were just emerging. Further, unlike other hospital populations, group therapy and socialization are more common in psychiatric units and may have contributed to patient infection (Xiang et al., 2020). Many patients on psychiatric units are concurrently being treated for SUDs, as there is often comorbidity between mental illness and SUDs (Sheidow, McCart, Zajac, & Davis, 2012; Toftdahl, Nordentoft, & Hjorthøj, 2016). This highlights the increasing need for education and encouragement around hand hygiene in this population during the COVID-19 pandemic. Additionally, the use of CM in SUD patients to help decrease the spread of COVID-19 is particularly important as this population is at increased risk of contracting COVID-19 and developing complications given their immune and cardiovascular risk factors, as previously discussed (Farhoudian et al., 2020; Marsden et al., 2020).
Second, we suggest a role for CM in money management during COVID-19. Finances are a known risk factor for substance use relapse (Levy, 2008). It has been observed that “payday” for individuals with SUDs often results in a surge of purchasing drugs. During the COVID-19 pandemic, many individuals are losing their jobs and experiencing financial struggles, which has led to an increase in government support funding, especially for low-income individuals (Government of British Columbia, 2021; Government of Canada, 2020). As a result, many of our patients are now receiving a temporary monthly subsidy from the government. Although helpful to ease financial stressors during this time, this large sum of money is a known risk factor for substance relapse as well as AWOLs from hospitals in individuals with SUDs (Levy, 2008). To help mitigate the increasing rates of drug relapse during the COVID-19 pandemic, expanding CM to money management during a time of new government subsidies could help manage this known risk factor. At our inpatient program, patients develop an individual plan prior to receiving the subsidy, including specific goals for the money. Patients then receive vouchers if they adhere to their financial plans and show receipts of their intended purchases or goals. Following this intervention, we have noted a reduction in AWOLs and relapses, although other factors may also be contributing to this outcome.
With the ongoing COVID-19 pandemic, there has been concern for an impending mental health and substance use crisis (Balanzá-Martinez, Atienza-Carbonell, Kapczinski, & De Boni, 2020; Bao, Sun, Meng, Shi, & Lu, 2020; Chatterjee, Barikar, & Mukherjee, 2020; Farhoudian et al., 2020; Lima et al., 2020; Yao, Chen, & Xu, 2020). Social isolation, economic depression, fear and panic, and the physical and emotional consequences of individuals and their families who have gotten sick or passed away from COVID-19 are likely to create increased psychological distress. As a result, this can lead to the emergence and exacerbation of mental illness and substance use, resulting in relapse into previous substance use or commencing new substance use as a means of coping with these added stressors (Farhoudian et al., 2020; Farhoudian, Hajebi, Bahramnejad, & Katz, 2013; Sun et al., 2020).
This further supports the role of CM as an increasingly important treatment tool in managing SUDs in the future. CM is a versatile and cost-effective intervention that can lead to benefits in many areas of patient health, including reducing stimulant use and relapse risk as well as additional health-promoting behaviors (Landovitz et al., 2015; McPherson et al., 2018a; Rash et al., 2017). Such benefits would likely lead to fewer hospital presentations and admissions for stimulant use disorder and stimulant-induced psychosis, resulting in both individual and societal benefits. Despite the evidence supporting CM, there remains significant disparity in the availability of CM programs for stimulant use across the world due to funding barriers and lack of knowledge on its efficacy by policymakers. With an expected worsening in the mental health and substance use crisis (Lima et al., 2020; Volkow, 2020) as a result of the COVID-19 pandemic, it underlines the need for increased awareness of addiction treatment resources such as CM to help this vulnerable population. It will also be important to maintain engagement of this already marginalized and hard-to-reach patient population during this time, as we may face ongoing barriers with engagement of patients in health care services due to patients’ fears and anxieties about COVID-19 infection.
Individuals with SUDs are a vulnerable and marginalized population, often facing additional challenges such as mental and physical comorbidities, weakened immune responses, high-risk behaviors, and barriers in accessing health care services (Farhoudian et al., 2020). They are often a difficult population to engage in treatment, which has intensified during the COVID-19 pandemic, where new barriers have emerged as a result of physical distancing, affecting already strained and limited addiction treatment services. In particular, the COVID-19 restrictions on health care resources significantly affect patients with SUD, for whom the most effective treatment options are usually psychosocial interventions, including CM programs, which typically rely on group and in-person interactions.
Consequently, during the COVID-19 pandemic they are at increased risk of negative outcomes like exacerbation or relapse in substance use as well as increased risk of contracting COVID-19 (Farhoudian et al., 2020).
As a result, our goal with this article is to highlight some strategies that can be used to adapt CM programs during the COVID-19 pandemic to balance continued support of SUD treatment while taking the appropriate safety precautions. Some suggested adaptations include increased communication with staff and patients, flexibility in the timing and size of groups to promote physical distancing, adjustments to the delivery model, and consideration of virtual CM options. We also highlight the importance of expanding the use of CM as an effective strategy for management of other drug relapse risk factors during this pandemic, such as for money management of new government subsidies and to help mitigate infection spread by incentivizing hand hygiene.
We hope this article will provide some practical strategies to help adapt and expand CM in SUD treatment during and after this pandemic in order to minimize the spread of COVID-19 and support stimulant abstinence during this increasingly challenging time.
Editor’s Note: This article was adapted from an article by the same authors previously published in the Journal of Substance Abuse Treatment (JSAT). This article has been adapted as part of Counselor’s memorandum of agreement with JSAT. The following citation provides the original source of the article:
Zastepa, E., Sun, J. C., Clune, J., & Mathew, N. (2020). Adaptation of contingency management for stimulant use disorder during the COVID-19 pandemic. Journal of Substance Abuse Treatment, 118, 10802.
Evelyn Zastepa, MD, PhD, is a second-year psychiatry resident at the University of British Columbia. Prior to obtaining her medical degree at the University of British Columbia, she completed a PhD in neuroscience at McGill University as well as a bachelor of science in human biology and anthropology at the University of Toronto.
Jennifer Clune, MD, is a third-year psychiatry resident at the University of British Columbia. Prior to completing her medical degree at the University of British Columbia, she completed a bachelor of science in kinesiology, and a certificate in health and fitness and a certificate in innovative leadership at Simon Fraser University. Dr. Clune is currently the chief psychiatry resident at Royal Columbian Hospital.
Jane C. Sun, PhD, trained at the University of California, Los Angeles, as a clinical psychologist. She is currently a director with British Columbia Mental Health and Substance Use Services, and conducts therapy and assessments in private practice.
Nickie Mathew, MD, ABPN, FRCPC, ABPM, completed an addiction psychiatry fellowship at Yale University and a forensic psychiatry fellowship at the University of British Columbia. He is a clinical associate professor at the University of British Columbia. Dr. Mathew is currently serving as the medical director of complex mental health and substance use services at the Provincial Health Services Authority.