Version July 2025
INTRODUCTION —
Contingency management (CM) is an outpatient behavioral intervention for substance use disorders where a tangible reinforcer (also known as an incentive or reward) is provided when a patient engages in a specific health-promoting behavior, such as abstinence from substance use [1-4]. Positive reinforcement is a powerful technique for helping people increase health-promoting behavior. This is particularly true in the treatment of substance use disorders; CM is an effective treatment for substance use disorders, including stimulant, alcohol, opioid, cannabis, and nicotine use disorders [5-9]. We typically use CM as part of a comprehensive program (eg, intensive outpatient program) that includes other interventions such as drug counseling, pharmacologic management, and motivational interviewing in group and individual settings. However, CM can also be offered as a stand-alone intervention. (See 'Clinical use' below and 'Efficacy' below.)
This topic reviews the use of CM in the treatment of substance use disorders, including principles of CM, elements of effective CM programs, CM models, clinical use, and challenges to implementing CM.
OVERVIEW AND PRINCIPLES —
Contingency management (CM) is based on the theory of operant conditioning, which is a method of learning that employs rewards for achieving desired behaviors [1]. In CM, positive reinforcement occurs when a desired behavior is achieved (eg, reward or reinforcement given immediately after a negative drug test establishes recent abstinence). CM is best suited to help individuals with active substance use disorder who want to stop, cut back, or take a break from use.
CM is most effective when implemented in a manner consistent with the following principles [10,11]:
Objective assessment of behavior — The behavior of focus is well-defined and objectively verified [12-14].
We typically use CM to reinforce substance abstinence (eg, stimulant drug abstinence), using point-of-care urine drug tests (UDTs) as the objective assessment of behavior. Point-of-care UDTs are widely available for many drugs and alcohol. Point-of-care UDTs provide in-office results, so a gift card or prize can be delivered at the time of the visit. Tests for stimulants and alcohol have a detection period of two to five days. Tests for cannabis may detect use for up to a month; however, it is very difficult to distinguish acute cannabis use from chronic cannabis use. CM procedures for cannabis use reduction are still being actively studied, and no firm methods have been fully established [14,15]. Other potential objective measures of abstinence include breath tests for alcohol and smoking and saliva tests for stimulants and nicotine.
Some behaviors (eg, medication adherence) may be challenging to objectively assess. Others, such as treatment attendance, are less challenging. Options for assessing medication adherence can include directly observing the individual taking medication or other technologically based strategies such as the medication event monitoring system, electronic pill bottle caps, or video observation.
Focus on a single behavior — We focus on a single behavior at a time with CM. For example, we focus on abstinence from a specific substance or substance class rather than multiple substances. While CM interventions that require abstinence from more than one drug class (eg, stimulants, cannabis) may be effective, focusing on one behavior or substance/class (eg, cocaine, stimulants), rather than multiple behaviors, produces stronger outcomes. Addressing one behavior (eg, stimulant use) may lead to secondary reductions in other related behaviors (eg, smoking) [12,16-22].
Reinforcers are contingent on achieving behavior — Reinforcers are only given when the patient objectively engages in the behavior of focus (ie, negative point-of-care UDT leads to reinforcement, whereas a positive test does not). We review this with the patient orally or in writing as per clinician preference. If a patient disputes a positive test, clinicians can reference this agreement. If clinicians are concerned about an inaccurate positive test, they can retest the sample provided. It is key to respect a patient’s concerns about a disputed test and encourage them to stay engaged and tell them that their next test is likely to be negative if the patient continues to be abstinent.
We are also vigilant to remain nonjudgmental and refrain from punitive consequences. Referral to additional supports, discussing problem-solving strategies, and offering encouragement (eg, not to give up) are key elements that are helpful in achieving goals [1,3,4,8].
Reinforcers are given immediately — CM is more effective when a reinforcer (eg, gift card, prize) is given immediately after the objectively assessed behavior is achieved (eg, stimulant-negative UDT) [12]. Immediate reinforcement pairs the pleasurable effects of receiving a gift card or prize with the health-promoting behavior and is associated with increased in-treatment and post-CM abstinence [23-25].
Frequent opportunities for reinforcement — CM is most effective when frequent opportunities for reinforcement are offered. Our preference is to provide at least two opportunities for reinforcement per week when addressing abstinence and at every relevant patient appointment if reinforcing attendance [13].
When using point-of-care tests with a two- to four-day detection window, individuals only have to refrain from use for a few days to receive a reinforcer, which is an achievable goal for most individuals. Further, in a CM program where reinforcers are offered twice weekly, if they do not submit a negative test the first time, they have a chance later the same week to try again. In a typical 12-week CM intervention focused on abstinence, patients have at least 24 opportunities to receive reinforcement.
Properties of reinforcers — Higher reinforcer amounts and longer CM intervention are associated with increased in-treatment and post-CM abstinence [3,4,11,12,23-25]. Evidence-based CM programs use tangible reinforcers with monetary value that are tailored to a specific population (eg, young adults) or community (eg, rural community) and offer enough choice to be desirable to the variety of clients/patients served. Many CM programs offer gift cards to grocery, online, or retail stores. Gift cards that cannot be spent on cigarettes, alcohol, and firearms are often required by state and federally funded CM programs.
●CM dose/magnitude – CM will be most effective if the dose or magnitude of reinforcers is high enough to motivate patients. As of 2024, reinforcers of USD $650 to $1800 total over the course of the treatment (ie, for 100 percent abstinence over a 12-week intervention) appear to be effective [12,26-28].
Most CM programs include features such as an escalation of reinforcers as the individual maintains behavior change (escalation bonus) and a reset of reinforcement to the original level after a behavior is not demonstrated. Many CM studies also allow patients to “recover” their bonus once they re-establish the behavior after a reset [11,12].
●CM duration – CM is effective when offered over a period of at least 12 weeks. Longer CM interventions are associated with increased odds of posttreatment abstinence [23]. This is consistent with research on other addiction treatments that find longer interventions are associated with better long-term outcomes [23,29].
ELEMENTS OF EFFECTIVE CONTINGENCY MANAGEMENT —
Effective contingency management (CM) programs have the following elements:
Adherence to CM principles — CM is most effective when implemented in a way consistent with the principles of CM while balancing practical feasibility. Without planning, ongoing training, and technical support, CM programs are often implemented in a way that is unlikely to lead to outcomes found in research studies [30,31]. (See 'Overview and principles' above.)
Training and education of providers — Education and training of providers and other staff is essential for successful implementation of evidence-based CM.
While all involved staff should be educated about CM concepts and policies (eg, financial considerations, reinforcement for desired behavior), individuals delivering CM (eg, nurses, licensed practitioners, mental health workers, physicians, physician assistants) require formal training. Training includes detailed didactic training in an evidence-based CM protocol, as well as ongoing coaching that addresses practical and clinical challenges that arise when implementing CM. This training and support is difficult to obtain due to a lack of a training workforce. Training might be obtained from those overseeing statewide implementations of CM, those overseeing the Veterans Affairs program, or other CM experts. A one-time training workshop is insufficient. Providers who are implementing CM should receive at least nine months of supervision or coaching from an individual with experience implementing CM [10,32-34]. Further information on CM training and guidance for implementation can be found at the Addiction Technology Transfer Center Network and the California Department of Health Care Services websites.
Education and training can help dispel misconceptions about the program, overcome practical challenges to developing the program, reduce time until adoption of the program, increase the effectiveness of the program (ie, enhanced fidelity to evidence-based principles), and help prevent Medicaid fraud [31,32,35-37]. (See 'Policy and financial barriers' below.)
Few clinicians have experience with evidence-based CM protocols, and misunderstandings about the intervention are not unusual. Furthermore, stigmatizing beliefs may lead to reduced motivation to provide effective treatment [31]. For example, in a survey of 43 substance use treatment providers, 44 percent were concerned that they could not trust their patients, 19 percent believed patients did not deserve reinforcers, and 23 percent believed that patients would object to the idea of using reinforcers in treatment [38]. An attitudinal shift often occurs when providers receive education about the health benefits of CM and observe the positive outcomes their patients experience [39].
Enroll patients with an interest in reducing or stopping use — We enroll individuals who are struggling with a behavior, typically a substance use disorder, such as stimulant or alcohol use disorder, and are interested in reducing or stopping use. If an individual engages in polysubstance use, it is preferable to focus the CM program on one substance class at a time. Other behaviors that are identified and appropriate for treatment include adherence to treatment visits and adherence to medication.
CM protocol development — Several CM protocols have been developed and are available for use. We suggest selecting an existing evidence-based CM protocol when implementing a new CM program. Aligning programs with currently existing guidelines and practices, such as the Veterans Administration program, or programs developed in Medicaid-waivered states such as California may be useful [10,12,31,40].
Providers may also obtain an approval for their program from the Office of Inspector General for their CM intervention. As CM becomes more available, resources to support protocol development will continue to expand. (See 'Policy and financial barriers' below.)
Integration into existing services — Successfully integrating CM into other existing services may improve adherence to the program by making visits more readily available [7,9,16,32,41]. CM programs fit well in settings where patients attend multiple sessions per week (eg, intensive outpatient programs, methadone maintenance, group counseling, medication-management programs). While frequent visits involved in CM might be challenging in primary care settings, with adjustments to workflow and staffing, office-based buprenorphine and other primary care programs can successfully implement CM [32]. When integrating the CM protocol into existing services, care should be taken to balance evidence-based best practices with feasibility. (See 'Overview and principles' above.)
Culturally responsive approach — Adaptations mainly focusing on reinforcers (eg, activities with family, beading kits) and/or setting can be made while maintaining fidelity to the components of CM that are associated with efficacy. CM has been adapted for treatment with several diverse populations including American Indian and Alaska Native communities [9,16,17,42,43].
CONTINGENCY MANAGEMENT MODELS —
Voucher contingency management (CM) and prize-draw CM are the two models that are well-supported by the evidence and can be delivered in outpatient treatment settings [12,28,44-46]. They appear to be equally effective. The voucher-based model allows for easier tracking due to a straightforward reinforcement schedule, while the prize-draw model has been shown to be effective at lower magnitudes. Both have been implemented at scale. Prize-draw CM is being used in the Veterans Administration, while statewide programs in California, Washington, and Montana use the voucher CM.
●Voucher CM – In voucher CM, sometimes referred to as voucher-based reinforcement therapy, individuals earn a set of financial payments (ie, vouchers) contingent on engaging in their behavioral goal (eg, stimulant drug abstinence) [44]. This amount increases the longer the individual is abstinent. For example, a person could earn a USD $10 voucher for their first stimulant-abstinent drug test. They could then receive $12 for their second consecutive stimulant-abstinent test and $14 for their third consecutive stimulant-abstinent test. The voucher can be converted to a gift card or prize of equivalent value, or can be “banked” to save up for something of greater value.
●Prize-draw CM – In prize-draw CM, sometimes referred to as the variable magnitude reinforcement procedure, individuals earn “prize draws” when they engage in their behavioral goal [12]. With each prize draw, an individual can receive an encouraging message or a prize that varies from $1 to $100. The odds of winning a small (eg, $1) prize are higher than winning a large (eg, $100) prize. The number of draws escalates the longer the individual maintains abstinence.
●Other models – Other models to facilitate the delivery of CM have been developed and studied for feasibility and efficacy. While these tools are promising, they must be integrated into clinical workflow (eg, prescribed by a provider, require provider follow-up).
•CM smartphone apps allow for CM to be offered remotely using either a voucher or prize-draw model. App or virtual approaches may be particularly beneficial to patients who cannot attend twice weekly in-person visits, or for practice settings where frequent CM visits are less feasible.
There are also web-based tools that can help providers track CM reinforcement amounts and can electronically dispense gift card reinforcers [35,47,48].
•A therapeutic workplace model has been developed that allows individuals to submit a urine drug test daily, and, if it is negative, they are rewarded with a chance to work for pay that day. While this approach has strong empirical support, it is not widely disseminated because it is designed for a workplace rather than a clinical care setting [49,50].
CLINICAL USE —
We typically use contingency management (CM) as part of a comprehensive program (eg, intensive outpatient program) that includes other interventions, such as drug counseling or motivational interviewing. The efficacy and use of CM in specific conditions are reviewed below and discussed in detail separately.
●Stimulant use disorder – CM appears to be the most effective treatment for stimulant use disorders [5,6,8,51,52]. Further discussion of the treatment of stimulant use disorder is found elsewhere. (See "Stimulant use disorder: Psychosocial management", section on 'Contingency management'.)
●Opioid use disorder – While CM can increase opioid abstinence, it is not recommended as a first-line intervention for opioid use disorder as medications such as methadone and buprenorphine are effective and provide protection against opioid poisoning [53]. (See "Opioid use disorder: Pharmacologic management" and "Opioid use disorder: Psychosocial management", section on 'Contingency management'.)
●Alcohol use disorder – Research evidence supports the use of urine ethyl glucuronide (uEtG) tests as the basis for assessing alcohol abstinence in a CM model [9,14,16,19,21,54,55]. The detection window of uEtG allows for implementation of a CM intervention that is very similar to stimulant CM (ie, CM visits twice weekly for 12 weeks) [56]. (See "Alcohol use disorder: Psychosocial management", section on 'Contingency management'.)
●Cannabis use disorder – CM is effective in the treatment of cannabis use disorder when used as an adjunctive combined with other psychosocial treatments (eg, cognitive-behavioral therapy, motivational enhancement therapy) [14,57-59]. Despite evidence to support CM for cannabis use disorder, limitations of cannabis urine tests make this model challenging to implement. (See "Cannabis use disorder: Clinical features, screening, diagnosis, and treatment", section on 'Augmentation with contingency management'.)
●Nicotine/smoking – A large body of literature supports CM as an intervention for smoking cessation [60-64], with quit rates that are double those of individuals who receive typical smoking cessation interventions [62]. CM can be used in combination with nicotine replacement or other pharmacologic approaches to smoking cessation [65]. The primary challenges to implementing CM for smoking cessation are the brief detection periods of smoking breath tests [66] and urine tests’ inability to distinguish smoking from nicotine replacement therapy [67]. (See "Behavioral approaches to smoking cessation" and "Overview of smoking cessation management in adults".)
●Polysubstance use – CM interventions that address one substance (eg, stimulants) have secondary reductions in co-use of other drugs, alcohol, and cigarette smoking [7,20,68]. For patients who use more than one substance (eg, stimulants and alcohol), it is appropriate to enroll them in a CM program that provides reinforcers for one drug class (eg, stimulants). Research indicates that CM focused on one substance (eg, stimulants) often leads to decreases in co-used drugs (eg, alcohol) [17,18].
For example, we use CM as part of a comprehensive program in the treatment of co-occurring stimulant and opioid use disorder [7,53,69]. The co-use of opioids, including fentanyl, and stimulants is common, deadly, and challenging to treat. Our preference is to reinforce stimulant abstinence using CM while treating with medications for opioid use disorder [7]. While CM can increase opioid abstinence, it is not recommended as a first-line intervention for opioid use disorder, as medications such as methadone and buprenorphine are effective and provide protection against illicit opioid poisoning [53]. (See "Stimulant use disorder: Treatment overview" and "Opioid use disorder: Psychosocial management", section on 'Contingency management'.)
EFFICACY —
Contingency management (CM) is an effective psychosocial treatment for substance use disorder in general and stimulant use disorder in particular [5-8,12,23,26,28,45,51,54,70]. For example, in a meta-analysis of psychosocial treatments for substance use disorders (34 trials, n = 2340), CM was found to have the largest effect size. The effect was nearly twice that of cognitive-behavioral therapy (Cohen d: 0.58 versus 0.28) [8]. Furthermore, in a meta-analysis including 23 trials of CM for substance use disorders, CM, as compared with community-based therapies, led to a greater likelihood of abstinence at one-year follow-up (odds ratio 1.22, 95% CI 1.01-1.44) [23]. Efficacy of CM for specific disorders is discussed above and in detail with topics on the specific disorder. (See 'Clinical use' above and "Alcohol use disorder: Psychosocial management", section on 'Contingency management' and "Cannabis use disorder: Clinical features, screening, diagnosis, and treatment", section on 'Augmentation with contingency management' and "Opioid use disorder: Psychosocial management", section on 'Contingency management'.)
CM interventions that focus on abstinence are also associated with higher levels of treatment retention and lower levels of psychiatric symptomatology [7,18,21,71,72].
Evidence supports the use of CM to increase substance use disorder treatment attendance and medication adherence. However, outside of direct observation of medication taking, objectively verifying medication adherence can be challenging [7,72]. CM interventions that directly reinforce attendance have a moderate effect on attendance if the reinforcement is offered at least once per week [72]. Additionally, CM interventions reinforcing attendance have a small effect on abstinence [72]. Providers must be aware that reinforcing treatment attendance in a manner that could lead to increased clinical revenue could potentially be construed as Medicaid fraud [73,74]. (See 'Policy and financial barriers' below.)
CHALLENGES TO IMPLEMENTING CM —
The primary challenges to widespread contingency management (CM) implementation are practical (eg, limited awareness of the treatment, frequency of visits, establishing objective assessment of the behavior, reinforcers being immediate and tangible) and policy related (eg, federal regulations limiting the use of incentives with many patients) [30,74-77].
Limited awareness of program — CM is not widely offered to individuals outside of the Veterans Affairs health care and state-based pilot programs. As it is relatively unknown among referral sources, we educate referral sources and the community at large about CM and its health-promoting benefits. Just like other new clinical services, visiting referring providers and social service agencies to talk to them about the program or giving brief presentations about CM at a local or state-wide substance use treatment meeting might be effective ways to spread the word about CM [70,74,78,79]. However, blanket advertising that emphasizes the monetary benefits of reinforcers is not recommended because providers are not allowed to induce patients into treatment. (See 'Policy and financial barriers' below.)
Frequency of visits — Frequent visits (eg, at least two times per week depending on behavior being reinforced) can limit enrollment/engagement in CM programs.
In settings where multiple appointments per week are the norm (eg, intensive outpatient treatment, methadone maintenance therapy), this may not be a challenge. However, in settings like office-based buprenorphine or primary care practices, these frequent visits may require adaptations to clinic workflow.
Solutions to alleviate the burden for patients are to schedule visits adjacent to other times the patient will already be coming to the clinic, such as for group or individual counseling, and to offer transportation support such as free bus passes. Solutions for the clinic to accommodate frequent visits are to offer windows for drop-in CM visits [35,47,48].
Objective assessments and immediate reinforcement — Use of point-of-care tests can be an implementation challenge in settings that rely on laboratory testing (eg, hospitals) or have not received a Clinical Laboratory Improvement Amendments (CLIA) waiver to use point-of-care tests. However, point-of-care tests for stimulants, cannabis, nicotine, and alcohol are highly accurate when compared with laboratory-based tests, and CLIA waivers are not difficult to obtain [14,80,81].
Policy and financial barriers — Other major barriers to widespread CM dissemination are policy-related and financial [74].
●Medicaid fraud – CM programs that serve patients enrolled in federally funded health care (eg, Medicaid) must be compliant with the US Department of Health and Human Services Office of Inspector General regulations related to the use of monetary and tangible incentives [73]. These can be found at the Office of Inspector General website.
If CM programs do not comply with these rules, health care providers may be engaging in practices that could be considered Medicaid fraud.
While general guidelines are provided, these are not specific to CM and are open to interpretation. The federal government is in the process of developing guidelines specific for CM.
Absent these specific guidelines, clinicians who would like to implement CM with Medicaid-funded patients should align their programs and practices with current guidelines, use established protocols, or obtain approval for their program from the Office of Inspector General [34,35,73,74,76]. (See 'CM protocol development' above.)
When providing CM to patients with private insurance, clinicians should adhere to all relevant state and federal statutes that apply to providing incentives to patients, including the Eliminating Kickbacks in Recovery Act [82].
●Lack of funding for reinforcers – CM dissemination is hampered by a lack of adequate federal funding. With some notable exceptions, the federal government and other payers do not provide funding for CM reinforcers or reimburse for CM. Thus, most providers must find other funding for CM reinforcers.
Outside of the Veterans Affairs Healthcare System, the federal government and other payers do not cover CM as a paid benefit. Most providers interested in implementing evidence-based CM must rely on their internal, local, state, or other grant funds to pay for CM reinforcers. Four states (Washington, Montana, Delaware, and California) have received approval from the federal government to offer CM as a covered Medicaid benefit. This provides both regulatory approval and funding for CM interventions that include reinforcer amounts that are consistent with research evidence [35,40,83]. Those interested in using these protocols can find more information online (eg, the California Department of Health Care Services website).
●Tax considerations – The Internal Revenue Service (IRS) has not commented on the classification of CM reinforcers for tax purposes. Therefore, patients who receive reinforcers in CM may be required to report the amount in their tax filings. If a patient earns more than USD $599 in cash or cash equivalents (eg, gift cards) in a tax year, providers may be required to submit a 1099-MISC form to the IRS. This presents a potential disincentive to patients and providers.
SUMMARY AND RECOMMENDATIONS
●Contingency management (CM) – CM, also referred to as motivational incentives, is an outpatient behavioral intervention for substance use disorders where a tangible reinforcer (also known as an incentive or reward) is provided when a patient engages in a specific health-promoting behavior (eg, drug, alcohol, or nicotine abstinence). Positive reinforcement is a powerful technique for helping to increase health-promoting behaviors, particularly abstinence from substances. (See 'Introduction' above.)
●Principles – CM is most effective when implemented in a manner consistent with the principles described below (see 'Overview and principles' above):
•Objective assessment of behavior
•Focus on a single behavior
•Tangible reinforcers are contingent on achieving the identified behavior
•Reinforcers are given immediately after the behavior is achieved or documented
•Frequent opportunities for reinforcement
•Reinforcers are tailored to specific populations and are of an adequate length of time
●Elements of effective CM programs – Effective CM programs have the following elements (see 'Elements of effective contingency management' above):
•Adherence to CM principles
•Training and education of providers
•Enroll patients interested in reducing or stopping use
•Use established protocols
•Integration into existing services
•Adapted for treatment with diverse populations
●CM models – Voucher CM and prize-draw CM are the two models that are well supported by the evidence and can be delivered in outpatient treatment settings. Other models, such as smartphone apps, are being developed to increase accessibility of programs. (See 'Contingency management models' above.)
●Clinical use – We use CM as part of a comprehensive treatment program (eg, intensive outpatient program) for individuals with substance use disorders who are interested in reducing or stopping use (or other behaviors). (See 'Clinical use' above.)
●Challenges to implementation – The primary challenges to widespread CM implementation are practical (eg, limited awareness of the treatment, the need for frequent visits, establishing CM protocols) and policy related (eg, federal regulations limiting the use of incentives with many patients). (See 'Challenges to implementing CM' above.)
ACKNOWLEDGMENTS —
The UpToDate editorial staff acknowledges Maxine Stitzer, PhD, Colin Cunningham, PhD, and Mary Sweeney, PhD, who contributed to earlier versions of this topic review.
