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Contingency Management in Drug Dependence. Fig. 1.

Percent of patients retained for the recommended 24 weeks of treatment (top panel) and percent of patients achieving two or months of continuous cocaine abstinence during treatment (bottom panel). * indicates a significant difference between conditions (p < 0.05). (Adapted from Higgins et al. 1993.)

CM has been used with subpopulation, special subpopulation such as pregnant cigarette smokers (Heil et al. 2008). Eighty-two women who were still smoking upon entering prenatal care were randomly assigned to a condition where they received vouchers contingent on abstinence from recent smoking through 12 weeks following delivery of the baby or to a control condition where they received vouchers independent of smoking status (even if they kept smoking). Significantly more women in the condition where vouchers were earned contingent on recent smoking abstinence successfully abstained from smoking during pregnancy (41% vs. 10%; Fig. 2).

Contingency Management in Drug Dependence. Fig. 2.

Point-prevalence smoking abstinence at the end of pregnancy. * indicates a significant difference between conditions (p < 0.05). (Adapted from Heil et al. 2008.)

Additionally, fetal growth was significantly greater in the condition where vouchers were earned contingent on smoking abstinence compared to the control condition (Fig. 3). Those outcomes were achieved with average payouts of $461 ± 461 in vouchers across, approximately 9 months of treatment.

CM has been successful in other applications with pregnant women. For example, it has been used effectively to increase abstinence from cocaine and heroin use among pregnant women (Silverman et al. 2002). CM is also effective at improving the likelihood of taking medication among those with infectious diseases. Improving compliance with antiretroviral medications for HIV/ AIDS patients with SUDs is one example in that area (Rounsaville et al. 2008). Another special population with whom there is growing evidence of CM's efficacy is the seriously mentally ill who also have SUDs (Sigmon and Higgins 2006). CM is effective at reducing substance use in that population and reducing other complicating factors such as re-hospitalization rates that often go along with drug abuse among the mentally ill. CM is effective with adolescents with SUDs, with the evidence mostly centering on cigarette smoking and marijuana use. Finally, CM is an essential component in multi-element treatments for homeless crack and other drug abusers (Milby and Schumacher 2008).


CM treatments represent an important part of evidence-based interventions for SUDs. They are effective and sufficiently versatile to be used in different settings and with different population in need of treatment for SUDs.

Contingency Management in Drug Dependence. Fig. 3. Mean (±SEM) rates of growth in estimated fetal weight (top panel), fetal femur length (bottom left panel), and fetal abdominal circumference (bottom right panel) between ultrasound assessments conducted during the third trimester. * Indicates a significant difference between conditions (p<0.05). (Adapted from Heil et al. 2008.)

While very effective, they do not represent a silver bullet. For example, improvements are needed to help the interventions succeed with a larger proportion of the patients treated, to develop methods that will ensure longer-term maintenance of beneficial effects over time, and to continue to develop and refine practical applications that will be used widely in society. The broad success to date should give great confidence in the continuing development and improvement of this approach to help address the adverse individual and societal consequences of SUDs. Moreover, CM interventions are being successfully extended to a wider range of public health problems, including, for example, increasing physical activity levels among the elderly and increasing weight reduction among obese adults. Taken together, CM interventions offer much promise for making important improvements in the public health.


Preparation of this chapter was supported by research grants DA009378 and DA008076 from the National Institute on Drug Abuse.


Alcohol Abuse and Dependence

► Behavioral Economics

Cocaine Dependence

Nicotine Dependence and Its Treatment

► Opioid Dependence and Its Treatment

► Reinforcement Disorders

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