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Contingency management (lower cost) for substance use disorders

Substance Use Disorders: Treatment for Adults
Benefit-cost methods last updated December 2024.  Literature review updated May 2014.
This program was archived December 2024.
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.
 
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 2023 Technical Documentation.
Benefit-Cost Summary Statistics Per Participant
Benefits to:
Taxpayers $588 Benefits minus costs $3,147
Participants $853 Benefit to cost ratio $11.67
Others $250 Chance the program will produce
Indirect $1,751 benefits greater than the costs 59%
Total benefits $3,442
Net program cost ($295)
Benefits minus cost $3,147

^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 to estimate its effect on an outcome. WSIPP systematically evaluates all credible evaluations we can locate on each topic. The outcomes measured are the program impacts measured in the research literature (for example, impacts on 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 on how we estimate effect sizes.

The effect size may be adjusted from the unadjusted effect size estimated in the meta-analysis. Historically, WSIPP adjusted effect sizes to some programs based on the methodological characteristics of the study. For programs reviewed in 2024 or later, we do not make additional adjustments, and we use the unadjusted effect size whenever we run a benefit-cost analysis.

Research shows the magnitude of effects may change 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. More details about these adjustments can be found in our 2023 Technical Documentation.

Meta-Analysis of Program Effects
Outcomes measured Treatment age No. of effect sizes Treatment N 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.  
 37 7 800 -0.196 0.116 37 0.000 0.075 38 -0.290 0.092
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.
 37 29 1595 -0.278 0.049 37 0.000 0.075 38 -0.278 0.001
Cannabis use^
Adult use of cannabis that does not rise to the level of “disordered.”
37 3 319 -0.049 0.118 37 n/a n/a n/a -0.049 0.676
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
Alcohol use disorder Property loss associated with alcohol abuse or dependence $0 $0 $1 $0 $1
Illicit drug use disorder Criminal justice system $0 $0 $1 $0 $1
Labor market earnings associated with illicit drug abuse or dependence $255 $601 $0 $0 $856
Health care associated with illicit drug abuse or dependence $242 $37 $248 $121 $648
Mortality associated with illicit drugs $91 $214 $0 $1,778 $2,083
Program cost Adjustment for deadweight cost of program $0 $0 $0 ($147) ($147)
Totals $588 $853 $250 $1,751 $3,442
Click here to see populations selected
Detailed Annual Cost Estimates Per Participant
Annual cost Year dollars Summary
Program costs $240 2012 Present value of net program costs (in 2022 dollars) ($295)
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 2023 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

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.