A plethora of data has demonstrated the efficacy of contingency management. Technology creates the potential to overcome many of the remaining obstacles to more widespread adoption among addiction treatment providers, David Gastfriend, MD, DFASAM, co-founder and chief medical officer for DynamiCare Health, told NCAD attendees on Sunday.
Gastfriend said addiction treatment providers “would be the envy of modern medicine if we incorporated this into routine care.”
“The reason for this is when you talk about chronic diseases like cancer, liver disease or heart disease, we look at 5-year survival rates or outcomes,” he said. “When you look at long-term, integrated evidence-based practices plus contingency management, we have 5-year physician recovery rates; 80% of doctors complete treatment using contingency management and are able to resume practice in full recovery.”
Gastfriend shared studies showing dramatic improvement in outcomes for individuals engaging in contingency management reward programs that augment traditional therapy modalities for substance use disorder. The incentive-based programs have been shown to increase negative drug tests among dual-diagnosis patients, increase abstinence among homeless and criminal justice-involved individuals, and increase the number of negative samples in opioid screenings for pregnant women, he said
Contingency management programs should break down the recovery process into a series of concrete and attainable goals, Gastfriend said. Programs should also subtly and subconsciously establish priorities for recovery by rewarding critical recovery behaviors and prioritizing behaviors through reward intensity.
Patient goals should be frequent (more than once a week), attainable, objective (attend therapy or support group, complete a screening, have a negative screening, etc.), and designed to prevent gaming of the system.
Rewards should be immediate (research shows immediate rewards are twice as effective as those that are delayed), tangible (and matched to patient needs), intermittent, and of value to patients, Gastfriend said.
Obstacles and the potential of tech
Several factors have prevented contingency management from being more common. Most drug testing, for example, is non-observed and non-random. Contingency management can also be labor-intensive for staff, especially those who do not have personal lived experience are thus less familiar with such programs. In recent months, COVID-19 has created a loss of contact between patients and providers and increased the need for premature take-homes for treatment medications and elongated refills.
Gastfriend explained several of the ways technology can address these challenges. Bluetooth-enabled breathalyzers, phone-connected “smokelyzers,” debit card financial management and smart card recovery protections are among the forms of tech that can augment in-person contingency management-related activities. Patients can also use smartphones to record themselves taking prescriptions or oral fluid drug screenings, and receive appointment reminders, surveys and cognitive behavioral therapy.
As an example, the implementation of technology allows for screenings to be conducted at random times on demand, Gastfriend said. Patients who test negative can then have funds electronically transferred to a debit card from a reserve account as a contingency management reward. Further, smart debit cards can be set up with features that limit access to cash at ATMs, prevent spending at bars, liquor stores and casinos, set curfews on spending, and provide additional behavioral data.
“We can use that data to get a very sophisticated prediction of when somebody is at risk,” Gastfriend said.