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In today's episode, Dr. DePhilippis tells us all about Contingency Management: what it is, how it works, and its evidence for the treatment of stimulant use disorders.
Publication Date: 06/03/2024
Duration: 43 minutes, 28 seconds
Transcript:
Dr. Capurso: Welcome to The Carlat Psychiatry Podcast. I’m Dr. Noah Capurso, The Editor-in-Chief of The Carlat Addiction Treatment Report and an associate Professor of Psychiatry at the Yale University School of Medicine. In this episode, we’ll learn about an effective and underutilized treatment for stimulant use disorders: Contingency Management, commonly referred to as CM. We will be joined by Dr. Dominick DePhilippis, a national CM expert, who will discuss the theoretical underpinnings of this behavioral-based treatment, share his insights into how best to implement CM principles into clinical practice and describe the evidence behind its use. Dr. DePhilippis, can you please introduce yourself and share some information about your background before we proceed?
Dr. DePhilippis: I’m Dominick DePhilippis. I am a clinical psychologist by training, licensed in the State of Pennsylvania. I currently serve as VA’s Deputy National Mental Health Director for Substance Use Disorders in the Office of Mental Health and Suicide Prevention in the Veterans Health Administration.
Dr. Capurso: Can we start by just having you define what is contingency management, how does it work?
Dr. DePhilippis: I certainly want to start by thanking you for this opportunity. It’s so important that we in the substance use disorder treatment community get the word out about this highly effective treatment that’s so greatly needed. And it’s needed because it’s the most effective treatment for stimulant use disorder. And stimulant use disorder is one of the primary drivers of our current crisis of fatal overdoses, as a matter of fact, of both veterans and nonveterans alike. And contingency management is a highly effective treatment that is not as available as it should be in the community. It’s available in VA. It’s one of the efforts in the VA that we’re very, very proud of, and I’m delighted to have this opportunity. So what is contingency management? Contingency management is an evidence-based treatment for substance use disorder that has particular effectiveness in the treatment of stimulant use disorder. So this would be disorders like cocaine use disorder or amphetamine use disorder, methamphetamine use disorder – again which are primary drivers of the crisis of fatal overdose in the United States. Now contingency management is based on fundamental learning principles. In fact, I like to say to folks that everything you need to know about the rationale for contingency management you probably already learned in a psychology 101 textbook. That is it’s based on fundamental learning principles that were elucidated by historic figures in behavioral like B.F. Skinner. It basically is the therapeutic procedural application of operant conditioning. Well, what does that mean? What it means is that we use a combination of positive reinforcement rewarding the recovery behaviors. We also use other ingredients in operant conditioning. We use extinction. Now if you recall extinction is when nothing follows a behavior so when the patient does not engage in a recovery behavior, for example, abstinence from stimulants, they receive no incentive. In addition, we also have a mild consequence or punisher in contingency management – that is when the patient does not abstain from stimulants verified by a drug test with immediate results – the patient not only receives no incentive that day, no positive reinforcement, that’s the extinction, but they also have their reinforcement reset to the starting amount. When they are consistently abstinent, consecutive negative samples, their reinforcement increases so that we are simultaneously rewarding that episode of abstinence – the past 2 to 3 days which is what a urine drug test reveals, the past 2 to 3 days of abstinence given the detection window, but consecutive samples reinforces enduring abstinence. So when we reset the reinforcement, that’s a penalty if you will; it’s a mild punisher, and by introducing that third contingency of the punisher we actually allow for a fourth contingency, a fourth active ingredient to be introduced: negative reinforcement. So I want you to think of positive and negative reinforcement not as good and bad, but think of them arithmetically: positive reinforcement is reinforcement by addition: I’m providing the patient with an incentive following their abstinence. Negative reinforcement is the patient avoids an unpleasant consequent – the reset – by maintaining the abstinence. So those four active ingredients are simultaneously working on supporting the recovery behavior – abstinence, and eliminating the unhealthy behavior – stimulant or substance consumption.
Dr. Capurso: So we have these behaviors and we’re reinforcing them either negative or positively through the use of incentives, can you talk about what those incentives are?
Dr. DePhilippis: Sure. The incentives should be broadly appealing to the patients that you are offering contingency management to because they have to compete against the inherent reinforcement associated with substance consumption. In fact, it’s important to really consider the daunting challenge a patient with a substance use disorder faces. On the one hand, you have the substance which is very seductive. It says, “I can make you feel good right now. I can take away some of these bad feelings right now. Oh, by the way down the road you’re more likely to die. You’re more likely to see your relationships suffer, your finances suffer, but right now in the immediate you’re gonna feel good.” And then you have recovery almost like the angel on the other shoulder saying, “Oh hang in there. If you just maintain your recovery, things will eventually get better. Oh by the way, in the immediate consequences of your decision to pursue recovery, you’re likely to not feel so good. You’re gonna experience withdrawal. You’re gonna have a more lucid, clear-eyed view of the devastation in your life brought on by substance use disorder.” So CM looks at the landscape and says gosh, that’s what we’re competing against so what we need to do is make recovery immediately reinforcing to be able to compete with the potent reinforcement of substances we want a broadly-appealing set of reinforcers so that we’re not just having those reinforcers appealing to one segment of the population, but be broadly appealing. Now in VA we are very fortunate in that we have a reinforcement system that is broadly appealing to veterans and it’s the use of the Veteran’s Canteen Service Coupon System. Now it’s important to remember that when I say coupons I’m not talking about the traditional coupons you might cut from a Sunday newspaper to get a discount on a product at the grocery store. These coupons are legal tender so they are like cash and can be used to purchase food, coffee and other merchandise at VCS operations throughout the enterprise. So VCS operates our cafeterias. VCS operates our coffee shops and VCS operates the retail stores known as canteens. And these retail stores are terrific for CM implementation because they offer a wide array of different merchandise from as simple a piece of merchandise as a candy bar to as expensive item as a laptop computer or flat screen TV. So the patients have at their disposal an opportunity to spend their earned coupons from their recovery behaviors immediately or save up for a larger ticket item.
Dr. Capurso: Let’s talk a little bit about the mechanics. There are different ways of doing it, of course. There’s frequency; there’s graded versus steady reward; there are all sorts of variables, can you talk about what those variables are, how you manipulate them and how do you optimize a program?
Dr. DePhilippis: Yeah, absolutely, great question. The first order of business when you’re talking about CM is to decide on what behavior it is we want to reinforce; what behavior we are gonna seek to strengthen with the CM reinforcement system. Now fortunately in the treatment of substance use disorders we have a behavior that for the most part is quintessentially associated with recovery from substance use disorder that is abstinence from substances. Now you might be saying, “Now hold on a second Dom., what about harm reduction? What about patients who don’t embrace an abstinence model?” Well the beauty of CM is that it does not compel a patient to embrace an abstinence goal. Instead what it says is, “If you are to dip your toe in the water, as it were, of abstinence; if you were to try abstinence for even a brief period of time, CM is there to provide reinforcement which could tip the motivational balance so that the patient realizes not only can I do this, it’s immediately worth doing. So once we’ve identified what target behavior we’re seeking to reinforce, typically that's going to be abstinence from stimulants because the treatment of substance use disorders is where the largest body of evidence supporting CMF effectiveness resides, we have to be able to tell if the patient was abstinent or not abstinent. So we have to introduce a monitoring system that can reliably and validly tell us that the patient has or has not met the contingency: abstinence from stimulants. Fortunately, again, in the treatment of substance use disorder we have such a system: urine drug testing with immediately-available results. And I can’t overstate the importance of immediately-available results because learning is best when consequences are immediate. Don’t take my word for it. Think back that that devil on the shoulder, angel on the shoulder scenario, consequences that are immediate are very, very appealing, very attractive to all of us and are very influential on our behavior. Take, for example, apart from what we’re discussing, anyone who has struggled with smoking cessation. You’d be hard-pressed to find the patient who is struggling with smoking cessation who isn’t able to tell you in detail what the negative consequences of smoking are: lung cancer, emphysema, chronic obstructive pulmonary disease and on and on, yet they struggle to stop smoking. Why, because the immediate consequences of the smoking are so potent. So we need to compete with the immediacy available from substance consumption. And the way we do that is by verifying abstinence as immediately as possible with rapidly-available drug tests and providing that reinforcement immediately. And the immediacy issue also is important because of the power or potency of the reinforcement that we’re competing against. There was a study out of Italy: Di Chiara and colleagues, if memory serves, that looked at the relative reinforcing power of different activities, and methamphetamine was orders of magnitude greater than just about any other behavior that a human can engage in. Well, you might say, “Well how can we compete against that? I can’t imagine if we had to compete on a pound for pound level as it were, how we could displace methamphetamine.” But the beauty of CM and the beauty of operant conditioning is that with immediacy we get a force multiplier. Modest magnitudes of reinforcement delivered immediately can displace high-powered, high-magnitude reinforcement. And the evidence for CM has made that case for decades on end. So we have our behavior, we have our means of monitoring it, now we apply the operant conditioning principles. If the patient is abstinent, i.e., they test negative for stimulants, they receive an incentive immediately and that incentive increases in magnitude with consequent performance of the behavior. Why is that so important? It’s so important because we know from the studies of CM that escalating reinforcement is associated with consistent performance of a behavior. So when you escalate the reinforcement you are more likely to get consistent abstinence verified by consecutive negative samples. Why is that so important? Well I would draw anyone’s attention to the work of Dr. Nora Volkow at the National Institute on Drug Abuse. What Dr. Volkow has shown with her studies looking at PET scans (positron emission tomography scans) of patients with stimulant use disorder is that with chronic exposure to stimulants you get this function in the dopaminergic areas of the brain, however with consistent abstinence those dysfunctional dopaminergic areas can recover function. Well what does that mean phenomenologically – experientially? It means that a patient for whom recovery behaviors initially may not be experiences that are terribly reinforcing, when the dopamine system is then functional again those behaviors: spending time with loved ones, working, enjoying a good meal become sufficiently reinforcing to sustain the abstinence. So that's the power of the positive reinforcement. Then we have the extinction, the punishment and the negative reinforcement as part of the active ingredient package in contingency management.
Dr. Capurso: First of all, thank you for that really clear explanation. You know I’m sure you’ve heard this. There’s this kind of knee-jerk reaction that people sometimes have when you describe contingency management and of course that knee-jerk reaction is this kind of moralistic response, right. “Why are we paying someone to do something that they should be doing anyway?” How do you explain that?
Dr. DePhilippis: I think it’s important to presume good faith on the part of anyone with a critique of contingency management that there’s a reasonable concern that could we be potentially be doing harm instead of good? A reasonable question to ask, “Gosh, is it a good idea to do this?” Well let’s take that concern about paying someone. I actually don’t think it’s a proper application of the word “pay” to equate it to what happens in contingency management. When I pay someone I am compensating that individual for performing a task that serves my best interest as the payor. I pay a plumber to unclog my drain. I pay an auto mechanic to fix my car In contingency management, we’re providing reinforcement to strengthen a behavior that's in the patient’s best interest. So even referring to it as “pay” is really not an accurate description. Furthermore, we know that managed contingencies: positive and negative reinforcement, extinction, and punishment are how we learn. In fact, that’s a large part of how the substance use disorder behaviors developed in the person. Why not leverage the same potent contingencies in the interest of therapeutics?
Dr. Capurso: You’ve alluded to the fact at the beginning of our discussion that contingency management is the treatment with the most evidence for stimulant use disorders in particular. Can you just describe what that evidence base is?
Dr. DePhilippis: Sure, absolutely. The strongest evidence supporting the application of contingency management to stimulant use disorder comes from studies known as meta-analyses. And what meta-analyses are is they are sophisticated means of assessing the effect of an intervention across multiple studies of that intervention. And because you’re not relying on a single study, you’re actually relying on a group of studies of a single phenomenon those analyses are very, very reliable in terms of their findings. And repeated meta-analyses of contingency management in the treatment of stimulant use disorder have revealed that it is the most effective treatment of stimulant use disorder. In addition, that evidence base in the literature is so compelling that both the VA Dept. of Defense Clinical Practice Guideline for the Management of Substance use disorder, which is a guideline established by a group of joint subject matter experts from the Dept. of Defense and VA in substance use disorder who scanned the empirical literature and developed treatment recommendations in the guideline. That guideline identifies CM as most effective. And most recently, the American Academy of Addiction Psychiatry and the American Society of Addiction Medicine jointly published its own set of clinical practice guidelines for the treatment of stimulate use disorder, and in that guideline, again based on a review of the literature, identifies contingency management as the very best treatment for stimulant use disorder.
Dr. Capurso: And what about other addictions outside of stimulant use disorder?
Dr. DePhilippis: That’s a great question because you might say, “Well, why just stimulant use disorder? If CM is so effective, let’s apply it to a variety of behaviors.” And theoretically, because CM is based on operant conditioning you should be able to apply it to a lot of different substance use disorders: alcohol use disorder, opioid use disorder, and so forth. However, the challenge is in the mechanics as you referred to it correctly before, the mechanics of CM. What do I mean by that? With stimulant use disorder, the detection window for stimulants in a urine sample is roughly 24-72 hours. So we can test a patient twice a week, which is the typical schedule of CM, twice a week over 12 weeks, and by testing twice a week with both testing days separated by 2 to 3 days – so a Monday and a Thursday or a Tuesday and a Friday, or even a Monday and a Friday, we’re surveilling a full week’s worth of behavior. In other words, if a patient tests negative at both tests we can be very confident that the patient has abstained all week, and if the patient had used at any time all week at least one of those tests will reveal that recent stimulant use. Now let’s take alcohol as an example. There’s some excellent work being done on alcohol-targeted CM out at Washington State University by Dr. Michael McDonell and colleagues. The challenge is with alcohol our gold standard if you will for surveillance is breath sampling – blood alcohol content determined by breathing sampling. The detection window for breath sampling to determine blood alcohol content is 6-12 hours. So if we’re truly going to surveil for abstinence on alcohol we’d have to test the patient every day; in fact, to be really precise, probably twice a day – a morning and an evening surveillance. That is impractical in an outpatient application of contingency management. Now there is promise. There is a biomarker for alcohol consumption called ethyl glucuronide (EtG). It is monitored through urine samples and its detection window is similar to that of stimulants 24-72 hours. The problem is we don’t have a reliable immediate test for EtG, and remember we must have the test results immediately. When such a test becomes available then alcohol-targeted CM can be more widely available. You mentioned the overdose crisis. Opioids are the principle driver of the overdose crisis, what about opioids? The challenge with opioids has several dimensions. One is we cannot rapidly surveil for the presence of fentanyl, and given the ubiquity of fentanyl in samples of opioids used by patients, if you cannot effectively rapidly surveil for fentanyl, you’re not going to be effectively applying a contingency management approach. Number two: Contingency management - while there is some evidence it can have some benefit for opioid use disorder in an abstinence approach: that is the patient testing negative and receiving reinforcement, the problem is a successful course, of contingency management could actually, unintentionally of course, raise the risk of a fatal overdose if the patient were to have a recurrence of use. Why? When a patient successfully abstains from opioids, as we all know their tolerance for those opioids goes down. If they were to have a recurrence which is a real possibility – we’re talking about a chronic relapsing disorder, that recurrence of use can result in a fatal exposure to opioids. Third, the evidence is clear in the literature: the most effective, life-saving treatments for opioid use disorder are the three FDA-approved medications: methadone, buprenorphine and buprenorphine combination products, and extended-release naltrexone. Not only are those treatments more effective, they offer a measure of safety that CM cannot offer because they can protect against overdose. So there are a variety of challenges to making CM available for the direct treatment of opioid use disorder. Now you might say, “Well how about we use CM for patients who are on methadone or buprenorphine?” Well the problem there is we would have difficulty differentiating the medicinal methadone vs. any supplemental methadone that the patient may have taken from nonmedicinal sources and likewise with buprenorphine. In addition, even if we were able to do that, we still have the fentanyl surveillance problem: if we cannot effectively surveil fentanyl on a rapid basis with rapid available results, we are not going to be able to effectively apply contingency management. So there’s promise for alcohol use disorder. Opioid use disorder is more challenging. Cannabis has a growing body of evidence for the effectiveness of CM in the application to cannabis use disorder. The challenge there is the lengthy detection window for THC in urine samples – upwards of 30 days to 6 weeks. Well that throws a complication into contingency management because a patient could have engaged in the very behavior we’re seeking to reinforcement – abstinence from cannabis – yet continue to test positive for cannabis and we couldn’t differentiate whether that positive test was due to residual metabolites or a recurrence of use. Now there are procedural accommodations that can be made and we have a protocol in VA for doing so, but the primary focus of our CM efforts is where the evidence is strongest – stimulant use disorder.
Dr. Capurso: It’s kind of fortuitous that the length of detection for stimulant use disorder lends itself to a contingency management approach because this is the very addiction for which we have the least medication treatment options.
Dr. DePhilippis: Absolutely. No FDA-approved medications. I would be remiss not to mention to several colleagues including Dr. Frances Levin out of Columbia University: there are six signals in the literature for pharmacotherapy for stimulant use disorder primary for subgroups of patients, but none of those studies of medicinal applications or pharmacotherapies for stimulant use disorder have equal effect to contingency management.
Dr. Capurso: Yeah, there is no methadone or buprenorphine equivalent for stimulant use disorders that’s for sure.Dr. DePhilippis: I’m not aware of any applications of contingency management supported by the use of fentanyl test strips as the means of detecting the substance. The other challenge you have is even if, let’s say, the test strips are effective for fentanyl, will they capture the growing ubiquity of fentanyl analogs, and the recent and growing availability of nitazene – the nitazene opioids which are extraordinarily potent and very, very dangerous and not exactly a fentanyl analog and so may not be detected by those test strips.
Dr. Capurso: Yeah, it’s interesting. One of my primary clinical roles is working with patients with opiate use disorders and it is really remarkable how the urine drug screen results of patients who have been knowingly using illicit opioids - we have no idea what is going to population up. It could be synthetic opioids. It could be fentanyl. It could be heroin, all sorts of stuff. And so if you were to implement a contingency management program you would need to test for a whole wide variety of drugs all of which have different half-lives and bioavailability and it could become very messy very quickly I would imagine.
Dr. DePhilippis: Excellent point. With opioids, you need to surveil the entire spectrum of opioids because of the profound physical dependence that opioids provide. So a patient with an opioid use disorder, to quell withdrawal or avoid withdrawal, which is an extraordinarily unpleasant experience, will seek out an opioid of any variety to quell that withdrawal symptom, and if you don’t surveil that spectrum you’re likely to miss the ones that might be used by patients. And if you provide reinforcement thinking that the patient is abstinent when in fact they’re using you are contravening the entire point of the contingency management protocol.
Dr. Capurso: And there are more of these available all the time and now we’re dealing with kratom and tianeptine and all these other things.
Dr. DePhilippis: And in addition to all of that we have as of April of last year, the Office of National Drug Control Policy has identified xylazine as an emerging drug threat – often contaminating samples of opioids and stimulants in the community. And xylazine is a particularly problematic substance. It has no human medicinal uses – it has veterinary medicinal uses and can have severe effects on the patient including very, very profound skin lesions and skin wounds as well as enhancing the effect of the opioids that it’s mixed with which can exacerbated an overdose threat.
Dr. Capurso: You talked about the importance of having a broadly-appealing incentive, and in the VA of course we have the canteen coupons which you described; in many research protocols patients are given cash – neither of those are feasible for many of our readers, so how can providers in the community who are not part of the VA and not part of a research protocol implement contingency management for their patients?
Dr. DePhilippis: That is a major challenge to implementation outside VA. I’ll also note by the way that an additional benefit of using veteran’s canteen coupons is the veteran’s canteen service does not market items that could complicate or contravene recovery. So there are no tobacco products, there are no intoxicants, and there is no gambling paraphernalia or pornography that could complicate recover from substance use disorder. So we can be very confident that when the patient is spending their coupons they are spending their coupons on rewarding pursuits, but none that are threatening their recovery. With cash, obviously that issue is; that protection is not available. Obviously, cash can be used on a variety of purposes. Now an interesting issue with cash - the concern with cash is that it is so easy to divert cash. So the same person who might say, “I’m concerned about this idea of reinforcing patients.” I don’t like the idea of paying them as you mentioned, they might say, “Well, gosh it doesn’t seem prudent to provide cash or frankly anything of value to a patient with a substance use disorder. They might divert those items, including cash, to support their substance consumption.” Well though that is a reasonable concern, the evidence suggests it is not as high a risk as one might think. The late Dr. David Festinger actually asked the research question regarding diversion of cash incentives. His hypothesis was - well if patients were given cash in a CM protocol, which is the easiest incentive to divert they should manifest higher levels of substance use than patients in CM who did not receive cash who received perhaps gift cards or merchandise. Well when he did that study and it was published if memory serves in 2014, he found no difference in the substance consumption between the cash and noncash groups. Now is that to suggest we can capriciously offer cash? Cash has other challenges too. It can be a cure trigger for substance use so there is some risk there. The most typical alternative to cash is gift cards. Gift cards especially that have a “smart” feature to them; that is they can’t be used for purchases that would complicate recovery: alcoholic beverages, gambling paraphernalia, and so forth, so that’s one option. Now the other complication, of course, is resourcing the gift cards that would be used. And that remains a challenge in the communities: getting resources to do so. Among the challenges related to that is attending to the Dept. of Health and Human Service’s final rule of December of 2020 that established ground rules if you will about the use of incentives in health care and their important regulatory concerns. For example, one known as the “anti-kickback statute” – the idea of providing something of value to a patient like a quid pro quo – come to my treatment program, receive reinforcement, and another regulation called a “stark rule.” There is an opportunity, however, for community agencies and providers who want to meet or not run afoul of those regulations by way of the Dept. of Health and Human Services, to apply for a waiver to do so. And, in fact, a large-scale application of that waiver has been underway in the State of California. California applied for and received a waiver to offer contingency management funded through Medicaid dollars, and they established their reinforcement level at $599 maximum per patient. Well why $599? Well interestingly when you reach $600 or more you trigger IRS reporting requirements. You would have to provide a 1099 form, and the patient potentially would have to report their earnings as taxable income. That, obviously, would create some implementation challenges. At below $600 that triggering requirement is not present. So is $599 an evidence-based amount of reinforcement? Well the studies of CM that are now in some cases decades old suggest that $500 for a voucher CM program, and what I mean by voucher is the patient earns prescribed and escalating dollar values of reinforcement. That’s not the model primarily used in VA. We use a prized CM system where the patient earns prescribed and escalating opportunities for high-value reinforcement, those opportunities coming in the form of prize slips drawn from a container containing a variety of prize slips. The container by the way typically historically was a plastic fish bowl and the prize CM bore the moniker “fish bowl CM.” Well in voucher CM the studies, again in some cases decades old, said that about $500 was the minimum that you could effectively reinforce abstinence. The problem is that those are decades old now so we likely need to increase the amount of reinforcement to accommodate for changes in cost of living over time. We don’t know for certain how much we have to adjust up $750 to $1,000 perhaps might be a reasonable estimate and that again has to be resourced in the community, but again through the waiver program a state, an agency could apply for that opportunity.
Dr. Capurso: And that amount of money is over the course of a year?
Dr. DePhilippis: Typically, the bulk of the studies of CM are 12 weeks in duration, so that was where that $500 figure largely emerged from. The California implementation is 24 weeks; they are at $599. It may bear out that reinforcement must be higher. We are all looking forward to the outcomes of the California implementation. With prize CM in VA – again VA being an ideal setting for CM – we are not bound by those regulatory challenges that apply to applications of CM outside VA. Case law and in fact the Dept. of Treasury have determined that CM incentives are not taxable; they are part of the VA package available to veterans so they’re not taxable, and we are not bound therefore by the taxable reporting requirements. In prize CM, therefore, we don’t have to worry about a patient reaching a threshold above which there could be tax implications. In prize CM patients can earn typically on average $250 to $300 over the course of a 12-week protocol. Their earnings, of course, are a function of both their success in CM and the outcome of the draws that they make from the fishbowl.
Dr. Capurso: I see. So it sounds like these programs that you’re describing are time limited –whether it’s 12 weeks or 24 weeks, what happens after that?
Dr. DePhilippis: Great question. In fact, that speaks to one of the critiques sometimes leveled at contingency management. “Okay, maybe you’re not paying them, but I suspect since you’re providing exogenous or outside reinforcement, as soon as you withdraw that reinforcement the patient’s condition is likely to return; you’re gonna have a recurrence of symptoms.” Well I actually challenge that perspective as an unfair critique of contingency management. Why do I believe it is unfair? We don’t say in the treatment of other chronic conditions: diabetes or hypertension, “Gosh, as soon as the patient stops taking their antihypertensive their blood pressure goes back up, I guess the treatment doesn’t work.” No, in fact, the recurrence of symptoms is evidence that the treatment did work while it was being applied. Well, am I suggesting that CM should be of unlimited duration? For some patients that may be possible. We just don’t know. What we know is that 12 weeks in duration is a standard, evidence-based course of treatment. Could a longer course of treatment be more beneficial? Likely yes, but here’s the tradeoff. Say you use a 24-week course of CM, we know that that will likely increase the swath of patients that will benefit. There are some patients for whom 12 weeks may be insufficient, but 20 or 24 might be. At the same time we’re likely going to be giving superfluous CM to a patient who could have benefitted from a 12-week course. And we don’t have the precision yet in the science to say, “John Doe, based on your constellation of symptoms, the ideal CM course is 16 weeks or 12 weeks or 24 weeks of CM.” Now the critique, therefore, is “Well if we’re providing outside reinforcement do we diminish internal motivation for recovery?” Reasonable concern: in fact, in the social psychology literature dating decades ago, there’s a phenomenon called the “overjustification effect.” What is that? It’s the effect you get when you provide external reinforcement for a behavior that’s automatically reinforcing that a person will engage in naturally. As an example, the study that elucidated overjustification was a study of children using coloring books. Now children like to color in coloring books; it’s automatically reinforcing. The researchers who studied this gave one group of children who liked to color external reinforcement for doing so, gave another group of children no external reinforcement, and interestingly when they withdrew the external reinforcement those kids that formerly would color spontaneously ceased their coloring or reduced their coloring. That had serious implications for the applications of incentives and recovery behaviors. However, there was no evidence for the longest time that the overjustification effect was borne out in the application of CM to recovery behaviors, and it’s not surprising why. Recovery is not automatically reinforcing in the immediate. As I mentioned earlier, the immediate effects of pursuing a recovery are often unpleasant. In fact, that’s why CM musts bring those immediate reinforcements. The most powerful evidence that we’re not diminishing internal motivation though came from a meta-analysis done by Meredith Ginley and colleagues published in the Journal of Consulting and Clinical Psychology in 2021, if memory serves. Dr. Ginley and her colleagues examined CM studies that actually followed patients after the course of CM was concluded for a year, after of course, reinforcement was discontinued when the course of CM was over; followed those patients including getting urine toxicology data on those patients. So these are studies that had long-term follow-up and biomarkers of continued use. And what Dr. Ginley’s meta-analysis showed is abstinence CM can have enduring benefits for up to a year after the incentives are discontinued. Now is that mysterious or hard to believe? No. Think back to Dr. Walkow’s studies. CM is a scaffolding that supports initiation and maintenance of early abstinence. During that time the dopaminergic system of the brain is starting to heal. When we deconstruct that scaffold and remove the reinforcements for many patients the dopaminergic system has been restored and recovery behaviors are supported by the outcomes that take time to accrue in recovery. For other patients, perhaps a longer course is needed to produce that type of brain healing that would be associated with long-term recovery. In addition, what CM does is effective at a nonneurological level. The patient develops self-efficacy. What do I mean by that? The patient learns two important expectations about their recovery. Number 1) I can do this. Number 2) It’s worth doing. And as self-efficacy increases, a behavior is more and more likely to be sustained.
Dr. Capurso: Great. And this is the final question. Do you have any resources that you would recommend for people who are curious about learning more about CM?
Dr. DePhilippis: Yeah, there are several good resources. Well certainly the Clinical Practice Guidelines I mentioned are a great overview, so both the VA/Dept. of Defense Clinical Practice Guideline for Substance Use Disorder Management and the what is known as the ASAM (American Society of Addiction Medicine, American Academy of Addiction Psychiatry) CPG or clinical practice guideline for the treatment of stimulant use disorder – terrific overviews of the science supporting CM. For materials on the actual mechanics of CM, California has its protocol available – the protocol that it’s using in its statewide pilot. The Addiction Technology Transfer Center has materials available – that’s a SAMHSA (substance abuse mental health services administration) supported network. And, in fact, the Northwest Addiction Technology Transfer Center has a variety of CM educational materials available in its repository. Those are some of the several different supports and sources of information about CM that are available outside VA. Ultimately in VA what we want to get out, and you know this, what we want to get out into the community, especially to veterans, we know that substance use disorder can be devastating to your life. And we know, unfortunately that there is stigma continuing to be associated with substance use disorder. We in VA are ready, eager, and able to help you reach your recovery goals. Come see us. We can help you pursue your recovery from substance use disorder with a variety of evidence-based treatments, including but not limited to CM.
Dr. Capurso: A version of this interview will be available for subscribers to read in an upcoming issue of The Carlat Addiction Treatment Report. Hopefully, people will check it out. Everything from Carlat Publishing is independently researched and produced. There is no funding from the pharmaceutical industry. Our newsletters and books depend entirely on reader support. There are no ads, and our authors have not received industry funding. That helps us to bring you unbiased information that you can trust. Don’t forget you can earn CME credits for listening to our podcasts. As always, thanks for listening, and have a great day!
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