Contingency management (CM) interventions consistently improve substance abuse treatment outcomes, yet CM remains a highly controversial intervention and is rarely implemented in practice settings. This paper briefly outlines the evidence base of CM and then describes four of the most often cited concerns about it: philosophical, motivational, durability, and economic. Data supporting and refuting each of these issues are reviewed. The paper concludes with suggestions to address these matters and other important areas for CM research and implementation, with the aims of improving uptake of this efficacious intervention in practice settings and outcomes of patients with substance use disorders.

The effectiveness of a competency-based supervision approach called Motivational Interviewing Assessment: Supervisory Tools for Enhancing Proficiency (MIA: STEP) was compared to Supervision-As-Usual (SAU) for increasing clinicians’ motivational interviewing (MI) adherence and competence and client retention and primary substance abstinence in a multisite Hybrid Type 2 effectiveness-implementation randomized controlled trial. Participants were 66 clinicians and 450 clients within one of eleven outpatient substance abuse programs. An independent evaluation of audio recorded supervision sessions indicated that MIA: STEP and SAU were highly and comparably discriminable across sites. While clinicians in both supervision conditions improved their MI performance, clinician supervised with MIA: STEP, compared to those in SAU, showed significantly greater increases in the competency in which they used fundamental and advanced MI strategies when using MI across seven intakes through a 16-week follow-up. There were no retention or substance use differences among the clients seen by clinicians in MIA: STEP or SAU. MIA: STEP was substantially more expensive to deliver than SAU. Innovative alternatives to resource-intensive competency-based supervision approaches such as MIA: STEP are needed to promote the implementation of evidence-based practices.

Objective-To evaluate the cost-effectiveness of a prize-based intervention as an addition to usual care for stimulant abusers.Methods-This cost-effectiveness analysis is based on a randomized clinical trial implemented within the National Drug Abuse Treatment Clinical Trials Network. The trial was conducted at eight community-based outpatient psychosocial drug abuse treatment clinics. 415 stimulant abusers were assigned to usual care (n = 206) or usual care plus abstinence-based incentives (n=209) for 12 weeks. Participants randomized to the incentive condition earned the chance to draw for prizes for submitting substance negative samples; the number of draws earned increased with continuous abstinence time. Incremental cost-effectiveness ratios were estimated to compare prize-based incentives relative to usual care. The primary patient outcome was longest duration of confirmed stimulant abstinence (LDA). Unit costs were obtained via surveys administered at the eight participating clinics. Resource utilizations and patient outcomes were obtained from the clinical trial. Acceptability curves are presented to illustrate the uncertainty due to the sample and to provide policy relevant information.Results-The incremental cost to lengthen the LDA by one week was $258 (95% confidence interval, $191 -$401). Sensitivity analyses on several key parameters show that this value ranges from $163 to $269.Conclusions-Compared with the usual care group, the incentive group had significantly longer LDAs and significantly higher costs.

Aim-To determine the cost effectiveness, from clinic and patient perspectives, of a computerbased version of cognitive-behavioral therapy (CBT4CBT) as an addition to regular clinical practice for substance dependence.Participants, Design and Measurements-This cost-effectiveness study is based on a randomized clinical trial in which 77 individuals seeking treatment for substance dependence at an outpatient community setting were randomly assigned to treatment as usual (TAU) or TAU plus biweekly access to computer-based training in CBT (TAU plus CBT4CBT). The primary patient outcome measure was the total number of drug-free specimens provided during treatment. Incremental cost-effectiveness ratios (ICERs) and cost-effectiveness acceptability curves (CEACs) were used to determine the cost-effectiveness of TAU plus CBT4CBT relative to TAU alone. Results are presented from both the clinic and patient perspectives and are shown to be robust to (i) sensitivity analyses and (ii) a secondary objective patient outcome measure.Findings-The per patient cost of adding CBT4CBT to standard care was $39 ($27) from the clinic (patient) perspective. From the clinic (patient) perspective, TAU plus CBT4CBT is likely to be cost-effective when the threshold value to decision makers of an additional drug-free specimen is greater than approximately $21 ($15), and TAU alone is likely to be cost-effective when the threshold value is less than approximately $21 ($15). The ICERs for TAU plus CBT4CBT also compare favorably to ICERs reported elsewhere for other empirically-validated therapies, including contingency management.Conclusions-TAU plus CBT4CBT appears to be a good value from both the clinic and patient perspectives.

Objective-To evaluate the cost-effectiveness of using prize-based and voucher-based contingency management (CM) as additions to standard treatment for cocaine-or heroin-dependent outpatients in community treatment centers.Methods-This cost-effectiveness analysis is based on a randomized clinical trial conducted at three community-based outpatient psychosocial substance abuse treatment clinics. A total of 142 cocaine-or heroin-dependent outpatients were randomly assigned to one of three treatment conditions: standard treatment (ST), ST with prizes (prize CM), or ST with vouchers (voucher CM) for 12 weeks. The primary patient outcome was the longest duration of confirmed abstinence (LDA) from cocaine, opioids and alcohol during treatment. Unit costs were collected from the three participating clinics. Resource utilizations and patient outcomes were obtained from the clinical trial. Incremental cost-effectiveness ratios (ICERs) and acceptability curves were used to evaluate the relative cost-effectiveness of the interventions.Results-Based on the ICERs and acceptability curves, ST is likely to be the most cost-effective intervention when the threshold value to decision makers of lengthening the LDA during treatment by 1 week is less than approximately $166, and prize CM is likely to be the most cost-effective intervention when the threshold value is greater than approximately $166.Conclusions-Prize CM was found likely to be the most cost-effective intervention over a comparatively wide range of threshold values for lengthening the LDA during treatment by 1 week. However, additional studies with alternative incentive parameters are required to determine the generalizability of our results.