From Pellets to Prizes: Preclinical and Clinical Perspectives on Contingency Management for the Treatment of Substance Use Disorder

Despite substantial evidence of its efficacy, contingency management as a treatment for substance use disorder remains widely underutilized. Lack of long-term efficacy, inability to address the cause of addiction, and lack of identifiable mechanism feature prominently among the concerns reported by both clinicians and the public. In this narrative review, we consider the possible mechanisms of change involved in treatment and recovery for substance use disorders, including intrinsic motivation, decision making, neural plasticity, and abstinence, with a particular focus on how contingency management may act as a vehicle for facilitating long-term change in people with a substance use disorder, employing our combined expertise as a preclinical behavioral neuroscientist and a licensed clinical social worker specializing in the translational behavioral science and treatment of substance use disorders respectively. We present a theoretical model that combines the behaviorist foundations of contingency management with recent preclinical and clinical data to explain how the use of external reinforcers might facilitate long lasting, intrinsic change in behavior that addresses the pathology of addiction. Ultimately, we suggest that the use of extrinsic reinforcers during the application of contingency management might reinforce immediate behaviors that permit the development of longer-term mechanisms of change, such as abstinence, inhibitory control, or self-efficacy, and that when extrinsic reinforcement is removed at the conclusion of a contingency management program, recovery-related behaviors might still be maintained by these mechanisms.