Drug and Alcohol Dependence 216 (2020) 108307

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Drug and Alcohol Dependence

journal homepage: www.elsevier.com/locate/drugalcdep

Contingency management for the treatment of methamphetamine use

disorder: A systematic review
Hayley D. Brown, Anthony DeFulio *
Western Michigan University, United States

A R T I C L E I N F O A B S T R A C T

Keywords: Methamphetamine use continues to be an important public health problem. Contingency management is among
Methamphetamine the most effective interventions for reducing methamphetamine use. It has been more than ten years since the
Contingency management last systematic review of contingency management for methamphetamine use disorder. Since then, an additional
Outpatient treatment
ten randomized controlled trials and a variety of other studies have been completed. The present systematic
Predictors
review includes 27 studies. Several factors, most notably problem severity, appear to predict treatment outcome.
However, the effectiveness of CM has been demonstrated in studies restricted to MSM, studies restricted to
implementation in community programs, and in studies of the general population of methamphetamine users
conducted in research treatment programs. There appear to be broad benefits of contingency management
intervention, including greater drug abstinence, higher utilization of other treatments and medical services, and
reductions in risky sexual behavior. Twenty of the twenty-one studies that reported abstinence outcomes showed
an effect of contingency management on abstinence, and seven of the nine studies that reported sexual risk
behavior outcomes showed an effect of contingency management in reducing risky sexual behavior. Taken
together, recent evidence suggests strongly that outpatient programs that offer treatment for methamphetamine
use disorder should prioritize adoption and implementation of contingency management intervention.

1. Introduction
Methamphetamine use is an important public health problem in the
United States that raises serious medical and criminal justice concerns.
In 2018 approximately 1.9 million Americans reported using metham­
phetamine (Substance Abuse and Mental Health Services Administra­
tion, 2019), and in the age-adjusted rate of overdose deaths involving
psychostimulants with abuse potential, including methamphetamine,
had increased nearly five times its 2012 level (Hedegaard et al., 2020).
Currently, there are no widely-approved pharmacotherapies to
curtail methamphetamine use. However, behavioral interventions have
proved promising (Rawson et al., 2006; Roll et al., 2006b). The most
effective intervention to date appears to be contingency management, a
behavioral intervention in which material incentives are delivered
contingent on biological confirmation of drug abstinence. Contingency
management is effective in promoting abstinence from a variety of
substances including alcohol, opioids, and stimulants (Prendergast et al.,
2006).
Many studies have shown that contingency management effectively
reduces stimulant use in general and cocaine use in particular (e.g.,
Higgins et al., 1991, 1993, 2000). However, cocaine and methamphet­
amine have different drug effects and consequences. Relative to cocaine
users, methamphetamine users are more likely to be people of color, and
more likely to experience severe medical and psychiatric consequences
(Rawson et al., 2000). Nevertheless, prior reviews of psychosocial
intervention for methamphetamine use disorder suggest that contin­
gency management intervention outcomes for methamphetamine users
parallel those of cocaine users (Baker and Lee, 2003; Lee and Rawson,
2008). The review by Baker and Lee recommended incorporation of
contingency management programs into residential and outpatient
treatments for methamphetamine use based on the findings of a single
study that was conducted in an inpatient setting (Melin and Götestam,
1973). The review by Lee and Rawson included a section on contingency
management that featured five studies, and a section on
cognitive-behavior therapy approaches for specific groups of users that
included three studies from a data set drawn from a controlled trial in
which participants were assigned to various combinations of
cognitive-behavior therapy and contingency management. Many of the

* Corresponding author at: 1903 W Michigan Ave, Kalamazoo MI, 49008-5439, United States.
E-mail address: anthony.defulio@wmich.edu (A. DeFulio).

https://doi.org/10.1016/j.drugalcdep.2020.108307
Received 3 June 2020; Received in revised form 13 September 2020; Accepted 16 September 2020
Available online 21 September 2020
0376-8716/© 2020 Elsevier B.V. All rights reserved.
H.D. Brown and A. DeFulio
eight studies include in that review included analyses of data sets that
were drawn from a broader population of stimulant users, and in some
cases were predominantly cocaine users. Despite these limitations, the
authors concluded that contingency management studies produced
substantial decreases in methamphetamine use during treatment. Sub­
stantial progress has been made in the evaluation of contingency man­
agement interventions for methamphetamine use since the time of those
reviews. Some of the more recent contingency management studies in
which methamphetamine use was targeted were included in a recent
systematic review of non-pharmacological interventions for metham­
phetamine use (AshaRani et al., 2020). This review included seven
studies, only one of which was included in the Lee and Rawson review,
and indicated that all seven showed a decrease in drug use, and that two
also showed improvements in other health behaviors. The discussion
also mentions other effects of contingency management, including
enhanced retention in treatment and improvements in psychological
symptoms, though these findings are not described in detail.
The prior reviews of non-pharmacological interventions for meth­
amphetamine use are helpful and clearly illustrate the efficacy of con­
tingency management in reducing methamphetamine use. The literature
as a whole now contains important information about the effects of
contingency management on drug abstinence, drug craving, treatment
engagement and retention, earning and spending of incentives, mood/
affect, sexual risk behaviors, and intervention acceptability. The goal of
the present review is to provide a fuller, more complete and detailed
review that is focused specifically on contingency management as an
intervention for methamphetamine use. The review is organized such
Fig. 1. Flowchart of the article search process.
2
Drug and Alcohol Dependence 216 (2020) 108307
that evidence from randomized controlled trials is presented first, and
other studies are presented in a second section. Within these sections,
the studies are organized by the specific outcomes reported in the con­
tingency management interventions.
2. Methods
2.1. Search strategy
MEDLINE, PsycINFO, and Web of Science databases were searched
using the keywords “contingency management” AND “methamphet­
amine.” There was no start date limitation on the search, and the last
search date for inclusion was conducted in August 2020. These articles
were evaluated for inclusion independently by both authors. Twenty-six
articles were found to meet the inclusion criteria. References within and
citations to all included articles were hand searched by the first author to
identify additional articles. This process yielded one more study for in­
clusion. That article did not yield additional articles, resulting 27
included studies. This process is outlined in a flowchart (see Fig. 1) and a
detailed listings of the included studies and their characteristics are
presented in Tables 1 and 2.
2.2. Eligibility criteria
Studies were included if they contained a contingency management
intervention that targeted methamphetamine abstinence and the ma­
jority of participants were methamphetamine users. All contingency
H.D. Brown and A. DeFulio
Table 1
Summary of Randomized Controlled Trials.
Author (year) N Inclusion/Exclusion Criteria
Carrico et al. 21 Inclusion: identify as male;
(2015) report having anal sex with a
man in the past year; and report
using meth at least weekly on
average during the 3 months
prior to CM.
Carrico et al. 110 Inclusion: 18 years of age or
(2018) older, report of anal sex with a
man in the past 12 months,
speak English, provide
documentation of HIV-positive
serostatus, provide a urine or
hair sample that was reactive
for meth
Chudzynski et al. 120 Inclusion: 18–65 years of age,
(2015) met DSM-IV criteria for meth
dependence, were willing and
able to comply with study
procedures, were willing and
able to provide written
informed consent. Exclusion:
had medical or psychiatric
conditions that precluded safe
study involvement, were unable
to comply with the research
requirements, a history of
violent criminal behavior or be
on parole, any other
circumstances that would
interfere with safe study
participation.
Corsi et al. 58 Inclusion: Meth use in the
(2012) previous 30 days (verified
through observed urinalysis
(UA) and self-report of meth
use, reported sex with an
opposite-sex partner in last 30
days, negative urinalysis for
opiates and methadone during
baseline screening period,
ability to provide reliable
contact information, not in drug
treatment in the 30 days prior
to the baseline interview,
willing to be tested for HIV at
baseline and follow-up, not
transient and committed to
being available for follow-up
interviews.
Corsi et al. 253 Inclusion: 18 years of age or
(2019) older and competent to give
informed consent at the time of
the interview, meth use
(verified through urine drug
screening and a self-report of
meth use of at least 4 times per
month for the last 3 months),
self-reported sex with someone
of the opposite sex in last 30
days, ability to provide a
reliable address and phone
number for contact, not in drug
treatment in the past 30 days,
willingness to be tested for HIV
at baseline and follow-up, not
transient and no known reason
why he/she would not be
Intervention Description
Positive affect + CM or CM
only for 12-weeks Follow-up: 3
and 6-month Design: RCT
Positive affect + CM or
attention-control + CM for 12
weeks Follow-up: 3-month
Design: RCT
Continuous reinforcement,
intermittent predictable
reinforcement, intermittent
unpredictable reinforcement,
or standard condition for 16
weeks Follow-up: 10 and 12-
weeks Design: RCT
CM or CM + strengths-based
case management for 17 weeks
Follow-up: 4 an 8-month
Design: RCT
CM or CM + strengths-based
case management (CM/SBCM)
for 17 weeks Follow-up: 4 and
8-month Design: RCT
3
Drug and Alcohol Dependence 216 (2020) 108307
Outcomes
Positive and negative affect,
self-reported stimulant use, total
non-reactive urine toxicology
results for stimulants during CM
Positive and negative affect,
mindfulness, methamphetamine
craving, self-reported stimulant
use, total non-reactive urine
toxicology results for stimulants
during CM
abstinence verified by urine
drug analysis results
Attendance at sessions, urine
results, total vouchers earned,
satisfaction with the
intervention and reported
barriers
Attendance at sessions, urine
results
Relevant Findings
Across groups, participants provided an
average of 30.5 (SD = 6.3) meth
negative samples out of 36 total
samples and provided an average of
20.7 (SD = 10.7) consecutive negative
samples. Positive affect + CM
participants reported an increase in
positive affect (B = 4.67, p < .05;
Cohen’s d = 0.24) at the end of
treatment. CM-only participants
reported a reduction in negative affect
(B=-7.69, p < .05; Cohen’s d=-0.23) at
the end of treatment.
Greater reductions in self-reported
stimulant use (Cohen’s d = − .46,
p = .030) and methamphetamine
craving (Cohen’s d = − .51, p = .026)
were observed at 3 months for the
positive affect condition.
Compared to standard treatment
participants, continuous CM
participants were almost two times
more likely to submit a negative meth
UA (OR = 1.98, p < .05), intermittent
predictable CM participants were 2.4
times more likely to submit a negative
meth UA (OR = 2.40, p < .05), and
intermittent unpredictable CM
participants were about 1.7 times more
likely to submit a negative meth UA
(OR = 1.72, p < .05). None of the CM
conditions’ OR differed significantly
(p < .05) from one another.
A significant reduction in amphetamine
and meth use was observed from
baseline to each follow-up (χ2 = 11.6,
p < 0.001). 100 % of samples at
baseline were positive for meth, 53.3 %
were positive at 4 and 8-month follow-
ups. Participants rated the intervention
highly and reported few barriers to
session attendance.
CM/SBCM was significantly associated
with attending at least one UA session
(p-value = 0.0139). CM/SBCM
participants were 2.7 times more likely
to attend at least one UA session than
partnered control group participants
(95% CI 1.2, 6.0, p-value = 0.0014).
Participants who earned more money
during session A (weeks 1− 4) were
more likely to submit negative UAs
during session B (weeks 5− 17) (p-value
<0.0001).
(continued on next page)
H.D. Brown and A. DeFulio
Table 1 (continued )
Author (year) N Inclusion/Exclusion Criteria
available for follow-up
interviews, not currently
mandated by the criminal
justice system to receive
treatment.
Menza et al. 127 Inclusion: age ≥18 years,
(2010) willingness to be randomized
and provide locator
information, no plans to move
from the study catchment area
within 6 months of enrollment,
≥1 episodes of anal sex, ≥2
episodes of meth use in the
month prior to screening
Exclusion: reported a mutually
monogamous relationship with
a partner of the same HIV status
lasting ≥2 years, men who
expressly asked for
detoxification, counseling, or
drug rehabilitation services.
Nyamenthi et al. 414 451 Inclusion: 18–46 years of age,
(2017); Zhang self-reported being homeless,
et al. (2018) GBM, stimulant use within the
past 3 months, no self-reported
participation in substance abuse
treatment in the past 30 days
Reback et al. 131 Inclusion: at least 18 years of
(2010, 2012); age, met DSM-IV criteria for
Fletcher and substance dependence, non-
Reback treatment-seeking, homeless,
(2013); self-reported sex with a man in
Fletcher et al. the previous 12 months
(2014) Exclusion: unable to
understand consent forms,
determined to have a more
serious psychiatric condition
Intervention Description
CM or referral to community
resources for 12-weeks Follow-
up: 3-month Design: RCT
Nurse case management (NCM)
+ CM or standard education
(SE) + CM for 16 weeks Follow-
up: 4 and 8-month Design: RCT
CM or TAU for 24-weeks
Follow-up: 7, 9, and 12-month
Design: RCT
4
Drug and Alcohol Dependence 216 (2020) 108307
Outcomes
Report of unprotected anal
intercourse (UAI) with a partner
of unknown or discordant HIV
status (non-concordant UAI) in
the prior six weeks, number of
non-concordant UAI partners,
results of methamphetamine
urine testing, self-reported
weekly or more frequent use of
methamphetamine, self-
reported use of >8 quarters (two
grams) of methamphetamine.
Urinalysis drug testing results,
self-report of number of sexual
partners HAV/HBV Twinrix
vaccine completion
Attendance and health-
promoting total scores
calculated at the end of the
intervention, individual urine
drug analysis and breathalyzer
results and aggregate Level 1
scores
Relevant Findings
CM and control participants were
comparably likely to provide urine
samples containing meth (adjusted
relative risk [aRR] = 1.09; 95 %CI:
0.71, 1.56) and to report non-
concordant UAI (aRR = 0.80; 95%CI:
0.47, 1.35). At follow-up: CM
participants were somewhat more
likely to provide urine samples
containing meth than control
participants (aRR = 1.21; 95%CI: 0.95,
1.54, P = 0.11). CM participants were
more likely to report at least weekly
meth use and use of more than eight
quarters over the prior six weeks at the
time of measurement than control
participants during the intervention
and post-intervention periods.
Proportion of participants in both
groups tested positive for meth use
decreased from more than 70 % at
baseline to less than 30 % at 8-months.
Proportion of participants in both
groups reported having sex with
multiple partners decreased from 38%
at baseline to 17.28% for the
NCM + CM participants and 21.59%
for the SE + CM participants at 8-
months. 85% of participants eligible to
receive vaccine in both groups
completed the three-dose vaccination
series during the intervention periods.
CM participants achieved greater
reductions in stimulant and alcohol use
(χ2 = 27.36, p < .01), especially
methamphetamine (χ2 = 21.78,
p < .01) than control participants. CM
participants achieved greater increases
in health-promoting behaviors
(χ2 = 37.83, p < .01) than control
participants. Treatment responders
were more likely to be Caucasian/
white than non-responders (76.5% vs.
46.8%; p < .05). Treatment responders
reported significantly fewer years of
lifetime cocaine use (2.5 [SD = 3.6] vs.
5.9 [SD = 7.7]; p < .05), fewer years of
lifetime meth use (3.8 [SD = 4.2] vs.
6.7 [SD = 6.7]; p < .05), and fewer
years of lifetime polysubstance use (7.8
[SD = 4.4] vs. 12.9 [SD = 8.5];
p < .05) than non-responders.
Treatment responders reported more
male sexual partners in the previous six
months (11.8 [SD = 16.7] vs. 5.5
[SD = 8.5]; p = .0587) and a greater
number of reported unprotected anal
intercourse events (24.9 [SD = 61.4]
vs. 2.5 [SD = 9.9]; p < .05) than
responders. ASPD status was
significantly positively associated with
meth abstinence (coefficient = 0.1
[SE = 0.05]; p < .05). Participants
with ASPD earned less per health-
promoting behavior than those without
ASPD ($10.21 [SD = &7.02] versus
$18.38 [SD = $13.60]; p < .01). Meth
use during the course of the
intervention was associated with
significant decreases in the number of
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H.D. Brown and A. DeFulio
Table 1 (continued )
Author (year) N Inclusion/Exclusion Criteria
Reback and Study 1: Inclusion: 18− 65 years of age,
Shoptaw 40 self-identified gay/bisexual
(2014) Study 2: men, seeking treatment for
46 methamphetamine use
Study 3:
171
Roll et al. (2013) 118 Inclusion: 18− 65 years of age,
met DSM-V criteria for meth
dependence, were willing and
able to comply with study
procedures and provide written
informed consent. Exclusion:
had medical or psychiatric
conditions that precluded safe
study involvement, were unable
to comply with the research
requirements, any other
circumstances that would
interfere with study
participation.
Roll et al. 88 Inclusion: adults seeking
(2006a) outpatient behavioral treatment
for meth use disorders
Roll et al. 113 Inclusion: had diagnoses of
(2006b) * either meth abuse or
dependence
Roll and 18 Inclusion: met DSM-IV criteria
Shoptaw for meth dependence
(2006)
Intervention Description
Study 1: CM, standard CBT,
CM + CBT, or GCBT Design:
RCT Study 2: GCBT or gay-
specific social support therapy
Design: RCT Study 3:
participated in a modified
GCBT + low-cost CM Design:
Pre-post (no control)
Standard psychosocial
treatment, standard
psychosocial
treatment + either 1 month, 2
months, or 4 months of CM
Follow-up: 6, 8, 10, and 12-
months Design: RCT
5 conditions with varying CM
reinforcement schedules for 12
weeks Follow-up: none Design:
RCT
Treatment as usual (TAU)
either Matrix Model, CBT, or
relapse prevention depending
on clinic or TAU plus CM for 12
weeks Follow-up: 3 and 6-
months Design: RCT
VBRT with reset or VBRT
without reset for 12 weeks
Follow-up: none Design: RCT
5
Drug and Alcohol Dependence 216 (2020) 108307
Outcomes
Average retention in weeks of
intervention, longest
consecutive abstinence period
verified by urine drug screen
results (in weeks), treatment
effectiveness score, percent of
urine samples negative for meth
metabolite, and number of days
of reported meth use in the
previous 30 days
Drug use measured by: longest
duration of continuous
abstinence during the treatment
phase, total percent of meth
urine analyses (UAs) indicating
abstinence during treatment
phase (e.g., 100% and 80%), and
proportion of negative meth UAs
submitted across the treatment
period (i.e., 3 samples per week
for 16 weeks).
Total abstinence from meth as
assessed by mean number of
metabolite-free urine samples
provided, continuous abstinence
measured by longest period of
uninterrupted abstinence, the
ability to initiate abstinence
from meth as defined as the
mean number of tests that
occurred in each condition prior
to producing the first meth-
negative test result, the ability to
protect against relapse following
a period of abstinence as
assessed by counting the number
of participants who relapsed
following a 4-week period of
abstinence
Retention as defined by the
number of weeks that elapsed
between the first and last study
urine samples submitted and
whether the participant
completed the study Treatment
participation was evaluated by
examining the number of
counseling sessions attended
during the 12-week period. Drug
use as measured by total number
of stimulant-and alcohol-
negative samples submitted by
each participant, test results for
stimulants and alcohol at each
visit and follow-up, and longest
documented duration of
sustained abstinence from
stimulant drugs and alcohol for
each participant.
abstinence verified by urine
drug analysis results
Relevant Findings
days between voucher redemptions
(IRR = 0.66; 95% CI = [.44− 0.99]).
Modified GCBT + CM produced fewer
consecutive weeks of meth abstinence
(− 0.44, CI: − 0.79, − 0.09) and fewer
male sexual partners (− 0.36, CI: − 0.71,
− 0.02) than the first trial of GCBT.
Modified GCBT + CM produced more
days of meth use (0.35, CI: 0.02, 0.68)
than the second trial of GCBT. Modified
GCBT + CM produced greater effects in
reducing the number of male sexual
partners (− 0.54, CI: − 0.89, − 0.19;
− 0.51, CI: − 0.84, − 0.18) at 26-week
follow-up.
Compared to the standard treatment
condition, 1 Month CM participants
were almost 4 times more likely to
submit a negative meth UA (odds ratio
(OR) = 3.58, p < 0.05), 2 Month CM
participants were about 2.5 times more
likely to submit a negative meth UA
(OR = 2.55, p < 0.05) and 4 Month CM
participants were about 7.25 times
more likely to submit a negative meth
UA (OR = 7.25, p < 0.05).
No significant differences were
observed between groups in either
mean total number of abstinences
during treatment (F(4, 78) = 0.4696,
p > 0.05) nor in the mean longest
period of continuous abstinence (F{4,
78) = 0.7551, p > 0.05). Schedule 5
initiated abstinence quicker than
Schedule 1 (q = 4.492) and Schedule 3
(q = 5.241). Participants assigned to
Schedule 5 were less likely to relapse
after 4 weeks of abstinence (Chi-
square = 8.084 (3), p < .05).
CM participants submitted significantly
more stimulant- and alcohol-negative
samples (mean = 13.9, SD = 8.8) than
TAU participants (mean = 9.9,
SD = 8.0) (t = 2.55, df = 110,
p = 0.01). CM participants had a longer
mean period of documented
continuous abstinence (approximately
4.6 weeks, based on a mean of 9.3
consecutive samples, SD = 9.2) than
TAU participants (approximately 2.8
weeks, based on a mean of 5.6
consecutive samples, SD = 7.2)
(t = 2.38, df = 110, p = 0.02). CM
participants were more likely to submit
negative urine samples than TAU
participants (odds ratio = 2.04, 95%
CI = 1.19–3.49; χ2 = 6.80, df = 1,
p = 0.009).
Escalating-with-reset participants
submitted more total meth-free urine
samples (80 % of all samples)
compared with escalating without-
reset participants (38% of all samples)
(t = 3.1, df = 16, p < 0.05).
Escalating-with-reset participants
achieved longer periods of continuous
abstinence (mean = 6.7 weeks,
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H.D. Brown and A. DeFulio Drug and Alcohol Dependence 216 (2020) 108307

Table 1 (continued )
Author (year) N Inclusion/Exclusion Criteria Intervention Description Outcomes Relevant Findings

SD = 3.2 weeks) than escalating-

Shoptaw et al. 162 Inclusion: Gay and bisexual
(2005)*; Ling men (GBM), aged 18–65, who
Murtaugh were seeking outpatient
et al. (2013) behavioral drug abuse
treatment for meth dependence
at a research clinic Exclusion:
had medical or psychiatric
conditions that precluded safe
study involvement, were unable
to comply with the research
requirements, or if their meth
dependence required more
intensive intervention than
outpatient treatment.
Shoptaw et al. 229 Inclusion: 18− 65 years of age,
(2006)* met DSM-IV criteria for MA
dependence or abuse
Exclusion: had a primary
medical condition that might
interfere with safe study
participation, current
pharmacotherapy for which
concurrent treatment with a
selective serotonin reuptake
inhibitor would be
contraindicated, a psychiatric
condition identified by the SCID
that required pharmacological
or behavioral intervention, or
SCID-diagnosed dependence on
opioids, cocaine, alcohol, or
benzodiazepines.
*
Indicates studies included in previous review by Lee and Rawson (2008).
CM, cognitive behavioral
therapy (CBT) + CM, CBT,
culturally-tailored cognitive
behavioral therapy (GCBT) for
16-weeks Follow-up: 6 and 12-
months Design: RCT
Sertraline + CM, sertraline-
only, placebo + CM, and
placebo-only conditions for 12
weeks Follow-up: none Design:
RCT
Recent stimulant use measured
by urine samples analyzed for
metabolites of meth and
cocaine. Results from urine drug
screening were compiled using
three indices: Treatment
Effectiveness Score (TES);
percent of urine samples that
were metabolite-free; and
longest period of consecutive
metabolite-free urine samples
(in days). Frequency and
magnitude of CM purchases,
purchase type as either hedonic/
utilitarian and consumable/
durable based on physical
records of purchases
Meth use (urine drug screening
and self-reported days of use),
retention (length of stay), drug
craving (visual analogue scale),
and mood symptoms (Beck
Depression Inventory)
without-reset participants (mean = 2.8
weeks, S. = 3.6 weeks) (t = 2.4,
df = 16, p < 0.05).
Significant differences were observed
in retention (F(3,158) = 3.78, p < .02),
longest consecutive period of urine
samples negative for meth metabolites
(F(3,158) = 11.80, p < .001), and TES
by condition during treatment (F
(3,158) = 7.35, p < .001) with CM and
CBT + CM conditions performing
better than standard CBT. GCBT
participants showed a reduction in
unprotected receptive anal intercourse
(URAI) during the first 4 weeks of
treatment (X2 = 6.75, p < .01).
Overall reductions in outcomes were
sustained to 1-year, but group
differences were not sustained at
follow-up. Participants who redeemed
CM earnings at any visit (“spenders”)
were significantly more likely to
produce stimulant-negative urine
samples in the subsequent visit than
those who did not redeem (“savers”)
1.011*[1.005, 1.017], Z = 3.43,
p < .001.
Participants in the sertraline-only
condition provided more metabolite-
positive urine samples compared to the
other conditions over the trial (GEE
model: χ2(1) = 5.02, p < 0.05). Fewer
sertraline-only participants (25.4%)
achieved the outcome criterion of at
least 3 weeks of consecutive meth
metabolite-free urine samples
compared to participants in other
conditions (sertraline + CM = 42.6%,
placebo + CM = 51.9%, and placebo-
only = 41.8%; χ2 (3) = 8.6,
p = 0.035). More participants
receiving CM (47.0%) achieved three
consecutive weeks of meth abstinence
than those not receiving CM (33.3%; χ2
(1) = 4.4, p = 0.036) when the four
study conditions were collapsed to
participants receiving CM versus those
not receiving CM.

management studies were considered including those selected for pre­
vious reviews. All study designs (included pilots), comparator groups,
and outcomes were considered. Outcomes reported here include drug
abstinence, retention in treatment, attendance/treatment engagement,
sexual risk behavior, drug craving, mood/affect, intervention accept­
ability, and treatment response predictors.
3. Results
3.1. Randomized controlled trials
3.1.1. Drug abstinence
Shoptaw et al. (2005) found that methamphetamine dependent men
who have sex with men who received contingency management or
contingency management + cognitive behavioral therapy achieved
greater Treatment Effectiveness scores (proportion of samples negative
for cocaine and methamphetamine metabolites) and longer durations of
abstinence than participants who received only cognitive behavioral
therapy. These reductions in methamphetamine use were sustained
through the 12-month follow-up; however, group differences
disappeared. Reback and Shoptaw (2014) compared the outcomes of
Shoptaw et al. (2005) and two other studies using a meta-analysis. Of the
three studies included in the meta-analysis, two included a contingency
management component. The second study did not include a contin­
gency management component, but rather evaluated a
culturally-tailored cognitive behavior therapy and a gay-specific social
support therapy (Shoptaw et al., 2008). Participants in the third study all
received a modified culturally-specific cognitive behavioral therapy
(reduced from 16 weeks to 8 weeks) in conjunction with a low-cost
contingency management intervention. The modified treatment and
the original culturally-specific cognitive behavioral therapy both pro­
duced reductions in methamphetamine use (Shoptaw et al., 2005), but
the modified treatment produced fewer consecutive weeks of metham­
phetamine abstinence than the original.
Roll et al. (2006b) reported that participants diagnosed with meth­
amphetamine dependence or abuse who received treatment as usual­
+ contingency management submitted significantly more stimulant-
and alcohol-negative samples and achieved longer periods of continuous
abstinence than participants who received only treatment as usual. This
difference was no longer apparent at the 3- and 6-month post-treatment

6
H.D. Brown and A. DeFulio
Table 2
Summary of Pre-post Studies.
Author (year) N Inclusion/Exclusion Criteria
Gómez et al. (2018) 131 Inclusion: meth using men who
have sex with men (MSM)
Landovitz et al. 53 Inclusion: self-identified as MSM,
(2012) were at least 18 years of age, were
HIV uninfected on rapid HIV ELISA
testing, self-reported meth use
within the previous 30 days, and
reported unprotected anal
intercourse (UAI) with an HIV-
positive or HIV-serostatus-
unknown partner in the previous
90 days.
Okafor et al. 30 Inclusion: met DSM-5 criteria for
(2019); meth use disorder, provided a
Krishnamurti urine sample that tested positive
et al. (2020); for meth during screening, were
Lake et al. (2020) aged 18–45 years, had a good
understanding of English
Exclusion: currently in treatment
for addiction to a substance other
than stimulants; met DSM-5
criteria for a substance-related
diagnosis other than meth,
tobacco, marijuana; current use of
a prescribed psychoactive
medication; inability to attend ≥ 4
visits during a 2-week screening
period or to complete screening
measures; physical or mental
illness that would require
intervention, alter brain imaging
findings, or interfere with safe
study participation; pregnancy;
claustrophobia; presence of metal
prostheses, cardiac pacemakers or
metal clips that are incompatible
with the magnetic resonance
imaging environment; HIV
seropositive status, previous head
injury.
Shoptaw et al. 111 Inclusion: men who have sex with
(2006) men with recent meth use
Strona et al. (2006) 178 Inclusion: met criteria for meth
dependency, reported using meth
in last 7 days, were not enrolled or
active in a drug treatment
program, participated in a 15-min
intake session, agreed to submit
thrice-weekly urine samples for 12
weeks
Intervention Description
Participated in community-
based CM program (PROP) +
individual and drop-in group
counseling for 12 weeks
Follow-up: none Design: Pre-
post (no control)
Participated in a CM
intervention for 12 weeks
Follow-up: 3-month Design:
Pre-post (no control)
Participated in a pilot CM
trial for 8 weeks Follow-up:
none Design: Pre-post (no
control)
Participated in community-
based CM program (PROP)
for 12 weeks Follow-up: none
Design: Pre-post (no control)
Participated in community-
based CM program (PROP)
for 12 weeks Follow-up: none
Design: Pre-post (no control)
7
Drug and Alcohol Dependence 216 (2020) 108307
Outcomes
abstinence verified by urine drug
analysis results
Urinalysis drug testing results, HIV
and STI testing results, medication
adherence via self-report and pill
counts
Therapeutic response defined as
abstinence from methamphetamine
(≥23 of 24 possible
methamphetamine-negative urine
samples). Urinalysis drug testing
results, records of purchases
acceptability (number of
enrollments/ time), impact (clinical
response to treatment and cost-
effectiveness as cost per patient
treated)
abstinence verified by urine drug
analysis results, self-report of number
of sex partners
Relevant Findings
Participants submitted a median of
22 out of 36 samples
(IQR = 10− 34) nonreactive to
meth, which equates to over 7
weeks abstinent of the 12 week
treatment duration
Mean number of days (of the past
30) of meth use decreased from 4.8
to 1.6 (p < 0.001) and mean
number of uses per day decreased
from 5.3 to 1.1 (p < 0.001) from
baseline to 3-month follow-up. The
percentage of participants who
provided metabolite-free urine
samples increased from 71.7 at
baseline to 89.47% at 3-month
follow-up (p < 0.05). Meth
abstinence during CM treatment
increased PEP adherence (2% [95%
CI + 1–3%] per metabolite-free
sample provided), and increased
the odds of PEP course completion
(OR 1.17, 95% CI 1.04–1.31).
68 % of participants submitted ≥23
meth-negative urine samples and
were classified as responders. Fewer
responders reported monthly
household income ≥25 000+ South
African Rand (ZAR; ~USD $1880;
vs. ZAR < 25 000) than non-
responders (15.8% vs. 63.6%;
P = 0.007). Responders had higher
median years of education (12 vs.
10; Kruskal–Wallis χ2 = 4.25,
DF = 1, P = 0.039) and lower
median body mass index than non-
responders (19 vs. 24;
Kruskal–Wallis χ2 = 6.84,
P = 0.008). Participants who spent
earnings at a previous visit
(“spenders”) were more likely to
produce stimulant-negative urine
samples at subsequent visit than
those who did not (“savers”)
[OR = 1.23, CI = 1.08− 1.53,
p = .002]. Partial responders
showed a greater preference for
large, immediate rewards over
smaller, short-term but larger long-
term rewards and long-term losses
than healthy controls [p = 0.038, g
= -0.77 (-1.09: -0.44)].
Participants produced an average of
15 (SD = 13.5) meth metabolite-
free urine samples of the possible 36
samples over the 12-week
treatment period. 52% of
participants achieved 12
metabolite-free urine samples;
17%, 24 metabolite-free samples;
and 8.1%, all 36 metabolite-free
samples. 60% of participants
completed 4 weeks of treatment;
48%, 8 weeks and 30%, 12 weeks.
Of submitted samples, 96 % were
negative for meth. A significant
reduction in number of self-
reported sex partners was achieved
(p < .05).
H.D. Brown and A. DeFulio
follow-ups.
Roll et al. (2006a) reported that five different schedules of rein­
forcement for contingency management incentives produced compara­
ble mean total number of negative samples and mean longest duration of
abstinence for participants seeking treatment for methamphetamine use
disorders. However, a schedule developed by Higgins et al. (1994)
initiated abstinence more rapidly than the two other schedules and
offered better protection against relapse than all other schedules.
Roll and Shoptaw (2006) found that methamphetamine dependent
participants assigned to an escalating-with-reset contingency manage­
ment schedule condition submitted more methamphetamine negative
samples and achieved longer periods of abstinence than participants in
the escalating-without-reset condition.
Shoptaw et al. (2006a) reported that significantly more participants
who met criteria for methamphetamine abuse or dependence assigned to
either a contingency management + sertraline or contingency man­
agement + placebo condition achieved three weeks of abstinence than
participants assigned to either sertraline- or placebo-only conditions.
Interestingly, participants in the contingency management groups ach­
ieved these results despite earning a considerably smaller proportion of
the incentives than had been observed in earlier contingency manage­
ment studies.
Reback et al. (2010) found that homeless, substance-using men who
have sex with men in a contingency management condition who
received incentives for abstinence, attendance, and completion of
health-promoting behaviors submitted more samples negative for
methamphetamine, amphetamines, PCP, and cocaine and a blood
alcohol <.05 than participants in a control group who received in­
centives only for attendance. Contingency management participants
retained reductions in drug use compared to control participants
through 9- and 12- month follow-ups.
Menza et al. (2010) did not find group differences in the submission
of negative samples during intervention for methamphetamine-using
men who have sex with men randomly assigned to receive contin­
gency management or referral to community resources. During inter­
vention and at follow-up the contingency management group was
significantly more likely to self-report weekly or daily methamphet­
amine use and using >8 quarters of methamphetamine.
In Corsi et al. (2012) and Corsi et al. (2019), non-transient men who
have sex with men were randomly assigned to a contingency manage­
ment group or a contingency management + strengths-based case
management group. Both studies showed improvements in participants
over time, but neither study indicated a significant difference between
groups on the main outcome variables. In the Corsi et al. (2012) study, a
significant reduction in the proportion of amphetamine- and
methamphetamine-positive samples from baseline to follow-ups were
reported in both conditions.
Roll et al. (2013) reported that for methamphetamine dependent
participants, consecutive days of abstinence and the number of partici­
pants who remained 100 % or 80 % abstinent increased as contingency
management duration increased (no contingency management, 1-, 2-, or
4-months). However, treatment attendance and consecutive days of
methamphetamine abstinence were positively correlated with duration
of contingency management making it difficult to separate the effects of
contingency management on abstinence and attendance. Specifically,
there is an interpretive difficulty that arises from imputing missing
samples as positive, especially when a direct effect of the intervention is
to reinforce attendance (Silverman et al., 2013).
Carrico et al. (2015) randomly assigned men who have sex with men
to receive contingency management only or contingency management
plus a positive affect intervention. They reported no differences in the
number of methamphetamine negative samples submitted or the mean
duration of continuous abstinence between groups. In both groups, the
majority of submitted samples were negative. Carrico et al. (2018) found
similar results with a sample of HIV-positive participants. No differences
between groups in the number of methamphetamine negative samples
8
Drug and Alcohol Dependence 216 (2020) 108307
were reported; however, participants assigned to the contingency
management + positive affect condition self-reported less stimulant use.
Chudzynski et al. (2015) reported that participants seeking treat­
ment for methamphetamine use disorders who received contingency
management submitted more negative samples than participants who
received standard care. Amongst contingency management participants,
there were no differences in the number of negative samples associated
with different frequencies of reinforcement.
Nyamathi et al. (2017) and Zhang et al. (2018) assigned homeless
stimulant-using men who have sex with men and transgender women to
either a Nurse Case Management + contingency management or to a
Standard Education + contingency management condition. However,
Nyamathi et al. (2017) excluded transgender women from their analysis
given the distinct needs of this population. In both studies, both condi­
tions produced a reduction in the number of participants who tested
positive for methamphetamine.
3.1.2. Retention
Shoptaw et al. (2005) reported that contingency management par­
ticipants retained for longer periods than cognitive behavioral therapy
participants. Reback et al. (2010) found that contingency management
participants submitted a higher proportion of samples, and Roll et al.
(2013) found that retention rates were significantly higher in the
4-month contingency management group than the standard treatment
group. However, Roll et al. (2006b) and Menza et al. (2010) found
similar retention rates between conditions.
3.1.3. Attendance/Treatment engagement
Six studies reported effects of contingency management on atten­
dance and/or treatment engagement. Shoptaw et al. (2005) found that
contingency management + cognitive behavioral therapy participants
attended significantly more therapy sessions over standard cognitive
behavioral therapy participants and achieved significantly higher pay­
outs than contingency management-only participants. Chudzynski et al.
(2015) found that participants in the intermittent predictable contin­
gency management condition were more likely to attend treatment than
those in the standard treatment condition. Corsi et al. (2019) found that,
among the subset of participants who had a regular sex partner, those
assigned to the contingency management + strengths-based case man­
agement condition were more likely to attend at least one session than
those in in the contingency management-only condition. Zhang et al.
(2018) found that the majority of participants eligible to receive the
HAV/HBV vaccination completed the vaccine series, independent of
whether they were assigned to the Nurse Case Manage­
ment + contingency management or the Standard Educa­
tion + contingency management conditions. Roll et al. (2006b) found
no effects of treatment on counseling attendance. Reback et al. (2010)
also reported no differences between conditions in attendance at study
visits or service program activities; however, contingency management
participants completed significantly more health-promoting behaviors.
3.1.4. Sexual risk behavior
Three studies reported reductions in risky sex. Shoptaw et al. (2005)
and Menza et al. (2010) found that participants across conditions re­
ported a decrease in unprotected anal intercourse at the end of treatment
from baseline; these reductions were maintained through follow-up.
Corsi et al. (2012) found that at the 4-month follow-up strengths-­
based case management + contingency management participants re­
ported greater reductions in sex risk behaviors including any sex in the
last 30 days, unprotected sex, sex under the influence, and sex for drugs
or money than contingency management-only participants. However, at
the 8-month follow-up the effect of treatment was reversed for sex under
the influence and sex for drugs or money.
Four studies reported reductions in the number of sexual partners.
Shoptaw et al. (2005) reported reductions in the number of sexual
partners across conditions. Nyamathi et al. (2017) and Zhang et al.
H.D. Brown and A. DeFulio
(2018) found that fewer participants in both groups (i.e., Nurse Case
Management + contingency management and Standard Educa­
tion + contingency management) reported sex with multiple partners
from baseline to the 4-month follow-up. Reback et al. (2014) found that
a modified culturally specific cognitive behavioral ther­
apy + contingency management intervention produced greater re­
ductions in number of male sexual partners at the end of treatment and
at follow-up than culturally specific cognitive behavioral therapy -only
interventions.
3.1.5. Drug craving
Shoptaw et al. (2006) did not find any interaction between treatment
and methamphetamine craving, but they did find an interaction be­
tween time and craving. Carrico et al. (2018) found that participants in
the positive affect group reported less intense cravings prior to the final
three positive affect sessions and at the end of treatment.
3.1.6. Mood/Affect
Carrico et al. (2015) found that participants in the positive
affect + contingency management condition reported increases in pos­
itive affect at the end of treatment and participants in the contingency
management-only group reported decreases in negative affect; however,
these differences were not maintained through follow-up. Carrico et al.
(2018) found that positive-affect + contingency management partici­
pants reported an increase in positive affect prior to sessions 3 and 5.
Shoptaw et al. (2006) did not find an interaction between treatment and
depressive symptoms.
3.1.7. Acceptability
Corsi et al. (2012) found that participants rated the contingency
management intervention positively and that participants in the
strengths-based case management + contingency management condi­
tion rated the testing schedule more positively and barriers to atten­
dance and participation less negatively than contingency
management-only participants. Zhang et al. (2018) found that vacci­
nation as a result of both Nurse Case Management + contingency
management and Standard Education + contingency management was
more cost-effective than HBV treatment and that Standard Educa­
tion + contingency management was more cost-effective and required
half of the staff time than did Nurse Case Management + contingency
management.
3.1.8. Treatment response predictors
HIV serostatus was associated with treatment response in three
studies. Menza et al. (2010) found that HIV-positive participants were
more likely to attend the 24-week study visit. Reback et al. (2010) found
that within the CM condition, HIV-positive participants accomplished
more health-promoting behaviors than HIV-negative participants and
across conditions, HIV-negative participants submitted more amphet­
amine, methamphetamine, and Level 1 composite negative samples than
HIV-positive participants. Nyamathi et al. (2017) reported that being
HIV-positive at baseline was a predictor for stimulant use at follow-up.
Ethno-racial identity was associated with treatment response in three
studies. Reback et al. (2010) reported that Caucasian participants
accomplished more health-promoting behaviors than African American
and Latino participants. and Caucasian participants submitted more
Level 1 composite negative samples than all other ethnic groups. Reback
et al. (2012) found that responders were more likely to be Caucasian.
Nyamathi et al. (2017) found that “other” race/ethnicity was inversely
related to stimulant-use at follow-up.
Reback et al. (2012) and Nyamathi et al. (2017) found associations
between a history of drug use and treatment response. In the Reback
et al. (2012) study, responders reported fewer years of lifetime use of
cocaine, methamphetamine, as well as polysubstance use. Nyamathi
et al. (2017) reported that recent injection drug use and testing positive
for amphetamines at baseline were predictors for stimulant use at
9
Drug and Alcohol Dependence 216 (2020) 108307
follow-up.
Fletcher et al. (2014) and Ling Murtaugh et al. (2013) evaluated
whether the frequency of voucher redemption was associated with
substance use. Fletcher et al. (2014) found that participants who used
methamphetamine throughout the intervention had less time between
their voucher exchanges. Contrarily, Ling Murtaugh et al. (2013) found
that participants who exchanged vouchers during a visit were more
likely to produce a stimulant-negative sample at the next visit than
participants who accumulated their vouchers.
Additional associations with treatment response were identified in
three studies. Reback et al. (2012) found that responders reported more
recent sexual partners and unprotected anal intercourse events. Corsi
et al. (2019) found that belonging to a class of participants who were in a
couple, had no history of sexual abuse, and reported less methamphet­
amine at baseline was a predictor for negative samples. Within this class
of participants, those in the strengths-based case manage­
ment + contingency management submitted more negative samples.
Fletcher and Reback (2013) found that participants diagnosed with
Antisocial personality disorder (ASPD) submitted more negative sam­
ples than participants without ASPD regardless of condition and that
ASPD participants completed a similar amount of health-promoting
behaviors but earned fewer vouchers for health-promoting behaviors
indicating that they completed smaller magnitude behaviors.
3.2. Pre-post studies
3.2.1. Drug abstinence
Strona et al. (2006); Shoptaw et al. (2006b), and Gómez et al. (2018)
evaluated the Positive Reinforcement Opportunity Project (PROP), a
contingency management intervention for reducing methamphetamine
use in men who have sex with men that was implemented by the San
Francisco Department of Public Health. Participants in the Shoptaw
et al. (2006b) study submitted an average of 15 of a possible 36
methamphetamine-negative samples, and participants in the Gómez
et al. (2018) study submitted a median of 22 of a possible 36 negative
samples over the course of the intervention, equating to over 7 weeks of
abstinence. Strona et al. (2006) reported that 96 % of all submitted
samples were methamphetamine-negative. This suggests that the large
majority of PROP participants who continued to use methamphetamine
during the Strona et al. (2006) study did not submit samples.
Landovitz et al. (2012) evaluated a contingency management inter­
vention among methamphetamine using men who have sex with men
who had recently reported a high-risk sexual or injection drug exposure
and were, therefore, initiated on Post-Exposure Prophylaxis (PEP). Over
the course of the intervention, participants reported a reduction in
methamphetamine use and submitted more methamphetamine negative
samples.
Okafor et al. (2019) conducted a secondary analysis of an 8-week
pilot contingency management intervention trial in South Africa and
reported that 68 % of participants submitted a majority of metham­
phetamine negative samples and 61 % remained abstinent throughout
the intervention.
3.2.2. Retention
Strona et al. (2006) and Shoptaw et al. (2006b) reported 35 % and 30
% retention rates at the end of treatment for PROP participants,
respectively. Okafor et al. (2019) reported a 93 % treatment completion
rate.
3.2.3. Attendance/treatment engagement
Landovitz et al. (2012) reported that the likelihood of PEP adherence
and course completion increased with the number of
methamphetamine-negative samples submitted.
3.2.4. Acceptability
Strona et al. (2006); Shoptaw et al. (2006b), and Gómez et al. (2018)
H.D. Brown and A. DeFulio
reported treatment effectiveness comparable to that of treatment
research programs. Additionally, Strona et al. (2006) and Shoptaw et al.
(2006b) reported retention rates comparable to research studies and
lower cost of treatment than other available treatments.
Krishnamurti et al. (2020) interviewed participants following an
8-week contingency management intervention in South Africa and
found that a majority of participants (12/17) viewed incentives for
abstinence positively and most participants (15/17) viewed them as
rewards which they were proud of earning.
3.2.5. Sexual risk behaviors
Strona et al. (2006) and Landovitz et al. (2012) observed a reduction
in the self-reported number of sex partners over the course of treatment.
Landovitz et al. (2012) also observed a reduction in the number of un­
protected anal intercourse events.
3.2.6. Treatment response predictors
Okafor et al. (2019) reported that responders to treatment had lower
monthly income, more years of education, and lower body mass index
than non-responders. Lower body mass index was also correlated with
lower monthly income, indicating that both may be a product of a
general relationship between socioeconomic status and response to
treatment.
Krishnamurti et al. (2020) found that participants who exchanged
vouchers at one study session were more likely to submit negative
samples at subsequent study sessions than participants who accumu­
lated vouchers, replicating the findings of Ling Murtaugh et al. (2013).
Lake et al. (2020) assessed the decision-making of partial responders
(participants who submitted one or more methamphetamine positive or
missing sample) compared to healthy controls using the Iowa Gambling
Task. While all participants show a preference for larger more imme­
diate rewards, partial responders made more choices for large, imme­
diate rewards over smaller short-term rewards relative to healthy
controls.
4. Discussion
The current literature strongly supports the use of contingency
management as an intervention for methamphetamine use and provides
further evidence for the use of contingency management as a treatment
for substance use more broadly. The present review provides the most
complete account to date regarding the broad beneficial effects of con­
tingency management in the treatment of methamphetamine use dis­
order. This includes its effects on drug abstinence, drug craving,
treatment engagement and retention, earning and spending of in­
centives, mood/affect, and sexual risk behaviors, as well as intervention
acceptability from the perspective of patients. The present review also
provides detailed summary of intervention parameters and predictor
variables correlated with the outcome of contingency management
intervention in methamphetamine use disorder patients.
4.1. Broad effects and correlates of success
Of the 27 studies included in this review, only one (Menza et al.,
2010) found that contingency management did not effectively reduce
methamphetamine use. This may have been the result of participants
completing twice-weekly urine screenings as opposed to thrice-weekly,
because longer inter-test intervals can allow methamphetamine use to
go undetected and potentially compromise the contingent reinforcement
of abstinence.
One study reviewed here evaluated the effects of contingency man­
agement duration and found that longer intervention (up to 4 months)
produced better outcomes (Roll et al., 2013). While no other study here
examined intervention duration, included study interventions ranged
from 2 to 4 months and were effective.
Several of the reviewed studies were evaluations of contingency
10
Drug and Alcohol Dependence 216 (2020) 108307
management in combination with another treatment, including nurse
case management (Nyamathi et al., 2017; Zhang et al., 2018), cognitive
behavioral therapy (Shoptaw et al., 2005), culturally-tailored cognitive
behavioral therapy (Reback and Shoptaw, 2014), pharmacotherapy
(Shoptaw et al., 2006a), strengths-based case management (Corsi et al.,
2012, 2019), and a positive affect intervention (Carrico et al., 2015,
2018). In the majority of these studies, treatment outcomes related to
methamphetamine use were not improved by the addition of another
treatment and one study found that it was more cost-effective to deliver
standard contingency management (Zhang et al., 2018). However,
Carrico et al. (2018) found that participants who also received a positive
affect intervention self-reported less stimulant use and methamphet­
amine craving than those who did not; and Reback and Shoptaw (2014)
found that while the addition of a culturally-tailored cognitive behav­
ioral therapy did not improve outcomes related to methamphetamine
use, it produced reductions in reported male sex partners.
Contingency management has been shown to be efficacious in
reducing methamphetamine use for special populations that are
impacted by methamphetamine use, including men who have sex with
men (Carrico et al., 2015, 2018; Gómez et al., 2018; Landovitz et al.,
2012; Nyamathi et al., 2017; Reback et al., 2010; Reback and Shoptaw,
2014; Shoptaw et al., 2006a; Strona et al., 2006; Zhang et al., 2018).
This may be especially important as methamphetamine is associated
with risky sexual behavior that significantly contributes to the trans­
mission of HIV and other sexually transmitted infections among men
who have sex with men (Colfax et al., 2004; Marshall et al., 2011).
Studies found a variety of collateral effects of contingency management
interventions for methamphetamine use disorder, including fewer sex
partners (Nyamathi et al., 2017; Reback and Shoptaw, 2014; Strona
et al., 2006; Zhang et al., 2018), fewer instances of unprotected anal
intercourse (Landovitz et al., 2012), increased completion of an
HAV/HBV vaccine series (Zhang et al., 2018) and adherence to PEP
(Landovitz et al., 2013).
Several studies identified possible predicters of treatment outcomes.
Contingency management interventions were least effective for partic­
ipants who reported a longer history of drug use (Reback et al., 2012) or
reported more methamphetamine use during baseline (Corsi et al.,
2019). Other possible predictors were race with Caucasian participants
being most likely to respond to treatment (Reback et al., 2010, 2012)
and HIV status with HIV negative participants responding more posi­
tively to treatment (Nyamathi et al., 2017; Reback et al., 2010). Okafor
et al. (2019) found that responders to treatment were more likely to
have a lower monthly income, more years of education, and a lower
body mass index. Lake et al. (2020) found that full responders were
similar to healthy controls, but partial responders preferred larger more
immediate rewards to a greater extent than healthy controls. Taken
together, these results suggest that greater problem severity and
increasingly complex constellations of medical, social, and psychologi­
cal challenges may reduce the efficacy of contingency management
intervention. However, it is not therefore appropriate to conclude that
contingency management should be withheld from a person with greater
problem severity. Rather, it may be necessary to provide even more
intensive, higher magnitude contingency management intervention
accompanied by a broader array of psychosocial services to especially
refractory patients.
Three studies included analyses to determine whether then spending
behavior of contingency management participants had implications for
treatment outcomes. Two studies (Ling Murtaugh et al., 2013; Krish­
namurti et al., 2020) found that participants who spent earned vouchers
were more likely to submit methamphetamine negative samples at
subsequent sessions. However, Fletcher et al. (2014) observed that
participants who saved vouchers were more likely to submit negative
samples.
The beneficial effects of contingency management for methamphet­
amine are also apparent when it is implemented in community pro­
grams. Three studies reviewed here (Gómez et al., 2018; Shoptaw et al.,
H.D. Brown and A. DeFulio
2006b; Strona et al., 2006) evaluated the effectiveness of a
community-based program in San Francisco, the Positive Reinforcement
Opportunity Project (PROP). Outcomes similar to those observed in
research treatment programs were observed for PROP participants as
well, and the intervention was found to be acceptable to participants and
feasible to implement.
4.2. Comparison to the treatment of other substance use disorders (SUDs)
The effects of contingency management on methamphetamine
abstinence and treatment retention and engagement are not surprising,
given that studies involving other SUDs have shown similar effects. For
example, contingency management has long been known to reduce use
of alcohol, cannabis, cocaine, nicotine, and opioids (Lussier et al., 2006).
Similarly, the effectiveness of contingency management in promoting
treatment attendance (Petry et al., 2018) and medication adherence
(DeFulio and Silverman, 2012) in SUD populations is well-established.
From a conceptual perspective, the view that drug taking is behavior
that is sensitive to its consequences is a cornerstone of behavioral
pharmacology (Thompson and Johanson, 1981). The potential for con­
tingency management intervention to have broad beneficial effects
beyond the behaviors specifically targeted by the intervention has also
been occasionally noted in studies targeting other SUDs (e.g., Silverman
et al., 1998). However, contingency management for methamphetamine
use disorder appears to be unique in terms of the level of support for the
collateral reduction is sexual risk behaviors. We speculate that this is
because contingency management studies involving methamphetamine
use disorder have been more likely to include assessment of sexual risk
behavior as part of the research plan, and perhaps because these studies
have focused on populations with high baseline levels of sexual risk
behaviors.
4.3. Gaps in the literature
There are two key gaps in the literature regarding contingency
management in the treatment of methamphetamine use disorders. These
gaps are related.
The first gap is the need for interventions that support long-term
drug abstinence. The state of affairs is well captured by a recent meta-
analysis, which showed that contingency management interventions
produced significant improvements in drug abstinence at three months
post-treatment, but not at six months post-treatment (Sayegh et al.,
2017). However, the situation may be better than the meta-analysis
implies. In a review of contingency management studies published be­
tween 2009 and 2014, the evidence for post-treatment effects was
summarized. During this period, 47 % of contingency management
studies reported post-intervention effects, and 62 % of these studies (i.e.,
29 % of the total) reported significant post-intervention increases in
drug abstinence (Davis et al., 2016). Long-term outcomes would likely
be much better if the drug abstinence contingencies were simply
maintained, and at least one practical method for achieving this has
been devised (Silverman et al., 2012). Nevertheless, a method for sup­
porting long-term abstinence that is both practical and scalable remains
an important challenge in the treatment of methamphetamine use dis­
order, and SUDs in general.
The second key gap is the adoption of contingency management by
substance abuse treatment providers. Based on the behavioral principles
that underlie contingency management, the decision to adopt contin­
gency management intervention is itself behavior that is a function of
the prior experience of the person making the decision and the contin­
gencies operating on the person at the moment of the decision. This
interpretation is consistent with studies of the barriers to adoption of
contingency management, which have found that intervention costs,
effort, exposure to contingency management, and training are critical
factors (Kirby et al., 2006). Post-treatment effects are also a key issue
(Petry, 2010). Technology may play a role in overcoming many of these
11
Drug and Alcohol Dependence 216 (2020) 108307
barriers (Kurti et al., 2015), but cost-benefit analyses, and intervention
refinements that improve cost-benefit are clearly priorities for future
research if the behavior of decision makers is to be changed in favor of
the adoption of contingency management. Robust post-treatment ef­
fects, in combination with clear evidence of cost-effectiveness and a
method of intervention delivery that reduces effort and obviates
expertise would almost certainly shift the decision making of potential
adopters. Although it may require substantial time and effort on the part
of substance abuse treatment researchers to produce an ideal contin­
gency management intervention, optimism is warranted. The Depart­
ment of Veterans Affairs has implemented contingency management on
a national scale (Petry et al., 2014), and incentives to promote health
behaviors are becoming increasingly accessible to Medicaid recipients
(Vulimiri et al., 2019). Given the persistence of the problem itself, the
lack of pharmacotherapies, contingency management’s solid empirical
and conceptual foundations, and the substantial progress that has been
made in intervention development and dissemination over the last
decade, the widespread provision of contingency management services
to people with methamphetamine use disorders appears realistic.
4.4. Limitations
There are several limitations of this review. First, because of the
variety of intervention combinations and outcome measure variables, it
may be hard to make comparisons between studies. Furthermore, this
review, like any other, is subject to publication bias. This review only
included published studies and as such may not reveal a full picture of
contingency management.
5. Conclusion
Contingency management is broadly effective in reducing metham­
phetamine use and promoting attendance to recovery-related appoint­
ments in people with methamphetamine use disorders, and appears to
produce broad beneficial effects beyond the behaviors targeted for
intervention. The available evidence supports the adoption of contin­
gency management in outpatient treatment programs that serve meth­
amphetamine users. Additional research designed to improve post-
treatment outcomes and enhance intervention adoptability is war­
ranted, but immediate widespread implementation of VBRT in a manner
consistent with published studies is a higher priority.
Contributors
Hayley D. Brown, principal author, contributed to all sections of the
manuscript, conducted review operations as described in the manu­
script, and created the table. Anthony DeFulio, second author, contrib­
uted to all sections of the manuscript, and conducted review operations
as described in the manuscript.
Role of funding source
Nothing declared.
Declaration of Competing Interest
The authors report no declarations of interest.
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