Contingency management drug treatment:

Have we tried this yet?

Larry Newman

In the June issue of IMAGE, I reviewed the book, The Age of Fentanyl, by Dr. Brodie Ramin. Dr. Ramin treats drug-addicted clients at the Sandy Hill Community Health Centre. Earlier this year, he mused on Twitter about a treatment called Contingency Management (CM) and why it hasn’t been used more often.

CM is not new. In some form, it’s been used by most parents. We use it when we reward our children for their good behaviour when they mow the lawn or bring in the garbage containers from the curb every week. In the case of drug addicts trying to kick the habit, the reward is for staying drug free for some period of time.

A common treatment is for the client to replace the addictive drug with a substitute, such as buprenorphine or methadone. These are opioids and can be used in place of other, more dangerous opioids such as fentanyl or heroin. The substitute opioids can be dispensed by prescription, assuring the user that the drug isn’t contaminated or containing a “filler” chemical, an all too common experience with street drugs.

In a recent New York Times article, Abby Goodnough writes about Steven Kelty, a Pennsylvania resident with a crack cocaine addiction. “He would come to a clinic twice a week to provide a urine sample, and if it was free of drugs, he would get to draw a slip of paper out of a fishbowl. Half of the slips of paper contained encouraging messages typically, “Good job!” but the other half were vouchers for prizes worth between $1 and $100,” the story reads.

As I searched for examples of CM to treat drug addiction, I found many instances of programs that have tried and written about it, but very few ongoing programs. However, searching the medical journals, I found nine articles reporting results of CM trials. All results showed CM provided better results than the control treatment.

One study evaluated 50 published and unpublished randomized control trials for 12 addiction treatments. CM plus community reinforcement was the only intervention that increased the number of abstinent patients at the end of treatment. The community reinforcement approach involves the patient’s family and/or local people in the treatment process to encourage abstinence.

CM is clearly effective. Why then don’t government and business rush to employ this clearly beneficial treatment? I suspect one reason is because CM requires rewards and counselling to operate effectively. That’s expensive. Also, there is probably little political support for a program that rewards drug users.

However, we know it works. Now’s the time, Ottawa Public Health. Let’s get off the fence and fund this drug addiction treatment. We have many clinics in Ottawa and a big illicit drug problem.