Contingency management

1. Introduction

Version followed: two reference protocols, used side by side. (a) Voucher-based CM as specified in the NIDA Therapy Manual A Community Reinforcement Plus Vouchers Approach: Treating Cocaine Addiction (Budney & Higgins, 1998). (b) Prize-based (fishbowl) CM in the UConn/VA form developed by Nancy Petry, as set out in the 2010 Contingency Management Competence Scale rating manuals (Ledgerwood & Petry; Petry & Ledgerwood), the VA national rollout materials (DePhilippis, 2019) and UConn training by Carla Rash (2023). Where a public programme differs, the California Recovery Incentives Program (DHCS/UCLA ISAP, 2025 slides) is named as the variant. [source: Budney & Higgins 1998; CMCS manuals 2010; DePhilippis 2019; Rash 2023; UCLA ISAP 2025]

What it is. Contingency management (CM) is not a stand-alone psychotherapy. It is a set of procedures, drawn from operant conditioning and token-economy work, that are added to ordinary treatment (counselling, CRA, medication for opioid use disorder) as an adjunct. A clearly defined, objectively verified target behaviour, most often abstinence from a specified drug confirmed by a urine or breath test, earns a tangible reinforcer each time it occurs. If the behaviour does not occur, the reinforcer is withheld. Reinforcers are retail vouchers (Stephen Higgins and colleagues, cocaine, early 1990s), chances to draw prizes from a bowl (Nancy Petry and colleagues, later 1990s), or clinic privileges such as take-home methadone doses. [source: Budney & Higgins 1998; Petry 2011; Wikipedia CM; Case Western Getting-Started Guide]

How change is thought to happen. Drug use is treated as operant behaviour maintained by powerful, immediate drug reinforcement. CM sets up a competing source of reinforcement that is frequent, immediate and certain, and that grows with continuous abstinence, so that stretches of abstinence get longer. During those stretches the client can build natural, non-drug reinforcers (work, relationships, recreation), which the accompanying counselling targets and which sustain change once the incentives end. Longest continuous abstinence during treatment is the outcome the procedures are built to produce, because it predicts later outcome. [source: Budney & Higgins 1998; Rash 2023]

2. Framework

CM has no therapeutic "phases" in the psychotherapy sense. It runs as a time-limited schedule alongside other treatment, in four operational stages. [source: Budney & Higgins 1998; Rash 2023; DePhilippis 2019; UCLA ISAP 2025]

Stage 0. Programme design (before any client starts). Goal: a written protocol that fixes the target behaviour, population, verification method, reinforcer type, magnitude, escalation, reset and recovery rules, excused-absence rules and duration. Rash advises piloting with 1–2 clients and role-playing the client explanation at least once before launch. Exit criterion: written protocol, tests and reinforcers in stock, staff trained (NICE requires staff competent in near-patient testing and CM delivery, introduced in a phased, evaluated way). [source: Rash 2023; NICE CG51 1.4.3.1–1.4.3.2]

Stage 1. Orientation and enrolment (session 1, about 10–12 minutes for the CM part). Goal: the client understands and agrees to the rules. Cover the target, test schedule, how reinforcers are earned and redeemed, resets, excused absences, sample-validity rules, the end date and any cap; obtain written consent or a behavioural contract. Exit criterion: signed agreement; client can explain back the rule linking result to reward. [source: Rash 2023; UCLA ISAP 2025; Case Western guide; NICE CG51 1.4.1.3]

Stage 2. Active reinforcement (initial intensive period).

Voucher protocol (Higgins/Budney): urine testing three times a week (e.g. Mon/Wed/Fri) for weeks 1–12; vouchers escalate with each consecutive cocaine-negative sample. [source: Budney & Higgins 1998]
Prize protocol (Petry/VA): testing two or three times weekly; draws start at 1 and rise with consecutive negatives to a cap of about 8; typical duration 12 weeks. [source: DePhilippis 2019; Rash 2023]
California Recovery Incentives variant: twice-weekly visits and tests in weeks 1–12. [source: UCLA ISAP 2025]
NICE variant (UK): three tests a week for the first 3 weeks, two a week for the next 3, then weekly until stable. [source: NICE CG51 1.4.1.4]
Each CM contact takes about 2–5 minutes after the first; CM is delivered at the start of the counselling session or as a separate brief visit. [source: Rash 2023; CMCS abstinence manual]

Stage 3. Step-down / maintenance. Goal: thin the schedule while maintaining abstinence. Voucher protocol: weeks 13–24, testing twice weekly and each negative earns one state lottery ticket (the 1998 manual's reinforcer). California: weeks 13–24, weekly visits and tests. Rash recommends total duration ideally 12–24+ weeks and at least 12. Movement from Stage 2 to 3 is calendar-based in all these protocols, not performance-based. [source: Budney & Higgins 1998; UCLA ISAP 2025; Rash 2023] Lottery tickets as reinforcers conflict with later practice (California prohibits lottery purchases with incentives; prize CM excludes people in gambling recovery) [synthesis; uncertain whether current Vermont CRA+V sites still use them].

Stage 4. Ending. Remind the client of the end date about two weeks ahead, discuss reactions openly, and mark completion (e.g. certificate). Counselling and other treatment continue. [source: Rash 2023]

Format and dose summary. Individual or group; outpatient, methadone/OTP, intensive outpatient; NICE also recommends it in inpatient/residential settings. Typical maximum earnings: voucher CM around $750–$1,500 (Higgins protocol about $997.50 over 24 weeks); prize CM about $200–$533 over 12 weeks; California capped at $599 per calendar year. [source: Rash 2023; DePhilippis 2019; UCLA ISAP 2025; NICE CG51 1.5.1.1] Magnitude limits in the USA are set by regulation and payer rules and change over time; check current local rules [uncertain].

3. Guiding principles

[source for the parameter list: Rash 2023 (UConn); Petry 2011; Budney & Higgins 1998; NICE CG51]

Objective verification. Reinforce only what you can measure (urine, breath, attendance record, documented receipt). Practical meaning: never pay on self-report; Rash's training states this in capitals.
One clear target. Choose a single drug or drug class, or a single behaviour. Practical meaning: the client must always know exactly what earns the reward; abstinence ranks above attendance when both are feasible.
Frequent monitoring. Test often enough that no use episode is missed and each abstinent stretch can be rewarded. Practical meaning: at least twice weekly for stimulants and opioids, three times is better; breath tests for alcohol or nicotine need several checks a day.
Immediacy. Deliver the reinforcer at the same visit as the result. Practical meaning: use on-site rapid tests; never "we'll sort your draws next week".
Reinforce every occurrence at first (FR1). Practical meaning: every negative sample earns something in the initial period.
Adequate magnitude. The reward must compete with the drug but be sustainable. Practical meaning: underpowered CM fails; do not dilute the schedule to save money without accepting reduced effect.
Escalation. Reinforcement grows with each consecutive success. Practical meaning: continuous abstinence is worth more than scattered abstinence.
Reset (and recovery). A positive or unexcused missed test returns the value to the start; a run of negatives restores the prior level. Practical meaning: lapses cost something, but the way back is short and stated in advance (5 consecutive negatives in Higgins; 2 in California).
Earned rewards are never taken away. Practical meaning: no fines, no confiscating vouchers already banked. [source: Budney & Higgins 1998]
Consistency and fidelity. Same rule every time, every client. Practical meaning: no discretionary extra draws, no withholding for unrelated misbehaviour; audit bowls and logs.
Adequate duration. At least 12 weeks; longer for higher-risk clients. Practical meaning: plan funding before enrolling.
Reinforcers that support a drug-free life. Practical meaning: no cash; vouchers redeemed for prosocial goods; prohibited purchases (alcohol, tobacco, cannabis, lottery, gambling, firearms in the California rules). [source: Budney & Higgins 1998; UCLA ISAP 2025; NICE CG51 1.4.1.3]
Client choice of reinforcer. Practical meaning: ask what the client wants and stock it; NICE requires that the incentive is perceived as reinforcing.
Warm, non-judgemental delivery. Practical meaning: praise effort, express confidence, never confront or blame after a positive; say "not negative" rather than "positive" unless the client says it first. [source: CMCS abstinence manual 2010]
Adjunct, not replacement. Practical meaning: CM sits on top of counselling or MOUD; for opioid use disorder it supplements medication. [source: Case Western guide]
Transparency. Practical meaning: all rules (including prize odds) explained at the start in writing; the ethics literature urges honesty about the low odds of large prizes. [source: Gagnon et al. 2021]

4. Intervention inventory

The procedures below cover programme set-up, the core reinforcement procedures (voucher and prize), alternative targets, and integration with counselling. Dollar figures are the published protocol values, given so the schedule logic is clear; adjust to local regulation and funding. Example language is illustrative unless quoted and cited.

4.1 Programme design: choosing target, population, reinforcer and schedule

Purpose / when: Before enrolling anyone, and whenever a programme is revised. Most CM failures in practice come from design drift; the 2023 VA/UConn implementation paper (J Subst Use Addict Treat 151:209079) separates evidence-based elements, acceptable modifications and non-recommended modifications. [source: PubMed 37230390 abstract; Rash 2023]
Steps:
1. Pick the population (e.g. stimulant use disorder; methadone patients with continued use; people with poor attendance). NICE names methadone patients and primary stimulant users; Case Western adds alcohol, tobacco, opioids, attendance, retention and medication adherence. [source: NICE CG51 1.4.1.1–1.4.1.2; Case Western guide]
2. Pick one target. Hierarchy: abstinence from one drug or class first; attendance if abstinence cannot be verified often enough. [source: Rash 2023]
3. Pick the verification method and confirm rapid on-site results are possible. Check for prescribed medications that cause false positives for the target; the VA treats such medications as a contraindication. [source: DePhilippis 2019]
4. Pick the reinforcer system (vouchers, prizes, privileges) and set magnitude, first value, escalation step, bonus, cap, reset and recovery rule, excused-absence rule and duration (≥12 weeks).
5. Write it down as the client-facing description and the staff protocol; define lateness, leaving early, valid absence reasons and documentation, refused or unavailable samples. [source: Rash 2023]
6. Pilot with 1–2 clients. [source: Rash 2023]
Watch for: Prior CM in the last 12 months, settings where test results could be used punitively (both VA contraindications), and clients in recovery from gambling disorder (exclude from prize CM). [source: DePhilippis 2019; Rash 2023]

4.2 Orientation and behavioural contract

Purpose / when: First CM contact, before the first test. Makes the contingency explicit, which NICE requires ("fully understands" the link between goal and incentive, paraphrased). [source: NICE CG51 1.4.1.3]
Steps:
1. Confirm eligibility before describing the programme (avoids disappointing ineligible clients). [source: Rash 2023]
2. Give the written description. Explain: target drug; visit and test days; how much is earned for the first negative and how it grows; what resets it (positive, unexcused absence, refusal, tampered sample) and how to recover; what counts as an excused absence and how to arrange one in advance; that earned rewards are never taken away; the end date; any annual cap; how vouchers or prizes are redeemed and what cannot be bought. [source: Budney & Higgins 1998; Rash 2023; UCLA ISAP 2025]
3. Tell the client that one use episode can produce several positive tests (cocaine metabolites persist), to pre-empt disputes. [source: Budney & Higgins 1998]
4. Explain prize odds plainly if using a bowl (about half the slips win nothing; one in 500 is the top prize). [synthesis, from Gagnon et al. 2021 on transparency]
5. Ask the client to explain the rules back; sign the agreement (voluntary participation, targets, schedule, monitoring, attendance expectations, review dates, duration). [source: Case Western guide; synthesis for teach-back]
Example language (illustrative): "Every time your test is negative for cocaine, you earn draws today, and the number goes up each time you're negative in a row. If a test isn't negative, or you miss without arranging it first, you get nothing that day and the count goes back to one. Two negatives in a row after that and you're back where you were. Nothing you've already won can be taken away."
Watch for: Client misunderstanding of reset rules (the most common source of later disputes); coercion when referral is legal (Gagnon et al. report 17–94% legal-system referral in prize-CM studies): emphasise that declining CM does not affect other care. [source: Gagnon et al. 2021; synthesis]

4.3 Reinforcer preference assessment

Purpose / when: At orientation and every visit; the reinforcer must actually be valued. NICE says to discuss which incentives the person finds reinforcing. [source: NICE CG51 1.4.1]
Steps: Ask what the client would like to work toward; show the prize cabinet or catalogue; invite suggestions for new items; note them and restock; respond with enthusiasm; never dismiss a request. [source: CMCS abstinence manual item 4; CMCS attendance item 4]
Example language: "What would you like to win?" (verbatim, CMCS abstinence manual). Illustrative follow-up: "Headphones are in the large category; at six draws next time your odds of a large go up."
Watch for: Items that could be traded for drugs (Rash notes abstinence-contingent CM is self-correcting because trading leads to positive tests, attendance CM is not); low interest in the stock, which predicts weak effect. [source: Rash 2023]

4.4 Objective verification: sample collection and on-site testing

Purpose / when: At every scheduled CM visit, before any reinforcer is discussed.
Steps:
1. Collect the sample at the scheduled time (urine for stimulants/opioids; breath for alcohol; nicotine via breath CO or cotinine). [source: Rash 2023; Budney & Higgins 1998]
2. Check validity: temperature and, where the device allows, pH and adulterant panels. If tampering is suspected, collect another sample the same day. Reserve the right to observed collection from the outset and use it when needed. [source: Rash 2023; UCLA ISAP 2025]
3. Read the result immediately, before the client leaves. VA guidance says collection need not be observed and non-target drugs need not be tested; Higgins screened one random sample a week for other drugs. California tests opiates and oxycodone for safety without linking them to incentives. [source: DePhilippis 2019; Budney & Higgins 1998; UCLA ISAP 2025]
4. Log the result, the reinforcement given and the next-visit value.
Watch for: Results arriving after the client leaves, which breaks immediacy; any positive opioid result triggers an opioid use disorder assessment, naloxone provision and MOUD referral as in the California protocol. [source: UCLA ISAP 2025]

4.5 The CM contact: structured result-and-reinforcement sequence

Purpose / when: Every CM visit. This sequence follows the competence elements in the Contingency Management Competence Scale (CMCS), which is the published fidelity standard for prize CM. The whole sequence usually takes under 10 minutes. [source: CMCS abstinence manual 2010; Rash 2023]
Steps (in order):
1. Greet warmly.
2. Ask directly about use, urges and cravings since the last visit, including drugs other than the target; do not assume abstinence. (VA lists this before giving the result; the CMCS rates it as its own element.) [source: CMCS item 5; DePhilippis 2019]
3. Show and state the result, naming each target substance. [CMCS item 1]
4. State exactly how many draws (or what voucher value) were earned today and why, checking the number against the schedule. [CMCS item 2]
5. Deliver the reinforcer immediately: client draws (in the attendance manual, the client shows open palms before drawing); record draws and prizes; return all slips to the bowl. [CMCS attendance item 3; DePhilippis 2019]
6. If the client reported use, connect the report to the result and to its consequence for draws, supportively. [CMCS items 6–7]
7. Praise effort, whatever the result. [CMCS item 8]
8. State what the next visit is worth if negative; give a written reminder slip. [CMCS item 3; DePhilippis 2019 "Prize Reminder Slip"]
9. Ask about desired prizes and link bigger chances to continued abstinence. [CMCS item 4]
10. Express confidence in future success, ideally citing past success. [CMCS item 9]
11. Move on to the counselling content. Rash's preferred flow is: sample, result and reinforcement, prize selection, then clinical content. [source: Rash 2023]
Example language (verbatim fragments, CMCS abstinence manual): "your drug test was negative for cocaine today"; "if your test is negative, you will have the chance to earn 6 draws"; "I know you can get back on track."
Watch for: Giving draws before the result is known, the wrong number of draws, indifference, or a CM segment that sprawls. CMCS rates each element on a 1–7 scale plus general skill, structure and empathy. [source: CMCS manuals]

4.6 Voucher-based reinforcement (Higgins/Budney schedule)

Purpose / when: Abstinence reinforcement where funding allows higher total magnitude; the original cocaine protocol, delivered with CRA.
Steps (1998 manual values):
1. Test three times weekly in weeks 1–12.
2. First cocaine-negative sample earns 10 points ($2.50; one point is about $0.25). Each consecutive negative adds 5 points (second 15 points/$3.75, third 20 points/$5.00, and so on).
3. Three negatives in one week earn an extra $10 bonus.
4. A positive or missed sample resets the next value to $2.50. Five consecutive negatives after a reset return the value to where it was before the reset.
5. Points already earned are banked and never lost.
6. Weeks 13–24: test twice weekly; each negative earns one state lottery ticket.
7. Show the client a running graph of negative results and attendance. [source: Budney & Higgins 1998]
Example language: The manual's sample praise at a negative result is "Good job, Jim. You're doing great." followed by friendly conversation about work and weekend plans. [source: Budney & Higgins 1998]
Watch for: Total cost (about $997.50 maximum over 24 weeks per Rash's summary); the lottery-ticket component is out of step with current gambling safeguards [synthesis]. [source: Rash 2023]

4.7 Voucher redemption linked to treatment goals

Purpose / when: Whenever the client spends voucher earnings; turns earnings into prosocial reinforcers that support CRA lifestyle goals.
Steps: Never give cash. The client requests an item; staff buy it in the community; the therapist approves only purchases consistent with drug-free prosocial activities in the treatment plan (the therapist has veto). Examples in the manual include ski passes, fishing licences, restaurant vouchers, camera or bicycle equipment, and continuing-education materials. [source: Budney & Higgins 1998]
Example language (illustrative): "You've got $85 banked. You mentioned getting back into fishing with your brother; a licence and some tackle would fit that goal. Want me to put the order in today?"
Watch for: Delays between request and delivery (weakens the reinforcer); purchases that could be converted to cash or drugs; staff time for purchasing. Modern programmes often use restricted gift cards with banned categories instead (California: no alcohol, cannabis, tobacco, lottery or gambling; some cards also block firearms). [source: UCLA ISAP 2025]

4.8 Prize-based (fishbowl) reinforcement

Purpose / when: Abstinence (or attendance) reinforcement at lower average cost than vouchers; the most widely implemented form (VA, many US states).
Steps (VA/UConn protocol):
1. Build the bowl: 500 slips, of which 250 say "Good job!" with no prize, 209 are small (about $1), 40 are large (about $20) and 1 is jumbo (about $100). [source: DePhilippis 2019; Rash 2023]
2. Escalate draws: 1 draw for the first negative, increasing by one with each consecutive negative, capped at about 8 per visit. [source: DePhilippis 2019; Rash 2023]
3. A positive sample or unexcused absence earns no draws and resets the next negative to 1 draw. An excused absence earns nothing but does not reset. Optional evidence-informed add-ons: weekly bonus draws, a guaranteed large prize, caps, return to the prior position after 2 weeks on target. [source: Rash 2023]
4. The client draws; staff read each slip aloud, hand over or record the prize, and return every slip to the bowl so odds stay constant. [source: DePhilippis 2019]
5. Expected total: about $432 for a client attending every visit with all negatives (164 draws over 12 weeks; that total matches twice-weekly visits with a cap of 8 [synthesis: arithmetic check]); about $206 with one no-show and two positives (Rash's worked example). Typical budget about $200 per patient over 12 weeks (VA). [source: Rash 2023; DePhilippis 2019]
Example language (illustrative): "That's your fourth negative in a row, so four draws today. Go ahead. A small, a good job, a good job, and a large! Next time, if you're negative, it's five."
Watch for: Bowl tampering or miscounting (audit slips and inventory); clients in gambling recovery (exclude). Gagnon et al. raise concerns about "priming" (making early draws especially attractive) and about the gap between the appeal of the jumbo prize and its low odds; disclose odds. [source: Rash 2023; Gagnon et al. 2021]

4.9 Prize cabinet and inventory management

Purpose / when: Ongoing; keeps reinforcers attractive and the programme honest.
Steps: Stock small items (50+ items across 25+ kinds: toiletries, food, socks, transit tokens, $1 food coupons), large items (15+: gift cards, small appliances, headphones, speakers, watches) and 2–3 jumbo options. Alternatively use mostly or wholly gift cards, preferring widely accepted cards and avoiding overbuying single-store cards. Restock from client requests. Keep an inventory log reconciled against draw records; audit the bowl contents regularly. [source: Rash 2023]
Watch for: Stale stock; supply shortfalls (a client who wins a large and finds nothing desirable has been effectively punished); fishbowl fraud, which VA lists as a concern without a stated remedy. Two-person counts and locked storage are reasonable controls [synthesis].

4.10 Responding to a negative result

Purpose / when: Each target-negative result; maximises the reinforcing value of the moment.
Steps: State the result; celebrate genuinely; deliver the reinforcer; ask what helped this time (therapist session, per Budney & Higgins); state next visit's value; express confidence. California's training uses the mnemonic JOY: join the celebration, offer encouragement, remind the client what more can be earned. [source: Budney & Higgins 1998; UCLA ISAP 2025]
Example language: "Great job! You worked hard to get to this point." (verbatim, CMCS abstinence manual). Illustrative: "Three weeks clean of meth. What did you do differently on Saturday night?"
Watch for: Flat or perfunctory delivery, which the CMCS rates as low competence; the counselling content should build on what helped (functional analysis of successful days). [source: CMCS abstinence manual]

4.11 Responding to a positive ("not negative") result

Purpose / when: Each target-positive, refused or invalid sample. Keeps the contingency intact without shaming, so the client returns.
Steps:
1. State the result plainly; the CMCS manual advises saying "not negative" unless the client uses "positive" first. [source: CMCS abstinence manual]
2. State the consequence: no reinforcer today and the reset value for the next negative. Then state the recovery rule ("two more negatives in a row and you're back where you were" in California; five in Higgins).
3. If the client disclosed use, thank them for honesty and link the report to the result. [CMCS items 6–7]
4. Praise attendance and effort; express confidence. California's mnemonic EASE: be non-judgemental, praise attendance, specify the next visit, offer support. [source: UCLA ISAP 2025]
5. In the counselling segment: reassure, then do a functional analysis of the use episode (triggers, thoughts, consequences, alternative plan). [source: Budney & Higgins 1998]
6. In the Higgins model the urine-collection staff member records amount and day of use, does not chat or advise, and refers the client straight to the therapist; the therapist hears the result as soon as possible. [source: Budney & Higgins 1998]
Example language: "so you won't get any draws today" and "I know you are trying very hard" (verbatim fragments, CMCS abstinence manual); California's script includes "we do have to base the incentive on the result of the urine drug test." [source: UCLA ISAP 2025] Illustrative: "Today's test wasn't negative, so no draws today, and next time starts at one. You came in anyway, and that matters. Let's look at what happened Friday."
Watch for: Confrontational remarks the CMCS cites as low competence (e.g. telling the client they ruined their streak); bargaining for partial credit (never give it); the counselling segment turning punitive.

4.12 Missed visits: excused and unexcused absences

Purpose / when: Any scheduled CM visit not attended.
Steps: Unexcused absence counts as a positive: no reinforcement, reset. Excused absence (arranged in advance with documentation, e.g. court date, surgery, clinician illness) earns nothing but does not reset; California allows up to two consecutive excused absences. Contact non-attenders promptly; Higgins sends an empathetic letter after 2 days without contact. Programmes define drop-out (Higgins research: 5 consecutive missed tests; California: more than 30 days without attending, with re-assessment for readmission). [source: Rash 2023; UCLA ISAP 2025; Budney & Higgins 1998]
Example language (illustrative): "We missed you Thursday. Today you can earn the starting amount if you're negative, and two negatives in a row gets you back to where you were. Let's book in with your counsellor too."
Watch for: Retroactive "excuses" (only accept as defined in the protocol); patterns of missing tests after weekends, which usually indicate use.

4.13 Attendance-based CM (individual)

Purpose / when: When retention, not verified abstinence, is the main problem, or when frequent testing is not feasible. Rash ranks it below abstinence as a target. [source: Rash 2023; CMCS attendance manual]
Steps: Reinforce each attended session (counselling or group) with prize draws; draws increase with each consecutive session attended and reset after an unexcused miss (excused absences do not reset). In each session, state draws earned and why, give a written reminder of next session's draws, administer draws with energy, discuss prize wishes, praise attendance and explicitly tie attendance to abstinence and recovery goals. [source: CMCS attendance manual 2010]
Example language (illustrative): "Five sessions in a row, so five draws. Coming every week is exactly what keeps the cravings in check."
Watch for: Prizes being traded for drugs (attendance CM is not self-correcting the way abstinence CM is); clients attending but continuing to use (consider adding or switching to abstinence targets). [source: Rash 2023]

4.14 Group CM: "name-in-the-hat"

Purpose / when: Group programmes wanting to raise attendance at low cost; Petry (2011) reports a New York programme where reinforcing group attendance raised group size and both client and staff morale. [source: Petry 2011]
Steps: For each attendee, add slips with their name to a hat, the number rising with consecutive attendance (reset after unexcused absence). Draw names for half the attendees; each drawn person makes a prize-bowl draw. Bring prizes to the room; allow exchanges. [source: CMCS attendance manual 2010]
Example language (illustrative): "Maria, that's your fourth week running, so four slips in the hat today. Let's see who's drawing."
Watch for: Public display of who is doing well or badly; keep it attendance-focused, not test results, in a group [synthesis].

4.15 Reinforcing goal-related (treatment-plan) activities

Purpose / when: To build non-drug reinforcers (job search, exercise, medical appointments, family activity) alongside or instead of abstinence. Petry (2011) describes reinforcing "objective evidence" of exercise routines. [source: Petry 2011]
Steps: Agree specific weekly activities tied to treatment goals, each with a stated proof (receipt, signed attendance slip, pay stub, photo); at the next visit, check the proof and reinforce each verified activity. [uncertain: the Petry activity-contracting protocol (Petry et al., early 2000s) is not drawn on; steps here are a cautious reconstruction from the principle of objective verification.]
Example language (illustrative): "This week: two job applications with the confirmation emails, and the dentist appointment with the card they give you. Each one you bring back earns a draw."
Watch for: Activities that cannot be verified; tasks too large for one week. Iguchi et al. (1996) found reinforcing problem-solving group attendance with take-home doses did less for abstinence than reinforcing drug-free urines, so do not substitute activity targets for abstinence when abstinence can be tested. [source: Iguchi et al. 1996]

4.16 Medication-adherence CM

Purpose / when: To raise adherence to medications such as HIV antiretrovirals or naltrexone; NICE recommends considering CM for all people on naltrexone maintenance. [source: Petry 2011; NICE CG51 1.4.5.1]
Steps: Verify adherence objectively, by supervised ingestion or electronic pill-cap openings (MEMS), and reinforce each verified dose or adherent period on an escalating schedule with reset. [source: Petry 2011] Detailed schedules are not drawn on [uncertain].
Watch for: Device failure (cap opened without ingestion); never tie medical access itself to adherence [synthesis].

4.17 Clinic privileges: contingent take-home methadone doses

Purpose / when: Methadone/OTP settings; uses a high-value, no-cost privilege as the reinforcer. NICE lists take-home doses as an incentive option. [source: NICE CG51 1.4.1.4; Schmitz et al. 1998; Iguchi et al. 1996]
Steps: Make additional take-home days contingent on drug-negative urine results (Schmitz et al. used a 12-week contingency phase after an 8-week baseline); describe how a positive result reduces or suspends take-home days and how they are regained. [source: Schmitz et al. 1998 abstract] Take-home eligibility is also governed by national OTP regulations and clinical safety judgement, which take precedence over any CM schedule [synthesis; uncertain about current local rules].
Watch for: Diversion and overdose risk with take-home medication (safety assessment and secure storage counselling before any increase) [synthesis]; perceived punitiveness when privileges are withdrawn.

4.18 Incentives for physical-health engagement

Purpose / when: NICE recommends one-off or short-term incentives (e.g. shopping vouchers up to about £10) for people who misuse drugs to complete hepatitis B/C and HIV testing, hepatitis B vaccination and TB testing. [source: NICE CG51 1.4.2.1]
Steps: Deliver the incentive at completion of each step (test done, each vaccine dose received), immediately and consistently.
Watch for: Linking these incentives to abstinence; keep them separate [synthesis].

4.19 Integrating CM with counselling (CRA plus vouchers)

Purpose / when: Every therapy session in the Higgins model; CM buys time and abstinence, counselling builds the lifestyle that maintains it. [source: Budney & Higgins 1998]
Steps:
1. Open the session by reviewing the urinalysis and attendance graph with the client. [source: Budney & Higgins 1998]
2. Negative: congratulate, ask what helped, reinforce those strategies. Positive: reassure, then functional analysis of the use.
3. Steer voucher spending toward the goals being worked on in CRA (recreation, employment, relationships).
4. Work the CRA components: treatment planning and goal setting; functional analysis and self-management planning; drug refusal; social and recreational counselling; vocational counselling; relationship counselling; social skills and assertiveness; problem-solving, time management and communication; relaxation; sleep hygiene; HIV/AIDS prevention; disulfiram where alcohol is involved. [source: Budney & Higgins 1998] Their procedures belong to CRA itself and are not repeated here.
Example language (illustrative): "Look at this graph: eight negatives since the first of the month. What's been different on the days you stayed clean?"
Watch for: CM delivered in isolation by staff who never talk to the therapist; results must reach the therapist the same day. [source: Budney & Higgins 1998]

4.20 Thinning, ending and maintenance

Purpose / when: Final weeks of the programme.
Steps: Thin the schedule on a pre-announced calendar (Higgins: weeks 13–24 at two tests a week with a lower-value reinforcer; California: weekly in weeks 13–24; NICE: testing frequency falls to weekly). Remind the client of the end date about two weeks ahead and discuss reactions openly. Give a certificate of completion on the last day. Keep counselling or MOUD going; plan which natural reinforcers (work, family, recreation) will replace the incentives. [source: Budney & Higgins 1998; UCLA ISAP 2025; NICE CG51 1.4.1.4; Rash 2023]
Example language (illustrative): "Two weeks from Thursday is the last week of draws. How are you feeling about that? Which parts of your week now keep you going besides the prizes?"
Watch for: Relapse risk after incentives stop; effects can fade after CM ends (Gagnon et al. cite a review showing no detectable effect at six months). Rash says clients usually prepare for the end rather than drop out, and the longest abstinence run during CM predicts later outcome. [source: Gagnon et al. 2021; Rash 2023]

4.21 Fidelity monitoring and supervision

Purpose / when: Throughout; clinician skill relates to outcomes, and drift is common. [source: Rash 2023]
Steps: Rate recorded or observed CM segments with the CMCS (abstinence or attendance version, items rated 1–7). Track simple adherence measures (correct draw counts, immediacy, resets applied). Audit bowls and inventory. In VA rollout: 2 planning calls before enrolment, 4 implementation calls in the first 6 months, then 6-monthly, with reports on samples collected, negatives and fidelity. [source: CMCS manuals 2010; DePhilippis 2019; Rash 2023]
Watch for: Staff beliefs that clients "should" stay abstinent without rewards, which the Case Western guide says supervision should address. [source: Case Western guide]

5. Handling problems

Tags: [source] where a named protocol addresses it; [synthesis] where the guidance is mine, built from CM principles.

Client never achieves a first negative ("stuck" at baseline). Hold the contingency; do not pay for "reduced" use on a qualitative test. Increase counselling contact and functional analysis of use days. Options within the evidence-informed modifications Rash lists: a guaranteed large prize or bonus draws to make the first negative more valuable, or switch the target temporarily to attendance while working toward abstinence. Review level of care if use is escalating or risky. [source: Rash 2023 for add-ons; synthesis for sequencing] Petry's group tested different reinforcement levels for clients who were positive at intake, but that work is not drawn on [uncertain].
Repeated cycling (short runs, then reset). Map the timing (e.g. paydays, weekends) in the functional analysis and build a specific plan for that window; remind the client of the short recovery path; check that the reinforcers still appeal (refresh stock). [synthesis; recovery rule from UCLA ISAP 2025 and Budney & Higgins 1998]
Disputed result ("I didn't use"). Stay non-confrontational but firm. Ask about recent use and any medications on the false-positive list; if the client claims tampering by others or an error, re-test the same day where possible, but base today's reinforcement on today's valid result. Remind them of the multiple-positives-from-one-episode rule given at orientation. [source: UCLA ISAP 2025; Budney & Higgins 1998; Rash 2023]
Negative test but self-reported use of the target. The CMCS manual says reinforcement stays tied to the test result; thank the client for honesty and use the report clinically. [source: CMCS abstinence manual] Rash's training poses this case without an answer; I follow the CMCS rule.
Negative for the target but using other substances. Do not withhold draws for non-target use; explain how other use threatens target abstinence; address it clinically. Rash reports no CM study has shown increases in non-reinforced drug use. For opioid or fentanyl positives, assess for OUD, offer naloxone and MOUD referral. [source: CMCS abstinence manual; Rash 2023; UCLA ISAP 2025]
Suspected tampering or substitution. Validity checks on every sample, a same-day repeat, and observed collection (reserved in the contract from the start). Treat a confirmed invalid sample as not negative, per the written rules. [source: Rash 2023]
Intoxicated on arrival. Follow standard clinic procedures, up to emergency services; do not deliver CM or other services that visit. [source: Rash 2023]
Non-adherence to testing schedule. Unexcused absences reset; contact promptly (Higgins: empathetic letter after 2 days); problem-solve transport, work hours and childcare; consider adjusting test days in the written schedule rather than making ad hoc exceptions. Rash notes testing burden as an eligibility concern. [source: Budney & Higgins 1998; Rash 2023; synthesis for problem-solving]
"Resistance": client finds CM patronising or says "I don't need bribes". Explain it as a recognised medical treatment that helps the brain re-learn non-drug rewards, used for a fixed period; respect a decision to decline without penalty. Rash cites evidence that CM does not undermine motivation and that prizes become less salient as recovery grows. [source: Rash 2023; synthesis for wording]
Staff resistance ("paying people to do what they should"). Supervision should address these beliefs directly; frame CM as positive reinforcement that competes with a very strong drug reinforcer and improves retention. [source: Case Western guide; UCLA ISAP 2025]
Overwhelm (client). Typical triggers are testing burden, many rules, or a positive after a long run. Keep the CM segment short (under 10 minutes), give the written reminder slip each time, and simplify the explanation to one rule: negative means you earn, more in a row means more. [source: CMCS manuals; synthesis]
Ruptures around fairness or disappointment (losing a long run, never winning a large, comparing with others). Acknowledge the feeling, restate the rules neutrally, highlight the short recovery path, and never add discretionary draws, which damages consistency for everyone. Gagnon et al. report providers wanting to prioritise honesty and certainty; disclose odds upfront to prevent a sense of being misled. [source: Gagnon et al. 2021; synthesis]
Gambling concerns. Exclude people in recovery from gambling disorder from prize CM; screen at intake. Rash and Petry report no cases of new pathological gambling in large samples; the scoping review argues the ethical question is not settled. Offer voucher or gift-card schedules to those excluded. [source: Rash 2023; Gagnon et al. 2021; synthesis for alternative]
Coercion and vulnerability. For court-referred clients, make clear that CM results are not reported for punitive use unless the client has consented and the programme design allows it; the VA lists punitive use of results as a contraindication. Consider incentive size relative to clients' incomes. [source: DePhilippis 2019; Gagnon et al. 2021]
Selling or trading prizes. In abstinence CM, trading for drugs leads to positive tests and lost rewards (self-correcting); in attendance CM, choose items with low resale value and use restricted cards. [source: Rash 2023; synthesis for item choice]
Reaching the annual cap early, or funding running out. Never stop mid-schedule without notice; plan budgets for maximum earnings per enrolled client before enrolment; if a cap will be reached, tell the client in advance and treat it like the planned end (Stage 4). [synthesis; cap from UCLA ISAP 2025]
Relapse after CM ends. Plan the end from the start; continue counselling; consider booster periods only if funded and pre-specified [synthesis]. Effects can fade after incentives stop. [source: Gagnon et al. 2021]
Emergent suicidality or crisis during a CM visit. Pause CM, assess risk using the service's standard procedure, include lethal-means counselling (safe storage or removal of medications including any take-home doses, and other means), and arrange the appropriate level of care. Neither reinforcement nor reset should depend on the crisis response. [synthesis]
Fidelity drift (wrong draw counts, delayed results, discretionary changes). Use the CMCS, audit logs, and the coaching-call model. [source: CMCS manuals; DePhilippis 2019; Rash 2023]

Sources

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