The U.S. overdose crisis has been described as waves of different drugs driving overdose deaths: Wave one representing prescription opioid use, wave two representing heroin use, and wave three representing fentanyl use.
Now, stimulants including cocaine and methamphetamine have increasingly been found in many overdose deaths, marking a fourth wave of the overdose crisis. Many recent overdose deaths involve combined opioid and stimulant use; for some individuals, this combined use is intentional, but other stimulant users who don’t intentionally use opioids face a greater risk of fatal overdose when they are exposed to opioids.
Dr. Richard Rawson, a research professor at the Vermont Center on Behavior and Health at the University of Vermont and professor emeritus at the University of California, Los Angeles’ Department of Psychiatry, has conducted numerous clinical trials on pharmacological and behavioral addiction treatments for people with opioid, cocaine, and methamphetamine disorders. These studies led to his support of contingency management (CM), a behavioral strategy that employs incentives to help people with stimulant use disorders reduce their use. Rawson advises states developing their own CM treatment programs, and is a member of the Contingency Management Policy Group, a coalition of CM experts advocating for evidence-based federal CM policy.
This interview with him has been edited for length and clarity.
Rawson: The stimulant problem in the U.S. is substantially contributing to overdose deaths. A recent study shows that in 2019, over 45% of drug overdose deaths involved cocaine or methamphetamine. Some of the individuals probably died from fentanyl mixed into the drug supply—they bought cocaine laced with fentanyl, for example, but their primary drug of interest was the stimulant. Others may have intentionally used both stimulants and opioids; opioids can help alleviate side effects like an “edgy” feeling after stimulant use.
If we’re not able to provide effective treatment for people’s stimulant use disorder, we’re not able to reduce their risk of exposure to fentanyl and fentanyl overdose. We’ve been so focused on fentanyl—and rightly so, it’s a remarkably lethal drug. But we need to understand the role of stimulants in the overdose crisis, and CM is the only treatment for stimulant use disorder that has any robust efficacy.
Rawson: CM is a very simple concept, one that impacts much of our lives: If you want to increase a behavior, you provide positive reinforcement.
CM is an approach that reinforces behaviors that are incompatible with drug use, such as providing a urine specimen that is negative for cocaine or methamphetamine metabolite. One of the most common ways to do this is to provide tangible reinforcers, often gift cards, for around $10 or $20, to people who test negative for stimulants. That’s rewarding people for not using stimulants. It’s that simple.
Rawson: Many years ago, when I went to work with people with addiction, we had medications for heroin but didn’t really know how to approach people using cocaine and methamphetamine. We started treating them with talk therapy and had limited success. We also tested all kinds of medications for cocaine and methamphetamine use, and nothing was working.
Then, in the early 1990s, I saw a publication where Steve Higgins, Ph.D., a researcher from the University of Vermont, used contingency management to treat individuals who used cocaine. The results were astonishing; I quite honestly didn’t believe them. So, with funding from the National Institute on Drug Abuse, I replicated the research, and I found the results were as good as previously reported. It was clear to me that CM was by far the most effective thing we have available to us to treat stimulant use disorder. And we now have numerous meta-analyses and systematic reviews that confirm that CM is the only treatment with robust evidence of effectiveness.
Rawson: For one thing, evidence shows that some aspects of cognitive function can be impaired by chronic stimulant use. So traditional talk therapy is challenging for these patients. CM is a different experience. A person comes in and gives a urine sample. If it’s negative for stimulants, they get a reward. If instead the urine sample is positive for stimulants, they’re encouraged to try again. There’s no confrontation or judgment; it’s all positive reinforcement. Anyone is able to respond to this approach.
One of the best indications that CM is effective is what we are seeing in the California CM project: many participants are being referred by other patients. People are finding that it’s directly helpful to their lives: We’ve heard a lot of anecdotes over the holidays of people using their CM earnings to buy Christmas presents for the first time in years, because they actually had some resources to do that.
In California, where Medicaid funds are used for a state CM program, there’s been 96% of urinalysis results negative for stimulants after one year. Even if you assume that every missed session is from someone who would have tested stimulant positive, participants attended 75% of scheduled sessions and provided a negative test. For a group of individuals who’ve chronically been using methamphetamine, that’s really impressive.
We also know it’s working because participant retention in California is also quite good—about 70% over 90 days. Behavioral therapy treatments I’ve used usually had about a 40% retention rate.
Rawson: Contingency management has been used in the Department of Veterans Affairs for the last decade or so due to the department’s mandate on providing evidence-based care to the people they serve. Research from June 2011 to December 2015 on CM’s effectiveness within the department showed very positive results, with over 90% of participants across 94 programs testing negative for stimulants.
More recently, California, Washington, and Montana started CM through a Medicaid 1115 waiver, which is a program that allows state Medicaid agencies to implement innovative health programs that may deviate from usual federal Medicaid requirements. But in California’s case, for instance, it took two years from the time the waiver application was submitted before the state actually started delivering contingency management. All the negotiation and documentation are not a simple process; 1115 waivers are a very useful approach to gaining federal approval to deliver CM, but it takes time to do a waiver.
Rawson: For states, a key obstacle is that Substance Abuse and Mental Health Services Administration grants, and other government-funded programs, limit the maximum incentive amount to $75 per year. This is well below the evidence base. It’s ineffective.
This $75-a-year cap essentially says you can use CM, but only at a level where it will be ineffective. With buprenorphine, that would be like saying “we have this great advancement in medication, but we can only use 2 milligrams on the patient.”
Then when people try CM with the $75 annual cap and it doesn’t work, they say the treatment itself is not effective. But that’s not the case. It’s just that the “dose”—in this case, the payment—was just too low.
Rawson: Most CM programs in the literature are about 12 weeks long, and people can earn a maximum of about $100 to $200 a month if all their samples are negative.
Rawson: There’s another financial block: It’s not clear whether the Internal Revenue Service (IRS) considers incentive money to be taxable income, which adds a layer of complication and limitations for both providers and patients.
There’s also the stigma of what people think of “paying people to not use drugs.” The idea of incentivizing behavior is not popular among some policymakers, who don’t see it as real treatment. I’ve gotten emails from politicians’ staffs saying, in so many words, “never in America will we pay addicts to not use drugs.” And even some providers will say they didn’t get their medical degrees to hand out gift cards. This stigma, and these misconceptions around CM, are preventing wider-scale adoption of CM—despite how effective it is.
Rawson: They have a few options. For example, they can put opioid settlement money toward CM. They can cover their administrative costs with State Opioid Response grants and federal dollars, and just use the settlement money for the incentives—which would allow them to use CM protocols with incentive amounts that are in line with the research studies on CM.
Rawson: I’d like to see the $75 cap eliminated. I’d like to see the IRS view the incentives as health benefits, not as taxable income. And I’d like the federal government to take leadership in promoting a systematic implementation and use of evidence-based protocols, because you can’t just improvise what you’re going to do and call it CM.