Federal Government Lifts Key Barrier to Stimulant Addiction Care

To expand the use of a proven approach to reducing the misuse of stimulants, the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) announced in January that it was raising the $75 annual per-person cap that can be offered to patients in what is known as contingency management (CM) treatment.

When receiving CM treatment, patients receive monetary rewards, such as gift cards, for displaying positive behavior changes, often determined through negative urine drug tests. The original cap had been imposed to reduce fraud and abuse in an unrelated statute, but SAMHSA heard from service providers that it was too low and increased the annual reward total amount 10 fold to $750.

The change addresses a pressing problem. Misuse of stimulants represents a serious and growing public health challenge. Many recent overdose deaths involve combined opioid and stimulant use, including psychostimulants such as methamphetamine and cocaine. Statistics published by the U.S. Centers for Disease Control indicate that deaths involving opioids and psychostimulants in 2021 occurred 22 times more often than in 2011, while deaths that year involving opioids and cocaine occurred 7.4 times more frequently than a decade earlier.

Sometimes this combined use is intentional, but in other cases, people who typically use stimulants may unintentionally consume opioids because of a contaminated drug supply and that increases their risk of overdose. More generally, stimulant use is associated with a range of health problems, including cardiovascular disease, HIV, hepatitis C, and skin infections.

CM has proved effective to treat stimulant use disorder (StUD) and has been widely used by the Veterans Health Administration since 2011. Critically, the approach complies with the government mandate to provide evidence-based care. The treatment also has gained traction in several state Medicaid programs, including in California, Montana, and Washington.

Research has found that amounts of $400 to $560 work to reduce stimulant use, with greater reductions occurring at higher monetary incentive amounts; now, state agencies will be able to use SAMHSA grants to fund CM more effectively.

Yet, there is more to CM than providing adequate gift cards. States interested in CM should follow specific, proven protocols in order to implement the intervention safely and successfully.

An established treatment

Decades of evidence show that the approach works to decrease stimulant use and increase stimulant abstinence. One study, for example, found that CM participants achieved about 4.4 weeks of continuous abstinence compared with around 2.6 weeks in the standard treatment group. Additionally, CM leads to greater retention in care and a better self-reported quality of life, including improvements in friendships, relationships, and home life. According to the American Society of Addiction Medicine and the American Society of Addiction Psychiatry, CM is the standard of care for treating StUD.

Despite some stigmatizing characterizations of CM as “paying people not to use drugs,” rewards have long been used to incentivize a variety of health behaviors. Some uses have been to encourage completing health screenings for people enrolled in employer-sponsored health insurance, increasing physical activity among people at risk for cardiovascular disease, and improving self-management of diabetes. When it comes to substance use disorder specifically, researchers believe incentives encourage people to change their behavior by helping their brains recognize—and ultimately seek—rewards other than those they receive from their use of drugs. The prior reward cap for SAMHSA-funded programs greatly limited CM incentives, but now that up to $750 per person is allowed, providers should consider several other implementation factors, including:

• Can they offer the full array of services? CM effectiveness increases when combined with other behavioral therapies and medications. The community reinforcement approach helps clients identify rewarding behaviors beyond substance use. Adding off-label medications to CM can further reduce stimulant use by reducing cravings, drug seeking behaviors, and depression severity while improving overall functioning.
• Do they have sufficient staffing? An increased workforce may be required to administer CM if there are not enough providers to administer the protocol. This could mean hiring outside staff or increasing the current staff capacity. The California program manual advises participating providers that they may need to hire full-time or part-time staff to meet program requirements.
• Is the site ready? Organizational factors such as size, funding, and administrative backing can influence CM implementation. Further, staff members must be receptive to the new approach, and may need training to increase their knowledge and support for CM.
• Can fidelity be monitored? If providers fail to provide CM according to an evidence-based approach, the treatment becomes ineffective. Using technology to track whether incentives are delivered appropriately, along with ongoing coaching, can ensure there is no drift in implementation from established safeguards.
• Have health equity factors been considered? Stimulant use affects a variety of populations, and tailoring treatment interventions that incorporate CM to these populations’ needs improves health outcomes and behaviors related to stimulant use. For example, a research team based at Washington State University partnered with American Indian and Alaska Native (AI/AN) communities to tailor CM implementation, accounting for cultural differences in treatment approaches, as well as AI/AN cultural history.

Despite the complexity of implementing and expanding the use of CM, the treatment remains a valuable tool for helping people with StUD achieve their treatment goals. By thoughtfully addressing these implementation challenges, health policymakers and practitioners can make significant strides in reducing stimulant use and improving overall public health.

Camille Clark works on The Pew Charitable Trusts’ substance use prevention and treatment initiative.