America’s drug overdose crisis is one of the greatest public health concerns of our time with significant loss of life and economic burden. Over 109,000 Americans died of a drug overdose in 2022 (Ahmad, Rossen, & Sutton, 2023)—roughly one-third of which were attributed to stimulants—and the estimated annual stimulant-related cost to U.S. hospitals alone (emergency department visits and inpatient hospitalizations) is upwards of $1.5 billion (Peterson et al., 2021). In addition to the first three “waves” of the opioid overdose crisis, involving prescription pain pills, heroin, and fentanyl, respectively, experts point to a “fourth wave” gathering force in the U.S. involving high mortality attributed to methamphetamine and cocaine (Ciccarone, 2021). In the 5-year period spanning 2017 to 2022, overdose deaths involving cocaine have doubled and methamphetamine-related deaths have more than tripled (Ahmad et al., 2023). While opioids, largely fentanyl, are unequivocally the primary drivers of overdose deaths, the rapid rise in stimulant-related deaths is concerning and requires intervention. Together, these findings underscore the need for greater adoption of evidence-based approaches to reduce negative consequences associated with stimulant use, improve rates of treatment initiation and engagement, and ultimately save lives.

Contingency Management

While a number of research teams, including NIDA-funded investigators, have been hard at work, testing novel medication targets and even immunotherapies such as vaccines, there is currently no FDA-approved medication for stimulant use disorder. However, there are several evidence-based psychosocial treatments, including contingency management. In fact, no other intervention (behavioral or pharmacological) for the treatment of stimulant use disorder has as strong an evidence base as contingency management (Rawson et al, 2023; Ronsley et al, 2020; Substance Abuse and Mental Health Services Administration [SAMHSA], 2020). Contingency management involves rewarding people with meaningful, often financial, incentives for achieving their recovery goals (negative drug screens, attendance at appointments, etc.) using one of two main reinforcement models: (1) Prize-Based, popularized by Dr. Nancy Petry, and (2) Voucher-Based, popularized by Dr. Stephen Higgins.

In real-world treatment settings, research shows 72% of programs use no-cost or low-cost rewards (< $25 total over duration of program), whereas in research trials, average reward values are often much higher (Rash et al., 2012; Rash et al., 2020). Voucher programs can involve maximum possible earnings of $180 to $1,950 per client (12 weeks), and the maximum possible earnings for prize programs can range from as low as $9 to as high as $1,391 per client (12 weeks). Other studies show prize programs typically range from $250 to $450 in average maximum expected earnings per client (12 weeks). By far the most common target behavior in research studies and real-world practice is negative urine drug screens (either for the client’s primary drug of choice only or all substances), but other recovery-oriented behaviors are viable targets as well, including attendance at individual or group therapy sessions (in-house or community-based self-help meetings such as Narcotics Anonymous or SMART Recovery), clinic appointments, case management visits, adherence to medication (if applicable), and completion of psychoeducational materials (learning modules, therapy practice assignments, etc.). Research has shown that rewarding appointment attendance is equally effective to rewarding abstinence (drug tests) with respect to treatment engagement (Iguchi et al, 1997; Pfund et al, 2022), and one study found that rewarding appointment attendance was superior to rewarding abstinence (Metrebian et al, 2021).

Treatment Outcomes

Seminal clinical trials from the 1990s provide strong evidence supporting contingency management for a number of substances (stimulants, opioids, nicotine, alcohol, etc.) and have since been systematically replicated nationally and internationally. Despite decades (and hundreds) of rigorous studies linking contingency management to a variety of positive outcomes, uptake in real-world settings has been limited due to a number of barriers such as cost, stigma, ethics, as well as moral, philosophical, and legal concerns, among other reasons described elsewhere (Proctor, 2022).

Two recent reviews provide strong evidence supporting the efficacy of contingency management for cocaine and methamphetamine addiction (Brown & DeFulio, 2020; De Crescenzo et al., 2018). The first study was a meta-analysis of 50 randomized controlled trials consisting of nearly 7,000 participants on 12 different psychosocial interventions for stimulant addiction (De Crescenzo et al., 2018). Primary outcomes included (a) abstinence, measured by urine drug screens, and (b) retention at both 12 weeks and the end of treatment, defined as the longest follow-up period. Results showed that the combination of contingency management + community reinforcement approach was associated with the highest rates of abstinence and retention both in the short- and long-term. However, community reinforcement approach alone was no different than control in the short-term, suggesting the powerful role of contingency management as an adjunctive intervention. Interesting, contingency management alone performed better than cognitive-behavioral therapy with respect to abstinence and was equally effective in terms of retention. Overall, findings suggest that the combined support of community reinforcement and contingency management was the most reliable and successful intervention for people with stimulant addiction.

The second study, a systematic review of 27 studies, also provided strong support for contingency management for methamphetamine use disorder (Brown & DeFulio, 2020). All but one of the studies evaluating abstinence (95% of studies) showed an effect of contingency management on improving abstinence, and 78% of studies evaluating sexual risk behavior outcomes showed an effect of contingency management on reducing risk sexual behavior. Findings showed broad benefits of contingency management, including greater drug abstinence, higher utilization of other treatments and medical services, as well as reductions in risk sexual behavior. Together, the findings from these two important review articles echo the position of a number of leading experts in that contingency management is the gold standard of care for stimulant use disorder, and no other treatment has as strong an evidence base.

Real-World Implementation

Although contingency management protocols can be high-, low-, or no-tech, a number of emerging technological solutions such as patient-facing mobile apps, combined with provider-facing dashboards, can facilitate tracking progress towards recovery goals and overall program-level management of the selected rewards system. In accordance with their approach to evaluate contingency management programs on a case-by-case basis, the Office of the Inspector General (OIG) posted an advisory legal opinion (OIG Advisory Opinion No. 22-04) in March 2022 approving the use of a digital contingency management program using smartphone and smart debit card technology, which could clear the way for wider use of similar programs in routine treatment settings. Also of particular interest, the OIG published a final rule in December 2020 dispelling the oft-stated $75 misconception, stating “…there is no OIG-imposed $75 limitation on contingency management program incentives.”

Several innovative technologies allow for many aspects of contingency management to be fully or partially automated, thereby addressing common logistical barriers to implementation (Proctor, 2022; Proctor et al., 2022; Kurti et al, 2016). Full automation is any solution not requiring action or verification by treatment staff before rewards can be delivered, whereas partial automation involves rapid delivery of rewards for certain recovery-oriented behaviors with other behaviors requiring manual verification by staff. New technologies can help with implementation (Dallery et al., 2023) via remote testing and drug sensing technologies to obtain objective evidence of abstinence, the ability to authenticate end-user’s identity, and syncing with a “smart” debit card with appropriate blocking capabilities.

Delivery of monetary rewards can be streamlined and safeguarded by using a pre-paid debit card with the option to apply spending restrictions. Smart debit cards allow card administrators (e.g., treatment program staff) to toggle specified blocking capabilities on/off to prevent cash withdrawals or purchases at identified high-risk vendors such as bars, liquor stores, casinos, strip clubs, etc. Research has shown that both providers as well as patients in treatment settings overwhelmingly prefer the use of “smart” debit cards relative to giving patients actual cash, and view spending restrictions as an appropriate safeguard, particularly early on in one’s recovery (Proctor et al., 2022). From a clinical standpoint, providers and patients may find it useful to collaboratively identify high-risk vendors or spending categories to block with clearly outlined expectations for the eventual withdrawal of some or all restrictions over time based on response to treatment.

Depending on the target behaviors, validation can be achieved via multiple easy and convenient methods. Supplementing patient or collateral self-report, smartphone video and GPS location capabilities, as well as external testing hardware have all been used to good effect to monitor and confirm abstinence, appointment attendance, and adherence (DeFulio et al., 2021; Brooklyn et al., 2021; Godersky et al., 2020; Kurti et al., 2020; Walker et al., 2019). Mobile apps (Dynamicare, WEconnect, among others) can help organize the protocol and aid in the delivery of rewards. With technology-enabled contingency management using a mobile app, patients are also incentivized to provide clinically meaningful outcomes data using the app, which can then be reviewed by the provider in real-time using the dashboard consistent with best practices for measurement-based care. The COVID-19 pandemic forced many addiction treatment programs to adapt workflows and embrace technology (Chan et al., 2022), especially with vulnerable populations, creating a unique opportunity to further incorporate innovative contingency management solutions into routine clinical practice.

Although real-world uptake of contingency management is slow, one encouraging example of successful widespread implementation is the Department of Veterans Affairs’ 2011 national rollout in their outpatient programs (Rash et al., 2020; DePhilippis et al., 2018; Ruan et al., 2017). The VA earmarked funding for programs and provided 1.5-day training workshops led by experts followed by pre- and post-implementation technical assistance and coaching. The recommended protocol involved twice-weekly prize-based contingency management reinforcing stimulant abstinence over the course of 12 weeks, with the opportunity for patients to receive average maximum earnings of $364. The VA rollout represents ideal conditions for implementation: strong support from leadership, expert involvement, funding, and provision of training & ongoing coaching.

Summary

Despite decades of rigorous clinical trials and robust meta-analyses showing considerable benefits for contingency management, a number of barriers exist. Fortunately, all hope is not lost in that many barriers can be overcome by holding specialized trainings, actively calling out stigma, advocating locally and nationally, fostering academic–industry partnerships, and incorporating innovative technologies. States, payers, and treatment programs looking to limit their risk exposure should leverage the 2022 OIG advisory opinions permitting rewards >$75 and approving the use of a digital contingency management program. In addition, the Biden administration has been transparent in its support for expanding access to contingency management, and the Office of National Drug Control Policy, has explicitly stated that addressing policy barriers and exploring reimbursement for motivational incentives and digital treatment for addiction are key priorities. Finally, the U.S. Surgeon General and several federal agencies (NIDA, SAMHSA, FDA, Veterans Affairs) have all taken actions signaling acceptance of contingency management as an effective intervention, and many states (CA, MT, WA, WV, etc.) are pushing for change by actively pursuing legislation and appealing to federal regulators to make contingency management more widely available. In light of the obvious return on investment, the question is not a matter of why providers and payers should consider contingency management for stimulant addiction, but rather why not? Support continues to grow, and many strict, often arbitrary federal regulations have been clarified or loosened, thereby setting the stage for greater adoption of contingency management.

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Steven L. Proctor, Ph.D.

Steven L. Proctor, PhD, is a licensed clinical psychologist and founder of PRO Health Group—a research and outcomes monitoring company. He is also Senior Program Director for Health Outcomes at Thriving Mind South Florida, a non-profit safety net payer in Miami. He holds faculty appointments at the rank of Clinical Associate Professor in the Department of Psychiatry and Behavioral Health at Florida International University's college of medicine, and Visiting Research Scholar in the Department of Mental Health Law & Policy at University of South Florida. He specializes in the evaluation of addiction treatment outcomes and has published extensively in this area. He collaborates with national and local agencies to improve their treatment systems through research, outcomes monitoring, training, technical assistance, and program evaluation.