Quality & Science

Editorial Comment 11/3/2020: Earthly Rewards

by Editor-in-Chief: Dr. William Haning, MD, DFAPA, DFASAM | November 2, 2020

The tail-end-Charley item in this week’s ASAM Weekly is arguably the most practicable and promising of recent approaches to stimulant addiction, pharmacological or behavioral.  The New York Times review of Contingency Management (CM)’s premises, benefits, and obstacles to implementation gives an accurate description for all levels of understanding.  Steve Shoptaw and colleagues have demonstrated the concept’s efficacy repeatedly since the early 2000s (e.g., https://pubmed.ncbi.nlm.nih.gov/16905197/; 2020 review https://www.sciencedirect.com/science/article/abs/pii/S0376871620304725 ).

As this approach is inexpensive, providing monetary or gift incentives of an embarrassingly low value for abstaining from substance use, the obvious question has always been “Why aren’t we (insert name of state here) doing this?”  The answer is both philosophical and political.  Philosophical, in that it is counterintuitive, that giving few dollars will work to replace a habit for which the drug user is willing to spend hundreds of dollars per week; a simplification of the process, but there is nothing to prohibit parallel rehabilitative efforts during CM.  Political, in that those who control the needed imbursements – tiny yet cumulatively significant – will perceive the approach as unethical, “bribing addicts.”  Not a great sound bite-from your opponent to your constituents.

Other approaches founder on the rocks of “counterintuition,” despite having terrific outcome benefits:  daily rigorous exercise, tobacco cessation (smoking as a co-factor for alcohol use, or as a mnemonic for vaping other drugs).  Communities in which AA and NA groups started, respectively in the 1930s and 1950s, are likely to have viewed the prospects with similar, intuitive suspicion.  “What would a group of alcoholics assembling in the evening do?  Why, drink, ultimately, of course!  NIMBY.”  So I am reminded of a former patient who, when asked why she was willing to interrupt her methamphetamine use for $5 (per negative UDS), responded:  “I really don’t understand what causes me to keep smoking and smoking more meth.  Why would I understand why this causes me to stop?”

CM’s proponents have for years sought approval from funders and legislatures, fielding similar objections; the NYT article provides a reasonable script for addressing such in the readers’ own communities. 

 Editor-in-Chief: Dr. William Haning, MD, DFAPA, DFASAM