ASAM Weekly Guest Article - Motivational Incentives Policy Group
With the rising numbers of overdoses attributed to psychostimulants, there is a compelling need to immediately deploy effective interventions. One such intervention is highly effective and has hardly been used: contingency management (CM).[i] [ii]
Overdose deaths involving psychostimulants other than cocaine – largely methamphetamine – more than doubled between 2016 and 2019,[iii] and increased 46% from 2018 to 2020.[iv] Concurrent use of opioids and methamphetamine is on the rise[v] and suggests the problem will only get worse. Although methamphetamine use has long been considered to primarily affect non-Hispanic Whites, several recent reports show disproportionate overdose death increases among American Indian and Alaska Native, Black, and Hispanic groups.[vi] Because there are no FDA-approved medications to treat stimulant use disorder (StUD), urgent action is needed by all providers, policymakers, and healthcare leaders to broadly and immediately implement CM.
CM is a behavioral intervention to treat StUD based on operant conditioning principles. CM provides financial incentives to patients for meeting objective behavioral goals, such as providing stimulant-free urine drug tests. The value of these incentives escalates over time to effectively compete with and override the powerful reinforcement provided by drug use at the brain’s reward center.[vii]
CM is similar to widely accepted general healthcare incentives provided by payers, e.g., to achieve a target weight or complete a health assessment. CM has five decades of NIH-sponsored research, more than 100 peer-reviewed scientific reports, and 10 recent meta-analyses and/or systematic reviews supporting its efficacy, as well as larger-scale field trials demonstrating real-world effectiveness. These studies also include the use of CM for alcohol use disorders and as an adjunct to medications for opioid use disorders. A recent meta-analysis shows 22% greater likelihood of abstinence 24 weeks after the cessation of incentives, and the longer the CM intervention, the more robust the sustained effects.[viii] Moreover, the beneficial effects of CM increase relative to the magnitude of the incentive.[ix]
Despite the evidence, controversy continues to surround the practice related to the application of CM with people with substance use disorders, furthering health disparities and discrimination against these human beings.[x]
A major obstacle to the use of CM was a 2008 Office of Inspector General (OIG) opinion that raised concerns among providers that they could be subject to fraud and abuse investigations by simply implementing CM. A more recent opinion (2020) provides reassurance that CM use is not prohibited if providers are implementing appropriate policies and safeguards; are not engaging in criminal fraud and abuse practices; and are not using CM to pay for referrals or marketing and/or inducements to select a particular provider. Incentives are permitted for “the purpose of enhancing access, quality or benefits from approved health services.”[xi] While the opinion also offers a safe harbor that limits incentives to $75.00 per year, research does not demonstrate that incentives at that level are effective, and therefore this is not a recommended practice. We recommend $100-$200 per month.
Another obstacle is the stigmatizing belief that CM is merely “paying drug users to stop using drugs.” CM is a health motivational practice that holds patients accountable for abstinence, as incentives are not received by the patient unless they are objectively determined to be abstinent. As extended periods of abstinence from stimulant use are achieved through CM, neurobiological recovery can begin.[xii] [xiii]
Individuals with stimulant use disorder deserve the very best that science has to offer. It’s time to bring on CM.
- Mady Chalk, PhD, MSW, Public/Private Strategic and Policy Consultant for Behavioral Health
- H. Westley Clark, Dean's Executive Professor of Public Health, Santa Clara University
- David R. Gastfriend, MD, DFASAM. Dr. Gastfriend is co-founder and Chief Medical Officer of DynamiCare Health, Inc. (Disclosures: stock and employment).
- Carol McDaid, Principal, Capitol Decisions Inc.
- A. Thomas McLellan, Professor, Dept of Psychiatry (Emeritus), Perelman School of Medicine, University of Pennsylvania. Dr. McLellan is on the Board of Directors of Affect Therapeutics, a provider of Contingency Management treatment services.
- Rick Rawson, Research Professor, University of Vermont; Professor Emeritus, University of California, Los Angeles.
- Sarah A. Wattenberg, LCSW-C, Director of Quality and Addiction Services, National Association for Behavioral Healthcare.
Members of the Motivational Incentives Policy Group, a stakeholder coalition concerned about the growing problem of stimulant (methamphetamine and cocaine) misuse, overdose and addiction, and expanding the implementation of contingency management behavioral therapy.
[i] Goodnough A. This Addiction Treatment Works. Why Is It So Underused? The New York Times. https://www.nytimes.com/2020/10/27/health/addiction-treatment-pays-drug-users-to-stay-clean.html. Published October 27, 2020.
[ii] The one exception has been the Veteran’s Health Administration that has used CM successfully. The National Implementation of Contingency Management (CM) in the Department of Veterans Affairs: Attendance at CM sessions and substance use outcomes. DePhilippis, D, Petry, NM, Bonn-Miller, MO, Rosenbach, SB, McKay, JR. Drug and Alcohol Dependence, v185, April 2018, p367-373.
[iii] Hedegaard H, Miniño AM, Warner M. Drug Overdose Deaths in the United States, 1999–2019. National Center for Health Statistics, Centers for Disease Control and Prevention. NCHS Data Brief, no 394. Accessed March 8, 2021.
[v] Beth Han, MD, PhD, MPH; Wilson M. Compton, MD, MPE; Christopher M. Jones, PharmD, DrPH, MPH; Emily B. Einstein, PhD; Nora D. Volkow, MD. Methamphetamine Use, Methamphetamine Use Disorder, and Associated Overdose Deaths Among US Adults. JAMA Psychiatry, Sept 22,2021.
[vi] Townsend T, Kline D, Rivera-Aguirre A, Bunting AM, Mauro PM, Marshall BDL, Martins SS, Cerdá M. Racial/Ethnic and Geographic Trends in Combined Stimulant/Opioid Overdoses, 2007-2019. Am J Epidemiol. 2022 Feb 8:kwab290. doi: 10.1093/aje/kwab290. Epub ahead of print. PMID: 35142341.
[vii] Some forms of CM do not use financial rewards, such as take-home methadone after reaching certain treatment goals or the use of professional licenses. However, these are unique populations and situations. CM with financial incentives has demonstrated efficacy across a broad spectrum of substances and populations.
[viii] Ginley, MK, Pfund, RA, Rash, CJ, Zajac, K. Long-Term Efficacy of CM Treatment Based on Objective Indicators of Abstinence from Illicit Substance Use Up to 1 Year Following Treatment: A Meta-Analysis. Journal of Consulting and Clinical Psychology. 2021. 89(1), 58-71. Doi.org/10.1037/ccp0000552.
[ix] Petry N, Tedford J, Austin M, Nich C, Carroll KM, Rounsaville BJ. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3709247/. Addiction. 2004; 99 (349–360). doi:10.1046/j.1360-0443.2004.00642.
[x] Goodnough A. 2020.
[xi] [xi] U.S. Dept. of HHS OIG - Office of the Inspector General. Public Inspection: Medicare and State Health Care Programs: Fraud and Abuse; Revisions to Safe Harbors under the Anti-Kickback Statute, and Civil Monetary Penalty Rules Regarding Beneficiary Inducements. Federal Register. Published November 20, 2020. Accessed November 29, 2020. doi:10.1111/add.12354.
[xii] Gowin JL, Stewart JL, May AC, et al. Altered cingulate and insular cortex activation during risk-taking in methamphetamine dependence: losses lose impact. Addiction. 2014;109(2):237-247. doi:10.1111/add.12354
[xiii] Shoptaw S. Commentary on Gowin et al. (2014): Brain is behavior—methamphetamine dependence and recovery. Addiction. 2014;109(2):248-249. doi:10.1111/add.12442