Although the current overdose crisis in the US is almost universally referred to as the “opioid” or “fentanyl crisis”1,2, the overdose death rate associated with psychomotor stimulants including methamphetamine and cocaine has also dramatically increased in recent years.  A recent report using CDC data documented a “50-fold increase in the methamphetamine mortality rate” from 1999-2021.3 Of the 32,353 total methamphetamine-associated deaths in 2021, 61.2% included fentanyl, meaning that that, 38.2% -- or 12, 617 deaths -- did not involve fentanyl. Other CDC data also indicated a tripling of cocaine-related deaths, with and without fentanyl.4 Thus, it would be a misrepresentation of the 2023 overdose crisis to be viewed as exclusively an opioid or fentanyl crisis.5

The rates of stimulant-related overdose deaths were substantially different according to race/ethnicity. Increases in methamphetamine-related overdose deaths among American Indian/Alaska Native (AI/AN) increased over eightfold between 2010 and 2019.6 Among Black individuals, overdose death rates associated with methamphetamine alone and in combination with opioids were found to have increased tenfold (compared to 3-fold among White individuals) over this period. 7 

There is only one treatment with robust evidence of efficacy for the treatment of individuals with cocaine and methamphetamine use disorder–contingency management (CM), a behavioral approach based on basic principles of positive reinforcement. (There are no FDA-approved medications for treatment of stimulant use disorder [StimUD]). The evidence for CM as a treatment for StimUD is supported by over three decades of NIH-sponsored research.8,9,10 The evidence from these decades of research suggests that incentives at the level of $100-200 per month is most effective. At this full-value level, incentives have a 77% likelihood of producing benefits that exceed the costs – beginning in the first year.11 However, federal policy continues to pose serious obstacles to implementation of CM.12,13

Recently, the Motivational Incentives Policy Group (MIPG) has successfully facilitated an important change in federal policy, emanating from the US Department of Health and Human Services Office of the Inspector General (OIG). Between 2008 and 2020 the OIG had been a perceived obstacle to implementation of CM: it had suggested that providers could be investigated for fraud and abuse simply by implementing CM. However, in December 2020 a new OIG Final Rule sought to reassure providers that CM use is not prohibited.14 The Final Rule permits CM if providers use appropriate safeguards are used to prevent fraud and abuse.  

Serious obstacles to implementation remain, nevertheless.

It was erroneously believed that the OIG required that the amount that could be used for incentives be limited to $75 and that only non-monetary rewards were acceptable. This erroneous belief is reflected in current HHS policy that puts a $75 limit on the total per patient amount that can be used in incentives in CM protocols. Specifically, SAMHSA and HRSA state this restriction in their 2022 and 2023 RFPs. CM for the treatment of StimUD cannot be done in line with the vast published research with a $75 per patient incentive limit.

The now arbitrary $75 ceiling is forcing some states to produce requests for proposals (RFPs) with a $75 ceiling on incentives. The evidence shows that the $75 ceiling is ineffective. Adhering to this limit wastes federal dollars, jeopardizes both clinical and scientific integrity, and undermines the entire effort at implementation of CM for StimUD as an evidence-based practice. This practice ensures that CM will fail. Although HHS, Assistant Secretary for Planning and Evaluation, Substance Abuse and Mental Health Services Administration and other agencies have the authority to reverse the misperception about the $75 limit, no action is evident.

If effective, evidence-based treatment for individuals who use psychostimulants is not available, these individuals will continue to be at very high risk for overdose death. It is essential that HHS agencies remove the language from their grant portfolios that reflects a $75 limit on incentives and instead align the language with the scientific evidence.

This issue is described in more detail in Rawson, et al, 2023.

Richard Rawson, PhD

For the Motivational Incentives Policy Group

H. Westley Clark, MD, JD
Mady Chalk, PhD
Tyler Erath, PhD
Erin McCrady, JD
Carol McDaid, BA
Sarah Wattenberg, PhD

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.  

For more on this, please see  Contingency Management for Stimulant Use Disorder: Progress, Challenges, and Recommendations in the Journal of Ambulatory Care Management.

References

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1. Incze, M. A., Kelley, A. T., & Singer, P. M. (2023). Implementing the White House’s Strategic Plan to Save Lives Amid the Opioid Crisis: Reaching for the “North Star”. JAMA, 329(9), 705-706.
   
   
2.  Jenkins, R. A. (2021). The fourth wave of the US opioid epidemic and its implications for the rural US: A federal perspective. Preventive medicine, 152, 106541.
   
   
3. Hoopsick, R. A., & Andrew Yockey, R. (2023). Methamphetamine-Related Mortality in the United States: Co-Involvement of Heroin and Fentanyl, 1999-2021. American Journal of Public Health, 113(4), 416–419. https://doi.org/10.2105/AJPH.2022.307212.
   
   
4. Hedegaard, H., Spencer, M. R., & Garnett, M. F. (2020). Increase in drug overdose deaths involving cocaine: United States, 2009–2018. NCHS Data Brief, (384).
   
   
5. Friedman, J., & Shover, C. (2022). Charting the Fourth Wave: Geographic, Temporal, Race/Ethnicity, and Demographic Trends in Polysubstance Fentanyl Overdose Deaths in the United States, 2010-2021. medRxiv, 2022-11. https://doi.org/10.1101/2022.11.04.22281945.
   
   
6. Friedman, J., Beletsky, L., & Jordan, A. (2022). Surging racial disparities in the US overdose crisis. American Journal of Psychiatry, 179(2), 166-169.
   
   
7. Han, B., Cotto, J., Etz, K., Einstein, E. B., Compton, W. M., & Volkow, N. D. (2021). Methamphetamine overdose deaths in the US by sex and race and ethnicity. JAMA Psychiatry, 78(5), 564-567.
   
   
8. De Crescenzo, F., Ciabattini, M., D’Alò, G. L., De Giorgi, R., Del Giovane, C., Cassar, C., ... & Cipriani, A. (2018). Comparative efficacy and acceptability of psychosocial interventions         for individuals with cocaine and amphetamine addiction: A systematic review and network meta-analysis. PLoS Medicine, 15(12), e1002715.
   
   
9. AshaRani, PV, Hombali, Aditi, Seow, Esmund, Jie Ong, Wei, Hui Tan, Jit, Subramaniam, Mythily.  Non-pharmacological interventions for methamphetamine use disorder: a systematic review, Drug and Alcohol Dependence, Volume 212, 2020, 108060, ISSN 0376-8716, https://doi.org/10.1016/j.drugalcdep.2020.108060.
   
   
10. Bentzley, B. S., Han, S. S., Neuner, S., Humphreys, K., Kampman, K. M., & Halpern, C. H. (2021). Comparison of treatments for cocaine use disorder among adults: a systematic  review and meta-analysis. JAMA network open, 4(5), e218049-e218049.
    
    
11. Cost-Benefit Analysis for Contingency Management.  Washington Institute on Public Policy Information document, January 2021,  institute@wsipp.wa.gov
    
    
12. Glass, J. E., Nunes, E. V., & Bradley, K. A. (2020). Contingency management: a highly effective treatment for substance use disorders and the legal barriers that stand in its way. Health Affairs Blog. Published March, 11.
    
    
13. Rawson, R. A., Erath, T. G., Chalk, M., Clark, H. W., McDaid, C., Wattenberg, S. A., ... & Freese, T. E. (2023). Contingency Management for Stimulant Use Disorder: Progress, Challenges, and Recommendations. Journal of Ambulatory Care Management, 46(2), 152-159.
    
    
14. Office of Inspector General, 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, Vol. 85, No. 232, December 2, 2020