In almost every state in the U.S, there is almost total network inadequacy for evidence-based care if your loved one suffers from Stimulant Use Disorder (StUD), which is increasing at an alarming rate. While there are no FDA approved medications for the treatment of StUD, like there are for other substances, the American Society of Addiction Medicine and the American Academy of Addiction Psychiatry have recently issued treatment guidelines for StUD which state that Contingency Management and Community Reinforcement Approach should be standard of care for StUD.

However, there is a stark disparity between what is recommended as standard of care, and what is currently reimbursed for through insurance.

What do the new ASAM Guidelines recommend for the treatment of StUD?

"Contingency management (CM) has demonstrated the best effectiveness in the treatment of StUDs compared to any other intervention studied and represents the current standard of care. CM can be combined with other psychosocial interventions and behavioral therapies, such as community reinforcement approach (CRA) and cognitive behavioral therapy (CBT)." Contingency Management (CM) should be a primary component of the treatment plan in conjunction with other psychosocial treatments for StUD.”. ASAM/AAAP Clinical Practice Guideline on the Management of Stimulant Use Disorder. American Society of Addiction Medicine, Inc. 2023.

What exactly is Contingency Management?

Contingency Management is a behavioral technique wherein the systematic delivery of positive reinforcement is provided for objective target behaviors that reflect progress in reducing/eliminating drug use (Higgins et al., 2007; Stitzer & Petry, 2006). Contingency Management is a protocol-driven intervention and includes a preset schedule of vouchers, gift cards, prizes, or other incentives that increase in value as participants demonstrate extended periods of stimulant abstinence (Higgins et al., 2007). Best practices in Contingency Management include higher value rewards (e.g. $599), objectively verifiable behaviors, and rapid delivery of rewards after desired behaviors have been performed.

Can you briefly describe the clinical data associated with Contingency Management for the treatment of StUD?

The research evidence supporting the use of CM for the treatment of individuals with cocaine and methamphetamine use disorder is extensive (for reviews, see AshaRani et al., 2020; Bentzley et al., 2021; Bolivar et al., 2021; Brown & DeFulio, 2020; De Crescenzo et al., 2018). Contingency management has a uniquely robust impact on in-treatment abstinence and treatment retention, as well as sustained impacts on abstinence for up to 1 year after treatment (Ginley et al., 2021). No other behavioral intervention for the treatment of StUD has as strong an evidence base. Although CM is recommended as an evidence-based treatment in US government documents (eg, SAMHSA Tip 33), only within the US Veterans Administration Health System (VA) is CM used in routine clinical practice (DePhilippis et al., 2018; Petry et al., 2014).

What have been the historic barriers to adoption for Contingency Management?

Contingency Management traditionally has entailed intensive and ongoing staff training and education in order to ensure fidelity to a clinically efficacious Contingency Management model. Typically this model has involved rudimentary fish bowl voucher prizes, or other manual methods of reward delivery, which entail manual record keeping and are subject to variability in how closely a clinical protocol is followed.

There have also been questions about what is allowable under federal regulations for disbursement of incentives, and how to comply with the rigorous reporting requirements under federal guidelines. However, DynamiCare has received an advisory opinion from the Health and Human Services Office of the Inspector General which states it, “would not impose sanctions under the Beneficiary Inducements CMP”. This provides legal clarity which enables systems to implement Contingency Management in a fashion that is compliant with federal guidelines.

How is CM implemented?

Overall CM can be implemented manually or using technology, however, the manual system tracked by treatment centers (using pen and paper) are not consistently reliable or scalable. Furthermore, the old manual system creates a staff burden and is subject to human error for the necessary CM tracking requirements needed.

Tech-based CM is the most practical and effective approach for payors and treatment programs, and also offers the most advantages for patients as well. In fact, the Office of National Drug Control Policy encouraged the use of technology-enabled CM in its drug control strategy:

These incentives are an integral part of protocol-driven and evidenced-based contingency management programs and can be offered through smartphone applications and smart debit card technology designed to provide comprehensive and personalized treatment for SUD (including, for opioid, stimulant, alcohol, and nicotine use disorders). These programs include tools that enable, for example, automated appointment reminders and attendance verification, automated medication reminders, drug, alcohol, and tobacco/nicotine testing, self-guided cognitive behavioral therapy, and recovery coaching.

The results from the first in the nation Medicaid funded CM pilot in West Virginia have been announced, and many other state systems are following suit. With the advancement of technology, payors and treatment programs can now consider offering evidence-based behavioral interventions delivered via digital health or web-based platforms as add-on components to treatment for StUD.

Specifically, DynamiCare Health offers a 12 month model to digitally implement CM through smartphone–smartcard platform, where a smartphone application allows for remote salivary and breathalyzer drug testing at individualized random schedules. The application tracks the individual’s history of drug tests and treatment attendance and provides appointment reminders. Incentives are delivered via a debit card that cannot be used to withdraw cash and has additional purchasing protections. Approximately half way through the treatment protocol, the DynamiCare system transitions from delivering external rewards of CM to focusing on the internal rewards such as education, jobs, relationships common in the Community Reinforcement Approach (CRA). Finally, DynamiCare Health offers weekly recovery coaching, CBT self-study library, and the evidence-based CRAFT family support system to complete its comprehensive behavioral health treatment offering.

In addition to the clinical advantages, has CM been able to show a cost advantage over standard treatment?

Yes, in fact, the Washington State Institute for Public Policy, an independent think-tank with the most comprehensive review of cost-benefit analyses in addiction treatment, has ranked Contingency Management for SUD as one of the most cost-effective interventions for addiction that they have studied. Their analysis concluded that CM yields $38.29 in overall benefit for every dollar invested. Looking at healthcare costs alone, they calculated $1,833 in benefits for every $548 spent (3.3x cost-benefit ratio) (WSIPP 2018). For comparison, they estimate that buprenorphine maintenance, a gold standard treatment for opioid use disorder, yields only $1.81 in benefits to society per dollar spent, and the cost-benefit ratio for healthcare costs is 0.3x (WSIPP 2018).