Produced in conjunction with the Center for Health Economics of Treatment Interventions for Substance Use Disorder, HCV, and HIV

The opioid epidemic has been one of the most pressing and challenging issues that the U.S. has faced in recent decades, with countless lives lost to this devastating crisis. Now, stimulant-related overdoses are among the next big drug-related concerns, with recent studies showing that the mortality rate linked to stimulant use in the U.S. has increased 50-fold in the last decade, and deaths involving both stimulants and opioids rising by 450%.

One effective but underutilized strategy for addressing stimulant use disorder is contingency management, which offers financial incentives like cash, gift cards, or small prizes to motivate positive behaviors. An evidence-based practice first introduced in the 1960s, contingency management is beginning to gain more recognition as a go-to treatment. Current contingency management protocols focus on total abstinence, and there are multiple barriers to accessing the treatment, limiting its impact. As the stimulant crisis escalates, there is a growing recognition of the importance of using a harm reduction strategy to make this effective treatment available to those who need it.

In a new commentary, LDI Fellows Gabriela Khazanov, Jim McKay, and University of Vermont colleague Richard Rawson consider adaptations for contingency management protocols that go beyond total abstinence, keep patients engaged in treatment, and allow the intervention to reach those who need it most. 

This list outlines their best suggestions for improving accessibility to the intervention and adjusting current protocols to match harm reduction principles.

Contingency management should focus on keeping patients engaged in treatment and finding ways to incentivize gradual reductions in substance use. According to the authors, potential ways to improve contingency management include providing higher rewards at the start of treatment, finding ways to keep participants engaged if they return to stimulant use, and developing tests that can detect a decrease in stimulant use in addition to abstinence. Such changes would help recognize different paths to recovery and make contingency management more inclusive.

Usually, contingency management programs have strict rules about how long they last and when someone can join again if they drop out. However, these protocols might not work well for everyone with stimulant use disorder. Changing the rules to allow for longer programs and more chances to join back in recognizes how tough addiction can be and helps people keep working on recovery.

New technology can make these programs more available to everyone, including people who live far away or cannot make it to a clinic in person. Studies are needed to learn more about the unique challenges to virtual contingency management and improve how these programs are delivered online. 

It is important to motivate doctors and health systems to use contingency management more widely. Appropriate compensation to doctors for providing the treatment and removal of legislative barriers to incentivizing patients for recovery would make the treatment more accessible and improve its impact. 

Purchasing and providing drug tests can be complicated and slow, making this tool difficult to use. Simplifying the testing process can make contingency management easier for providers to offer. 

It is crucial to raise awareness about contingency management to folks who may be struggling with stimulant use disorder. Advertising directly to consumers can help encourage people to ask for the treatment and receive it if it’s a good fit for them. 

Recognizing the distinct characteristics of each community is vital for implementing this tool. Adapting the protocols to align with the target population’s cultural, social, and economic context promotes greater acceptance and efficacy, leading to lasting improvements.

Contingency management currently is the most effective option available for treating stimulant use disorder, which currently has no FDA-approved medications. Finding ways for contingency management to make a meaningful impact on stimulant use is critical to lowering stimulant-related overdoses.

Gabriela Khazanov, PhD

The commentary, “Should Contingency Management Protocols and Dissemination Practices be Modified to Accommodate Rising Stimulant Use and Harm Reduction Frameworks?,” was published on April 16, 2024 in Addiction. Authors included Gabriela Khazanov, Jim McKay, and Richard Rawson.


Nadiyah Browning, MPH, PMP

Senior Project Coordinator

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