Opinion | Contingency management is an effective way to help people with meth addictions. We should use it. – The Washington Post

When I first crossed paths with Anileah Buswell, she was living with her infant daughter in Nashua, N.H., and trying to stay off meth. And for the first time in many years, she was succeeding.
Buswell, 21, was enrolled in a program with a radically simple premise: Get paid to abstain from drugs. The approach, known as “contingency management,” or CM, has racked up a slew of successes. It has been shown to dramatically reduce people’s smoking during pregnancy and to help decrease binge drinking. It is also highly promising for combating methamphetamine addictions.
The treatment, however, is vastly underused. Buswell is among the relatively small number of Americans involved in a CM program, at a time when methamphetamines are increasingly contributing to the country’s devastating overdose crisis.
Between April 2020 and April 2021 alone, the nation recorded more than 100,000 overdose deaths. Most of those deaths involved opioids, but in recent years the country has also seen a spike in addiction and deaths involving psychostimulants — largely meth. According to provisional data from the Centers for Disease Control and Prevention, overdose deaths involving stimulants besides cocaine increased more than fivefold between 2015 and 2021, from 5,777 per year to more than 30,000.
Meth’s growing role is concerning. While the Food and Drug Administration has approved medications, including methadone, that can ease people’s opioid cravings, there are no such FDA-approved medications for methamphetamine. That is why contingency management could prove to be so crucial: It has consistently been shown to increase abstinence among stimulant users more effectively than other, more ubiquitous methods, such as 12-step programs or cognitive behavioral therapy.
Contingency management
increased abstinence
People in contingency management programs were more likely to be abstinent at the end of the treatment than those in other programs.
Contingency management +
community reinforcement approach
2.84 times more likely*
Contingency management alone
2.2
Contingency management
+ 12-step program
1.82
12-step program alone
1.35
Cognitive behavioral therapy alone
1.17
* Compared to the control group.
 
Source: “Comparative efficacy and acceptability of
psychosocial interventions for individuals with
cocaine and amphetamine addiction,”
De Crescenzo et al. (2018)
THE WASHINGTON POST
Contingency management
increased abstinence
People in contingency management programs were more likely to be abstinent at the end of the treatment than those in other programs.
Contingency management +
community reinforcement approach
2.84 times more likely*
Contingency management alone
2.2
Contingency management + 12-step program
1.82
12-step program alone
1.35
Cognitive behavioral therapy alone
1.17
* Compared to the control group.
 
Source: C”omparative efficacy and acceptability of psychosocial
interventions for individuals with cocaine and amphetamine
addiction,” De Crescenzo et al. (2018)
THE WASHINGTON POST
Contingency management increased abstinence
People in contingency management programs were more likely to be abstinent at the end of the treatment than those in other programs.
Contingency management + community reinforcement approach
2.84 times more likely*
Contingency management alone
2.2
Contingency management + 12-step program
1.82
12-step program alone
1.35
Cognitive behavioral therapy alone
1.17
* Compared to the control group.
Source: “Comparative efficacy and acceptability of psychosocial interventions for individuals with
cocaine and amphetamine addiction,” De Crescenzo et al. (2018)
THE WASHINGTON POST
It’s no wonder, then, that several states — including California, Montana and Washington — are either engaged in or spinning up CM pilot programs. And for those who can pay out of pocket, a growing number of telehealth companies are offering fully remote contingency management.
“The science is well established,” said H. Westley Clark, an adviser to California’s pilot program and a former director of the federal Center for Substance Abuse Treatment. “When you compare it to other treatments, CM ranks at the head of the pack.”
The way it works is straightforward. When people pass a drug test, they earn rewards, usually a draw from a bowl containing prizes — written phrases of affirmation (“Good job!”), gift certificates in amounts from a few dollars to $50. Testing occurs twice a week or more, and rewards often escalate to encourage people to stick it out long term; you might get one draw from the prize bowl for your first drug-free sample, three draws the next week and five the following week. Some programs remove the element of chance or offer straight cash instead of gift cards. Sometimes, a different behavior is rewarded, such as showing up for counseling. But the rewards are always immediate, to help the positive reinforcement land.
To some, this all might sound a bit fishy. Paying people to stay off drugs? One can imagine the arguments: Isn’t anyone struggling with addiction just going to spend the money they earn on drugs again? Why should states devote taxpayer dollars to this?
Incentives for health-related behaviors will always make some people balk, as shown by criticism of covid-19 campaigns promising to award doughnuts, cruises, even millions of dollars to those who got vaccinated. When drugs enter the picture, the stigma often increases. But even people with staggeringly different views are getting behind contingency management.
In California, state legislators who couldn’t agree on whether Donald Trump had won the 2020 election did agree last summer — without a single “no” vote — to expand access to CM programs statewide. State Sen. Scott Wiener (D), who introduced the California bill, told me that although he “assumed it would be hyper-controversial … it turned out, even though there are people who have that initial reaction, once people look at it more closely, they tend to be persuaded.”
What convinces the skeptics? For some, it’s the taxpayer benefits: CM is incredibly cost-effective. (No surprise there — a single emergency-room visit for meth-induced psychosis can easily cost more than three months of cash rewards.) For others, it’s understanding that CM won’t just fund someone’s drug habit. Participants earn rewards only when they offer objective evidence of abstinence; someone who isn’t ready to stop using simply will not earn money.
Cost comparison
Maximum rewards for a typical
contingency management program
$600
Average cost of one stimulant-related ER visit
$570
Typical cost of one ambulance ride
$1,211
Typical costs for two weeks in prison
$1,360
Note: All costs for 2019.
Sources: Health Care Cost and Utilization Project
(ER visit); ValuePenguin (ambulance ride);
Federal Bureau of Prisons (prison costs); author’s
calculations
THE WASHINGTON POST
Cost comparison
Maximum rewards for a typical
contingency management program
$600
Average cost of one stimulant-related ER visit
$570
Typical cost of one ambulance ride
$1,211
Typical costs for two weeks in prison
$1,360
Note: All costs for 2019.
Sources: Health Care Cost and Utilization Project (ER visit);
ValuePenguin (ambulance ride); Federal Bureau of Prisons
(prison costs); author’s calculations
THE WASHINGTON POST
Cost comparison
Maximum rewards for a typical
contingency management program
$600
Average cost of one stimulant-related ER visit
$570
Typical cost of one ambulance ride
$1,211
Typical costs for two weeks in prison
$1,360
Note: All costs for 2019.
Sources: Health Care Cost and Utilization Project (ER visit); ValuePenguin (ambulance ride);
Federal Bureau of Prisons (prison costs); author’s calculations
THE WASHINGTON POST
So if moral objections to CM aren’t as common as one might expect, why isn’t it already more widespread? The major obstacles, as we shall see, aren’t moral ones at all. They’re mundane and bureaucratic — and easily fixed.
No matter what anyone thinks we should do to address the addiction crisis — legalize or criminalize all drugs, attempt to restrict supply, induce the government to provide a safe supply — there will always be people in this country struggling to change their relationship to mind-altering substances. And those people deserve all the help they can get.
People like Anileah Buswell.
In March 2020, Buswell was living with her boyfriend in a condemned Florida trailer park — without phone service, electricity or running water, both of them high on meth and other drugs. She was 20 and at the peak of her addiction after years of using. For weeks, she’d been wrapped in her high, oblivious to the outside world.
Hunger finally drove the two outside. When they emerged, they found a ghost town.
They tried to enter a McDonald’s to charge their phones, but the doors were locked. A nearby homeless shelter was closed. Eventually, they made their way to a pizza shop where Buswell’s mother sometimes worked, and there they watched the news and discovered with horror that people across the country were dying from a mysterious new virus.
This was how it often went with her addiction: The whole world could be falling apart, and she wouldn’t even know.
Buswell and her boyfriend spent a night with her grandmother, who bought them bus tickets to New Hampshire, where the two had previously lived. In that first year back, she experienced several cycles of sobriety and relapse — until just before her 21st birthday, in April 2021, when she learned she was pregnant.
The pregnancy motivated Buswell to stop using. She entered a residential treatment program for women and children, where she gave birth. And several months later, she moved into her own apartment with her baby daughter.
It is in such transitional moments — fraught with instability and uncertainty — that many people find it difficult to stay sober. Navigating the stresses of life without enough support, or encountering familiar triggers, can lead to relapse.
It is worth mentioning that some people who use drugs, even so-called hard drugs, do so without throwing their lives off balance. But for others, drug use can quickly spiral into chaos. Although cutting back might unlock natural rewards in a person’s life — the chance to repair loving relationships, find meaningful employment, create a home — for someone trying to quit a substance, those benefits might seem incredibly remote. Meanwhile, the biological and psychological rewards for using a drug, and the punishments for abstaining, are immediate.
Buswell, caring for her infant, had been “white-knuckling it,” she told me — worried about her sobriety and her well-being. Then she was offered a space in the contingency management program.
Initially, she had her doubts. “It’s going to be stupid,” she thought. “What am I going to want with some piece of paper that says ‘Good job’?”
But then she made her first prize draw — and received her first positive affirmation. As she described the experience, she teared up. “People don’t realize how hard it is,” she said. “There’s a lot of struggles that people don’t see. It just feels good to have somebody recognizing that.”
Contingency management is not new. In fact, researchers have been experimenting with it for decades, and the road to its development is lined with many of the familiar components of scientific discovery — peer-reviewed studies, randomized experiments — as well as a few unusual ones. For instance: porpoises.
Maxine L. Stitzer, a professor emerita at Johns Hopkins University School of Medicine, was a graduate student in psychopharmacology at the University of Michigan in the 1960s when a paper about “creative porpoises” — show animals — crossed her desk. Stitzer’s main interest was understanding the effects of psychoactive drugs on behavior. When she read about the porpoises, she became intrigued.
Show animals are often taught to perform specific tricks: wagging their tails to music, leaping over ropes in unison. But this paper described how porpoises that were offered positive reinforcements (i.e., food) for new behaviors began inventing moves unlike any their trainers had ever seen.
Stitzer was no stranger to animal-behavior studies. Her lab had published several reports showing that animals will repeatedly dose themselves with drugs when given the opportunity. But the porpoise study showed there could be other powerful motivators — modest rewards, strategically applied. She wondered: What if these reinforcers were to compete? Could strategic positive reinforcement be strong enough to counter the pull of drugs?
When Stitzer moved to Johns Hopkins, in the 1970s, she had a chance to investigate these questions. Patients in a clinic at Baltimore City Hospital, now known as Johns Hopkins Bayview Medical Center, were managing their heroin addictions with daily doses of methadone — which, taken as prescribed, reduces cravings and staves off the agonizing withdrawal that drives so many people to keep using. Some had quit heroin but were still using other drugs, such as cocaine and benzodiazepines (benzos), commonly abused anti-anxiety medications.
Stitzer and her colleagues recruited 10 patients for a tiny “demonstration” trial in which they could earn rewards if they stopped using benzos. Before the intervention, nine of the 10 patients had tested positive for benzos. After three months — during which time participants were tested twice a week and rewarded with modest prizes for benzo-free urine — seven of the 10 patients had clearly reduced their use. “Wow,” Stitzer recalled thinking. “We’re on to something here.”
Stitzer’s research is at the foundation of a field that has generated scores of reports about contingency management’s efficacy. The work has produced many insights: It has shown that the “fishbowl” approach (drawing for prizes) and the “voucher” approach (earning fixed amounts over time) both work. It has shown that contingency management is effective across different racial and ethnic groups and income levels. And it has shown that CM can have positive spillover effects. During a 2013 randomized trial of people with stimulant dependence and serious mental illness, not only was the CM group 2.4 times more likely to submit a stimulant-negative urine sample, but those receiving CM also had fewer psychiatric symptoms and hospitalizations.
The data are more mixed on CM’s lasting effects. In some studies — including Stitzer’s early trials — patients started using again when the incentives went away. But a recent analysis found that CM had better long-term benefits than other approaches. As with many treatments, it helps to avoid an abrupt end to support. One review concluded that the best long-term results came when CM was paired with the “community reinforcement approach,” which deliberately assists people in building rewarding social lives, to carry them along after a program ends.
In other words, contingency management is not a panacea. But a massive body of research tells us that it is the best tool we have to help people abstain from stimulant use.
Yet today, if you’re trying to quit stimulants and want access to the treatment, odds are your health provider won’t offer it to you — unless you’re a veteran.
In 2010, the Department of Veterans Affairs commissioned an evaluation of its behavioral health-care services and found that only 1 percent of its patients had access to contingency management, even though the treatment had robust scientific credentials. Determined to change this, it appointed Dominick DePhilippis, a gregarious clinical psychologist from Brooklyn, to implement and oversee an ambitious operation that included trainings for VA providers in the basics of CM.
Over a decade after VA began pouring resources into contingency management, more than 5,000 patients have gone through its programs, according to DePhilippis, with impressive results: 92 percent of participants’ samples come back free of the target substance. In short, VA has shown that CM’s usefulness isn’t a fantasy.
With so many people in the United States battling addiction, why is a tested, effective treatment still barely used?
The biggest obstacles to contingency management’s wider adoption turn out to be a complicated mix of regulatory and bureaucratic hurdles. The good news is that if we want to expand access — to offer evidence-backed care to more Americans — the federal government could take two actions now to give CM the recognition and push it deserves.
First — and this will sound ridiculously basic — CM needs a billing code. Billing codes are how providers get paid, and CM doesn’t have one. If providers can’t bill for a service, they can’t get reimbursed, which makes them less likely to offer it at all. And while it’s possible to pay for CM without a code — through private grants, for instance — it shouldn’t take that much effort to pay for such a well-researched therapy. (Consider that individual and group psychotherapy for addiction both have billing codes, and that contingency management has been shown to increase abstinence more effectively than therapy.)
The Centers for Medicare and Medicaid Services should create a code to pave the way for greater CM availability — not only for the privately insured but also for those on government health insurance, who tend to be lower-income and to face more hurdles to overcoming addiction.
Second, the Biden administration — which named expansion of CM a year-one priority — should move more boldly to clear up regulatory confusion that has discouraged states and clinics from offering full-throated contingency management.
In a significant development, the watchdog arm of the Department of Health and Human Services did recently sign off on a specific third-party CM provider — DynamiCare Health, a private telehealth company with established safeguards against fraud whose services are offered through a phone-based app. This was a big deal: Any entity partnering with DynamiCare can now skirt the dreaded regulatory confusion that has long deterred many states from offering full-fledged CM.
But states that choose not to work with a third-party provider must still navigate a complicated regulatory landscape. The Biden administration can and should do more to help states seamlessly expand their CM programs.
One simple move would be for the federal Substance Abuse and Mental Health Services Administration (SAMHSA), which funds treatment programs across the country, to lift its absurdly low $75-per-year restrictions on CM rewards. This is important because data suggest that such low reward levels aren’t very effective. Running CM pilot programs with too-low rewards would be like running a vaccine trial with doses at less than half the strength of what experts suggest would offer adequate protection — and then, even worse, grounding future policy on the results of that flimsy pilot.
As more states and clinics launch programs with funding from SAMHSA, they should be free to offer rewards at levels that actually work. And SAMHSA should attach useful strings to the funding, such as requiring programs to adhere to evidence-based protocols and to continually assess outcomes.
These recommendations are not to suggest that CM’s broader adoption depends on the government’s efforts alone. The public — those of us who are open to behavioral interventions, and who believe in getting people the best possible care — has a role to play, too.
First, we need to demonstrate patience. If all goes well — if more states and providers begin offering contingency management — you will probably hear a lot more about the treatment in coming years. But something will almost certainly go wrong. Maybe you’ll read about unscrupulous or ineffective providers, or an individual who made poor choices with their rewards. Or maybe you’ll know people who try CM and then relapse.
It might be tempting to condemn the treatment outright. Instead, we should ask tough but fair questions: Did the program adhere to what studies have shown are the most effective protocols? What kinds of safeguards were in place to prevent fraud? Did people receive sufficient support after they’d graduated from the program? Taking time to learn from those questions will help ensure that people are consistently offered a gold standard of care.
Second, the public needs to demonstrate impatience — the right kind. Patient and family advocacy matters. It’s time to start asking direct questions of providers: Do you offer contingency management? If so, does your version match what the evidence shows is effective? If not, what exactly do you offer, and what is the proof that it works?
It’s important to be realistic about what widespread CM can achieve. Addiction programs have their limits, and most Americans wrestling with substance use don’t seek formal treatment. In addition, because many people battling addiction have other pressing threats to their well-being — homelessness, for example — any approach that can’t attend to these other needs might not yield success.
But CM just might change the lives of an untold number of Americans. And they should have the chance to find out whether it works for them.
When I last spoke with Anileah Buswell, in mid-March, she had been sober for 11 months and two days. She had graduated from her CM program in February and enrolled in a data analytics course. Her daughter, she said, was “crawling like a maniac.”
CM hasn’t been a silver bullet for Buswell. So many things steadied her along the way, including the affordable housing initiative that helped her land her own apartment and the residential program where she was staying when her daughter was born. But contingency management has played a pivotal role. And she says she’s grateful for the regimen that has allowed her to find her bearings and proud of the life she’s building with her daughter and boyfriend, who has also been sober for months, thanks to other treatments and supports.
Buswell’s meth-free streak has won her several gift cards, one of which she used to buy cleaning supplies and toilet paper for her new apartment. During one of our conversations, she was tidying up the place while we spoke — her daughter had eaten her first-ever freeze pop that day and had made a mess.
“I like it,” Buswell said about finally having her own nest. “It’s small. But it’s a good place to start.”
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