Contingency Management for Treatment of Stimulant Use Disorder and Strategies to Address Polysubstance Use
March 22, 2023
As state and local governments identify the most effective ways to address the opioid and overdose crises in their communities, strategies to address more than just opioid use disorder are needed. With the dramatic increase of cocaine and methamphetamine use and the presence of fentanyl in the supplies of these drugs, effective treatment for individuals with stimulant use disorder is essential for many communities. Some advocates support using opioid settlement funds to support contingency management programs to address stimulant use disorder. To better understand how contingency management can help address the overdose epidemic, we spoke with Richard Rawson, PhD, Professor Emeritus, UCLA, Research Professor, University of Vermont.
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We’ve heard a lot about the changing nature of the overdose crisis. Can you tell us a little bit more about polysubstance use? What does it mean exactly and how is it contributing to the rising rates of overdose deaths across the country?
A ‘fourth wave’ of high mortality involving methamphetamine and cocaine use has been gathering force in the USA. While the availability and use of illicit fentanyls are still the major drivers of overdose deaths, many individuals are exposed to fentanyl, knowingly and unknowingly, through their purchase and use of fentanyl-laced cocaine and methamphetamine.
The growing role of psychostimulants in the overdose death crisis can be illustrated in recently released data from CDC. Despite the fact that the current overdose crisis in the US is almost universally referred to as the “opioid” or “fentanyl crisis”, the overdose death rate associated with cocaine and methamphetamine has also dramatically increased in recent years. Data on fentanyl only tells part of the story of the current overdose death crisis.
What strategies can help individuals with stimulant use disorder? And what does the evidence say about these programs?
At the present time there are no FDA-approved medications for the treatment of individuals with stimulant use disorder. However, there is one behavioral treatment with robust evidence that it works. Contingency management (CM), which is based on basic principles of positive reinforcement, is supported by an extensive collection of research studies supported by the National Institute on Drug Abuse. CM involves the immediate delivery of tangible rewards/incentives (e.g., gift cards) when treatment participants perform specific behaviors indicating non-use of stimulants. For example, a common CM protocol is to provide a gift card when individuals in treatment provide urine samples that test negative for cocaine or methamphetamine.
In the past five years, there have been at least seven meta-analyses or systematic reviews which overwhelmingly support the conclusion that contingency management has rich evidence as a treatment for stimulant use disorder. However, there are some major obstacles to the use of CM. At present, the most significant impediment to the use of CM is that there is a limit of $75 per participant that can be used in CM programs using any federal funds, including grant funds. It is not possible to deliver evidence-based CM with a $75 limit. Incentive levels in the range of $200-$300 per month for 3-6 months are needed to produce meaningful reductions in stimulant use and development of positive recovery behaviors.
How can opioid settlement funds be used to promote programs that address polysubstance use?
Because the methamphetamine / cocaine supply on the street now contains fentanyl, effective treatment for stimulant use disorder will significantly reduce the risk of fentanyl overdose. Conversely, efforts to reduce the deaths caused by fentanyl must address stimulant use disorder.
Opioid litigation dollars could be used in a number of ways to support implementation of effective contingency management programs.
- First, they could be used to support the training that is needed to establish this type of program, and in providing implementation support over the first 6-12 months of a program’s operation.
- Second, they could be used to supplement federal funds that are available to pay for staff that are needed to deliver contingency management and pay for urine testing supplies.
- Finally, and most importantly, the settlement money can be used to fund the incentives at a level consistent with research. This is the one aspect of contingency management treatment that is currently essential for effective treatment of cocaine and methamphetamine use disorder.
Overall, opioid settlement funds would be of tremendous value in funding contingency management programs for the treatment of stimulant use disorder. Several states are currently considering this use for their funds. Reduced cocaine and methamphetamine use will significantly reduce fentanyl overdose deaths.
What are some policy concerns around these types of interventions?
CM has primarily been used in treatment projects funded by the National Institute on Drug Abuse. CM only works when it is done correctly, by properly trained staff. At the present time, there are no established guidelines or training models to ensure that the CM programs are properly designed and operated. For implementation in “real world” treatment settings, it will be important that the protocols developed are consistent with the research literature, and are delivered with fidelity and fraud prevention guardrails to ensure accountability of funds.
What are some examples of programs or jurisdictions that have implemented contingency management programs?
Contingency management is being used throughout the Veterans Affairs healthcare system as the primary treatment approach for stimulant use disorder.
California is in the process of initiating a large pilot trial of contingency management for stimulant use disorder for their Medicaid program via a waiver that was recently approved by the federal government. Other states should consider this pathway for the long-term funding of contingency management, although this waiver process is time consuming and can require several years to implement.
What else do you think jurisdictions should know as they start making decisions about how to spend their settlement funds?
Individuals with stimulant use disorder are at very high risk for overdose from opioids, including fentanyl, because fentanyl and methamphetamine / cocaine are blended together in the drug supply. These individuals seek out and purchase cocaine and methamphetamine; their primary diagnosis is stimulant use disorder. They are not interested in and may not be appropriate for treatment for an opioid use disorder. At present, most of these individuals face difficulty in finding evidence-based treatment. Use of opioid settlement funds for contingency management for treating individuals with stimulant use disorder will be a life-saving treatment option for these people.
Where can people go for more information?
Information on funding of contingency management using opioid settlement funds can be obtained from members of the Motivational Incentives Policy Group, a group of professionals who are working to reduce obstacles to the use of contingency management for treatment of stimulant use disorder.
Members of the Motivational Incentives Policy Group:
Westley Clark, MD, JD
Mady Chalk, PhD
Tyler Erath, PhD
Carol McDaid
Richard Rawson, Ph.D.
Sarah Wattenberg, LCSW
Contact person: Richard Rawson: rrawson@mednet.ucla.edu